肺结核全肺切除术——一种希望与风险并存的手术方式

Pneumonetomy for pulmonary tuberculosis： a surgical procedure with hope and risk coexist

目的总结肺结核全肺切除术的临床经验,提高治愈率,降低并发症发生率及死亡率. 方法 搜集2009年1月至2016年9月在龙潭医院胸外科施行全肺切除术的29例肺结核患者,对该组患者的临床资料进行回顾性分析.其中男11例,女18例;平均年龄（38±11）岁;全肺毁损15例,不完全毁损者14例;左侧23例,右侧6例.术前肺功能检查：第1秒用力呼气容积（FEV1）为（1.78±0.50） L,FEV1/用力肺活量（FEV1/FVC,FEV1%）为（57.67±12.82） %,最大通气量（MVV）为（78.53±27.08） L, MVV 占预计值百分率（MVV%）为（59.20±14.36） %.左全肺切除23例（包括左余肺切除2例）,右全肺切除6例（包括右余肺切除1例）.结果28例手术顺利,1例左余肺切除术患者术中损伤肺动脉因失血性休克而死亡.手术平均时间（315±131） min,术中出血量为900（600-1500） ml.3例术前痰菌阳性的患者术后全部阴转.3例（10.34%,3/29）出现术后并发症,其中大出血1例,剖胸止血治愈;急性肺水肿1例,予静脉快速点滴西地兰,并静脉注射速尿、地塞米松并持续泵入硝酸甘油后症状缓解;切口线头反应1例,患者每月复查时将暴露于切口的线头取出,9个月后取净而愈合.术后随访6-34个月,1例术后16个月时痰菌出现阳性,根据药物敏感性试验结果调整治疗方案,患者于18个月后治愈.无脓胸及支气管胸膜瘘发生.总体结果为：死亡1例（3.45%）,发生并发症3例（10.7%）,治愈28例（96.55%）.结论 选择合适的患者行全肺切除术,治愈率高、并发症发生率及死亡率在可以接受的范围之内.但是该类手术的难度大、术中失血多、手术时间长也是客观存在的问题,故这类手术不主张在综合医院推广,宜在条件较好的结核病专科医院开展.

Objective To summarize the experience of pneumonectomy for pulmonary tuberculosis, improve the cure rate, reduce the incidence of postoperative complications rate and motality rate. Methods From January 2009 to September 2016,we selected and analyzed retrospectively 29 appropriate patients with pulmonary tuberculosis to treat by pnemonectomy, There were 11 males and 18 females.Average age were （38±11） years old.Complete lung destroyed in 15 cases and incomplete lesion in 14 cases.There were 23 in left lung and 6 in right lung.Preoperative pulmonary functions were as follows： FEV1 （1.78±0.50） L,FEV1/FVC （FEV1%） （57.67±12.82） %,MVV （78.53±27.08） L and MVV% （59.20±14.36） %.Left pneumonectomy in 23 cases （including left completion pneumonectomy in 2 cases）, right pneumonectomy in 6 cases （including right completion pneumonectomy in 1 cases）. Results The operations were successful in 28 patients.One patient underwent left completion pneumonectomy was died due to the pulmonary artery injured and hemorrhagic shock.Operation time was （315±131） mins and bleeding was 900（600-1500） ml.Three patients with sputum positive were converted negative after operation.There were 3 cases （10.34%） postoperative complications occurred within 1 month.One case was postoperative bleeding and was cured by thoracotomy.Acute pulmonary edema in 1 case and was cured by fast intravenous driped cedilanid, intravenous injected furosemide and dexamethasone,continuous pumped glyceryl trinitrate.Incision thread reaction in 1 case and was cured by taking out silk thread every month.Patients were followed up for 6-34 months, 1 patient sputum convertd positive in the sixteenth months after operation, according to the result of drug sensitivity, chemotherapy regimen was adjusted according to the drug susceptible test （DST） and cured until 18 months.There were 1 death （3.45%）, 3 complications （10.34%） and 28 cure （96.55%）. Conclusion The cure rate is high and the complication rate and mortality rate are acceptable in appropriate patients with pulmonary tuberculosis to treat by pnemonectomy.But this kind of operation is difficult with intraoperative blood loss and long operation time, such surgery wound not be advocated in general hospitals and should be carried out in better tuberculosis hospital.