非体外循环冠状动脉旁路移植术取左乳内动脉胸膜破损后不同应对方法的随机对照试验

Different methods to treat injured pleural following off-pump coronary artery bypass grafting using an internal mammary artery:A randomised controlled trial

目的乳内动脉采备过程中造成的胸膜破损会显著增加非体外循环冠状动脉旁路移植术术后早期胸腔积液的可能。我们对比了不同处理方式对患者术后早期胸腔积液、疼痛程度以及肺功能差异的作用,以期探讨最佳的应对方法。方法 2012年8月至2016年3月连续选取我院行非体外循环旁路移植术取左乳内动脉并出现左侧胸膜破损的300例患者,其中男176例、女124例,年龄(63.1±8.7)岁。术中完成搭桥后,将出现胸膜破损的患者随机分成3组:经剑突组(n=100),分别放置心包引流管及经剑突下左胸腔32号弯引流管各一根;经侧胸壁组(n=100),放置心包引流管一根、经左腋中线第6肋间32号直胸腔引流管一根;关闭胸膜组(n=100),缝闭胸膜破损,放置心包引流管及32号纵膈引流管各一根。拔除气管插管后第1 d及术后第5 d分别测量患者安静状态下及用力咳嗽时的疼痛程度,拔除引流管后检查胸腔积液量,术后第5 d测量肺功能及动脉血气分析。经统计学处理后,对3种方法进行分析评价。结果术后总引流量:经侧胸壁组>关闭胸膜组>经剑突组,经侧胸壁组与关闭胸膜组差异无统计学意义,但两组分别与经剑突组差异有统计学意义(P<0.05)。拔除引流管后出现中等量以上胸腔积液者:经剑突组>经侧胸壁组>关闭胸膜组,3组间差异均有统计学意义(P<0.05)。拔除气管插管后第1 d患者疼痛程度:经侧胸壁组>经剑突组>关闭胸膜组,3组间差异均有统计学意义(P<0.05)。术后第5 d疼痛程度、第一秒用力呼气量(FEV1)和二氧化碳分压3组间差异均无统计学意义。术后第5 d肺活量(VC)关闭胸膜组与经侧胸壁组差异无统计学意义,但两组均大于经剑突组(P<0.05)。术后第5 d氧分压(PO_2)关闭胸膜组最高且与经剑突组差异有统计学意义(P<0.05)。结论术中缝闭破损的胸膜、而后仅放置心包加纵隔引流管的方法可以减轻患者术后疼痛程度,降低胸腔积液发生的概率,对患者肺功能的恢复也有优势,可以作为术者首选方法。

[Abstract] Objective The pleural injury caused by harvesting internal mammary artery （LIMA） can significantly increase the possibility of early pleural effusion after off-pump coronary artery bypass grafting （OPCABG）. We compared the differences in pleural effusion, pain severity, and early lung function in different treatments to find the optimal strategy. Methods A total of 300 patients receiving OPCABG using LIMA with left pleural lesion were selected （176 males and 124 females, mean age of 63.1＋8.7 years）. After bypass surgery, patients with pleural rupture were randomly divided into three groups： group A （n=100） received a pericardial drainage tube and a left chest tube inserted from the midline （subxyphoid）; group B （n--100） had a pericardial drainage tube and a tube placed in the sixth intercostal space at the midaxillary line; group C （n= 100） with the broken pleura sutured, had a pericardial drainage tube and a mediastinal drainage tube inserted. All patients underwent pulmonary function testing and arterial blood gas analysis on postoperative days （PODs） 5. The three methods were analyzed and evaluated. Results Total drainage： group B （852±285 ml）〉group C （811±272 ml）〉group A （703±226 ml）; there was no significant difference between the group B and group C, but they were statistically different from the group A （P〈0.05）. Patients with pleural effusion after removal of drainage tubes： group A （13 patients）〉group B （7 patients）〉group C （3 patients）, and there was significant difference among the three groups （P〈0.05）. Pain sensation the day after extubation： group B （2.4±0.8, 3.8±0.9）〉group A （1.9±0.7, 3.3±0.8）〉group C （1.1±0.6, 2.5±0.8）, there was significant difference among the three groups （P〈0.05）. Pain sensationon on postoperative days 5： group B （0.3±0.2, 0.6±0.5）〉group A （0.3±0.3, 0.5±0.4）〉group C （0.2±.2, 0.5±0.3）, and there was no significant difference among the three groups. Vital capacity on postoperative days 5： there was no significant difference between the group B and group C, and both groups were greater than group A （P〈0.05）. There was no difference in FEV1 and PCO2 among the three groups. Group C was better than group A in PO2 on postoperative day 5 （P〈0.05）. Conclusion Suturing the broken pleura during the operation can not only reduce the degree of postoperative pain but also have less pleural effusion and better pulmonary function. It can be used as the preferred method.