Ugalde Paula, Miro Santiago, Provencher Steve, Quevillon Mathieu, Chau Luc, Deslauriers Deborah R, Lacasse Yves, Ferland Sylvie, Simard Serge, Deslauriers Jean
Department of Thoracic Surgery, Université Laval, Québec, Canada.
Ann Thorac Surg. 2008 Dec;86(6):1745-51; discussion 1751-2. doi: 10.1016/j.athoracsur.2008.05.081.
The physiologic advantages of preserving phrenic nerve integrity and normal diaphragmatic motion (DM) during the course of pnemonectomy are incompletely understood. This study was conducted to investigate potential benefits of this strategy on postoperative lung function.
Among 523 consecutive patients who underwent pneumonectomy for lung cancer between January 1992 and September 2001, 117 were alive at the time of study (March to December 2006) and thus had 5 years' minimum follow-up. Of those, 17 were excluded and 12 could not have magnetic resonance imaging (MRI), leaving 88 patients available for study. Diaphragmatic motion was assessed by MRI during deep breathing, and patients were classified as having normal and synchronous diaphragmatic motion (n = 44) or abnormal diaphragmatic motion (immobile or paradoxical, n = 44). These findings were correlated with expiratory volume measurements, gas exchange (arterial blood gases), and exercise tolerance (6-minute walk test).
The mean follow-up time was 9.3 years. Patients with abnormal DM were younger than patients with normal DM and were more likely to have had a right or an extended pneumonectomy (p < 0.01). Despite comparable preoperative lung function, patients with abnormal DM had significantly worse postoperative lung volumes (forced expiratory voume in 1 second, forced vital capacity, lung diffusion capacity for carbon monoxide; p < 0.01) and exercise capacity (6-minute walk test, percent predicted, p < 0.05) than patients with normal DM.
Because the long-term effects of a paralyzed hemidiaphragm in pneumonectomy patients are characterized by significant alterations in lung function, all surgeons doing this type of work should take every precaution to avoid technical errors that could lead to phrenic nerve injury or interruption.
肺切除术中保留膈神经完整性和正常膈肌运动（DM）的生理优势尚未完全明确。本研究旨在探讨该策略对术后肺功能的潜在益处。
在1992年1月至2001年9月期间连续接受肺癌肺切除术的523例患者中，117例在研究时（2006年3月至12月）仍存活，因此至少有5年的随访时间。其中，17例被排除，12例无法进行磁共振成像（MRI），最终有88例患者可供研究。通过MRI在深呼吸时评估膈肌运动，患者被分为具有正常和同步膈肌运动（n = 44）或异常膈肌运动（不动或矛盾运动，n = 44）。这些结果与呼气量测量、气体交换（动脉血气）和运动耐量（6分钟步行试验）相关。
平均随访时间为9.3年。异常DM患者比正常DM患者年轻，且更可能接受了右肺或扩大肺切除术（p < 0.01）。尽管术前肺功能相当，但异常DM患者术后肺容积（第1秒用力呼气量、用力肺活量、一氧化碳肺扩散能力；p < 0.01）和运动能力（6分钟步行试验，预测百分比，p < 0.05）明显比正常DM患者差。
由于肺切除患者中麻痹半侧膈肌的长期影响表现为肺功能的显著改变，所有从事此类手术的外科医生都应采取一切预防措施，避免可能导致膈神经损伤或中断的技术失误。
