The incidence and severity of complications of bronchoscopic interventions are significantly different from those of diagnostic bronchoscopy [1]. The authors have been working in this area for more than 10 years and have experienced many serious complications, one of which is hemorrhage. Bleeding of more than 100 ml in the airway or lung at one time or more than 200 ml within one hour associated with bronchoscopy is considered major bleeding. In this paper, we summarize the treatment experience of 38 cases of hemorrhage related to tracheoscopic interventions, and hope to take it as a warning.
I. Clinical data
We retrospectively analyzed 4698 cases of tracheoscopic interventions performed in our hospital from August 2004 to March 2011, and 38 cases and 40 cases of hemorrhage related to tracheoscopic interventions occurred, 26 males and 11 females, aged 9-78 years (average 54.2±2.6 years).
II. Operation of tracheoscopic interventions
Among the 38 patients, 18 cases were operated under general anesthesia rigidoscopy, 2 cases were operated under general anesthesia tracheal intubation, and 8 cases were operated under local anesthesia with the application of electronic bronchoscopy.
(1) Argon plasma coagulation (APC) [2]
The equipment used was a German-made CESEL 3000. The APC probe was extended through the electronic bronchoscopic biopsy hole at the insertion end of the bronchoscope (the probe mark was visible), and cautery was started within 0.5 cm of the lesion. The APC output power was 30~50 W, and the argon gas flow rate was 0.8~1.6 L/min.
(2) CO2 freezing [2]
The freezing machine was produced by Beijing Kulan Medical Equipment Co., Ltd. with a soft bendable freezing probe diameter of 1.9~2.3 mm and probe end length of 5 mm. the cold source was liquid carbon dioxide. The metal head of the freezing probe is placed on the surface of the tumor or pushed into the tumor and frozen for 5-10 seconds to produce the largest volume of ice ball around it.
III. Results
1. Diseases suffered by 38 patients with hemorrhage
Benign diseases were found in 6 cases (1 case each of lipoma, salivary adenoma, sarcoidosis, tracheal stent placement, varicocele, and vascular malformation).
A B C
Figure 1 Squamous carcinoma of the right middle lobe (male, 50 years old)
A Enhanced CT of the lung showed a huge mass in the right lower middle lobe with abundant blood flow
B The right middle segment bronchus was completely occluded by neoplastic organisms, and the surface was covered with necrotic material with a central blood blister
C Most of the intraluminal tumor was removed by CO2 freeze extraction combined with APC, and death occurred from hemorrhage when freeze extraction was performed near the opening of the right middle lobe
A B C
Figure 2 Squamous carcinoma of the left lung with total pulmonary atelectasis (male, 53 years old)
A Pulmonary CT showing left main bronchial occupancy with left total pulmonary atelectasis
B Tracheoscopy showed complete occlusion of the left main bronchus by neoplasm with tumor infiltration in the wall and surface covered with necrotic material
C Most of the intraluminal tumor was removed by CO2 freeze extraction combined with APC, and no major bleeding occurred during the operation. The opening of the left upper lobe was visible 10 days after surgery, and the lumen was still blocked, while the lumen of the left lower lobe was open. 20 days later, hemoptysis occurred and death occurred.
2. The site of hemorrhage
It occurred in the main trachea 17 times, the right bronchus 15 times (including the right main bronchus 9 times, the right middle segment bronchus 2 times, the right upper lobe, right middle lobe and right lower lobe bronchus 1 time each), and the left bronchus 9 times (including the left main bronchus 2 times and the left lower lobe bronchus 7 times). One of the cases involved both bronchi.
3. Timing and causative factors of hemorrhage
There were 27 cases of hemorrhage during tracheoscopy, 6 cases during the perioperative period (within 1 month), 7 cases of delayed hemorrhage, and 2 cases of hemorrhage occurred again within 1 month after successful rescue of intraoperative hemorrhage. Tracheoscopic interventions associated with hemorrhage were argon plasma coagulation (APC) 30 times (75.0%), CO2 freeze extraction 20 times (50.0%), stent placement 7 times (17.5%), and mucosal biopsy 1 time (2.5%).
4.Treatment effect
Forty cases of hemorrhage were successfully rescued in 22 cases (55%), and 18 cases of death (45%), including 14 cases of death at the time of hemorrhage (77.8%) and 4 cases of death from respiratory failure within 1 week after surgery (22.2%). There were 3 intraoperative deaths (3/40, 7.5%), including 1 case of right middle lobe squamous carcinoma frozen at the end of treatment, 1 case of right middle lobe treponema frozen at the end of treatment and 1 case of adenoid cystic carcinoma treated with recurrent granuloma formation APC), 2 cases of intraoperative hemorrhagic shock resuscitated successfully (treated with local hemostatic drugs + bronchial artery interventional embolization) followed by re-hemorrhagic death within 1 month, 2 cases without intraoperative hemorrhage but Six of the seven patients with stents were tracheoesophageal fistulas, five had stents placed on both sides of the trachea and esophagus and died of hemorrhage within 1 week to 10 months, and one patient with tracheal stent placed by tracheotomy for traumatic brain injury died of hemoptysis 2 months later (etiology unknown).
Follow-up: The 20 surviving patients were followed up for 1 month to 2 years, and the mean survival time of the patients was 8.0 months, as calculated from the Kaplan-Mierer survival curve. Among them, 13 cases (65.0%) survived for >6 m and 9 cases (45.0%) for >12 m.
n
Figure 3 Kaplan-Mierer survival curves
Discussion
In recent years, the incidence of serious complications (7.39‰) and mortality (0.13‰) (Xi’an and Chongqing, 2004) have increased significantly compared with the previous ones due to the wide application of tracheoscopic treatment techniques, such as microscopic freezing, microwave, high-frequency electric knife, laser, argon knife, balloon dilation and placement of endoprosthesis [1]. In the last 7 years (July 2004 to March 2011), the authors performed 4698 bronchoscopic interventions and 4 intraoperative deaths (0.8‰) occurred, of which 3 (0.6‰) were due to haemorrhage and 1 was due to asphyxia. Hemorrhage related to tracheoscopic interventions occurred in 38 patients 40 times (0.85%).
Malignant tumors accounted for the majority of the 38 patients (84.8%), with significantly more metastatic airway tumors than primary tumors (62.5% vs. 37.5%, P<0.01). Among the primary malignant tumors, tracheobronchial adenoid cystic carcinoma was the most common, followed by squamous lung carcinoma. Adenoid cystic carcinoma of the trachea is a locally invasive, low-grade malignant tumor. 1/3 of the tumors occur at the beginning of the large bronchi, and the surface mucosa is usually undamaged. The tumor is polypoid, hard, and rich in blood flow, so it is very easy to bleed during surgery. All five cases of adenoid cystic carcinoma in this group occurred in the middle and lower trachea, and the airway blockage was more than 50% during tracheoscopic intervention, and the lesion length was more than 4 cm. Therefore, the treatment of this disease should be prepared for hemorrhage.
Among metastatic tumors, squamous lung cancer is the most common, followed by kidney cancer. It is especially worth mentioning that kidney cancer and esophageal cancer are extremely rich in airway metastasis blood flow and also have the potential of hemorrhage, so one should be fully prepared before surgery. Benign diseases are seen in giant lipoma, salivary adenoma, sarcoidosis, aspergillosis and vascular malformation, etc. In a patient with right middle and lower lung atelectasis, cavity-like changes were seen in the lung before surgery (the etiology was unknown at that time), the right middle and lower lobe bronchial granulation tissue was removed during surgery, and the lumen was open, but a large amount of necrotic material was seen to gush out from the lung. 3000ml, after treatment by bronchial artery embolization and systemic and local hemostasis, the bleeding stopped for a time, but death by hemoptysis still occurred the day after the operation, and the pathology afterwards was treponemal disease.
The occurrence of hemorrhage is related to the site of the lesion, mainly in the central airway, such as the main trachea most often (42.5%), followed by the right bronchus 37.5% (the right main bronchus most often, followed by the right middle segment bronchus), and the left lower lobe bronchus most often (77.8%) among the 9 cases of left bronchus, especially 3 cases occurred in the left lower lobe dorsal segment opening. It is worth mentioning that two of the three patients who died of hemorrhage occurred in the right middle segment bronchus and one in the main trachea.
Hemorrhage occurred in 27 cases (67.5%) during the tracheoscopic procedure (3 of them died), followed by the perioperative period. 2 cases of death from hemorrhage occurred again within 1 month after successful intraoperative hemorrhage rescue, which may be related to the failure of complete healing after vascular injury. In 2 other cases, although intraoperative hemorrhage did not occur, postoperative hemorrhage occurred 1 week and 4 weeks after surgery. This is because the treatment was more thorough at that time and the blood vessels were shallowly exposed, which led to secondary vascular rupture. If you estimate the possibility of hemorrhage before surgery, make sure to test and prepare blood so that you will not be caught unawares.
The most common tracheoscopic interventional operation associated with hemorrhage in this study was APC accounting for 75.0%.APC is a non-contact high-frequency electrocoagulation technique.APC can rapidly ablate tumors in the airway and relieve obstructive symptoms [3].APC is supposed to be an effective hemostatic tool, why was APC the culprit of hemorrhage in this study? It may be related to the shallow exposure and rupture of blood vessels after APC disrupted the mucosa on the surface of the tumor, which APC was too late to deal with. There were also 2 cases of superficially exposed blood vessels in this study (1 case of vascular malformation, 1 case of local granuloma formation or superficial exposure of large blood vessels after 28 times of repeated APC treatment, the blood vessels were mistakenly ablated during APC treatment, the former 1 case stopped bleeding after bronchial artery embolization and has survived for 2 years without further hemoptysis, 1 case died of hemorrhagic shock at that time). Therefore, for tumors with rich blood flow, the APC probe should be cauterized away from the tumor during treatment to avoid the needle charring material from poking the tumor and secondary bleeding. If necessary, the tumor vessels should be embolized before the tracheoscopic intervention, and bleeding during treatment can be greatly reduced.
Cryotomy is one of the most effective methods to rapidly get rid of tumors in the airway [2]. The probe and its adherent tumor tissue are removed in the frozen state, and the frozen probe cannot be withdrawn from the clamped channel of the flexible mirror, but can only be removed together with the flexible mirror and the frozen adherent tissue, and this operation can be repeatedly and rapidly performed through the rigid mirror. Due to the removal of large pieces of tumor tissue, the possibility of causing hemorrhage is higher [4]. In this study, 20 cases (52.6%) were operated under general anesthesia (18 of them were rigid scopes), and major bleeding caused by CO2 freeze extraction accounted for 50.0%. How to avoid or reduce hemorrhage is an issue that should be taken into account during cryotomy. For tumors with abundant blood vessels, arterial embolization treatment can be performed before cryotomy to truncate the large blood supply arteries or APC cauterize the superficial exposed blood vessels to reduce bleeding. In 7 cases of stenting, 6 cases were tracheoesophageal fistulae and 5 cases had stents placed on both sides of trachea and esophagus, which may cause necrosis of tissues between the two stents and enlarge the fistulae, or tumor development and erosion of blood vessels, causing hemorrhage from rupture of blood vessels. Such patients should be carefully explained before surgery and be prepared for hemorrhage at any time. Unfortunately, all the 7 patients died of hemorrhagic shock (bleeding volume >3000ml), and none of them was successfully rescued.
Do not panic when hemorrhage occurs, do not exit the airway easily with the tracheoscope, adjust the position to the affected side, and prepare blood as soon as possible when the bleeding volume is large, and transfuse blood if necessary. If local anesthesia is used, tracheal intubation should be performed quickly to facilitate the operation. While continuing negative pressure suction, local and systemic hemostatic drugs should be used continuously (posterior pituitary hormone if necessary), and the accumulated blood in the airway should be aspirated in time. If pharmacological hemostasis is still ineffective, a double-lumen balloon catheter should be inserted rapidly to stop the bleeding by compression (successful in one case in this group) or emergency bronchial artery embolization (successful in all three cases in this group). The mortality rate of hemorrhage associated with bronchoscopic interventions is extremely high (45%), so be sure to sign an informed consent form before the procedure and do a good job of aftercare. Fortunately, there was no medical incident and no dispute in this group of cases, mainly because all cases in this group were in advanced and serious condition. The average survival time of the surviving patients was about 8 months.