Yuan Miao,Xu Chang,Cheng Kaisheng,et al.Preliminary study of thoracoscopic anatomic lesion resection for congenital lung malformations in children[J].Journal of Clinical Pediatric Surgery,2022,21(07):612-616.[doi:10.3760/cma.j.cn101785-202106065-003]
胸腔镜下解剖性病灶切除术治疗儿童先天性肺畸形的初步探讨
- Title:
- Preliminary study of thoracoscopic anatomic lesion resection for congenital lung malformations in children
- 摘要:
- 目的 初步探讨胸腔镜下解剖性病灶切除（anatomic lesion resection，ALR）治疗儿童先天性肺畸形（congenital lung malformations，CLMs）的安全性与有效性。方法 以2019年10月至2020年10月在四川大学华西医院接受ALR的72例先天性肺畸形患儿为研究对象，其中男50例，女22例，年龄5个月至3岁，平均年龄10个月。所有患儿于术前行胸部增强及高分辨薄层CT检查，明确肺部病灶位置及边界，初步评估后再结合术中病灶边界行ALR治疗，术后病检结果均支持CLMs，其中先天性肺气道畸形（congenital pulmonary airway malformation，CPAM）45例，叶内型肺隔离症（intralobar pulmonary sequestration，ILS）27例。所有患儿术后接受至少3个月的随访，并于术后3个月和1年复查胸部平扫CT。结果 72例均在胸腔镜下顺利完成手术，无一例中转开放手术。手术时间（68.2±18.6） min （38~142 min）；术中出血量（6.2±2.4） mL，病灶直径（4.2±1.7） cm。病灶位置：38例位于右肺下叶，2例位于右肺上下叶，2例位于右肺中下叶，22例位于左肺下叶，8例位于左肺上叶。所有患儿术中置16Fr引流管1根，引流管拔除时间为术后（1.32±0.25） d。所有患儿术后无支气管胸膜瘘、出血、肺不张、肺部感染、病灶残留、复发、再次手术等情况发生。1例术后1个月出现气胸，予重新置入胸腔闭式引流管、保守治疗1周后愈合出院。2例术后1个月因咳嗽、发热就诊于呼吸内科，胸部CT提示病灶切除位置出现规则圆形囊腔，予以抗炎等对症治疗后康复出院。术后住院时间为（3.3±0.2） d。3例术后3个月胸部平扫CT提示肺部有代偿性气肿表现，其余患儿患侧肺叶复张良好。结论 ALR结合术前薄层CT和术中病灶边界，基于肺静脉行解剖性肺内游离，是仅切除病灶的保肺手术，治疗CLMs具有较高的安全性与有效性。但该术式需要精准的肺内操作，对术者要求较高，且需严格掌握适应证。
- Abstract:
- Objective To explore the safety and efficacy of thoracoscopic anatomic lesion resection (ALR) in the treatment of congenital pulmonary malformations in children.Methods A retrospective review of clinical data was conducted for 72 children undergoing ALR from October 2019 to October 2020.The average age was 10(5-36) months.Results All cases were operated under thoracoscope without any conversion into open surgery.The average operative duration was (68.2±18.6)(38-142) min, the average intraoperative bleeding volume (6.2±2.4)(2-10) ml and the average diameter of lesion (4.2±1.7)(3-7) cm.The lesions were located in right lower lobe (n=38), right upper/lower lobe (n=2), middle/lower lobe (n=2), left lower lobe (n=22) and left upper lobe (n=8).There was no onset of bronchopleurothelial fistula, hemorrhage, atelectasis or pulmonary infection.One child of pneumothorax at Month 1 post-operation was cured by closed thoracic drainage.Two cases were hospitalized in respiratory medicine at Month 1 post-operation due to cough and fever.Chest CT revealed a regular cyst at the location of lesion (n=2).Both were discharged after anti-inflammatory treatment.The postoperative hospital stay was (3.3±0.2) days.Chest computed tomography (CT) hinted at compensatory emphysema at Month 3 post-operation (n=3) and the remainders recovered well.Conclusion In conjunctions with preoperative thin-slice CT and intraoperative lesion boundary and anatomic intrapulmonary dissociation based upon pulmonary vein, ALR, as a lung sparing surgery, offers high safety and effectiveness in the treatment of CLMs.However, operation requires more accurate lung maneuver, greater operator requirements and stricter control of its indications.
参考文献/References:
[1] Elhattab A, Elsaied A, Wafa T, et al.Thoracoscopic surgery for congenital lung malformations:Does previous infection really matter?[J].J Pediatr Surg, 2021, 56(11):1982-1987.DOI:10.1016/j.jpedsurg.2021.01.036.
[2] Zheng J, Tang H, Xu H, et al.Thoracoscopic versus open resection for symptomatic congenital pulmonary airway malformations in neonates:a decade-long retrospective study[J].BMC Pulm Med, 2021, 21(1):82.DOI:10.1186/s12890-021-01445-2.
[3] 李帅, 黄格元, 汤绍涛.胸腔镜解剖性肺段切除治疗先天性肺气道畸形国内外研究现状[J].中华小儿外科杂志, 2021, 42(2):171-176.DOI:10.3760/cma.j.cn421158-20191117-00638.Li S, Huang GY, Tang ST.Application of thoracoscopic anatomic segmentectomy for congenital pulmonary airway malformations:current status based upon literatures[J].Chin J Pediatr Surg, 2021, 42(2):171-176.DOI:10.3760/cma.j.cn421158-20191117-00638.
[4] Kapralik J, Wayne C, Chan E, et al.Surgical versus conservative management of congenital pulmonary airway malformation in children:A systematic review and meta-analysis[J].J Pediatr Surg, 2016, 51(3):508-512.DOI:10.1016/j.jpedsurg.2015.11.022.
[5] 程凯昇, 袁淼, 徐畅, 等.胸腔镜解剖性肺段切除治疗儿童先天性肺疾病临床分析[J].四川大学学报(医学版), 2019, 50(4):594-597.Cheng KS, Yuan M, Xu C, et al.Retrospective analysis on the safety and feasibility of thoracoscopic anatomical segmentectomy in the treatment of congenital lung malformations[J].Journal of Sichuan University (Medical Science Edition), 2019, 50(4):594-597.
[6] Fascetti-Leon F, Gobbi D, Pavia SV, et al.Sparing-lung surgery for the treatment of congenital lung malformations[J].J Pediatr Surg, 2013, 48(7):1476-1480.DOI:10.1016/j.jpedsurg.2013.02.098.
[7] Criss CN, Musili N, Matusko N, et al.Asymptomatic congenital lung malformations:Is nonoperative management a viable alternative?[J].J Pediatr Surg, 2018, 53(6):1092-1097.DOI:10.1016/j.jpedsurg.2018.02.065.
[8] Wong K, Flake AW, Tibboel D, et al.Congenital pulmonary airway malformation:advances and controversies[J].Lancet Child Adolesc Health, 2018, 2(4):290-297.DOI:10.1016/S2352-4642(18)30035-X.
[9] Boucherat O, Jeannotte L, Hadchouel A, et al.Pathomechanisms of congenital cystic lung diseases:focus on congenital cystic adenomatoid malformation and pleuropulmonary blastoma[J].Paediatr Respir Rev, 2016, 19:62-68.DOI:10.1016/j.prrv.2015.11.011.
[10] Style CC, Mehollin-Ray AR, Verla MA, et al.Accuracy of prenatal and postnatal imaging for management of congenital lung malformations[J].J Pediatr Surg, 2020, 55(5):844-847.DOI:10.1016/j.jpedsurg.2020.01.020.
[11] Kunisaki SM, Leys CM.Surgical pulmonary and pleural diseases in children:lung malformations, empyema, and spontaneous pneumothorax[J].Adv Pediatr, 2020, 67:145-169.DOI:10.1016/j.yapd.2020.03.006.
[12] Zhang Y, Xin W, Xu C, et al.Thoracoscopic lobectomy through the pulmonary hilum approach for the treatment of congenital lung malformation[J].Surg Endosc, 2022, 36(1):711-717.DOI:10.1007/s00464-021-08339-8.
[13] 银秀春.小儿肺隔离症的临床诊疗进展[J].临床小儿外科杂志, 2021, 20(1):74-80.DOI:10.12260/lcxewkzz.2021.01.015.Yin XC.Advances in diagnosis and treatment of pediatric pulmonary sequestration[J].J Clin Ped Sur, 2021, 20(1):74-80.DOI:10.12260/lcxewkzz.2021.01.015.
[14] Park S, Kim ER, Hwang Y, et al.Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation:an analysis of learning curve[J].Surg Endosc, 2017, 31(10):3932-3938.DOI:10.1007/s00464-017-5425-0.
[15] Bagrodia N, Cassel S, Liao J, et al.Segmental resection for the treatment of congenital pulmonary malformations[J].J Pediatr Surg, 2014, 49(6):905-909.DOI:10.1016/j.jpedsurg.2014.01.021.
[16] Lee S, Kim DH, Lee SK.Efficacy of segmental resection in patients with prenatally diagnosed congenital lung malformations[J].Interact Cardiovasc Thorac Surg, 2017, 24(3):425-429.DOI:10.1093/icvts/ivw408.
[17] Johnson SM, Grace N, Edwards MJ, et al.Thoracoscopic segmentectomy for treatment of congenital lung malformations[J].J Pediatr Surg, 2011, 46(12):2265-2269.DOI:10.1016/j.jpedsurg.2011.09.012.
备注/Memo
收稿日期:2021-06-23。
基金项目:国家自然科学基金（31201095）
通讯作者:徐畅,Email:xcxcxc52229081@163.com