大量咯血的肺切除手术治疗32例临床分析

目的：探讨肺切除治疗大咯血手术的适应证及手术时机。方法：对1985－2000年32例肺切除治疗大咯血病人的手术效果进行回顾分析。结果：大咯血病人施行肺切除32例，治愈率87．5％，并发症12．5％。结论：手术适应证趋于积极，即非手术治疗效果不佳，出血部位确定，肺功能，全身状况良好，尽早施行手术，当患者出现窒息或低血压时应抓紧手术时机。因并发症和死亡率仍高于常规肺切除，故需严格掌握手术指征。     

肺结核全肺切除术后严重并发症18例分析

目的　探讨肺结核全肺切除术后并发症发生原因及防治对策。方法 对我院69例肺结核全肺切除的术后发生严重并发症18例进行回顾分析。结果 69例病人中术后出现呼吸功能不全6例,支气管残端瘘3例,术后病灶向对侧播散2例,术后失血性休克(胸腔广泛渗血所致)5例,术后上消化道出血2例。术后急性呼吸衰竭死亡2例,胸腔内大面积渗血死亡2例。全组术后并发症发生率26.1%(18/69),治愈好转率94.2%(65/69),死亡比例5.8%(4/69)。结论 全肺切除仍是治疗某些肺结核的有效手段之一,但应掌握好手术适应证和手术时机。结果表明:肺结核化疗效果不满意(包括耐药因素)、术中操作失误及术后管理不当仍是肺结核的外科治疗,特别是全肺切除术后产生并发症的主要原因。     

肺结核并发肺曲菌球47例外科治疗

目的　探讨肺曲菌球与肺结核的关系及其诊断和治疗;方法 对13年经外科手术治疗的47例肺结核合并曲菌球病人进行回顾性分析;结果 男性31例,占66.0%,病程>5年27例。咯血症状突出,41例,占87.2%。47例肺结核合并曲菌球中,术前明确诊断32例,占68.1%,漏误诊率31.8%。45例治愈,占95.7%,死亡2例,占4.2%。术后并发症10例,分别为胸腔感染、支气管胸膜瘘、肺炎、肺不张、支气管哮喘、呼吸衰竭和失血性休克。结论 肺曲菌球病见于肺结核空洞患者,在长期规律抗结核治疗后仍反复咯血,漏诊率较高,手术治疗为首选,效果较好。     

长期排菌肺结核的外科治疗

目的　探讨肺结核化疗时代胸外科手术治疗长期排菌病例的重要性,手术适应征及手术时机的选择。方法 对内科治疗一年以上仍排菌的63例肺结核空洞或结核性毁损肺采用不同术式切除不可逆病灶或附加胸廓成型术。结果 59例痰菌阴转,阴转率达93.7%,4例术后出现并发症,无手术死亡。结论 肺外科手术是治疗长期排菌合并空洞及毁损肺患者有效的方法。术后应继续抗结核治疗至少一年。     

耐药性肺结核的手术治疗(附36例报告)

目的　探讨耐药肺结核的手术适应症及手术时机。方法 对1990～1997年我院收治的7000肺结核和36例耐药肺结核已手术治疗的病人的手术效果进行回顾分析。结果 36例肺结核病人,临床治愈率94%,痰菌阴转率84%,并发症发生率为13%。结论 对部分耐2～3种药的肺结核病人选择外科治疗仍是可行的,可提高耐药肺结核的治愈率,耐4种以上的肺结核病人术后并发症发生率高,应慎重选择。     

38例单侧毁损肺的外科治疗

目的　总结单侧毁损肺的外科治疗经验。方法 1982～1998年应用胸膜全肺切除术治疗38例单侧毁损肺。结果 手术失血800～7200ml,1000ml以上27例 (71.0%),其中,3000ml以上13例 (34.2%)。治愈37例 (97.4%),死亡1例 (2.6%),术后并发症者3例 (7.9%)。结论 毁损肺手术难度大,游离肺和处理肺门困难,出血多,术后并发症多。应严格掌握手术指征,作好术中循环监护,积极预防残腔感染。     

难治性肺结核的外科治疗

目的　探讨外科治疗难治性肺结核的效果及方法。方法 对 1996～1998年收治的96例进行手术治疗的难治性肺结核病人进行回顾分析。结果 在应用氟嗪酸方案治疗有效的同时行外科治疗,93.8%术后痰菌持续阴转,且随访两年无复发;5.2%术后继续化疗痰菌阴转;1.0%痰菌持续阳性。结论 应用氟嗪酸方案化疗的同时手术切除病灶,是一种有效的根治难治性肺结核的方法。     

32例空洞性肺结核的外科治疗

目的　探讨外科手术在空洞性肺结核治疗中的地位、适应症及手术方式。方法 对我院外科1987～1997年手术的空洞性肺结核32例进行回顾分析。结果 手术疗效满意,手术治愈率96.9%。结论 外科手术仍是目前我国消灭慢性传染源和解决空洞性肺结核病人复治失败以及严重后遗症的一种有效的治疗手段。     

487例结核性毁损肺外科治疗的效果分析

目的 探讨结核性毁损肺外科治疗的临床效果。方法 搜集成都市公共卫生临床医疗中心2007年1月至2017年3月收治的487例结核性毁损肺患者的临床资料,所有患者在规范抗结核药物(个体化方案)治疗2周后或结核病灶稳定、完善相关术前检查、符合手术指征后行手术治疗。对比患者手术前后临床症状变化,以及胸廓塌陷、脊柱侧弯、痰菌检测、肺功能变化、手术方式、并发症及随访等改变情况。应用SPSS 17.0软件进行统计学处理,计量资料采用t检验,以P<0.05为差异有统计学意义。结果 本组487例患者中,右上肺切除93例、右全肺切除69例、左上肺切除112例、左全肺切除193例、分次行双上肺切除20例。453例患者术前有明显咳嗽、胸闷、气促、患侧胸部塌陷,78例纵隔明显偏向患侧;385例反复咯血、113例出现大咯血、32例反复大咯血;82例痰菌检查阳性(含涂阳患者47例,培阳患者35例),57例患者经纤维支气管镜刷片检测抗酸杆菌阳性;术后仅23例患者有轻微咳嗽、胸闷,全肺切除术患者胸廓塌陷有改善,非全肺切除患者纵隔移位有明显恢复;5例患者随访6个月至2年后仍然有少量痰中带血;术后痰菌检测阳性的151例患者均阴转。术后患者肺活量(VC)占预计值的百分数为(85.20±10.10)%、用力肺活量(FVC)[(88.00±9.80)%]、第1秒用力呼气容积(FEV₁)[(84.60±7.36)%]、最大呼气流速峰值(PEF)[(80.65±9.25)%]、最大通气量(MVV)[(83.20±5.73)%]均较术前[分别为(67.50±11.37)%、(71.60±13.21)%、(66.10±10.03)%、(65.90±9.54)%、(61.20±13.60)%]明显改善(t值分别为-7.56、-8.63、-5.37、-6.40、-4.66,P值分别为0.024、0.015、0.037、0.022、0.012)。53例患者出现并发症,发生率为10.88%(53/487),出现在术后3d至6个月;分别为胸腔感染22例(其中发生支气管胸膜瘘5例)、残肺复张不全13例、严重肺部感染7例、切口感染6例、声音嘶哑5例。1例右全肺切除患者因胸腔粘连致密、手术时间超过9h、术中失血量超过2000ml,于术后3h死于呼吸衰竭。433例在术后3~6个月后恢复了正常生活及工作,25例患者在家休养,已经恢复日常生活但未外出工作,总有效率为94.05%(458/487)。结论 结核性毁损肺在规范有效抗结核药物治疗的基础上,采用外科手术治疗的有效率高、并发症少、肺功能改善明显,对提高患者生活质量、达到临床治愈意义重大。     

17例肺支气管囊肿长期误诊肺结核原因分析

目的　通过对肺支气管囊肿(pulmonary bronchogenic cyst,PBC)长期误诊为肺结核的原因分析,提高对二种疾病的鉴别诊断能力。方法 对17例经手术病理证实的PBC长期误诊肺结核原因进行回顾性分析。结果 长期误诊肺结核的PBC患者占同期手术治疗的PBC的43.6%(17/39)。主要症状:咳嗽、咳痰、咯血、胸痛、低热和乏力。X线表现形态多样,球形病变10例,部分有卫星灶及钙化灶、空洞或溶解等,大片密度不均匀阴影5例,一侧毁损肺1例,叶间裂积液1例。所有病人均查痰结核菌阴性。正规抗结核治疗后反复咳痰、咯血、发热11例(64.7%),无效6例(35.3%)。结论 误诊原因是对不典型的PBC缺乏认识。痰结核菌阴性而临床症状和X线表现与肺结核相似、经正规抗结核治疗后仍反复发作或无效的病人,应考虑到PBC。     

The surgical emergent therapy for massive hemoptysis in 52 cases]

The result of surgical emergent operation in 52 cases with massive hemoptysis failed by medical therapy was reported. Hemoptysis ceased in 51 of the 52 cases. One patient died after operation, giving a mortality rate of 1.9%. Other complications were occurred in two patients, but none was bronchial fistula. The complication rate was 3.8%. The surgical indication of this series would include: (1) The amount of hemoptysis more than 600 ml per 24 h, failed by medical treatment. (2) Massive hemoptysis repeated or a history of suffocation. (3) Irreversible lesion in the lung with the bleeding site identified accurately. (4) The general condition and vital organs of the patient would permit surgical therapy. Various types of pulmonary resection with successful results should be selected.     

86例大咯血急诊肺切除术临床分析

目的探讨因大咯血施行急诊肺切除术的临床特点及疗效。方法对86例因大咯血施行急诊肺切除的患者资料进行分析。结果大咯血病因以肺结核、支气管扩张、曲菌病等病因为主。本组治疗有效率100%,术后并发症12例,发生率13.95%,无死亡病例。结论大咯血患者在出血部位确定,病变局限;有咯血引起窒息先兆、窒息或低血压时应行急诊手术,手术以肺叶切除为主,止血效果好,临床疗效满意。加强术中残端处理及术后治疗管理,有望降低急诊手术的并发症和死亡率。     

巨大风湿性心脏瓣膜病瓣膜置换手术治疗体会

目的 :提高巨大风湿性心脏瓣膜病瓣膜置换术手术效果。方法 :回顾性分析 79例巨大风湿性心脏患者 ,心胸比 >0 7。根据心脏大小分为四型 :Ⅰ型为左右心房扩大及右心室扩大 11例 ;Ⅱ型全心扩大 ,左心室舒张末期直径 (LEVDd) 4 5～ 6 9mm 14例 ;Ⅲ型双心房扩大及右心室扩大 ,小左心室 ,LEVDd <4 4mm 19例 ;Ⅳ型左心房扩大或 加右心扩大及大左心室 (LVEDd≥ 70mm) 35例。术前心功能Ⅲ级 5 4例 ,Ⅳ级 2 5例。二尖瓣置换术 (MVR) +三尖瓣成形术 (TVP) 32例 ,MVR +主动脉瓣置换术 (AVR)+TVP 4 7例。结果 :早期死亡率为 5 1%。发生低心排 39例 ,心律失常 4 1例。术后随访 3个月～ 4年 ,长期生存 75例 ,心功能Ⅰ级 2 1例 ,Ⅱ级 32例 ,Ⅲ级 19例 ,Ⅳ级 3例。晚期死亡 3例。Ⅲ型术后早期低心排发生率高 (P <0 0 2 )。Ⅳ型术后心律失常发生率高 (P <0 0 0 1)。大左室远期效果较差。结论 :巨大风湿性心脏瓣膜病并非都是危重病人 ,但是小左室 (Ⅲ型 )和大左室 (Ⅳ型 )手术风险大 ,应加强术中心肌保护和置换适宜的人工瓣。术后加强正性肌力药物使用。当发生瓣膜性心肌病者 ,是否换瓣手术值得商榷。     

217例空洞性肺结核的外科治疗

目的探讨空洞性肺结核的外科治疗适应症,手术方法,术后管理。方法自2000年1月～2009年12月,外科治疗217例空洞性肺结核,其中厚壁空洞73例,薄壁空洞34例,张力空洞26例,慢性空洞127例。痰菌阳性94例,78例均有不同程度耐药。结果择期手术191例,大咯血急症手术26例。空洞清除18例,肺段切除27例,肺叶切除44例,上叶加下叶背段切除34例,上叶加下叶背段病灶清除21例,中下叶切除20例,中上叶切除14例,右全肺切除12例,左全肺切除23例。全组无手术死亡,6例复发,4例术后合并脓胸,4例合并支气管胸膜瘘,5例合并支气管残端瘘,其余全部病例无复发,治愈率97.1%。痰菌阴转率93.6%。讨论外科手术是空洞性肺结核内科治疗失败者较有效的手段。手术原则为宁小勿大,以肺叶切除方式为主。     

Embolectomy in massive lung embolism

Pulmonary embolism was first described by Laennec in 1819. After introduction of the Trendelenburg surgical technique, Kirschner, in 1925, performed the first successful embolectomy. In a review of the literature, in 42 patients, survival rate was 45% on use of a modified Trendelenburg method employing cross-clamping of the vena cava. The use of this intervention can still be considered justified if extracorporeal circulation is not available. Establishment of the indication and anatomical fundamentals The indication for surgical embolectomy is considered established in the presence of massive pulmonary arterial obstruction with pending death of the patient. The difficulty lies in identification of the patient with massive pulmonary embolism who will succumb and in defining the extent of pulmonary arterial obstruction which will lead to death. Limitation of the indication to only those patients in shock led to mortality rates up to 93%. Immediate death after pulmonary embolism is not the rule. Of 52 patients with massive pulmonary embolism, 50% survived more than two hours; in those with no preexistent cardiopulmonary disease up to eight hours. Surgical intervention can be considered accordingly. Anatomically, massive pulmonary embolism implies at least 60 to 70% obstruction of the pulmonary arterial bed. In 85 of 100 patients who died of pulmonary embolism, voluminous emboli were found in both pulmonary arteries. In the presence of preexistent cardiopulmonary disease, lesser degrees of obstruction can lead to a critical condition. In consideration of the indication as above, the following comments are considered appropriate: 1. Quantification of the obstruction: Pulmonary angiography remains the most appropriate diagnostic examination. The degree of obstruction can be quantified according to a number of indices. As of 60%-obstruction, surgical intervention can be considered. 2. Justification of embolectomy: The classical indication can be established in 2 to 6% of the patients based on treatment-refractory hypotension. In Table 1, the classical stages of massive pulmonary embolism are shown with the indication for embolectomy being considered as of stage IV but these characteristics are unreliable in everyday practice. If surgery is delayed until vasoactive drugs are no longer effective, an irreversible condition is frequently incurred in spite of operative removal of the obstruction. More favorable results can be achieved when the indication for surgery is based only on the degree of obstruction since, in this case, the condition of shock will not be prolonged and a hemodynamically-stable patient can be subjected to surgery. 3. Thrombolytic treatment     

Pre- and postoperative examinations in congential aortic stenoses]

70 patients with congenital aortic stenosis had been operated upon between the age of 7 months and 23 years (average 8 years). For evaluation of the surgical result recatheterization and angiocardiography had been carried out on all patients between 1 and 12 years after operation (mean 7 years). The pre- and postoperative catheter findings, angiocardiograms, ECG, heart-size and clinical findings were analysed and compared with each other. In 2/3 of the cases the operative results could be defined as good or satisfactory. In the last third the operative results had been poor and a reoperation unavoidable. In half of the cases the poor results had been due to a significant residual aortic stenosis and in the other half it was due to massive aortic regurgitation. The prognosis and the indication to operation had been discussed.     

先天性心脏病合并艾森曼格综合征的外科治疗

目的回顾分析28例先天性心脏病合并艾森曼格综合征患者外科手术结果,评价手术治疗效果,探讨手术适应证。方法所有病例术前均予以靶向降肺动脉压为主的综合治疗,以动脉SaO2≥90％作为手术指征进行手术。结果围术期无死亡,术后随访4～24个月。1例出院后2个月猝死于肺高压危象;2例患者随访结果欠佳,心功能Ⅳ级,其中1例术后经常晕厥,反复咯血,1例术后3个月肺动脉高压右心衰伴三尖瓣大量反流。其余25例患者均较术前有不同程度的改善。结论部分以往被列为手术禁忌的艾森曼格患者仍可经充分靶向治疗后获得手术机会,并可拥有一个满意的预期结果。正确的手术适应证以及手术时机的选择,合理的围手术期处理,术后长期靶向药物治疗是降低手术风险、改善预后的关键。     

老年外伤性颅内血肿192例的手术治疗

报告１９２例经手术治疗的老年人外伤性颅内血肿，指出临床上有误诊率高，手术后合并症多（３８．５％），死亡率高（２９．７％）的特点；年龄、哥拉斯科昏迷（ＧＣＳ）评分、血肿量、病情进展的速度、术前重要脏器器质性病变和术后合并症等是影响预后的主要因素；ＣＴ检查的指征应予放宽。手术治疗要结合老年人特点，宜采取损伤小、时间短、确实有效的手术方式，合理用药，加强对合并症的防治，可提高治愈率。