胸导管与静脉吻合术在复发性重症乳糜胸治疗中的临床应用

Clinical application of thoracic duct and vein anastomosis in the treatment of recurrent severe chylous thorax

目的探讨胸导管与静脉吻合术治疗复发性重症乳糜胸治疗中的应用价值。方法根据引流量以及有无胸导管损伤,将我院2014年1月至2021年12月收治的乳糜胸病人63例分为A、B两组。其中,A组37例,每日胸腔引流量<1000 ml且无胸导管损伤;B组26例,每日引流量>1000 ml且淋巴管造影证实有胸导管损伤。分别采用保守治疗、胸导管结扎或胸导管与静脉吻合等不同方式进行干预,观察病人的症状、胸腔闭式引流液的性状及量、术后恢复时间和预后等。结果根据多因素分析,年龄>60岁(P<0.01)、长期吸烟(P=0.04)、长期饮酒(P=0.03)、曾有恶性肿瘤病史(P=0.02)的病人发生B组乳糜胸的几率更大。A组乳糜胸多数经保守治疗可治愈,而B组中21例保守治疗无效。这些病人采用胸导管结扎手术治疗,其中3例结扎后仍反复乳糜胸病人采用胸导管与静脉吻合术治愈。结论每日引流量>1000 ml伴胸导管损伤类型的乳糜胸应积极手术治疗,胸导管结扎术对常规类型的乳糜胸有良好的治疗效果,但对于持续反复的重症乳糜胸,胸导管与无名静脉或奇静脉吻合术更为有效。

Objective To investigate the potential benefits of thoracic duct vein anastomosis in the management of recurrent and severe chylothorax.Methods According to the drainage volume and presence of thoracic duct injury,63 chylothorax patients admitted to our hospital from January 2014 to December 2021 were divided into two groups:A and B.Among them,a total of 37 patients in Group A had a daily thoracic drainage volume of<1000 ml and no thoracic duct injury;a total of 26 patients in Group B had a daily drainage volume of>1000 ml and had thoracic duct injury confirmed by lymphangiography.Different methods of intervention such as conservative treatment,thoracic duct ligation or thoracic duct and vein anastomosis are used to intervene,and the patient’s symptoms,the characteristics and amount of thoracic closed drainage fluid,postoperative recovery time and prognosis are observed.Results According to multifactor analysis,patients over the age of 60(p<0.01),with a long history of smoking(p=0.04),prolonged alcohol consumption(p=0.03),and a history of malignancy(p=0.02)exhibited a higher incidence of Group B chylothorax.Most chylothorax cases in Group A were successfully treated using conservative methods.Among the 21 patients in Group B treated through thoracic duct ligation surgery,3 cases showed recurrence of chylothorax.These 3 patients were cured by performing thoracic duct with venous anastomosis.Conclusion Chylothorax cases with a daily drainage volume exceeding 1000 ml and accompanying thoracic duct injury should be treated promptly and aggressively with surgical intervention.Thoracic duct ligation has shown favorable treatment outcomes for typical chylothorax cases.However,in the event of persistent and recurrent severe chylothorax,a thoracic duct surgery with innominate or odd vein anastomosis may prove to be more effective.