1 "The role of tracheal stenting in the alternative treatment of tracheal stenosis" Bagheri. R. MD Assistant professor of thoracic surgery, Quaem hospital,

1

"The role of tracheal stenting in the

alternative treatment of tracheal stenosis"

"The role of tracheal stenting in the

alternative treatment of tracheal stenosis"

Bagheri. R. MD Assistant professor of thoracic surgery, Quaem hospital, Mashad, IRAN

Bannazadeh M. MD Assistant professor of thoracic surgery, Valiasr Hospital, Tehran, IRAN

Bagheri. R. MD Assistant professor of thoracic surgery, Quaem hospital, Mashad, IRAN

Bannazadeh M. MD Assistant professor of thoracic surgery, Valiasr Hospital, Tehran, IRAN

2

Etiology of tracheal stenosisEtiology of tracheal stenosis Etiology of tracheal stenosisEtiology of tracheal stenosis

• Common cause: Common cause: (a)(a) Prolonged intubationProlonged intubation

(b)(b) Tracheal tumor (benign or malignant)Tracheal tumor (benign or malignant)

• Uncommon cause: Uncommon cause: (a)(a) Trauma Trauma

(b)(b) InfectionInfection

(c)(c) Postaspiration Postaspiration

• Common cause: Common cause: (a)(a) Prolonged intubationProlonged intubation

(b)(b) Tracheal tumor (benign or malignant)Tracheal tumor (benign or malignant)

• Uncommon cause: Uncommon cause: (a)(a) Trauma Trauma

(b)(b) InfectionInfection

(c)(c) Postaspiration Postaspiration

3

Treatment of tracheal stenosisTreatment of tracheal stenosis

• The best method of treatment is tracheal The best method of treatment is tracheal resection.resection.

• Tracheal surgery demands very skilled Tracheal surgery demands very skilled surgeons.surgeons.

• The most important complication of tracheal The most important complication of tracheal resection is tracheal stenosis.resection is tracheal stenosis.

• The best method of treatment in posttracheal The best method of treatment in posttracheal resection stenosis is repeated tracheal resection stenosis is repeated tracheal resection.resection.

• The best method of treatment is tracheal The best method of treatment is tracheal resection.resection.

• Tracheal surgery demands very skilled Tracheal surgery demands very skilled surgeons.surgeons.

• The most important complication of tracheal The most important complication of tracheal resection is tracheal stenosis.resection is tracheal stenosis.

• The best method of treatment in posttracheal The best method of treatment in posttracheal resection stenosis is repeated tracheal resection stenosis is repeated tracheal resection.resection.

4

Material & methodMaterial & method

• This is a prospective study (case series) This is a prospective study (case series) in patients with tracheal stenosis who in patients with tracheal stenosis who weren’t candidate for tracheal surgery in weren’t candidate for tracheal surgery in Tehran Vali Asr hospital from 2001 to Tehran Vali Asr hospital from 2001 to 2003.2003.

• Patient selection : Patient selection : (1)(1)Inoperable tracheal malignancy Inoperable tracheal malignancy (2)(2) Non tumoral stenosis which is complicated with Non tumoral stenosis which is complicated with previous surgery previous surgery (3)(3)Inability to stand a major operation (poor general Inability to stand a major operation (poor general condition or CNS problem)condition or CNS problem)

5

Method of studyMethod of study

• Patient’s that Exclude from study:Patient’s that Exclude from study:

(1)(1) Inability to perform rigid Inability to perform rigid bronchoscopy (vocal cod paralysis) bronchoscopy (vocal cod paralysis)

(2)(2) Patient’s disagreementPatient’s disagreement

(3)(3) Follow up less than 6 monthFollow up less than 6 month

6

Stent propertiesStent properties

• Polyflex stent with introducer systemPolyflex stent with introducer system• Silicon stent with polyester mesh for Silicon stent with polyester mesh for

maintaining airway patencymaintaining airway patency• Size : inner diameter : 6-22 mm in 2 mm steps Size : inner diameter : 6-22 mm in 2 mm steps

length : 20-80 mm in 10 mm stepslength : 20-80 mm in 10 mm steps

7

Appropriate stent sizeAppropriate stent size

• Stent internal diameter: Maximum size of tracheal dilation with rigid bronchoscope +3mm +4mm

• Stent length: length of stenosis +2cm

8

Technique of stent insertionTechnique of stent insertion

9


10


11


12


13


14


15


16


17


18


19


20

Internal view of trachea after Internal view of trachea after stent insertionstent insertion

21

Radiography of patient after Radiography of patient after stent insertionstent insertion

22

Radiography of patient after Radiography of patient after stent insertionstent insertion

23

Result of study Result of study

24

Age frequency Age frequency

50 to 59 y50 to 59 y

16.67%16.67%

1010 to 19 y to 19 y

8.33%8.33%

20 to 29 y20 to 29 y

41.67%41.67%

40 to 49 y40 to 49 y

8.33%8.33%

30 to 39 y30 to 39 y

25%25%

25

Sex frequency Sex frequency

Female Female

33.33%33.33%

Male Male

66.67%66.67%

26

The cause of tracheal stenosis The cause of tracheal stenosis

Tracheal Tracheal malignancymalignancy

16.67%16.67%

Chemical Chemical gas gas

inhalationinhalation

8.33%8.33%

Post intubationPost intubation

75%75%

27

Time between extubation and beginning Time between extubation and beginning of symptom’s of stenosis of symptom’s of stenosis

31 to 45 31 to 45 daysdays

22.22%22.22%

0 to 15 days0 to 15 days

22.22%22.22%


55.66%55.66%

28

Internal diameter of stenosisInternal diameter of stenosis

percent Frequency Internal diameter of stenosis

50.00%60 to 0.5 cm

25.00%30.51 to 0.6 cm

25.00%30.61 to 0.7 cm

100.00%

12Total

29

Evaluation of stent efficacy Evaluation of stent efficacy (A)(A) Clinical symptoms: Clinical symptoms: 1.1. Improvement of stridor Improvement of stridor 2.2. Activity of patientActivity of patient

Percent Frequency Activity of patient

16.67%2Excellent

66.67%8Good

16.67%2Intermediate

0.00%0Fair

100.00%12Total

30

Evaluation of stent efficacyEvaluation of stent efficacy

Percent Frequency One month after stent

insertion

16.67%2Excellent

50.00%6Good

33.33%4Intermediate

0.00%0Fair

100.00%12Total

31


Percent Frequency Two weeks after stent removed

0.00%0Excellent

18.18%2Good

9.09%1Intermediate

72.73%8Fair

100.00%11Total

32


(B) Paraclinic study : (B) Paraclinic study : 1.1. P.F.T (before and after stental inserties)P.F.T (before and after stental inserties)2.2. Peakflowmetry (before and after stental inserties)Peakflowmetry (before and after stental inserties)

Displacement Displacement of 3 columned of 3 columned

8.33%8.33%Displacement Displacement

of 1 of 1 columned columned

33.33%33.33%

DisplacemeDisplacement of2 nt of2

columned columned

58.33%58.33%

33

Stenting complications Stenting complications

Without Without complicatiocomplicatio

n n

25%25%

With With complication complication

75%75%

34

Stenting complicationStenting complication

Late Late

77.78%77.78%

Intera operative Intera operative

11.11%11.11%

Immediately Immediately

11.11%11.11%

35

Late complication Late complication

77.78%

Granulation tissueGranulation tissue Retention Retention of of

secretionsecretion

Automatic Automatic stental stental

extrusionextrusion

Mouth bad smellMouth bad smell Tumoral Tumoral growthgrowth

44.44%

11.11% 11.11% 11.11%

0

10%

20%

30%

40%

50%

60%

70%

80%

36

Duration of stenting Duration of stenting


20%20%


20%20%


30%30%


30%30%

37

Cause of stent removalCause of stent removal

(A)(A) In benign disease : In benign disease :

The stent was removed in 30% of The stent was removed in 30% of patients in ideal time (3 to 4 month) patients in ideal time (3 to 4 month) without complication but in 70% of without complication but in 70% of patients because of some patients because of some complications we removed had to complications we removed had to stent obligatory in less than 3 month.stent obligatory in less than 3 month.

38

Cause of early stent removal Cause of early stent removal

Mouth bad Mouth bad smellsmell

14.29%14.29%

granulatiogranulationn

85.71%85.71%

39

Cause of stent removalCause of stent removal

(B) In malignancy : (B) In malignancy :

In one patient stent was kept in place In one patient stent was kept in place until death time but in one patient until death time but in one patient because of tumoral ingrowth at first the because of tumoral ingrowth at first the stent was removed and after rigid stent was removed and after rigid bronchoscopy, tumor removed and the bronchoscopy, tumor removed and the stent replaced again and patient was stent replaced again and patient was reffered to radiotherapy. reffered to radiotherapy.

40

conclusionconclusion

• Stent removal in benign conditions Stent removal in benign conditions showed signs of recurrence which showed signs of recurrence which needed another alternative treatment. needed another alternative treatment. This problem makes the role of stent This problem makes the role of stent insertion questionable. But the use of insertion questionable. But the use of stent in malignant conditions is stent in malignant conditions is indicated where it is the only indicated where it is the only alternative, and its role is approved.alternative, and its role is approved.

41

Documents

1 "The role of tracheal stenting in the alternative treatment of tracheal stenosis" Bagheri. R. MD Assistant professor of thoracic surgery, Quaem hospital,