肝癌肝切除术后并发胸腔积液影响因素临床分析

目的分析肝癌肝切除术后胸腔积液的发生率及其影响因素,探讨防治肝切除术后并发胸腔积液的可能措施,方法回顾性分析我院2002年1月～2007年7月间行肝切除术的226例肝癌的临床资料。运用x2检验分析其年龄、性别、病理类型、术前肝功能分级、肿瘤直径、肿瘤部位、手术时间、失血量、肝门阻断时间、切除方式、术后腹水量与术后胸腔积液发生率的关系。结果肝癌肝切除术后胸腔积液发生率为23．01％。从X2检验的结果可见：在α=0．05水平上,术后并发胸腔积液的主要影响因素为：肿瘤部位、手术时间、术中失血量、肝门阻断时间、肝切除术式、术后腹水量（P〈0．01）。结论严格掌握手术适应证,加强术前及术后护肝治疗;术中不盲目扩大切除范围,尽可能在较短的时间内完成肝癌的切除;尽量缩短肝门阻断时间,可以减少术后胸腔积液的发生。     

预防肝切除术后发生胸腔积液

目的：探讨508胶在预防肝切除术后胸腔积液的效果。方法：对15例肝切除术应用508胶后预防术后胸腔积液的效果与17例未应用508胶的肝切除对照组进行比较。结果：应用508胶组术后胸腔积液发生率为13．3％（2例），对照组为47．1％（8例）（P＜0．05），结论：508胶对减少肝除术后胸腔积液和腹腔感染有显著的效果。且使用方便，费用较少，值得推广应用。     

Thoracoscopic parietal pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax.

OBJECTIVE: The obliteration of pleural space is useful to prevent recurrences of spontaneous pneumothorax. We retrospectively compared the results of pleural argon beam coagulation versus pleural abrasion in the treatment of primary spontaneous pneumothorax. METHODS: Between 1996 and 2004, 136 patients underwent surgery for primary spontaneous pneumothorax, with 143 surgical procedures, all performed by VATS. Indications were recurrent pneumothorax in 107 patients, a complicated first episode in 29 and occupational activity in 7. Six patients were excluded because of postoperative histopathological diagnosis other than pulmonary emphysema. In 70 cases pleurodesis was performed with argon beam coagulation and in 67 by Marlex degrees mesh abrasion. These techniques were employed during two different periods. Median follow-up was 68 months in the Marlex degrees group and 41 in the argon group. The two groups resulted as being homogeneous for gender, age, smoking attitude and surgical indication. Statistical analysis was done with chi2 and Fisher's test. RESULTS: No postoperative mortality was observed. Mean recovery time was 5 days. There were three patients with postoperative bleeding who underwent re-operation. There were nine cases of prolonged air-leak, one needing surgical exploration. Nine recurrences were noted, all requiring surgery. Two recurrences were observed in the group treated by pleural abrasion (3.4%) and seven in the group treated by argon coagulation (10.7%). The Fisher's test failed to demonstrate a statistical significance between the two procedures in terms of recurrence rate (p=0.18). Multivariate analysis yielded no risk factors for recurrences. Postoperative complications resulted as being equally distributed in both groups. CONCLUSION: After primary spontaneous pneumothorax, pleurodesis induced by argon beam parietal pleural coagulation resulted as being no better than that obtained by pleural abrasion in the prevention of recurrences. No benefits in terms of postoperative complications resulted by use argon beam coagulation.     

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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。     

Application of argon beam coagulation in urological surgery.

Argon beam coagulation is a new form of electrocautery that has proved useful to control diffuse bleeding in other surgical specialties. We report its application to urology. Three cases are presented in which argon beam coagulation provided excellent hemostasis in situations that are often difficult to control, such as partial nephrectomy for penetrating trauma, hemorrhagic cystitis refractory to other forms of treatment and after anterior exenteration for bladder cancer. The basis, technique and advantages of argon beam coagulation are discussed, as well as other instances in urological surgery in which it may have application. Argon beam coagulation is an alternative to conventional methods of hemostasis whenever there is a diffusely bleeding operative site.     

Postoperative mechanical ventilation preventing the occurrence of pleural effusion after hepatectomy

To determine factors leading to pleural effusion after hepatectomy, the frequency of pleural effusion was investigated in 68 patients who underwent hepatic resection, with or without dissection of the right coronary ligament. In 36 of 44 patients (81.8%) who underwent hepatic resection with complete dissection of the right coronary ligament, and in two of 24 (8.3%) who underwent the procedure without dissection of this ligament, pleural effusion developed in the right hemithorax (p less than 0.001). Difference in pressure between the abdominal and thoracic cavities was considered to lead to ascites in the chest via the diaphragmatic triangular area (where there is no parietal peritoneum). While investigating the preventive effect of mechanical ventilation following hepatic resection on the occurrence of pleural effusion in 12 patients, we concluded that effusion could be prevented with use of mechanical ventilation--an approach that retained the intrathoracic pressure in a positive state.     

Endoscopic ablation of Barrett's esophagus using argon plasma coagulation (APC) following surgical laparoscopic fundoplication

BACKGROUND: Barrett's esopagus (BE) is considered a risk factor for the development of esophageal carcinoma. Recently, partial restoration of squamous mucosa after ablation of BE with endoscopic techniques has been described. METHODS: From November 1996 to November 1999, 23 patients with histologically proven BE have been treated by endoscopic argon plasma coagulation (APC) following suppression of gastro-esophageal reflux by laparoscopic fundoplication. Histological follow-up after completed ablation ranged from 16 to 45 months (mean, 31.9 months). RESULTS: Histologically, complete squamous reepithelialization was observed in 20/23 patients, whereas a regrowth of a mixed squamous and gastric type mucosa was observed in 1 patient. Small islands of intestinal metaplasia were observed under the neosquamous epithelium in two patients (9%) during follow-up. CONCLUSION: The success rate of APC ablation following laparoscopic antireflux surgery in our series may be as high as 91%. Nevertheless, small islands of intestinal metaplasia under the new squamous epithelium may persist in some patients. In these circumstances, the authors recommend that endoscopic ablation of BE should be confined to controlled clinical trials.     

Diagnosis of post-traumatic pleural effusion

A rare case of post-traumatic pleural effusion is reported. A 19 year old male patient was admitted after a road traffic accident with a scalp wound, femoral shaft fracture and haematuria related to a ruptured bladder. Shortly after extubation following bladder surgical repair, the patient had to be reintubated because of acute respiratory failure. A large left-sided pleural effusion was then diagnosed. The liquid was sero-haematic and contained a high concentration of creatinine (839 mumol.l-1). Thoracic CT scan and intravenous urography displayed a left epirenal collection and a dilatation of the upper urinary tract with rupture of the renal pelvis. The surgical treatment of this urinothorax consisted of the rupture repair of the posterior diaphragm and of the urinary tract.     

Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations

Seventeen patients who underwent a cardiac operation developed a recurrent, symptomatic pleural effusion ultimately requiring video-assisted thoracic surgery (VATS) and talc pleurodesis. These patients represented 0.4% of all patients undergoing a cardiac operation over the same time period. Compared with an age- and sex-matched control group of cardiac surgery patients, patients requiring VATS for recurrent pleural effusion were more obese with higher body mass index (31.9 +/- 1.2 versus 28.3 +/- 1.4 kg/M2, P = 0.03), were more likely to have undergone a complex cardiac operation (8/17 versus 1/17, P =.01) and were more frequently on anticoagulation and antiplatelet agents besides aspirin (8/17 versus 2/17, P =.02). Patients underwent 1.86 +/- 0.34 thoracenteses with drainage of 846 +/- 166 mL/thoracentesis prior to referral for VATS. On average, patients underwent VATS 4.83 +/- 1.49 months after their cardiac operation. There were 3 VATS-related complications (17.6%) and no deaths. VATS talc pleurodesis led to symptomatic and radiologic improvement in all patients with a mean follow-up of 8.2 +/- 1.5 months. VATS talc pleurodesis effectively and safely treats the unusual postcardiac surgery patient with refractory pleural effusion.     

Re-expansion pulmonary edema following video-assisted thoracic surgery for recurrent malignant pleural effusion

A rare case of a unilateral re-expansion pulmonary edema following video-assisted thoracic surgery for malignant pleural effusion is described.     

Late postoperative pleural effusion following lung transplantation: characteristics and clinical implications.

OBJECTIVE: Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14-45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX. METHODS: Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined. RESULTS: The median time for late pleural effusion appearance was 23 days (range, 14-34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100-1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients. CONCLUSION: Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome.     

Prevention of the neoplastic progression of Barrett's oesophagus by endoscopic argon beam plasma ablation

BACKGROUND: Patients with Barrett's oesophagus have a risk of approximately 1 per 100 patient-years for the development of oesophageal adenocarcinoma. Endoscopic ablation of Barrett's oesophagus has been shown to lead to the regrowth of a 'neo' squamous epithelium if gastro-oesophageal reflux is controlled, but the incidence of subsequent tumour formation is unknown. METHODS: The follow-up of 55 patients who underwent endoscopic ablation of Barrett's oesophagus by argon beam plasma coagulation (ABPC) is reported. Of the 55 patients, nine had low-grade dysplasia, nine had high-grade dysplasia and the remainder had non-dysplastic Barrett's metaplasia. Twelve patients had reflux control by antireflux surgery and the remainder received proton pump inhibitor therapy. Barrett's metaplasia was ablated by ABPC to within 2 cm of the gastro-oesophageal junction. RESULTS: To date, one patient has died and one patient was unable to complete treatment. The remaining patients were followed by regular endoscopic surveillance for a mean of 38.5 months to give a total follow-up of 173.5 patient-years. No malignancy has developed in any patient during follow-up. CONCLUSION: The absence of malignant complications in this study of prophylactic ablation of long-segment Barrett's oesophagus strengthens the argument for endoscopic ablation in the prevention of oesophageal adenocarcinoma.     

A simple method of using a foley catheter to drain pleural effusion

Pleural effusion is a common problem, and various techniques of pleural fluid drainage have been described. We report our experience of using a Foley-type catheter to drain pleural effusion. After the injection of local anesthesia, the catheter is inserted, usually through the 7th intercostal space, with the patient sitting upright. The size of the catheter is selected according to the predicted fluid characteristics, and ranges from 18 to 24 F. Once the catheter is positioned in the pleural space, the balloon is inflated with diluted soluble contrast material and connected to a urine collection bag. During the last 10 years, we have used 3500 catheters for this purpose. The catheter site can be used as a port for various procedures, including needle biopsy of the parietal pleura, talc-slurry pleurodesis, and intra-pleural fibrinolysis. This method of pleural drainage is simple, reliable, and inexpensive.     

Laparoscopic treatment using an argon beam coagulator for nonparasitic liver cysts

BACKGROUND: Laparoscopic deroofing has been shown to produce good patient satisfaction and to have results similar to those of open surgical techniques. We evaluated the feasibility and efficacy of laparoscopic deroofing using an argon beam coagulator (ABC) in the patients with nonparasitic liver cysts. METHODS: Laparoscopic deroofing for the treatment of liver cysts was attempted on 14 patients. After the deroofing, the secreting epithelium within the residual cystic cavity wall was destroyed using the ABC. RESULTS: Laparoscopic deroofing was successful in all patients. No deaths or surgical morbidity occurred, and no postoperative complications were recorded. The median postoperative hospital stay was 7 days. The median follow-up was 56 months for all patients, and all patients have remained completely asymptomatic for 6 months after the surgery, with no recurrence of the cysts. CONCLUSIONS: Our results indicate that laparoscopic deroofing using the ABC method in patients with nonparasitic liver cysts was effective in preventing cyst recurrence.     

Successful treatment of watermelon stomach / GAVE syndrome by using argon plasma coagulation

This case report describes a 50-year-old female patient with liver cirrhosis presented with anemia. She was found to be suffering from gastric antral vascular ectasia (watermelon stomach) on upper gastrointestinal endoscopy. She underwent multiple sessions with Argon plasma coagulation, a non-contact thermal method of hemostasis for the management of watermelon stomach. After 3 sessions, the lesions disappeared and the hemoglobin increased by 2.4 gm/dl without any need of transfusion.     

Endoscopic argon plasma coagulation of Barrett mucosa

BACKGROUND: Up to 10% of patients with Barrett's esophagus develop adenocarcinoma of the distal esophagus. Endoscopic surveillance is recommended. We studied the potential of Argon plasma coagulation (APC) for eradication of Barrett's esophagus. METHODS: Indication for APC was the histologic evidence of columnar epithelium with a length of > or = 2 cm, located proximal of the cardia and with the presence of goblet cells. Endoscopic therapy was performed using an Argonbeamer (Beamer 2, Erbe Company, Tübingen, Germany) under i.v. sedation and repeated in intervals of 2-3 weeks with the aim of complete eradication of Barrett's epithelium. One month after macroscopic Barrett eradication, superficial and deep biopsies were obtained every 2 cm in 4 quadrant technique to confirm the endoscopic aspect of complete eradication. RESULTS: We report our results (follow-up median: 12 mths., 3-25) in the first 12 patients (8m/4f, median age 57 yrs., 42-69) in which treatment was completed. In one case there was evidence of moderate dysplasia. A mean of 5 (4-11) sessions were required for complete Barrett eradication in 11 patients (median size of Barrett-segment: 4 cm, range 2-11), in one patient partial regression of 50% was observed treatment was discontinued after 17 sessions while only. Deep biopsies showed subepithelial columnar epithelium islands in one case, recurrence of Barrett occurred in 2 cases after 3 and 6 months. Under APC-treatment, 11/12 patients complained about retrosternal pain and odynophagia. No other complications were observed. CONCLUSION: Our preliminary results indicate that APC is safe and effective to eradicate Barrett's epithelium. Follow-up in a larger number of patients is necessary to assess longterm results (Barrett recurrence, decrease in the incidence of the adenocarcinoma), before APC may generally be recommended.