Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Instructions | Online submissionContact Us   |  Subscribe   |  Advertise   |  Login  Page layout
Wide layoutNarrow layoutFull screen layout
Lung India Official publication of Indian Chest Society  
  Users Online: 2037   Home Print this page  Email this page Small font size Default font size Increase font size


 
  Table of Contents    
CASE LETTER
Year : 2018  |  Volume : 35  |  Issue : 3  |  Page : 272-274  

Seven years in the trachea


1 Cardio Vascular Specialist Center, Dammam, KSA
2 1st Department of Respiratory Medicine, The National and Kapodistrian University of Athens, Athens, Greece
3 Department of Respiratory, Hellenic 251 Airforce General Hospital, Athens, Greece

Date of Web Publication26-Apr-2018

Correspondence Address:
Dr. Abdelfattah Ahmed Touman
Cardio Vascular Specialist Center, Dammam
KSA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_325_17

Rights and Permissions

How to cite this article:
Touman AA, Vitsas VV, Leonidas AS, Stratakos GK. Seven years in the trachea. Lung India 2018;35:272-4

How to cite this URL:
Touman AA, Vitsas VV, Leonidas AS, Stratakos GK. Seven years in the trachea. Lung India [serial online] 2018 [cited 2019 Nov 15];35:272-4. Available from: http://www.lungindia.com/text.asp?2018/35/3/272/231218



Sir,

Postintubation/tracheostomy tracheal stenosis (PITS) is an increasingly recognized complication requiring multidisciplinary management and long-term follow-up. Silicone stent placement is a treatment option which needs surveillance for possible complications and revision to confirm that stenting is still needed. In benign diseases, silicone stents if uncomplicated are usually kept for a period ranging from 18 to 24 months to allow healing and eventual stabilization of the trachea. If after removal, prosthesis is still necessary, a stent can be replaced.

We are reporting on a 67-year-old male, current smoker of 47 pack/years, who sought medical attention at our unit due to halitosis and exertional dyspnea.

His medical history starts 10 years ago after a prolonged hospitalization in Intensive Care Unit (ICU) following a sudden cardiac arrest. He was intubated and subsequently tracheostomized. Being diagnosed with dilated cardiomyopathy and atrial fibrillation, he was implanted a pacemaker and permanent implantable cardioverter defibrillator (ICD).

After discharge from ICU, he started complaining of exertional dyspnea and stridor and was undertaken by ENT surgeons who diagnosed PITS and treated it with laser ablation and tracheal dilatation. Later during the stenosis relapse, the patient had his tracheostomy re-established. In November 2009, he was referred to the interventional pulmonology unit of our institution, and after interdisciplinary evaluation, he was diagnosed with complex tracheal stenosis and was treated with stent insertion (Dumon ® silicone 16 mm × 50 mm). Following tracheal stent insertion, he received instructions regarding tracheal stent care, and he had regular follow-up appointment including bronchoscopic inspection of the stent. However, after the 2nd year of his follow-up, he resumed smoking and did not attend his scheduled appointments. He stopped answering phone calls from our team; 7 years after the stent insertion, he came again to our attention.

On admission, bronchoscopic inspection proved that the stent was in place; however, its lumen was plugged with a thick biofilm of mucopurulent secretions. At the distal end of the stent, granulation tissue formation was noted. Passing the scope distally confirmed normal peripheral airways [Figure 1].
Figure 1: (a) Tracheal view few months after uncomplicated stent placement, (b) bronchoscopy showing normal tacheal mucosa two years after the stent placement, (c and d) mucopurulent biofilm and granulation tissue formation partially obstructing the distal end of the stent 7-year postplacement

Click here to view


Removal of the stent with possible replacement was scheduled. As eventual use of electrocautery devices during bronchoscopy was deemed probable. After intubating the patient with the rigid scope, folding the stent and retracting it within the shaft proved extremely hard because the stent had lost its elasticity. The lumen of the stent was critically obstructed by purulent and necrotic materials. Stent removal in one piece was finally successful with a prolonged forceful upward pulling of the stent and the scope [Figure 2].
Figure 2: Efer–Dumon® silicone stent removed after 7 years of its placement in the trachea of active smoker

Click here to view


Thereafter, the base of the granulation tissue at the distal end of the prosthesis was cauterized and removed with the forceps and the bevel of the rigid scope; the patient's tracheal lumen was patent with no sign of tracheomalacia or excessive dynamic airway collapse while no immediate postoperative complications occurred [Figure 3].
Figure 3: (a) The trachea imediately after the stent removal. (b and c) Two days later, the previously noted granulation tissue and thick biofilm have been removed

Click here to view


Stents are foreign bodies which are placed in hollow organs to secure their patency. The commercially available stents for management of tracheal stenosis are manufactured either of silicone, metal, or hybrid materials.[1] After the U.S. Food and Drug Administration has issued a black box warning against using metal stents for patients with benign tracheobronchial stenosis, only silicone or hybrid stents are to be used.[2] Tumors or granulation tissue cannot grow through silicone stents due to their solid wall; on the other hand, this design interferes with the mucociliary clearance mechanism, and hence, the direct consequence is accumulation of thick mucus secretions. In case of tracheomalacia, the trachea wall where the stent has been deployed may progressively solidify with time, making stent removal possible. Nonetheless, the optimal time of stent removal should be carefully decided by an experienced pulmonologist.

In an early publication by Dumon,[3] it was recommended to keep the stent for 6–12 months. Subsequent studies showed that the restenosis rate reached 70% when silicone stents were removed 6 months after placement.[4] In study by Galluccio et al.,[5] all simple stenosis stents were successfully removed at the end of the 2 years. Importantly, removal of the stents is not exclusive for the silicone ones; studies have shown that the self-expandable metallic stents can be effectively and safely removed if necessary without major sequelae.[6]

Up to our knowledge, this is the first case of tracheal Dumon ® silicone stent which although complicated stayed in place for 7 years and then was safely removed. This case highlights Dumon ® silicone stent long durability, feasibility, and safety of removal after so many years.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Stratakos GR. Postintubation tracheal stenosis and endoscopic management. Pneumon 2003;16:252-61.  Back to cited text no. 1
    
2.
FDA Public Health Notification: Complications from Metallic Tracheal Stents in Patients with Benign Airway Disorders; 29 July, 2005. Available from: https://wayback.archive-it.org/7993/20170112171022/http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm153009.htm. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm153009.htm. [Last accessed on 2017 May 27].  Back to cited text no. 2
    
3.
Dumon JF. A dedicated tracheobronchial stent. Chest 1990;97:328-32.  Back to cited text no. 3
[PUBMED]    
4.
Brichet A, Verkindre C, Dupont J, Carlier ML, Darras J, Wurtz A, et al. Multidisciplinary approach to management of postintubation tracheal stenoses. Eur Respir J 1999;13:888-93.  Back to cited text no. 4
[PUBMED]    
5.
Galluccio G, Lucantoni G, Battistoni P, Paone G, Batzella S, Lucifora V, et al. Interventional endoscopy in the management of benign tracheal stenoses: Definitive treatment at long-term follow-up. Eur J Cardiothorac Surg 2009;35:429-33.  Back to cited text no. 5
[PUBMED]    
6.
Noppen M, Stratakos G, D'Haese J, Meysman M, Vinken W. Removal of covered self-expandable metallic airway stents in benign disorders: Indications, technique, and outcomes. Chest 2005;127:482-7.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed777    
    Printed11    
    Emailed0    
    PDF Downloaded203    
    Comments [Add]    

Recommend this journal