氩等离子体凝固联合分叉型被膜金属内支架置入治疗气管隆突周围复合狭窄和气管食管瘘

Argon Plasma Coagulation Combined with Covered Stent Placement for Management of Tracheobronchial Stenoses/occlusions as well as Esophagorespiratory Fistulas

背景与目的气管下端、隆突和双侧主支气管发生的狭窄称为多发性狭窄或复合狭窄,治疗非常棘手。本研究旨在探讨氩等离子体凝固(argon plasma coagulation,APC)联合分叉型被膜金属内支架(covered Z-type stents,CZTS)置入治疗气管隆突周围狭窄和气管食管瘘的安全性和疗效。方法回顾性分析32例气道病变的患者,在支气管镜引导下行APC,在X线透视和/或支气管镜引导下置入CZTS。结果 19例伴有气道狭窄的患者先行APC,术前气道狭窄发生率为57.4%-72.1%,术后均明显缓解(气道狭窄发生率仅为12.8%-25.8%)。32例患者中30例技术上成功放置32个支架,2例失败。APC及成功放置支架的患者术后气促指数明显下降,KPS明显升高。13例气管下端瘘口置入分叉型CZTS,12例(92.3%)达临床治愈。术中、术后未出现大出血等并发症。两种术式术后短期内均产生大量分泌物,用气管镜可有效清除。置入内支架的患者1个月后易在支架两端形成肉芽,用APC结合冷冻可有效处理。结论使用APC联合CZTS置入治疗气道复合狭窄和气管食管瘘快速有效,安全可靠。

Background and objective It is a complex problem and difficult treatment for tracheobronchial stenoses/occlusions involving in carina.The aim of this study is to investigate the feasibility and efficiency of argon plasma coagulation（APC） and bifurcated covered Z-type stents（CZTS） placement for the treatment of tracheobronchus stenoses and esophagorespiratory fistula（ERF）.Methods Thirty-two cases with airway disorders were retrospectively reviewed for the treatment of APC and CZTS placement.Under the bronchoscopic guidance,APC was first given in patients with airway stenoses,then CZTS was placed under the fluoroscopic and flexible bronchoscopic guidance either with airway stenoses or ERF.Results APC was first given in 19 patients with airway stenoses.Airway structures were significantly improved after APC procedure（57.4%-72.1% before APC vs 12.8%-25.8% after APC）.Thirty-two CZTS were technically successfully placed in 30 out of 32 cases involving in carinal bifurcation.After APC and stent placement,short breath index was significantly reduced and karnofsky physical score（KPS） increased obviously.The endobronchial defects were successfully palliated with bifurcated CZTS placed under fluoroscopy and flexible bronchoscopy in 12 out of 13 patients with ERFs.There is no bleeding introprocedure.Mucous retention was very common in all types of the stents less than 2 weeks after stenting,which required debridement by bronchoscopy and could be prevented by normal saline solution nebulizations.Granuloma developed at the ends of stents after 1 month of stenting which all of them were treated successfully with APC and CO2 cryosurgery.Conclusion Utilization of APC and retrieval bifurcated CZTS placement is a simple and safe protocol for the management of airway complex stenoses involving the tracheal carina and ERF.