鄭　曦　丁明超　程　鋼　楊明洪

[摘要] 目的 探討老年人群胸部病變CT引導(dǎo)下穿刺活檢的價(jià)值和安全性。方法 128例行CT穿刺活檢的老年胸部病變患者,含肺內(nèi)病變115例,縱隔病變8例,胸膜病變5例。CT掃描確定并引導(dǎo)穿刺途徑,達(dá)預(yù)定位置取材。回顧總結(jié)分析其診斷正確率及并發(fā)癥發(fā)生率。結(jié)果 128例老年患者的胸部病變中最終診斷惡性106例,良性22例,CT引導(dǎo)下穿刺活檢病理診斷的正確率為91.4%(117/128)。其中良、惡性病變的診斷正確率分別為75.0%(21/28)、90.6%(96/106),惡性病變病理分型的診斷正確率為91.7%(77/84)。23例出現(xiàn)并發(fā)癥,總發(fā)生率為18.0%。包括氣胸17例(13.3%),皮下氣腫6例,縱隔氣腫1例,肺內(nèi)出血4例,發(fā)生率分別為13.3%、4.7%、0.8%、3.1%;無針道種植播散、肺扭轉(zhuǎn)及空氣栓塞等并發(fā)癥發(fā)生。2例氣胸患者需行閉式引流,其余患者無須特殊處理。結(jié)論 CT引導(dǎo)下穿刺活檢術(shù),在老年人群的胸部疾病中是一種安全、準(zhǔn)確、有效的診斷及鑒別診斷手段。

[關(guān)鍵詞] 胸部病變; 活檢組織檢查; 體層攝技術(shù); X線計(jì)算機(jī)

[中圖分類號(hào)] R446.8 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1673-9701(2009)23-08-04

Clinical Analysis of CT-guided Biopsy in Elderly Patients with Chest Disease

ZHENG Xi1 DING Mingchao1 CHENG Gang1 YANG Minghong2

1.Department of Radiology,Beijing Geriatrics Hospital,Haidian District,Beijing 100095,China;2.Hubu Hospital,Shandong 262303,China

[Abstract] ObjectiveTo study the value and safety of CT-guided percutaneous transthoracic biopsy in the elderly with chest diseases. MethodsWe used CT-guided biopsy for 128 elderly patients with chest diseases,of which 115 cases of lung disease,8 cases of mediastinal disease and 5 cases of pleural diseases. The way of guided puncture was determined by CT scan and when the needle reached the desired target,a tissue specimen was taken. The final diagnosis need to be confirmed by surgery,and pathology. The diagnostic accuracy rate and the incidence of complications were analyzed. ResultsIn the 128 elderly patients with chest diseases,the final diagnosis showed 106 cases of m alignant tumor and 22 cases of benign,with the correct diagnosis rate of CT-guided biopsy as 91.4%(117/128). The correct diagnosis rates of benign and m alignant lesions were 75.0%(21/28),and 90.6%(96/106),respectively and the diagnostic accuracy for pathological typing of the m alignant lesions was 91.7%(77/84). And 23 cases had complications. The total incidence was 18.0%,including 17 cases of pneumothorax(13.3%),6 cases of subcutaneous emphysema,1 case of mediastinal emphysema and 4 cases of pulmonary hemorrhage ,with the incidence of 13.3%,4.7%,0.8% and 3.1%,respectively. No complications like reverse pulmonary and air embolism were found. Drainage was required for 2 cases of pneumothorax,and the remaining patients needed no special treatment. ConclusionCT-guided biopsy in the elderly with chest diseases is a safe,accurate and effective diagnostic techniquee,and can also be used in the differential diagnosis.

[Key Words]Chest disease; Biopsy examination; Tomography; X-ray computer

CT引導(dǎo)下胸部病變穿刺活檢作為一種微創(chuàng)診斷和鑒別診斷方法,越來越受到臨床醫(yī)師和影像醫(yī)師的重視;并有較多文獻(xiàn)討論其應(yīng)用價(jià)值和并發(fā)癥的發(fā)生率[1-4]。但針對(duì)老年患者的胸部病變CT引導(dǎo)下穿刺活檢分析尚無報(bào)道。文中回顧總結(jié)128例行CT引導(dǎo)下胸部病變穿刺活檢的老年患者資料,探討老年人群胸部病變CT引導(dǎo)下穿刺活檢的價(jià)值和安全分析。

1 資料與方法

1.1 一般資料

2000年1月～2006年12月行CT引導(dǎo)下胸部病變穿刺活檢的128例老年患者,男75例,女53例;年齡61～82 歲,平均年齡為(66.74±4.62)歲。病灶直徑1.4～10.3cm,平均直徑(4.82±1.31)cm;病灶位于上肺野39例,中肺野28例,下肺野48例,縱隔8例,胸膜5例。115例肺內(nèi)病變中斑片狀病變19例,見圖1。單發(fā)結(jié)節(jié)或腫塊病變78例,見圖2。多發(fā)結(jié)節(jié)或彌漫性病變18例,見圖3。病灶距離皮膚1.3～10.2cm,平均(5.23±1.82)cm;距離胸膜0～6.7cm,平均(2.12±0.62)cm?；顧z時(shí)仰臥位49例,側(cè)臥位24例,俯臥位42例,斜臥位13例。氣促分級(jí)0～3級(jí),平均(1.82±0.89)級(jí)。

組中128例老年患者并發(fā)癥發(fā)生率之所以低于文獻(xiàn)報(bào)道,主要與以下因素有關(guān):①術(shù)前皆對(duì)病變充分分析,包括病變形態(tài)、病變最大層面、病變與周圍血管及氣管的關(guān)系、患者肺質(zhì)量的評(píng)價(jià)等,術(shù)前便基本掌握穿刺點(diǎn)選擇、穿刺角度、穿刺路徑和穿刺區(qū)域的技術(shù)指標(biāo),提高了穿刺成功率,減少了操作時(shí)間;②術(shù)前對(duì)患者進(jìn)行呼吸訓(xùn)練,采取平靜呼吸狀態(tài)下屏氣,最大程度的保證了病變位置的相對(duì)穩(wěn)定性;③進(jìn)針路徑盡可能短的通過肺組織,并避開血管、葉間裂及肺大泡等,穿刺針通過胸膜時(shí)務(wù)必屏氣;④文中有37例呼吸配合較差的患者,包括結(jié)節(jié)病變5例,斑片狀病變14例,彌漫性病病變18例;有3例一次取材失敗未能明確診斷,出現(xiàn)并發(fā)癥7例,發(fā)生率為18.9%,低于文獻(xiàn)報(bào)道;這歸因于患者術(shù)前2h給予了平喘鎮(zhèn)咳藥物,并采取病灶側(cè)斜臥位或側(cè)臥位,縮短穿刺深度,而且一次取材,避免了多次穿刺,在很大程度上降低了并發(fā)癥發(fā)生的幾率;⑤對(duì)于遠(yuǎn)離胸膜病變,應(yīng)分步穿刺,先在胸壁軟組織內(nèi)調(diào)整進(jìn)針的方向,確定進(jìn)針路線無誤后,見圖2、5,經(jīng)胸膜達(dá)病灶;⑥需要多次穿刺,要避免重復(fù)穿刺胸膜,要以原穿刺點(diǎn)為中心,扇形穿刺;⑦文中合并胸膜粘連的67例中發(fā)生局限性氣胸8例,發(fā)生率為11.9%,低于氣胸總發(fā)生率13.3%;其形成原因?yàn)?組中合并胸膜粘連的病例,在遵循穿刺層面和穿刺路徑選擇標(biāo)準(zhǔn)的前提下,盡量選擇沿胸膜粘連較重層面進(jìn)針,這樣即使氣胸發(fā)生后,也僅局限于粘連胸膜之間,見圖6,限制了其進(jìn)一步進(jìn)展形成中等量氣胸的可能;這對(duì)肺彌漫病變和纖維化較重的患者,不僅可一定程度的降低氣胸的發(fā)生率,也可減少嚴(yán)重氣胸的發(fā)生幾率;⑧縱隔病變穿刺時(shí)可經(jīng)胸膜外脂肪進(jìn)針,對(duì)于存在胸腔積液病例可通過改變病人體位利用體液產(chǎn)生臟層胸膜外進(jìn)針路徑,或胸膜外注射生理鹽水和1%利多卡因產(chǎn)生胸膜外路徑進(jìn)針。

綜上所述,CT引導(dǎo)下穿刺活檢術(shù),在老年人群的胸部疾病中是一種安全、有效的診斷和鑒別診斷手段,值得臨床推薦。

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(收稿日期:2009-05-03)