The modern and commercial era of airway stenting (AS) started in Marseille in 1987, ushered in by the development of a dedicated airway silicone stent designed by Dumon.1 In 2017, AS celebrates its 30th birthday. This gives us the opportunity to pause and reflect on the evolution of AS practice at our center in the last 30 years.
During the first decade, the number of stents placed in our center increased rapidly to an approximate number of 600 per year. During the second decade, this number dropped down to an average of 300 stents a year. Finally, this past decade has witnessed an ongoing decrease in the number of stents placed, now at a relatively stable number of 150 stents per year. While the reasons for this evolution are not immediately obvious, we would like to propose the following explanations.
In 1987, AS was meant to treat symptomatic malignant or benign central airway diseases that had formerly been considered either completely untreatable or treatable only via extensive and often prohibitively dangerous surgical procedures. Marseille was the only center in the world practicing AS and, as a matter of fact, was channeling all stent placements in France and its surrounding countries. Rapidly, Dumon started training physicians coming from other French regions and, almost immediately, from all over the world, in order to share his knowledge and skill set and educate a generation of interventional pulmonologists who became the pioneers of our specialty. This explains in part the initial drop in stent placement seen at our institution.
One may also wonder if, as is typically observed with other medical innovations, stent placement was perhaps initially overutilized. Indeed, stents were placed to treat a broad range of central airway diseases: malignant obstruction or compression,2 benign tracheal stenosis, benign bronchial stenosis,3,4 airway fistulas,5 tracheobronchomalacia (TBM), and miscellaneous indications such as tracheobronchial amyloidosis, tracheobronchopathia osteochondroplastica,6 adenoid cystic carcinoma, or recurrent respiratory papillomatosis, among others.7 One may call the first years of AS the “carpet period”: diseases were being hidden underneath a covering stent so that no one would need to see them anymore. More pragmatically, however, it is more likely that stents were being tested in a large variety of diseases in order to determine the legitimate indications for the technique. Wood et al8 wrote in 2003 that “stent placement is indicated when benefit from stenting appears technically feasible and clinically meaningful.” The first decade helped us define in which situations AS does appear clinically meaningful. For instance, we found that stenting TBM provided a short-time improvement in symptoms but that mid-term and long-term results were poor. Ernst et al9 confirmed our experience and found that AS was associated with a substantial rate of complications in TBM. In case of benign tracheal stenosis, the majority of patients treated in Marseille were stented as the first step in their management. Surgical treatment of this condition became rare, and our surgeons nearly lost a valuable skill set. Indeed, while AS can be curative in benign tracheal stenosis and is associated with a high rate of success,10 it requires long-term care of the stents with frequent and lifelong nebulizations of saline. It is also associated with rare but potentially life-threatening stent-related complications. We eventually found that the balance tilted in favor of AS strictly only for patients in whom surgical or anesthetic contraindications precluded surgical correction, which typically represent a small percentage of patients. In case of malignant obstruction, the rule was to place a stent even after successful tumor debulking in order to prevent reobstruction in case of failure of oncologic treatment. Recently, the SPOC (Silicone Prothesis in Obstructive lung Cancer) trial11 showed that a stent is only required as a palliative treatment when oncologic treatment has proven insufficient. In case of malignant tracheoesophageal or bronchoesophageal fistulas, the initial management was double stenting (esophageal and tracheal or bronchial stents).3,4 Now, we only perform double stenting in case of persisting aspiration or symptomatic secondary compression of the airway after esophageal stenting. Indeed, esophageal stenting alone is much better tolerated in our experience. Indeed, AS in Marseille has dramatically decreased in the past 30 years, because of the evolution of our practice that allows us to better refine the indications for the technique. Other important points also need to be raised. The landscape of lung cancer has been significantly altered in the same time period, with a shift from proximal invasive squamous cell carcinomas to a majority of peripheral parenchymal adenocarcinomas. While the reasons for this change remain to be elucidated, this has almost certainly contributed to a significant reduction in the need for central airway interventions.
Thoracic surgical techniques have also markedly improved. For instance, in lung transplantation, our anastomotic complications requiring AS have been reduced by 50% in the last decade, and, while sleeve resections for lung cancer are providing new challenges, the net result has been a decrease in the need for stenting.12
In Marseille, after 30 years of practice, the main messages we would like to convey are the following: (1) AS is indicated as palliation, irrespective of the underlying etiology. Palliation means that it should be considered only after all medical or surgical options have been exhausted. (2) Stenting can be considered as a primary treatment in some cases as a bridge to other more defective treatment but may also be curative in itself. (3) Stent placement and removal using rigid bronchoscopy remains the safest and most effective method, regardless of the type of stent inserted. In our center, silicone stent placement has dropped from 100%, in 2000, to 65%, in 2017. The remaining 35% are now fully covered, self-expandable, metallic stents, which are deemed more suitable in some indications such as airway fistulas or curvilinear and tortuous lesions.13–15 (4) Finally, remember that “A stent is a foreign body and nobody is perfect”; stents require long-term management and close follow-up, and hence the optimal stent is still probably the one that can be avoided!
The authors acknowledge Fabien Maldonado, MD (Vanderbilt University, Nashville) for his help in the English version of this editorial.
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