胸腔镜胸膜剥脱术在治疗Ⅲ期结核性脓胸中的临床应用

Efficacy of video-assisted thoracoscopic surgical decortication for stageⅢtuberculous empyema

目的探讨"两孔法"胸腔镜胸膜剥脱术对Ⅲ期结核性脓胸患者的临床疗效及其对胸廓形态恢复的影响。方法本研究属于单中心回顾性研究,收集2017年6月至2021年4月在成都市公共卫生临床医疗中心胸外科接受胸腔镜胸膜剥脱术的Ⅲ期结核性脓胸患者49例,其中男性38例,女性11例,年龄13~60(27.5±10.4)岁,分析其临床特征及围手术期相关资料,探究其安全性及可行性,利用CT自带软件分别测量患者术前、术后隆突及剑突层面胸廓周长,将术前、术后胸廓周长通过配对样本t检验的方法对比分析术后患者胸廓塌陷恢复情况。结果49例患者手术时间(186±61)min,术中出血量(366±267)ml,围手术期8例(16.33%)患者出现术后并发症,主要为术后肺持续漏气及肺部感染等,术后随访期间无脓胸复发及结核播散。术前经隆突层面胸廓周长为(655±54)mm,经剑突层面胸廓周长为(720±69)mm,术后随访12~36个月,与术前胸廓周长相比,术后第1个月,经隆突层面及剑突层面胸廓周长分别为(658±50)和(724±66)mm,差异均无统计学意义(P=0.173、P=0.057)。术后第3、6、12个月经隆突层面胸廓周长分别为(666±51)、(667±47)和(671±47)mm,均较术前明显增大(均P<0.05)。术后第3、6、12个月,经剑突层面测量胸廓周长分别为(730±65)、(733±63)和(735±63)mm,均较术前明显增大(均P<0.05)。术后第6个月患者年龄<20岁及FEV1占预计值%<80%者隆突平面胸廓周长改善差异有统计学意义(P=0.015、P=0.003),胸膜增厚≥8 mm者较<8 mm者隆突平面胸廓周长有所改善,但差异无统计学意义(P=0.070)。结论对于部分Ⅲ期结核性脓胸患者,胸腔镜下胸膜剥脱术安全、可行,并可明显恢复患者胸廓周长,改善患者胸廓塌陷,临床疗效显著。"两孔法"的胸腔镜技术理念具有创伤小、手术视野广、操作空间大,技术容易掌握等优点,值得进一步探索其临床应用价值。

Objective To investigate the clinical efficacy,safety and feasibility of"double-portal"video-assisted thoracoscopic surgical(VATS)decortication among patients with stageⅢtuberculous empyema,and then to evaluate the recovery of chest deformity.Method This study was a single center retrospective study.A total of 49 patients with stageⅢtuberculous empyema who underwent VATS pleural decortication at the Department of Thoracic Surgery,Public Health Clinical Center of Chengdu between June 2017 and April 2021 were enrolled,including 38 males,and 11 females,aged 13-60(27.5±10.4)years.The safety and feasibility of VATS were further evaluated.The inner circumference of the chest on sternal and xiphoid planes on chest CT scans before and 1,3,6,12months after decortication were collected through the measuring software of the CT.The samples in-pair test was used to compare the changes in the chest to reflect the recovery of the chest deformity.Results In the 49 patients,The surgical time was(186±61)min,and the volume of blood loss was(366±267)ml.There were 8 cases(16.33%)with postoperative complications during the perioperative period.Constant air leak and pneumonia were the main postoperative complications.No relapse of empyema or dissemination of tuberculosis occured during the period of follow-up.Before surgery,the inner thoracic circumference of the thorax at the level of the carina plane was(655±54)mm,and the inner thoracic circumference of the thorax at the level of the xiphoid plane was(720±69)mm.Patients were followed for 12-36 months.The inner thoracic circumference of the thoracic cavity at the level of carina was(666±51),(667±47)and(671±47)mm at the 3rd,6th and 12th months after operation,which were significantly larger than that at the level of carina before operation(all P<0.05).The inner thoracic circumference diameter of the thoracic cavity measured at the xiphoid level at the 3rd,6th and 12th months after the operation was(730±65),(733±63)and(735±63)mm respectively(all P<0.05).The inner thoracic circumference of the thoracic cavity increased significantly than that before surgery(P<0.05).At 6 months after operation,there was significant difference in the improvement of the inner thoracic circumference of the carina plane in patients with age less than 20 years and FEV1%less than 80%(P=0.015,P=0.003).The improvement in the inner thoracic circumference of the carina plane in patients with pleural thickening≥8 mm compared with those with less than 8 mm was not statistically different(P=0.070).Conclusions For some patients with stageⅢtuberculous empyema,pleural decortication under thoracoscopy is safe and feasible,and can significantly restore the inner thoracic circumference of the patient′s chest,improve the collapse of the patient′s chest,and have significant clinical effect.The"double-portal VATS"surgical technology has the advantage of less trauma,wide operation field,large operation space and is easy to master,which is worth further exploring for clinical application.