单孔胸腔镜手术治疗肺隔离症8例

目的 总结单孔胸腔镜手术治疗肺隔离症的经验体会。方法 2019年4月～2022年9月我科对8例肺隔离症采用单孔胸腔镜肺叶切除或隔离肺切除术，常规于腋前线第5肋间做一长约3 cm切口作为观察孔和操作孔，置入一次性切口保护牵开器，一次性导尿管或无菌手套袖口处的橡皮筋将胸腔镜固定于切口的上极，切口余下的空间用于手术操作。对于叶内型肺隔离症，依次处理肺动脉、肺静脉及支气管，松解下肺韧带，游离并断扎异常动脉血管；对于叶外型隔离肺，在膈肌上方找出异常动脉血管，用Hem-o-lok双重结扎其根部，远端用超声刀切断。结果 8例均在单孔胸腔镜下完成手术，无中转开胸。术中出血量(170±65) ml,手术时间(132±66)min。术后住院时间4～20 d,中位数9 d。1例因手术切口愈合不良，导致术后住院20 d,无严重并发症发生。8例经电话或门诊随访1个月～3年，中位数23个月，无再次出现呼吸道感染症状或咯血症状。结论 单孔胸腔镜手术治疗肺隔离症安全、可行且有效。     

肺隔离症4例诊治体会及文献复习

目的 探讨肺隔离症的诊断和治疗策略。方法 2017年7月至2019年6月收治的4例肺隔离症患者,3例患者行胸腔镜手术治疗,1例行介入下血管塞封堵迷走供血动脉,对其诊治过程和临床资料进行回顾性分析,总结诊治过程中的体会。结果 4例肺隔离症患者均接受治疗,1例患者接受介入下血管塞封堵迷走供血动脉后恢复顺利;1例患者胸腔镜下肺叶切除术后恢复顺利;2例患者接受胸腔镜下隔离肺叶切除术,其中1例恢复顺利,1例因胸腔进行性出血行胸腔镜下开胸止血术,后恢复顺利。术后3月复查胸部螺旋计算机体层摄影血管造影显示,3例行胸腔镜下隔离肺叶或肺叶切除手术患者的异常肺叶及供血动脉消失,行介入下血管塞封堵异常血管的1例患者的迷走供血动脉被栓塞,栓塞血管远端已无血流供应,隔离肺组织充血表现较前明显好转,4例患者随访7~31个月,未见复发。在手术时间、术中出血量、术后疼痛、术后胸腔闭式引流量、术后并发症、住院时间及住院费用等方面,介入栓塞治疗均优于胸腔镜手术治疗。结论 胸腔镜手术是目前处理肺隔离症的主要方式,介入栓塞治疗肺隔离症同样是一种安全、有效、微创的治疗方法,尤其对以咯血为主要症状,凝血功能异常且病情较重者效果佳。     

全胸腔镜解剖性肺段切除术治疗结核性支气管扩张症

目的探讨全胸腔镜解剖性肺段切除治疗结核性支气管扩张症的可行性。方法我院2014年1月~2018年2月采用全胸腔镜下解剖性肺段切除治疗结核性支气管扩张症46例。采用单操作孔,操作孔位于腋前线第4或5肋间,应用切口保护器,不使用肋骨牵开器,观察孔取腋中线第7或腋后线第8肋间,在全胸腔镜下完成解剖性肺段切除。结果无中转开胸,1例中转行肺叶切除,其余45例在全胸腔镜下完成解剖性肺段切除,其中右肺上叶间后段14例,右肺下叶背段6例,右肺下叶基底段2例,左肺上叶固有段15例,左肺上叶舌段2例,左肺下叶背段5例,左肺下叶基底段1例。手术时间100~330 min(中位数135 min);术中出血量100~650 ml(中位数230 ml);术后引流液总量380~2250 ml(中位数550 ml);术后带管时间4~16 d(中位数5 d);术后住院时间6~18 d(中位数9 d)。围手术期无死亡。术后并发症5例:漏气3例,肺膨胀不全1例,少量咯血1例。46例随访1~36个月(中位数21个月),86.9%(40/46)症状消失,无复发、死亡。结论全胸腔镜解剖性肺段切除治疗结核性支气管扩张症安全、可行,值得临床推广。     

单孔胸腔镜手术治疗肺隔离症的临床应用

目的 探讨单孔胸腔镜手术治疗肺隔离症的可行性和安全性。方法 回顾性分析2015年1月～2022年1月单孔胸腔镜手术治疗66例肺隔离症资料。左下肺叶内型42例,右下肺叶内型22例,左胸叶外型2例。均有明确异常体循环来源的供血血管,来源于胸降主动脉63例,腹主动脉2例,右后纵隔肋间动脉1例。手术采用腋中线第5或6肋间2～3 cm切口,行病变肺叶切除、肺段切除或病变楔形切除。结果 62例单孔胸腔镜完成手术,中转开胸4例。行肺叶切除54例,肺段切除8例,病灶楔形切除2例,叶外型隔离肺切除2例。手术时间(84.8±25.7)min,术中出血量(64.4±39.1)ml。无严重并发症及死亡。中位随访时间52(4～86)个月,无再发肺部感染、咯血,复查胸部CT无肺不张、液气胸。结论 单孔胸腔镜肺隔离症切除手术安全、可行。     

胸腔镜手术治疗肺隔离症:附16例报告

目的探讨全胸腔镜手术治疗肺隔离症的安全性、可行性和有效性。方法回顾性分析我院2011年1月~2015年12月全胸腔镜下以肺叶切除为主手术治疗肺隔离症16例临床资料。16例病变肺叶全为下叶,包括左肺下叶13例,右肺下叶3例,均为叶内型肺隔离症(PryceⅡ型15例,Ⅰ型1例),且未见合并其他发育畸形。双腔气管插管全麻,三孔法行胸腔镜肺下叶切除术。结果全组无中转开胸。行肺叶切除术15例,仅离断异常血管保留肺叶手术1例(PryceⅠ型)。15例肺叶切除术手术时间(149.4±40.7)min,术中出血量(105.0±20.1)ml。全组术后带管时间(4.6±1.4)d,术后住院时间(5.7±1.6)d。围手术期无死亡,无严重并发症。15例随访12~60个月,平均31.2月。术前咳嗽、咳痰、咯血症状均完全缓解。结论全胸腔镜手术治疗肺隔离症安全、可行、有效。     

胸腔镜下后基底段解剖性病灶切除治疗小儿先天性肺气道畸形北大核心CSCD

目的探讨胸腔镜下后基底段(S^(10))解剖性病灶切除治疗小儿先天性肺气道畸形(congenital pulmonary airway malformation,CPAM)的可行性。方法2021年2月~2022年2月我科对14例小儿CPAM行胸腔镜S^(10)解剖性病灶切除,电钩标记出病灶的外在边界,解剖并保留病灶与正常肺组织之间的段间静脉或亚段间静脉作为内在边界,切断进入病灶的动静脉及支气管,LigaSure切开并封闭内外边界之间的肺组织完成解剖性病灶切除。结果14例均在胸腔镜下完成手术,无中转开胸。右侧解剖性病灶切除10例,左侧解剖性病灶切除3例;1例拟行右侧解剖性病灶切除,因病变肺组织炎症反应较重,血管及支气管结构不清晰,内在边界确定困难,沿病变边缘行扩大不规则切除。手术时间50~170 min,中位数71 min;术中出血量5~30 ml,中位数5 ml。13例术后留置引流管2~4 d,中位数3 d;漏气1例,引流9 d。术后住院时间4~12 d,中位数6 d。病理诊断:1型3例,2型9例,3型2例。术后漏气1例,考虑创面漏气,调整引流管位置并延长留置引流管时间后漏气消失;单纯皮下气肿2例,保守观察后皮下气肿消失;无出血、支气管胸膜瘘、肺不张等并发症。14例随访1~12个月,中位数8个月,复查胸部CT均未见残余病灶,患侧胸腔无残腔。结论对于病灶位于S^(10)外周的小儿CPAM,胸腔镜下经下肺韧带入路进行解剖性病灶切除是安全、可行的。     

肺隔离症的诊断与外科治疗

目的总结肺隔离症的诊断及外科治疗经验,以提高治疗效果。方法1958年1月至2007年12月共手术治疗肺隔离症患者63例,男36例,女27例;年龄2个月~69岁。63例隔离肺位于左肺39例,右肺24例;肺内型48例,肺外型15例。行左肺下叶切除术28例及并行胸膜纤维板剥脱术1例,右肺下叶切除术19例,左肺楔形切除术7例,右肺楔形切除术3例,右双肺叶切除术2例,左全肺切除术2例,左侧肺段切除术1例。异常血管来源于胸主动脉36例,腹主动脉25例,肋间动脉2例,血管直径1.5~15.0 mm。结果围术期死于术后呼吸衰竭1例。发生脓胸1例,经相应的治疗治愈,其余患者均痊愈出院。随访24例,随访时间2个月~5年,其中1例食管癌患者于术后1年因癌肿复发死亡,其余患者恢复正常生活或工作。结论CT增强扫描血管成像术等检查能较好地显示肺隔离症的病变特征,其治疗方法以外科手术为主。     

单操作孔全胸腔镜肺癌根治术124例

目的探讨单操作孔全胸腔镜肺叶切除术治疗肺癌的临床应用价值。方法 2015年6月~2016年5月,采用单操作孔全胸腔镜肺叶切除术治疗肺癌124例。手术经一个操作孔和一个观察孔完成,观察孔取腋中线第7肋间,约1.5cm,操作孔取腋前线第4肋间,3~4 cm,术后常规放置1或2根胸腔引流管。结果无围手术期死亡,无中转开胸,无严重并发症发生。手术时间(139.2±43.1)min,术中出血量中位数55 ml(30~200 ml),术中淋巴结清扫(16.9±5.2)枚。术后住院时间(7.7±4.1)d。术后肺不张4例,经加强咳嗽咳痰后1周内均肺复张;1例持续少量漏气,经负压吸引7 d后停止漏气。116例随访2~13个月,(6.8±3.4)月,1例因心律失常术后11个月死亡,其余115例无复发、转移。结论单操作孔全胸腔镜肺叶切除术治疗肺癌安全、可行。     

完全胸腔镜手术治疗叶内型肺隔离症7例

肺隔离症是一种少见的先天性肺畸形,目前国内以开放手术治疗为主[1],胸腔镜治疗报道较少[2].2009至2011年我们采用完全胸腔镜手术治疗7例叶内型肺隔离症,现总结报道如下. 资料和方法 全组男4例,女3例;年龄15～46岁,平均34.2岁.其中体检偶然发现者2例,咳嗽、咳痰者4例,咯血者1例;病程10天～1年;全组纤维支气管镜检查均未发现明显异常.胸部增强CT示病变位于左下肺叶5例,右下肺叶2例.肺下叶后基底段不规则椭圆形肿块,密度不均4例,肺下叶囊性不规则影3例.血管重建示隔离肺异常供血动脉为1支5例,2支、3支各1例;起源于降主动脉5例(7支异常供血动脉),起源于腹主动脉2例(3支异常供血动脉).血管直径4 ～ 12 mm.     

叶外型肺隔离症合并扭转误诊为神经源性肿瘤1例北大核心CSCD

10岁男性患儿, 进食凉食后腹痛、呕吐3天入院。胸部CT检查示右后纵隔脊柱旁软组织包块并右侧胸腔少量积液, 增强检查示软组织包块未见明确强化。2021年11月在全麻下行胸腔镜探查术, 右后纵隔旁可见一大小约4.0 cm×3.0 cm×3.0 cm的暗红色实性包块, 其根部可见一直径约5 mm、起源于胸主动脉的滋养血管, 滋养血管扭转整3周约1 080°, 术中诊断叶外型肺隔离症合并扭转。术后病理检查示肺隔离症并出血、坏死改变。免疫组化检查示CD34(血管+), CK(上皮+), PHOX2B(-), TTF-1(-)。患者术后腹痛症状消失, 恢复良好。叶外型肺隔离症合并扭转临床表现缺乏特异性, 影像学诊断难度较大, 诊断多依赖手术及病理, 治疗以手术为主, 完整切除病变后预后良好。     

单操作孔胸腔镜手术治疗肺隔离症的临床体会

目的 总结单操作孔胸腔镜手术治疗肺隔离症的临床经验,评价其安全性、有效性。方法 回顾性分析2015年1月至2019年5月共21例单操作孔胸腔镜手术治疗的肺隔离症患者临床资料,其中男性10例,女性11例,年龄21~57（39.5±9.2）岁,21名患者均为下肺病变,包括左下肺13例,右下肺8例;叶外型1例,叶内型20例,术前均行增强CT扫描和三维重建;双腔气管插管全麻下单操作孔胸腔镜行肺叶或肺段切除20例,中转开胸1例。结果 胸腔严重粘连者8例,行下肺叶切除术20例,下肺后基底段切除1例;手术均顺利完成,手术时间（167.3±61.5）min,术中出血量（157.3±30.2）mL,术后带管时间（5.3±1.6）天,术后住院时间（6.2±1.5）天,围手术期无死亡及严重并发症发生;随访21例无失访,随访时间7~59个月,21例患者复查胸片或CT无复发。结论 单操作孔胸腔镜手术治疗肺隔离症安全可行,术前合理的检查评估和术中对隔离肺异常血管的合理处理是手术成功的关键。     

Median sternotomy for bilateral pulmonary metastasectomy in children

BackgroundComplete resection of metastatic pulmonary nodules in some children may increase survival. We present a series of 16 children who underwent median sternotomy for bilateral pulmonary metastasectomy from January 1, 1999, to December 31, 2010.MethodsWe reviewed the records of 16 children (3-18 years old, 12 boys, 4 girls) with bilateral pulmonary metastases who underwent median sternotomy with the intent of curative resection. All were treated with alternating single-lung ventilation and careful bilateral manual palpation for nodules.ResultsThe mean number of lesions resected was 11.6 (range, 2-33). Two patients who were found to have lesions that were too numerous to count underwent biopsy only. There were no major complications, and median length of hospital stay was 4 days. One patient had postoperative atelectasis, and another had an air leak; both were discharged on the fifth postoperative day. Seven patients have since died, 2 of whom underwent further resection for recurrent disease, with a median survival of 30 months. Nine patients are currently alive with a median follow-up of 30 months, 2 of whom have recurrent disease.ConclusionsMedian sternotomy allows excellent exposure of both lungs. In our series, there were no lesions that could not be resected because of inadequate exposure, including several in the left lower lobe posteriorly, and most patients were discharged within 4 days without major complications. In children with metastatic lung disease, median sternotomy is safe and avoids treatment delay and a second operation.     

How common is severe pulmonary hypertension after pediatric cardiac surgery?

BACKGROUND: Pulmonary hypertension may result in significant morbidity and mortality after pediatric cardiac surgery. The objective of this study was to determine the incidence and outcome of severe pulmonary hypertension, defined as a ratio of pulmonary to systemic arterial pressure equal to or greater than 1.0, after cardiac surgery in children. METHODS: Data from all children younger than 18 years who had undergone cardiothoracic surgery from January 1, 1994, to December 31, 1998, were examined. To find children with severe pulmonary hypertension, we reviewed intensive care unit charts from patients who had been monitored with a pulmonary artery catheter after the operation (n = 151), had received mechanical ventilation for more than 4 days after the operation (n = 124), or had died in the operating room or the intensive care unit (n = 22). Intraoperative and postoperative measurements of mean pulmonary arterial pressure and postoperative echocardiographic studies during the first 3 postoperative days were used to select the children. RESULTS: During the study period, 1349 children (including 164 neonates and 511 infants, median age 12 months) underwent cardiac operations with an overall perioperative mortality of 22 patients (1.6%). Twenty-seven children (2%, median age 4.2 months) had severe pulmonary hypertension. Of these, 2 (7.4%) died within 30 days of the operation, and 3 others (11%) died within a year (median follow-up 53 months). Nitric oxide inhalation was used in 5 of the 27 cases, and it probably saved the life of 1 patient, may have helped in 1 case, and had no discernible effect in 3 cases. Severe pulmonary hypertension was most common after correction of complete atrioventricular septal defects (14%, n = 12/85). Thirteen of 131 children with Down syndrome (9.9%) had severe pulmonary hypertension. CONCLUSION: Severe postoperative pulmonary hypertension occurred after 2% of the cardiac procedures and in most cases was managed successfully with conventional treatment and had a favorable postoperative outcome. The low incidence relative to previous reports may reflect the benefits of early correction and improved intraoperative and postoperative care.     

Video-assisted thoracoscopic lobectomy in infants

Objective: Congenital lung malformations are often discovered on routine prenatal sonography or postnatal imaging. Lesions such as congenital cystic adenomatoid malformation or pulmonary sequestration may be asymptomatic at birth, and their management is controversial. Thoracoscopy in children has been mainly used for lung biopsy and for the treatment of empyema and recurrent pneumothorax. Very few reports of more technically demanding procedures, such as lobectomy, are currently available. This report evaluates the safety and efficacy of video-assisted thoracoscopic (VATS) lobectomy in infants and small children with asymptomatic prenatally diagnosed lung lesions. Methods: During 2004, six patients underwent VATS lobectomy without a mini-thoracotomy. Mean age was 10 months (range, 6–19 months). Preoperative diagnosis included congenital cystic adenomatoid malformation (n = 5) and an extralobar pulmonary sequestration. All patients were asymptomatic and surgery was performed electively. Three or four 3–5 mm ports were used. Single lung ventilation and controlled low pressure pneumothorax were used in every case. A bipolar sealing device was the preferred mode of vessel ligation and bronchi were closed with interrupted sutures. A chest tube was left in all cases. Results: All the procedures were completed thoracoscopically. Operating times ranged from 70 to 215 min (mean, 130 min). There were five lower lobe and one middle lobe resections. There were no intraoperative complications and chest tubes were left in place 1–4 days. Two patients showed postoperative hemothorax that stopped spontaneously. Hospital stay ranged from 4 to 9 days (mean, 7 days). Conclusions: VATS lobectomy in small infants is a feasible and safe technique. Decreased postoperative pain, a shorter hospital stay, and a better cosmetic result are definite advantages of this minimally invasive procedure. Long-term morbidity due to a major thoracotomy incision is avoided.     

Video-assisted thoracoscopic surgery for ligation of anomalous systemic arterial supply to pulmonary sequestration

A 52-year old female with anomalous systemic arterial supply to pulmonary sequestration was reported. The patient was admitted because of an abnormal lung shadow on chest X-ray film. Computed tomography (CT) showed an anomalous systemic arterial supply to pulmonary sequestration of the left lower lung without lung infection. Video-assisted thoracoscopic surgery for ligation of the anomalous systemic artery was performed. Postoperative course has been uneventful for 14 months after surgery. Blood supply increased to the left lower lung by 3-dimensional CT after surgery. The ligation of anomalous systemic arterial is enough for this disease.     

Surgical indications in persistent atelectasis in early childhood

Between 1980 and 1989 46 lung resections were performed in 45 children (0-9 years of age) for recurrent or persistent "atelectasis". Indications for surgery were intralobar sequestration (6), bronchial malformations and stenoses (7), chronic pneumonia following infection or aspiration (11), bronchiectases (4), pyocele associated with pulmonary artery ligation (1), upper lobe torsion (1), compression by cysts (6) or lobar emphysema (10). Overall mortality: 4/45 (2 of them within 4 weeks postoperatively) secondary to long-term artificial ventilation and associated or intercurrent disturbances.     

Pulmonary sequestration in older child and in adults.

Pulmonary sequestration is often found in children with recurrent pneumonia, but is not rare in adults. During the last 6 years (1985-1990), 6 patients with pulmonary sequestration were surgically treated. One 40-year-old patient had an extralobar sequestration, and 5 patients ranging in age from 14 to 26 years had an intralobar sequestration. The patient with extralobar sequestration was asymptomatic. In cases of intralobar sequestration, 4 patients were symptomatic. All 6 patients had an abnormal chest roentgenogram. Preoperative arteriography revealed anomalous blood supply came from a systemic artery in 4 patients. All cases with intralobar sequestration had a lower lobectomy, and one case with extralobar sequestration had an extirpation. Even in cases without any symptoms, there was the possibility of a microscopic infection in the sequestrated lesion with the occurrence of later symptoms. Therefore, patients diagnosed with pulmonary sequestration should be considered for surgical resection.     

Management of congenital stenosis of a branch pulmonary artery with balloon dilation angioplasty. Report of 52 procedures

Twenty-four children, aged 4 months to 16 years (nine patients 2 years old or younger), underwent balloon dilation angioplasty of hypoplastic or stenotic branch pulmonary arteries between July, 1981, and April, 1984. Most children had tetralogy of Fallot, with or without pulmonary atresia, or isolated peripheral pulmonary artery stenosis. Fifty-two dilations were attempted, 44 in the catheterization laboratory and eight in the operating room. Of these, 26 (50%) were judged successful; the average vessel diameter on angiogram increased from 4.1 +/- 0.3 to 7.2 +/- 0.3 mm (76%), the gradient across the narrowed segment fell from 60 +/- 10 to 36 +/- 5 mm (40%), pressure in the main pulmonary artery or right ventricle proximal to the obstruction decreased from 83 +/- 10 to 66 +/- 6 mm Hg (20%), and the radionuclide-determined fraction of cardiac output directed to the lung ipsilateral to the dilated pulmonary artery increased from 40 +/- 4 to 51 +/- 4 (28%). All changes were significant at the p less than 0.005 level. Reasons for failure included inadequate technique (balloon too small, inability to position balloon or wire) in 14 and the refractory nature of the lesion itself in 11. Technical failures were age independent. Nondilatable lesions were more common in children more than 2 years old (10/25 versus 1/10) or with isolated peripheral pulmonary artery stenosis (5/7). Five of seven stenoses near previous shunts were nondilatable. One child exsanguinated when the pulmonary artery ruptured during dilation, but other complications were few. Eight dilations, followed up for an average of 6 months after dilation, showed angiographic persistence of improvement; two of four lesions were successfully redilated to a larger size. Balloon dilation angioplasty appears beneficial, both short and long term, for some patients with hypoplastic or stenotic branch pulmonary arteries, especially if performed early in life.     

The multiple facets of pulmonary sequestration

PURPOSE: The goal of this study was to identify the proportion of sequestrations that were atypical or associated with other entities, such as congenital cystic adenomatoid malformations, communicating bronchopulmonary foregut malformations, bronchogenic cyst, and scimitar syndrome. METHODS: All charts of patients with pulmonary sequestration admitted at 2 children's hospitals from 1982 to July 1999 were reviewed retrospectively. The authors included all anomalies with a systemic arterial supply or without bronchial connection. RESULTS: Only 22 of the 39 patients (56%) had a classic isolated extralobar or intralobar sequestration, whereas the others presented with a spectrum of anomalies. Of the 13 cases diagnosed prenatally, 85% were asymptomatic at birth. In contrast, 26 cases diagnosed postnatally were all symptomatic, with those patients less than 2 weeks old presenting with various degrees of respiratory distress, and those older than 2 weeks old presenting with respiratory infections. The correct diagnosis was made preoperatively in 59% of cases. Only 4 patients did not undergo resection of their lesion, of which, 1 underwent interventional radiology with embolization of the anomalous arterial supply. Follow-up issues of importance included pneumonia, asthma, gastroesophageal reflux, and pectus excavatum. CONCLUSIONS: Sequestrations represent a spectrum of anomalies that overlap with other lung lesions. To facilitate management, they should be described according to their (1) connection to the tracheobronchial tree, (2) visceral pleura, (3) arterial supply, (4) venous drainage, (5) foregut communication, (6) histology, (7) mixed/multiple lesions, and (8) whether there are associated anomalies. Surgeons should be aware that approximately 50% of sequestrations could be atypical or associated with other anomalies. This should be kept in mind when weighing the benefits of resection versus conservative management of pulmonary sequestrations.