闭合式与开放式纤维板剥脱术治疗慢性结核性脓胸的对比研究

Comparative Study of Closed and Open Stripping of Pleural Fibrous Plate in the Treatment of Chronic Tuberculous Empyema

目的探讨闭合式纤维板剥脱术治疗慢性结核性脓胸的手术方式和疗效。方法选择2012年9月至2015年9月问于首都医科大学附属北京胸科医院行外科手术治疗的139例慢性结核性脓胸患者为研究对象，数字表法随机分为闭合式胸膜纤维板剥脱术组（简称“闭合式组”）与开放式胸膜纤维板剥脱术组（简称“开放式组”）。闭合式组患者74例，男52例，女22例；开放式组患者65例，男42例，女23例。分析两组间手术治疗方式差异及两种治疗方案对慢性结核性脓胸患者的治疗效果。结果闭合式组手术时间平均为（168．8±51．5）min、术中出血量平均为（682．7±572．8）ml；开放式组则分别为（194．7±68.3）mim、（842．3±733．7）ml。两组比较，t值分别为2．507、1．438．P值分别为0．014、O．153；闭合式组手术时间较短，差异有统计学意义。闭合式组术后引流量平均为（1937．9±1289．0）ml、带管时间平均为（7．7±4．6）d、术后住院时间平均为（15．8±7．1）d；开放式组则分别为（1822．5±1558．3）ml、（9．0±6．2）d、（17．9±10．3）d。两组比较，t值分别为0．478、．1．388、1．384，P值分别为O．633、0．168、0．169，差异均无统计学意义。闭合式组患者治愈率为100．0％（74／74），开放式组则为69．2％（45／65）；两组比较，P=O．000（FiSher确切概率法）。闭合式组二次开胸止血发生率为1．4％（1／74）、支气管胸膜瘘发生率为1．4％（1／74）、Ⅱ型呼吸衰竭发生率为1．4％（1／74）、低蛋白血症发生率为2．7％（2／74）、肺部感染发生率为2．7％（2／74）及心律失常发生率为1．4％（1／74）：开放式组则分别为1．5％（1／65）、6．2％（4／65）、3．1％（2／65）、4．6％（3／65）、9．2％（6／65）及4．6％（3／65）。两组比较，X2值分别为0．000、1．125、0．013、0．022、1．648、O．410，P值分别为1．000、0．289、0．910、0．883、0．199、0．522，差异均无统计学意义。术后并发症闭合式组总发生率为10．8％（8／74），开放式组为29．2％（19／65）；两组比较，x2=10．467，P=0．001。结论慢性结核性脓胸的外科治疗中，手术方式的选择至关重要。闭合式纤维板剥脱术治疗慢性结核性脓胸与开放式纤维板剥脱术比较，治愈率高、术后炎症反应发生率低、总体手术并发症发生率低，具有重要的临床应用价值。

Objective To investigate the surgical approach and efficacy of closed decortication in the treatment of chronic tuberculous empyema. Methods Totally 139 patients of chronic tuberculous empyema treated surgically in Beijing Chest Hospital from September 2012 to September 2015 were assigned randomly into two groups in order to analyze the surgery method and observe the curative effect. Seventy-four patients in the closed pleural decortication group, 52 males, 22 females. 65 patients in the open pleural decortication group, 42 males and 23 females. Results The average operation time and intraoperative blood loss were （168.8 ± 51.5） min and （682.7 ±572.8） ml in closed pleural decortication group compared with （194.7± 68.3） min and （842.3 ± 733.7） ml in the open pleural decortication group.The t values of the two groups were 2.507 and -1.438, the P values were 0.014 and 0.153 respectively, the operative time in closed group is lower, the difference was statistically significant.The average post-operative drainage volume, the average the time and the post-operative hospitalization time were （1937.9 ±1289.0） ml, （7.7 ± 4.6） d and （15.8 ± 7.1） d in closed pleural decortication group eornpare with （1822.5 ± 1558.3） ml, （ 9.0 ± 6.2） d and （17.9 ±10.3） d in the open pleural decortication group.The t values of the two groups were 0,478, -1.388 and -1.384, the P values were 0.633, 0.168 and 0.169 respectively. The curative effect of closed pleural decortication group was better than that of open group. The cure rate of the closed group was 100. 0% （74/74）, compared with 69.2% （45/65） of the open group, Fisher exact probability test, P = 0.000, the difference was statistically significant.The incidence ofthoracotomy to stop bleeding, bronchial pleural fistulas, type Ⅱ respiratory failure,hypoproteinemia, lung infection and arrhythmias were 1.4% （1/74）, 1.4% （1/74）, 1.4% （I/74）, 2.7% （2/74）, 2.7% （2/74）, 1.4% （1/74） in closed group compared with 1.5% （1/65）, 6.2% （4/65）, 3.1% （2/65）, 4.6% （3/65）, 9.2% （6/65）, 4.6% （3/65） in the open group.The X2 of the two groups were 0.000, 1.125, 0.013, 0.022, 1.648 and 0.410 respectively, P values were 1.000, 0.289, 0.910, 0.883, 0.199, 0.522. The total incidence of postoperative complications was 10.8% （8/74） in the closed group compared with 29.2% （19/65） in the open group. The difference was statistically significant （ X2=10.467, P = 0. 001）. Conclusion The choice of surgical treatment in patients with chronic tuberculous empyema is very important. Closed decortieation was shown to have more significant clinical application and value with the advantage of a high cure rate, lower incidence of postoperative inflammatory response and fewer operative complications compared with open decorticationo .