The tactics of management of patients with mycobacteriosis of the lungs]

Recently, pulmonary mycobacteriosis patients more often attract researchers' attention. On the basis of observations at the institute clinic and the literature data an opinion was voiced concerning diagnosis, registration and taking on record, therapeutic tactics and dispensary follow-up. Discussion of the work by phthisiatrists who follow up these patients will contribute to the elaboration of a unified effective approach to pulmonary mycobacteriosis patients.     

外科手术治疗74例肺结核并发肺曲菌球病患者的临床价值

目的 分析外科手术治疗肺结核并发肺曲菌球病的临床价值。方法 搜集2007—2016年在广西壮族自治区龙潭医院行外科手术的74例肺结核并发肺曲菌球病患者,对手术方式、手术治疗转归、并发症、术后随访等临床资料进行回顾性分析。结果 74例患者中,择期手术68例(91.9%),急诊手术6例(8.1%);73例(98.6%)手术顺利,术中因大出血死亡1例;行肺叶切除术54例(73.0%),肺段切除术5例,全肺切除术2例,复合肺切除术9例,肺楔形切除术4例。24例(32.4%)出现术后并发症:术后大出血1例,再次开胸止血治愈;呼吸功能衰竭1例,呼吸机辅助呼吸28d后成功脱机治愈;肺不张5例,4例经纤维支气管镜吸痰后肺膨胀良好,1例纤维支气管镜吸痰无效,继发呼吸功能衰竭后自动放弃治疗出院后死亡;脓胸4例,3例细菌性脓胸经持续引流治愈,1例曲霉菌性脓胸于术后15个月行电视胸腔镜脓胸廓清术时发生肺动脉破溃大出血,改为体外循环下左余肺切除术,但因不能纠正休克而死亡;肺泡胸膜瘘5例,3例经持续胸腔引流,2例行碘伏胸膜固定术加持续胸腔引流后治愈;支气管胸膜瘘1例,给予患者持续的胸腔引流3周后瘘口逐渐闭合治愈;胸部净化残腔7例,未处理。72例患者术后获得随访,1例患者随访期间死亡。最终治愈71例(96.0%),随访1~48个月,平均(11±3)个月,未见肺结核及肺曲菌球病复发。结论 选择合适的患者行外科手术,治愈率高,并发症发生率及死亡率在可以接受的范围之内,绝大多数患者能治愈。     

Functional morphology of the lungs in patients with tuberculosis and diabetes mellitus]

The lungs of 20 patients (between the ages of 14 and 46 years) with tuberculosis and type I diabetes mellitus were subjected to a morphological examination with the help of a light and electron microscope. Thirteen patients were operated on for fibrous-cavernous tuberculosis and 7 for pulmonary tuberculoma. A duration of the concurrent diseases was 3 to 10 years (5.5 years, on average). All patients had a serious form of diabetes mellitus. The combined affection was characterized by a progressive course of tuberculosis with involvement of bronchi in the process. Specific features of tissue reactions pertinent to this combined pathology were revealed which comprised defective defense mechanisms (alveolar macrophages, type II alveolocytes and fibroblasts in the form of their dystrophy) generalized affection of pulmonary vessels, intensive fibre formation and disorganization of the forming connective tissue, which has a bearing on the development of the pathological process.     

Atelectasis after segmental resection of the lungs in patients with tuberculosis]

Study of 219 tuberculosis patients who underwent segmental resections showed that the rate of atelectasis development constituted 16.4%. In the right-sided operations atelectases developed 3 times more frequently than those in the left-sided ones (27.5 and 7.5%, respectively) and were mainly segmental (atelectasis of the anterior segment after excision of the ++apico-posterior segment), while in the left-sided intervention they were total in the majority of patients. The character of atelectasis in the right- and left-sided operations was determined by specific features of bronchial structure of the right and left lungs. As a result of therapeutic measures all total atelectases were relieved within 3-5 days, while segmental atelectases persisted for a long time; in 6 patients they still remained by the time of discharge.     

23例脊柱结核并发艾滋病患者的手术疗效观察

目的 探讨手术治疗脊柱结核并发艾滋病(AIDS)患者的临床疗效。方法 采用回顾性分析方法,搜集2014年1月至2018年1月成都市公共卫生临床医疗中心行手术治疗的23例脊柱结核并发AIDS患者的临床资料,包括手术时间、术中出血量、手术并发症,术前及末次随访时视觉模拟评分(VAS评分)、血红细胞沉降率(ESR)、C反应蛋白(CRP)、CD4 ⁺T淋巴细胞计数情况、神经功能情况,以及末次随访时植骨融合情况等,分析研究对象手术治疗的效果。结果 23例患者均顺利完成手术,平均手术时间为(268.4±11.3)min,平均出血量为(490.6±101.5)ml,无手术切口感染。患者均获得随访。末次随访VAS评分为(1.0±0.7)分,明显低于术前的(8.2±0.6)分,疼痛较术前明显改善,差异有统计学意义(t=6.15,P=0.001)。4例术前有神经功能损伤的患者完全恢复正常。经抗结核药物治疗及手术治疗,末次随访时患者的ESR和CRP分别为(9.3±2.6)mm/1h和(4.8±1.2)mg/L,较术前的(79.4±4.6)mm/1h和(57.5±5.9)mg/L均明显下降,差异均有统计学意义(t=64.66,P=0.000;t=47.73,P=0.000);经围手术期管理及后续以高效抗逆转录病毒治疗为主的综合治疗,末次随访时患者CD4 ⁺T淋巴细胞计数为(267.5±38.5)个/μl,较术前的(233.3±41.1)个/μl上升,差异有统计学意义(t=-36.57,P=0.001)。所有患者植骨融合符合Bridwell Ⅰ~Ⅱ级标准,植骨融合中位时间为6个月,随访期间未见内固定器断裂。2例患者术后1d出现癫痫,5例术后肺不张、高热,11例术后出现腹胀,对症处理后均恢复正常。结论 通过加强围手术期管理、合理选择手术时机,脊柱结核并发AIDS的患者手术治疗临床效果较好。     

Morphological diagnosis of chronic bronchitis in patients with tuberculosis of the lungs]

A morphofunctional insufficiency of the bronchial epithelium which is a pathognomonic symptom of chronic bronchitis, was examined in 105 biopsy specimens of the bronchial mucosa of patients with different forms of pulmonary tuberculosis by morphometry. It was found that epithelial changes typical of chronic bronchitis, were observed in 100% of the cases. However, 64.76% of the patients had Stages I and II morphofunctional insufficiency, which corresponded to the presence of chronic nonobstructive bronchitis. The epithelial changes traced in the remaining observations were characteristic of chronic obstructive bronchitis. The presence and the extent of morphofunctional insufficiency were not associated with the form of tuberculosis. The examination of biopsy specimens of the bronchial mucosa taken in the vicinity of the upper bronchus spur is considered to be an adequate and sufficient method of an objective detection of chronic bronchitis in tuberculosis.     

NSCLC合并活动性肺结核患者外科手术治疗预后的意义

目的分析非小细胞肺癌(NSCLC)合并活动性肺结核患者外科手术治疗预后生存影响因素。 方法选取2016年2月至2020年2月我院NSCLC合并活动性肺结核患者89例,均行外科手术治疗,根据术后1年患者生存情况分为死亡者23例与生存者63例。统计预后生存情况及一般资料,并进行单因素分析,采用Logistic多元回归方程分析预后的影响因素。 结果89例NSCLC合并活动性肺结核患者经手术治疗后,随访1年内失访3例,剩余86例患者中生存63例,死亡23例,病死率(26.74%);术后出现痰液潴留9例、肺不张4例、肺部感染1例;死亡者吸烟史、刺激性咳嗽、TNM分期为Ⅲa期、原结核病灶病变高于生存者,手术方式为肺叶切除术低于生存者(P<0.05);经Logistic回归分析,吸烟史、刺激性咳嗽、TNM分期、原结核灶病变均为NSCLC合并活动性肺结核患者的危险因素,手术方式为NSCLC合并活动性肺结核患者的保护因素(P<0.05)。 结论NSCLC合并活动性肺结核患者经外科手术治疗预后不佳,吸烟史、刺激性咳嗽、TNM分期、原结核灶病变、手术方式等为预后的重要影响因素。