在过去二十年间，麻醉技术和手术技术的改进使肺部恶性肿瘤患者的手术死亡率大大降低，但术后并发症仍是主要问题。肺切除术后的常见并发症是肺部并发症[1]，主要表现是低氧血症，尤其在肺功能减退的肺切除患者中发病率更高[2]。目前国内对低氧血症的诊断缺乏统一的诊断标准，一些作者采用Russell等[3]提出的标准，吸空气氧的情况下，患者动脉血氧饱和度（SpO2）≤92%，大于30 s就可诊断为术后低氧血症。也有作者建议[4]将一次或以上血气检查PaO2lt;8 kPa或PaO2/FiO2lt;300 mm Hg（1 mm Hg=0.133 kPa）作为诊断低氧血症的标准。30%~50%的术后患者可发生低氧血症，一般认为这样的低氧血症是一过性的，对大多数患者是无害的[5]。但如果合并心脑或其他器官动脉硬化或其他原因的血管阻塞，这种低氧血症就是很危险的[6]。常见低氧血症的原因是肺萎陷不张和误吸、心源性肺水肿、静脉输入液体过量、通气血流比例失调和急性肺损伤/急性呼吸窘迫综合征（ALI/ARDS）[7]，其中ALI/ARDS是肺切除术后患者死亡的主要原因[8-10]。
Objective To investigate the postoperative treatment of pleuropneumonectomy for tuberculosis destroyed lung in ICU, in order to improve the therapeutical efficacy for these patients. Methods Clinical data of 52 patients who suffered from tuberculosis destroyed lung and underwent pleuropneumonectomy from June 2008 to June 2010 were analyzed retrospectively. All of subjects received routine treatment in ICU after the operation. Meanwhile，appropriate targeting treatments were applied including diagnosis and treatment of postoperative bleeding; application of fiberbronchoscope to aspirate the sputum after the operation,sequential non-invasive ventilation after the invasive ventilation for acute respiratory failure after operation ,etc.Results A total of 52 patients received the pleuropneumonectomy operation. Bleeding occurred in 11 cases after operation and stopped after the integrated therapy. 8 patients suffered from acute respiratory failure and attenuated after sequential ventilation. No patients died for postoperative bleeding or acute respiratory failure. Conclusions Patients who suffered from tuberculosis destroyed lung and received pleuropneumonectomy with postoperative bleeding and acute respiratory failure have a good prognosis after appropriate postoperative treatment in ICU.
Abstract： Objective To explore the impact of obesity on postoperative morbidity and mortality after pneumonectomy. Methods Clinical data of 3 494 patients with pulmonary diseases who underwent pneumonectomy in Shanghai Pulmonary Hospital from September 2003 to December 2007 were retrospectively analyzed. All the 3 494 patients were divided into two groups according to the patients’ preoperative body mass index （BMI）. There were 3 340 patients in the non-obesity group （BMI＜28 kg/m2） including 2 502 males and 838 females with their average age of 61.9±10.7 years， and 154 patients in the obesity group （BMI≥28 kg/m2） including 87 males and 67 females with their average age of 59.7±9.6 years. Univariate analysis and logistic regression were used to analyze the impact of obesity （BMI≥28 kg/m2） on postoperative morbidity after pneumonectomy. Results There were a total of 26 cases of perioperative death， including 23 patients in the non-obesity group and 3 patients in the obesity group. There was no statistical difference in mortality between the two groups ［0.7% （23/3 340） vs. 1.9% （3/154）， P=0.118］. There was no statistical difference in any particular postoperative morbidity or incidence of pulmonary complications between the two groups （P＞0.05）. Other than pulmonary complications， the incidence of postoperative complication in other body systems of the obesity group was significant higher than that of the non-obesity group （P＜0.05）. The incidence of cerebrovascular accidents， myocardial infarction and acute renal failure of the obesity group was significant higher than those of the non-obesity group （P＜0.05）. Logistic regression showed that obesity （BMI≥28 kg/m2） was not an independent risk factor for postoperative morbidity after pneumonectomy ［B=0.648， OR=1.911， 95% CI（0.711， 5.138），P=0.199］. Conclusion Obesity is not a significant risk factor of postoperative mortality or morbidity after pneumonectomy.
Abstract： Air leak is still a common postoperative complication after selective lobectomy. The majority of patients undergoing lobectomy have some risk factors of postoperative air leak or persistent air leak. Nowadays，preventive measures of postoperative air leak mainly include preoperative, intraoperative （surgical technique，reinforcement material，pleural cavity reduction），and postoperative （pleurodesis，chest drainage management） strategies. Many of these new measures have been applied in clinical practice with satisfactory outcomes.
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.
Abstract: Objective To summarize the clinical experiences and surgical treatment of pulmonary sequestration (PS) in order to improve the diagnosis and treatment of PS. Methods Between August 1993 and February 2007, our department enrolled 21 PS patients, 8 male patients and 13 female patients, with the age ranging from 13 to 70 years old. The patients were examined by chest radiography, computerized tomography (CT), computerized tomography angiography (CTA), magnetic resonance imaging (MRI), position emission tomographyCT(PET-CT) before the surgery. Sequestrectomy was performed on patients with extralobar sequestration (ELS) and lobectomy was performed on patients with intralobar sequestration (ILS). There were 10 cases of left lower lobectomy, 3 cases of right lower lobectomy, 4 cases of left sequestrectomy, 3 cases of right sequestrectomy and 1 case of total pneumonectomy. Results Postoperative pathology confirmed all cases of PS, including 7 cases of ELS and 14 cases of ILS. Seven patients were diagnosed to have PS by preoperative diagnostic procedures. During the surgery, we found aberrant supporting arteries from the general circulation in 18 cases among which 11 were supported by the thoracic aorta, 6 by the abdominal aorta and 1 by both the thoracic and abdominal aorta. The diameter of the aberrant artery was between 0.2 cm and 1.1 cm (mean 0.7 cm). Double ligation and transfixion were performed during the operation. In addition, we found venous drainage through the inferior pulmonary vein in 3 patients and double ligation was performed. No perioperative death or complications occurred. Followup was done till January 2009 on all the patients but one with a followup rate of 95.2% (20/21). The followup time ranged from 12 to 67 months. All patients survived well except that 1 died from liver metastasis 2 years after the operation because of lung cancer. Conclusion PS is rare and its symptoms are nonspecific, which can cause misdiagnosis and missed diagnosis. The diagnosis of PS mainly depends on CT, CTA, MRI and selected arteriography. Once diagnosed, PS should be removed by surgery. During the surgery, aberrant vessels should be separated and treated with double ligation and transfixion. As for those big aberrant vessels, transfixion can be performed after vascular decompression.
Abstract： Objective To analyze possible associated risk factors of postoperative pulmonary complications (PPC) after lung resection in order to decrease the incidence and mortality of PPC. Methods We reviewed the data of 302 patients including 228 males and 74 females undergoing lung resection from January 2007 to December 2009 in our department. The age of the patients ranged from 23 to 91 years old with an average age of 63.38 years. Based on the present definition of PPC, we recorded the related information and data before, during and after the operation, and observed the rate of PPC. The independent risk factors of PPC were evaluated by multiple logistic regression analysis. Results A total of 22 patients (7.28%) died during the operation and 75 patients (24.83%) experienced 110 times of PPC, the majority of which were prolonged air leak/bronchopleural fistula (8.94%, 27/302), nosocomial pneumonia (6.95%, 21/302) and acute respiratory failure (6.29%, 19/302). The results of logistic regression analysis showed that an American Society of Anesthesiology (ASA) score ≥3 (OR=2.400，P=0.020) and prolonged duration of immediate postoperative mechanical ventilation (OR=1.620，P=0.030) were independent factors associated with the development of PPC.Conclusions The ASA score based on the patients’ general condition and the function status of the main organs, and the prolonged duration of immediate postoperative mechanical ventilation are independent risk factors of PPC. In order to decrease the PPC rate, more attention should be paid to perfecting preoperative preparation, improving the function and condition of the organs, preserving pulmonary function and decreasing the duration of immediate postoperative mechanical ventilation for patients with high risk factors.