胸腔镜肺叶切除术后肺叶扭转的外科诊治分析
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摘要
目的分析胸腔镜肺叶切除术后肺叶扭转的临床特征和处理原则。方法回顾性分析3例胸腔镜肺叶切除术后并发肺叶扭转病例的临床资料,2例行胸腔镜右肺上叶切除+系统性淋巴结清扫术,1例行胸腔镜右肺上叶切除+淋巴结取样术。结果 3例术后均发生右肺中叶扭转。术后胸片提示肺不张1例,肺不张伴实变2例。支气管镜均见右肺中叶管腔不同程度狭窄。确诊肺扭转距初次手术的时间为1～6天,平均(3.67±2.52)天,再次手术行扭转肺叶切除2例,术中行扭转肺复位1例。二次手术术后住院时间为5～14天,平均(8.67±4.73)天,无并发症。结论肺裂发育完全和手术所致余肺活动度增大是胸腔镜肺叶切除术后发生肺叶扭转的主要危险因素。对于高度怀疑肺扭转者,应及早再次胸腔镜手术治疗,在肺功能允许的情况下切除病肺仍是首选。
Objective To discuss the clinical presentations and therapeutic principles of postoperative lobar torsion after video assisted thoracoscopic surgery(VATS)pneumonectomy.Methods To analyze retrospectively 3 cases of postoperative lobar torsion after VATS right upper lobectomy,including 2 systematic lymph node dissection and 1 lymph node sampling.Results 3 cases were all the postoperative middle lobar torsions.Postoperative radiographs demonstrated atelectasis in 1 patient and atelectasis and consolidation in 2 patients.Bronchoscopy showed different narrowing bronchus orifice of the middle lobe.The diagnosis of lobar torsion was made an average of(3.67±2.52)d(range 1 to 6 days)after the initial operation;2 patients underwent direct resection and 1 patient underwent reposition.Average hospitalization was(8.67±4.73)d and range from 5 to 14 days.No Complications happened after reoperation.Conclusion Complete pulmonary fissure and higher range of motion of the residuary lobe are the major risk factors of postoperative lobar torsion after VATS pneumonectomy.For patients with high suspicion of lobe torsion,re-VATS should be performed as quickly as possible.Indirect resection is still preferred if the lung function permits.
Objective To discuss the clinical presentations and therapeutic principles of postoperative lobar torsion after video assisted thoracoscopic surgery(VATS)pneumonectomy.Methods To analyze retrospectively 3 cases of postoperative lobar torsion after VATS right upper lobectomy,including 2 systematic lymph node dissection and 1 lymph node sampling.Results 3 cases were all the postoperative middle lobar torsions.Postoperative radiographs demonstrated atelectasis in 1 patient and atelectasis and consolidation in 2 patients.Bronchoscopy showed different narrowing bronchus orifice of the middle lobe.The diagnosis of lobar torsion was made an average of(3.67±2.52)d(range 1 to 6 days)after the initial operation;2 patients underwent direct resection and 1 patient underwent reposition.Average hospitalization was(8.67±4.73)d and range from 5 to 14 days.No Complications happened after reoperation.Conclusion Complete pulmonary fissure and higher range of motion of the residuary lobe are the major risk factors of postoperative lobar torsion after VATS pneumonectomy.For patients with high suspicion of lobe torsion,re-VATS should be performed as quickly as possible.Indirect resection is still preferred if the lung function permits.
引文
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[9] 谢冬,姜格宁,陈晓峰,等.肺扭转病因分析与诊疗进展[J].中华胸心血管外科杂志,2011,27(10):631-632.
[10] Purohit M,Zacharias J.A simple reproducible method of preventing lobar torsion[J].J Cardiothorac Surg,2008,3:22.
[11] Uramoto H,Takenoyama M,Hanagiri T.Simple Prophylactic Fixation for Lung Torsion[J].Ann Thorac Surg,2010,90(6):2028-2030.
[12] Kutlu CA,Olgac G.Pleural flap to prevent lobar torsion:a novel technique[J].Eur J Cardiothorac Surg,2006,30(6):943-944.
[2] Sakai M,Kurimori K,Saeki Y,et al.Video-assisted thoracoscopic conservative repair of postoperative lobar torsion[J].Ann Thorac Surg,2014,98(5):e119-121.
[3] Cable DG,Deschamps C,Allen MS,et al.Lobar torsion after pulmonary resection:presentation and outcome[J].J Thorac Cardiovasc Surg,2001,122(6):1091-1093.
[4] Chung SH,Nam JE,Choe KO,et a1.Radiologic findings of lung lobe torsion in reconstructed muhidetector computed tomography image lead to early detection[J].Clin Imaging,2010,34(5):400-403.
[5] Yanagihara T,Ichimura H,Kobayashi K,et al.Computed tomography detection of stapled interlobar fissure facilitates diagnosing postoperative lobar torsion:A case report[J].Int J Surg Case Rep,2017,41:86-88.
[6] Apostolakis E,Koletsis EN,Panagopoulos N,et al.Fatal stroke after completion pneumonectomy for torsion of left upper lobe following left lower lobectomy[J].J Cardiothorac Surg,2006,l:25.
[7] Taira N,Kawasaki H,Takahara S,et al.Postoperative lung torsion with retained viability:The Presentation and Surgical Indications[J].Heart Lung Circ,2017,27(7):849-852.
[8] 李厚怀,张庆震,许林,等.胸部手术后肺(叶)扭转的病因分析[J].中华医学杂志,2007,87(27):1915-1917.
[9] 谢冬,姜格宁,陈晓峰,等.肺扭转病因分析与诊疗进展[J].中华胸心血管外科杂志,2011,27(10):631-632.
[10] Purohit M,Zacharias J.A simple reproducible method of preventing lobar torsion[J].J Cardiothorac Surg,2008,3:22.
[11] Uramoto H,Takenoyama M,Hanagiri T.Simple Prophylactic Fixation for Lung Torsion[J].Ann Thorac Surg,2010,90(6):2028-2030.
[12] Kutlu CA,Olgac G.Pleural flap to prevent lobar torsion:a novel technique[J].Eur J Cardiothorac Surg,2006,30(6):943-944.