内科胸腔镜在顽固性肝性胸腔积液检查中的应用及治疗效果

The value of thoracoscopy for diagnosis and management of refractory hepatic hydrothorax

目的探讨内科胸腔镜对顽固性肝性胸腔积液的检查及应用价值。方法对26例顽固性肝性胸腔积液患者行内科胸腔镜检查,观察胸膜腔的形态变化,并在胸腔镜直视下对其中24例患者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26例患者中19例胸壁静脉显露扩张,6例奇静脉明显充盈扩张,16例存在膈肌小泡。24例行胸膜腔闭锁术,14例完全闭锁,8例部分闭锁,2例无效。胸痛及发热为常见的不良反应,但程度较轻;肝功能损害是重要的不良反应。术后随访6个月至3年,4例患者分别于术后1个月及0.5、1、1.5年死于上消化道出血,1例患者术后1.5年再次出现大量胸腔积液。结论胸腔静脉及奇静脉扩张、压力升高是行成肝源性胸腔积液的因素之一,膈肌小泡破裂形成膈肌小孔是另一重要发病机制。在局部麻醉下经胸腔镜医用灭菌滑石粉喷撒法胸膜腔闭锁治疗顽固性胸腔积液有肯定的疗效。

Objective To study the value of thoracoscopy for diagnosis and management of refractory hepatic hydrothorax （HH）. Methods Twenty-six patients with refractory HH were enrolled in this study. Twenty-four of them underwent therapeutic thoracoscopy to achieve pleurodesis by application of talc poudrage. Results Nineteen of the 26 patients had dilated chest wall veins, 6 had dilated azygos veins, and 16 had diaphragm blebs. Of the 24 patients who received pleurodesis via thoracoscope, 14 cases showed complete response, and 8 showed partial response. Mild chest pain and temperature elevation were the most complaints during or after the procedure. Liver function abnormalities were the most serious side effects after pleurodesis. During the follow-up period ranging from 6 months to 3 years, 1 patient died of upper gastrointestinal hemorrhage and encephalopathy in 1 month, 3 patients died of hemorrhage in 6, 12, 18 months respectively, and 1 case experienced recurrence in 18 months. Conclusions Defects in the diaphragm seemed to be the main cause for the development of HH. Pleurodesis achieved by thoracoscopy and talc poudrage was effective in the treatment of HH, but complications and impaired liver functions should be considered.