Stewart Duncan J, Martin-Ucar Antonio E, Edwards John G, West Kevin, Waller David A
Departments of Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK.
Eur J Cardiothorac Surg. 2005 Mar;27(3):373-8. doi: 10.1016/j.ejcts.2004.12.028.
With the increasing incidence of malignant pleural mesothelioma and renewed interest in radical surgery as a therapeutic option, we have examined our experience of extra-pleural pneumonectomy, to document the incidence and management of its peri-operative complications.
This analysis was conducted using prospectively entered data contained within the departmental database, with additional information from retrospective case note review. Details of patient selection criteria and operative modifications are included.
Over a 59-month period, extra-pleural pneumonectomy was carried out on 74 patients (66 men; 8 women; median age 57 years). Fifteen patients (20%) received cisplatin-doublet induction chemotherapy. The majority (80%) of patients had epithelial tumours and 85% of patients had disease in International Mesothelioma Interest Group stages III and IV. The 30-day post-operative mortality was 6.75% (five patients) and significant morbidity was recorded in 47 patients (63%). Major complications included those of technical origin (diaphragmatic patch dehiscence 8.1%; chylothorax 6.7%; intra-thoracic haemorrhage 6.7%; bronchopleural fistula 6.7%), cardiovascular morbidity (atrial fibrillation 17.5%; mediastinal shift with subacute tamponade 10.8%; right ventricular failure 4%; pulmonary embolus 2.7%) and respiratory morbidity (pneumonia 10.8%; acute lung injury 8.1%). Admission to intensive care was required in 19 patients (26%). Univariate analysis identified the incidence of acute lung injury and mediastinal shift to be significantly associated with induction chemotherapy (P=0.005 and 0.014, respectively). In addition to this, laterality of operation influenced respiratory morbidity (P=0.018) and admission to intensive care (P=0.025). Finally, prolonged operations (greater than the median) were associated with an increased risk of technical (P=0.018) and gastro-intestinal (P=0.023) complications.
Extra-pleural pneumonectomy is associated with a high rate of morbidity, but an acceptable mortality rate can be achieved with increasing peri-operative experience. Surgery following induction chemotherapy requires extra vigilance for the development of post-operative respiratory complications.
随着恶性胸膜间皮瘤发病率的上升以及人们对根治性手术作为一种治疗选择的兴趣再度增加，我们回顾了我们的胸膜外全肺切除术经验，以记录其围手术期并发症的发生率及处理情况。
本分析使用了前瞻性录入部门数据库中的数据，并通过回顾性病例记录审查获取了额外信息。纳入了患者选择标准及手术改良的详细信息。
在59个月期间，对74例患者（66例男性；8例女性；中位年龄57岁）实施了胸膜外全肺切除术。15例患者（20%）接受了顺铂双联诱导化疗。大多数患者（80%）为上皮样肿瘤，85%的患者处于国际间皮瘤兴趣小组分期III期和IV期。术后30天死亡率为6.75%（5例患者），47例患者（63%）出现了严重并发症。主要并发症包括技术原因导致的并发症（膈肌补片裂开8.1%；乳糜胸6.7%；胸腔内出血6.7%；支气管胸膜瘘6.7%）、心血管并发症（心房颤动17.5%；伴有亚急性心脏压塞的纵隔移位10.8%；右心室衰竭4%；肺栓塞2.7%）及呼吸系统并发症（肺炎10.8%；急性肺损伤8.1%）。19例患者（26%）需要入住重症监护病房。单因素分析显示，急性肺损伤和纵隔移位的发生率与诱导化疗显著相关（分别为P = 0.005和0.014）。除此之外，手术部位影响呼吸系统并发症的发生率（P = 0.018）及入住重症监护病房的情况（P = 0.025）。最后，手术时间延长（超过中位数）与技术并发症（P = 0.018）及胃肠道并发症（P = 0.023）风险增加相关。
胸膜外全肺切除术的并发症发生率较高，但随着围手术期经验的增加，可实现可接受的死亡率。诱导化疗后的手术需要对术后呼吸系统并发症的发生格外警惕。
