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1.  Effect of fibreoptic bronchoscopy on pulmonary function. 
Thorax  1990;45(1):38-41.
Several studies have shown that after fibreoptic bronchoscopy there may be a deterioration in lung function but it is not known whether this is due to the premedication, the topical anaesthetic, or the obstruction produced by the bronchoscope. The effects of each part of the procedure on spirometric measurements were studied in patients with lung disease and in normal non-smokers. Measurements were made after premedication (papaveretum and atropine) in seven patients and after topical anaesthesia of the bronchial tree (340 mg lignocaine) with and without the bronchoscope in the trachea in 21 patients and 10 control subjects. Premedication had no effect. In the normal subjects lignocaine produced significant falls in FEV1, forced vital capacity (FVC), peak expiratory flow (PEF), and peak inspiratory flow (PIF), and insertion of the bronchoscope caused further falls that were also significant. In the patients, however, although anaesthesia produced significant falls in FEV1, FVC, PEF, and PIF of similar magnitude to those found in the normal subjects, there was no further important decrease when the bronchoscope was inserted. It is concluded that the major effect of bronchoscopy on lung function is due to topical lignocaine in the airways, and in patients with lung disease (excluding asthma or a central obstructing carcinoma) the insertion of the bronchoscope causes little additional obstruction.
PMCID: PMC475640  PMID: 2321176
2.  Fibreoptic bronchoscopic electrosurgery under local anaesthesia for rapid palliation in patients with central airway malignancies: a preliminary report. 
Thorax  1994;49(12):1243-1246.
BACKGROUND--Obstruction of a major airway by tumour causes serious morbidity. There is still scope for a widely applicable, simple and effective treatment to provide rapid palliation. METHODS--A fibreoptic bronchoscope prototype with an insulated inner sheath was used under local anaesthesia in 17 patients with locally advanced tracheobronchial malignancies. An insulated flexible electro-surgery probe was used to coagulate intraluminal tumour mass using standard electrosurgery equipment. RESULTS--Immediate reopening of the airway was obtained in 15 of the 17 patients. Two appeared to have extraluminal disease. Eleven patients had an obvious bronchoscopic response in whom a > 75% reopening of the normal airway diameter was achieved. Eight patients had subjective improvement of their dyspnoea, but only in four cases was there an objective improvement in physiological parameters. Haemoptysis resolved in four. There were no deaths resulting from treatment. Minor bleeding occurred in one patient and an aspiration pneumonia occurred in one. Three patients received additional treatment. CONCLUSIONS--Fibreoptic bronchoscopic electrosurgery is a simple technique for rapid palliation and immediate tumour debulking in patients with central tracheobronchial tumours. Further work is needed to compare its efficacy with other techniques.
PMCID: PMC475333  PMID: 7533334
3.  Treatment of congenital tracheal stenosis by balloon-expandable metallic stents in paediatric intensive care unit 
The aim of this study was to evaluate the use of balloon-expandable metallic stents in the treatment of children with congenital tracheal stenosis in whom conventional therapy has failed. From 2010 to 2011, balloon-expandable metallic stents were implanted into the trachea of eight infants aged 2–20 months in the paediatric intensive care unit. The infants had severe airway obstruction caused by congenital tracheal stenosis. Tracheal stents were placed after intraluminal balloon dilatation of the tracheal stenosis, inserted with balloon catheters and implanted into the desired position bronchoscopically. The stents were 12 to 29 mm long and 4 mm in diameter. Seven children were relieved of airway obstruction after this procedure. However, a child died due to severe sepsis after the placement of bronchial stents. No granulation tissue developed over the stents in any of the children. Stents have been in place for 1–6 months after insertion without any other complication. Balloon-expandable metallic stents are effective in relieving airway obstruction by congenital tracheal stenosis in children. This technique may provide an important remedy for congenital tracheal stenosis in children.
PMCID: PMC3329307  PMID: 22361127
Congenital tracheal stenosis; Balloon-expandable metallic stents; Paediatric intensive care unit
4.  Removal of self expandable metallic airway stent: A rare case report 
Covered self expandable metallic airway stents (SEMS) have been used for benign tracheal stenosis, post intubation tracheal stenosis, tracheal burn or trauma, tracheo-broncho-malacia, and extrinsic compression of trachea. Their placement is considered to be permanent, with open surgery the only way to remove the stent, though there are few cases reports of their removal with the bronchoscope, but the complications after their removal are very high. In our patient, one and a half years after placement of SEMS, she developed cough with dyspnoea, video bronchoscopy showed stenosis above the level of stent with granulation tissue inside the stent, stent fracture in lower part and stent migration to right main bronchus, thus she had all conceivable complications of stent placement. The stent was removed with the help of rigid bronchoscope under general anaesthesia. She was discharged the following day. The case is being reported because it was unique in having all the possible complications of stent placement, and rare as we could take out the stent in Toto. Thirdly, the stent could be removed without any complication.
PMCID: PMC3644838  PMID: 23661920
Granulation tissue inside the stent; stenosis above the stent; stent fracture; stent migration
5.  Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction 
World Journal of Hepatology  2013;5(3):114-119.
AIM: To investigate the clinical efficiency of percutaneous trans-hepatic bilateral biliary metallic stenting for the management of Bismuth IV malignant obstructive disease.
METHODS: Our hospital’s database was searched for all patients suffering from the inoperable malignant biliary obstruction Bismuth IV, and treated with percutaneous bilateral trans-hepatic placement of self-expandable nitinol stents. The indication for percutaneous stenting was an inoperable, malignant, symptomatic, biliary obstruction. An un-correctable coagulation disorder was the only absolute contra-indication for treatment. Bismuth grading was performed using magnetic resonance cholangiopancreatography. Computed tomography evaluation of the lesion and the dilatation status of the biliary tree was always performed prior to the procedure. All procedures were performed under conscious sedation. A single trans-hepatic track technique was preferred (T-configuration stenting) and a second, contra-lateral trans-hepatic track (Y-configuration stenting) was used only in cases of inability to access the contra-lateral lobe using a single track technique. The study’s primary endpoints were clinical success, defined as a decrease in bilirubin levels within 10 d and patient survival rates. Secondary endpoints included peri-procedural complications, primary and secondary patency rates.
RESULTS: A total of 35 patients (18 female, 51.4%) with a mean age 69 ± 13 years (range 33-88) were included in the study. The procedures were performed between March 2000 and June 2008 and mean time follow-up was 13.5 ± 22.0 mo (range 0-96). The underlying malignant disease was cholangiocarcinoma (n = 10), hepatocellular carcinoma (n = 9), pancreatic carcinoma (n = 5), gastric cancer (n = 2), bile duct tumor (n = 2), colorectal cancer (n = 2), gallbladder carcinoma (n = 2), lung cancer (n = 1), breast cancer (n = 1) or non-Hodgkin lymphoma (n = 1). In all cases, various self-expandable bare metal stents with diameters ranging from 7 to 10 mm were used. Stents were placed in Y-configuration in 24/35 cases (68.6%) using two stents in 12/24 patients and three stents in 12/24 cases (50%). A T-configuration stent placement was performed in 11/35 patients (31.4%), using two stents in 4/11 cases (36.4%) and three stents in 7/11 cases (63.6%). Follow-up was available in all patients (35/35). Patient survival ranged from 0 to 1763 d and the mean survival time was 168 d. Clinical success rate was 77.1% (27/35 cases), and peri-procedural mortality rate was 5.7% (2/35 patients). Biliary re-obstruction due to stent occlusion occurred in 25.7% of the cases (9/35 patients), while in 7/11 (63.6%) one additional percutaneous re-intervention due to stent occlusion resulting in clinical relapse of symptomatology was successfully performed. In the remaining 4/11 patients (36.4%) more than 1 additional reintervention was performed. The median decrease of total serum bilirubin was 60.5% and occurred in 81.8% of the cases (27/33 patients). The median primary and secondary patency was 105 (range 0-719) and 181 d (range 5-1763), respectively. According to the Kaplan-Meyer survival analysis, the estimated survival rate was 73.5%, 47.1% and 26.1% at 1, 6 and 12 mo respectively, while the 8-year survival rate was 4.9%. Major and minor complication rates were 5.7% (2/35 patients) and 17.1% (6/35 patients), respectively.
CONCLUSION: Percutaneous bilateral biliary stenting is a safe and clinically effective palliative approach in patients suffering from Bismuth IV malignant obstruction.
PMCID: PMC3612569  PMID: 23556043
Bismuth IV; Malignant biliary obstruction; Percutaneous bilateral stenting; Nitinol stents; Palliative treatment; Fluoroscopically-guided
6.  Physiological effect of endobronchial radiotherapy in patients with major airway occlusion by carcinoma. 
Thorax  1993;48(2):110-114.
BACKGROUND: Endobronchial radiotherapy by a high dose rate remote after-loading technique (high dose rate brachytherapy) has become an established treatment for major airway occlusion by inoperable carcinoma of the bronchus. Only limited objective data on its effect on pulmonary physiology and on radiographic and bronchoscopic appearances are available. The aim of this study was to make a detailed assessment of patients before and after high dose rate brachytherapy to determine which investigations were useful and to generate data for comparing this with other methods of treatment. METHODS: Twenty patients with major airway obstruction by inoperable lung cancer underwent a detailed assessment before receiving endobronchial radiotherapy (15 Gy at 1 cm in a single fraction) and six weeks after treatment. This included chest radiography, computed tomography of the thorax, bronchoscopy including an obstruction index, five minute walking tests, isotope ventilation and perfusion lung scanning, and full lung function tests with maximum inspiratory and expiratory flow-volume loops. RESULTS: Nineteen patients (mean age 69 years) completed the study. Symptomatic improvement occurred in 17 patients. A collapsed lobe or lung, seen on the chest radiograph in 13, reexpanded in nine. Bronchoscopic appearances improved in 18, the mean obstruction index decreasing from 6.2 to 2.8. The isotope scans showed significant increases in the percentage of total lung ventilation (V) and perfusion (Q) measured over the abnormal lung (V 17.7% to 27.7%, Q 15.1 to 21.9%). Five minute walking distance (305 to 329 m), forced expiratory volume in one second (FEV1 1.45 to 1.61 l), forced vital capacity (FVC 2.17 to 2.48 l) and ratio of forced expiratory to forced inspiratory flow rate at 50% vital capacity (FEF50/FIF50 0.58 to 0.88) all increased significantly. CONCLUSIONS: Endobronchial radiotherapy led to subjective benefit in most cases in terms of symptoms and bronchoscopic and radiological appearances. There was objective improvement in spirometric indices and in exercise tolerance with increased pulmonary ventilation and perfusion and evidence of decreased intrathoracic airway obstruction.
PMCID: PMC464283  PMID: 8388128
7.  Stenting for Large Bowel Obstruction – Evolution of a Service in a District General Hospital 
Stenting for obstructing large bowel malignancy is a technique that is gradually increasing in popularity. The two main indications are for palliation and as a ‘bridge to surgery’. Some of the proposed advantages of colonic stenting are safety, reduced morbidity and mortality, avoidance of a stoma and shorter hospital stay.
This was a retrospective study of consecutive patients who had self-expanding metal stents deployed between February 2001 and June 2006. Data were collected from the MEDITECH electronic integrated healthcare information support system and case note review. Data concerning demographics, primary diagnosis, and location of malignant stricture, indication for stenting, method of stenting, outcome, complications and mortality rates were obtained and analysed on Microsoft Excel.
Colonic stenting was first performed in the Countess of Chester Hospital in 2001. Thirty-two procedures have been performed since then. The median age was 80 years and the majority of cases were palliative (28 of 32), with three of the remaining cases successfully stented as a ‘bridge to surgery’. Initially, this was performed as a radiological procedure; however, the success rate was noted to be better if a surgical endoscopist was also involved. We recorded a 57% clinical success rate in the group of patients that had the colonic stent inserted radiologically; however, the group where this was inserted as a combined radiological and endoscopic procedure yielded a clinical success rate of 78%. We experienced stent-migration in four patients (13%) and rectal perforation in one patient (3%). There was no tumour re-obstruction or stent-related mortality.
A colonic stenting service can be introduced into a district general hospital with low morbidity and mortality. A well-motivated team is required and combined endoscopic and radiological approach in our hands appears to offer the best results.
PMCID: PMC2752245  PMID: 19126335
Self-expanding metal stent; Large bowel obstruction; Stent
8.  Metallic Stents for Proximal Tracheal Stenosis: Is It Worth the Risk? 
Case Reports in Otolaryngology  2012;2012:450304.
Objective. To demonstrate the risk associated with blocked proximal tracheal stents when a patient presents with acute respiratory distress, with blockage of stent and what is the best management we can offer without damage to the stent and its associated complications. Case Report. A 22-yr-old, male patient, presented in severe respiratory distress. He had history of corrosive poisoning for which he was tracheotomised. A stainless steel wire mesh stent was placed in the trachea, from the subglottis, to just above the carina. One month later, he presented with a critically compromised airway with severe respiratory distress. Emergency tracheostomy was done and the metallic stent had to be cut open, in order to provide an airway. Conclusion. Management of blocked proximal stents with patient in respiratory distress remains a challenge. Formation of granulation tissue is common and fibreoptic bronchoscopic assisted intubation may not always be possible. A regular follow up of all patients with stents is essential. Placement of stents within a few centimetres of cricotracheal junction should not be encouraged for long term indications.
PMCID: PMC3420591  PMID: 22953113
9.  Bilateral self-expandable metallic stents for lung cancer involving the carina 
Respirology Case Reports  2013;1(2):48-51.
Central airway obstruction needs interventional pulmonology and malignant main carinal involvement is one of the most challenging scenarios requiring rigid bronchoscopic intervention under general anesthesia. However, these patients tend to be in poor condition for such interventions. A 91-year-old male patient with lung cancer accompanied by obstructive pneumonia underwent an Ultraflex self-expandable metallic stent placement in the right mainstem bronchus. The extranodal extension of the carcinoma from mediastinal lymph nodes metastases to the carina was so fast that severe stenosis of the bilateral mainstem bronchi was observed 6 weeks later accompanied by the deterioration of dyspnea. To salvage the carina, bilateral Ultraflex covered stents were placed by “side-by-side” method using fiberoptic bronchoscopy under topical anesthesia. This strategy was quite safe and the time needed for the entire procedure was within 20 min. He never experienced dyspnea thereafter and died of a cardiac sudden death 7 months after the initial stenting.
PMCID: PMC4184527  PMID: 25473542
Bilateral self-expandable metallic stents; central airway obstruction; interventional pulmonology; malignant main carinal involvement; side-by-side method
10.  Clinical Experience of Rigid Bronchoscopy in Single Center 
The aim of this study was to analyze clinical situations requiring rigid bronchoscopy and evaluate usefulness of rigid bronchoscopic intervention in benign or malignant airway disorders.
We retrospectively reviewed 29 patients who underwent rigid bronchoscopy from November 2007 to February 2011 at St. Paul's Hospital, The Catholic University of Korea School of Medicine.
Of the 29 patients, the most frequent underlying etiology was benign stenosis of trachea (n=20). Of those 20 patients, 16 had post-intubation tracheal stenosis (PITS), 2 had tracheal stenosis due to inhalation burn (IBTS) and other 2 had obstructive fibrinous tracheal pseudomembrane (OFTP). Other etiologies were airway malignancy (n=6), endobronchial stenosis due to tuberculosis (n=2), and foreign body (n=1). For treatment, silicone stent insertion was done in 16 cases of PITS and IBTS and mechanical removal was performed in 2 cases of OFTP. In 6 cases of malignant airway obstruction mechanical debulking was performed and silicone stents were inserted additionally in 2 cases. Balloon dilatation and electrocautery were used in 2 cases of endobronchial stenosis due to tuberculosis. In all cases of stent, airway obstructive symptom improved immediately. Granulation tissue formation was the most common complication.
Tracheal stenosis was most common indication and silicone stenting was most common procedure of rigid bronchoscopy in our center. Rigid bronchoscopic procedures, at least tracheal silicone stenting, should be included in pulmonary medicine fellowship programs because it is a very effective and indispensable method to relieve critical airway obstruction which needs training to learn.
PMCID: PMC3475459  PMID: 23101015
Bronchoscopy; Pulmonary Medicine; Tracheal Stenosis; Airway Obstruction
11.  Placement of self-expandable metallic stents for tracheal stenosis secondary to thyroid cancer 
Molecular and Clinical Oncology  2014;2(6):1003-1008.
The indications and suitable approaches for treating upper airway obstruction secondary to thyroid cancer are controversial. Patients with thyroid cancer generally have a good prognosis, but airway stenosis and vocal cord paralysis are not uncommon. Subglottic airway stenting may be challenging, due to stent migration, granulation tissue formation and supraglottic stenosis. In this study, we evaluated the application of covered self-expandable metallic stents to relieve upper airway obstruction. This was a retrospective study of 5 patients with airway stenosis due to thyroid cancer treated in 2009 and 2010. Immediate airway enlargement was achieved in 3 patients with stenosis at the middle mediastinum. Gradual enlargement over 2 months was observed in the remaining 2 patients with stenosis at the cervical level. The performance status was improved in all 5 patients, including a case with anaplastic carcinoma. The follow-up averaged 13 months (range, 8–27 months). Granulation tissue developed at both ends of the stent in 3 patients, sputum was retained in 2 cases and bacterial colonization was detected in all 5 cases. No stent migration was reported. Additional tracheostomy was required in 2 patients, due to proximal tumor growth or progressive bilateral vocal cord paralysis after 10 and 6 months, respectively. In conclusion, stenting for central airway stenosis secondary to thyroid cancer may be beneficial, even in patients with anaplastic carcinoma. Long-term regular bronchoscopic follow-up is required to monitor complications, as patients with thyroid cancer are at high risk of granulation tissue formation, sputum retention and bacterial colonization.
PMCID: PMC4179784  PMID: 25279189
self-expandable metallic stents; tracheal stenosis; airway obstruction; thyroid cancer; flexible bronchoscopy
12.  Self-Expandable Metallic Stent Placement in the Palliative Treatment of Malignant Obstruction of Gastric Outlet and Duodenum 
Clinical Endoscopy  2013;46(1):59-64.
To asses the usefulness of flexible metallic stents in the palliation of malignant obstruction of gastric outlet and duodenum.
Retrospective review was performed between January 2006 and December 2011 in 30 patients. Thirty consecutive patients with obstruction of the gastric outlet underwent palliative treatment with self-expandable flexible metallic stents. Complications and clinical outcomes were assessed.
Twenty-four patients had advanced gastric carcinoma at the antrum and/or pylorus, four patients had obstruction at the pylorus due to pancreas tumours and one patient had duodedum and one patient had gall bladder tumour. Symptoms improved in 82.7% of the patients after the procedure. The improvement in ability to eat using the score system was statistically significant (p<0.001). Tumor ingrowth and/or overgrowth were seen in four patients (13.3%), and a second stent was inserted in these patients. The mean stent patency was 100 days (range, 5 to 410). The mean survival was 120.76±38.96 days.
Endoscopic placement of self-expendable metallic stents under fluoroscopy is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach or pancreas cancer.
PMCID: PMC3572353  PMID: 23423384
Gastric outlet obstruction; Self expendable metallic stents; Advanced malignancies
13.  Nintinol Self-Expandable Metallic Stenting in Management of Malignant Obstructive Jaundice: A Case Series 
Hepatitis Monthly  2010;10(1):57-61.
Background and Aims
Palliation therapy is the only available therapeutic method for most patients with tumor-induced obstructive jaundice. Metallic stents are now performed percutaneously as an alternative route to the endoscopic approach. It is widely accepted because of its safety, good patency rate, and minimal invasiveness. This study was designed to evaluate the long-term results of metallic self-expandable stent insertion in patients with malignant stenosis of the biliary tree.
It is a longitudinal study of patients with percutaneously biliary stenting from September 2005 to March 2009. The patients had unresectable malignant biliary obstruction with unsuccessful endoscopic stenting and access. Percutaneous transhepatic cholangiogram performed after adequate local anesthesia, under sonographic or fluoroscopic guidance. Stenting or balloon dilation was performed through the hydrophilic guide wire. Among 50 patients, 45 stents were placed in biliary tree stenosis sites. Patients’ follow-up was during the first, second, third, and then the sixth month after insertion of biliary stents. Stent patency was considered successful in our patients, when there were no lab results or sonographic appearance of biliary tree obstruction.
10(20%) patients’ stent placement treatment failed because of unsuccessful technical procedure. The stenosis of biliary tract was complete and passage of guide wire was not possible through the tumor growth. 6 (15 %) patients with successful stent placements died within one month (mean, 22 days). Total serum bilirubin resolved to below 1.5 mg/dl within 30 days for 36 (90%) patients with successful stent placements. Early complications not leading to death occurred in 28% of cases. The mean survival time for all patients who underwent stent placement was 140 days (16-420days). The mean patency rate for all stents was 147 days.
Percutaneous biliary stenting is a safe procedure with few technical complications and a high success rate of palliation for patients with malignant biliary jaundice. Early complications are mostly managed conservatively and death is mainly due to systemic effects of the malignant disease.
PMCID: PMC3270347  PMID: 22308128
Malignant Jaundice; Biliary Metal Stents; Percutaneous Biliary Stenting
14.  Is stent insertion via flexible bronchoscopy a feasible alternative to surgery in inoperable thyroid related tracheobronchial stenosis? 
Journal of Thoracic Disease  2013;5(3):302-305.
The use of endobronchial stents in the treatment of tumour related tracheobronchial stenosis has been well described. While many forms of stent exist, their use has invariably been described in the context of rigid bronchoscopy and general anaesthesia. Few reports exist on the use of endobronchial stents for the treatment of thyroid goitre related stenosis.Our objective was to retrospectively analyse the use of self expanding metal stent (SEMS) insertion for thyroid related tracheobronchial stenosis under sedation with flexible bronchoscopy in the treatment of this condition. Patient charts were reviewed on all patients who had stent insertion in our unit since 1999-2005.
We analysed the indication for stenting, pathology, stent size and location and detail any complications of therapy. Particular attention was paid to those with benign disease to evaluate the recommendation made by the U.S Food and Drug Administration (FDA) in 2005 on the use of metal stents in benign airways disease. A total of five patients (4 female, 1 male) who were too unfit for surgery had stent insertion for thyroid related tracheobronchial stenosis over this period. All patients experienced complications which became prolonged and recurrent in those with benign disease who survived longer. We conclude that SEMS insertion via flexible bronchoscopy is not appropriate for the treatment of benign thyroid goitre related tracheobronchial stenosis until all other interventions have been exhaustively explored.
PMCID: PMC3698266  PMID: 23825763
Tracheobronchial stenosis; multinodular goitre; interventional pulmonology; flexible bronchoscopy; Ultraflex stent; stridor
15.  Impact of biliary stents on EUS-guided FNA of pancreatic mass lesions 
Gastrointestinal endoscopy  2012;76(1):76-83.
Few studies have evaluated the impact of biliary stents on EUS-guided FNA.
To compare diagnostic yield of EUS-FNA in patients with or without biliary stents.
Retrospective study.
Tertiary referral center.
Patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-FNA over 5 years.
Main Outcome Measures
The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic stents or self-expandable metal stents (SEMSs). Secondary objectives were to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis and to identify predictors of a false-negative diagnosis.
Of 214 patients who underwent EUS-FNA, 150 (70%) had biliary stents and 64 (30%) had no stents in place. Of 150 patients with biliary stents, 105 (70%) were plastic and 45 (30%) were SEMSs. At EUS-FNA, the diagnosis was pancreatic cancer in 155 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%), and indeterminate in 11 (5%). There was no difference in rates of diagnostic accuracy between patients with or without stents (93.7% vs 95.3%; P = .73) and between plastic or SEMSs (95.2% vs 95.5%, P = .99), respectively. Median number of passes to diagnosis was not significantly different between patients with or without stents (2 [interquartile ratio range (IQR) = 1–3] vs 2 [IQR = 1–4]; P = .066) and between plastic or SEMS (2.5 [IQR = 1–4] vs 2 [IQR = 1–4], P = .69), respectively. On univariate analysis, EUS-FNA results were false-negative in patients with large pancreatic masses (>3 cm vs <3 cm, 9.35% vs 0.93%, P = .005) that required more FNA passes (<2 vs >2 passes, 0% vs 11.8%, P < .0001).
Retrospective study.
The presence or absence of a biliary stent, whether plastic or metal, does not have an impact on the diagnostic yield or technical difficulty of EUS-FNA.
PMCID: PMC4163947  PMID: 22726468
16.  AB 63. Management of complex benign post-tracheostomy tracheal stenosis with bronchoscopic insertion of silicon tracheal stents, in patients with failed or contraindicated surgical reconstruction of trachea 
Journal of Thoracic Disease  2012;4(Suppl 1):AB63.
Tracheal stenosis is a potentially life-threatening condition. Tracheostomy and endotracheal intubation remain the commonest causes of benign stenosis, despite improvements in design and management of tubes. Post-tracheostomy stenosis is more frequently encountered due to earlier performance of tracheostomy in intensive care units, while the incidence of post-intubation stenosis has decreased with application of high-volume low-pressure cuffs. We present tracheal stenting in complex post-tracheostomy stenoses.
Patients and methods
We inserted tracheal silicone stents (Dumon) under general anaesthesia through rigid bronchoscopy in two patients with benign post-tracheostomy stenoses: a 39-year old woman treated for acute respiratory failure (dyspnoea, hemoptysis, alveolar bleeding, attributed to seronegative lung vasculitis) who initially underwent surgical resection and end-to-end anastomosis, but developed restenosis (anastomotic granulation/scarring), and suffered continuous relapses after multiple bronchoscopic interventions, underwent silicone stenting (length 4.5 cm, diameter 12 mm). A 20-year old man treated for severe head trauma after a car accident developed a long tracheal stricture involving the subglottic larynx (lower posterior part), having inflamed tracheostomy site tissues (positive for methicillin resistant staphylococcus aureus), underwent silicone stenting (length 7 cm, diameter 14 mm).
The airway was immediately re-establish, without complications (tracheal rupture/pneumomediastinum, bleeding). At 15 and 10 months follow-up (respectively) there was no stent migration, luminal patency was maintained without: adjacent structure erosion, secretion adherence inside the stents, granulation at the ends. Tracheostomy tissue inflammation was resolved (2nd patient), new infection was not noted. The patients maintain good respiratory function and will be evaluated for scheduled stent removal.
In symptomatic benign tracheal stenosis the gold standard is surgical reconstruction (often after interventional bronchoscopy). Stenting is reserved for symptomatic tracheal narrowing deemed inoperable due to local or general reasons: inflammation, long strictures, previous failed operation, poor respiratory, cardiac or neurological status. When stenting is decided, silicone stent insertion is considered treatment of choice in the presence of inflammation and/or when removal is desirable. Silicone stents are removable, resistant to microbial colonization and are associated with minimal granulation. In benign post-tracheostomy stenosis silicone stenting was safe and effective in re-stenosis after surgery and multiple bronchoscopic interventions, and in long stenosis in the presence on inflammation and poor neurological status.
PMCID: PMC3537415
17.  Timing of silicone stent removal in patients with post-tuberculosis bronchial stenosis 
Annals of Thoracic Medicine  2013;8(4):218-223.
In patients with post-tuberculosis bronchial stenosis (PTBS), the severity of bronchial stenosis affects the restenosis rate after the silicone stent is removed. In PTBS patients with incomplete bronchial obstruction, who had a favorable prognosis, the timing of stent removal to ensure airway patency is not clear.
We evaluated the time for silicone stent removal in patients with incomplete PTBS.
A retrospective study examined PTBS patients who underwent stenting and removal of a silicone stent.
Incomplete bronchial stenosis was defined as PTBS other than total bronchial obstruction, which had a luminal opening at the stenotic segment on bronchoscopic intervention. The duration of stenting was defined as the interval from stent insertion to removal. The study included 44 PTBS patients and the patients were grouped at intervals of 6 months according to the duration of stenting.
Patients stented for more than 12 months had a significantly lower restenosis rate than those stented for less than 12 months (4% vs. 35%, P = 0.009). Multiple logistic regression revealed an association between stenting for more than 12 months and a low restenosis rate (odds ratio 12.095; 95% confidence interval 1.097-133.377). Moreover, no restenosis was observed in PTBS patients when the stent was placed more than 14 months previously.
In patients with incomplete PTBS, stent placement for longer than 12 months reduced restenosis after stent removal.
PMCID: PMC3821282  PMID: 24250736
Airway obstruction; bronchoscopy; device removal; stents; tuberculosis
18.  Sequential brush biopsy and conventional biopsy: direct comparison of diagnostic sensitivity in lung malignancy. 
Thorax  1980;35(12):929-931.
One hundred and sixteen patients with suspected lung malignancy who were referred for bronchoscopy were examined using both the flexible fibreoptic bronchoscope and the rigid bronchoscope. Both instruments were used sequentially under the same general anaesthetic. Brush biopsies were obtained through the fibreoptic bronchoscope and conventional biopsies, for histological examination, through the rigid bronchoscope. Both specimens were taken from the same area. Eighty-two per cent of those in whom there was a final clinical diagnosis of malignancy were found to have abnormal cytology via the fibreoptic bronchoscope, while abnormal histology was found in 50% by means of the rigid bronchoscope. For those in whom malignancy was confirmed, 16.9% showed disagreement between the two methods in cell typing. Brush biopsy through the flexible fibreoptic bronchoscope under general anaesthesia is confirmed as a sensitive method for diagnosing lung malignancy.
PMCID: PMC471417  PMID: 7268669
19.  Removal of metallic tracheobronchial stents in lung transplantation with flexible bronchoscopy 
Airway complications are among the most challenging problems after lung transplantation, and Self-Expandable Metallic Stents (SEMS) are used to treat airway complications such as stenosis or malacia at the bronchial anastomosis sites. Several transplantation centers are reluctant to use SEMS since their removal is sometimes needed and usually requires the use of rigid bronchoscopy under general anesthesia. The objective of the current report is to describe our experience in SEMS retrieval by flexible bronchoscopy under conscious sedation.
A retrospective review was done of patients requiring tracheobronchial stent placement after lung transplantation in which the SEMS had to be removed. The retrieval procedure was done by flexible bronchoscopy on a day-care ambulatory basis.
Between January 2004 and January 2010, out of 305 lung transplantation patients, 24 (7.8%) underwent SEMS placement. Indications included bronchial stenosis in 20 and bronchomalacia in 4. In six patients (25%) the SEMS had to be removed due to excessive granulation tissue formation and stent obstruction. The average time from SEMS placement to retrieval was 30 months (range 16-48 months). The stent was completely removed in five patients and partially removed in one patient; no major complications were encountered, and all patients were discharged within 3 hours of the procedure. In all procedures, new SEMS was successfully re-inserted thereafter.
The retrieval of SEMS in patients that underwent lung transplantation can be effectively and safely done under conscious sedation using flexible bronchoscopy on a day-care basis, this observation should encourage increasing usage of SEMS in highly selected patients.
PMCID: PMC2945334  PMID: 20831830
20.  Surgical failure after colonic stenting as a bridge to surgery 
World Journal of Gastroenterology : WJG  2014;20(33):11826-11834.
AIM: To identify risk factors for surgical failure after colonic stenting as a bridge to surgery in left-sided malignant colonic obstruction.
METHODS: The medical records of patients who underwent stent insertion for malignant colonic obstruction between February 2004 and August 2012 were retrospectively reviewed. Patients with malignant colonic obstruction had overt clinical symptoms and signs of obstruction. Malignant colonic obstruction was diagnosed by computed tomography and colonoscopy. A total of 181 patients underwent stent insertion during the study period; of these, 68 consecutive patients were included in our study when they had undergone stent placement as a bridge to surgery in acute left-sided malignant colonic obstruction due to primary colon cancer.
RESULTS: Out of 68 patients, forty-eight (70.6%) were male, and the mean age was 64.9 (range, 38-89) years. The technical and clinical success rates were 97.1% (66/68) and 88.2% (60/68), respectively. Overall, 85.3% (58/68) of patients underwent primary tumor resection and primary anastomosis. Surgically successful preoperative colonic stenting was achieved in 77.9% (53/68). The mean duration, defined as the time between the SEMS attempt and surgery, was 11.3 d (range, 0-26 d). The mean hospital stay after surgery was 12.5 d (range, 6-55 d). On multivariate analysis, the use of multiple self-expanding metal stents (OR = 28.872; 95%CI: 1.939-429.956, P = 0.015) was a significant independent risk factor for surgical failure of preoperative stenting as a bridge to surgery. Morbidity and mortality rates in surgery after stent insertion were 4.4% (3/68) and 1.5% (1/68), respectively.
CONCLUSION: The use of multiple self-expanding metal stents appears to be a risk factor for surgical failure.
PMCID: PMC4155374  PMID: 25206288
Colorectal neoplasms; Endoscopy; Intestinal obstruction; Risk factors; Stents
21.  Airway and Esophageal Stenting in Patients with Advanced Esophageal Cancer and Pulmonary Involvement 
PLoS ONE  2008;3(8):e3101.
Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC.
Methods and Findings
The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58±\−8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/−10 weeks and was significantly shorter in group 1 (6+/−7.6 weeks) than in group 2 (28+/−11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases.
Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience.
PMCID: PMC2518104  PMID: 18769726
22.  Palliative stenting of the digestive tract: a case series of a single centre 
Background and aim
Obstruction of the gastrointestinal tract due to cancer can be treated with stenting. The aim was to review the local experience with endoscopic stenting. All patients treated with stenting in a ten years period from 2001-2010 were studied.
Fifty one patients received 57 stents because of oesophageal cancer. Mean survival after stent placement was 141 days. No case of perforation occurred. In nine cases (17%) clogging with food occurred. Tumour overgrowth was noted in four cases. Twenty four patients received 28 stents in their colon or rectum. The stents were placed in the rectum (n=6), the sigmoid (n=14), the descending colon (n=1), and the transverse colon (n=3). Mean survival was 276 days. Perforation did not occur. Tumour ingrowth was seen in two patients. One patient received a second stent. Dislocation occurred in two cases. There were two cases of clogging (8%) by stool.
Fourteen patients received a total of 18 stents because of obstructing stomach cancer. Mean survival after placement was 121 days. There was no perforation, one case of clogging, and four cases of tumour ingrowth. Eight patients had stent placement in their duodenum. Mean survival after stent placement was 84 days. No perforation or clogging occurred. But three cases of tumour ingrowth were seen.
The present series shows that placement of expandable stents in the digestive tract in normal daily practice is feasible, safe, with a low number of complications, and provides good palliation for their remaining life.
PMCID: PMC3562623  PMID: 23450097
Endoscopic stent placement; wall stent; obstructing tumours; palliation; endoscopy
23.  Palliative Care of Malignant Ureteral Obstruction with Polytetrafluoroethylene Membrane-Covered Self-Expandable Metallic Stents: Initial Experience 
Korean Journal of Urology  2012;53(9):625-631.
We assessed the efficacy and safety of insertion of a polytetrafluoroethylene membrane-covered self-expandable metallic stent (UVENTA stent) for palliation of malignant ureteral obstruction on the basis of our early results.
Materials and Methods
Eighteen patients underwent UVENTA stent insertion for extrinsic malignant ureteral obstructions of 20 ureters. The UVENTA stents were deployed retrogradely under cystoscopy and fluoroscopy. Candidates for the procedure had preexisting double-J stents that were nonfunctional or caused excessive bladder irritation. We recorded the success and patency rate in addition to any complications associated with the procedure.
The mean length of obstruction was 10.6 cm (range, 2 to 20 cm). Two ureters were obstructed in the upper ureter, 9 in the lower ureter, and 9 in multiple levels of ureter. Simultaneous balloon dilation was performed in 12 ureters. UVENTA stents were successfully inserted in all patients. No obstruction of the UVENTA stents occurred during the mean follow-up period of 7.3 months (patency rate 100%), but de novo ureteral obstruction developed in 4 ureters. There were no instances of stone formation, hyperplastic reaction, encrustation, or migration. Abnormally elevated serum creatinine decreased to normal levels and hydronephrosis gradually resolved during the 4 weeks after UVENTA insertion. No significant complications developed except for transient and self-limiting hematuria and mild lower abdominal pain.
UVENTA stents may relieve malignant ureteral obstruction safely and easily. Long-term follow-up is necessary to assess the role of this stent in the treatment of malignant ureteral obstruction.
PMCID: PMC3460005  PMID: 23061000
Palliative care; Stents; Ureteral obstruction
24.  Clinical outcomes of self-expandable metal stents in palliation of malignant anastomotic strictures caused by recurrent gastric cancer 
AIM: To examine the technical feasibility and clinical outcomes of the endoscopic insertion of a self-expandable metal stent (SEMS) for the palliation of a malignant anastomotic stricture caused by recurrent gastric cancer.
METHODS: The medical records of patients, who had obstructive symptoms caused by a malignant anastomotic stricture after gastric surgery and underwent endoscopic insertion of a SEMS from January 2001 to December 2007 at Kangnam St Mary’s Hospital, were reviewed retrospectively.
RESULTS: Twenty patients (15 male, mean age 63 years) were included. The operations were a total gastrectomy with esophagojejunostomy (n = 12), subtotal gastrectomy with Billroth-I reconstruction (n = 2) and subtotal gastrectomy with Billroth-II reconstruction (n = 8). The technical and clinical success rates were 100% and 70%, respectively. A small bowel or colon stricture was the reason for a lack of improvement in symptoms in 4 patients. Two of these patients showed improvement in symptoms after another stent was placed. Stent reobstruction caused by tumor ingrowth or overgrowth occurred in 3 patients (15%) within 1 mo after stenting. Stent migration occurred with a covered stent in 3 patients who underwent a subtotal gastrectomy with Billroth-II reconstruction. Two cases of partial stent migration were easily treated with a second stent or stent repositioning. The median stent patency was 56 d (range, 5-439 d). The median survival was 83 d (range, 12-439 d).
CONCLUSION: Endoscopic insertion of a SEMS provides safe and effective palliation of a recurrent anastomotic stricture caused by gastric cancer. A meticulous evaluation of the presence of other strictures before inserting the stent is essential for symptom improvement.
PMCID: PMC2715979  PMID: 19630108
Stents; Surgical anastomosis; Stricture; Endoscopic gastrointestinal surgery; Stomach neoplasms
25.  A three year follow up of self expanding metal stents in the endoscopic palliation of longterm survivors with malignant biliary obstruction. 
Gut  1995;36(4):618-621.
Effective palliation of malignant biliary obstruction with conventional 10 or 12 French gauge straight polyethylene endoprostheses is limited by stent occlusion, which typically occurs four to five months after insertion. Short term follow up studies of self expanding metal stents (Wallstent, Schneider, UK) in the treatment of patients with malignant biliary obstruction have shown that their use is associated with fewer episodes of stent occlusion compared with plastic stents. There are few data, however, on the longterm patency and durability of metal stents in malignant disease. Between May 1989 and May 1992, metal stents were inserted in 28 patients with malignant bile duct strictures secondary to ampullary tumour (n = 10), pancreatic carcinoma (n = 10), cholangiocarcinoma (n = 7), and porta hepatis nodes from colorectal carcinoma (n = 1). The follow up of these patients until May 1993 is reported with a median follow up of 14.6 months. Twenty two of 28 (78.6%) patients remained free of jaundice or cholangitis. The median period of stent patency was 8.2 months (range 1.0-32.5). Thirteen patients represented with jaundice or cholangitis and endoscopic retrograde cholangiopancreatography showed evidence of stent occlusion due to tumour ingrowth. Successful clearance of metal stents was achieved by balloon trawling, or insertion of a polyethylene stent. In conclusion, metal stents provide improved longterm palliation for patients with malignant biliary strictures with fewer episodes of occlusion compared with conventional stents.
PMCID: PMC1382508  PMID: 7537708

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