电视硬质气管镜治疗复杂大气道疾病及其基本策略分析

目的探讨硬质气管镜治疗纤维支气管镜无法完成的复杂大气道疾病的可行性。方法 2002年9月～2011年8月的9年间,共计110例复杂大气道疾病接受140次电视硬质气管镜手术治疗,回顾性分析所有患者的临床资料并行系统随访。术前均接受过至少一次纤维支气管镜检查及内镜下治疗,因效果欠佳或治疗失败而选择接受硬质气管镜手术,均属于复杂大气道疾病。结果无围手术期死亡及严重并发症。病变位于气管55例,右主支气管29例,左主支气管20例,隆突6例。病理诊断良性病变42例,恶性病变68例。手术方式为内镜下病变剜除75次,病变完全切除30次,气道内瘢痕清除15次,异物取出11次,支架放置或取出9次。8例恶性肿瘤和1例平滑肌瘤患者在硬质气管镜清除气道病变后即刻同期行开胸行根治性手术。内镜操作时间32～120 min,（52.5±23.9）min,术后住院时间1～12 d,（3.3±3.0）d。术中出现少量出血（150 ml）1例,一过性低氧血症2例,牙齿脱落2例,经对症治疗好转。截至2012年9月,8例良性和5例恶性患者失访,随访率88.2%（97/110）。34例良性病变随访时间13～110个月,平均51.5月,3例外伤后气管瘢痕患者（3/10）于术后1个月出现再狭窄并接受多次手术治疗,其余均无复发。63例恶性病变随访时间14～75个月,平均25.9月;其中8例开胸根治性切除者无瘤生存时间（DFS）均超过12个月,生存期最短13个月（神经内分泌癌）,最长75个月（类癌）;51例肿瘤清除术后带瘤生存者生存期最短3个月（腺癌）,最长达71个月（腺样囊性癌）;9例支架置入者中2例于术后1个月因其他疾病猝死,1例外伤后气道瘢痕形成患者存活至今（84个月）,其余6例恶性患者生存3～10个月。结论经选择合适的适应证以及治疗策略,电视硬质气管镜手术可适用于多数复杂大气道疾病,并可作为特定患者的首选治疗措施。

Strategy of Video-assisted Rigid Bronchoscopy in the Treatment of Complex Tracheobronchial Disease

Objective To assess the feasibility of video-assisted rigid bronchoscopy in the treatment of complex tracheobronchial disease that is difficult for fibrous bronchoscopy. Methods From September 2002 to August 2011, totally 110 patients with complex tracheobronchial disease, who were failed in fibrous bronchoscopic operations, were enrolled into this study. Totally 140 operations by using video-assisted rigid bronchoscopy were performed on the patients. All the clinical and follow-up data of the patients were analyzed. All of the patients received at least once examination by fibrous bronchoscopy and endoscopic treatment before the procedure. Results There was no mortality or major morbidity perioperatively. The lesion was located at the trachea in 55 cases, at the right main bronchus in 29 cases, the left main bronchus in 20 cases, and the earina in 6 cases. Pathological examination revealed benign lesions in 42 patients and malignancy in the other 68. The operations included lesion clearance （75 times） , radical resection （30 times） , scar clearance （15 times） , foreign body removal （11 times） , and stent insertion or removal （9 times）. Thoracotomy was carried out immediately after removing the airway lesions in 9 patients for malignant cancer （8 patients） or leiomyoma （l patient）. The operation time for endoscopy was （52.5 ± 23.9） min in average （ranged from 32 to 120 min）. The patients were discharged from hospital after the surgery in a mean of （3.3 ± 3.0） d （ranged from 1 to 12 d）o Mild hemorrhage, transient hypoxemia, and tooth loss occurred in one, two, and two patients respectively during the procedure; all of these patients were cured by conservative treatment. Until September 2012, the rate of follow-up was 88.2% （97/110） , 8 patients with benign lesions and 5 patients with malignancy were lost. A follow-up for a mean of 51.5 months （13 -110 months） was achieved in 34 patients with benign lesions. Three patients who had trauma-caused tracheal scars （3/10） developed restenosis in one month after the surgery, andthus received several sessions of reoperation, the other patients showed no recurrent stenosis. 63 patients with malignancy were followed up for 14 to 75 months with a mean of 25.9 months; among the patients, the 8 who received thoracotomy all showed a DFS over 12 months （the shortest was 13 months in a patient with neuroendocrine carcinoma, and the longest one was 75 months in a patient with carcinoid tumor）. The overall survival of the 51 cases of tumor clearance were longer than 3 months, and the shortest and longest survival time were 3 and 71 months in a patient with adenocarcinoma＇and a one with adenoid cystic carcinoma respectively. Among the 9 patients who received stent grating, 2 died of other diseases in one month, 6 patients survived for 3 to 10 months, and the other one was still surviving when this article was submitted （84 months）. Conclusions With appropriate indications and treatment strategy, video-assisted rigid bronchoscopy is a safe and effective choice for most complex tracheobronchial diseases, and is a preferred choice for some certain patients.