结核性支气管狭窄的诊断及外科治疗

目的探讨药物治疗不愈的结核性支气管狭窄患者的诊断及外科治疗。方法对４６例外科诊断明确的结核性支气管狭窄采用肺切除和支气管成型术。支气管成型术包括肺叶状成型术，总支气管楔形切除术及总支气管袖状切除术。结果４６例结核性支气管狭窄患者得到治愈，无残端和吻合口瘘；痰菌全部转阴；无狭窄复发。结论治疗结核性支气管狭窄肺切除是常规的治疗方法，支气管成形术是理想的手术方法     

结核性支气管狭窄的外科治疗

目的报告３２例结核性支气管狭窄的外科治疗经验及体会。方法３２例中袖状肺叶切除１９例，肺叶切除４例，全肺切除７例，左主支气管节段切除２例。结果无手术死亡。术后出现并发症３例，１例为支气管胸膜瘘，经Ⅱ期手术带蒂大网膜覆盖支气管残端治愈，另２例分别于手术后１２个月及１８个月时出现轻度吻合口狭窄。结论对结核性支气管狭窄应及时采用外科治疗的方法。将狭窄阻塞病变的支气管连同受累肺叶一并切除的袖状肺叶切除术是首选的术式。     

结核性气管支气管狭窄球囊扩张并发症影响因素分析

目的 研究结核性气管支气管狭窄经球囊扩张后出现并发症的影响因素。方法 回顾2017年4月1日-2022年4月1日在武汉市金银潭医院接受支气管镜下球囊扩张术用以改善气道狭窄的气管支气管结核患者,所有患者均经敏感方案抗结核治疗并于全麻下行球囊扩张术,按是否发生并发症分为两组,统计分析两组的临床资料。结果 共214例患者,其中男性56例,女性158例,年龄15～74岁,出现并发症者35例(16.4%),其中27例(12.6%)出现无法自行缓解的出血,5例(2.3%)出现管壁透壁撕裂,3例(1.4%)扩张后出现管壁软化。单因素Logistic回归分析提示狭窄长度(P<0.01,OR=2.023)、狭窄类型(P<0.01,OR=3.733)差异有显著统计学意义;多因素Logistic回归显示狭窄长度(P<0.01,OR=1.815)差异有显著统计学意义,狭窄类型(P<0.05,OR=2.668)差异有统计学意义。结论 狭窄长度较长及瘢痕挛缩型结核性气管支气管狭窄患者更易在接受球囊扩张后出现并发症。     

气管、支气管结核的手术治疗

1983～2004年,我们对69例气管、支气管结核患者施行手术治疗。现作回顾性分析,探讨其治疗方法。     

支气管结核78例外科治疗分析

目的:介绍药物及介入治疗不愈的支气管结核的外科治疗经验。方法:对78例诊断明确的支气管内膜结核,且造成支气管狭窄或肺不张的患者进行外科治疗,术前规则抗结核治疗6个月以上,术后继续抗结核治疗9~12个月。其中全肺切除12例,肺叶切除58例,袖状肺叶切除8例。结果:78例患者均治愈,无手术死亡,无支气管胸膜瘘及结核播散。术后有2例出现支气管狭窄,经球囊扩张后,管腔通气正常。1例术后出现吻合口肉芽肿,给予冷冻治疗后治愈。随访1年以上无复发。结论:支气管结核造成支气管狭窄或肺不张,外科手术治疗是一种安全有效的方法。     

气道支架治疗气管、支气管狭窄研究进展

气道狭窄可引起呼吸困难、顽固性咳嗽、咯血、感染等 ,严重者可出现呼吸衰竭 ,甚至窒息死亡。导致气道狭窄的原因很多 ,主要有炎性肉芽肿、疤痕、结核、外伤、气管软化症、淀粉样变、肿瘤等。气道狭窄的治疗非常困难 ,传统的外科手术对于病变范围小、局限性的气道狭窄疗效较好 ,一般采用袖式切除和端端吻合。但晚期肿瘤造成的气道狭窄、狭窄较长或多处狭窄、术后复发再狭窄及年龄大、一般情况差的患者均不宜行手术治疗。近年来 ,临床采用内支架治疗气道狭窄疗效显著。下面就其研究进展综述如下。1　气道支架的历史196 5年 Montgonery发明了…     

糖皮质激素治疗气管支气管结核的对照研究

目的探讨糖皮质激素（GC）对浸润型及坏死型气管支气管结核的治疗价值。方法 1997年1月至2009年2月住院的浸润型及坏死型气管支气管结核84例,随机分为治疗组（用GC组）和对照组（不用GC组）各42例,治疗组在全身抗结核治疗基础上加用强的松口服6周,对照组常规全身抗结核治疗。观察比较两组的疗效及转归。结果治疗组的有效率97.2%,显著高于对照组81.0%（P〈0.05）。治疗后18个月纤支镜复查,治疗组结核性气管支气管狭窄发生率7.14%,显著低于对照组31.0%（P〈0.01）。结论对炎症浸润型及溃疡坏死型气管支气管结核,早期适量应用糖皮质激素可提高疗效改善预后,减少气管支气管狭窄的发生。     

气管-主支气管分支型部分覆膜内支架治疗主支气管内膜结核瘢痕性狭窄随访研究

目的观察气管-主支气管分支型部分覆膜内支架植入治疗主支气管内膜结核瘢痕性狭窄后长期疗效和并发症。方法选择2003年4月至2007年1月郑州大学第一附属医院放射科17例有较完整的随访资料的主支气管内膜结核瘢痕性狭窄放置气管-主支气管分支型部分覆膜内支架患者,17例患者分别在支架取出后第1、6个月行视觉类比测试法(VAS)。其中14例分别于支架取出后第1、6个月门诊行胸部CT和支气管镜复查,电话随访与信访3例。结果17例均一次性植入支架成功并在25～90d内成功取出支架,随访6～50个月,1例患者在支架取出后7d发生再狭窄,经治疗后未再发生呼吸困难,其余患者均未再次出现呼吸困难。支架取出后第1、6个月,17例患者VAS均较术前有明显改善(P<0.05)。结论气管-主支气管分支型部分覆膜内支架植入治疗主支气管内膜结核瘢痕性狭窄,操作成功率高,远期疗效可靠。     

支气管镜介入辅助治疗气管支气管结核的价值

目的探讨支气管镜介入辅助治疗气管支气管结核的价值。方法选择2014年5月至2015年5月医院收治的气管支气管结核患者64例,分成观察组和对照组各32例。对照组患者应用常规抗结核药物治疗,观察组患者在其基础上加用支气管镜介入治疗。比较两组的痰菌转阴率、影像学疗效、支气管镜下疗效、并发症以及复发率等。结果观察组患者的痰菌转阴率、影像学总有效率、支气管镜下总有效率都明显高于对照组患者(P0.05);观察组中,单纯冷冻治疗的支气管镜下总有效率明显低于冷冻联用球囊扩张(P0.05);观察组的1年复发率明显低于对照组(P0.05)。结论气管支气管结核患者应用支气管镜下介入治疗,疗效确切,安全可靠,值得加以推广。     

Surgical treatment for tuberculous tracheobronchial stenosis

Thirty-nine patients with bronchial tuberculosis underwent bronchoplastic surgery. The modes of procedures were left upper sleeve lobectomy in 13 patients, sleeve resection of the left main bronchus in 11 patients, sleeve resection of the left main bronchus with concomitant left upper lobectomy in 2 patients, right upper sleeve lobectomy in 6 patients, sleeve resection of the right intermediate bronchus in 2 patients, right sleeve superior segmentectomy of the lower lobe in one patient, sleeve resection of the trachea with concomitant left pneumonectomy in one patient, left lower sleeve lobectomy in one patient, carinal resection with right upper sleeve lobectomy and middle lobectomy in one patient, and dilatation of the left main bronchus with a free skin graft reinforced with a steel wire in one patient. There were one operation death and one operation related death in 1950's. FEV 1.0% of 12 patients whose records of pulmonary function tests performed before and after surgery were available, were increased significantly from 67 +/- 10% to 82 +/- 8% in average. Three patients of laryngotracheal stenosis due to tuberculosis were treated with silicon T-tube. In 2 patients their stenotic lesions were repaired by stenting only, for 36 and 56 months. In one patient, T-tube could not be removed due to laryngeal malacia for more than 12 years.     

球囊扩张术治疗支气管结核气道狭窄的临床价值

目的 探讨经支气管镜球囊扩张术治疗支气管结核气道狭窄的临床应用价值.方法 北京市结核病胸部肿瘤研究所2005年1月至2009年9月经支气管镜球囊扩张术治疗149例支气管结核气道狭窄患者,其中男18例,女131例;年龄16-59岁,平均(32±9)岁.回顾性分析患者治疗前后的临床表现、气道直径及肺复张情况.结果 支气管结核的临床表现不典型,且合并气道狭窄等重症患者较为多见.经球囊扩张后气道直径即刻均有不同程度的增加,狭窄段气道直径由扩张前的(2.7±1.4)mm增至扩张结束时的(6.8±2.0)mm,扩张后3个月和12个月随访时气道直径仍为(6.4±1.7)mm和(6.3±2.3)mm.患者的阻塞性肺炎等症状随气道通畅而缓解或消失.扩张结束后12个月随访结果表明,37例肺不张患者中34例肺复张,再狭窄发生率为3.4%(5/146).治疗前与治疗后3个时段比较,患者气道内径变化和肺复张的差异均有统计学意义(t值为13.09-20.50,均P<0.01),治疗后12个月各项随访结果与治疗结束时和治疗后3个月比较均无明显差别.本组球囊扩张术的成功率为93.3%(139/149),失败率为6.7%(10/149),严重并发症发生率仅为4.0%(6/149).结论 经支气管镜球囊扩张术治疗支气管结核气道狭窄是一种安全、有效的治疗手段.     

气管支气管结核的局部药物治疗进展

气管支气管结核(tracheobronchial tuberculosis,TBTB)临床表现缺乏特异性,检查手段受限,极易漏诊误诊。近年来,随着支气管镜和支气管介入技术的普及和发展,TBTB的检出率大幅提高,治疗手段也日益丰富,除全身抗结核药物治疗外,也发展出了气道内局部给药、球囊扩张、冷冻、热消融及支架置入等治疗技术,但目前尚缺乏统一的操作规范及指导方案。笔者通过总结TBTB局部抗结核治疗、防止气道狭窄的常用方法及耐多药TBTB的局部用药策略,以及近年来新的局部用药方式和新型吸入制剂的研究进展,对TBTB的气道内局部用药策略进行综述,以期为TBTB的局部治疗提供快速有效的组合方案。     

11例儿童气管支气管结核支气管镜诊断与介入治疗效果观察

为观察电子支气管镜诊断与介入治疗儿童气管支气管结核(TBTB)的效果,笔者收集2018年1月至2019年10月于昆明市儿童医院住院并进行支气管镜诊断和介入治疗的11例TBTB患儿作为研究对象。研究对象先通过影像学检查,结核菌素皮肤试验,γ-干扰素释放试验,痰液、胃液查结核分枝杆菌及培养;可疑者再经过支气管镜镜下观察其特异性改变并对活检组织进行病理检查,最终确诊。研究对象在非紧急情况下先行抗结核药物治疗2周后再行支气管镜介入治疗;其中,10例经电子支气管镜行钳夹术、冷冻治疗术治疗,1例经球囊扩张术及钬激光、冷冻治疗。研究对象经支气管镜检查发现肉芽增生性改变3例;干酪样坏死物破溃性改变8例,其中1例并发瘢痕性狭窄。11例患儿经支气管镜治疗2~6次/例,阻塞、狭窄的管腔恢复通畅。经追踪复查,全部患儿均介入治疗有效,均无发生气道痉挛、大出血、气胸、肺部继发感染、结核扩散等并发症。结果表明,TBTB在抗结核药物治疗的基础上,经支气管镜介入治疗可有效清除干酪样坏死物、减少肉芽增生,解除呼吸道梗阻,促进病灶吸收,从而有利于肺不张恢复,且安全可靠。     

经气管镜介入治疗结核性气道狭窄临床分析

目的 探讨目前经气管镜介入治疗结核性气道狭窄的临床效果、并发症及展望.方法 回顾性分析北京天坛医院2006年10月至2008年10月间经气管镜介入治疗结核性气道狭窄的临床资料.结果 目前的介入方法如氩等离子体凝固术、冷冻术、球囊扩张、金属支架放置等联合治疗结核性气道狭窄12例,全部即时效果理想,经治疗后胸闷、气促、咳嗽、咯痰等症状均明显好转,气道直径由治疗前的(2.71±1.89)mrn增加到(8.42±.75)mm(P<0.01).气促指数由治疗前的(2.83±1.14)减少到(0.83±0.69)(P <0.01).远期再狭窄率为75%,对再次介入治疗依然反应良好.结论 目前经气管镜介入治疗结核性气道狭窄是一种可供选择的治疗方法,但远期再狭窄发生率较高.     

气管与主支气管良性狭窄金属支架植入后再狭窄及处理

目的观察良性气管、主支气管狭窄金属支架植入后再狭窄的发生情况,评价球囊扩张、冷冻、高频电凝对再狭窄的疗效。方法对30例良性气管狭窄(A组)、35例支气管结核(EBTB)性主支气管狭窄(B组)者行金属支架植入术,随访观察再狭窄的发生情况,对再狭窄者行球囊扩张、冷冻和高频电凝联合治疗。评价治疗前及病情稳定后狭窄段气道内径、气促指数和肺通气功能。结果(1)A组发生再狭窄者6例,B组发生再狭窄者8例,再狭窄率分别为20%和22.86%。共植入国产支架30枚,6例发生再狭窄,再狭窄率为20%(6/30);共植入Ultraflex支架36枚,8例发生再狭窄,再狭窄率为22.2%(8/36)(P>0.05)。气管上段支架植入再狭窄率为4/9,中下段支架植入再狭窄率为9.09%(χ2=5.114,P<0.05,但χ2c=3.100,P>0.05)。纤维化期EBTB再狭窄率为16.67%,炎症反应期EBTB再狭窄率为60%(χ2=4.564,P<0.05,但χ2c=2.437,P>0.05)。(2)A组再狭窄治疗有效率为4/6,其中上段和中下段分别为2/4和2/2。B组再狭窄治疗有效率为7/8。(3)2组患者病情稳定后与治疗前相比,狭窄段内径均增加,气促指数均下降,肺活量均升高,第1秒钟用力呼气容积均上升。结论良性气管狭窄、结核性主支气管狭窄金属支架植入后有部分患者发生再狭窄。气管上段再狭窄发生率高于中下段,对这部分患者行金属支架植入术时应慎重。处于炎症反应期的EBTB再狭窄发生率高于纤维化期,应尽量避免对这部分患者行金属支架植入术。球囊扩张、冷冻和高频电凝是治疗支架植入后再狭窄的有效方法。     

Response of the tracheobronchial epithelium to hemoprotein tracers

The response of the tracheobronchial epithelium to intratracheal administration of microperoxidase, cytochrome c, myoglobin, and horseradish peroxidase (HRP) was investigated in hamsters and gerbils. Using diaminobenzidine cytochemistry and transmission electron microscopy, we found that cytochrome c was the only tracer to reach lateral intercellular spaces, most probably due to its toxic effect on the airway epithelium. Myoglobin did not bind to the plasma membrane and hence was not internalized by the epithelial cells. Both HRP and microperoxidase were seen in contact with the plasma membrane and within pinocytotic vesicles, the fate of which was not apparent. As early as 5 min after administration, HRP was distributed in a diffuse and intense manner in a small percentage of ciliated and nonciliated cells but by 30 min this effect had decreased significantly. HRP was seen in the basement membrane and lamina propria beneath some intensely reactive cells at 5 and 30 min. Whether these cells reflect a degenerate condition and hence are incapable of excluding HRP or whether HRP is itself toxic is unknown. The rapid rate at which these cells appear raises the possibility that they may represent a conduit that allows small but significant amounts of foreign molecules to reach subepithelial mast cells thus triggering or augmenting the Type I hypersensitivity response. Supported by NIH grant HL-23495     

Surgical treatment and endobronchial stentplacement for tuberculous tracheobronchial strictures

MATERIALS AND RESULTS: We have seventeen cases of operation for the tuberculous tracheobronchial cicatric strictures. Ten of them were tracheobronchial reconstructions to the strictures, and other seven cases were resections of the peripheral destroyed or infected pulmonary tissues (lobectomy 1, pneumonectomy 6). In the reconstructions seven cases were of sleeve lobectomy (left 6, right 1), three were of segmental resection of left main bronchus and trachea. The results were good in 6 sleeve lobectomies and 2 segmental resections of left main bronchus. All these 8 cases had no marked tracheal strictures, and their postoperative troubles were mild. Two cases with tracheal stricture (left sleeve lobectomy and tracheal segmental resection with left pneumonectomy) suffered from postoperative major complications. In the former the tracheal stentplacement was needed for a long time, in the latter its tracheal anastomosis was disrupted and the patient died six months later. Peripheral pulmonary resections could get the good results to disappear their longstanding various symptoms and signs. We tried to do the endoscopic dilatation or stenting to three tracheal strictures. One case was treated by the endoscopic electrocauteries and baloon dilatations totally in 15 times, but its late prognosis was poor and the patient died of the ventilatory disturbance 53 months later. Another one was the case of left upper sleeve lobectomy with tracheal stricture, and already mentioned its tracheal stent. In the third case the tracheal wall was damaged so deeply and extensively that the tracheomalacia might cause to suffocate. Then the tracheal stricture had been dilated with several sized stents step by step, finally a silicon long T-tube was inserted into the trachea successfully. But 10 days later a hard mucous plug impacted inside the tube and the patient died. In recent Japanese literatures and meeting reports, there were sixty cases of endoscopic surgeries and stentplacement for tuberculous tracheobronchial strictures. In these cases about half ones were for the left main bronchus, one third for the trachea. In the former the rupture of bronchial wall happened in 6%, the dislocations of stent in 22% and restrictures came out in 26%. In the latter the complication death occurred in 14%, stent dislocations in 30% and restrictures in 46%, so it was only 30% to become to be free from tracheal stents. CONCLUSIONS: For the treatment of tuberculous cicatric tracheobronchial strictures, the reconstruction of main bronchus in cases without marked tracheal stenosis is a good indication to regain the lost pulmonary function. The resection of peripheral lung is also a good indication to reduce many symptoms and signs from them. However various endoscopic treatments involving stentplacement has not been established yet enough, especially in a point of late prognosis, so we have to be careful to do such procedures. The new apparatus with more durable and easily handled will be expected to develop in near future.     

球囊扩张术治疗结核性气道狭窄的疗效评价

目的探讨球囊扩张术治疗结核性气道狭窄的价值。方法15例结核性气管和支气管狭窄病人,经临床、肺功能评价后,在透视下经纤维支气管镜进行气道球囊扩张术,每周扩张1次,连续3次,多叶狭窄病例采用分段扩张法,评价气道开放、近期疗效和肺功能改善情况。结果15例病人共扩张50次,平均3．3次,气道开放为90．6％,气道直径在扩张前后有显著性差异(t=6．783 0,P＜0．05),扩张后肺功能有明显的改善(t=5．152 7,P＜0．05);6个月内再狭窄率为18％,4例支气管狭窄合用支架。结论球囊扩张术对以纤维疤痕为主的气道狭窄疗效好,以肉芽增生为主的气道狭窄应多次扩张,必要时并用其他手段。球囊扩张术治疗结核性气道狭窄是气道开放、改善肺功能的较好介入手段。