Experience with Ultraflex expandable metallic stents in the management of endobronchial pathology

BACKGROUND: Experience with Ultraflex expandable metallic stents (Micro-invasive, Boston Scientific, Watertown, MA) in the management of endobronchial pathologies leading to airway compromise is reported. METHODS: Between January 1999 and August 2000, twenty-eight expandable metallic stents were inserted into 25 patients (7 men and 18 women; median age, 65 years) who presented with respiratory distress. Each patient had comorbid medical conditions or end-stage malignancy that precluded formal surgical repair. Seventeen patients had intrinsic airway obstruction, 5 had extrinsic compression, 2 had a tracheal tear, and 1 had a tracheoesophageal fistula. Stents were inserted through a bronchoscope under direct vision. Eighteen patients received tracheal stents alone (1 of these patients received two tracheal stents), and 5 patients received bronchial stents only. Two patients received a tracheal and a bronchial stent. Twenty-one stents were covered and seven were uncovered. RESULTS: All patients had successful stents with restoration of airway patency and closure of tracheal defects. One patient developed a respiratory infection early after the operation. Follow-up bronchoscopy confirmed satisfactory stent position in each patient. Late complications included sputum retention, halitosis, and granulation tissue formation. CONCLUSIONS: Ultraflex expandable metallic stents should be considered in the management of airway compromise in selected patients for whom formal surgical repair is inappropriate or contraindicated.     

Esophageal stents for leaks and perforations

Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak.     

Covered expandable tracheal stents in the management of benign tracheal granulation tissue formation

BACKGROUND: Tracheal obstruction secondary to benign proliferation of granulation tissue is a difficult problem to address if tracheal resection is contraindicated. Some patients may benefit from Nd:YAG (neodymium: yttritium-aluminum garnet) laser fulguration or tracheal stenting. If uncovered expandable metallic stents are employed granulation tissue can regrow and proliferate through the mesh, thereby obstructing the lumen once again. Covered metallic stents confer the advantage of preventing granulation tissue proliferation and therefore maintain patency of the tracheal lumen. METHODS: Two patients who developed tracheal obstruction secondary to proliferating granulation tissue formation after tracheostomy and who were medically unfit for prolonged general anesthesia were successfully treated using covered expandable metallic tracheal stents. RESULTS: Each patient demonstrated a significant improvement in respiratory status, and in both patients, at 6 and 9 months' follow-up, stent position has not changed, tracheal lumen remains patent, and there has been no proliferation of granulation tissue through the stent. CONCLUSIONS: Covered expandable metallic stents should be considered in the management of patients with proliferating tracheal granulation tissue when tracheal resection is contraindicated.     

Self-expandable metal stents to treat gastric leaks.

OBJECTIVES: Anastomotic leak is a major complication after gastric bypass (GBP) surgery, and it usually necessitates reoperation and is associated with long-term recovery and death. We present our experience with the use of self-expandable metal stents (SEMS) to treat this complication. METHODS: Seventeen patients (14 males and 3 females, mean body mass index of 43.7 kg/m(2)) with gastro-jejunal leak after GBP underwent covered SEMS placement 1 to 3 weeks after surgery: 8 laparoscopic, 5 open, and 4 revisional procedures. All patients who underwent laparoscopic and revisional procedures had abdominal drains placed at surgery. No drains were placed in the open cases. Five patients required surgery to drain an abdominal abscess. RESULTS: Tolerance for oral feeding was achieved between 2 and 3 days after SEMS placement. One patient persisted with a minimal leak for 2 weeks. To date, all stents have been removed endoscopically 3.2 +/- 1.2 months after placement. Four patients needed a second session to complete removal of the uncovered top of the stent. Two esophageal mucosal tears occurred; both were managed conservatively. Sixteen patients had a totally sealed leak. One remained with a gastro-gastric fistula. One stent spontaneously migrated to the splenic flexure and was removed colonoscopically. CONCLUSIONS: SEMS placement for gastro-jejunal leaks is a safe therapeutic option.     

Removal of esophageal expandable metal stents

BACKGROUND: Expandable metallic stents (EMS) have seen wide application in patients with malignant stricture and fistulas. They have not seen wide application for benign disease because of concern over acute complications and long-term sequelae. METHODS: Between June 1999 and October 2000, six patients with EMS in place for malignant stricture (n = 3), benign stricture (n = 1), anastomotic leak (n = 1) and benign esophagorespiratory fistula (n = 1) had their stents endoscopically removed. Removal was performed secondarily to the following complications: secondary stricture (n = 1), epidural abscess (n = 1), diskitis (n = 1), resolution of fistula (n = 2), and resolution of anastomotic leak (n = 1). RESULTS: Four patients had one EMS: Ultraflex (n = 3) and Z-stent (n = 1). In two patients, two stents (Ultraflex and Z-stent) were retrieved simultaneously. No procedurally related complications occurred. Two patients with esophageal cancer required additional stents. All three patients with benign fistula and stricture recovered uneventfully. CONCLUSIONS: The safe removal of current brands of EMS may facilitate the wider application of these devices to include selective patients with benign disease.     

自展不锈钢支架在肝门部胆管癌治疗中的应用

肝门部胆管癌早期诊断困难，手术切除率低多采用外引流的方法，存在引流不畅。逆行感染，生活不便等缺点。作者自行选材制成“Ｚ”形不锈钢自展支架，对４例无法手术切除的肝门部胆管癌病人行胆道支架放置术，术后短期随访效果良好。文章对胆道支架的种类放置途径及优缺点，手术操作注意事项、技巧、并发症等问题进行了讨论。认为自制的不锈钢自展支架支困人格便宜，效果满意，是可供选择的方法之一；但由于本组病例少，尚需进一步积     

Use of expandable metal stents in the treatment of bronchial obstruction.

An expandable metal stent has been used to treat bronchial collapse due to polychondritis in one patient and extrinsic bronchial compression secondary to bronchogenic tumour in another.     

Endoscopic internal drainage by double pigtail stents in the management of laparoscopic sleeve gastrectomy leaks

BackgroundLeaks and fistulas after laparoscopic sleeve gastrectomy (SG) are major adverse events of bariatric surgery. Endoscopic management of post-SG leaks has evolved from closure with covered self-expanding metallic stents to endoscopic internal drainage (EID).ObjectiveTo report our experience with the management of post-SG leaks treated with EID, either as primary therapy or after failure of closure therapy with self-expanding metallic stents.SettingSingle-center observational study.MethodsA retrospective study of 20 patients treated for post-SG leaks with EID by deployment of double pigtail stents across the leak orifice, positioning one end inside the collection and the other end in the lumen of the stomach.ResultsThere were 13 (65%) males and 7 (35%) females with a mean age of 34.2 ± 11.6 years. EID was performed after a mean 62 days after SG. Three patients had gastrobronchial fistula. Seventeen (85%) patients had failed some form of prior therapy for the leak. The mean duration of EID was 83 days and 17 (85%) patients had complete healing of the leak with a mean follow-up of 16 months. There were 2 (10%) adverse events and no mortalities. The success of EID in healing post-SG leak was significantly associated with the absence of a gastrobronchial fistula (P < .05).ConclusionsEID is an effective and safe endoscopic treatment of leaks after SG and is well tolerated. It allows early feeding and has fewer adverse events than other techniques. The presence of a gastrobronchial fistula is associated with higher failure rates. Long-term follow-up confirms a good outcome with no mortality.     

Endoscopic palliation for pancreatic cancer with expandable metal stents

Pancreatic cancer is generally not amenable to curative resection. Consequently, therapeutic efforts for these patients are most commonly directed at palliation of symptoms. Historically, surgery has been considered the most effective method of providing relief for biliary and/or enteric obstruction. However, less invasive methods have become available that can provide effective relief of jaundice and duodenal obstruction. Surgeons should still play an integral role in the management of these patients. We present a case report in which self-expanding metallic stents were used to relieve obstruction of the bile duct and duodenum in a patient with unresectable pancreatic cancer.     

Treatment of tracheobronchomalacia with expandable metallic stents

Tracheomalacia is an unfrequent disease that causes tracheal collapse during breathing. It is generally associated to esophageal atresia, but cases of primary tracheomalacia and others secondary to extrinsic compression, have also been described. Spontaneous resolution is generally the rule and only a few cases need surgical treatment. When this therapy fails or is not indicated for any reason, endoluminal tracheobronchial stents may be used. We have treated two patients with four expandable metallic stents: one had severe tracheomalacia associated to esophageal atresia and the other tracheobronchomalacia secondary to cardiomegaly. Results have been good in both cases.     

Predictors of alveolar air leaks

Persistent air leaks are caused by the failure of the postoperative lung to achieve a configuration that is physiologically amenable to healing. The raw pulmonary surface caused by the dissection of the fissure often is separated from the pleura, and the air leak fails to close. Additionally, higher air flow thorough an alveolar-pleural fistula seems to keep the fistula open. Other factors that interfere with wound healing, such as steroid use, diabetes, or malnutrition, can result in persistence of the leak. A thoracic surgeon can minimize the incidence of air leak through meticulous surgical technique and can identify patients in whom the balance of risks (Table 1) and benefits warrant operative intervention based on an understanding of the underlying pathophysiology.     

静脉内支撑治疗布加综合征临床研究

为了研究静脉内支撑治疗布上的临床疗效,作者采用该方法对１０例布加综合征患者实施的治疗,根据血管病变的部位和范围选择下腔静脉扩张内支撑、肝脉扩张内支撑和肝内门体分流术。结果显示：术后患者临床症状明显改善、门静脉压力、下腔差显著下降,支撑血管血液流动正常,无操作并发症。经１－２１个月随访,出血复发１例,静造影示肝内分流道狭窄１例,下腔静再狭窄１例,均行丙次介入治疗。作者认为,静脉内支撑治疗布加综合片人