Khanbhai Mustafa, Dunning Joel, Yap Kok Hooi, Rammohan Kandadai S
Department of Cardiothoracic Surgery, University Hospital of South Manchester, Manchester, UK.
Interact Cardiovasc Thorac Surg. 2013 Aug;17(2):403-6. doi: 10.1093/icvts/ivt144. Epub 2013 Apr 28.
A best evidence topic was written according to a structured protocol. The question addressed was whether dissection of the pulmonary ligament during an upper lobectomy would result in improved outcomes. A total of 85 articles were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Reported measures were complications associated with dissection (atelectasis, bronchial stenosis, bronchial obstruction and bronchial deformation) and preservation (insufficient lung expansion, pooling of effusion and atelectasis) of the pulmonary ligament, ratio (%) of dead space in longitudinal axis (movement of nonoperated lobes), change in the angle (degrees) of main bronchus on the operated side, overall morbidity and mortality, overall survival and conversion rates. In a randomized control trial, the dissection of the pulmonary ligament revealed no significant difference in the dead space ratio or change in the angle of the main bronchus when compared with preservation. Dissection of the ligament, in theory, reduces the free space in the upper thorax by increasing the mobility of the residual lobes. Dissection of the ligament may lead to bronchial deformation, stenosis, obstruction or lobar torsion. Preservation of the ligament may prevent this complication by suppressing the upward movement of residual lobes. However, this may result in pleural effusion in the free thoracic space that may potentially become infected resulting in an empyema or bronchial fistula. Five large case series were analysed; three routinely dissected the pulmonary ligament and two did not. There was no observed difference in clinical outcomes between the two groups. There is no convincing evidence that dissection of the pulmonary ligament in an upper lobectomy significantly improves outcomes and reduces complications.
根据结构化方案撰写了一篇最佳证据主题。所探讨的问题是，在上叶切除术中解剖肺韧带是否会带来更好的结果。通过报告的检索共找到85篇文章，其中8篇代表了回答该临床问题的最佳证据。现将作者、日期、期刊、研究类型、人群、主要结局指标和结果制成表格。报告的指标包括与肺韧带解剖相关的并发症（肺不张、支气管狭窄、支气管阻塞和支气管变形）以及保留肺韧带的并发症（肺扩张不足、积液积聚和肺不张）、纵轴死腔比率（未手术肺叶的移动情况）、手术侧主支气管角度的变化（度数）、总体发病率和死亡率、总生存率以及转化率。在一项随机对照试验中，与保留肺韧带相比，解剖肺韧带在死腔比率或主支气管角度变化方面无显著差异。理论上，解剖韧带会通过增加残留肺叶的活动度来减少上胸部的自由空间。解剖韧带可能导致支气管变形、狭窄、阻塞或肺叶扭转。保留韧带可能通过抑制残留肺叶的向上移动来预防这种并发症。然而，这可能导致胸腔自由空间出现胸腔积液，进而可能感染形成脓胸或支气管瘘。分析了5个大型病例系列；其中3个常规解剖肺韧带，2个未解剖。两组之间未观察到临床结局的差异。没有令人信服的证据表明在上叶切除术中解剖肺韧带能显著改善结果并减少并发症。
