Clinical evaluation of a new bifurcated dynamic airway stent: a 5-year experience with 135 patients.

The Dynamic stent, a bifurcated airway prosthesis facilitating coughing, was clinically evaluated. The stents were inserted bronchoscopically in 135 patients (84 male, 51 female, age 12-90 years, mean 59 years) suffering from compression stenoses, strictures or malacias of the central airways, or tracheo-esophageal fistulas. Extrinsic compression from malignant and semi-malignant tumors was the leading indication for stenting (47.4%), followed by esophago-airway fistulas (22.2%) and post-intubation stenoses (14%). Stent insertion turned out to be very easy and could be performed without complications. The Dynamic stent was well tolerated and gave immediate relief of dyspnea in most cases. Follow-up data, three months after the last implantation revealed that at least 24 patients were still alive with a stent in place and free of complaints. In 27 cases, the stent had been removed after response to treatment. One of these patients received a second in order to seal a fistula, two months after removal of the first one. 85 patients, 79 with malignant, 6 with non-malignant diseases had died, with a mean survival time of 123 days (0 to 611 days). Complications directly attributable to the stent were rare. Two patients who had received the stent to counteract severe tracheal compression from aortic abnormalities died from arrosion and hemoptysis. There were no other severe complications. Cephalad migration occurred in 4/136 inserted stents. The Dynamic stent can be considered feasible, effective, and comparitively safe.

Management of malignant esophagotracheal fistulas with airway stenting and double stenting.

Prognosis of inoperable or recurrent esophageal carcinoma is, at best, poor. Once an esophagotracheal fistula has developed, the overall condition of the patient declines rapidly. Aspiration pneumonia and severe coughing are common. The introduction of esophageal tubes does not always seal the fistula sufficiently and may compromise the airway causing stridor and dyspnea. In 30 patients (25 male, 5 female; age 23 to 74 years; mean, 56 years) with very large fistulas and airway problems, we inserted an airway stent (Dynamic) (n = 12) or an esophageal tube combined with a Dynamic airway stent (n = 18) with the aim of sealing the fistula and restoring patency of the airway and GI passage. The tracheobronchial Dynamic stent was chosen because its slightly concave, flexible posterior silicone membrane adapts ideally to the convex esophageal tube. The stents were well tolerated and significantly improved the quality of life. Of 30 patients, 16 could breathe and swallow unimpaired until shortly before their death. Moderate complaints persisted in five patients, dysphagia in eight patients, and dyspnea in one patient. Mean survival time in the double stent group was significantly greater (110 days) than in the airway stent-only group (24 days) or comparable groups in the literature treated with esophageal tubes only. We conclude that carefully selected patients can benefit from double stenting of esophagus and airways.

[Experiences with fluorescence diagnosis and photodynamic therapy in a multimodality therapy concept of operated, recurrent bronchial carcinoma]. / Erfahrungen mit Fluoreszenzdiagnostik und photodynamischer Therapie im multimodalen Therapiekonzept des operierten, rezidivierenden Bronchialkarzinoms.

Even of those few patients who are operated because of bronchial cancer up to a quarter develop a recurrence. One reason is certainly that tumor-cells already present at the time of surgery are bronchoscopically invisible. Fluorescence methods might be able to detect these malignant cells. For patients with post-surgical recurrences the therapeutical choices are limited due to the loss of parenchyma. Photodynamic therapy (PDT) with the hematoporphyrine derivative Photofrin is one laborious but promising option. Based on an argon-dye laser we have developed a combined system for the diagnostical measurement of autofluorescence and Photofrin-induced fluorescence at 488 nm and the therapeutical PDT at 630 nm. Under the excitation with blue light from the argon laser, differences in the autofluorescence of malignant and benign cells can be distinguished. Following the injection of Photofrin a spectrum peak at 628 nm clearly delineates tumor cells. In six out of twelve patients with post-surgical recurrences a single PDT course resulted in tumor eradication. With additional PDT courses and brachytherapies local tumor control could be achieved in all cases. The general photosensitivity and the necessary light protection were tolerated by all patients. In order to avoid severer complications such as asphyxia, obstruction of bronchi and pneumotharaces resulting from fibrin-plugs and necrotic tissue following PDT must be considered. Especially in patients with pneumonectomy a careful surveillance and debridement is mandatory.

[Bilateral lung volume reduction in patients with severe pulmonary emphysema]. / Bilaterale Lungenvolumenreduktion bei Patienten mit schwerem Lungenemphysem.

For selected patients with severe pulmonary obstructive disease (COPD) and dyspnea despite conservative treatment, lung volume reduction (LVR) may to be of significant value as a surgical option. From May 1994 to March 1996 43 patients with COPD underwent through different procedures a LVR, 25 of them bilateral through median sternotomy or thoracotomies. With regard to chest computed tomography and perfusion/ventilation scan of the lungs the most affected portions are excised with the use of a linear stapling device. In all patients staplers was fitted with strips of bovine pericardium attached on both sides to eliminate postoperative leakage. There has been no early postoperative mortality (30 days). Follow-up ranges from 1 to 21 months. Preoperative and postoperative assessment of lung function tests, efficiency of respiratory pump, grading of dyspnea and life quality was prospective investigated. The mean improvement of FEV1 was 79%, PO2 at rest 8 mmHg. TLC has been reduced by 19%, RV by 31%. These changes have been associated with marked relief of dyspnea (grading of dyspnea reduced from 3.4 to 1.6) and improvement in exercise tolerance (6-min walk-test from 137 +/- 65 m to 265 +/- 175 m). Also significant changes the maximal inspiratory pressure, the mouth occlusion pressure and the transdiaphragmatic pressure as parameter of respiratory muscle function. Although the follow-up period is short, these results suggest that in selected patients with COPD, LVR improve lung function, gas exchange, efficiency of respiratory pump and quality of life and reduce the grading of dyspnea.

Development of a new insertion technique and a new device for the placement of bifurcated airway stents.

We developed a new insertion technique and designed a forceps device for the placement of bifurcated airway stents; 131 of 142 endoscopically placed tracheobronchial Y-stents were inserted with a forceps and a laryngoscope. For the last 52 stent implantations we used the new stent forceps. It was determined to be a simple and safe method without major complications. In 11 cases alternative techniques had to be used. Technique and device are described in detail.

Three years experience with a new balloon catheter for the management of haemoptysis.

For the management of severe haemoptysis we have developed a double-lumen, bronchus-blocking catheter that can be introduced through the working channel of a standard fibrebronchoscope. We wondered whether this catheter would be suitable to control pulmonary haemorrhage in clinical practice. Over a period of 36 months, 30 of these catheters were used in 27 patients with moderate and massive pulmonary bleeding from various lesions. Underlying diseases were: malignancies (11), vascular deformities (5), tuberculosis (4), silicosis (2), carcinoids (2), silicosis (2), endometriosis (1), bronchiectasis (1). In 26 cases, the transbronchoscopic balloon tamponade was successful. In one patient, tumour growth close to the carina prevented securing of the balloon and double-lumen tube intubation was required. There were only minor complications attributable to the balloon. With the catheter in place for up to seven days, patients underwent surgery, received radiation, chemotherapy, drug treatment or bronchial arterial embolization. In conclusion, we found this double-lumen, bronchus-blocking device safe and the technique practicable to control pulmonary haemorrhage.