Iatrogenic Tracheobronchial Injury: A Support to Nonsurgical Management

Iatrogenic Tracheobronchial Injury: A Support to Nonsurgical Management Massimo Conti, Lotfi Benhamed, Henri Porte and Alain Wurtz Ann Thorac Surg 2008;85:1843-1844 DOI: 10.1016/j.athoracsur.2007.10.027

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://ats.ctsnetjournals.org/cgi/content/full/85/5/1843-a

The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the Southern Thoracic Surgical Association. Copyright © 2008 by The Society of Thoracic Surgeons. Print ISSN: 0003-4975; eISSN: 1552-6259.

Downloaded from ats.ctsnetjournals.org by on June 6, 2013

Ann Thorac Surg 2008;85:1839 – 44

CORRESPONDENCE

Christophoros N. Foroulis, MD Nikolaos Charokopos, MD Christos Papakonstantinou, MD Department of Thoracic and Cardiovascular Surgery Aristotle University of Thessaloniki Medical School AHEPA University Hospital 1 Stilponos Kiriakidi Street Thessaloniki 54636, Greece e-mail: [email protected]

References 1. Husain SA, Finch D, Ahmed M, Morgan A, Hetzel MR. Long-term follow-up of Ultraflex metallic stents in benign and malignant central airway obstruction. Ann Thorac Surg 2007;83:1251– 6. 2. FDA Public Health Notification: Complications from metallic tracheal stents in patients with benign airway obstruction. Available at: http://www.fda.gov/cdrh/safety/072905-tracheal. html. Accessed March 28, 2008. 3. Madden BP, Loke TK, Sheth AC. Do expandable metallic airway stents have a role in the management of patients with benign tracheobronchial disease? Ann Thorac Surg 2006;82:247– 8. 4. Saad CP, Murthy S, Krizmanich G, Mehta AC. Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis. Chest 2003;124:1993–9.

Reply To the Editor: We thank Dr Foroulis and colleagues [1] for their interest in our article [2]. However, we believe that the issues raised in their letter are somewhat out of context with the messages in it. In our series, we have only used Ultraflex endobronchial stents (Boston Scientific, Watertown, MA) in carefully selected patients with benign airway obstruction in whom conventional surgery was not an option. There was never any question of them being suitable for any other therapeutic procedure in the future, and they had severe symptoms; so the only choice for treatment was between expanding wire or silicone stents. We have certainly not recommended Ultraflex stents (Boston Scientific) in benign upper airways obstruction as a first-line treatment with a view to some other subsequent intervention. Because there was no intention to remove these stents at a later date in our patients, the fact that they are difficult to remove after the first few weeks is not, in our opinion, a major consideration in using them. Whereas Foroulis and colleagues’ [1] letter reports problems with granuloma obstruction, as stated in our article, this was not a problem in our experience. The article by Saad and colleagues [3] reports similarly favorable results for expanding wire stents in benign airway obstruction, but it also stresses the importance of careful patient selection. We note that the complications in the 2 patients described by Foroulis and colleagues [1] involved use of covered Ultraflex stents; whereas we have exclusively used uncovered Ultraflex metallic stents in our benign cases. We do not see the logic of using covered stents in benign airway obstruction, because there is no risk of tumor infiltration through the stent and no fistula is present. It is common knowledge that it is potentially hazardous to use medical lasers anywhere near combustible materials within the patient’s airway and the airway fire that may result can prove fatal. We would therefore question the wisdom of

trying to remove granulation tissue around a covered stent with a laser, no matter how skillful the endoscopist might be. If these patients had been treated with uncovered stents, there would have been no risk of using laser resection to clear any granulation obstruction. Moreover repeated laser resection would be possible if granulations recurred at a later date. Madden and colleagues [4] report using the neodymium yttrium–aluminum– garnet laser to clear granulation tissue from Ultraflex stents in 10 cases in their series, and they did not have any complications, but it is not clear from their article how many of these involved covered stents. Nevertheless, we would suggest that this technique is absolutely contraindicated in the presence of covered stents, because there are other methods available by which granulations can be more safely removed. In conclusion, we maintain our view that Ultraflex stents are a safe and effective treatment in carefully selected patients with symptomatic benign upper airways obstruction in which attempts at curative surgical treatment are not possible. We would advise that uncovered stents are the most appropriate type for this group of patients. Future randomized studies comparing long-term results for Ultraflex metallic expandable wire stents versus silicone stents would be immensely valuable. Syed A. Husain, MBBS, MRCP Department of Respiratory Medicine Maidstone Hospital Hermittage Lane Maidstone Kent ME16 9QQ, United Kingdom e-mail: [email protected] Anthony Morgan, FRCS Department of Thoracic Surgery Bristol Royal Infirmary Bristol, B52 8HW United Kingdom e-mail: [email protected] Martin Hetzel, MD, FRCP Department of Respiratory Medicine Severn Postgraduate School of Medicine Bristol Royal Infirmary Bristol, B52 8HW United Kingdom e-mail: [email protected]

References 1. Foroulis NC, Charokopos N, Papakonstantinou C. Should Ultraflex metallic stents be used in benign airway obstruction (letter)? Ann Thorac Surg 2008;85:1842–3. 2. Husain SA, Finch D, Ahmed M, Morgan A, Hetzel MR. Longterm follow-up of Ultraflex metallic stents in benign and malignant central airway ostruction. Ann Thorac Surg 2007;83:1251– 6. 3. Saad CP, Murthy S, Krizmanich G, Mehta AC. Selfexpandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis. Chest 2003;124:1993–9. 4. Madden BP, Loke TK, Sheth AC. Do expandable metallic airway stents have a role in the management of patients with benign tracheobronchial disease? Ann Thorac Surg 2006;82:247– 8.

Iatrogenic Tracheobronchial Injury: A Support to Nonsurgical Management To the Editor: We read with great interest the article by Schneider and colleagues [1]. We would like to congratulate the authors for this interesting article. However, a few points should be discussed.

© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc

Downloaded from ats.ctsnetjournals.org by on June 6, 2013

0003-4975/08/$34.00

MISCELLANEOUS

and colleagues with the use of Ultraflex metallic stents in benign airway obstruction [1], we have to report our recent experience of granulation tissue formation at the end of two Ultraflex metallic tracheal stents that had as result late tracheal obstruction, and to advise caution with the use of metallic stents in benign airway obstruction.

1843

1844

CORRESPONDENCE

Ann Thorac Surg 2008;85:1839 – 44

Massimo Conti, MD Lotfi Benhamed, MD Henri Porte, MD, PhD Alain Wurtz, MD Clinique de Chirurgie Thoracique Hôpital Calmette 1, Bd du Prof Leclercq CHRU Lille 59037, France e-mail: [email protected]

References

Fig 1. Treatment algorithm for tracheobronchial rupture (TBR).

MISCELLANEOUS

The authors recommended surgery when: (1) mechanical ventilation was not possible, (2) subcutaneous or mediastinal emphysema was progressive, (3) there was an open perforation into the pleural cavity, and (4) an endobronchial tube could not be placed beyond the laceration [1]. We disagree with these recommendations for surgery. Our approach for these patients is based on two key factors: (1) the need for continued mechanical ventilation, and (2) the ability to bridge the tracheobronchial rupture (TBR) if mechanical ventilation is mandatory [2]. First, if pneumothorax and subcutaneous emphysema are properly drained, the consequences of TBR on the respiratory mechanics are usually minimal in patients breathing spontaneously [3–5]. In our experience, and also in a different, recent series, extent of the TBR is not a criterion for surgical treatment, and outcome is independent of the TBR length [2, 6]. Last, transient noninvasive, positive pressure, ventilatory support can be used to treat respiratory failure due to intraluminal esphageal herniation [2]. In ventilated patients, the cuff of a single-lumen tube placed distal to the TBR assures effective ventilation. Consequently, it is unclear why the authors operated on 7 ventilated patients in whom placement of a distal single-lumen tube was feasible. Moreover, when TBRs are too close to the carina, we were able to achieve separated bilateral endobronchial intubation through tracheostomy [2]. Finally, we believe that the real issue is to avoid unnecessary or harmful surgery. In patients breathing spontaneously, surgery represents an additional trauma, because nonsurgical management is sufficient for healing. In patients ventilated for medical failure, operation is usually a high-risk procedure due to the underlying disease. In conclusion, we recommend conservative treatment as the best approach to post-intubation TBR: (1) in patients who have spontaneous ventilation, (2) for patients when extubation is scheduled within 24 hours from the time of diagnosis, or (3) for patients who will require continued ventilation to treat their underlying medical problems. Surgical repair should be reserved for cases in whom bridging the lesion is technically not feasible (Fig 1) or for injuries diagnosed during thoracic surgery.

1. Schneider T, Storz K, Dienemann H, Hoffmann H. Management of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases. Ann Thorac Surg 2007;83:1960 – 4. 2. Conti M, Pougeoise M, Wurtz A, et al. Management of postintubation tracheobronchial ruptures. Chest 2006;130: 412– 8. 3. d’Odemont JP, Pringot J, Goncette L, et al. Spontaneous favorable outcome of tracheal laceration. Chest 1991;99: 1290 –2. 4. Ross HM, Grant FJ, Wilson RS, et al. Non-operative management of tracheal laceration during endotracheal intubation. Ann Thorac Surg 1997;63:240 –2. 5. Leo F, Solli P, Veronesi G, Spaggiari L, Pastorino U. Efficacy of microdrainage in severe subcutaneous emphysema. Chest 2002;122:1498 –9. 6. Gomez-Caro Andres A, Moradiellos Diez FJ, Ausin HP, et al. Successful conservative management in iatrogenic tracheobronchial injury. Ann Thorac Surg 2005;79:1872– 8.

Reply To the Editor: We appreciate the comments by Conti and colleagues [1] on our article [2]. We generally agree with their approach to the management of iatrogenic tracheobronchial injuries and their comments are consistent with our statements in the article. With growing experience and favorable results after conservative therapy of tracheal injuries, our rate of surgical therapy declined. This retrospective review [2] also represents our learning curve in the management of tracheal injuries. The extent of the mediastinal emphysema was an important criterion for indication toward surgery in the earlier cases, whereas the instability of ventilation management was the main criterion in the later cases. Pneumothorax per se may not be an indication for surgery if the patient can be sufficiently ventilated. Whenever possible we opt for nonoperative therapy, and the criteria for conservative treatment are redeemed. Hans Hoffmann, MD, PhD Thomas Schneider, MD Konstantina Storz, MD Hendrik Dienemann, MD, PhD Department of Thoracic Surgery Thoraxklinik am Universitätsklinikum Heidelberg Amalienstrasse 5 Heidelberg D-69126, Germany e-mail: [email protected]

References 1. Conti M, Benhamed L, Porte H, Wurtz A. Iatrogenic tracheobronchial injury: a support to nonsurgical management (letter). Ann Thorac Surg 2008;85:1843– 4. 2. Schneider T, Storz K, Dienemann H, Hoffmann H. Mangement of iatrogenic tracheobronchial injuries: a retrospective analysis of 29 cases. Ann Thorac Surg 2007;83:1960 – 4.

Downloaded from ats.ctsnetjournals.org by on June 6, 2013

Iatrogenic Tracheobronchial Injury: A Support to Nonsurgical Management Massimo Conti, Lotfi Benhamed, Henri Porte and Alain Wurtz Ann Thorac Surg 2008;85:1843-1844 DOI: 10.1016/j.athoracsur.2007.10.027 Updated Information & Services

including high-resolution figures, can be found at: http://ats.ctsnetjournals.org/cgi/content/full/85/5/1843-a

References

This article cites 6 articles, 3 of which you can access for free at: http://ats.ctsnetjournals.org/cgi/content/full/85/5/1843-a#BIBL

Citations

This article has been cited by 1 HighWire-hosted articles: http://ats.ctsnetjournals.org/cgi/content/full/85/5/1843-a#otherarticl es

Subspecialty Collections

This article, along with others on similar topics, appears in the following collection(s): Trachea and bronchi http://ats.ctsnetjournals.org/cgi/collection/trachea_bronchi

Permissions & Licensing

Requests about reproducing this article in parts (figures, tables) or in its entirety should be submitted to: http://www.us.elsevierhealth.com/Licensing/permissions.jsp or email: [email protected].

Reprints

For information about ordering reprints, please email: [email protected]

Downloaded from ats.ctsnetjournals.org by on June 6, 2013