内科胸腔镜对肝性胸水的发生机制和治疗作用研究

The value of video-assisted thoracoscopy for the mechanism investigation and management of refractory hepatic hydrothorax

目的 探讨内科胸腔镜对肝性胸水的发生机制和临床治疗作用。方法 对 2 6例肝性胸水患者行胸腔镜检查 ,并对其中 2 4例在胸腔镜直视下向胸腔内均匀喷撒医用灭菌滑石粉 3～ 5 g行胸膜腔闭锁治疗 ,观察其治疗效果及不良反应。结果 胸腔镜检查示 2 5例胸膜光滑无粘连带形成 ,其中 19例胸壁及膈肌静脉显露扩张 ,6例奇静脉明显充盈扩张 ,16例存在膈肌小泡。 2 4例经胸腔镜行胸膜腔闭锁术 ,其中 14例完全闭锁 ,8例部分闭锁 ,2例无效。术后随访 3个月至 3年 ,3例死于上消化道大出血、肝性脑病 ;1例于术后 1.5年胸水复发 ,1例失访。结论 膈肌小泡破裂形成膈肌小孔 ,腹水经膈肌小孔进入胸腔是产生肝性胸水的主要机制 ,而奇静脉、胸壁及膈肌静脉压力升高是构成肝性胸水形成的因素之一。内科胸腔镜胸膜腔闭锁治疗肝性胸水有肯定疗效 ,但需注意适应证并密切观察患者肝功变化。

Objective To study the value of video-assisted thoracoscopy for the mechanism investigation and management of refractory hepatic hydrothorax.Methods Thoracoscopy was performed in 26 patients with refractory hepatic hydrothorax,24 therapeutic thoracoscopies were underwent to achieve pleurodesis using talc poudrage.Results Of all patients 19 cases had hypertensive chest and diaphragm veins,6 cases had hypertensive azygos veins.19 cases presented diaphragm blebs.Of 24 patients who received pleurodesis via thoracoscope,14 cases acquired complete response(CR),8 cases acquired partial response(PR) and 2 cases had non-change(NC).Mild chest pain and fever were the most complains during or after the procedure,liver function damage was the most important side reactions after pleurodesis.The follow up period was from 3 months to 3 years.During this periods,1 case died of hemorrhage and encephalopathy in 1 month;3 patients died of hemorrhage in 6,12,18 months respectively;1 case had recurrence in 18 months.Conclusions Defects in the diaphragm seem to be the main mechanism to explain the development of hepatic hydrothorax.Thoracoscopy talc poudrage pleurodesis is effective in the treatment of hepatic hydrothorax but the complications and changed liver function should be emphasized.