【作者】 张铎；

【导师】 李辉；

【作者基本信息】 首都医科大学 ， 外科学（胸心外）， 2017， 硕士

【摘要】 目的:原发性自发性气胸(PSP)是胸外科常见疾病,其发病原因被认为多与胸膜下肺大疱自发破裂有关。目前,电视胸腔镜(VATS)肺大疱切除术是治疗原发性自发性气胸的最主要方式,但是术后肺持续漏气仍是影响患者术后恢复的最常见并发症。本研究的目的是探讨管状奈维(NEOVEIL)垫片在原发性自发性气胸VATS肺大疱切除术后防治漏气的应用价值。方法:根据入组条件将2015年1月-2016年6月首都医科大学附属北京朝阳医院胸外科收治的原发性自发性气胸患者随机分为实验组和对照组。两组均采用全身麻醉双腔气管插管、单操作孔VATS肺大疱切除术。实验组术中应用内镜直线切割吻合器加管状奈维垫片切除肺大疱;对照组术中直接应用内镜直线切割吻合器切除肺大疱。两组患者在切除肺大疱后均在切缘覆盖网片状奈维,并用纱布球摩擦壁层胸膜行胸膜固定术。监测并记录2组患者术后每天体温、术后引流量、术后漏气时间、拔除引流管时间、术后住院时间、术后并发症发生率及术后复发率。结果:最终纳入本研究的患者共计134例,其中实验组60例,对照组74例,两组患者基线资料无统计学差异。全部患者均手术顺利,无死亡和术后严重并发症病例。实验组中44例患者术后即刻无漏气(73.33%),对照组有40例患者术后即刻无漏气(54.05%),两组相比差异有统计学意义(P=0.031)。但术后1天、2天、3天、4天及大于5天持续漏气的发生率两组无明显差别。实验组平均漏气时间(0.57±1.11)天,术后带管时间(3.03±0.92)天,术后住院时间(3.98±0.92)天,与对照组相比差异均有统计学意义,P值分别为:P=0.048,P=0.012和P=0.010。实验组术后有5例患者体温大于38.5℃,而对照有16例患者术后体温超过38.5℃,明显多于实验组(P=0.035)。此外,实验组术后1例患者肺复张不全,1例患者出现肺部感染征象,术后并发症发生率为(3.33%),明显少于对照组(3.33%vs.16.22%,P=0.021)。两组患者术后中位随访时间为16个月(8-25个月),均无复发。结论:原发性自发性气胸行VATS肺大疱切除术中应用管状奈维垫片可以有效防治术后早期漏气,缩短术后拔管和术后住院时间,减少术后并发症发生率。操作方法简单易行,并且无相关副作用,尤其适用于PSP患者。更多还原

【Abstract】 Purpose:Primary spontaneous pneumothorax(PSP)is a common disease in thoracic surgery,and thespontaneous rupture of subpleural bullae is thought to bethe primary cause of PSP.Currently,video-assisted thoracoscopic(VATS)bullectomyis widely performed as the most common surgical treatment for PSP.However,a prolonged postoperative air leakage is still the most frequent and troublesome early complication after the bullectomy.Thisstudy aimed to explore the efficacy of polyglycolic acid(NEOVEIL)sleeve inpreventing postoperative air leakage after a VATS bullectomy for PSP.Methods:The patients who underwent a VATS bullectomy were continuously enrolled from January 2015 to June 2016 in Beijing Chaoyang Hospital,Capital Medical University,and were randomly assigned to the experimental and control groups.All patients underwent a 2-port unilateral VATS bullectomy under general anesthesia with a double-lumen endotracheal tube,and single lung ventilation during the operation.The experimental group applied a Neoveil sleeve combined with an automatic stapler in the bullectomy,while in the control group,the bullae were resected using an automatic stapler alone during the operation.In addition,the staple lines in both groups were covered with an absorbable polyglycolic acid sheet and both groups performed pleural abrasion after the resection.Useful clinical data were recorded,including the postoperativetemperature per day,the postoperative volume of drainage,postoperative air leakage time,the drainage tube removal time,the postoperative hospital stay,the postoperative complications,and the postoperative recurrence.Results:A total of 134 patients were enrolled in this study.The experimental group consisted of 60 subjects,and there were 74 in the control group.No operative related mortality was observed in either group.In the experimental group,44 of the 60 patients did not have an air leakage immediately after the operation,while in the control group 40 patients did not have animmediatelyair leakage,which was significantly lower than the experimental group(P=0.031).But,there was no significant difference in the number of patients with a air leakage one day,two days,three days,four days and more than five days between the two groups.Compared with the control group,the average postoperative air leakage(0.57±1.11 days),the chest tube removal time(3.03±0.92 days),and the postoperative hospital stay(3.98±0.92 days)were all significantly shorter in the experimental group(P=0.048,P=0.012,and P=0.010,respectively).There were 5 patients in the experimental group,16 patients in the control group,with a postoperativetemperature higher than 38.5℃(P=0.035).Moreover,the rate of postoperative complications in the experimental group was lower than the control group(3.33% vs.16.22%,P=0.021).No postoperative recurrence was observed in either group during the follow-up period that ranged from 8 to 25 months.Conclusion:The use of polyglycolic acid sleeve during VATS bullectomysurgery for PSP might effectively prevent early postoperative air leakage,as well as reduce the postoperative drainage tube removal time and the postoperative hospital stay.And the procedure is easy to perform without relevant side-effect,so it is very appropriate forthe treatment in patients with PSP.更多还原