综述
ENGLISH ABSTRACT
经支气管镜导航系统在周围型肺病变治疗中的应用
王拢拢
黎秀玉
王思云
叶广林
高兴林
李静
作者及单位信息
·
DOI: 10.3760/cma.j.issn.1001-0939.2019.02.014
Application of transbronchial navigation system in treatment of peripheral pulmonary nodules
Wang Longlong
Li Xiuyu
Wang Siyun
Ye Guanglin
Gao Xinglin
Li Jing
Authors Info & Affiliations
Wang Longlong
Li Xiuyu
Wang Siyun
Ye Guanglin
Gao Xinglin
Li Jing
·
DOI: 10.3760/cma.j.issn.1001-0939.2019.02.014
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摘要

经支气管镜导航系统包括虚拟导航支气管镜和电磁导航支气管镜,这些导航工具能够引导支气管镜按照术前规划好的路径或者实时引导气管镜到达病灶部位,从而实施对周围型肺病变(PPL)的诊断或者治疗。本文旨在综述将导航系统应用于PPL治疗方面的可行性分析,如引导外科术前定位、光动力学疗法、射频消融术等,以期为PPL寻找一种简便精准的定位方法及为不能手术的周围型肺癌患者探索一种新的微创精准的治疗模式。

引用本文

王拢拢,黎秀玉,王思云,等. 经支气管镜导航系统在周围型肺病变治疗中的应用[J]. 中华结核和呼吸杂志,2019,42(2):140-144.

DOI:10.3760/cma.j.issn.1001-0939.2019.02.014

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随着影像技术的发展,周围型肺病变(peripheral pulmonary lesion,PPL)的发现率为8%~51%,这些肺结节中为恶性肿瘤的概率为3.8%~13% [ 1 ]。而对于Ⅰ、Ⅱ期的非小细胞肺癌来说,外科手术切除后的5年生存率分别为60%~80%和40%~50%,因此肺癌的早期诊治非常重要,指南推荐外科手术仍然为早期肺癌的首选治疗手段 [ 2 ]。目前,PPL常采取电视辅助胸腔镜(video-assisted thoracoscopic surgery,VATS)或机器人辅助的胸腔镜(robotic-assisted thoracoscopic surgery,RATS)下切除治疗。但是,当病灶直径<15 mm,且距离胸膜>10 mm,以磨玻璃成分为主时,胸腔镜下很难看到或触摸到病灶,往往需要增加肺的切除范围,甚至中转开胸术,增加了患者的创伤、手术时间等 [ 3 ]。因此,近年来新的术前定位方法不断出现,主要分为两大类:CT引导下的经皮肺穿刺定位和经支气管定位技术。前者可能引起出血、气胸、栓塞,甚至猝死等并发症,且定位需要在CT室进行,定位后需要将患者转移至手术室进行手术,不仅需要学科间的合作,而且在转运患者或等待手术的过程中,定位物有移位或脱落的可能,并且增加了患者的辐射暴露。因此有研究者尝试利用经支气管镜导航系统引导在手术室对PPL进行术前定位,证明了其有效性及安全性。
对于早期周围型肺癌的治疗目前仍然推荐外科胸腔镜手术。但是某些患者由于有严重的共患病而存在手术禁忌证,或者无肺癌基因突变靶点不能行靶向药物治疗,或者拒绝手术治疗。对于这类患者,现往往采取放疗或CT引导下经皮射频消融术等治疗技术。但由于CT引导的经皮治疗技术往往有以上的并发症存在,其应用受到一定程度的限制。而经支气管介入治疗技术,是通过自然腔道进入病灶部位,大大减少了上述并发症的发生。但经支气管介入治疗周围型肺癌,需要精准定位,而经支气管镜导航系统往往能准确地引导气管镜到达病灶部位,实施精准局部治疗。
经支气管镜导航系统包括虚拟导航支气管镜(virtual bronchoscopic navigation,VBN)和电磁导航支气管镜(electromagnetic navigational bronchoscopy,ENB),VBN是将患者的高分辨率胸部螺旋CT图像以医学数字成像和通信(digital imaging and communication in medicine,DICOM)数据格式导入导航系统中,然后抽取支气管树,显示三维的气管支气管影像。在经支气管肺活检的过程中,可通过手动调整虚拟支气管镜影像的方向使其与实际支气管方向一致,指导支气管镜在支气管分叉处的走向,使支气管镜准确快速地到达PPL处,进行活检、刷检、灌洗等操作。与VBN不同的是,ENB具有实时导航功能。首先,ENB利用患者的高分辨率胸部CT图像重建出三维虚拟支气管镜图像,并根据病变的位置预设到达病灶的路径。支气管镜操作过程中,患者躺于电磁版上(胸部处于磁场中),插入支气管镜钳子管道的外带鞘管的定位传感器可实时提供三维空间坐标及方向信息,通过支气管镜下的实际图像与虚拟图像进行对照,从而准确地引导定位传感器到达病变部位,后固定鞘管,抽出定位传感器,通过鞘管进行活检、刷检、注入染料,治疗等操作。
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备注信息
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李静,Email: mocdef.qabq080225274
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所有作者均声明不存在利益冲突
C
气管支气管病变介入治疗器械的系列研制 (1561000148)
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