无胸膜损伤微创经皮肾镜取石术并发胸腔积液成因的初步研究

Clinical Research on the Cause of Complicating Hydrothorax of Mini-percutaneous Nephrolithotripsy without Pleural Injury

目的:探讨微创经皮肾镜取石术(MPCNL)并发胸腔积液的成因。方法:对285例上尿路结石患者行MPCNL治疗,其中输尿管上段结石91例,肾结石167例,输尿管上段结石并肾多发性结石27例;均为单侧结石。结石大小1.2～4.5cm,平均2.3cm。术中在超声引导下于第12肋下腋中线至肩胛线之间穿刺,明确避开胸膜后建立经皮肾通道取石。用含0.1%中华墨汁的生理盐水作为灌洗液。术后行胸部X线及B超检查,必要时行CT检查。并发胸腔积液较多者在B超定位后行胸腔穿刺抽液并抽取外周血进行镜检,寻找有无碳颗粒,对相关数据进行分析。结果:手术均获得成功,术中无胸膜损伤及气胸等并发症发生。术后B超检查发现16例并发胸腔积液,CT检查发现5例并发少量胸腔积液。其中13例抽出术侧胸腔积液,离心后提取沉淀物镜检可见碳颗粒,而抽取外周血镜检未见碳颗粒。胸腔积液组结石大小、数目、术中冲洗液灌洗时间、灌洗压力和用量明显高于无胸腔积液组(P<0.05),其中灌洗时间、术中灌洗压和灌洗液用量是胸腔积液发生的独立影响因素(P<0.05)。结论:无胸膜损伤MPCNL并发胸腔积液,可能因术中灌洗液量大、灌洗时间长和灌洗压力高导致术中灌洗液外渗至腹膜后间隙和(或)腹腔,再通过膈肌进入胸腔形成。

Objective：To research the cause of complicating hydro：thorax of MPCNL. Methods.. A total of 285 cases with upper urinary tract calculi underwent MPCNLs. They included 174 males and lll females, aged from 11 years to 72 years （median, 32 years）. 91 cases were ureteral calculi, 167 were renal calculi, and 27 were renal calculi with upper ureteral calculi. The size of the calculi ranged from 1.2 to 4.5 cm （median, 2.3 cm）. In all operations, the 12th rib subcostal punctures were guided by ultrasound to avoid injuring pleura between midaxillary line and scapular line. Physiological saline with Chinese ink was used as irrigation fluid. Hydrothorax identified postoperatively by Chest X-ray, B ultrasound or CT scan was tested under microscope to find carbon granule. At last, the influencing factors were analyzed. Results： All the procedures were successful. Hydrothoraxes were occurred in 16 cases identified by B ultrasound, while the other 5 cases complicating hydrothorax were identified by CT scan. Hydrothoraxes were acquired in 13 cases by thoracentesis and carbon granules were found in hydrothorax under microscope in all 13 cases, while it can not be found in peripheral blood. After comparing the data of cases complicating hydrothorax with the clinical data of cases without hydrothorax, we find that the stone size, stone multiplicity, operative perfusion time, the perfusion pressure and the perfusion volume of irrigation fluid in cases with this complication were significantly higher than those without complication （P〈0.05）, meanwhile operative perfusion time, the perfusion pressure and the perfusion volume of irrigation fluid were independent factors （P〈 0.05）. Conclusions： Hydrothoraxes were occurred after MPCNLs without injury of pleura. We conjecture that the long operative perfusion time, the high per：fusion pressure and the large perfusion volume of irrigation fluid promote irrigation fluid extravasation to retroperitoneal space and abdominal cavity, and then it can enter into the pleural cavity and cause hydrothorax.