局部麻醉支气管软镜下氩气刀治疗中心气道阻塞性病变的困难

目的观察评价局部麻醉支气管软镜下氩等离子体凝固（argon plasma coagulation，APC简称氩气刀）治疗中心气道阻塞性病变的困难。方法局部麻醉支气管软镜下应用ERBE的APC300型氩气刀治疗中心气道阻塞性病变，观察治疗中的困难。结果2003年11月～2006年1月，28例中心气道阻塞的患者，共接受APC治疗71例次。术中遇到的主要困难如下。3例气管严重堵塞的患者，1例在APC治疗中少量出血，患者不愿承担手术风险而放弃继续手术，另2例术中窒息，其中1例改用全身麻醉完成手术，另外1例双侧主支气管严重堵塞未完成手术；肿物完全堵塞气道超过4cm以上的7例患者，每例患者短期内都进行了多次长时间APC治疗。患者难以耐受，其中3例被迫改用全身麻醉；8例患者在15例次的治疗中，靶组织结构不清，通过优先凝切、剥离管腔中心病变和分次治疗完成治疗；12例病变广泛的患者，在24例次的治疗中，清创费时，使用冷冻探头清创缩短了时间。3例因伴有软骨环损害气道塌陷和管壁外压，联合使用气道支架方才缓解了气道阻塞。结论局部麻醉软镜下氩气刀治疗气道阻塞性病变有一些困难，应该选择风险小、短时间能完成的手术。靶组织结构不清需要采取分次治疗。清创费时，冷冻探头能缩短清创时间。其局限性决定了软骨环损害致管壁塌陷和管壁外压者需联用支架。

Difficulty of endobronchial argon plasma coagulation for treating airway obstruction via the flexible bronchoscope under local anesthesia

Objective To evaluate the difficulty of endobronchial argon plasma coagulation (APC) for treating central airway obstruction (CAO) with the flexible bronchoscope under local anesthesia. Methods Endobronchial therapy with APC 300 made by ERBE in Germany was performed via flexible bronchoscopy under local anesthesia for patients with CAO. The difficulty of APC therapy was recorded. Results From November 2003 to October 2005,28 patients underwent 71 endobronchial APC procedures. Main difficulties were as follows. 3 cases with serious trachea stenosis caused by carcinoma,little bleeding during APC procedures,1 did not take possible risk caused by APC procedure and gave up continuing treatment; asphyxia happened to other 2 patients during treatments,and 1 of these 2 patients had to be administered general anesthesia for continuing APC procedure. 1 patient with severe bilateral mainstem bronchi stenosis could not bear APC procedure under local anesthesia. Tumor length was >4.0 cm in 7 cases,each patient underwent several long-time APC procedures during a short period,every case was very difficult to bear it,and 3 out of 7 patients had to be administered general anesthesia for following operations. The margin between tumor and normal airway was vague in 8 cases,it might get clear after removing necrotic tissue caused by APC in the centre of the tube,so ablating tumor needed to be divided into several APC procedures. The removal of the necrotic tissue with flexible forceps was an arduous and time-consuming task,and it got easier after using the cryotherapy probe as forceps. Combination of stents to open airway in 3 cases with airway stenosis caused by extrinsic compression or tracheobronchial cartilage lesions. Conclusion There are some difficulties for endobronchial APC to treat CAO lesions via a flexible bronchoscope under local anesthesia. Those patients with low risk and short duration operation should be selected. Ablating tumor needs to be divided into several APC procedures if tumor and normal tissues can not be identified. If the probe of cryotherapy is used as forceps to clean necrotic tissue,operating time can be shortened.