局部麻醉胸腔镜检查未确诊的胸腔积液
1Respiratory Research Unit PLUZ, Department of Respiratory Medicine,Zealand University Hospital, 2Institute of Regional Health Research,University of Southern Denmark, 3Pleural Medicine Unit, Department of Internal Medicine,Hospital Universitari Arnau de Vilanova, IRBLleida, 4Respiratory Department, Southmead Hospital,North Bristol NHS Trust, 5Academic Respiratory Unit,University of Bristol, 6Lancashire Teaching Hospitals, 7University of Central Lancashire, 8Centre for HR and Education,Copenhagen Academy for Medical Education and Simulation
Summary
局部麻醉胸腔镜检查 （LAT） 对于诊断复发性、未确诊的胸腔积液至关重要，当基于指南的病情检查无法提供特定病因时。LAT 可以作为胸科医生的日间手术进行。在这里，我们提出了一个成功和安全的手术的分步方法。
Abstract
局部麻醉胸腔镜检查 （LAT） 是一种微创诊断程序，在治疗未确诊的胸腔积液方面得到了胸科医生的认可。这种单端口手术是在患者轻度镇静下进行的，涉及对侧褥疮位。它在无菌环境中进行，通常是支气管镜检查室或手术室，由一名操作员在以手术为重点的护士和以患者为中心的护士的支持下进行。
该手术从胸部超声开始，以确定最佳进入点，通常在沿腋窝中线的 IV-V 肋间隙。利多卡因/甲哌卡因，联合或不联合肾上腺素，用于麻醉皮肤、胸壁层和壁层胸膜。通过一个 10 mm 的切口插入指定的套管针和套管，轻轻旋转到达胸膜腔。胸腔镜通过套管引入，用于系统检查从心尖到膈肌的胸膜腔。对可疑的壁层胸膜病变进行活检（通常为 6-10 次）以进行组织病理学评估，必要时进行微生物学分析。由于存在出血或漏气的风险，通常避免进行内脏胸膜活检。在通过套管插入胸管或留置胸膜导管之前，可以进行滑石灌注术。缝合皮肤切口，并使用三室或数字胸腔引流系统去除胸腔内空气。一旦没有气流，胸管就会被拔除，并且肺已经令人满意地重新扩张。患者通常在观察 2-4 小时后出院，并在门诊随访。成功的 LAT 依赖于仔细的患者选择、准备和管理，以及操作员教育，以确保安全性和高诊断率。
Introduction
胸膜疾病的发病率和患病率在世界范围内呈上升趋势，尤其是胸腔积液，胸腔积液有 50 多种公认原因 1,2。胸膜恶性肿瘤是复发性胸腔积液的主要原因，主要由胸膜外肺、乳腺或淋巴瘤恶性肿瘤转移引起3。现有指南建议，如果病史、体格检查、放射学和胸膜穿刺细胞学、培养和生物化学检查不能提供诊断，则应进行胸膜活检4。胸膜活检可以通过图像引导或直视进行。在最近的一项系统评价中，超声 （US） 或 CT 引导下的经皮核心活检允许从壁胸膜肋部的大多数病变中取样，诊断率分别为 84% 和 93%5。超声引导的胸膜活检在并发症发生率较低（4% vs. 7%）、无需放疗和可作为床旁手术方面更胜一筹5。病例报告显示，纵隔胸膜病变可使用超声内窥镜取样 6.
胸腔镜检查可直接目视检查纵隔、膈膜或肋胸膜的病变，使其成为诊断不明原因复发性胸腔积液的金标准4,7。胸腔镜检查可作为局部麻醉胸腔镜检查 （LAT） 或视频辅助胸腔镜手术 （VATS） 进行8。LAT（也称为医学胸腔镜检查或胸膜镜检查）是一种单端口手术，由肺科医生在支气管镜检查套件中常规执行，恶性肿瘤的诊断率为 93%9,10。LAT 可以使用半刚性或刚性内窥镜进行，通常连接到视频成像源。一些出版物讨论了这些方法的优点和缺点8,11,12,13。简而言之，半刚性胸腔镜类似于支气管镜，使用类似的镊子进行活检。刚性内窥镜具有更大的直径，更便宜，并且允许更大的活检，尽管这不容易转化为诊断率的显着差异10,14,15。LAT 的安全性很高，死亡率低于 0.5%，这与原有疾病密切相关 3,4。LAT的禁忌证少于VATS的禁忌证，包括由于粘连导致的胸膜腔完全闭塞、进入部位的皮肤感染、呼吸衰竭、心脏不稳定和无法纠正的凝血病7,8,12。VATS 是由胸外科医生在医院内进行的 2 孔或 3 孔手术，必须在手术室进行，需要全身麻醉、插管、单肺通气和术后入院。VATS的诊断率和并发症发生率与LAT相似，但允许进行更复杂的程序10,16。
指南推荐 LAT 作为首选胸腔镜检查，因为它具有诊断率高、风险低、成本低且可用于日间病例管理，因此将 VAT 保留给特定病例4。刚性或半刚性胸腔镜的选择通常由当地偏好决定。LAT 并不是一种新手术，因为它早在 19 世纪中叶就被描述过，由 Jacobaeus 于 1910 年推广，直到 1950 年代才越来越多地用于治疗胸膜结核，并在 1980 年代被“重新发现”为诊断复发性胸腔积液的重要工具 8,17。
Protocol
以下协议将描述如何在临床环境中执行 LAT。该方案符合作者所在医院（欧登塞、奈斯特韦德、莱里达、布里斯托尔和普雷斯顿）的临床实践和指南。在手术前获得患者的书面知情同意书。该手术的主要纳入标准是原因不明的复发性胸腔积液，尽管进行了基于指南的病情检查。排除标准包括由于粘连导致的胸膜腔完全闭塞、进入部位的皮肤感染、呼吸衰竭、心脏不稳定和无法纠正的凝血功能障碍。…
Representative Results
所描述的使用刚性或半刚性胸腔镜（图 1 和图 2）的 LAT 技术使操作者能够从内脏胸膜（图 3）进行确凿的活检取样，在对 5000 多个手术的大型系统评价中诊断率为 93%（表 1 和补充文件 1）（刚性：93% [95% 置信区间 91%-95%]; 半刚性： 93% [89%-97%]）10.所描述的LAT手术是安全的，总体并发症发?…
Discussion
本文提供了执行 LAT 的实用方法。
一项随机试验比较了刚性 LAT 和半刚性 LAT，发现在诊断率或安全性方面没有差异15。关于如何优化关键步骤的证据很少。其中一位作者提出了半刚性LAT的八个关键步骤，并根据他们自己的经验、叙述性综述8,10,12,15,26、试验和系统综述…
Declarações
The authors have nothing to disclose.
Acknowledgements
没有收到任何资金。JP和MM拍摄了 图1A所示的照片。RB 和 MM 捕获了 图 3 中所示的那些。
Materials
| Chest tube | 16-24F | ||
| Forceps | narrow tip, straight or curved | ||
| Indwelling pleural catheter | Rocket Medical plc. | R55400-16-MT | or PleurX (from Becton Dickinson) or similar |
| Local anaesthetics | 20 mL of lidocaine 1% (or mepivacaine 2%) ± adrenaline | ||
| Non-absorbable suture | Eg. Dafilon 2/0 | ||
| Rigid thoracoscope | Karl Storz GmbH | Hopkins-II | with forceps 26072A and cannula+trocar 30120 NOL (or similar from eg. Richard Wolf GmbH) |
| Scalpel | triangular | ||
| Semirigid thoracoscope | Olympus | LTF-160 | with forceps FB-420K and cannula+trocar N1002130 |
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Citar este artigo
Bodtger, U., Porcel, J. M., Bhatnagar, R., Maskell, N., Munavvar, M., Jensen, C., Clementsen, P. F., Rasmussen, D. B. Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion. J. Vis. Exp. (201), e65734, doi:10.3791/65734 (2023).