单侧肺全切除术治疗单侧结核性全肺毁损48例分析

目的总结结核性单侧全肺毁损的外科治疗经验。 方法对48单侧结核性全肺毁损患者行全肺切除术,回顾性分析临床资料。结果48例中胸膜外全肺切除36例,术中出血500～5300ml,术后近期并发症12例（25%）：急性肺水肿3例,呼吸衰竭4例,脓胸3例,纵隔摆动2例,远期并发症为1例（2.1%）缩窄性心包炎;治愈45例（93.8%）;死亡2例（4.2%）。结论对单侧结核性全肺毁损患者,如果持续排菌或有明显症状,其心肺功能能代偿,应积极进行手术治疗,效果较满意。     

Role of surgical treatment in thoracic empyema with bronchopleural and/or thoracic empyema]

Sixty-nine patients with thoracic empyema treated surgically were experienced from May, 1978 through December, 1990. Thirty-nine cases had bronchopleural and/or thoracic fistula. Thirty-two patients were associated with pulmonary tuberculosis, of whom fourteen had tuberculous empyema and eighteen were sequelae of pulmonary tuberculosis or tuberculous pleurisy. The remainder were postoperative, postpneumonic, and posttraumatic empyemas. Of fourteen patients who developed postoperative bronchopleural fistula, there were ten patients who had lobectomy or pneumonectomy for lung cancers. Omental pedicle flap method, in which empyema space was filled with the omentum and pedicled muscle flap, was performed on 19 patients with bronchopleural or thoracic fistula or both. Fifteen patients were cured successfully by single-stage procedure, though there was one operative death due to aspiration pneumonia, and two recurrences which were treated by muscle plombages. There was another patient who had multiple surgical procedures in the past resulting in partial recurrences, but the fistula of this patient subsequently closed without reoperation. Postoperative decrease of %VC, FEV1.0/PVC were minimal. Treatment of long standing bronchopleural fistula is a difficult problem, and our omental pedicle flap method is relatively simple and safe which can be most suitably applied to those patients in whom other procedures have failed and to those with poor pulmonary functions.     

Lung function following sleeve bronchoplastic lobectomy for bronchogenic carcinoma]

Twenty-five patients who underwent upper sleeve lobectomy for lung cancer were studied by spirometric examination to evaluate postoperative pulmonary function, including Vital Capacity (VC), %Vital Capacity (%VC), Forced Expiratory Volume in one second (FEV1.0), and Forced Expiratory Volume in one second as a percentage of the forced vital capacity (FEV1.0%). The results of the patients with bronchoplasty were compared with those of patients with lobectomy alone and of patients with pneumonectomy. Lung function was periodically examined postoperatively following bronchoplasty. VC, %VC and FEV1.0 were decreased postoperatively in the patients with upper sleeve lobectomy, while FEV1.0% was increased. There were no differences in postoperative %VC or FEV1.0% between the patients with bronchoplasty and those with upper lobectomy alone. However, the postoperative %VC of the patients with pneumonectomy was significantly decreased compared with patients who underwent postoperative %VC of the patients with pneumonectomy was significantly decreased compared with patients who underwent bronchoplasty or lobectomy alone. %VC in the patients with bronchoplasty was decreased at 3 months after operation, but it to gradually returned to the preoperative value by 13 to 24 months after operation.     

自体肌皮瓣植入治疗慢性结核性难治性脓胸(附12例报告)

目的 总结自体肌皮瓣植入治疗慢性结核性难治性脓胸的经验。方法 2004年1月至2017年12月共有12例患者因慢性结核性难治性脓胸于上海市肺科医院行自体肌皮瓣植入治疗。伤口换药清洁后,既往有同侧手术史者,行肌皮瓣移植填充手术;既往无同侧手术史者,行肌皮瓣移位填充手术。术前行三联(异烟肼、利福平、吡嗪酰胺)常规标准化抗结核药物治疗3个月以上,术后维持抗结核药物治疗12个月。耐药结核病依据药物敏感性试验(简称“药敏试验”)结果进行调整。患者均为男性;中位年龄52.5岁(26.0~65.0岁)。7例因肺结核病变既往行肺切除术(2例全肺切除);5例开窗时存在支气管胸膜瘘(BPF),引流等保守治疗无法治愈,再行胸壁开窗,并进行长期换药。其余5例无既往手术史,因慢性结核性难治性脓胸保守治疗(引流等)无法治愈,肺无法复张,进行开窗换药。结果 全组患者无死亡,术后均未发生呼吸道并发症。5d内顺利拔除胸腔引流管,术后3~6周出院。中位随访时间9个月,11例患者无脓胸复发和肌皮瓣坏死,1例患者脓胸局部复发(取出老式封堵器,开窗换药后于非水肿期采用新型谢氏封堵器置入,准备二次肌皮瓣填入)。结论 将特种材料(记忆合金支架)、显微外科技术、抗结核药物治疗、结核性脓胸传统手术相结合,运用自体肌皮肌瓣植入治疗慢性结核性难治性脓胸具有良好的临床效果。     

Factors affecting morbidity in chronic tuberculous empyema

BACKGROUND: Chronic empyema is not a rare complication of pulmonary tuberculosis. Various treatment modalities ranging from open drainage to pneumonectomy, depending on the status of the disease, have been used to treat this complication. However, the best strategy for this disease remains unknown. This study examined the results of different treatment strategies for chronic tuberculous empyema. METHODS: Between January 1993 and December 2002, 36 patients (29 male and 7 female) with an average age of 29.3 years (range 13 - 52 years) presented with chronic tuberculous empyema characterized by empyema cavity and persistent pleural infections that were secondary to tuberculosis. The series consisted of patients who had had tube thoracostomy and underwater drainage without complete re-expansion. All patients were treated with open drainage. Of these, 6 patients had Eloesser flap for complete drainage of pleural pus and resolution of pleural infection. RESULTS: Eloesser-flap drainage resulted in a higher morbidity compared to the open-drainage-only method ( P = 0.011). Pneumonectomy, used as a final therapeutic option, resulted in more complications postoperatively ( P = 0.034). Antituberculosis therapy lasting six months or longer reduced the morbidity rate (54 % vs. 33.3 %), but the difference was not significant. CONCLUSIONS: Our findings indicate that open drainage leads to better results compared to those of Eloesser flap in patients with chronic tuberculous empyema. Patients who underwent pneumonectomy were expected to have higher complication rates and the procedure must therefore be avoided when possible.     

Thoracic malignancies in patients with chronic tuberculous empyema

OBJECTIVES: To clarify features of thoracic malignancies occurred in patients with chronic tuberculous empyema. MATERIALS AND METHODS: We analyzed clinicopathological data of 15 patients with thoracic malignancies who had chronic tuberculous empyema, encountered at Tokyo National Hospital during the period from 1977 to 2002. RESULTS: There were 13 men and 2 women, with a mean age of 67 years. Most of all (13/15) patients had history of surgery for tuberculosis including artificial pneumothorax (9 cases). Malignancies consisted of pyothorax-associated lymphoma (PAL; 9 cases), lung cancer (4 cases), malignant fibrous histiocytoma (1 case), and angiosarcoma (1 case). There were no differences in background factors between PAL patients and the other patients. Common symptoms were chest pain (10 cases), fever (7 cases), and bloody sputum (4 cases) and it seemed that these symptoms were more evident in patients with PAL than in patients with other diseases. Plain chest X-ray films often failed to detect the tumor, and the diagnosis was often obtained by sputum cytology, bronchofiberscopy, transcutaneous biopsy, and resection with support of CT and/or MRI films. On radiographs, all tumors located in empyema cavities or around empyema walls, and a pulmonary mass adjacent to the empyema wall was characteristic of lung cancer. PAL showed certainly good outcome; 40% 5-year survival rate with resection or chemoradiotherapy. On the other hand, all of lung cancer cases were diagnosed at stage III, and had poor outcome, and the remaining patients with the other malignancies also had poor outcome. CONCLUSION: Clinicians should keep in mind occurrence of several thoracic malignancies during the follow-up of patients with chronic tuberculous empyema.     

手术治疗结核性脓胸并发静止期肝硬化患者的疗效分析

目的 探讨手术治疗结核性脓胸并发静止期肝硬化患者的疗效。方法 收集2013年4月至2018年4月西安市胸科医院收治的36例结核性脓胸并发静止期肝硬化患者,行结核性脓胸病灶清除、纤维板剥脱术。对患者的手术时间、术中出血量、术后引流量、拔管时间、肺部并发症、术后住院天数、肺功能变化进行分析。结果 本组患者术中出血量、术后3天总引流量、术后拔胸管时间、术后胸腔感染率分别为(423.6±32.8)ml、 (664.8±49.9)ml、 (5.6±1.2)d、16.7%(6/36)。本组患者术后3个月肺功能指标用力肺活量(FVC)为(90.6±8.6)%;第1秒用力呼气容积(FEV1)为(85.0±6.6)%;用力呼气峰流速(PEF)为(72.9±2.7)%;最大自主通气量(MVV)为(84.7±4.4)%,与术前[分别为(68.9±7.5)%、(63.5±5.6)%、(64.1±3.6)%、(61.6±4.1)%]比较,差异均有统计学意义(t=-11.37, P<0.01;t=-10.94, P<0.01;t=-13.36,P<0.01;t=-21.14, P<0.01)。36例患者均获得9个月随访,症状消失,34例伤口一期愈合;2例伤口延迟愈合,局部换药1个月后愈合。无复发患者。结论 手术治疗静止性肝硬化并发结核性脓胸安全性、可行性、疗效均较好,未出现肝硬化活动及结核播散情况,但对于术中渗血及手术引流量值得引起警惕。     

388例肺结核外科切除病例分析

目的探讨当前肺结核病的外科治疗效果和手术适应症。方法总结胸外科1999年1月—2007年12月手术切除的388例肺结核病的临床疗效。全组浸润肺结核116例,结核球或干酪性肺炎85例,慢性纤维空洞性肺结核66例,肺结核合并曲菌球形成18例,结核性支气管狭窄28例,结核性毁损肺75例。结果全肺切除术95例,肺叶切除术217例,气管或支气管成形术11例,其他手术65例。外科切除临床治愈372例治愈率95.9%,并发症33例发生率为8.5%,手术无死亡。结论虽然肺结核是以抗结核药物为主要治疗方法,但目前仍有部分患者需要外科治疗。外科手术可提高重症和耐多药肺结核的临床治愈率。     

70例结核性毁损肺全肺切除术治疗的临床分析

目的探讨全肺切除术在结核性毁损肺治疗中的临床效果。方法对70例结核性毁损肺患者实施全肺切除术治疗,观察所有患者手术前后肺功能及血气分析指标变化。结果 70例患者手术均成功,其中行左全肺切除术43例,右全肺切除术27例;3例支气管胸膜瘘患者未行肺功能检查,余67例患者FEV1%、MVV%均显著优于术前(P<0.01);术后1年70例患者PaO2显著高于术前(P<0.01),PaCO2则显著低于术前(P<0.01)。结论全肺切除术在结核性毁损肺患者中具有确切疗效,但需严格把握手术指征,同时术中操作、麻醉等均需给予高度重视,避免各种术中不良后果的发生。     

耐药肺结核病的外科治疗（附40例报告）

４０例耐药肺结核病人，经肺切除或附加胸廓成形术治疗。病变以空洞和肺毁损为主。二药以上耐药率８７．５％，对ＲＦＰ的耐药率８０％。半数以上病人合并对侧肺病灶。手术并发率１５％，其中脓胸瘘管并发率７．５％。术后痰菌阴转率８７．５％，无手术死亡。出院随访３５例，３４例痰菌复查阴性，２０例恢复正常工作。     

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。     

结核性毁损肺发生的相关因素分析

目的 分析结核性毁损肺发生的相关因素,为避免毁损肺发生提供依据。 方法 对2005年5月至2010年5月住院的结核性毁损肺患者100例和同期非毁损肺的肺结核患者100例进行比较。对患者的一般资料、病程、用药是否规律、耐药情况、肺内感染情况、肺病变数量、合并症、咯血、脓胸及是否有呼吸衰竭等相关因素做统计分析。结果 在单因素中,结核病病程（χ²=84.040,P<0.001）、耐药(χ²=53.107,P<0.001)、是否发生呼吸衰竭(χ²=11.753,P=0.001)、血红蛋白计数（Hg）(χ²=12.106,P=0.001)、是否有肺内感染(χ²=8.036,P=0.005)、咯血(χ²=11.293,P=0.001)、是否排菌(χ²=8.413, P=0.035)、有无脓胸发生(χ²=13.211,P<0.001),以及病变数量(χ²=22.917,P<0.001)是结核性毁损肺发生的危险因素,两组患者相比差异有统计学意义。 不规律治疗(χ²=25.149,P<0.001)、有无慢性阻塞性肺疾病(COPD)(χ²=5.647, P=0.017)、血清白蛋白（ALB）(χ²=6.650,P=0.010)亦是结核性损毁肺的危险因素,两组患者相比差异有统计学意义。在多因素分析中：病程长短［Wald χ²=24.47,P<0.01,OR=3.81(95%CI：2.24～6.64)］、耐药［Waldχ²=20.09,P<0.01,OR=27.11 (95%CI：6.40～114.79)］、合并症［Wald χ²=9.76,P<0.01, OR=4.88 (95%CI：1.81～13.20)］是结核性毁损肺发生的危险因素,两组患者相比差异有统计学意义;Hg［Wald χ²=3.95,P=0.050,OR=0.38(95%CI：0.14～0.99)］、是否排菌［Wald χ²=4.68,P=0.030,OR=0.61(95%CI：0.39～0.95)］、肺病变数量［Wald χ²=5.08,P=0.020,OR=26.53 (95%CI：1.54～458.52)］也是结核性毁损肺的危险因素,两组患者相比差异有统计学意义（P≤005）。结论 结核性毁损肺发生的原因是多方面的,为避免结核性毁损肺的发生要进行早期整体综合治疗。     

胸腔镜辅助小切口在慢性包裹性结核性脓胸手术中的应用

目的 探讨胸腔镜辅助小切口在慢性包裹性结核性脓胸手术中的应用经验及疗效。方法 回顾性分析2006年1月至2016年12月山东大学附属山东省胸科医院采用胸腔镜辅助小切口施行胸膜剥脱术治疗的164例患者的临床资料。其中男 103例,女61例;年龄6~65岁,平均(31.0±3.7)岁;病史3~18个月,平均(5.0±1.7)个月。对患者术中情况、术后并发症处理,以及治疗转归进行总结分析。结果 164例患者均经一次手术治愈,无围手术期死亡患者。13例患者出现不同程度的心律失常,经对症处理后治愈;15例发生迁延性肺漏气,经过继续胸腔闭式引流后治愈;9例切口愈合不良,经过换药护理治愈。结论 胸腔镜辅助小切口对慢性包裹性结核性脓胸的手术治疗,较好地兼顾了微创、效率和安全性,是可选择的一种较为合理的手术方式。     

The role of surgery in the treatment of chronic empyema]

For the last ten years we had 56 patients operated for the empyema which occupied almost all the thoracic cavity. We evaluated their postoperative pulmonary functions and their sequelae. The pathological features of the resected lung and empyema wall were also examined. Surgical procedures consisted of 25 extraperiostal air plombage, 14 pleuropneumonectomy, 8 decortication, and 9 other procedures (lobectomy, muscle-flap, omental flap, and others). Preoperative %VC of patients with extraperiostal air plombage, those with pleuropneumonectomy, those with decortications and those with other procedures were 59.6 +/- 12.6, 46.4 +/- 11.1, 63.0 +/- 10.1, and 53.8 +/- 11.7 respectively. Of 11 patients who developed severe respiratory impairments (%VC less than 40 and/or FEV 1/VC predicted less than 30) post operatively, 4 had extraperiostal air plombage, 4 had pleuropneumonectomy, and 3 had other procedures. In general, degree of respiratory impairment was more severe in patients who underwent multiple surgical procedures. Of 18 patients who survived 5 years or more, %VC was under 50% in 9, and of those nine patients five had 30% decrease in VC compared to the preoperative values and there were 2 patients with extraperiostal air plombage in whom extreme shrinkage and deformity of hemithorax were observed though they had neither additional surgeries nor recurrences. Hemangioma was often seen on the walls of empyema and in some they became so large as to cause mediastinal shift. There were patients with round atelectasis, which, we thought, could have caused abscess or inflammatory granuloma.     

205例肺结核合并支气管结核的外科治疗回顾分析

目的探讨肺结核合并支气管结核的外科治疗效果和手术适应症。方法总结1973年1月至2007年底手术切除的205例肺结核合并支气管结核的临床疗效。全组肺结核包括：原发综合征3例、浸润性肺结核19例、空洞性肺结核53例、慢性纤维空洞性肺结核45例、结核瘤或干酪性肺炎48例、结核性支气管狭窄27例、毁损肺10例。按照支气管结核分型,I型30例、Ⅱ型91例、川型50例、IV型34例。结果全肺切除术15例、全肺切除+胸廓成形术（胸改术）32例、肺叶切除术106例、肺叶切除术+胸改29例、支气管袖状成形术14例,其他手术9例。全组临床治愈率93.0%,手术并发症率为11.2%,手术死亡率为0.05%。结论虽然肺结核合并支气管结核是以抗结核药物为主要治疗方法,但目前仍有部分患者需要外科治疗。手术可提高肺结核合并支气管结核的临床治愈率。     

266例毁损肺的外科治疗

目的总结单侧毁损肺的外科治疗经验。方法选取从1983年10月至2004年2月手术治疗毁损肺266例进行回顾性分析。结果男性120例，女性146例。年龄19至68岁；左侧179例，右侧87例。MVV〈30％25例。病理结果：肺囊肿87例，结核合并支扩129例，肺化脓症11例，支扩并曲霉菌感染39例。伴发糖尿病42例，占15．8％。围术期死亡3例，占1．13％，手术并发症12例，呼吸机支持7例。结论毁损肺临床可首选手术治疗。手术不但切除病变组织。还可明确病因。改善肺功能。重度低肺功能对毁损肺病人并非都是手术禁忌证。     

胸膜纤维板剥脱术治疗慢性结核性脓胸分析

目的：分析胸膜纤维板剥脱术治疗20例慢性结核性脓胸及合并症。方法：所有病例均行胸膜纤维板剥脱术，同时行2例干酪病灶清除，4例空洞清除,2例支气管胸膜瘘修补和1例T12L1椎体结核病灶清除术。结果：脓腔全部灭，空洞清除，瘘口闭合，肺内结核病灶稳定,肺功能明显改善。结论：胸膜纤维板剥脱术是治疗慢性结核性脓胸较理想的手术方法，可以扩大手术适应证。     

Completion pneumonectomy: indications, complications, and results

Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when performed in patients with benign diseases. In our study we aimed to evaluate all patients underwent completion pneumonectomy in our clinic and to compare indications, complications and postoperative results with the literatures. Between January 1987 and December 2001, 27 consecutive patients who underwent completion pneumonectomy in our clinic were retrospectively reviewed. Postoperative morbidity and mortality rates were calculated according to indications and the results were compared to the standard pneumonectomies. There were 27 patients, 13 (48.1%) women and 14 (51.9%) men, with a median age of 26 (range, 10 to 62 years). Completion pneumonectomy was performed for benign diseases in 23 (85.2%) patients and for malign diseases in 4 (14.8%). Malign indications included 2 second primary tumors and 2 local recurrences. In the group with benign diseases; completion pneumonectomy was performed for tuberculosis in 5, bronchiectasis in 14, bronchopleural fistula in 2 and necrosis of lung in 2. Hospital mortality was 7.4% including 1 intraoperative and 1 postoperative deaths and both of them had undergone completion pneumonectomy for benign diseases. Complications occurred in 9 (33.3 %) patients, bronchopleural fistula + empyema were seen in 6 patients, cardiac rhythm disorders in 2 and wound infection in 1. All complications occurred in the patients operated for benign indications (39.1%). Completion pneumonectomy can be performed with an acceptable morbidity and mortality (similar to standard pneumonectomy) in selected cases. But the complication risk is higher in benign diseases, especially in tuberculosis. Surgical technique is important to avoid serious complications such as bronchopleural fistula and empyema.     

全肺切除治疗低肺功能肺结核毁损肺患者的临床研究

目的探讨全肺切除治疗低肺功能肺结核毁损肺患者的临床应用价值。方法选择低肺功能肺结核毁损肺患者36例,所有患者均选择全肺切除术,其中左侧全肺切除19例,右侧全肺切除17例,术前及术后应用抗结核药物。观察患者治疗后的治愈率、肺结核转阴率、并发症发生情况及死亡率。比较患者术前、术后3、6个月肺功能情况。结果临床治愈35例,治愈率97.22%。术前痰培养阳性36例,术后痰培养阴性34例,转阴率为94.44%。术后患者肺功能逐渐改善,与术前相比,患者术后3个月及6个月FEV1、MVV水平均逐渐升高,其差异均具有统计学意义(P<0.05)。结论全肺切除在选择性低肺功能肺结核毁损肺患者的治疗中具有很高临床应用价值。     

Analysis of pulmonary function in leukemia patients after bone marrow transplantation: effects of prior chemotherapy

To evaluate the effects of prior chemotherapy on pulmonary function after bone marrow transplantation(BMT), pulmonary function tests were performed prior to and after BMT on 7 acute leukemia (AL) and 13 chronic myelogenous leukemia (CML) patients given with CY (60 mg/kg x 2 days), total body irradiation (3 Gy x 4 days, 10 cGy/min), and CyA plus short-term MTX. No patient had graft-versus-host disease or lung complications. Pulmonary function after BMT did not deteriorate in the AL patients; however, both %Vital Capacity(%VC) and DL/VA decreased significantly in the CML patients (%VC before BMT: 112.1 +/- 11.5%, after BMT: 93.7 +/- 9.4%; DL/VA before BMT: 79.2 +/- 14.6%, after BMT: 54.1 +/- 10.6%). Although prior regimens of busulfan (BU) or interferon (IFN) were equal risk factors for decreased %VC after BMT, decreases in DV/VA were more significant in CML patients who received IFN. CML patients, especially those who have received BU or IFN, should be carefully monitored for pulmonary function to prevent respiratory failure after BMT.