35例原发性自发性气胸术后再次手术治疗

35 cases of postoperative recurrent primary spontameous pneumothorax treatment

目的 探讨使用胸腔镜对原发性自发性气胸术后复发者的再治疗.方法 回顾2004年1月至2013年11月的35例原发性自发性气胸胸腔镜或开胸术后复发者再次行胸腔镜手术的临床资料和随访结果.应用x2检验、t检验和Kaplan-Meier曲线对数据进行统计学分析.结果 患者中男30例,女5例;年龄16～ 50岁,平均（22±6）岁.两次手术间隔1～106个月,平均（15±24）个月.胸腔镜下完成手术用时40～ 190 min,平均（100±34）min;术中出血5～ 200 ml,平均（50±48） ml;住院3～13天,平均（7±2）天.其中34例胸腔内有不同程度的粘连;26例胸腔内可见到肺大疱,其中9例位于原手术切缘附近.9例胸腔内未见肺大疱者再次手术均距首次手术18个月内.35例全部进行了随访,随访12～133个月,中位随访（49±33）个月,随访期内无气胸复发.结论 新生肺大疱是导致气胸复发的主要原因.对于反复发作,保守治疗无效的原发性自发性气胸术后复发可选择手术.对于术后18个月以上复发者可能存在新生肺大疱,建议手术治疗.胸腔镜手术对再手术安全有效,是以切除新生成的肺大疱、松解影响肺组织复张的粘连带和消除胸腔内残腔为目的.

Objective To Evaluate the feasibility of video-assisted thoracoscopic surgery（VATS） reoperation for recurrent primary spontaneous pneumothorax.Methods The clinical and follow-up date of 35 recurrent pneumothorax patients,who received reoperation from January 2004 to November 2013 at the Beijing Haidian Hospital and Peking University People＇s Hospital were retrospectively reviewed.Chi square,t test and Kaplan-Meier curve was used to evaluate risk factors.Results The relapsed 35 patients included male 30,female 5.The median age was 22 years old（range 16-50 years）.The median operating time was 100 min （range 40-190 min）,the median blood loss was 50 ml （range 5-200 ml） and the median postoperative stay in the hospital was 7 days（range 3-13 days）.VATS was successfully performed for all patients,without conversion.No morbidity or mortality occurred.The median follow-up time was 49months（range 12-133 months）.Adhesions were observed from 34 patients,wherein,the severity ranged from mild to dense.New bullae or blebs were found in 26 patients （74.29%）,9 （34.62%） of which were adjacent to the stapled incisal margin.No bullae or blebs were found on the 9 patients （26.71%）that underwent reoperation within 18 months from their initial operation.No recurrence was observed during the follow-up.Conclusion The recurrence of spontaneous pneumothorax was mostly caused by the formation of new bullae or blebs near the staple lines.Reoperation for recurrent pneumothorax was safe and advocated.VATS operation includes the dissection of pleural adhesions,wedge resection of neoformative bullae or blebs and elimination of the residual apical space.