Endobronchial Management of Benign, Malignant, and Lung Transplantation Airway Stenoses

Transcription

1 Endobronchial Management of Benign, Malignant, and Lung Transplantation Airway Stenoses Joshua R. Sonett, MD, Robert J. Keenan, MD, Peter F. Ferson, MD, Bartley P. Griffith, MD, and Rodney J. Landreneau, MD Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Since 1991, we have managed 57 patients with benign (10), malignant (23), or lung transplantation (24) airway obstructions using silicone stenting and debridement (manual/neodymium:yttrium-aluminum garnet laser). Ten patients with benign lesions (4 intubation, 4 inflammatory, 1 malacia, 1 bronchial fistula) had 4 T tubes, 3 Y stents, 3 bronchial stents, and 1 straight tracheal stent placed. Eight of 10 patients (80%) received symptomatic relief with the stents in place for up to 43 months. Twenty-three patients with malignant strictures (18 lung, 5 metastatic) had 26 stents inserted (13 s, 12 bronchial, 1 T tube) of which 16 required combined debridement and stenting. Four stents required repositioning. Three hospital deaths were due to unrelated causes. Of 20 discharged patients, 6 remain alive at 2 to 10 months, whereas 14 patients who died of progressive disease obtained effective palliation for months. Significant bronchial anastomotic complications developed in 24 of 212 lung transplants (11.3%). Thirtyone stents were placed in 19 of the patients; 5 patients were managed with laser debridement alone. Of the 19 patients receiving stents, 3 required only temporary stents (6 to 15 days), 11 patients needed long-term stents (40 to 507 days), and 5 patients died with their stents in place functioning well. All patients received symptomatic relief with stenting. There were no procedure-related deaths and one bronchial laceration during attempted stent placement. Early, aggressive treatment of benign and malignant tracheobronchial strictures with endoscopic debridement and stenting is safe and well tolerated, and effectively palliates airway obstruction. Repositioning of stents frequently may be required in the transplant population. Techniques of stent insertion require no specialized equipment and may be performed expeditiously with minimal morbidity. (Ann Thorac Surg 1995;59: ) E ndoscopic management of symptomatic tracheobronchial complications can be an important adjunct to the surgical care of patients with unresectable benign or malignant airway obstruction [1, 2], For the majority of these patients endobronchial dilation, debridement, or stenting may offer significant palliation and improved quality of life [3-6]. Anastomotic complications also have been recognized after lung transplantation and also may require aggressive endoscopic management to assure good functional outcome [6-9]. We report the University of Pittsburgh experience with the endoscopic management of 56 patients with benign, malignant, and lung transplantation airway complications, with emphasis on our endobronchial stent selection and insertion techniques. Material and Methods Patients Since 1991, 57 patients with benign, malignant, or lung transplantation airway complications have been referred for endoscopic management using debridement (manual Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10 12, Address reprint requests to Dr Keenan, Section of Thoracic SurgeD', University of Pittsburgh, Suite 300, 3471 Fifth Ave, Pittsburgh, PA by The Society of Thoracic Surgeons and neodymium:yttrium-aluminum garnet [Nd:YAG] laser) and silicone stenting. In 23 patients, ranging in age from 41 to 85 years, endobronchial complications of malignant disease developed: 10 squamous cell 7 adenocarcinoma, 5 metastatic, and 1 small cell. All patients presented with progressive dyspnea and lobar atelectasis, with 9 patients also experiencing significant hemoptysis. Thirteen patients had undergone previous treatment with external beam radiation, chemotherapy, or operation. Patients with benign disease ranged in age from 55 to 70 years. Benign lesions included 4 intubation strictures, 4 inflammatory lesions, 1 case of severe bronchomalacia, and 1 case of bilateral bronchopleural fistulas. Benign tracheal disease presented primarily with progressive shortness of breath. Two patients with bronchial tuberculous strictures demonstrated progressive dyspnea and lobar atelectasis. One patient was symptomatic from a bronchopleural fistula that occurred as a complication of transhiatal esophagectomy. Significant bronchial anastomotic complications developed in 24 lung transplant recipients out of 212 transplantations performed since 1991 (11.3%). Distribution of transplants included 117 single-lung and 95 double-lung transplants. Presenting symptoms included retained secretions (14 patients), pneumonia (4 patients), dyspnea (4 patients), and wheezing (2 patients). The time course to /95/$ (95)

2 1418 SONETT ET AL Ann Thorac Surg ENDOBRONCHIAL STENTS 1995;59: Table 1. Cause of Lung Transplantation Stricture and Time to Clinical Presentation No. of Time to Presentation Complication Patients (days) Technical difficulty Dehiscence Ischemic stricture presentation of symptoms varied according to the cause of the anastomotic complication (Table 1). Technique All procedures were performed with the aid of intravenous general anesthesia using short-acting narcotics and benzodiazepines. Ventilation was established using an endotracheal tube and positive-pressure techniques or by a technique previously described by our group using jet ventilation delivered through a small-bore catheter placed in the proximal trachea [10]. Initial bronchoscopic evaluation was used to define and visualize the pathology. Through a rigid bronchoscope, direct mechanical debridement or Nd:YAG laser ablation was used to debride exophytic lesions or cicatricial scar tissue. Dilation of stenotic airways was performed for lesions with residual stenosis using the rigid endoscope, Jackson dilators, or pneumatic angiographic balloons. Stents then were placed for lesions that exhibited (1) significant luminal narrowing despite debridement and dilation, (2) lesions with extensive extrinsic compression not amenable to debridement, (3) benign lesions with circumferential cicatricial narrowing, and (4) lesions in which rapid tissue growth was expected after primary success with endoscopic debridement. The choice of stent was dictated primarily by anatomic considerations. Tracheobronchial s (Hood Laboratories, Pembroke, MA) were used for patients with distal tracheal or carinal lesions, whereas Montgomery T tubes were used in patients with existing obstructive proximal or middle tracheal lesions. Silicone bronchial stents were chosen for main bronchial lesions without carinal involvement by the obstructive airway process. The findings from the bronchoscopic examination of the airway obstruction dictated the length and diameter of the bronchial stent chosen. In general, stents with an internal diameter of 10 to 12 mm were chosen to bridge bronchial obstructions in the adult airway. We usually chose the Hood bronchial stent (Hood Laboratories) to manage tight circumferential lesions where the likelihood of stent migration was minimal. The Dumon bronchial stent (Bryan Corp, Woburn, MA) was chosen for less critically stenotic lesions in which bronchomalacia may have been a significant component to the obstruction. The unique feature of the Dumon stent design is that it incorporates numerous "'studs" along its outer diameter, which effectively reduces postoperative stent migration (Fig 1). "BRONCHIAL STENT" INSERTION TECHNIQUES. The technique of bronchial stent insertion we employ has been described previously [2]. We use a 6.5-mm-diameter Fig 1. Smooth Hood bronchial stent and studded Dumon bronchial stent in proper position across obstructing lesions. adult rigid bronchoscope (Karl Storz Endoscopy- America, Inc, Culver City, CA). A shortened 36F chest tube is inserted over the bronchoscope after adequate lubrication with silicone spray, and is used subsequently to stabilize the stent on the tip of the endoscope and to help "unload" the stent in the airway (Fig 2A). With the chest tube in place on the endoscope, the stent then is "loaded" onto the distal tip of the scope. The stent is positioned so that its distal extent is just proximal to the bevel on the bronchoscope. This stent/pusher tube/ bronchoscope assembly then is introduced through the vocal cords into the trachea. Once in the trachea, it is important to maintain a steady forward advance of the bronchoscope, toward the stricture without retraction, to prevent premature dislodgement of the stent. The chest tube then is stabilized in position using a Kelly forceps, and the bronchoscope is withdrawn; this action "'unloads" the stent from the bronchoscope. Final positioning of the stent then may be adjusted using alligator forceps (Fig 2B). TRACHEOBRONCHIAL Y STENT INSERTION TECHNIQUES. In this approach, a Fogarty catheter is first placed through the short limb of a and guided under laryngoscopic vision into the airway and directed toward the right main bronchus with an intent to enter a basilar a,. B Fig 2. (A) Endoscopic placement of bronchial stent using a 36F chest tube to keep the stent in position during insertion (see text). (B) Final adjustment of stent with endoscopic forceps.

3 Ann Thorac Surg SONETT ET AL ;59: ENDOBRONCHIAL STENTS RUL bronchus Fig, 4. Folding of the short limb, a complication of insertion, can be avoided by using the Fogarty catheter guide technique. B C,jY - cqv Fig 3. (A) Fogarty catheter, inserted through the short limb of the Y stent as a guide, is placed into a distal right lower lobe bronchus (see text). (B) The is loaded onto the rigid bronchoscope with the tip of the scope protruding from the long limb of the stent. (C) Final placement of long limb of by direct bronchoscopic insertion, with Fogarty gaidance of short limb into the right main bronchus. used by us to overcome the problem of stent intussusception is to narrow the proximal tracheal limb of the Y stent against the bronchoscope with a 2-0 silk suture ligature (Fig 5B). The chest tube pusher then can be advanced to seat the stent without the problem of intussusception. The silk stitch is cut and removed at the end of the procedure through the rigid bronchoscope with endoscopic scissors and forceps. MONTGOMERY T TUBE STENTS. After bronchoscopic examination and fulguration of the airway obstruction, T tube stents were inserted through a tracheostomy incision or existing stoma using a technique previously described II11. POSTOPERATIVE AIRWAY MAINTENANCE. After stent placement, "'heavy droplet" saline nebulization treatments were instituted to avoid incrustation of secretions within the airway. Arrangements were made so that these treatments could be continued after discharge from the hospital. bronchoscope chest or pusher tube ster~l segment of the right lower lobe. Bronchoscopy is used to confirm placement of the Fogarty balloon in a segmental bronchus, and the balloon then is inflated to fix the catheter in position (Fig 3A). The long limb of the then is loaded onto a rigid bronchoscope, again with a proximally loaded chest tube as described previously (Fig 3B). The bronchoscope and long limb of the then are inserted into the trachea and directed down the left main bronchus, while the short limb of the stent is guided into the right main bronchus by the Fogarty catheter (Fig 3C). This Fogarty catheter technique is used to avoid backward folding or lateral malpositioning of the short limb of the during its insertion (Fig 4). Because of the soft nature of the silicone Hood, intussusception of the chest tube pusher can occur. This may cause difficulty in extracting the bronchoscope successfully without dislodging the stent. This can be overcome by using an endoscopic forceps to stabilize the stent while the bronchoscope and pusher tube are withdrawn from the airway (Fig 5A). An alternative method A Fig 5. (A) Use of endoscopic forceps to support in final position while bronchoscope is withdrawn. (B) Alternative technique using a suture to narrow the proximal limb of the, thereby preventing intussusception of the chest tube into the stent (see text).

4 1420 SONETF ET AL Ann Thorac Surg ENDOBRONCHIAL STENTS 1995;59: Table 2. Patients With Malignant Disease Requiring Removal of Stents Stent Indication LOS (mo) Bronchial Progressive disease in distal airway 3 Bleeding secondary to granulation tissue induced by stent 10 Patient received tracheostomy for 1 ventilatory support Obstruction improved with 1 external beam radiation therapy Definitive resection after neoadjuvant therapy 4 LOS = length of stent placement. Results Malignant Disease Twenty-six stents were inserted, which included 13 Y stents, 12 bronchial stents (10 right, 2 left), and 1 T tube. Eleven patients received s: 5 for proximal right bronchial obstruction, 4 for distal tracheal obstruction, 1 for proximal left bronchial obstruction, and 2 for bilateral bronchial obstruction. Sixteen patients (16/23; 70%) underwent combined debridement and stenting. Twenty of 23 patients (87%) receiving stents were discharged after obtaining symptomatic improvement; 3 patients died before discharge of causes unrelated to the stent. Of the 20 discharged patients, 6 remain alive at 2 to 10 months, and 14 patients who died of progressive disease obtained significant palliation for 10.5 _+ 5.6 months. In 4 patients the tumor initially was managed by debridement, with stents being placed an average of 151 days (range, 7 to 300 days) later. Two patients receiving Y stents required replacement of their first stent. Four stents required repositioning or replacement including one in a patient who initially had received a and later was given a Dumon straight bronchial stent. Three patients underwent debridement after stents became blocked by tumor. Five patients received adjuvant brachytherapy, 2 before stent placement and 3 after stenting. An average of 2.15 procedures were performed on each patient (range, 1 to 5). Five patients had their stents removed for a variety of reasons, including ability to undergo pulmonary resection after extensive neoadjuvant therapy in 1 patient (Table 2). Complications of stenting in malignant disease included granulation tissue requiring stent removal, replacement of one stent secondary to mucus plugging, coughing out of the stents (2 patients) and replacement of the stents secondary to migration (2 patients). Benign Disease Ten patients with benign obstruction received 4 T tubes, 3 s, 3 bronchial stents, and I straight tracheal stent. Four patients underwent combined debridement and stenting, and 1 patient had combined dilation and stenting. Eight of the patients (80%) obtained immediate symptomatic relief of their obstructive symptoms. One patient with bronchial fistulas that developed after trans- hiatal esophagectomy received bilateral bronchial stents and experienced significant improvement in ventilation management, but died of complications of his original operation. One patient with distal bronchomalacia and a long tracheal stricture coughed out his straight tracheal stent after 1 day, and was managed with laser debridement alone. A second patient with severe bronchomalacia extending into the segmental airways and end-stage heart failure had a placed that was well tolerated but did not result in any symptomatic improvement; the stent was removed after 2 months. One patient who experienced symptomatic improvement with a was able to have the stent removed after 1 month when his tracheal inflammation had resolved. An average of 3.5 procedures were performed on each patient (range, 2 to 8). Only one major operative complication occurred, in a patient with a tuberculous stricture who required a thoracotomy to repair a lacerated bronchus. Two patients required readjustment or downsizing of their T tubes secondary to laryngeal edema. Several instances of stent encrustation required bronchoscopy to clear secretions. Posttransplantation Of 212 lung transplantations performed since 1991, 24 patients (11.3%) had significant bronchial anastomotic complications. Time from lung transplantation to symptomatic presentation was dependent on the cause of the stricture (see Table 1). Among 11 double-lung transplantations, left-sided complications were significantly more common than right (10 versus 5; p = ), and 4 patients had bilateral problems. Stents were used in 19 of 24 recipients. Five patients were managed with laser debridement alone, requiring a range of two to five treatments per patient. Fifty-six procedures (range, I to 9 per patient) using 31 bronchial stents in combination with laser debridement and dilation were performed. Symptomatic improvement of presenting symptoms occurred in all patients undergoing endobronchial debridement or stenting. Eighteen of 31 stents required readjustment by repeat bronchoscopy. Five patients have died with their stents in place and functioning well. Among the 14 survivors who received stents, 3 patients required only temporary stenting (6 to 15 days), whereas 11 patients required stenting for longer periods (40 to 507 days). Six recipients could only be successfully discharged from the hospital after their endobronchial problems were managed by stenting. There were no significant complications of stent insertion in the transplant group. In our total experience, 46 bronchial stents were used. Hood stents were used more frequently in our early experience, and a total of 40 Hood stents versus six Dumon stents were placed in bronchial strictures. Twenty episodes of stent migration occurred, primarily in the transplant population, and all episodes of stent migration occurred with the use of the Hood stent. No episode of stent migration was life-threatening. Comment The thoracic surgeon often is asked to assist in the management of patients with tracheobronchial airway

5 Ann Thorac Surg SONETF ET AL ;59: ENDOBRONCHIAL STENTS compromise. Primary treatments to be considered include endoscopic debridement (manual fulguration or Nd:YAG laser vaporization), dilation, stenfing~ or any combination of these approaches. External beam or brachytherapy radiation treatment in malignant disease also must be considered in the overall management of patients with malignant airway obstruction [12]. Effective palliation of obstructive airway symptoms usually can result in significant improvement in functional status and in the quality of life for patients with benign and malignant airway problems [1, 2]. In this article we have described our approach, results, and techniques involved in the palliation of unresectable tracheobronchial airway obstruction. The treatment approach to airway compromise is dictated by the underlying pathologic condition and the location of the obstructing lesion. Patients with malignant tracheobronchial obstruction are best approached with a multimodality treatment plan in which debridement or stenting of the lesion plays a major role. Primary debridement of exophytic endobronchial lesions has been shown to provide effective short-term management of malignant obstructions [1]. However, if significant luminal narrowing remains or if rapid tumor growth is expected, we proceed with stent placement. Lesions that primarily are causing external compression without an endobronchial component are not amenable to debridement, and for these patients primary airway stenting is used. Adjuvant radiotherapy, either external beam or brachytherapy, was used in 16 of our patients and has been shown to help control the local disease process and reduce the rate of tumor overgrowth about the stents [5]. When tumor overgrowth is noted after stenting, subsequent periodic mechanical or laser debridement can be effective in avoiding airway obstruction. No complications were encountered in our experience with the use of the laser to debride lesions through a previously placed stent. Patients with benign tracheobronchial stenoses that are not amenable to resection or to endoscopic debridement are best managed with either a Montgomery T tube or Y tracheobronchial stents. The Montgomery T tube is reserved for patients with primary upper or mid-tracheal stenoses, whereas s are chosen for patients with distal tracheal or main bronchial lesions encroaching upon the carina. Although straight silicone stents of the Hood or Dumon variety can be used to treat tracheal obstructive lesions, migration and "coughing out" of the stent remains a concern. One patient in our series experienced stent migration when the stent was used to manage a conical tracheal lesion, an experience also noted in other reports [5]. Because of this problem we prefer to rely upon the to manage such lesions. Stents were otherwise well tolerated and offered significant palliative relief of symptoms. Successful lung transplantation is now being widely practiced. Although anastomotic airway problems have been significantly reduced as the ideal suturing techniques are becoming more well defined, bronchial complications are still present in 7% to 14% of most clinical series [6, 7, 13]. The postoperative airway stenoses in these patients are usually secondary to granulation tissue or fibrous stricture formation. Both of these problems have been shown to be amenable to aggressive anastomotic debridement, dilation, and selective bronchial stenting [8]. The results of our series support such an aggressive management approach. Indeed, the endoscopic relief of obstructive obstruction was often a key factor in improving a recipient's functional status, allowing discharge after lung transplantation. As with malignant lesions, manual or laser debridement of stenotic lesions often was attempted first to regain luminal patency. Three patients in our series underwent stent placement within 2 weeks of the transplantation to acutely palliate obstructive symptoms and improve function of the graft while the airway was healing. Once remodeling occurred, stents were able to be removed and luminal patency was maintained. Bronchial stents were used predominantly as most of the lesions were distal to the carina. Adjustment of the stents was required frequently, but the stents were otherwise well tolerated, both acutely and chronically. Minor problems with stent enerustation did occur; however, these were handled easily with flexible bronchoscopy. The occurrence of this problem has been minimized by subscribing to a nebulized saline airway humidification program and close surveillance by our thoracic surgical team. Migration can occur; however, this complication also has lessened with use of the Dumon stent for noncritical stenoses with a component of malacia that we had previously managed generically with the Hood stent. Endoscopic adjustment can be performed readily when necessary. Likewise, stent removal also is accomplished easily when this is desired. Recent reports have proposed and encouraged the use of expandable wire stents in tracheobronchial airway obstruction [14]. Wire expandable stents are said to have the advantages of low internal to external diameter ratio, reduced impairment in mucociliary clearance of secretions, and also resistance to migration [15]. However, these stents are not able to be adjusted or removed once implanted, and do not prevent growth of tumor through the interstices of the stent. The Gianturco metal stent has been reported to cause hemorrhage secondary to airway erosion [16], and has had documented stent fractures ]17]. Multiple techniques for insertion of silicone tracheobronchial stents have been described in the literature [2, 5, 18, 19]. In this report we describe and illustrate our techniques of stent insertion. These techniques involve no specialized equipment, and can be performed expeditiously with minimal morbidity. Manual and laser debridement are used in a complementary fashion, with a tendency to use laser debridement for patients with hemoptysis or circumferential scar tissue. In benign lesions that initially respond to aggressive debridement, repeat early bronchoscopy is performed to ensure that restricturing does not require stent placement. After debridement is performed, the use of a silicone stent is considered if significant luminal narrowing remains, or if rapid tissue growth is suspected. Routine repeat bronchoscopy to assess tumor response to radiotherapy, or

6 1422 SONETT ET AL Ann Thorac Surg ENDOBRONCHIAL STENTS 1995;59: airway remodeling in benign disease, may indicate significant healing that allows for stent removal at a later date. The results of this clinical series demonstrate that endoscopic stenting provides effective palliation of tracheobronchial stenoses resulting from both benign and malignant causes. We consider such stenting as the primary management option for airway obstruction after lung transplantation. Silicone stents are well tolerated and may be left in place for years, but consideration should be given to removing them once airway healing has occurred. Silicone stent insertion is a safe, readily mastered technique that should be included in the armamentarium of the thoracic surgeon faced with these airway problems. References 1. Mathisen DJ, Grillo HC. Endoscopic relief of malignant obstruction. Ann Thorac Surg 1989;48: Cooper JD, Pearson FG, Patterson GA, et al. Use of silicone stents in the management of airway problems. Ann Thorac Surg 1989;47: Gaer JAR, Tsang V, Khaghani A, et al. Use of endotracheal silicone stents for relief of tracheobronchial obstruction. Ann Thorac Surg 1992;54: Bollinger CT, Probst R, Tschopp K, Soler M, Perruchoud AP. Silicone stents in the management of inoperable tracheobronchial stenosis. Chest 1993;104: Petrou M, Kaplan D, Goldstraw P. Bronchoscopic diatherm resection and stent insertion: a cost effective treatment for tracheobronchial obstruction. Thorax 1993;48: Griffith BP, Hardesty RL, Armitage JM, et al. A decade of lung transplantation. Ann Surg 1993;218: Shennib H, Massard G. Airway complications in lung transplantation. Ann Thorac Surg 1994;57: Colt HG, Janssen JP, Dumon JF, Noirclerc JM. Endoscopic management of bronchial stenosis after double lung transplantation. Chest 1992;102: Colquhoun IW, Gascoigne AD, Au J, et al. Airway complications after pulmonary, transplantation. Ann Thorac Surg 1994;57: Magee MJ, Klain M, Ferson PF, Keenan RJ, Landreneau RJ. Nasotracheal jet ventilation for rigid endoscopy. Ann Thorac Surg 1994;57: Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82: Seagren SL, Harrell JH, Horn RA. High dose rate intraluminal irradiation in recurrent endobronchial carcinoma. Chest 1985;88: Schafers HJ, Haydock DA, Cooper JD. The prevalence and management of bronchial anastomotic complications in lung transplantation. Ann Thorac Surg 1991;101: Carrasco CH, Nesbitt JC, Charnsangavej C, et al. Management of tracheal and bronchial stenosis with the Gianturco stent. Ann Thorac Surg 1994;58: De Souza AC, Keal R, Hudson N, Leverment JN, Spyt TJ. Use of expandable wire stents for malignant airway obstruction. Ann Thorac Surg 1994;57: Schafers HJ, Hamm M, Wagner TOF. Gianturco selfexpanding metallic stents [Letter]. Eur J Cardiothorac Surg 1992;6: Spatenka J, Khaghani A, Irving JD. Gianturco self-expanding metallic stents [Letter]. Eur J Cardiothorac Surg 1992;6: Dumon JF. A dedicated tracheobronchial stent. Chest 1990; 97: Acuff TE, Mack MJ, Ryan WH. Simplified placement of a silicone tracheal. Ann Thorac Surg 1994;57: DISCUSSION DR FREDERICK L. GROVER (Denver, CO): I congratulate Dr Sonett on a very nice presentation on a difficult group of patients. One problem we have had when we have had to use stents is that the silicone stents tend to be fairly thick, so that the internal to external diameter ratio is not as great as one would like. We have used stents more often for malignant disease, because only one of our 38 patients with lung transplants has had a bronchial complication. We have used expandable Palmaz wire stents; however, a major problem with these stents is in-growth and stimulation of granulation tissue from the wire, 1 presume. According to Dr Joel Cooper, there is a stent that is being developed that takes advantage of the expandable wire support and has a very thin silicone coating on the outside. Have you had any experience with this type of stent? DR SONETT: We have limited experience with the wire stents, although I agree with you that silicone stents are not ideal, especially in regard to migration and in the ratio of the internal to the external diameter of the stent. I think wire stents at present have had limited use in North America, and the use they have had in Europe has shown significant complications. We too are looking forward to the stent that Dr Cooper has talked about with a silicone coating. It is sort of a combination between the expandable wire stent and the silicone stent that may allow an expandable stent to have a good purchase in a short stricture as well as being able to be removed. DR LEWIS WETSTEIN (Freehold, NJ): This is a rather new and exciting modality. Unfortunately I do not have any significant experience with these techniques, but I do have substantial experience with the endoesophageal prosthesis. In an attempt to extrapolate from that experience, an extremely difficult problem occurs when the gastroenterologists attempt to pass or dilate an unresectable malignant esophageal obstruction and they perforate the esophagus. In those instances I have occluded the perforation and bypassed the obstruction with an exophageal prosthesis [1]. My question to you, therefore, is could you generate similar results with bronchial perforations by inserting a stent? I am sure you would agree that an esophageal perforation is a more devastating complication than a bronchial one. We have obviated a major operative procedure with our stents; don't you think you could do likewise? DR SONETT: I suppose you may be able to, but I think the safest thing, as we knew we tore it right away, was to go in and fix it appropriately, as the patient was a good risk for standard repair. We have used endobronchial stents in the past for persistent fistulas in patients with septic lung transplants that were unrelated to iatrogenic fistulas. But I think in this situation the safest thing to do was to repair it primarily and not to try to see if a stent could work. Reference 1. Wetstein L, Kirby DF. Esophageal perforation [Letter]. Arch Surg 1989;124:876.