Communications to the Editor |

How Much Incidence Is Enough? FREE TO VIEW

Klaus Wassermann, MD, FCCP
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Universitätsklinik Köln Köln, Germany

Correspondence to: Klaus Wassermann, MD, FCCP, Division of Pulmology and Bronchology, Medizinische Klinik III, Universitätsklinik Köln, Josef-Stelzmann-Strasse 9, 50924 Köln, Germany; e-mail: klaus.wassermann@uni-koeln.de

Chest. 2001;120(2):686-687. doi:10.1378/chest.120.2.686-a
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To the Editor:

It is with great interest that I read the article by Matsuo and Colt in CHEST (November 2000) about routine surveillance bronchoscopy after stent placement.1 Some comments from the point of view of a practicing bronchologist seem warranted.

Strict adherence to the study objective, namely assessing the rate of stent-related complications in asymptomatic receivers of the devices (n = 31), ends up in nine asymptomatic patients with stent-related complications (29%), four of whom required reintervention. In other words, 13% of all asymptomatic patients undergoing routine bronchoscopy needed endoscopic revision due to side effects of stents. There is no sense at all in minimizing this rate by relating it to the total number of stented patients. If surveillance bronchoscopy was supposed to serve as a preventive measure against respiratory emergencies, then this goal was not attained because only a minority of patients remained asymptomatic until the scheduled control date.

Eighteen individuals of the entire sample (n = 88) died before bronchoscopic control was thought of. No evidence is given that, had they survived, they would have remained asymptomatic until the time of scheduled surveillance bronchoscopy. Nor is it “unlikely that death[ of at least some of them] resulted from a stent-related complication,” since the authors do not substantiate this assumption. Thirty-one patients underwent emergency bronchoscopies due to respiratory symptoms before the date of scheduled surveillance, and eight patients were symptomatic at the time of surveillance. Thus, on the whole, 57 patients did not reasonably belong to the group where surveillance was (or, in case of the deceased, would possibly have been) indicated or performed.

But, apart from the message that surveillance ended up in quite a few (13%) of patients requiring reintervention, the data tell us a different and not less interesting story about the natural history of stents: after stent placement, 39 of 70 alive patients (56%) had newly occurring respiratory symptoms that necessitated bronchoscopy; in 33 of them (47%), these symptoms proved to be stent related, and in 22 of them (31%) these stent-related symptoms needed bronchoscopic treatment. Moreover, addition of the asymptomatic group resulted in 26 of 70 stented patients (37%) needing reintervention at some time or other ≤ 2 to 3 months after stent insertion.

My conclusions are the following: (1) if surveillance bronchoscopy is planned at an interval of 2 to 3 months, only a minority of patients will benefit (in this study, 31 of 70 patients); therefore, (2) there is no reason to reject any surveillance. It should only be performed at shorter intervals, at least at the outset. Unfortunately, the authors do not detail when symptoms occurred after stent placement. Had they done or should they do so, it would facilitate defining best set points for surveillance, although I myself favor individualizing those time intervals. There is an unpredictable tendency in some—but not in others—towards early and repeated mucus plugging, whereas in others, growth of obstructing granulation tissue prevails. I think dislocation occurs—if it does at all—very soon after implantation (“soon” and “early” are supposed to designate 1 week or 2 weeks at most after stent placement). Late dislocations seem to be due to widening of the stenosis by additional therapeutic interventions like radiotherapy or afterloading. In these patients, stents should be removed anyway.


Matsuo, T, Colt, HG (2000) Evidence against routine scheduling of surveillance bronchoscopy after stent insertion.Chest118,1455-1459




Matsuo, T, Colt, HG (2000) Evidence against routine scheduling of surveillance bronchoscopy after stent insertion.Chest118,1455-1459
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