自发性气胸肺大疱分型及胸腔镜手术方法探讨

目的 探讨肺大疱分型及胸腔镜手术方法.方法 采用胸腔镜微创手术治疗自发性气胸1027例,其中左侧409例(39.8％),右侧606例(59.0％),双侧12例(1.2％).原发型肺大疱972例(94.6％),继发型肺大疱55例(5.4％).根据肺大疱形态和分布特点,将原发型肺大疱分为6型:Ⅰ型:单发型;Ⅱ型:成簇型；Ⅲ型:多发型；Ⅳ型:被膜下型；Ⅴ型:弥漫型；Ⅵ型:隐匿型.根据肺大疱不同分型选择经完全胸腔镜(VATS)和胸腔镜辅助小切口(VAMT)切除或缝(结)扎肺大疱.Ⅰ型、Ⅱ型、Ⅲ型多采取经VATS切除方法,Ⅳ型、Ⅴ型、Ⅵ型、继发型及经济较困难者多采取经VAMT切除或缝(结)扎方法.结果 全组1039侧,经VATS 857侧(82.5％),VAMT 182侧(17.5％).肺大疱切除948侧(91.2％),缝(结)扎66侧(6.4％),切除+缝(结)扎25侧(2.4％).单侧手术时间15 ～50 min,平均25 min,术中出血量20 ～150 ml,平均35 ml.术后住院4 ～12 d,(5.5±1.4)d,术后留置胸腔引流管时间3～7d,(4.3±1.2)d.术后并发症9例(0.9％),无手术死亡.随访882例,随访率85.9％,随访时间1个月～14年,其中＜12个月582例,1～3年160例,3～5年72例,≥5年68例.气胸复发11例(1.1％),包括Ⅲ、Ⅴ型各4例,Ⅰ、Ⅱ、Ⅵ型各1例.4例再次手术.结论 此分型能够基本概括肺大疱特点,根据肺大疱分型采取不同的手术处理方法切除或缝(结)扎肺大疱,术后复发率低,临床效果满意.

Discussion of Classification of Pulmonary Bulla of Spontaneous Pneumothorax and Methods of Video-assisted Thoracoscopic Surgery

Objective To investigate the classification of pulmonary bulla,and the selection of thoracoscopic surgical methods and treatment of spontaneous pneumothorax according to the classification.Methods All 1027 cases of spontaneous pneumothorax,including 409 cases（39.8%） of left-side,606 cases（59.0%） of right-side and 12 cases（1.2%） of both-sides received minimally invasive thoracoscopic surgery.There were 972 cases（94.6%） of primary bulla and 55 cases（5.4%） of secondary bulla.The primary pulmonary bulla was classified into the following types： Type Ⅰ： solitary type,Type Ⅱ： cluster type,Type Ⅲ： multiple type,Type Ⅳ： subcapsular type,Type Ⅴ： diffuse type,Type Ⅵ： dormant type.The VATS or VAMT（video-assisted minithoraeotomy） was performed on the basis of the classification to resect,transfix or ligate the bulla.Patients of Type Ⅰ,Ⅱ,Ⅲ generally underwent VATS while those of Type Ⅳ,Ⅴ,Ⅵ,secondary bulla or patients with financial difficulty generally chose VAMT resection or transfixion（ligation）.Results All 1039 cases/sides were composed of 948 sides（91.2%）of bulla resection（BR）,66 sides（6.4%）of transfixion or ligature（T or L） and 25 sides（2.4%）of BR＋T or L.857 sides（82.5%） underwent VATS and 182 sides（17.5%）underwent VAMT.The operation time for unilateral side was 15-50 min,with an average of 25 min,the blood loss was 20-150 ml,with an average of 35 ml.The postoperative hospital stay was 4-12 d,with a mean of（5.5±1.4） d.The time for chest tube drainage was 3-7 d,（4.3±1.2） d on average.9 cases（0.9%） were found to have postoperative complications,and no deaths occurred.The follow-up period was 1 month to 14 years in 882 cases（85.9%）,including 12 months in 582,1-3 years in 160,3-5 years in 72,≥5 years in 68.Recurrent pneumothorax was found in 11 cases（1.1%）（4 cases in Ⅲ,Ⅴ and 1 in Ⅰ,Ⅱ,Ⅵ respectively） and 4 cases received a second surgery.Conclusion The classification could cover different characteristics of pulmonary bulla,and the surgical management selected on the basis of this classification could lead to lower recurrent rate and satisfactory clinical results.