电视胸腔镜诊治不明原因胸腔积液

电视胸腔镜外科(VATS)是诊治胸膜腔疾病的一种重要手段,比常规开胸手术显示出更多的优点.我院自1995年7月至2000年4月对124例胸膜腔疾病患者施行VATS,其中不明原因的胸腔积液26例,现报道如下.     

电视胸腔镜对不明原因胸腔积液的诊断价值

1996年7月-2004年12月，我院对146例胸腔积液经胸部X线片、CT检查、胸水常规、胸水找脱落细胞、胸水细菌培养、胸水找结核菌、胸膜活检等手段不能明确原因，电视胸腔镜下进行胸膜活检。146例均确诊，恶性病度64例，其中恶性胸膜皮间瘤13例，肺癌胸膜转移35例，乳腺癌胸膜转移16例；良性病变82例，其中胸膜结核59例，乙型肝炎发展为肝硬化导致胸液腔积19例，乳糜胸4例。     

电视胸腔镜手术诊治255例不明原因胸腔积液

目的 探讨电视辅助胸腔镜手术（video assisted thoracoscopic surgery,VATS）对胸腔积液的诊治价值。方法 回顾分析1995年3月～2005年12月255例不明原因胸腔积液经电视胸腔镜手术的临床资料。均经双腔气管插管静吸复合全麻,健肺单肺通气。对包裹形成者先做包裹分离,然后吸尽胸腔积液,再探查有无胸膜结节及肺部结节或肿块,对可疑病灶多点取材做冰冻切片活检。肺复张不完全者,进行纤维板剥脱术。根据病理结果采取胸腔冲洗、胸膜固定及胸腔内化疗等处理方法。结果 255例均经术中冰冻病理检查确诊,其中57例恶性,153例结核性,45例炎性。全组无术中并发症。手术时间60～140min,平均97min。出血量100～850ml,平均226ml。术后222例肺膨胀完全,33例因肿瘤压迫肺膨胀不完全。恶性胸腔积液患者术后随访存活者14例,存活时间12～20个月,平均16.8个月,其余43例在6～12个月内死亡。结核性胸腔积液者142例随访2年,2例在术后1年左右复发,经胸穿治疗好转。炎性胸腔积液41例随访1年无复发。结论 电视胸腔镜在胸腔积液的处理中具有快速、安全、微创、准确诊断等优点,是有效的治疗手段。     

胸腔镜在恶性胸腔积液诊治中的应用

自１９９２年１１月至１９９６年１０月间,作者用胸腔镜技术对２０例恶性胸腔积液患者进行了诊断和治疗,均获得明确诊断;其中恶性胸膜间皮瘤８例,转移癌１２例。２０例行滑石粉胸膜固定术;其中１８例获得可靠的胸膜固定。有２例未成功的原因为肺实性变而不能复张。术后有２例短暂发热和轻度哮喘,对症治疗后症状明显缓解。作者认为,胸腔镜手术可以大大提高恶性胸腔积液的病因诊断率和胸膜固定术的效果,术中应尽可能将附着于脏、壁层胸膜的纤维素剥除,以利于肺复张。     

电视胸腔镜手术治疗恶性胸腔积液37例临床分析

目的探讨电视胸腔镜手术治疗恶性胸腔积液的方法,总结其临床经验。方法回顾性分析2009年1月至2011年12月宝鸡市中心医院37例恶性胸腔积液患者的临床资料,男21例、女16例,年龄43～75岁。其中肺癌15例,乳腺癌7例,食管癌7例,胃癌4例,胸膜间皮瘤3例,卵巢癌1例;均为单侧胸腔积液,其中左侧胸腔积液22例,右侧胸腔积液15例。所有患者均行电视胸腔镜手术（VATS）或VATS辅助小切口完成手术,在电视胸腔镜下行胸膜剥脱术,并喷洒滑石粉固定胸膜。结果围术期无死亡,7例（18.9%）延长切口,手术时间（40.32±19.06）min,术中出血量（90.09±41.03）ml,术后（7.31±2.08）d拔除胸腔引流管,术后住院时间（9.02±3.11）d。手术有效率100%,其中完全缓解19例（51.4%）。术后出现轻度并发症,如肺部感染、持续性漏气和切口感染等,经对症处理治愈。结论电视胸腔镜治疗恶性胸腔积液是一种微创、有效、实用的治疗方法。     

硬质胸腔镜与可弯曲电子胸腔镜在不明原因胸腔积液中的应用价值

目的对比硬质胸腔镜与可弯曲电子胸腔镜在胸腔积液病因诊断中的价值。方法收集1992年4月~2013年11月在我院所有内科胸腔镜检查98例的资料,2011年前79例行硬质胸腔镜检查,以后19例行可弯曲电子胸腔镜检查。比较2组确诊率及操作并发症等方面的差异。结果硬质胸腔镜组镜下表现对恶性肿瘤的阳性预测值为89.1%(41/46),可弯曲胸腔镜组为75.0%(9/12),2组间差异无显著性(χ2=0.631,P=0.427)。胸腔镜活检病理与最终诊断方面,硬质胸腔镜组的总体确诊率为62.0%(49/79),对恶性肿瘤的确诊率为87.8%(43/49);可弯曲胸腔镜组的总体确诊率为63.2%(12/19),对恶性肿瘤的确诊率为100%(9/9),2组间差异无显著性(总体:χ2=0.008,P=0.927;恶性肿瘤:P=0.576)。硬质胸腔镜组2例(2.5%)胸腔镜活检病理结果与临床最终诊断不一致,但2组间差异无显著性(P0.05)。2组均未出现严重并发症。结论硬质胸腔镜与可弯曲电子胸腔镜对不明原因胸腔积液的诊断价值相当,对恶性胸腔积液有良好的诊断价值,两者均具有良好的安全性。     

胸腔镜检查在胸腔积液诊断中的价值

目的　评价胸腔镜检查对疑难胸腔积液的诊断价值。　方法　 4 5例胸腔积液行胸腔镜检查 ,直视下取病变组织行病理检查。　结果　确诊胸膜转移癌 2 5例 ,胸膜间皮瘤 1例 ,胸膜结核 4例 ,结节病 1例 ,非特异性炎症 10例 ,胸腔镜诊断率为 91.1% (41/ 4 5 )。胸膜间皮瘤、转移癌、结核性胸膜炎胸腔镜下形态不同。无严重并发症。　结论　胸腔镜检查对胸腔积液是一种安全、有效、诊断率高的检查手段。     

可曲式内科电子胸腔镜在不明原因胸腔积液诊断中的应用

目的探讨可曲式内科电子胸腔镜在不明原因渗出性胸腔积液诊断中的应用价值。方法回顾性总结2007年11月至2008年11月行可曲式内科电子胸腔镜检查的不明原因渗出性胸腔积液病例28例，分析可曲式内科电子胸腔镜检查的诊断效率及并发症等。结果28例不明原因胸腔积液患者经可曲式内科电子胸腔镜检查后，25例（89％）最终确诊，其中肺癌胸膜转移18例，恶性胸膜问皮瘤1例，卵巢癌胸膜转移1例；结核性胸膜炎5例；3例未能明确诊断。28例患者在可曲式内科电子胸腔镜检查术中、术后无严重不良反应发生。结论可曲式内科电子胸腔镜在不明原因胸腔积液的诊断中具有重要的应用价值：     

电视胸腔镜诊治胸腔积液的临床体会

目的:探讨电视胸腔镜手术诊治胸腔积液的应用价值。方法:回顾分析2006年3月至2012年8月为152例胸腔积液患者行电视胸腔镜手术的临床资料。双腔气管插管全麻后置入胸腔镜及活检钳,取胸膜组织送病理检查,并根据病理检查结果决定治疗方案。结果:152例患者中肺癌胸膜转移83例,恶性胸膜间皮瘤18例,胸腺瘤3例,恶性肿瘤胸膜转移16例,来源不明的转移肿瘤4例,结核性胸水25例,3例未明确诊断。恶性胸腔积液患者行滑石粉胸膜固定,根据病理类型术后予以规范化抗肿瘤治疗。结核性胸腔积液患者,术后予以正规抗结核治疗。余者均根据病理回报结果进行相应后续治疗。结论:电视胸腔镜手术诊治胸腔积液微创,确诊率高,疗效确切,为进一步治疗疾病提供了有力证据。     

电视纵隔镜在胸腔积液诊治中的应用

目的 探讨电视纵隔镜检查术在胸腔积液诊治的应用价值。方法 侧卧位,腋中线第7肋间做2cm小切口,插入纵隔镜,吸净胸腔积液后进行探查,从镜管内伸入活检钳钳取胸膜组织,恶性胸腔积液撒入滑石粉行胸膜固定。结果 手术时间30～70min,平均42min。32例电视纵隔镜术后确诊：腺癌22例,低分化鳞癌2例,侵袭性胸腺瘤1例,胸膜结核5例,炎症2例。结论 电视纵隔镜可作为病因未明的胸腔积液诊治方法之一。     

Primary thoracoscopic evaluation of pleural effusion with local anesthesia: an alternative approach.

OBJECTIVE: The development of a thoracoscopically assisted technique to be performed with the patient under local anesthesia for both diagnostic and therapeutic purposes when treating pleural effusions and empyemas in high-risk surgical patients. METHODS: Twenty patients with pleural effusion or empyema who were also determined to be at high risk for complications following a thoracotomy, pleural biopsy, general anesthesia, or all of these, underwent placement of a thoracoscope while under local anesthesia followed by thoracic fluid drainage, pleural biopsy, and pleurodesis as required. Patients were retrospectively evaluated for a variety of factors including personal history, pre-existing medical conditions, and pre- and postoperative course. RESULTS: The average age of the patients was 59 years (18 to 89) with a 55% male/45% female sex distribution. Patients had this procedure as a consequence of malignancy (50%), empyema (30%), spontaneous pneumothorax (10%), bronchiectasis (50%), or heart failure (5%). The average duration of the procedure was 62 minutes (20 to 190), with an average of 861 mL of fluid drainage, and 114 mL of estimated blood loss. The tube thoracostomy was usually removed on the sixth (0 to 13) postprocedure day. This procedure was well tolerated by the patients with the majority of pain management being achieved with patient controlled analgesia (58%). The direct complication rate was 10%, with 2 patients requiring endotracheal intubation. CONCLUSION: This novel thoracoscopic procedure represents an acceptable alternative to the traditional treatment of pleural effusions and empyema with comparable outcome parameters and morbidity. This technique may eventually become the standard of care for the treatment of pleural effusions.     

The role of thoracoscopy in the treatment of pleural empyema in children

Background The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently, thoracoscopy often is used to treat this disease in some thoracic surgery centers. This report aims to present the authors’ experience with the treatment of pleural empyema and the benefits of thoracoscopy. Methods From 1997 to 2005, 49 children with a diagnosis of pleural empyema were treated by means of thoracoscopy in the authors’ department. The study group consisted of 21 girls and 28 boys, ages 1 to 17 years (mean age, 9.2 years). Thoracoscopic cleaning and drainage of the pleural cavity was performed for all the patients. Results Intraoperatively, stage I empyema was recognized in 7 children (14.3%), stage II in 30 children (61.2%), and stage III in 12 children (24.5%). Very good results were obtained for all the patients. There were no intra- or postoperative major complications. The drainage time was less than 5 days for 63.3% of the children. In the remaining group of patients, drainage exceeded 8 days only for 16.3%. The postoperative time was short. Emptying of the pleural cavity and full lung decompression were achieved in all cases. In four cases, pleural biopsy showed TB, which enabled early proper treatment. Conclusions Thoracoscopy can offer good visualization and cleansing of the empyema chambers, establishing efficient drainage even for patients with advanced stages of pleural empyema. Thoracoscopy enables collection of material not only for bacteriologic, but also for histopathologic examination. The method is minimally invasive, and risk for complication is comparable with that for classical thorax drainage.     

Thoracoscopic palliative treatment of malignant pleural effusions

Background The aim of this study was to analyze the results of pleurodesis for malignant pleural effusion performed by surgeons. Patients and methods A series of 273 patients with malignant pleural effusion underwent thoracoscopy with the aim of performing a palliative pleurodesis. There were 94 males (34.4%) and 175 females (64.1%), ranging in age from 15 to 94 years (mean age: 60.6 years). The effusion was on the right side in 136 patients (49.8%), on the left side in 110 (40.3%), and bilateral in 27 (9.9%). Thoracoscopy was performed under general anaesthesia in all patients. Pleural biopsy was performed in two thirds of the patients (70.7%). Pleurodesis was produced by instillation of 5g of sterile asbestos-free talc; the chest tube was left in place a minimum of 3 days. It was removed when fluid drainage was less than 200 ml/24 h. Patients were usually discharged the day after chest tube removal. Results There was no intraoperative mortality. Two patients (0.7%) had intraoperative complications; 17 (6.2%) underwent a bilateral pleurodesis, and 10 (3.7%) had a pericardiopleural window. In 32 patients (11.7%) no pleurodesis was done, either because the lung did not properly re-expand (5.2%), or because of suspected infection, e.g., false membranes (1.9%), or because of multiple adhesions (4.6%). Finally, only 241 patients (88.3%) had a talc poudrage at the time of thoracoscopy. Duration of postoperative pleural drainage ranged between 1 and 11 days (mean: 3.64 days). The postoperative hospital stay ranged from 2 to 21 days (mean: 7.1 days). Pleural empyema occurred in 4 patients (1.5%) and was lethal in one patient. The mean follow-up period was 8.39 (7.2 months, and 172 patients had regular follow up. In this group, there were 24 recurrences (14%), 12 of which were treated by repeat pleurodesis. The results were very good in 133 patients (77.3%), acceptable in 35 patients (20.3%), and there was a failure in 4 patients (2.4%). Conclusions Results of surgical thoracoscopy for malignant pleural effusion are good, with low morbidity. However, in debilitated patients, bedside talc slurry may be preferable. Presented at the 13th Congress of the EAES (European Association for Endoscopic Surgery), Venice, June 2005.     

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目的 探讨右肝癌切除术后胸腔积液的防治。方法 对27例右肝癌切除术中膈及后腹膜创面腹膜化和纤维蛋白胶封闭膈及后腹膜创面来预防术后胸腔积液，观察其效果，并与对照组进行比较。结果 实验组术后胸腔积液发生率为14．8％，而对照组术后胸腔积液发生率为28．6％（P＜0．01）。结论 右肝癌切除术中膈及后腹膜创面腹膜化和纤维蛋白胶封闭膈及后腹膜创面是预防术后胸腔积液的有效方法。     

Abdominal wall pseudohernia following video-assisted thoracoscopy and pleural biopsy

A rare case of pseudohernia of the abdominal wall following video-assisted thoracoscopy (VAT) and pleural biopsy in a 61-year-old male is presented. The patient presented with a recurrent pleural effusion following fractured ribs after a road traffic accident. Computerised tomography (CT) showed thickened pleura, which was biopsied using VAT. Access to the pleural cavity was obtained with two laparoscopic ports inserted at the 8th intercostal space on the posterior chest wall. Following the procedure, the patient experienced sharp pain over the right hypochondrium, which was followed by the development of a diffuse bulge associated with the loss of skin sensation. Ultrasound and CT disclosed no musculofascial defect. Electromyography showed denervation changes affecting the muscles innervated by the 8th intercostal nerve. With expectant treatment over a year, cutaneous sensation recovered partially; however, the size of the pseudohernia remained unchanged. To the authors’ knowledge, this is the first report of a pseudohernia in the English literature following VAT and pleural biopsy.     

局限性胸膜、肺切除术治疗肺癌伴癌性胸水

目的　探讨局限性胸膜、肺病灶切除术治疗肺癌伴癌性胸水的可行性。　方法　１９９４年１ 月～１９９７ 年１２ 月采用局限性肺切除、胸膜转移灶切除、心包转移灶切除、胸膜微小转移灶电灼及纵隔淋巴结清扫,治疗肺癌伴癌性胸水１４ 例。　结果　所有病历均得到随访,已死亡８ 例,仍存活６例,存活期７～３０ 个月。中位生存期１６－５ 个月。所有病例均未见胸水复发,胸闷、呼吸困难、胸痛及上腹痛症状明显缓解。　结论　此术式操作简单、创伤小、术后恢复快而平稳,控制胸水疗效肯定,其术后生存期明显长于仅做姑息性癌灶切除和内科治疗者,并可缓解胸膜转移所致胸腹部疼痛