超声引导下横突-胸膜中点阻滞与胸椎旁神经阻滞用于单孔胸腔镜手术后镇痛效果的比较

目的 比较超声引导下横突-胸膜中点阻滞(MTPB)与胸椎旁神经阻滞(TPVB)用于单孔胸腔镜手术术后镇痛的效果。
方法 选择择期行单孔胸腔镜手术患者80例,男36例,女44例,年龄18～65岁,BMI 19～28 kg/m²,ASA Ⅰ―Ⅲ级。采用随机数字表法分为MTPB组（M组）和TPVB组（P组）,每组40例。手术结束后M组行超声引导下MTPB,P组行TPVB,两组均注射0.5%罗哌卡因15 ml。两组患者术后均采用PCIA。记录神经阻滞操作时间、穿刺深度,记录术后2、6、12、24、48 h安静和咳嗽时VAS疼痛评分,记录镇痛泵首次按压时间、总按压次数、舒芬太尼使用量和补救镇痛例数,记录穿刺相关并发症、镇痛不良反应发生情况。
结果 与P组比较,M组神经阻滞操作时间明显缩短（P<0.05）,进针深度明显变浅（P<0.05）。术后2、6、12、24、48 h两组安静和咳嗽时VAS疼痛评分差异无统计学意义。两组患者术后镇痛泵首次按压时间、总按压次数、舒芬太尼用量和补救镇痛率差异无统计学意义。两组患者术后恶心、呕吐等不良反应差异无统计学意义。
结论 MTPB或TPVB联合术后PCIA应用于单孔胸腔镜手术患者,术后均可取得良好的镇痛效果,但MTPB操作简单、安全,可作为单孔胸腔镜手术患者术后镇痛方案的选择。     

Multiple calcifying fibrous pseudotumors of the pleura: ultrastructural analysis provides insight on mechanism of dissemination

ABSTRACT

Calcifying fibrous pseudotumor (CFP) is a rare, benign soft tissue tumor that may uncommonly arise in the pleura. These tumors can show multifocal dissemination across the pleural surface, but the mechanism underlying this dissemination is unclear. Review of previously reported cases of pleural CFP demonstrates a strong predilection for basal and diaphragmatic pleural surfaces, and a significantly higher rate of multifocality compared with other locations. We present a 59-year-old male with multiple CFP of the pleura. Reactive-appearing adhesions spanning the pleural surfaces were present, and by electron microscopy, were involved by tumor. We suggest this is the likely mode of dissemination across the pleural surfaces.     

Surgical Treatment of Hydatidothorax Series of 79 Cases

Objective: A retrospective review of 79 cases of ruptured intrapleural pulmonary hydatid cysts. We analyse and evaluate our experience in the surgical treatment of this complication.

Materials and Methods: In a ten-year period, from 1990 to 1999, 79 patients were operated on in our service for intrapleural rupture of a pulmonary hydatid cyst. There were 51 males and 28 females with a mean age of 35.4 years. The diagnosis was established on the basis of different clinical signs and imaging studies.

Surgical approach consisted of a posterolateral thoracotomy in all cases. After decortication, different procedures were performed on the pulmonary lesions according to the importance of lung destruction.

Results: Radical resections were done in 48 cases, including lobectomies (15), segmentectomies (33) and conservative treatment: simple capitonnage and bronchial fistula closure (31).

Postoperative complications occurred in 8 cases (10.1%), including one pyothorax, one haemothorax, one prolonged air leak, two pneumonias and two wound infections.

There was one postoperative death, by respiratory failure. Ninety-five percent (95%) of patients were free of recurrence of thoracic hydatid disease in a follow-up ranging from 1 to 10 years (mean: 5.4 years).

Conclusion: Hydatid cysts of the lung should be treated before complications occur, particularly intrapleural rupture because it considerably increases morbidity.     

胸部微创切口治疗结核性脓胸

目的探讨结核性脓胸的微创治疗方法。方法1993年至2003年经腋下微创剖胸切口行胸膜剥脱术治疗结核性脓胸,包括肺结核球切除8例,肺结核空洞切除2例,穿透性脓胸4例。结果术后并发血胸2例,皮下气肿14例,刀口Ⅱ期愈合11例,肋骨骨折36例。无手术死亡,无结核复发及播散。结论微创剖胸,具有损伤小,出血少,刀口位置隐蔽,易为病人接受等特点;电视胸腔镜外科辅助治疗,扩大了其手术适应症。     

Primary pleural precursor B‐Cell lymphoblastic lymphoma

Intrathoracic lymphoblastic lymphoma (LBL) is classically of T‐cell lineage, but these cases of pleural B‐cell LBL suggest that this is not always the case. Despite the clinical challenges involved every attempt should be made to secure a biopsy and histological diagnosis, as we move into an era of lineage‐directed therapies.     

由胸腔镜检查探讨经皮穿刺胸膜盲检对结核性胸膜炎及恶性胸腔积液确诊率差异的原因

目的研究经皮穿刺胸膜盲检对结核性胸膜炎及恶性胸水确诊率差异的原因。方法回顾性分析结核性胸膜炎20例、恶性胸水12例胸腔镜检查结果,观察两组患者镜下形态学差异,分析胸膜结节或白斑样病变间黏膜组织的活检病理结果;结果肿瘤与结核均以弥漫性分布、结节状病变为主。在病变之间的胸膜组织也均呈现出充血、水肿、增厚、粗糙、纤维粘连等异常的形态特点。对病变间黏膜组织进行活检的结果提示:结核性胸膜炎组(95%)病理符合率显著高于恶性胸水组(16.7%)(P0.01)。结论结核特征性病变分布更广泛,是导致经皮穿刺胸膜盲检对结核、恶性胸水确诊率差异的主要原因。     

Pneumothorax-associated pleural eosinophilia is tumour necrosis factor-alpha-dependent and attenuated by steroids

Background and objectives: The pathogenesis and the optimal treatment of eosinophilic pleural effusions are unknown. We aimed to examine whether pneumothorax‐associated pleural eosinophilia in mice is dependent on tumour necrosis factor (TNF)‐alpha, and whether it is affected by systemic administration of corticosteroids. Methods: Mice were injected intrapleurally with 0.4 mL air to create pneumothoraces. Animals were sacrificed 24 or 48 h later, and pleural lavage (PL) was performed. In the first experiment, comparisons were made between wild‐type and TNF‐α knockout mice with pneumothorax. In the second experiment, wild‐type mice were injected intraperitoneally with different doses of dexamethasone (0, 0.25, 0.5 and 1 mg/kg), 5 min before and 24 h after the induction of pneumothorax. Results: After induction of a pneumothorax, TNF‐α knockout mice had significantly fewer total number of cells (P = 0.004), mononuclear cells (P = 0.01), neutrophils (P = 0.017) and eosinophils (P = 0.002) in their PL compared with wild‐type animals. TNF‐α was detected in the PL of most of the control mice but not in TNF‐α knockouts. Dexamethasone induced a significant, dose‐dependent reduction of PL total cells (P < 0.001), eosinophils (P < 0.001), mononuclear cells (P = 0.007) and lymphocytes (P = 0.04) at 48 h, and significantly reduced the number of PL total cells (P = 0.045) and eosinophils (P = 0.005) at 24 h. Furthermore, dexamethasone prevented eosinophil infiltration of lung and pleural tissue. Conclusion: Pneumothorax‐associated pleural eosinophilia in mice is TNF‐α‐dependent and is significantly attenuated by corticosteroid treatment. In addition, both TNF‐α deficiency and dexamethasone treatment were associated with a significant reduction of other types of inflammatory cells in PL.     

脏层胸膜在胸膜腔液体循环中作用机制的临床研究

目的　结合心力衰竭、肺淋巴管癌病和肺淋巴管平滑肌瘤病的临床和病理特征 ,探讨脏层胸膜在胸膜腔液体循环中的作用机制。方法　 (1)分析 1999～ 2 0 0 1年 5 31例心力衰竭患者胸膜腔积液的发生率 ,其中冠心病等所致的左心功能 级 32 9例 ,慢性肺原性心脏病右心功能失代偿 2 0 2例 ;(2 )分析 1998～ 2 0 0 2年 6例肺内淋巴管性疾病胸膜肺组织活检的病理表现和肺内淋巴管的分布特征。结果　 (1)胸腔积液的发生率左心功能 级者为14.89%;肺心病右心功能失代者为 0 %,两者差异有显著性 (p<0 .0 1) ;(2 )肺内淋巴管性疾病的胸膜肺组织病理可见肺内淋巴管起源于胸膜脏层。结论　肺内淋巴管起源于胸膜脏层 ,在胸膜腔液体的循环过程中和壁层胸膜一样发挥着重要的作用。     

Recent discovery of an old disease: malignant pleural mesothelioma in a village in south-east Turkey

BACKGROUND AND OBJECTIVE: Environmental asbestos exposure is reportedly common in some districts of Turkey. The aim of this study was to investigate the presence and effect of environmental asbestos exposure in a village in Gaziantep, Turkey, with reported cases of mesothelioma. METHODS: All villagers > or =14 years old were subject to an interview rediagnosis and a detailed questionnaire. Chest microfilms were performed in all cases, and additional standard CXRs were obtained when necessary. Samples collected from the natural mantle, and whitewash from the houses were analysed for the presence of asbestos. RESULTS: In total, 269 villagers took part in the study. The incidence of histopathologically diagnosed malignant pleural mesothelioma was 0.32% relative to the total village population in the year 2000. The verbal autopsy revealed eight possible cases of malignant pleural mesothelioma, all of whom had died within the past 12 years. Of these eight, there was a first-degree kinship between three, and additionally, these patients had a third-degree relationship with a biopsy proven case. Radiological evaluation showed pleural calcification and/or thickness in 3.3%, and pleural effusion in 0.4% of patients undergoing CXR. All houses in the village were constructed using adobe soil, and the interior whitewash was made from soil containing asbestos. Analysis of soil samples revealed tremolite and/or actinolyte asbestos. CONCLUSION: The current findings suggest that environmental asbestos exposure continue to be a serious health concern in the Gaziantep region of Turkey.