title: Transtracheal single-point stent fixation in posttracheotomy tracheomalacia under cone-beam computer tomography guidance by transmural suturing with the Berci needle - a perspective on a new tool to avoid stent migration of Dumon stents.
abstract: Tracheomalacia or tracheobronchomalacia (TM or TBM) is a common problem especially for elderly patients often unfit for surgical techniques. Several surgical or minimally invasive techniques have already been described. Stenting is one option but in general long-time stenting is accompanied by a high complication rate. Stent removal is more difficult in case of self-expandable nitinol stents or metallic stents in general in comparison to silicone stents. The main disadvantage of silicone stents in comparison to uncovered metallic stents is migration and plugging. We compared the operation time and in particular the duration of a sufficient Dumon stent fixation with different techniques in a patient with severe posttracheotomy TM and strongly reduced mobility of the vocal cords due to Parkinson's disease. The combined approach with simultaneous Dumon stenting and endoluminal transtracheal externalized suture under cone-beam computer tomography guidance with the Berci needle was by far the fastest approach compared to a (not performed) surgical intervention, or even purely endoluminal suturing through the rigid bronchoscope. The duration of the endoluminal transtracheal externalized suture was between 5 minutes and 9 minutes with the Berci needle; the pure endoluminal approach needed 51 minutes. The alternative of tracheobronchoplasty was refused by the patient. In general, 180 minutes for this surgical approach is calculated. The costs of the different approaches are supposed to vary widely due to the fact that in Germany 1 minute in an operation room costs on average approximately 50-60€ inclusive of taxes. In our own hospital (tertiary level), it is nearly 30€ per minute in an operation room for a surgical approach. Calculating an additional 15 minutes for patient preparation and transfer to wake-up room, therefore a total duration inside the investigation room of 30 minutes, the cost per flexible bronchoscopy is per minute on average less than 6€. Although the Dumon stenting requires a set-up with more expensive anesthesiology accompaniment, which takes longer than a flexible investigation estimated at 1 hour in an operation room, still without calculation of the costs of the materials and specialized staff that the surgical approach would consume at least 3,000€ more than a minimally invasive approach performed with the Berci needle. This difference is due to the longer time of the surgical intervention which is calculated at approximately 180 minutes in comparison to the achieved non-surgical approach of 60 minutes in the operation suite.
authors.affiliation: Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany ; II Medical Clinic, "Coburg" Hospital, University of Wuerzburg, Coburg, Germany.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Hohenforst-Schmidt
authors.affiliation: Department of Thoracic Surgery, Medinos Clinic Sonneberg, Sonnerberg, Germany.
authors.forename: Bernd
authors.initials: B
authors.lastname: Linsmeier
authors.affiliation: Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
authors.forename: Paul
authors.initials: P
authors.lastname: Zarogoulidis
authors.affiliation: Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Essen-Duisburg, Tueschener Weg, Essen, Germany.
authors.forename: Lutz
authors.initials: L
authors.lastname: Freitag
authors.affiliation: Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Essen-Duisburg, Tueschener Weg, Essen, Germany.
authors.forename: Kaid
authors.initials: K
authors.lastname: Darwiche
authors.affiliation: Pulmonary and Critical Care Medicine, Interventional Pulmonology, National Naval Medical Center, Walter Reed Army Medical Center, Bethesda, MD, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Browning
authors.affiliation: Division of Interventional Pulmonology and Medical Oncology, Cancer Treatment Centers of America, Western Regional Medical Center, Goodyear, AZ, USA.
authors.forename: J Francis
authors.initials: JF
authors.lastname: Turner
authors.affiliation: Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai, People's Republic of China.
authors.forename: Haidong
authors.initials: H
authors.lastname: Huang
authors.affiliation: Department of Respiratory Diseases Shanghai Hospital, II Military University Hospital, Shanghai, People's Republic of China.
authors.forename: Qiang
authors.initials: Q
authors.lastname: Li
authors.affiliation: Department of Diagnostic and Interventional Radiology, Goethe University of Frankfurt, Frankfurt, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Vogl
authors.affiliation: Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Zarogoulidis
authors.affiliation: II Medical Clinic, "Coburg" Hospital, University of Wuerzburg, Coburg, Germany.
authors.forename: Johannes
authors.initials: J
authors.lastname: Brachmann
authors.affiliation: Medical Clinic I, "Fuerth" Hospital, University of Erlangen, Fuerth, Germany.
authors.forename: Harald
authors.initials: H
authors.lastname: Rittger
keywords: Berci needle; Dumon stents; airway; cone-beam computer tomography; stent; tracheobronchomalacia