内镜下支架置入术治疗大气道狭窄的体会

大气道狭窄可由良、恶性病变引起,重度狭窄时患者出现呼吸困难、难治性呼吸感染等,甚至危及生命;为了缓解呼吸困难等症状、改善其生活质量和进一步治疗争取时间,可对此类患者置入气管内支架。我院于1998年12月至2004年12月在纤维支气管镜(简称纤支镜)直视下置入镍钛合金(N-T)支架治疗大气道狭窄患者23例,取得较好效果,现将体会总结如下。1资料与方法1.1资料患者23例,男10例,女13例;年龄39-74岁,平均年龄56岁。原发病:气管癌4例,气管息肉1例,支气管肺癌11例,食管癌8例,其中1例气管癌侵及隆突及左、右主支气管,气管下端及左、右主支气管均重…     

气管肿瘤经纤支镜置入支架治疗

目的探讨气管肿瘤经纤支镜支架置入治疗技术的应用价值。方法12例中晚期气管肿瘤引起气道恶性狭窄,通过纤支镜及胸部CT扫描发现气管肿瘤,均有不同程度吸气性呼吸困难。12例均采取在X线透视下经纤支镜置入支架。结果12例均成功置入支架,狭窄气道明显撑开,呼吸困难立即改善。患者1至6个月随访,10例支架无移位、塌陷或阻塞,2例肿瘤向支架内生长,引起支架内再阻塞。12例术后均进行放、化疗。结论对失去外科手术治疗机会的中晚期气管肿瘤所引起的气道恶性狭窄,经纤支镜置放支架治疗能迅速解除气道狭窄,为进一步治疗提供机会。     

气管狭窄的急诊支架置入治疗

目的 :评价急诊支架置入治疗气管狭窄的临床效果。方法 :对 16例因恶性肿瘤 (气管或支气管癌、食管癌、肺癌、纵隔肿瘤 )致气管狭窄的患者 ,在X线下经纤支镜放置镍钛记忆合金支架。结果 :16例中放置气管支架 14例 ,支气管支架 2例 ,均置入成功。所有病例支架置入后呼吸困难即刻好转。随访观察 3～ 2 6个月 ,8例经放化疗仍存活者 ,无呼吸困难及支架移位。结论 :采用气管支架急诊治疗气管狭窄是十分有效的方法     

^125Ⅰ粒子气管支架治疗癌性气管狭窄疗效观察

目的观察125Ⅰ粒子气管支架治疗癌性气管狭窄的临床疗效。方法将49例不适合外科手术治疗的癌性气管狭窄患者分为两组,观察组25例经纤支镜置入125Ⅰ粒子气管支架（粒子支架）;对照组24例经纤支镜置入普通气管支架（普通支架）,术后行放疗。结果两组均顺利置入支架,术后呼吸困难立即缓解。与对照组比较,观察组放疗毒性反应小,术后气管再狭窄率明显降低（P〈0.05）。结论 125Ⅰ粒子气管支架治疗癌性气管狭窄安全、有效,毒性反应小,局部复发率低。     

经纤支镜同时置入气管支架和食管支架治疗气管和食管狭窄

气管金属支架和食管金属支架近年逐步应用于临床，对呼吸困难和吞咽困难症状均能起到缓解症状，解除患者痛苦的作用。但经纤支镜单独置入气管支架和胃镜置入食管支架报道颇多，经纤支镜同时置入气管支架和食管支架的报道少见。2002年6月至2003年10月，我们用此方法治疗晚期癌症所致气管食管双狭窄患者10例。现报告如下。     

左主支气管内支架置入术的护理

气管及支气管狭窄多因肿瘤或支气管内膜结核引起 ,患者常会出现呼吸困难。阻塞性肺气肿、肺不张 ,严重影响患者的呼吸功能。通过气管或支气管内支架置入 ,也能有效地改善患者的肺功能 ,提高患者的生活质量。我科于今年 11月初收治了一例因支气管内膜结核导致左主支气管狭窄的患者 ,在电透下行左主支气管内支架置入术 ,使狭窄的支气管重新扩张 ,明显改善了通气功能。现将在该患者治疗中的护理体会介绍如下。临床资料患者男性 ,37岁 ,患有支气管内膜结核、肺结核 6月余 ,经抗痨治疗 (方案为 2 HREZ/4HR)肺内病灶完全吸收 ,胸部 CT显示 :左…     

纤支镜和透视下放置支架治疗肿瘤性重度气道狭窄

目的观察纤支镜联合透视导向下放置镍钛记忆合金支架治疗晚期肿瘤导致的气道狭窄的疗效。方法选取6例因晚期肿瘤所致气管或支气管重度狭窄的患者,在纤支镜联合透视导向下放置镍钛记忆合金支架。结果6例患者置入支架后呼吸困难立即缓解,一般情况好转,收到立竿见影的效果。3～7d复查纤支镜支架无移位,管腔通畅。结论使用镍钛记忆合金支架治疗晚期肿瘤引起的气道狭窄的疗效可即刻缓解气道狭窄和改善患者生活质量,方法简单,易行,疗效可靠。     

纤维支气管镜联合胸部CT对周围型肺癌的诊断价值

目的探讨胸部CT联合纤支镜在周围型肺癌中诊断和肺癌分期中的价值。方法24例肺癌患者均做胸部CT及纤支镜检查,9例加做经皮肺穿刺针吸活检术,加上手术标本,24例患者均取得病理标本。结果CT“支气管征”阳性的7例中5例经纤支镜活检阳性,阳性率70％。肿瘤直径〈3cm的经纤支镜活检均为阴性。经纤支镜活检阳性的6例中,肿瘤位于肺中心5例,肺外周仅1例。经纤支镜活检阴性的18例中13例肿瘤位于肺外周,5例位于肺中心。4例胸部CT示结节状改变,手术证实为腺癌。24例患者的胸部CT中均未发现有大气道的浸润,但纤支镜检查发现有2例肿瘤近端在段支气管开口,1例叶支气管近端。结论胸部CT阳性“支气管症”能预测经纤支镜活检的阳性率。肺癌新国际TNM分期标准,使腔内病变的发现更趋重要,故周围型肺癌联合纤支镜检查是必要的。     

经纤维支气管镜诊治支气管结核临床分析

目的探讨经纤维支气管镜诊断、治疗支气管内膜结核的价值。方法 47例患者采用日本Olympus BF-P20型纤维支气管镜刷片检查抗酸杆菌和病理检查诊断为支气管内膜结核,并于纤支镜下局部多点注射异烟肼治疗。结果 47例患者根据纤支镜下表现可分为浸润型9例,溃病型16例,增殖型15例和纤维狭窄型7例;发病部位:左上叶气管受累10例,左舌叶气管受累10例,左下叶气管受累9例,右上叶气管受累7例,右中叶气管受累6例,右下叶气管受累5例;经纤支镜局部注射药物治疗后症状好转,糜烂、坏死、溃疡、息肉病灶消散。结论纤支镜检是支气管内膜结核最重要的检查方法之一。经纤支镜多点药物局部注射治疗是支气管内膜结核有效治疗手段。     

气管支架植入腔内近距离放疗气道狭窄的临床研究

大气道狭窄常为恶性肿瘤的急危重症之一，需行紧急气管或支气管支架植入术治疗，但支架植入术后肿瘤组织生长可使支架压扁或肿瘤组织沿网孔生长，致呼吸困难症状短期内复发，故单纯行支架植入术仅为临时缓解症状的手段之一，为取得较长时间的治疗效果，常需结合其它治疗方法，有鉴于此，我们对18例因恶性肿瘤致气道狭窄的患者行支架植入术后进行了经纤支镜介入后装放疗，结果报道如下。     

自膨式金属气道支架的并发症分析及处理方案

自膨式金属气道支架可迅速扩张气道,改善通气,有效缓解多种原因所致的气道狭窄症状,广泛应用于良恶性气道狭窄.其置入后常见并发症有支架内肉芽组织形成、分泌物潴留、支架相关的气道感染、支架移位、支架断裂等.提高支架的组织相容性、促进气道上皮化及适时置入及取出支架可减少肉芽组织形成.本文就镍钛记忆合金气道支架的相关并发症及其治疗方法进行论述,并着重分析肉芽组织形成的机制及处理方法.     

Palliative treatment of malignant esophageal stenosis: the role of self-expanding stent endoscopic implantation

Endoscopic tube implantations were carried out in 40 patients with malignant stenosis of the esophagus and gastric cardia using self-expanding metallic stents. The indications for endoscopic intubation were the advanced stage of the tumor in 27 cases and risk factors that made resection inadvisable in 13 cases. In three patients, it proved impossible to implant a stent endoscopically because we were not able to pass the guide wire through the stenosis, whereas correct stent placement was achieved in 37 cases. Functional results were good in 33 patients, but four patients did not show any improvement of symptoms. Complications occurred in nine patients (24.3%): two bleedings, three neoplastic obstructions, one food obstruction, and three distal dislodgements of the prosthesis were observed, but could be readily corrected. No deaths occurred. The median survival time was 151 days (range 25-545 days). This study suggests that endoscopic placement of metallic self-expanding stents is safe and is to be preferred to plastic stents for easier implantation and lower morbidity.     

Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence

Bronchial dehiscence after lung transplantation is difficult to treat and associated with high mortality. We describe our experience using self-expanding metallic stents to treat post-lung transplant bronchial dehiscence. From January 1995 to June 2004, 189 single and 118 double lung transplants were performed in our institution, totaling 425 at-risk bronchial anastomoses. Seven (1.6%) incidents of life-threatening bronchial dehiscence were treated with self-expanding metallic stents. The interval between transplant and diagnosis of dehiscence was 29.1 +/- 18.5 days. All patients presented with respiratory distress, and three required mechanical ventilation. Self-expanding metallic stent placement resulted in complete bronchial healing. All three patients with respiratory failure requiring mechanical ventilation were successfully weaned after stent placement. In two later cases, the stents were electively removed after adequate healing of the dehiscence. Complications included stent migration (one patient) and in-stent stenosis (three patients). Two of these patients required repeat stent insertion after removal, due to bronchomalacia. In patients with life-threatening bronchial dehiscence, self-expanding metallic stents offer prospects for a successful outcome. Self-expanding metallic stents are known to be associated with significant granulation tissue formation, and this property provides a platform for healing of dehiscence and, in time, peribronchial soft tissue grows in to cover the defect, allowing stent removal.     

Tracheal restenosis after removal of long-term placed Ultraflex expandable metallic stents

Restenosis of trachea after stent placement and removal in patients with malignant airway obstruction has rarely been reported. Here, we reported a 47-year-old woman with large B cell lymphoma at the mediastinum. It was obstructing the trachea and left main bronchus. Two Ultraflex expandable metallic stents were placed immediately due to acute respiratory distress. She underwent concurrent chemoradiotherapy for the lymphoma with good response. Because granulation tissue overgrew the upper margin of the trachea stent and caused frequent sputum impaction, stents were removed after 21 months. Dyspnea developed 8 months later. Bronchoscopy revealed restenosis from granulation tissue and fibrosis at the previous upper margin of the trachea stent. Segmental resection of trachea with primary anastomosis was performed and the patient recovered. Thus, tracheal restenosis may still occur in malignant obstruction patient undergoing Ultraflex stents insertion. Surgery remains a feasible treatment if underlying malignancy is in remission.     

Placement of self-expanding metallic stents in the pancreatic duct for treatment of obstructive complications of pancreatic cancer

BACKGROUND: Stents have been placed through malignant pancreatic strictures, mainly to alleviate pain of presumed obstructive origin. Self-expanding metallic stents have major advantages over plastic stents when used for treatment of malignant biliary strictures. However, there are few reports of their use in patients with malignant pancreatic duct strictures, especially those with complications related to ductal obstruction. METHODS: Self-expanding metallic stents were placed in the pancreatic ducts of 3 patients with obstructive complications of pancreatic cancer: smoldering pancreatitis, a disrupted pancreatic duct with pseudocyst caused by open surgical biopsy, and a disrupted pancreatic duct with fistula and resultant liver abscess. All 3 patients had metallic stents placed concomitantly in the biliary tract; one had enteral stents placed as well. Clinical and pathology records and imaging studies were reviewed retrospectively. OBSERVATIONS: In all cases, there was resolution of the specific clinical problem and reasonable survival (1.5 years in one patient). CONCLUSIONS: The use of self-expanding metallic stents for treatment of certain obstructive complications of pancreatic tumors is feasible and effective.     

Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies

INTRODUCTION: The treatment of malignant obstruction of the left colon or rectum usually requires emergency surgery on poor-risk patients, and the creation of a stoma is usually inevitable. With the use of self-expanding metallic stents, the prompt relief of large-bowel obstruction without surgery has become possible. This report describes our results in the use of self-expanding metallic stents in the treatment of left-sided colonic obstruction resulting from advanced malignancies. METHODS: From November 1997 to March 1999, insertion of self-expanding metallic stents was attempted in 24 patients with acute left-sided colonic obstruction caused by primary or recurrent malignancies. All the procedures were performed by colorectal surgeons. The guidewire was inserted through the channel of the endoscope, and its position was confirmed with fluoroscopy. Uncovered Wallstent® esophageal endoprostheses were used in all except the first case. The insertion and deployment of the stents were under both endoscopic and fluoroscopic guidance. RESULTS: There were 24 patients (15 males) with a mean age of 63.6 (range, 36–98) years. Thirteen patients had primary colorectal cancer and 11 had recurrent cancers (colorectal cancer, 5; gastric cancer, 5; other, 1). In the treatment of primary colorectal cancer, seven procedures were palliative, and no subsequent surgery was planned because of extensive liver metastasis or poor medical risk. The other six patients underwent elective resection after mechanical bowel preparation. There was no mortality related to the procedure. Stenting was successful in the relief of obstruction in 23 patients. Perforation of the colon occurred in one patient, and an emergency Hartmann's operation was performed. Migration of the stents occurred in three patients. Only 3 of the 18 patients in the palliation group required the subsequent creation of stomas. CONCLUSION: The use of the self-expanding metallic stents can achieve rapid and effective nonsurgical means to relieve left-sided colonic obstruction. It provides good palliation for unresectable advanced tumors that cause colonic obstruction. It may also have a role in the temporary relief of obstruction so that subsequent colonic resection can be performed under elective conditions.Poster presentation at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Successful endoscopic ultrasound-guided overstenting biliary drainage through a pre-existing proximal migrated metal biliary stent

Biliary endoscopic drainage using metallic self-expanded stents has become a well-established method for palliative treatment of malignant biliary obstruction. However, its occlusion, mainly by tumor overgrowth, is still the main complication without a standard treatment. We here describe a new method of treatment for biliary metallic stent occlusion, through the echo guided biliary drainage. We present a 68-year-old patient with metastatic pancreatic cancer previously treated for jaundice with ERCP and self-expandable metallic stent insertion. Four weeks later, the patient developed jaundice and symptoms of gastric outlet obstruction. A new ERCP confirmed obstruction of the second portion of the duodenum, due to diffuse tumor growth. EUS was performed, and the previous metal biliary stent was seen occluded at the distal portion in the common bile duct. A EUS-guided choledocododenostomy was performed and then, an overlapping self-expanding metal enteral stent was placed through the malignant obstruction. There were no early complications and the procedure was also clinically effective in relieving jaundice and gastric outlet obstruction symptoms. If ERCP fails in the management of occluded biliary metallic stents, EUS biliary drain can provide effective biliary decompression and should be considered an alternative to other endoscopic techniques.     

Airway stenting for the treatment of laryngotracheal stenosis secondary to thyroid cancer

Background and objective:   Airway stenting can be a valuable therapeutic option for symptomatic airway stenosis, but its role in the palliation of advanced thyroid cancers invading the upper airway is unclear. This study examined the hypothesis that durable and replaceable silicone stents would give better results than self-expanding metallic stents.
Methods:   A retrospective analysis was conducted of consecutive patients stented for laryngotracheal obstruction due to thyroid cancer. Stenting was performed via a rigid bronchoscope when airway patency after dilatation was ≤50% of normal. Symptomatic improvement, Hugh-Jones (H-J) classification, Eastern Cooperative Oncology Group performance status (PS), and complications were analysed.
Results:   There were 37 stenotic lesions treated in 35 patients. The most common sites for these lesions were in the inclusive area extending from the cricoid cartilage to the first tracheal ring (26/37 lesions, 70%). Forty-five stents (12 silicone, 20 metallic, 13 T-tubes) were used in 43 interventions. All patients showed immediate symptomatic relief and significant improvement in both PS and H-J classifications. Critical complications were supraglottic stenosis (5/43 interventions, 12%) and, of those same five cases, stent migration was seen in all but one (4/45 implantations, 9%). As these complications occurred only in patients in whom the silicone stents had been placed in close proximity to the cricoid cartilage (5/10 patients, 50%), this emphasizes the unsuitability of silicone stents in such cases. The median survival time from stenting was 8 months. The 1-year survival rate was 40%.
Conclusions:   Airway stenting can achieve significant palliation in patients with thyroid cancer and airway obstruction. The study showed that for the most common lesions, the uncovered Ultraflex stent is associated with fewer critical complications than the silicone stents.     

Airway stenting: Technological advancements and its role in interventional pulmonology

AS offers rapid and sustained relief of symptoms in most patients treated for malignant or benign CAO and can also be curative in itself in cases of benign tracheobronchial stenosis. In the past 30 years, this field has seen significant progress, from the misuse of vascular non‐covered metallic stents to the development of silicone airway stents with an increasingly large panel of shapes and of hybrid, partially or fully covered, SEMS customized to the airways. This study aims to offer an overview on: (i) the respective advantages and drawbacks of these two main categories of devices; (ii) the main indications for AS and the rationale behind the choice of stent in each situation; and (iii) the main promises borne from the progress made in the field in the past few years, including the development of drug‐eluting, biodegradable or patient‐specific customized AS.     

累及气道的复发性多软骨炎的临床特征及其处理

目的提高对侵犯气管、支气管的复发性多软骨炎的临床特征及治疗方法的认识。方法回顾性分析2000年8月至2006年10月收治的13例侵犯气管、支气管的复发性多软骨炎患者的临床资料。结果13例累及气管、支气管的复发性多软骨炎患者中男9例，女4例，年龄30-61岁，平均年龄50岁。疾病早期临床表现以咳嗽、咽喉痛及声嘶多见，疾病后期常表现为胸闷、气促、呼吸困难，重者可表现为下呼吸道反复感染和（或）呼吸衰竭。支气管镜检查早期可见喉、声带水肿，气管、支气管黏膜充血、水肿，软骨环肿胀及管腔狭窄；疾病后期由于气管、支气管软骨破坏而出现气道软骨环消失，管壁软化，呼气时部分气道陷闭。胸部CT检查早期可见气管、支气管壁弥漫性增厚伴管腔狭窄；疾病后期出现管腔重度狭窄，部分患者可有气道壁的钙化。肺功能测定表现为不同程度的阻塞性通气功能障碍。13例患者中有12例患者接受了糖皮质激素和（或）免疫抑制剂治疗，其中6例疾病早期患者症状均有不同程度的改善，其余6例患者症状无改善，在给予气道金属支架置入后（共放置气管、支气管支架12枚）5例患者气道阻塞明显改善，1例无缓解，仍需呼吸机辅助通气。随访1—48个月后有12例存活，1例随访2年后死亡。结论侵犯气管、支气管的复发性多软骨炎患者疾病早期糖皮质激素治疗可显著改善症状，疾病后期出现明显气道阻塞时可行支架置入、气管切开及呼吸机辅助通气治疗，以延长生存期。