Landreneau R J, Keenan R J, Hazelrigg S R, Mack M J, Naunheim K S
Section of Thoracic Surgery, University of Pittsburgh, USA.
Chest. 1996 Jan;109(1):18-24. doi: 10.1378/chest.109.1.18.
Video-assisted thoracic surgery (VATS) has assumed greater importance in the management of pleural disease. Since 1990, we have performed VATS procedures to manage a variety of pathologic pleural processes in 306 patients. The 99 patients with complex empyemas or hemothoraces are the focus of this report. Seventy-six patients with complex empyemas (including 26 chronic) were approached with VATS after inadequate chest tube drainage. The causes associated with the thoracic empyemas were parapneumonic collections in 47, after hemothorax in 8, infected sympathetic effusions associated with intra-abdominal sepsis in 6, postresectional in 5, prolonged bronchopleural fistula following spontaneous pneumothorax in 4, chronic drainage of malignant pleural effusions in 4, and chronic drainage of pleural effusion in 2 patients undergoing chemotherapy. Ages ranged from 14 to 78 years. Sixty-three patients (83%) were treated with thoracoscopic drainage +/- decortication alone. Thirteen patients (17%) required subsequent thoracotomy for decortication, including 12 of the 26 (46%) chronic empyemas known to be greater than 3 weeks old. Chest tubes were removed 3.3 +/- 2.9 days postoperatively in 67 patients; 9 patients (12%) were sent home with empyema tubes. Postoperative hospital stay for these patients with empyema averaged 7.4 +/- 7.2 days. There were five deaths, all related to progressive sepsis from associated pneumonia (6.6%). Twenty-three patients underwent thoracoscopic evacuation of hemothoraces that resulted following open heart surgery in 6, thoracic trauma in 7, were iatrogenic in 7, and bleeding into malignant effusions in 3. All were successfully treated by thoracoscopic drainage and pleural debridement alone. Chest tubes were removed 2.8 +/- 0.5 days postoperatively and hospital stay averaged 4.3 +/- 1.9 days. There were no complications; one patient with a hemothrax (after heart transplant) died of unrelated causes. In our experience, VATS has been highly successful in the early management of empyemas and hemothoraces. Conversion to open thoracotomy must always be anticipated, especially when approaching chronic empyemas.
电视辅助胸腔镜手术（VATS）在胸膜疾病的治疗中发挥着越来越重要的作用。自1990年以来，我们已对306例患者实施VATS手术，以处理各种病理性胸膜病变。本报告重点关注99例患有复杂性脓胸或血胸的患者。76例复杂性脓胸患者（包括26例慢性脓胸患者）在胸腔闭式引流效果不佳后接受了VATS手术。与胸腔脓胸相关的病因包括：47例为肺炎旁积液，8例为血胸后，6例为与腹腔内感染相关的感染性交感神经积液，5例为切除术后，4例为自发性气胸后长期支气管胸膜瘘，4例为恶性胸腔积液的慢性引流，2例为化疗患者的胸腔积液慢性引流。患者年龄在14至78岁之间。63例患者（83%）仅接受胸腔镜引流+/-胸膜剥脱术治疗。13例患者（17%）随后需要开胸进行胸膜剥脱术，其中26例慢性脓胸患者中有12例（46%）病程超过3周。67例患者术后3.3 +/- 2.9天拔除胸腔引流管；9例患者（12%）带脓胸引流管出院。这些脓胸患者的术后平均住院时间为7.4 +/- 7.2天。共有5例死亡，均与相关肺炎导致的进行性脓毒症有关（占6.6%）。23例患者接受了胸腔镜血胸清除术，其中6例因心脏直视手术后出现血胸，7例因胸部创伤，7例为医源性，3例为恶性胸腔积液出血。所有患者均通过胸腔镜引流和胸膜清创术成功治疗。术后2.8 +/- 0.5天拔除胸腔引流管，平均住院时间为4.3 +/- 1.9天。无并发症发生；1例血胸患者（心脏移植后）死于无关原因。根据我们的经验，VATS在脓胸和血胸的早期治疗中非常成功。必须始终考虑转为开胸手术，尤其是在处理慢性脓胸时。
