Aconsiderable percentage of patients with advanced lung cancer has stenosis of the central airways.1 In these patients, interventional pulmonology is considered as a method of maintaining airway patency.2 Although endoscopic resection of intraluminal tumors by means such as laser photo resection, argon plasma coagulation, or cryotherapy is possible, placing airway prosthesis is also considered to be one of the palliative interventions.3–5 There are many types of endobronchial stents, such as silicone, hybrid and expandable metal stents.5–9 Bifurcated stents are also available for the palliation of carinal lesions. These stents have been effective in the management of carinal compression associated with malignant tumors, trachea-esophageal fistulas, and tracheobronchomalacia.10–16 While expandable metal stents are relatively easy to implant, placement of silicone stents, especially bifurcated ones seems to be more complicated and need more experience.17
The purpose of this study was to evaluate the clinical efficacy of a novel “Karakoca Forceps” in the insertion of silicone straight and bifurcated stents.
MATERIALS AND METHODS
Design and Features of Karakoca Forceps
The main feature of Karakoca Forceps is at its distal end, which can be opened with a 45-degree angle in a reverse direction to capture the distal end of the stent and moved further down under direct supervision. The mechanism is quite simple and the ease of use facilitates stent implantation and reduces the procedure time. The forceps are made of stainless steel and have a length of 60 cm and diameter of 3 mm.
Between February 2004 and January 2006, 34 patients underwent rigid bronchoscopy and were treated with stent placement using Karakoca Forceps for malignant (n=33) and benign (n=1) symptomatic central airway obstruction. Except for 1 patient with postintubation tracheal stenosis, all patients were at World Health Organization 3 and 4 performance status. All of the patients had severe dyspnea, 4 of the patients were intubated and required mechanical ventilation, 9 of the patients required noninvasive mechanical ventilation before the intervention. Postobstructive pneumonia was present and caused poor general status in all of the cases. The patient demographic information is displayed in Table 1.
All procedures were performed under general anesthesia. Dumon-Harrel Universal rigid bronchoscope (Efer, France), Olympus Evis 240 video-bronchoscope (Olympus, Japan), Nd-YAP laser (Neodymium yttrium aluminum pevroskite) (Loki, France), Cryotherapy (Erbe, Germany) and Dumon silicone stents (Dumon Endoxane stents; Novatech, Aubagne, France) were used during procedures.
When the endoluminal tumoral tissue was resected, stent implantation was performed due to external compression. Karakoca Forceps were especially useful in deformed airways to capture the distal end of the stent and to place it into an appropriate position. We also experienced that while positioning the long arm of the Y stent using the Karakoca Forceps, the stent automatically corrected its placement over the carina.
In all cases, stent implantation was performed quickly and easily with the aid of Karakoca Forceps. Karakoca Forceps were used in 29 cases to place Y stents and in 5 cases to place straight silicone stents. We also felt that the mean procedure time was significantly reduced with the aid of Karakoca Forceps.
The stents are repositioned to its correct place with the aid of Karakoca Forceps in 24 to 60 s without pulling them out of airways. We did not experience any episode of low oxygen saturation levels during any of the procedures. In all cases but one, better respiratory parameters were encountered immediately after the procedures. Two patients were extubated and referred to the oncology department for chemotherapy. The patients who required noninvasive mechanical ventilation had better dyspnea scores after the procedure. A patient with metastatic lung cancer was extubated after the procedure and had better respiratory parameters yet died a day after the procedure because of disseminated intravascular coagulation and acute renal failure.
The technique of implanting silicone stents involves stent deployment across the obstruction with the aid of stent applicator, and subsequently to reposition it to a correct position using forceps. If the stent cannot be placed across the obstruction, it has to be removed and reinserted. Straight silicone stents are placed more easily than the Y stents. On occasion, placing Y stents can be quite difficult. It needs experience to insert Y stents using the stent applicator. In patients with a deformed and severely obstructed carina, Y stent implantation time could be prolonged and complications, such as hypoxemia, bleeding and perforation, can occur.
Over the last 10 years, we inserted 113 bifurcated stents using the conventional method and observed some difficulties during their proper positioning, especially in patients with a deformed carina. Particularly in patients with poor general status, a prolonged therapeutic procedure due to stenting difficulties may cause cardiac or hemodynamic complications. We designed forceps that can be opened in a reversed direction and could grasp distal end of the bifurcated stent for its easy repositioning. We used the forceps (Karakoca Forceps) in most of our cases for the last few years (Figs. 1, 2). Most difficulty was experienced during insertion of both the legs of the stent, initially into one of the main bronchi, especially in the presence of carinal deformation. In this situation, we grasped the distal end of the stent with the novel forceps and inserted stent leg into the desired main bronchus.
All of the patients had poor general status and respiratory insufficiency while therapeutic interventions were being performed. After the laser photoresection of endoluminal tumors and balloon or mechanical dilatation, we inserted silicone stents. When difficulties in proper positioning were encountered, we used the forceps and the insertion procedure was clearly shortened and performed easily. Stent removal was not needed in any of the cases and even stent repositioning was not required. A maximum of 60 s was required to carry out the maneuver. Therefore, we believe that the procedure time was also shortened.
We describe our experience with these forceps in our complicated cases. Before we designed these forceps, we inserted bifurcated stents by using a balloon catheter and a flexible bronchoscope.18,19 It was also necessary to remove and reinsert the stents using the applicator, which added more than 20 minutes to the procedure time. Although we did not fail inserting bifurcated stents in any of the cases, despite poor general status of the patient and deformed carina, we observed that use of this forceps made the procedure simple and shorter. In 34 of the patients for whom we inserted silicone stents easily and successfully, we observed no intraoperative and postoperative complications. These forceps can be also useful for repositioning migrated straight stents without their removal.
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Keywords:© 2008 Lippincott Williams & Wilkins, Inc.
therapeutic bronchoscopy; stent placement; tracheobronchial stenosis