A very rare and advanced interventional pulmonology procedure performed at a city hospital saved a patient’s life.
A 50 year old male patient diagnosed with cancer of esophagus(food pipe) was referred to Department of Pulmonology, KRIMS Hospitals with complaints of recurrent lung infections. The patient had undergone stenting of the esophagus in May 2018. After 6 months of undergoing chemotherapy, the patient developed complaints of aspiration pneumonia due to tracheo-esophageal fistula, a condition in which there is an abnormal opening between the food pipe and wind pipe due to cancer growth. Interventional Pulmonologist, Dr Sameer Arbat performed a procedure of Tracheal Stenting in which a metallic stent was inserted in the wind-pipe to prevent leakage of food material from food pipe into the lungs.
Tracheal stenting is an advanced interventional pulmonology procedure which is used in cases of cancer and stenosis. A barium swallow study was done which confirmed no leakage after stenting. The patient was discharged with no complaints.
The patient came back after one month with increased cancer growth leading to recurrence of symptoms. On bronchoscopy it was seen that the cancer had lead to erosion of tracheal wall leading to displacement of the tracheal stent from its original position. This was causing leakage into the wind pipe leading to distress to the patient. Displacement of the metallic stent although very rare is a documented complication in cancer cases. The cause for displacement in this case was the erosion of the tracheal wall due to cancer disease and the radial force exerted by the esophageal stent as it is relatively much larger in size as compared to tracheal stent.
The team of pulmonologists at KRIMS Hospitals had to prepare for a gargantuan task of repositioning the metallic stent without wasting much time. Interventional Pulmonologist, Dr Sameer Arbat with his team devised a very rare stent management strategy called the “Double Hitch Stitch”. This is a surgical technique in which the stent is anchored to the wind pipe through a stitch which is tied outside the neck but inside the subcutaneous tissue leaving no scar at all. The procedure although challenging was performed without any complications. The patient was discharged in few days and has been symptom free for the past 1 month post procedure.
Lung airway stenting is an uncommon procedure and this is the first time the innovative and rare Double Hitch Stitch technique was performed in the city. “Interventional pulmonology deals with minimally invasive techniques to diagnose and treat complicated cases of cancer,TB, ILD. This was a very rare case requiring an innovative solution to treat a case of double stent,” commented Dr Sameer Arbat. Dr Sameer Arbat has trained in Italy and isa pioneer inInterventional Pulmonology in the city with region’s only EBUS and Cryobiopsy Unit.
Double Stenting-Airway stent with Esophageal stent is inserted with patients having malignanttracheo-esophageal fistula ie: abnormal opening between the food pipe and wind pipe due to cancer.
The Hitch Stitch– In literature this is an external stent fixation technique using a percutaneous anchoring stitch, tied in the subcutaneous tissue applicable for both silicone and metal stents.
Patient Xray showing both stents in position after the Double-Hitch Stitch