Bialas Ryan C, Weiner Timothy M, Phillips J Duncan
Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Children's Hospital, Chapel Hill, NC 27599, USA.
J Pediatr Surg. 2008 Dec;43(12):2151-5. doi: 10.1016/j.jpedsurg.2008.08.041.
Video-assisted thoracic surgery (VATS) for treatment of spontaneous pneumothorax refractory to nonoperative management was first reported in children by Rodgers in 1986 (Ann Surg. 1986; 204:677-680). Small series have shown success with apical blebectomy, mechanical or chemical (talc) pleurodesis, or combination techniques. We report the largest pediatric series of VATS for primary spontaneous pneumothorax (PSP) to date, to assess outcomes and compare techniques.
Retrospective review of all children undergoing VATS for PSP between 1999 and 2007 at 2 university-affiliated hospitals by the same group of surgeons. Mann-Whitney U tests and chi(2) used (P < .05 = significant).
Thirty-two patients underwent 41 VATS procedures (32 initial-30 unilateral, 2 bilateral; 9 subsequent-7 contralateral, 2 ipsilateral recurrences). Mean age at presentation was 16.5 years (range, 13-20 years). Blebs were identified at the time of VATS in 95% of patients, but in 12.5%, they were on lower lobes. Mean duration of postoperative air leak was 2.7 days, postoperative hospital length of stay was 5.0 days, and postoperative chest tube duration was 5.1 days; 2 patients required Heimlich valves, which were managed at home. Five different surgical techniques were used as follows: blebectomy plus mechanical pleurodesis had the shortest length of stay (4.3 days) and need for chest tube drainage (4.1 days) but had a higher recurrence risk (6% major, 16% minor) than blebectomy plus chemical pleurodesis. The risk of requiring an additional VATS procedure (ipsilateral or contralateral) was 28%. Mean follow-up was 46 months.
Blebectomy plus either mechanical or chemical pleurodesis were both associated with acceptable outcomes. Blebectomy plus chemical pleurodesis appears to have less risk of ipsilateral recurrence but longer postoperative stay and chest tube drainage.
1986年，罗杰斯首次报道了采用电视辅助胸腔镜手术（VATS）治疗非手术治疗无效的儿童自发性气胸（《外科学年鉴》。1986年；204:677 - 680）。小规模研究显示，采用肺尖部肺大疱切除术、机械或化学（滑石粉）胸膜固定术或联合技术取得了成功。我们报告了迄今为止最大规模的儿童VATS治疗原发性自发性气胸（PSP）的系列研究，以评估治疗效果并比较不同技术。
由同一组外科医生对1999年至2007年期间在两家大学附属医院接受VATS治疗PSP的所有儿童进行回顾性研究。采用曼 - 惠特尼U检验和卡方检验（P < 0.05为有统计学意义）。
32例患者接受了41次VATS手术（32例初次手术 - 30例单侧，2例双侧；9例再次手术 - 7例对侧，2例同侧复发）。就诊时的平均年龄为16.5岁（范围13 - 20岁）。95%的患者在VATS手术时发现有肺大疱，但12.5%的肺大疱位于下叶。术后平均漏气时间为2.7天，术后住院时间为5.0天，术后胸腔引流管留置时间为5.1天；2例患者需要Heimlich瓣膜，在家中处理。采用了五种不同的手术技术，具体如下：肺大疱切除术加机械性胸膜固定术的住院时间最短（4.3天），胸腔引流管留置时间最短（4.1天），但与肺大疱切除术加化学性胸膜固定术相比，复发风险更高（6%为严重复发，16%为轻微复发）。需要再次进行VATS手术（同侧或对侧）的风险为28%。平均随访时间为46个月。
肺大疱切除术加机械或化学性胸膜固定术均取得了可接受的治疗效果。肺大疱切除术加化学性胸膜固定术同侧复发风险似乎较低，但术后住院时间和胸腔引流管留置时间较长。
