胸腔镜肺减容术围手术期处理

Perioperative management of video-assisted thoracoscopic lung volume reduction

目的总结40例电视胸腔镜肺减容术（lung volume reduction surgery，LVRS）围手术期处理经验。方法1999年7月～2005年12月，我院对40例重症慢性阻塞性肺部疾病行电视胸腔镜肺减容术（23例附加胸壁小切口），术中均采用内镜切割缝合器切除一侧肺容积的20％～30％。结果双肺减容术13例（单纯胸腔镜手术7例，辅助小切口6例），单肺减容术27例（单纯胸腔镜手术10例，辅助小切口17例）。本组无手术死亡。40例术后住院9～41d，平均18d。术后呼吸困难症状明显缓解，呼吸指数均上升1～2级。术前与术后1个月肺功能比较：第1秒用力呼气量（forced expiratory volume in 1 second，FEV1）占预计值百分比（48.3±4.9）％vs（68．5±5.6）％（t=17．169，P=0．000）；残气量（residual volume，RV）占预计值百分比（270．0±23．6）％vs（188．0±19．8）％（t=16．835，P=0．000）；肺总量（total lung capacity，TLC）占预计值百分比（123．0±9．8）％vs（102．0±8．7）％（t=10．135，P=0．000）。10例术后肺漏气，5例肺部感染，3例支气管哮喘，患者经对症治疗后均痊愈。37例随访3～77个月，平均46个月，3例术后6、10、20个月死于肺癌，2例术后3个月和8个月死于食管癌，1例术后6个月死于脑血管病，余31例全部存活。结论术中熟练掌握胸腔镜手术技巧，围手术期积极预防和处理并发症，是保证手术成功和患者早日康复的关键。

Objective To summarize the experience of perioperative management of lung volume reduction surgery （LVRS） under video-assisted thoracoscopy. Methods A total of 40 patients with severe chronic obstructive pulmonary disease （COPD） underwent LVRS under video-assisted thoracoscopy. A mini-incision thoracotomy was given in 23 of them. During the operation, the Endo-GIA was utilized to resect 20%～30% of total volume of affected lung. Results The LVRS was performed in bilateral lungs in 13 patients （under thoracoscopy only in 7 patients and with the assistance of mini-incision thoracotomy in 6 patients） and in unilateral lung in 27 patients （under thoracoscopy only in 10 patients and with the assistance of mini-incision thoracotomy in 17 patients）. There were no surgery-related deaths. All the patients were discharged from the hospital 9～41 days （mean, 18 days） after operation. Not only symptoms of dyspnea were obviously relieved but also the respiratory index was upgraded by 1～2 grades. The comparisons on pulmonary functions between preoperative time and 1 month after operation indicated a great improvement postoperatively, including the forced expiratory volume in 1 second （FEV1） （48.3%±4.9% vs 68.5%±5.6% predicted; t = 17.169, P = 0.000）, the residual volume （RV） （270.0%±23.6% vs 188.0%±19.8% predicted; t = 16.835, P =0.000）, and the total lung capacity （TLC） （123.0%±9.8% vs 102.0%±8.7% predicted; t = 10.135, P = 0.000）. Postoperative complications included air leakage in 10 patients, lung infection in 5 patients, and bronchial asthma in 3 patients, all of whom were cured after symptomatic management. A follow-up was conducted in 37 patients for 3～77 months （mean, 46 months）. Three patients died of lung cancer at 6, 10, and 20 postoperative months, respectively. Two patients died of esophageal cancer at 3 and 8 postoperative months, respectively. And one patient died of cerebrovascular disease at 6 postoperative months. The remaining 31 patients survived. Conclusions Proper perioperative management is of great importance for a successful surgery and a rapid postoperative recovery.