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针式胸腔镜胸膜固定术治疗原发自发性气胸
Needlescopic Video-Assisted Thoracic Surgery and minocycline pleurodesis for the
Treatment of Primary Spontaneous Pneumothorax
陈晋兴 Jin-Shing Chen, Hsao-Hsun Hsu, Pei-Ming Huang, et al.
Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National
Taiwan University College of Medicine.
【Background】 Previously we have shown that needlescopic video-assisted thoracic surgery (VATS)
is feasible and produces less pain and better cosmetic results than conventional VATS in treating primary
spontaneous pneumothorax (PSP). In addition, we also use additional minocycline after VATS to decrease
ipsilateral recurrence. In this study, we report our results of needlescopic VATS and additional minocycline
pleurodesis for the treatment of PSP.
【Methods】 Between April 2001 and August 2007, 200 patients (ages: 23.6 + 6.8 years, range: 15 to
48 years) with primary spontaneous pneumothorax underwent 212 needlescopic VATS procedures (188
unilateral and 12 bilateral) at National Taiwan University Hospital. The blebs were resected with
endoscopic linear staplers. Pleurodesis was achieved by pleural abrasion with additional minocycline
instillation.
【Results】 Mean operation duration for each procedure was 78 + 23 minutes. Complications
developed in 15 patients: prolonged air leaks in 12 patients and pleural detachment in 3 patients. The mean
postoperative hospital stay was 4.1 + 2.3 days. After a mean follow-up of 21 months, ipsilateral recurrence
of pneumothorax was noted in 5 patients (2.5 %).
【Conclusion】 Needlescopic VATS with minocycline pleurodesis is a safe and effective method for
the treatment of primary spontaneous pneumothorax.
肺移植治疗终末期肺病54例报告
Lung transplantation in the treatment of end-stage pulmonary diseases: 54 cases report.
陈静瑜 郑明峰 朱艳红 等
江苏省无锡市胸科医院肺移植中心, 无锡,214073
【目的】 对比国外开展肺移植情况,结合单中心经验,探讨我国目前临床肺移植主要存在的
问题及对策.
【方法】 2002年5月,我院成立肺移植团队,开展猪肺移植动物实验,在此基础上于2002年9月
至2006年12月我院共完成临床肺移植54例,其中男性45例,女性9例,年龄15-74岁,平均53
岁.受体术前均为重症呼吸衰竭,长期靠呼吸机依赖9例.术式及病种:单肺移植,包括肺气肿14
例,肺纤维化19例,矽肺2例,肺结核1例,肺淋巴管平滑肌瘤病1例及室间隔缺损合并艾森曼格
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综合征4例.双肺移植13例,包括肺气肿6例,支气管肺囊肿4例,矽肺1例,肺结核1例,弥漫
性泛细支气管炎1例.
【结果】 术后短期住院内死亡9/54 (16.7%),死亡原因包括原发性移植肺功3例,严重感染4
例,急性排斥1例,肺梗塞1例.中位生存时间26.5(9-60)月.1,2,3年生存率分别是74.1%,
63.2% 和 52.6%,第一例病人目前生存5年,大部分病人生存质量良好,肺功能极大改善.
【结论】 本组肺移植的结果与国际发达国家的疗效相似,肺移植在我国新世纪会迎来一个快
速发展阶段,组建肺移植团队,多学科合作是肺移植手术成功开展,术后长期生存的关键;术后的
缺血再灌注损伤,排斥和感染仍是肺移植短期死亡的主要原因.
关键词 肺移植,终末期肺病
影响胸腔镜下成人漏斗胸矫正术疗效的因素分析
Analysis of factors that influence the therapeutic effect of chondrosternoplasty in the
adult under thoracoscope
陈周苗,王永清,何启才,等
浙江大学医学院附属邵逸夫医院心胸外科
【Objective】To evaluate the factors that influence the therapeutic effect of chondrosternoplasty in the
adult under thoracoscope.
【Methods】 Four adult patients received the chondrosternoplasty under thoracoscope.
【Results】 The four patients received five times of operation,some related complications occured in
two,and the other two recovered smoothly.
【Conclusion】The therapeutic effect of chondrosternoplasty in the adult under thoracoscope is related
with many preoperative,operative and postoperative factors.
Key words Thoracoscope Pectus excavatum Therapeutic effect Adult
漏斗胸(pectus excavatum)是属于先天性胸壁畸形常见的一种疾病.临床上常表现为前胸壁胸
骨中下部与其两侧肋骨异常向后弯曲凹陷呈漏斗样畸形.畸形严重者可影响循环和呼吸系统,如异
位心,反复上呼吸道感染,短暂性缺氧,反常呼吸等,轻者出现脊柱侧弯,驼背,凸肚等体形改变,
导致患者(尤其是青少年)精神消沉孤僻.所以大多数患者均是因为心理上的因素才去求医要求手
术.
胸腔镜下微创漏斗胸矫正术1998由NUSS.D开展,与传统手术相比具有创伤小,恢复快,矫
形效果与传统手术无差异等优点.在小儿病人中取得较大成功.但是在成人漏斗胸患者中的效果,
研究报道仍然较少.我院自2006年4月开展胸腔镜下微创漏斗胸矫正术,共诊治4例病人,就近期
效果及围术期并发症进行讨论.
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1.资料和方法
病例1 患者,男,20岁,因"挺胸后呼吸困难10余年,加重6月"入院.查体:一般情况良
好,胸骨中下部明显凹陷,深约6cm,于2006.4.7在全麻下行"胸腔镜辅助下漏斗胸矫正术",手术
疗效满意,术后第6天出院,于2006.5.14因"漏斗胸复发"再次入院.查体发现:胸骨下段凹陷,
深达3cm.X线检查发现矫形钢板移位.于2006.5.17再次行"胸腔镜辅助下漏斗胸矫正术",手术
顺利,疗效满意.术后第8天出院.术后1年复查未见异常.
病例2 患者,男,16岁,因"发现胸廓畸形10余年"收治入院.查体:一般情况良好,胸骨下
部明显凹陷,深达5cm.于2006.4.24在全麻下行"胸腔镜辅助下漏斗胸矫正术",手术疗效满意,
术后第4天出院.术后1年复查未见异常.
病例3 患者,男,17岁,因"发现胸廓畸形7年余"收治入院.查体:一般情况良好,胸骨下
部明显凹陷,深达4cm.于2006.7.31在全麻下行"胸腔镜辅助下漏斗胸矫正术",手术疗效满意,
术后第7天出院.术后1年复查未见异常.
病例4 患者,男,19岁,因"发现胸廓畸形10余年"收治入院.查体:一般情况良好,胸骨下
部明显凹陷,深达2.5cm.术前胸片提示:脊柱侧弯,于2006.8.3在全麻下行"胸腔镜辅助下漏斗
胸矫正术",手术疗效满意,术后第5天出院.术后1周回医院复查发现因疼痛出现强迫体位,X线
检查发现脊柱侧弯较术前加重.术后3月疼痛消失恢复正常行走姿势,术后1年复查脊柱侧弯恢复
至术前形状.
手术采用传统的NUSS手术方法,选用美国W.Lorenz公司的矫形钢板及其配套手术材料和器械.
患者仰卧体位,双上肢外展.标记漏斗胸最凹陷点附近的骨性组织为支撑点,漏斗状胸壁双侧的最
高点的肋间隙为插入点,并作冠状位水平测量,两端以腋中线后2cm为界;常规消毒铺单;测量胸
廓后作矫形钢板的塑形,根据矫形钢板的定位作双侧的胸壁切口,均位于腋中线前后约2～4cm长;
经切口在肌肉下分离出一个能容矫形钢板穿过的隧道直至插入点;在右侧切口下方间隔1个肋间的
腋中线水平作一观察孔置入胸腔镜,在胸腔镜的监视下经右侧隧道在插入点插入穿通器,在胸壁支
撑点和心包之间用穿通器钝性向左紧贴胸壁分离直至左侧的插入点,并从内穿透胸壁进入左侧胸壁
的隧道;在胸壁左侧用细带固定矫形钢板的一端和穿通器,将矫形钢板的弓面朝后,用穿通器缓慢
将矫形钢板拉过纵隔和右侧胸腔进入右侧的隧道;翻转矫形钢板180 使其弓面朝向前方;检查右侧
胸腔,确定没有出血后退出胸腔镜;在肌层下用固定片固定矫形钢板的两端并用钢丝捆绑;清洗双
侧切口,止血,缝合切口;经观察孔置入胸管,反复鼓肺充分排气后拔除胸管,缝合观察孔.
2.结果
本组患者共4例5次手术,首例患者因术后1月钢板移位行2次手术矫形;第四例患者术前伴
有脊柱侧弯,术后由于疼痛原因出现脊柱侧弯加重,3个月后疼痛消失,术后1年脊柱侧弯恢复至
术前形状;其余2例手术均顺利,无并发症发生.
3.讨论
由于我们开展的NUSS手术例数较少,无法用统计学方法加以统计,但是国内外大量的文献资
料早已证实NUSS手术的可行性和其较之传统的Ravitch改良胸骨抬举法有着明显的创伤小,美观,
并发症少,患者恢复快但疗效一致等优点.但是许多病例的年龄均在4~12岁之间,有关青少年和成
人的报道仍然较少.我们通过复习大量的国内外文献和结合自己的临床经验发现有如下并发症:矫
形不完全,心包,心脏破裂引起的大出血,气胸,矫形钢板移位,疼痛,切口感染等.现总结了一
些心得加以讨论影响NUSS手术的因素如下.
影响NUSS手术的一些因素主要分为术前,术中,术后三个方面.
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术前因素是指漏斗胸的畸形类型,程度和患者的年龄.1 HYUNG JOO PARK提出通过术前CT
对漏斗胸进行分型,漏斗胸主要分为对称型和非对称型.对称型的漏斗胸分为2个亚型,以胸骨和
两侧肋软骨的内陷为常见,以胸骨为中心,最内陷点常是胸骨下端或剑突.此类型术后的矫形效果
较好,出现术后矫形钢板的移位率比较低.而非对称型漏斗胸又分为5个亚型,多以胸骨侧斜,一
侧的前胸壁内陷为主,最内陷处并非胸骨下段,两侧的胸廓呈非对称型,这就使两侧的插入点不在
同一水平,因此术后矫形效果明显不尽人意,难以达到术前期望的效果.术前CT可以对对称及非对
称的亚型进行确认,根据不同类型的漏斗胸,尤其对于严重非对称型漏斗胸患者,矫形所应用的钢
板需要在术前行特殊塑型,以便矫形时应对解剖学上畸形最严重的位置,钢板固定应采用多点固定,
即在钢板末端上下,右胸骨外侧缘跨肋钢丝固定.本组4例患者均为对称型漏斗胸,术后矫形效果
满意.因此漏斗胸的类型是影响疗效的重要因素之一.2 漏斗胸的畸形程度使指漏斗胸的内陷程度
和范围.术前通过CT可以观察胸骨凹陷程度,通常使用CT漏斗胸指数b/a评价其严重程度,心脏翻
转角度以及双肺发育情况.近年来有人提出F2I指数表达凹陷程度,F2I=(a×b×c)/(A×B×C),
a漏斗胸凹陷纵径;b漏斗胸凹陷横径;c漏斗胸凹陷深度;A胸骨长度;B胸廓横径;C胸骨角到胸椎
前缘的最短距离.术后CT根据漏斗胸指数也可以帮助判断疗效.胸骨凹陷程度严重者术后对心脏和
肺的压迫明显改善,疗效显著.对于畸形范围较大的患者,建议采用"双钢板法"固定,否则凹陷
胸骨的抬举难以到位或者术后矫形钢板移位.3 患者的年龄也是影响手术疗效的一个因素.大量的
国内外文献报道年龄在4～12岁之间的儿童由于肋软骨长,骨质软便于矫形,而且小患儿对疼痛不
敏感,避免了术后疼痛造成获得性脊柱侧弯等不良反应,所以此年龄段内的儿童矫形疗效最好;而
成人由于胸壁的伸展性,柔韧性降低,加之畸形时间长,对心肺等脏器的损害和胸廓的发育已经造
成了难以挽回的后果,患者因手术并发症而再手术的机会增加,矫形效果相对较差.
术中因素是指手术中间一些不当的手术设计或操作手法所造成的不良结果或并发症.1 矫形钢
板型号的选择:目前矫形钢板的型号有8～17#,我们在术中要根据测量结果来选择合适的型号,
过长的钢板会导致术后钢板的两端过于靠后,将胸壁软组织顶离原本的位置,加剧术后疼痛甚至切
口积液,感染,组织坏死;过短的矫形钢板导致固定困难甚至移位.2 矫形钢板的塑形:我们在术
中根据测量的结果来进行矫形钢板的塑形,将钢板扳成和患者胸壁相同大小的弓形,中间的最凸点
刚好能在漏斗胸的最凹点,凸出处必须要有足够的范围能顶起漏斗状之胸壁,否则很容易由于外力
引起钢板的移位而影响手术的矫形效果.另外钢板的弧度一定要和双侧的胸壁密切贴合,过紧能加
剧术后的疼痛,过松容易导致隧道内的积液甚至出现感染.3 插入点的选择:必须在漏斗状前胸壁
的两侧最高点.从力学的角度来分析手术本身就是利用杠杆原理将漏斗状胸壁强行前抬,双侧最高
点就是最佳的支撑点,矫形钢板固定后钢板受到三个力的作用,一是中间部分受到漏斗状胸壁向后
的压力,两个是在双侧插入点上向前的支撑力,在插入点上的支撑力主要来自插入点下方紧邻的肋
骨和肋间内,外斜肌,在手术操作过程中肋间内,外斜肌势必有一定程度的向后撕裂,如撕裂过多
就会导致插入点后移,使钢板一侧或者双侧向后移位,导致矫形不到位甚至失败.4 术中操作:在
选择双侧切口时,必须考虑到插入点和切口前端的距离,由于在穿通器要经切口处肌层下潜行至插
入点再进入胸腔,再向左胸穿通的过程中,穿通器必须尽可能将右侧胸壁软组织拉向前方使穿通器
能水平操作,此时插入点要承受较大的向后的压力,尤其在穿通器要抬举起漏斗状胸壁从左侧的插
入点穿通时,压力更为巨大,这就要求术者必须用力抬举穿通器,减少穿通器对插入点的压力,否
则薄弱的肋间内,外斜肌势必向后撕裂,造成插入点后移,影响矫形效果;穿通器在右侧胸腔内的
操作依赖胸腔镜的监视,在穿通纵隔时要尽可能紧贴胸壁操作,注意心电图和血压的变化,尽量减
少对心脏的压迫,尤其在穿通器进入左侧纵隔后,必须让手术助手用手指来感受胸壁内穿通器尖端
对前胸壁的压力,否则极容易穿透左侧纵隔胸膜引起左侧气胸或者穿透心包甚至心脏导致大出血;
用细带固定穿通器和矫形钢板时,两者之间最好有1cm的距离,过长或过短都容易在牵拉过程中使
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矫形钢板损伤插入点的肌肉和心包;在翻转矫形钢板时要向前下用力,避免插入点肋间内外肌受压
撕裂和肋间神经的损伤;固定固定片时最好用丝线带上一些周围的结缔组织,必要时可考虑用钢丝
捆绑肋骨和矫形钢板,避免移位;缝合切口前必须冲洗创面,彻底止血,尽量避免切口下的积液和
感染,必要时术后局部加压包扎;鼓肺排气必须充分,避免气胸.
术后因素是指在手术后出现的一些并发症或不当的活动对矫形疗效的影响或者失败. 1 疼痛:
由于矫形钢板的植入和畸形胸壁的强行抬举,使患者术后的疼痛极为严重,容易导致术后的一些并
发症,如不敢深呼吸,咳嗽和呼吸功能锻炼从而导致呼吸道感染;如某个长时间的强迫体位而出现
获得性脊柱侧弯等,所以术后镇痛有着重要的意义.我们常采用罗派卡因作肋间神经阻滞和病人自
控硬膜外镇痛泵给患者止痛.本组第四例患者术后由于疼痛出现强迫体位而加重了脊柱侧弯,术后
3个月疼痛消失,1年后才恢复到术前状态.2 切口感染:矫形钢板和固定片是合金材料,一般不
出现排异反应.多因为切口下积液继之并发感染.除了术中不严格的无菌操作外,术中隧道分离范
围过大,粗暴操作造成胸壁肌肉坏死,矫形钢板过松,没有紧贴胸壁而使切口处组织向外凸起人为
造成较大的间隙,止血不完全等均是造成积液和感染的重要因素.部分病人由于切口的感染不得不
拆除矫形钢板,导致手术失败.3 矫形钢板移位:围手术期内除了呼吸功能锻炼外,我们要求患者
在术后1个月内禁止做曲胸,弯腰,扭腰和翻滚动作,2个月内禁止搬重物,3个月内不进行对抗性
运动.早期的钢板移位除了手术因素外,大多是由于患者躯体运动造成的,本组第一例患者因为在
术后1个月时做"俯卧撑"运动后出现矫形钢板移位而导致手术失败.
目前NUSS手术在国内已经有多家医院开展,但关于手术失败的报道甚少,我们根据自己的体
会作了一些粗浅的分析,仅供大家参考.
食道恶性神经鞘瘤-病例报告
Malignant schwannoma of the esophagus—a case report
陈卫洲 Wei-Chou Chen, * Yih-Leong Chang, Yung-Chie Lee
Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
*Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
An extremely rare case of esophageal malignant schwannoma is reported. Gastrointestinal
schwannomas are rare, and most of them originate in the stomach or the intestine. Malignant schwannomas
of the esophagus are extremely rare.
A 46-year-old man, a cigarette, alcohol, betel nut consumer for more than ten years, complained of
swallowing disturbance and was diagnosed with an esophageal spindle cell sarcoma in outside hospital. He
received preoperative concurrent chemoradiotherapy for stage T3N1M0 in outside hospital. The tumor size
was decreased. The post CCRT barium esophagogram showed an ulcerative polypoid tumor with irregular
surface in the middle thoracic esophagus. The chest computed tomography showed dilated esophagus with
diffuse wall thickening at middle esophagus. The endoscopic ultrasonography showed an esophageal tumor
with destruction of whole layer which located 22 to 32 cm from the incisors, and involvement of about half
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of circumference. The maximal thickness was 2 cm. A right posterolateral thoracotomy and median
laparotomy for subtotal esophagectomy and retrosternal route-gastric tube reconstruction were performed.
Postoperative course was uneventful. The tumor measures 7.8x2.4x2.0 cm in size and was composed of
S-100 protein immunoreactive oval to spindle tumor cells with increase of mitoses.
Benign esophageal schwannomas are rare tumors with only 14 cases reported in the English literature.
Among the English and Japanese literatures, there was only five malignant esophageal schwannomas
reported. Most previous reports describe excision without major esophageal resection. There have been
four other reports of esophagectomy. Only two esophagectomies were performed for malignant
schwannomas.
食管粘液息肉:2例报道并文献综述
Esophageal Mucocele:Report of Two Cases and Review of Literature
陈政隆 Cheng-Lung Chen1, Fur-Jiang Leu2
Division of Thoracic Surgery, Department of Surgery1.
Department of pathology2 ,Cardinal Tien Hospital, Taipei Hsiang , Taiwan
【Background】
Esophageal bypass without eophagectomy is frequently performed for patients with benign stricture or
unresectable esophageal cancer with obstruction. Esophageal mucocele may develop after exclusion of
proximal end of distal esophagus. Mucocele may or may not produce side effect and it is difficult to be
detected without computer tomography of chest and are rarely reported
Its managements also varies according to clinical manifestations.
【Material and Method】
Computer tomography of the chest is the tool for detection of esophageal mucocele whenever the
symptoms develop. Collection of 46 cases from twelve English papers published from 1984 to 2007,
including our two cases were analyzed according to their underlying diseases, clinical manifestations,
management and outcomes.
Case presentation (1)
A 72-year-old male, was admitted on account of persistent nausea sensation after meal for weeks.He
received cervical esophagocolostomy for unresectable cardiac cancer with obstruction of lower esophagus
four months ago. Although no problems in swallowing of food and postoperatively, nausea sensation
occurred three weeks ago and exaggerated after each meal. Computer tomography of chest disclosed huge
dilated esophagus contains fluid. Right thoracotomy revealed an aorta-like esophagus parallel with aorta in
posterior mediastinum. The cystic esophagus was resected, lot of yellowish turbid fluid was found. After
esophagectomy the symptom of nausea subsided. Patient died of disease itself four months later.
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Case presentation (2)
A 28-year-old male, was admitted on account of persistent nausea sensation for months. Three years
ago, he received cervical end to side esophagocolostomy without esophagectomy for benign stricture at the
level of thoracic inlet after caustic injury. Recently he began to experience persistent nausea sensation,
especially after each meal. Esophagography showed stricture of cervical esophagocolostomy with proximal
dilation of cervical esophagus but still patency of the passage. Computer tomography of chest showed a
cystic lesion in posterior mediastinum comparable with dilated esophagus due to obliteration of the
esophagus just below the carina level of trachea due to previous corrosive injury. Under the impression of
esophageal mucocele, right thoracotomy revealed dilated upper esophagus filling of milk like fluid due to
distal obstruction. Esophagectomy was done as high as possible. Patient has been free of symptom of
nausea after esophagectomy.
【Conclusions】
Esophageal bypass without esophagectomy for unresectable esophageal malignancy and benign
stricture due to caustic injury are not uncommon. Esophageal mucocele may develop and produce symptom.
Surgical intervention occasionally is indicated in patients with severe symptom and may improve the
quality of life.
肺癌的再手术治疗:31例报告
Reoperation for lung cancer: experience with 31 cases
陈志毅 Chie-Yi Chen1, Nan-Yung Hsu1, Chun-Yi Shiah2, et al.
1Division of Chest Surgery, China Medical University Hospital, Taichung, Taiwan
2Division of Chest Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
【Background】 Analysis of three institutions experience with reoperation for lung cancer, to assess
operative mortality and late outcome.
【Methods】 From 1999 to 2006, 31 consecutive cancer patients having been surgically treated for
lung cancer previously received subsequent lung resection (mean age 69 years; 30-79). ( There were 14
patients (13 males and 1 female) with a median age of 64 years (range 51-74).) They constituted 2.3% of
1359 patients who had undergone lung resection for lung cancer in the same period in three institutes.
There were 3 patients having been operated for lung cancer previously received reoperation because of
non-malignant conditions (fibrosis in 1, lung abscess in 1 and squamous metaplasia in 1). Among 28
patients, fourteen patients (group 1) had a local recurrence that developed at a median interval of 13 months
(range 6-21), and the other 14 patients (group 2) had a new primary lung cancer that developed at a median
interval of 38 months (range 25-91).
【Results】 For 14 patients of group 1, the first lung resection was bilobectomy in one patient,
lobectomy in nine and lesser resection in four. The second operation consisted of completion
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pneumonectomy in two cases, lobectomy in three and wedge resection in nine. For another 14 patients of
group 2, the first lung resection was bilobectomy in 3 patients, lobectomy in six and lesser resection in five.
The second lung resection was completion pneumonectomy in two patients, completion lobectomy in three
and lesser resection in nine. Operative mortality was 3.2% (n=1). Survival rate following second operation
will be presented.
【Conclusions】 An aggressive surgical approach is safe, effective and warranted in patients with
either a second primary lung cancer or relapse from their primary lung cancer, if there is no evidence of
distant metastasis and the patients are in good health.
食管癌术后胸内吻合口瘘分期手术治疗体会
Experience of the treatment of thoracic anastomotic leakage after surgery of esophageal
cancer
高炜,张世范,贾书斌,等
兰州军区兰州总医院胸外科,兰州,730050
90年以来我们采用分期手术的方法对11例食管癌切除术后吻合口瘘的患者进行治疗,无一例
死亡,现就有关手术治疗问题谈几点体会:
1.临床资料
1.1 一般资料:本组中男性8例,女3例.年龄32～72岁,病程6～13个月,均系中晚期患
者,首次手术均采用左后外侧开胸食管癌切除,食管胃弓上吻合术.分别于术后2～22天经口服美
蓝证实为吻合口瘘,急诊行开胸探查术.术中见胸腔内有大量分隔包裹之脓液和胃液;胸膜胃壁肿
胀;胃,肺,心包表面均有脓苔.瘘发生部位:3例发生于近吻合处之胃壁;2例发生于胃体中部;
2例位于吻合口前壁;4例位于吻合口后壁.
1.2 手术方法:手术分两期进行,Ⅰ期为急诊开胸探查,颈部食管外置,胸胃造瘘术,待患者
体质基本恢复后,一般于Ⅰ期手术后三个月行Ⅱ期手术——结肠代食管术.
2.讨 论
2.1 尽早明确吻合口瘘之诊断
术后患者持续高热,特别是进食后再次出现39℃以上高热,突然出现胸痛,胸闷,气急,脉搏
细速,术侧呼吸音降低或消失,均应高度怀疑发生吻合口瘘之可能,此时应口服美蓝或造影剂,如
观察到胸引液呈蓝色或有食物残渣,唾液或透视下有造影剂外溢,则可确立吻合口瘘的诊断.
2.2 手术时机的选择及手术要点
手术分两期完成.
Ⅰ期手术:在吻合口瘘之诊断确立后立即进行.取原切口进胸,清除胸腔积脓及胃液,探明瘘
口位置后剪断吻合口,将食管于颈部牵出外置.游离颈部食管时位置不宜高,尽可能的多保留颈部
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食管,以保证Ⅱ期手术时有足够长度与结肠吻合.荷包缝合封闭胃底残端,用生理盐水,3%双氧水
和0.2%灭滴灵反复冲洗胸腔,彻底剥除附着于肺表面之脓苔和纤维膜,使肺充分复张,于胃侧壁行
胃造瘘术,造瘘管由肋缘下或近肋膈角之肋间穿出体表.将胃体妥善缝合固定于肋膈角,造瘘口侧
贴于膈面,以防医源性胃壁瘘的发生.术后应注意保持胸腔引流通畅,加强静脉营养支持和有效的
抗感染治疗,一般于手术后五天开始给予管喂.以确保营养供应.
Ⅱ期手术:一般在Ⅰ期手术后三个月左右,患者精神,体质均明显好转后进行.术前常规行钡
灌肠检查,并认真做好结肠的清洁准备工作,可根据术者习惯和患者具体情况选择胸骨前或胸骨后
径路结肠代食管术.术中应仔细分离粘连,防止误伤结肠血管,在结肠血液供应允许的情况下尽可
能采用右半结肠或横结肠替代食管,以防术后因逆蠕动液体返流误吸而引起肺部并发症.
2.3 分期手术的优点
(1)Ⅰ期手术操作简单,时间短,创伤小,安全可靠,能及时有效地控制胸腔感染,减轻对患者
体质的消耗.颈部食管外置造瘘有效地防止了口腔细菌随唾液进入胸腔,从而消除了一个主要的污
染源.胃造瘘术有效地避免了胃液对胸腔腐蚀和污染;加之术中彻底清除了胸腔的脓苔,脓液及纤
维分隔,大量液体反复冲洗,有效地胸腔引流使肺充分复张,所有这一切都有利于控制胸腔惑染,
促进患者康复.
(2)胸胃造瘘术既起到胃肠减压作用,又为术后患者营养支持提供了有力保障,特别是造瘘于胸
腔内杜绝了胸腔感染向腹腔漫延.
(3)过去对吻合口瘘均行Ⅰ期修复,此时患者处于严重负氮平衡状态,胸腔内感染严重,组织难
以修复,手术失败率高.分期手术法将食管重建手术改在Ⅰ期手术后三个月,患者负氮平衡得以纠
正后进行,大大提高了手术的成功率.
(4)Ⅱ期手术操作简单,不需开胸,对患者心脏功能影响小,特别是在患者体质基本恢复后进行,
故安全可靠,益于患者康复.
VATS在小儿支气管源性肺囊肿外科治疗上的应用
The application of VATS in the surgical treatment of pediatric branchiogenic lung cyst.
1黄俊, 1刘君,1陈汉章,等
1,广州呼吸疾病研究所,广州医学院第一附属医院,广州,510120
2,深圳市人民医院,深圳
摘要
【目的】 探讨VATS在小儿支气管源性肺囊肿中的治疗作用.
【方法】 回顾性分析我院和深圳市人民医院1996年1月至2007年1月经VATS切除并病理证
实的33例小儿支气管源性肺囊肿患者的临床资料,麻醉方式全部采取吸入麻醉,手术采取胸腔镜进
行,必要辅助小切口协助将病灶以及肺组织取出;气管残端采取间断缝合或者Endo-cutter钉合,统
计分析手术时间,切口大小,术后引流时间及总量,术后住院时间.
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【结果】 本组患者均经VATS手术治疗.年龄从8d~12岁,平均为5.17岁.1例纵隔型支气
管囊肿行VATS纵隔囊肿切开+翻转术,10例肺内型行肺楔形切除术,22例肺内单发性囊肿或局限
于肺段的多发性肺囊肿行肺叶切除术.全组手术时间为(45~265)min,平均101.36min;切口为(1.5~7)
cm,平均4.67 cm;术中失血(5~400)ml,平均82.42 ml;术后均放置胸管(1~2)条,引流(1~7)
天,待引流完全后拔除胸管,平均3.39 d;总引流量(85~770)ml,平均292.18ml;平均术后住院
时间为(4~25)d,平均11.54 d.
【结论】 VATS的小儿支气管源性肺囊肿治疗是可行,安全,彻底,微创的,可成为标准术式.
关键词 支气管源性肺囊肿;电视辅助胸腔镜手术;小儿
Abstract
【Objective】 To discuss the use of VATS in treatment of pediatric bronchogenic pulmonary cyst.
【Methods】 A retrospective analysis of 33 pediatric patients who had been pathologically
confirmed with bronchial pulmonary cyst, underwent VATS treatment between Jan 1996 and Jan 2007.
We adopted inhalational anesthesia in each patient. Use of thoracoscope intraoperatively, small incision is
necessity to obtain lung tissue and to remove focus of infection out. Bronchial stump is stitched with
disjunction saturation or GIA saturation. We collected date of incision size, operation time, drain quantity,
placed time of chest tube drainage and postoperative length of stay.
【Results】 All of the patients underwent VATS surgery. Age is between 8days~12yrs,average is
5.17yrs.1 cases of mediastinal bronchogenic performed cyst incision + turnover operation, 10 cases of
intrapulmonary performed pulmonary wedge resection, 22 cases of pulmonary single cyst or multiple cysts
confined to one lobe of lung performed lobectomy. The operation time is between (45~265)mins, (mean
101.36mins); the incision is (1.5~7)cm(mean ,4.67±1.28cm); Intraoperative bleeding is (5~400)
ml(mean 82.42ml);postoperative chest tube drainage placed (1-7 )days ,1~2 tube, (mean 3.39d),
the whole drainage volume is (85~770)ml(mean 292.18ml); length of postoperative hospital stay is
(4~25)d(mean 11.54d).
【Conclusions】 Pediatric bronchogenic pulmonary cysts treated by VATS is feasible, safe,
thorough and minimal invasive, it could be the standard operation method.
Key words Bronchogenic Cyst; VATS; Pediatric
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应用纳米炭在微创肺癌淋巴结清扫术中的研究
李树本 *何建行 陈汉章 等
广东省广州呼吸疾病研究所胸外科,广州,510120
【目的】观察与评价纳米炭在肺癌淋巴结清扫术中的临床应用价值.
【方法】选用2005年12月至2006年3月我科收治术前确诊为肺癌的42例患者.根据微创胸
腔镜辅助淋巴结清扫术中有否运用纳米炭,将其分为实验组20例,对照组22例.通过实验比较两
组术中清扫淋巴结的时间,术后根椐病理结果比较清扫淋巴结的数目,癌性淋巴结转移情况并观察
围手术期副作用的发生.
【结果】局部组织注射纳米炭未见严重副作用发生.两组术中清扫淋巴结时间经比较无明显差
异(P>0.05).实验组清扫淋巴结平均25.5枚,对照组14.6枚,经统计学比较两组有显著性差异(P0.05).
3.讨论
近几年来,许多学者将VATS应用于原发性肺癌的综合治疗,取得了显著的近期疗效[1].VATS已
成功地用于肺叶切除,甚至全肺切除等高难度的肺部手术,说明治疗性VATS在肺外科手术中的应用
已走向成熟.目前公认的VATS肺癌手术的适应证是I期肺癌, 许多临床研究表明I期患者VATS肺叶切
除可以达到与传统开胸手术相当的根治效果,我们之前已有部分统计报道,但有关其术后远期疗效
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仍有待大量临床病例积累与总结.
VATS能否进行肺门和纵隔淋巴结清扫,一直是胸科医师关心和争议的论题,其直接影响肺癌的
远期疗效.何建行等认为在多角度的胸腔镜暴露下,VATS行肺门和纵隔各组淋巴组织的清扫是可行
的,其主要适应证为T1N0M0,T1N1M0,T2N0M0 的肺癌.我们的体会是Ⅰ期周围型肺癌,病灶相
对较小,未侵及胸膜和胸壁,无胸内粘连,VATS肺叶切除后进行肺门及纵隔淋巴结清扫,这样纵隔
暴露较清楚,并根据淋巴结转移与淋巴引流方向,能较好进行肺门纵隔淋巴结系统性清扫,本组清
扫数目和清扫范围与传统开胸手术相当,差异无显著性.Watanabe等报道VATS清扫淋巴结数,每组
淋巴结数及术后死亡率,复发率等与传统开胸组无显著差异.说明VATS手术完成系统性肺门纵隔淋
巴结清扫并不逊色于传统开胸.
目前国内外有关I期肺癌VATS术后3,5年生存率的报道不多.本组资料显示,VATS组和对照组
术后3年,5年生存率分别为90.91%,86.36%和90%,85%,统计学无显著性差异(P>0.05).Gharagozloo
等报道Ⅰ期肺癌VATS肺叶切除术后3年,5年生存率分别为88%,85%.我们认为Ⅰ期肺癌VATS肺
叶切除,系统淋巴结清扫术在技术上可行, 符合肿瘤切除原则,能够达到标准后外侧切口同样的根
治效果,并具有创伤小,恢复快,出血少,对心肺功能影响小等临床优点.可作为I期肺癌的一个标
准术式,值得进一步推广.
硝酸甘油和异搏定对犬移植用供肺组织诱生型一氧化氮合酶及腺苷酸的影响
The Effect of Nitroglycerin and Verapamil for The Contents of iNOS ATP and TAN in canine's Donor
Lung Tissues
刘建新 冯俊波
湖南长沙中南大学湘雅三医院心胸外科,长沙,410013
【目的】本实验在肺保护液(LPD液)中加入硝酸甘油和异搏定,观察其对移植后供肺组织中
的诱生型一氧化氮合酶(iNOS)及三磷酸腺苷酸(AT P),腺苷酸池(TAN)的影响,评定LPD液
中加入硝酸甘油和异搏定对供肺的保护效果.
【方法】40只健康杂种犬,雌雄不拘,按体重配对,随机分成四组.供体分组情况:(1)对照
组,单纯用LPD液保存;(2)硝酸甘油组,在LPD液中加入硝酸甘油(0.1mg/ml);(3)异搏定组,
在LPD液中加入异搏定(0.1mg/ml);(4)硝酸甘油加异搏定组,在LPD液中加入硝酸甘油(0.1mg/ml)
和异搏定(0.1mg/ml).肌肉注射戊巴比妥钠麻醉后,气管插管,呼吸机支持呼吸,左侧第四肋间开
胸,肝素化(3mg/kg),停用呼吸机,结扎上下腔静脉,剪开右室流出道,插入灌注管至左肺动脉,
同时阻断右肺动脉,剪开左心耳.以40cmH2O的压力灌注4oC保护掖,待左肺由红变白,左心耳流
出的灌注液澄清为止.手工膨肺,使肺适度膨胀后,以支气管钳夹闭左主支气管,将灌注好的左肺
及心脏取下放入保护液中,修剪供肺,移除心脏.将供肺浸入4oC保护液,保存6小时.受体的麻
醉等准备同供体,移去受体左肺.按支气管,肺动脉,左房袖的顺序吻合供肺与受体.吻合完成,
静脉注射甲强龙后,顺序开放肺静脉动脉.再灌注两小时后,取左肺舌叶部分肺组织,将其放入-70oC
冰箱中保存备用.待标本收齐后,应用比色法测定肺组织中的iNOS的含量,应用高效液相色谱仪测
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定肺组织中的AT P,TAN的量.
【结果】(1)各组肺组织中iNOS含量比较,4个组的肺组织中iNOS含量有差异(F=26.38,
P<0.05),与1组(对照组)比较,2,3,4组肺组织中iNOS含量均低于1组(P<0.05);4组iNOS
含量低于2,3组(P<0.05 );2,3组之间肺组织中iNOS含量无明显差异(P＞0.05).(2)各组肺
组织中AT P含量比较,4个组的肺组织中AT P的含量有差异(F=47.42, P<0.05),与1组(对照组)
比较,2,3,4组肺组织中AT P的含量均高于1组(P<0.05);4组AT P的含量高于2,3组(P<0.05 );
2,3组之间肺组织中AT P的含量无明显差异(P＞0.05). (3)各组肺组织中TAN含量比较,
4个组的肺组织中TAN的含量有差异(F=23.22, P<0.05),与1组(对照组)比较,2,3,4组肺组
织中TAN的含量均高于1组(P<0.05);4组TAN的含量高于2,3组(P<0.05 );2,3组之间肺组
织中TAN的含量无明显差异(P＞0.05).
【结论】1.在LPD液中加入NTG或异搏定能减少移植后肺组织中iNOS的含量,且联合应用
的效果优于单独应用.2.在LPD液中加入NTG或异搏定能增加移植后肺组织中腺苷酸的含量,且
联合应用的效果优于单独应用.
关键词 肺移植,硝酸甘油,异搏定,诱生型一氧化氮合酶,腺苷酸
【Objective】 Add Nitroglycerin and Verapamil in low-potassium-dextran (LPD) solution, we
observe the contents of iNOS,ATP and TAN in different lung tissues , and evaluate the protection effect .
【Method】 Native-bred canines of either sex (weight 14-16 kg) were paired by weight. 20 canines
served as donors and 20 canines each served as recipients for the lungs. We separate them into 4 groups,
each groups has 5 pairs. (1)Control group, we only use LPD solution to protect the donor lung ; (2)
Nitroglycerin group, we add Nitroglycerin in the LPD solution; (3) Verapamil group, we add Verapamil in
the LPD solution ; (4) Experimental group, we add Nitroglycerin and Verapamil in the LPD solution.
Anesthesia was induced by intramuscular injection of pentobarbital sodium(30mg/kg), then we put the
endotracheal tube into the trachea. Animals were ventilated with a tidal volume of 15 ml/kg and a
respiratory rate of 15-20 breaths/min at FiO2 of 1.0 with an animal ventilator. Donor Procedure: In the
right-sided position, a left antero-lateral thoracotomy was performed through the fourth intercostal space.
After incision of the mediastinal pleura and pericardium, upper and lower caval veins and right pulmonary
artery were dissected free from surrounding tissues. Systemic heparinization (3mg/kg), was given by
intravenously, then we ligate the upper and lower caval veins. Turn-off the ventilator , A cannula was
inserted into right pulmonary artery and fixed by a tourniquet. The lungs of the different groups were
flushed with different cold lung protection liquid(0-4oC) by gravitation, with a constant height of 40 cm
H2O ,The flushing procedure was started after an incision of the left auricle, thus permitting the effluent to
emerge into the thorax. When the lungs turn into white and the effluent turn into clarification,we stop
flushed with the cold lung protection liquid. The lungs were deflated and the heart-lung bloc was removed.
Put the bloc into the cold lung protection liquid, the lungs were reinflated and the trachea was
cross-clamped, cut, and submerged under the solution. The heart was dissected and the donor lung bloc was
immersed in fresh cold lung protection liquid and stored for 6 hr at 0-4°C.Recipient Procedure: Single-lung
transplantation was performed in the right-sided position, a left antero-lateral thoracotomy was performed
through the fourth intercostal space. The mediastinal pleura and pericardium was incised and a tourniquet
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was placed around the left pulmonary artery. After pneumonectomy, heparin(1.5mg/kg) was administered
intravenously, and implantation commenced with the bronchial anastomoses, followed by the pulmonary
arterial and left atrial anastomoses. Before we open the right pulmonary artery, Prednisolone(80mg) was
administered intravenously. The graft was ventilated and reperfusion started. The chest wall was closed
with towel clamps.After 2 hr reperfusion, a potion of lung tissue was resected. we observe the contents of
iNOS,ATP and TAN in different lung tissues.
【Results】 (1)The content of iNOS: The contents of iNOS in contral group are higher than other
groups(p<0.05). The contents of iNOS in Experimental group are lower than group 2 and 3(p0.05). (2)The content of ATP: The contents of ATP in
contral group are lower than other groups(p<0.05). The contents of iNOS in Experimental group are higher
than group 2 and 3(p0.05). (3) The content
of TAN:The contents of TAN in contral group are lower than other groups(p<0.05). The contents of TAN in
Experimental group are higher than group 2 and 3(p0.05).
【Conclusion】 (1)The low-potassium-dextran with Nitroglycerin or Verapamil can reduce the
content of iNOS in the donor lung tissues, and the result is better when we add both Nitroglycerin and
Verapamil in the LPD liquid .(2)The low-potassium-dextran with Nitroglycerin or Verapamil can improve
the content of ATP and TAN in the donor lung tissues, and the result is better when we add both
Nitroglycerin and Verapamil in the LPD liquid.
Key words Lung transplantation,Nitroglycerin Verapamil, Inducible nitric oxide synthase ,
Adenine nucleotid
胸腔镜肺癌切除纯腔镜手术新模式易化操作(附20例报告)
New procedure of thoracoscopic lobectomy for lung cancer faciliate operation.
刘伦旭,蒲强,吴艺根,等
四川大学华西医院胸外科,成都610041
Abstract
【Purpose】To investigate the more feasible procedure of thoracoscopic lobectomy for lung cancer.
【Method】From may 2006 to August 2007,the lately developed new manipulation of thoracoscopic
lobectomy was applied in 20 cases of lung cancer.
【Result】18 operations were completed with this technique.Two procedures were converted to
minithoracotomy for dense adhesion of lymph nodes.One pulmonary artery injury was repaired without
conversion of incision.The operation time was 120-200min with average of 150min.Operation bleeding
was 10-500ml with average of 150ml.Number of lymph nodes resected was 7-22 with average of
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12.Postoperative hospital stay was 6-9 days with average of 7.5 days.
【Conclusion】The improved manipulation of thoracoscopic lobectomy for lung cancer optimized the
operative processes,and made it more feasible and more acceptable.
胸腔镜技术用于肺癌切除虽然逐渐被接受,但由于其技术要求高,操作难度大,以及患者肺裂
发育不全,要求淋巴结清扫等原因,在临床推广中应用并不广泛,特别是不辅助小切口,不撑开肋
骨的纯屏幕操作胸腔镜,掌握的医生更少.而对于合适的病例,如果能采用创伤少,美观,恢复快
的微创术式达到传统大开胸同样的切除范围,无疑会大大提高手术质量.近年国际上出现的胸腔镜
肺癌切除纯屏幕操作新模式,使手术操作易于进行,为此术式的广泛开展提供了技术支持.我们从
2006年5月—2007年8月利用此方法并根据国人特点有所改进,切除肺癌20例,现总结如下.
1.临床资料与方法
1.1一般资料
20例患者男8例,女12例,年龄38-75岁.平均52岁.病变部位:右上肺7例,右中肺3例,
右下肺2例,左上肺5例,左下肺3例.病理类型:腺癌18例,鳞癌2例.手术病理分期IA期(T1N0M0)
3例,IB期(T2N0M0)14例,ⅡB期(T2N1M0)2例,ⅢB期(T4N1M0)1例(胸腔种植转移).
1.2手术方法
1.2.1体位与切口设计 侧卧位,患侧上肢前举,术者站在患者的腹侧.胸腔镜镜孔选在腋中
线偏前第7肋间,约1.5cm;主操作孔以腋前线为中心约4cm,上叶切除在第三肋间,正对肺上静脉,
中下叶切除在第4肋间;副操作孔在腋后线偏后第8,第9肋间,正对单肺通气时下叶肺与隔面接
触点,此孔用于牵引肺,切割缝合器等进入,可容2个器械同时进入,长约2cm.
1.2.2肺叶切除操作流程
1.2.2.1右上肺叶切除 从副操作孔用腔镜环钳将右上肺夹持并向后卷起,显露右侧肺门前方.
用乳突拉钩将主操作孔皮下及肌肉组织撑开.通过主操作孔用电凝钩剥离右肺上静脉,其间用分离
钳或吸引器从副操作孔伸入协助.用常规直角钳绕过右肺上静脉,10号丝线绕线牵引.将肺牵引钳
从副操作孔换至主操作孔,向背侧推开右上肺,从副操作孔伸入2.5mm切割缝合器离断右肺上静脉.
此时右肺动脉干被显露,沿右肺动脉主干游离血管鞘膜,并游离出至右上肺的第一分支,丝线牵引
此分支,同法从副操作孔伸入切割缝合器离断.然后将上肺向下及向前牵引,电刀游离右肺门上,
后方,显露右上叶支气管,钛夹处理支气管动脉.用吸引头加电钩相互配合,游离上叶支气管下,
后方.10号丝线绕线牵引上叶支气管,同法从副操作孔伸入4.1mm或4.8mm切割缝合器,离断上
叶支气管.支气管离断后右上叶的其余肺动脉分支易于显露,游离后从主操作孔用4号丝线推结器
结扎2次.此时上叶的支气管,肺动脉,肺静脉均已离断,仅剩下肺裂部分.从副操作孔伸入环钳
将中下叶向下牵引,从主操作孔伸入环钳将上叶向上牵引,将切割缝合器从主操作孔伸入完成肺裂
部分的肺切除.
1.2.2.2 右肺中叶切除 将右肺中叶后向牵引显露右肺门前方,游离右肺中叶静脉属支并用切割
缝合器离断.游离中叶支气管,直角钳带10号丝线绕线牵引,用3.5mm切割缝合器离断.环钳从
副操作孔伸入向上牵引右肺中叶,游离右肺中叶的1-2支肺动脉分支,从主操作孔用4号丝线推结
器结扎并离断中叶肺动脉分支.然后用切割缝合器切开剩下的肺裂组织.
1.2.2.3 右肺下叶切除 将肺向上牵引,电刀切断肺下韧带,显露右肺下静脉,用切割缝合器从
主操作孔伸入离断右肺下静脉.从下方游离右下肺支气管至右肺中叶支气管分叉平面.然后将肺向
下牵引,游离出右下肺动脉的基底干和背段分支.依次从主操作孔伸入切割缝合器离断右肺下叶支
气管,肺动脉及肺裂肺组织.肺动脉分支可用丝线结扎.
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1.2.2.4 左肺上叶切除 将左上肺向后牵引,游离右肺上静脉,从副操作孔伸入切割缝合器离断
肺上静脉.将上肺向下牵引,显露左上叶肺动脉第一分支,适当游离.游离右上叶支气管,从副操
作孔伸入切割缝合器离断.夹住左上叶支气管残端将肺向上后牵引,此时可显露出左肺动脉干及至
左上叶的各分支,分别游离,丝线结扎.然后用切割缝合器离断肺裂肺组织.
1.2.2.5 左肺下叶切除 左肺下叶切除与右肺下叶切除步骤基本相同.先处理肺静脉,然后支气
管,肺动脉,最后肺裂.
1.2.2.6 淋巴结清扫 肺门,支气管淋巴结在行肺叶切除过程中可遇见,通过钝性推离,锐性
解剖及电凝等方式在处理肺叶各结构时同时切除.隆突下淋巴结切除:用环钳将肺在靠近肺门部全
部夹住,向前推移,显露出肺门后方及后纵隔.用电刀切开肺门后方奇静脉下方纵隔胸膜,显露支
气管分叉隆突部位.腔镜鼠齿钳夹住淋巴结,采用电凝烧灼,吸引头钝性推开,钛夹钳夹等方法切
除隆突下淋巴结.气管前腔静脉后淋巴结切除:将肺向下牵引,分离钳提起上纵隔胸膜,电刀沿上
腔静脉后方纵行切开,止于奇静脉.用吸引头从主操作孔伸入将上腔静脉向前内侧推开,以及将奇
静脉向下推开,鼠齿钳夹住腔静脉后软组织,分别沿上腔静脉后方及气管前方纵行切开纵隔软组织,
用鼠齿钳整块钳夹,电凝切除纵隔脂肪组织及淋巴结.淋巴结位于奇静脉后方较难处理时可离断奇
静脉.主动脉弓下淋巴结切除:将肺向下牵引,电凝切开纵隔胸膜,吸引头钝性推开主动脉弓下脂
肪组织,显露出淋巴结,鼠齿钳钳夹,电凝或钛夹处理切除淋巴结.注意避免损伤喉返神经.
2. 结果
全组无围术期死亡.2例因肺动脉周围淋巴结粘连难以游离中转10cm辅助小切口.1例术中游
离肺动脉分支时根部撕裂,镜下缝合,未中转切口.全组手术时间120~200min,平均150min.术中
出血10ml~500ml,平均150ml.淋巴结切除7-22枚,平均12枚.术后住院6-9天,平均7.5天.
3. 讨论
本组采用的胸腔镜手术并非是一种全新的术式,但与以前的腔镜手术相比,在切口设计,操作
流程上有重要改进,从而使得纯屏幕操作胸腔镜肺癌切除术更加容易施行,使高难度手术"简单化".
3.1 切口设计
与以前相比主操作孔设计偏前,偏上,正对肺上静脉(上肺叶切除时),对肺门结构的游离直
接而方便.副操作孔移至后下方,从此孔伸入的器械与肺门结构大致呈垂直关系,非常有利于切割
缝合器的置放,使支气管,肺静脉,肺动脉用切割缝合器离断时在方向调节上不至于"别扭".对较
小的肺血管分支,用推结器从主操作孔结扎容易进行.
3.2 操作流程
本术式操作流程主要特点为遵循肺静脉→支气管→肺动脉→肺裂的游离及离断顺序,相对于肺
门结构而言由表及里,层次游离.在处理完上一个解剖结构后下一个处理目标便被显露出来.操作
中避开了解剖叶间裂,不需在发育不全的肺裂中游离肺动脉,而把肺裂放在最后处理,这时已经没
有支气管和肺血管的干扰,用切割缝合器离断非常容易.而肺裂处理正是以前腔镜手术的难点,甚
至把肺裂发育不全列为腔镜手术中转开胸指征.应用此术式操作流程,能很好解决肺裂发育不全问
题.
3.3 淋巴结清扫
将全肺根部用环钳钳夹向前或向下牵引后,对淋巴结清扫部位如隆突下,气管前腔静脉后,主
动脉窗能很好地显示,通过电刀,钛夹,吸收头相互配合,清扫淋巴结并不困难.应用超声刀应是
不错的方法,有待下一步尝试.
3.4 手术适应征
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此术式仅适合于周围型肺癌.肿瘤(T)小于4-5cm,无重要结构侵犯.纵隔淋巴结(N)最好无
转移,但对于某一站孤立的转移淋巴结切除在技术上可行.应在增强CT片上仔细评估肺门,支气
管周围淋巴结,此部位肿大淋巴结会对手术造成困难.肺裂发育不全对手术影响不大.其它原则遵
循腔镜手术及肿瘤手术适应征.
腔镜手术除需要常规开胸手术的熟练技术外还需要熟练的腔镜器械操作及屏视操作技术.但有
时手术的难度并非来自术者的操作不熟练,而是受限于手术流程设计不合理,这种手术本身的固有
缺陷会限制手术的开展.本文描述的胸腔镜肺癌切除流程,优化了切口设计及操作步骤,且基本能
做到每一个步骤程序化,使手术变得容易,相信会为此技术更加广泛的开展提供帮助.
胸腔镜手术切除周围型实性肺动脉血管瘤一例报道
Successful thoracoscopic resection of solitary peripheral pulmonary artery aneurysm: A case report
卢建志 Chien-Chih Lu*, Yun-Hen Liu, Hui-Ping Liu
Department of general thoracic surgery, Chi Mei Medical Center Liou Ying Campus, Tainan, Taiwan*
Division of thoracic and cardiovascular surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
Peripheral aneurysm of the segmental pulmonary artery is a rare vascular anomaly and associates in a
wide variety of conditions, such as congenital weakness of the arterial wall, infection, trauma, pulmonary
hypertension, cystic medial necrosis and generalized vasculitis. When operation is indicated, central lesions
involving the pulmonary trunk usually need cardiopulmonary bypass and peripheral aneurysms in
segmental intrapulmonary arteries have been managed most frequently by lobectomy, but occasionally by
aneurysmectomy and pulmonary artery repair, especially in patients with limited respiratory reserved.
Minimal invasive therapy such as transcatheter embolization using wire coils has been proposed in some
cases also but video-assisted thoracoscopic resection was rarely discussed. Here we report a case of
31-year-old woman with solitary peripheral pulmonary artery aneurysm which was found incidentally
treated by thoracoscopic wedge resection.
A 31-year-old woman was noted to have a solitary pulmonary nodule over left low lobe by routine
chest x ray before admission. There were no fever, no productive cough, no hemoptysis, no body weight
loss and no chest pain. From chest x ray findings, the mass was a smooth, discrete coin-sized lesion at left
low lobe. It had remained unchanged in size during follow up. The medical history was unremarkable.
Computed tomography of chest showed an homogenous contrast-enhanced ovoid mass with smooth margin.
She was referred to our clinics for tissue proof and thoracoscopy examination was arranged.
Left three ports VATS approach was planned for mass evaluation first. Under thoracoscopy, a
intra-pulmonary pulsatile mass was noted to protrude from the segmental branch of pulmonary artery over
left low lobe. The mass was soft in consistency, size about 1.5 cm and pulsatile movement disappeared
obviously when the base been clamped by ring forceps. Dark reddish blood was noted by fine needle
aspiration of the mass. Solitary peripheral pulmonary artery aneurysm was highly suspected and wedge
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resection by endoscopic vascular staples was performed after multiple tries to get adequate margins. The
post-operative course was smooth without complications.
Historically, a cystic dilated arterial aneurysm with irregularly thickening or thinning of the vascular
wall away from the resection margin was noted. The adjacent lung parenchyma showed mild interstitial
fibrosis and no evidence of a mycotic or inflammatory process could be found.
电视胸腔镜引流治疗下行性坏死性纵隔炎
Is Video-assisted Thoracoscopic Drainage an Optimal Approach for Descending
Necrotizing Mediastinits
吕宏益 Hung-I Lu, Hsu-Ting Yen, Ming-Jang Hsieh, et al
Department of Cardiothoracic Surgery , Chang Gung Memorial Hospital, Kaohsiung, Taiwan
【Purpose】 Descending necrotizing mediastinitis is a rare but lethal disease. Aggressive surgical
approach has been emphasized but the optimal form of mediastinal drainage remains controversial.
【Materials and Methods】 This retrospective report reviews the experience in 8 patients with severe
deep neck infection associated with descending necrotizing mediastinits ( involved the posterior and lower
mediastinum ) who had underwent surgical treatment in the past 5 years at out institution. Surgical
treatments consisted of cervical drainage combined with unilateral or bilateral mediastinal drainage via
thoracoscopic exploration.
【Results】 The outcome was favorable in 7 patients except one patient died of uncontrolled sepsis. All
patients underwent one cervical drainage and another mediastinal drainage via thoracoscopic approach, two
of them had bilateral thoracoscopic drainage. All post-operative chest roentgenogram did not show residual
empyema. But one of them developed delayed loculated empyema due to pulmonary atelectasis required a
second limited thoracotomy for adequate drainage. Another one patient with liver cirrhosis received
repeated thoracoscopic drainage of residual hematoma. All survived patients recoverd well after a follow
-up of 6-60 months without residual infection.
【Conclusion】 In our limited experience, video-assisted thoracoscopic drainage is a feasible and
effective as a less invasive approach for initial surgical drainage of descending necrotizing mediastinitis
when applied early. But in critically ill patients, delayed empyema formation due to post-operative lung
atelectasis should be mentioned.
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继发性气胸的外科治疗
Secondary Pneumothorax: How well are we doing it
吕明宪 Ming-Shian Lu, MD
Div. of Thoracic & Cardiovascular Surgery Chang Gung Memorial Hospital, Taiwan
【Objective】To determine the surgical outcome of patients with secondary pneumothorax.
【Material】Form January 2003 to July 2007, 27 patients with secondary pneumothorax undergoing
surgical treatment were reviewed retrospectively.
【Results】There were 26 males (96.3%), raging in age between 16 to 81 years (median= 61.48 years).
The underlying lung condition was chronic obstructive lung disease, 23 patients; pulmonary tuberculosis,
11 patients; bronchiectasis, 1 patient and radiation pneumonitis, 1 patient. Twenty-one patients were current
or past smokers. The indication of surgery was prolonged air leaks, 19 patients (70.4%), collapsed lung, 6
patients (22.2%) and contralateral pneumothorax history (7.4%). According to the predominant location of
bulla; right upper lobe, 66.7% (n=18); whole lung, 18.5% (n=5); left upper lobe, 11.1% (n=3) and right
lower lobe, 3.7% (n=1). Surgical procedure included bulla ablation, 17 patients (63%); lung wedge
resection, 7 patients (25.9%), and combined bulla ablation/wedge resection, 3 patients (11.1%). The mean
follow up was 20.70 months. The mean operation time was 1:28 hours. The type of pleurodesis included
mechanical, 63% (n=17), pleurectomy, 7.4% (n=2) and chemical pleurodesis in one patient (3.7%). The
intensive care unit length of stay and hospital length of stay were 3.25 and 10.14 days respectively. Nearly
thirty percent of patient (n=8) required post-operative mechanical ventilation for more than three days. The
morbidity and mortality rate was 37% and 11.1% respectively.
【Conclusion】Surgical treatment for secondary pneumothorax carries an acceptable morbid-mortality
risk; however, the post-operative respiratory rate is high.
电视胸腔镜脓胸的治疗
Video-assisted thoracic surgery in the treatment of pyothorax
马金山,杨勇伟,李先锋,等
新疆维吾尔自治区人民医院胸外科
随着电视胸腔镜技术的广泛应用,因其具有安全,微创,有效的优点,几乎应用于胸外科的各
个领域.脓胸是胸腔镜治疗理想的适应症之一.我院于1996年3月~2007年4月应用电视胸腔镜共
治疗脓胸105例,效果良好,报告如下:
1.临床资料与方法
84
1.1 一般资料 1996年3月～2007年4月,共有105例确诊脓胸患者在我科接受电视胸腔镜手
术治疗,其中男性78例,女性27例;年龄6-78岁,平均45.6岁;肺炎引起42例,外伤继发感染
29例,结核性脓胸30例,其他原因4例;急性脓胸60例,慢性脓胸45例;88例为局限性脓胸,
17为全脓胸,病程10-65天.术前均行胸部X线,CT及B超检查,行胸腔穿刺证实为脓胸,病例
选择标准:全脓胸,局限性脓胸,脓胸呈多房性或胸腔引流不畅者.
1.2 方法 术前准备同常规开胸手术,备开胸器械.均采用静脉复合全身麻醉,双腔气管插管,
取健侧卧位,根据术前影像学检查取脓腔最低位或腋中线第六,七肋间,做一个1.5厘米横行切口,
逐层切开皮肤,皮下组织,钝性分离肋间肌后进胸,先用手指钝性分离粘连.如为脓腔渗出期,则
只需再切一个1-1.5厘米小切口,置入吸引器吸尽脓液,用卵圆钳或吸引器打破脓腔分隔,钝性分离
粘连带,较粗粘连带可用电凝钩烧断,再用卵圆钳或抓钳清除脓苔纤维分隔及坏死组织.若肺表面
纤维板已形成,可用大弯钳先撕一点致正常肺组织,由此点进一步扩大剥离范围,对难以分离者则
在胸腔镜引导下做一个长约5-8厘米小切口,在镜视或直视下清除脓苔及纤维分隔,用手指,纱布
球辅以常规器械将脏层胸膜纤维板剥离切除,以盐水纱布压迫创面止血,在镜视下对较严重渗血部
位进行电凝或结扎止血.用生理盐水冲洗胸腔并鼓肺,观察肺膨胀及漏气情况,对少许肺表面漏气
可不予处理,若漏气较重,可用1号线行U形缝扎.再用生理盐水及甲硝唑冲洗胸腔,于胸腔镜切
口置胸腔引流管,对于有肺表面漏气者同时置上胸管,结核性脓胸患者术后正规抗结核治疗6个月.
2.结果
85例行胸腔镜下脓胸清除引流术,17例行胸腔镜辅助小切口纤维膜剥离术,3例中转开胸.手
术时间50~160分钟,平均70分钟;出血量30～200毫升;胸腔引流7~360天,平均2 0天;胸腔
引流量500-2100毫升,平均700毫升;术后住院天数7-22天,平均15天,105例手术术后随访6-24
个月,平均12个月,无脓胸复发及并发症发生.
3.讨论
脓胸病理生理学上分为:(1)急性渗出期(2)亚急性纤维化脓期(3)慢性纤维脓肿期,临床
上将前二期称急性脓胸,后者称慢性脓胸[1].胸部X线,CT及B超检查,有利于脓胸分期和发现
包裹性脓胸,多房性及肺表面纤维板形成,有效指导临床工作.
电视胸腔镜手术具有切口小,出血少,痛苦轻的优点,可以清除及取出坏死组织及打通分隔,
在胸腔镜引导下将引流管放置在最恰当位置,同时经胸腔镜直接找到脓胸原因,明确病因诊断,并
可在术中直接去除病因,可取得良好的效果.但我们认为,胸腔镜手术并非适用于各期脓胸,并非
所有的脓胸都需要行胸腔镜手术治疗,急性渗出期和亚急性纤维化脓期可行电视胸腔镜手术治疗,
若胸腔镜剥离有困难,则行胸腔镜辅助小切口下行纤维板剥离,在直视下可获得极佳的手术视野,
操作接近于常规开胸手术,大大降低手术难度,慢性纤维脓肿期因肺纤维板增厚,粘连致密不宜行
胸腔镜手术,而需要开胸手术治疗.化脓性脓胸胸腔镜手术时间在发病2～6周为宜.胸腔镜脓胸清
创引流术后,根据药敏试验合理使用敏感抗生素,同时加强营养支持,鼓励患者咳嗽,咳痰,吹气
球以促使肺复张及闭合脓腔,对于结核性脓胸患者术后给予正规的抗结核治疗.
85
胸腔镜胸腺切除术治疗重症肌无力120例临床报告
Video assisted thoracoscopic Thymectomy (VATT) for Myasthenia Gravis with
Clinical reports on 120 cases
马山,李建业,于磊,等
首都医科大学附属北京同仁医院胸外科,北京,100000
【目的】探讨胸腔镜胸腺切除术治疗重症肌无力的可行性和术后疗效.
【临床资料】 自2002年2月至2007年1月120例胸腔镜下行胸腺切除并清除前纵隔区域及颈根
部的异位胸腺和脂肪组织治疗重症肌无力.男47例,女73例,年龄13-71岁(平均30.6岁) Osserman
分型:Ⅰ型(眼肌型)72例,Ⅱ型 31例(Ⅱa型24例,Ⅱb型7例),Ⅲ型14例,Ⅳ型3例.合
并甲亢9例,视神经炎5例,AchR抗体 79例>2.99 mol/L,41例<2.99 mol/L;术后病理诊断:胸腺
瘤14例(良性11例,恶性3例), 胸腺囊肿3例,单纯胸腺增生86例, 胸腺萎缩5例,正常胸腺2
例.
【方法】双腔气管插管,静脉复合气管吸入麻醉.以术前胸部CT片胸腺分布特点决定经右胸
或左胸手术入路.右侧胸腔入路取左侧45°卧位, 以腋中线 第5肋间隙切口作为镜孔, 腋前线第3
肋间及第5肋间各做2cm切口为操作孔.于上腔静脉-右心房交界处向上剪开纵隔胸膜,游离并保护
膈神经并分离胸腺右叶外缘,清理上腔静脉-右乳内静脉前后的脂肪组织,将右叶上极自颈根部游离
出,并显露左无名静脉;剪开胸骨后纵隔胸膜,将胸腺整片游离达胸腺左叶下极, 清理或切除对侧
胸膜后转向上沿左侧肺门游离胸腺左叶.沿右无名-上腔-左无名静脉解剖出胸腺静脉1-4支,分别予
以切断,自颈根部仔细游离牵出胸腺左叶上极,清理周围1-2-3组脂肪组织.继续自左肺门游离直至
将整个胸腺切除. 清理主-肺动脉间隙的4-5-6组脂肪-异位胸腺,向下清除心包周7-8-9组脂肪以免
异位胸腺组织残留.成人患者加颈部切口行气管前第10组脂肪清理.
【结果】 无手术中及术后死亡.全组中116例完全在电视胸腔镜下手术完成(108例经经右胸
入路12例经左胸), 4例中转开胸手术完成(3例因胸腺瘤部分与上腔静脉或无名静脉粘连紧密,1
例左无名静脉损伤).平均手术时间 2小时06分钟 ,平均胸腔引流2-3天,平均术后住院时间9天.
全部病例术后均更换鼻插管回监护病房呼吸机辅助通气(2.99 mol/L,82例 4 Lh6 7p¨" 7(M-6 7\/24 / E YGM-6 7(M-6 x ("… -x7\/24 )¨Jq /
6 7N 4ì~ 6 P| 4 Lh6 7p¨Jq tJ / 6 7N UJ { (" U) , #
) E' {6 7p E@ $/ ~" 7(-·AEM-6 * 6 7NM-6 ¨JoJ K` ~ N\F…$
/ J UE'+( 7N U~' 7 6 7N" U *" ¨ 7 N\F…^+( 7N U¨!8E /
^ # L811-64 '1104 !4 Lh6 6~4 4 ~ # L8 ) d~
3. 4§ p
0.05 4 ·:+ ~ ><4 _MG'<4 )[(CSR%)48%¨ )[E'88.71%¨ II^III^IV_!¤EW¨4
2 P',P 0.45^0.047'0.016, _MG'<5~6 7Nr*ó 6 7N!7^6 7N9 4 4 K¨!¤EW*ü 2 P'¨P 0.00'0.47,
6 7Nr*ó,X+ CSRE'45.4%¨ )[E'87.5%~ p ,X6 7N!74 CSR 27.8%¨
)[44.4%¨'5 K¨ :+ ~
4. A|A
MGFA4 4 2003H 6 7N L8 4 2O 1^4 N\ L8~ '= ×T-1a'T-1b¨2^
6 7(K0 L8~ '= GVAT S'VATET×T-2a'T-2b¨3^4 6 P| L8~ '= ×T-3a
'T-3b¨4^4 N\-6 P|6( L8T-4~A :5 AxT-3b'T-46 óE''H L86 7N !6 7N
89
的要求,收到理想术后效果.Jaretzki在主张扩大胸腺切除时,列举了15例 经T-1a 和 T-3a手术术
后复发患者,在其行经颈-胸骨联合切除T-4的二次手术中均发现有残存胸腺组织,其中的13例术后
取得了良好效果.而T-1 和 T-2手术的支持者认为他们在减少并发症的同时也可以完全地切除胸腺
及异位胸腺组织.
国外屡有学者尝试对经颈,经胸骨,"扩大"胸腺切除术的死亡率,好转情况及远期效果进行比
较,却由于病人年龄,药物治疗情况,病程及评定标准等诸因素的差异,终无法得出全面而权威的
结论,但均认为三种术式效果基本相似,对任何一种术式的选择都是比较合理的.近些年随着胸腔
镜微创技术的发展,世界各国的胸外科医生对胸腔镜下胸腺切除产生越来越浓厚兴趣.但同时也给
人们留下一个疑问,单纯胸腔镜下胸腺切除是否能达到良好的显露前纵隔及颈根部,完整切除胸腺,
彻底清除前纵隔及颈根部内异位胸腺及脂肪组织的目的.
我院自1991年至2001年底,采用经胸骨正中劈开胸腺切除术治疗重症肌无力(非胸腺瘤)209
例,术后随访到161例(胸骨劈开组);自2002年初至2003年5月,采用胸腔镜行胸腺切除治疗重
症肌无力43例(胸腔镜组),见表1.经χ2检验两组患者性别,手术时年龄,术前临床分型无显著
差异.我们曾报道过胸腔镜下胸腺切除治疗效果的可靠性.手术中胸腔镜下能达到良好的显露前纵
隔及颈根部,完整切除胸腺,彻底清除前纵隔及颈根部内异位胸腺及脂肪组织,但手术时间相对较
长.本研究胸腔镜组平均手术时间132分钟,而胸骨劈开组为96分钟,二者差异有显著性.但事实
上,胸腔镜手术经适当改进手术器械和手术技能的熟练其时间仍可缩短.
胸腔镜胸腺切除术其特有的优越性主要表现在手术创伤和术后恢复上.胸腺切除术最严重并发
症(见表2)-肌无力危象的发生与手术对机体的损伤程度密切相关,而胸腔镜胸腺切除术避免了纵
劈胸骨所造成的创伤,从而避免或减轻危象的发生,在43例胸腔镜患者中仅4例出现肌无力危象,
与纵劈胸骨手术相比,差异有显著性(P=0.023).另外,胸腔镜手术创伤相对较小,呼吸和咳嗽排
痰时疼痛减轻,缩短了呼吸机辅助时间和减少肺部感染的发生.同样,ICU监护时间和住院时间也
相应缩短.
术后的疗效及能否达到完全稳定缓解是医患共同关心之所在.胸腺切除手术的有效性主要与胸
腺及周围脂肪组织切除量,病程,病人年龄,是否并生胸腺瘤等因素有关.本组T-2a组术后1,2,
3年的CSR分别是34.9%,41.9%和46.5%,从表面上看,较T-3a组的26.7%,31.7%,35.4%有明显
提高,但应注意到T-3a组患者基本上在1991年至2001间诊断治疗;而T- 2 a组的是2002年以后的
患者.不同时间段内的诊治水平所造成的差异在很大程度上影响了数据统计.EMG和螺旋CT技术
的应用提高了对重症肌无力诊断的准确性,特别是对症状不典型的重症肌无力.再者,患者对手术
接受情况也对术前病程产生影响.在我院手术的患者中,一半以上(尤其是年轻患者)不能接受胸
骨劈开的方法,而对胸腔镜的小切口,在不影响美观的情况下,为了治疗疾病,还是愿意行胸腺切
除术.术前病程胸腔镜组平均8.2个月,而胸骨劈开组则为16.7个月.病程的长短直接关系到神经
肌肉接头处Ach-R受体永久不可逆性损害程度,影响远期疗效.所以,尽管T-2a组术后的CSR较
T-3a组有提高,只能说胸胸腔镜下胸腺切除术治疗MG能取得同样较为理想的治疗效果,不仅可行
而且安全,但还不能认为胸腔镜胸腺切除术中远期疗效优于胸骨正中劈开.
一般来讲,MG患者胸腺切除术后随时间延长,手术效果越好.T-2a组患者1年到3年术后随
访CSR呈现提高趋势,而且达到CSR的患者无症状复发. T-3a组患者术后5年随访,CSR从术后
第1年的26.7%提高到40.4%,与国外相关研究结果相仿.故我们相信T-2a组CSR将随随访时间延
长,达到更为理想远期疗效.
从表4中可以看到I型MG较之II型,III型和IV型手术效果好.部分学者对无胸腺瘤的单
纯眼肌型病人不主张手术治疗.而另一部分学者则认为,胸腺切除对单纯眼肌型病人亦有效; 尽早清
除胸腺组织可阻断病情向全身型进展的倾向.本组98例眼肌型重症肌无力完全缓解率(CSR%)48%,
90
有效率达88.71%,尽管较之II型差异无显著性,但明显好于III型,IV型的60~70%有效率,差
异有显著性.故我们认为对单纯眼肌型患者应尽早手术治疗.
从表5中可以看到胸腺增生较胸腺正常,胸腺萎缩效果好.胸腺增生的病人术后CSR达45.4%,
有效率达87.5%.术后效果最差的是胸腺正常的MG病人CSR仅为27.8%,有效率为44.4%.胸腺
正常的MG病人术后效果最差原因有可能是:一,胸腺外因素的存在;二,往往临床上症状多系球
状肌无力,对胆碱酯能抑制剂效果不显,AchR血清抗体阴性,2001年前者缺此项,顾推测其中多
属Musk抗体阳性者亦或由于病程长而有胸腺外因素的存在;三,有可能存在诊断的失误,这是我
们一直强调治疗重症肌无力与神经内科合作的必要性.
总之,胸腺切除手术是治疗MG的重要手段,对MG病人诊断确立应尽早手术治疗,切除后可
结合激素或免疫抑制剂治疗.胸腔镜下胸腺切除术能取得胸骨正中劈开手术同样理想的中远期治疗
效果,但对于其 5年甚至更长的远期疗效则有待进一步观察研究.
电视胸腔镜手术治疗自发性气胸附56例报告
Tretment of Spontaneous Pneumothorax by Vodeo-assisted Minithracotomy
钱勇,罗化,袁跃西,等
湖南省长沙市中心医院胸外科,长沙,410004
【目的】探讨电视胸腔镜手术治疗自发性气胸的适应症,手术方法和疗效.
【方法】回顾分析56例自发性气胸的临床资料.本组男性50例,女性6例,平均年龄44.5岁.
其中双侧气胸2例,血气胸2例.首发病例24例,2次以上复发者32例,合并肺结核10例,合并
慢支肺气肿7例.全组均在双腔气管插管全麻下进行.置入胸腔镜全面观察胸膜腔的病变情况.对
胸腔内广泛粘连或VATS下难以发现漏气的病灶或肺大疱较多及巨大肺大疱,则采用VATS的改良
操作法.采用胸腔镜辅助小切口操作法(VAMT)切口,约6cm,配合常规开胸器械,完成胸内操
作.采用切割缝合器(Endo-G1A)切除肺大疱48例,结扎法处理肺大疱8例,同时行干纱布摩擦
壁层胸膜,使肺的脏层胸膜与壁层胸膜粘连,防止气胸复发,术毕放置胸腔引流管.
【结果】所有患者手术均顺利,平均手术时间80min,术中出血量70-180ml,术后置管时间3-10d,
拔管时间3.5d,无手术死亡例及继发胸腔出血例.1例多发肺大疱患者术后创面持续漏气,后并发
胸腔感染,经过处理后全组均治愈出院,平均住院时间9天.随访3个月-12个月,无复发病例.
【结论】电视胸腔镜手术治疗自发性气胸安全,可靠.
关键词 电视胸腔镜手术 自发性气胸 肺大疱
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42例巨大纵隔肿瘤的临床表现及外科治疗
Clinical presentation and surgical treatment of 42 big mediastinal tumor
邱宁雷,许 林,张 勤,等
江苏省肿瘤医院,南京,210009
ABSTRACT
【Objective】To discuss the clinic feature and the surgical treatment of huge mediastinal tumor.
【Methods】42 patients with huge mediastinal tumor were treated surgically from Jan.1997 to Dec.
2001.
【Results】 Among 42 patients, there were 31 patients with benign tumor, and a radical excision of
the tumor was performed in 30 patients; there were 11 patients with malignant tumor, and a radical excision
of the tumor was performed in 7 patients, part excision was performed in 4 patients. Postoperative
complications included postoperative re-expansive pulmonary edema (2 patients), breath failure (2 patients)
and bleeding in chest (1 patient). Postoperative death occurred in 2 patients, one was re-expansive
pulmonary edema and the other was breath failure, and the mortality was 4.76%.
【Conclusion】 The principles of treatment for huge mediastinal tumor is radical surgical excision,
and the choice of the incision is the key points to success. The technique of the segmental resection or
entire resection is available, the postoperative prevention of re-expansive pulmonary edema and breath
failure can increase the complete resection rate and decrease the mortality.
巨大纵隔肿瘤是胸部肿瘤中较罕见的病例,手术复杂,难度大,风险大.我科自1977年1月～
2005年12月间共收治纵隔肿瘤病人487例,其中直径大于10cm的巨大纵隔肿瘤42例,占8.62%,
均经手术病理证实,现报道如下.
回顾性总结自1977年1月～2001年12月我科收治的42例巨大纵隔肿瘤.其中男24例,女19
例;良性31例,恶性11例.良性肿瘤中,胸腺类肿瘤(12例),畸胎瘤(9例),神经源性肿瘤(7
例)较多.恶性肿瘤中,恶性胸腺瘤(4例),恶性畸胎瘤(2例),内胚叶窦瘤(2例)较多.临床
症状中37例有胸闷,胸痛,气短,呼吸困难等症状,27例伴肺部反复感染史,16例伴有低热,18
例有患侧胸壁隆起或饱满,21例气管向健侧移位.
所有手术均在全麻下进行.手术切口:(1)后外侧切口19例,(2)前外侧切口14例.(3)胸
骨正中纵劈切口4例.(4)横断胸骨切口4例.(5)胸骨正中纵劈+前外侧切口1例.31例良性肿
瘤中,完整切除30例;11例恶性肿瘤中,根治性切除7例,姑息性切除4例.术后合并症5例,
复张性肺水肿2例,呼吸衰竭2例,胸腔出血1例.术后死亡2例,复张性肺水肿及呼吸衰竭各1
例,死亡率4.76%.
结合国内外文献,我们倾向于将巨大纵隔肿瘤定义为直径大于10cm且在胸部侧位片上肿瘤占
据一个以上纵隔分区的纵隔肿瘤.影像学诊断中,常规透视与胸片是重要的检查筛选手段,但准确
率较低,仅为28.57%(12/42).胸部CT及MRI检查能清晰分辨纵隔肿瘤与气管,心脏大血管及食
管椎旁的关系,并能判断肿瘤对心脏大血管的外侵程度和范围,准确率较高,为81.81%(18/22).
巨大纵隔肿瘤手术成败的关键是切口的选择,我们认为手术切口应根据肿瘤部位而定:(1)局限一
侧胸腔的肿瘤以后外侧切口为宜.(2)位于前纵隔的肿瘤,若偏向一侧,宜用前外侧切口,若肿瘤
延伸到对侧,可横断胸骨,延伸切口.(3)对于突向两侧胸腔的肿瘤,可采用胸骨正中纵劈切口.
巨大纵隔肿瘤手术时不必强求完整切除,可行肿瘤分块切除或先行瘤内减压.对肿瘤巨大,长期压
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迫心脏大血管的病例,去除肿瘤时,应用手缓慢托起肿瘤,避免心跳骤停或心功能衰竭等情况的发
生;对与肺有粘连或侵犯的病例,可行部分肺,肺叶或一侧全肺切除.由于患侧肺长期受压,易引
起术后复张性肺水肿的发生.我们体会:(1)复张性肺水肿常发生于术后4-72小时.(2)术中,术
后缓慢复张受压肺,充分供氧,纠正低蛋白血症和低血容量,预防肺部感染等措施可预防肺水肿的
发生.(3)治疗上可采用强心,利尿,提高血浆胶体渗透压等方法.局部可行纤支镜吸痰,气管切
开,呼吸机辅助呼吸等措施.(4)若肺水肿保守治疗无效,并危及生命,可再次手术切除患侧肺.
巨大纵隔肿瘤病程长,临床症状复杂,不易判断良恶性,其他治疗方法效果不佳,积极手术切
除是治疗原则.该病手术难度较高,术前详细检查,充分准备,术中仔细操作,可提高手术切除率
并降低死亡率.
胸腔镜治疗自发性气胸临床分析
The clinic analysis of treatment of spontaneous pneumothorax by video-assisted
thoracoscopic methods.
邵立新,金 炜,袁 军,等
上海中山医院青浦分院,上海,201700
【目的】 探讨胸腔镜技术在治疗自发性气胸患者中的应用和围手术期的处理.
【方法】 本组患者共58例,其中男性56例,女性2例,平均年龄48岁.都有自发性气胸经
胸腔插管引流后无好转,左胸51例,右胸7例,其中有6例合并有自发性血胸,术前胸部CT检查
肺尖部有肺大泡存在.放入胸腔镜操作器械,先分离肺与壁层胸膜的粘连,找到肺大泡,用切割吻
合器钳夹后作切除,用生理盐水冲洗胸腔.对60岁以上的患者可采用胸腔内喷洒消毒滑石粉,以作
胸膜固定术,而对年青患者则可采用壁层胸膜磨擦的方法来固定胸膜,防止术后复发.
【结果】 本组病人经胸腔镜切除肺大泡治疗,肺复张良好,3天后拔除胸管,均治愈,自发
性血气胸者行胸腔镜下用钛夹钳夹出血处或加电凝止血,用切割吻合器切除肺大泡,吸尽胸内积血,
无其他并发症发生.
【结论】 胸腔镜在治疗自发性气胸中有许多优点,值得在临床推广应用.
关键词 胸腔镜 自发性 气胸 临床分析
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局部麻醉下经电视胸腔镜和小切口开胸诊治胸膜,肺疾病
Clinical Application of Minithoracotomy and Video-Assistanted Thoracic
Surgery(VATS) on pleura-pulmonary diseases under Local Anesthesia
宋言峥,江南,王萍 等
河南省胸科医院胸外科,郑州,450008
【目的】探讨局部麻醉下经电视胸腔镜和胸部小切口诊治胸膜肺疾病的可行性.
【方法】自2000年2月到2005年3月,对30例胸膜,肺疾病患者实施了局部麻醉下开胸手
术.术中按手术的不同将病例分为2组:小切口开胸组和电视胸腔镜组,小切口开胸组是在局部麻
醉下利用胸部小切口在开放性气胸状态下对增厚的胸膜和弥漫性肺疾病进行活检;电视胸腔镜组在
局部麻醉下经电视胸腔镜在闭合性气胸状态下诊治恶性胸水,复发性气胸等.
【结果】小切口开胸组胸膜活检13例,其中10例为恶性肿瘤胸膜转移,胸膜淀粉样变1例,
胸膜纤维增生样改变2例;弥漫性肺疾病活检3例,3例中间质性纤维化2例,Ⅱ型肺结核1例.电
视胸腔镜组14例中除1例因发现胸腔内有致密粘连,而行全麻下开胸手术外,其余均在局麻下完
成胸膜活检,复发性气胸肺大疱切除,顽固性胸水的胸膜固定术电视胸腔镜组中诊断性胸腔镜诊断
恶性胸水4例,肝性胸水1例;治疗性胸腔镜10例,其中顽固性(含肝性胸水)胸水行胸膜固定
术8例,复发性气胸行肺大疱切除和胸膜固定术2例.全组患者无手术并发症和死亡.
【结论】局部麻醉下经电视胸腔镜和小切口能够完成胸膜肺疾病活检术和简单的手术.该方法
经济,微创,对麻醉要求低,有利于临床普遍开展.
关键词 胸膜肺活检术,电视胸腔镜,局部麻醉,小切口
电视胸腔镜食管癌切除术
Video-assisted thoracoscopic esophagectomy for esophageal squamous carcinoma
谭黎杰 王群 冯明祥 等
复旦大学附属中山医院胸外科 上海 (200032)
【目的】总结电视胸腔镜食管切除术的临床经验.
【方法】2004年6月至2007年8月共有29例食管癌患者行胸腔镜食管切除术,男性21例,女
性8例,平均年龄57.3岁,食管中段癌24例,食管下段癌4例,术前分期为0期(原位癌)2例,
I期10例,IIA期17例.胸腔镜游离食管清扫淋巴结后,开腹游离胃或结肠,行食管胃或结肠吻合.
【结果】27食管切除后管状胃代食管,2例行结肠代食管术.术后吻合口瘘4例,心率失常2例,
肺部感染1例,肺损伤1例,并发症发生率27.6%,无死亡病例.平均手术时间4.1h,出血量175ml,
平均胸管置管时间2.6天,住院时间平均8.2天.
【结论】电视胸腔镜食管切除术在技术上是安全可行的,可以减少患者的手术创伤,具有广阔的
应用前景.
94
关键词 食管癌;电视胸腔镜;食管切除术
【Purpose】To summarize the clinical experience of video-assisted thoracoscopic esophagectomy for
treatment of esophageal squamous carcimona.
【Methods】 From June 2004 to July 2007, video-assisted thoracoscopic esophagectomy was performed
in 29 patients.There were 21 men, 8 women.Median age was 57.3 years (range,37-72).The tumor located at
middle segment in 24 cases and lower segment in 4 cases. Preoperative assessment showed stage 0
(cTisN0M0) tumor in 2 cases,stage Ⅰ(cT1N0M0) in 10 cases,and stage Ⅱa(cT2N0M0 and cT3N0M0) in
17 cases.Surgical procedures inclduded thoracoscopic resection of the esophagus with lyphnodes dissection
combined with mobilization the stomach or colon by open laprotomy.Anastomosis were made at the neck.
【Result】Operative morbidity was 27.6%(anastomtic leak 4 case,atrial fibrillation 2 cases,pneumonia 1
case,acute lung injury 1 case), no perioperative mortality.The mean operatve time was 4.1 hours, hospital
stay was 8.2 days(range,6-12).
【Conclusion】Video-assisted thoracoscopic esophagectomy is technically feasible and safe, lower
morbidity and shorter hospital stay compared to open procedure. It has the potential to replace open
esophagectomy in selected patients.
Key Words Esophageal carcinoma; video-assisted thoracscopic surgery; Esophagectomy
VATS lobectomy: From LMTV to LVATS
王群 WANG Qun
Department of Thoracic Surgery, Zhongshan Hospital, Shanghai, 200000,China.
【Objectives】 Summarize our experience of VATS lobectomy. Compare two methods of VATS
lobectomy: LVATS and LMTV.
【Materials and Methods】 From June 1995 to July 2007, 139 cases of VATS lobectomy were
performed in our hospital. LMTV were performed in 58 cases, and other 81cases were treated by LVATS.
Indications for VATS lobectomy included: early stage NSCLC and some lung benign disease
(bronchiectasis, aspergilloma, pulmonary tuberculosis, pulmonary sequestration and lung cyst).
【Results】 Four cases were converted to open thoractomy. Median operation time was 145min and
average operative blood loss was 110ml. For non small cell lung cancer patients, average 11.3(3-38)
mediastinal lymph nodes were dissected. One case died following VATS lobectomy from acute respiratory
distress syndrome (ARDS), 30-day mortality rate was 0.7%. 19 cases had complications after VATS
lobectomy, including pneumonia ,air leakage , atrial fibrillation and bleeding, average morbidity rate was
95
13.7%. Median hospital stay after operation was 6 days. A significantly lower incidence of postoperative
pain and less analgesic requirement occurred in the LVATS group than in the LMTV group.
【Conclusion】 VATS lobectomy is a safe procedure with low morbidity and mortality. For lung
cancer patients, complete nodal dissection is possible with VATS procedure. We believe this technique
should become the operation of choice for early stage NSCLC and some lung benign disease.
胸腔镜支气管动脉夹闭治疗咯血:1例报道
Thoracoscopic Bronchial Artery Clipping for Treatment of Hemoptysis - One Case Report
吴星贤 Hsing-Hsien Wu, M.D.; *Chang-Hung Chen, M.D.
Department of Surgery, *Department of Internal Medicine, Tainan Municipal Hospital, Tainan city, Taiwan
【Introduction】
Hemoptysis especially life-threatening hemoptysis is a challenging issue in thoracic surgery. Till now
bronchial artery embolization (BAE) and surgical pulmonary resection are the main options of
managements. We report a case who received thoracoscopic bronchial artery clipping for treatment for
hemoptysis, which was recurred after BAE.
【Method】
The 52-year-old patient was a case of bronchiectasis under stable status, but he had been suffered from
mild hemoptysis for times in recent years. In October 2006, he developed one episode of moderate amount
hemoptysis and received BAE for treatment of hemoptysis. In January 2007, the hemoptysis was recurred.
This time we performed thoracoscopic bronchial artery clipping to treat hemoptysis. The procedure was
approached via three ports (one 10mm, two 5mm) video-assisted thoracic surgery (VATS). Under video
vision we identified the kinked bronchial artery near the hilar area via interlobar space and occluded the
blood stream by endoscopic clips (Pic.1).
【Results】
The procedure was performed smoothly and the blood loss was minimal. The chest tube was extracted
2 days later. The length of day was 4 days. The postoperative angiography revealed total occlusion of the
kinked bronchial artery at the interlobar level (Pic.2). There was no complication developed and
postoperative recovery was uneventful. Till now the patient was followed up to be not recurred.
【Conclusions】
The thoracoscopic bronchial artery clipping is an effective minimal invasive surgical procedure for
treatment of hemoptysis. This procedure is more effective than bronchial artery embolization and less
invasive than pulmonary resection. Rather than BAE and pulmonary resection, the procedure may become
another option in treatment of hemoptysis.
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The roles of tumor-infiltrated macrophages, CD4+CD25+ regulatory T cells and apoptosis in the
microenvironment of lung cancer
吴怡成 Yi Cheng Wu, Yen Chu DVM, Hui Ping Liu
Div. of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Lin-Kou, Taiwan
【Background】 In non-small-cell lung cancer (NSCLC), stage of the disease is still the most
important prognostic factor. Other than stage, many biological markers and many other prognostic factors
are studied to define their effects on prognosis of lung cancer. This study examined the relation between
tumor-infiltrating macrophagess (TIM), tumor-regulatory T cells (Treg), as well as apoptosis to determine
whether they correlated with 5-year survival.
【Patients and Methods】In our tissue databank, the identified 45 consecutive pathologic stage Ia to
IIIa NSCLC patients who had surgical resection in 2001 were enrolled in this study. Immunohistochemical
analyses and Western blot were performed on liquid nitrogen-preserved lung tumor tissue and the relation
among Treg, TIM, and apoptosis were determined.
【Results】In our survival cases (55.56%, 25/45), the levels of TIM specific marker CD-68 and Treg
were significantly higher in stage IIIa patients. The expressions of Bcl-2/Bax and active caspase-3 and
PARP may be involved in an intrinsic apoptosis pathway. In our survival cases, the levels of Bcl-2/Bax
were found up-regulated whereas the levels of caspase-3 and PARP were significantly lower in stage IIIa
patients.
【Conclusions】 Patients with stage IIIa NSCLC who have a higher proportion of TIM and Treg had
a significantly higher survival rate. Higher expressions of anti-apoptosis protein implicated better survival.
Keywords tumor-infiltrated macrophages, CD4+CD25+ regulatory T cells, apoptosis, lung cancer
胸腔镜辅助微创漏斗胸矫正术治疗体会
Experience on the treatment of funnel chest via video-assisted mini-invasive surgery
肖开提,王小雷,努尔兰,等
新疆维吾尔自治区人民医院胸外科,乌鲁木齐,830001
漏斗胸是一种常见的先天性胸壁畸形,除了畸形造成的精神负担和性格影响以外,畸形本身对呼
吸和循环功能的损害也需要手术纠正.传统的漏斗胸矫正手术存在切口大,影响美观,损伤胸壁肌
肉及骨性支架,患者术后疼痛明显,影响胸廓活动度,恢复慢等弊端,Nuss手术应用胸腔镜微创技
术及特殊支架,符合外表美观,创伤小,恢复快的要求,在严格掌握适应症的前提下,与传统手术
相比,达到了相同,甚至更好的手术效果,应合了目前外科手术发展趋向,具有很强的实用推广价
值.国内2003年前后引进该技术并在少数几家医院开展,我院在2006年9月率先在新疆引进"Nuss
97
手术"技术并应用于临床,取得满意的效果.
1.资料与方法
1.1 一般资料 病例5例,男4例,女1例,年龄5~13岁,漏斗指数(FI)为0.21~0.25,漏斗部容水量
为50~100ml.
1.2 临床表现 患儿家属诉自小发现前胸部畸形,随着年龄的增长,畸形越发明显.幼儿常反复
呼吸道感染,有一例活动后感心悸,气短.五例均未发现其它脏器合并畸形.
1.3 辅助检查 胸片可见肋骨后部平直,前部向前下急倾下降,心影向左侧胸腔移位,右心缘
与脊柱重叠,心影中部可见放射状半透明区,2例患者伴有脊柱侧弯.侧位胸片及CT可见胸骨体明
显向后弯曲.2例患者心电图示不完全性右束支传导阻滞,心脏彩超检查五例均未见异常.
1.4 手术方法
手术适应症 接受Nuss手术的患者应符合下列条件中的2项或2项以上.(1)肺功能检查示限
制性或阻塞性通气障碍;(2)伴有二尖瓣脱垂,右束支传导阻滞;(3)畸形程度进展且症状进行性加重;(4)
胸骨抬举术后复发的患儿;(5)Nuss手术后复发的患儿;(6)有患儿及家属精神因素,有强烈矫正愿望.最
佳适应症为年龄在6~12岁,广泛对称性的漏斗胸,尤其是合并扁平胸者.该五例患者均有明显手术
指征.
术前准备 测量漏斗指数及胸廓横径,评估凹陷程度.据此选用合适的特制钢板并弯曲成弓状,
弧度与预抬举高度一致.在钢板拟行通过的胸骨凹陷最低点及起始点以及切口处用亚甲蓝标记.
手术步骤 气管插管,全身麻醉,采用胸腔镜直视下胸骨后钢板置入胸骨抬举法(Nuss技术).
根据凹陷程度在双侧腋中线第3,4肋间或第4,5肋间做横切口2.5cm,肌下游离至同侧凹陷边缘.
右腋中线第7,8肋间Ve r e s s针穿刺入胸腔,注入CO2建立气胸,使右侧肺萎陷.拔出Ve r e s s针,切开
约2cm长切口,置胸腔镜.直视下,从右侧切口将引道器由右侧凹陷边缘第3,4肋间刺入胸腔,经
胸骨后凹陷最低点,心包前至对侧凹陷边缘穿出.将弓形支架用细绳系在引道器头部的孔上,后退
引道器将支架拖到胸骨后,细绳相连处经右侧切口出胸膛,翻转支架使弓背向上,将胸骨撑起.胸
腔镜下观察胸腔内无出血,无其它脏器损伤,撤除胸腔镜,支架右端上固定器,使局部呈T字形,用
尼龙线将支架缝合固定在胸膜上,左端也用同样的缝合方法固定好后缝合肌层及皮肤.右胸腔第7,
8肋间置胸腔引流管,包扎伤口,术毕.
术后处理 术后心电监护,呼吸机辅助呼吸,常规拔除气管内插管,系统抗炎,雾化,支持治
疗,并定时观察胸管引流量,性质变化.术后平卧1~3天,避免扭转及屈曲活动,完善胸片检查,
观察钢板的位置.术后三个月内尽量不要进行对抗性运动,支架在体内保留两年以上.
2.结果
5例患者行Nuss手术治疗后均获得良好的效果,术后第三天下地活动,术后7~10天恢复出院.
患者及家属均满意矫正效果.手术切口与传统术式相比明显缩小,术中出血量约50ml,明显低于传
统术式(约200~300ml)[4].本术式微创,对机体影响小,与传统术式相比,在严格掌握适应症的前
提下,达到同样,甚至更好的预期效果,适应美容美观的要求.术前,术中,术后对比照片如下:
3.讨论
3.1漏斗胸是一种先天性并常常是家族性的疾病,属伴性显性遗传,男女之比为4:1.大多数
人认为漏斗胸是由下胸骨部肋软骨及肋骨发育过度,胸骨代偿性地向后移位而形成的畸形.患儿常
因胸廓畸形,心肺受压,肺功能降低,表现为活动耐力差,肺活量低,易发生心悸及呼吸道感染,
严重影响小儿生长发育,同时影响外观.因漏斗胸对心肺功能及体型外观均有影响,主张早期手术
98
治疗,专家认为6~12岁为手术最佳时期[3,5],也有人主张只要看到明显的畸形,无论年龄大小都应
立即手术[5].传统的手术方法有肋骨成型术,胸骨抬高术,胸骨肋骨抬高术,胸骨翻转术等,需取
前胸部切口,切断肋骨,胸骨及游离胸壁肌肉皮瓣,对机体损伤较大,较不易被患者及家属接受.
1998年美国人Nuss首先介绍了无骨切除矫正治疗小儿漏斗胸的方法,Nuss在胸腔镜辅助下进行的微
创矫正小儿漏斗胸的方法(Nuss手术),与传统术式相比,具有切口隐蔽,手术时间短,出血少,活
动早,不需要游离胸壁肌肉皮瓣,不需肋骨或胸骨的切除,长期保持胸部伸展性,扩张性,柔韧性
和弹性等优点,为漏斗胸患者的治疗创立了一个崭新的思路.有文献报道,148例Nuss手术与76例
传统术式进行对比,随访两组发现,术后一年内,2年内及取支架后,患儿及家属满意度均无显著
性差异的前提下,Nuss组平均手术时间,术中出血量,术后引流量,下地活动时间,术后平均住院
天数均优于传统手术组[1,2,5].但同时需指出,Nuss手术与传统手术相比,术后并发症发生率较高,
文献报道可达10~67%左右[6],主要有气胸,胸腔积液,肺不张,术后钢板滑动和旋转,排异反应等.
但作为一种崭新的术式,我们认为随着经验的积累,并发症一定能下降(本组五例患者术后恢复较
顺利,术后未出现明显近期并发症).6~12岁是Nuss手术矫正漏斗胸的最佳时机,广泛对称性的漏
斗胸尤其是合并扁平胸是Nuss手术的最佳选择.凹陷重的局限型漏斗胸及严重不对称的漏斗胸应选
择传统术式.只要我们能掌握好手术指征,汲取经验教训,逐步在临床推广Nuss手术,定能为广大
漏斗胸患者带来福音.
3.2 Nuss手术由于具有微创,美观,恢复快等优点而得到推广应用,但其需要使用特制的价格
昂贵钢板(全套费用约2万元)及配套工具,全部治疗费用约3万元左右,昂贵的费用限制部分患
儿接受此手术,目前国产矫形钢板正进行上市准备,届时费用将有大幅度下降.随着社会经济的不
断发展,人民生活水平的改善,将会有更多的患者能够接受此手术.
自体腹直肌皮瓣移植治疗慢性难治性脓胸:附4例报告
Transplantation of rectus abdominis musculocutaneous flap after open-window
thoracostomy to manage chronic refractory pleural empyema and fistula with 4 cases
report
谢博雄 姜格宁 董佳生* 等
上海市肺科医院胸外科 *上海市第九人民医院整形外科,上海,200433
【Objective】To report a new method of using rectus abdominis musculocutaneous flap after
open-window thoracostomy to manage refractory chronic pleural empyema.
【Method】 From 2004.11 to 2007.3, Intrathoracic transplantation of the musculocutaneous flap was
performed successfully in 4 patients with empyema and fistula after upper lobectomy. The rectus abdominis
myocutaneous flap were designed in such a way that the muscles were not only bearing skin paddle but
epigastrica vessels connecting thoracodorsalic vessels.
【Results】 The rectus abdominis myocutaneous flap has provided sufficient bulk for tract
obliteration. Over a mean follow-up period of 10 months, two patients are free of further infectious squeal
99
and muscle atrophy.
【Conclusion】 It is a new and effective method that transplantation of rectus abdominis
musculocutaneous flap after open-window thoracostomy can manage chronic refractory pleural empyema
and fistula.
Key words Chronic refractory pleural empyema; Rectus abdominis musculocutaneous flap;
Open-window thoracostomy; transplantation
表现为肺部实性肿块的肺癌与活动性肺结核并存病例报告
Retrospective study of coexisting lung cancer and active pulmonary tuberculosis patients presenting
as asolitary or mutiple lung mass
谢敏璋 Ming-Jang Hsieh, Hsu-Ting Yen, Hung-Yi Lu, et al.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery
Chang Gung Memorial Hospital at Kaohsiung, Taiwan, R. O. C.
【Purpose】 Pulmonary mass on a chest radiograph is common. High-risk cancer patients may
require surgical resection. Occasionally, lung masses, clinically diagnosed as lung cancer are evaluated to
be tuberculoma or coexisting cancer and tuberculosis (TB). In this study, we evaluated presentations of
lung mass/nodule(s) to identify specific clinical presentations. And excluded scar cancer.
【Material and Methods】 We retrospectively chart review since 1995-2003 there were 15 patients
received surgical intervention and pathological prove coexisting lung cancer and pulmonary tuberculosis
with acid-fast bacilli positive, in the same patient. Charts were reviewed for demographics, clinical
presentation, laboratory and radiographic findings, and outcome.
【Results】 In the patients who were identified coexisting lung cancer and pulmonary tuberculosis
were relative younger and male predominant. There was a predominance of squamous cell carcinoma in the
patient group. Upper lobe involvement was found radiographically in 70% of patients. All patients received
complete coarse of anti-TB drug therapy at preoperative or postoperative time. Some of them received the
operative chemotherapy at the Department of Oncology or chest service.
【Conclusion】 Patients with concurrent lung cancer and pulmonary tuberculosis presented at a
significantly younger age. There was a predominance of squamous cell cancer in the group with concurrent
disease. Early diagnosis for this group patient is difficult. Especial if the patient revealed bilateral lung
masses maybe considered lung-to-lung metastasis and upgraded then arranged chemotherapy, miss the
opportunity for early surgical treatment.
100
电视胸腔镜手术治疗气管源性食管囊肿:7例报告
Video-assisted thoracoscopic surgery (vats) in bronchogenic cyst of the esophagus:
clinical and imaging features of seven cases
谢敏璋 MING-JANG HSIEHa, SHEUNG-FAT KOb, JUI-WEI LINc, et al.
a Department of Cardiovascular and Thoracic Surgery, Chang Gung University, Chang Gung Memorial
Hospital at Kaohsiung, Taiwan
b Department of Radiology, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, Taiwan
c Department of Pathology, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, Taiwan
【Purpose】 Bronchogenic cysts are one of the most common bronchopulmonary malformations. The
unusual location and uncommom in Esophagus. Limited number reports concerning intramural
bronchogenic cysts of the esophagues.
【Materials & Methods】 From 1987 to 2005, a total seven cases of surgical proven Esophageal
bronchogenic cyst were collected Female: Male=6:1; mean age, 29.9 years. Such cases were characterized
by dysphagia and chest pain. Clinical image: Radiographs and computed tomographs typically appears 3 to
4 cmmidthoracic cystic masses close abutting to the mid-third esophagues. Total cyst excision by
Video-Assisted Thoracoscopic surgery.
【Results】 Clinical features & images showed three cystic lesion at upper asygosophageal recess
level two in lower retrotracheal, and two were asymptomatic. During surgery, submucosal esophageal
masses that originated from the right side of mid-third esophague in five patients. One in left
hemidiaphragm and oneprotruding into left lower lung. Six cases were resection by VATS smoothly long
term follow without recurrence.
【Conclusions】 Different from mediastinal or pulmonary bronchogenic cyst, Esophageal
bronchogenic cyst predominately affect young women. A 3-4 cm midthoracic cystic mass presents with
Dysphagia & Chest pain. VATS be tried before thoracotomy total cyst excision has shown satisfactory
outcomes for this uncommon disease.
脓胸手术病患利用APACHE II 计分系统及危险因子的评估
Apache ii scoring system and risk factors of surgical management for thoracic empyema
谢明儒 Ming-Ju Hsieh, Hui-Ping Liu, Yi-Cheng Wu, et al.
Division of Thoracic & Cardiovascular Surgery, Chang Gung Memorial Hospital, Taiwan
【Objective】 To evaluate the surgical result, APACHE II scoring system and risk factors of patients
with thoracic empyema.
【Design】 Retrospective chart review.
101
【Setting】 A 3,000-bed, university-affiliated urban teaching hospital
【Patients】 Between May 2003 to May 2004, 79 patients with empyema thoracis who were
surgically treated were retrospective evaluated.
【Measurements and results】 All patients have tried surgical intervention including total
pneumonolysis and evacuation of pleura empyema cavity. APACHE II scoring system and factors that may
influence the outcome were analyzed. This group included 63 men and 16 women with an average age of
53 years. The causes of empyema include: parapneumonic effusion (n=65), lung abscess (n=1), malignancy
(n=3), cirrhosis (n=1), esophageal perforation (n=1), post traumatic empyema (n=4) and post thoracotomy
complication (n=4). In-hospital mortality rate was 6.33% (5/69). The mean follow up was 6 months.
【Conclusions】 We present the clinical features and outcomes of 79 patients with empyema thoracis
who underwent surgical treatment. The surgical mortality was 6.33% and significant APACHE II scoring
parameters and risk factors as below: Biopsy proven cirrhosis: P=1.23, COPD: P=0.009<0.01, CV disease:
P=0.123, chronic hemodyalysis: N/A, Immune compromise: P=0.129. The other significant parameters are
blood pressure P=0.000 <0.001. heart rate: p=0.000<0.001, and total score of APACHE II: p=0.003<0.05.
We suggested APACHE II score and some parameter are predictable risk factors of empyema and surgical
treatment of empyema thoracic should not be delay due to acceptable postoperative complications and
mortality.
手术切除的I期非小细胞肺癌病人中人乳头瘤病毒16/18的E6癌蛋白的表达
Expression of E6 oncoprotein of human papillomavirus 16/18 in patients with resected
stage I non-small cell lung cancer
许南荣 Nan-Yung Hsu1, Ya-Wen Cheng2, Heng-Chien Ho3, et al
1Division of Chest Surgery, China Medical University Hospital, Taichung, Taiwan
2Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
3Department of Biochemistry, College of Medicine, China Medical University, Taichung, Taiwan
【Background】 Our previous reports have indicated that human papillomavirus (HPV) 16/18
infection were more frequently dectected in non-small cell lung cancer (NSCLC) of nonsmoking Taiwanese
women.
【Methods】 In this study, we analysed a series of 222 patients with resected stage I NSCLC for the
present of E6 oncoprotein of HPV 16 and 18 by using immunohistochemistry.
【Results】 Our data showed that 50 (22.5%), 33 (14.9%) and 64 (28.8%) of 222 patients had
expression of E6 oncoprotein of HPV 16, 18, and 16 or 18, respectively. When study subjects were
stratified by gender, age, smoking status, histology, tumor status, and differentiation, data showed that
female patients, nonsmoker and adenocarcinoma had significantly high prevalence of expression of E6 of
HPV 16, 18, and 16 or 18. The odds ratio of expression of E6 oncoprotein of HPV 16 or 18 of female,
102
nonsmoker and adenocarcinoma is significantly higher at 2.983 (95% confidence interval, 1.613-5.516,
p<0.0001) than male; that of nonsmoker is significantly higher at 2.483 (95% confidence interval,
1.297-4.753, p<0.05) than smoker; and that of adenocarcinoma is significantly higher at 3.198 (95%
confidence interval, 1.632-6.264, p3.0cm的食管平滑肌瘤,摘除后缝合食管肌层及纵隔
胸膜,对于较小的食管平滑肌瘤,摘除后不缝合肌层及纵隔胸膜,随访67个月,无发生食管憩室形
成.
【结论】电视胸腔镜手术治疗食管平滑肌瘤符合小手术,小切口的要求,为首选治疗方法.
关键词 电视胸腔镜手术 食管平滑肌瘤
原发性淋巴上皮瘤样肿瘤:一例报告
Primary lymphoepithelioma-like carcinoma of the lung : a case in which the patient was
free of recurrence nine years postoperatively.
曾繁颖 Kevin Fan-Ying Tseng, Ming-Sung Yang, Jean-John Fu
Division of Thoracic Surgery, Department of Surgery, Cheng-Hsin Rehabilitation Medical Center, Taipei
City, Taiwan
Primary Lymphoepithelioma-like carcinoma (LELC) of the lung is a very rare disease. It was first
reported on 1987. In the past decades since it was discovered, very little long term follow-up data reported.
As from the reported literature, this uncommon disease has a predilection among young Asian nonsmokers
without gender distinction. The histological feature of the tumor is indistinguishable from undifferentiated
nasopharyngeal carcinoma and the carcinogenic role of latent Epstein-Barr virus infection make this tumor
predominately in Asian population as compare to Caucasians. We encountered a case of a 57 year-old
female who was admitted into our service in August of 1998 due to dry cough and dyspnea for three
months. Chest x-ray was suspected of malignant lung tumor over right lower lobe. The patient received
right lower lobectomy on the September of the same year. The pathological diagnosis was confirmed of
LELC of the lung with pathological stage to be T2N0M0-Stage IB. The patient's tumor cells were negative
for EBV as examined with immunohistochemical analysis. Postoperatively, the patient received regular
follow-ups and was free from tumor recurrence during these years. We reported this case for its rarity and
the EBV negative nature of the tumor.
105
非小细胞肺癌前哨淋巴结扫描活检术的临床研究
Clinical Research on the Technique of Sentinel Lymph Node Biopsy In Patients with
NSCLC
曾亮,倪旭东,王群,等
复旦大学附属中山医院胸外科,病理科,上海,200032
Abstract
【Background & Objective】 The metastasis status of regional lymph node is an important
prognostic factor of non-small-cell lung cancer (NSCLC). Sentinel lymph node (SLN) mapping and biopsy
is a quick and high efficient technique to intraoperatively detect occult micrometastatic disease, however,
its application in NSCLC is immature. This study was designed to investigate the feasibility of detecting
SLN in patients with NSCLC using 99mTc colloid and a hand-held gamma detection probe (GDP) during
radical surgery, and to evaluate its accuracy of predicting metastasis status of regional lymph node.
【Methods】 The study was carried out on 24 patients (M/F/11/13, mean age 64.98 years) with
resectable NSCLC (StageⅠ-). After thoracotomy, a total of 2 ml 99mTc sulfur colloid was injected into Ⅲ
each quadrant of lung tissue immediately surrounding the tumor (3, 6, 9, 12 o'clock sites) with a total dose
of 2mCi. All SLNs were detected and obtained with a hand-held gamma counter (GDP). And then a
systematic mediastinal and hilar lymph nodal dissection were performed on each patient. All lymph nodes
were first analyzed by HE staining, and sect serial sections combined with CK19 immunohistochemical
(IHC) staging was used to detect the micrometastic tumor cells in HE staining negative lymph nodes.
Statistical analysis was performed using spss.
【Results】 The SLN was successfully identified in all of 24 no-small cell lung cancer patients;
detection rate was 100% (24/24). 50 SLNs and 143 NSLNs were found of 24 patients, 31 nodes were found
to have metastases disease in 50 SLNs, and 27 nodes were found to have metastases disease in 143 NSLNs.
The possibilities of SLNB and systematic lymph nodal dissection remove pathologically positive nodes
were 62% (31/50), 30.1%(58/193), respectively (P '<6 7(K0 6 L8 J# ¨4§# " +ks M2 4 6 6 , 10
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112
探查.如果发现可疑纵隔淋巴结或肺,胸膜转移和播散结节,冰冻病理证实为恶性,应及时调整手
术诊治方案.
B. 肺门的解剖
若有胸腔粘连,应在肺门处理前彻底游离,以便于灵活牵拉肺组织暴露肺门结构.叶裂不全不
是胸腔镜手术的反指证,可以在尽可能处理肺门血管甚至支气管后,予以自动切割闭合器闭合离断.
胸腔镜下无法触摸肺门血管,需要依靠术者对手术器械头端的感觉.常规手术剪刀,钳子和电刀轻
巧易掌控,是我们作为肺门血管解剖游离的主要器械.血管充分游离后,可以使用自动切割闭合器
闭合离断血管,也可以在安全前提下尽可能经切口使用推结器结扎血管后离断,降低手术器材费用.
支气管的游离也如同常规手术,残端多使用相应的自动切割闭合器闭合离断.残端闭合的完整性通
过注水于胸腔,气道加压鼓肺后证实,若有漏气,应在胸腔镜下使用常规缝线缝合加固.我们对肺
门结构和肺裂处理原则顺序并根据术中实际解剖结构,在安全的前提下进一步灵活应变操作.
C. 淋巴结切除
胸腔镜下的淋巴结切除相对操作困难,但优良的术野照明及放大效果是其优势所在.在打开纵
隔胸膜清扫纵隔淋巴结时,应注意多使用钛夹预防性地钳夹淋巴结周围组织,防止支气管动脉出血
和术后淋巴瘘.清扫右侧最上纵隔淋巴结和左侧主动脉弓下淋巴结时注意避免喉返神经的损伤.对
于胸腔镜手术中可疑淋巴结转移并经冰冻切片证实的情况,转为常规开胸手术.
D. 标本的取出
除了避免胸腔镜手术切除中对肿瘤的挤压外,较小的标本可经切口直接取出,而较大的标本均
应在胸腔内置入手套中经小切口拔出,避免小切口对肿瘤的挤压.手术完成后,在反复冲洗胸腔及
切口后,放置胸管和缝合切口.一系列措施是为了尽可能避免肿瘤在胸腔内或切口的种植.
2.结果
10例肺癌手术均在完全胸腔镜下完成,无1例中转常规开胸手术,手术时间91~211分钟,平
均178分钟.手术切口长度3～4厘米,平均3.6厘米.左胸平均清扫淋巴结4.63组,右胸平均清扫
淋巴结6.79组.术中出血量50~200ml,平均92ml,1例因术后发现右上叶支气管旁支气管动脉分支
出血再次胸腔镜探查止血外,余病例均未输血.术后住院天数3~10天,平均4.8天.全组除1例再
次止血外,无其他并发症.
3.讨论
3.1 完全胸腔镜下能完成解剖学肺叶切除 我院完全胸腔镜肺癌手术病例均对肺血管和支气管
分别进行离断结扎.肺裂的广泛粘连不是VA M T肺叶切除术的反指征,我们采取先处理肺血管和支
气管,然后用胸腔镜用自动切割闭合器处理肺裂,利于避免肺门血管损伤,清晰解剖肺裂,严密缝
合余肺创面,避免术后漏气.
3.2 完全胸腔镜下能完成系统淋巴结清扫 可切除非小细胞肺癌手术治疗的金标准:切除所在
肺叶外,必须清扫胸内相关引流淋巴结及其他区域肿大淋巴结,以达到根治和标准术后分期的目的.根
据2005年国际肺癌学会(IASLC)建议的肺癌手术根治标准,除了切除至少3个以上的肺内或肺门
淋巴结外,还至少切除来源于纵隔的3个淋巴结: (a)右上,中叶肺癌—须切除隆突下淋巴结和上纵隔
中的至少两组淋巴结;(b)右下叶肺癌—须切除气管支气管,隆突下淋巴结和下肺韧带淋巴结(或
食管旁淋巴结);(c)左上叶肺癌—主动脉弓下,隆突下和前纵隔淋巴结;(d)左下叶肺癌—隆突下,
食管旁和下肺韧带淋巴结.除肺门和肺内淋巴结外,纵隔淋巴结清扫在右胸应至少包括第2,4,7～
9组,在左胸应至少包括第5,6,7～9组.在充分保证手术安全的前提下,左胸平均清扫淋巴结4.63
组,右胸平均清扫淋巴结6.79组,符合系统清扫的要求.
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3.3手术时间 有学者认为胸腔镜下手术操作困难,有可能因延长手术时间而削弱胸腔镜微创价
值.虽然胸腔镜下手术操作相对困难,但由于开关胸时间短以及使用自动切割闭合器,多数报道胸
腔镜肺癌手术时间与常规开胸并无显著差异.我们的胸腔镜手术时间约在3小时以上,参照以往我
们的常规开胸经验,虽然胸腔镜肺癌手术时间较长,但随着经验的增长积累,我们相信能进一步缩
短手术时间.胸腔镜学会建议如果由于胸腔广泛粘连,钙化淋巴结与肺门血管粘连紧密等因素,胸
腔镜手术时间将有显著延长可能时,术者应果断判断并及时中转为常规开胸手术.
3.4 手术安全性 综合以往较大宗胸腔镜肺癌手术病例报道,手术死亡率在0～2%,极少是由
于术中无法控制的大出血死亡.Yim指出使用自动切割闭合器闭合血管失败仅是偶发事件,胸腔镜
器械发展至今应是安全可靠的,即使血管闭合处有轻度渗血,可以在胸腔镜下进一步缝合加固.我
们的1例病例术后须再次止血,究其原因是支气管旁支气管动脉分支出血,再次手术中发现该分支
残端残留自动切割闭合钉,但闭合不佳.我们分析是手术中是使用自动切割闭合器一并处理支气管
及其动脉分支,但由于支气管和支气管动脉分支管径相差悬殊,导致动脉分支闭合不良.今后应注
意手术中充分游离及处理支气管旁组织,术毕仔细探查支气管残端及其周围组织有无出血.
3.5 术后恢复 胸腔镜手术切口长度明显小于常规手术,术后平均住院时间4.8天,而常规开
胸手术多在9天以上,具有显著差异,间接表明由于完全胸腔镜下肺叶切除术创伤小,疼痛轻,早
期肺功能损伤少,术后恢复更快.
3.6 符合美容要求 完全胸腔镜手术切口疤痕小,符合现代美容需求.
3.7 费效比 胸腔镜肺癌手术中大量自动切割闭合器的使用无疑大大增加手术费用,这是制约
这项微创手术在我国开展的重要因素.如前所述,我们可以在安全的前提下使用常规缝,结扎技术
处理肺门结构,以降低耗材的使用.但是如果完全分叶不全,胸腔镜下仍多依赖自动切割闭合器完
成叶间裂的分离闭合.有日本学者报道胸腔镜肺癌手术的住院费用低于常规手术,可能与发达国家
术后住院,监护等日均费用较高有关.
3.8 我们使用的特殊器械值得推广 我们将常用的胸腔镜用肺钳(弯把)改为直把,以适应大
多外科医师操作习惯,易于入门医师的掌控,缩短胸腔镜手术的适应时间.临床外科手术特别是肿
瘤外科手术中须常规清扫淋巴结,这已达成共识,在实际操作中通常运用某种器械钳夹淋巴结再予
以切除,但是目前钳夹淋巴结的器械多为Allis钳,血管钳或镊子等,操作中非但难以牢固钳夹淋巴
结及其周围疏松脂肪组织,反而容易切割,挤压淋巴结,破坏摘除淋巴结的完整性,不利于手术切
除的迅速进行和正确的病理诊断,胸腔镜下肺癌手术更增加了淋巴结清扫难度.我们的淋巴结摘除
钳特别便于手术中对淋巴结钳夹,有助于降低手术清扫难度.
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·上一篇：胸腔灌洗加闭式引流治疗急性脓胸的护理体会
·下一篇：冬季是前列腺增生症状加
Needlescopic Video-Assisted Thoracic Surgery and minocycline pleurodesis for the
Treatment of Primary Spontaneous Pneumothorax
陈晋兴 Jin-Shing Chen, Hsao-Hsun Hsu, Pei-Ming Huang, et al.
Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National
Taiwan University College of Medicine.
【Background】 Previously we have shown that needlescopic video-assisted thoracic surgery (VATS)
is feasible and produces less pain and better cosmetic results than conventional VATS in treating primary
spontaneous pneumothorax (PSP). In addition, we also use additional minocycline after VATS to decrease
ipsilateral recurrence. In this study, we report our results of needlescopic VATS and additional minocycline
pleurodesis for the treatment of PSP.
【Methods】 Between April 2001 and August 2007, 200 patients (ages: 23.6 + 6.8 years, range: 15 to
48 years) with primary spontaneous pneumothorax underwent 212 needlescopic VATS procedures (188
unilateral and 12 bilateral) at National Taiwan University Hospital. The blebs were resected with
endoscopic linear staplers. Pleurodesis was achieved by pleural abrasion with additional minocycline
instillation.
【Results】 Mean operation duration for each procedure was 78 + 23 minutes. Complications
developed in 15 patients: prolonged air leaks in 12 patients and pleural detachment in 3 patients. The mean
postoperative hospital stay was 4.1 + 2.3 days. After a mean follow-up of 21 months, ipsilateral recurrence
of pneumothorax was noted in 5 patients (2.5 %).
【Conclusion】 Needlescopic VATS with minocycline pleurodesis is a safe and effective method for
the treatment of primary spontaneous pneumothorax.
肺移植治疗终末期肺病54例报告
Lung transplantation in the treatment of end-stage pulmonary diseases: 54 cases report.
陈静瑜 郑明峰 朱艳红 等
江苏省无锡市胸科医院肺移植中心, 无锡,214073
【目的】 对比国外开展肺移植情况,结合单中心经验,探讨我国目前临床肺移植主要存在的
问题及对策.
【方法】 2002年5月,我院成立肺移植团队,开展猪肺移植动物实验,在此基础上于2002年9月
至2006年12月我院共完成临床肺移植54例,其中男性45例,女性9例,年龄15-74岁,平均53
岁.受体术前均为重症呼吸衰竭,长期靠呼吸机依赖9例.术式及病种:单肺移植,包括肺气肿14
例,肺纤维化19例,矽肺2例,肺结核1例,肺淋巴管平滑肌瘤病1例及室间隔缺损合并艾森曼格
62
综合征4例.双肺移植13例,包括肺气肿6例,支气管肺囊肿4例,矽肺1例,肺结核1例,弥漫
性泛细支气管炎1例.
【结果】 术后短期住院内死亡9/54 (16.7%),死亡原因包括原发性移植肺功3例,严重感染4
例,急性排斥1例,肺梗塞1例.中位生存时间26.5(9-60)月.1,2,3年生存率分别是74.1%,
63.2% 和 52.6%,第一例病人目前生存5年,大部分病人生存质量良好,肺功能极大改善.
【结论】 本组肺移植的结果与国际发达国家的疗效相似,肺移植在我国新世纪会迎来一个快
速发展阶段,组建肺移植团队,多学科合作是肺移植手术成功开展,术后长期生存的关键;术后的
缺血再灌注损伤,排斥和感染仍是肺移植短期死亡的主要原因.
关键词 肺移植,终末期肺病
影响胸腔镜下成人漏斗胸矫正术疗效的因素分析
Analysis of factors that influence the therapeutic effect of chondrosternoplasty in the
adult under thoracoscope
陈周苗,王永清,何启才,等
浙江大学医学院附属邵逸夫医院心胸外科
【Objective】To evaluate the factors that influence the therapeutic effect of chondrosternoplasty in the
adult under thoracoscope.
【Methods】 Four adult patients received the chondrosternoplasty under thoracoscope.
【Results】 The four patients received five times of operation,some related complications occured in
two,and the other two recovered smoothly.
【Conclusion】The therapeutic effect of chondrosternoplasty in the adult under thoracoscope is related
with many preoperative,operative and postoperative factors.
Key words Thoracoscope Pectus excavatum Therapeutic effect Adult
漏斗胸(pectus excavatum)是属于先天性胸壁畸形常见的一种疾病.临床上常表现为前胸壁胸
骨中下部与其两侧肋骨异常向后弯曲凹陷呈漏斗样畸形.畸形严重者可影响循环和呼吸系统,如异
位心,反复上呼吸道感染,短暂性缺氧,反常呼吸等,轻者出现脊柱侧弯,驼背,凸肚等体形改变,
导致患者(尤其是青少年)精神消沉孤僻.所以大多数患者均是因为心理上的因素才去求医要求手
术.
胸腔镜下微创漏斗胸矫正术1998由NUSS.D开展,与传统手术相比具有创伤小,恢复快,矫
形效果与传统手术无差异等优点.在小儿病人中取得较大成功.但是在成人漏斗胸患者中的效果,
研究报道仍然较少.我院自2006年4月开展胸腔镜下微创漏斗胸矫正术,共诊治4例病人,就近期
效果及围术期并发症进行讨论.
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1.资料和方法
病例1 患者,男,20岁,因"挺胸后呼吸困难10余年,加重6月"入院.查体:一般情况良
好,胸骨中下部明显凹陷,深约6cm,于2006.4.7在全麻下行"胸腔镜辅助下漏斗胸矫正术",手术
疗效满意,术后第6天出院,于2006.5.14因"漏斗胸复发"再次入院.查体发现:胸骨下段凹陷,
深达3cm.X线检查发现矫形钢板移位.于2006.5.17再次行"胸腔镜辅助下漏斗胸矫正术",手术
顺利,疗效满意.术后第8天出院.术后1年复查未见异常.
病例2 患者,男,16岁,因"发现胸廓畸形10余年"收治入院.查体:一般情况良好,胸骨下
部明显凹陷,深达5cm.于2006.4.24在全麻下行"胸腔镜辅助下漏斗胸矫正术",手术疗效满意,
术后第4天出院.术后1年复查未见异常.
病例3 患者,男,17岁,因"发现胸廓畸形7年余"收治入院.查体:一般情况良好,胸骨下
部明显凹陷,深达4cm.于2006.7.31在全麻下行"胸腔镜辅助下漏斗胸矫正术",手术疗效满意,
术后第7天出院.术后1年复查未见异常.
病例4 患者,男,19岁,因"发现胸廓畸形10余年"收治入院.查体:一般情况良好,胸骨下
部明显凹陷,深达2.5cm.术前胸片提示:脊柱侧弯,于2006.8.3在全麻下行"胸腔镜辅助下漏斗
胸矫正术",手术疗效满意,术后第5天出院.术后1周回医院复查发现因疼痛出现强迫体位,X线
检查发现脊柱侧弯较术前加重.术后3月疼痛消失恢复正常行走姿势,术后1年复查脊柱侧弯恢复
至术前形状.
手术采用传统的NUSS手术方法,选用美国W.Lorenz公司的矫形钢板及其配套手术材料和器械.
患者仰卧体位,双上肢外展.标记漏斗胸最凹陷点附近的骨性组织为支撑点,漏斗状胸壁双侧的最
高点的肋间隙为插入点,并作冠状位水平测量,两端以腋中线后2cm为界;常规消毒铺单;测量胸
廓后作矫形钢板的塑形,根据矫形钢板的定位作双侧的胸壁切口,均位于腋中线前后约2～4cm长;
经切口在肌肉下分离出一个能容矫形钢板穿过的隧道直至插入点;在右侧切口下方间隔1个肋间的
腋中线水平作一观察孔置入胸腔镜,在胸腔镜的监视下经右侧隧道在插入点插入穿通器,在胸壁支
撑点和心包之间用穿通器钝性向左紧贴胸壁分离直至左侧的插入点,并从内穿透胸壁进入左侧胸壁
的隧道;在胸壁左侧用细带固定矫形钢板的一端和穿通器,将矫形钢板的弓面朝后,用穿通器缓慢
将矫形钢板拉过纵隔和右侧胸腔进入右侧的隧道;翻转矫形钢板180 使其弓面朝向前方;检查右侧
胸腔,确定没有出血后退出胸腔镜;在肌层下用固定片固定矫形钢板的两端并用钢丝捆绑;清洗双
侧切口,止血,缝合切口;经观察孔置入胸管,反复鼓肺充分排气后拔除胸管,缝合观察孔.
2.结果
本组患者共4例5次手术,首例患者因术后1月钢板移位行2次手术矫形;第四例患者术前伴
有脊柱侧弯,术后由于疼痛原因出现脊柱侧弯加重,3个月后疼痛消失,术后1年脊柱侧弯恢复至
术前形状;其余2例手术均顺利,无并发症发生.
3.讨论
由于我们开展的NUSS手术例数较少,无法用统计学方法加以统计,但是国内外大量的文献资
料早已证实NUSS手术的可行性和其较之传统的Ravitch改良胸骨抬举法有着明显的创伤小,美观,
并发症少,患者恢复快但疗效一致等优点.但是许多病例的年龄均在4~12岁之间,有关青少年和成
人的报道仍然较少.我们通过复习大量的国内外文献和结合自己的临床经验发现有如下并发症:矫
形不完全,心包,心脏破裂引起的大出血,气胸,矫形钢板移位,疼痛,切口感染等.现总结了一
些心得加以讨论影响NUSS手术的因素如下.
影响NUSS手术的一些因素主要分为术前,术中,术后三个方面.
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术前因素是指漏斗胸的畸形类型,程度和患者的年龄.1 HYUNG JOO PARK提出通过术前CT
对漏斗胸进行分型,漏斗胸主要分为对称型和非对称型.对称型的漏斗胸分为2个亚型,以胸骨和
两侧肋软骨的内陷为常见,以胸骨为中心,最内陷点常是胸骨下端或剑突.此类型术后的矫形效果
较好,出现术后矫形钢板的移位率比较低.而非对称型漏斗胸又分为5个亚型,多以胸骨侧斜,一
侧的前胸壁内陷为主,最内陷处并非胸骨下段,两侧的胸廓呈非对称型,这就使两侧的插入点不在
同一水平,因此术后矫形效果明显不尽人意,难以达到术前期望的效果.术前CT可以对对称及非对
称的亚型进行确认,根据不同类型的漏斗胸,尤其对于严重非对称型漏斗胸患者,矫形所应用的钢
板需要在术前行特殊塑型,以便矫形时应对解剖学上畸形最严重的位置,钢板固定应采用多点固定,
即在钢板末端上下,右胸骨外侧缘跨肋钢丝固定.本组4例患者均为对称型漏斗胸,术后矫形效果
满意.因此漏斗胸的类型是影响疗效的重要因素之一.2 漏斗胸的畸形程度使指漏斗胸的内陷程度
和范围.术前通过CT可以观察胸骨凹陷程度,通常使用CT漏斗胸指数b/a评价其严重程度,心脏翻
转角度以及双肺发育情况.近年来有人提出F2I指数表达凹陷程度,F2I=(a×b×c)/(A×B×C),
a漏斗胸凹陷纵径;b漏斗胸凹陷横径;c漏斗胸凹陷深度;A胸骨长度;B胸廓横径;C胸骨角到胸椎
前缘的最短距离.术后CT根据漏斗胸指数也可以帮助判断疗效.胸骨凹陷程度严重者术后对心脏和
肺的压迫明显改善,疗效显著.对于畸形范围较大的患者,建议采用"双钢板法"固定,否则凹陷
胸骨的抬举难以到位或者术后矫形钢板移位.3 患者的年龄也是影响手术疗效的一个因素.大量的
国内外文献报道年龄在4～12岁之间的儿童由于肋软骨长,骨质软便于矫形,而且小患儿对疼痛不
敏感,避免了术后疼痛造成获得性脊柱侧弯等不良反应,所以此年龄段内的儿童矫形疗效最好;而
成人由于胸壁的伸展性,柔韧性降低,加之畸形时间长,对心肺等脏器的损害和胸廓的发育已经造
成了难以挽回的后果,患者因手术并发症而再手术的机会增加,矫形效果相对较差.
术中因素是指手术中间一些不当的手术设计或操作手法所造成的不良结果或并发症.1 矫形钢
板型号的选择:目前矫形钢板的型号有8～17#,我们在术中要根据测量结果来选择合适的型号,
过长的钢板会导致术后钢板的两端过于靠后,将胸壁软组织顶离原本的位置,加剧术后疼痛甚至切
口积液,感染,组织坏死;过短的矫形钢板导致固定困难甚至移位.2 矫形钢板的塑形:我们在术
中根据测量的结果来进行矫形钢板的塑形,将钢板扳成和患者胸壁相同大小的弓形,中间的最凸点
刚好能在漏斗胸的最凹点,凸出处必须要有足够的范围能顶起漏斗状之胸壁,否则很容易由于外力
引起钢板的移位而影响手术的矫形效果.另外钢板的弧度一定要和双侧的胸壁密切贴合,过紧能加
剧术后的疼痛,过松容易导致隧道内的积液甚至出现感染.3 插入点的选择:必须在漏斗状前胸壁
的两侧最高点.从力学的角度来分析手术本身就是利用杠杆原理将漏斗状胸壁强行前抬,双侧最高
点就是最佳的支撑点,矫形钢板固定后钢板受到三个力的作用,一是中间部分受到漏斗状胸壁向后
的压力,两个是在双侧插入点上向前的支撑力,在插入点上的支撑力主要来自插入点下方紧邻的肋
骨和肋间内,外斜肌,在手术操作过程中肋间内,外斜肌势必有一定程度的向后撕裂,如撕裂过多
就会导致插入点后移,使钢板一侧或者双侧向后移位,导致矫形不到位甚至失败.4 术中操作:在
选择双侧切口时,必须考虑到插入点和切口前端的距离,由于在穿通器要经切口处肌层下潜行至插
入点再进入胸腔,再向左胸穿通的过程中,穿通器必须尽可能将右侧胸壁软组织拉向前方使穿通器
能水平操作,此时插入点要承受较大的向后的压力,尤其在穿通器要抬举起漏斗状胸壁从左侧的插
入点穿通时,压力更为巨大,这就要求术者必须用力抬举穿通器,减少穿通器对插入点的压力,否
则薄弱的肋间内,外斜肌势必向后撕裂,造成插入点后移,影响矫形效果;穿通器在右侧胸腔内的
操作依赖胸腔镜的监视,在穿通纵隔时要尽可能紧贴胸壁操作,注意心电图和血压的变化,尽量减
少对心脏的压迫,尤其在穿通器进入左侧纵隔后,必须让手术助手用手指来感受胸壁内穿通器尖端
对前胸壁的压力,否则极容易穿透左侧纵隔胸膜引起左侧气胸或者穿透心包甚至心脏导致大出血;
用细带固定穿通器和矫形钢板时,两者之间最好有1cm的距离,过长或过短都容易在牵拉过程中使
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矫形钢板损伤插入点的肌肉和心包;在翻转矫形钢板时要向前下用力,避免插入点肋间内外肌受压
撕裂和肋间神经的损伤;固定固定片时最好用丝线带上一些周围的结缔组织,必要时可考虑用钢丝
捆绑肋骨和矫形钢板,避免移位;缝合切口前必须冲洗创面,彻底止血,尽量避免切口下的积液和
感染,必要时术后局部加压包扎;鼓肺排气必须充分,避免气胸.
术后因素是指在手术后出现的一些并发症或不当的活动对矫形疗效的影响或者失败. 1 疼痛:
由于矫形钢板的植入和畸形胸壁的强行抬举,使患者术后的疼痛极为严重,容易导致术后的一些并
发症,如不敢深呼吸,咳嗽和呼吸功能锻炼从而导致呼吸道感染;如某个长时间的强迫体位而出现
获得性脊柱侧弯等,所以术后镇痛有着重要的意义.我们常采用罗派卡因作肋间神经阻滞和病人自
控硬膜外镇痛泵给患者止痛.本组第四例患者术后由于疼痛出现强迫体位而加重了脊柱侧弯,术后
3个月疼痛消失,1年后才恢复到术前状态.2 切口感染:矫形钢板和固定片是合金材料,一般不
出现排异反应.多因为切口下积液继之并发感染.除了术中不严格的无菌操作外,术中隧道分离范
围过大,粗暴操作造成胸壁肌肉坏死,矫形钢板过松,没有紧贴胸壁而使切口处组织向外凸起人为
造成较大的间隙,止血不完全等均是造成积液和感染的重要因素.部分病人由于切口的感染不得不
拆除矫形钢板,导致手术失败.3 矫形钢板移位:围手术期内除了呼吸功能锻炼外,我们要求患者
在术后1个月内禁止做曲胸,弯腰,扭腰和翻滚动作,2个月内禁止搬重物,3个月内不进行对抗性
运动.早期的钢板移位除了手术因素外,大多是由于患者躯体运动造成的,本组第一例患者因为在
术后1个月时做"俯卧撑"运动后出现矫形钢板移位而导致手术失败.
目前NUSS手术在国内已经有多家医院开展,但关于手术失败的报道甚少,我们根据自己的体
会作了一些粗浅的分析,仅供大家参考.
食道恶性神经鞘瘤-病例报告
Malignant schwannoma of the esophagus—a case report
陈卫洲 Wei-Chou Chen, * Yih-Leong Chang, Yung-Chie Lee
Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
*Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
An extremely rare case of esophageal malignant schwannoma is reported. Gastrointestinal
schwannomas are rare, and most of them originate in the stomach or the intestine. Malignant schwannomas
of the esophagus are extremely rare.
A 46-year-old man, a cigarette, alcohol, betel nut consumer for more than ten years, complained of
swallowing disturbance and was diagnosed with an esophageal spindle cell sarcoma in outside hospital. He
received preoperative concurrent chemoradiotherapy for stage T3N1M0 in outside hospital. The tumor size
was decreased. The post CCRT barium esophagogram showed an ulcerative polypoid tumor with irregular
surface in the middle thoracic esophagus. The chest computed tomography showed dilated esophagus with
diffuse wall thickening at middle esophagus. The endoscopic ultrasonography showed an esophageal tumor
with destruction of whole layer which located 22 to 32 cm from the incisors, and involvement of about half
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of circumference. The maximal thickness was 2 cm. A right posterolateral thoracotomy and median
laparotomy for subtotal esophagectomy and retrosternal route-gastric tube reconstruction were performed.
Postoperative course was uneventful. The tumor measures 7.8x2.4x2.0 cm in size and was composed of
S-100 protein immunoreactive oval to spindle tumor cells with increase of mitoses.
Benign esophageal schwannomas are rare tumors with only 14 cases reported in the English literature.
Among the English and Japanese literatures, there was only five malignant esophageal schwannomas
reported. Most previous reports describe excision without major esophageal resection. There have been
four other reports of esophagectomy. Only two esophagectomies were performed for malignant
schwannomas.
食管粘液息肉:2例报道并文献综述
Esophageal Mucocele:Report of Two Cases and Review of Literature
陈政隆 Cheng-Lung Chen1, Fur-Jiang Leu2
Division of Thoracic Surgery, Department of Surgery1.
Department of pathology2 ,Cardinal Tien Hospital, Taipei Hsiang , Taiwan
【Background】
Esophageal bypass without eophagectomy is frequently performed for patients with benign stricture or
unresectable esophageal cancer with obstruction. Esophageal mucocele may develop after exclusion of
proximal end of distal esophagus. Mucocele may or may not produce side effect and it is difficult to be
detected without computer tomography of chest and are rarely reported
Its managements also varies according to clinical manifestations.
【Material and Method】
Computer tomography of the chest is the tool for detection of esophageal mucocele whenever the
symptoms develop. Collection of 46 cases from twelve English papers published from 1984 to 2007,
including our two cases were analyzed according to their underlying diseases, clinical manifestations,
management and outcomes.
Case presentation (1)
A 72-year-old male, was admitted on account of persistent nausea sensation after meal for weeks.He
received cervical esophagocolostomy for unresectable cardiac cancer with obstruction of lower esophagus
four months ago. Although no problems in swallowing of food and postoperatively, nausea sensation
occurred three weeks ago and exaggerated after each meal. Computer tomography of chest disclosed huge
dilated esophagus contains fluid. Right thoracotomy revealed an aorta-like esophagus parallel with aorta in
posterior mediastinum. The cystic esophagus was resected, lot of yellowish turbid fluid was found. After
esophagectomy the symptom of nausea subsided. Patient died of disease itself four months later.
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Case presentation (2)
A 28-year-old male, was admitted on account of persistent nausea sensation for months. Three years
ago, he received cervical end to side esophagocolostomy without esophagectomy for benign stricture at the
level of thoracic inlet after caustic injury. Recently he began to experience persistent nausea sensation,
especially after each meal. Esophagography showed stricture of cervical esophagocolostomy with proximal
dilation of cervical esophagus but still patency of the passage. Computer tomography of chest showed a
cystic lesion in posterior mediastinum comparable with dilated esophagus due to obliteration of the
esophagus just below the carina level of trachea due to previous corrosive injury. Under the impression of
esophageal mucocele, right thoracotomy revealed dilated upper esophagus filling of milk like fluid due to
distal obstruction. Esophagectomy was done as high as possible. Patient has been free of symptom of
nausea after esophagectomy.
【Conclusions】
Esophageal bypass without esophagectomy for unresectable esophageal malignancy and benign
stricture due to caustic injury are not uncommon. Esophageal mucocele may develop and produce symptom.
Surgical intervention occasionally is indicated in patients with severe symptom and may improve the
quality of life.
肺癌的再手术治疗:31例报告
Reoperation for lung cancer: experience with 31 cases
陈志毅 Chie-Yi Chen1, Nan-Yung Hsu1, Chun-Yi Shiah2, et al.
1Division of Chest Surgery, China Medical University Hospital, Taichung, Taiwan
2Division of Chest Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
【Background】 Analysis of three institutions experience with reoperation for lung cancer, to assess
operative mortality and late outcome.
【Methods】 From 1999 to 2006, 31 consecutive cancer patients having been surgically treated for
lung cancer previously received subsequent lung resection (mean age 69 years; 30-79). ( There were 14
patients (13 males and 1 female) with a median age of 64 years (range 51-74).) They constituted 2.3% of
1359 patients who had undergone lung resection for lung cancer in the same period in three institutes.
There were 3 patients having been operated for lung cancer previously received reoperation because of
non-malignant conditions (fibrosis in 1, lung abscess in 1 and squamous metaplasia in 1). Among 28
patients, fourteen patients (group 1) had a local recurrence that developed at a median interval of 13 months
(range 6-21), and the other 14 patients (group 2) had a new primary lung cancer that developed at a median
interval of 38 months (range 25-91).
【Results】 For 14 patients of group 1, the first lung resection was bilobectomy in one patient,
lobectomy in nine and lesser resection in four. The second operation consisted of completion
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pneumonectomy in two cases, lobectomy in three and wedge resection in nine. For another 14 patients of
group 2, the first lung resection was bilobectomy in 3 patients, lobectomy in six and lesser resection in five.
The second lung resection was completion pneumonectomy in two patients, completion lobectomy in three
and lesser resection in nine. Operative mortality was 3.2% (n=1). Survival rate following second operation
will be presented.
【Conclusions】 An aggressive surgical approach is safe, effective and warranted in patients with
either a second primary lung cancer or relapse from their primary lung cancer, if there is no evidence of
distant metastasis and the patients are in good health.
食管癌术后胸内吻合口瘘分期手术治疗体会
Experience of the treatment of thoracic anastomotic leakage after surgery of esophageal
cancer
高炜,张世范,贾书斌,等
兰州军区兰州总医院胸外科,兰州,730050
90年以来我们采用分期手术的方法对11例食管癌切除术后吻合口瘘的患者进行治疗,无一例
死亡,现就有关手术治疗问题谈几点体会:
1.临床资料
1.1 一般资料:本组中男性8例,女3例.年龄32～72岁,病程6～13个月,均系中晚期患
者,首次手术均采用左后外侧开胸食管癌切除,食管胃弓上吻合术.分别于术后2～22天经口服美
蓝证实为吻合口瘘,急诊行开胸探查术.术中见胸腔内有大量分隔包裹之脓液和胃液;胸膜胃壁肿
胀;胃,肺,心包表面均有脓苔.瘘发生部位:3例发生于近吻合处之胃壁;2例发生于胃体中部;
2例位于吻合口前壁;4例位于吻合口后壁.
1.2 手术方法:手术分两期进行,Ⅰ期为急诊开胸探查,颈部食管外置,胸胃造瘘术,待患者
体质基本恢复后,一般于Ⅰ期手术后三个月行Ⅱ期手术——结肠代食管术.
2.讨 论
2.1 尽早明确吻合口瘘之诊断
术后患者持续高热,特别是进食后再次出现39℃以上高热,突然出现胸痛,胸闷,气急,脉搏
细速,术侧呼吸音降低或消失,均应高度怀疑发生吻合口瘘之可能,此时应口服美蓝或造影剂,如
观察到胸引液呈蓝色或有食物残渣,唾液或透视下有造影剂外溢,则可确立吻合口瘘的诊断.
2.2 手术时机的选择及手术要点
手术分两期完成.
Ⅰ期手术:在吻合口瘘之诊断确立后立即进行.取原切口进胸,清除胸腔积脓及胃液,探明瘘
口位置后剪断吻合口,将食管于颈部牵出外置.游离颈部食管时位置不宜高,尽可能的多保留颈部
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食管,以保证Ⅱ期手术时有足够长度与结肠吻合.荷包缝合封闭胃底残端,用生理盐水,3%双氧水
和0.2%灭滴灵反复冲洗胸腔,彻底剥除附着于肺表面之脓苔和纤维膜,使肺充分复张,于胃侧壁行
胃造瘘术,造瘘管由肋缘下或近肋膈角之肋间穿出体表.将胃体妥善缝合固定于肋膈角,造瘘口侧
贴于膈面,以防医源性胃壁瘘的发生.术后应注意保持胸腔引流通畅,加强静脉营养支持和有效的
抗感染治疗,一般于手术后五天开始给予管喂.以确保营养供应.
Ⅱ期手术:一般在Ⅰ期手术后三个月左右,患者精神,体质均明显好转后进行.术前常规行钡
灌肠检查,并认真做好结肠的清洁准备工作,可根据术者习惯和患者具体情况选择胸骨前或胸骨后
径路结肠代食管术.术中应仔细分离粘连,防止误伤结肠血管,在结肠血液供应允许的情况下尽可
能采用右半结肠或横结肠替代食管,以防术后因逆蠕动液体返流误吸而引起肺部并发症.
2.3 分期手术的优点
(1)Ⅰ期手术操作简单,时间短,创伤小,安全可靠,能及时有效地控制胸腔感染,减轻对患者
体质的消耗.颈部食管外置造瘘有效地防止了口腔细菌随唾液进入胸腔,从而消除了一个主要的污
染源.胃造瘘术有效地避免了胃液对胸腔腐蚀和污染;加之术中彻底清除了胸腔的脓苔,脓液及纤
维分隔,大量液体反复冲洗,有效地胸腔引流使肺充分复张,所有这一切都有利于控制胸腔惑染,
促进患者康复.
(2)胸胃造瘘术既起到胃肠减压作用,又为术后患者营养支持提供了有力保障,特别是造瘘于胸
腔内杜绝了胸腔感染向腹腔漫延.
(3)过去对吻合口瘘均行Ⅰ期修复,此时患者处于严重负氮平衡状态,胸腔内感染严重,组织难
以修复,手术失败率高.分期手术法将食管重建手术改在Ⅰ期手术后三个月,患者负氮平衡得以纠
正后进行,大大提高了手术的成功率.
(4)Ⅱ期手术操作简单,不需开胸,对患者心脏功能影响小,特别是在患者体质基本恢复后进行,
故安全可靠,益于患者康复.
VATS在小儿支气管源性肺囊肿外科治疗上的应用
The application of VATS in the surgical treatment of pediatric branchiogenic lung cyst.
1黄俊, 1刘君,1陈汉章,等
1,广州呼吸疾病研究所,广州医学院第一附属医院,广州,510120
2,深圳市人民医院,深圳
摘要
【目的】 探讨VATS在小儿支气管源性肺囊肿中的治疗作用.
【方法】 回顾性分析我院和深圳市人民医院1996年1月至2007年1月经VATS切除并病理证
实的33例小儿支气管源性肺囊肿患者的临床资料,麻醉方式全部采取吸入麻醉,手术采取胸腔镜进
行,必要辅助小切口协助将病灶以及肺组织取出;气管残端采取间断缝合或者Endo-cutter钉合,统
计分析手术时间,切口大小,术后引流时间及总量,术后住院时间.
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【结果】 本组患者均经VATS手术治疗.年龄从8d~12岁,平均为5.17岁.1例纵隔型支气
管囊肿行VATS纵隔囊肿切开+翻转术,10例肺内型行肺楔形切除术,22例肺内单发性囊肿或局限
于肺段的多发性肺囊肿行肺叶切除术.全组手术时间为(45~265)min,平均101.36min;切口为(1.5~7)
cm,平均4.67 cm;术中失血(5~400)ml,平均82.42 ml;术后均放置胸管(1~2)条,引流(1~7)
天,待引流完全后拔除胸管,平均3.39 d;总引流量(85~770)ml,平均292.18ml;平均术后住院
时间为(4~25)d,平均11.54 d.
【结论】 VATS的小儿支气管源性肺囊肿治疗是可行,安全,彻底,微创的,可成为标准术式.
关键词 支气管源性肺囊肿;电视辅助胸腔镜手术;小儿
Abstract
【Objective】 To discuss the use of VATS in treatment of pediatric bronchogenic pulmonary cyst.
【Methods】 A retrospective analysis of 33 pediatric patients who had been pathologically
confirmed with bronchial pulmonary cyst, underwent VATS treatment between Jan 1996 and Jan 2007.
We adopted inhalational anesthesia in each patient. Use of thoracoscope intraoperatively, small incision is
necessity to obtain lung tissue and to remove focus of infection out. Bronchial stump is stitched with
disjunction saturation or GIA saturation. We collected date of incision size, operation time, drain quantity,
placed time of chest tube drainage and postoperative length of stay.
【Results】 All of the patients underwent VATS surgery. Age is between 8days~12yrs,average is
5.17yrs.1 cases of mediastinal bronchogenic performed cyst incision + turnover operation, 10 cases of
intrapulmonary performed pulmonary wedge resection, 22 cases of pulmonary single cyst or multiple cysts
confined to one lobe of lung performed lobectomy. The operation time is between (45~265)mins, (mean
101.36mins); the incision is (1.5~7)cm(mean ,4.67±1.28cm); Intraoperative bleeding is (5~400)
ml(mean 82.42ml);postoperative chest tube drainage placed (1-7 )days ,1~2 tube, (mean 3.39d),
the whole drainage volume is (85~770)ml(mean 292.18ml); length of postoperative hospital stay is
(4~25)d(mean 11.54d).
【Conclusions】 Pediatric bronchogenic pulmonary cysts treated by VATS is feasible, safe,
thorough and minimal invasive, it could be the standard operation method.
Key words Bronchogenic Cyst; VATS; Pediatric
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应用纳米炭在微创肺癌淋巴结清扫术中的研究
李树本 *何建行 陈汉章 等
广东省广州呼吸疾病研究所胸外科,广州,510120
【目的】观察与评价纳米炭在肺癌淋巴结清扫术中的临床应用价值.
【方法】选用2005年12月至2006年3月我科收治术前确诊为肺癌的42例患者.根据微创胸
腔镜辅助淋巴结清扫术中有否运用纳米炭,将其分为实验组20例,对照组22例.通过实验比较两
组术中清扫淋巴结的时间,术后根椐病理结果比较清扫淋巴结的数目,癌性淋巴结转移情况并观察
围手术期副作用的发生.
【结果】局部组织注射纳米炭未见严重副作用发生.两组术中清扫淋巴结时间经比较无明显差
异(P>0.05).实验组清扫淋巴结平均25.5枚,对照组14.6枚,经统计学比较两组有显著性差异(P0.05).
3.讨论
近几年来,许多学者将VATS应用于原发性肺癌的综合治疗,取得了显著的近期疗效[1].VATS已
成功地用于肺叶切除,甚至全肺切除等高难度的肺部手术,说明治疗性VATS在肺外科手术中的应用
已走向成熟.目前公认的VATS肺癌手术的适应证是I期肺癌, 许多临床研究表明I期患者VATS肺叶切
除可以达到与传统开胸手术相当的根治效果,我们之前已有部分统计报道,但有关其术后远期疗效
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仍有待大量临床病例积累与总结.
VATS能否进行肺门和纵隔淋巴结清扫,一直是胸科医师关心和争议的论题,其直接影响肺癌的
远期疗效.何建行等认为在多角度的胸腔镜暴露下,VATS行肺门和纵隔各组淋巴组织的清扫是可行
的,其主要适应证为T1N0M0,T1N1M0,T2N0M0 的肺癌.我们的体会是Ⅰ期周围型肺癌,病灶相
对较小,未侵及胸膜和胸壁,无胸内粘连,VATS肺叶切除后进行肺门及纵隔淋巴结清扫,这样纵隔
暴露较清楚,并根据淋巴结转移与淋巴引流方向,能较好进行肺门纵隔淋巴结系统性清扫,本组清
扫数目和清扫范围与传统开胸手术相当,差异无显著性.Watanabe等报道VATS清扫淋巴结数,每组
淋巴结数及术后死亡率,复发率等与传统开胸组无显著差异.说明VATS手术完成系统性肺门纵隔淋
巴结清扫并不逊色于传统开胸.
目前国内外有关I期肺癌VATS术后3,5年生存率的报道不多.本组资料显示,VATS组和对照组
术后3年,5年生存率分别为90.91%,86.36%和90%,85%,统计学无显著性差异(P>0.05).Gharagozloo
等报道Ⅰ期肺癌VATS肺叶切除术后3年,5年生存率分别为88%,85%.我们认为Ⅰ期肺癌VATS肺
叶切除,系统淋巴结清扫术在技术上可行, 符合肿瘤切除原则,能够达到标准后外侧切口同样的根
治效果,并具有创伤小,恢复快,出血少,对心肺功能影响小等临床优点.可作为I期肺癌的一个标
准术式,值得进一步推广.
硝酸甘油和异搏定对犬移植用供肺组织诱生型一氧化氮合酶及腺苷酸的影响
The Effect of Nitroglycerin and Verapamil for The Contents of iNOS ATP and TAN in canine's Donor
Lung Tissues
刘建新 冯俊波
湖南长沙中南大学湘雅三医院心胸外科,长沙,410013
【目的】本实验在肺保护液(LPD液)中加入硝酸甘油和异搏定,观察其对移植后供肺组织中
的诱生型一氧化氮合酶(iNOS)及三磷酸腺苷酸(AT P),腺苷酸池(TAN)的影响,评定LPD液
中加入硝酸甘油和异搏定对供肺的保护效果.
【方法】40只健康杂种犬,雌雄不拘,按体重配对,随机分成四组.供体分组情况:(1)对照
组,单纯用LPD液保存;(2)硝酸甘油组,在LPD液中加入硝酸甘油(0.1mg/ml);(3)异搏定组,
在LPD液中加入异搏定(0.1mg/ml);(4)硝酸甘油加异搏定组,在LPD液中加入硝酸甘油(0.1mg/ml)
和异搏定(0.1mg/ml).肌肉注射戊巴比妥钠麻醉后,气管插管,呼吸机支持呼吸,左侧第四肋间开
胸,肝素化(3mg/kg),停用呼吸机,结扎上下腔静脉,剪开右室流出道,插入灌注管至左肺动脉,
同时阻断右肺动脉,剪开左心耳.以40cmH2O的压力灌注4oC保护掖,待左肺由红变白,左心耳流
出的灌注液澄清为止.手工膨肺,使肺适度膨胀后,以支气管钳夹闭左主支气管,将灌注好的左肺
及心脏取下放入保护液中,修剪供肺,移除心脏.将供肺浸入4oC保护液,保存6小时.受体的麻
醉等准备同供体,移去受体左肺.按支气管,肺动脉,左房袖的顺序吻合供肺与受体.吻合完成,
静脉注射甲强龙后,顺序开放肺静脉动脉.再灌注两小时后,取左肺舌叶部分肺组织,将其放入-70oC
冰箱中保存备用.待标本收齐后,应用比色法测定肺组织中的iNOS的含量,应用高效液相色谱仪测
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定肺组织中的AT P,TAN的量.
【结果】(1)各组肺组织中iNOS含量比较,4个组的肺组织中iNOS含量有差异(F=26.38,
P<0.05),与1组(对照组)比较,2,3,4组肺组织中iNOS含量均低于1组(P<0.05);4组iNOS
含量低于2,3组(P<0.05 );2,3组之间肺组织中iNOS含量无明显差异(P＞0.05).(2)各组肺
组织中AT P含量比较,4个组的肺组织中AT P的含量有差异(F=47.42, P<0.05),与1组(对照组)
比较,2,3,4组肺组织中AT P的含量均高于1组(P<0.05);4组AT P的含量高于2,3组(P<0.05 );
2,3组之间肺组织中AT P的含量无明显差异(P＞0.05). (3)各组肺组织中TAN含量比较,
4个组的肺组织中TAN的含量有差异(F=23.22, P<0.05),与1组(对照组)比较,2,3,4组肺组
织中TAN的含量均高于1组(P<0.05);4组TAN的含量高于2,3组(P<0.05 );2,3组之间肺组
织中TAN的含量无明显差异(P＞0.05).
【结论】1.在LPD液中加入NTG或异搏定能减少移植后肺组织中iNOS的含量,且联合应用
的效果优于单独应用.2.在LPD液中加入NTG或异搏定能增加移植后肺组织中腺苷酸的含量,且
联合应用的效果优于单独应用.
关键词 肺移植,硝酸甘油,异搏定,诱生型一氧化氮合酶,腺苷酸
【Objective】 Add Nitroglycerin and Verapamil in low-potassium-dextran (LPD) solution, we
observe the contents of iNOS,ATP and TAN in different lung tissues , and evaluate the protection effect .
【Method】 Native-bred canines of either sex (weight 14-16 kg) were paired by weight. 20 canines
served as donors and 20 canines each served as recipients for the lungs. We separate them into 4 groups,
each groups has 5 pairs. (1)Control group, we only use LPD solution to protect the donor lung ; (2)
Nitroglycerin group, we add Nitroglycerin in the LPD solution; (3) Verapamil group, we add Verapamil in
the LPD solution ; (4) Experimental group, we add Nitroglycerin and Verapamil in the LPD solution.
Anesthesia was induced by intramuscular injection of pentobarbital sodium(30mg/kg), then we put the
endotracheal tube into the trachea. Animals were ventilated with a tidal volume of 15 ml/kg and a
respiratory rate of 15-20 breaths/min at FiO2 of 1.0 with an animal ventilator. Donor Procedure: In the
right-sided position, a left antero-lateral thoracotomy was performed through the fourth intercostal space.
After incision of the mediastinal pleura and pericardium, upper and lower caval veins and right pulmonary
artery were dissected free from surrounding tissues. Systemic heparinization (3mg/kg), was given by
intravenously, then we ligate the upper and lower caval veins. Turn-off the ventilator , A cannula was
inserted into right pulmonary artery and fixed by a tourniquet. The lungs of the different groups were
flushed with different cold lung protection liquid(0-4oC) by gravitation, with a constant height of 40 cm
H2O ,The flushing procedure was started after an incision of the left auricle, thus permitting the effluent to
emerge into the thorax. When the lungs turn into white and the effluent turn into clarification,we stop
flushed with the cold lung protection liquid. The lungs were deflated and the heart-lung bloc was removed.
Put the bloc into the cold lung protection liquid, the lungs were reinflated and the trachea was
cross-clamped, cut, and submerged under the solution. The heart was dissected and the donor lung bloc was
immersed in fresh cold lung protection liquid and stored for 6 hr at 0-4°C.Recipient Procedure: Single-lung
transplantation was performed in the right-sided position, a left antero-lateral thoracotomy was performed
through the fourth intercostal space. The mediastinal pleura and pericardium was incised and a tourniquet
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was placed around the left pulmonary artery. After pneumonectomy, heparin(1.5mg/kg) was administered
intravenously, and implantation commenced with the bronchial anastomoses, followed by the pulmonary
arterial and left atrial anastomoses. Before we open the right pulmonary artery, Prednisolone(80mg) was
administered intravenously. The graft was ventilated and reperfusion started. The chest wall was closed
with towel clamps.After 2 hr reperfusion, a potion of lung tissue was resected. we observe the contents of
iNOS,ATP and TAN in different lung tissues.
【Results】 (1)The content of iNOS: The contents of iNOS in contral group are higher than other
groups(p<0.05). The contents of iNOS in Experimental group are lower than group 2 and 3(p0.05). (2)The content of ATP: The contents of ATP in
contral group are lower than other groups(p<0.05). The contents of iNOS in Experimental group are higher
than group 2 and 3(p0.05). (3) The content
of TAN:The contents of TAN in contral group are lower than other groups(p<0.05). The contents of TAN in
Experimental group are higher than group 2 and 3(p0.05).
【Conclusion】 (1)The low-potassium-dextran with Nitroglycerin or Verapamil can reduce the
content of iNOS in the donor lung tissues, and the result is better when we add both Nitroglycerin and
Verapamil in the LPD liquid .(2)The low-potassium-dextran with Nitroglycerin or Verapamil can improve
the content of ATP and TAN in the donor lung tissues, and the result is better when we add both
Nitroglycerin and Verapamil in the LPD liquid.
Key words Lung transplantation,Nitroglycerin Verapamil, Inducible nitric oxide synthase ,
Adenine nucleotid
胸腔镜肺癌切除纯腔镜手术新模式易化操作(附20例报告)
New procedure of thoracoscopic lobectomy for lung cancer faciliate operation.
刘伦旭,蒲强,吴艺根,等
四川大学华西医院胸外科,成都610041
Abstract
【Purpose】To investigate the more feasible procedure of thoracoscopic lobectomy for lung cancer.
【Method】From may 2006 to August 2007,the lately developed new manipulation of thoracoscopic
lobectomy was applied in 20 cases of lung cancer.
【Result】18 operations were completed with this technique.Two procedures were converted to
minithoracotomy for dense adhesion of lymph nodes.One pulmonary artery injury was repaired without
conversion of incision.The operation time was 120-200min with average of 150min.Operation bleeding
was 10-500ml with average of 150ml.Number of lymph nodes resected was 7-22 with average of
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12.Postoperative hospital stay was 6-9 days with average of 7.5 days.
【Conclusion】The improved manipulation of thoracoscopic lobectomy for lung cancer optimized the
operative processes,and made it more feasible and more acceptable.
胸腔镜技术用于肺癌切除虽然逐渐被接受,但由于其技术要求高,操作难度大,以及患者肺裂
发育不全,要求淋巴结清扫等原因,在临床推广中应用并不广泛,特别是不辅助小切口,不撑开肋
骨的纯屏幕操作胸腔镜,掌握的医生更少.而对于合适的病例,如果能采用创伤少,美观,恢复快
的微创术式达到传统大开胸同样的切除范围,无疑会大大提高手术质量.近年国际上出现的胸腔镜
肺癌切除纯屏幕操作新模式,使手术操作易于进行,为此术式的广泛开展提供了技术支持.我们从
2006年5月—2007年8月利用此方法并根据国人特点有所改进,切除肺癌20例,现总结如下.
1.临床资料与方法
1.1一般资料
20例患者男8例,女12例,年龄38-75岁.平均52岁.病变部位:右上肺7例,右中肺3例,
右下肺2例,左上肺5例,左下肺3例.病理类型:腺癌18例,鳞癌2例.手术病理分期IA期(T1N0M0)
3例,IB期(T2N0M0)14例,ⅡB期(T2N1M0)2例,ⅢB期(T4N1M0)1例(胸腔种植转移).
1.2手术方法
1.2.1体位与切口设计 侧卧位,患侧上肢前举,术者站在患者的腹侧.胸腔镜镜孔选在腋中
线偏前第7肋间,约1.5cm;主操作孔以腋前线为中心约4cm,上叶切除在第三肋间,正对肺上静脉,
中下叶切除在第4肋间;副操作孔在腋后线偏后第8,第9肋间,正对单肺通气时下叶肺与隔面接
触点,此孔用于牵引肺,切割缝合器等进入,可容2个器械同时进入,长约2cm.
1.2.2肺叶切除操作流程
1.2.2.1右上肺叶切除 从副操作孔用腔镜环钳将右上肺夹持并向后卷起,显露右侧肺门前方.
用乳突拉钩将主操作孔皮下及肌肉组织撑开.通过主操作孔用电凝钩剥离右肺上静脉,其间用分离
钳或吸引器从副操作孔伸入协助.用常规直角钳绕过右肺上静脉,10号丝线绕线牵引.将肺牵引钳
从副操作孔换至主操作孔,向背侧推开右上肺,从副操作孔伸入2.5mm切割缝合器离断右肺上静脉.
此时右肺动脉干被显露,沿右肺动脉主干游离血管鞘膜,并游离出至右上肺的第一分支,丝线牵引
此分支,同法从副操作孔伸入切割缝合器离断.然后将上肺向下及向前牵引,电刀游离右肺门上,
后方,显露右上叶支气管,钛夹处理支气管动脉.用吸引头加电钩相互配合,游离上叶支气管下,
后方.10号丝线绕线牵引上叶支气管,同法从副操作孔伸入4.1mm或4.8mm切割缝合器,离断上
叶支气管.支气管离断后右上叶的其余肺动脉分支易于显露,游离后从主操作孔用4号丝线推结器
结扎2次.此时上叶的支气管,肺动脉,肺静脉均已离断,仅剩下肺裂部分.从副操作孔伸入环钳
将中下叶向下牵引,从主操作孔伸入环钳将上叶向上牵引,将切割缝合器从主操作孔伸入完成肺裂
部分的肺切除.
1.2.2.2 右肺中叶切除 将右肺中叶后向牵引显露右肺门前方,游离右肺中叶静脉属支并用切割
缝合器离断.游离中叶支气管,直角钳带10号丝线绕线牵引,用3.5mm切割缝合器离断.环钳从
副操作孔伸入向上牵引右肺中叶,游离右肺中叶的1-2支肺动脉分支,从主操作孔用4号丝线推结
器结扎并离断中叶肺动脉分支.然后用切割缝合器切开剩下的肺裂组织.
1.2.2.3 右肺下叶切除 将肺向上牵引,电刀切断肺下韧带,显露右肺下静脉,用切割缝合器从
主操作孔伸入离断右肺下静脉.从下方游离右下肺支气管至右肺中叶支气管分叉平面.然后将肺向
下牵引,游离出右下肺动脉的基底干和背段分支.依次从主操作孔伸入切割缝合器离断右肺下叶支
气管,肺动脉及肺裂肺组织.肺动脉分支可用丝线结扎.
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1.2.2.4 左肺上叶切除 将左上肺向后牵引,游离右肺上静脉,从副操作孔伸入切割缝合器离断
肺上静脉.将上肺向下牵引,显露左上叶肺动脉第一分支,适当游离.游离右上叶支气管,从副操
作孔伸入切割缝合器离断.夹住左上叶支气管残端将肺向上后牵引,此时可显露出左肺动脉干及至
左上叶的各分支,分别游离,丝线结扎.然后用切割缝合器离断肺裂肺组织.
1.2.2.5 左肺下叶切除 左肺下叶切除与右肺下叶切除步骤基本相同.先处理肺静脉,然后支气
管,肺动脉,最后肺裂.
1.2.2.6 淋巴结清扫 肺门,支气管淋巴结在行肺叶切除过程中可遇见,通过钝性推离,锐性
解剖及电凝等方式在处理肺叶各结构时同时切除.隆突下淋巴结切除:用环钳将肺在靠近肺门部全
部夹住,向前推移,显露出肺门后方及后纵隔.用电刀切开肺门后方奇静脉下方纵隔胸膜,显露支
气管分叉隆突部位.腔镜鼠齿钳夹住淋巴结,采用电凝烧灼,吸引头钝性推开,钛夹钳夹等方法切
除隆突下淋巴结.气管前腔静脉后淋巴结切除:将肺向下牵引,分离钳提起上纵隔胸膜,电刀沿上
腔静脉后方纵行切开,止于奇静脉.用吸引头从主操作孔伸入将上腔静脉向前内侧推开,以及将奇
静脉向下推开,鼠齿钳夹住腔静脉后软组织,分别沿上腔静脉后方及气管前方纵行切开纵隔软组织,
用鼠齿钳整块钳夹,电凝切除纵隔脂肪组织及淋巴结.淋巴结位于奇静脉后方较难处理时可离断奇
静脉.主动脉弓下淋巴结切除:将肺向下牵引,电凝切开纵隔胸膜,吸引头钝性推开主动脉弓下脂
肪组织,显露出淋巴结,鼠齿钳钳夹,电凝或钛夹处理切除淋巴结.注意避免损伤喉返神经.
2. 结果
全组无围术期死亡.2例因肺动脉周围淋巴结粘连难以游离中转10cm辅助小切口.1例术中游
离肺动脉分支时根部撕裂,镜下缝合,未中转切口.全组手术时间120~200min,平均150min.术中
出血10ml~500ml,平均150ml.淋巴结切除7-22枚,平均12枚.术后住院6-9天,平均7.5天.
3. 讨论
本组采用的胸腔镜手术并非是一种全新的术式,但与以前的腔镜手术相比,在切口设计,操作
流程上有重要改进,从而使得纯屏幕操作胸腔镜肺癌切除术更加容易施行,使高难度手术"简单化".
3.1 切口设计
与以前相比主操作孔设计偏前,偏上,正对肺上静脉(上肺叶切除时),对肺门结构的游离直
接而方便.副操作孔移至后下方,从此孔伸入的器械与肺门结构大致呈垂直关系,非常有利于切割
缝合器的置放,使支气管,肺静脉,肺动脉用切割缝合器离断时在方向调节上不至于"别扭".对较
小的肺血管分支,用推结器从主操作孔结扎容易进行.
3.2 操作流程
本术式操作流程主要特点为遵循肺静脉→支气管→肺动脉→肺裂的游离及离断顺序,相对于肺
门结构而言由表及里,层次游离.在处理完上一个解剖结构后下一个处理目标便被显露出来.操作
中避开了解剖叶间裂,不需在发育不全的肺裂中游离肺动脉,而把肺裂放在最后处理,这时已经没
有支气管和肺血管的干扰,用切割缝合器离断非常容易.而肺裂处理正是以前腔镜手术的难点,甚
至把肺裂发育不全列为腔镜手术中转开胸指征.应用此术式操作流程,能很好解决肺裂发育不全问
题.
3.3 淋巴结清扫
将全肺根部用环钳钳夹向前或向下牵引后,对淋巴结清扫部位如隆突下,气管前腔静脉后,主
动脉窗能很好地显示,通过电刀,钛夹,吸收头相互配合,清扫淋巴结并不困难.应用超声刀应是
不错的方法,有待下一步尝试.
3.4 手术适应征
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此术式仅适合于周围型肺癌.肿瘤(T)小于4-5cm,无重要结构侵犯.纵隔淋巴结(N)最好无
转移,但对于某一站孤立的转移淋巴结切除在技术上可行.应在增强CT片上仔细评估肺门,支气
管周围淋巴结,此部位肿大淋巴结会对手术造成困难.肺裂发育不全对手术影响不大.其它原则遵
循腔镜手术及肿瘤手术适应征.
腔镜手术除需要常规开胸手术的熟练技术外还需要熟练的腔镜器械操作及屏视操作技术.但有
时手术的难度并非来自术者的操作不熟练,而是受限于手术流程设计不合理,这种手术本身的固有
缺陷会限制手术的开展.本文描述的胸腔镜肺癌切除流程,优化了切口设计及操作步骤,且基本能
做到每一个步骤程序化,使手术变得容易,相信会为此技术更加广泛的开展提供帮助.
胸腔镜手术切除周围型实性肺动脉血管瘤一例报道
Successful thoracoscopic resection of solitary peripheral pulmonary artery aneurysm: A case report
卢建志 Chien-Chih Lu*, Yun-Hen Liu, Hui-Ping Liu
Department of general thoracic surgery, Chi Mei Medical Center Liou Ying Campus, Tainan, Taiwan*
Division of thoracic and cardiovascular surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
Peripheral aneurysm of the segmental pulmonary artery is a rare vascular anomaly and associates in a
wide variety of conditions, such as congenital weakness of the arterial wall, infection, trauma, pulmonary
hypertension, cystic medial necrosis and generalized vasculitis. When operation is indicated, central lesions
involving the pulmonary trunk usually need cardiopulmonary bypass and peripheral aneurysms in
segmental intrapulmonary arteries have been managed most frequently by lobectomy, but occasionally by
aneurysmectomy and pulmonary artery repair, especially in patients with limited respiratory reserved.
Minimal invasive therapy such as transcatheter embolization using wire coils has been proposed in some
cases also but video-assisted thoracoscopic resection was rarely discussed. Here we report a case of
31-year-old woman with solitary peripheral pulmonary artery aneurysm which was found incidentally
treated by thoracoscopic wedge resection.
A 31-year-old woman was noted to have a solitary pulmonary nodule over left low lobe by routine
chest x ray before admission. There were no fever, no productive cough, no hemoptysis, no body weight
loss and no chest pain. From chest x ray findings, the mass was a smooth, discrete coin-sized lesion at left
low lobe. It had remained unchanged in size during follow up. The medical history was unremarkable.
Computed tomography of chest showed an homogenous contrast-enhanced ovoid mass with smooth margin.
She was referred to our clinics for tissue proof and thoracoscopy examination was arranged.
Left three ports VATS approach was planned for mass evaluation first. Under thoracoscopy, a
intra-pulmonary pulsatile mass was noted to protrude from the segmental branch of pulmonary artery over
left low lobe. The mass was soft in consistency, size about 1.5 cm and pulsatile movement disappeared
obviously when the base been clamped by ring forceps. Dark reddish blood was noted by fine needle
aspiration of the mass. Solitary peripheral pulmonary artery aneurysm was highly suspected and wedge
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resection by endoscopic vascular staples was performed after multiple tries to get adequate margins. The
post-operative course was smooth without complications.
Historically, a cystic dilated arterial aneurysm with irregularly thickening or thinning of the vascular
wall away from the resection margin was noted. The adjacent lung parenchyma showed mild interstitial
fibrosis and no evidence of a mycotic or inflammatory process could be found.
电视胸腔镜引流治疗下行性坏死性纵隔炎
Is Video-assisted Thoracoscopic Drainage an Optimal Approach for Descending
Necrotizing Mediastinits
吕宏益 Hung-I Lu, Hsu-Ting Yen, Ming-Jang Hsieh, et al
Department of Cardiothoracic Surgery , Chang Gung Memorial Hospital, Kaohsiung, Taiwan
【Purpose】 Descending necrotizing mediastinitis is a rare but lethal disease. Aggressive surgical
approach has been emphasized but the optimal form of mediastinal drainage remains controversial.
【Materials and Methods】 This retrospective report reviews the experience in 8 patients with severe
deep neck infection associated with descending necrotizing mediastinits ( involved the posterior and lower
mediastinum ) who had underwent surgical treatment in the past 5 years at out institution. Surgical
treatments consisted of cervical drainage combined with unilateral or bilateral mediastinal drainage via
thoracoscopic exploration.
【Results】 The outcome was favorable in 7 patients except one patient died of uncontrolled sepsis. All
patients underwent one cervical drainage and another mediastinal drainage via thoracoscopic approach, two
of them had bilateral thoracoscopic drainage. All post-operative chest roentgenogram did not show residual
empyema. But one of them developed delayed loculated empyema due to pulmonary atelectasis required a
second limited thoracotomy for adequate drainage. Another one patient with liver cirrhosis received
repeated thoracoscopic drainage of residual hematoma. All survived patients recoverd well after a follow
-up of 6-60 months without residual infection.
【Conclusion】 In our limited experience, video-assisted thoracoscopic drainage is a feasible and
effective as a less invasive approach for initial surgical drainage of descending necrotizing mediastinitis
when applied early. But in critically ill patients, delayed empyema formation due to post-operative lung
atelectasis should be mentioned.
83
继发性气胸的外科治疗
Secondary Pneumothorax: How well are we doing it
吕明宪 Ming-Shian Lu, MD
Div. of Thoracic & Cardiovascular Surgery Chang Gung Memorial Hospital, Taiwan
【Objective】To determine the surgical outcome of patients with secondary pneumothorax.
【Material】Form January 2003 to July 2007, 27 patients with secondary pneumothorax undergoing
surgical treatment were reviewed retrospectively.
【Results】There were 26 males (96.3%), raging in age between 16 to 81 years (median= 61.48 years).
The underlying lung condition was chronic obstructive lung disease, 23 patients; pulmonary tuberculosis,
11 patients; bronchiectasis, 1 patient and radiation pneumonitis, 1 patient. Twenty-one patients were current
or past smokers. The indication of surgery was prolonged air leaks, 19 patients (70.4%), collapsed lung, 6
patients (22.2%) and contralateral pneumothorax history (7.4%). According to the predominant location of
bulla; right upper lobe, 66.7% (n=18); whole lung, 18.5% (n=5); left upper lobe, 11.1% (n=3) and right
lower lobe, 3.7% (n=1). Surgical procedure included bulla ablation, 17 patients (63%); lung wedge
resection, 7 patients (25.9%), and combined bulla ablation/wedge resection, 3 patients (11.1%). The mean
follow up was 20.70 months. The mean operation time was 1:28 hours. The type of pleurodesis included
mechanical, 63% (n=17), pleurectomy, 7.4% (n=2) and chemical pleurodesis in one patient (3.7%). The
intensive care unit length of stay and hospital length of stay were 3.25 and 10.14 days respectively. Nearly
thirty percent of patient (n=8) required post-operative mechanical ventilation for more than three days. The
morbidity and mortality rate was 37% and 11.1% respectively.
【Conclusion】Surgical treatment for secondary pneumothorax carries an acceptable morbid-mortality
risk; however, the post-operative respiratory rate is high.
电视胸腔镜脓胸的治疗
Video-assisted thoracic surgery in the treatment of pyothorax
马金山,杨勇伟,李先锋,等
新疆维吾尔自治区人民医院胸外科
随着电视胸腔镜技术的广泛应用,因其具有安全,微创,有效的优点,几乎应用于胸外科的各
个领域.脓胸是胸腔镜治疗理想的适应症之一.我院于1996年3月~2007年4月应用电视胸腔镜共
治疗脓胸105例,效果良好,报告如下:
1.临床资料与方法
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1.1 一般资料 1996年3月～2007年4月,共有105例确诊脓胸患者在我科接受电视胸腔镜手
术治疗,其中男性78例,女性27例;年龄6-78岁,平均45.6岁;肺炎引起42例,外伤继发感染
29例,结核性脓胸30例,其他原因4例;急性脓胸60例,慢性脓胸45例;88例为局限性脓胸,
17为全脓胸,病程10-65天.术前均行胸部X线,CT及B超检查,行胸腔穿刺证实为脓胸,病例
选择标准:全脓胸,局限性脓胸,脓胸呈多房性或胸腔引流不畅者.
1.2 方法 术前准备同常规开胸手术,备开胸器械.均采用静脉复合全身麻醉,双腔气管插管,
取健侧卧位,根据术前影像学检查取脓腔最低位或腋中线第六,七肋间,做一个1.5厘米横行切口,
逐层切开皮肤,皮下组织,钝性分离肋间肌后进胸,先用手指钝性分离粘连.如为脓腔渗出期,则
只需再切一个1-1.5厘米小切口,置入吸引器吸尽脓液,用卵圆钳或吸引器打破脓腔分隔,钝性分离
粘连带,较粗粘连带可用电凝钩烧断,再用卵圆钳或抓钳清除脓苔纤维分隔及坏死组织.若肺表面
纤维板已形成,可用大弯钳先撕一点致正常肺组织,由此点进一步扩大剥离范围,对难以分离者则
在胸腔镜引导下做一个长约5-8厘米小切口,在镜视或直视下清除脓苔及纤维分隔,用手指,纱布
球辅以常规器械将脏层胸膜纤维板剥离切除,以盐水纱布压迫创面止血,在镜视下对较严重渗血部
位进行电凝或结扎止血.用生理盐水冲洗胸腔并鼓肺,观察肺膨胀及漏气情况,对少许肺表面漏气
可不予处理,若漏气较重,可用1号线行U形缝扎.再用生理盐水及甲硝唑冲洗胸腔,于胸腔镜切
口置胸腔引流管,对于有肺表面漏气者同时置上胸管,结核性脓胸患者术后正规抗结核治疗6个月.
2.结果
85例行胸腔镜下脓胸清除引流术,17例行胸腔镜辅助小切口纤维膜剥离术,3例中转开胸.手
术时间50~160分钟,平均70分钟;出血量30～200毫升;胸腔引流7~360天,平均2 0天;胸腔
引流量500-2100毫升,平均700毫升;术后住院天数7-22天,平均15天,105例手术术后随访6-24
个月,平均12个月,无脓胸复发及并发症发生.
3.讨论
脓胸病理生理学上分为:(1)急性渗出期(2)亚急性纤维化脓期(3)慢性纤维脓肿期,临床
上将前二期称急性脓胸,后者称慢性脓胸[1].胸部X线,CT及B超检查,有利于脓胸分期和发现
包裹性脓胸,多房性及肺表面纤维板形成,有效指导临床工作.
电视胸腔镜手术具有切口小,出血少,痛苦轻的优点,可以清除及取出坏死组织及打通分隔,
在胸腔镜引导下将引流管放置在最恰当位置,同时经胸腔镜直接找到脓胸原因,明确病因诊断,并
可在术中直接去除病因,可取得良好的效果.但我们认为,胸腔镜手术并非适用于各期脓胸,并非
所有的脓胸都需要行胸腔镜手术治疗,急性渗出期和亚急性纤维化脓期可行电视胸腔镜手术治疗,
若胸腔镜剥离有困难,则行胸腔镜辅助小切口下行纤维板剥离,在直视下可获得极佳的手术视野,
操作接近于常规开胸手术,大大降低手术难度,慢性纤维脓肿期因肺纤维板增厚,粘连致密不宜行
胸腔镜手术,而需要开胸手术治疗.化脓性脓胸胸腔镜手术时间在发病2～6周为宜.胸腔镜脓胸清
创引流术后,根据药敏试验合理使用敏感抗生素,同时加强营养支持,鼓励患者咳嗽,咳痰,吹气
球以促使肺复张及闭合脓腔,对于结核性脓胸患者术后给予正规的抗结核治疗.
85
胸腔镜胸腺切除术治疗重症肌无力120例临床报告
Video assisted thoracoscopic Thymectomy (VATT) for Myasthenia Gravis with
Clinical reports on 120 cases
马山,李建业,于磊,等
首都医科大学附属北京同仁医院胸外科,北京,100000
【目的】探讨胸腔镜胸腺切除术治疗重症肌无力的可行性和术后疗效.
【临床资料】 自2002年2月至2007年1月120例胸腔镜下行胸腺切除并清除前纵隔区域及颈根
部的异位胸腺和脂肪组织治疗重症肌无力.男47例,女73例,年龄13-71岁(平均30.6岁) Osserman
分型:Ⅰ型(眼肌型)72例,Ⅱ型 31例(Ⅱa型24例,Ⅱb型7例),Ⅲ型14例,Ⅳ型3例.合
并甲亢9例,视神经炎5例,AchR抗体 79例>2.99 mol/L,41例<2.99 mol/L;术后病理诊断:胸腺
瘤14例(良性11例,恶性3例), 胸腺囊肿3例,单纯胸腺增生86例, 胸腺萎缩5例,正常胸腺2
例.
【方法】双腔气管插管,静脉复合气管吸入麻醉.以术前胸部CT片胸腺分布特点决定经右胸
或左胸手术入路.右侧胸腔入路取左侧45°卧位, 以腋中线 第5肋间隙切口作为镜孔, 腋前线第3
肋间及第5肋间各做2cm切口为操作孔.于上腔静脉-右心房交界处向上剪开纵隔胸膜,游离并保护
膈神经并分离胸腺右叶外缘,清理上腔静脉-右乳内静脉前后的脂肪组织,将右叶上极自颈根部游离
出,并显露左无名静脉;剪开胸骨后纵隔胸膜,将胸腺整片游离达胸腺左叶下极, 清理或切除对侧
胸膜后转向上沿左侧肺门游离胸腺左叶.沿右无名-上腔-左无名静脉解剖出胸腺静脉1-4支,分别予
以切断,自颈根部仔细游离牵出胸腺左叶上极,清理周围1-2-3组脂肪组织.继续自左肺门游离直至
将整个胸腺切除. 清理主-肺动脉间隙的4-5-6组脂肪-异位胸腺,向下清除心包周7-8-9组脂肪以免
异位胸腺组织残留.成人患者加颈部切口行气管前第10组脂肪清理.
【结果】 无手术中及术后死亡.全组中116例完全在电视胸腔镜下手术完成(108例经经右胸
入路12例经左胸), 4例中转开胸手术完成(3例因胸腺瘤部分与上腔静脉或无名静脉粘连紧密,1
例左无名静脉损伤).平均手术时间 2小时06分钟 ,平均胸腔引流2-3天,平均术后住院时间9天.
全部病例术后均更换鼻插管回监护病房呼吸机辅助通气(2.99 mol/L,82例 4 Lh6 7p¨" 7(M-6 7\/24 / E YGM-6 7(M-6 x ("… -x7\/24 )¨Jq /
6 7N 4ì~ 6 P| 4 Lh6 7p¨Jq tJ / 6 7N UJ { (" U) , #
) E' {6 7p E@ $/ ~" 7(-·AEM-6 * 6 7NM-6 ¨JoJ K` ~ N\F…$
/ J UE'+( 7N U~' 7 6 7N" U *" ¨ 7 N\F…^+( 7N U¨!8E /
^ # L811-64 '1104 !4 Lh6 6~4 4 ~ # L8 ) d~
3. 4§ p
0.05 4 ·:+ ~ ><4 _MG'<4 )[(CSR%)48%¨ )[E'88.71%¨ II^III^IV_!¤EW¨4
2 P',P 0.45^0.047'0.016, _MG'<5~6 7Nr*ó 6 7N!7^6 7N9 4 4 K¨!¤EW*ü 2 P'¨P 0.00'0.47,
6 7Nr*ó,X+ CSRE'45.4%¨ )[E'87.5%~ p ,X6 7N!74 CSR 27.8%¨
)[44.4%¨'5 K¨ :+ ~
4. A|A
MGFA4 4 2003H 6 7N L8 4 2O 1^4 N\ L8~ '= ×T-1a'T-1b¨2^
6 7(K0 L8~ '= GVAT S'VATET×T-2a'T-2b¨3^4 6 P| L8~ '= ×T-3a
'T-3b¨4^4 N\-6 P|6( L8T-4~A :5 AxT-3b'T-46 óE''H L86 7N !6 7N
89
的要求,收到理想术后效果.Jaretzki在主张扩大胸腺切除时,列举了15例 经T-1a 和 T-3a手术术
后复发患者,在其行经颈-胸骨联合切除T-4的二次手术中均发现有残存胸腺组织,其中的13例术后
取得了良好效果.而T-1 和 T-2手术的支持者认为他们在减少并发症的同时也可以完全地切除胸腺
及异位胸腺组织.
国外屡有学者尝试对经颈,经胸骨,"扩大"胸腺切除术的死亡率,好转情况及远期效果进行比
较,却由于病人年龄,药物治疗情况,病程及评定标准等诸因素的差异,终无法得出全面而权威的
结论,但均认为三种术式效果基本相似,对任何一种术式的选择都是比较合理的.近些年随着胸腔
镜微创技术的发展,世界各国的胸外科医生对胸腔镜下胸腺切除产生越来越浓厚兴趣.但同时也给
人们留下一个疑问,单纯胸腔镜下胸腺切除是否能达到良好的显露前纵隔及颈根部,完整切除胸腺,
彻底清除前纵隔及颈根部内异位胸腺及脂肪组织的目的.
我院自1991年至2001年底,采用经胸骨正中劈开胸腺切除术治疗重症肌无力(非胸腺瘤)209
例,术后随访到161例(胸骨劈开组);自2002年初至2003年5月,采用胸腔镜行胸腺切除治疗重
症肌无力43例(胸腔镜组),见表1.经χ2检验两组患者性别,手术时年龄,术前临床分型无显著
差异.我们曾报道过胸腔镜下胸腺切除治疗效果的可靠性.手术中胸腔镜下能达到良好的显露前纵
隔及颈根部,完整切除胸腺,彻底清除前纵隔及颈根部内异位胸腺及脂肪组织,但手术时间相对较
长.本研究胸腔镜组平均手术时间132分钟,而胸骨劈开组为96分钟,二者差异有显著性.但事实
上,胸腔镜手术经适当改进手术器械和手术技能的熟练其时间仍可缩短.
胸腔镜胸腺切除术其特有的优越性主要表现在手术创伤和术后恢复上.胸腺切除术最严重并发
症(见表2)-肌无力危象的发生与手术对机体的损伤程度密切相关,而胸腔镜胸腺切除术避免了纵
劈胸骨所造成的创伤,从而避免或减轻危象的发生,在43例胸腔镜患者中仅4例出现肌无力危象,
与纵劈胸骨手术相比,差异有显著性(P=0.023).另外,胸腔镜手术创伤相对较小,呼吸和咳嗽排
痰时疼痛减轻,缩短了呼吸机辅助时间和减少肺部感染的发生.同样,ICU监护时间和住院时间也
相应缩短.
术后的疗效及能否达到完全稳定缓解是医患共同关心之所在.胸腺切除手术的有效性主要与胸
腺及周围脂肪组织切除量,病程,病人年龄,是否并生胸腺瘤等因素有关.本组T-2a组术后1,2,
3年的CSR分别是34.9%,41.9%和46.5%,从表面上看,较T-3a组的26.7%,31.7%,35.4%有明显
提高,但应注意到T-3a组患者基本上在1991年至2001间诊断治疗;而T- 2 a组的是2002年以后的
患者.不同时间段内的诊治水平所造成的差异在很大程度上影响了数据统计.EMG和螺旋CT技术
的应用提高了对重症肌无力诊断的准确性,特别是对症状不典型的重症肌无力.再者,患者对手术
接受情况也对术前病程产生影响.在我院手术的患者中,一半以上(尤其是年轻患者)不能接受胸
骨劈开的方法,而对胸腔镜的小切口,在不影响美观的情况下,为了治疗疾病,还是愿意行胸腺切
除术.术前病程胸腔镜组平均8.2个月,而胸骨劈开组则为16.7个月.病程的长短直接关系到神经
肌肉接头处Ach-R受体永久不可逆性损害程度,影响远期疗效.所以,尽管T-2a组术后的CSR较
T-3a组有提高,只能说胸胸腔镜下胸腺切除术治疗MG能取得同样较为理想的治疗效果,不仅可行
而且安全,但还不能认为胸腔镜胸腺切除术中远期疗效优于胸骨正中劈开.
一般来讲,MG患者胸腺切除术后随时间延长,手术效果越好.T-2a组患者1年到3年术后随
访CSR呈现提高趋势,而且达到CSR的患者无症状复发. T-3a组患者术后5年随访,CSR从术后
第1年的26.7%提高到40.4%,与国外相关研究结果相仿.故我们相信T-2a组CSR将随随访时间延
长,达到更为理想远期疗效.
从表4中可以看到I型MG较之II型,III型和IV型手术效果好.部分学者对无胸腺瘤的单
纯眼肌型病人不主张手术治疗.而另一部分学者则认为,胸腺切除对单纯眼肌型病人亦有效; 尽早清
除胸腺组织可阻断病情向全身型进展的倾向.本组98例眼肌型重症肌无力完全缓解率(CSR%)48%,
90
有效率达88.71%,尽管较之II型差异无显著性,但明显好于III型,IV型的60~70%有效率,差
异有显著性.故我们认为对单纯眼肌型患者应尽早手术治疗.
从表5中可以看到胸腺增生较胸腺正常,胸腺萎缩效果好.胸腺增生的病人术后CSR达45.4%,
有效率达87.5%.术后效果最差的是胸腺正常的MG病人CSR仅为27.8%,有效率为44.4%.胸腺
正常的MG病人术后效果最差原因有可能是:一,胸腺外因素的存在;二,往往临床上症状多系球
状肌无力,对胆碱酯能抑制剂效果不显,AchR血清抗体阴性,2001年前者缺此项,顾推测其中多
属Musk抗体阳性者亦或由于病程长而有胸腺外因素的存在;三,有可能存在诊断的失误,这是我
们一直强调治疗重症肌无力与神经内科合作的必要性.
总之,胸腺切除手术是治疗MG的重要手段,对MG病人诊断确立应尽早手术治疗,切除后可
结合激素或免疫抑制剂治疗.胸腔镜下胸腺切除术能取得胸骨正中劈开手术同样理想的中远期治疗
效果,但对于其 5年甚至更长的远期疗效则有待进一步观察研究.
电视胸腔镜手术治疗自发性气胸附56例报告
Tretment of Spontaneous Pneumothorax by Vodeo-assisted Minithracotomy
钱勇,罗化,袁跃西,等
湖南省长沙市中心医院胸外科,长沙,410004
【目的】探讨电视胸腔镜手术治疗自发性气胸的适应症,手术方法和疗效.
【方法】回顾分析56例自发性气胸的临床资料.本组男性50例,女性6例,平均年龄44.5岁.
其中双侧气胸2例,血气胸2例.首发病例24例,2次以上复发者32例,合并肺结核10例,合并
慢支肺气肿7例.全组均在双腔气管插管全麻下进行.置入胸腔镜全面观察胸膜腔的病变情况.对
胸腔内广泛粘连或VATS下难以发现漏气的病灶或肺大疱较多及巨大肺大疱,则采用VATS的改良
操作法.采用胸腔镜辅助小切口操作法(VAMT)切口,约6cm,配合常规开胸器械,完成胸内操
作.采用切割缝合器(Endo-G1A)切除肺大疱48例,结扎法处理肺大疱8例,同时行干纱布摩擦
壁层胸膜,使肺的脏层胸膜与壁层胸膜粘连,防止气胸复发,术毕放置胸腔引流管.
【结果】所有患者手术均顺利,平均手术时间80min,术中出血量70-180ml,术后置管时间3-10d,
拔管时间3.5d,无手术死亡例及继发胸腔出血例.1例多发肺大疱患者术后创面持续漏气,后并发
胸腔感染,经过处理后全组均治愈出院,平均住院时间9天.随访3个月-12个月,无复发病例.
【结论】电视胸腔镜手术治疗自发性气胸安全,可靠.
关键词 电视胸腔镜手术 自发性气胸 肺大疱
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42例巨大纵隔肿瘤的临床表现及外科治疗
Clinical presentation and surgical treatment of 42 big mediastinal tumor
邱宁雷,许 林,张 勤,等
江苏省肿瘤医院,南京,210009
ABSTRACT
【Objective】To discuss the clinic feature and the surgical treatment of huge mediastinal tumor.
【Methods】42 patients with huge mediastinal tumor were treated surgically from Jan.1997 to Dec.
2001.
【Results】 Among 42 patients, there were 31 patients with benign tumor, and a radical excision of
the tumor was performed in 30 patients; there were 11 patients with malignant tumor, and a radical excision
of the tumor was performed in 7 patients, part excision was performed in 4 patients. Postoperative
complications included postoperative re-expansive pulmonary edema (2 patients), breath failure (2 patients)
and bleeding in chest (1 patient). Postoperative death occurred in 2 patients, one was re-expansive
pulmonary edema and the other was breath failure, and the mortality was 4.76%.
【Conclusion】 The principles of treatment for huge mediastinal tumor is radical surgical excision,
and the choice of the incision is the key points to success. The technique of the segmental resection or
entire resection is available, the postoperative prevention of re-expansive pulmonary edema and breath
failure can increase the complete resection rate and decrease the mortality.
巨大纵隔肿瘤是胸部肿瘤中较罕见的病例,手术复杂,难度大,风险大.我科自1977年1月～
2005年12月间共收治纵隔肿瘤病人487例,其中直径大于10cm的巨大纵隔肿瘤42例,占8.62%,
均经手术病理证实,现报道如下.
回顾性总结自1977年1月～2001年12月我科收治的42例巨大纵隔肿瘤.其中男24例,女19
例;良性31例,恶性11例.良性肿瘤中,胸腺类肿瘤(12例),畸胎瘤(9例),神经源性肿瘤(7
例)较多.恶性肿瘤中,恶性胸腺瘤(4例),恶性畸胎瘤(2例),内胚叶窦瘤(2例)较多.临床
症状中37例有胸闷,胸痛,气短,呼吸困难等症状,27例伴肺部反复感染史,16例伴有低热,18
例有患侧胸壁隆起或饱满,21例气管向健侧移位.
所有手术均在全麻下进行.手术切口:(1)后外侧切口19例,(2)前外侧切口14例.(3)胸
骨正中纵劈切口4例.(4)横断胸骨切口4例.(5)胸骨正中纵劈+前外侧切口1例.31例良性肿
瘤中,完整切除30例;11例恶性肿瘤中,根治性切除7例,姑息性切除4例.术后合并症5例,
复张性肺水肿2例,呼吸衰竭2例,胸腔出血1例.术后死亡2例,复张性肺水肿及呼吸衰竭各1
例,死亡率4.76%.
结合国内外文献,我们倾向于将巨大纵隔肿瘤定义为直径大于10cm且在胸部侧位片上肿瘤占
据一个以上纵隔分区的纵隔肿瘤.影像学诊断中,常规透视与胸片是重要的检查筛选手段,但准确
率较低,仅为28.57%(12/42).胸部CT及MRI检查能清晰分辨纵隔肿瘤与气管,心脏大血管及食
管椎旁的关系,并能判断肿瘤对心脏大血管的外侵程度和范围,准确率较高,为81.81%(18/22).
巨大纵隔肿瘤手术成败的关键是切口的选择,我们认为手术切口应根据肿瘤部位而定:(1)局限一
侧胸腔的肿瘤以后外侧切口为宜.(2)位于前纵隔的肿瘤,若偏向一侧,宜用前外侧切口,若肿瘤
延伸到对侧,可横断胸骨,延伸切口.(3)对于突向两侧胸腔的肿瘤,可采用胸骨正中纵劈切口.
巨大纵隔肿瘤手术时不必强求完整切除,可行肿瘤分块切除或先行瘤内减压.对肿瘤巨大,长期压
92
迫心脏大血管的病例,去除肿瘤时,应用手缓慢托起肿瘤,避免心跳骤停或心功能衰竭等情况的发
生;对与肺有粘连或侵犯的病例,可行部分肺,肺叶或一侧全肺切除.由于患侧肺长期受压,易引
起术后复张性肺水肿的发生.我们体会:(1)复张性肺水肿常发生于术后4-72小时.(2)术中,术
后缓慢复张受压肺,充分供氧,纠正低蛋白血症和低血容量,预防肺部感染等措施可预防肺水肿的
发生.(3)治疗上可采用强心,利尿,提高血浆胶体渗透压等方法.局部可行纤支镜吸痰,气管切
开,呼吸机辅助呼吸等措施.(4)若肺水肿保守治疗无效,并危及生命,可再次手术切除患侧肺.
巨大纵隔肿瘤病程长,临床症状复杂,不易判断良恶性,其他治疗方法效果不佳,积极手术切
除是治疗原则.该病手术难度较高,术前详细检查,充分准备,术中仔细操作,可提高手术切除率
并降低死亡率.
胸腔镜治疗自发性气胸临床分析
The clinic analysis of treatment of spontaneous pneumothorax by video-assisted
thoracoscopic methods.
邵立新,金 炜,袁 军,等
上海中山医院青浦分院,上海,201700
【目的】 探讨胸腔镜技术在治疗自发性气胸患者中的应用和围手术期的处理.
【方法】 本组患者共58例,其中男性56例,女性2例,平均年龄48岁.都有自发性气胸经
胸腔插管引流后无好转,左胸51例,右胸7例,其中有6例合并有自发性血胸,术前胸部CT检查
肺尖部有肺大泡存在.放入胸腔镜操作器械,先分离肺与壁层胸膜的粘连,找到肺大泡,用切割吻
合器钳夹后作切除,用生理盐水冲洗胸腔.对60岁以上的患者可采用胸腔内喷洒消毒滑石粉,以作
胸膜固定术,而对年青患者则可采用壁层胸膜磨擦的方法来固定胸膜,防止术后复发.
【结果】 本组病人经胸腔镜切除肺大泡治疗,肺复张良好,3天后拔除胸管,均治愈,自发
性血气胸者行胸腔镜下用钛夹钳夹出血处或加电凝止血,用切割吻合器切除肺大泡,吸尽胸内积血,
无其他并发症发生.
【结论】 胸腔镜在治疗自发性气胸中有许多优点,值得在临床推广应用.
关键词 胸腔镜 自发性 气胸 临床分析
93
局部麻醉下经电视胸腔镜和小切口开胸诊治胸膜,肺疾病
Clinical Application of Minithoracotomy and Video-Assistanted Thoracic
Surgery(VATS) on pleura-pulmonary diseases under Local Anesthesia
宋言峥,江南,王萍 等
河南省胸科医院胸外科,郑州,450008
【目的】探讨局部麻醉下经电视胸腔镜和胸部小切口诊治胸膜肺疾病的可行性.
【方法】自2000年2月到2005年3月,对30例胸膜,肺疾病患者实施了局部麻醉下开胸手
术.术中按手术的不同将病例分为2组:小切口开胸组和电视胸腔镜组,小切口开胸组是在局部麻
醉下利用胸部小切口在开放性气胸状态下对增厚的胸膜和弥漫性肺疾病进行活检;电视胸腔镜组在
局部麻醉下经电视胸腔镜在闭合性气胸状态下诊治恶性胸水,复发性气胸等.
【结果】小切口开胸组胸膜活检13例,其中10例为恶性肿瘤胸膜转移,胸膜淀粉样变1例,
胸膜纤维增生样改变2例;弥漫性肺疾病活检3例,3例中间质性纤维化2例,Ⅱ型肺结核1例.电
视胸腔镜组14例中除1例因发现胸腔内有致密粘连,而行全麻下开胸手术外,其余均在局麻下完
成胸膜活检,复发性气胸肺大疱切除,顽固性胸水的胸膜固定术电视胸腔镜组中诊断性胸腔镜诊断
恶性胸水4例,肝性胸水1例;治疗性胸腔镜10例,其中顽固性(含肝性胸水)胸水行胸膜固定
术8例,复发性气胸行肺大疱切除和胸膜固定术2例.全组患者无手术并发症和死亡.
【结论】局部麻醉下经电视胸腔镜和小切口能够完成胸膜肺疾病活检术和简单的手术.该方法
经济,微创,对麻醉要求低,有利于临床普遍开展.
关键词 胸膜肺活检术,电视胸腔镜,局部麻醉,小切口
电视胸腔镜食管癌切除术
Video-assisted thoracoscopic esophagectomy for esophageal squamous carcinoma
谭黎杰 王群 冯明祥 等
复旦大学附属中山医院胸外科 上海 (200032)
【目的】总结电视胸腔镜食管切除术的临床经验.
【方法】2004年6月至2007年8月共有29例食管癌患者行胸腔镜食管切除术,男性21例,女
性8例,平均年龄57.3岁,食管中段癌24例,食管下段癌4例,术前分期为0期(原位癌)2例,
I期10例,IIA期17例.胸腔镜游离食管清扫淋巴结后,开腹游离胃或结肠,行食管胃或结肠吻合.
【结果】27食管切除后管状胃代食管,2例行结肠代食管术.术后吻合口瘘4例,心率失常2例,
肺部感染1例,肺损伤1例,并发症发生率27.6%,无死亡病例.平均手术时间4.1h,出血量175ml,
平均胸管置管时间2.6天,住院时间平均8.2天.
【结论】电视胸腔镜食管切除术在技术上是安全可行的,可以减少患者的手术创伤,具有广阔的
应用前景.
94
关键词 食管癌;电视胸腔镜;食管切除术
【Purpose】To summarize the clinical experience of video-assisted thoracoscopic esophagectomy for
treatment of esophageal squamous carcimona.
【Methods】 From June 2004 to July 2007, video-assisted thoracoscopic esophagectomy was performed
in 29 patients.There were 21 men, 8 women.Median age was 57.3 years (range,37-72).The tumor located at
middle segment in 24 cases and lower segment in 4 cases. Preoperative assessment showed stage 0
(cTisN0M0) tumor in 2 cases,stage Ⅰ(cT1N0M0) in 10 cases,and stage Ⅱa(cT2N0M0 and cT3N0M0) in
17 cases.Surgical procedures inclduded thoracoscopic resection of the esophagus with lyphnodes dissection
combined with mobilization the stomach or colon by open laprotomy.Anastomosis were made at the neck.
【Result】Operative morbidity was 27.6%(anastomtic leak 4 case,atrial fibrillation 2 cases,pneumonia 1
case,acute lung injury 1 case), no perioperative mortality.The mean operatve time was 4.1 hours, hospital
stay was 8.2 days(range,6-12).
【Conclusion】Video-assisted thoracoscopic esophagectomy is technically feasible and safe, lower
morbidity and shorter hospital stay compared to open procedure. It has the potential to replace open
esophagectomy in selected patients.
Key Words Esophageal carcinoma; video-assisted thoracscopic surgery; Esophagectomy
VATS lobectomy: From LMTV to LVATS
王群 WANG Qun
Department of Thoracic Surgery, Zhongshan Hospital, Shanghai, 200000,China.
【Objectives】 Summarize our experience of VATS lobectomy. Compare two methods of VATS
lobectomy: LVATS and LMTV.
【Materials and Methods】 From June 1995 to July 2007, 139 cases of VATS lobectomy were
performed in our hospital. LMTV were performed in 58 cases, and other 81cases were treated by LVATS.
Indications for VATS lobectomy included: early stage NSCLC and some lung benign disease
(bronchiectasis, aspergilloma, pulmonary tuberculosis, pulmonary sequestration and lung cyst).
【Results】 Four cases were converted to open thoractomy. Median operation time was 145min and
average operative blood loss was 110ml. For non small cell lung cancer patients, average 11.3(3-38)
mediastinal lymph nodes were dissected. One case died following VATS lobectomy from acute respiratory
distress syndrome (ARDS), 30-day mortality rate was 0.7%. 19 cases had complications after VATS
lobectomy, including pneumonia ,air leakage , atrial fibrillation and bleeding, average morbidity rate was
95
13.7%. Median hospital stay after operation was 6 days. A significantly lower incidence of postoperative
pain and less analgesic requirement occurred in the LVATS group than in the LMTV group.
【Conclusion】 VATS lobectomy is a safe procedure with low morbidity and mortality. For lung
cancer patients, complete nodal dissection is possible with VATS procedure. We believe this technique
should become the operation of choice for early stage NSCLC and some lung benign disease.
胸腔镜支气管动脉夹闭治疗咯血:1例报道
Thoracoscopic Bronchial Artery Clipping for Treatment of Hemoptysis - One Case Report
吴星贤 Hsing-Hsien Wu, M.D.; *Chang-Hung Chen, M.D.
Department of Surgery, *Department of Internal Medicine, Tainan Municipal Hospital, Tainan city, Taiwan
【Introduction】
Hemoptysis especially life-threatening hemoptysis is a challenging issue in thoracic surgery. Till now
bronchial artery embolization (BAE) and surgical pulmonary resection are the main options of
managements. We report a case who received thoracoscopic bronchial artery clipping for treatment for
hemoptysis, which was recurred after BAE.
【Method】
The 52-year-old patient was a case of bronchiectasis under stable status, but he had been suffered from
mild hemoptysis for times in recent years. In October 2006, he developed one episode of moderate amount
hemoptysis and received BAE for treatment of hemoptysis. In January 2007, the hemoptysis was recurred.
This time we performed thoracoscopic bronchial artery clipping to treat hemoptysis. The procedure was
approached via three ports (one 10mm, two 5mm) video-assisted thoracic surgery (VATS). Under video
vision we identified the kinked bronchial artery near the hilar area via interlobar space and occluded the
blood stream by endoscopic clips (Pic.1).
【Results】
The procedure was performed smoothly and the blood loss was minimal. The chest tube was extracted
2 days later. The length of day was 4 days. The postoperative angiography revealed total occlusion of the
kinked bronchial artery at the interlobar level (Pic.2). There was no complication developed and
postoperative recovery was uneventful. Till now the patient was followed up to be not recurred.
【Conclusions】
The thoracoscopic bronchial artery clipping is an effective minimal invasive surgical procedure for
treatment of hemoptysis. This procedure is more effective than bronchial artery embolization and less
invasive than pulmonary resection. Rather than BAE and pulmonary resection, the procedure may become
another option in treatment of hemoptysis.
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The roles of tumor-infiltrated macrophages, CD4+CD25+ regulatory T cells and apoptosis in the
microenvironment of lung cancer
吴怡成 Yi Cheng Wu, Yen Chu DVM, Hui Ping Liu
Div. of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Lin-Kou, Taiwan
【Background】 In non-small-cell lung cancer (NSCLC), stage of the disease is still the most
important prognostic factor. Other than stage, many biological markers and many other prognostic factors
are studied to define their effects on prognosis of lung cancer. This study examined the relation between
tumor-infiltrating macrophagess (TIM), tumor-regulatory T cells (Treg), as well as apoptosis to determine
whether they correlated with 5-year survival.
【Patients and Methods】In our tissue databank, the identified 45 consecutive pathologic stage Ia to
IIIa NSCLC patients who had surgical resection in 2001 were enrolled in this study. Immunohistochemical
analyses and Western blot were performed on liquid nitrogen-preserved lung tumor tissue and the relation
among Treg, TIM, and apoptosis were determined.
【Results】In our survival cases (55.56%, 25/45), the levels of TIM specific marker CD-68 and Treg
were significantly higher in stage IIIa patients. The expressions of Bcl-2/Bax and active caspase-3 and
PARP may be involved in an intrinsic apoptosis pathway. In our survival cases, the levels of Bcl-2/Bax
were found up-regulated whereas the levels of caspase-3 and PARP were significantly lower in stage IIIa
patients.
【Conclusions】 Patients with stage IIIa NSCLC who have a higher proportion of TIM and Treg had
a significantly higher survival rate. Higher expressions of anti-apoptosis protein implicated better survival.
Keywords tumor-infiltrated macrophages, CD4+CD25+ regulatory T cells, apoptosis, lung cancer
胸腔镜辅助微创漏斗胸矫正术治疗体会
Experience on the treatment of funnel chest via video-assisted mini-invasive surgery
肖开提,王小雷,努尔兰,等
新疆维吾尔自治区人民医院胸外科,乌鲁木齐,830001
漏斗胸是一种常见的先天性胸壁畸形,除了畸形造成的精神负担和性格影响以外,畸形本身对呼
吸和循环功能的损害也需要手术纠正.传统的漏斗胸矫正手术存在切口大,影响美观,损伤胸壁肌
肉及骨性支架,患者术后疼痛明显,影响胸廓活动度,恢复慢等弊端,Nuss手术应用胸腔镜微创技
术及特殊支架,符合外表美观,创伤小,恢复快的要求,在严格掌握适应症的前提下,与传统手术
相比,达到了相同,甚至更好的手术效果,应合了目前外科手术发展趋向,具有很强的实用推广价
值.国内2003年前后引进该技术并在少数几家医院开展,我院在2006年9月率先在新疆引进"Nuss
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手术"技术并应用于临床,取得满意的效果.
1.资料与方法
1.1 一般资料 病例5例,男4例,女1例,年龄5~13岁,漏斗指数(FI)为0.21~0.25,漏斗部容水量
为50~100ml.
1.2 临床表现 患儿家属诉自小发现前胸部畸形,随着年龄的增长,畸形越发明显.幼儿常反复
呼吸道感染,有一例活动后感心悸,气短.五例均未发现其它脏器合并畸形.
1.3 辅助检查 胸片可见肋骨后部平直,前部向前下急倾下降,心影向左侧胸腔移位,右心缘
与脊柱重叠,心影中部可见放射状半透明区,2例患者伴有脊柱侧弯.侧位胸片及CT可见胸骨体明
显向后弯曲.2例患者心电图示不完全性右束支传导阻滞,心脏彩超检查五例均未见异常.
1.4 手术方法
手术适应症 接受Nuss手术的患者应符合下列条件中的2项或2项以上.(1)肺功能检查示限
制性或阻塞性通气障碍;(2)伴有二尖瓣脱垂,右束支传导阻滞;(3)畸形程度进展且症状进行性加重;(4)
胸骨抬举术后复发的患儿;(5)Nuss手术后复发的患儿;(6)有患儿及家属精神因素,有强烈矫正愿望.最
佳适应症为年龄在6~12岁,广泛对称性的漏斗胸,尤其是合并扁平胸者.该五例患者均有明显手术
指征.
术前准备 测量漏斗指数及胸廓横径,评估凹陷程度.据此选用合适的特制钢板并弯曲成弓状,
弧度与预抬举高度一致.在钢板拟行通过的胸骨凹陷最低点及起始点以及切口处用亚甲蓝标记.
手术步骤 气管插管,全身麻醉,采用胸腔镜直视下胸骨后钢板置入胸骨抬举法(Nuss技术).
根据凹陷程度在双侧腋中线第3,4肋间或第4,5肋间做横切口2.5cm,肌下游离至同侧凹陷边缘.
右腋中线第7,8肋间Ve r e s s针穿刺入胸腔,注入CO2建立气胸,使右侧肺萎陷.拔出Ve r e s s针,切开
约2cm长切口,置胸腔镜.直视下,从右侧切口将引道器由右侧凹陷边缘第3,4肋间刺入胸腔,经
胸骨后凹陷最低点,心包前至对侧凹陷边缘穿出.将弓形支架用细绳系在引道器头部的孔上,后退
引道器将支架拖到胸骨后,细绳相连处经右侧切口出胸膛,翻转支架使弓背向上,将胸骨撑起.胸
腔镜下观察胸腔内无出血,无其它脏器损伤,撤除胸腔镜,支架右端上固定器,使局部呈T字形,用
尼龙线将支架缝合固定在胸膜上,左端也用同样的缝合方法固定好后缝合肌层及皮肤.右胸腔第7,
8肋间置胸腔引流管,包扎伤口,术毕.
术后处理 术后心电监护,呼吸机辅助呼吸,常规拔除气管内插管,系统抗炎,雾化,支持治
疗,并定时观察胸管引流量,性质变化.术后平卧1~3天,避免扭转及屈曲活动,完善胸片检查,
观察钢板的位置.术后三个月内尽量不要进行对抗性运动,支架在体内保留两年以上.
2.结果
5例患者行Nuss手术治疗后均获得良好的效果,术后第三天下地活动,术后7~10天恢复出院.
患者及家属均满意矫正效果.手术切口与传统术式相比明显缩小,术中出血量约50ml,明显低于传
统术式(约200~300ml)[4].本术式微创,对机体影响小,与传统术式相比,在严格掌握适应症的前
提下,达到同样,甚至更好的预期效果,适应美容美观的要求.术前,术中,术后对比照片如下:
3.讨论
3.1漏斗胸是一种先天性并常常是家族性的疾病,属伴性显性遗传,男女之比为4:1.大多数
人认为漏斗胸是由下胸骨部肋软骨及肋骨发育过度,胸骨代偿性地向后移位而形成的畸形.患儿常
因胸廓畸形,心肺受压,肺功能降低,表现为活动耐力差,肺活量低,易发生心悸及呼吸道感染,
严重影响小儿生长发育,同时影响外观.因漏斗胸对心肺功能及体型外观均有影响,主张早期手术
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治疗,专家认为6~12岁为手术最佳时期[3,5],也有人主张只要看到明显的畸形,无论年龄大小都应
立即手术[5].传统的手术方法有肋骨成型术,胸骨抬高术,胸骨肋骨抬高术,胸骨翻转术等,需取
前胸部切口,切断肋骨,胸骨及游离胸壁肌肉皮瓣,对机体损伤较大,较不易被患者及家属接受.
1998年美国人Nuss首先介绍了无骨切除矫正治疗小儿漏斗胸的方法,Nuss在胸腔镜辅助下进行的微
创矫正小儿漏斗胸的方法(Nuss手术),与传统术式相比,具有切口隐蔽,手术时间短,出血少,活
动早,不需要游离胸壁肌肉皮瓣,不需肋骨或胸骨的切除,长期保持胸部伸展性,扩张性,柔韧性
和弹性等优点,为漏斗胸患者的治疗创立了一个崭新的思路.有文献报道,148例Nuss手术与76例
传统术式进行对比,随访两组发现,术后一年内,2年内及取支架后,患儿及家属满意度均无显著
性差异的前提下,Nuss组平均手术时间,术中出血量,术后引流量,下地活动时间,术后平均住院
天数均优于传统手术组[1,2,5].但同时需指出,Nuss手术与传统手术相比,术后并发症发生率较高,
文献报道可达10~67%左右[6],主要有气胸,胸腔积液,肺不张,术后钢板滑动和旋转,排异反应等.
但作为一种崭新的术式,我们认为随着经验的积累,并发症一定能下降(本组五例患者术后恢复较
顺利,术后未出现明显近期并发症).6~12岁是Nuss手术矫正漏斗胸的最佳时机,广泛对称性的漏
斗胸尤其是合并扁平胸是Nuss手术的最佳选择.凹陷重的局限型漏斗胸及严重不对称的漏斗胸应选
择传统术式.只要我们能掌握好手术指征,汲取经验教训,逐步在临床推广Nuss手术,定能为广大
漏斗胸患者带来福音.
3.2 Nuss手术由于具有微创,美观,恢复快等优点而得到推广应用,但其需要使用特制的价格
昂贵钢板(全套费用约2万元)及配套工具,全部治疗费用约3万元左右,昂贵的费用限制部分患
儿接受此手术,目前国产矫形钢板正进行上市准备,届时费用将有大幅度下降.随着社会经济的不
断发展,人民生活水平的改善,将会有更多的患者能够接受此手术.
自体腹直肌皮瓣移植治疗慢性难治性脓胸:附4例报告
Transplantation of rectus abdominis musculocutaneous flap after open-window
thoracostomy to manage chronic refractory pleural empyema and fistula with 4 cases
report
谢博雄 姜格宁 董佳生* 等
上海市肺科医院胸外科 *上海市第九人民医院整形外科,上海,200433
【Objective】To report a new method of using rectus abdominis musculocutaneous flap after
open-window thoracostomy to manage refractory chronic pleural empyema.
【Method】 From 2004.11 to 2007.3, Intrathoracic transplantation of the musculocutaneous flap was
performed successfully in 4 patients with empyema and fistula after upper lobectomy. The rectus abdominis
myocutaneous flap were designed in such a way that the muscles were not only bearing skin paddle but
epigastrica vessels connecting thoracodorsalic vessels.
【Results】 The rectus abdominis myocutaneous flap has provided sufficient bulk for tract
obliteration. Over a mean follow-up period of 10 months, two patients are free of further infectious squeal
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and muscle atrophy.
【Conclusion】 It is a new and effective method that transplantation of rectus abdominis
musculocutaneous flap after open-window thoracostomy can manage chronic refractory pleural empyema
and fistula.
Key words Chronic refractory pleural empyema; Rectus abdominis musculocutaneous flap;
Open-window thoracostomy; transplantation
表现为肺部实性肿块的肺癌与活动性肺结核并存病例报告
Retrospective study of coexisting lung cancer and active pulmonary tuberculosis patients presenting
as asolitary or mutiple lung mass
谢敏璋 Ming-Jang Hsieh, Hsu-Ting Yen, Hung-Yi Lu, et al.
Division of Thoracic and Cardiovascular Surgery, Department of Surgery
Chang Gung Memorial Hospital at Kaohsiung, Taiwan, R. O. C.
【Purpose】 Pulmonary mass on a chest radiograph is common. High-risk cancer patients may
require surgical resection. Occasionally, lung masses, clinically diagnosed as lung cancer are evaluated to
be tuberculoma or coexisting cancer and tuberculosis (TB). In this study, we evaluated presentations of
lung mass/nodule(s) to identify specific clinical presentations. And excluded scar cancer.
【Material and Methods】 We retrospectively chart review since 1995-2003 there were 15 patients
received surgical intervention and pathological prove coexisting lung cancer and pulmonary tuberculosis
with acid-fast bacilli positive, in the same patient. Charts were reviewed for demographics, clinical
presentation, laboratory and radiographic findings, and outcome.
【Results】 In the patients who were identified coexisting lung cancer and pulmonary tuberculosis
were relative younger and male predominant. There was a predominance of squamous cell carcinoma in the
patient group. Upper lobe involvement was found radiographically in 70% of patients. All patients received
complete coarse of anti-TB drug therapy at preoperative or postoperative time. Some of them received the
operative chemotherapy at the Department of Oncology or chest service.
【Conclusion】 Patients with concurrent lung cancer and pulmonary tuberculosis presented at a
significantly younger age. There was a predominance of squamous cell cancer in the group with concurrent
disease. Early diagnosis for this group patient is difficult. Especial if the patient revealed bilateral lung
masses maybe considered lung-to-lung metastasis and upgraded then arranged chemotherapy, miss the
opportunity for early surgical treatment.
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电视胸腔镜手术治疗气管源性食管囊肿:7例报告
Video-assisted thoracoscopic surgery (vats) in bronchogenic cyst of the esophagus:
clinical and imaging features of seven cases
谢敏璋 MING-JANG HSIEHa, SHEUNG-FAT KOb, JUI-WEI LINc, et al.
a Department of Cardiovascular and Thoracic Surgery, Chang Gung University, Chang Gung Memorial
Hospital at Kaohsiung, Taiwan
b Department of Radiology, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, Taiwan
c Department of Pathology, Chang Gung University, Chang Gung Memorial Hospital at Kaohsiung, Taiwan
【Purpose】 Bronchogenic cysts are one of the most common bronchopulmonary malformations. The
unusual location and uncommom in Esophagus. Limited number reports concerning intramural
bronchogenic cysts of the esophagues.
【Materials & Methods】 From 1987 to 2005, a total seven cases of surgical proven Esophageal
bronchogenic cyst were collected Female: Male=6:1; mean age, 29.9 years. Such cases were characterized
by dysphagia and chest pain. Clinical image: Radiographs and computed tomographs typically appears 3 to
4 cmmidthoracic cystic masses close abutting to the mid-third esophagues. Total cyst excision by
Video-Assisted Thoracoscopic surgery.
【Results】 Clinical features & images showed three cystic lesion at upper asygosophageal recess
level two in lower retrotracheal, and two were asymptomatic. During surgery, submucosal esophageal
masses that originated from the right side of mid-third esophague in five patients. One in left
hemidiaphragm and oneprotruding into left lower lung. Six cases were resection by VATS smoothly long
term follow without recurrence.
【Conclusions】 Different from mediastinal or pulmonary bronchogenic cyst, Esophageal
bronchogenic cyst predominately affect young women. A 3-4 cm midthoracic cystic mass presents with
Dysphagia & Chest pain. VATS be tried before thoracotomy total cyst excision has shown satisfactory
outcomes for this uncommon disease.
脓胸手术病患利用APACHE II 计分系统及危险因子的评估
Apache ii scoring system and risk factors of surgical management for thoracic empyema
谢明儒 Ming-Ju Hsieh, Hui-Ping Liu, Yi-Cheng Wu, et al.
Division of Thoracic & Cardiovascular Surgery, Chang Gung Memorial Hospital, Taiwan
【Objective】 To evaluate the surgical result, APACHE II scoring system and risk factors of patients
with thoracic empyema.
【Design】 Retrospective chart review.
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【Setting】 A 3,000-bed, university-affiliated urban teaching hospital
【Patients】 Between May 2003 to May 2004, 79 patients with empyema thoracis who were
surgically treated were retrospective evaluated.
【Measurements and results】 All patients have tried surgical intervention including total
pneumonolysis and evacuation of pleura empyema cavity. APACHE II scoring system and factors that may
influence the outcome were analyzed. This group included 63 men and 16 women with an average age of
53 years. The causes of empyema include: parapneumonic effusion (n=65), lung abscess (n=1), malignancy
(n=3), cirrhosis (n=1), esophageal perforation (n=1), post traumatic empyema (n=4) and post thoracotomy
complication (n=4). In-hospital mortality rate was 6.33% (5/69). The mean follow up was 6 months.
【Conclusions】 We present the clinical features and outcomes of 79 patients with empyema thoracis
who underwent surgical treatment. The surgical mortality was 6.33% and significant APACHE II scoring
parameters and risk factors as below: Biopsy proven cirrhosis: P=1.23, COPD: P=0.009<0.01, CV disease:
P=0.123, chronic hemodyalysis: N/A, Immune compromise: P=0.129. The other significant parameters are
blood pressure P=0.000 <0.001. heart rate: p=0.000<0.001, and total score of APACHE II: p=0.003<0.05.
We suggested APACHE II score and some parameter are predictable risk factors of empyema and surgical
treatment of empyema thoracic should not be delay due to acceptable postoperative complications and
mortality.
手术切除的I期非小细胞肺癌病人中人乳头瘤病毒16/18的E6癌蛋白的表达
Expression of E6 oncoprotein of human papillomavirus 16/18 in patients with resected
stage I non-small cell lung cancer
许南荣 Nan-Yung Hsu1, Ya-Wen Cheng2, Heng-Chien Ho3, et al
1Division of Chest Surgery, China Medical University Hospital, Taichung, Taiwan
2Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
3Department of Biochemistry, College of Medicine, China Medical University, Taichung, Taiwan
【Background】 Our previous reports have indicated that human papillomavirus (HPV) 16/18
infection were more frequently dectected in non-small cell lung cancer (NSCLC) of nonsmoking Taiwanese
women.
【Methods】 In this study, we analysed a series of 222 patients with resected stage I NSCLC for the
present of E6 oncoprotein of HPV 16 and 18 by using immunohistochemistry.
【Results】 Our data showed that 50 (22.5%), 33 (14.9%) and 64 (28.8%) of 222 patients had
expression of E6 oncoprotein of HPV 16, 18, and 16 or 18, respectively. When study subjects were
stratified by gender, age, smoking status, histology, tumor status, and differentiation, data showed that
female patients, nonsmoker and adenocarcinoma had significantly high prevalence of expression of E6 of
HPV 16, 18, and 16 or 18. The odds ratio of expression of E6 oncoprotein of HPV 16 or 18 of female,
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nonsmoker and adenocarcinoma is significantly higher at 2.983 (95% confidence interval, 1.613-5.516,
p<0.0001) than male; that of nonsmoker is significantly higher at 2.483 (95% confidence interval,
1.297-4.753, p<0.05) than smoker; and that of adenocarcinoma is significantly higher at 3.198 (95%
confidence interval, 1.632-6.264, p3.0cm的食管平滑肌瘤,摘除后缝合食管肌层及纵隔
胸膜,对于较小的食管平滑肌瘤,摘除后不缝合肌层及纵隔胸膜,随访67个月,无发生食管憩室形
成.
【结论】电视胸腔镜手术治疗食管平滑肌瘤符合小手术,小切口的要求,为首选治疗方法.
关键词 电视胸腔镜手术 食管平滑肌瘤
原发性淋巴上皮瘤样肿瘤:一例报告
Primary lymphoepithelioma-like carcinoma of the lung : a case in which the patient was
free of recurrence nine years postoperatively.
曾繁颖 Kevin Fan-Ying Tseng, Ming-Sung Yang, Jean-John Fu
Division of Thoracic Surgery, Department of Surgery, Cheng-Hsin Rehabilitation Medical Center, Taipei
City, Taiwan
Primary Lymphoepithelioma-like carcinoma (LELC) of the lung is a very rare disease. It was first
reported on 1987. In the past decades since it was discovered, very little long term follow-up data reported.
As from the reported literature, this uncommon disease has a predilection among young Asian nonsmokers
without gender distinction. The histological feature of the tumor is indistinguishable from undifferentiated
nasopharyngeal carcinoma and the carcinogenic role of latent Epstein-Barr virus infection make this tumor
predominately in Asian population as compare to Caucasians. We encountered a case of a 57 year-old
female who was admitted into our service in August of 1998 due to dry cough and dyspnea for three
months. Chest x-ray was suspected of malignant lung tumor over right lower lobe. The patient received
right lower lobectomy on the September of the same year. The pathological diagnosis was confirmed of
LELC of the lung with pathological stage to be T2N0M0-Stage IB. The patient's tumor cells were negative
for EBV as examined with immunohistochemical analysis. Postoperatively, the patient received regular
follow-ups and was free from tumor recurrence during these years. We reported this case for its rarity and
the EBV negative nature of the tumor.
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非小细胞肺癌前哨淋巴结扫描活检术的临床研究
Clinical Research on the Technique of Sentinel Lymph Node Biopsy In Patients with
NSCLC
曾亮,倪旭东,王群,等
复旦大学附属中山医院胸外科,病理科,上海,200032
Abstract
【Background & Objective】 The metastasis status of regional lymph node is an important
prognostic factor of non-small-cell lung cancer (NSCLC). Sentinel lymph node (SLN) mapping and biopsy
is a quick and high efficient technique to intraoperatively detect occult micrometastatic disease, however,
its application in NSCLC is immature. This study was designed to investigate the feasibility of detecting
SLN in patients with NSCLC using 99mTc colloid and a hand-held gamma detection probe (GDP) during
radical surgery, and to evaluate its accuracy of predicting metastasis status of regional lymph node.
【Methods】 The study was carried out on 24 patients (M/F/11/13, mean age 64.98 years) with
resectable NSCLC (StageⅠ-). After thoracotomy, a total of 2 ml 99mTc sulfur colloid was injected into Ⅲ
each quadrant of lung tissue immediately surrounding the tumor (3, 6, 9, 12 o'clock sites) with a total dose
of 2mCi. All SLNs were detected and obtained with a hand-held gamma counter (GDP). And then a
systematic mediastinal and hilar lymph nodal dissection were performed on each patient. All lymph nodes
were first analyzed by HE staining, and sect serial sections combined with CK19 immunohistochemical
(IHC) staging was used to detect the micrometastic tumor cells in HE staining negative lymph nodes.
Statistical analysis was performed using spss.
【Results】 The SLN was successfully identified in all of 24 no-small cell lung cancer patients;
detection rate was 100% (24/24). 50 SLNs and 143 NSLNs were found of 24 patients, 31 nodes were found
to have metastases disease in 50 SLNs, and 27 nodes were found to have metastases disease in 143 NSLNs.
The possibilities of SLNB and systematic lymph nodal dissection remove pathologically positive nodes
were 62% (31/50), 30.1%(58/193), respectively (P '<6 7(K0 6 L8 J# ¨4§# " +ks M2 4 6 6 , 10
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112
探查.如果发现可疑纵隔淋巴结或肺,胸膜转移和播散结节,冰冻病理证实为恶性,应及时调整手
术诊治方案.
B. 肺门的解剖
若有胸腔粘连,应在肺门处理前彻底游离,以便于灵活牵拉肺组织暴露肺门结构.叶裂不全不
是胸腔镜手术的反指证,可以在尽可能处理肺门血管甚至支气管后,予以自动切割闭合器闭合离断.
胸腔镜下无法触摸肺门血管,需要依靠术者对手术器械头端的感觉.常规手术剪刀,钳子和电刀轻
巧易掌控,是我们作为肺门血管解剖游离的主要器械.血管充分游离后,可以使用自动切割闭合器
闭合离断血管,也可以在安全前提下尽可能经切口使用推结器结扎血管后离断,降低手术器材费用.
支气管的游离也如同常规手术,残端多使用相应的自动切割闭合器闭合离断.残端闭合的完整性通
过注水于胸腔,气道加压鼓肺后证实,若有漏气,应在胸腔镜下使用常规缝线缝合加固.我们对肺
门结构和肺裂处理原则顺序并根据术中实际解剖结构,在安全的前提下进一步灵活应变操作.
C. 淋巴结切除
胸腔镜下的淋巴结切除相对操作困难,但优良的术野照明及放大效果是其优势所在.在打开纵
隔胸膜清扫纵隔淋巴结时,应注意多使用钛夹预防性地钳夹淋巴结周围组织,防止支气管动脉出血
和术后淋巴瘘.清扫右侧最上纵隔淋巴结和左侧主动脉弓下淋巴结时注意避免喉返神经的损伤.对
于胸腔镜手术中可疑淋巴结转移并经冰冻切片证实的情况,转为常规开胸手术.
D. 标本的取出
除了避免胸腔镜手术切除中对肿瘤的挤压外,较小的标本可经切口直接取出,而较大的标本均
应在胸腔内置入手套中经小切口拔出,避免小切口对肿瘤的挤压.手术完成后,在反复冲洗胸腔及
切口后,放置胸管和缝合切口.一系列措施是为了尽可能避免肿瘤在胸腔内或切口的种植.
2.结果
10例肺癌手术均在完全胸腔镜下完成,无1例中转常规开胸手术,手术时间91~211分钟,平
均178分钟.手术切口长度3～4厘米,平均3.6厘米.左胸平均清扫淋巴结4.63组,右胸平均清扫
淋巴结6.79组.术中出血量50~200ml,平均92ml,1例因术后发现右上叶支气管旁支气管动脉分支
出血再次胸腔镜探查止血外,余病例均未输血.术后住院天数3~10天,平均4.8天.全组除1例再
次止血外,无其他并发症.
3.讨论
3.1 完全胸腔镜下能完成解剖学肺叶切除 我院完全胸腔镜肺癌手术病例均对肺血管和支气管
分别进行离断结扎.肺裂的广泛粘连不是VA M T肺叶切除术的反指征,我们采取先处理肺血管和支
气管,然后用胸腔镜用自动切割闭合器处理肺裂,利于避免肺门血管损伤,清晰解剖肺裂,严密缝
合余肺创面,避免术后漏气.
3.2 完全胸腔镜下能完成系统淋巴结清扫 可切除非小细胞肺癌手术治疗的金标准:切除所在
肺叶外,必须清扫胸内相关引流淋巴结及其他区域肿大淋巴结,以达到根治和标准术后分期的目的.根
据2005年国际肺癌学会(IASLC)建议的肺癌手术根治标准,除了切除至少3个以上的肺内或肺门
淋巴结外,还至少切除来源于纵隔的3个淋巴结: (a)右上,中叶肺癌—须切除隆突下淋巴结和上纵隔
中的至少两组淋巴结;(b)右下叶肺癌—须切除气管支气管,隆突下淋巴结和下肺韧带淋巴结(或
食管旁淋巴结);(c)左上叶肺癌—主动脉弓下,隆突下和前纵隔淋巴结;(d)左下叶肺癌—隆突下,
食管旁和下肺韧带淋巴结.除肺门和肺内淋巴结外,纵隔淋巴结清扫在右胸应至少包括第2,4,7～
9组,在左胸应至少包括第5,6,7～9组.在充分保证手术安全的前提下,左胸平均清扫淋巴结4.63
组,右胸平均清扫淋巴结6.79组,符合系统清扫的要求.
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3.3手术时间 有学者认为胸腔镜下手术操作困难,有可能因延长手术时间而削弱胸腔镜微创价
值.虽然胸腔镜下手术操作相对困难,但由于开关胸时间短以及使用自动切割闭合器,多数报道胸
腔镜肺癌手术时间与常规开胸并无显著差异.我们的胸腔镜手术时间约在3小时以上,参照以往我
们的常规开胸经验,虽然胸腔镜肺癌手术时间较长,但随着经验的增长积累,我们相信能进一步缩
短手术时间.胸腔镜学会建议如果由于胸腔广泛粘连,钙化淋巴结与肺门血管粘连紧密等因素,胸
腔镜手术时间将有显著延长可能时,术者应果断判断并及时中转为常规开胸手术.
3.4 手术安全性 综合以往较大宗胸腔镜肺癌手术病例报道,手术死亡率在0～2%,极少是由
于术中无法控制的大出血死亡.Yim指出使用自动切割闭合器闭合血管失败仅是偶发事件,胸腔镜
器械发展至今应是安全可靠的,即使血管闭合处有轻度渗血,可以在胸腔镜下进一步缝合加固.我
们的1例病例术后须再次止血,究其原因是支气管旁支气管动脉分支出血,再次手术中发现该分支
残端残留自动切割闭合钉,但闭合不佳.我们分析是手术中是使用自动切割闭合器一并处理支气管
及其动脉分支,但由于支气管和支气管动脉分支管径相差悬殊,导致动脉分支闭合不良.今后应注
意手术中充分游离及处理支气管旁组织,术毕仔细探查支气管残端及其周围组织有无出血.
3.5 术后恢复 胸腔镜手术切口长度明显小于常规手术,术后平均住院时间4.8天,而常规开
胸手术多在9天以上,具有显著差异,间接表明由于完全胸腔镜下肺叶切除术创伤小,疼痛轻,早
期肺功能损伤少,术后恢复更快.
3.6 符合美容要求 完全胸腔镜手术切口疤痕小,符合现代美容需求.
3.7 费效比 胸腔镜肺癌手术中大量自动切割闭合器的使用无疑大大增加手术费用,这是制约
这项微创手术在我国开展的重要因素.如前所述,我们可以在安全的前提下使用常规缝,结扎技术
处理肺门结构,以降低耗材的使用.但是如果完全分叶不全,胸腔镜下仍多依赖自动切割闭合器完
成叶间裂的分离闭合.有日本学者报道胸腔镜肺癌手术的住院费用低于常规手术,可能与发达国家
术后住院,监护等日均费用较高有关.
3.8 我们使用的特殊器械值得推广 我们将常用的胸腔镜用肺钳(弯把)改为直把,以适应大
多外科医师操作习惯,易于入门医师的掌控,缩短胸腔镜手术的适应时间.临床外科手术特别是肿
瘤外科手术中须常规清扫淋巴结,这已达成共识,在实际操作中通常运用某种器械钳夹淋巴结再予
以切除,但是目前钳夹淋巴结的器械多为Allis钳,血管钳或镊子等,操作中非但难以牢固钳夹淋巴
结及其周围疏松脂肪组织,反而容易切割,挤压淋巴结,破坏摘除淋巴结的完整性,不利于手术切
除的迅速进行和正确的病理诊断,胸腔镜下肺癌手术更增加了淋巴结清扫难度.我们的淋巴结摘除
钳特别便于手术中对淋巴结钳夹,有助于降低手术清扫难度.
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