单孔胸腔镜胸膜纤维板剥脱术在耐药结核性脓胸治疗中的应用

目的探讨单孔胸腔镜纤维板剥脱术治疗耐药结核性脓胸的安全性和疗效。方法回顾性分析2018年1月至2020年12月在武汉市肺科医院外科行纤维板剥脱术治疗的122例结核性脓胸患者的资料, 男性100例, 女性22例, 年龄[M(IQR)]29.5(28.0)岁(范围:13～70岁)。根据手术入路和是否耐药, 将患者分为三组, 单孔耐药组(22例, 行单孔胸腔镜纤维板剥脱术)、开胸耐药组(28例, 行开胸纤维板剥脱术)、单孔敏感组(72例, 行单孔胸腔镜纤维板剥脱术)。三组间手术和预后指标比较采用Kruskal-Wallis 检验、χ2检验两两比较采用Mann-WhitneyU检验或Bonferroni法。结果单孔耐药组、开胸耐药组和单孔敏感组的术中出血量[200(475)ml比300(200)ml比225(300)ml, H=2.74, P=0.254]和治疗效果(χ2=4.76, P=0.575)无明显差异。单孔耐药组比开胸耐药组有更长的手术时间和术后肺复张时间[302.5(187.5)min比200.0(60.0)min, U=171.0, P=0.007;4.5(3.0)个月比3.0(...     

胸膜纤维板剥脱术治疗结核性脓胸114例

上海市肺科医院胸外科1972年12月-2006年11月采用胸膜纤维板剥脱术治疗结核性脓胸114例。现总结其经验。     

电视胸腔镜下胸膜纤维板剥脱术治疗脓胸及包裹性胸腔积液

电视胸腔镜下胸膜纤维板剥脱术治疗脓胸及包裹性胸腔积液朱成楚叶加洪叶中瑞郭剑波作者单位：３１７０００浙江省台州医院胸外科我们自１９９５年７月至１９９７年７月，应用胸腔镜作脓胸、包裹性胸腔积液清除术４８例，其中３７例作了胸膜纤维板剥脱术，现报告如下：临床...     

单孔胸腔镜全纤维板剥脱术治疗Ⅲ期结核性脓胸158例临床分析

目的探讨利用单孔胸腔镜技术对Ⅲ期结核性脓胸患者进行全纤维板剥脱术的可行性和技术要点。方法回顾性分析2017年8月至2020年7月158例在上海市肺科医院胸外科接受单孔胸腔镜全纤维板剥脱治疗的Ⅲ期结核性脓胸患者的资料。男性127例, 女性31例, 年龄[M(IQR)]为32(28)岁(范围:14～78岁)。所有患者于全身麻醉下节段切除特定5 cm长肋骨, 借助切口保护套暴露切口, 获得操作空间, 进而借助特殊器械进行全纤维板剥脱术。在无漏气、引流液清亮<50 ml/d后复查CT, 肺较前复张后拔除胸腔引流管, 继续抗结核治疗, 术后3～6个月进行最终手术效果评估, 后续门诊及电话随访至患者停药。结果早期1例患者因纤维板过厚无法有效牵拉进而中转开胸, 其他患者均按原计划完成手术。手术时间2.75(2.50)h(范围:1.5～7.0 h), 术中出血量100(500)ml(范围:50～2 000 ml), 术后住院时间5.00(2.25)d(范围:2～15 d), 术后胸腔引流时间21.00(22.50)d(范围:3～77 d)。术后1例患者因胸腔引流量多进行开胸止血, 1例发生切口感...     

胸膜纤维板剥脱术治疗小儿慢性脓胸62例

本文报道胸膜纤维板剥脱术治疗小儿慢性脓胸６２例，随访４０例，全部治愈，讨论了手术适应征，认为术前纠正患儿的消耗状态有助于提高手术的安全性。着重讨论了手术方法，强调应尽可能完整切除胸膜纤维板。     

分析胸膜纤维板剥脱术治疗慢性结核性脓胸的效果及安全性

目的分析胸膜纤维板剥脱术治疗慢性结核性脓胸的效果及安全性。方法选取2017-07-2019-07间濮阳市第五人民医院收治的62例慢性结核性脓胸患者,均行胸膜纤维板剥脱术治疗。回顾性分析近期治疗效果。结果本组术中出血量为(650.24±45.16)mL,术后病理学检查结果均为结核性病变。术后脓腔消失,未发生感染、肺不张、出血、肺漏气等并发症,均顺利出院。随访3个月,其间53例(85.48%)病情完全改善,7例(11.29%)病情好转,2例(3.23%)脓胸复发。结论胸膜纤维板剥脱术是治疗慢性结核性脓胸有效和安全的术式。     

结核性脓胸的外科治疗

本院1982～2000年收治结核性脓胸508例，采用不同的手术方式进行外科手术治疗，效果满意，现报告如下。     

慢性结核性脓胸461例外科治疗回顾性分析

目的 探讨慢性结核性脓胸的外科治疗经验.方法 回顾性分析2006年1月至2011年12月在山东省胸科医院胸外科接受手术治疗的461例慢性结核性脓胸患者的临床资料.其中男性317例,女性144例;年龄6～79岁,平均年龄32岁.术前病程3个月至50年,其中1年以内347例,1～2年61例,2年以上53例.根据患者情况采用不同手术方法.结果 全组患者无围手术期死亡,461例中一次手术治愈445例,分期手术治愈6例.1例脓胸合并支气管胸膜瘘患者,行胸膜剥脱术+肺叶切除术后再发支气管胸膜瘘,引流半年后行瘘修补+肌瓣填塞术+局限性胸廓成形术后治愈.3例切口愈合不良,经过换药治愈.5例出院后3个月内出现同侧切口附近胸壁脓肿,经过病灶清除附加局限性胸廓成形术治愈.1例胸膜全肺切除术患者于手术后1年因支气管残端瘘致余肺播散,死于呼吸功能衰竭.结论 在慢性结核性脓胸的治疗当中,手术治疗仍然有不可替代的作用,根据患者病情及身体状况选择恰当的手术方式能够取得良好的治疗效果.     

改进胸膜纤维板剥脱术治疗慢性脓胸

应用改进的胸膜纤维板剥脱术治疗慢性脓胸４２１例（结核性脓胸４０８例），治愈率９５．４％。改进的胸膜纤维板剥脱术在治疗脓胸的同时清除了肺内的病灶或空洞、修补了支气管胸膜瘘，提高了痰菌转阴率，扩大了手术适应证。文中介绍了手术操作要点；清除肺内病灶或空洞及修补支气管胸膜瘘的方法；预防和消灭残腔的有效措施。还强调了手术中认真止血，术后保持呼吸道和胸腔引流系统通畅的重要性，并应适当延长带管时间。     

结核性脓胸伴支气管胸膜瘘的外科治疗

目的：总结１９６５￣１９８６年间,１２６例结核性脓胸支气管胸膜瘘病人的外科治疗经验。方法：全组病人分别接受闭式引流、Ｈｅｌｌｅｒ胸改加瘘修补术、胸膜外全肺切除或余切除术、带蒂网膜移植术等方法治疗。结果：１１２例获得临床治占８８．９％;好转８例;死亡例。结论：外科手术是结核性脓胸支气管胸膜瘘唯一有效的治疗方式。闭式引流、Ｈｅｌｌｅｒ胸改术仍具有不可替代的作用。     

经椎旁肌间隙入路在胸腰椎骨折治疗中的应用

 目的 探讨经椎旁肌间隙入路治疗胸腰椎骨折的手术方法及其与传统手术方法的比较。方法 2006年 10月至 2008年 10月, 52例无神经损伤表现的胸腰椎骨折患者被纳入研究。±据 Denis骨折分型, 压缩型骨折 17例, 爆裂型骨折 35例, 其中男 37例, 女 15例;年龄 18耀59岁, 平均 46.5岁。 T4骨折 1例, T7骨折 2例, T8骨折 1例, T10骨折 3例, T11骨折 5例, T12骨折 14例, L1骨折 16例, L2骨折 9例, L3骨折 1例。影像学检查示: 椎管内占位约1/3, 突入椎管骨块均匀完整, 无碎裂及翻转。患者±次纳入研究, 分为两组, 其中 20例患者采用传统后正中入路, 其他 32例患者采用经椎旁肌间隙入路, 均行后路椎弓根螺钉固定。结果两组患者在性别、年龄、损伤节段、受伤至手术时间及随访时间方面比较, 差异均无统计学意义。经肌间隙入路较传统后正中入路在手术时间、术中出血量、引流放置时间、术后引流量、术后下地时间, 疼痛视觉模拟评分及 Oswestry功能障碍指数等方面具有显著优势, 两组间比较各项指标差异均有统计学意义。至 2009年 10月, 所有患者均获得随访, 平均时间 21.5个月(12耀36个月), 所有患者伤椎椎体高度均无丢失, 内固定无松动、断裂。结论与传统手术方法相比, 经椎旁肌间隙入路治疗胸腰椎骨折可完整保留脊柱后方复合体结构, 具有创伤小、出血少和恢复快等优点, 是一种安全实用的手术方法, 疗效满意。     

A nomogram to predict residual cavity formation after thoracoscopic decortication in chronic tuberculous empyema

Open in a separate window OBJECTIVESThe goal of this study was to develop and validate a nomogram for predicting residual cavity formation after video-assisted thoracoscopic decortication in patients with chronic tuberculous empyema (CTE).METHODSWe retrospectively analysed patients who were diagnosed and treated for CTE at our hospital from January 2017 to December 2020. We used univariable and binary logistic regression analyses to identify independent risk factors. A predictive nomogram was developed and validated for predicting the risk of residual cavity formation after video-assisted thoracoscopic decortication in patients with CTE. The receiver operating characteristic (ROC) was used to evaluate the nomogram.RESULTSData from 103 patients were analysed. The contact area between the lung and empyema (P = 0.001, odds ratio [OR] 1.017, 95% confidence interval [CI] 1.007–1.028), calcification (P = 0.004, OR 0.12, 95% CI 0.029–0.501) and thickness of the pleura (P = 0.02, OR 1.315, 95% CI 1.045–1.654) were risk factors for residual cavity formation after video-assisted thoracoscopic decortication. A 50% residual cavity formation rate was used as the cut-off to validate the nomogram model. The area under the ROC curve for the nomogram was 0.891 (95% CI, 0.82–0.963). The sensitivity and specificity of the nomogram were 86.67% and 82.19%, respectively. The calibration curve indicated good consistency between the predicted and actual risks.CONCLUSIONSThe preliminary nomogram could contribute to preventing postoperative residual cavity formation and making appropriate surgical decisions.     

经椎旁肌入路治疗胸腰段椎体骨折

目的 探讨经椎旁肌入路内固定治疗胸腰段椎体骨折的方法和临床疗效.方法 2005年6月至2006年8月,共62例无神经损伤表现的胸腰段椎体骨折患者接受手术治疗.男48例,女14例;平均年龄45.2岁(21～58岁).T12骨折21例,L1骨折24例,L2骨折17例;依据Denis骨折分型,压缩型骨折15例,余下的47例为爆裂型骨折,并且椎管占位均小于1/3,所有骨折后柱均完整.随机选取其中34例患者接受经椎旁肌入路的手术治疗,其余28例患者则采用传统的后正中入路治疗.经椎旁肌人路沿最长肌与多裂肌间隙进入,保留椎旁肌肉的完整性,既可行椎弓根螺钉的内固定操作,也可行横突尖或关节突的植骨融合.术后一般无须放置引流管,术后早期患者即可佩带支具下床行走.结果 通过围手术期疗效观察,发现经椎旁肌入路手术与传统后正中手术相比较在手术时间上差异不大,但在出血量、术后引流量、卧床时间以及术后疼痛视觉模拟评分(visual analogue scale,VAS)等方面都具有显著的优势,差异有统计学意义(P＜0.05).截至2007年8月,共56例患者获得随访,平均随访时间18.6个月(12～26个月),所有随访患者的骨折椎体均获得愈合,无一例发生骨折复位丢失及内固定物的松动、断裂,两组间远期疗效无差异.结论 经椎旁肌入路内固定治疗胸腰段椎体骨折具有创伤小、出血少、术者操作简单、术后患者恢复快等优点.     

Surgical treatment of thoracolumbar fracture through an approach via the paravertebral muscle

Objective: To investigate the methods for, and clinical outcome of, the operative treatment of thoracolumbar fractures through an approach via the paravertebral muscle (PVM). Methods: From June 2005 to August 2006, 62 patients, comprising 48 men and 14 women with an average age of 45.2 years (range, 21–58) with thoracolumbar fractures without neurological involvement underwent surgical treatment. Twenty‐one fractures were located at T12, 24 at L1 and 17 at L2. The study comprised 15 compression and 47 burst fractures with an intact posterior column. Thirty‐four cases were selected randomly to undergo surgery through the above approach, while the other 28 cases underwent the traditional procedure. After making a posterior midline incision, which not only facilitates insertion of pedicle screws and fusion of the graft bone at facet joints, but spares the attachment of PVM, the interval between the longissimus and multifidus muscles was undermined. Drainage was not routinely needed and the patients became ambulant with a brace earlier post‐operatively. Results: The new approach had statistically significant advantages (P < 0.005) over the traditional one in regard to blood loss, drainage, duration of recumbency and visual analogue scale (VAS), although the time required was almost the same for the two procedures. Till August 2007, 56 patients were successfully followed up for 12 to 26 months (mean, 18.6) and bone fusion was identified in all cases. Neither reduction loss nor loosening or breakage of the fixation occurred. Conclusion: The technique of operating through an approach between the PVM is recommended for thoracolumbar fractures because it is much less invasive, can reduce blood loss and accelerates rehabilitation.     

微创截骨治疗(足母)外翻的远期疗效分析

目的 评价微创截骨治疗(足母)外翻的远期疗效.方法 对1996年2月至1999年5月在我院行微创截骨治疗的(足母)外翻患者进行回顾性分析,共79例(150足)获得5年以上随访,男6例(10足),女73例(140足);年龄13～75岁,平均47岁.术后随访5.3～13.2年,平均7.5年.观察手术前、后(足母)外翻角(hallux valgus angles,HVA),第一、二跖骨间角(intermetatarsal angles,IMA),胫侧籽骨位置(tibial sesamoid bone position,TSP),(足母)趾-跖趾-趾间关节美国足与踝关节协会(American orthopedic foot and ankle society,AOFAS)评分,第一跖趾关节活动度和第二、三跖骨头下胼胝体(肼胝痛)等指标.根据温建民等的临床疗效评价标准(2001年)对临床疗效进行评价.结果 临床疗效评价优56足,占37.3%;良88足,占58.7%;差6足,占4.0%;优良率为96.0%(144/150).术后AOFAS评分为60～100分,平均(84.20±4.32)分.HVA较术前矫正20.97°;IMA较术前矫正4.95°;TSP较术前矫正1.22;第一跖趾关节活动度减少0.67°.术前合并有跖骨头下疼痛97足,占64.7%.术后疼痛消失35足(23.3%),疼痛改善54足(36.0%),疼痛无改善(或加重)8足(5.3%).结论 微创截骨治疗(足母)外翻方法简单、并发症少、远期疗效肯定,是治疗(足母)外翻的一种较好的、疗效可靠的手术方法.     

Chronic postpneumonic pleural empyema: comparative merits of thoracoscopic versus open decortication

Objective: We seek to evaluate the comparative merits of thoracoscopic versus open decortication in the surgical management of patients with chronic postpneumonic pleural empyema. Methods: From January 1996 to December 2006, 308 patients (180 males, 128 females, mean age: 56.3 years, range: 17–82 years) with chronic postpneumonic pleural empyema underwent decortication after failure of conservative treatment. Results: Decortication was performed by open thoracotomy in 123 (39.9%) patients (OT) and by videothoracoscopy (VT) in 185 (60.1%). Mortality was 1.29% (4/308). Morbidity was 21.1% (65/308). At 6 months follow-up, three VT patients showed recurrent empyema and underwent re-do surgery by video-assisted-thoracoscopy (VATS) (one patient) or by thoracotomy (two patients). The videothoracoscopic approach showed statistically significant better results in terms of in-hospital postoperative (day 1 and day 7), pain (p < 0.0001), postoperative air leak (p = 0.004), operative time (p < 0.0001), hospital stay (p = 0.020) and time to return to work (p < 0.0001). The analysis of postoperative pain at 6 months follow-up showed no significant differences among the different groups. Conclusions: In the light of our experience, videothoracoscopic decortication appears to be the surgical treatment of choice for chronic postpneumonic pleural empyema even if a multicentric-randomised trial should be performed before videothoracoscopic decortication becomes the gold standard for the treatment of pleural empyema.     

Ideal timing of thoracoscopic decortication and drainage for empyema in children

Background: Thoracoscopy may be required for resistant empyema in children. This study aimed to determine the advantages of thoracoscopy performed soon after diagnosis and its ideal timing. Methods: Between 1996 and 2002, 21 children who had undergone thoracoscopy as an initial procedure or after failure of medical treatment were retrospectively reviewed. The study compared outcome of early thoracoscopy (fewer than 4 days after diagnosis) and that of later surgery. The 4-day limit was chosen for physiopathologic reasons (organization of pleuresia in 72 h). Results: In the early thoracoscopy group, the findings showed shorter operative time (p = 0.03) and postoperative hospital stay (p < 0.05), fewer technical difficulties, fewer complications, and no recourse to other surgical procedures. Conclusions: Early thoracoscopy is greatly beneficial for children with empyema by shortening disease progression. An initial short trial of medical treatment for nonorganising empyema may be attempted on the condition that thoracoscopy not be delayed more than 4 days.     

经皮内镜下病灶清除灌洗引流术治疗单节段化脓性脊柱炎的早期效果

目的 :评价经皮内镜下病灶清除灌洗引流术治疗化脓性脊柱炎的临床应用价值。方法 :回顾分析2014年6月至2015年12月收治的18例单节段化脓性脊柱炎患者的资料,其中男11例,女7例;年龄46~75(58.89±9.46)岁。术后根据诊断及药敏结果给予抗感染治疗。术后随访时间12~24(15.50±3.45)个月,监测术前、术后相关时间节点的红细胞沉降率及C-反应蛋白评估疾病控制情况。采用疼痛视觉模拟评分(visual analogue scale,VAS)评价患者疼痛症状的缓解情况。采用神经功能ASIA分级评价患者神经功能恢复情况。采用Kirkaldy-Willis功能评分标准评价患者术后临床疗效。通过影像学资料评价患者脊柱稳定性及感染复发情况。结果:所有病例顺利完成手术,术后均无血肿、神经损伤、感染、脑脊液漏、置管部位窦道形成、混合感染等并发症发生。术后细菌学报告培养阳性12例,无细菌生长6例,13例病理明确其诊断。术后2周、3个月、末次随访的ESR、CRP及VAS评分与术前比较,均明显改善(P0.05)。术后1周~3个月患者临床症状明显改善。按Kirkaldy-Willis功能评分,优14例,良3例,可1例。末次随访时神经功能ASIA均恢复正常,Cobb角丢失度为(1.11±1.18)°,与术前比较差异无统计学意义(P0.05)。随访期间均未出现感染复发。结论:经皮内镜下病灶清除灌洗引流术是治疗为化脓性脊柱炎微创、有效、安全的手术方式,该技术为化脓性脊柱炎的治疗提供了一种新的选择方法。     

Outcome of minimally invasive surgery in the management of tuberculous spondylitis

Introduction:

With the advancement of instrumentation and minimally access techniques in the field of spine surgery, good surgical decompression and instrumentation can be done for tuberculous spondylitis with known advantage of MIS (minimally invasive surgery). The aim of this study was to assess the outcome of the minimally invasive techniques in the surgical treatment of patients with tuberculous spondylodiscitis.

Materials and Methods:

23 patients (Group A) with a mean age 38.2 years with single-level spondylodiscitis between T4-T11 treated with video-assisted thoracoscopic surgery (VATS) involving anterior debridement and fusion and 15 patients (Group B) with a mean age of 32.5 years who underwent minimally invasive posterior pedicle screw instrumentation and mini open posterolateral debridement and fusion were included in study. The study was conducted from Mar 2003 to Dec 2009 duration. The indication of surgery was progressive neurological deficit and/or instability. The patients were evaluated for blood loss, duration of surgery, VAS scores, improvement in kyphosis, and fusion status. Improvement in neurology was documented and functional outcome was judged by oswestry disability index (ODI).

Results:

The mean blood loss in Group A (VATS category) was 780 ml (330-1180 ml) and the operative time averaged was 228 min (102-330 min). The average preoperative kyphosis in Group A was 38° which was corrected to 30°. Twenty-two patients who underwent VATS had good fusion (Grade I and Grade II) with failure of fusion in one. Complications occurred in seven patients who underwent VATS. The mean blood loss was 625 ml (350-800 ml) with an average duration of surgery of 255 min (180-345 min) in the percutaneous posterior instrumentation group (Group B). The average preoperative segmental (kyphosis) Cobb''s angle of three patients with thoracic TB in Group B was 41.25° (28-48°), improved to 14.5°(11°- 21°) in the immediate postoperative period (71.8% correction). The average preoperative segmental kyphosis in another 12 patients in Group B with lumbar tuberculosis of 20.25° improved to –12.08° of lordosis with 32.33° average correction of deformity. Good fusion (Grade I and Grade II) was achieved in 14 patients and Grade III fusion in 1 patient in Group B. One patient suffered with pseudoarthrosis/doubtful fusion with screw loosening in the percutaneous group.

Conclusion:

Good fusion rate with encouraging functional results can be obtained in caries spine with minimally invasive techniques with all the major advantages of a minimally invasive procedures including reduction in approach-related morbidity.