术中应用聚乙醇酸材料预防COPD患者肺手术后长期漏气

目的探讨慢性阻塞性肺疾病(COPD)患者行肺切除时,术中应用聚乙醇酸材料预防术后长期肺漏气这一常见并发症的作用,适应证及手术方法。方法对36例COPD患者在肺切除时,应用聚乙醇酸管型(tube type)和/或网片型(sheet type)材料行肺创面加强修补,观察术后肺漏气情况。结果全组36例中,24例为COPD合并肺大疱,同时合并气胸15例,行胸腔镜下肺大疱切除;5例为终末期COPD行胸腔镜下肺减容术,其中3例为双侧肺减容术,2例为单肺移植术后保留侧肺减容术;7例为肺癌合并COPD行肺叶切除。全组无手术死亡,术后4例需机械辅助通气,术后平均肺漏气时间(2.8±1.1)d。未见与聚乙醇酸材料相关的并发症发生。结论术中应用聚乙醇酸管型和/或网状材料行肺创面加强修补,可有效预防COPD患者肺切除术后长期肺漏气。     

单肺移植结合对侧肺减容术治疗终末期肺气肿一例

目的　探讨单肺移植结合对侧肺减容术治疗终末期肺气肿的手术适应证及疗效。方法　对 1例呼吸机依赖的重症肺气肿、肺功能严重下降的 4 7岁患者行左肺移植。术后第 7天因患者对侧肺逐渐过度膨胀致纵隔左移 ,压迫移植肺 ,而行右侧胸腔镜辅助小切口肺减容术。结果　肺减容术后第 1天患者纵隔移位明显改善 ,移植肺扩张良好 ;术后第 9、15天移植肺 2次出现急性排斥反应 ,用免疫抑制剂治疗 ,并于术后第 15天行气管切开、呼吸机间断辅助呼吸 ,病情缓解 ;术后第 2 4天患者下床活动 ,第 2 6天拔除气管插管 ;术后 2个月检查患者肺功能明显改善 ;术后第 71天出院。结论　单肺移植结合对侧肺减容术能治疗重症肺气肿单肺移植后的对侧肺过度膨胀 ,明显改善肺功能。     

肺减容术治疗重度肺气肿

目的 评价肺减容术治疗重度肺气肿的疗效、手术适应证选择及围手术期处理经验.方法 对我们收治的27例重度肺气肿病人所实施的肺减容术进行分析总结,27例中18例行单侧肺减容,9例行双肺肺肺减容.其中5例电视胸腔镜肺减容术（4例单肺,1例双肺）,13例电视胸腔镜辅助小切口肺减容术（9例单肺,4例双肺）,5例行经后外侧切口单肺减容术,4例为胸骨劈开双肺减容术.结果 LVRS术后FEV1平均提高42%,术后6～12个月,FEV1改善达高峰.手术死亡率为0,术后并发症发生率38%.结论 肺减容术能明显改善部分具有手术适应证的重度肺气肿病人的临床症状和生理状况.     

COPD并自发性气胸行肺大疱切除加单侧肺减容术临床分析

目的报道急诊或亚急诊肺大疱切除加单侧肺减容术治疗COPD并自发性气胸的临床结果。方法对32例COPD并自发性气胸患者实施肺大疱切除加单侧肺减容术,术后随访24个月,分别于术后第6、12、24个月测定动脉血气分析值。结果术后第6、12、24个月与术前相应数值比较,均有明显好转（P〈0.05）。全组无手术死亡,术后并发症发生率在35%左右。结论肺大疱切除加单侧肺减容术可以改善COPD并自发性气胸患者的临床症状,且手术死亡率低,尽量切除肺大疱及病变侧过度气肿的肺组织和防止残肺漏气为手术关键,做好围手术期的处理,能明显减少术后并发症。     

右肺移植同期左肺减容术治疗终末期肺气肿的报告

目的　探讨人体单肺移植同期行对侧肺减容术(LVRS)在治疗慢性阻塞性肺气肿(COPD)中的治疗效果及经验。方法　供体:脑死亡患者,使用改良的4℃LPD肺保护液,顺行灌注后再逆行灌注,肺膨胀状态下取下整体肺块无菌冷保护下送受体手术室,解剖修整后取右肺供移植用。受体:终末期双侧COPD ,右侧重于左侧,切除右全肺,适当保留右主支气管、右肺动脉及右肺静脉心房袖供吻合,将供体右肺移植于受体右胸腔内,再作左肺上叶减容术,减容达左肺2 5 %。结果　手术经过顺利,移植肺成活,无急性排异反应。左肺减容侧因术后胸腔内活动性渗血再次开胸。患者肺功能恢复满意,已长期存活。结论　使用改良LPD液顺灌及逆灌供肺对保护其功能及减轻排异反应有明显的效果,气管套叠式吻合及吻合口周围使用生物蛋白胶对减轻支气管吻合口并发症有益。单肺移植同时进行另一侧肺减容对患者术后肺功能的改善有明显作用。     

单肺移植术后活动性血胸的外科治疗

2004年7月及2004年12月，我们分别为2例终末期肺气肿患者成功实施了单肺移植，对侧肺减容术，术后均合并活动性血胸，经手术治愈，现报道如下。     

小切口结扎式单肺减容术治疗COPD疗效观察

目的探讨小切口结扎式单肺减容手术治疗慢性阻塞性肺疾病(COPD)的疗效。方法分析26例接受小切口结扎式单肺减容术切割过度气肿肺组织治疗重度COPD患者的临床治疗资料。结果 (1)患者平均住院时间及术后平均肺部漏气时间均低于传统单侧肺减容术(P0.05);(2)患者术后平均呼吸困难指数低于术前(P0.05)。患者术后生活质量显著提高,Karnofsky评分高于术前(P0.05)。术后1年随访,患者肺部各项功能指标均明显改善(P0.05)。结论小切口结扎式单肺减容术治疗COPD疗效好,安全性高,值得临床推广应用。     

肺移植术后移植肺自发性气胸1例

2004年7月26日，我们为1例终末期肺气肿患者成功实施了右单肺移植，同期左肺减容术，取得了满意的效果，术后14月移植肺合并自发性气胸，现报道如下。     

1例肺移植患者围手术期健康教育

目的探讨健康教育在器官移植围手术期的重要性。方法对本院第一例肺移植患者进行与围手术期有关的健康教育,以及手术出院后的指导。结果该患者行右单肺原位移植及同期左侧肺减容术,术后60天出院,已生存18个月,生活质量明显提高。结论正确的健康教育对调动病人的主观能动性及抗病能力,使疾病向良好的方向转归起着事半功倍的作用。     

肺移植治疗呼吸机依赖的终末期肺病三例

目的探讨肺移植治疗呼吸机依赖终末期肺病患者的合理选择、围手术期处理、撤机策略问题。方法我院2002年9月至2005年3月行15例肺移植，其中3例为术前呼吸机依赖终末期肺气肿患者，术前呼吸机依赖89、120、107d。手术行单肺移植1例，非体外循环下序贯式双侧单肺移植2例。结果3例患者分别于术后第22、6、11天脱机，第71、41、67天出院，生活质量明显改善，至今分别存活22、4、2个月。结论肺移植可有效治疗经选择的呼吸机依赖的终末期肺病。     

Surgical therapy for chronic obstructive pulmonary disease

Many patients with severe chronic obstructive pulmonary disease (COPD) experience incapacitating breathlessness and exercise limitation. Multiple surgical techniques have been utilized to achieve resection of giant, localized bullae with documented short-term benefit in pulmonary function and dyspnea in highly selected patients. The poorest long-term outcome has been noted in those with greater degrees of emphysema in the remaining lung, greater underlying chronic bronchitis, and a bulla occupying less than one third of the hemithorax, particularly if compressed normal lung is not evident. Lung volume reduction surgery (LVRS) in the absence of giant bullae has become more widely accepted in selected patients. Bilateral LVRS procedures appear to result in greater short-term improvement than unilateral LVRS, whereas physiological benefits appear similar with video-assisted thoracoscopy (VATS) or median sternotomy (MS) techniques. Improvement in dyspnea and health status after LVRS has been documented and appears to be better preserved over longer-term follow-up than physiological improvement. Clear direction has been provided in identifying optimal candidates for bilateral LVRS; patients with a postbronchodilator forced expiratory volume in 1 second (FEV (1)) < or = 20% predicted and a diffusing capacity for carbon monoxide (DL (CO)) < or = 20% predicted or homogeneous emphysema exhibit a much higher mortality with LVRS than with medical management. Patients with upper-lobe predominant emphysema and a low postrehabilitation exercise tolerance exhibited a decreased risk of mortality after LVRS. Patients with non-upper lobe predominant emphysema on high-resolution computed tomography (HRCT) and a high postrehabilitation exercise capacity exhibit an increased risk of death after LVRS. Patients with upper lobe predominant emphysema and a high postrehabilitation exercise capacity or patients with non-upper lobe predominant emphysema and a low postrehabilitation exercise capacity do not have a survival advantage or disadvantage, whereas those with upper lobe predominant emphysema treated surgically are more likely to improve their exercise capacity after surgery. Lung transplantation is an option for a more limited number of patients. Consistent short-term spirometric improvement after both single- and double-lung transplant has been documented. Long-term results of lung transplantation are limited by significant complications that impair survival; an approximately 80% 1-year, 50% 5-year, and 35% 10-year survival has been reported. Bronchiolitis obliterans is the most important long-term complication of lung transplantation resulting in decreased pulmonary function. In general, a COPD patient can be considered an appropriate candidate for transplantation when the FEV (1) is below 25% predicted and/or the paCO (2) is > or = 55 mm Hg.     

肺移植治疗肺纤维化10例临床分析

目的 探讨肺移植治疗肺纤维化的手术适应证、围手术期的处理及疗效.方法 2002年9月至2005年12月无锡市胸科医院采用肺移植治疗肺纤维化10例,包括特发性肺间质纤维化9例、术前长期依赖呼吸机（150 d）的重症肺炎后肺纤维化1例.手术方式均为单肺移植,其中2例在体外循环下进行,有1例为左侧供肺植入右胸腔.结果 术后1例于137 d死于重症肺部感染合并急性呼吸窘迫综合征,其余9例患者痊愈出院,平均术后住院时间为44 d.随访中1例术后9个月死于肺部感染,1例术后25个月溺水意外死亡,其余7例均健在,且肺功能有极大的改善.结论 单肺移植是治疗特发性肺间质纤维化的有效方法.     

Surgical aspects and techniques of lung volume reduction surgery for severe emphysema.

Lung volume reduction surgery (LVRS) has become an accepted procedure for palliative treatment of diffuse, nonbullous emphysema. Single or multiple peripheral segmental wedge resections of the most destroyed areas of the lungs are performed with the use of stapling devices, in order to decrease hyperinflation and restore diaphragmatic function. Median sternotomy, videoendoscopy or anterior muscle sparing thoracotomies have been used as surgical approaches. The functional improvement after bilateral resections exceed those after a unilateral approach. LVRS has demonstrated its potential as an alternative to transplantation, and with growing experience, the indications for the procedure have been widened. In selected patients with peripheral lung cancer who have been considered unsuitable for a surgical resection, the combination of both tumour resection and LVRS has successfully been performed. In contrast to LVRS, laser surgery of the emphysematous lung has been abandoned in most institutions.     

Outcomes of COPD lung transplant recipients after lung volume reduction surgery

STUDY OBJECTIVES: We sought to assess the outcomes of COPD lung transplant recipients who had previously undergone lung volume reduction surgery (LVRS), and to compare these patients to those COPD lung recipients who had not previously undergone LVRS. DESIGN: Retrospective analysis of the United Network for Organ Sharing transplant database over the period between October 25, 1999, and December 31, 2002. PATIENTS: All COPD patients who were listed and underwent transplantation during the time period were analyzed and categorized according to who did and did not have a history of LVRS. The two groups were compared for demographics, severity of illness, and various measures of outcomes after transplantation, including survival. RESULTS: There were 791 COPD patients who underwent transplantation, of whom 50 had a history of LVRS. The two groups had similar demographics and severity of disease. There was no difference in the need for reoperation, hospital length of stay, or survival between the groups. CONCLUSION: A history of LVRS does not impact on outcomes after lung transplantation and should not influence a patient's candidacy for transplantation. Similarly, a patient's potential need for lung transplantation should not impact on the decision-making process for undergoing LVRS.     

Management of COPD: surgical options.

Dyspnoea on exertion and exercise intolerance are the hallmarks of chronic obstructive pulmonary disease (COPD); the primary causes appear to be respectively, increased airway resistance with reduced maximal ventilatory capacity and peripheral skeletal muscle dysfunction with early onset of anaerobic metabolism. Patients with end-stage COPD usually show little or no benefit from conventional medical treatment. Physical training is capable of ameliorating exercise tolerance, but improvement is usually modest in the advanced disease state. Two surgical options are generally accepted for carefully selected patients with emphysema: resection of large bullae, when identified, and lung transplantation. Transplantation, the only effective cure for advanced COPD, is of limited use primarily because of age, comorbidity, limited availability of organs and cost. A different approach for severe emphysema, lung volume reduction surgery (LVRS), has been increasingly utilized during the past several years. In carefully selected emphysematous patients, LVRS improves lung volumes and mechanics, and reduces exertional dyspnoea. Unfortunately, surgical mortality still remains high and some patients show no measurable improvement after surgery. There is an urgent need for data on long-term effects of LVRS; the results of large, randomized trials will soon be forthcoming. The aim of this brief review is to summarize the available knowledge on the effects of LVRS, the criteria for patient selection, short- versus long-term effects and, finally, to propose future directions in this field.     

Alternatives to lung transplantation: lung volume reduction for COPD

Emphysema is disabling and progressive and hallmarked by decreased exercise tolerance and impaired quality of life. Surgical interventions that reduce lung volume have been the focus of multiple interventions for decades; however, until recently, limited evidence has documented their effectiveness. Lung volume reduction surgery (LVRS) underwent rigorous study in the National Emphysema Treatment Trial (NETT), which demonstrated its short-term and long-term effectiveness, associated morbidity and mortality, and the essential factors that predict LVRS success or failure. This article summarizes the major results of the NETT and briefly reviews newer bronchoscopic lung volume reduction techniques that show promise as alternative treatments for select patients with COPD undergoing consideration for lung transplantation.     

Thoracoscopic appearance of bilateral spontaneous pneumothorax

STUDY OBJECTIVES: We investigated the macroscopic features of bilateral pneumothorax (BLP) and compared them with those of unilateral pneumothorax (ULP). METHODS: Surgical cases of spontaneous pneumothorax (236 cases) were divided into two groups based on unilateral occurrence (206 cases) or bilateral occurrence (30 cases). The patients were divided into three groups by the macroscopic findings of lung disease. The first group consisted of those patients with solitary and small bullae (type I pneumothorax), the second group consisted of those with multiple and large bullae (type II pneumothorax), and the third group consisted of those with an aggregation of diffuse and tiny bullae (type III pneumothorax). RESULTS: In metachronous BLP cases, 18 patients (66.7%) revealed type III pneumothorax in the first occurrence site, and 13 of 18 patients (72.2%) revealed type III pneumothorax in the contralateral site. Type III pneumothoraces were more frequently found in patients with BLP (18 of 27 patients; 66.7%) compared with ULP (73 of 206 patients; 35.4%; p = 0.0086 [chi(2) test]). During a follow-up ranging from 12 to 129 months (median, 69 months), 7 patients (23.3%) in the BLP group developed recurrences. This rate was higher than that of the ULP group (5.3%; p = 0.0009 [chi(2) test]). Contralateral CT scan findings of their first occurrence were retrospectively reviewed. In 3 patients (15.8%) in the BLP group and 17 patients (12.3%) in the ULP group, apical lung bullae and blebs (ruptured or intact) could be detected on the contralateral lung (p = 0.703 [chi(2) test]). CONCLUSIONS: The patients with an aggregation of diffuse and tiny bullae in their thoracoscopic findings had a high risk of contralateral recurrence. Macroscopic lung appearance in the contralateral site in such patients tended to reveal the same type as that in the primary site. CT scanning was not useful for predicting the risk of contralateral occurrence.     

Can CT scanning be used to select patients with unilateral primary spontaneous pneumothorax for bilateral surgery?

STUDY OBJECTIVES: Despite advances in the surgical treatment of spontaneous pneumothorax, the timing of surgical intervention continues to be a subject of controversy. We test the hypothesis that CT scanning can help to predict the probability of the occurrence of primary spontaneous pneumothorax (PSP) by detecting lung bullae. DESIGN: Prospective, longitudinal cohort study. PATIENTS AND METHODS: Between May 1994 to March 1995, 28 consecutive patients (23 men; age range, 18 to 47 years; mean, 29 years) with unilateral PSP who were to undergo video-assisted thoracic surgery (VATS) received preoperative CT of the thorax. CT scans were interpreted by one radiologist blinded to the clinical data for the presence of bullae in both lungs. All patients were followed-up in our outpatient clinic for an average of 59.0 months (range, 54 to 64 months). RESULTS: Eighty-eight percent of the blebs or bullae identified intraoperatively were demonstrated on preoperative CT scans. CT scans also showed the presence of lung blebs or bullae in the contralateral lung in 15 patients (53.6%). During the follow-up period, 4 of these 15 patients (26.7%) with contralateral blebs developed PSP in the untreated lung; none of the patients who did not have contralateral blebs (n = 13) developed PSP (p = 0.04 [chi(2) analysis]). CONCLUSIONS: The detection of lung bullae by CT scanning in the contralateral lung following unilateral PSP is associated with a higher rate of subsequent occurrence of pneumothorax in that lung. Thus, CT scanning can be used to predict the risk of occurrence of this condition, allowing preemptive surgical intervention in selected patients.     

A case of Recklinghausen's disease associated with multiple emphysematous bullae and lung cancer

A 36-year-old man was admitted with cough and sputum. He had cafe-au-lait spots and multiple subcutaneous neurofibromas. Chest X-ray revealed multiple emphysematous bullae in bilateral upper lobes and a tumor in the bulla of the right upper lobe. Needle aspiration biopsy of the tumor showed small cell carcinoma. Although chemotherapy and radiation resulted in decrease in tumor size, it subsequently increased in size and he died 11 months after admission. Including this case there have been 7 reports of Recklinghausen's disease associated with multiple lung cysts and 8 reports with lung cancer in Japan. However, cases with lung cysts and cancer are very rare. The cancer of this case was considered to be associated with emphysematous bulla rather than Recklinghausen's diseases.