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微创胸膜腔置管注入尿激酶治疗结核性胸腔积液

【摘要】 目的 探讨微创胸膜腔置入中心静脉导管(简称导管)注入尿激酶治疗结核性包裹性胸腔积液(简称积液)的临床价值。方法 2008年6月-2009年8月在正规抗结核治疗基础上,选取确诊积液患者72例,按数字随机法分为治疗组和对照组,治疗组36例经超声引导导管置入胸膜腔并注入生理盐水50 mL加尿激酶10万 U,对照组36例多次穿刺抽液,比较两组疗效及积液引流量、胸膜厚度、积液吸收时间等。结果 治疗组28例显效,5例好转,3例无效;对照组10例显效,13例好转,13例无效,两组疗效差异具有统计学意义(Plt;0.05)。治疗组与对照组平均积液引流量分别为1 421 mL和756 mL,胸膜厚度分别为(1.9±0.4) mm和(3.7±1.2) mm,积液吸收时间分别为(13.3±1.2)d和(17.3±1.6)d,两组间比较差异均有统计学意义(Plt;0.05)。结论 超声引导导管置入胸膜腔并注入尿激酶治疗结核性包裹性胸腔积液疗效显著,可增加引流量,减轻胸膜肥厚,改善肺功能,减少穿刺机会。

Dignosis and Management of Parapneumonic Effusions in 97 Cases

Objective To elucidate the clinical features and treatment of parapneumonic effusions ( PPE) . Methods Ninety-seven patients were analyzed retrospectively in Guangzhou First Municipal People’s Hospital fromJanuary 2004 to July 2008. The data of 54 patients with complicated parapneumonic effusion ( CPPE) and 9 cases with empyema were compared with 49 patients with tuberculosis pleural effusions. Results Of 97 cases, 34 patients with uncomplicated parapneumonic effusion ( UPPE) were treated with antibiotics only, whose hospitalization time was ( 14. 8 ±7. 6) days, and 27 cases were cured ( 79. 4% ) . Of 54 CPPE patients, 42 were treated with antibiotics and pleural space drainage with central venous catheter, whose hospitalization time was ( 21. 7 ±13. 0) days, and 32 were cured ( 76. 2% ) . Another12 CPPE patients were treated with interapleural urokinase and drainage from the chest tube, whose hospitalization time was ( 22. 5 ±9. 3) days, and 8 were cured ( 66. 7% ) . Nine cases with empyema were rinsed the pleural with metronidazole solution, whose hospitalization time was ( 25. 7 ±17. 4) days, and 8 were cured( 89. 0% ) . Compared with the tuberculous pleurisy patients, most CPPE and empyema occurred in middle and old aged patients with an average age of ( 63. 3 ±19. 3) years. Polykaryocyte and lactate dehydrogenase increased significantly. Adenosine deaminase ( ADA) was lt; 45 U/L in most UPPE and empyema patients, but was gt; 45 U/L in 7 cases ( 11% ) . Conclusions UPPE is simple and preferably treated with antibiotics alone. While CPPE and empyema should be drainaged as early as possible, and the low-dose urokinase may be helpful. The level of ADA can not absolutely distinguish parapneumonic effusion from tuberculous pleural effusion.

以胸腔积液为首要表现的多发性骨髓瘤一例

目的 分析多发性骨髓瘤合并胸膜转移患者的临床特征。方法 回顾性分析1例多发性骨髓瘤合并胸腔积液患者的临床资料、实验室检查、影像学检查、病理学结果及预后，并复习相关文献。结果 患者为52岁女性，经血常规、生化常规、血清肿瘤标志物及胸腔穿刺行积液常规、生化、肿瘤标志物及细胞学等检查，发现患者中度贫血、肿瘤标志物神经元特异性烯醇化酶显著升高，胸腔积液沉渣见大量浆细胞。经局部麻醉内科胸腔镜胸膜活检，镜下见胸膜肥厚，血管扩张、紊乱，部分结节样增生。后组织病理诊断为浆细胞瘤，结合后续尿蛋白电泳等检查，确诊为多发性骨髓瘤。经化疗及自体干细胞移植术等治疗，患者于13个月后因疾病复发死亡。多发性骨髓瘤出现胸膜浸润的患者较为罕见，多为预后不良的标志，神经元特异性烯醇化酶升高也可作为其预后相关指标。对于疑难胸膜疾病，创伤性相对较小的内科胸腔镜手术可作为诊断的重要手段。 结论 合并胸腔积液的多发性骨髓瘤患者临床特征不典型，需重视胸腔积液细胞学检查并及时获取组织病理。

Prevention and Treatment for Hepatic Hydrothorax

Value of Tumor Type M2 Pyruvate Kinase in Differential Diagnosis of Pleural Effusion

Objective To investigate the value of tumor type M2 pyruvate kinase ( M2-PK) in the differential diagnosis of pleural effusion. Methods A total of 146 patients with pleural effusion during January 2006 to December 2008 were recruited at the department of respiratory medicine of the Shantou Affiliated Hospital and the First Affiliated Hospital of Sun Yat-sen Medical College. Pleural effusion was malignant in 72 cases ( 52 cases with lung cancer and 20 cases with metastatic lung cancer) and benign in 74 cases ( 54 cases with infective pleural effusion and 20 with transudation effusion) . The patients were divided into a malignant pleural effusion group, an infective pleural effusion group, and a transudation group.Then the infective group was further divided into subgroups of tuberculosis pleural effusion group andparapneumonic effusion group. The concentration of tumor M2-PK in pleural fluid obtained during the first thoracocentesis was measured by enzyme-linked immunosorbent assay( ELISA) . Results The concentration of tumor M2-PK was significantly higher in the malignant pleural effusion group compared with the benignpleural effusion groups ( P lt; 0. 01) . Significant differences were also found in the concentration of tumor M2-PK between malignant pleural effusion caused by lung cancer and metastatic lung cancer( P lt; 0. 05) .When the cutoff value of tumor M2-PK was set at 18. 68 U/mL, the sensitivity, specificity, and accuracy for the diagnosis of malignant pleural effusion was 87. 6% , 86. 0% , and 87. 4%, respectively. Furthermore,the detection of tumor M2-PK in combination with CEA showed better diagnostic sensitivity( 96. 0% ) ,specificity ( 85. 0% ) , and accuracy ( 91. 1% ) . Conclusions The detection of tumor M2-PK in pleural effusion is of some clinical significance in the differential diagnosis of benign and malignant pleural effusion.The detection of tumor M2-PK in combination with CEA is a good diagnostic tool with high sensitivity andspecificity.

The Value of Pleural Biopsy in the Etiological Diagnosis of Pleural Effussion

目的:探讨胸膜活检对胸腔积液病因诊断的价值。方法:对127例胸腔积液患者行首次胸膜活检术。结果:127例患者获取胸膜组织125例, 穿刺成功率98.4%,经病理检查有41例为正常胸膜组织,特异性病理诊断84例,病理诊断阳性率(67.2%)。恶性胸腔积液胸膜活检阳性38例(45.2%),结核性胸腔积液胸膜活检阳性31例(36.9%),非特异性炎15例(17.9%)。38例恶性肿瘤经免疫组织化学和特殊染色分类,腺癌27例,小细胞肺癌2例,鳞癌2例,恶性间皮瘤2例,转移癌3例,淋巴瘤1例,未分化癌1例。发生并发症者4例(3.1%),全部为气胸,肺压缩均小于15%,未做特殊处理数日后自行吸收。结论:胸膜活检是一项安全、简单、有效的胸膜疾病的重要的内科确诊手段。

局限性胸膜肺切除术治疗伴癌性胸水非小细胞肺癌的远期结果

目的 评估局限性胸膜肺切除术治疗伴癌性胸水非小细胞肺癌的远期效果和应用价值. 方法 对1994年1月至1998年12月间采用该术式治疗的16例伴癌性胸水肺癌患者进行定期随访,了解患者生活质量、复发情况和生存时间.计算术后中位数复发和中位数生存时间. 结果 本组无手术死亡,无严重手术并发症.术后胸闷、呼吸困难、胸腹壁疼痛症状明显缓解,恶病质迅速消失,未见胸水复发,但后期均发生远处脏器转移.术后肿瘤复发距手术时间3～36个月,中位数复发时间12个月.随访至2000年8月,所有病例死亡,存活期7～39个月.存活1年以上15例,1年生存率94%;存活18个月以上13例,生存率81%;存活2年以上7例,生存率44%;存活3年以上2例,生存率13%;中位数生存期21.5个月. 结论 此术式控制胸水、缓解症状效果肯定.术后晚期均发生远处脏器转移,但其中位数生存期明显长于仅做姑息性肺内癌灶切除或内科治疗患者,且长于全胸膜肺切除术.本术式有推广应用价值.

The Value of Pleural Biopsy in the Etiological Diagnosis of Pleural Effussion

目的：探讨胸膜活检对胸腔积液病因诊断的价值。方法:对268例胸腔积液患者行经胸壁胸膜活检术。结果:268例患者共行胸膜活检289次，二次及以上活检者19例，获取胸膜组织244例，穿刺成功率91%，经病理检查有18例为正常胸膜组织，阳性诊断者为226例，阳性率92.6%（226/244），其病理诊断为结核104例（46%）、肿瘤54例（23.9%）、慢性炎症68例（30.1%）；发生并发症者19（6.6%），全部为气胸，肺压缩均小于30%，未做特殊处理数日后自行吸收。结论:从本组资料可以看出，经胸壁胸膜活检术对于胸腔积液的病因诊断具有非常好的效果，相比胸水涂片或病理检查具有更高的阳性率。因此经胸壁胸膜活检术由于它的简单、安全、高效等特点，目前在胸腔积液病因诊断方面仍是一项重要的手段。

电视胸腔镜手术治疗恶性胸腔积液37例临床分析

目的探讨电视胸腔镜手术治疗恶性胸腔积液的方法，总结其临床经验。 方法回顾性分析2009年1月至2011年12月宝鸡市中心医院37例恶性胸腔积液患者的临床资料, 男21例、女16例, 年龄43～75岁。其中肺癌15例，乳腺癌7例，食管癌7例，胃癌4例，胸膜间皮瘤3例，卵巢癌1例；均为单侧胸腔积液，其中左侧胸腔积液22例, 右侧胸腔积液15例。所有患者均行电视胸腔镜手术(VATS)或VATS辅助小切口完成手术，在电视胸腔镜下行胸膜剥脱术，并喷洒滑石粉固定胸膜。 结果围术期无死亡，7例（18.9%）延长切口，手术时间（40.32±19.06）min，术中出血量（90.09±41.03）ml，术后（7.31±2.08）d拔除胸腔引流管，术后住院时间（9.02±3.11）d。手术有效率100%，其中完全缓解19例（51.4%）。术后出现轻度并发症，如肺部感染、持续性漏气和切口感染等, 经对症处理治愈。 结论电视胸腔镜治疗恶性胸腔积液是一种微创、有效、实用的治疗方法。

胸腔积液及高脂血症对重症急性胰腺炎发生的预测作用

目的探讨胸腔积液、高脂血症与重症急性胰腺炎（SAP）早期诊断的关系。 方法2010年1月-2014年3月对入院24 h内的120例急性胰腺炎患者按2013年《中国急性胰腺炎诊治指南》的诊断标准分为SAP组（68例）和轻症急性胰腺炎（MAP）组（52例）。两组均行胸腹部CT及血脂分析检查，记录胸腔积液、高脂血症以及胸腔积液并高脂血症与SAP发病例数、病死率、腹水、肝功能不全、胰腺假性囊肿的关系。 结果SAP组与MAP组胸腔积液分别为57例（83.8%）和12例（23.1%），高脂血症分别为52例（76.5%）和17例（32.7%），胸腔积液并高脂血症分别为47例（69.1%）和7例（13.5%），差异有统计学意义（P＜0.001）。SAP组患者中，是否并发胸腔积液者病死率、胰腺假性囊肿发生率差异无统计学意义（P＞0.05），并发胸腔积液者腹水、肝功能不全发生率发生率高于无胸腔积液者（P＜0.05）；是否合并高脂血症者病死率、胰腺假性囊肿发生率差异无统计学意义（P＞0.05），合并高脂血症者腹水和肝功能不全发生率均高于未合并高脂血症者（P＜0.05）；是否同时合并胸腔积液和高脂血症者胰腺假性囊肿发生率差异无统计学意义（P＞0.05），同时合并胸腔积液和高脂血症者病死率、腹水发生率、肝功能不全发生率均高于未同时合并胸腔积液和高脂血症者（P＜0.05）。 结论胸腔积液、高脂血症与SAP发生有密切关系，同时还与部分并发症有关，检测这两项指标，对SAP早期诊断及并发症的早期干预有意义。