A modified technique to simplify external fixation of the subglottic silicone stent

A modified technique to simplify external fixation of the subglottic silicone stent Abstract Several techniques have been previously proposed to fix silicone stents for subglottic tracheal stenosis. However, they require special tools or cumbersome manoeuvres. The proposed modified procedure offers a potential alternative fixing technique using absorbable suture buried subcutaneously and not requiring special devices. This procedure was successfully performed in 27 patients with inoperable complex subglottic stenosis. The mean distance from vocal folds, the mean length and mean diameter of stenosis were 17 ± 2 mm, 20 ± 2.9 mm and 6.9 ± 0.9 mm, respectively. The mean procedural time for fixing the stent was 5 ± 0.3 min. No intraoperative or postoperative complications such as stent damage, dislocation, plugging or vocal folds dysfunction were reported (mean follow-up 20 ± 7.7 months). Subglottic stenosis , Rigid bronchoscopic , Fixation stent INTRODUCTION Endoscopic dilation and straight-type silicone stent placement are palliative treatment for inoperable subglottic stenosis [1]. However, respiratory movement, coughing and swallowing may cause stent dislocation [2, 3]. To avoid this complication, several techniques [4–7] have been previously proposed to fix the silicone stent, often requiring special tools or cumbersome manoeuvres. To simplify the stent-securing procedure, a modified fixing technique was proposed, evaluating its feasibility. TECHNIQUE The procedure was performed in the operating room under local anaesthesia with 2% xylocaine and intravenous deep sedation with short-acting narcotics and benzodiazepines. The patient was intubated with a 14-mm rigid Efer-Dumon bronchoscope, and the ventilator was connected to it. An adequate airway lumen was obtained with laser radial incisions and mechanical dilation of stenosis, and then a straight-type silicone stent was inserted to maintain the airway patency. The length and diameter of the stent were chosen according to the characteristics of the stenosis. The stent was loaded into a dedicated introducer, manually expulsed into the stenosis and then held in the exact position with forceps. Following antiseptic preparation of the skin, the patient’s neck was extended, identifying the cricoid, the first and the second tracheal rings. Under endoscopic view, a 14-gauge intravenous angiocatheter was inserted transcutaneously between the first and the second tracheal rings into the stent lumen. The needle was then removed, and the Teflon catheter sheath was left in place inside the stent lumen. A 0-0 absorbable vycril suture was passed through the sheath, grasped with forceps and withdrawn through the bronchoscope. A knot was tied at the proximal end of the suture, and traction was placed on the free distal end until the knot was secured to the anterior wall of the stent. A second catheter was inserted at the same level alongside few millimetres from the first catheter, and the above-reported procedure was repeated, thus a second knot anchored the stent. Following this, a skin incision was performed at the exit site of the sutures, the 2 free ends were tied to secure the stent on the anterior neck and the knot was buried subcutaneously. Finally, the skin was closed over the knots. Figure 1 and Video 1 summarize the procedure. Figure 1: View largeDownload slide A suture is inserted through the Teflon catheter sheath into the stent lumen (A), a knot is externally tied at the proximal end (B) and the stent is fixed (C), another knot is tied to fix the stent (D), the sutures are tied (E) and the skin is closed over the knot (F). Figure 1: View largeDownload slide A suture is inserted through the Teflon catheter sheath into the stent lumen (A), a knot is externally tied at the proximal end (B) and the stent is fixed (C), another knot is tied to fix the stent (D), the sutures are tied (E) and the skin is closed over the knot (F). Video 1: The main steps of the procedure in a patient with subglottic stenosis are shown. The stent is first placed using a traditional technique, migrated and it was successfully anchored with the proposed technique. Video 1: The main steps of the procedure in a patient with subglottic stenosis are shown. The stent is first placed using a traditional technique, migrated and it was successfully anchored with the proposed technique. Close STUDY POPULATION From January 2015 to December 2017, the proposed technique was performed to anchor straight-type silicone stent in 27 patients (Table 1) with postintubation (n = 15) and post-tracheotomy (n = 12) complex subglottic stenosis. Tracheal resection was contraindicated due to cardiovascular (n = 13), pulmonary (n = 11) and cerebrovascular (n = 3) comorbidities. The mean distance from vocal folds, the mean length and diameter of stenosis were 17 ± 2 mm, 20 ± 2.9 mm and 6.9 ± 0.9 mm, respectively. In 7 patients, the stent, placed first through a traditional technique, migrated, and it was successfully reinserted and then anchored using the proposed technique. The mean procedural time to fix the stent was 5 ± 0.3 min. No intraoperative or postoperative complications such as stent damage, dislocation, plugging or vocal folds dysfunction were observed (mean follow-up 19 ± 9.0 months). Table 1: Study population Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 SD: standard deviation. Table 1: Study population Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 SD: standard deviation. COMMENT Migration is a troublesome complication of straight-type silicone stent and has been reported to occur in up to 18% of patients with subglottic stenosis undergoing endoscopic treatment [8]. Over the years, different strategies [4–7] have been proposed to secure the stent placed in the subglottic trachea. However, all reported methods displayed specific advantages and disadvantages, and, thus, there is still not an easy and standardized protocol to ensure good results. Mace et al. [4] directly sutured the stent using a needle holder placed outside the body. However, the thickness of the tracheal wall and of the stent could complicate the needle insertion into the stent. Colt et al. [5] introduced a suture into the stent lumen through an angiocatheter and then withdraw it through another angiocatheter using a wire threader. On the basis of this principle, other authors [6, 7] used more sophisticated devices to capture the suture and then to extract it from the airway. In all these procedures, the suture was secured to the skin with an external button that could be complicated by a skin infection or unsatisfactory motility during deglutition. To offer an alternative method, the original Colt’s technique [5] was modified by tying a knot at the proximal end of the suture that was then intraluminally secured to the anterior wall of the stent. The main advantages of the proposed procedure over previous techniques are that no special device is required to withdraw the suture from the airway, and the absorbable suture for fixing the stent is buried subcutaneously. The use of absorbable rather than non-absorbable sutures prevented the risk of subcutaneous infection. In addition, there was no need to remove the stich later, because the knots dissolve by themselves and were coughed out. The formation of tenacious adhesions safely secured the stent with no dislocation when suture dissolved as well. The proposed technique is feasible and easy to perform, although it should be accomplished with appropriate cautions. The angiocatheter should be inserted perpendicularly to the trachea and gently advanced into the lumen of the stent to prevent overstepping the posterior wall of the stent and damaging the trachea. During these manoeuvres, the tip of the bronchoscope is wedged against the proximal end of the stent to prevent its displacement. During the anchoring manoeuvre, the 2 suture ends should be gently knotted to prevent the laceration of the anterior wall of the stent. The proposed procedure should be indicated for patients with severe malacia or without extrinsic compression, because they have a higher risk of dislocation. A second potential indication could be a reinsertion of a silicone stent that was previously placed through the traditional technique (with no stent securing) and was then migrated. CONCLUSION In conclusion, the proposed modified fixing technique could be a simple alternative to secure a subglottic silicone stent in selected cases. No special device is required. The absorbable suture, buried subcutaneously, could provide a long-term fixation with good aesthetic results. Conflict of interest: none declared. REFERENCES 1 Fiorelli A , Mazzone S , Di Crescenzo VG , Costa G , Del Prete A , Vicidomini G et al. Simple technique to control placement of Dumon stent in subglottic tracheal stenosis . Interact CardioVasc Thorac Surg 2014 ; 18 : 390 – 2 . Google Scholar CrossRef Search ADS PubMed 2 Menna C , Poggi C , Ibrahim M , D’Andrilli A , Ciccone AM , Maurizi G et al. Coated expandable metal stents are effective irrespective of airway pathology . J Thorac Dis 2017 ; 9 : 4574 – 83 . Google Scholar CrossRef Search ADS PubMed 3 Fiorelli A , Caterino U , Raucci A , Santini M. A conical self-expanding metallic stent for the management of critical complex tracheobronchial malignant stenosis . Interact CardioVasc Thorac Surg 2017 ; 24 : 293 – 5 . Google Scholar PubMed 4 Mace A , Sandhu G , Howard D. Securing tracheal stents: a new and simple method . J Laryngol Otol 2005 ; 119 : 207 – 8 . Google Scholar CrossRef Search ADS PubMed 5 Colt HG , Harrell J , Neuman TR , Robbins T. External fixation of subglottic tracheal stents . Chest 1994 ; 105 : 1653 – 7 . Google Scholar CrossRef Search ADS PubMed 6 Majid A , Fernandez-Bussy S , Kent M , Folch E , Fernandez L , Cheng G et al. External fixation of proximal tracheal airway stents: a modified technique . Ann Thorac Surg 2012 ; 93 : e167 – 9 . Google Scholar CrossRef Search ADS PubMed 7 Miwa K , Takamori S , Hayashi A , Fukunaga M , Shirouzu K. Fixation of silicone stents in the subglottic trachea: preventing stent migration using a fixation apparatus . Ann Thorac Surg 2004 ; 78 : 2188 – 90 . Google Scholar CrossRef Search ADS PubMed 8 Martinez-Ballarin JI , Diaz-Jimenez JP , Castro MJ , Moya JA. Silicone stents in the management of benign tracheobronchial stenoses. Tolerance and early results in 63 patients . Chest 1996 ; 109 : 626 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

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Abstract

Abstract Several techniques have been previously proposed to fix silicone stents for subglottic tracheal stenosis. However, they require special tools or cumbersome manoeuvres. The proposed modified procedure offers a potential alternative fixing technique using absorbable suture buried subcutaneously and not requiring special devices. This procedure was successfully performed in 27 patients with inoperable complex subglottic stenosis. The mean distance from vocal folds, the mean length and mean diameter of stenosis were 17 ± 2 mm, 20 ± 2.9 mm and 6.9 ± 0.9 mm, respectively. The mean procedural time for fixing the stent was 5 ± 0.3 min. No intraoperative or postoperative complications such as stent damage, dislocation, plugging or vocal folds dysfunction were reported (mean follow-up 20 ± 7.7 months). Subglottic stenosis , Rigid bronchoscopic , Fixation stent INTRODUCTION Endoscopic dilation and straight-type silicone stent placement are palliative treatment for inoperable subglottic stenosis [1]. However, respiratory movement, coughing and swallowing may cause stent dislocation [2, 3]. To avoid this complication, several techniques [4–7] have been previously proposed to fix the silicone stent, often requiring special tools or cumbersome manoeuvres. To simplify the stent-securing procedure, a modified fixing technique was proposed, evaluating its feasibility. TECHNIQUE The procedure was performed in the operating room under local anaesthesia with 2% xylocaine and intravenous deep sedation with short-acting narcotics and benzodiazepines. The patient was intubated with a 14-mm rigid Efer-Dumon bronchoscope, and the ventilator was connected to it. An adequate airway lumen was obtained with laser radial incisions and mechanical dilation of stenosis, and then a straight-type silicone stent was inserted to maintain the airway patency. The length and diameter of the stent were chosen according to the characteristics of the stenosis. The stent was loaded into a dedicated introducer, manually expulsed into the stenosis and then held in the exact position with forceps. Following antiseptic preparation of the skin, the patient’s neck was extended, identifying the cricoid, the first and the second tracheal rings. Under endoscopic view, a 14-gauge intravenous angiocatheter was inserted transcutaneously between the first and the second tracheal rings into the stent lumen. The needle was then removed, and the Teflon catheter sheath was left in place inside the stent lumen. A 0-0 absorbable vycril suture was passed through the sheath, grasped with forceps and withdrawn through the bronchoscope. A knot was tied at the proximal end of the suture, and traction was placed on the free distal end until the knot was secured to the anterior wall of the stent. A second catheter was inserted at the same level alongside few millimetres from the first catheter, and the above-reported procedure was repeated, thus a second knot anchored the stent. Following this, a skin incision was performed at the exit site of the sutures, the 2 free ends were tied to secure the stent on the anterior neck and the knot was buried subcutaneously. Finally, the skin was closed over the knots. Figure 1 and Video 1 summarize the procedure. Figure 1: View largeDownload slide A suture is inserted through the Teflon catheter sheath into the stent lumen (A), a knot is externally tied at the proximal end (B) and the stent is fixed (C), another knot is tied to fix the stent (D), the sutures are tied (E) and the skin is closed over the knot (F). Figure 1: View largeDownload slide A suture is inserted through the Teflon catheter sheath into the stent lumen (A), a knot is externally tied at the proximal end (B) and the stent is fixed (C), another knot is tied to fix the stent (D), the sutures are tied (E) and the skin is closed over the knot (F). Video 1: The main steps of the procedure in a patient with subglottic stenosis are shown. The stent is first placed using a traditional technique, migrated and it was successfully anchored with the proposed technique. Video 1: The main steps of the procedure in a patient with subglottic stenosis are shown. The stent is first placed using a traditional technique, migrated and it was successfully anchored with the proposed technique. Close STUDY POPULATION From January 2015 to December 2017, the proposed technique was performed to anchor straight-type silicone stent in 27 patients (Table 1) with postintubation (n = 15) and post-tracheotomy (n = 12) complex subglottic stenosis. Tracheal resection was contraindicated due to cardiovascular (n = 13), pulmonary (n = 11) and cerebrovascular (n = 3) comorbidities. The mean distance from vocal folds, the mean length and diameter of stenosis were 17 ± 2 mm, 20 ± 2.9 mm and 6.9 ± 0.9 mm, respectively. In 7 patients, the stent, placed first through a traditional technique, migrated, and it was successfully reinserted and then anchored using the proposed technique. The mean procedural time to fix the stent was 5 ± 0.3 min. No intraoperative or postoperative complications such as stent damage, dislocation, plugging or vocal folds dysfunction were observed (mean follow-up 19 ± 9.0 months). Table 1: Study population Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 SD: standard deviation. Table 1: Study population Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 Patients Sex Age (years) Stenosis aetiology Comorbidities Characteristics of stenosis Characteristics of silicone stent Follow-up (months) Complications Distance from vocal folds (mm) Length (mm) Diameter (mm) Length (mm) Diameter (mm) 1 Male 55 Postintubation Cardiovascular 18 21 5 40 15 34 None 2 Male 47 Post-tracheotomy Pulmonary 15 23 7 50 15 32 None 3 Male 59 Postintubation Cardiovascular 20 24 8 50 16 32 None 4 Male 68 Post-tracheotomy Pulmonary 13 21 6 40 15 31 None 5 Male 69 Postintubation Cerebrovascular 18 20 6 40 16 29 None 6 Female 73 Post-tracheotomy Cardiovascular 20 20 7 40 15 27 None 7 Female 67 Postintubation Cerebrovascular 20 24 8 50 15 25 None 8 Male 59 Post-tracheotomy Pulmonary 18 25 9 40 16 25 None 9 Female 55 Post-tracheotomy Cardiovascular 17 26 8 50 15 24 None 10 Male 65 Post-tracheotomy Pulmonary 13 20 7 40 16 24 None 11 Female 63 Postintubation Cerebrovascular 17 20 6 40 14 23 None 12 Male 68 Post-tracheotomy Cardiovascular 15 25 7 50 15 21 None 13 Female 69 Post-tracheotomy Pulmonary 14 20 6 40 15 21 None 14 Male 72 Postintubation Pulmonary 20 22 7 40 15 20 None 15 Female 71 Postintubation Cardiovascular 20 20 5 40 14 19 None 16 Male 64 Post-tracheotomy Cardiovascular 16 18 6 40 16 18 None 17 Female 57 Postintubation Pulmonary 18 15 7 40 14 17 None 18 Male 59 Post-tracheotomy Cardiovascular 17 20 8 40 16 16 None 19 Female 64 Postintubation Cardiovascular 20 15 6 40 16 15 None 20 Male 63 Postintubation Pulmonary 17 23 7 50 16 14 None 21 Male 69 Postintubation Pulmonary 20 21 8 40 16 13 None 22 Male 71 Postintubation Cardiovascular 16 22 7 40 16 12 None 23 Male 63 Post-tracheotomy Pulmonary 15 20 7 40 15 9 None 24 Male 69 Postintubation Cardiovascular 18 15 6 40 14 7 None 25 Male 65 Postintubation Pulmonary 18 18 8 40 16 5 None 26 Male 66 Postintubation Cardiovascular 20 20 7 40 16 3 None 27 Male 67 Post-tracheotomy Cardiovascular 16 17 8 40 15 2 None Mean ± SD 64 ± 6 17 ± 2 20 ± 2.9 6.9 ± 0.9 42 ± 4.2 15 ± 0.7 19 ± 9.0 SD: standard deviation. COMMENT Migration is a troublesome complication of straight-type silicone stent and has been reported to occur in up to 18% of patients with subglottic stenosis undergoing endoscopic treatment [8]. Over the years, different strategies [4–7] have been proposed to secure the stent placed in the subglottic trachea. However, all reported methods displayed specific advantages and disadvantages, and, thus, there is still not an easy and standardized protocol to ensure good results. Mace et al. [4] directly sutured the stent using a needle holder placed outside the body. However, the thickness of the tracheal wall and of the stent could complicate the needle insertion into the stent. Colt et al. [5] introduced a suture into the stent lumen through an angiocatheter and then withdraw it through another angiocatheter using a wire threader. On the basis of this principle, other authors [6, 7] used more sophisticated devices to capture the suture and then to extract it from the airway. In all these procedures, the suture was secured to the skin with an external button that could be complicated by a skin infection or unsatisfactory motility during deglutition. To offer an alternative method, the original Colt’s technique [5] was modified by tying a knot at the proximal end of the suture that was then intraluminally secured to the anterior wall of the stent. The main advantages of the proposed procedure over previous techniques are that no special device is required to withdraw the suture from the airway, and the absorbable suture for fixing the stent is buried subcutaneously. The use of absorbable rather than non-absorbable sutures prevented the risk of subcutaneous infection. In addition, there was no need to remove the stich later, because the knots dissolve by themselves and were coughed out. The formation of tenacious adhesions safely secured the stent with no dislocation when suture dissolved as well. The proposed technique is feasible and easy to perform, although it should be accomplished with appropriate cautions. The angiocatheter should be inserted perpendicularly to the trachea and gently advanced into the lumen of the stent to prevent overstepping the posterior wall of the stent and damaging the trachea. During these manoeuvres, the tip of the bronchoscope is wedged against the proximal end of the stent to prevent its displacement. During the anchoring manoeuvre, the 2 suture ends should be gently knotted to prevent the laceration of the anterior wall of the stent. The proposed procedure should be indicated for patients with severe malacia or without extrinsic compression, because they have a higher risk of dislocation. A second potential indication could be a reinsertion of a silicone stent that was previously placed through the traditional technique (with no stent securing) and was then migrated. CONCLUSION In conclusion, the proposed modified fixing technique could be a simple alternative to secure a subglottic silicone stent in selected cases. No special device is required. The absorbable suture, buried subcutaneously, could provide a long-term fixation with good aesthetic results. Conflict of interest: none declared. REFERENCES 1 Fiorelli A , Mazzone S , Di Crescenzo VG , Costa G , Del Prete A , Vicidomini G et al. Simple technique to control placement of Dumon stent in subglottic tracheal stenosis . Interact CardioVasc Thorac Surg 2014 ; 18 : 390 – 2 . Google Scholar CrossRef Search ADS PubMed 2 Menna C , Poggi C , Ibrahim M , D’Andrilli A , Ciccone AM , Maurizi G et al. Coated expandable metal stents are effective irrespective of airway pathology . J Thorac Dis 2017 ; 9 : 4574 – 83 . Google Scholar CrossRef Search ADS PubMed 3 Fiorelli A , Caterino U , Raucci A , Santini M. A conical self-expanding metallic stent for the management of critical complex tracheobronchial malignant stenosis . Interact CardioVasc Thorac Surg 2017 ; 24 : 293 – 5 . Google Scholar PubMed 4 Mace A , Sandhu G , Howard D. Securing tracheal stents: a new and simple method . J Laryngol Otol 2005 ; 119 : 207 – 8 . Google Scholar CrossRef Search ADS PubMed 5 Colt HG , Harrell J , Neuman TR , Robbins T. External fixation of subglottic tracheal stents . Chest 1994 ; 105 : 1653 – 7 . Google Scholar CrossRef Search ADS PubMed 6 Majid A , Fernandez-Bussy S , Kent M , Folch E , Fernandez L , Cheng G et al. External fixation of proximal tracheal airway stents: a modified technique . Ann Thorac Surg 2012 ; 93 : e167 – 9 . Google Scholar CrossRef Search ADS PubMed 7 Miwa K , Takamori S , Hayashi A , Fukunaga M , Shirouzu K. Fixation of silicone stents in the subglottic trachea: preventing stent migration using a fixation apparatus . Ann Thorac Surg 2004 ; 78 : 2188 – 90 . Google Scholar CrossRef Search ADS PubMed 8 Martinez-Ballarin JI , Diaz-Jimenez JP , Castro MJ , Moya JA. Silicone stents in the management of benign tracheobronchial stenoses. Tolerance and early results in 63 patients . Chest 1996 ; 109 : 626 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Jun 2, 2018

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