【摘要】 目的 总结肺移植术后支气管吻合口裂开(BAD)患者的临床表现、影像学特征，探讨其治疗方法和预后。方法 回顾性分析2019年1月—2023年5月郑州大学第一附属医院经胸部CT和纤维支气管镜确诊的9例肺移植术后BAD患者的临床资料。记录9例患者的临床表现、影像学特征、治疗方法、随访情况。结果 9例患者中原发病为肺间质纤维化4例，肺气肿2例，支气管扩张2例，细支气管肺泡癌1例。行左侧单肺移植1例，右侧单肺移植1例，双侧肺移植7例。双侧肺移植者第1侧冷缺血时间171～510(392±108)min,第2侧冷缺血时间442～745(612±93)min。4例无BAD症状，5例表现为气胸、皮下气肿。胸部CT示气胸和皮下气肿5例，支气管壁缺损或吻合口周围新发含气腔9例，供体受体大小不匹配1例，裂开程度均≤25%。7例双侧肺移植者中右侧单发BAD 6例，双侧BAD 1例。3例术后发生原发性移植物功能障碍。术后3个月内，经痰培养或肺泡灌洗液检出鲍曼不动杆菌7例，其中合并肺炎克雷伯杆菌或铜绿假单胞菌或黄曲霉5例，同时存在3种以上病原体感染3例。8例行保守治疗，给予抗感染、营养支持、纤维支气管镜检查、胸腔闭式引流等措施。7例双侧肺移植患者中，1例二次右侧肺移植后再次发生BAD者行气道内支架植入治疗。随访12个月，4例因感染性休克、脓毒血症死亡，2例放弃治疗后死亡。6例死亡患者术后正压机械通气时间42～187(113.83±49.15)h, 3例存活患者术后正压机械通气时间19～35(28.00±8.19)h。结论 双侧肺移植术后BAD好发于右侧支气管吻合口；肺移植术后BAD经胸部CT和纤维支气管镜检查可明确诊断；小裂口可采用保守治疗，但总体预后欠佳；供体受体大小匹配、减少术中缺血时间、缩短术后机械通气时间及有效的抗感染治疗等可减少BAD发生。更多还原

【Abstract】 Objective To summarize the clinical manifestations and imaging features of bronchial anastomotic dehiscence(BAD) after lung transplantation, and to explore its treatment modalities and prognosis. Methods The clinical data were retrospectively analyzed in 9 patients with post-lung transplantation BAD confirmed by chest CT and fiberoptic bronchoscopy in the First Affiliated Hospital of Zhengzhou University between January 2019 and May 2023. The clinical manifestations, imaging features, treatment modalities, and follow-up results were recorded. Results Primary diseases among 9 recipients included interstitial pulmonary fibrosis(4 cases), emphysema(2 cases), bronchiectasis(2 cases), and bronchioloalveolar carcinoma(1 case). Surgical types included unilateral left lung transplantation(1 case), unilateral right lung transplantation(1 case), and bilateral lung transplantation(7 cases). For bilateral lung transplantation recipients, the cold ischemia for the first side was 171 to 510(392±108) min and for the second side was 442 to 745(612±93) min. Clinical presentations of BAD were asymptomatic(4 cases) and accompanied by pneumothorax/subcutaneous emphysema(5 cases). Chest CT revealed bronchial wall defects or peri-anastomotic air-filled cavities in all 9 cases, pneumothorax/subcutaneous emphysema in 5 cases, and donor-recipient size mismatch in 1 case. All BAD lesions had dehiscence ≤25%. Among 7 bilateral lung transplantation recipients, 6 had right-sided unilateral BAD and 1 had bilateral BAD. Primary graft dysfunction occurred postoperatively in 3 cases. Within 3 months postoperatively, 7 cases of Acinetobacter baumannii infection were detected by sputum or bronchoalveolar lavage fluid culture, among whom 5 cases were complicated with Klebsiella pneumoniae, Pseudomonas aeruginosa, or Aspergillus flavus,and 3 cases had concurrent infections with more than three pathogens.Conservative treatments(antibiotics,nutritional support,bronchoscopy,and closed thoracic drainage) were applied in 8 cases.In 7 bilateral lung transplantation recipients,1 received airway stent implantation due to recurrent BAD after secondary right lung transplantation.During 12-month follow-up,4 patients died from septic shock and sepsis,and 2 died after discontinuing treatment.The duration of postoperative positive-pressure mechanical ventilation was 42 to 187(113.83±49.15)h for the deceased patients,and was 19 to 35(28.00±8.19)h for the survivors.Conclusions BAD predominantly occurs at the right bronchial anastomosis after bilateral lung transplantation.Postoperative BAD can be definitively diagnosed through chest CT and fiberoptic bronchoscopy.Conservative management may suffice for minor dehiscence,but overall prognosis remains poor.Strategies to reduce BAD risk include donor-recipient size matching,minimizing intraoperative ischemia time,shortening postoperative mechanical ventilation,and aggressive anti-infective therapy.更多还原