Lung volume reduction surgery

In the late 1950s, Brantigan and Mueller first proposed lung volume reduction surgery for patients with diffuse emphysema. The rationale was that under normal conditions, the elasticity of the inflated lungs can be transmitted to relatively small bronchi and through the circumference. The elastic pulling force keeps the small bronchi in an open state, and the circumferential traction force of the patient with emphysema keeping the bronchus open is lost. Treatment of diseases: tuberculosis emphysema Indication (1) The diagnosis has been confirmed as end-stage emphysema without serious heart, liver and kidney disease. (2) The difficulty of breathing is progressively worsened, and medical treatment is ineffective. (3) Age: Unilateral LVRS should be <65 years old, and bilateral LVRS should be <60 years old. (4) The forced expiratory volume in the first second is < or = 35% of the predicted value, the lung residual volume is >200%, the total lung volume is >120%, the lung diffusion function is >30%, the average pulmonary artery pressure is <45 mmHg, PaO2>50 mmHg , PaCO2 <50mmHg. (5) Smoking cessation for at least 3 months. The radionuclide scan showed that there was a significant ventilated blood flow uneven target area in the upper or surrounding lung area. (6) 6-minute walk test > 200m. (7) LVRS is used as a bridge surgery in the process of waiting for lung transplantation (10). According to the above conditions, only 10% to 20% of patients with chronic obstructive pulmonary disease are suitable for LVRS (3). Contraindications (1) Age > 75 years old. (2) Severe diffuse emphysema, no obvious target area was detected by radionuclide scanning. (3) severe pulmonary hypertension: mean pulmonary artery pressure > 40 mmHg, pulmonary systolic blood pressure > 50 mmHg. (4) high-dose adrenocortical steroid hormone dependent. (5) There are severe bronchitis, asthma, and bronchiectasis. (6) Those who are still smokers from March to June. (7) with advanced cancer, severe coronary heart disease, severe obesity. (8) CO2 retention causes PaCO2> or =50mmHg to be a ventilator dependent. Preoperative preparation Patients with emphysema are at high risk for surgery, and many organs in the body have a reduced function. Therefore, good preoperative preparation is particularly important. Preoperative preparation mainly has the following items: l, general improvement, including nutritional status, water, electrolyte balance. 2, gradually reduce the amount of oral hormones, can be replaced by hormone inhalation. 3, phlegm and cough, if necessary, sputum culture + drug sensitivity. 4, rehabilitation training, including breathing and physical rehabilitation training. 5, on the day of surgery, bronchodilators can be used to prevent bronchospasm, hormones in patients who take hormones for a long time. Surgical procedure Posterior lateral incision: The posterolateral incision is best for the field, and is most suitable for patients with lower lobe or pneumonectomy, as well as patients with more estimated intrathoracic adhesions. The disadvantage of this incision is that the muscle wall of the chest wall is cut off, the wound is large, the blood is bleeding, and it takes time. In addition, due to the lateral position, the contralateral lung is compressed under the lower side, which is disadvantageous for elderly patients with poor respiratory function. Anterior lateral incision: Although the incision is worse than the posterior lateral incision, it can successfully complete the resection of the upper or middle lobe of the lung, and has the advantages of less chest muscles, less blood loss, and faster chest. Because the supine position has little interference with the lungs, it is more conducive to elderly patients with respiratory insufficiency. Underarm incision: The advantage of this incision is that it is aesthetically pleasing, has little trauma, and does not cut off any muscles. Suitable for local excision of small peripheral lesions and foreign body removal. Median sternal incision: mainly used for the resection of bilateral lung metastases. complication Intraoperative complications In addition to complications related to anesthesia, there are three types of life-threatening complications in pneumonectomy: (1) Pulmonary vascular injury: accidental injury to the pulmonary blood vessels during surgery can cause major bleeding and life-threatening. There are 1 anatomical variation; 2 adhesion is tight; 3 is improperly handled; 4 is poorly exposed. Once it occurs, the rupture of the blood vessel should be immediately pressed with a finger or a ball of yarn, but the force should be appropriate to avoid further damage. At this time, if the field is not enough, it should be expanded. Then carefully dissect the proximal and distal ends of the ruptured blood vessel. After the proximal and distal vessels are blocked, the fingers or the ball of the yarn can be removed, the blood is collected, the wound is seen, and the suture is sutured continuously or in a suture. Sometimes, the proximal blood vessels are dissected and blocked from the pericardium. After pulmonary vascular injury, avoid panic, do not use ordinary vascular clamps, you should ask experienced doctors to help you. If the mouth is not big, the blood can be quickly clamped with 1 to 3 non-invasive Allis jaws, or the suture can be directly sutured, and the proximal and distal ends of the breach are not necessarily free. (2) contralateral pneumothorax: more occurs in patients with large pulmonary vesicles, contralateral pulmonary vesicle rupture causes contralateral pneumothorax. In patients with extensive mediastinal lymphadenectomy, if the mediastinal pleura ruptures, it can also cause contralateral pneumothorax. After the pneumothorax occurs, the contralateral lung ventilation becomes more and more difficult, and eventually respiratory insufficiency occurs, which is life-threatening. Once the complication is discovered during surgery, the gas in the contralateral pleural cavity should be evacuated immediately, or the mediastinal opening should be expanded or the thoracic drainage tube placed percutaneously. The incidence of this complication is very low, as reported in the literature at 0.8%. (3) arrhythmia and myocardial ischemia: patients with a history of heart disease, but no heart disease before surgery, temporary physical disorders during surgery can cause arrhythmia and myocardial ischemia. In order to prevent and reduce such complications, 1 carefully evaluate cardiac function before surgery, should be prepared for drugs or other treatments for high-risk groups; 2 should avoid some factors of cardiac dysfunction during surgery, such as hypoxemia, hypokalemia, high Blood volume, hypovolemia, tachycardia and acidosis, etc., should be corrected immediately if the above factors occur; 3 Do not squeeze or stimulate the heart during surgery. Once the arrhythmia and myocardial ischemia are caused by squeezing or stimulating, the operation should be stopped immediately, and the operation should be continued after the cardiac function is restored. 4 Strict electrocardiogram monitoring during operation, once the arrhythmia and myocardial ischemia are found, the corresponding drugs are quickly administered. Treatment, please consult a cardiologist if necessary. 2. Early complications after pneumonectomy (1) Postoperative intrathoracic hemorrhage: intrathoracic hemorrhage after pneumonectomy, forced to re-enter the chest to stop bleeding, accounting for about 1% of lung resection. Causes: 1 pleural adhesions bleeding or oozing, usually in the top of the chest; 2 chest wall vascular injury after bleeding, such as intercostal artery or internal thoracic artery bleeding, due to bleeding from the systemic circulation, higher pressure, not easy to stop; 3 The large blood vessel damage of the lungs is mostly caused by the loosening of the ligature line, and the blood loss is fierce, and it is often too late to rescue. Treatment: In any of the following situations, you should not hesitate to seek early chest exploration and stop bleeding, and prepare enough whole blood to supplement the lack of blood volume. 1 The blood volume of the closed thoracic drainage tube is 150-200ml per hour in 5h; 2 the blood drawn out quickly solidifies, indicating that there is a large active bleeding in the chest; 3 bedside chest X-ray shows The affected side has a larger density of the film, the lung is compressed, the mediastinum shifts to the healthy side, the patient feels difficulty breathing, indicating that there are more clots in the chest; 4 patients have hemorrhagic shock, although the whole blood is given and the antibiotic is given Shock measures, but no improvement in blood loss symptoms. Surgery usually involves the original incision into the chest, sucking the blood in the chest and clearing the clot. If the blood in the chest is not polluted, and the patient is in urgent need of blood supplementation, consider adopting the method of autologous blood return, that is, adding blood and filtering the appropriate amount of antibiotics to return. If the patient's blood pressure is not too low, the active bleeding point can be found after the chest is opened, and the bleeding is stopped. Sometimes after the blood clot is removed, no bleeding can be found. If this situation is encountered, wait for about 10 minutes. If you have not seen the bleeding point, you can safely close the chest. There is very little rebleeding after surgery. In recent years, with the increase in bronchoplasty, bronchial-pulmonary spasm has led to fatal bleeding in the chest. Some authors have a statistical rate of 3%. The reason is that there is a small sputum in the bronchial anastomosis, causing a small abscess, and a small abscess erodes the nearby pulmonary artery. The prevention method is to free a piece of pleura or other tissue during surgery to isolate the bronchial anastomosis from the pulmonary artery. (2) cardiac complications 1 cardiac spasm: pericardial incision or partial resection without suturing or repairing, postoperative cardiac spasm may occur. This complication is rare, but it is very dangerous and the mortality rate is as high as 50%. It usually occurs after pneumonectomy, but there are also reports of heart failure after lobectomy. Typical clinical manifestations are sudden hypotension, tachycardia, and cyanosis. The cause is suction in the chest, suction in the trachea, severe cough, position change and positive pressure ventilation. Diagnosis is extremely difficult, mainly based on vigilance and experience. The emergency chest X-ray film is very helpful for judging the right side of the sputum. It can be seen that the heart is displaced from the original to the right side, but it is difficult to judge the left side. The right iliac crest not only causes the upper and lower vena cava to twist, but also causes the left ventricular outflow tract to be distorted and blocked. The left iliac crest is a true stenosis, which can seriously affect left ventricular filling and ejection and myocardial blood supply. ECG can show similar myocardial infarction. Once the clinical consideration of the possibility of cardiac spasm, the patient should be immediately placed on the healthy side, and individual patients may have a cardiac arrest. If the condition does not improve, it should be decisively open at the bedside for chest exploration, cardiac arrest and pericardial defect repair. There are several methods for repairing right pericardial defects, including epicardial and pericardial fixation, artificial materials or autologous tissue repair. If the left pericardial defect is enlarged downward to the diaphragm, it may not be repaired. At this time, although the heart is very severe, it is not easy to be narrowed and infarcted. 2 cardiac tamponade (pericardial tamponade): open the pericardium during lung resection, may miss the treatment of bleeding points, resulting in blood accumulation in the pericardium. When the blood in the pericardium reaches a certain level, hypotension, central venous pressure, odd pulse, and heart failure may occur. Ultrasound and X-ray examination can confirm the diagnosis. Treatment should quickly drain the blood in the pericardium, open from the original incision in the chest, or make an incision under the xiphoid process. 3 arrhythmia: patients over the age of 60 often have arrhythmia after lung resection. The incidence after pneumonectomy is 20% to 30%, and 15% to 20% after lobectomy. Among all arrhythmias, atrial fibrillation is the most common, followed by sinus tachycardia, atrial flutter, ventricular extrasystole, knot rhythm, chronic arrhythmia, and bipolar law. Paroxysmal atrial tachycardia with block, multi-source atrial tachycardia, ventricular tachycardia, sick sinus syndrome and atypical ventricular tachycardia are relatively rare. More than half of the arrhythmias occurred in the first 24 hours after surgery, and the peak period was 2 to 3 days after surgery. The cause of arrhythmia is not yet clear. It has been suggested that it is related to mediastinal shift, hypoxia, abnormal blood pH, vagus nerve stimulation, etc., but it has not been confirmed. However, elderly, patients with coronary heart disease, preoperative electrocardiogram showed atrial or ventricular premature beats, complete or incomplete right bundle branch block, pneumonectomy in the pericardial vascular, intraoperative hypotension Post-prone arrhythmia has been recognized by everyone. Postoperative arrhythmias, especially persistent or recurrent supraventricular tachycardia, not only prolong the length of hospital stay, but also increase the risk of perioperative period. It has also been suggested that postoperative arrhythmias affect the long-term survival of lung cancer patients. In this case, do you need preventive medication before surgery? So far, there is still debate. Opponents believe that preventive medication is not only ineffective, but also has side effects and dangers. Treatment: In some patients, the heart rhythm returns to normal without special treatment. Some patients, only sporadic atrial or ventricular premature beats, or transient atrial fibrillation, can also be closely observed without special measures. However, most patients require medical treatment, and fatal arrhythmias require urgent treatment. The treatment of arrhythmia is first to remove the cause, such as improving hypoxia, proper sedation and analgesia, correcting water and electrolyte disorders, and maintaining acid-base balance. Then apply different drugs or take other measures depending on the type of arrhythmia. Rapid atrial arrhythmia can be used for digitalis preparations. Adults should use 0.8 to 1.2 mg in general. Verapamil (isopidine) is effective in terminating rapid supraventricular arrhythmia. For the first time, it is slowly pushed 5-10 mg, and if necessary, repeated 10 to 15 minutes later. After supraventricular arrhythmia control, changed to verapamil orally, 40 ~ 80mg, maintained 3 times a day. Synchronous DC cardioversion should be used for atrial arrhythmias that are ineffective for medical therapy and have hemodynamic disorders. The first choice for ventricular tachycardia medication is lidocaine, 50 ~ 100mg intravenous bolus, and then continued to maintain intravenous infusion of 1 ~ 2mg / min. Atropine or intravenous isoproterenol can treat bradycardia. When a third degree atrioventricular block or sick sinus syndrome occurs, an artificial cardiac pacemaker should be considered. 4 myocardial ischemia and myocardial infarction: It has been reported that the incidence of asymptomatic myocardial ischemia after pneumonectomy is about 3.8%, patients with coronary heart disease and those who have had myocardial infarction are prone to occur, often after the second postoperative ~ 4 days appeared. Therefore, strict cardiac monitoring should be performed after pneumonectomy. Once diagnosed, enteric-coated aspirin can be given, 160-325 mg daily. It has been suggested that appropriate beta blockers should be used to prevent myocardial infarction and death. The incidence of myocardial infarction after pneumonectomy is about 1.2%. Preoperative diagnosis of coronary heart disease is easy to occur, and the mortality rate is as high as 50% to 75%. Once diagnosed, you should urgently consult the cardiology department for assistance. 5 orthostatic hypoxemia: after pneumonectomy or lobectomy (usually right upper lobe or upper right or middle lobe), the patient has no or slight dyspnea in the supine position, and the oxygen saturation is normal or slightly lower than normal, but When the patient sits up or stands up, dyspnea or dyspnea is aggravated, and the oxygen saturation becomes abnormal or further decreased. This is called "orthodeoxia". There are 24 reports in the literature. The reason for this is a change in the position of the heart after pneumonectomy, which causes the blood of the inferior vena cava to flow to the patent foramen ovale or atrial septal defect, resulting in a right-to-left shunt. Cardiac ultrasound, cardiac catheterization and cardiovascular angiography can help with diagnosis. Closed to the foramen ovale or atrial septal defect can be cured after the diagnosis is clear. (3) pulmonary complications 1 pulmonary edema after total pneumonectomy: total lung resection, especially after right pneumonectomy, if there is progressive dyspnea, cyanosis, tachycardia and irritability, cough pink foam sputum and lungs full of wet A voice should be diagnosed as pulmonary edema after pneumonectomy. Although the incidence is not high (about 2% to 5%), the mortality rate is high (7% to 80%). The mechanism of this complication is not yet clear, but clinical observations and experiments have shown that excessive fluid input during the perioperative period is an important cause. Since the fluid filtered from the pulmonary capillaries exceeds the ability of lymphatic reflux, the fluid begins to accumulate in the space around the small bronchi, the lungs become stiff and the work of breathing increases. When the gap around the small bronchi is completely filled with water, the alveoli are also quickly involved, so hypoxemia occurs and even death.

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