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Securing stent during multi-stage laryngotracheoplasty—An evolved technique
International Journal of Pediatric Otorhinolaryngology 79 (2015) 1418–1420
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Securing stent during multi-stage laryngotracheoplasty—An evolved technique Bianca Siegel a,b,*, John P. Bent c,d,e a
Children’s Hospital of Michigan, Detroit, MI, United States Wayne State University School of Medicine, Detroit, MI, United States c Albert Einstein College of Medicine, Bronx, NY, United States d Montefiore Medical Center, Bronx, NY, United States e Children’s Hospital at Montefiore, Bronx, NY, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 April 2015 Accepted 12 June 2015 Available online 22 June 2015
Background: Multi-stage laryngotracheoplasty (LTP) typically requires a stent be secured to the airway for 2–6 weeks. Our technique has evolved over time to securing the stent to the strap muscles and tying a series of knots long enough to leave the suture tail protruding through the skin incision, which simplifies stent removal. Methods: Retrospective chart review. Results: Twenty-four patients underwent multi-stage LTP at our institution from 2007 to 2013. Eight patients were excluded from the study because they either did not have a stent placed (n = 4), or they had a t-tube placed which was not sutured in place (n = 4). Of the remaining 16 patients, 62.5% (n = 10) had their stent secured via sutures which were buried below the skin, and 37.5% (n = 6) via a long suture tail which was left protruding through the end of the skin incision. An incision was required for stent removal 100% of buried sutures patients, and 33% of exposed suture patients (p = 0.0009). Average operative time for stent removal was 60 min in the buried sutures group, and 25 min in the exposed sutures group (p = 0.0075). Conclusions: Securing stents via an exposed suture technique decreases the need for making a skin incision during the second stage of the operation, and significantly decreases the operative time of the second stage. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Multi-stage LTP Airway stent Laryngotracheoplasty Laryngotracheal reconstruction
1. Introduction Since Fearon and Cotton initially described laryngotracheoplasty (LTP) in 1972 [1], it has become a widely accepted method to achieve tracheotomy decannulation in children with subglottic stenosis. LTP may be classified as single-stage or multi-stage techniques [2,3]. By definition, a single-stage technique refers to a procedure in which the patient is decannulated after only one reconstructive surgery. In a multi-stage technique the tracheotomy tube remains in place after the initial reconstruction, deferring decannulation for a future date, after additional procedure(s). Multi-stage procedures require temporary placement of a stent, which is typically removed 2–6 weeks later [4]. Several different
* Corresponding author at: 1247 Woodward Ave #1007, Detroit, MI 48226, United States. Tel.: +1 734 358 1503. E-mail address: [email protected] (B. Siegel). http://dx.doi.org/10.1016/j.ijporl.2015.06.015 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
types of stents have been described, including Aboulker stents, endotracheal tubes, Montgomery t-tubes and silastic sheet rolls [5]. Regardless of stent type, it must be secured to the airway, usually by suturing it in place, and then removed under general anesthesia. Our technique of securing the stent has evolved from a subcutaneously buried suture, either isolated or secured to a button, to a long suture tail left exposed through the skin incision. Herein, we describe our evolved technique, which simplifies the stent removal. 2. Methods Patients undergoing multi-stage LTP at our institution from 2007 to 2013 were identified by searching our IRB approved airway database. Twenty-four patients who underwent multi-stage laryngotracheal reconstruction were identified, and their charts were reviewed for the type of stent placed, and how the stent was secured, which was defined either as buried sutures or exposed
B. Siegel, J.P. Bent / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1418–1420
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sutures. Patients who did not have a stent placed or who underwent t-tube placement without suturing were excluded. Charts were then further reviewed for operative time of the stent removal procedure as well as the need for an incision during the stent removal procedure; a t-test was performed to compare the buried suture group with the exposed suture group on these two parameters. For patients undergoing the exposed suture technique, an endotracheal stent was placed in standard fashion, and sutured to the trachea using prolene suture. It was secured to the strap muscles, and approximately 15–20 kn were tied in the suture, until the tail was long enough to leave it exposed through the lateral edge of our incision, as shown in Fig. 1. At the time of stent removal, the exposed suture was grasped, retracted to expose the first knot, divided (as depicted in Fig. 2), and removed, allowing release and transoral stent removal.
3. Results Twenty-four patients underwent multi-stage LTP at our institution from 2007 to 2013. Eight patients were excluded from the study because they either did not have documentation of how the stent was secured (n = 4), or they had a t-tube placed which was not sutured in place (n = 4). Of the remaining 16 patients, 62.5% (n = 10) had their stent secured via sutures buried subcutaneously, and 37.5% (n = 6) via a long suture tail protruding through the skin incision edge. Average age of buried suture patients [4.0 years (range 2–9)] approximated the exposed sutures group [3.6 years (range 2–6)]. Stents remained in place for an average of 36 days (range 21–64) in the buried suture group compared to 30 days (range 15–43) in the exposed suture group. An incision was required for stent removal in 100% of buried sutures patients, and 33% of exposed suture patients (p = 0.0009). Average operative time for stent removal was 60 min in the buried sutures group, and 25 min in the exposed sutures group (p = 0.0075). These results are depicted in Table 1. Patients in this series experienced no infections or other complications from having a suture extend transcutaneously.
Fig. 2. Suture removal at time of 2nd stage of operation-exposed suture tail is grasped and retracted, allowing identification and division of the base of the suture overlying the strap muscles.
Table 1 Operative time and need for incision in buried suture vs. exposed suture patients. Exposed suture n (Sample size) Mean time for stent removal (min) % Requiring incision
10 25 (SD 12.2) 33
Buried suture 6 60 (SD 25.2) 100
p 0.0075 0.0009
4. Discussion Conventional methods of stent removal in multistage-LTP are unnecessarily complicated. It can be quite challenging to locate and cut a subcutaneous suture securing the laryngeal stent. To minimize these frustrations, we have modified our technique using the exposed suture described in this paper. Leaving the exposed suture tail usually eliminates the need for an incision to cut the suture. Traction on the exposed suture typically enables division of the suture base, allowing stent removal. In the event that this is not possible, it may still be necessary to make a small incision to release the suture, as we had to do in two of our cases. The surgeon also has the option of cutting the suture inside the stent lumen as an alternative to making a 5 mm skin incision. Whether the suture is cut at the skin or endolaryngeal, eliminating the hunt for the suture knot greatly simplifies stent removal. Average operative time for stent removal with this technique was significantly reduced from 60 min to 25 min. Our preliminary data suggests that this technique is simple and safe; it has become the standard at our institution.
5. Conclusions
Fig. 1. Exposed sutures protruding from skin incision following double-stage laryngotracheoplasty.
Securing stents via an exposed suture technique significantly decreased the operative time and need for a skin incision during the second stage of LTP. If widely implemented, the average 35 min reduced operative time would offer meaningful patient benefit and economic savings.
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B. Siegel, J.P. Bent / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1418–1420
References [1] B. Fearon, R. Cotton, Surgical correction of subglottic stenosis of the larynx. Preliminary report of an experimental technique, Ann. Otol. Rhinol. Laryngol. 81 (4) (1972) 508–513. [2] L.P. Smith, K.B. Zur, I.N. Jacobs, Single- vs double-stage laryngotracheal reconstruction, Arch. Otolaryngol. Head Neck Surg. 136 (1) (2010) 60–65.
[3] R.T. Cotton, C.M. Myer III, D.M. O’Connor, M.E. Smith, Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the singlestage approach, Laryngoscope 105 (1995) 818–821. [4] S.S. Choi, H. George, G.H. Zalzal, Pitfalls in laryngotracheal reconstruction, Arch. Otolaryngol. Head Neck Surg. 125 (1999) 650–653. [5] G.H. Zalzal, Use of stents in laryngotracheal reconstruction in children: indications, technical considerations, and complications, Laryngoscope 98 (1988) 849–854.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Securing stent during multi-stage laryngotracheoplasty—An evolved technique Bianca Siegel a,b,*, John P. Bent c,d,e a
Children’s Hospital of Michigan, Detroit, MI, United States Wayne State University School of Medicine, Detroit, MI, United States c Albert Einstein College of Medicine, Bronx, NY, United States d Montefiore Medical Center, Bronx, NY, United States e Children’s Hospital at Montefiore, Bronx, NY, United States b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 April 2015 Accepted 12 June 2015 Available online 22 June 2015
Background: Multi-stage laryngotracheoplasty (LTP) typically requires a stent be secured to the airway for 2–6 weeks. Our technique has evolved over time to securing the stent to the strap muscles and tying a series of knots long enough to leave the suture tail protruding through the skin incision, which simplifies stent removal. Methods: Retrospective chart review. Results: Twenty-four patients underwent multi-stage LTP at our institution from 2007 to 2013. Eight patients were excluded from the study because they either did not have a stent placed (n = 4), or they had a t-tube placed which was not sutured in place (n = 4). Of the remaining 16 patients, 62.5% (n = 10) had their stent secured via sutures which were buried below the skin, and 37.5% (n = 6) via a long suture tail which was left protruding through the end of the skin incision. An incision was required for stent removal 100% of buried sutures patients, and 33% of exposed suture patients (p = 0.0009). Average operative time for stent removal was 60 min in the buried sutures group, and 25 min in the exposed sutures group (p = 0.0075). Conclusions: Securing stents via an exposed suture technique decreases the need for making a skin incision during the second stage of the operation, and significantly decreases the operative time of the second stage. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Multi-stage LTP Airway stent Laryngotracheoplasty Laryngotracheal reconstruction
1. Introduction Since Fearon and Cotton initially described laryngotracheoplasty (LTP) in 1972 [1], it has become a widely accepted method to achieve tracheotomy decannulation in children with subglottic stenosis. LTP may be classified as single-stage or multi-stage techniques [2,3]. By definition, a single-stage technique refers to a procedure in which the patient is decannulated after only one reconstructive surgery. In a multi-stage technique the tracheotomy tube remains in place after the initial reconstruction, deferring decannulation for a future date, after additional procedure(s). Multi-stage procedures require temporary placement of a stent, which is typically removed 2–6 weeks later [4]. Several different
* Corresponding author at: 1247 Woodward Ave #1007, Detroit, MI 48226, United States. Tel.: +1 734 358 1503. E-mail address: [email protected] (B. Siegel). http://dx.doi.org/10.1016/j.ijporl.2015.06.015 0165-5876/ß 2015 Elsevier Ireland Ltd. All rights reserved.
types of stents have been described, including Aboulker stents, endotracheal tubes, Montgomery t-tubes and silastic sheet rolls [5]. Regardless of stent type, it must be secured to the airway, usually by suturing it in place, and then removed under general anesthesia. Our technique of securing the stent has evolved from a subcutaneously buried suture, either isolated or secured to a button, to a long suture tail left exposed through the skin incision. Herein, we describe our evolved technique, which simplifies the stent removal. 2. Methods Patients undergoing multi-stage LTP at our institution from 2007 to 2013 were identified by searching our IRB approved airway database. Twenty-four patients who underwent multi-stage laryngotracheal reconstruction were identified, and their charts were reviewed for the type of stent placed, and how the stent was secured, which was defined either as buried sutures or exposed
B. Siegel, J.P. Bent / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1418–1420
1419
sutures. Patients who did not have a stent placed or who underwent t-tube placement without suturing were excluded. Charts were then further reviewed for operative time of the stent removal procedure as well as the need for an incision during the stent removal procedure; a t-test was performed to compare the buried suture group with the exposed suture group on these two parameters. For patients undergoing the exposed suture technique, an endotracheal stent was placed in standard fashion, and sutured to the trachea using prolene suture. It was secured to the strap muscles, and approximately 15–20 kn were tied in the suture, until the tail was long enough to leave it exposed through the lateral edge of our incision, as shown in Fig. 1. At the time of stent removal, the exposed suture was grasped, retracted to expose the first knot, divided (as depicted in Fig. 2), and removed, allowing release and transoral stent removal.
3. Results Twenty-four patients underwent multi-stage LTP at our institution from 2007 to 2013. Eight patients were excluded from the study because they either did not have documentation of how the stent was secured (n = 4), or they had a t-tube placed which was not sutured in place (n = 4). Of the remaining 16 patients, 62.5% (n = 10) had their stent secured via sutures buried subcutaneously, and 37.5% (n = 6) via a long suture tail protruding through the skin incision edge. Average age of buried suture patients [4.0 years (range 2–9)] approximated the exposed sutures group [3.6 years (range 2–6)]. Stents remained in place for an average of 36 days (range 21–64) in the buried suture group compared to 30 days (range 15–43) in the exposed suture group. An incision was required for stent removal in 100% of buried sutures patients, and 33% of exposed suture patients (p = 0.0009). Average operative time for stent removal was 60 min in the buried sutures group, and 25 min in the exposed sutures group (p = 0.0075). These results are depicted in Table 1. Patients in this series experienced no infections or other complications from having a suture extend transcutaneously.
Fig. 2. Suture removal at time of 2nd stage of operation-exposed suture tail is grasped and retracted, allowing identification and division of the base of the suture overlying the strap muscles.
Table 1 Operative time and need for incision in buried suture vs. exposed suture patients. Exposed suture n (Sample size) Mean time for stent removal (min) % Requiring incision
10 25 (SD 12.2) 33
Buried suture 6 60 (SD 25.2) 100
p 0.0075 0.0009
4. Discussion Conventional methods of stent removal in multistage-LTP are unnecessarily complicated. It can be quite challenging to locate and cut a subcutaneous suture securing the laryngeal stent. To minimize these frustrations, we have modified our technique using the exposed suture described in this paper. Leaving the exposed suture tail usually eliminates the need for an incision to cut the suture. Traction on the exposed suture typically enables division of the suture base, allowing stent removal. In the event that this is not possible, it may still be necessary to make a small incision to release the suture, as we had to do in two of our cases. The surgeon also has the option of cutting the suture inside the stent lumen as an alternative to making a 5 mm skin incision. Whether the suture is cut at the skin or endolaryngeal, eliminating the hunt for the suture knot greatly simplifies stent removal. Average operative time for stent removal with this technique was significantly reduced from 60 min to 25 min. Our preliminary data suggests that this technique is simple and safe; it has become the standard at our institution.
5. Conclusions
Fig. 1. Exposed sutures protruding from skin incision following double-stage laryngotracheoplasty.
Securing stents via an exposed suture technique significantly decreased the operative time and need for a skin incision during the second stage of LTP. If widely implemented, the average 35 min reduced operative time would offer meaningful patient benefit and economic savings.
1420
B. Siegel, J.P. Bent / International Journal of Pediatric Otorhinolaryngology 79 (2015) 1418–1420
References [1] B. Fearon, R. Cotton, Surgical correction of subglottic stenosis of the larynx. Preliminary report of an experimental technique, Ann. Otol. Rhinol. Laryngol. 81 (4) (1972) 508–513. [2] L.P. Smith, K.B. Zur, I.N. Jacobs, Single- vs double-stage laryngotracheal reconstruction, Arch. Otolaryngol. Head Neck Surg. 136 (1) (2010) 60–65.
[3] R.T. Cotton, C.M. Myer III, D.M. O’Connor, M.E. Smith, Pediatric laryngotracheal reconstruction with cartilage grafts and endotracheal tube stenting: the singlestage approach, Laryngoscope 105 (1995) 818–821. [4] S.S. Choi, H. George, G.H. Zalzal, Pitfalls in laryngotracheal reconstruction, Arch. Otolaryngol. Head Neck Surg. 125 (1999) 650–653. [5] G.H. Zalzal, Use of stents in laryngotracheal reconstruction in children: indications, technical considerations, and complications, Laryngoscope 98 (1988) 849–854.