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(Chest. 2002;122:1069-1072.)
© 2002 American College of Chest Physicians

Rigid Bronchoscopy and Stenting for Esophageal Cancer Causing Airway Obstruction*

Kenneth Ping Wah Chan, MBBS, MMed; Philip Eng, MBBS, FCCP; Anne A.L. Hsu, MBBS, FCCP; Goh Meng Huat, MBBS, MMed and Mark Chow, MBBS, MMed

* From the Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.

Correspondence to: Kenneth Ping Wah Chan, MBBS, MMed, Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Rd, Singapore 169608; e-mail: gm3cpw{at}sgh.com.sg


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Background: Thirty percent of patients with esophageal cancer have malignant involvement of the major airways, leading to respiratory distress and life-threatening major airway obstruction. Tracheobronchial stenting has been reported to be effective in providing sustained relief from obstruction.

Methods: We conducted a chart review of all patients with advanced inoperable esophageal cancer who had malignant tracheobronchial obstruction requiring rigid bronchoscopy and airway stenting at our institution between June 1998 and July 2001. Outcome measures, which included survival, efficacy, and complications, were recorded.

Results: There were 11 patients (4 women) with a mean age of 61 years. Five patients had distant metastases at the time they underwent rigid bronchoscopy. Four patients who required mechanical ventilation for respiratory failure were successfully weaned off mechanical ventilation after the stenting procedure. All patients with dyspnea had immediate relief of respiratory symptoms, which was sustained for seven patients (64%). The mean duration of survival was 61 days. Two patients required repeat procedures, one for stent dislodgment on extubation and the other for stent migration.

Conclusion: Stenting in patients with malignant tracheobronchial obstructions due to advanced esophageal cancer achieves immediate, dramatic, and sustainable relief in respiratory symptoms, conferring a survival benefit in patients whose conditions are otherwise deemed to be terminal.

Key Words: airway obstruction • esophageal cancer • mechanical ventilation • rigid bronchoscopy • stent


   Introduction
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 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Advanced esophageal cancer has a poor prognosis with a 5-year survival rate of < 10%.1 It is a devastating illness, with considerable morbidity from local effects including dysphagia, dysphonia, airway involvement, chest pain, and, rarely, catastrophic hemorrhage from aortic erosion. In malignant obstruction of the esophagus, dilatation and stenting have been well-described, leading to good palliation of dysphagia and improved quality of life.2 Laser resection and stenting in major airway obstruction also have been documented to be safe and efficacious, in patient with both malignant and benign tracheobronchial stenoses.3 4 However, there has been little data regarding the bronchoscopic treatment of patients with esophageal cancer and airway complications like obstruction and fistulation.

We describe our experience with 11 patients who had advanced, inoperable, esophageal cancer and who had undergone Nd-YAG laser photoresection and stenting for major airway obstruction.


   Materials and Methods
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 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
We reviewed the records of all patients with advanced, inoperable, esophageal cancer who underwent laser resection and placement of an airway stent for malignant airway obstruction between June 1998 and July 2001 at our institution. All patients underwent deep IV sedation and rigid bronchoscopy with the Dumon ventilating bronchoscope.

In patients with malignant invasion of the airway, tumor debulking was achieved mainly by application of the Nd-YAG laser and by using the rigid bronchoscope. The laser was set in a discontinuous mode, at a power of 30 W, and with a pulse duration of 0.5 s. Supplemental oxygen was administered via the ventilating port of the rigid bronchoscope to keep the oxygen saturation at > 90%. During the application of the laser, the fraction of inspired oxygen was kept at < 0.4. In patients with extrinsic compression, the patency of the airway was restored by balloon dilatation. Balloon dilatation was achieved using a 7F, 15-mm esophageal balloon (Microinvasive; Boston Scientific Corporation; Watertown, MA). The balloon was inflated using normal saline solution injected through a syringe until strong resistance was felt at the plunger of the syringe. Balloon inflation was sustained for at least 20 s before deflation was allowed. This inflation-deflation cycle was repeated for an average of 10 times. Each patient subsequently had a Dumon silicone stent (Endoxane; Axion Corporation; Aubagne, France) of an appropriate size and length placed, using the technique described by Dumon.4

Outcome indices including survival, relief of symptoms, ability to wean from mechanical ventilation, and complications were recorded.


   Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
There were 11 patients (4 women) with a mean age 61 years (age range, 40 to 69 years). The clinical characteristics are presented in Table 1 . All patients had advanced inoperable disease. Five patients (patients 4 to 7 and 9) had distant metastases at the time of the stenting procedure. Four patients (patients 1, 8, 9, and 10) had esophageal stenting as well, with one of them (patient 10) having developed extrinsic compression of the trachea after the procedure. Eight patients (73%) had obstruction in the trachea. The others had obstruction in the left main bronchus. Two patients (patients 9 and 10) had tracheoesophageal fistulae (TOFs) [Fig 1 ]. Four of the patients (patients 3, 5, 6, and 10) had required emergent mechanical ventilation for life-threatening airway compromise. Three patients had resting dyspnea, including one who was stridorous (patient 11), and had been confined to bed prior to undergoing bronchoscopic intervention. The other three patients (patients 1, 4, and 8) required intervention because of critical major airway stenoses found on routine bronchoscopic evaluation.


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  		Table 1.. Clinical Characteristics, Adjunctive Therapy, and Survival Time of the 11 Patients*

 


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  		Figure 1.. Bronchoscopic image of esophageal cancer invading the mid-trachea in one of our patients, causing partial obstruction and fistulation.

 
All patients with dyspnea had immediate relief after the placement of an airway stent. Four patientsrequiring emergent mechanical ventilation were weaned successfully off the ventilator within a day of the procedure. All these patients were able to ambulate on discharge from hospital. Of the patients who died, four (50%) had no dyspnea until 1 week before death. The three patients who are still alive have experienced minimal dyspnea thus far. The mean survival time (determined by Kaplan-Meier analysis) was 61 days.

With regard to complications, two patients (patients 5 and 7) required repeat procedures. Patient 5 had the airway stent inadvertently removed during extubation. This was safely reinserted. Patient 7 had a stent that migrated distally 2 months after the initial procedure, causing obstruction of the left upper lobe bronchus and leaving the proximal part of the tumor uncovered. The stent was safely readjusted without complications. We undertook this intervention as no further adjunctive treatment was administered to this patient and restenosis of the airway from tumor progression was inevitable.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Airway involvement contributes significantly to the morbidity and mortality of esophageal cancer. Tracheobronchial stenting provided immediate relief of respiratory symptoms in all of our patients, thus providing an improved quality of life. This effect was sustained in seven patients (64%), four of whom have since died and three of whom are still alive. Of the few studies of airway stenting involving this particular group of patients,5 6 7 all reported relief of dyspnea. The largest case series to date (Belleguic et al7 ; 51 patients) reported relief of respiratory symptoms in all but 4 of their patients.

The efficacy of airway stenting in facilitating weaning from mechanical ventilation has been documented previously.8 9 Schaffer and Allen8 were able to wean seven of eight patients from the ventilator following the placement of an expandable metallic stent. Six of their patients had malignant obstructions of the airways. Our group also had reported9 similar success with seven patients (100%) following stenting. In this case series, we were able to extubate all four patients requiring emergent mechanical ventilation within a day of the stenting procedure. One of these patients (patient 3) went on to live another 85 days without respiratory symptoms, thus fueling the contention that there is a significant and sustained clinical benefit in this cohort of patients whose conditions would otherwise be deemed terminal.

Two of our patients (patients 9 and 10) had concomitant TOFs, one of which occurred after stenting of the esophagus. A TOF traditionally has been thought to worsen the prognosis considerably.10 However, in their series, Belleguic et al7 found no difference in survival. This may be true if patients with TOFs are treated with double stenting, as opposed to just stenting, of the esophagus. An observational study by Freitag et al11 demonstrated a difference in survival (110 vs 24 days, respectively) between patients who had double stents placed compared to those who only had an airway stent placed. The reported survival time of 110 days was also superior to the survival time of patients in the literature who were treated only with esophageal prostheses. However, it is duly noted that this is only an observational study without a control group. Also, it is not evident whether the two groups in that study were entirely comparable with respect to performance status and stage of disease.

One of our patients developed airway obstruction as a complication of esophageal stenting. The incidence of this complication following esophageal stenting ranges from about 1 to 10%.5 12 13 Our own center has previously described14 a series of five patients with airway complications, including obstruction, following esophageal stenting. It is interesting to note that in all these patients, covered metallic stents (ie, the Wallstent and the Gianturco stent) were used. Airway stenting has been reported to be efficacious in this setting,5 as with our own experience with our patient. Although bronchoscopic inspection of the airway prior to insertion of an esophageal stent is routine practice in many centers, including our own, it is still not clear from the literature whether this procedure is beneficial and cost-effective.

Radiation therapy is known to be effective in palliating dysphagia in 34 to 48% of patients with inoperable esophageal cancer.15 16 Serious complications are low (2%) and include the development of a TOF or an esophageal stricture.15 Concurrent chemotherapy with radiotherapy affords even greater benefit in terms of survival and locoregional control.1 It was, however, difficult to draw any conclusions regarding the efficacy of radiation or concurrent chemoradiation in our patients, whose adjunctive therapy was heterogenous in terms of timing and modality received.

The mean duration of survival for patients requiring airway stenting for obstruction due to esophageal cancer has been reported previously5 6 7 to range from 35 to 121 days. In the previously mentioned study, Belleguic et al7 reported a mean survival time of 107 days. In our study, the mean survival time was lower at 61 days (range, 22 to 110 days). The wide range in reported survival times can be attributed largely to small sample sizes and possibly to different patient populations. Although all of our patients had a reasonable performance status, 45% had distant metastases. The stage of disease is not fully described in the above-mentioned studies.

As this was a retrospective study, we found it difficult to determine the cause of death and whether it was due to respiratory complications. Many of our patients died at home or in a hospice.

We chose the Dumon silicone stent mainly because of institutional preference. Its advantages include its safety profile and ease of adjustment in case of migration. It also provides protection against tumor invasion and causes minimal irritation.4 7 Its main disadvantage is the need for rigid bronchoscopy and general anesthesia, which can be poorly tolerated in this group of patients, as they are usually malnourished and have significant cardiopulmonary disease. The relative thickness of the stent wall also tends to lower the maximum achievable luminal diameter. Nevertheless, we were able to perform the stenting procedure safely in all of our patients. This is mainly because, compared to flexible bronchoscopy, rigid bronchoscopy affords superior airway control and the ability to ventilate the patient during the procedure.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Excellent, sustainable palliation can be achieved with the stenting of malignant airway obstruction due to esophageal cancer, preventing a progressive asphyxiating death, even in patients whose conditions may be deemed to be terminal due to critical tracheobronchial obstruction.


   Acknowledgements
 
We would like to acknowledge Stephanie Fook Cheong, Biostatistician, Department of Clinical Research, Singapore General Hospital, for her kind assistance.


   Footnotes
 
Abbreviation: TOF = transesophageal fistula

Received for publication October 2, 2001. Accepted for publication February 5, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

  1. Herskovic, A, Martz, K, Al-Sarraf, M, et al (1992) Combined chemotherapy and radiotherapy compared to radiotherapy alone in patients with cancer of the esophagus. N Engl J Med 326,1593-1598[Abstract]
  2. Watkinson, AF, Ellul, J, Entwisle, K, et al Esophageal carcinoma: initial results of palliative treatment with self-expanding endoprostheses. Radiology 1995;195(3),821-827[Abstract/Free Full Text]
  3. Bolliger, CT, Probst, R, Tschopp, K, et al Silicone stents in the management of inoperable tracheobronchial stenoses: indications and limitations. Chest 1993;104,1653-1659[Abstract/Free Full Text]
  4. Dumon, JF A dedicated tracheobronchial stent. Chest 1990;97,328-332[Abstract/Free Full Text]
  5. Colt, HG, Meric, B, Dumon, JF Double stents for carcinoma of the esophagus invading the tracheo-bronchial tree. Gastrointest Endosc 1992;38,485-489[ISI][Medline]
  6. Takamori, S, Fujita, H, Hayashi, A, et al Expandable metallic stents for tracheobronchial stenoses in esophageal cancer. Ann Thorac Surg 1996;62,844-847[Abstract/Free Full Text]
  7. Belleguic, C, Lena, H, Briens, E, et al Tracheobronchial stenting in patients with esophageal cancer involving the central airways. Endoscopy 1999;31,232-236[CrossRef][ISI][Medline]
  8. Shaffer, J, Allen, J The use of expandable metal stents to facilitate extubation in patients with large airway obstruction. Chest 1998;114,1378-1382[Abstract/Free Full Text]
  9. Lo, C, Hsu, A, Eng, P Endobronchial stenting in patients requiring mechanical ventilation for major airway obstruction. Ann Acad Med Singapore 2000;29,66-70[Medline]
  10. Duranceau, A, Jamieson, G Malignant tracheo-esophageal fistula. Ann Thorac Surg 1984;37,346-354[Abstract]
  11. Freitag, L, Tekolf, E, Steveling, H, et al Management of malignant esophagotracheal fistulas with airway stenting and double stenting. Chest 1996;110,1155-1160[Abstract/Free Full Text]
  12. Ramirez, F, Dennert, B, Ziener, S, et al Esophageal self-expandable metallic stents: indications, practice, technique and complications: results of a national survey. Gastrointest Endosc 1997;45,360-364[CrossRef][ISI][Medline]
  13. Kozarek, RA, Ball, TJ, Patterson, DJ Metallic self-expanding stent application in the upper gastrointestinal tract: caveats and concerns. Gastrointest Endosc 1992;38,1-6[ISI][Medline]
  14. Lo, C, Hsu, A, Eng, P, et al Airway problems related to metallic stenting for the palliation of malignant esophageal obstruction. J Bronchol 1999;6,280-282
  15. Petrovich, Z, Langholz, B, Formenti, S, et al Management of carcinoma of the esophagus: the role of radiotherapy. Am J Clin Oncol 1991;14,80-86[ISI][Medline]
  16. Albertsson, M, Ewers, S-B, Widmark, H, et al Evaluation of the palliative effect of radiotherapy for esophageal cancer. Acta Oncol 1989;28,267-270[ISI][Medline]



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