胸膜癒着が胸腔鏡下肺悪性腫瘍手術に及ぼす影響

Influence of Pleural Adhesions on Thoracoscopic Surgeries for Malignant Lung Tumors

胸腔には少量の胸水が存在し，本来，臓側胸膜と壁側胸膜が滑らかに動いて呼吸運動を行っているが，肺炎，胸膜炎，胸部手術などの炎症反応により胸膜癒着（以下，癒着）が生じることがある．肺切除において癒着が存在すると，出血量の増加，手術時間の延長，臓側胸膜の損傷に伴う肺瘻リスクの増加，周辺臓器・組織の損傷に伴う合併症増加の要因となり，胸腔鏡下手術では開胸手術への移行を余儀なくされることがある．これらの事象はすでに経験的に認知されたことではあるが，胸腔鏡下手術が主流となった現在において，癒着がどの程度肺切除に影響しているのかは明確でない．また，癒着の状態は多様であり，その程度によって手術への影響が大きく異なる．本研究では癒着の状態を系統的に分類（種類，強さ，範囲）し，胸腔鏡下肺悪性腫瘍手術に及ぼす影響について検討を行った．

In the present study, influences of pleural adhesions on thoracoscopic lung surgeries were investigated. A total of 666 consecutive patients who had undergone thoracoscopic surgeries for lung malignant tumors were retrospectively analyzed. Pleural adhesions were present intraoperatively in 289 cases, of which 6 required conversion to thoracotomy due to the adhesions. The influences of pleural adhesions on the perioperative period were comparatively large under following conditions （level-A）；the adhesion-type was tight which meant lung and pleural wall sticked closely even if lung collapse was encouraged, the strength was middle （required sharp-dissection） or strong （hard to dissect between visceral and parietal pleura）, and the range was more than 10％ of total pleural surface. Significant influences of the level-A of pleural adhesions were as follows；prolonged operation time in all procedures, frequent intraoperative lung fistula and prolonged pleural drainage period in wedge resections, and increased blood loss, intraoperative and postoperative lung fistula with prolonged pleural drainage time and postoperative hospitalization period in lobectomy. Other postoperative complications （pneumonia, empyema, exacerbation of interstitial pneumonitis, and arrhythmias） were not associated with pleural adhesions. Careful dissection procedure for pleural adhesions that minimize damage of visceral pleura would be the most important.