外科手术在非结核分枝杆菌肺病治疗中的作用探讨

目的 探讨外科手术治疗非结核分枝杆菌(NTM)肺病患者中的作用与疗效。方法 收集2009年1月至2017年12月广州市胸科医院收治的24例NTM肺病患者作为研究对象。其中,男9例,女15例;年龄范围20~73岁,年龄中位数(四分位数)为44.50(30.75,55.00)岁;NTM肺病病程0~6年,病程中位数(四分位数)为1.0(0.5,3.8)年。回顾性分析研究对象病历资料,包括基础疾病、发病特点、临床症状、分枝杆菌培养和菌种鉴定结果、胸部CT扫描结果、手术情况及治疗结果等。 结果 24例患者中鸟-胞内分枝杆菌(MAC)肺病患者11例(45.8%),龟-脓肿分枝杆菌肺病患者13例(54.2%)。患者术前接受了3~18个月的化疗,其中,痰菌阴转1例(4.2%),反复痰菌阳性未阴转者23例(95.8%);肺部病灶反复进展与好转交替/病灶恶化13例(54.2%),空洞增大或未愈且多伴有复合病变17例(70.8%),23例(95.8%)并存以右中叶、左上叶舌段囊、柱状支气管扩张;病灶分布侵犯肺叶1~6个不等,侵犯肺叶中位数(四分位数)为4.0(3.3,5.0)个。所有患者术中和术后均无死亡,其中,全肺切除1例(4.2%)、单肺叶切除术12例(50.0%)、复合肺叶切除11例(45.8%)。术后连续随访1年,19例患者治愈和治疗成功(79.2%);5例治疗失败(20.8%),该5例患者病变侵犯范围在5个或6个肺叶。手术并发症发生率为33.3%(8/24),包括手术残端肉芽组织增生、干酪样坏死2例;胸腔出血、感染5例、伤口愈合不良1例。20例切除病灶患者的分枝杆菌培养阳性14例,阴性6例,术后痰菌阴转并治愈分别为11例和6例,差异无统计学意义(χ ²=0.30,P=0.585)。MAC肺病和龟-脓肿分枝杆菌肺病患者手术治愈分别为9例和10例。结论 手术联合化疗治疗NTM肺病能够提高患者痰菌阴转率及治疗成功率。

The role of surgery in the treatment of non-tuberculous mycobacterium pulmonary disease

Objective To investigate the role and efficacy of surgical treatment in patients with non-tuberculous mycobacterium (NTM) pulmonary disease. Methods Totally, 24 patients with NTM lung disease admitted to Guangzhou Chest Hospital from January 2009 to December 2017 were collected as subjects, including 9 males and 15 females, with the median age of 44.50 (30.75,55.00) years. The course of NTM pulmonary disease ranged from 0 to 6 years, with a median course of 1.0 (0.5,3.8) years. The medical records of the study subjects, including basic diseases, onset characteristics, clinical symptoms, mycobacterial culture and strain identification results, chest CT scan results, surgical conditions and treatment results, were retrospectively analyzed. Results Among the 24 patients, there were 11 (45.8%) cases with Mycobacterium avian-intracellular (MAC) pulmonary disease and 13 (54.2%) cases with Mycobacterium turtle-abscess pulmonary disease. The patients received preoperative chemotherapy for 3 to 18 months, among which, 1 patient (4.2%) experienced sputum negative conversion, and 23 patients (95.8%) experienced repeated positive sputum negative conversion. There were 13 cases (54.2%) of pulmonary lesions with recurrent progression and improvement or deterioration, 17 cases (70.8%) of pulmonary lesions with enlarged or unhealed cavities and accompanied by complex lesions, and 23 cases (95.8%) with the coexistence of cystic bronchiectasis in the tongue segment of the right middle lobe and the left upper lobe. The distribution of lesions that invaded the pulmonary lobe ranged from 1 to 6, with a median of 4.0 (3.3, 5.0) lesions. None of the patients died intraoperatively or postoperatively, including 1 case of total pneumonectomy (4.2%), 12 cases of single lobectomy (50.0%) and 11 cases of combined lobectomy (45.8%). Postoperative follow-up was conducted for 1 year, and 19 patients (79.2%) were cured and treated successfully, while treatment failed in 5 patients (20.8%) with lesion involvement in 5 or 6 lobes. The incidence of surgical complications was 33.3% (8/24), including 2 cases with residual granulation tissue hyperplasia and caseous necrosis, 5 cases with pleural hemorrhage and infection, and 1 case with poor wound healing. Among the 20 patients with excised lesions, 14 were positive for Mycobacterium culture and 6 were negative, while 11 cases experienced sputum negative conversion and 6 cases were cured after operation, with no significant difference (χ ²=0.30, P=0.585). MAC pulmonary disease and Mycobacterium turtle-abscess pulmonary disease were cured by surgery in 9 and 10 patients, respectively. Conclusion Surgery combined with chemotherapy can improve the rate of sputum negative conversion and treatment success rate for NTM pulmonary disease.