Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2702_Библиотеки_им_академика_М_И_Перельмана
.pdf
References
https://t.me/medicina_free
Fig. 1.32 EBUS-GS
21
EBUS
Outline of the EBUS-GS [18]
An ultrasonic probe with a guide sheath is inserted into the
working channel of the bronchoscope to reach the lesion.
The transducer in the ultrasonic probe is rotated and
scanned with an ultrasonic beam to obtain an ultrasonic
image (Fig.1.32).
References
1. General Rule for Clinical and Pathological Record of Lung Cancer.
7th ed, in Japanese by The Japan Lung Cancer Society. Tokyo:
Kanehara Publishing; 2010. (in Japanese)
2. Yamashita H.Roentgenologic anatomy of the lung. Tokyo: IgakuShoin, Ltd.; 1978.
3. Arai T, Shiozawa M. Pulmonary resections: anatomy and surgical
technique. Tokyo: Asakura Publishing; 1983. (in Japanese)
4. Nishiwaki Y. A handbook of roentgenological diagnosis of lung
cancer. Tokyo: Kyowa Kikaku Tsusin; 1984. (in Japanese)
5. Oho K, Amemiya R.Practical beroptic bronchoscopy: the analysis of the procedure and its ndings, bronchovideoscopy and its
explanation, 6th ed. Tokyo: Igaku-Shoin; 1994. (in Japanese)
6. Furuse K, Tsuchiya R. Bronchoscopy: techniques and diagnostic
imaging for clinicians, 1st ed. The Japan Society for Bronchoscopy.
Tokyo: Igaku-Shoin; 1998. (in Japanese)
7. Fukuoka M, Tsuchiya R. Bronchoscopy: techniques and diagnostic imaging for clinicians, The Japan Society for Respiratory
Endoscopy. 2nd ed. Tokyo: Igaku-Shoin; 2004. (in Japanese).
8. Asano F, Miyazawa T.The best techniques for performing bronchoscopy, 1st ed. Tokyo: Cyugai Igakusha; 2012. (in Japanese)
9. Itoh H.Anatomy of daughter bronchus and related diseases. J Jpn
Soc Bronchol. 1988;9:312–23.
10. Katoh S, Koba H, Suzuki A.Daughter branches and the areas supplied by them. J Jpn Soc Bronchol. 1988;10:488–93. (in Japanese)
11. Katoh S, Koba H. Analysis of bronchial branching pattern using
inated and xed human lung: with special reference to comparison between daughter branches and the other types of branches, in
Japanese. Sapporo Med J. 1991;60(5):479–88.
12. Itoh H.About the bronchial daughter branch, moderator summary.
J Jpn Soc Bronchol. 1988;10:485–87. (in Japanese)
13. Kurimoto N, Murayama M, Yoshioka S, etal. Analysis of the internal structure of peripheral pulmonary lesions using endobronchial
ultrasonography. Chest. 2002;122:1887–94.
14. Hayward J, Reid LM.Observations on the anatomy of the intrasegmental bronchial tree. Thorax. 1952;7:89–97.
15. Itoh H. Anatomic bases of the airways and vessels of the lung
periphery. J Jpn Soc Respir Endosc 2006;28:9–14. (in Japanese)
16. Onuma K, Ebina M, Takahashi T, et al. Irregularity of airway
branching in a mouse bronchial tree: a 3-D morphometric study.
Tohoku J Exp Med. 2001;194:157–64.
17. Koushi N.The basis and system for ultrasound: in the compact
ultrasonic α series, 4th ed. Tokyo: VECTOR CORE; 2013. (in
Japanese)
18. Kurimoto N, Miyazawa T, Okimasa S, et al. Endobronchial
ultrasonography using a guide sheath increases the ability to
diagnose peripheral pulmonary lesions endoscopically. Chest.
2004;126:959–65.
Actual Identification ofBronchial
https://t.me/medicina_free
Branch
2
Organization of this chapter.
In this chapter, representative cases for each subsegment
illustrate how to follow the bronchi actually and how to
think.
I will describe the description in each subsegment with a rep-
resentative case.
CT images are arranged in the head-to-foot direction.
The reading CT anatomy (bronchial branch diagram) is
described from the CT images and illustrates the point of
reading the bronchial route.
Furthermore, I explain the nomenclature of the bronchi with
actual bronchoscopic ndings (Figs.
Right upper lobe
Typical branching of the right upper lobe bronchus (Fig.2.5).
The point of the anatomy of the right upper lobe bronchus
(Fig.2.6):
S1 (Segment 1): located at the apex of the right upper lobe,
divided into S1a of the apex area of S1 and S1b of the
dorsal area of S
S2: located on the caudal/dorsal side of the right upper
lobe, divided into S2a of the cranial/dorsal side of S2
and S2b on the caudal/lateral side of S
S3: located on the caudal/ventral side of the right upper
lobe, divided into S3a of the lateral side of S3 and S3b
of the ventral side of S
The longitudinal-running folds in the membranous portion
of the right main bronchus are entering to B2.
The rough direction of each area/subsegment:
B1: toward the lung apex
B2: toward the dorsal/cranial side
B3: toward the ventral side
B1a: toward the lung apex
1
B
1
3
b: toward the ventral/cranial side of the lung
apex
2.1, 2.2, 2.3 and 2.4).
2
2
a: toward the dorsal/cranial side
B
B2b: toward the dorsal/lateral side
B3a: toward the ventral/lateral side
B3b: toward the ventral side
Pulmonary veins of the right upper lobe
The right upper pulmonary vein is often classied into V
ascending under the visceral pleura on the medial side, V3
running on the ventral side, and V2 running on the dorsal
and cranial side. Considering the types of the route of the
pulmonary veins, central vein type implies the V2 trunk
joined with the branches of V2 runs between the B2 and B3
to the dorsal/cranial side (80% of the cases), and the semicentral vein type implies V2 trunk joined with the branches
of V2 runs on the ventral side of B3 (10%). In the remaining 10% of cases, noncentral vein type implies V2 does
not form central vein, and the branches of V2 join with V1
and V3, respectively (Fig.2.7).
Correlation of bronchial branches and central vein on the
right upper lobe (Fig.2.8).
In most cases, V2c runs at the boundary between S3a and S2b.
Central vein type: V2 trunk (central vein) into which V2c,
V2a, and V2b ow in 80% of cases is located between B3
and B2 (left gure).
Semi-central vein type: In the case of 10%, the central vein in
which V2c, V2a, and V2b ow does not run between B3 and
B2 and runs on the medial side of the bifurcation between
B1 and B3.
Noncentral vein type: In the remaining 10%, V2c, V2a, and
V2b do not join; V2c, V2a, and V2b join with V1 and V3 in
the caudal side of B2.
Route of the right upper lobe bronchus on CT axial images
rotated counterclockwise by 90° (Figs.2.9 and 2.10).
1
© Springer Nature Singapore Pte Ltd. 2020
N. Kurimoto, K. Morita, Bronchial Branch Tracing, https://doi.org/10.1007/978-981-13-9905-3_2
23
24
cranial
caudal
B
ventral
2 Actual Identication ofBronchial Branch
https://t.me/medicina_free
6
B
medial
8
B9+B
10
10
7
B
B8+B9+B
B
9+10
B
7
B
B9+B
dorsal
B
9
B
7
B
8
B
10
6
B
lateral
B9b
8
B
B9b
B
9
a
B9b
B
10
B
6
B
Fig. 2.2 Bronchial branch diagram
9
a
9
a
B
Fig. 2.1 CT
9
b
B
B9bii
B9bii
B9b
B
8
B
10
B
9
B
B
Fig. 2.3 Bronchoscopic ndings
9
bi
B
9
9
bi
10
B
B
Fig. 2.4 Bronchoscopic ndings
Right upper lobe
front view lateral view
2 Actual Identication ofBronchial Branch
https://t.me/medicina_free
Fig. 2.5 Bronchial anatomy in the right upper lobe
Fig. 2.6 Typical branching of
the right upper lobe bronchus
25
1
B1a
2
B
a
b
B
1
a
B
1
b
B
2
a
B
2
B
b
3
a
B
3
b
B
2
b
B
3
B
a
3
b
B
26
1
B
https://t.me/medicina_free
2 Actual Identication ofBronchial Branch
Fig. 2.7 Pulmonary veins in
the right upper lobe (quoted
from “A Handbook of
Roentgenological Diagnosis
of Lung Cancer. p15. Kyowa
Kikaku Tsushin. 1984”)
2
a, A2a
2
V
V
B
2
t
V
V
b
2
t
2
b, A2b
V
V
B1a, A1a
1
t
V
2
a
2
c
V
lateral view
2
a
2
V
b
2
c
lateral view front view
1
a
V
1
B
b, A1b
3
B
a, A3a
3
a
V
central vein type (80%)
1
V
a
1
t
V
3
a
V
1
V
B
V
V
b
3
b, A3b
V
3
b
1
b
V
b, A1b
B
2
a
V
2
B
a, A2a
2
V
b
2
B
b, A2b
3
c
V
3
a, A3a
B
3
c
V
V
3
b
1
t
V
2
c
2
c
V
3
b
A
3
B
3
V
a
front view
2
V
2
V
b
1
V
t
3
a
3
V
1
a, A1a
B
1
a
V
1
b
V
3
b
b
V
a
1
a
V
1
b
V
b
semi-central vein type (10%)
1
V
2
t
V
2
a
V
2
b
V
a
2
a
V
2
V
b
1
b
V
2
c
V
1
V
a
1
V
b
3
c
V
2
c
V
lateral view front view
3
V
a
3
V
b
3
V
a
3
b
V
non-central vein type (10%)
2 Actual Identication ofBronchial Branch
https://t.me/medicina_free
V2c
central vein
Fig. 2.8 Central vein and V2c
27
Regarding the bifurcations of B1, B2, and B3 from the right
upper lobe bronchus with a bronchoscope, B3b is on the
ventral side, B3a and B2b on the lateral side, B2a on the
dorsal side, and B1 on the cranial side.
B1 toward the apex of the lung branches into B1a in the dorsal
direction and B1b in the ventral direction. In many cases,
B1a and B1b diverge to B1ai and B1bi heading toward the
apex of the lungs and B1aii and B1bii heading toward the
lateral, oblique, and cranial side, respectively.
The typical branching pattern of the right upper lobe bron-
chus (Fig.2.11).
As shown in the typical branching pattern of Fig.2.11, B1 is
located in the 12 o’clock direction, B2 (in which the lon-
gitudinal-running folds of the membranous portion of the
right main bronchus exist) in the 4 o’clock direction, and
B3 in the 7 o’clock direction. It may exhibit a branch pat-
tern typied by the right four gures. While the reading
CT anatomy of B1, B2, and B3 at the right upper lobe bron-
chus repeats to page CT images several times, these vali-
date the positional relationship of B
1
, B2, and B3 and the
formation of the common trunk of the bronchus.
medial
1
B
B3b
central
ventral
B3a
Fig. 2.9 CT image rotated counterclockwise by 90° (1)
Fig. 2.10 CT image rotated
counterclockwise by 90° (2)
vein
lateral
B
2
B
b
2
a
dorsal
Column
I. Tip to improve bronchoscopic procedures
II. How to improve bronchoscopic procedures
What is a skillful bronchoscopic procedure?
In my opinion, the four main points of the skillful broncho-
scopic procedures are as follows:
Not to contact the tip of the bronchoscope with the bronchial
wall.
Pick up the bronchial ndings of the bronchial lumen fully.
Shorten the time required for bronchoscopy.
Collect the cells/tissues from the lesion.
Not to contact the tip of the bronchoscope with the bronchial
wall.
medial
1
B
1
bi
B
ai
B
A
ventral
B1bii
lateral
1
aii
B
dorsal
28
https://t.me/medicina_free
2 Actual Identication ofBronchial Branch
1
B
1
B
3
B
Fig. 2.11 The typical branching pattern of the right upper lobe bronchus
2
B
3
B
2
B
fold
1
B
3
B
Do not push the tip of the bronchoscope into contact with
the bronchial wall; it is imperative to control this step so that
the tip of the bronchoscope advances in the center of the
bronchial lumen. To move the tip of the exible bronchoscope in the intended direction, the bronchoscopist monitors
the up-/down-angle lever with one hand (left hand if righthanded) and rotates around the long axis of the bronchoscope
as required while moving the bronchoscope back and forth
with the remaining hand (right hand if right-handed).
Furthermore, when pulling the bronchoscope, try to return to
the center of the same bronchial lumen as you insert the
bronchoscope.
Pick up the bronchial ndings of the bronchial lumen fully.
First, determine the setting of the endoscopic machine.
Observing in the white light, we set A5 for the structural
emphasis of Olympus machine and “peak” of light adjustment amid marked light reection. To observe bronchial
ndings clearly, “Do not make contact with the bronchial
wall” is a necessary condition.
Based on my experience, several key points are as
follows:
(i) Start observing the healthy tissue around the lesion, the
marginal border of the lesion, and then the inside of the
lesion.
(ii) Place the area you want to observe at the center of the
screen.
(iii) Observe changes in normal structures, blood vessels,
and convert to words.
(iv) Approach proximately to the area you want to observe
within the range of focus.
2
a
B
2
B
b
B1b
B
3
1
B
a
2
B
3
B
1
B
2
B
Shorten the time required for bronchoscopy.
We will keep the tip of the bronchoscope at the center of
the bronchial lumen to shorten the time required for the
bronchoscopic procedure.
Collect cells/tissues from the lesion.
While performing a biopsy at the visible area in the bronchial lumen where cells and tissues could be collected, open
the biopsy forceps inserted through the working channel,
advance the opened forceps and bronchoscope, push the
cups against the site of the lesion you want to biopsy, and
close the cups to collect the tissue.
For biopsies of peripheral lesions, it is essential for the
operator to biopsy after determining the site to be collected
on the uoroscopic screen.
Steps for branch reading of right B1 on axial CT images:
1. Rotate CT images of the right upper lobe counterclockwise 90° (as the lateral side of the chest wall
comes downward).
2. Follow the bronchi to nd in which subsegment the
lesion is approximately located.
3. Follow the bronchus gradually from the slice at the
entrance of the upper lobe bronchus to the slice where
the lesion is located.
4. Many bronchi are orthogonal to the horizontal direction on CT slices, diverging to the dorsal or ventral
direction and lateral or medial direction. We should
draw bronchi and the angle of the spur in the same
direction on axial CT images.
CT
caudal
2 Actual Identication ofBronchial Branch
https://t.me/medicina_free
29
5. It is unusual that bronchial branching runs parallel to
the axial CT slices in this area; however, when it does,
it is necessary to consider in which direction (cranial/
caudal, dorsal/ventral, lateral/medial) the bifurcated
bronchus approaches/leaves.
Right B1a
We follow the right B1a from caudal side to cranial side on
CT images rotated counterclockwise 90°.
Right upper lobe bronchus branches into B3 combined with
B1b, B2b, and B1a and combined with B2a. Naming the
bronchi while considering the range where normal bronchi were present.
B1a+B2a branched into B1a and B2a. Draw the same angle of
the spur of bifurcation corresponding to the CT images.
B1a branches into B1ai and B1aii. B1ai branches into B1aiα
and B1aiβ. B1aiα reaches the lesion (Figs.2.12, 2.13, 2.14
and 2.15).
The position of the transducer at the tip of the ultrasonic
probe is veried on the X-ray uoroscopic screen.
Perform the biopsy at the memorized position of the
transducer on the uoroscopic screen (Fig. 2.16).
The probe is located within the lesion. The internal echo is
relatively heterogeneous, and no hyperechoic points or
lines are found—it is diagnosed as type IIIb (Fig. 2.17).
Right B1b
Follow the bronchus from the caudal side to the cranial side
on CT images rotated counterclockwise 90°. On the CT
images, the right upper lobe bronchus has three branches—
B1, B2, and B3 (Fig.2.18).
When the bronchi are nearly orthogonal to the axial CT sec-
tion, the spur between B1a and B1b of the bronchial branch
diagram is drawn at the same angle based on the angle of
the spur between B1a and B1b on the CT images.
Fig. 2.12 A lesion in the right S1a
Fig. 2.13 CT, bronchial branch diagram and bronchoscopic ndings
When the bronchus is nearly orthogonal to the CT section,
the spur of the bronchial branch in the bronchial branch
cranial
ventral
3
B
caudal
dorsal
Rt. upper lobe
bronchus
caudal
cranial
https://t.me/medicina_free
30
B1b
2 Actual Identication ofBronchial Branch
cranial
1
a+B2a
B1b
B
dorsal
2
b
B
3
B
1
B
2
B
a+B2a
b
ventral
candal
1
a
B
1
1
B
a
a
B
B2a
B2a
1
a
B
2
B
a
B2a
B1a
B1ai
B
B1b
B
2
b
B
3
2
B
b
B1a
1
a
B1b
B
B
B2a
2
B
b
3
B
B2a
2
b
B1ai
1
aii
B
2
a
B1b
1
aii
3
B
B
2
B
b
B1ai
1
B
aii
Fig. 2.14 CT, bronchial branch diagram and bronchoscopic ndings
B1aib
B1ai
B1ai
1
B
aib
B1aii
2
B
a
1
B
aia
B1b
3
B
2
B
b
B1ai a
CT
2 Actual Identication ofBronchial Branch
https://t.me/medicina_free
31
B1aib
1
B
aia
B1aia
Fig. 2.15 CT, bronchial branch diagram and bronchoscopic ndings
B1aii
B1b
3
B
B1aib
B1aii
B1b
3
B
B1aia
B
B2b
B1aia
B
B2b
2
a
B1aia
2
a
Fig. 2.16 Fluoroscopy
Fig. 2.17 EBUS
Fig. 2.18 A lesion in the right S1b
Соседние файлы в папке Библиотека им академика М.И. Перельмана