单肺移植术治疗终末期肺疾病11例

目的总结单肺移植治疗终末期肺病的早期临床结果和经验。方法2003年1月至2005年9月，为11例终末期肺疾病患者施行了单肺移植术，其中右侧单肺移植7例，左侧单肺移植4例。有2例受者接受同一供者的左、右肺。结果目前有6例单肺移植受者术后生存1年以上，其中3例存活2年以上；3例存活6个月以上。9例存活的受者生活均能自理，活动良好。术后2个月肺功能复查：动脉血氧分压（PaO2）均〉80mmHg，较术前提高37．6％；有8例受者第1秒用力呼气量（FEV1）较术前提高165．2％。2例死亡的受者中，1例因术中大出血死亡；1例淋巴管平滑肌瘤受者术后3个月后死于顽固性乳糜胸。受者术后急性排斥反应平均发生率为1．2次；4例术后并发曲霉菌感染；3例术后出现支气管狭窄；2例术后并发严重肺部感染；1例术后36h出现缺血／再灌注损伤；1例术后7d并发胃底黏膜撕脱继发上消化道大出血；1例术后1年出现慢性排斥反应。结论单肺移植是治疗终末期肺疾病的有效方法。肺移植术后并发症发生率高，应进行有效的预防和治疗。     

单肺移植同期行肺减容术纠正移植肺容积不匹配

目的 探讨单肺移植同期行肺减容术纠正移植肺容积不匹配的有效性和安全性.方法 24例次单肺移植的受者中,男性20例,女性4例,年龄(54.6±12.2)岁(28～75岁).原发病为终末期慢性阻塞性肺疾病(COPD)14例,COPD合并上叶毁损肺1例,COPD合并尘肺1例,终末期肺间质纤维化6例,淋巴管血管平滑肌瘤病1例,肺移植术后闭塞性细支气管炎综合征1例.采用右侧单肺移植16例,左侧单肺移植8例.肺减容采用开胸手术,移植肺减容在移植同期的手术视野下操作,自体肺减容采用移植肺对侧的前外侧小切口进胸.术后将受者分为减容组和对照组.减容组有8例受者,其中移植肺减容5例,自体病肺减容2例,移植肺和自体肺共减容1例.将未接受肺减容术的16例受者作为对照组.观察和比较上述两组受者间肺功能等各项临床指标的差异.结果 原发病为COPD的受者中有2例接受了肺减容术,占14.3%(2/14),明显低于其他原发病者接受肺减容术的比例(60%,6/10),二者间差异有统计学意义(P＜0.05).减容组和对照组分别有50.0%和25%的受者术后胸部X线片显示纵隔位置居中,两组比较,差异有统计学意义(P＜0.05).两组间其余各项临床指标的比较,差异均无统计学意义(P＞0.05).但减容组受者的机械通气时间、胸管引流时间、漏气时间、胸管引流量都有增加的趋势,术后胸穿抽液次数和总量都有下降的趋势.有8例未行术后肺功能复查,其余16例次移植肺功能资料齐全,减容组4例,对照组12例,两组间术后第1秒用力呼气容积(FEV1)改善的差异无统计学意义(P＞0.05).结论 单肺移植同期行移植肺或自体肺减容术对纠正移植肺容积不匹配是安全、有效的方法,可以改善移植肺的通气血流比例.     

肺移植治疗终末期肺疾病的单中心十年经验总结

目的 探讨肺移植治疗终末期肺疾病的效果,并对单中心肺移植的经验进行总结.方法 回顾2003年1月至2012年12月间52例肺移植病例的临床资料,受者年龄为24～76岁,≥65岁者13例;受者原发病主要为肺气肿33例(63.5％)及特发性肺间质纤维化8例(15.4％).术后对所有受者的并发症发生率、死亡情况及存活率进行分析.结果 供肺缺血时间＞6 h者28例(53.8％),其中缺血超过10 h者20例(38.5％).术后出现吻合口狭窄3例(5.8％),住院期间发生细菌感染14例(26.9％),真菌感染13例(25.0％),巨细胞病毒性肺炎1例(1.9％).发生急性排斥反应20例(38.5％),经甲泼尼龙冲击治疗3d后均逆转;发生慢性排斥反应7例(13.5％),其中2例接受再次肺移植后效果良好,3例调整免疫抑制方案后缓解,2例死亡.术后1年内死亡9例(17.3％),术后1、3和5年的总体累积存活率分别为81.4％,54.5％和30.9％.结论 肺移植是治疗终末期肺疾病的有效方法,恰当的病例选择、良好的肺保护、正确的围手术期处理及系统的术后管理是肺移植成功的关键.     

肺隔离药物灌注治疗肺癌临床研究

目的　探讨肺隔离药物灌注(ILP)治疗晚期肺癌的临床疗效。方法　对3 9例不可切除的肺癌、肺功能不能耐受肺切除手术者或多发性转移性肺癌患者进行肺隔离药物灌注化疗,即建立与体循环完全隔离的受累肺/肺叶的体外循环并以阿霉素灌注,灌注起始浓度为6mg/L ,心泵流量(2 0 0±5 0 )ml/min分,维持平均肺动脉压在2 0～2 5mmHg(1mmHg =0 .13 3kPa) ,常温(3 7℃)灌注,持续转流45min。结果　(1)灌注前后生命体征平稳,ILP术后1hMPaP、PVR及PAP升高,PaO2 降低,但循环稳定。(2 )灌注时肺隔离完全,能达到有效的肺内血药浓度[(4 .0 5±1.0 4)mg/L～(4 .19±0 .3 3 )mg/L]。(3 )肿瘤细胞坏死率97.9%。(4 )全组肿瘤治疗总有效率89.7%。(5 )术后1年生存率76.9%。(6)术后并发症主要是肺损伤,但阿霉素起始灌注浓度在6mg/L时肺损伤是可逆的。结论　ILP直接通过肺动脉灌注给药,能大幅度提高局部化疗药物的浓度,提高患者的1年生存率,是治疗晚期肺癌的一种可供选择的有效方法之一     

The effect of malignancy on morbidity rates in thoracotomy patients

Background  A comparison of the morbidity rates between the patients who had undergone thoracotomy for malignant and non-malignant pathologies. Methods  The records of 337 patients who were performed standard posterolateral thoracotomy were retrospectively evaluated. The patients were evaluated in two groups as the patients with malignant pathologies (Group-A) and the patients with non-malignant pathologies (Group-B). Results  Of 337 patients, 130 (38.6%) were in Group A, and 207 were in Group B. In Group A, 110 (84.6%) patients were male, and 20 patients were female. In Group B, 118 (57%) patients were male, and 89 patients were female. The mean age for each group was 53.9 and 38.7 years, respectively. Group A had a higher incidence of postoperative complications (17% (n=22) than Group B (8.7%; n=18) (p=0.035)). In both groups, the morbidity rate was directly correlated with age, the incidence of comorbidity, and the pulmonary resection. However, it was more significant in Group A than the Group B. The most common complication was prolonged air leak in Group A (n=10; 7.7%), while it was wound infection in Group B (n=6, 2.9%). The hospital follow-up (postoperative hospitalization) time for the patients in Group A (17.1±8.0 days) was longer than in Group B (14.3±7.9 days) (p=0.001). Conclusions  The results of this study suggest that in addition to common predisposing factors in this group of patients such as advanced age, comorbidity, and pulmonary resection that increase postoperative complication risk, the characteristics of malignant diseases may be predictive factors for increased morbidity.     

肺癌胸腔冲洗液细胞学研究

目的　探讨无胸水肺癌病人胸腔游离癌细胞的存在及相关病理因素 ,及肺癌胸腔冲洗液细胞学 (PLC)研究的临床意义。方法　 1998 7～ 1999 2治疗无胸水、无远处转移的原发性肺癌 5 8例。每个病例均收集开胸后 (A液 )、关胸前 (B液 )胸腔冲洗液 ;其中 47例收集JSS法所获液体 (C液 )。所得液体经处理后涂片病理检验。数据行 χ2 统计。结果　A液阳性 6例 (10 34 % ) ,同肿瘤N分期、TNM分期有关。B液阳性 2例 (3 45 % )。C液阳性 8例 (17 12 % ) ,阳性病例均为P1或P2 期。结论　无胸水肺癌病人胸膜腔中可存在癌细胞 ,应重视。A液检测可列为常规检查。对于A液阳性或肿瘤累及脏层胸膜病例 ,应行胸腔内局部处理。     

The role of oxygen tension in the regulation of embryonic lung development

Background/Purpose

Oxygen tension is an important physiologic mediator of embryonic and fetal development. In vitro studies have demonstrated that the proper embryonic development is dependent upon low oxygen tension and even short exposure to normoxic environments (21%) can be detrimental to embryonic development. We hypothesized that low oxygen tension promotes lung growth in embryonic organ culture and therefore designed this study to investigate embryonic lung growth in normoxic and hypoxic conditions using simple closed chamber.

Methods

Fetal rat lungs were harvested on day 13.5 and placed in organ culture containing serum-free Dulbecco's modified Eagle's medium with antibiotics. The lung cultures were divided into normoxic group, with a 21% oxygen concentration (n = 15), and hypoxic group (n = 15). Hypoxic condition (6% oxygen) was achieved using Oxoid Campygen in a closed chamber. The lungs were placed in 5% carbon dioxide, 37°C incubator for 48 hours. Media were not changed during the incubation period. The morphometric analysis was measured at 0 hour and at 48 hours by counting total terminal buds and entire epithelial contour using Image J software. The fold increase in branching was calculated as the ratio of buds present at 48 hours minus the buds present at 0 hour divided by the number of buds at 0 hour. The increase in entire epithelial contour over 48 hours was calculated in exactly the same way as described above.

Results

There was no significant difference in the increase in total terminal buds count in the hypoxic group (2.06 ± 0.19) compared with the normoxic group (2.59 ± 0.21), and no significant difference in the increase in entire epithelial contour in the hypoxic group (1.45 ± 0.11) compared with the normoxic group (1.63 ± 0.11).

Conclusions

Although hypoxia has been reported to be an important regulator of murine vascular development, our data show that the embryonic lung growth in whole lung organ culture under hypoxic condition is not significantly different from that in normoxic condition.     

肺部微小结节的微创伤诊治

目的 确定肺部微小病灶的微创诊治方法。方法 对ＣＴ和Ｘ线胸片发现肺部病灶在１．３ｃｍ以下的２６例病人,利用胸部微创伤外科技术将之楔形切出,肿物完整送作快速连续多层病理冲冻切片以确诊,恶性者作进一步肺叶切除加淋巴清扫。淋巴结各组病理切片均未发现转移。术后１４例未作化疗和疗效,５例化疗１～２疗程。结果 １９例最后诊断为恶性,占７３％,全部为Ⅰ期;６例为良性,占２７％。术后病理诊断与术前ＣＴ定性诊断相符     

中国肺移植面临的困难及对策

肺移植是治疗多种肺部疾病唯一有效的方法,术后很大程度上能改善患者的生活质量,生存期也得到明显延长。但肺移植与肝肾移植相比,全国除几个大中心以外,大多数中心移植例数较少,手术技术尚不成熟,严重制约了肺移植的发展。经过多年的努力,中国肺移植已经开始起步,且发展迅速,但国内肺移植面临多重困难,亟待制定对策处理。     

Evaluation of surgical resection of pulmonary metastasis of trophoblastic tumor

Objective: To evaluate the role of the lung lobectomy in gestational trophoblastic tumor patients with lung metastases. Methods: A total of 45 cases of trophoblastic tumor with pulmonary metastases treated by lung lobectomy from 1985~2002 at PUMC hospital were retrospectively analyzed. Seven cases were diagnosed as invasive mole and thirty-eight as choriocarcinoma. Results: Lung lobectomy was performed in all of these patients after several courses of chemotherapy. Seven cases of invasive mole reached complete remission. Eleven cases of choriocarcinoma with stage Ⅲa had received average 13 courses of chemotherapy, 10 of them reached complete remission. Seventeen cases of choriocarcinoma with stage Ⅲb had received average 14.3 courses of chemotherapy, 11 of them reached complete remission. Ten cases of choriocarcinoma with stage Ⅳ had received average 15 courses of chemotherapy, six of them reached complete remission. In the 45 patients, histologic examination disclosed haemorrhagic necrotic tissue in 27 patients, 17 of them reached complete remission(63%). Histologic examination also revealed fibrosis around the focus in 16 patients, 14 of them reached complete remission(88%). Tuberculosis was found in 2 patients.Conclusions: Although the development of effective chemotherapy has resulted in improved survival of patients with gestational trophoblastic tumor, lung lobectomy remains an important adjunct treatment in a selected subset of patients. Pathological examinations can help to estimate the prognosis.     

机械通气致肺水肿损伤机制的研究进展

背景 机械通气致肺损伤(ventilator induced lung injury,VILI)的机制研究众多,传统认为生物学损伤为主要机制,机械性损伤为触发因素.VILI的致死因素之一就是肺水肿的发生发展或以全身炎症反应综合征及多器官功能衰竭而终结. 目的 探讨肺水肿发生的机械损伤机制及其干预措施. 内容 现就生物学损伤及机械性损伤致VILI肺水肿的发生机制的最新研究作一综述,以期预防肺水肿的发生,为临床麻醉及重症监护过程中VILI致肺水肿的发生奠定理论基础. 趋向 机械性损伤触发肺水肿的发生,做为机械通气诱发肺损伤的特殊感受器,研究综述了机械力直接损伤、瞬时感受电位(transient receptor potential,TRP)超家族介导机械刺激诱发神经源性炎症反应(neurogenic inflammation,NI)在肺水肿的发生中所起的闸门作用,阻断早期肺损伤的诱发因素对于围术期肺保护具有重要意义.     

非体外循环下序贯式双侧单肺移植治疗终末期肺气肿

目的 探讨非体外循环下序贯式双侧单肺移植治疗终末期肺气肿的可行性及手术技术。方法 2004年12月28日为1例肺功能重度低下且呼吸机依赖的终末期肺气肿病人进行了非体外循环下序贯式双侧单肺移植。结果 术后106h脱机，术后第15d发生1次急性排斥反应，经大剂量甲基强的松龙冲击治疗后症状消退。术后28d胸部CT显示两肺扩张、血液灌注良好，左侧胸腔少量包裹性积液。病人术后肺功能明显改善，第41d出院。结论 非体外循环下序贯式双侧单肺移植治疗终末期肺气肿是可行的，该方法可和单肺移植一样在我国得以普及。     

CT引导一次性半自动活检针经皮肺结节穿刺活检46例分析

目的探讨CT引导一次性半自动活检针经皮肺穿刺活检对诊断肺部结节价值。方法收集46例常规病检有困难的肺结节病例，应用一次性半自动活检针，在CT引导下做经皮穿刺活检，分析其诊断的准确性，安全性。结果46例病人，获得明确病理诊断40例(87％)，包括恶性肿瘤24例，结核10例，炎性病变4例，其它良性病变2例。有症状并发症发生率13％(6／46)，包括1例严重气胸和5例少量咯血。结论CT引导一次性半自动活检针经皮肺穿刺活检因取材确切、定位准确，对肺部结节的病理诊断具有重要的实用价值。     

Explanted malignancies after lung transplantation: the University of Michigan experience

The management of patients with an explanted malignancy after lung transplantation is not well understood. We reviewed our institutional experience and outcomes at a single academic medical centre between December 1997 and April 2021 for patients with malignancies of all histologic types identified on explant pathology. Primary lung cancers were reclassified using the 8th Edition TNM staging and the 2021 World Health Organization histologic classification of lung cancers. Of the 733 patients undergoing lung transplantation, 15 (2.05%) were found to have malignancy on the explanted lungs, including 6 (0.82%) primary lung cancers. Four patients were found to have early-stage lung cancers, while 2 patients had advanced-stage IV disease. Survival ranged from 0 to 109 months for the entire cohort with median 23.2 [49.9] months in those with primary lung cancers. There were 2 recurrences following explanted stage I (15 months) and stage IV (53 months) diseases. Other explant pathologies included carcinoid tumourlets in 6 patients, lymphoma in 2 and metastatic leiomyosarcoma in 1. In conclusion, explanted lung malignancies are an infrequent but significant finding on explant pathology. Further data are needed to better characterize and stratify this patient cohort.     

人参皂甙Rb1对肺缺血再灌注损伤的保护作用

目的探讨人参皂甙Ｒｂ１对肺缺血再灌注损伤的保护作用。方法按肺移植供肺获取和保存的方法，对３５只家兔的肺分别获取，保存；然后采用体外装置，建立体外肺缺血再灌注损伤模型。在即将再灌流前，将不同剂量的Ｒｂ１加入到５０ｍｌ再灌流血液中。结果Ｒｂ１可使肺组织中超氧化物歧化酶（ＳＯＤ）含量升高，丙二醛（ＭＤＡ）含量降低；使肺动脉压（ＰＡＰ）降低，湿肺干肺比重降低和改善肺组织病理变化。Ｒｂ１在再灌流血液中浓度为８０ｍｇ／Ｌ时，已有明显效果。结论Ｒｂ１对肺缺血再灌注损伤具有明显的保护作用。     

Transtracheal drainage of lung abscesses in children

Experience with three patients with primary ling abscesses indicates that transtracheal catheter drainage of lung abscesses is a safe and beneficial procedure in childhood. The ability to drain abscesses not easily reached percutaneously will promote emptying and collapse of the abscess and provide bacteriological information which will enable the physician to select the correct antibiotics.