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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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72
2 Actual Identication ofBronchial Branch
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Fig. 2.92 EBUS
The peripheral branch of B
1 + 2
aiiiβ disappeared on CT
images, and then the accompanying pulmonary artery
1 + 2
(A
aiiiβ) is traced. A
the cranial direction and A
1 + 2
tion. A
bronchus (B
aiiiβy enters in the lesion. We suspect that a
1 + 2
1 + 2
aiiiβ branches into A
1 + 2
aiiiβy in the ventral direc-
1 + 2
aiiiβy) is accompanied by A
aiiiβx in
1 + 2
aiiiβy
(Fig.2.115).
In the X-ray uoroscopic screen, the ultrasonic probe and
guide sheath are guided into the lesion through the 4-mm
bronchoscope (Fig.2.116).
The lesion depicted by EBUS is surrounding the probe in
360°, following which the probe is within the lesion. The
internal echo of the lesion is heterogeneous, with no
hyperechoic lines in the lesion; the EBUS image is diagnosed as type IIIb (Fig.2.117).
When the transducer of the probe is withdrawn into the guide
sheath, and the transducer is entirely hidden in the guide
sheath, the ultrasonic waves emitted from the transducer
are reected by the guide sheath and weakened. Owing to
the attenuation of these ultrasonic waves, the brightness
of the EBUS image of the lesion becomes dark
(Fig.
2.118).
Fig. 2.93 Fluoroscopy (1)
Fig. 2.94 Fluoroscopy (2)
1 + 2
Left B
b (Figs. 2.119, 2.120, 2.121, 2.122, 2.123 and
2.124)
Because the lesion is in the left superior segment, rotate
the CT images 90° clockwise, and follow the CT images
from the caudal direction to the cranial direction. The
left superior segment bronchus branches into B3 in the
ventral direction and B
branches into B
1 + 2
B
b in the cranial and dorsal directions. In this case,
1 + 2
1 + 2
in the dorsal direction. B
a in the direction of the apex and
the dorsal branch of B3a distributed in the normal S
1 + 2
1 + 2
c
area.
1 + 2
B
b branches into B
1 + 2
B
a and B
1 + 2
B
bii branches into B
from B3), and B
slightly ventral side (close to B3). B
1 + 2
B
biiβy in the ventral direction and B
in the dorsal direction (away from B3). B
1 + 2
1 + 2
bi in the direction of the apex near
bii in the dorsal and lateral directions.
1 + 2
1 + 2
biiα in the dorsal direction (far
bii branches into B
1 + 2
1 + 2
bii β in the
biiβ branches into
1 + 2
biiβx heading
1 + 2
biiβx enters in
the lesion (Fig.2.119).
cranial
caudal
Right
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B9b
73
ventral
6
B
medial lateral
7
B
B8+B9+B
B
9+10
B
10
8
7
B
B9+B
dorsal
10
B9+B
*
B
8
B
10
8
B
10
6
B
B
9
B
*
B
B9b
9
B
8
B
9
B
10
9
a
6
B
B
*
B
B
B9b
B
B9b
B
7
B
9
a
10
B
9
a
B9b
B9bii
B9bii
B9b
B
B9bii B9bi
9
a
9
b
8
7
B
B
B
B9a
10
B
*
9
B
bi
9
B
bi
B
6
B
9
a
B
9
B
bii
9
bi
B
Fig. 2.95 CT, bronchial branch diagram and bronchoscopic ndings
cranial
caudal
2 Actual Identication ofBronchial Branch
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74
B9bii
9
bi
B9biib
B
B9biia
B9bi
9
biia
B
A9biib
9
biia
A
9
bii
B
8
7
B
10
B
∗
B
B
6
B
9
a
B
B9biib
A9biia
A9biia
Fig. 2.96 CT, bronchial branch diagram and bronchoscopic ndings
Rotate the bronchscope
180°
B9biia
9
B
biib
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Fig. 2.97 EBUS
Fig. 2.98 Fluoroscopy (1)
75
Fig. 2.100 Fluoroscopy (3)
1 + 2
b branches into B
B
in the caudal direction. B
the dorsal direction and B
The probe enters in B
1 + 2
bi in the cranial direction and B
1 + 2
bii branches into B
1 + 2
biiβ in the ventral direction.
1 + 2
biiβ (Fig.2.120).
1 + 2
1 + 2
bii
biiα in
The ultrasonic probe is surrounded circumferentially with
the lesion on the EBUS image, and we call “within.” The
internal echo of the lesion is heterogeneous, with almost
no linear echoes in the lesion; it is judged as type IIIb
(Fig.2.121).
In the X-ray uoroscopic screen, the guide sheath/probe is
guided from the 4-mm bronchoscope tip to the lesion
(→), and it enters “within” the lesion (Fig.2.122).
A guide sheath is left within the lesion.
Brushing cytology is performed at the same site (→).
A guide sheath is left within the lesion.
Biopsy is performed at the same site (→) (Figs.2.123 and
2.124).
Fig. 2.99 Fluoroscopy (2)
After rotating the bronchoscope 180° clockwise at the tra-
cheal bifurcation, apply the down-angle lever to observe
the left main bronchus, left upper lobe bronchus, and left
superior segment bronchus. To approach the caudal area
of the left superior segment, this rotation is useful. B
has no B
1 + 2
c and branches into B
1 + 2
a and B
1 + 2
1 + 2
Left B
c (In this case, “horizontal pattern” is useful.)
(Figs.2.125, 2.126, 2.127 and 2.128)
Owing to the lesion in the left superior segment, rotate the
CT images clockwise 90°, and follow the CT images from
the caudal side to the cranial side. The left superior segment bronchus branches into B3 in the ventral direction
1 + 2
and B
B
1 + 2
B
c branches into B
in the dorsal direction. First, B
1 + 2
c in the lateral direction as usual.
1 + 2
ci in the cranial direction and B
1 + 2
branches into
1 + 2
cii
in the caudal direction (horizontal–vertical pattern).
1 + 2
B
cii branches into B
1 + 2
B
ciiβ in the ventral direction (horizontal–horizontal
1 + 2
pattern). B
direction and B
1 + 2
tal–vertical pattern). B
b.
the cranial direction and B
ciiβ branches into B
1 + 2
1 + 2
ciiα in the dorsal direction and
1 + 2
ciiβx in the cranial
ciiβy in the caudal direction (horizon-
1 + 2
ciiβy branches into B
1 + 2
ciiβyy in the caudal direction
1 + 2
ciiβyx in
76
cranial
caudal
Right
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2 Actual Identication ofBronchial Branch
B10a
7
B
*
B
B10b + B10c
B7+B8+B9+B
B8+B9+B
8
B
10
B9+B
9
B
10
B
B10a
B10a
10
10
B
medial
7
B
ventral
8
B
7
9
B
10
B
*
B
lateral
7
B
dorsal
8
B
B
B
10
8
B
+
+
8
B
9+B10
9
B
9
B
10
B
*
B
B10aiB10ai
B10a
B10aii
B10aii
B10aii
B10aii
7
B
B10ai
B10b+
B10c
10
B
b+
B10c
B
B
B10a
*
*
9
B
B10b+B10c
10
B
aii
8
B
9
B
10
ai
B
10
B
a
10
B
aii
B10aii
Fig. 2.101 CT, bronchial branch diagram and bronchoscopic ndings
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Fig. 2.102 EBUS
77
(horizontal–vertical pattern). B
1 + 2
B
ciiβyxx in the dorsal direction and B
ventral direction (horizontal–horizontal pattern). B
1 + 2
ciiβyx branches into
1 + 2
ciiβyxy in the
1 + 2
ciiβyxx enters in the lesion (Fig.2.125).
The X-ray uoroscopic image is rotated 180°. With the guide
sheath marginally extended from the 4-mm bronchoscope
tip, the transducer (→) in the ultrasonic probe rotates and
scans at a position overlapping the lower edge of the rib
(Fig.2.126).
The probe is surrounded circumferentially with the lesion
depicted by EBUS, called “within.” The internal echo of
this lesion is homogeneous, short lines (→) are found in
the lesion, and blood vessels are also present. I diagnosed
this lesion as type Ia (Fig.2.127).
Then, the biopsy forceps are inserted into the guide sheath
through the working channel of the bronchoscope, and a
biopsy is performed on the X-ray uoroscopic screen
rotated 180°. The position of the edge of the rib where the
transducer is scanning is memorized, and the biopsy is
performed at the same position (the position of the edge
of the rib: →) (Fig.2.128).
Fig. 2.103 Fluoroscopy
Left B3a (Figs. 2.129, 2.130, 2.131, 2.132 and 2.133)
Rotate the CT images clockwise 90° because of the lesion in
the left superior segment, and follow the CT images from
the caudal side to the cranial side. The left superior segment bronchus branches into B3 in the ventral direction
1 + 2
and B
in the dorsal direction. B3 branches into B3a and
B3b+B3c. B3a branches into B3ai in the dorsal and caudal
directions and B3aii in the ventral and cranial directions
(horizontal–oblique pattern). As the angle in the dorsal–
ventral direction between B
3
ai and B3aii is larger than that
in the cranial–caudal direction, the branch on the dorsal
side is named B3ai.
B3ai branches into B3aiα in the dorsal direction and B3aiβ in
the lateral and cranial directions (horizontal–horizontal
3
pattern). B
aiβ branches into B3aiβx to the cranial direction and B3aiβy to the caudal and lateral directions (horizontal–vertical pattern). B3aiβy branches into B3aiβy∗
cranial
caudal
Right
2 Actual Identication ofBronchial Branch
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78
B10b
B10b+B10c
7
B
B10b+B10c
B10b+B10c
6
B
8+B9+B10
B
8
B
9+B10
B
B10c
B
ventral
B10b
8
B
9
7
B
B
4+B5
7+B8+B9+B10
B
6
B
medial lateral
9
B
10
B
B10b+B10c
*
B10a
*
dorsal
B10a
B
6
8
B
9+B10
B
B10a
B10c
B10b
B
B10b
B10bii
10
B
B10bib
B
B10bib
B10bib
10
B
10
b
b+B10c
B10bii
*
10
B
b
*
10
B
c
B
10
b+B10c
10
B
b
*
10
b
B
10
B
c
10
B
a
bi
B10b+B10c
10
bia
*
10
bia
B
10
bib
B
B10c
Fig. 2.104 CT, bronchial branch diagram and bronchoscopic ndings
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79
Fig. 2.105 Fluoroscopy and EBUS
suspected of the lateral branch in the dorsal direction,
A3aiβyx (same-name blood vessel as deduced from the
bronchus) in the dorsal direction, and A3aiβyy in the ventral direction (horizontal–horizontal pattern). B3aiβyy
accompanying A3aiβyy enters the lesion. The probe is
inserted in B3aiβy (Fig.2.129).
The ultrasonic probe covered by the guide sheath (probe/GS)
is guided near the lesion by the working channel of the
bronchoscope, and the EBUS image is barely visible
(Fig.2.130).
By applying the up-angle lever of the bronchoscope, the
probe/GS could be close to the lesion (Fig.2.131).
By pulling or pushing the probe/GS while applying the up-
angle lever of the bronchoscope, the probe/GS could be
guided to the bronchi very close to the lesion (Fig.2.132).
Brushing cytology and biopsy are performed through the
guide sheath adjacent to the lesion (Fig.2.133).
Fig. 2.106 Fluoroscopy
Left B3b (Figs. 2.134, 2.135, 2.136 and 2.137)
Rotate the CT images clockwise 90° because of the lesion in
the left superior segment, and track the CT images from the
caudal side to the cranial side. The left superior segment
bronchus branches into B
1 + 2
and B
b, and B3. B3 branches into B3a and B3b. B3b
1 + 2
c, and common stem of B
1 + 2
a
branches into B3bi in the lateral and dorsal directions (close
to B3a) and B3bii in the ventral direction (far from B3a;
horizontal–horizontal pattern). All branches of B
1 + 2
c, B3a,
B3bi, and B3bii are in a horizontal–horizontal pattern.
B3bi branches into B3biβ in the caudal direction (near the
lingular segment) and B3biα in the cranial and horizontal
1 + 2
directions (close to B
1 + 2
a+B
b). B3biα reaches the cra-
nial site of the lesion (Fig.2.134).
As the lesion is in the left superior segment, rotate CT images
clockwise 90°, and follow the CT images from the caudal
side to the cranial side. The left superior segment bron-
80
cranial
caudal
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Right B10c
10
B
b+B10c
B10b+B10c
B10b+B10c
B10c
B
10
B
B10a
b
B10cii
10
B10a
ci
medial
10
B
ventral
b+B10c
10
c
B
B10cii*B10cii
B
dorsal
B10b
9
8
B
B10a
10
10
B
B
b+B10c
lateral
B10a
10
B
a
10
c
B
10
b
B
10
cii
B
10
ci
B
B
B10cii
B10cii
*
Fig. 2.107 CT, bronchial branch diagram and bronchoscopic ndings
10
ci
10
cii
B
10
B
cii* with saline
injection
*
10
B
cii
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Fig. 2.108 Fluoroscopy and
EBUS (1)
Fig. 2.109 Fluoroscopy and
EBUS (2)
81
Fig. 2.110 Fluoroscopy
chus branches into B
1 + 2
B
b, and B3. B3 branches into B3a and B3b running in the
1 + 2
c, common stem of B
1 + 2
lateral (B3bi: close to B3a) and ventral direction (B3bii: far
from B3a). The bronchial branch diagram is rotated in the
counterclockwise direction to compare with bronchoscopic ndings.
a and
3
B3bi branches into B
biβ in the caudal direction (close to
the lingular segment) and B3biα in the cranial direction
(close to B
1 +2
a + B
1 + 2
b). B3biα reaches the cranial site of
the lesion (rotating the bronchial branch diagram in the
counterclockwise direction to compare with bronchoscopic ndings). The probe is inserted into B3bi
(Fig.2.135).
The ultrasonic probe is assumed to have entered a small
branch (B
3
biβ) in the caudal side in B3bi and is adjacent
to (Fig.2.136).
With the tip of the bronchoscope facing toward the head side
under X-ray uoroscopy, the probe is pulled back and
inserted into B3bi, and it reaches within the marginal part
of the lesion (Fig.2.137).
Column
“What is the next step?”
The last two decades have witnessed remarkable progress in
the procedure using the bronchoscope for diagnosing
peripheral pulmonary lesions regarding the detection of
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