Clamshell切口和双侧后外侧切口开胸行双肺移植的临床效果比较

目的  探讨Clamshell切口和双侧后外侧切口序贯双肺移植术治疗终末期肺病的疗效差异。方法  回顾性分析接受双肺移植的120例受者的临床资料，按照手术方式不同分为双侧后外侧切口组（108例）和Clamshell切口组（12例）。收集并比较两组术中相关指标，包括手术时间、出血量、输血量、是否体外膜肺氧合（ECMO）支持、第一侧冷缺血时间、第二侧冷缺血时间，同时比较两组术后相关指标，包括住院时间、重症监护室（ICU）入住时间、气管插管时间、ECMO支持时间、用力肺活量（FVC）、第1秒用力呼气容积（FEV1）、吻合口狭窄发生率、支气管胸膜瘘发生率、围手术期病死率、术后第1次6 min步行距离。结果  Clamshell切口组出血量、输血量均多于双侧后外侧切口组（均为P < 0.05），Clamshell切口组ECMO支持率和第二侧冷缺血时间低于或短于双侧后外侧切口组（均为P < 0.05）。Clamshell切口组气管插管时间及ECMO支持时间均短于双侧后外侧切口组（均为P < 0.05）。结论  Clamshell切口和双侧后外侧切口的手术方案应用于序贯双肺移植均安全有效，双侧后外侧切口在不明显增加手术时间的情况下，可显著减少受者的出血量和输血量。而与双侧后外侧切口比较，Clamshell切口供肺冷缺血时间、气管插管时间和ECMO支持时间显著缩短。

Comparison of clinical efficacy between Clamshell incision and bilateral posterolateral incision for double lung transplantation

Objective To compare the clinical efficacy between Clamshell incision and bilateral posterolateral incision in the sequential double lung transplantation for end-stage lung disease. Methods Clinical data of 120 recipients undergoing double lung transplantation were retrospectively analyzed. All recipients were divided into bilateral posterolateral incision group (n=108) and Clamshell incision group (n=12) according to different surgical methods. Intraoperative parameters were collected and statistically compared between two groups, including operation time, amount of blood loss, amount of blood transfusion, use of extracorporeal membrane oxygenation (ECMO) or not, cold ischemia time on the first side, and cold ischemia time on the second side. Postoperative parameters were also compared between two groups, including the length of hospital stay, length of intensive care unit (ICU) stay, tracheal intubation duration, ECMO duration, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), incidence of anastomotic stenosis, incidence of bronchopleural fistula, perioperative fatality, and 6-minute walk test for the first time after operation. Results In the Clamshell incision group, the amount of blood loss and blood transfusion was significantly higher than those in the bilateral posterolateral incision group (both P < 0.05). The proportion of ECMO and cold ischemia time on the second side in the Clamshell incision group were significantly lower or shorter than those in the bilateral posterolateral incision group (both P < 0.05). In the Clamshell incision group, the tracheal intubation duration and ECMO duration were significantly shorter compared with those in bilateral posterolateral incision group (both P < 0.05). Conclusions Both Clamshell incision and bilateral posterolateral incision are safe and effective in sequential double lung transplantation. Bilateral posterolateral incision approach can significantly reduce the amount of blood loss and blood transfusion of the recipients without significantly prolonging the operation time. Compared with bilateral posterolateral incision approach, the cold ischemia time of lung graft, tracheal intubation duration and ECMO duration are significantly shortened via the Clamshell incision.