Sugarbaker David J, Jaklitsch Michael T, Bueno Raphael, Richards William, Lukanich Jeanne, Mentzer Steven J, Colson Yolonda, Linden Phillip, Chang Michael, Capalbo Leah, Oldread Elizabeth, Neragi-Miandoab Siyamek, Swanson Scott J, Zellos Lambros S
Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.
J Thorac Cardiovasc Surg. 2004 Jul;128(1):138-46. doi: 10.1016/j.jtcvs.2004.02.021.
Extrapleural pneumonectomy for therapy of mesothelioma has been associated with significant perioperative mortality and morbidity. Postoperative complications of this procedure require a unique management approach. We developed treatment algorithms for most of the common complications of extrapleural pneumonectomy resulting in reduced mortality and hospital stay. Complications after extrapleural pneumonectomy were further analyzed to elucidate means of prevention, early detection, and treatment.
A total of 496 patients undergoing extrapleural pneumonectomy were reviewed for mortality rates, with a subset of 328 consecutive patients between 1980 and 2000 who were examined for detailed morbidity data by using a prospective clinical database.
Median age was 58 years (range, 28-77 years), with a 10-day (range, 4-101 days) median length of stay. One hundred ninety-eight (60.4%) of 328 patients experienced minor and major complications, and 11 of 328 patients died, for an overall mortality rate of 3.4%. Complications included the following: atrial fibrillation (145 [44.2%]), prolonged intubation (26 [7.9%]), vocal cord paralysis (22 [6.7%]), deep vein thrombosis (21 [6.4%]), technical complications (patch dehiscence, hemorrhage, or both; 20 [6.1%]), tamponade (12 [3.6%]), acute respiratory distress syndrome (12 [3.6%]), cardiac arrest (10 [3%]), constrictive physiology (9 [2.7%]), aspiration (9 [2.7%]), renal failure (9 [2.7%]), empyema (8 [2.4%]), tracheostomy (6 [1.8%]), myocardial infarction (5 [1.5%]), pulmonary embolus (5 [1.5%]), and bronchopleural fistula (2 [0.6%]). Clinical data demonstrated the following: (1) prophylaxis for atrial fibrillation is recommended; (2) early ambulation, aspiration precautions, endoscopic assessment of the vocal cords, and avoidance of fluid overload are crucial; (3) perioperative diagnosis and aggressive management of deep vein thrombosis are important; (4) immediate reoperation and open cardiac massage are essential for relief of cardiac herniation and tamponade from cardiac patch dysfunction; (5) diaphragmatic patch dehiscence, hemorrhage, or both require immediate reoperation; (6) early signs of infection might indicate bronchopleural fistula or empyema and should be treated with thoracoscopic or open drainage and staged removal of patch material; and (7) excessive perioperative mediastinal shift is treated with a catheter placed intraoperatively.
Complications after extrapleural pneumonectomy require a unique approach to management, and mortality can be minimized by early detection and aggressive treatment.
胸膜外全肺切除术治疗间皮瘤与显著的围手术期死亡率和发病率相关。该手术的术后并发症需要独特的管理方法。我们针对胸膜外全肺切除术的大多数常见并发症制定了治疗算法，从而降低了死亡率和住院时间。对胸膜外全肺切除术后的并发症进行了进一步分析，以阐明预防、早期检测和治疗方法。
对496例行胸膜外全肺切除术患者的死亡率进行了回顾，并对1980年至2000年间连续328例患者的详细发病率数据进行了前瞻性临床数据库检查。
中位年龄为58岁（范围28 - 77岁），中位住院时间为10天（范围4 - 101天）。328例患者中有198例（60.4%）发生了轻微和严重并发症，328例患者中有11例死亡，总死亡率为3.4%。并发症包括：心房颤动（145例[44.2%]）、长时间插管（26例[7.9%]）、声带麻痹（22例[6.7%]）、深静脉血栓形成（21例[6.4%]）、技术并发症（补片裂开、出血或两者兼有；20例[6.1%]）、心脏压塞（12例[3.6%]）、急性呼吸窘迫综合征（12例[3.6%]）、心脏骤停（10例[3%]）、缩窄性生理改变（9例[2.7%]）、误吸（9例[2.7%]）、肾衰竭（9例[2.7%]）、脓胸（8例[2.4%]）、气管切开术（6例[1.8%]）、心肌梗死（5例[1.5%]）、肺栓塞（5例[1.5%]）和支气管胸膜瘘（2例[0.6%]）。临床数据表明：（1）建议预防心房颤动；（2）早期活动、误吸预防措施、声带内镜评估以及避免液体过载至关重要；（3）围手术期深静脉血栓形成的诊断和积极管理很重要；（4）立即再次手术和开胸心脏按压对于缓解因心脏补片功能障碍导致的心脏疝和心脏压塞至关重要；（5）膈肌补片裂开、出血或两者兼有需要立即再次手术；（6）感染的早期迹象可能提示支气管胸膜瘘或脓胸，应采用胸腔镜或开放引流治疗，并分期取出补片材料；（7）围手术期过度的纵隔移位可通过术中放置导管进行治疗。
胸膜外全肺切除术后的并发症需要独特的管理方法，通过早期检测和积极治疗可将死亡率降至最低。
