Tovar E A, Roethe R A, Weissig M D, Lloyd R E, Patel G R
Department of Cardiothoracic Surgery, St Jude Medical Center, Fullerton, California, USA.
Ann Thorac Surg. 1998 Mar;65(3):803-6.
Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained.
Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia.
All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome.
We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.
肺叶切除术后的大多数并发症与疼痛、麻醉镇痛及活动减少有关。当手术以尽量减少术后疼痛为目标，且能实现活动的快速恢复和患者的自主独立时，大多数术后并发症可避免，患者可早期出院。
自1996年3月起，我们连续对10例患者进行了择期大肺切除术（8例肺叶切除术和2例双肺叶切除术），病变包括肿瘤性病变（n = 8）和良性炎性病变（n = 2）。10例患者中，4例为男性，6例为女性，年龄在58至77岁之间（平均年龄66岁）。在外科医生办公室对患者及其家属进行了广泛的术前教育。患者当日入院，随后行保留斜肌的小切口开胸术进入胸腔。手术操作精细，特别注意减少漏气和术后不适。肋间神经冷冻消融术作为主要镇痛方法。
所有患者均通过小切口开胸术完成了计划手术，并在手术室拔除气管插管。所有患者在恢复室中同侧肩带活动均正常，离开该病房后均无需静脉注射麻醉剂。所有患者均在手术当天下床活动。2例患者在手术当晚拔除胸管，6例患者在术后次日上午拔除，1例患者在术后第二天拔除。1例带Heimlich瓣膜出院的患者在术后4天在办公室取出该装置。拔除胸管后，未发生气胸。所有10例患者在术后第一天均能独立行走。8例患者在术后次日上午出院，2例在术后第二天出院。所有患者均未因手术需要再次入院，也未出现开胸术后疼痛综合征的迹象。
我们基于患者教育、精细的微创手术、冷冻镇痛及身体活动的快速恢复制定了一条临床路径。我们采用这种方法的初步经验显示，发病率极低，能迅速恢复到术前状态，且对大多数患者而言，大肺切除术后住院1天。
