CAJ | 학술논문

目的总结采用再次手术瘘修补结合自体带蒂肌瓣组织包盖残端的方法治疗23例肺切除术后早期支气管胸膜瘘(BPF)(9例伴有胸腔感染)的经验,并对治疗选择进行探讨.方法 23例中第一次手术方式全肺切除13例,肺叶切除10例.BPF发生时间为术后5～40天,平均21天.BPF确诊后,立即行胸腔闭式引流术并考虑行二次开胸瘘修补术.4例采用直接缝合修补瘘口,10例重新切除残端至正常组织后再次缝合,7例切除残端后行支气管成形或隆凸成形术,2例将带蒂肌瓣缝合到瘘口边缘达到封闭;瘘修补后残端后包埋的肌瓣包括肋间肌瓣5例,肋背阔肌瓣10例、前锯肌瓣6例、骶棘肌2例.瘘修补术后常规给予胸腔冲冼.结果无术中及术后近期死亡.术后并发严重并发症4例,均对症治疗后痊愈.21例瘘口修补成功,失败2例,成功率为91.3％.1例修补后2年因残端复发致BPF伴脓胸,其余均无BPF复发.结论肺切除术后早期BPF,即使有胸腔感染,如果预期可耐受手术,应尽早积极手术修补瘘口并以带蒂胸壁肌瓣包盖,结合术后胸腔持续冲洗,可获得良好效果.
목적 총결채용재차수술루수보결합자체대체기판조직포개잔단적방법치료23례폐절제술후조기지기관흉막루(BPF)(9례반유흉강감염)적경험,병대치료선택진행탐토.방법 23례중제일차수술방식전폐절제13례,폐협절제10례.BPF발생시간위술후5～40천,평균21천.BPF학진후,립즉행흉강폐식인류술병고필행이차개흉루수보술.4례채용직접봉합수보루구,10례중신절제잔단지정상조직후재차봉합,7례절제잔단후행지기관성형혹륭철성형술,2례장대체기판봉합도루구변연체도봉폐;루수보후잔단후포매적기판포괄륵간기판5례,륵배활기판10례、전거기판6례、저극기2례.루수보술후상규급여흉강충승.결과무술중급술후근기사망.술후병발엄중병발증4례,균대증치료후전유.21례루구수보성공,실패2례,성공솔위91.3％.1례수보후2년인잔단복발치BPF반농흉,기여균무BPF복발.결론 폐절제술후조기BPF,즉사유흉강감염,여과예기가내수수술,응진조적겁수술수보루구병이대체흉벽기판포개,결합술후흉강지속충세,가획득량호효과.
Objective Bronchopleural fistula (BPF) is a common but potentially lethal complication after pulmonary resection.Currently,there is still controversy over the appropriate management strategy for BPF,especially when pleural space contamination develops.The purpose of this study was to evaluate the efficacy and safety of surgical repair fistulas combined with pedicled muscle flaps coverage in patients with early BPF after pulmonary resection based on our experience with 23 cases.Methods The clinical data for 23 patients who underwent surgical repair of early BPF from January 1999 to December 2010 at our hospital were reviewed.Thirteen patients had undergone a prior pneumonectomy and 10 patients had undergone a prior lobectomy.BPF occurred from postoperative day 5 to40 (mean postoperative day 21 ).Nine patients had a contaminated pleural space.After BPF was clearly diagnosed,prompt closed pleural drainage was instituted,followed by surgical repair of BPF.Four patients underwent a direct suture repair of fistula,ten patients underwent stump revision and suture closure,seven patients underwent stump revision and bronchoplasty or carina plasty,and a pedicled muscle flap was sewn to the edges of the fistula in two patients.The stump was covered with various muscle flaps,including interostal muscle flap in five cases,latissimus dorsi muscle flap in ten cases,serratus anterior muscle flap in six cases,and erector spinae muscle flap in two cases.Postoperatively,the pleural space was routinely irrigated and drained.Results No intraoperative or early postoperative death occurred.Four patients developed severs complications,including respiratory failure in two cases,pulmonary embolism in one case,and empyema in one case.All four cases recovered well after treatment.The mean duration of hospitalization was 33 days (range 8 - 120 days ).Surgical repair of BPF was successful in 21 cases (91.3％) but failed for 2 patients..BPF recurrence developed in only one patient two years postoperatively due to stump recurrence.He died of extensive metastatic disease 2 years after BPF recurrence.Conclusion Excellent results can be achieved by early surgical repair combined with stump pedicled muscle flaps coverage in patients with BPF who can tolerate reoperation,even if they have a contaminaled pleural space.