自体肌皮瓣植入治疗慢性结核性难治性脓胸（附12例报告）

Myocutaneous flap implantation for the treatment of chronic refractory tuberculous empyema（12 cases report）

目的 总结自体肌皮瓣植入治疗慢性结核性难治性脓胸的经验。方法 2004年1月至2017年12月共有12例患者因慢性结核性难治性脓胸于上海市肺科医院行自体肌皮瓣植入治疗。伤口换药清洁后,既往有同侧手术史者,行肌皮瓣移植填充手术;既往无同侧手术史者,行肌皮瓣移位填充手术。术前行三联（异烟肼、利福平、吡嗪酰胺）常规标准化抗结核药物治疗3个月以上,术后维持抗结核药物治疗12个月。耐药结核病依据药物敏感性试验（简称“药敏试验”）结果进行调整。患者均为男性;中位年龄52.5岁（26.0~65.0岁）。7例因肺结核病变既往行肺切除术（2例全肺切除）;5例开窗时存在支气管胸膜瘘（BPF）,引流等保守治疗无法治愈,再行胸壁开窗,并进行长期换药。其余5例无既往手术史,因慢性结核性难治性脓胸保守治疗（引流等）无法治愈,肺无法复张,进行开窗换药。结果 全组患者无死亡,术后均未发生呼吸道并发症。5d内顺利拔除胸腔引流管,术后3~6周出院。中位随访时间9个月,11例患者无脓胸复发和肌皮瓣坏死,1例患者脓胸局部复发（取出老式封堵器,开窗换药后于非水肿期采用新型谢氏封堵器置入,准备二次肌皮瓣填入）。结论 将特种材料（记忆合金支架）、显微外科技术、抗结核药物治疗、结核性脓胸传统手术相结合,运用自体肌皮肌瓣植入治疗慢性结核性难治性脓胸具有良好的临床效果。

Objective To sum up experience in the treatment of chronic tuberculous refractory empyema with autologous myocutaneous flap implantation.Methods From January 2004 to December 2017, 12 patients with chronic tuberculous refractory empyema were treated with autologous myocutaneous flap implantation in Shanghai Pulmonary Hospital. After dressing up the wound, transplantation and filling of rectus abdominis myocutaneous flap or latissimus dorsi myocutaneous flap was performed in patients with history of ipsilateral surgical operation and the ipsilateral latissimus dorsi myocutaneous flap or pectoralis major myocutaneous flap was transfered and filled in patients without the history of ipsilateral surgical operation. The patients were treated with triplex regimen including isoniazid, rifampicin and pyrazinamide for more than 3months before operation, and continue this regimen for 12months after operation. The regimen was adjusted by the result of drug susceptibility test. All patients were males with median age 52.5 （26.0-65.0） years old. Seven cases had previous pneumonectomy including pneumonectomy in 2 cases due to pulmonary tuberculosis and bronchopleural fistula （BPF）, drainage and other conservative treatment not be cured, then chest wall fenestration, and long-term dressing change in 5 cases. Chronic tuberculous refractory empyema conservative treatment （drainage, etc.） could not be cured and the lung could not be reopened for opening window to change medicine in the other 5 cases without previous operation history.Results No death cases and no respiratory complications occurred in these patients. Thoracic drainage tube was successfully removed within 5days and discharged from hospital for 3 to 6 weeks after operation. The median follow-up time was 9months. There was no recurrence of empyema and myocutaneous flap necrosis in 11 patients. Local recurrence of empyema in 1 case （removal of old occluder, application of a new type of Sheffler occluder during non-edema period, preparation for secondary musculocutaneous flap filling）.Conclusion The application of auto-logous myocutaneous flap implantation combined with special materials （memory alloy scaffold）, microsurgical techniques, chemotherapy and traditional operation of tuberculous empyema, in the treatment of chronic tuberculous refractory empyema has a good clinical effect.