気管病変に対するシリコンステント療法の有用性と問題点(<特集>気道狭窄に対する気管支鏡下治療)  [in Japanese] Clinical Evaluation of Placement of a Silicone Stent in Tracheobronchial Disorders  [in Japanese]

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Abstract

背景.気管病変に対するステント療法は,多くの気道疾患患者のQOL向上に寄与したと言えるが,その適応,手技,合併症,成績に関する問題が未だ山積している.本稿では気管および気管分岐部のシリコンステント療法の有用性と問題点に論点を絞り,我々の経験例を中心に分析したので報告する.対象.1992年4月から2003年4月に経験した気管および気管分岐部の狭窄病変32例で,部位は気管14例,気管分岐部18例,疾患別では,肺癌16例,食道癌11例,悪性リンパ腫2例,気管切開後狭窄2例,甲状腺腫1例であった.ステント種別では,Dumon直型14例,Dumon-Y型13例,Dynamic型5例であった.結果.肺癌による狭窄のうち,気管病変は縦隔のbulky転移リンパ節によるものですでに予後不良であり,留置後の多くが1ヶ月以内に死亡したが,気管分岐部病変では,3ヶ月以上の生存例が10例中7例(70%)あり生存が見込まれた.一方,食道癌では,気管病変にせよ気管分岐部病変にせよ,ステント療法に加えて化学放射線治療が奏効するので,3ヶ月以上の生存例は予後が判明している10例中6例(60%)にあった.ステント留置後の腫瘍の再増生や瘻孔発生の可能性を考えると,本病変ではワイアーステントよりもシリコンステントの有用性が高いと考えられた.ステント留置に際して気管分岐部病変では,狭窄程度のみならず気道軸の偏位を重視しなくてはならず,高度偏位例では術中に出血に基づく換気障害による一時的な低酸素血症に留意しなくてはならなかった.留置後療喀出障害はステント全長が90mm以上の例で高率にあり,またステント内面の細菌増生は,留置後4ヶ月以上経過した12例で検討すると,全例でbiofilmの形成を認め,留置後の定期的な経過観察が必要と思われた.結論.シリコンステント療法は,その侵襲度は大きいが確実な気道確保のもとで行う安全な療法である.これを実践するには万全の体制でよき指導者のもとで臨まなくてはならない.呼吸器科医は今後硬性気管支鏡の苦手意識を取り去り,軟性気管支鏡のみならず硬性気管支鏡も熟知して,確実な気道確保のもとで多くの治療法を選択できるようになることが望まれる.

Background. Stent placement for airway stenosis has improved the quality of life of patients with tracheobronchial disorders. However, there are still many questions on its indications, techniques, complications, and results. This report summarizes our experience with stent placement for airway stenosis and discusses problems we encountered. Methods. From 1992 to 2003, 32 patients with airway stenosis that involved the trachea or tracheal bifurcation were treated with a silicone stent (Dumon straight stent, n=14; Dumon-Y stent, n=13; Dynamic stent, n=5). The causes of airway stenosis were as follows: lung cancer (n=16), esophageal cancer (n=11), malignant lymphoma (n=2), and large goiter (n=1). Results. Among the lung cancer patients, 6 teaminal patients who had tracheal stenosis due to bulky mediastinal lymph node metastasis died within one month after stent placement, but 7 (70%) of the 10 patients with stenosis near the tracheal bifurcation survived over 3 months. In the esophageal cancer patients, chemoradiotherapy was effective for the airway stenosis, and 6 (60%) of the 10 patients with stent placement survived over 3 months. Considering the possibility of tumor regrowth or fistula formation, the silicone stent seems to be more useful than the wire stent. During placement of the stent, we had to consider not only the degree of stenosis but also the degree of airway deviation. In a patient with severe airway deviation, intraoperative hypoxemia due to hypoventilation as a result of bleeding was observed. After stent placement, incrustation of mucous was prominent in patients with a stent over 90 mm in length. Biofilm formation was found on the inner surface of the stent in all of the 12 patients, indicating that routine bronchoscopic examinations are necessary after placement. Conclusions. Placement of a silicone stent is invasive, but it is a safe treatment for airway stenosis, which should be performed by a skilled pneumologist. Pneumologists should learn various kinds of treatments, and be comfortable in performing not only flexible bronchoscopy but also rigid bronchoscopy.

Journal

  • The Journal of the Japan Society for Respiratory Endoscopy

    The Journal of the Japan Society for Respiratory Endoscopy 26(2), 138-144, 2004

    The Japan Society for Respiratory Endoscopy

References:  7

Cited by:  4

Codes

  • NII Article ID (NAID)
    110002812988
  • NII NACSIS-CAT ID (NCID)
    AN00357687
  • Text Lang
    JPN
  • Article Type
    Journal Article
  • ISSN
    0287-2137
  • Data Source
    CJP  CJPref  NII-ELS  J-STAGE 
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