同期心脏直视手术联合肺楔形切除的安全性及疗效分析

Safety and efficacy of simultaneous open heart surgery combined with pulmonary wedge resection

目的探讨心脏病合并肺部小结节的患者采用同期心脏直视手术联合肺楔形切除的安全性及临床疗效。方法回顾性分析2010年8月至2018年11月18例心脏病合并肺部小结节,采用同期心脏直视手术联合肺楔形切除的患者的临床资料,其中不停跳冠状动脉搭桥11例,二尖瓣置换5例,主动脉瓣置换2例。手术均采用胸骨正中切口,在完成冠脉搭桥及瓣膜置换手术后打开纵隔胸膜楔形切除肺部结节。观察并记录手术时间,呼吸机辅助时间,ICU治疗时间,胸腔引流量,胸腔引流管放置时间,术后平均住院时间以及术后围手术期并发症,评估手术的安全性。出院后门诊随访心功能改善情况、瓣膜情况、血管桥通畅情况以及肺癌是否转移及复发情况,评估手术的有效性。结果无围手术期死亡病例。2例术后发生房颤,1例发生肺部感染,经药物治疗后均痊愈出院。病理提示腺癌15例(其中原位腺癌2例,微浸润腺癌8例,浸润性腺癌5例),结核肉芽肿1例,慢性炎症2例。患者出院后门诊随访6~64个月,心脏超声检查示心功能恢复至Ⅰ~Ⅱ级,较术前改善,人工瓣膜未见异常,桥血管通畅,无心绞痛症状发作。15例肺癌患者行头、胸、腹部CT及骨扫描未发现局部复发及远处转移。结论对心脏手术的患者若发现肺周围型≤2 cm且高度怀疑为恶性的结节,同期施行心脏直视手术及肺楔形切除是安全的,能达到满意的临床疗效。

Objective To investigate the safety and clinical effect of open heart surgery combined with pulmonary wedge resection in patients with heart disease and pulmonary nodules.Methods From August 2010 to November 2018,the clinical data of 18 patients with heart disease and pulmonary nodules,who underwent open heart surgery combined with pulmonary wedge resection in the same period,were analyzed retrospectively.Among them,there were 11 cases of coronary artery bypass grafting,5 cases of mitral valve replacement and 2 cases of aortic valve replacement.Mediastinal pleura wedge resection was performed after coronary artery bypass and valve replacement.The safety of the operation was evaluated by observing and recording the operation time,ventilator assistance time,ICU treatment time,thoracic drainage flow,thoracic drainage tube placement time,postoperative average hospital stay time and postoperative perioperative complications.The effectiveness of the operation was evaluated by the improvement of cardiac function,the condition of valves,the patency of blood vessels and the metastasis and recurrence of lung cancer.Results There were no perioperative deaths.Atrial fibrillation occurred in 2 patients and pulmonary infection in 1 patient.All patients were cured and discharged after medication.Pathological examination demonstrated 15 cases of adenocarcinoma(2 cases of adenocarcinoma in situ,8 cases of microinvasive adenocarcinoma,and 5 cases of invasive adenocarcinoma),1 case of tuberculosis granuloma and 2 cases of chronic inflammation.After discharge,the patients were followed up for 6-64 months.The cardiac function was restored to gradeⅠ-Ⅱby echocardiography,which was better than that before surgery.There was no abnormality in the artificial valve,the bridge vessels were unobstructed,and there was no angina.The 15 patients with lung cancer were followed up.No local recurrence or distant metastasis was found on CT and bone scan of head,chest,abdomen.Conclusion It is safe to perform open heart surgery and pulmonary wedge resection at the same time for patients with pulmonary peripheral nodule less than or equal to 2 cm and highly suspicious for malignancy.