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      An outcome analysis of self-expandable metallic stents in central airway obstruction: a cohort study

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          Abstract

          Background

          Self-expandable metallic stents (SEMSs) have provided satisfactory management of central airway obstruction. However, the long-term benefits and complications of this management modality in patients with benign and malignant obstructing lesions after SEMS placement are unclear. We performed this cohort study to analyze the outcomes of Ultraflex SEMSs in patients with tracheobronchial diseases.

          Methods

          Of 149 patients, 72 with benign and 77 with malignant tracheobronchial disease received 211 SEMSs (benign, 116; malignant, 95) and were retrospectively reviewed in a tertiary hospital.

          Results

          The baseline characteristics of patients who received SEMS implantation for benign conditions and those who underwent implantation for malignant conditions were significantly different. These characteristics included age (mean, 63.9 vs. 58; p < 0.01), gender (male, 62% vs. 90%; p < 0.0001), smoking (47% vs. 85%; p < 0.0001), forced expiratory volume in 1 second (mean, 0.9 vs. 1.47 L/s; p < 0.0001), follow-up days after SEMS implantation (median; 429 vs. 57; p < 0.0001), and use of covered SEMS (36.2% vs. 94.7%; p < 0.0001). Symptoms improved more after SEMS implantation in patients with benign conditions than in those with malignant conditions (76.7% vs. 51.6%; p < 0.0001). The overall complication rate after SEMS implantation in patients with benign conditions was higher than that in patients with malignancy (42.2% vs. 21.1%; p = 0.001). Successful management of SEMS migration, granulation tissue formation, and SEMS fracture occurred in 100%, 81.25%, and 85% of patients, respectively.

          Conclusions

          Patients who received SEMS implantation owing to benign conditions had worse lung function and were older than those who received SEMS for malignancies. There was higher complication rate in patients with benign conditions after a longer follow-up period owing to the nature of the underlying diseases.

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          Most cited references 22

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          ERS/ATS statement on interventional pulmonology. European Respiratory Society/American Thoracic Society.

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            Multidisciplinary approach to management of postintubation tracheal stenoses.

            The optimal management of postintubation tracheal stenosis is not well defined. A therapeutic algorithm was designed by thoracic surgeons, ear, nose and throat (ENT) surgeons, anaesthetists and pulmonologists. Rigid bronchoscopy with neodymium-yttrium aluminium garnet (Nd-YAG) laser resection or stent implantation (removable stent) was proposed as first-line treatment, depending on the type of stenosis (web-like versus complex stenosis). In patients with web-like stenoses, sleeve resection was proposed when laser treatment (up to three sessions) failed. In patients with complex stenoses, operability was assessed 6 months after stent implantation. If the patient was judged operable, the stent was removed and the patient underwent surgery if the stenosis recurred. This algorithm was validated prospectively in a series of 32 consecutive patients. Three patients died from severe coexistent illness shortly after the first bronchoscopy. Of the 15 patients with web-like stenosis, laser resection was curative in 10 (66%). Among the 17 patients with complex stenoses, three remained symptom-free after stent removal. Bronchoscopy alone was thus curative in more than one-third of the patients. Six patients underwent surgery, two after failure of laser resection and four after failure of temporary stenting. Surgery was always performed with the patient in good operative condition. Palliative stenting was the definitive treatment in nine cases. Tracheostomy was the definitive solution in two cases. This approach, including an initial conservative treatment, depending on the type of the stenosis, appears to be applicable to almost all patients and allows secondary surgery to be performed with the patient in good condition.
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              Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis.

              s: To report and analyze our 6-year experience with implanting 112 self-expandable metallic stents (SEMSs) using flexible bronchoscopy (FB). Retrospective study, tertiary-care hospital. The studied population consisted of 82 patients (mean age, 59.1 years; range, 37 to 83 years), who received SEMSs from 1995 to 2001 using Wallstent (Boston Scientific; Galway, Ireland) or Ultraflex (Boston Scientific) stents. The indications for stent placement were airway obstruction caused by neoplasia (lung carcinoma [CA], n = 50), airway complications of lung transplantation (LTx) [n = 11], and miscellaneous benign conditions (BCs) [n = 21]. The most frequent clinical presentations for the airway obstruction were moderate-to-severe dyspnea (80%) and coughing (45%). The median follow-up duration for the CA group was 42.0 days (range, 1 to 672 days), 329.0 days (range, 35 to 1,540 days) for patients receiving LTx, and 336.0 days (range, 7 to 2,184 days) for the patients with miscellaneous BCs. The observed complications included infection (15.9%), obstructive granulomas (14.6%), and migration (4.7%). The incidence of granulomas was significantly lower in the patients with CA (4.0%) vs LTx and BC groups (17.3% and 33.3% respectively; p = 0.002). All other assessed variables showed no difference between the three analyzed groups. No cases of mucus plugging or fatal hemoptysis were observed. Forty-four patients (53.7%) had no complications related to the SEMS. The incidence of complications was not related to the type of stent (Wallstent or Ultraflex) or SEMS version (covered or uncovered). Fourteen of the 16 patients (87.5%) who were receiving mechanical ventilation could be weaned after the procedure. There were no deaths related to SEMS placement. An SEMS is a safe and effective modality for malignant as well as selected benign airway obstruction. An SEMS is an acceptable therapeutic alternative in patients with central airway obstruction who are not considered good surgical candidates and are receiving mechanical ventilation. Careful patient selection is of outmost importance for a good outcome after airway stenting. Insertion using FB adds to the ease of the procedure.
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                Author and article information

                Journal
                J Cardiothorac Surg
                Journal of Cardiothoracic Surgery
                BioMed Central
                1749-8090
                2011
                8 April 2011
                : 6
                : 46
                Affiliations
                [1 ]Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, No. 199 Tun Hwa N. Rd., Taipei City 10507, Taiwan
                [2 ]Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, No. 259, Wun Hua 1st Rd., Gueishan Township, Taoyuan County 333, Taiwan
                Article
                1749-8090-6-46
                10.1186/1749-8090-6-46
                3090328
                21477303
                Copyright ©2011 Chung et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Research Article

                Surgery

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