Animal Study of a Newly Designed Metal Airway Brachytherapy Stent Loaded with Radioactive 125I Seeds

Aim: To evaluate dynamic tissue changes after airway stenting (AS) with a newly designed metal brachytherapy stent (BS) loaded with radioactive 125I seeds in normal rabbits.Method: Forty-five normal New Zealand white rabbits were divided into three groups (Group A: stent without seeds; Group B: stent with 0.4 mCi active seeds; Group C: stent with 0.8 mCi active seeds) and underwent AS under C-arm guidance. Then, 5 rabbits were sacrificed from each group at 2, 4, and 8 weeks for further examination. Laboratory tests (including routine blood tests, liver function, kidney function, electrolytes and ROS levels), gross observations, and tissue changes of Masson/hematoxylin-eosin staining, plus immunohistochemistry of α-SMA, NOX4, and TGF-β were performed at each time point.Result: All animals underwent AS successfully without procedure-related death, but one animal died at 6 weeks due to severe pulmonary infection in Group C. Apart from a transient increase in white blood cells (P < 0.05) and a gradual increase in ROS levels (P < 0.05), other blood test items showed no significant changes (P > 0.05). The brachytherapy injury score increased with irradiation dose accumulation (P < 0.05), but tissue hyperplasia at the stent end in Group C was less severe than that in Groups A and B (P < 0.05). Airway lateral fibrosis was observed in all groups by histopathologic analysis; however, fibrosis in Group C was more severe than that in Groups A and B (P < 0.05).Conclusion: The brachytherapy injury score increased with irradiation dose accumulation, while granulation tissue hyperplasia at the stent end was inhibited by 125I brachytherapy within 8 weeks.

Airway Management of the Deformed Trachea Using T-Tube Stents in Patients with Mucopolysaccharidosis Type IVA

Introduction: Mucopolysaccharidosis (MPS) type IVA usually results in airway obstruction due to thoracic cage deformity and crowding of intrathoracic structures, causing tracheal compression by the tortuous innominate artery. Objectives: To offer an alternative and effective method in dealing with the challenged deformity of the airway in patients with MPS type IVA. Methods: We present 3 patients with MPS type IVA who underwent airway stenting using Montgomery® T-tube stents. Three-dimensional reconstructed computed tomography was essential to design the T-tube and evaluate the anatomical relationship between the innominate artery and the trachea. The Y-shaped Montgomery® Pediatric Safe-T-Tube™ is more suitable for MPS type IVA. Regular follow-ups using fiberoptic bronchoscopy are necessary to evaluate the complications. Results: All 3 patients had good outcomes during the follow-ups until present, despite the complication of granulation formation, which was resolved by revising the limbs of the T-tube. Conclusions: T-tube stents placed below the vocal cord may restore airway patency and preserve laryngeal function, including respiration, phonation, and swallowing, in patients with MPS type IVA.

Sequential Treatment of Severe Airway Stenosis Caused by Esophageal Cancer by Using Airway Stent Implantation and Arterial Infusion Chemotherapy

Purpose: This study was aimed at investigating the safety and efficacy of airway stent implantation and transarterial infusion chemotherapy for the treatment of severe airway stenosis caused by esophageal cancer. Methods: Data of patients with advanced esophageal cancer complicated by severe airway stenosis treated with airway stent implantation and transarterial infusion chemotherapy were retrospectively analyzed. Furthermore, dyspnea, clinical efficacy, adverse reactions, and survival were evaluated. Results: Of the 71 patients included, 28, 43, 34, 35, and 2 patients had grade III dyspnea, grade IV dyspnea before airway stenting, grade I dyspnea, grade III dyspnea, and grade III dyspnea after airway stenting, respectively. After airway stent implantation and 1–3 courses of transarterial infusion chemotherapy, complete response, partial response, and stable disease were noted in 11, 41, and 19 patients, respectively. Total objective response rate (ORR) and disease control rate (DCR) were 73.2% and 100.0%, respectively. During follow-up, 32, 24, and 10 patients died of organ failure, tumor-related respiratory failure, and gastrointestinal bleeding, respectively. The median survival time was 8 months, and the 1-year survival rate was 40.8%.Conclusions: Airway stent implantation combined with arterial infusion chemotherapy is safe and effective in the sequential treatment of esophageal cancer with severe airway stenosis.

Arterial Infusion Chemotherapy for Neoplastic Esophagogastric Anastomotic Strictures After Esophagectomy

BackgroundNeoplastic esophagogastric anastomotic strictures after resection of esophageal cancer is a very difficult problem in clinical practice. We aim at to investigate the safety and feasibility of arterial infusion chemotherapy in treatment of neoplastic esophagogastric anastomotic strictures after esophagectomy.MethodsFrom October 2014 to December 2019, 50 patients with Neoplastic esophagogastric anastomotic strictures after resection of esophageal cancer were assessed retrospectively. Preoperative dysphagia was grade III in 34 cases and grade IV in 16 cases. Thirty-eight patients had different degrees of dyspnea before surgery Twenty-five patients had intolerable (grade IV) dyspnea and airway stenting was undertaken before surgery. Thirteen patients had tolerable dyspnea that did not require airway stenting, and preoperative dyspnea was grade III.ResultsAll patients were successfully treated with arterial infusion chemotherapy, no paraplegia or death occurred. The dysphagia grade of 50 patients after AIC was compared: one case had grade I, 40 cases had grade II, and nine cases had grade III. Thirteen patients had tolerable dyspnea that did not necessitate airway stenting. Dyspnea was classified as grade I in five cases and grade II in eight cases. After 1–3 courses of AIC, 50 patients were followed up for a complete response (eight cases), partial response (28) and stable disease (14 cases). Total objective effective rate (complete response+ partial response) and disease control rate(complete response + partial response + stable disease)were 72.0% and 100.0%, respectively. The median duration of follow-up was 8.5 months. One-year survival was 46.0%.ConclusionArterial infusion chemotherapy is safe and efficacious treatment for Neoplastic esophagogastric anastomotic strictures after esophagectomy.

Bronchotracheal Stenting Management by Rigid Bronchoscopy under Extracorporeal Membrane Oxygenation (ECMO) Support: 10 Years of Experience in a Tertiary Center

Purpose. Airway stenting offers good palliation and improves the quality of life in patients with inoperable bronchotracheal stenosis. However, in some cases, the management of stenting can be life-threatening. Hence, a strategy for maintaining oxygenation and hemodynamic stability should be anticipated to avoid critical situations. Herein, we report the use of extracorporeal membrane oxygenation (ECMO) in bronchotracheal stenting management to secure oxygenation and facilitate interventions. Methods. We retrospectively reviewed all patients who underwent rigid bronchoscopy under ECMO support for the management of bronchotracheal stenting at CHU UCL Namur hospital (Belgium), between January 2009 and December 2019. Results. We included 14 bronchoscopy cases performed on 11 patients (3 patients underwent 2 bronchoscopies) in this study; 12 were performed on males and 2 on females. The median age was 54 years. There were 11 benign and 3 malignant etiologies for the central airway obstruction/stenosis. Eight cases were supported by venovenous ECMO and six by venoarterial ECMO. The median ECMO time was 267 minutes. The weaning of ECMO support was successful in all cases. In most cases, the procedures were performed effectively and safely. Only two local complications caused by the cannulation of ECMO were reported, and anticoagulation was adapted to avoid bleeding at the operating site and clot formation in the system. Conclusion. Elective ECMO support was helpful and safe for the high-risk management of bronchotracheal stenting with rigid bronchoscopy and was not associated with any additional significant complications.

Intraoperative Cone Beam Computed Tomography of Tracheal Stenting for Stenosis and Fistula Diseases: A Retrospective Cohort Study

Background and objectives: Previous experience has shown that angiographic CT is useful in various medical contexts, but little research has been presented regarding the application of Cone beam Computer Tomography (CBCT) in airway stenting. In this study, we retrospectively evaluated the clinical feasibility of CBCT in airway stent placement by conducting a single-center retrospective cohort study.Methods: A total of 228 patients with stenosis or fistula diseases were treated with metallic airway stents in our hospital from January 1, 2015, to December 31, 2018. CBCT scanning was performed on 100 patients during and after treatment, and the images were compared with those from postoperative CBCT. We also assessed the outcomes and complications in the CBCT-guided and the fluoroscopy-guided group.Results: Tracheal stenting was performed successfully on the first attempt in 90 patients in the CBCT-guided group and 123 patients in the fluoroscopy-guided group. The measured diameters and lengths of the central airway as shown in CBCT were not significantly different from those obtained by MDCT. However, there were significant differences in the visibility of the distal bronchus, pulmonary parenchyma and airway above the upper stent graft; nonetheless, 2 of the 3 anatomical areas were reproduced in a diagnostically relevant way. The rate of major complications was rather low in the CBCT-guided group compared with the fluoroscopy-guided group.Conclusions: CBCT images were proven to have sufficient quality to replace MDCT as a reasonable control measure after stent implantation and reduce the complications of airway stent placement when performed in the operation.

Self-expanding covered metallic stents as a transition to silicone stent implantation in management of severe post-tuberculosis bronchial stenosis

Background and aims: Post-tuberculosis bronchial stenosis (PTBS) is one of the most common complications of tracheobronchial tuberculosis. Silicone stent serves as a major treatment for maintaining airway patency. However, silicone stent placement remains a large challenge in patients with severe cicatricial PTBS. Our objective was to evaluate the efficacy and safety of covered, self-expanding, metallic stents (SEMSs) as a transition to silicone stent implantation for treating severe PTBS. Methods: We retrospectively reviewed the data of patients with severe PTBS who received airway stenting in the First Affiliated Hospital of Guangdong Medical University between September 2015 and May 2019. The types of the stent, intervention procedures, bronchoscopic findings, clinical outcomes and related complications were collected and analyzed. Results: Fifty-eight cases with severe PTBS were included in this study. Thirteen (22.4%) of the patients received bronchial silicone stent implantation immediately after dilations. For the remaining 45 (77.6%) patients, silicone stents could not be deployed after dilations and SEMSs implantation was implemented as a bridge to silicone stenting. The SEMSs were placed for an interval of 28.4 ± 11.1 days. All of the silicone stents were inserted successfully following the removal of SEMSs. No SEMS-related complication occurred. The subgroup analysis showed that patients who received transitional SEMSs had less luminal caliber but fewer transbronchial dilations before silicone stent implantation ( p < 0.05). Conclusion: Covered SEMS placement as a transition to silicone stenting could serve as a feasible procedure to reduce complications and improve the success rate of silicone stent implantation in patients with severe PTBS. The reviews of this paper are available via the supplemental material section.

Bronchoscopic treatment of inoperable nonsmall cell lung cancer

Patients with unresectable lung cancer range from those with early-stage or pre-invasive disease with comorbidities that preclude surgery to those with advanced stage disease in whom surgery is contraindicated. In such cases, a multidisciplinary approach to treatment is warranted, and may involve medical specialties including medical oncology, radiation oncology and interventional pulmonology. In this article we review bronchoscopic approaches to surgically unresectable lung cancer, including photodynamic therapy, brachytherapy, endoscopic ablation techniques and airway stenting. Current and past literature is reviewed to provide an overview of the topic, including a highlight of potential emerging approaches.