不可切除气管、支气管内肿瘤的纤维支气管镜CO_2冷冻治疗

Fibro-bronchoscopic Cryosurgery for Unresectable Endobronchial Tumors

背景与目的气管、支气管肿瘤性的狭窄或闭塞,大多发生于病程的晚期,患者会出现十分痛苦的症状,如呼吸困难、咯血、阻塞性肺炎和顽固性高热。全身情况较差,心肺功能受限,原发灶和转移灶均不能耐受根治性手术切除。呼吸道梗阻严重影响了生存质量,甚至引起呼吸衰竭导致死亡。因此,一种能够有效解除梗阻的治疗方法就显得尤为重要。我们选择在纤维支气管镜下运用二氧化碳(carbon dioxide,CO2)冷冻技术对气管、支气管腔内肿瘤进行切除,探讨其治疗效果。方法对126例气管、支气管肿瘤进行冷冻治疗(2004年8月-2014年2月),观察近期及远期治疗效果。术前需要进行计算机断层扫描(computed tomography,CT)加气管、支气管的三维重建,纤维气管镜检查后评估冷冻的部位和深度;术中采用全麻或表面麻醉加静脉强化,置入纤维支气管镜至肿物上端约0.5 cm,后将软式冷冻探头经支气管镜活检孔插入。冷冻探头的金属末端置于肿瘤中心,冷冻约30 s-120s,冷冻温度-50 oC--70 oC。在冷冻后未完全溶解前"撕脱"切除肿瘤(冻切法)或者冻时间4 min-6 min后通过负压吸引清除冷冻后坏死的肿瘤组织(冻融法),两种方法相结合可以较为彻底地清除气道内肿瘤,直至管腔通畅。2周后复查气管镜,决定是否需要再次冷冻治疗。结果患者咳嗽、呼吸困难、咯血均有不同程度缓解,显效率为65.1%,总有效率77.0%。围手术期死亡1例,术后气道内出血2例,支气管瘢痕狭窄4例,气管烧灼伤2例,气管软化2例,心房纤颤3例。中位生存期为14个月,1年、2年、3年的生存率分别为58.6%、24.2%、12.2%。结论纤维支气管镜CO2冷冻技术是一种十分简便而有效的微创治疗方法。治疗管腔内生长的中央型气道肿瘤,可以去除肿瘤阻塞气道的部分,重新疏通管腔,迅速控制和缓解气道梗阻所导致的症状,显著提高生存质量。部分患者可以解决麻醉气管插管问题,为下一步治疗创造条件,从而达到根治性切除原发肿瘤的目的。

Background and objective Patients with tracheobronchial tumor are too frail for curative surgical treat-ment, and the original sites are unsuitable for radical resection. hTey always suffered from dyspnea, hymoptosis, obstructive pneumonia, and fever. Airway obstruction has a strong bad impact on the quality of life, and is the main cause of respiratory failure and death. An effective method of palliative is very important. We choose ifbro-bronchoscopic cryosurgery for destruc-tion of endobronchial tumors and analyze the outcomes. Methods Clinical records of 126 cases who under went endobroncho-scopic cryosurgery were reviewed retrospectively from August 2004 to February 2014. Techniques and survival outcomes were analyzed. hTe precise position and length of the cryosurgery was evaluated through three dimension chest computed tomog-raphy （CT） and reconstruction of trachea and bronchus. Local inifltration and general intravenous anesthesia are two options before surgical procedure. Endobronchial tumor was removed by combining two methods of“Cryo-Resecion”and“Cryo-Melt”. Bronchoscopic examination was rechecked 2 weeks later to evaluate if it is necessary to redo the endobronchoscopic cryosur-gery. Results hTe symptoms of cough, short of breath, and hemoptysis were alleviated to different extend. hTe rate of dramati-cally improved and partial improved were 65.1%and 77.0%respectively. hTe mortality is 0.79%. Postoperative Complications included 2 cases of airway bleeding, 4 cases of bronchial stenosis, 2 cases of trachea burning injury, 2 cases of tracheomalacia, and 3 cases of atrium ifbrillation. hTe median survival is 14 months, 1-, 2-, 3-yr survival rates were 58.6%, 24.2%, and 12.2%respectively, based on Kaplan-Meier estimates. Conclusion Endobronchial cryosurgery is an easy and effective minimally invasive choice for controlling and releasing the airway obstructive symptoms resulting from the trachea or bronchial tumors. Besides, the problem of diffcult endotracheal intubation could be resolved atfer removing the tracheal tumor with the beneift of cryotreatment. Some patients could get the chance for further treatment or radical resection. hTerefore, the patients’ quality of life could be improved and the lifetime could be prolonged.