单侧肺减容术治疗COPD的临床分析

目的评价单侧肺减容术（unilateral lung volume reduction surgery，LVRS）治疗晚期慢性阻塞性肺疾病（chronic obstructive pulmonary disease，COPD）的疗效、手术适应证，总结手术操作要点及围手术期的处理。方法分析2003年9月—2006年9月间我院胸心外科进行单侧LVRS的24例COPD患者资料。术前利用CT平扫、血气分析和核素肺通气灌注成像确定“靶区”。24例患者全部行胸腔镜或胸腔镜辅助小切口手术；使用直线切割缝合器TLC-75或胸腔镜专用切缝器（Endo-GIA）切除过度充气破坏的肺组织。比较术前、术后1年、术后2年的呼吸困难程度及肺功能和6 min步行距离的变化，以评价单侧LVRS的临床疗效。结果单侧LVRS后1s用力呼气容积（FEV1）平均提高（38±7）%；6 min步行距离（6MWD）平均提高（70±25）%；呼吸困难指数再分级：16例术Ⅲ级中10例转为Ⅰ级，6例转为Ⅱ级；8例术前Ⅳ级中4例转为Ⅱ级，3例转为Ⅲ级，1例转为Ⅰ级。本组1、2年生存率分别为100%、92.8%，无手术中死亡，术后并发症发生率为35.7%。结论单侧LVRS可以改善具备手术指征的COPD患者的肺功能和临床症状，并且围手术期死亡率及手术并发症发生率低。尽量切除术侧无功能肺组织，防止肺漏气为手术要点。

Clinical outcome of unilateral lung volume reduction surgery on patients with chronic obstructive pulmonary disease

Objective To evaluate the effect of unilateral lung volume reduction surgery （LVRS） on treatment of patients with severe chronic obstructive pulmonary disease （COPD）. Methods The follow-up data of 24 patients with COPD who had undergone unilateral LVRS from September 2003 to September 2006 were analyzed. The operative targets were determined by preoperative CT noncontrast enhanced scan, blood gas analysis and pulmonary ventilation perfusion （V/Q） scintigraphy. All LVRS were performed through video assisted thoracoscopy surgery （VATS）. Destroyed pulmonary tissues were resected by liner stapler （ TLC-75 ） or special stapler （Endo-GIA）. The changes of dyspnea score, pulmonary function quality of life and 6 rain walking distance （6MWD） were analyzed prior to operation, and again, 1 or 2 years after operation to evaluate the effect of unilateral LVRS. Results The mean forced expiratory volume in one second （FEV1） was increased （38 ± 7） % and 6MWD increased （70 ± 25） %. For dyspnea score, among 16 patients with a preoperative grade of Ⅲ, 10 were converted to grade Ⅰ , 6 to grade Ⅱ ; among 8 patient s with a preoperative grade of Ⅳ, 4 were converted to grade Ⅱ, 3 to grade Ⅲ, and 1 to grade Ⅰ. One-and 2-year survival rate were 100% and 92.8% respectively. There was no perioperative death in this group and the total postoperative complication was 35.7%. Conclusion Unilateral LVRS shows significant clinical benefits for the selected patients with severe COPD and has lower perioperative mortality and morbidity. The key points of LVRS are to resect dysfunctional lung tissue as much as possible and to prevent pulmonary air leakage.