Novel treatment (new drug/intervention; established drug/procedure in new situation)

CASE REPORT

Insertion of a Dumon Y-stent via a permanent

BMJ Case Rep: first published as 10.1136/bcr-2018-226500 on 28 November 2018. Downloaded from file:/ on 11 December 2018 by guest. Protected by copyright.
tracheostoma without using a rigid bronchoscope
Kazuki Hayashi,1 Makoto Motoishi,2 Satoru Sawai,3 Jun Hanaoka1

1
Division of General Thoracic
Surgery, Department of Surgery,
Shiga University of Medical
Science, Otsu, Japan
2 developed fistulas in the left and right main bronchi
Division of General Thoracic
Surgery, Mitsubishikyoto
Hospital, Kyoto, Japan
3
Division of General Thoracic
Surgery, National Hospital
Organization Kyoto Medical
Center, Kyoto, Japan
Correspondence to
Dr Kazuki Hayashi,
hayashik@belle.shiga-med.ac.jp
SUMMARY
A 63-year-old man who had received a permanent
tracheostoma after oesophageal cancer surgery
and suffered repeated aspiration pneumonia. Placing an
indwelling Dumon Y-stent using a rigid bronchoscope
is an option to treat fistula and stenosis at the tracheal
bifurcation, but in some cases, it may be difficult to
use a rigid bronchoscope in patients with a permanent
tracheostoma. In this study, we report placing a Dumon
Y-stent in a patient with a permanent tracheostoma
using a specially modified stent and forceps instead of a
rigid bronchoscope.

Accepted 31 October 2018
© BMJ Publishing Group
Limited 2018. No commercial
re-use. See rights and
permissions. Published by BMJ.
To cite: Hayashi K,
Motoishi M, Sawai S,
et al. BMJ Case Rep
2018;11:e226500.
doi:10.1136/bcr-2018-
226500
BACKGROUND  subcarinal lymph nodes and at the periphery of the left
Placing a Dumon stent using a rigid bronchoscope
is appropriate for fistula and stenosis in the trachea
and at the tracheal bifurcation1; however, in some
cases, it may be difficult to use a rigid broncho-
scope in patients with a permanent tracheostoma.
In this case study, we report the placement of a
Dumon Y-stent through a permanent tracheostoma
without using a rigid bronchoscope to treat fistulas
located distal to the left and right main bronchial
branches.
CASE PRESENTATION
A 63-year-old man underwent subtotal oesophagec-
tomy, total laryngectomy and permanent tracheos-
toma surgery for oesophageal cancer 2 years prior
to presentation at our hospital. Mediastinal lymph
node metastasis was being treated with chemoradio-
therapy and during follow-up, bronchomediastinal
and gastrointestinal bronchial fistulas occurred with
fever and bloody sputum. Although an oesophageal
stent had been placed in the stomach tube previ-
ously, he was referred to our department without
improved symptoms.
Contrast CT revealed free air in the subcarinal
lymph nodes and at the periphery of the left and
right main bronchi, and a bronchomediastinal
fistula was observed (figure 1A). In addition, the
gastric mucosa was not continuous and a gastro-
intestinal bronchial fistula was identified. Consol-
idations were found in the left upper, lower, right
and middle lung lobes, and pneumonia secondary
to aspiration was suspected. Bronchoscopy revealed
fistulas immediately after the right main bronchus
bifurcation and approximately 2 cm from the left
main bronchus branch (figure 1B).
Hayashi K, et al. BMJ Case Rep 2018;11:e226500. doi:10.1136/bcr-2018-226500
Figure 1 (A) Chest contrast CT showing free air in the
and right main bronchi, and a bronchomediastinal fistula
(arrow). (B) Bronchoscopy showing a fistula immediately
after the right main bronchus branch and a fistula located
approximately 2 cm after the left main bronchus branch
(arrow).
TREATMENT
The patient was considered suitable for Dumon
Y-stent placement, but because the tracheal angle
was almost vertical from the permanent tracheos-
toma (figure 2), there was a risk of damaging the
membranous wall of the trachea using a rigid bron-
choscope. For this reason, it was necessary to place
the stent without using a rigid bronchoscope. The
length of the stent was adjusted according to the
position of the fistulas and a nylon suture of suffi-
cient length was placed on the proximal side of the
stent for stent position adjustments after placement
and for emergency removal. First, based on previous
reports,2 we tried to grasp the stent with Kelly
forceps and insert it through the permanent trache-
ostoma. However, the diameter of the tracheostoma
was small and it was impossible to guide the stent to
the distal side of the bronchus. As an alternative, we
made a small hole in the left main bronchus side of
the stent (figure 3A), gripped the specially modified
stent using rigid bronchoscope forceps and then
inserted the stent into the trachea (figure 3B). Next,
we guided the stent to the periphery of the left main
bronchus under the guidance of a flexible bron-
choscope and fluoroscopy, and then left the stent
indwelling. We checked the distal side of the bron-
chus with a flexible bronchoscope and were careful
not to damage the fistula site. The strength of the
forceps was sufficient as a substitute for the rigid
bronchoscope, which allowed us to place the stent
1
 Novel treatment (new drug/intervention; established drug/procedure in new situation)
Figure 2 An image of a sagittal slice of the chest CT shows that the
angle between the trachea and the permanent tracheal hole (white
dotted line) is relatively steep.
smoothly and leave it as an indwelling stent. After confirming
that the stent was also placed appropriately in the right main
bronchus, the tracheal branch of the stent was compressed with
forceps and stabilised (figure 3C). We then removed the nylon
suture after confirming the appropriate stent position using chest
radiography (figure 3D) (stent size: tracheal diameter 16 mm,
Figure 3 (A) A small hole was made in the left main bronchus part of
the stent (circle). (B) Gripping the small hole with forceps to replace the
rigid endoscope and to guide the stent (arrow). (C) After stabilisation
by compressing the tracheal bifurcation of the stent with the forceps. A
nylon thread of sufficient length is placed on the proximal side of the
stent so that it can be removed in an emergency. (D) Chest radiography
showing that the stent has been placed in the proper position.
2 Hayashi K, et al. BMJ Case Rep 2018;11:e226500. doi:10.1136/bcr-2018-226500
main bronchial diameter 13 mm, tracheal length 30 mm, right
main bronchus length 10 mm (mediastinum side is 15 mm), left
main bronchus length 40 mm). Stent placement was performed
BMJ Case Rep: first published as 10.1136/bcr-2018-226500 on 28 November 2018. Downloaded from file:/ on 11 December 2018 by guest. Protected by copyright.
under sedation with midazolam and spontaneous breathing was
maintained. The time required was 50 min, and we encountered
no obvious complications.
OUTCOME AND FOLLOW-UP
Bronchoscopy was performed 2 months after placing the
indwelling stent and lumen patency was confirmed. No abnor-
mality such as stenosis was seen and following stent placement,
the patient’s subjective symptoms were relieved. He resumed oral
intake and his quality of life was restored. After placement of the
stent, humidification with a nebuliser was performed appropri-
ately. Unfortunately, he developed haemoptysis 4 months after
receiving the stent and died shortly thereafter.
DISCUSSION
Tracheo-oesophageal fistula and tracheomediastinal fistula are
terminal complications of intrathoracic malignant tumours.
These fistulas result in death secondary to chronic aspiration
pneumonia and the decline in patient quality of life is marked.
Although oesophageal stent placement is the first choice for
trachea-oesophageal fistula, if the fistula cannot be closed with
an oesophageal stent, placement of the airway stent is used in
combination. In our case, no improvement of the symptoms was
obtained with the oesophageal stent placement and it was neces-
sary to add an airway stent.
Dumon stent placement is useful as a palliative treatment for
fistulas and stenosis in the trachea and tracheal bifurcation, and
is generally performed using a rigid bronchoscope. However, in
some patients with a permanent tracheostoma, it may be difficult
to use a rigid bronchoscope because of the tracheal curvature.
Kim et al reported on the experience of placing a metallic stent
in the tracheal carina and demonstrated that depending on the
part of the fistula, it was possible to place a metallic stent in the
trachea bifurcation. However, in our case, the fistulas of the left
and right main bronchi were located very close to the trachea
bifurcation. Therefore, it was difficult to obtain compatibility
between covering the two fistulas and securing the patency of the
airway by indwelling the metallic stent. Therefore, we obtained
symptomatic relief of the patient by placing the Dumon Y stent.3
Several reports discuss Dumon stent placement without using
a rigid bronchoscope. Nomori and Horio inserted a straight
Dumon stent through the intubation tube4 and Nakamura et al
deployed a Y-stent transcranial using a flexible bronchoscope.5
Watanabe et al placed a straight stent through a permanent
tracheostoma using a flexible bronchoscope6 and Izumi et al
placed a straight stent grasped by Kelly forceps through a perma-
nent tracheostoma.2 However, to our knowledge, no reports
have discussed placing an indwelling Y-stent through the perma-
nent tracheostoma. In our patient with fistulas in the left and
right main bronchial branches, an indwelling Dumon Y-stent was
indicated, but because of the tracheal curvature (almost a right
angle), it was difficult to insert the rigid bronchoscope through
the permanent tracheostoma. Therefore, we made a small hole
in the long side of the main bronchus part of the stent. Gripping
the stent with rigid scope forceps and using these forceps as a
substitute for the rigid bronchoscope, we placed the Y-stent in
the tracheal bifurcation. Forceps for rigid bronchoscopy have
strength and moderate suppleness similar to bamboo. Even in
a patient for whom a rigid bronchoscopy cannot be inserted
because the angle between the permanent tracheostoma and the
 Novel treatment (new drug/intervention; established drug/procedure in new situation)
trachea is steep, we safely guided the stent into the trachea using
rigid bronchoscopy forceps. This is the first report to discuss
placing an indwelling Y-stent through the permanent tracheos-
toma and our method is useful for placing a Dumon Y-stent in
patients who cannot undergo rigid bronchoscopy because of a
permanent tracheostoma with a sharp tracheal curvature.
Learning points
Ź For fistulous lesions in the tracheal bifurcation, placement of
a Dumon Y-stent is a good indication, but in some cases rigid
bronchoscopy cannot be used for patients with permanent
tracheostoma.
Ź Dumon Y-stent was indwelled by a modified procedure using
forceps and flexible bronchoscopy for a patient for whom
a rigid bronchoscopy could not be inserted because of the
tracheal curvature.
Ź The use of rigid bronchoscope forceps, which are ‘supple’ like
bamboo, can be used to replace a rigid bronchoscope with a
specially modified stent.
Ź This method is simple and safe for the indwelling of a
Dumon Y-stent to a patient with a tracheostoma and should
be considered positively for alleviating symptoms of the
patient.
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Hayashi K, et al. BMJ Case Rep 2018;11:e226500. doi:10.1136/bcr-2018-226500
Acknowledgements We thank Jane Charbonneau, DVM, from Edanz Group (
www.edanzediting.com/ac) for editing a draft of this manuscript.
Contributors KH, MM, and SS carried out the procedure and care of the patient.
BMJ Case Rep: first published as 10.1136/bcr-2018-226500 on 28 November 2018. Downloaded from file:/ on 11 December 2018 by guest. Protected by copyright.
KH was a major contributor in writing the manuscript. MM, SS and JH contributed to
data collection and interpretation, and critically reviewed the manuscript. All authors
read and approved the final manuscript.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Next of kin consent obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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