支气管腺样囊性癌袖状切除术后支气管胸膜瘘1例

摘要(中文译文)

气管支气管腺样囊性癌（ACC）是一种罕见的恶性气道肿瘤，以生长缓慢但黏膜下浸润广泛为特征，常导致完整切除困难。当术中反复遇到切缘阳性时，术者必须在肿瘤根治性与保留肺功能及气道重建安全性之间取得平衡。术后支气管胸膜瘘（BPF）是支气管重建术后不常见但可能危及生命的并发症。患者为33岁女性，主诉持续性咳嗽伴咯血及1年前发现的气管支气管肿物，近3个月症状加重。外院纤维支气管镜检查显示肿物起源于支气管壁。在本院排除手术禁忌后，患者接受了达芬奇机器人辅助右中间支气管袖式切除术。术中冰冻切片反复提示支气管切缘阳性，最终实施了保留功能的R1袖式切除术。术后第18天，患者吻合口部位出现支气管胸膜瘘，仅通过胸腔闭式引流即成功处理，症状明显缓解。随访5个月时，患者无症状，影像学及支气管镜检查均无肿瘤复发或持续性瘘的证据。本病例说明了气管支气管ACC管理中的两个关键决策点。第一，当R0切除在解剖上困难时，保留功能的R1袖式切除术后辅以计划性放疗，对于特定患者可能是替代全肺切除术的合理选择。第二，术后吻合口BPF并非一定需要内镜或手术干预；对于经过仔细选择的瘘口较小、胸腔引流充分、肺复张良好且无未控制感染的患者，保守治疗可以有效。

Abstract

Tracheobronchial adenoid cystic carcinoma (ACC) is a rare malignant airway tumor characterized by slow growth but marked submucosal extension, which often makes complete resection difficult. When repeated positive margins are encountered intraoperatively, the surgeon must balance oncologic radicality against preservation of lung function and the safety of airway reconstruction. Postoperative bronchopleural fistula (BPF) is an uncommon but potentially life-threatening complication after bronchial reconstruction. A 33-year-old female was admitted with a chief complaint ofpersistent cough with hemoptysis and a tracheobronchial mass identified 1 year earlier, with symptom aggravation over the preceding three months. Fiberoptic bronchoscopy performed at an outside hospital revealed a mass arising from the bronchial wall. After excluding surgical contraindications at our institution, the patient underwent da Vinci robot-assisted right intermediate bronchial sleeve resection. Intraoperative frozen sections repeatedly demonstrated positive bronchial margins, and a function-preserving R1 sleeve resection was ultimately performed. On postoperative day 18, the patient developed a bronchopleural fistula at the anastomotic site, which was successfully managed with Chest tube drainage alone, resulting in significant symptom relief. At 5-month follow-up, the patient remained asymptomatic, with no radiological or bronchoscopic evidence of tumor recurrence or persistent fistula. This case illustrates two key decision points in the management of tracheobronchial ACC. First, when R0 resection is anatomically difficult, function-preserving R1 sleeve resection followed by planned adjuvant radiotherapy may represent a reasonable alternative to pneumonectomy in selected patients. Second, postoperative anastomotic BPF does not invariably require endoscopic or surgical intervention; in carefully selected patients with a small fistula, adequate pleural drainage, preserved lung re-expansion, and no uncontrolled infection, conservative management can be effective.

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