Ann Thorac Surg 2004;78:2188-2190
© 2004 The Society of Thoracic Surgeons
How to do it
Fixation of Silicone Stents in the Subglottic Trachea: Preventing Stent Migration Using a Fixation Apparatus
Keisuke Miwa, MDa,*,
Shinzo Takamori, MDa,
Akihiro Hayashi, MDa,
Mari Fukunaga, MD,
Kazuo Shirouzu, MDa
a Department of Surgery, Kurume University School of Medicine, Kurume, Japan
Accepted for publication October 16, 2003.
* Address reprint requests to Dr Miwa, Department of Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
keisuke{at}med.kurume-u.ac.jp
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Abstract
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Silicone stents are widely used to treat benign or malignant airway stenosis. However, since straight silicone stents placed into the subglottic trachea to treat stenosis display a high risk of migration, novel approaches are required. The present report outlines our method of external fixation for silicone stents in the subglottic trachea. This technique utilizes a fixation apparatus, is readily performed, and may help to overcome the hesitation seen in placing silicone stents for subglottic tracheal stenosis.
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Introduction
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Stent placement represents a vital intervention in the provision of care for patients with central airway stenosis. Various types of stents, such as the Montgomery T-tube [1], self-expandable metallic stents [2–4], dynamic stents [5], and silicone stents [6] have been used to treat tracheal stenosis. However, each stent displays specific advantages and disadvantages in terms of complications and costs. At our institution, silicone stents are used as the first choice for central airway stenosis, in consideration of safety, cost, and removability. However, for subglottic tracheal stenosis, stent migration cannot be adequately prevented using a stud, and Y-type stents are overly long, increasing the risk of luminal obstruction due to airway secretions. We therefore perform external fixation of silicone stents in the subglottic trachea using a fixation apparatus. This technique is reported herein.
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Technique
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At our institution, placement of a silicone stent in the subglottic trachea in all patients involves the use of a straight-type Dumon stent (Dumon Tube BD; Novatech, Aubagne, France) designed according to the extent of stenosis. The stent is placed using a rigid bronchoscope under general anesthesia with spontaneous respiration. Before stent placement, an adequate tracheal lumen is obtained by laser cauterization, balloon dilation, or debulking. When the final location of the stent is determined, the stent is fixed to the anterior neck using nylon thread and a fixation apparatus (Loop Fixture; Create Medic, Yokohama, Japan) under local anesthesia. The fixation apparatus comprises a pair of 20-gauge puncture needles for holding and inserting the thread, and the puncture needle contains a wire loop for holding the thread. With the insertion of a stylet, a wire loop is directly formed immediately below the puncture needle for thread insertion (Fig 1). Fixation of the stent to the neck is performed in six steps under the guidance of a rigid bronchoscope. These steps comprise: (1) the special wire loop for thread holding is retracted into the puncture needle, and puncture is performed; (2) after bronchoscopic confirmation of suitable needle position, a stylet is inserted to form a wire loop for thread holding directly below the second needle; (3) nylon thread is inserted via the puncture needle and passed through the wire loop for thread holding; (4) the wire loop for thread holding is retracted into the puncture needle; (5) the fixation apparatus is removed from the body; (6) the nylon thread is tied to secure the stent on the anterior neck (Fig 2). The rigid bronchoscope is then removed, completing the surgery.
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Fig 1. Loop fixture comprising a pair of 20-gauge puncture needles for thread insertion (A) and thread holding, with a retractable wire loop (B), and with a stylet (C).
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Fig 2. Fixation of the stent to the neck is performed in six steps: (1) the puncture is performed; (2) a stylet is inserted to form a wire loop for thread holding directly below the other puncture needle; (3) nylon thread is inserted via the puncture needle and passed through the wire loop for thread holding; (4) the wire loop for thread holding is retracted into the puncture needle; (5) the fixation apparatus is removed from the body; (6) the nylon thread is tied, securing the stent to the anterior neck.
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Comment
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Various stents are used for main airway stenosis, and their usefulness has been reported [1–6]. However, selection of the appropriate stent remains controversial. We use Dumon stents designed according to the extent of stenosis as a first choice for tracheal stenosis, considering factors of safety, cost, and removability. However, when a straight-type Dumon stent is placed in the subglottic trachea, movement of the head and neck or coughing tend to induce stent migration. Direct suturing of the stent using a needle holder placed outside the body is difficult, as the thickness of the tracheal wall and stent make needle insertion to the stent difficult. We have placed straight-type Dumon stents and performed external fixation using our apparatus in 6 patients with subglottic tracheal stenosis. Of the 6 patients, 5 displayed malignant stenosis and 1 had benign stenosis. Distance between the upper end of the stent and the vocal cords was at least 2 cm, and was often 3 to 4 cm. The patient with benign stenosis subsequently underwent tracheal resection. In 2 patients with advanced esophageal cancer, tracheotomy became necessary for bilateral paralysis of the recurrent laryngeal nerve due to direct invasion of metastasized lymph nodes after stent placement, but stents were readily removed via tracheal incision and replaced with Montgomery T-tubes. The procedure for external fixation takes only about 1 minute, and no intraoperative or postoperative complications have been encountered. Patients underwent 3 to 13 months of follow-up after stent placement, during which time no complication of external fixation with the ligation thread was noted. However, subglottic straight-type Dumon stent with external fixation may display some complications, such as closure disturbance of the vocal cords, discomfort, and dyspnea due to formation of granulation tissue at the end of the stent.
At our facility, subglottic straight-type Dumon stent placement is merely a palliative therapy, and open surgery such as tracheal resection and cricoid resection represents the first choice when possible. In patients requiring emergency securing of the airway for subglottic tracheal stenosis or in those unable to tolerate emergency surgery, a Dumon stent is inserted to serve as either a temporary or permanent stent. We consider that indications for subglottic straight-type Dumon stent placement with external fixation may be inoperable subglottic tracheal stenosis, severe malacia, and when tracheotomy is undesirable for treatment with a Montogomery T-tube due to recurrent stomal infection or substantial tracheal tumor growth.
The present fixation apparatus was originally developed in Japan for fixation of the stomach to the abdominal wall, for gastropexy in endoscopic gastrostomy. The device was approved by the Japanese Ministry of Health and Welfare for marketing as clinical equipment in October 1992. The primary advantage of this apparatus is that a wire loop for thread holding is readily and accurately formed immediately below the other puncture needle, allowing the nylon thread inserted via the puncture needle to be held without special procedures or skills. This is the first report of the application of this apparatus to the airway. For fixation of a stent placed in the subglottic trachea, Amemiya and colleagues [7] reported a fixation technique of a Teflon tube using two epidural catheters, while Colt and colleagues [8] reported a puncture apparatus with wire using two angiocatheters. Our method is fundamentally based on their ideas. However, the present fixation apparatus offers advantages in terms of simplicity and accuracy. Our technique using this fixation apparatus may help to overcome the reluctance to place silicon stents for subglottic tracheal stenosis.
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References
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- Montgomery WW. T-tube tracheal stent. Arch Otolaryngol. 1965;82:320–321
- Wallance MJ, Charnsagavej C, Ogawa K, et al. Tracheobronchial tree. Expandable metallic stents used in experimental and clinical applications. Radiology. 1986;158:309–312[Abstract/Free Full Text]
- Rousseau H, Dahan M, Lauque D, et al. Self-expandable prosthesis in the tracheobronchial tree. Radiology. 1993;188:199–203[Abstract/Free Full Text]
- Yanagihara K, Mizuno H, Wada H, et al. Tracheal stenosis treated with self-expanding nitinol stent. Ann Thorac Surg. 1997;63:1786–1789[Abstract/Free Full Text]
- Freitag L, Eicker R, Linz B, et al. Theoretical and experimental basis for the development of a dynamic airway stent. Eur Respir J. 1994;11:2038–2045
- Dumon JF. A dedicated tracheobronchial stent. Chest. 1990;97:328–332[Abstract/Free Full Text]
- Amemiya R, Matsushima Y, Kunii T, et al. Palliative tracheal tube stent without tracheotomy in tracheal stenosis. J Thorac Cardiovasc Surg. 1985;90:631–632[Medline]
- Colt HG, Harrell J, Neuman TR, et al. External fixation of subglottic tracheal stents. Chest. 1994;105:1653–1657[Abstract/Free Full Text]
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Abstract
Introduction
