CAJ | 학술논문

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<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<30 s-120 s，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。揹景與目的氣管、支氣管腫瘤性的狹窄或閉塞，大多髮生于病程的晚期，患者會齣現十分痛苦的癥狀，如呼吸睏難、咯血、阻塞性肺炎和頑固性高熱。全身情況較差，心肺功能受限，原髮竈和轉移竈均不能耐受根治性手術切除。呼吸道梗阻嚴重影響瞭生存質量，甚至引起呼吸衰竭導緻死亡。因此，一種能夠有效解除梗阻的治療方法就顯得尤為重要。我們選擇在纖維支氣管鏡下運用二氧化碳（carbon dioxide, CO2）冷凍技術對氣管、支氣管腔內腫瘤進行切除，探討其治療效果。方法對126例氣管、支氣管腫瘤進行冷凍治療（2004年8月-2014年2月），觀察近期及遠期治療效果。術前需要進行計算機斷層掃描（computed tomography, CT）加氣管、支氣管的三維重建，纖維氣管鏡檢查後評估冷凍的部位和深度；術中採用全痳或錶麵痳醉加靜脈彊化，置入纖維支氣管鏡至腫物上耑<0.5 cm，後將軟式冷凍探頭經支氣管鏡活檢孔插入。冷凍探頭的金屬末耑置于腫瘤中心，冷凍<30 s-120 s，冷凍溫度-50 oC--70 oC。在冷凍後未完全溶解前“撕脫”切除腫瘤（凍切法）或者凍時間4 min-6 min後通過負壓吸引清除冷凍後壞死的腫瘤組織（凍融法），兩種方法相結閤可以較為徹底地清除氣道內腫瘤，直至管腔通暢。2週後複查氣管鏡，決定是否需要再次冷凍治療。結果患者咳嗽、呼吸睏難、咯血均有不同程度緩解，顯效率為65.1%，總有效率77.0%。圍手術期死亡1例，術後氣道內齣血2例，支氣管瘢痕狹窄4例，氣管燒灼傷2例，氣管軟化2例，心房纖顫3例。中位生存期為14箇月，1年、2年、3年的生存率分彆為58.6%、24.2%、12.2%。結論纖維支氣管鏡CO2冷凍技術是一種十分簡便而有效的微創治療方法。治療管腔內生長的中央型氣道腫瘤，可以去除腫瘤阻塞氣道的部分，重新疏通管腔，迅速控製和緩解氣道梗阻所導緻的癥狀，顯著提高生存質量。部分患者可以解決痳醉氣管插管問題，為下一步治療創造條件，從而達到根治性切除原髮腫瘤的目的。
배경여목적기관、지기관종류성적협착혹폐새，대다발생우병정적만기，환자회출현십분통고적증상，여호흡곤난、각혈、조새성폐염화완고성고열。전신정황교차，심폐공능수한，원발조화전이조균불능내수근치성수술절제。호흡도경조엄중영향료생존질량，심지인기호흡쇠갈도치사망。인차，일충능구유효해제경조적치료방법취현득우위중요。아문선택재섬유지기관경하운용이양화탄（carbon dioxide, CO2）냉동기술대기관、지기관강내종류진행절제，탐토기치료효과。방법대126례기관、지기관종류진행냉동치료（2004년8월-2014년2월），관찰근기급원기치료효과。술전수요진행계산궤단층소묘（computed tomography, CT）가기관、지기관적삼유중건，섬유기관경검사후평고냉동적부위화심도；술중채용전마혹표면마취가정맥강화，치입섬유지기관경지종물상단<0.5 cm，후장연식냉동탐두경지기관경활검공삽입。냉동탐두적금속말단치우종류중심，냉동<30 s-120 s，냉동온도-50 oC--70 oC。재냉동후미완전용해전“시탈”절제종류（동절법）혹자동시간4 min-6 min후통과부압흡인청제냉동후배사적종류조직（동융법），량충방법상결합가이교위철저지청제기도내종류，직지관강통창。2주후복사기관경，결정시부수요재차냉동치료。결과환자해수、호흡곤난、각혈균유불동정도완해，현효솔위65.1%，총유효솔77.0%。위수술기사망1례，술후기도내출혈2례，지기관반흔협착4례，기관소작상2례，기관연화2례，심방섬전3례。중위생존기위14개월，1년、2년、3년적생존솔분별위58.6%、24.2%、12.2%。결론섬유지기관경CO2냉동기술시일충십분간편이유효적미창치료방법。치료관강내생장적중앙형기도종류，가이거제종류조새기도적부분，중신소통관강，신속공제화완해기도경조소도치적증상，현저제고생존질량。부분환자가이해결마취기관삽관문제，위하일보치료창조조건，종이체도근치성절제원발종류적목적。
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.