INTRODUCTION: Tracheal stenting is an accepted treatment for benign and malignant bronchial stenosis. However, the application of Gianturco self-expandable metallic stents in benign stenosis has been questioned as serious complications including massive hemoptysis, tracheobronchial perforation, and esophageal perforation have been reported.We report, herein, a patient who had Gianturco stent insertion for benign bronchial stenosis complicated by tracheobronchial and esophageal erosion.
CASE PRESENTATION: A 46-year-old man had a known history of endobronchial tuberculosis with left main bronchial stenosis requiring repeated dilatation. A Gianturco self-expandable metallic stent was inserted in May, 1999. The patient was well until he noticed on and off blood-stained sputum in October, 2002. Fiber-optic bronchoscopy was performed and showed evidence of stent migration with protrusion of its struts out from the left main bronchus into the right main bronchus. Subsequent contrast CT thorax confirmed migration of the left main bronchial stent into the right main bronchus [fig 1]. There was also evidence of stent erosion into the esophagus. Esophagoscopy confirmed erosion into the esophagus by the bronchial stent. Under general anesthesia, right posterolateral thoracotomy was performed. Intra-operatively, erosion of the lower trachea, left and right main bronchi by the metallic stent was found. Fragments of the bronchial stent had eroded into the esophagus at the level of the azygous vein. Esophagectomy, cervical esophagostomy and gastrostomy were performed.One month later, a left-sided posterolateral thoracotomy was performed. The superior and posterior parts of the bronchial stent were found to have eroded out of the left main bronchus, with one of the struts impinging on the posterior aortic wall. The strut was removed and the aortic impinged site was repaired with pledgetted 4/O prolene purse-string sutures. At the distal end of the stent, three struts were found protruding out of the bronchial wall, facing the descending thoracic aorta. All the protruding struts were removed. Gastrointestinal continuity was restored by gastric pull-up two months later. The stomach conduit was brought up to the neck via the retrosternal route. Recovery from these operations was smooth with no complications. Interval reassessment CT thorax 3 months later showed no evidence of further migration of the residual stent fragments.
DISCUSSIONS: Insertion of Gianturco self-expandable metallic stents is considered permanent. Its spikes frequently embed into the bronchial walls, making removal difficult. Progressive expansion of the bronchial stent may eventually erode through the trachea or bronchus and injure adjacent organs. Fatal complications including tracheobronchial wall erosion, esophageal perforation and aortic pseudoaneurysms have been reported in the literature and have deterred their use [1, 2]. Not infrequently, salvage procedures are difficult, if not impossible, and the patients do not survive these complications.Although esophagectomy and subsequent gastric pull-up reconstructive procedure is a major undertaking, this aggressive approach is considered indicated in patients with benign disease that is likely to have a favourable long-term outcome. Early recognition of potentially fatal complications and a multidisciplinary approach have enabled successful salvage of this patient.
CONCLUSION: Self-expandable metallic stents are nowadays not commonly recommended for palliation of benign bronchial stenosis because of their relative difficulty in removal and their potential fatal complications. Regular surveillance imaging and a high index of suspicion are required for early recognition of potential problems. Aggressive management, including extensive surgical resection is indicated for treatment of these complications.
DISCLOSURE: Flora Tsang, None.