亚肺叶切除术后迟发性纵隔气肿机制

Mechanism of delayed pneumomediastinum after sublobectomy

目的探讨亚肺叶切除术且拔除胸腔闭式引流管后迟发性纵隔气肿的发生机制,并提供预防和处理经验。方法回顾分析2021至2022年期间绍兴市人民医院4例经亚肺叶切除术,且拔管出院后再次出现迟发性纵隔气肿的病例资料。结果大范围楔形切除和不完全的肺段切除术可能产生累及肺段/亚肺段支气管的高危肺切割创面,术后迟发性纵隔气肿发生率相对较高。迟发性纵隔气肿常由肺泡压力突然升高诱发,常表现为快速进展的纵隔和皮下气肿,易导致患者焦虑和恐惧。胸腔闭式引流术是有效的治疗方法,一般无须手术干预。对闭合张力较高且可能涉及细小支气管的高危肺切割创面,术中采用连续往返缝合加固,可以防迟发性纵隔气肿的发生。结论亚肺叶切除术后的迟发性纵隔气肿有其独特的发生机制,可能与大范围楔形切除和不完全的肺段切除术产生的高危肺切割创面有关,术中对上述高危肺切割创面缝合加固,可以防迟发性纵隔气肿的发生。

Objective To explore the unique mechanism and provide clinical experience in the prevention and management of delayed pneumomediastinum occurring after sublobectomy and extubation of thoracic closed drainage tube.Methods Four clinical cases with delayed pneumomediastinum that occurred after sublobectomy,extubation and discharge from 2021 to 2022 at the Shaoxing People’s Hospital were retrospectively analyzed.Results High-risk lung incision involving segmental/subsegmental bronchi,which might cause extensive wedge resection and substandard segmentectomy,increase the incidence of postoperative delayed pneumomediastinum.Delayed pneumomediastinum were often induced by a sudden increase in alveolar pressure,with a typical manifestation of rapidly progressive mediastinal and subcutaneous emphysema,and resulted in anxiety and fear in patients easily.Delayed pneumomediastinum generally does not require surgical intervention,and thoracic closed drainage is an effective treatment.For high-risk lung incision with high closure tension and possibly involving small bronchi,continuous back-and-forth suture reinforcement during the operation may prevent the occurrence of delayed pneumomediastinum.Conclusions Delayed pneumomediastinum after sublobectomy has its own unique mechanism,which may be related to the high-risk lung incision caused by extensive wedge resection and substandard segmentectomy.Intraoperative suture reinforcement of the above-mentioned high-risk lung incision might reduce or even prevent the occurrence of delayed pneumomediastinum.