【作者】 刘楠；

【导师】 崔有斌；

【作者基本信息】 吉林大学 ， 临床医学， 2008， 硕士

【摘要】 目的:探讨恶性胸腔积液的不同治疗方法及疗效。方法:回顾了我院自2003年至2008年收治的128例恶性胸腔积液病例,并对其治疗方法和治疗效果进行了系统分析。诊断方法:所有患者经胸水脱落细胞学检查,阳性确诊,三次检查阴性者,行胸腔镜下胸膜活检术确诊。全部患者均得到确诊。治疗方法:胸腔镜组:患者取健侧卧位,全麻双腔管插管全身麻醉满意后,术中健侧单肺通气。于腋中线第7肋间处切开皮肤长约1.5cm,钝性分离皮下组织,肌肉至胸膜,插入胸腔镜套管,经套管尽量将胸腔积液抽吸干净。然后放入胸腔镜观察胸腔情况。在胸腔镜引导下于腋后线7肋间,腋前线4肋间各作一切口,用卵圆钳钳夹纱布分离疏松粘连,条索状粘连用电刀烧灼切开。探查胸腔,如见胸膜有转移结节,用活检钳取3块组织活检,出血处用电刀止血。让麻醉师行患侧通气,如患侧能基本复张,即可行胸膜固定术。用粗糙纱布垫磨壁层胸膜,使之表面充血或有血性渗出,取一根长约30cm长的橡皮管,管壁剪数个侧孔,把其一端经套管插入胸腔内,一端接装有滑石粉的腹腔冲洗器,钳夹橡皮管前端,挤压冲洗器皮囊,把滑石粉均匀地喷洒在胸膜腔内,改作双肺通气,并于腋中线第7肋间切口处放置胸腔引流管。然后持续胸腔负压闭式引流,当引流液<100mL/d时拔出引流管。胸穿或胸腔闭式引流组:B超或X线定位下胸穿抽液或经胸腔闭式引流管抽液,尽量抽尽胸液后注入治疗药物,同时抗感染、支持、对症处理。随访4周。结果:128例病例均确诊为恶性胸腔积液,按照治疗方法及疗效的不同分为2组:胸腔镜组:胸腔镜下行胸膜活检、并胸腔内注入滑石粉治疗58例,CR(40例)+PR(17例)病例为57例,有效率达98.28%,失败1例因胸膜腔脏壁两层胸膜粘连较重,无法剥离,肺组织无法完全复张,导致失败。其中发热22例,胸痛38例,出现胃肠道反应9例,经对症治疗后好转。胸穿或胸腔闭式引流组:经过胸穿或胸腔闭式引流管向胸腔内注入博莱霉素、顺铂、白介素-2等药物70例,CR(33例)+PR(22例)病例为55例,总有效率为78.57%。其中发热17例,胸痛34例,出现胃肠道反应14例,出现白细胞减少3例,出现肝肾功能异常3例。无气胸、ARDS等严重并发症的出现。两组间在性别、年龄方面无明显差异(X2=0.001,P>0.05),在治疗有效率上有显著差异,胸腔镜组疗效优于胸穿或胸腔闭式引流组(CMH-X2=10.92,P<0.05),且两组间不良反应均无明显差异(P>0.05)。胸腔穿刺或胸腔闭式引流组根据用药不同分为3组:粘连剂组、细胞毒性药物组及生物调节剂组。粘连剂23例,主要是博莱霉素,CR(13例)+PR(7例),病例为20例,有效率为86.96%,其中胸痛11例,发热6例,胃肠道反应4例,出现肝肾功能异常1例;细胞毒性药物26例,主要药物是顺铂,CR(11例)+PR(10例),病例为21例,有效率为80.77%,其中胸痛14例,发热6例,胃肠道反应7例,出现白细胞减少2例,出现肝肾功能异常3例;生物调节剂21例,主要药物是白介素-2,CR(9例)+PR(5例),病例为14例,有效率为66.67%,其中胸痛9例,发热5例,胃肠道反应3例,出现白细胞减少1例。经对症、支持治疗后可好转。三组间在性别、年龄方面无明显差异(P>0.05),在治疗有效率、不良反应无明显差异(P>0.05)。综上所述,粘连剂、细胞毒性药物及生物调节剂治疗恶性胸腔积液在疗效上无显著性差异无明显差异。结论:胸腔镜下行胸膜活检并胸腔内注入滑石粉治疗恶性胸腔积液疗效较好,胸穿或胸腔闭式引流充分引流胸腔积液后,行不同药物胸腔内注入,疗效无明显差异。胸腔镜手术具有创伤小,痛苦轻,效果好的优点,既可用于胸腔积液的诊断,又可对恶性胸腔积液进行有效的治疗。胸腔镜手术可集诊断与治疗一体,较其他诊断治疗方法,具有无法比拟的优越性。随着微创技术的进一步发展,胸腔镜下喷洒滑石粉胸膜固定术将成为治疗恶性胸腔积液最常用的、最有效的方法之一,值得临床推广使用。更多还原

【Abstract】 Malignant pleural effusion is a common complication of cancer found mostly in advanced lung cancer, breast cancer and lymphoma,which are about 75%, a few from ovarian cancer, stomach cancer, cervical cancer and sarcoma caused. The rapid growth of malignant pleural effusion, and continued existence can cause compression atelectasis and restrictive ventilatory dysfunction, and mediastinal shift to result in a serious impact on respiratory and circulatory functions. Therefore effective control of malignant pleural effusion, relieving symptoms and reducing the suffering of patients and improving the quality of life of patients, the extension of life is of great significance. Traditional repeated puncture and injection of anti-cancer drugs or pleural fixation is not effective because of incompletely pumping pleural effusion or parcels to the injected anti-cancer drug agent which can not be fixed or pleural uniform spread and be compressed on lungs which can not expand, and also cause iatrogenic pneumothorax, chest infection, empyema, and other serious complications. Thoracoscope with modern technology development, pleural fixation by thoracoscope achieves very good therapeutic success ,was classified as one of preferred methods of treatment in malignant pleural effusion. In thoracoscopic surgery, pleural effusion cleared away completely, isolated parcels and adhesion removed from pleural surface fiber membrane, quickly the lung expanded and the heart of oppression released, the patients with clinical symptoms apparently ease immediately. Therefore, no pleural effusion repeatedly taken to reduce the suffering of many patients, and greatly enhance the quality of life of patients. This paper reviews 128 patients with malignant pleural effusion treated from 2003 to 2008 in the hospital, as well as different methods and effect in the treatment were analyzed for malignant pleural effusion that the clinical diagnosis and treatment provide some help. Analysis of the report are as followsObjective: To study the different therapeutic methods and effect of malignant pleural effusion.Methods: 128 clinical data of malignant pleural effusion were analyzed retrospectively from 2003 to 2008,which was divided in two groups: thoracoscope and the thoracentesis or thoracic close drainage. the group of thoracoscope involves 58 cases,including 34 males, 24 female and age between 19 and 82 years old (mean age 59.1years old). the group of the thoracentesis or thoracic close drainage involves 70 cases,including 40 males, 30 female and age between 32 and 84 years old (mean age 60.0 years old).The methods of diagnosis and therapy: The diagnosis of all cases depends on cast-off cell from pleural fluid. For those cases which are not diagnosed by shedding cells in pleural fluid not less than three times, the biopsy of pleura will be done to diagnose them by thoracoscope.Thoracoscopic groups: patients are on the contralateral lying, with satisfactory intubation of double-lumen tube, general anesthesia, and in the contralateral lung ventilation. In the middle section seventh axillary intercostal incision, skin ,subcutaneous tissue, blunt muscle to the pleura are cutted open at approximately 1.5 cm, thoracoscope inserted, pleural effusion is suctioned cleanly. then observe thoracic situation by thoracoscope.skin at approximately 1.5 cm is cutted open in the seventh intercostals and posterior axillary line and the fourth intercostal and anterior axillary line. adhesion is separated andcutted with the cable-burning electricity knife. observe thoracic situation and cut pleural metastasis or nodules with biopsy forceps for three tissue biopsy, stop bleeding with electricity knife. Anaesthetists ventilate, if the lung can rehabilitate,pleural fixation will be in prograss. Rough gauze pad is with pleural wear until the pleura is on congestive or bloody exudate, talc powder is sprinkled uniformly by the peritoneal washes through 30 cm long rubber tubing with a few side holes by the end of its casing into the chest cavity, and tube drainage is keeping in the middle section seventh axillary intercostal line at the chest after the lungs is ventilated. Then closed suction drainage sustained until draining liquid<100mL/d. The thoracentesis or thoracic close drainage were used to treated malignant pleural fluid. After the pleural fluid was almost absorbed, therapeutic medicine were injected into thoracic cavity. The duct of thoracic close drainage was pulled out when the pleural fluid of drainage was less than 100ml/d. All the cases were followed up for four weeks. Results: The group of thoracoscope: 57 cases were healed well with an effective rate of 98.28% in this group,in which there were 40 cases completely released and 17 cases partly released. The only one failed because that pleural adhesions was too severe to separate and inflate the lung. There were 22 cases who were low-grade fever, 38 cases who were in light thoracalgia and 9 cases who had the symptom of sicchasia and vomiting in the side-effect of this treatment.those cases improved in health after symptomatic treatment. The thoracentesis or thoracic close drainage: 55 cases were healed well with an effective rate of 78.57% in this group,in which there were 33 cases complete released and 22 cases partly released. There was no significant difference on the factor of sex,age and side reaction (P>0.05), but there was significant difference in the treatment (P<0.05), and the group of thoracoscope is more effective than the another one.The group of thoracentesis or thoracic close drainage involve three groups, which consist of Bleomycin, Cisplatin and IL-2.20 cases were healed well with an effective rate of 89.96% in 23 cases into whose thoracic cavity Bleomycin was injected,in which there were 13 cases completely released and 7 cases partly released. 21 cases were healed well with an effective rate of 80.77% in 26 cases into whose thoracic cavity Cisplatin was injected,in which there were 11 cases completely released and 10 cases partly released.14 cases were healed well with an effective rate of 66.67% in 21 cases into whose thoracic cavity IL-2 was injected, in which there were 9 cases completely released and 5 cases partly released. There were 17 cases who were low-grade fever, 34 cases who were in light thoracalgia ,14cases who had the symptom of sicchasia and vomiting, 3 case leucopenia happened in and 3 case who had dysfunction of liver and kidney in the side-effect of this treatment.those cases improved in health after symptomatic treatment. All of them have no severe complications after surgery such as pneumothorax、ARDS etc. There was no significant difference in the three groups on the factor of sex ,age,treatment and side reaction (P>0.05).Conclusion: Thoracoscopic surgery to treat malignant pleural effusion is better than closed thoracic drainage.It is minimally invasive, painful light, the effective advantages not only can be used in the diagnosis of pleural effusion, but also the treatment of malignant pleural effusion. Thoracoscopic surgery can be integrated diagnosis and treatment, with more incomparable superiority than other methods. Along with the further development of minimally invasive technique, Thoracoscopic surgery will become one of the most commonly effective treatments of malignant pleural effusion, it is for clinical use.更多还原