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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2702_Библиотеки_им_академика_М_И_Перельмана
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Noriaki Kurimoto
Katsuhiko Morita
Bronchial Branch
Tracing
123
Bronchial Branch Tracing
NoriakiKurimoto • KatsuhikoMorita
Bronchial Branch Tracing
NoriakiKurimoto
Division of Medical Oncology and Respiratory
Medicine
Shimane University Hospital
Izumo, Shimane, Japan
KatsuhikoMorita
Department of Chest Surgery
Shimonoseki Medical Center
Shimonoseki, Yamaguchi, Japan
The Work was rst published in 2015 by Igakushoin Ltd. with the following title: Kikanshikyo
Edayomijutsu.
This English edition was published as a co-edition with its original Japanese language edition,
Masshou byouhen wo toraeru kikanshikyou “Edayomi” jutsu, copyright © 2015 by Igaku-Shoin Ltd.,
Tokyo Japan
ISBN 978-981-13-9904-6 ISBN 978-981-13-9905-3 (eBook)
https://doi.org/10.1007/978-981-13-9905-3
© Springer Nature Singapore Pte Ltd. 2020
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore
Preface by Dr. Noriaki Kurimoto
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In 2015, we published a book on tracing bronchial branch for bronchoscopy in Japan. To diagnose a peripheral pulmonary lesion represented by lung cancer using a bronchoscope, accurately grasping the bronchial route to reach the peripheral pulmonary lesion is necessary. In
recent years, the use of virtual bronchoscopic navigation has become widespread. However, it
is ideal if, by looking at the axial computed tomography (CT) images, doctors think and
accordingly perform the tracing branch technique, which draws the bronchial route.
We started endobronchial ultrasonography (EBUS) in 1994 and established the standard
procedure 23 years after starting EBUS-GS using a guide sheath in 1996. The method is
described in detail in this book because the tracing branch technique has been improving since.
The progress of the tracing branch technique can be attributed to the emergence of helical CT,
which has made it possible to obtain CT images in slices of about 1mm thickness. In this book,
Chap. 1 explains the principles of tracing branch technique, and considering the running direction of the bronchus, the bronchi are divided into vertical and horizontal branches. Chapter 2
provides typical cases in each subsegment, helping the doctors to continuously study.
Furthermore, the readers can trace the bronchial branch on the aligned CT images and compare
it with actual bronchoscopic ndings. Finally, in Chap. 4, Dr. Morita, another author, describes
a detailed study on comparing EBUS images and histopathological ndings. For the progress
in bronchoscopic diagnosis, it is important to accumulate bronchial-epithelial and subepithelial ndings, which can be explained from histopathological ndings.
The collaboration of staff who worked together at Iwakuni Minami Hospital,
Higashihiroshima Medical Center, St. Marianna University, and Shimane University Hospital,
where I worked, was essential for the publication of this book.
In addition, several doctors who came from foreign countries to attend the EBUS training
have requested an English version of the textbook on tracing bronchial branch. We hope this
book will help several overseas doctors gain the skill of tracing bronchial branch and they will
apply this skill on overseas patients.
Izumo, Japan NoriakiKurimoto
v
Preface by Dr. Katsuhiko Morita
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Do you remember your rst ever case of bronchoscopy? When I was at a small hospital in a
remote area of Japan, 3years after I graduated from medical school, I met a patient I could not
forget. This patient left me with the very impressive words “It was tougher than the time I had
a myocardial infarction!” The bronchoscope that I used then was old and thick, one which the
operator must look directly into. Of course, it was an era when endobronchial ultrasound
(EBUS) was not yet commercialized, anesthesia was inadequate, and the procedure was probably immature. Moreover, I did the bronchoscopy after seeing only a couple of times how the
procedure was done. Realizing that everything was unprepared, I went to Iwakuni Minami
Hospital every week to study bronchoscopy under Dr. Kurimoto and his colleagues, Dr.
Murayama and Dr. Enomoto. More than 20years ago, only the larger bronchi and central airways could be reached, because only a thick bronchoscope was available.
Returning to the present, let’s look at the structure of the lungs. Unlike the gastrointestinal
tract, the peripheral airways branch out and subdivide from the trachea for several bronchial
generations. Therefore, there is a myriad of routes to choose from in order to reach peripheral
lesions precisely. In gastrointestinal endoscopy, particularly colonoscopy, insertion technique
is important, whereas in bronchoscopy for peripheral lesions, selection technique is important.
In my opinion, bronchoscopy to obtain cytologic and histologic diagnosis of peripheral lung
lesions requires three techniques/technologies, including (1) accurate localization of a lesion,
(2) safe and accurate approach to the lesion, and (3) sampling that is safe and would yield
qualitatively optimal cells and tissues. Owing to the recent advancements to date, lesion localization had been made clear by computed tomography (CT), the ability of EBUS to detect
lesions has been conrmed, and safe and optimal sampling had been enabled by the use of a
guide sheath.
Notably, approaching the lesion is the most difcult task. Although advancements in bronchial navigation can address this difculty, the limitations of high equipment cost, extraction
of navigation data from CT, and the time and effort required to create a navigation image
remain. Moreover, the navigation itself cannot always accurately represent the peripheral bronchi. On the other hand, the “branch reading technique” by Dr. Kurimoto requires only paper
and pencil. At one bronchoscopy conference, when this “branch reading technique” was not
yet popular, it was strange that only Dr. Kurimoto was able to draw a schematic representation
of the bronchial branching on the white board, based on the consecutive CT images that
showed the branches that led to the peripheral bronchus involved with the lesion. At that time,
the doctors around me, including myself, were only copying the gure. It seemed that we
began to recognize the necessity of using this navigation technique only after the extra smalldiameter bronchoscope had been used routinely and enabled observation of the peripheral
airways, from the fth generation and after. Being able to correctly read the bronchial branches,
insert a bronchoscope to the periphery, and directly observe peripheral lesions, which used to
seem unreachable, strengthened my enthusiasm for learning this branch reading technique.
vii
viii
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We are now in an era when peripheral lesions can be directly observed endoscopically, the
ndings of which can even be correlated with the pathology ndings. In order to deepen and
spread the understanding of endoscopic ndings based on pathology, improvements in both
diagnostic rate and branch reading are necessary. Sufcient preparation and planning before
bronchoscopy are essential for a safe and successful diagnostic procedure for peripheral pulmonary lesions.
Shimonoseki, Japan KatsuhikoMorita
Preface by Dr. Katsuhiko Morita
c
B
Tsushin. 1984” with minor alteration)
Appearance of Bronchus
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1+2
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(quoted from “A Handbook of Roentgenological
Diagnosis of Lung Cancer. p5. Kyowa Kikaku
ix
Contents
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1 To Trace the Bronchial Branch Accurately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Nomenclature of the Bronchial Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 CT Imaging Condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Method of the Reading Branch Using CT Images . . . . . . . . . . . . . . . . . . . . . . 4
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2 Actual Identification of Bronchial Branch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3 EBUS-GS for Peripheral Pulmonary Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
3.1 Pharyngeal/Laryngeal Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
3.2 Preparing the Guide Sheath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
3.3 Setting of the Ultrasonic Processor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
3.4 Insertion of a Bronchoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
3.5 Guiding the Ultrasonic Probe/Guide Sheath to the Peripheral Bronchus . . . . 132
3.6 Scanning by the Probe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
3.7 Solutions When the Probe Does Not Enter Within the Lesion . . . . . . . . . . . . 136
3.7.1 Re-select the Appropriate Bronchus Under
the Bronchoscopic Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
3.7.2 Re-select the Appropriate Bronchus Under X-Ray Fluoroscopy
(Fig. 3.13) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
3.7.3 Re-select the Appropriate Bronchus Under
the EBUS (Fig. 3.14) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
3.7.4 Re-select the Appropriate Bronchus Using the Guiding
Device Under X-Ray Fluoroscopy (Fig. 3.15) . . . . . . . . . . . . . . . . . 137
3.7.5 Countermeasure Taken When the Bronchus Is Obstructed
at the Margin of the Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
3.7.6 Pinpoint Biopsy (Fig. 3.16) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
3.8 Leave the Guide Sheath In Situ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
3.9 Cells and Tissue Collection Through the Guide Sheath . . . . . . . . . . . . . . . . . 140
3.10 Removing the Guide Sheath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
3.11 Complications and Countermeasures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
3.11.1 Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
3.11.2 Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
3.11.3 The Bending of the Guide Sheath . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
4 Comparison of Endobronchial Ultrasonography Images and Resected
Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
4.1 Ination-Fixation of Excised Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
4.1.1 Things to Do Before Ination-Fixation to Enable
a Proper Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
4.1.2 Make Every Effort to Restore the Lung to Its In Vivo State . . . . . . . 144
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4.2 Cutting Out. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
4.2.1 Overall Observation and Photography . . . . . . . . . . . . . . . . . . . . . . . . 144
4.2.2 Make an Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
4.2.3 Spread Out the Cut Slices of the Specimen and Photograph
the Cut Surfaces (Fig. 4.5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
4.2.4 Reconstruction of the Specimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
4.3 Comparison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
4.3.1 Analysis of Histological Presentation and Correlation
with Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Contents
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