VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR PRIMARY SPONTANEOUS PNEUMOTHORAX

Video-assisted thoracoscopic surgery (VATS) has been suggested as the most appropriate choice for spontaneous pneumothorax. Thirty-two patients (30 males, two females, age range from 16 to 42) with primary spontaneous pneumothorax (PSP) are reported. All had mechanical pleurodesis with Marlex mesh. Blebs or bullae could be identified in 24 patients (75%). All bullae over 2 cm were either excised (11 patients) or ligated (five patients). The median operating time was 45 min. There was minimal postoperative discomfort and the median postoperative hospital stay was 4 days. There was one minor wound infection and one recurrence (mean follow up of 11 months). It is concluded that VATS is a quick, safe and effective approach for the treatment of PSP. Long-term results will better define its true merit in thoracic surgery.     

PNEUMOTHORAX DURING LAPAROSCOPIC MOBILIZATION OF THE OESOPHAGUS

During laparoscopic dissection of the oesophagus, the left pleura is easily breached, resulting in pneumothorax. This complication has not been widely reported, although it is likely to be common. Management depends on subsequent cardiorespiratory effects, which are variable. Five cases are reported from an initial experience of 190 laparoscopic Nissen fundoplications, illustrating a variety of presentations and management options.     

原发性肝癌自发性破裂出血的特点和治疗分析

目的 探讨原发性肝癌自发性破裂出血的临床特点和有效的治疗方法.方法 回顾性分析1990～2005年间收治的21例原发性肝癌自发性破裂出血患者的临床资料.结果 经手术治疗的15例全部达到止血目的.急诊肝癌切除术10例,局部缝扎加肝动脉结扎、大网膜填塞缝扎各2例;介入治疗3例中止血2例,1例中转手术治疗,另4例非手术治疗.手术组1、3、5年存活率分别为66.7%、13.3%、6.7%,非手术治疗组1年生存率为零.结论 原发性肝癌自发性破裂出血并不一定是肝癌的终末期表现.手术治疗仍是本病最为有效的治疗方法.     

Spontaneous pneumothorax and a coexistent azygos lobe

We present a primary spontaneous pneumothorax involving a possible diagnostic and surgical pitfall. A 25-year-old man with a previously identified azygos lobe was admitted to our hospital because of right primary spontaneous pneumothorax. A preoperative chest X-ray at the onset of the pneumothorax as well as after resolution by tube drainage showed an azygos fissure but no azygos vein. Chest computed tomography revealed the dislocated azygos vein external to the azygos fissure on the mediastinal side of the reexpanded upper lobe. Thoracoscopic bullectomies were uneventfully performed. The azygos arch was found dangling in the free inferior border of the mesoazygos. An azygos vein located in this position can be a potential surgical hazard especially in video-assisted thoracic surgery. This case suggests that the presence of an azygos lobe can be missed on chest X-ray when a pneumothorax occurs in a patient with an azygos lobe.     

微创快速康复外科技术在治疗原发性自发性气胸中的应用进展

原发性自发性气胸(PSP)是一种比较常见的胸部疾病,绝大部分患者合并肺大疱形成,病情严重,其治疗方法多样,包括保守治疗或开胸手术、电视胸腔镜手术(VATS)等治疗,各有优缺点。采用不同的流程方法治疗,治疗的效果亦不相同。文章就近年来国内外在PSP的诊断、快速康复外科(FTS)治疗、临床应用方面做一简要综述。     

电视胸腔镜治疗全肺不张型原发性自发性气胸

目的评价电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)治疗全肺不张型原发性自发性气胸(primary spontaneous pneumothorax,PSP)的价值。方法 2002年4月～2008年5月,对38例全肺不张型PSP均行VATS。用内镜切割缝合器(Endo-GIA)切除肺大疱(6例)或丝线结扎(32例)。结果 37例手术顺利,因胸腔粘连呈蔓状中转小切口手术1例。手术时间45～256min,(115±31)min。术中出血量30～300ml,(110±95)ml。术后并发症2例(1例术后锁骨下动脉分支小血管出血,1例脓胸,均再次VATS手术),无围术期死亡。38例术后随访2～85个月,(43.2±16.1)月,气胸无复发。结论全肺不张型PSP应积极行VATS治疗。     

Management of primary spontaneous pneumothorax: a review

Primary spontaneous pneumothorax is a common problem faced by doctors in medical practice. It is a significant global health problem affecting adolescent and young adults. This article will review the etiopathology, diagnosis and current management guidelines. It aims to improve clinical practice and compliance to the complexities of procedures involved in management.     

婴幼儿先天性胆总管囊肿自发穿孔的诊治

目的探讨先天性胆总管囊肿自发性穿孔的诊断和治疗。方法回顾性分析11例婴幼儿先天性胆总管囊肿自发性穿孔患儿的临床资料。结果本组8例经术前腹腔穿刺确诊胆道自发性穿孔,其中5例经B超或CT诊断胆总管囊肿。3例行一期胆总管囊肿切除加胆道重建术(胆总管空肠Roux-Y吻合术);6例行胆道外引流加腹腔引流术,2例行胆囊置管引流加腹腔引流术,3~6个月后行胆总管囊肿切除加胆道重建术。11例患儿治疗后均恢复良好。结论婴幼儿胆总管囊肿自发穿孔容易误诊,掌握其临床特点、提高诊断意识以及根据患儿具体情况选择合理的手术方式是提高术前诊断率和减少术后并发症的关键。     

电视胸腔镜手术与胸腔闭式引流术治疗老年白发性气胸的疗效分析

目的对比分析电视胸腔镜手术与传统胸腔闭式引流术对于老年自发性气胸治疗的疗效差异。方法回顾性分析2011年3月至2013年5月135例老年自发性气胸患者的临床治疗及其效果。结果采用电视胸腔镜手术的97例患者,其住院时间、术后并发症及气胸复发的几率均明显低于采用胸腔闭式引流术的38例患者,两者比较,差异具有统计学意义（P〈0．01）。结论电视胸腔镜治疗老年自发性气胸,具有患者痛苦小,并发症的发生率低,病程短,复发率低,疗效确切等优点,与胸腔闭式引流相比较,其疗效有明显的优势。     

Thoracoscopic treatment of spontaneous pneumothorax in children

Background/purpose

This study describes the authors experience and results with thoracoscopic treatment of spontaneous pneumotrorax (SP) in 22 children.

Methods

A total of 32 thoracoscopic procedures were performed in 22 children. The patients ranged in age from 9 to 21 years at the time of their first thoracoscopy. SP was primary in 9 and secondary in 13 patients. Pleurodesis was performed in all thoracoscopies using talc in 28 and pleural abrasion in 4 procedures. In 2 of these, apical pleurectomy was added to abrasion. Blebectomy was the additional surgical procedure associated with pleurodesis in 4 patients.

Results

Thoracoscopy usually was performed with the patient under general anesthesia. In children with severe respiratory insufficiency, regional anesthesia was used. The mean operative time was 42.6 minutes (range, 8 to 114 minutes). The mean time of postoperative chest tube drainage was 4.6 days (range, 2 to 12 days). Three patients with cystic fibrosis had prolonged air leak lasting longer than 7 days after thoracoscopy. None of them required an additional surgical intervention, and the air leak ceased in 8, 8, and 12 days with continuous suction. One patient required a repeat thoracoscopy for bleeding from an intercostal artery on postoperative day one. The mean follow-up was 4 years (range, 2.5 months to 14 years). There have been 2 partial recurrences (6.25%), both in patients with secondary SP, which were treated by a repeat thoracoscopy and talc pleurodesis.

Conclusions

Thoracoscopic treatment of SP is safe and effective in children. It can be performed under regional anesthesia also in children with severe respiratory insufficiency. Because the complications and recurrences are encountered more frequently in children with an underlying lung disease, special care in surgical manipulation is required in this subgroup of patients with SP.     

首次发作原发自发性气胸的治疗方案探讨

目的：探讨首次发作的原发自发性气胸最佳治疗方案。方法分析我院2008年1月－2011年1月期间首次发作的原发自发性气胸患者76例,其中保守治疗组共42例,VATS 手术组共34例。比较二组患者临床特征及治疗的指标。结果二组患者中性别、年龄、气胸部位及吸烟均无统计学差异,保守治疗无效而行 VATS 手术者14例（33．3％）,其中肺部持续漏气9例（21．4％）,肺膨胀不全5例（11．9％）。VATS 组气胸的范围（56．91±15．52）％,与保守治疗组（48．57±19．36）％比较差异有统计学意义（P ＝0．045）。VATS 组无中转开胸,二组中均未出现肺炎、脓胸、血胸等并发症。行 VATS 手术患者,术中发现明确肺大疱共30例（88．2％）,VATS 组与保守治疗组在止痛药的应用时间[（3．35±0．65）d vs （1．04±0．89）d,P ＜0．05]及拔除胸引管的时间[（4．82±0．58）d vs （4．09±0．76）d,P ＜0．05]方面比较差异有统计学意义。经过平均28．4个月的随访, VATS 组与保守治疗组气胸的复发[1例（2．9％）vs 16例（38．1％）,P ＜0．05]。平均住院日期 VATS组与保守治疗组[（7．74±0．86）d vs （5．29±1．04）d,P ＜0．05]。结论与保守治疗相比,VATS 能明显降低首次发作的自发性气胸复发率,在特定的患者中,该术式值得推荐。     

不同术式治疗自发性气胸的对比研究

目的　比较前 /后外侧切口开胸、腋下小切口开胸和电视胸腔镜手术治疗自发性气胸的临床效果。方法　 89例自发性气胸患者接受外科治疗 ,其中 3 4例施行常规前 /后外侧切口开胸 ,3 1例行腋下小切口开胸 ,2 4例行电视胸腔镜手术治疗。对比各组切口长度、术中出血量及术后胸液量、哌替啶用量、拔管时间、住院天数等指标。结果　腋下小切口开胸组和电视胸腔镜组在上述指标等方面均明显优于常规开胸手术组 (P <0 .0 1) ,而腋下小切口开胸组和电视胸腔镜组之间无显著差别 (P >0 .0 5 )。结论　手术治疗自发性气胸疗效肯定 ,腋下小切口开胸术更经济、简单 ,符合现阶段多数病人的实际经济承受能力以及医疗安全和质量的需要 ,值得推广应用     

Unexpected Histopathological Diagnosis of Placental Transmogrification of the Lung after Bullectomy for Recurrent Spontaneous Pneumothorax: A Case Report and Literature Review

We report a 33-year-old man who presented with recurrent right pneumothorax. Computed tomography (CT) showed the presence of a large bulla with a maximum diameter of 8 cm in the right middle lobe; he subsequently underwent bullectomy. Histopathology revealed that pulmonary parenchyma adjacent to the bulla represented nodular proliferation of clear cells characterized by a papillary structure resembling placental chorionic villi. Immunohistochemically, clear cells were positive for CD10, suggesting placental transmogrification of the lung (PTL). We reviewed 36 surgical cases of PTL, and only 2 cases (5.6%), including our case, were operated for spontaneous pneumothorax. Bullous lesions secondary to PTL tend to appear as unilateral large cystic masses in non-upper lobes, which is atypical for primary spontaneous pneumothorax (PSP). Although PTL is considered a very rare cause of secondary pneumothorax, we must carefully differentiate this condition.     

低成本两孔胸腔镜手术治疗原发性气胸

目的探讨一种简单、微创、经济的腔镜方法治疗自发性气胸。 方法收集2011年10月至2016年2月胸腔镜手术治疗自发性气胸84例,其中两孔胸腔镜肺大疱结扎54例(试验组),三孔胸腔镜肺大疱切割缝合器楔形切除30例(对照组)。试验组,根据胸壁不同厚度把肺大疱拉近操作孔或拉至操作孔或拉出操作孔用手直接结扎/缝扎后做机械摩擦的胸膜固定术;对照组按常规进行,用切割缝合器行肺楔形切后做机械摩擦的胸膜固定术。 结果两组患者的临床效果差异无统计学意义(P>0.05),试验组的住院费用低于对照组[(16 747.30±2 586.41) 元 vs (21 088.54±6 005.68)元,P<0.05]。 结论两孔胸腔镜下肺大疱用手缝扎/结扎技术治疗自发性气胸简单、微创、经济。     

Recurrence rate after thoracoscopic surgery for primary spontaneous pneumothorax

Objectives: There is an on-going discussion regarding the recurrence rate after surgery for primary spontaneous pneumothorax by video assisted thoracic surgery (VATS) or by thoracotomy access. This study aimed to describe the recurrence rate, and to identify a possible learning curve, following surgery for primary spontaneous pneumothorax by VATS. Design: All patients who underwent surgery for primary spontaneous pneumothorax by VATS at Karolinska University Hospital 2004–2013 were reviewed. Preoperative and operative characteristics were obtained from medical records. Patients were followed-up through telephone interviews or questionnaires and by review of medical records. The primary outcome of interest was time to recurrence of pneumothorax requiring intervention. Outcomes were compared between patients operated during 2004-June 2010 and July 2010–2013. Results: 219 patients who underwent 234 consecutive procedures were included. The mean follow-up times were 6.3 and 2.9 years in the early and late period, respectively. The postoperative recurrence rate in the early period was 16% (11%–25%), 18% (12%–27%), and 18% (12%–27%), at 1, 3 and 5 years, compared to 1.7% (0.4%–6.8%), 7.6% (3.7%–15%), and 9.8% (4.8%–19%) at 1, 3 and 5 years, in the late period (p?=?0.016). Conclusions: We found that the recurrence rate after thoracoscopic surgery for primary spontaneous pneumothorax decreased significantly during the study period. Our results strongly suggest that thoracoscopic surgery for pneumothorax involve a substantial learning curve.     

Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to evaluate the application of video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population. PATIENTS AND METHODS: Between 1995 and 1997, four patients with recurrent spontaneous pneumothorax were treated. Ages varied from 14 to 17 years. There were three males and one female. Two patients had spontaneous pneumothorax twice, and the other two had it three times. Three patients had primary spontaneous pneumothorax, and the fourth one had spontaneous pneumothorax secondary to cystic fibrosis. Computerized tomography of the chest demonstrated blebs in two patients, and in the other two it was suggestive of apical blebs but not definitive. All patients had failed treatment by tube thoracostomy. Video-assisted thoracoscopy demonstrated blebs in all patients. Removal was easily accomplished with an endoscopic automatic stapling device. The procedure was completed with mechanical pleurodesis, multiple intercostal blocks and intrapleural bupivacaine for control of pain. RESULTS: All patients had a quick and uneventful recovery. Follow-up ranged from one to three years. There were no complications or subsequent recurrences of the pneumothorax. CONCLUSIONS: Video-assisted thoracoscopy is a safe and effective technique in recurrent spontaneous pneumothorax. It allows for accurate identification and removal of the blebs, with quick recovery, minimal discomfort and good cosmetic results.