单肺移植术治疗终末期肺疾病11例

目的总结单肺移植治疗终末期肺病的早期临床结果和经验。方法2003年1月至2005年9月，为11例终末期肺疾病患者施行了单肺移植术，其中右侧单肺移植7例，左侧单肺移植4例。有2例受者接受同一供者的左、右肺。结果目前有6例单肺移植受者术后生存1年以上，其中3例存活2年以上；3例存活6个月以上。9例存活的受者生活均能自理，活动良好。术后2个月肺功能复查：动脉血氧分压（PaO2）均〉80mmHg，较术前提高37．6％；有8例受者第1秒用力呼气量（FEV1）较术前提高165．2％。2例死亡的受者中，1例因术中大出血死亡；1例淋巴管平滑肌瘤受者术后3个月后死于顽固性乳糜胸。受者术后急性排斥反应平均发生率为1．2次；4例术后并发曲霉菌感染；3例术后出现支气管狭窄；2例术后并发严重肺部感染；1例术后36h出现缺血／再灌注损伤；1例术后7d并发胃底黏膜撕脱继发上消化道大出血；1例术后1年出现慢性排斥反应。结论单肺移植是治疗终末期肺疾病的有效方法。肺移植术后并发症发生率高，应进行有效的预防和治疗。     

人体右侧单肺移植围术期处理一例

探讨肺移植术的围术期处理，提高肺移植患者的生存率。方法对慢性阻塞性肺病（ＣＯＰＤ）合并右上肺癌（Ｔ１Ｎ０Ｍ０）患者施行了右侧单肺移植。结果患者术后恢复顺利，３天后经口进食，７天后能在室内步行３００～５００米。术后第９天和２１天发生两次急性排斥反应，均采用甲基强的松龙冲击治疗后好转。术后４８天死于肺部感染与多器官功能衰竭。结论肺移植术围术期处理对患者肺移植后的近、远期疗效起着重要的作用     

体外循环下单肺移植一例的体会与教训

目的 总结体外循环下单肺移植的经验和教训。方法 在体外循环下给１例终末期双肺纤维化患者施行左侧单肺移植术,供肺采用Ｅｕｒｏ－Ｃｏｌｌｉｎｓ液灌洗,管道吻合时间为５５ｍｉｎ。术后联合应用环孢素Ａ、激素及硫唑嘌呤进行免疫抑制治疗。结果 移植肺术后即刻发挥功能,术后第１、２ｄ因出血致心脏压塞,２次剖胸止血,第３、７ｄ发生急性排斥反应,第９ｄ死于急性排斥反应。结论 肺移植术后应注重出血及急性排斥反应的监测     

单肺移植治疗肺淋巴管平滑肌瘤病1例

2003年8月，我们为1例肺淋巴管平滑肌瘤病病人行右单肺移植术。术后病人发生严重的支气管吻合口和肺内毛霉菌感染，经治疗已痊愈；移植肺支气管软化造成狭窄，反复扩张治疗，目前病情稳定。现报道如下。     

胸腔镜肺门解剖肺切除术的探讨

作者报告了自１９９３年８月至１９９４年１２月在香港地区最大的两家医院采用电视胸腔镜手术（ＶＡＴＳ）方法施行肺门解剖肺切除术的经验。本组成功施行胸腔镜肺门解剖肺切除术共６０例。其中男性４３例，女性１７例。年龄由３７至８５岁（平均６６岁）。术后病理诊断为腺癌３７例、鳞癌１１例、支气管肺泡癌２例、腺鳞癌１例、未分化癌１例、鼻咽癌肺转移１例、肺结核３例、肺炎性假瘤２例、支气管扩张１例、硬化性血管瘤１例。手术方式为单肺叶切除５５例、双肺叶切除２例、全肺切除２例以及肺段切除１例。术后随访平均１０个月（８～１９个月）。本组有１例术后死亡。术后出现并发症１０例，分别为：持续漏气超过１０天４例；切口感染２例；室上性心动过速３例；切口瘢痕出现癌种植转移１例。术后平均住院时间为７．２天。术后镇痛的度冷丁用量平均为２７５ｍｇ，与既往施行常规后外侧胸廓切开肺切除术的一组病例相比，其术后镇痛药的用量显著减少。作者认为采用ＶＡＴＳ方法进行肺门解剖肺切除术是可行的。但由于此方法是通过一个较小的切口进行操作，因而伴有一些特殊的并发症，需引起重视。并要进一步改善技术以提高疗效。本方法的远期疗效，尤其在治疗原发性肺癌方面仍有待进一步的观察研究。     

骨髓输注减轻大鼠肺移植急性排斥反应的研究

目的 研究供体骨髓细胞输注减轻大鼠肺移植急性排斥反应。方法 应用Cuff技术改进大鼠原位单肺移植模型，同时输注供体骨髓细胞，采集受体鼠外周血动态监测嵌合；存活4周大鼠杀死后切取移植肺进行排斥反应分级，切取脾应用免疫组织化学方法检测组织嵌合。结果 流式细胞术在骨髓输注组外周血中检测到明显的嵌合，在脾脏中得到组织嵌合。骨髓输注组移植肺急性排斥反应明显减轻。结论 肺移植同时输注供体骨髓细胞，可以产生显著的供体细胞与受体细胞嵌合，有效地抑制大鼠肺移植急性排斥反应。     

肺移植术后并发症的诊治

我们于１９９６年１２月２４日为１例严重肺功能损害患者施行右侧同种异体肺移植。术后患者存活了４５天，死于脑干、脑实质多发性出血。在此期间，成功地控制了４次急性排斥反应及防止了严重肺部感染的进一步蔓延。认为（１）诱导－辅助性Ｔ细胞／抑制Ｔ细胞的监测有助于发现肺急性排斥反应；（２）支所管纤维镜检查对防治术后并发症有重要作用；（３）术后应选用有针对性抗生素及联合应用抗真菌药物抗感洒。     

肺移植治疗肺纤维化一例报告

作者于１９９５年２月２３日为一男性４８岁特发性肺纤维化患者行左侧单肺移植，至今良好存活。术后半年复查肺功能基本正常，核素扫描左肺通气及灌注良好。术间未用体外循环。术后用三联免疫抑制剂，加抗胸腺细胞球蛋白５天。术后３个月中发生３次急性排斥，第三次肺活检病理改变已达最严重的Ⅳ级，用甲基强的松龙冲击治疗，效果良好。     

双肺移植治疗终末期原发性肺动脉高压

双肺移植治疗原发性肺动脉高压１例。男病人，３０岁。多年来有气短等症状，晕厥４次，反复咯血４年，近期大咯血３次。肺动脉压２０．３／７．３（１３．７）ｋＰａ，全肺阻力３５４．９７８ｋＰａ·ｓ／Ｌ，有中至重度三尖瓣关闭不全。１９９８年１月２０日在体外循环（心脏不停跳）支持下手术。术毕肺动脉压基本正常，三尖瓣关闭不全及反流消失。术后给予三联免疫抑制剂。围手术期有明显的血液动力学紊乱，无明确的急性排斥发生，最主要的并发症是左主支气管吻合口、右上叶及中间干支气管狭窄，目前仍间断行球囊扩张治疗。病人已生存８个多月，状态稳定，在扩张狭窄的支气管后可出院外自由活动     

肺移植术后的结核感染一例

目的 探讨肺移植后结核杆菌感染的诊断与治疗。方法 １例接受左单肺移植的患者术后１３个月发生胸壁结核感染,曾疑为急性排斥反应而予以激素冲击治疗,后经左前胸季肋部局部肿块穿刺抽吸物（脓液）涂片及培养,发现结核杆菌而诊断为胸壁结核脓肿,后又发生混合感染,给予抗结核药头及头孢他定治疗,同时行脓肿切开引流。结果 经治疗,患者的病情迅速得到控制,体温恢复正常,３个月后伤口愈合。结论 肺移植后发生结核病,其症状     

Reimplantation response in isografted rat lungs. Analysis of causal factors

The function of transplanted lungs may be critically impaired in the early postoperative period by the reimplantation response. Several factors of the transplantation procedure, such as disruption of hilar structures (hilar stripping), stenotic anastomoses, and graft ischemia, are considered to cause this reimplantation response. In this study the individual contributions of these factors have been analyzed in rats, after isogeneic transplantation or hilar stripping of left lungs. Marck's technique for orthotopic transplantation of the left lung in rats was refined so that an 85% postoperative survival rate was achieved. Transplanted and hilar-stripped lungs were investigated by lung perfusion scintigraphy and chest roentgenography at regular intervals up to 168 days after operation. Macroscopic and histologic morphology was examined at corresponding intervals. Our results show that perfusion and ventilation of lung grafts are independently affected by distinct factors of the transplantation procedure. Hilar stripping did decrease graft perfusion transiently. Permanent decrease of perfusion was found to be caused by stenosis of the anastomosed pulmonary artery. Hilar stripping also impaired ventilation, by causing interstitial and alveolar edema. After transplantation, edema and consequent impairment of ventilation were aggravated by graft ischemia, proportionally to its duration. Our improved technique for transplantation of left lungs in rats provides a new opportunity for investigating the immunologic problems of lung transplantation.     

Incidentally Detected Chronic Lymphocytic Leukemia in Hilar Lymph Nodes at the Time of Lung Transplantation: A Case Report

A 68-year-old man with interstitial pulmonary fibrosis underwent bilateral lung transplantation. Histopathologic examination of hilar lymph nodes in the explanted lungs showed effacement of normal nodal architecture by the proliferation of small lymphocytes, consistent with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL). Unexpectedly discovered malignancies at the time of lung transplantation is uncommon, especially in the lymph nodes. The clinical management was challenging because of attempts to balance treatment of CLL and immunosuppressive treatment to prevent graft rejection. Here, we report a case of incidentally detected CLL in hilar lymph nodes with explanted lungs and review the relevant literature.     

Surgical factors affecting growth potential of the immature rat lung

The transplanted immature rat lung has been shown capable of fulfilling its growth potential after left lung transplantation (LLTx) and concomitant right cardiac lobe resection (RCLR). However, unexpected findings in these studies included an abnormal rise in lung volume in the contralateral lung due to alveolar multiplication, and significant dilatation of the bronchi in the transplanted left lung. In the present study, the influence of surgical factors that could have contributed to these changes, i.e. RCLR, denervation, and anastomotic stenosis, were studied individually. Immature Lewis rats aged 4 and 6 weeks were used and (a) RCLR, (b) RCLR and right hilar stripping, and (c) RCLR and left pulmonary artery (PA) banding were performed in groups 1 (n = 12), 2 (n = 5) and 3 (n = 6), respectively. Animals were killed after 6 months and the lungs studied using quantitative morphometric techniques. In groups 1 and 2, right lungs did not show any significant increase in volume. Alveolar number and airway diameter in both lungs in all groups were not significantly different from controls. In group 3 both right and left lungs presented an increase in alveolar size (p less than 0.02 on the right and p less than 0.01 on the left). Changes seen after LLTx in the rat, such as alveolar multiplication, cannot be explained by compensatory growth (RCLR), denervation (RCLR and hilar stripping), or arterial stenosis at the anastomotic site (RCLR and left PA banding), but must be regarded as a consequence of transplantation per se. A role for neuropeptides in lung growth following transplantation is suggested.     

Experimental studies on reimplantation response after lung transplantation

The reimplantation response after lung transplantation may critically impair the function of transplanted lungs in the early postoperative period. The purpose of this study is to evaluate the factors which cause this reimplantation response. Using canine left lungs, four groups were studied. Group I underwent complete hilar stripping (n = 6). Group II underwent complete hilar stripping and kept in warm ischemia for 60 min. by clamping left pulmonary artery and veins (n = 6). Group III underwent the same surgery as Group II and administered superoxide dismutase (SOD) (12000 U/kg/h) during reperfusion (n = 7). Group IV underwent autotransplantation of left lung (n = 6). To evaluate the function of left lung, arterial blood gas, pulmonary arterial pressure, aortic pressure, cardiac output and left extravascular lung water (liter EVLW) were measured in a transient contralateral pulmonary arterial occlusion before operation and 60 min. after reventilation and reperfusion. The measurement of EVLW was performed by thermal-green dye double indicator dilution method. The results obtained were as follows. 1) The values of liter EVLW measured in rt. pulmonary arterial occlusion were extremely well correlated with those of both lung EVLW. (r = 0.943 p less than 0.001). 2) The ratios of postoperative-liter EVLW: preoperative-liter EVLW and postoperative-total pulmonary resistance (TPR): preoperative-TPR were as follows: Group I; 1.29 +/- 0.19 and 1.23 +/- 0.36, Group II; 1.85 +/- 0.49 and 1.69 +/- 0.36, Group III; 1.28 +/- 0.17 and 1.50 +/- 0.36 Group IV; 2.28 +/- 0.40 and 1.70 +/- 0.34. These data indicate that the most important factor of reimplantation response at the time of this acute phase is the oxygen free radical-induced reperfusion injury. Hilar stripping, ischemic injury and surgical trauma are also important factors of reimplantation response. Vascular anastomosis is not so important when it is done well technically. 3) Administration of SOD provides protection against lung edema after lung transplantation.     

大白鼠淋巴结移植——功能结构和细胞学的变化以及影响其再生的因素

本实验研究了大白鼠肠系膜淋巴结移植后的结构、功能以及细胞学的变化。同时观察了白细胞间介素2(Il-2)和棒状杆菌(Corynebacterium Parum C.P.)对移植后淋巴结再生的影响。结果表明淋巴结移植后体积逐渐缩小,细胞成份不断减少,丧失了正常的组织结构和功能。而淋巴结移植后其输入淋巴管再生的失败是导致其退化的主要原因。IL-2可能具有调节淋巴结内再循环淋巴细胞的作用而有利于维持移植后淋巴结的完整性。     

Physiologic sufficiency of regenerated lung lymphatics.

The physiologic sufficiency of regenerated lung lymphatics after surgical transection of the lung hilum was studied experimentally. Dogs were prepared by surgical interruption of all left lung hilar tissues and structures except the skeletonized pulmonary artery and the pulmonary veins; continuity of the bronchus was restored by anastomosis. Anatomic reconnection of lung lymphatics to mediastinal lymph vessels was determined by injecting a sky blue dye marker into peribronchial tissues distal to the bronchial anastomosis at different intervals after surgical preparation. From a series of 50 experimental animals it was demonstrated that the surgical procedcure interrupted lymphatic drainage and that anatomic reconnection with mediastinal lymphatics developed 7-28 days after preparation. Physiologic sufficiency of regenerated lymphatics was studied in 60 animals by rapid intravascular volume expansion as a test of lymph flow capacity. By gravimetric determination of lung water and histologic examination of lung specimens this study revealed a significant incapacity to maintain lung water homeostasis 3 days after preparation with return toward normal lymph flow capacity 35 days after preparation. This study indicated that lung lymphatic drainage is re-established 7--28 days after surgical interruption and becomes relatively sufficient after 35 days.     

肺叶、肺段淋巴结引流的解剖学特征

目的探讨肺叶、肺段淋巴结引流的解剖学特征。 方法对9具成人尸体采用解剖乳胶填充剂行胸部淋巴结灌注,然后游离标本的纵隔前、纵隔后及中纵隔淋巴结,同时游离并清扫右肺上、中、下肺叶和各个肺段,以及左肺上、下肺叶和各个肺段的肺内淋巴结、肺门淋巴结;观察淋巴结的分布、数目和淋巴回流状况。 结果在标本上共观察到212个纵隔淋巴结,平均每例23.5个;各区淋巴结的数目以隆突下淋巴结7区和右下气管旁4R最多,其次为右气管支气管旁(10R)、左支气管旁(10L)和主-肺动脉窗区(5区)淋巴结;纵隔各区以隆突下区(7区)淋巴结最大,其次是右气管支气管旁(10R)淋巴结,气管旁淋巴结自上而下直至隆突下淋巴结逐渐增大,并且右侧大于左侧,即下大于上,右大于左。左肺和右肺的肺内淋巴结一般按照亚段淋巴结→段淋巴结→叶淋巴结→叶间淋巴结/肺门淋巴结;右肺上叶、中叶及肺门淋巴结通常回流至上纵隔淋巴结及隆突下淋巴结,下叶回流至下纵隔淋巴结。而左肺上叶一般引流至主—肺动脉窗区淋巴结及隆突下淋巴结,下叶也引流至下纵隔淋巴结。 结论肺叶及纵隔淋巴回流具有一定的规律性,从而为肺叶特异性/系统性淋巴结清扫方式的选择提供了解剖学依据。     

Anatomical pathways of lymphatic flow between lung and mediastinum

The knowledge of anatomical lymphatic drainage pathways between lung and mediastinum and metastatic spread patterns of lung cancer forms the basis for the modern TNM classification for the staging of lung cancer. Clinical and anatomical studies divided pulmonary nodes into intrapulmonary and bronchopulmonary, the latter distinguished into lobar and hilar nodes. Mediastinal nodes are grouped into anterior prevascular, tracheobronchial, paratracheal and posterior nodes. The different pathways of lymphatic drainage of the lungs to the mediastinal lymph nodes are presented with the consequent surgical implications.     

Experimental studies on changes of SOD activity levels and reperfusion injury after lung transplantation

The purpose of this study is to evaluate the role of superoxide dismutase (SOD) in reperfusion injury after lung transplantation in mongrel dogs. Canine left lungs were used and three groups were studied. Group I underwent complete hilar stripping (n = 6). Group II underwent complete hilar stripping and was kept in warm ischemia for 60 min. by clamping left pulmonary artery and veins (n = 6). Group III underwent the same surgery as Group II and kept in warm ischemia for 120 min (n = 6). To evaluate the function of the lung, arterial blood gas, left total pulmonary resistance (ITPR) and lung wet to dry weight ratio (W/D ratio) were measured in transient contralateral pulmonary arterial occlusion periodically for 7 days after reperfusion. Also, plasma and bronchoalveolar lavage fluid (BALF) levels of SOD like activity, angiotensin converting enzyme (ACE) activity and ceruloplasmin were measured before operation and periodically after reventilation and reperfusion. Additionally, using dialyzer and electron spin resonance (ESR) spectrometry, plasma levels of extracellular SOD (EC-SOD) activity were measured. The results obtained were as follows. 1) In Group II and III, W/D ratio, ITPR and arterial blood gas were significantly increased in comparison with Group I. 2) Though there were no significant changes in the BALF levels of SOD like activity, ACE and ceruloplasmin and in the plasma levels of ACE and ceruloplasmin, the plasma level of SOD like activity rose 3 hours after reperfusion. 3) The plasma level of EC-SOD activity rose along with that of SOD like activity without any change in intra-cellular SOD levels. The above results suggest that EC-SOD plays an important role in cyto-protection against reperfusion injury after lung transplantation.     

Broncholithiasis: clinical experience of three operated cases

Three patients with broncholithiasis had an operation in our hospital. Patient 1 had no history of tuberculosis. She had the pulmonary stones removed bronchoscopically twice. The stones were composed of inflammatory granulomas. Patient 2 had a history of pulmonary tuberculosis. Endoscopical removal of the pulmonary stone was not successful. After 6 days, she coughed up a large amount of blood, and the operation was performed. Patient 3 coughed up blood for 10 years. The amount of blood gradually increased and the operation was performed. All three cases had calcification of the hilar lymph nodes. Broncholithiasis appears to be related not only to pulmonary tuberculosis but also to other chronic inflammatory diseases of the lung.