Rapicetta Cristian, Voltolini Luca, Lococo Filippo, Vecchioni Ilaria, Tenconi Sara, Paci Masimiliano, Ricchetti Tommaso, Rossi Marcello, Gotti Giuseppe
Unit of Thoracic Surgery, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy.
Thoracic Surgery Unit, University Hospital of Siena, Siena, Italy.
Thorac Cardiovasc Surg. 2016 Dec;64(8):654-660. doi: 10.1055/s-0035-1547450. Epub 2015 Mar 31.
The aim of this study was to assess long-term pulmonary and diaphragmatic function in two cohorts of patients: the first one affected by diaphragmatic palsy (DP) who underwent plication reinforced by rib-fixed mesh and the second one affected by chronic diaphragmatic hernia (TDH) who underwent surgical reduction and direct suture. From 1996 to 2011, 10 patients with unilateral DP and 6 patients with TDH underwent elective surgery. Preoperative and long-term (12 months) follow-up assessments were completed in all patients, including pulmonary function tests (PFTs) with diffusion of the lung for carbon monoxide (DLCO), measure of maximum inspiratory pressure (MIP) assessed both in standing and in supine positions, blood gas analysis, chest computed tomographic (CT) scan, and dyspnea score. The Pearson chi-square test, Fisher exact test, and Student -test were applied when indicated. At long-term (12 months) postoperative follow-up, patients operated for DP showed a significant improvement in terms of forced expiratory volume in 1 second (FEV1%) (+ 18.2%, < 0.001), forced vital capacity (FVC%) (+ 12.8%, < 0.001), DLCO% (+ 8.3%, = 0.04), and Po (+ 9.86 mm Hg, < 0.001) when compared with baseline values. Conversely, when considering the TDH group, only the levels of Po were found to be significantly higher in the postoperative assessment (+ 8.3 mm Hg, = 0.04). Although MIP increased in both the groups after surgery, a persistent and significant decrease of MIP was detected in TDH group when comparing the levels assessed in supine position with those measured in the standing position ( < 0.001). Medical Research Council dyspnea scale improved in the DP group by a factor of 0.80 ( < 0.001) and in the TDH group by a factor of 0.33 ( = 0.175). In patients who underwent surgery for DP, good long-term results may be predicted in terms of pulmonary flows, volumes, and DLCO. Conversely, in patients who underwent elective surgery for chronic TDH, a persistent overall restrictive pattern, lower MIP values in supine position, and paradoxical motion could be expected.
第一组为膈肌麻痹（DP）患者，接受了肋骨固定网片加强的膈肌折叠术；第二组为慢性膈肌疝（TDH）患者，接受了手术复位和直接缝合。1996年至2011年，10例单侧DP患者和6例TDH患者接受了择期手术。对所有患者进行了术前和长期（12个月）随访评估，包括一氧化碳肺弥散功能（DLCO）的肺功能测试（PFTs）、站立位和仰卧位的最大吸气压力（MIP）测量、血气分析、胸部计算机断层扫描（CT）以及呼吸困难评分。在适当时应用Pearson卡方检验、Fisher精确检验和Student检验。术后长期（12个月）随访时，接受DP手术的患者在1秒用力呼气量（FEV1%）（+18.2%，P<0.001）、用力肺活量（FVC%）（+12.8%，P<0.001）、DLCO%（+8.3%，P=0.04）和氧分压（Po）（+9.86mmHg，P<0.001）方面与基线值相比有显著改善。相反，在考虑TDH组时，术后评估中仅发现氧分压水平显著升高（+8.3mmHg，P=0.04）。虽然两组术后MIP均增加，但与站立位测量值相比，TDH组仰卧位评估的MIP水平持续且显著下降（P<0.001）。医学研究委员会呼吸困难量表在DP组改善了0.80（P<0.001），在TDH组改善了0.33（P=0.175）。对于接受DP手术的患者，在肺流量、容积和DLCO方面可预测良好的长期结果。相反，对于接受慢性TDH择期手术的患者，可能会出现持续的整体限制性模式、仰卧位较低的MIP值和矛盾运动。
