When necessary, Nd:YAG laser resection was performed using standard techniques. The flexible fiberoptic bronchoscope (FFB) was used through the rigid tube to clear the airways of secretions and blood before and after stent placement. Straight silicone stents were inserted into the area of stenosis using a specially designed instrument (Stent Introducer System, EFER, LaCiotat, France). This system allows stent insertion under direct endoscopic guidance after dilating the area of stenosis with the rigid tube. Stents are loaded into an introducer and manually expulsed into the stenosis. In high stenoses, the bronchoscopist must gently maintain the distal extremity of the RB between the vocal cords. Exact positioning of the stent is accomplished under direct endoscopic control by grasping it with universal forceps, and if necessary, wedging it against the tip of the rigid tube as it is moved into position. A poorly placed stent can be pulled into the rigid tube and withdrawn with the bronchoscope, taking care to avoid cricoid cartilage and vocal cord injury. After reoxygenation and aspiration of pharyngeal secretions, the bronchoscope is reinserted and stent placement is reattempted.
Once the stent is in the correct position, the rigid tube is placed so that its beveled tip is wedged against the stent’s proximal extremity, preventing proximal migration, Universal forceps are introduced and the stent is grasped to prevent distal migration during further manipulations. Canadian helth& care mall read only The anterior neck is prepped and draped in usual sterile fashion. Under direct videobronchoscopic control, a 14-gauge intravenous angiocatheter (Jelco) is inserted through the skin, subcutaneous tissues, anterior tracheal wall, and anterior wall of the silicone stent. A second catheter is inserted about 1-cm distal to the first. The needles are removed, and the teflon catheter sheaths are left in place inside the stent lumen. A 0-polyester or 0-polypropylene suture is inserted through the distal angiocatheter and directed toward the vocal cords. The suture is threaded through a wire retention loop (in our case, a Bodkin threader) that has been inserted through the proximal catheter (Fig 1). Once secured, the wire retention loop is removed through the catheter, thereby withdrawing the suture proximally. Both catheters are removed, and the suture is pulled taut, taking care to not tear the stent. The free ends of the suture are passed through a polypropylene button that is tied snugly to the anterior neck. Stent position is verified endoscopically, bronchial cleansing is performed, and the patient is extubated.
Figure 1. Both angiocatheters are inserted through the anterior wall of a silicone stent (Dumon). The braided, polyester suture is grasped within the loop of the threader (Bodkin).