支气管覆膜支架封堵治疗右肺中下叶切除术后支气管残端瘘经验1例  

Occlusion with Bronchial Covered Stent in the Management of Bronchial Stump Fistula after Right Middle and Lower Lobectomy:A Case Report and Literature Review

作　　者：黄淼 鲁方亮 李少雷 裴宇权 王亮 杨跃 Miao HUANG;Fangliang LU;Shaolei LI;Yuquan PEI;Liang WANG;Yue YANG(Department of Thoracic SurgeryⅡ,Peking University Cancer Hospital,Beijing 100142,China)

机构地区：[1]北京肿瘤医院胸外二科,北京100142

出　　处：《中国肺癌杂志》2021年第4期299-304,共6页Chinese Journal of Lung Cancer

摘　　要：背景与目的支气管胸膜瘘是临床上较为严重且罕见的术后并发症之一,尤其是肺叶/全肺切除术后支气管残端瘘,处理起来较为棘手。常见治疗方案包括内科保守治疗联合外科手术,但由于瘘口迁延不愈导致胸腔持续与外界相通,患者容易合并严重的胸腔感染及呼吸衰竭等合并症,以至于身体状况无法耐受二次手术。而内镜下治疗,为该合并症的治疗提供了新的思路。方法回顾性分析了北京大学肿瘤医院胸外二科2016年6月收治的1例右肺鳞癌患者的诊断、治疗过程,并文献复习。结果患者男性,65岁,因"咳嗽伴痰中带血3月余"入院,胸部计算机断层扫描提示右肺下叶软组织密度肿块影,气管镜提示右肺中叶及下叶基底段开口可见肿物,活检病理证实为鳞癌。诊断考虑:右肺中下叶鳞癌(c T2aN2,IIIa期)。患者接受了吉西他滨+顺铂方案新辅助化疗2个周期,评效为疾病稳定(stable disease,SD)。末次化疗结束4周之后,患者接受了胸腔镜辅助右肺中下叶切除、纵隔淋巴结清扫术。术后第5天患者出现急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)再次气管插管转入重症加强护理病房(intensive care unit,ICU),并给予激素冲击治疗。术后第7天患者出现右肺中间干支气管残端瘘,但由于合并ARDS,患者身体情况无法耐受二次手术。遂于体外人工膜肺(extracorporeal membrane oxygenation,ECMO)支持下,经硬质支气管镜在中间干支气管残端置入一枚定制的覆膜、可膨胀金属铰链支架,并成功封堵。由于患者的ARDS未见好转,出现不可逆的肺间质纤维化,经过系统的抗感染治疗之后,患者成功接受了双肺移植手术。结论内镜下放置覆膜支架是一种简单、安全、有效的支气管残端瘘闭合术。当患者的临床情况不适合立即手术时,内镜下支架植入可作为一种优选的治疗方法,为后续治疗创造机会。Background and objective Bronchopleural fistula(BPF)is one of the most serious and rare postoperative complications,especially the bronchial stump fistula after lobectomy/pneumonectomy.Common treatment options include conservative medical treatment combined with surgery.However,due to the delayed healing of the fistula,the chest cavity continues to communicate with the outside world,and the patient is prone to complicated with severe thoracic infection and respiratory failure,so that the physical condition can hardly tolerate the second surgical procedure.Endoscopic treatment provides a new option for the treatment of this complication.Methods A case of right pulmonary squamous cell carcinoma was admitted to the Department of Thoracic Surgery II,Peking University Cancer Hospital in June 2016.The diagnosis and treatment was retrospectively analyzed,and the literature was reviewed.Results A 65 year old male patient was admitted to hospital because of"cough with blood in sputum for 3 months".Chest computed tomography(CT)showed soft tissue density mass shadow in the right lower lobe.A tumor could be seen in the opening of the right middle lobe and basal segment of lower lobe.Biopsy confirmed squamous cell carcinoma.Diagnosis consideration:squamous cell carcinoma of the middle and lower lobe of the right lung(cT2 aN2,IIIa).Patients received gemcitabine plus cisplatin neoadjuvant chemotherapy for 2 cycles,and the effect of chemotherapy showed stable disease(SD).Four weeks after chemotherapy,the patient underwent video-assisted thoracic surgery(VATS)assisted right middle and lower lobectomy and mediastinal lymph node dissection.On the 5 th day after operation,the patient developed acute respiratory distress syndrome(ARDS)and was transferred to intensive care unit(ICU)again after endotracheal intubation.On the 7 th day after operation,the patient developed a right intermediate trunk bronchial stump fistula,but due to ARDS,the patient’s physical condition could not tolerate the second operation.Under the support of extr

关 键 词：右肺中下叶切除术 支气管残端瘘 覆膜支架 

分 类 号：R734.2[医药卫生—肿瘤]