Anaesthetic management of a patient with low tracheal obstruction requiring placement of a T-Y stent

Double stenting for malignant oesophago-respiratory fistula

Introduction

The close anatomical relationship between the oesophagus and bronchial tree results in formation of an oesophago-respiratory fistula in a subset of patients with advanced oesophageal or lung cancer. In those patients stenting of both the oesophagus and tracheobronchial tree is a valid option of palliative treatment.

Aim

To determine the effectiveness, tolerance, quality of life, safety and survival after double stenting procedures.

Material and methods

Retrospective analysis of a prospectively collected database was performed, concerning consecutive patients with oesophago-respiratory fistulas treated with double stenting. In all patients the degree of dysphagia, respiratory function before and after the procedure, and quality of life were evaluated. Partially covered oesophageal self-expanding metallic stents (PCESEMS) were used for oesophageal stenting, and silicone Y-type or partially covered self-expanding bronchial and tracheal stents (PCASEMS) were used to restore airway patency.

Results

Between 2003 and 2015, 31 patients underwent double stenting due to oesophago-respiratory fistulas. Twenty-nine patients were diagnosed with oesophageal squamous cell carcinoma and 2 with bronchial carcinoma. In all patients, improvement in the general condition and quality of life was observed after airway patency restoration. Two patients required mechanical ventilation due to respiratory failure immediately after the procedure. Seven patients with oesophageal fistulas died because of bleeding in the long-term follow-up. Four patients required endoscopic re-intervention. Mean survival time was 67.1 days.

Conclusions

Double stenting is an effective procedure improving patients’ quality of life. However, life-threatening complications can occur.

Airway stenting for unresectable esophageal cancer

Because of the close anatomical relationship between the upper esophagus and the tracheobronchial tree, many patients with advanced esophageal cancer will suffer from airway complications. These include airway stenosis or esophago-respiratory fistulation. Airway stenting is proven to offer effective palliation for patients with both these complications. When managing such patients, the thoracic surgeon faces different options in terms of pre-stenting investigation, choice of stents and stenting strategy. Although airway stenting is a safe and effective procedure in experienced hands, there are nonetheless complications which await the unwary. This review discusses the currently available options for airway stenting in these patients, and offers practical advice on avoiding the pitfalls.

Anesthesia for tracheal and endobronchial interventions

Tracheal and endobronchial interventions constitute a wide variety of procedures offering unique challenges in perioperative airway management and ventilatory support. Elective or emergent anesthetic management is individualized according to underlying airway pathology, coexisting disease, and patient age. This review explores recent literature and reports on relevant advances in anesthetic care.