单孔胸腔镜胸膜纤维板剥脱治疗Ⅲ期结核性脓胸临床疗效

Clinical effect of uniportal thoracoscopic decortication for stageⅢtuberculous empyema

目的探讨单孔胸腔镜胸膜纤维板剥脱治疗Ⅲ期结核性脓胸的可行性和安全性。方法回顾性分析2020年6月至2022年6月在深圳市第三人民医院胸外科行单孔胸腔镜胸膜纤维板剥脱的52例Ⅲ期结核性脓胸患者的临床资料,男性38例,女性14例;年龄21~72岁,平均(36.96±14.24)岁。所有患者均行全身麻醉,在脓腔中心处做4~5cm的切口,肋间隙严重狭窄者切除一段肋骨,壁胸膜外分离出操作空间,切口保护器协助暴露,单孔下游离切除增厚的脏壁层胸膜纤维板。胸腔引流管内无漏气、引流液颜色变淡,引流量<100ml,拔除胸腔引流管。胸部影像学显示肺膨胀良好,沟槽引流管引流量<50ml,拔除沟槽引流管,根据细菌学检查结果制定抗结核治疗方案,术后随访12个月,术后6个月和12个月胸部CT与术前CT对比评价手术效果。结果27例预后优秀,21例预后良好,4例预后一般,术后治愈优良率92.3%,无患者复发。1例患者中转开胸,其余患者均单孔胸腔镜下完成手术。手术时间110~430min,平均(268±110)min;术中出血量50~300ml,平均(126±68)ml,术后胸腔引流管引流时间3~16d,平均(5.0±2.5)d,沟槽引流管引流时间7~21d,平均(9.0±2.8)d,术后住院时间3~7d,平均(5.0±2.5)d。1例患者因肺漏气带胸腔引流管时间较长,术后16d拔除胸腔引流管,术后1例患者因包裹性胸腔积液穿刺引流治愈,2例切口延迟愈合,术后1个月治愈,其余患者无并发症。结论单孔胸腔镜胸膜纤维板剥脱治疗Ⅲ期结核性脓胸安全可行,效果良好。

Objective To explore the safety and feasibility of uniportal thoracoscopic decortication in the treatment of stageⅢtuberculous empyema.Method From June 2020 to June 2022,52 patients including 38 males and 14 females with stageⅢtuberculous empyema who underwent uniportal thoracoscopic decortication were retrospectively analyzed in Department of Thoracic Surgery,The Third People's Hospital of Shenzhen.The mean age was(36.96±14.24)years(range:21 to 72 years).general After general anesthesia,a 4-5cm incision was made in the center of the pus cavity.In the case of severe intercostal stenosis,a section of rib was removed.And the outer parietal pleural space was separated.With the help of incision protector the thickened visceral parietal pleural fibreboard was removed free under a single hole.Follow‐up was performed in the outpatient clinic monthly.When there is no air leakage in the thoracic drainage tube,the color of the drainage fluid is pale,and the drainage volume is less than 100ml/d,the chest tube was removed.If chest imaging showed good lung dilation,the drainage volume of the trench drainage tube was<50ml/d,the trench drainage tube was removed,and the anti-tuberculosis treatment plan was formulated according to the bacteriological examination results.The postoperative follow-up was 12 months.The postoperative imagings were performed at 6 and 12 months.and compared with preoperative chest CT.Result Among the 52 cases,27 cases had excellent recovery,21 cases had good recovery and 4 cases general recovery.The excellent and good rate of postoperative cure was 92.3%,No patients had recurrence.Among the 52 patients,51 cases underwent uniportal thoracoscopic decortications,and 1 case changed to thoracotomy.The operative time was(268±110)min(range:110 to 430)min;and median blood loss was(126±68)ml(range:50 to 300 ml).All patients were discharged with 2 chest tubes,and the median duration drainage was(5±2.5)days(range:3 to 16 days),and(9.0±2.8)days(range:7 to 21 days)separately.The postoperative hospital stay was(5.0±2.5)days(range:3 to 7 days).There were no major complications except 1 case of prolonged lung leakage with the thoracic tube was removed 16 days after surgery,2 cases of incision infection and 1 case encapsulated pleural effusion.Conclusion Uniportal thoracoscopic decortication is safe,feasible and effective for patients with stageⅢtuberculous empyema.