末期肺部疾病病患用腹腔鏡手術可能是安全的


  April 24, 2007 (拉斯維加斯) — 根據一篇於美國胃腸內視鏡外科醫師學會年會中發表的報告,末期肺部疾病病患用腹腔鏡手術可能是安全的。
  
  一般認為嚴重肺部疾病是腹腔鏡手術的禁忌症,有部分是因為考量氣體交換能力缺損、高碳酸血症和腹腔膜積氣,此項結果由布萊根婦女醫院胸腔科的Abraham Leventhal醫師發表,評估末期肺部疾病患者接受腹腔鏡基底摺疊術的手術與術後呼吸表現。
  
  該研究對566位胃食道逆流病患接受選擇性腹腔鏡抗逆流手術的病歷回溯研究;在手術的時候,這些病患中有24位有末期肺部疾病且符合器官分享聯合網絡之肺臟移植規範,研究評估這24位病患的手術間和手術後呼吸事件、手術時間、動脈血液氣體分析(ABG)和延長插管的需求。
  
  平均手術時間是 220分鐘(範圍從158-390分鐘),這 24位病患全部在手術結束時拔氣管內管,且在住院期間未再插管;手術中,14位病患 (進行ABG者的58%)平均pCO2是49.4 mm Hg (範圍從32-82 mm Hg),手術結束後,18位病患(進行ABG者的75%)平均pCO2是48.3 mm Hg;24小時後,平均ABG 是48.6 mm Hg,沒有顯著的術後併發症。
  
  研究者結論認為,在有胸腔麻醉和手術經驗的三級醫學中心,可以對末期肺部疾病患者進行腹腔鏡手術;在這項研究中,高碳酸血症並不是主要的結果;手術間處置包括適當的硬腦(脊)膜外的疼痛控制、小心注意和微調呼吸參數、以及有經驗的胸腔麻醉醫師和腹腔鏡外科醫師參與,將可以更安全的處置。
  
  Lebenthal醫師表示,對末期肺部疾病患者進行這些手術有一些限制,需要多方面的處置。
  
  梅約診所大腸直腸外科主任Tonia Young-Fadok醫師建議,需考量這些病患的高碳酸血症,以及他們手術時二氧化碳值升高的問題;不過,這些病患也傾向接受傷口小的腹腔鏡手術的好處(術後疼痛少、呼吸更自由)。
  
  Lebenthal醫師之報告沒有相關財金關係。Young-Fadok醫師報告與US Surgical 和 W.L. Gore有財金關係。
  
  SAGES 2007年會:摘要 P010。發表於April 20, 2007。

Laparoscopic Surgery May be Sa

By Lexa W Lee, ND
Medscape Medical News

April 24, 2007 (Las Vegas) — Laparoscopic surgery can be safely performed on patients with advanced lung disease, according to a study presented here at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Severe lung disease is widely believed to be a contraindication to laparoscopic surgery, partly due to concerns over impaired gas exchange, hypercarbia, and pneumo-peritoneum. The results, reported by Abraham Leventhal, MD, thoracic surgery fellow at Brigham and Women's Hospital in Boston, Massachusetts, evaluated the operative and immediate postoperative respiratory performance of patients with end-stage lung disease undergoing laparoscopic fundoplication.

The study was based on a retrospective chart review of 566 patients with gastroesophageal reflux disease who underwent elective laparoscopic antireflux surgery; at the time of surgery, 24 of these patients had advanced lung disease which met United Network for Organ Sharing criteria for lung transplantation. The perioperative and postoperative respiratory events of these 24 patients, such as operative time, arterial blood gas (ABG), and the need for prolonged intubation, were examined.

Average operative time was 220 minutes (range, 158-390 minutes); all 24 patients were extubated at the completion of surgery and remained extubated while they were hospitalized. During surgery, 14 patients (58% of the group who had ABG done) had a mean pCO2 of 49.4 mm Hg (range, 32-82 mm Hg). Immediately after surgery, 18 patients (75% of the group who had ABG done) had a mean of 48.3 mm Hg. At 24 hours, mean ABG was 48.6 mm Hg. No significant postoperative complications were reported after patients were released.

The researchers concluded it is possible to perform laparoscopic surgery in patients with advanced lung disease in a tertiary academic center where thoracic anesthesia and sufficient surgical expertise is readily available. Hypercarbia proved not to be a significant outcome of laparoscopic surgery in this setting. Intraoperative management including adequate pain control with thoracic epidural, careful attention to and fine-tuning of ventilation parameters, and the combination of an experienced thoracic anesthesiologist and advanced laparoscopic surgeon can enable the safe management of patients with end-stage lung disease.

Dr. Lebenthal cautioned, "There is a limited margin for error in performing these procedures on patients with advanced lung disease. Multidisciplinary management is needed."

Tonia Young-Fadok, MD, head of colon and rectal surgery at the Mayo Clinic in Phoenix, Arizona, commented, "There are concerns about hypercarbia in these patients, and their CO2 levels rise during surgery. However, these patients also tend to benefit the most when smaller incisions are made, as in laparoscopic surgery (less pain postop, patients breathe more freely)."

Dr. Lebenthal reports no relevant financial relationships. Dr. Young-Fadok reports financial relationships with US Surgical and W.L. Gore.

SAGES 2007 Annual Scientific Session: Abstract P010. Presented April 20, 2007.

    
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