余肺切除治疗肺部疾患临床分析

目的探讨余肺切除的手术适应证、手术方法、并发症防治和远期疗效。方法回顾1985年1月至2006年8月进行的24例余肺切除[占同期全肺切除的2．3％（24／1026）]患者的临床资料。余肺切除距第1次肺切除的时间为5．5个月-30年,平均65个月;肺癌复发患者间隔时间为术后5．5个月～10年,平均32个月。手术历时4-7h,平均5．5h;术中失血300-3000ml,平均1270ml。结果手术切除23例,切除率为95．8％。术后并发症发生率及住院死亡率分别为29．2％（7／24）和4．2％（1／24）。术后病理诊断为支气管扩张症2例、原发性肺癌4例、复发性肺癌18例。术后随访率为91．7％（22／24）。肺癌余肺切除患者的1、3、5年生存率分别为77．3％（17／22）、50．0％（9／18）和29．4％（5／17）;其中复发性肺癌患者余肺切除术后的1、3、5年生存率为72．2％（13／18）、47．1％（8／17）和29．4％（5／17）。结论严格选择患者,术中精细操作,做好围手术期并发症的防治,余肺切除可有效延长患者的生存期。     

Elective Pneumonectomy for Non-Small Cell Lung Cancer: Factors Affecting Early Operative Mortality and Morbidity

Background: The aim of this study was to investigate the factors influencing the morbidity and mortality of the non-small cell lung cancer (NSCLC) cases where pneumonectomy was performed.

Material & methods: All 101 patients who had underwent a pneumonectomy for NSCLC between 1994–2001 in our hospital were included in the retrospective study. There were 97 males and 4 females with a mean age of 56 ± 9.6. Factors affecting morbidity and mortality were analysed by univariate and multivariate analysis. Results: The morbidity rate was 53% and the mortality rate was 9%. Morbidity was related to cardiopulmonary complications in 40% of the cases. The risk factors for cardiopulmonary morbidity with univariate analysis were age

> 60 years (p = 0.004), FEV1 < 2 lt (p = 0.016), early bronchopleural fistula (p = 0.0001), tumour size > 4 cm (p = 0.033), vital capacity < 3.7 lt (p = 0.016), forced vital capacity < 3.5 lt (p = 0.033). With multivariate analysis the risk factors cardiopulmonary morbidity were age (60 >) (p = 0.012) and tumour size > 4 cm (p = 0.043). The risk factors mortality with univariate analysis were right pneumonectomy (p = 0.025), respiratory morbidity (p = 0.0001), cardiac morbidity (p = 0.002), cell type (Epidermoid CA) (0.047), tumour size > 6 cm (p = 0.036), fluid infusion (p = 0.009), forced vital capacity < 78% (p = 0.039), forced expiratory volume in 1 second < 75% (p = 0.039), PO2 (p = 0.037), PCO2

> 42 mmHg (p = 0.023).

Conclusion: Among the pneumonectomies performed for NSCLC, the causes of postoperative morbidity were multi-factorial, however, multivariate analysis did not show any significant factor affecting the mortality, related to this procedure.     

Factors affecting major morbidity after video-assisted thoracic surgery for lung cancer

Background

Video-assisted thoracic surgery (VATS) has been widely applied in the treatment of lung cancer. However, few studies have focused on the clinical factors predicting the major postoperative complications.

Methods

Clinical data from 525 patients who underwent resection of primary lung cancer with VATS from January 2007–August 2011 were retrospectively analyzed. Risk factors related to major postoperative complications were assessed by univariate and multivariate analyses with logistic regression.

Results

Major complications occurred in 36 (6.86%) patients, of which seven died (1.33%) within 30 d, postoperatively. Major complications included respiratory failure, hemothorax, myocardial infarction, heart failure, bronchial fistula, cerebral infarction, and pulmonary embolism. Univariate and multivariate logistic regression analyses demonstrated that age >70 y (odds ratio [OR], 2.105; 95% confidence interval [CI] 1.205–3.865), forced expiratory volume during the first second expressed as a percentage of predicted ≤70% (OR, 2.106; 95% CI 1.147–3.982) combined with coronary heart disease (OR, 2.257; 95% CI 1.209–4.123) were independent prognostic factors for major complications.

Conclusions

Age >70 and forced expiratory volume during the first second expressed as a percentage of predicted ≤70% combined with coronary heart disease are independent prognostic factors for postoperative major complications. Patients in these groups should undergo careful preoperative evaluation and perioperative management.     

Early Prediction of Symptomatic Hypocalcemia after Total Thyroidectomy

Background : Hypocalcemia is the most common postoperative complication after total thyroidectomy. The aim of this prospective study was to determine biochemical parameters in the early postoperative period that could identify patients with significantly increased risk of symptomatic hypocalcemia development.

Methods : The study included 100 individuals undergoing total thyroidectomy from January to May 2009. In all patients PTH, calcium, inorganic phosphate, magnesium, and albumin levels were measured immediately preoperatively, 30 minutes postoperatively and every morning for the following five days.

Results : Clinically significant hypocalcemia was observed in 19% of all cases. Fall of the iPTH values by more than 88% from preoperative values, 30 min after completion of the surgery, showed 100% sensitivity and 100% specificity for the occurrence of symptomatic hypocalcemia.

Conclusions : According to our results immediate postoperative measurement of the iPTH may be considered as a useful method to predict with high certainty which patients will need calcium supplementation, and to separate them from patients who can be safely and early discharged.     

Veno-venous extra-corporeal membrane oxygenation-assisted right tracheal-sleeve pneumonectomy

Tracheal sleeve pneumonectomy for lung cancer is an old technique, and it is reserved for exceptional cases with tracheal carina involvement. Intra-operative airways management of this operation is incredibly complex, involving thoracic surgeons, anaesthesiologists and pulmonologists. We report a case of a 38-year-old male with no clinical history, referred to our department for an adenoid-cystic carcinoma involving distal trachea, carina and main right bronchus. Tracheal sleeve pneumonectomy was performed using extra-corporeal membrane oxygenation (ECMO). A veno-venous ECMO circuit was established through a heparin-coated percutaneous cannula in the right femoral vein and a heparin-coated percutaneous cannula in the internal right jugular vein by ultrasound assistance. No major complications occurred, and the patient was discharged after 30-day bronchoscopic control, showing the absence of fistula and negativity of the methylene blue test. ECMO-assisted surgery ensures adequate respiratory support, haemodynamic stability, lower risk of bleeding complications with a clean operating field and better brain and myocardial oxygenation.     

Early simultaneous esophagopleural and bronchopleural fistula after right pneumonectomy

Background: Esophagopleural and bronchopleural fistulas represent a rare, but life-threatening complication after lung resections, most often after a right pneumonectomy.

Case study: A 64 years old woman was indicated for right pulmectomy for local recurrence of initially stage IIB lung cancer treated by lower lobectomy. On the postoperative day 34, an esophagopleurobronchial fistula occurred. Further course required thoracostomy with closure of the bronchial stump and vacuum-assisted closure therapy and two-phase esophagectomy with 6 weeks interval to the esophageal reconstruction. Patient represents 2 years of disease-free survival with good functional results.

Conclusion: The therapy of esophagopleural and bronchopleural fistula is long-term and complicated, requiring a multidisciplinary approach and several basic principles must be adhered to the management including treatment of infection and prevention of sepsis, local treatment of the fistula and pleural empyema, and adequate ventilation and nutritive care.     

Completion pneumonectomy for recurrent or second primary lung cancer

OBJECTIVE: We studied 8 patients undergoing completion pneumonectomy for recurrent or second primary lung cancer. METHODS: Subjects were men who averaged 62 years of age. Of these 6 had p-stage I, and 2 p-stage II disease at initial operation. At the second operation, we diagnosed 3 with second primary lung cancer and 5 with recurrent lung cancer. We predicted postoperative pulmonary function by calculating the predicted forced expiratory volume in 1.0 second (FEV1.0) from residual numbers of subsegments after completion pneumonectomy. All predicted FEV1.0 in our 8 cases ranged from 544 to 926 (773 +/- 144) ml/m2. RESULTS: Six patients experienced postoperative complications and morbidity was 75%. One patient undergoing completion sleeve pneumonectomy after radiation therapy for local carina recurrence died on 7th postoperative day due to anastomotic dehiscence and pneumonia. Overall operative mortality was 12.5% (1/8). Four remain alive and actuarial 5-year survival was 37.5%. CONCLUSIONS: Careful consideration is needed in determining operative indications for completion pneumonectomy for patients after radiation therapy. Patients with recurrent squamous cell carcinoma who have p-stage I disease at initial operation and those with second primary lung cancer and p-stage I or II disease can expect relatively a long-term survival, and we concluded that completion pneumonectomy could be conducted in these cases with a satisfactory prognosis.     

心包内处理肺血管治疗中晚期肺癌57例手术体会

目的总结心包内处理肺血管全肺切除术或肺叶切除术治疗中晚期肺癌的经验。方法回顾性分析1996年至2006年期间,57例因中晚期肺癌接受心包内处理肺血管全肺切除术或肺叶切除术患者的临床资料。结果全组患者无手术死亡,术后出现心律失常7例,肺水肿3例,肺部感染2例,均治愈。术后获得随访52例,随访率91.2%,随访时间1～5年。术后1,3,5年生存率分别为44.2%、17.3%和11.5%。结论掌握好适应证,心包内处理肺血管全肺切除术或肺叶切除术是一种安全可靠的手术方法,可明显提高中晚期肺癌的肿瘤切除率和手术安全性。     

经心包内全肺切除治疗中晚期中央型肺癌临床分析

目的探讨经心包内处理肺血管全肺切除术的手术操作、术后呼吸、血气及心功能的变化。方法回顾性分析42例经心包内全肺切除术患者的临床资料。结果42例患者术中无一例因心包切开引起不可逆性心律失常，术后并发呼吸衰竭及术后死亡均与切开心包无明显关系。结论经心包内处理肺血管全肺切除术安全性较好，可提高肺癌切除率、延长术后生存期。     

Pericardial flap for bronchial stump coverage after extrapleural pneumonectomy; is it feasible?

Bronchial stump reinforcement with viable tissue after pneumonectomy is an important prophylactic measure against the development of bronchopleural fistula. We present our technique of utilizing the pericardium on the posterior wall of the left atrium as a flap to cover the bronchial stump after extrapleural pneumonectomy. From January 1999 to March 2008, we used this technique in 50 patients (29 on the right side and 21 on the left side) with no incidence of bronchopleural fistula or empyema. This technique is proved to be feasible, safe and effective; also it does not increase operative time or surgical trauma.     

补充性全肺切除术治疗肺癌

目的　评估补充性全肺切除术的适应证、危险性和结果。　方法　回顾性分析 49例残肺恶性病变患者的补充性全肺切除术 ,其中第二原发性肺癌 14例 ,肺癌复发 35例 ;再次手术平均间隔期为 2 9个月。　结果　全组死亡6例 ,1例死于术中 ,5例死于术后 ,手术死亡率为 12 .2 4%。术后随访 1个月～ 5年 ,中位数生存时间 2 .5年 ,5年生存率为 33%。　结论　补充性全肺切除术治疗残肺癌 ,手术死亡率和术后 5年生存率接近标准的全肺切除术     

Principles of posterolateral thoracotomy and pneumonectomy

Posterolateral thoracotomy is required to gain access to the thoracic cavity. The patient is placed on the operating table in a lateral decubitus position and a single-lung ventilation technique is used with a double-lumen endotracheal tube. The incision is made on the side of the chest towards the back between the ribs. Many thoracic surgical procedures can be performed by this approach including lung resections.Pneumonectomy is a surgical procedure to remove whole lung and usually performed by posterolateral thoracotomy. It can also be performed by video-assisted thoracoscopic surgery (VATS). Pneumonectomy is indicated where curative surgical resection is not possible with lesser resection. Prior to pneumonectomy a thorough preoperative assessment of the patient is performed as per British Thoracic Society guidelines. This procedure leads to considerable reduction in respiratory reserve of the patient and is also associated with significant morbidity and mortality. Common complications include arrhythmias, myocardial infarction, pulmonary embolism, pneumonia, empyema, respiratory failure and bronchopleural fistula. The perioperative mortality rate ranges between 6% and 8%. Very dedicated and careful postoperative management is required in specialized centres to avoid complications.     

Principles of posterolateral thoracotomy and pneumonectomy

Posterolateral thoracotomy is required to gain access to the thoracic cavity. The patient is placed on the operating table in a lateral decubitus position and a single-lung ventilation technique is employed by using a double-lumen endotracheal tube. The incision is made on the side of the chest towards the back between the ribs. Many thoracic surgical procedures can be performed using this approach including lung resections.     

建立非小细胞肺癌全肺切除术后早期支气管胸膜瘘临床风险模型

目的 探讨非小细胞肺癌全肺切除术后早期支气管胸膜瘘发生的危险因素,建立一个可以评估其风险的临床模型,为早期干预提供可能.方法 回顾性分析429例非小细胞肺癌全肺切除术患者,通过单因素和多因素分析发现非小细胞肺癌全肺切除术后早期支气管胸膜瘘发生的独立危险因素,综合独立危险因素建立临床模型.结果 早期支气管胸膜瘘发生率为6.5％(28/429),其相关独立危险因素分别为新辅助治疗(HR:2.406)、围术期失血量(HR:2.171)、术前合并糖尿病(HR:1.144).根据相对危险比建立新的评分系统,新辅助治疗和围术期失血量≥1000ml定义为2分,术前合并糖尿病定义为1分.视每位患者得分情况分为3组:低危组(0～1分),中危组(2～3),高危组(＞3),术后早期支气管胸膜瘘发生率分别为3.0％、11.3％和55.6％(P＜0.000).结论 这个临床模型建立在独立危险因素基础上,可以作为预测非小细胞肺癌全肺切除术后发生早期支气管胸膜瘘的工具,为提早干预提供依据.     

Low-molecular-weight heparin for treatment of submassive pulmonary embolism after pneumonectomy

Pulmonary embolism (PE) after lung resection has a high mortality rate, and it is one of the most severe complications after lung resection. Early diagnosis and treatment are essential. We present a case of severe PE after left pneumonectomy for lung cancer. Computed tomography angiography was useful for confirming the diagnosis of PE. Low-molecular-weight heparin (LMWH) was used to treat the embolism, and the patient was discharged on the seventh day. LMWH is an effective and safe agent for the treatment of PE after pneumonectomy and may reduce the need for surgery. It may be used as an initial procedure. Secondary severe complications, including hemorrhage and subsequent empyema, may be avoided with the use of LMWH.     

良性病变全肺切除术后近期并发症危险因素分析

目的 探讨良性疾病全肺切除术的手术指征和术后近期并发症的影响因素.方法 回顾性分析136例良性疾病全肺切除术患者的临床资料,随访术后30天内发生的并发症.采用单因素和多因素分析良性疾病全肺切除术后并发症发生的危险因素.结果 33例(24.26％)出现术后并发症,围术期死亡5例(3.68％).单因素分析显示疾病类型(P=0.041)、术侧(P =0.014)、出血量(P=0.010)及手术持续时间(P =0.009)是术后并发症的主要影响因素.多因素分析显示疾病类型(HR3.158,95％ CI 1.248～7.992,P=0.015)和手术持续时间(HR2.508,95％ CI 1.035 ～6.080,P=0.042)为良性病变全肺切除术后发生并发症的独立危险因素.结论 良性疾病全肺切除术后伴有高并发症发生率.但通过严格掌握手术适应证和科学合理进行围术期管理可以有效降低围术期死亡率和并发症发生率.全肺切除仍然可以作为良性肺疾病治疗的选择.     

Perioperative and long-term outcomes after radical cystectomy in hemodialysis patients

Purpose

Patients on hemodialysis have an increased risk of developing advanced stage bladder cancer. They also have a significant risk of noncancer–related mortality. Radical cystectomy (RC) is the standard of care for nonmetastatic muscle–invasive bladder cancer, however little is known regarding outcomes in this population.