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Safety and feasibility of no chest tube after thoracoscopic pneumonectomy: A systematic review and meta-analysis

ObjectiveTo discuss the safety and feasibility of no chest tube (NCT) after thoracoscopic pneumonectomy.MethodsThe online databases including PubMed, EMbase, The Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Database, VIP, China Biology Medicine disc (CBMdisc) were searched by computer from inception to October 2020 to collect the research on NCT after thoracoscopic pneumonectomy. Two reviewers independently screened the literature, extracted the data, and evaluated the quality of the included studies. The RevMan 5.3 software was used for meta-analysis.ResultsA total of 17 studies were included. There were 12 cohort studies and 5 randomized controlled trials including 1 572 patients with 779 patients in the NCT group and 793 patients in the chest tube placement (CTP) group. Meta–analysis results showed that the length of postoperative hospital stay in the NCT group was shorter than that in the CTP group (SMD=–1.23, 95%CI –1.59 to –0.87, P<0.000 01). Patients in the NCT group experienced slighter pain than those in the CTP group at postoperative day (POD)1 (SMD=–0.97, 95%CI –1.42 to –0.53, P<0.000 1), and POD2 (SMD=–1.10, 95%CI –2.00 to –0.20, P=0.02), while no statistical difference was found between the two groups in the visual analogue scale of POD3 (SMD=–0.92, 95%CI –1.91 to 0.07, P=0.07). There was no statistical difference in the 30-day complication rate (RR=0.93, 95%CI 0.61 to 1.44, P=0.76), the rate of postoperative chest drainage (RR=1.51, 95%CI 0.68 to 3.37, P=0.31) or the rate of thoracocentesis (RR=2.81, 95%CI 0.91 to 8.64, P=0.07) between the two groups. No death occurred in the perioperative period in both groups.ConclusionIt is feasible and safe to omit the chest tube after thoracoscopic pneumonectomy for patients who meet the criteria.

肺切除術后心臟疝一例

Progress on Prevention and Treatment of Postpneumonectomy Complications

Pneumonectomy is known as an effective treatment of lung cancer, lung tuberculosis, and damaged lung. But the incidences of complications and mortality are significantly higher in patients undergoing pneumonectomy than those undergoing lobectomy. The complication rate within 30 days after pneumonectomy is 11%-49% and the mortality is 3%-25%. Mortality of right pneumonectomy is triple that of left pneumonectomy. Postpneumonectomy complications include cardiopulmonary failure, bronchopleural fistula and postpneumonectomy syndrome. Besides the symptomatic treatment, which includes flushing drainage, plugging and operation, observation and prompt diagnosis are necessary for prevention. This review is focused on the prevention and treatment of complications after pneumonectomy.

Postpneumonectomy Hypoxemia

在過去二十年間，麻醉技術和手術技術的改進使肺部惡性腫瘤患者的手術死亡率大大降低，但術后并發癥仍是主要問題。肺切除術后的常見并發癥是肺部并發癥[1]，主要表現是低氧血癥，尤其在肺功能減退的肺切除患者中發病率更高[2]。目前國內對低氧血癥的診斷缺乏統一的診斷標準，一些作者采用Russell等[3]提出的標準，吸空氣氧的情況下，患者動脈血氧飽和度（SpO2）≤92%，大于30 s就可診斷為術后低氧血癥。也有作者建議[4]將一次或以上血氣檢查PaO2lt;8 kPa或PaO2/FiO2lt;300 mm Hg（1 mm Hg=0.133 kPa）作為診斷低氧血癥的標準。30%~50%的術后患者可發生低氧血癥，一般認為這樣的低氧血癥是一過性的，對大多數患者是無害的[5]。但如果合并心腦或其他器官動脈硬化或其他原因的血管阻塞，這種低氧血癥就是很危險的[6]。常見低氧血癥的原因是肺萎陷不張和誤吸、心源性肺水腫、靜脈輸入液體過量、通氣血流比例失調和急性肺損傷/急性呼吸窘迫綜合征（ALI/ARDS）[7]，其中ALI/ARDS是肺切除術后患者死亡的主要原因[8-10]。

肺切除術聯合化療治療耐多藥肺結核51例

摘要： 目的 探討肺切除聯合化療治療耐多藥肺結核的臨床應用價值，總結治療經驗。 方法 1999年1月至2007年1月，我科共收治51例主病灶局限于肺葉或單側全肺的耐多藥肺結核患者，男38例，女13例；年齡18～56歲，平均年齡36.5歲。施行肺葉切除術30例，肺葉加同側肺段切除術或同側雙肺葉切除術11例，全肺切除術10例；分析術后繼續抗結核化療18~24個月的療效。 結果 51例患者均手術成功，46例完成化療（18~24個月）后治愈；治療失敗5例，其中3例在療程最后6個月痰菌仍為陽性，2例于圍手術期內死于術后并發癥。術后發生并發癥12例，其中術后1個月內發生9例：呼吸功能衰竭3例，均經呼吸機輔助呼吸治愈；膿胸3例，2例經胸腔閉式引流治愈，1例術后3周死于多器官功能衰竭；支氣管胸膜瘺1例，經留置胸腔引流管3個月后瘺口逐漸閉合治愈；暫時性視力障礙1例，未作特殊處理，1個月后視力恢復正常，急性肺水腫1例，治療無效死亡。1個月后發生并發癥3例：切口感染2例，經開放引流每日換藥，行二期縫合傷口Ⅲ/丙愈合；支氣管胸膜瘺1例，行胸部肌瓣填塞+胸廓成形術后支氣管胸膜瘺再度復發，給予胸壁開放式引流，長期未愈，72個月后因大咯血窒息死亡。 結論 對主病灶局限的耐多藥肺結核患者施行肺切除聯合抗結核化療，治愈率高，并發癥發生率及病死率均在可接受范圍內。

局限性胸膜肺切除術治療伴癌性胸水非小細胞肺癌的遠期結果

目的 評估局限性胸膜肺切除術治療伴癌性胸水非小細胞肺癌的遠期效果和應用價值. 方法 對1994年1月至1998年12月間采用該術式治療的16例伴癌性胸水肺癌患者進行定期隨訪,了解患者生活質量、復發情況和生存時間.計算術后中位數復發和中位數生存時間. 結果 本組無手術死亡,無嚴重手術并發癥.術后胸悶、呼吸困難、胸腹壁疼痛癥狀明顯緩解,惡病質迅速消失,未見胸水復發,但后期均發生遠處臟器轉移.術后腫瘤復發距手術時間3～36個月,中位數復發時間12個月.隨訪至2000年8月,所有病例死亡,存活期7～39個月.存活1年以上15例,1年生存率94%;存活18個月以上13例,生存率81%;存活2年以上7例,生存率44%;存活3年以上2例,生存率13%;中位數生存期21.5個月. 結論 此術式控制胸水、緩解癥狀效果肯定.術后晚期均發生遠處臟器轉移,但其中位數生存期明顯長于僅做姑息性肺內癌灶切除或內科治療患者,且長于全胸膜肺切除術.本術式有推廣應用價值.

The association of intraoperative positive end-expiratory pressure with pulmonary complications after thoracoscopic lung surgery: A propensity score-matching study

ObjectiveTo evaluate the correlation between positive end-expiratory pressure (PEEP) level and postoperative pulmonary complications (PPCs) in patients undergoing thoracoscopic lung surgery. MethodsThe clinical data of patients who underwent elective thoracoscopic lung surgery at West China Hospital of Sichuan University from January 2022 to June 2023 were retrospectively analyzed. Patients were divided into 2 groups according to intraoperative PEEP levels: a PEEP 5 cm H2O group and a PEEP 10 cm H2O group. The incidence of PPCs in the two groups after matching was compared using a nearest neighbor matching method with a ratio of 1∶1, setting the clamp value as 0.02. ResultsA total of 538 patients were screened, and after propensity score-matching, a total of 229 pairs (458 patients) were matched, with an average age of 53.9 years and 69.4% (318/458) females. A total of 118 (25.8%) patients had PPCs during hospitalization after surgery, including 60 (26.2%) patients in the PEEP 5 cm H2O group and 58 (25.3%) patients in the PEEP 10 cm H2O group, with no statistically significant difference between the two groups [OR=0.997, 95%CI (0.495, 1.926), P=0.915]. Multivariate logistic regression analysis showed that PEEP was not an independent risk factor for PPCs [OR=0.920, 95%CI (0.587, 1.441), P=0.715]. ConclusionFor patients undergoing thoracoscopic lung surgery, intraoperative PEEP (5 cm H2O or 10 cm H2O) is not associated with the risk of PPCs during hospitalization after surgery, which needs to be further verified by prospective, large-sample randomized controlled studies.

開窗換藥治療全肺切除術后氣管殘端瘺伴食管胸膜瘺一例

Progress of Thoracoscopic Pulmonary Segmentectomy for Early-Stage Non-small Cell Lung Cancer

Abstract： The principles of 2010 National Comprehensive Cancer Network（NCCN） clinical practice guidelines in non-small cell lung cancer address that anatomic pulmonary resection is preferred for the majority of patients with non-small cell lung cancer and video-assisted thoracic surgery (VATS) is a reasonable and acceptable approach for patients with no anatomic or surgical contraindications. By reviewing the literatures on general treatment, pulmonary segmentectomy, pulmonary function reserve, and the anatomic issue of early stage non-small cell lung cancer surgery, the feasibility and reliability of thoracoscopic pulmonary segmentectomy are showed.

全肺切除治療肺毛霉菌病合并肺膿腫一例并文獻復習

目的 探討侵襲性支氣管肺毛霉菌病合并毛霉菌肺膿腫內科治療無效時外科手術的可行性。方法 報告1例2022年在解放軍總醫院第八醫學中心住院的支氣管肺毛霉菌病合并毛霉菌肺膿腫患者內科治療及外科手術過程，并對外科手術在肺毛霉菌病治療中的有關文獻進行復習。結果 患者男性，29歲，某藥廠排污廠房工人，既往患有糖尿病。因咳嗽，咳痰，咯血40余天，高熱5天入院。經支氣管鏡活檢診斷為左主支氣管毛霉菌病，積極內科治療無效時，行左全肺切除術，術后治愈出院。術后病理示支氣管肺毛霉菌病并左下肺毛霉菌肺膿腫。文獻復習顯示外科手術是支氣管肺毛霉菌病治療手段之一，但目前肺毛霉菌病手術治療多限于單純孤立病灶和肺葉切除術，全肺切除術罕見。未檢索到類似本例全肺切除治愈支氣管肺毛霉菌病，毛霉菌肺膿腫的報告。結論 侵襲性支氣管肺毛霉菌病，合并毛霉菌肺膿腫在內科治療無效時，外科手術治療亦應值得考慮。