带蒂肋间肌瓣防治支气管胸膜瘘17例临床分析

目的探讨采用带蒂肋间肌瓣包埋支气管残端预防和治疗支气管胸膜瘘的临床意义,总结治疗经验。方法回顾性分析2001年10月至2009年6月重庆市江津中心医院对17例肺癌、肺结核伴支气管扩张、支气管扩张患者行肺切除术后采用带蒂肋间肌瓣包埋支气管残端的临床资料。14例为预防性治疗,男8例,女6例;年龄21~69岁;其中6例行全肺切除术,8例行肺叶切除术。3例行肺癌肺叶切除术后支气管胸膜瘘二期修补术,男2例,女1例;年龄58~68岁。结果预防性治疗14例患者,手术时间135~275 min,均治愈,无并发症;随访12例,随访时间6~60个月,随访期间无1例发生支气管胸膜瘘。3例肺癌术后支气管胸膜瘘接受带蒂肋间肌瓣治疗患者手术时间75~165 min,2例痊愈,1例同时行局部胸膜内胸廓成形术痊愈;3例均随访6~24个月,无1例再发支气管胸膜瘘。结论带蒂肋间肌瓣包埋支气管残端防治支气管胸膜瘘安全有效,尤其适用于肺切除术后支气管残端或吻合口的加固预防支气管胸膜瘘的发生。     

肺结核合并支气管内膜结核的外科治疗

目的 总结肺结核合并支气管内膜结核的外科治疗经验.方法 分析1967年3月到2004年10月间肺结核合并支气管内膜结核患者85例,其中支气管狭窄45例,气管狭窄4例.43例行肺叶切除术,其中袖式切除8例;37例行全肺切除术,其中袖式切除4例,气管右下壁部分切除后使用右主支气管内壁组织修补术3例;3例行气管节段切除成形术;1例行左上叶支气管、肺动脉双袖式切除术;1例行开胸活检术.结果 无手术死亡病例.肺叶切除术35例(不包括袖式肺叶切除术)中,术后并发支气管胸膜瘘1例、脓胸1例;全肺切除术33例(不包括袖式全肺切除术)中,术后并发支气管胸膜瘘3例、脓胸4例;两种术式间差异有统计学意义.肺叶切除术后肺不张发生率(5/35)低于袖式肺叶切除术(3/8)(P＜0.01).随访3～10年,随访率98%;1例患者术后7年后死于急性呼吸功能衰竭.结论 肺结核合并支气管内膜结核的外科治疗应切除病变组织,根据狭窄的部位、长度、程度及狭窄远端的肺组织是否正常决定手术方式,并结合围手术期正规抗结核治疗,尽量少作全肺切除.     

肺曲菌病的诊断与外科治疗

目的总结肺曲菌病的诊断和外科治疗经验。方法57例肺曲菌病患者中17例（29．8％）术前已明确诊断，21例（36．8％）于术前误诊为肺结核、肺部占位病变、肺囊肿和肺脓肿等，19例（33．3％）术前漏诊。行肺叶切除术27例，肺段或肺楔形切除术18例；在电视胸腔镜辅助下行肺段或局部病变切除术5例，电视胸腔镜辅助下小切口肺楔形切除或局部病变切除术7例。结果无住院死亡。术后出现包裹性液气胸4例，胸腔积液、积气2例，切口感染1例，肺部感染3例，均经3～7d的相应处理治愈。术后积极治疗肺部基础疾病，同时均给予氟康唑400mg／d，治疗4～8周。所有患者均得到随访，随访时间6个月～12年，肺曲菌病未复发，患者生活质量良好。结论肺曲菌病误诊、漏诊率高，术前应加强对肺曲菌病的认识，认真检查诊断；手术切除病变是治疗肺曲菌病的有效方法。     

胸廓造口开窗引流术在结核性脓胸伴支气管胸膜瘘中应用的疗效分析

【摘要】 目的 总结分析胸廓造口开窗引流术(OWT)在结核性脓胸伴支气管胸膜瘘中应用的治疗经验。方法 对我科在2003年至2012年56例结核性脓胸伴支气管胸膜瘘病例采用胸廓造口开窗引流术的外科治疗进行回顾性分析。本组病例胸廓造口开窗换药引流3~12个月后,分别采用Heller胸廓成形术加瘘修补术、胸膜外全肺切除术或余肺切除术、永久的开放性胸廓造口术等方法治疗。结果 全组患者有效地控制胸腔感染后,36例行Heller胸廓成形术加瘘修补术;14例胸膜外全肺切除术或余肺切除术后关闭胸廓造口,其中有5例术后出现围手术期胸腔再次感染并发症发生再次行胸廓造口术;6例患者选择永久的开放性胸廓造口开窗换药引流,无围术期死亡病例发生。结论 对结核性脓胸伴支气管胸膜瘘的患者应用胸廓造口术能有效地控制胸腔感染,降低死亡率,改善身体状况,为二期瘘修补术及消灭残腔手术创造有利条件并提高手术成功率。     

肺曲菌球的诊断与外科治疗

目的 总结65例肺曲菌球菌的诊断和外科治疗经验。方法 根据65例肺曲菌球患者的特点,探讨其病因、诊断、手术指征和手术治疗。结果 本组择期手术57例,急诊手术8例,无手术死亡且均经术后病理证实。术后大都无症状。有5例并发症：脓胸2例,支气管胸膜瘘1例,伤口感染2例,均治愈。随访1－44a,无一例复发。结论 肺切除术是治疗本病较妥当的一种方法。     

肺曲菌球病胸腔镜手术治疗195例临床分析

目的探讨肺曲菌球病的胸腔镜手术治疗临床疗效及并发症。方法回顾性分析我院胸外科胸腔镜手术治疗肺曲菌球病共195例临床资料,单纯性肺曲菌球病89例,复合性肺曲菌球病106例。全部在完全胸腔镜（VATS）或胸腔镜辅助小切口（VAMT）下完成手术。结果治愈191例,治愈率97．9％,无手术死亡,术后发生并发症54例,包括出血、心律失常、肺部感染、肺漏气复张不全、支气管胸膜瘘、弥漫性血管内凝血、切口感染等。结论外科手术为曲菌球病首选的确切有效治疗方法。对于肺部病变局限、胸膜粘连轻、高龄、体质差的患者,胸腔镜手术治疗具有微创、并发症少的巨大优势。早诊断早手术治疗,有利于减少手术时间、术中出血量及术后并发症。     

胸腔镜手术治疗肺隐球菌病11例报告

目的探讨肺隐球菌病的临床特点及胸腔镜手术的疗效. 方法回顾分析1996年1月～2002年12月我院11例肺隐球菌病的临床资料,其中胸腔镜肺楔形切除术8例,胸腔镜辅助改良后外侧小切口肺叶切除术2例,肺楔形切除术1例. 结果术前误诊10例.孤立性病变8例,双肺多发性病变3例.完全切除病灶8例,肺活检术3例.术后除2例伤口皮下积液外无其它并发症.术后随访12～72个月,(38.6±10.8)个月,无脓胸、支气管胸膜瘘发生,无肺隐球菌病复发. 结论肺隐球菌病多无基础疾病及症状,以孤立性病变多见.术前难以明确诊断,胸腔镜手术能彻底切除病灶,创伤小,恢复快.     

原发性十二指肠恶性肿瘤的外科治疗

目的探讨原发性十二指肠恶性肿瘤的外科治疗策略。方法回顾性分析1997~2004年我院收治的72例原发性十二指肠恶性肿瘤病人的临床资料。52例行胰十二指肠切除术,8例行肿瘤局部切除术,5例行胆肠和/或胃肠吻合术解除梗阻,4例行肿瘤活检术以明确诊断,3例确诊后拒绝手术治疗。结果随访62例。46例行胰十二指肠切除术病人术后1年、3年和5年的生存率分别为76.1%,54.3%和28.3%。3例放弃手术治疗者及3例行肿瘤活检术者均于1年内死亡。4例仅行胆肠和/或胃肠吻合术者术后1年生存率为25%。6例行肿瘤局部切除术者均于术后短期内复发,仅2例存活1年。52例行胰十二指肠切除术病例中出现并发症的有8例。应用单层褥式交锁缝合进行胰肠重建的20例及保留幽门的8例术后经过均良好,无1例出现严重并发症。结论胰十二指肠切除术系原发性十二指肠恶性肿瘤的首选治疗方法,应严格掌握肿瘤局部切除术的适应证。     

肺切除术后支气管胸膜瘘的外科治疗

目的探讨肺切除术后支气管胸膜瘘的外科治疗。方法26例患者分别采取胸腔引流、支气管残端修补、胸膜余肺切除、胸廓成形术等治疗方式。结果23例（88．5％）患者经各种治疗最终获得治愈，手术死亡1例，瘘口未愈失访2例。结论充分胸腔引流能控制感染，彻底消除残腔，妥善封闭支气管瘘口是外科治疗肺切除术后支气管胸膜瘘的关键环节。     

Dukes D期大肠癌的手术治疗及疗效观察

目的　探讨DukesD期大肠癌手术治疗的意义及疗效。方法　对 1 991～ 1 998年间我科收治的行手术治疗的 82例DukesD期大肠癌患者进行回顾性分析。结果　 2 1例患者行联合脏器切除术 ,2 9例行姑息性切除术 ,1 9例行改道手术 ,1 3例行剖腹探查活检术。行联合脏器切除术后患者生存期明显延长 ,71 .4%生活质量为优、2 3 .8%为良、4 .8%为中 ,明显优于其它三种术式 (P<0 .0 1 ) ;行姑息性切除术后患者生活质量为优者占 62 .1 % ,良为 1 7.2 % ,中为1 3 .8% ,差为 6 .9% ,优于改道手术及剖腹探查活检术 (P<0 .0 5) ;行改道手术及剖腹探查活检术后疗效较差 ,生存期短 ,生活质量评估多为差或中。结论　DukesD期大肠癌有手术指征者经手术治疗可延长患者生命及改善生活质量     

Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis

BACKGROUND: Surgical treatment of chronic necrotizing pulmonary aspergillosis is hazardous and controversial. METHODS: Ten patients (8 men, 2 women; mean age, 50 years) with chronic necrotizing pulmonary aspergillosis underwent pulmonary resection between 1989 and 2000. Single segmentectomy or lobectomy, pneumonectomy, or bilobectomy and multisegmentectomy were performed. Clinicopathologic features of these patients were reviewed to clarify the role of surgical intervention for chronic necrotizing pulmonary aspergillosis. RESULTS: The mean time from the onset of clinical symptoms to operation was 5.3 years. Surgical intervention was undertaken because of prolonged illness in 4 patients and hemoptysis in 6 patients. All patients survived. Three major complications (1 late empyema, 2 bronchopleural fistulas) occurred in the large dead space in the right pleural cavity. All survivors were free of aspergillosis at a mean follow-up time of 4.8 years, and only 1 patient required antifungal drugs for relapse during the follow-up period. CONCLUSIONS: Aggressive pulmonary resection in chronic necrotizing pulmonary aspergillosis should be considered when patients have prolonged illness or frequent hemoptysis. Empyema and bronchopleural fistula are the main complications. Concomitant thoracoplasty or intrathoracic transposition of the chest wall musculature is recommended in cases involving a large residual pleural cavity on the right side.     

A case of omental pedicle flap plombage for fungus ball type pulmonary aspergillosis

The usual surgical treatment for fungus ball type pulmonary aspergillosis is lobectomy, but in cases of aspergillosis located in a post-lobectomy space a second lobectomy is difficult because of the accompanying inflammatory process. A 53-year-old male underwent left upper lobectomy for pulmonary tuberculosis eight years ago. Six year postoperatively, he developed fungus ball type aspergillosis in the post-lobectomy space with bronchopleural fistula and recurrent hemoptysis. We performed an omental pedicle flap plombage via the post-sternal route to resect the pleural cavity fungus ball. The post operative course was uneventful and clinically the bronchopleural fistula was closed.     

Surgery for pulmonary aspergillosis

Objective: Surgery of pulmonary aspergillosis followed by higher incidence of post-operative complications. This was the purpose to evaluate our material. Methods: Between January 1983 and December 1995, the operation was carried out on a total of 84 patients for pulmonary aspergillosis. The patients were comprised of 71 males and 13 females, with a mean age of 49 years (range, 24–71). Previous lung disorders were observed in about half of the cases (most frequently tuberculosis), while in the other half aspergillosis was developed on the basis of (sub)-acute infections. Haemoptysis was present in 48% of patients. The diagnosis was suspected in 47 cases by chest X-ray. Aspergilloma was diagnosed in 50 patients pre-operatively (excluding 12 typical aspergillomas for cavernostomies), with the other pre-operative diagnoses being tuberculosis, lung cancer, pyoscelrosis, etc. Results: In 71 cases pulmonary resection was carried out (52 lobectomies, 13 wedge resections and six pulmonectomies). A total of 12 cavities were opened by cavernostomy and one lung biopsy was performed for disseminated lung disease. The post-operative mortality rate was 9.5%. The most common complications were bleeding, empyema, bronchial fistula and wound infection. In 23 patients with developed prolonged air leak and/or residual air space, complications were observed more frequently in patients with greater cavitation near the chest wall. Conclusions: In most cases of pulmonary aspergilloma surgical intervention remains the only effective therapy. The operation has a lower risk factor in asymptomatic patients and in patients without pleural or chest wall involvement. In some cases, cavernostomy may be the only remaining surgical choice.     

Pleural tenting following upper lobectomies or bilobectomies of the lung to prevent residual air space and prolonged air leak.

OBJECTIVE: Apical residual air space and prolonged air leak are not uncommon entities following resection of upper lobe of the lung. This study was carried out to observe the efficacy of pleural tenting in preventing these problems. METHODS: This is a prospective randomised study. Pleural tenting after upper or upper and middle lobectomies was performed in 20 patients. In another 20 patients who underwent upper lobectomy or bilobectomy, pleural tenting was not performed. Both groups were compared in respect to durations of postoperative chest tube drainage and hospital stay, amount of total pleural drainage, and the presence of need for any additional intervention for prolonged air leak. RESULTS: Age, sex, pathology and pulmonary function tests of two groups were similar. Duration of chest tube drainage was shorter in whom pleural tenting was performed when compared to whom pleural tenting was not performed (4.3+/-0.16 days versus 7.40+/-0.68 days, P<0.0001). Mean hospital stay was shorter in tented group (7.60+/-0.4 days versus 9.35+/-0.6 days, P=0.024). Although the mean amount of total pleural drainage was less in tented group (667.5+/-57.7 ml versus 802.5+/-83.3 ml, P=0.1911), the difference was not statistically significant. Three (15%) patients in non-tented group needed an apical chest tube insertion in postoperative period for prolonged air leak with an apical pleural space. Asymptomatic apical residual space was observed in 3 patients in tented group. There was no morbidity in patients in tented group. CONCLUSION: Pleural tenting following upper lobectomy or bilobectomy of the lung shortens the duration of chest tube drainage and hospital stay, and it prevents apical residual air spaces and related complications. Pleural tenting is safe and relatively simple procedure, which has no associated morbidity.     

单孔胸腔镜手术的临床应用

目的 总结采用单孔胸腔镜手术(single port VATS,SPVATs)治疗胸部疾病的临床经验,探讨其在胸部疾病治疗中的应用价值.方法 2011年3月至2011年5月32例单孔胸腔镜手术中男28例,女4例；年龄18～72岁,平均(26.5±9.2)岁.病种包括自发性气胸27例(其中2例行双侧同期手术),不明原因胸腔积液3例,双肺多发结节和肺转移瘤各1例.术中均使用自主研发的双关节手术器械和专用切口保护器,操作过程与传统胸腔镜手术类似.行肺大疱切除27例,脓性纤维板剥脱胸腔冲洗引流术3例,壁层胸膜活检术1例,肺楔形切除术1例.结果 全组手术顺利,无中转传统VATS或开胸手术,无死亡及并发症发生.全组手术时间(22.O±9.5) min,术中出血(14.5±8.8)ml,术后插管(3.1±0.6)天,总住院(6.8±1.6)天.结论 单孔胸腔镜手术治疗部分胸部疾病近期疗效满意,并发症少,患者创伤更小、恢复快.     

Video-assisted thoracoscopic surgery in the diagnosis and treatment of chest diseases

Video-assisted thoracoscopic surgery (VATS) has been used recently in the diagnosis and management of thoracic diseases. In this report, VATS experience with 95 cases, focusing on indications, surgical procedures, complications, and failure rates, are reviewed. Over the past 5 years, 95 VATS procedures for diagnostic and therapeutic purposes were performed in 59 men and 36 women. The specific indications for VATS were lung biopsy for undiagnosed diffuse lung disease (48), mediastinal biopsy (12) and cyst (2), pleural effusion (10), empyema (5), pneumothorax and bullous lung disease (6), pericardial effusion (2) and cyst (2), paravertebral abscess (2), solitary pulmonary nodules (3), and thoracic trauma (3). In all patients, postoperative pain was controlled with non-narcotic analgesics and was measured according to the visual analogue scale (VAS). There was no surgical mortality. Postoperative nonfatal complications were seen in seven cases (7.5%). The overall median duration of chest tube drainage was 2.7 days and the mean postoperative hospital stay was 3 days. For diffuse lung disease, a tissue diagnosis was obtained in all the cases. Definitive diagnosis in the patients with undiagnosed pleural effusion was obtained in 90% of cases, and the overall diagnostic rate was 98.5%. The success rate of the therapeutic procedures was 100% after a mean follow-up of 12 months (range, 6-30 months). Conversion to thoracotomy was needed in six cases (6.6%). All patients scored postoperative pain <50% according to the VAS. Video-assisted thoracoscopic surgery should be considered as a procedure of choice, with exceptional results in the following chest diseases: (a) undiagnosed pleural effusions; (b) recurrent, post-traumatic, or complicated spontaneous pneumothorax; (c) stage II empyema; (d) accurate staging of lung cancer; (e) emergency traumatic injuries of the chest; (f) peripheral solitary pulmonary nodule <3 cm; and (g) lung biopsy for pulmonary diffuse disease.     

A single 24F Blake drain after wedge resection or lobectomy: a study on 100 consecutive cases.

OBJECTIVE: To evaluate the results of chest drainage using one 24F Blake drain after standard thoracic operations (wedge resection and lobectomy). METHODS: In 2005, 100 consecutive patients underwent drainage of their pleural cavity following lobectomy or wedge resection(s). There were 70 men and 30 women, with a mean age of 55 years (17-83). There were 47 lobectomies (23 upper, 5 middle, 19 lower), 3 bilobectomies (2 right upper and middle, 1 right lower and middle), and 2 anatomical segmentectomies. All these anatomical resections were performed by standard thoracotomy, mainly for cancer diseases (45 cases). Furthermore, 48 atypical resections by single or multiple wedge(s) were realized, 20 of them by VATS. They included 14 various benign diseases, 16 malignant diseases, 8 significant emphysema bullous, and 10 blebs. Chest X rays were performed regularly in the postoperative period to detect residual pleural effusion or pneumothorax necessitating additional drainage or reoperation. Patients were controlled one month after discharge. RESULTS: One patient with pleural carcinosis died of pulmonary embolus on day 8. Neither replacement of chest tube nor reoperation was necessary for pleural space problems. Median duration of drainage was 5 days (3-15), 6 days after lobectomy and 4 days after wedge resection. In 15 cases, the duration of drainage was more than 8 days: 11 persistent air leaks and 4 drainages exceeding 150-200 cm3 daily. Ninety percent of patients were discharged the day following the drain removal. CONCLUSIONS: Postoperative courses after standard thoracic procedures using a single 24F Blake drainage appear similar to that accounting after a classical semi-rigid drainage. Such single drainage may appear now as an acceptable option. The flexible quality of the drain, its reduced caliber, and the character unique of the drainage, may contribute to improve comfort of the operated patients.     

Predictors of Postoperative Complications After Radical Resection for Pulmonary Aspergillosis

Objective Although surgery has proven to be the best treatment for pulmonary aspergillosis, with the highest chance of achieving complete remission, it is difficult to determine the surgical indications for this disease because of the high incidence of postoperative complications. We conducted this study to identify some predictors of postoperative complications, in an attempt to reduce the morbidity rate. Methods We retrospectively analyzed the medical records of 31 patients (18 men, 13 women; median age 53 years) who underwent radical resection for pulmonary aspergillosis between 1976 and 2004. The clinical manifestations, surgical procedures, and postoperative complications were reviewed to clarify the predictors of postoperative complications. Results The morbidity rate associated with major complications such as intrapleural bleeding, bronchopleural fistula, and empyema, resulting in further surgery, was 19%. Univariate analysis revealed the predictors of major complications to be sex, severe preoperative symptoms, and extensive pulmonary resection. Multivariate analyses also indicated that preoperative symptom severity was an independent predictor of major complications. Conclusions Pulmonary aspergillosis should be resected before the symptoms become too severe if the patient is a surgical candidate.     

Stapler blebectomy and pleural abrasion by video-assisted thoracoscopy for spontaneous pneumothorax

BACKGROUND: This study aims to evaluate the efficacy of video-assisted thoracoscopic surgery (VATS) pleurodesis in the treatment of spontaneous pneumothorax with particular reference to the postoperative period and the rate of recurrence after pleural abrasion. METHODS: One hundred and thirty-three patients who underwent VATS management of primary spontaneous pneumothorax were retrospectively reviewed. They were 113 males and 20 females with median age of 26 (range 12-37). Among these patients, 114 underwent VATS for recurrent pneumothorax and 19 for persistent air-leakage at the first episode. During surgical procedure, in 78% of cases, parenchymal blebs were identified and resected by stapler resection. All patients were submitted to pleural abrasion. RESULTS: No intra- or postoperative deaths occurred. Postoperative complications were persistent air-leak for more than 7 days in 6 patients (4.3%) bleeding in 3 patients (2.2%). The median chest-tube duration and hospital stay were 2 (range 2-11) and 3 (range 3-12) days, respectively. Median follow-up period of 53 (range 6-96) months was complete for all patients. Five episodes of recurrent pneumothorax were encountered and 4 of them, because of major entity, required re-do VATS with stapler resection and pleural abrasion: their postoperative period and residual follow-up was uneventful. CONCLUSIONS: The goal in the surgical management of spontaneous pneumothorax, which often affects "apparently healthy" young patients, is to secure the less recurrence rate with no mortality and quite null morbidity and functional impairment. VATS stapler resection and pleural abrasion is a safe procedure allowing a good management of the disease with low complication rate, short chest-drain duration, hospital stay and recurrence rate quite similar to those referred for other procedures such as pleural poudrage or limited pleurectomy.     

电视胸腔镜手术在胸外科的应用

目的探讨电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)在胸外科的应用. 方法回顾分析1998年7月～2002年12月78例胸腔镜手术的临床资料.其中:自发性气胸肺大疱切除40例,胸外伤探查12例,肺包块楔形切除9例,胸膜活检 胸膜固定6例,纵隔肿瘤切除4例,肺叶切除4例,肺叶切除术后支气管胸膜瘘2例,食管平滑肌瘤切除1例. 结果无一例中转开胸,5例因胸膜顶粘连辅助小切口.3例中老年自发性气胸术后持续漏气,分别于第7,8,13天拔除胸管,其余均在48h内拔除胸管.5例引流管口延期愈合.手术并发症发生率10.3%(8/78). 结论 VATS在胸外科有广阔的发展空间,一次性耗材价格昂贵限制其临床应用,腔镜下缝合技术或打结技术的应用比较适合目前的国情,节省医疗费用.