摘要
背景:重度阻塞性肺气肿时采用功能锻炼及保守治疗效果不佳。肺减容术是近年来治疗重度阻塞性肺气肿的有效方法,切除多少气肿肺组织才能实现最佳疗效。目的:评价单侧肺减容术后阻塞性肺气肿兔肺功能和肺泡形态学的变化,并比较肺切除量对两者的影响。设计:完全随机分组设计,对照实验。单位:解放军第三军医大学大坪医院全军胸外科中心。材料:实验于2003-08/2004-02在解放军第三军医大学大坪医院全军胸外科中心实验室完成。选用清洁级纯种雄性新西兰大白兔50只。随机分为5组,每组10只,分别为肺气肿组、小量肺减容术组、中量肺减容术组、大量肺减容术组和假手术组。方法:建立肺气肿模型:将50只兔置于自制有机玻璃箱内被动吸烟,每次点燃香烟(银象牌)15支,1次/d,持续30min,每周5次,连续7周。第4周时气管内注入猪胰弹性蛋白酶溶液3mL(2kU/kg)。分组干预:肺气肿组正常喂养,不进行手术。小量肺减容术组、中量肺减容术组、大量肺减容术组和假手术组肌注速眠新Ⅱ全麻后,仰卧位固定,气管插管(3mm内径),接HX-200型动物呼吸机机械通气,潮气量为12mL/kg,呼吸频率为40～50次/min。于右侧第4肋间入胸,小量肺减容术组切除右肺第一肺叶上外侧肺组织,中量肺减容术组切除右肺第一、二肺叶上外侧肺组织,大量肺减容术组切除右肺第一、二、三肺叶上外侧肺组织,切除量约各肺叶总量的1/2,切缘先用3-0无损伤缝线褥式缝合,然后喷注医用生物蛋白胶,以防术后漏气。假手术组只开胸,不切除肺组织。肺减容术后满8周时进行肺功能和肺组织形态学定量分析。主要观察指标:不同肺切除量的肺减容术后肺气肿兔的肺功能和肺泡形态定量分析。结果:进入结果分析兔50只,每组10只。①各组肺通气功能比较:中量肺减容术组的潮气量、第0.3秒用力呼气量和第0.3秒用力呼气量占用力肺活量的百分比明显高于肺气肿组[(6.69±0.83)mL,(6.39±1.35)mL,(64.5±16.1)%;(5.76±0.84)mL,(5.23±1.37)mL,(50.2±15.6)%,P<0.05=,而功能残气量明显低于肺气肿组[(14.3±1.9)mL,(19.3±3.1)mL,P<0.05=。小量肺减容术组、大量肺减容术组、假手术组的上述肺功能指标与肺气肿组相近(P>0.05)。②中量和大量肺减容术组肺组织病理观察结果:中量肺减容术组肺泡管、肺泡囊及肺泡扩张及破坏明显修复,巨噬细胞及中性粒细胞在终末细支气管内聚集减少。大量肺减容术组支气管内炎细胞减少,但肺泡扩张、破坏更为明显。③各组兔肺总容积比较:中量肺减容术组明显低于肺气肿组[(42.1±5.8),(58.5±7.6)mL,P<0.05。小量肺减容术组、大量肺减容术组、假手术组与肺气肿组相近(P>0.05)。④各组肺泡形态定量分析结果:中量肺减容术组每视野的平均肺泡数和肺泡隔密度明显高于肺气肿组[(17.6±3.1)个/视野,(18.6±2.1)%;(11.3±2.7)个/视野,(15.2±3.6)%,P<0.05],而肺泡直径明显低于肺气肿组[(78.1±7.1),(93.4±10.2)μm,P<0.05]。小量肺减容术组、大量肺减容术组、假手术组与肺气肿组相近(P>0.05)。结论:烟雾与弹性蛋白酶联合诱导的方法成功建立了兔阻塞性肺气肿模型。对模型兔行单侧肺减容术能改善阻塞性肺气肿兔的肺功能。仅切除右肺第一肺叶上外侧的小量肺减容术(约右侧肺的12.5%)和切除右第一、二、三肺叶的大量肺减容术(约占右侧肺的37.5%)对肺功能改善不明显。而切除适量的气肿肺组织(约单侧肺的25%)能有效地消除气道炎症,减轻余肺肺泡扩张与破坏,从而改善肺的通气换气功能。
BACKGROUND: Rehabilitation exercise and conservative treatment do not bring about good therapeutic effect for severe obstructive emphysema. And lung volume reduction surgery (LVRS) is an effective method for this kind of disease. How much emphysematous tissue should be resected in LVRS to achieve the best curative effect has been a concern. OBJECTIVE: To evaluate the pulmonary functional and alveolar morphologic changes in emphysematous rabbits after unilateral LVRS, and to compare the effects of different resection volumes. DESIGN: A completely randomized and controlled trial. SETTING: Thoracic Surgery Center of Daping Hospital of the Third Military Medical University of Chinese PLA. MATERIALS: This study was completed at the Laboratory of Thoracic Surgery Center of Daping Hospital of the Third Military Medical University of Chinese PLA from Frebruary 2003 to August 2003. Totally 50 New Zealand white male rabbits of cleaning grade were involved. These animals were divided randomly into groups of emphysema (A), less volume LVRS (B), middle volume LVRS (C), larger volume LVRS (D), and shame operation (E) . METHODS: Making of the rabbit emphysema model: Rabbits were put into an organic glass box and they inhaled passively smog produced from the cigarettes. Within seven weeks, 15 cigarettes (Yinxiang Brand) were lighted for about 30 minutes every time, once per day and five times a week. Elastase for 3 mL(2000 U/kg) from porcine pancreas (SERVA Co., Ltd) was injected into the rabbits' trachea in the fourth week. Intervention for different groups: Rabbits in Group A received no operation at all. Animals in other four groups were given general anesthesia by muscular injection of Sumianxin Ⅱ and they were then fixed supinely on the operation table. The rabbits were intubated with a 3-mm endotracheal tube and mechanically ventilated (HX-200 ventilator) with a tidal volume of 12 mL/kg and a respiratory rate of 40-50/minute. Thoracotomy was conducted through anterolateral incision of the fourth right intercostals area. The upper and lateral pulmonary tissues of the first lobe of the right lung were resected in Group B. For group C, the upper and lateral pulmonary tissues of the first and the second lobes of the lung were resected. For Group D, the upper and lateral pulmonary tissues of the first, second and the third lobes of the right lung were resected. The pulmonary removal was about a half of the total volume of the lobe. The specimens were removed, followed by 3-0 mattress suture of the wounds. Then, fibrin sealant was insufflated to avoid air leakage after the operation. Thoracotomies without any resection of lung parenchyma were carried out in Group E. Histologic inspection and quantitatively morphologic analysis of the left lung was postoperatively carried out eight weeks later. MAIN OUTCOME MEASURES: Quantitative analysis of pulmonary functions and alveolar morphology in rabbits with emphysema after lung volume reduction surgery with different resection volumes RESULTS: All the fifty rabbits were analyzed, and there were ten animals in each group. ① Comparison of ventilation volume in each group : In Group C, vital volume (VT), forced expiratory volume in 0.3 s (FEV0.3),FEV0.3/ forced expiratory capacity (FVC) were all higher than those of Group A [(6.69±0.83) mL, (6.39±1.35) mL, (64.5±16.1)%; (5.76±0.84) mL, (5.23±1.37)mL, (50.2±15.6)%, P< 0.05], while functional residual capacity (FRC) was lower than that in group A [(14.3±1.9)mL; (19.3±3.1)mL, P< 0.05]. Compared with Group A, no obvious difference in the above lung functions of Groups B, D and E was observed (P >0.05). ② Histopathological observation results: In group C, obvious repairs to dilatation and destruction of alveolar ducts or cyst were observed and the aggregation of macrophage and neutrophils in the end-terminal bronchiole decreased. In Group D, the inflammatory cells decreased, but alveolar destruction and dilatation became more marked. ③Comparison of the total lung capacity (TLC): TLC of Group C was less than that of group A [(42.1±5.8)mL, (58.5±7.6)mL, P< 0.05]. Compared with group A, no obvious difference in the above lung functions of Groups B, D and E was observed (P >0.05). ④ Quantitative analysis result of alveolar morphology: The number of alveoli (Na) and density of alveolar septum (Ds) in Group C were much larger than those of group A [(17.6±3.1)/field, (18.6±2.1)%; (11.3±2.7)/field, (15.2±3.6)%, P< 0.05] while the diameter of the alveoli (Da) in Group C was significantly lower than those of Group A[(78.1±7.1),(93.4±10.2)μm , P < 0.05]. CONCLUSION: Combination of smog and elastase successfully induced rabbit model of obstructive emphysema. Unilateral LVRS could improve emphysematous rabbits' pulmonary functions. Improved in pulmonary functions was not obvious by LVRS with less (12.5%) or larger (37.5%) resection volume of lung parenchyma. LVRS with appropriate resection volume (25%) could effectively eliminate airway inflammation, alleviate alveolar dilatation and destruction of the residual lung parenchyma, and thus improve pulmonary ventilation function.
出处
《中国临床康复》
CSCD
北大核心
2005年第23期251-253,共3页
Chinese Journal of Clinical Rehabilitation
基金
重庆市科技攻关项目(20033301)~~
