Empyema is one of the most dangerous complications in thoracic surgery. It can easily progress to severe empyema with life-threatening conditions that are extremely challenging to treat. We successfully treated a patient with critically severe empyema via extracorporeal membrane oxygenation (ECMO), and the patient eventually recovered and was discharged. A 64-year-old male developed empyema 5 years ago. The thoracic infection led to a breakdown of the left chest wall. During hospitalisation, the patient's condition gradually deteriorated. We promptly initiated ECMO support and performed multiple debridement surgeries, fistula closure, targeted anti-infection treatment, and nutritional support. Ultimately, the patient's condition improved, as he eventually recovered and was discharged.

Background Chronic empyema with chest wall sinus is a difficult and complex disease caused by multiple causative factors. It is difficult to control local infection due to its possible combination of bronchopleural fistula (BPF) and residual bone.The relevant literature emphasizes some risk factors for empyema progression after pneumonectomy, while the correlation between empyema and BPF after pneumonectomy increases mortality by infecting the remaining lungs. After pneumonectomy, the lung function of the contralateral side is particularly important. Case presentation This paper reports a 62-year-old male patient who underwent right pneumonectomy for squamous cell carcinoma of the lung 12 years ago and began to develop empyema with anterior chest wall sinus 3 years ago. After admission, chest computed tomography (CT) showed right pleural effusion and formation of chest wall sinus. According to his clinical symptoms and imaging examination, he was diagnosed as chronic empyema with chest wall sinus.Due to the huge residual cavity of the patient,the clinical effect of using free vastus lateralis myocutaneous flap combined with pedicled pectoralis major muscle flap to fill the abscess cavity was satisfactory,but acute respiratory failure occurred due to left lung aspiration pneumonia after operation. Conclusions After a series of treatment measures such as tracheal cannula, tracheotomy, anti-infection, maintenance of circulatory stability, and rehabilitation training, the patient was ultimately rescued and cured. Postoperative follow-up showed that the muscle flaps survived and empyema was eliminated.

目的:探讨壮医灯草灸疗法对脓毒症患者临床指标的改善效果.方法:选择60例脓毒症患者,按随机数字表法分为观察组和对照组各30例.对照组予西医常规治疗,观察组在对照组基础上增加壮医灯草灸治疗,两组均治疗7 d.采用酶联免疫吸附试验(ELISA)、流式细胞术等方法检测患者治疗前后的免疫功能指标CD3+、CD4+、CD8+、CD4+/CD8+、免疫球蛋白A(IgA)、免疫球蛋白G(IgG)、免疫球蛋白M(IgM)等及炎症指标白细胞(WBC)、C反应蛋白(CRP)、降钙素原(PCT)、中性粒细胞百分比(N%)、白介素-6(IL-6)等水平;采用序贯器官衰竭的检测(SOFA)评分、急性生理学和慢性健康状况评分系统Ⅱ(APACHE Ⅱ)评分评估患者器官衰竭及病危情况,采用医院壮医证候量表评估疗效.结果:治疗7 d后,观察组CD8+、WBC、CRP、PCT、N(%)、IL-6等水平均低于对照组(P<0.05),CD4+、CD4+/CD8+、IgA、IgG、IgM等水平均高于对照组(P<0.05);治疗7 d后,观察组壮医证候量表评分、SOFA评分、APACHE Ⅱ评分等均低于对照组(P<0.05).结论:加用壮医灯草灸疗法对脓毒症进行辨证治疗,可进一步改善患者免疫功能,降低炎症指标水平,值得临床推广应用.

RATIONALE:Fungal empyema is a chronic refractory disease. It is difficult to control thoracic infection, and it is faced with the problem of recurrence. How to control the infection and reduce the probability of recurrence is a difficult problem. Surgical operation combined with endobronchial therapy was used to control infection, seal the fistula and eliminate residual cavity and achieved good results.PATIENT CONCERNS:A total of 5 patients with fungal empyema were treated from 2019 to 2021, aged 27 to 72 years, with an average age of 54.8 ± 7.6 years. Two cases were on the left side and 3 cases on the right side.DIAGNOSIS:While meeting the diagnostic criteria of empyema, the diagnosis of fungus in pus culture or the discovery of fungus in deep tissue pathology confirmed the diagnosis of fungal empyema in the 5 cases.INTERVENTIONS:Through surgical operations combined with bronchoscopy and individualized treatment, the infection was controlled, the fistulas were blocked, and the pus cavity was filled.OUTCOMES:After 11 to 30 months of follow-up, the muscle flap in the abscess cavity was mildly atrophied, and there was no recurrence of empyema. Three patients who completed the second-stage operation had their chest tubes removed and returned to normal life. The 2 patients who did not complete the second-stage operation had no recurrence of thoracic infection and no recurrence of cough or fever, and their quality of life was greatly improved.LESSONS:Surgical operation combined with bronchoscopy is a reliable method for the treatment of fungal empyema, which can find and plug the fistula more efficiently and eliminate the residual cavity by surgery to avoid recurrence. Therefore, it is a recommended treatment method.

RATIONALE:Pulmonary sequestration, which can be divided into 2 main types: intralobar pulmonary sequestration (IPS) and extralobar pulmonary sequestration, is an uncommon congenital condition for which surgical resection is usually indicated. Video-assisted thoracoscopic surgery, as compared with open thoracotomy, has increasingly become the preferred operative procedure in the treatment of PS, owing to less postoperative pain and faster recovery. This report describes a rare and challenging case with a giant IPS undergoing video-assisted thoracic lobectomy.PATIENT CONCERNS:A 39-year old woman suffered from recurrent pneumonia for nearly 3 years. An enhanced computed tomography scan performed in our hospital revealed a 12.0 cm × 10.0 cm-sized IPS in the left lower lobe, supplied by an 8-mm aberrant artery originating from the descending thoracic aorta.DIAGNOSIS:Histology of the resected lobe confirmed the diagnosis of giant intralobar pulmonary sequestration associated with infection.INTERVENTIONS:Thoracoscopic left lower lobectomy was performed.OUTCOMES:The patient has been discharged from the hospital on the ninth day after surgery with an uneventful recovery, she was in good health after a 1-year follow-up.LESSONS:Although full of challenges, thoracoscopic lobectomy for giant IPS is a safe and feasible surgical procedure associated with reduced surgical trauma and postoperative pain as well as improved cosmetic results compared with traditional thoracotomy.

Objective:To evaluate the safety and clinical efficacy of transplanting a muscle flap to treat the postoperative refractory empyema with a bronchopleural fistula.Methods:From July 2015 to December 2019, the clinical data of 15 patients who suffered from postoperative refractory empyema with bronchopleural fistula was retrospectively summarized. There were 13 males and two females with a mean age of 61.7 years. Ten cases had previous posterolateral thoracotomy and four cases underwent minimally invasive surgery. After conservative and endoscopic therapy, a pedicled latissimus dorsi muscle flap, a pectoralis major muscle flap, or a free vastus lateralis myocutaneous flap was harvested from the ipsilateral local thorax or thigh and was transferred to cover the intrathoracic cavity.Results:There was no perioperative death. During a mean follow-up of 14.8 months, one patient was dead, one suffered from a recurrence of refractory empyema, and l3 patients had an uneventful course with no recurrence of refractory empyema and bronchopleural fistula. Postoperative chest computed tomography or magnetic resonance imaging showed the empyema cavity was satisfactorily covered with a pedicle or free muscle flap.Conclusions:Muscle flap transplantation is an effective alternative for treating the postoperative refractory empyema with bronchopleural fistula, which can achieve promising short-medium-term results.

目的 比较术前运用Hook-wire和医用胶两种定位方式行胸腔镜手术(VATS)切除孤立性肺小结节(SPN)的临床疗效.方法 选取2016年3月至2019年9月在浙江省立同德医院心胸外科同一医疗组行VATS的SPN患者共70例.所有患者均为单个结节定位,其中采用CT引导下Hook-wire定位者42例,医用胶定位者28例,观察和比较两组患者定位时间、定位成功率,气胸、出血、刺激性咳嗽等定位相关并发症发生率,同时记录比较两组患者VATS时间,统计两组术中冷冻切片病理检查结果.结果 所有患者均顺利完成术前CT引导下肺结节穿刺定位.两组患者定位时间比较差异无统计学意义(P>0.05);Hook-wire组定位成功率明显低于医用胶组,差异有统计学意义(P<0.05).Hook-wire组气胸和渗血的发生率均明显高于医用胶组,差异均有统计学意义(均P<0.05);医用胶定位组咳嗽的发生率明显高于Hook-wire组,差异有统计学意义(P<0.05).所有患者均顺利完成VATS,Hook-wire组VATS时间明显长于医用胶组,差异有统计学意义(P<0.05);而两组患者术中冷冻切片病理检查结果比较差异无统计学意义(P>0.05).结论 CT引导下Hook-wire或医用胶定位均可用于VATS切除SPN,安全性高,可简化VATS操作难度,缩短时间,医用胶相比Hook-wire定位成功率高、手术用时更短,相关并发症少,予以优先推荐.

目的 总结1例闭合性颈段气管断裂伤的诊治经验,进一步提高对该病的认识和诊疗水平.方法 患者,男性,41岁.颈部被钢板撞击伤后出现高度皮下气肿、呼吸困难,皮下排气后症状改善不明显,紧急行颈胸部CT检查发现高度皮下和纵隔气肿、颈部气管不连续,考虑气管断裂伤,在急诊手术中发现气管1～2环间全断离,伴软骨骨折、周围软组织损伤,行气管断端吻合、低位气管切开术.结果 术后恢复顺利,2周后拔除气管套管,病人呼吸、进食正常,但出现声音嘶哑,喉镜检查发现声带固定,半年后复查胸部CT气管断端吻合口无狭窄,因声音嘶哑未改善行双侧声带切除和气管切开术,带气管套管至今2年余.结论 闭合性颈段气管断裂伤可能引起气道梗阻而窒息死亡,救治成功的关键是确保气道通畅、早期做出正确诊断和及时重建断裂气管,气管吻合术能取得满意的疗效.

目的 总结和分析支气管胸膜瘘合并难治性脓胸个体化综合治疗的方法和疗效.方法2015年7月—2019年11月共收治支气管胸膜瘘合并难治性脓胸患者12例,其中男性10例,女性2例;年龄23～78岁,平均(60.75±15.05)岁.初始手术为非小细胞肺癌4例,肺部良性疾病4例,包裹性胸腔积液3例,恶性胸腺瘤肺转移1例.胸膜瘘发生后,采取经脓胸引流控制感染和介入封堵瘘口治疗;病情基本稳定后,行肌瓣移植术填塞脓腔等综合措施,并根据病情进行个体化治疗.结果全组无围手术期死亡病例;在平均17.45个月的随访中,1例患者因肿瘤转移死亡;1例复发小脓腔;其余10例无支气管胸膜瘘和脓胸复发,肌瓣存活,复查胸部CT/MRI显示脓腔被彻底填塞.结论对支气管胸膜瘘合并难治性脓胸患者采取个体化综合治疗措施,能达到彻底根治的目的,成功率高,疗效显著,值得推广.

2015年5月至2019年9月应用游离股外侧肌皮瓣移植术治疗7例顽固性慢性脓胸，其中男5例，女2例；年龄23～70岁，平均(66.38±11.24)岁。脓胸均为胸部外科手术后并发症，右侧6例，左侧1例。术中取游离股外侧肌皮瓣填塞脓腔，显微镜下行旋股外侧动脉降支动脉、静脉与胸背动、静脉间断缝合，以提供该组织瓣的血供。术后游离肌皮瓣成活6例，失活1例。术后随访(26.5±18.2)个月，1例恶性胸腺瘤转移复发，术后半年死亡；其他6例均肌瓣成活，脓腔填塞良好，无脓胸复发，无胸闷等不适。肌瓣供区愈合良好，下肢功能无明显影响。游离股外侧肌皮瓣移植术能有效填塞脓胸残腔，不改变胸廓外形，不影响下肢功能，适用于含有巨大脓腔、无法使用带蒂和其他游离肌皮瓣的术后慢性脓胸，近、中期疗效满意，是一种可供选择的理想方法，值得临床推广。

慢性脓胸通过开窗引流、胸膜剥脱术、胸廓成形术、介入封堵等治疗可以取得比较理想的效果,但临床上仍有一些患者因存在不易被彻底清除的巨大脓腔,也可能合并胸膜支气管瘘、胸壁窦道、残留骨和软骨等坏死组织,从而导致局部感染不易控制而难以彻底根治.笔者应用联合带蒂肌瓣移植术治疗慢性难治性脓胸15例.现报道如下.

目的 探讨西妥昔单抗联合化疗治疗中晚期食管癌的临床观察.方法 选取浙江中医药大学附属同德医院2013年2月～2016年5月收治的中晚期食管癌患者80例为研究对象,采用随机数字表法将患者分为对照组(n=40)和研究组(n=40),对照组给予氟尿嘧啶联合顺铂(FP)化疗治疗,研究组在此基础上联合西妥昔单抗治疗,比较两组患者临床疗效、肿瘤标志物水平、生存质量、生存率以及不良反应.结果 研究组治疗4个周期后临床总有效率高于对照组(P＜0.05).两组患者治疗4个周期后鳞状细胞癌抗原(Scc)、癌胚抗原(CEA)均降低,且研究组低于对照组(P＜0.05).两组治疗4个周期后欧洲癌症研究组织生存质量测定(EORTC QLQ-C30)量表评分均升高,且研究组高于对照组(P＜0.05).研究组随访12、18、24个月后生存率高于对照组,但组间比较差异无统计学意义(P＞0.05).两组治疗期间不良反应发生率比较,差异无统计学意义(P＞0.05).结论 西妥昔单抗联合化疗治疗中晚期食管癌,效果确切,可有效改善肿瘤标志物水平,改善患者生存质量,且不增加不良反应发生率,临床应用价值较高.

目的 评价游离股外侧肌皮瓣移植术治疗顽固性慢性脓胸和胸壁窦道的疗效.方法 于2012年9月至2016年3月对5例顽固性慢性脓胸和胸壁窦道患者采用游离股外侧肌皮瓣移植术治疗,通过显微外科技术将患者的游离肌皮瓣旋股外侧血管降支与胸背或颈横血管间断吻合给肌皮瓣提供血供,术后予抗感染、抗痉挛、抗凝等治疗,观察皮瓣成活、创面愈合及脓胸、窦道消失情况.结果 术后游离肌皮瓣均成活,随访(20.04±6.20)个月,均未见原疾病复发,胸部CT或MRI显示脓胸和窦道消失,游离肌皮瓣活性良好.结论 应用游离股外侧肌皮瓣移植术治疗顽固性慢性脓胸和胸壁窦道是一种可供选择的有效方法,近中期临床疗效满意.

Spontaneous coronary artery rupture (SCAR) is an extremely rare, life-threatening entity without any previous underlying diseases. The clinical presentation may differ according to the site of the rupture and some patients may deteriorate early into sudden death due to the abrupt evolution of the associated cardiac tamponade and cardiogenic shock.1) The correct diagnosis of SCAR deserves a high level of suspicion. It may be confirmed as a differential diagnosis in patients with cardiac tamponade using transthoracic echocardiography (TTE) and computed tomography angiography (CTA) following emergency pericardiocentesis, and a definite diagnosis can be achieved by selective angiography. Although SCAR is associated with a dismal prognosis, some patients have recovered through emergency surgical operations or catheter interventions.2) We report the case of a patient presenting cardiac tamponade and cardiogenic shock due to spontaneous rupture of the circumflex branch of the left coronary artery, which was successfully isolated by bilateral ligation.

Abstract Rationale: Chronic chest wall fistula is a refractory and agonizing disease that results from multiple predisposing etiologies, including radiation-induced damage. Successful management remains challenging when this condition is combined with osteomyelitis, and a limited number of reports have been published in the literature concerning this management. Patient concerns: Two Chronic chest wall fistula patients were selected to undergo surgery in our hospital because they could not be cured by conventional therapy for several years. One is a 74-year-old female who has received a right radical mastectomy and had radiation therapy 23 years ago; the other is a 59-year-old male who underwent a excision of thyroid cancer and had chemoradiation therapy 20 years earlier. Diagnosis: Both patients were diagnosed with radiation-induced chest wall fistula combined with osteomyelitis. Interventions: After total resection of the diseased chest walls, both patients underwent free vastus lateralis musculocutaneous flap transfers, in which the vessels were microvascularly anastomosed to the transverse carotid artery and vein via a subcutaneous tunnel or a direct incision. Histologic evaluations of the specimens demonstrated inflammation and osteomyelitis. Outcomes: The patients recovered very well and currently have no recurrence of chest wall fistulae during the postoperative follow-up. Lessons: It is crucial to not only completely resect chest wall fistulae and the surrounding diseased tissues but also reconstruct the chest wall. Thus, the use of the free vastus lateralis musculocutaneous flap transfer method for radiation-induced chest wall fistulae, combined with osteomyelitis, is a useful option for treatment and is also a feasible and efficient surgical procedure with promising results.

目的 观察血管内皮生长因子(VEGF)对大鼠离体心脏骨髓间充质干细胞(BMSCs)滞留率的影响.方法 取20只雄性SD大鼠,腹腔注射麻醉无菌条件下取股骨和胫骨,用DMEM培养基缓慢冲洗骨髓腔,离心收集细胞,接种到DMEM培养基原代培养,取传代3代后的BMSCs.另取100只雌性SD大鼠随机分成正常灌注BMSCs组、正常灌注BMSCs+VEGF组、缺血再灌注BMSCs组、缺血再灌注BMSCs+VEGF组,每组25只.正常灌注BMSCs组大鼠建立心脏离体灌注模型,灌注1 ×106/mL BMSCs细胞1mL,停2min后重新灌注,于5、10、30、60、120min时间点收集从心脏流出的灌注液,每个时间点5只.正常灌注BMSCs+VEGF组大鼠灌注BMSCs前预先向心脏注入浓度1000μmol/L的VEGF 1mL,其他实验步骤与正常灌注BMSCs组相同.缺血再灌注BMSCs组大鼠建立心脏离体灌注模型,待心脏稳定搏动15min后,关闭灌注系统使心肌缺血30min,建立缺血再灌注模型,其他实验步骤与正常灌注BMSCs组相同.应用荧光定量聚合酶链反应(RT-PCR)检测各组大鼠高体心脏不同时间点骨髓间充质干细胞滞留率.结果 正常灌注BMSCs组大鼠5、15、30、60、120min时间点之间平均BMSCs滞留率差异无统计学意义(P＞0.05);缺血再灌注BMSCs组大鼠5、15、30、60、120min时间点平均BMSCs滞留率均高于正常灌注BMSCs组[(36.96±4.79)％比(16.32±3.84)％、(35.88±4.76)％比(14.02±5.23)％、(28.05±3.46)％比(12.48±3.46)％、(27.04±6.35)％比(12.42±3.61)％、(27.06±5.84)％比(12.42±3.49)％,P均＜0.05];与正常灌注BMSCs+VEGF组比较,缺血再灌注BMSCs+VEGF组平均BMSCs滞留率明显增加[(41.46±5.88)％比(19.38±4.66)％、(37.82±5.74)比(19.54±5.11)％、(32.82±3.53)比(16.68±2.64)％、(33.24±6.19)比(16.06±2.12)％、(31.60±3.24)比(15.60±2.00)％,P均＜0.05);正常灌注BMSCs+VEGF组与正常灌注BMSCs组同时间点平均BMSCs滞留率比较,差异无统计学意义(P＞0.05);缺血再灌注BMSCs+VEGF组与缺血再灌注BM-SCs组同时间点平均BMSCs滞留率比较,差异无统计学意义(P＞0.05).结论 缺血再灌注可显著增加大鼠离体心脏骨髓间充质干细胞滞留率;而血管内皮生长因子对其无明显干预作用.

Chronic empyema combined with chest wall sinus is a refractory and agonizing disease resulting from multiple predisposing etiologies. Successful management remains challenging. Hemophilia A is a sex-linked recessive hereditary disease in which the blood does not clot normally due to lack of coagulation factor VIII and may lead to high risk of excessive surgical bleeding.

目的 探讨胸腔镜探查联合小切口辅助对多发肋骨骨折内固定治疗的临床疗效.方法 回顾分析2015年8月至2018年2月间我科收治的严重胸部钝性伤行手术内固定病人共32例,所有患者均于伤后一周内在胸腔镜下探查,并辅助予8 cm左右的小切口,选用镍钛记忆合金肋骨环抱器固定肋骨,重塑胸壁的结构及稳定性,同时记录与手术相关数据指标.结果 32例患者均顺利完成胸腔探查+肋骨内固定手术,平均肋骨固定数5.6根(4～11根),平均手术时间为126 min(86～180 min),术中平均出血量:130 mL(100～250 mL),术后平均拔管时间3 d(2～5 d),术后平均住院时间:8.5 d(6～15 d),术后平均随访6月,2例患者出现胸壁慢性疼痛,无死亡及其他严重并发症患者.结论 胸腔镜辅助小切口治疗严重多发肋骨骨折安全、有效,它能使内固定手术更加微创化,促进患者快速康复.

Objective To study the treatment of huge empyema with free vastus lateralis muscle flap. Methods From May 2015 to December 2015, 3 cases of empyema were treated with free vastus lateralis muscle flaps, ( unilateral vastus lateralis muscle flap, n=2;bilateral vastus lateralis muscle flaps with Flow-through technique, n=1). The volumes of defects were 12. 4 cm × 5. 1 cm × 6. 4 cm, 11. 8 cm × 6. 9 cm × 5. 6 cm, and 14. 4 cm × 7. 6 cm × 9. 4 cm, respectively. Result All flaps was survived after 23-29 months follow-up. The pus cavities were filled well. There was no empyema reoccurred. The patients felt good, without chest distress. The donor site of flap healed well. The function of lower limb was not affected. Conclusions Vastus lateralis muscle can fill the pus cavity of empyema successfully, without the sacrifice of chest shape. Free vastus lateralis muscle flap is an ideal choice to repair large empyema defection. For young patient, bilateral free vastus lateralis muscle flap can be used if the cavity is too large to fill with one flap.

From the Department of Cardiothoracic Surgery (X.M.H., Z.L.H.), Tongde Hospital of Zhejiang Province; and Department of Emergency (H.L.L), Hangzhou, Zhejiang, China. Address for reprints: Zhongliang He, MD, Department of Cardiothoracic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang, China; email: [email protected].