肺移植手术技术及围手术期管理3例报告

Surgical techniques and perioperative management of lung transplantation:a report of 3 cases

目的探讨肺移植手术技术及围手术期管理经验。方法浙江大学医学院附属第一医院于2011年8月至2012年6月共完成3例肺移植,依次为55岁特发性肺纤维化患者(例1)、71岁双侧肺气肿患者(例2)和56岁双侧支气管扩张患者(例3)。手术方式为单肺移植(例1)和序贯式双肺移植(例2,3)。例1和例3术中采用体外膜式氧合辅助。供肺获取采用心肺整块切取后体外分离修剪。移植术后予以常规控制肺水、免疫抑制、抗感染等治疗。结果供肺热缺血时间均控制在8min以内。3例受者均顺利接受手术,手术时间依次为:143min、316min、336min,冷缺血时间分别为:140min、左肺182min和右肺288min、右肺245min和左肺377min,术中出血量分别为2850mL、3200mL、1300mL。例1和例3术后24h内拔除气管插管,术后第2周转普通病房,术后第5周出院,截至2012年11月分别存活10个月、5个月,各项指标均满意。例2出现移植肺严重感染,无法撤除呼吸机,于术后第82天因感染性脑病死亡。3例均未发生手术相关并发症和移植物排斥。结论全面有效的手术技术及围手术期管理是肺移植成为治疗终末期肺部疾病的关键。

Objective To investigate the management points to note and effective program during perioperative period of lung transplant surgery. Methods Three cases of lung transplantation were carried out in the First Affiliated Hospital, College of Medicine, Zhejiang University from August 2011 to June 2012. The patients were a 55-year-old male with idiopathic pulmonary fibrosis （case 1 ）, a 71-year-old female with double emphysema associated with chronic bronchitis （case 2 ） , and a 56- year-old male with bilateral bronchiectasis （case 3 ）. The surgical approaches were lung transplantation （case 1 ） and sequential bilateral single-lung transplantation （case 2 and 3 ）. Auxiliary extracorporeal membrane oxygenation was used during the surgery in case 1 and 3. The lung grafts were harvested en bloc with the hearts and then were separated and pruned in vitro before transplantation. After transplantation, measures for lung water control, immunosuppression, and anti-infection were carried out. Results The 3 patients received successful surgeries, and the operative time was 143, 316, and 336 min, respectively. The cold ischemia time was 140 min, left 182 min and right 288 min, and right 245 min and left 377 min, respectively. The blood loss during the operation was 2850, 3200, and 1300 mL, respectively. Two patients （ case 1 and 3 ） were pulled out trachea cannula extubation within 24 h and then were moved into general ward in 2 weeks, and were discharged from hospital in 5 weeks. By now, they have been alive in satisfactory condition for 10 and 5 months. Case 2, however, was with serious infection after operation and failed to get rid of the ventilator and died of infection encephalopathy on postoperative day 82. Surgical complications and graft rejection did not occur in all 3 patients. Conclusion Comprehensive effective surgical techniques and perioperative management are the key to successful lung transplantation for the treatment of end-stage lung diseases.