全胸腔镜体外循环下二尖瓣置换术与常规开胸二尖瓣置换术的比较研究

发布时间：2018-06-10 05:35

本文选题：全胸腔镜手术 + 胸骨正中切开术　；参考：《河北医科大学》2017年硕士论文

【摘要】：全胸腔镜心脏手术是指术野完全依靠胸腔镜进行显露,胸腔内手术操作均在胸腔镜所提供的术野下进行。过去20余年来,随着体外循环技术的发展、手术器械的改进,二尖瓣置换术(mitral valve replacement MVR)已经由原来的胸骨正中切口逐渐向全胸腔镜化发展。对于许多病人来说全胸腔镜体外循环(cardiopulmonary bypass CPB)下二尖瓣置换术已经成为一个安全、有效的手术方式,同传统开胸行二尖瓣置换相比,全胸腔镜体外循环行二尖瓣置换术在保证手术安全及疗效的同时,并没有增加围手术期的死亡率,病人则获得了降低手术创伤,更轻微的疼痛,更少的术后住院天数以及更快的恢复到术前状态等诸多好处。如今全胸腔镜二尖瓣置换术已经是许多心脏中心的常规手术。我院心脏外科在2012到2106年间成功为20例二尖瓣病变的患者实施了全胸腔镜体外循环下二尖瓣置换术,此研究对这些患者的临床结果进行了分析并总结了全胸腔镜体外循环下二尖瓣置换术的经验。目的:通过比较全胸腔镜体外循环下二尖瓣置换术与常规开胸行二尖瓣置换术的术中及术后指标,探讨全胸腔镜体外循环下二尖瓣置换术的优势及临床应用价值。方法:将20例行全胸腔镜体外循环下二尖瓣置换术的患者定为全胸腔镜(totally thoracoscopy TT)组,以年龄、性别、左室射血分数(left ventricular ejection fractions LVEF)、二尖瓣疾病类型及体重指数(body mass index BMI)为匹配因素按成组匹配原则,选取同期行胸骨正中切口、体外循环下二尖瓣置换术20例作为传统开胸(conventional sternotomy CS)组,选取总手术时间、体外循环时间、升主动脉阻断时间作为术中指标,选取呼吸机辅助呼吸时间、重症监护室(intensive care unit ICU)停留时间、术后应用杜冷丁、吗啡等阿片类镇痛药的病人比例、术后尿管留置时间、术后总引流量、术后住院天数、半年后复查超声心动图观察两组患者机械瓣功能及心功能情况作为术后指标。对比两组患者术中及术后指标,以α=0.05为检验水准。此研究在取得我院伦理委员会许可且在家属知情同意情况下进行。结果:TT组与CS组患者相比,平均总手术时间(250.1±7.5min vs.225.4±9.1min;P0.001);平均体外循环时间(113.1±6.4min vs.84.1±4.6min;P0.001);平均升主动脉阻断时间(85.2±3.1min vs.59.8±2.2min;P0.001),上述指标TT组均明显长于CS组且经统计学检验有统计学意义。TT组术后呼吸机辅助呼吸时间平均为(12.5±0.8)h,明显长于CS组(11.0±0.7)h(P0.001),且有统计学意义。TT组与CS组相比平均监护室停留时间和平均术后住院天数分别为(38.2±1.5h vs.44.0±1.8h;P0.001)和(8.0±0.8d vs.9.4±0.9d;P0.001),TT组明显短于CS组,TT组术后总引流量平均为(366.5±29.8ml),明显少于CS组(499.9±29.5ml P0.001)。TT组术后导尿管留置天数平均为(3.7±0.7d),明显短于CS组(4.4±0.5d P=0.02)。TT组术后使用杜冷丁、吗啡等阿片类镇痛药的病人比例为20%,亦明显低于CS组60%(P=0.02)。两组患者均恢复顺利,伤口愈合良好,顺利出院,术后6个月复查超声心动图,两组患者机械瓣功能均未见异常,两组EF值无显著性差异。结论:同开胸手术相比,全胸腔镜体外循环下二尖瓣置换术总手术时间、体外循环时间、升主动脉阻断时间和术后辅助呼吸时间较长,但胸腔镜手术创伤小,ICU停留时间短、住院时间短,恢复时间快,美容效果好。
[Abstract]:Full thoracoscopic surgery means that the operation field is fully exposed by thoracoscopy, and the intrathoracic surgery is performed under the operation field provided by the thoracoscope. Over the past 20 years, with the development of the cardiopulmonary bypass technique, the improvement of the surgical instruments and the mitral valve replacement (mitral valve replacement MVR) have evolved from the original median sternum incision. For many patients, full thoracoscopic cardiopulmonary bypass CPB mitral valve replacement has become a safe and effective surgical procedure. Compared with the traditional thoracotomy for mitral valve replacement, full thoracoscopic cardiopulmonary bypass for mitral valve replacement can ensure the safety and efficacy of the operation. There was no increase in the peri operative mortality rate, and the patient received many advantages, such as lower surgical trauma, less pain, less postoperative hospitalization, and faster recovery to the pre operation state. Now full thoracoscopic mitral valve replacement has been a routine hand in many heart centers. Our hospital has a success of 2 between 2012 and 2106. 0 patients with mitral valve disease performed mitral valve replacement under full thoracoscopic cardiopulmonary bypass. This study analyzed the clinical results of these patients and summarized the experience of mitral valve replacement under full thoracoscopic cardiopulmonary bypass. Objective: To compare mitral valve replacement and conventional thoracotomy for mitral valve replacement under full thoracoscopic extracorporeal circulation. The advantage and clinical value of intraoperative and postoperative mitral valve replacement under full thoracoscopic cardiopulmonary bypass were discussed. Methods: 20 patients were treated with total thoracoscopic mitral valve replacement (totally thoracoscopy TT), with age, sex, and left ventricular ejection fraction (left ventricular ejection fract). Ions LVEF), the type of mitral valve disease and the body mass index (body mass index BMI) as matching factors according to the group matching principle, select the median sternum incision in the same period, and 20 cases of mitral valve replacement under extracorporeal circulation as the traditional open chest (conventional sternotomy CS) group, select the total operation time, the extracorporeal circulation time, the ascending aorta blocking time. Intraoperative indexes, ventilator assisted respiration time, intensive care unit ICU stay time, the proportion of opioid analgesics such as dopenin and morphine, postoperative indwelling time of urethral catheterization, postoperative total flow rate, postoperative hospitalization days, and two groups of patients with mechanical valve function and heart after half a year were examined by echocardiography. Function as a postoperatively. Compared to the two groups of patients during and after the operation and postoperative indicators, the level of alpha =0.05 was tested. This study was carried out under the permission of the ethics committee of our hospital and under the informed consent of the family members. Results: the average total operation time (250.1 + 7.5min vs.225.4 + 9.1min; P0.001) was compared with the CS group, and the average extracorporeal circulation was compared. Between (113.1 + 6.4min vs.84.1 + 4.6min, P0.001), the mean ascending aorta blocking time (85.2 + 3.1min vs.59.8 + 2.2min; P0.001), the above indexes were significantly longer in the CS group than in the CS group and statistically significant in the.TT group (12.5 + 0.8) h, which was significantly longer than that of the group (11 + 0.7). The average length of stay of the.TT group and the average postoperative hospital stay were (38.2 + 1.5h vs.44.0 + 1.8h, P0.001) and (8 + 0.8d vs.9.4 + 0.9d, P0.001), and the TT group was significantly shorter than that of the CS group. The average flow rate after operation was (366.5 +), which was significantly less than that of the group (499.9 +). The average number of days was (3.7 + 0.7d), obviously shorter than group CS (4.4 + 0.5d P=0.02).TT, the proportion of opioid analgesics, such as morphine, was 20%, and 60% (P=0.02) in the group CS. The two groups recovered smoothly, the wound healed well, was discharged from the hospital smoothly, the ultrasonic cardiogram was rechecked 6 months after the operation, and the function of the two group of the mechanical valves was not. There was no significant difference in the EF value of the two groups. Conclusion: compared with the open thoracotomy, the total operation time, the time of extracorporeal circulation, the time of extracorporeal circulation, the interruption time of the ascending aorta and the time of assisted respiration were longer, but the thoracoscopic surgery was small, the time of ICU was short, the time of hospitalization was short, the time of recovery was fast, and the beauty effect was improved. OK.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R654.2

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