ISSN: 2754-8880
Published 00 11 0000
OPEN ACCESS
Edited by
A.Hussain
Submitted 10 Mar. 2024
Accepted 19 Mar. 2024
Citation
H. Bourja, S. Boubia, M.
Ridai .An Eight Year
Experiene Of Rigid
Bronchoscopy. Editorial
article:BJOSS:2025:(5);136-
141
An Eight Year Experiene Of Rigid Bronchoscopy
H. Bourja
1*
, S. Boubia
1
, and M. Ridai
1
1
Thoracic surgery department of University hospital of Casablanca
*
Correspondence author : Hind Bourja; Email address: Dr.bourja@gmail.com
O R IGI N A L
Abstract
Purpose: Rigid bronchoscopy contributes a great deal in insuring survival for malignant airway
obstruction and airway restoration for benign airway stenosis.
Methods: We retrospectively studied 101 RBs done for 73 patients during the 8-year period
between 2016 to 2023 in the University Hospital of Ibn Rochd Of Casablanca.
Results: Benign airway stenosis was slightly more frequent than Malignant airway stenosis
(n=56 vs n=46). The tracheal lesion was more frequent at 55.3 %. Pulmonary cancer was the
more dominant malignant etiology and stenosis post-prolonged intubation was dominant in
the benign airway category. A Dumon stent was placed in 30 cases. 16.43% of patients had a
minimum second Rigid Bronchoscopy where Granulation tissue removal was the more frequent
indication. Complications were few with 3 cases of tracheostomy and 2 cases of tracheal resection
anastomosis.
Conclusion: Rigid Bronchoscopy is a safe procedure and very proceduralist-dependent. However,
the demand for it is still very low even though its indications are current.
Keywords : bronchoscopy, stents, Benin Airway Stenosis, Malignant Central Airway Obstruction.l
Introduction
Since the 19th century, Rigid bronchoscopy has been playing a major role in airway diseases. It
allows more airway control and better suction, especially since it’s done in the operating room with
general anesthesia with less inconvenience to the patient who is awake in flexible bronchoscopy.
It plays a major role in insuring survival for people with Malignant Central Airway Obstruction
(MCAO) (
1
) and could be an alternative to surgery in restoring airway patency for patients with
Benin airway stenosis (BAS); helps with massive hemoptysis; blood clot removal and foreign body
extractions.(2)
We are here to share an eight-year experience at Casablanca University Hospital with rigid
bronchoscopy, in the thoracic surgery department.
Methods
We conducted a retrospective study for patients who underwent rigid bronchoscopy tests in the
thoracic surgery department of University Hospital Ibn Rochd of Casablanca from January 2016
until December 2023. An 8-year data collection with descriptive statistics (age, sex, and medical
history), as well as image findings and initial flexible bronchoscopy results; if existent; for the 102
RB done during this period. Every patient was hospitalized in the thoracic surgery department
or the ICU if necessary. Different endoscopic maneuvers were applied from debridement to
stent placement according to each case. Some cases required two procedures either at the same
surgical time or in different scheduled procedures.
The bronchoscope used in this study is type Efer-Dumon. The design of the Rigid Bronchoscope
is quite universal; it is a 40 to 45-cm metal tube that has 2 openings from each side; with other
holes on the side that allow ventilation and other instruments insertion. The distal side of the
bronchoscope is slightly fluted which allows the opening of the vocal cords during bronchoscope
introduction as well as the mechanical resection of obstructive lesions (
3
). There are different
scope diameters available adaptable for adults as well as a pediatric size. Through the hole; a
rigid telescope with a light source is introduced to allow better visualization of the trachea. Other
instruments are also available such as biopsy forceps; and suction catheters. A prior understanding
was held between the anesthesiologist and the operator how the ventilation should be.
Results
73 patients underwent 102 RB throughout the 8-year period. The average age was 46.8 years with
an IQR of 20.75 where 37% of the patients were female. The slightly more frequent indications
were BAS (n=56) compared to MAO(n=46). In benign lesions; stenosis post-prolonged intubation
was at 85.7% whereas 18,7% of post-prolonged intubation stenosis is due to COVID. As for
Malignant obstructive diseases, pulmonary tumors were the most common etiologies with a
percentage of 45.65%. The location of the anomaly varied in our study. The tracheal lesion was
more dominant in 55.3%, the second most frequent was the left bronchus with a percentage of
14.8% followed by the carinal lesion (13.8%) and right bronchus (11.9%).
Many interventions were executed during rigid bronchoscopy including stent placement (n=30);
The stents used during Rigid bronchoscopy were silicone-based; usually used in benign lesions
(66% of the cases), unblocking (28 where 20 were tumoral and 8 were inflammatory) biopsies
(n=40) laser treatment (n=4) foreign body extraction (n=2) stent removal (n=5).
Figure 1. Locations Of Different Airway Lesions.
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Figure 2. A: Image Still Of A Stent Placement During Rigid Bronchoscopy. B: Image Of A
Stenosis Blocking A 100 Percent Of The Airway. C: Image Of A Biopsy Using Forceps During
Rigid Bronchoscopy.
Figure 3. Therapeutic And Diagnostic Interventions Done Through RB During The Study.
Out of the 73 RB; 12 patients required 29 repeated RB (16,43%). The time lapse between the 29
RB redoes; 16 cases were before the 6-month period; 11 cases were done between the 6-month
to 1-year period; 1 case before the 2-year period and only 1 case surpassed the 3-year time
period. In the BAO category; the most frequent case of an RB repeat was granulation tissue
removal in 12 cases (41.3%) 3 patients went for RB a second time for stent placement (10.3%), 3
cases of stent removal (10.3%) and 2 cases of Stent change for a more adequate size; and other 3
cases had an RB redo when the stent migrated and had to be remobilized; and 2 cases for tumor
debulking.
Complications of RB have been few but remain noted. There were cases where RB failed to
accomplish their therapeutic purposes with 3 cases of tracheostomy and 2 cases that were
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Table 1. Malignant etiologies in our study.
Malignant etiology n
Pulmonary 21
Tracheal 13
Thyroid 5
Oesophagus 2
Mediastinum 4
Larynx 1
Table 2. Cases of benign airway stenosis.
BAO n
Prolonged intubation Tracheostomy 48
• Brain Trauma 29
• COVID 9
• Ischemic stroke 5
• Toxic encephalopathy 1
• Thyroidectomy 1
• Respiratory Insufficiancy post 3
Oesotracheal fistula 2
Foreign body 3
Tuberculosis stricture 2
Hemoptysis 1
Table 3. Indications for RB redo.
BAO n
Granulation tissue removal 12
Stent placement 3
Stent removal 3
Stent change 2
Stent mobilisation (migration) 3
Exploration 3
MAO n
Tm debulking 2
Stent placement 1
followed by tracheal resection anastomosis after failure to widen the tracheal stenosis. Moreover;
3 cases where silicone stents had migrated and an additional bronchoscopy was necessary to
correct it.
Discussion
Although RB has many indications; this study indicated that the demand for it is still quite low
for an average of 1.06 patients per month. Our study could be compared to another done in
a tertiary hospital in Singapore where the average demand was 1.1 patients per month (
1
) in
a 10-year period. On a slightly bigger scale, South Korea has an average of 2.6 patients per
month (
4
;
5
) over 10 10-year period. In addition; an even bigger study in the USA of 733 RB
was done over a 5-year period with an average of 12.2 patients per month (
6
). The low demand
for RB can be explained by the limited indication compared to flexible bronchoscopy; as well;
as being very trainee-dependent. It demands practice and skills with a wide knowledge of its
possible complications.
Benin airway stenosis was slightly more frequent than malignant airway obstruction with a
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percentage of 54.9 %; tracheal stenosis post prolonged intubation or tracheostomy is the most
common reason, especially with the submergence with COVID in 2020 (
7
). RB was a first-line
treatment before moving on to other invasive procedures like tracheal resection and anastomosis
or tracheostomy. A silicone stent was placed in 66% of benign airway stenosis; the stent used is
type Dumon. And only 3 Y-shaped stents were placed during the 8-year period. Their placement
is much more difficult than regular silicone stents. Different techniques have been described to
properly place a Y shape but remain operator-dependent (
8
). As for the Malignant airway stenosis,
pulmonary cancer obstruction (n=21) followed by primary tracheal tumors (n=13) were more
prevalent of malignant etiologies; Rigid bronchoscopy improved the survival rate, especially with
tumor debulking. Stent placement was avoided in most cases because most stents used in this
study were silicone although proven effective in benign stenosis, but has yet to be discussed in
their benefit in tumoral obstruction as palliative treatment (9).
Only 16,43% of patients required a minimum of a second RB and the most common reason was
granulation tissue removal in 41.3% of the cases. 18.5% of patients developed granuloma tissue
after silicone stent placement. In other studies, Chung and al (
10
) found granulation tissue was
noted in 15.2% of patients with Self Expanding Metal Stents (SEMS). Ost and Al (
11
) compared
different kinds of stents and granulation tissue formation rates according to every type of stent
placed; it was found that silicone stents were more likely to develop granulation tissue in a shorter
period. The average time, in our study, between granuloma tissue formation after silicone stent
placement is 13,2 months with an IQR of 6 to 21 months. Similar results have been found in
Verma and al with silicone and SEMS (
1
). A shorter time was noted in Chung and al of 2.6 months
with the use of SEMS (10).
There is a wide range of complications concerning Rigid Bronchoscopy, from simple mucostasis to
hypoxic arrest (
8
). However; during this study, complications have been few and merely related
to the procedure’s failure to fulfill its therapeutic purpose; where a secondary procedure was
needed; such as a second Rigid Bronchoscopy for stent migration; tracheostomy and resection
anastomosis when rigid bronchoscopy wasn’t enough to treat tracheal stenosis.
Conclusion
Rigid bronchoscopy remains the gold standard for the management of many complex airway
pathologies and also for prolonging survival for terminal-stage cancer. Whether used by inter-
ventional pneumologists or thoracic surgeons, its indications remain present despite flexible
bronchoscopy. It is also safe in the hands of a well-trained specialist and has an economic ben-
efit if repetitive FB can be avoided and direct indication for Rigid bronchoscopy is maintained,
especially when there is granulation tissue formation.
Conflict Of Interest
Author declare no conflict of interest and no funding for this study.
References
[1]
Verma A, Tai DY, Goh SK, Goyal R, Kor AC, Ng AW. Review of a 10-year experience of rigid
bronchoscopy at a tertiary centre in Singapore. Precision and Future Medicine. 2020;4(3):99-
106.
[2]
Petrella F, Borri A, Casiraghi M, Cavaliere S, Donghi S, Galetta D, et al. Operative rigid
bronchoscopy: indications, basic techniques and results. Multimed Man Cardiothorac Surg.
2014;2014:mmu006.
[3]
Paradis TJ, Dixon J, Tieu BH. The role of bronchoscopy in the diagnosis of airway disease.
Journal of thoracic disease. 2016;8:3826-37.
140/141
[4]
Shin B, Chang B, Kim H, Jeong BH. Interventional bronchoscopy in malignant central airway
obstruction by extra-pulmonary malignancy. BMC Pulmonary Medicine. 2018;18:46.
[5]
Jeong BH, Um SW, Suh GY, Chung MP, Kwon OJ, Kim H, et al. Results of interventional
bronchoscopy in the management of postoperative tracheobronchial stenosis. The Journal
of Thoracic and Cardiovascular Surgery. 2012;144:217-22.
[6]
Ost DE, Ernst A, Grosu HB, Lei X, Diaz-Mendoza J, Slade M, et al. Complications following
therapeutic bronchoscopy for malignant central airway obstruction: results of the AQuIRE
registry. Chest. 2015;148:450-71.
[7]
Palacios JM, Bellido DA, Valdivia FB, Ampuero PA, Figueroa CF, Medina C, et al. Tracheal
stenosis as a complication of prolonged intubation in coronavirus disease 2019 (COVID-19)
patients: a Peruvian cohort. Journal of thoracic disease [Internet]. 2022[cited 2023 may
4];14. Available from: https://jtd.amegroups.com/article/view/62496.
[8]
Semaan R, Yarmus L. Rigid bronchoscopy and silicone stents in the management of central
airway obstruction. Journal of thoracic disease [Internet]. 2015 [cited 2023 may 11];7.
Available from: https://jtd.amegroups.com/article/view/5778.
[9]
Ortiz-Comino RM, Morales A, López-Lisbona R, Cubero N, Diez-Ferrer M, Tebé C, et al.
Silicone stent versus fully covered metallic stent in malignant central airway stenosis. The
Annals of thoracic surgery. 2021;111:283-9.
[10]
Chung FT, Chen HC, Chou CL, Yu CT, Kuo CH, Kuo HP, et al. An outcome analysis of
self-expandable metallic stents in central airway obstruction: a cohort study. Journal of
cardiothoracic surgery. 2011;6:46.
[11]
Ost DE, Shah AM, Lei X, Godoy MC, Jimenez CA, Eapen GA, et al. Respiratory infections
increase the risk of granulation tissue formation following airway stenting in patients with
malignant airway obstruction. Chest. 2012;141:1473-81.
141/141
