Stefano Santoprete

Long-term safety and tolerance of silicone and self-expandable airway stents: an experimental study

BACKGROUND A variety of respiratory stents are currently available, but the ideal airway prosthesis seems far from being recognized. The objective of this study was to verify safety and long-term effect on the bronchial wall of three different types of airway stents. METHODS Twelve healthy adult sheep were divided in three groups, scheduled to receive: (1) bare self-expandable metallic stents (Gianturco); (2) silicone stents (Dumon); and (3) covered self-expandable synthetic stents (Polyflex). Insertions were performed through a rigid bronchoscope under general anesthesia. Chest roentgenogram was performed 1 and 6 months after surgery, and flexible bronchoscopy after 6 months. Twelve months postoperatively, the animals were killed and a postmortem examination was carried out. RESULTS All Polyflex stents migrated during the observation period; one late migration was observed in the Dumon group. Microscopic study showed: (1) Gianturco stents: full-thickness perforation of the bronchial wall covered by a thick layer of a chronic inflammatory infiltrate. Infection by Candida at the bottom of some ulcerations; (2) Dumon stents: mild bronchial inflammation (squamous metaplasia, submucosal inflammatory infiltrates; granuloma-like infiltrates). In case of displacement, no significant changes of the previously stented bronchus occurred; and (3) Polyflex stents: no changes of the previously stented bronchi. CONCLUSIONS Gianturco stents proved unsafe in the long term, owing to the risk of severe airway wall damage. The Polyflex stent is well tolerated but presents a high migration rate. Silicone stents show several limitations but appear to be well tolerated by the host mucosa.

Resection With Curative Intent After Endoscopic Treatment of Airway Obstruction

BACKGROUND Endoscopic treatment of malignant central airway obstructions usually is done for palliation. The exact role of such a procedure as preparatory to operation remains controversial. METHODS From 1987 through 1996, 24 patients at our institution underwent tracheobronchial pulmonary resection after preliminary endoscopic treatment. During the same period, 304 patients underwent 449 operative rigid bronchoscopies for airway obstructions, most involving the use of a neodymium:yttrium-aluminum-garnet laser. The indications for operation were squamous cell carcinoma in 14 patients, bronchial gland tumors in 8 patients, and papillary thyroid cancer infiltrating the trachea in 2 patients. The total resection rate was 9.5% (5% for squamous cell carcinoma, 75% for low-grade malignant bronchial tumors, and 75% for papillary thyroid cancer). The median period between operative rigid bronchoscopy and operation was 18 days. RESULTS No complications were observed after endoscopic treatment. There were two perioperative deaths (adult respiratory distress syndrome after carinal resection and pulmonary embolism after pneumonectomy) and one major complication (poor postoperative pulmonary function after pneumonectomy). No anastomotic complications were observed in the tracheobronchoplastic procedures. Follow-up was possible in every patient but 1: 6 patients died at a median of 30.5 months after operation (range, 3 to 46 months), 2 patients are alive with disease, and the rest are alive without evidence of disease at a median of 21 months (range, 2 to 61 months). CONCLUSIONS Most patients who require endoscopic therapy for malignant airway obstructions are not candidates for operative resection. Preliminary endoscopic relief of obstruction can increase operability and improve surgical results in a highly selected group of patients.

Thyroid cancer invading the airway: diagnosis and management.

INTRODUCTION Aim of this study is to analyze outcome and the decision making process to approach airway invasion by thyroid tumors. METHODS Retrospective study of 30 years experience in thyroid surgery for cancer invading airway. Clinical records, surgical and pathology reports have been analyzed to assess which principles and procedural details are significant to facilitate efficient diagnosis, staging and treatment. Medical therapy was not evaluated. RESULTS Out of a consecutive series of 2165 thyroid cancer patients, T4a cancers are 303 (14%). Airway invasion was found in 141 (6.5%) cases. Well-differentiated pattern was determined in 110 (78%) while other histology was reported in 31 (22%). Airway-related symptoms have been recorded in 111 (78%) patients. Flexible bronchoscopy was performed in all patients. Rapidly evolving disease or non-resectable airway was found in 105 (74.5%) cases. Permanent tracheotomy was performed in 43 (30.5%) cases, airway lumen restoration with or without stenting in 39 (27.7%), laryngectomy in 8 (5.7%), segmental airway resection and reconstruction in 28 (19.9%). Perioperative mortality was recorded after palliative treatment only. In resected patients, completely radical surgery was not always achievable. All patients with positive margin after resection underwent adjuvant treatment and showed comparable survival to radical surgery patients after 5 years. Tumor relapse occurred in 8 (28.6%) cases (distant or locoregional). Patients with unresectable disease require treatment for symptoms relief but survival is poor. CONCLUSION Although some patients are currently referred with a severely advanced disease, the indication for tracheotomy, salvage procedures or supportive care has decreased over time. Resection is feasible for differentiated tumors with an overall good outcome.

External longitudinal titanium support for the repair of complex pectus excavatum in adults

Several techniques exist for the repair of complex pectus excavatum. The placement of retrosternal metal bars improves the results by reducing the recurrence rate, but entails several possible risks, complications and disadvantages. A new method, specifically conceived for the repair of severe, asymmetric forms in adult patients, is reported. The corrected bone is fixed in the proper position by two, patient-customized, titanium struts, externally screwed to the manubrium and sternal body. Any retrosternal bar is thus avoided, reducing possible complications, without hampering the chest wall dynamic. In this particularly difficult issue, this technique provides long-term good functional, mechanical and cosmetic results and does not entail a second surgery for struts removal.

The forgotten goiter: casuistic contribution and considerations for the choice of surgical approach

Aim. A residual mediastinal thyroid (“forgotten goiter”) is a well-known, though uncommon, complication of total thyroidectomy. Materials of study. The authors analyze their experience with three cases of goiter forgotten, observed in a series of 2946 thyroid resections in the period 2005–2010. In the study, a preoperative CT of the chest with three-dimensional reconstruction was always performed to examine the topographical relationships of the lesion. Excision was performed through cervicotomy, cervicosternotomic approach and cervicosternotomy, and posterolateral right thoracotomy. Results. There were no complications. Histological examination was suggestive of malignancy in one case (follicular carcinoma with pulmonary metastases). Discussion. The indication for surgery in cases of forgotten goiter is intrinsic to the diagnosis. Preoperative evaluation with accurate topographic imaging is required in all cases in order to understand the nature and location of mediastinal pathological tissue and to identify the most suitable access route. The cervicotomy is the ideal access for low surgical trauma and is easily extendable into a partial or complete sternotomy. A thoracotomy, on the other hand, which is usually reserved for the right side, must be planned preoperatively.

Surgery and perioperative management for post-intubation tracheoesophageal fistula: Case series analysis

BACKGROUND Post-intubation tracheoesophageal fistula (PITEF) is an often mistreated, severe condition. This case series reviewed for both the choice and timing of surgical technique and outcome PITEF patients. METHODS This case series reviewed ten consecutive patients who had undergone esophageal defect repair and airway resection/reconstruction between 2000 and 2014. All cases were examined for patients: general condition, medical history, preparation to surgery, diagnostic work-up, timing of surgery and procedure, fistula size and site, ventilation type, nutrition, post-operative course and complications. RESULTS All patients were treated according to Grillos technique. Overall, 6/10 patients had undergone a preliminary period of medical preparation. Additionally, 3 patients had already had a tracheostomy, one had had a gastrostomy and 4 had both. One patient had a Dumon stent with enlargement of the fistula. Concomitant tracheal stenosis had been found in 7 patients. The mean length of the fistulas was 20.5 mm (median 17.5 mm; range, 8-45 mm), at a median distance from the glottis of 43 mm (range, 20-68 mm). Tracheal resection was performed in all ten cases. The fistula was included in the resection in 6 patients, while it was excluded in the remaining 4 due to their distance. Post-repair tracheotomy was performed in 3 patients. The procedure was performed in 2 ventilated patients. Morbidity related to fistula and anastomosis was recorded in 3 patients (30%), with one postoperative death (10%); T-Tube placement was necessary in 3 patients, with 2/3 decannulations after long-stenting. Definitive PITEF closure was obtained for all patients. At 5-year follow-up, the 9 surviving patients had no fistula-related morbidity. CONCLUSIONS Primary esophageal closure with tracheal resection/reconstruction seemed to be effective treatment both short and long-term. Systemic conditions, mechanical ventilation, detailed preoperative assessment and appropriate preparation were associated with outcome. Indeed, the 3 patients who had received T-Tube recovered from anastomotic complications.

Reply to Actis Dato et al.

We thank the editor for the opportunity to explain better the rationale for our recently proposed technique [1]. When many different procedures are described for the treatment of the same disease, it is clear that the ideal technique has not been identified yet. In our opinion, the method devised by Actis Dato et al. [2] has a valid theoretical basis and has, in their hands, proved to be safe and effective. Furthermore, the authors have such a considerable experience in this field that their opinion has to be taken into the utmost consideration by the scientific community. In conceiving our technique, we aimed to avoid some drawbacks associated with the use of metallic retrosternal bars while trying to maintain similar long-term results. In fact, a transverse posterior bar limits the thoracic compliance, causes exposures to serious damage in the case of trauma, can be painful and requires a second operation for removal. We think that such disadvantages may justify the research on novel methods. The use of new titanium plates specifically built for sternal stabilization avoids the need for a posterior support, while ensuring the same solidity of the reconstructed sternum. These results can be achieved thanks to the highest strength-to-weight ratio of titanium: the Synthes struts (Synthes, Canada Ltd.) modelled on the anatomical sternal shape are so thin and light that their removal is not required. As correctly noted by Actis Dato et al., the procedure is relatively expensive [3]. This disadvantage is undoubtedly more than offset by the avoidance of a second surgery for the bar removal. Finally, the economic impact of the procedure is limited, as it is indicated in a carefully selected group of patients, with a condition difficult to correct such as the severe asymmetric pectus excavatum.