Novel scheme for treating secondary spontaneous pneumothorax in operation mode
Through single-hole thoracoscopic parietal pleural pleural exfoliation combined with pulmonary bulla ligation, the problem of high lung air leakage and recurrence rates after secondary spontaneous pneumothorax surgery was solved, and the effects of reducing postoperative complications, improving quality of life and reducing medical costs were achieved.
Patent Information
- Application Number
- CN202411986705.5
- Authority / Receiving Office
- CN · China
- Patent Type
- Applications(China)
- Current Assignee / Owner
- Filing Date
- 2024-12-31
- Publication Date
- 2025-03-11
- Estimated Expiration
- Not applicable · inactive patent
AI Technical Summary
Patients with secondary spontaneous pneumothorax often face complications such as lung air leakage after surgical treatment, and the recurrence rate of spontaneous pneumothorax is high, resulting in high treatment difficulty and high mortality.
A new surgical method of single-hole thoracoscopic parietal pleural pleural exfoliation combined with pulmonary bullae ligation is used to treat emphysema and lung bullae by performing surgery under intravenous compound anesthesia and double-cavity tracheal intubation, and ligating lung bullae and emphysema tissues at 1/3 of the periphery of the lung, avoiding the use of cutting staplers and suture reinforcement.
Minimize postoperative pulmonary air leakage, reduce the incidence of complications, improve the quality of life and survival time of patients, significantly reduce the rate of spontaneous pneumothorax recurrence, and reduce hospitalization time and medical expenses.
Smart Images
Figure CN119587136A_ABST
Abstract
Description
Technical Field
[0001] The invention relates to the field of medical technology, and in particular to a new surgical method for treating secondary spontaneous pneumothorax. Background Art
[0002] Spontaneous pneumothorax refers to the entry of air from the lungs into the pleural cavity without trauma. It is divided into primary spontaneous pneumothorax and secondary spontaneous pneumothorax. Secondary spontaneous pneumothorax is often associated with underlying lung diseases, the most common of which is chronic obstructive pulmonary disease (COPD), and others include tuberculosis, bronchiectasis, silicosis, etc. Studies have shown that the incidence of secondary spontaneous pneumothorax is higher than that of primary spontaneous pneumothorax. Compared with primary spontaneous pneumothorax, patients with secondary spontaneous pneumothorax are more difficult to treat, and the recurrence rate, surgical complications and mortality of spontaneous pneumothorax are higher. Emphysema and bullae formation are one of the main phenotypes of COPD, and lung transplantation is required for continued progression of lesions. Patients have poor lung function. Once spontaneous pneumothorax occurs, prolonged lung leakage can easily lead to respiratory failure or even death, which is a difficulty in clinical treatment. Surgery is the preferred treatment for persistent air leakage or recurrent pneumothorax in secondary spontaneous pneumothorax. There are great differences in the surgical treatment of secondary spontaneous pneumothorax in related studies. The incidence of postoperative complications is 20.6%-25.2%, the mortality rate is 4.1%-4.7%, and the recurrence rate of spontaneous pneumothorax is 0.9%-18.75%. Persistent lung air leakage is the most common complication after surgery for secondary spontaneous pneumothorax. Previous related studies believe that the removal of bullae without staplers is a significant risk factor for complications. Common methods for preventing spontaneous pneumothorax include surgery (lung wedge resection of bullae, bullae suture), mechanical pleurodesis (parietal pleural abrasion, parietal pleurectomy), and other methods include chemical pleurodesis or autologous blood. The ACCP and BTS guidelines also recommend the use of pleurodesis to prevent pneumothorax recurrence. Compared with chemical pleurodesis, surgical mechanical pleurodesis intervention has a higher success rate (78%-91% VS 95%-100%). Despite the use of reinforced staplers (bovine pericardium, polytetrafluoroethylene, etc.), persistent pulmonary air leakage is the most common complication after pleurodesis for secondary spontaneous pneumothorax in patients with COPD, mainly due to leakage of staplers and missed bullae or fistulas.
[0003] After searching the literature, there are no research reports on "single-port thoracoscopic parietal pleura decortication combined with bulla ligation for the treatment of secondary spontaneous pneumothorax" at home and abroad. Summary of the invention
[0004] The main purpose of the present invention is to provide a new surgical method for treating secondary spontaneous pneumothorax, so as to effectively solve the problems raised in the background technology.
[0005] To achieve the above object, the present invention adopts the following technical solution: a new surgical method for treating secondary spontaneous pneumothorax, comprising the following steps:
[0006] Step 1. Surgical preparation: All surgeries were performed under intravenous combined anesthesia and double-lumen endotracheal intubation. Continuous end-tidal carbon dioxide (ETCO2) monitoring and multiple arterial blood gas analysis were performed during the operation to adjust the respiratory rate. For example, the partial pressure of carbon dioxide (PaCO 2 )>70mmHg, or (and) blood oxygen saturation (PaO 2 )<90% were switched to bilateral low tidal volume ventilation;
[0007] Step 2: Design of surgical incision: The surgical incision is made through the 4th or 5th intercostal space in the anterior axillary-midline, with an incision of about 3.0-3.5 cm. The thoracoscope light source and operating instruments are inserted through a single port;
[0008] Step 3: Treatment of emphysema and bullae: First, separate the thoracic adhesions. When there is emphysema or giant bullae without lung collapse, use an energy device (electric hook incision) to shrink the lungs. Do not ligate all bullae, but focus on ligating bullae and emphysematous tissue located in the outer 1 / 3 of the lungs.
[0009] Preferably, the surgery does not use a cutting stapler or suture reinforcement, but only uses No. 7 or No. 10 silk thread to ligate three times along the root of emphysema and bullae at a distance of 2 cm from normal lung tissue.
[0010] Preferably, in the case of giant bullae, excess diseased lung tissue is removed after ligation, and the lungs are inflated with water to check for air leaks.
[0011] Step 4: Stripping of the parietal pleura: gradually separate the parietal pleura and the chest wall muscle layer along the inner side of the incision, and use double-jointed forceps and separation forceps to strip;
[0012] Preferably, the range of parietal pleura separation is: the upper edge to the 2nd rib, the lower edge to the 8th rib, the front edge to 1 cm beside the internal thoracic artery, and the rear edge to 2 cm beside the sympathetic trunk.
[0013] Preferably, the parietal pleura is not removed after stripping and remains in the chest cavity. The parietal pleura has blood supply and will not undergo necrosis. The stripped parietal pleura covers the surface of the lung tissue and can promote adhesion between the lung tissue and the chest wall.
[0014] Preferably, if there is spurting bleeding from a vessel during pleural decortication, electrocoagulation or ultrasonic scalpel is used to stop the bleeding. At the end of the operation, two chest tubes are placed at the seventh intercostal space and the incision, respectively, and connected to an underwater sealed drainage tube.
[0015] The beneficial effects of the present invention are as follows: 1. Minimizing postoperative lung air leakage: For patients with multiple bullae in both lungs, emphysema and other poor lung function, complete removal of the bullae is not pursued. Only ligation of some larger bullae in the periphery of the lungs (without using a cutting stapler, etc.) can effectively reduce postoperative air leakage, and suturing of emphysematous tissue is not performed, which can effectively reduce lung wound trauma and postoperative lung tissue bleeding.
[0016] 2. Better recovery: The single-port thoracoscopic incision is small, the chest drainage tube is removed 2-3 days after surgery, the wound pain is mild, the incidence of postoperative complications is lower, the quality of life is higher, and the survival time is longer.
[0017] 3. Restore some lung function: Ligation of ineffectively ventilated emphysema or bullous tissue is similar to lung volume reduction surgery, preserving more relatively normal lung tissue.
[0018] 4. Effectively reduce hospitalization time and medical expenses: Compared with traditional surgical methods, patients' postoperative hospitalization time and medical expenses are lower. According to the current DRG payment management model standards, each operation saves an average of about 10,000 yuan.
[0019] 5. Effectively reduce complications and recurrence of postoperative spontaneous pneumothorax: Up to now, 31 patients have been followed up and no recurrence of spontaneous pneumothorax has been found.
[0020] 6. Previous related studies have suggested that not using staplers to remove bullae is a significant risk factor for complications: We used bullae ligation combined with parietal pleural decortication, and clinical data results showed that the incidence of postoperative pulmonary air leakage was greatly reduced. BRIEF DESCRIPTION OF THE DRAWINGS
[0021] Attached Figure 1 It is a flow chart of the present invention. DETAILED DESCRIPTION
[0022] The technical solutions in the embodiments of the present invention will be clearly and completely described below in conjunction with the embodiments of the present invention. Obviously, the described embodiments are only part of the embodiments of the present invention, rather than all of the embodiments. Based on the embodiments of the present invention, all other embodiments obtained by ordinary technicians in this field without making creative work are within the scope of protection of the present invention.
[0023] A new surgical approach to treat secondary spontaneous pneumothorax includes the following steps:
[0024] Step 1. Surgical preparation: All surgeries were performed under intravenous combined anesthesia and double-lumen endotracheal intubation. Continuous end-tidal carbon dioxide (ETCO2) monitoring and multiple arterial blood gas analysis were performed during the operation to adjust the respiratory rate. For example, the partial pressure of carbon dioxide (PaCO 2)>70mmHg, or (and) blood oxygen saturation (PaO 2 )<90% were switched to bilateral low tidal volume ventilation;
[0025] Step 2: Design of surgical incision: The surgical incision is made through the 4th or 5th intercostal space in the anterior axillary-midline, with an incision of about 3.0-3.5 cm. The thoracoscope light source and operating instruments are inserted through a single port;
[0026] Step 3: Treatment of emphysema and bullae: First, separate the thoracic adhesions. When there is emphysema or giant bullae without lung collapse, use an energy device (electric hook incision) to shrink the lungs. Do not ligate all bullae, but focus on ligating bullae and emphysematous tissue located in the outer 1 / 3 of the lungs.
[0027] The operation did not use cutting staplers or suture reinforcement. Only No. 7 or No. 10 silk thread was used to ligate three times along the root of emphysema and bullae 2 cm away from normal lung tissue.
[0028] If it is a giant bulla, remove the excess diseased lung tissue after ligation, and inflate the lungs with water to check for air leaks.
[0029] Step 4: Stripping of the parietal pleura: gradually separate the parietal pleura and the chest wall muscle layer along the inner side of the incision, and use double-jointed forceps and separation forceps to strip;
[0030] The range of parietal pleura separation: the upper edge is to the 2nd rib, the lower edge is to the 8th rib, the front edge is to 1 cm beside the internal thoracic artery, and the rear edge is to 2 cm beside the sympathetic nerve trunk.
[0031] The parietal pleura is not removed after stripping and remains in the chest cavity. The parietal pleura has blood supply and will not undergo necrosis. The stripped parietal pleura covers the surface of the lung tissue and can promote adhesion between the lung tissue and the chest wall.
[0032] If there is vascular spurting bleeding during pleural decortication, electrocoagulation or ultrasonic scalpel will be used to stop the bleeding. At the end of the operation, two chest tubes are placed at the seventh rib and the incision respectively and connected to the underwater sealed drainage tube.
[0033] Case 1
[0034] The patient was a 71-year-old male who was hospitalized for 2 days due to cough and shortness of breath after activity. Chest CT showed right secondary spontaneous pneumothorax, old pulmonary tuberculosis, bullae, emphysema, COPD, and bronchiectasis. GCS score was 50%–75% with parenchymal degeneration and vascular loss. After 10 days of chest drainage, there was continuous pulmonary leakage and subcutaneous emphysema. The operation time was 118 minutes, and the intraoperative blood loss was 200 ml. No pulmonary leakage was observed on the day after the operation, and the chest drainage tube was removed 2 days after the operation. There were no perioperative complications and the patient was discharged on the 5th day after the operation.
[0035] Case data summary: Clinical data of 33 consecutive patients with secondary spontaneous pneumothorax who underwent surgical treatment in Hunan Chest Hospital from August 2023 to August 2024 were collected. One case with incomplete data and one case lost to follow-up were excluded, and finally 31 cases were included in the study. The study was conducted in accordance with the Declaration of Helsinki and obtained ethical approval from the Clinical Research Ethics Committee of Hunan Chest Hospital. All 31 patients completed the operation under single-port thoracoscopic surgery. There was no perioperative death, no transfer to the intensive care unit (ICU) or re-intubation and ventilator-assisted breathing after surgery. The median operation time was 125.84±34.95min (69-195min); the median intraoperative blood loss was 198.94±151.38ml (50-600ml), and the median postoperative blood loss was 157.27±272.87 ml (10-1200ml); median postoperative lung leakage time: 1.93±4.41d (0-18d); median postoperative chest drainage tube removal time: 3.65±4.48d (1-20d); median postoperative hospital stay: 9.24±3.28d (5-16d); postoperative complications 6.13% (5 / / 31), including: 1 case of delayed chest bleeding on the 3rd day after surgery, which was cured after blood transfusion. 1 case had arrhythmia on the day after surgery, which was cured after antiarrhythmic treatment; 1 case had aggravated bronchial asthma on the 3rd day after surgery, which was cured by antispasmodic and antiasthmatic treatment; 2 cases had postoperative lung infection, which was cured by anti-infection treatment.
[0036] Postoperative grade II pulmonary leakage was 6.45% (2 / 31), 1 case of pulmonary leakage lasted 4 days, and the drainage tube was removed 5 days after surgery, and 1 case of pulmonary leakage lasted 9 days, and the drainage tube was removed 11 days after surgery. Grade III pulmonary leakage was 3.32% (1 / 31), 18 days after surgery, and the drainage tube was removed 20 days after surgery. The incidence of prolonged pulmonary leakage > 5 days was 6.45% (2 / 31). The follow-up time was 142.81±45.44d (90-236d). No spontaneous pneumothorax recurred or died at the end of follow-up. According to the short form of quality of life and health survey (SF-36) and 6-minute walk test to evaluate lung function, 93.55% (29 / 31) of patients had improved lung function.
[0037] Although the present invention has been described in detail with reference to the aforementioned embodiments, it is still possible for those skilled in the art to modify the technical solutions described in the aforementioned embodiments, or to make equivalent substitutions for some of the technical features therein. Any modifications, equivalent substitutions, improvements, etc. made within the spirit and principles of the present invention should be included in the protection scope of the present invention.
Claims
1. A new surgical approach for treating secondary spontaneous pneumothorax, characterized in that: It includes the following steps: Step 1. Surgical preparation: All surgeries are performed under intravenous combined anesthesia and double-lumen endotracheal intubation. Continuous end-tidal carbon dioxide (ETCO2) monitoring and multiple arterial blood gas analysis are performed during the operation to adjust the respiratory rate. If the intraoperative monitoring of blood gas analysis shows that the carbon dioxide partial pressure (PaCO2) is greater than 70 mmHg, or (and) the blood oxygen saturation (PaO2) is less than 90%, bilateral low tidal volume ventilation is performed. Step 2: Design of surgical incision: The surgical incision is located at the 4th or 5th intercostal space in the anterior axillary-midline, with an incision of about 3.0-3.5 cm. The thoracoscope light source and operating instruments are inserted through a single port; Step 3: Treatment of emphysema and bullae: First, separate the thoracic adhesions. When there is emphysema or giant bullae without lung collapse, use an energy device - electric hook to cut and shrink the lungs. Do not ligate all bullae, but focus on ligating bullae and emphysematous tissue located in the outer 1 / 3 of the lung. Step 4: Stripping of the parietal pleura: gradually separate the parietal pleura and the space between the chest wall muscle layer along the inner side of the incision, and use double-jointed forceps and separation forceps for stripping.
2. A new surgical method for treating secondary spontaneous pneumothorax according to claim 1, characterized in that: In step 2, the surgical incision is located at the 4th or 5th intercostal space in the anterior axillary-midline, with an incision of approximately 3.0-3.5 cm. The thoracoscope light source and operating instruments are inserted through a single port.
3. A new surgical method for treating secondary spontaneous pneumothorax according to claim 1, characterized in that: In step 3, the surgery does not use cutting staplers or suture needles. Only No. 7 or No. 10 silk thread is used to ligate three times along the roots of emphysema and bullae 2 cm away from normal lung tissue.
4. A new surgical method for treating secondary spontaneous pneumothorax according to claim 1, characterized in that: In step 3, if the bulla is huge, the excess diseased lung tissue is removed after ligation, and the lungs are inflated with water to check for air leaks.
5. A new surgical method for treating secondary spontaneous pneumothorax according to claim 1, characterized in that: In step 4, the range of parietal pleura separation is: the upper edge is to the 2nd rib, the lower edge is to the 8th rib, the front edge is to 1 cm beside the internal thoracic artery, and the rear edge is to 2 cm beside the sympathetic trunk.
6. A new surgical method for treating secondary spontaneous pneumothorax according to claim 1, characterized in that: In step 4, the parietal pleura is not removed after stripping and is retained in the chest cavity. The parietal pleura has blood supply and will not undergo necrosis. The stripped parietal pleura covers the surface of the lung tissue and can promote adhesion between the lung tissue and the chest wall.
7. A new surgical method for treating secondary spontaneous pneumothorax according to claim 1, characterized in that: In step 4, if there is spurting bleeding from blood vessels during pleural stripping, use electrocoagulation or ultrasonic scalpel to stop the bleeding. At the end of the operation, two chest tubes are placed in the seventh intercostal space and at the incision, respectively, and connected to the underwater sealed drainage tube.