肺移植术后气道狭窄并发症的诊断和治疗

Diagnosis and treatment of airway stenosis after lung transplantation

目的探讨肺移植术后气道狭窄并发症的诊断和治疗。方法回顾性分析2002年9月至2010年12月间100例肺移植受者的临床资料。100例受者中，接受单肺移植者72例，接受序贯式双肺移植者28例，共有128个气管吻合口。2007年5月前术中支气管吻合均采用套人式，2007年6月后均采用间断吻合。术后对所有受者进行长期随访，监测受者的肺功能，并根据临床需要及时行胸部CT和纤维支气管镜等检查。结果共有10例受者的12个气管吻合口出现狭窄，发生率为9．4％（12／128）。发生时间为术后（60．1±35．6）d（15～120d），中位时间为术后59d，均经纤维支气管镜等检查明确诊断。纤维支气管镜引导保护性毛刷培养阳性8例次，其中铜绿假单胞菌阳性3例，肺炎克雷伯菌阳性2例，曲霉阳性2例，以及大肠埃希菌阳性1例。10例发生气道狭窄的受者均采用了纤维支气管镜球囊扩张治疗，有5例联合应用了高频电切治疗，4例植入金属支架，1例应用氩气刀治疗。经治疗后，7例好转，3例死亡。结论肺移植术后气道狭窄并发症严重影响受者的存活，纤维支气管镜检查是诊断的“金标准”，纤维支气管镜下球囊扩张为首选治疗，其他治疗方式还包括高频电切、氩气刀和金属支架植入等。

Objective To analyze the diagnosis and treatment of airway stenosis in a consecutive series of bronchial anastomosis after lung transplantation in our center. Methods We performed a retrospective study on 100 cases of lung transplants in our center from September 2002 to December 2010. Seventy-two cases were subjected to single lung transplants （SLT）, and twenty-eight to bilateral sequential single lung transplantation （BSSLT）. There were totally 128 bronchial anastomoses. All recipients received long-term follow-up to monitor the lung function. Lung CT and fibrobronchoscopic examinations were done when necessary. Results Twenty-five cases with 37 bronchial anatomoses were died. A total of 12 airway stenosis occurred in 10 cases （12/128, 9. 4 %）. Four cases underwent telescopic anastomosis and 6 cases underwent end-to-end anastamosis. Mean diagnosis time was 60.1 35.6 days post-operation （ranging from 15-120 days, median 59 days）. There were 8 cases of unilateral airway stenosis （3 on the left, and 5 on the right） and 2 cases of bilateral airway stenosis. The number of simple airway stenosis was 3, that of exophytic granulation tissue was 8, and that of bronchus intermedius stenosis was i. Culture of bacteria by fibrobronchoscopy with protected specimen brush revealed： 3 strains of Pseudomonas aeruginosa, 2 strains of Klebsiella pneumoniae, 2 strains of Aspergillus, 1 strain of Escherichia CoIL 10 cases were treated with fiberoptic bronchoscopic balloon dilation： 5 cases with high-frequency electrotome, 4 cases with stent placement, and 1 case with argon plasma coagulation （APC）. Seven cases were cured or improved and 3 cases died. Conclusion Airway stenosis after lung transplantation remains a maior problem. The fiberoptic bronchoscopic procedure is the gold standard to diagnose. The preferred treatment is fiberoptic bronchoscopic balloon under expansion, and other approaches include high-frequency electrotome, APC and stent placement, etc.