经硬质气管镜气道金属支架取出方法及相关并发症处理措施

Airway metal stents removal by rigid bronchoscopy

目的 探讨全身麻醉下经硬质气管镜取出气道金属支架的方法及其相关并发症的处理措施.方法 回顾性分析首都医科大学附属北京天坛医院呼吸科2008年1月至2015年1月收治的来自全国各地的20例气道金属支架并发症患者经硬质气管镜取支架的临床资料.对气道金属支架并发症的原因、种类、取出方法及难易程度评估,以及气道金属支架取出时的相关并发症等进行分析及经验总结.结果 20例患者需取出气道金属支架的原因为移位3例,移位合并瘢痕再狭窄5例,断裂4例,断裂合并移位1例,断裂合并瘢痕再狭窄4例,塌陷1例,瘢痕再狭窄2例.20个气道金属支架取出19个,其中包括9个覆膜金属支架,中位放置时间为（7.4＆#177;6.9）个月（5d至24个月）,完整取出6个,破碎取出3个;裸金属支架11个,中位放置时间为（10.2＆#177;7.0）个月（20 d至24个月）,完整取出3个,破碎取出7个,1个未能取出.支架取出后并发症主要包括气道出血11例,气道塌陷6例（即刻再置入支架5例,气管插管1例）,黏膜撕裂导致气管食管瘘1例,气道内失火1例,支架未能取出导致气道阻塞窒息死亡1例.结论 气道金属支架的取出是一项风险极大的手术操作,首先应充分评估支架取出的指征,分析取出的利弊.在取气道金属支架之前,应根据金属支架的种类、放置位置、放置时间及瘢痕肉芽组织包埋程度等充分评估支架取出的难易程度,尽可能将包埋的支架充分剥离于气道壁,然后再取出,以减少出血、气道撕裂及气道阻塞窒息等并发症,同时要备好新支架以防支架取出后气道塌陷.此外还应注意,气道金属支架的取出操作应由技术熟练、经验丰富的呼吸介入团队实施才能保证手术的成功和患者的安全.

Objective To explore the techniques and related complication management of airway metal stents removal with rigid bronchoscope under general anesthesia.Methods We reviewed 20 patients who had received rigid bronchoscopic stents removal under general anesthesia from Jan.2008 to Jan.2015.The clinical data were analyzed retrospectively.The indications for stents removal and potential difficulties encountered,the relationship between techniques and related complications of stents removal were discussed and analyzed,and our experiences were summarized.Results The indications for airway metal stents removal included stent migration,fracture,and granulation related in-stent restenosis.Nineteen airway metal stents were removed from 20 patients,which included 9 covered metal stents,6 without fragmentation and 3 with fragmentation.The average duration of stenting before removal was （7.4 ± 6.9） months （5 days-24 months）.Of the 11 uncovered metal stents,which had stayed in the airway for （10.2 ± 7.0） months （20 days-24 months）,10 were removed successfully and 1 failed.Three of them were removed intact and 7 fragmented.Complications were as follows：airway bleeding requiring management （n =11）,airway collapse （n =6）,re-obstruction requiring temporary stent placement （n =5）,postoperative tracheal intubation （n =1）,mucosal tear with tracheoesophageal fistula （n =1）,airway firing （n =1）,airway obstruction,and death as a result of attempted stent removal （n =1）.Conclusions Airway metal stent removal is a high-risk operation.Indications for stents removal should be evaluated thoroughly and all the advantages and disadvantages should be evaluated.Once stent removal is decided,the type of the metal stent,the position of the stent implanted,the duration of stenting,and the extent of the stent embedded in granulation tissue should be carefully considered to assess the difficulty of the procedure.Dissection of the stent from the airway wall before extracting it can reduce complications such as airway bleeding,mucosal tear and airway obstruction.At the same time,a standby stent is needed to deal with possible airway collapse after stent removal.Removal of metal airway stents should only be performed by a proficient and experienced interventional pulmonology team to ensure successful operation and to improve patient safety.