肺部手术后肺持续漏气闭合技术的进展

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5　术后闭合肺漏口的手段

多数肺漏气可经24～ 48h 引流自行愈合, 无需特殊处理。施行肺部分切除术后既有肺漏气又有气胸的患者大多用胸腔闭式引流是安全的, 无需负压吸引。但对大的漏气(呼气性漏气3 度) 并/或气胸≥8cm 的患者, 采用水封瓶闭式引流, 还是负压吸引仍需前瞻性的统计试验分析进行比较^{[ 29} ^]。对延迟愈合的患者,均需以积极的内科或外科干预进行闭合。

5. 1　化学粘合剂行胸膜固定术　化学制剂如滑石粉、四环素是最早使用的粘合剂, 最先用于顽固发作的自发性气胸或癌性胸水、乳糜胸难以耐受手术者疗效确切。标准的化学性胸膜固定术药品滴注后要夹闭一段时间胸管; 但这种方法对漏气未愈的患者却可能导致张力性气胸。Kilic 等^{[ 30 ]}在实践中将胸腔引流管倒置成倒“U ”形而不夹闭胸腔引流管, 中部拱起60cm , 成功解决了上述问题。6 例患者经该方法处理后顺利康复, 平均16. 2 个月未复发。许川等^{[ 31 ]}对50例肺叶或肺楔形切除术后发生Ⅱ～ Ⅲ 级漏气≥2d 的患者, 经胸腔引流管注入凝血酶联合高渗糖后夹管,利用高渗糖的理化刺激作用和凝血酶的生物刺激作用, 取得了良好的疗效, 治愈率超过93. 3% , 高于未用此方法组(70% 的治愈率)。但是使用化学制剂最突出的问题是易引起胸内炎症以及患者剧烈的胸痛不适;同时广泛的胸膜增厚或脏层胸膜纤维板样增生, 有可能影响余肺功能, 所以应慎重使用。

5. 2　自体血液　自体血液由于规避了外源性血液及血液制品的诸多副作用, 从而得到更多临床医师的关注。2006 年Shackclo th 等^{[ 5 ]}对22 例患者进行随机前瞻性研究, 以灌注自体血液120m l, 观察到24h 后58.6% 患者漏气停止。自体血液灌注组平均漏气时间为5d, 远低于对照组的11d。胸腔引流管拔除时间、患者的住院时间差异有统计学意义。同年D roghet t i等^{[ 4 ]}再次报道21 例以自体血灌注治疗肺叶切除后肺持续漏气患者, 其中81% 的患者仅用此方法1 次, 于24h 内起效, 其余19% 的患者于灌注2 次后在12h 内停止漏气, 总的平均漏气时间为15d, 因而评价为100% 有效。

5. 3　气腹　气腹的原理可能为肺下叶切除后可使横膈抬高与肺脏层胸膜接触, 产生粘连闭绝漏气, 有临床研究显示该技术可显著减少肺部手术后肺持续漏气时间和胸腔引流管引流时间^{[ 32 ]} , 因此, 值得更多的关注。

总之, 肺部手术后肺持续漏气一直是同行们关注的重要问题, 数十年来, 虽探讨了多种治疗手段, 但仍难得到满意的早期漏口闭合的疗效。因此, 有关肺部手术后肺持续漏气的基础和临床研究需要进一步深入研究, 以期找到符合其病理生理机制的早期促进愈合的方法, 改善预后。

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