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Article(id=1208862371175600488, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208862365714616539, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.09.16, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1621958400000, receivedDateStr=2021-05-26, revisedDate=1624896000000, revisedDateStr=2021-06-29, acceptedDate=null, acceptedDateStr=null, onlineDate=1766144848865, onlineDateStr=2025-12-19, pubDate=1632758400000, pubDateStr=2021-09-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766144848865, onlineIssueDateStr=2025-12-19, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766144848865, creator=13701087609, updateTime=1766144848865, updator=13701087609, issue=Issue{id=1208862365714616539, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='9', pageStart='849', pageEnd='953', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766144847562, creator=13701087609, updateTime=1766144914151, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1208862645055254758, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208862365714616539, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1208862645055254759, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208862365714616539, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=940, endPage=945, ext={EN=ArticleExt(id=1208862371527922043, articleId=1208862371175600488, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Comparison of video-assisted thoracoscopy and traditional thoracotomy in treatment of traumatic hemothorax: A propensity score matching study, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To compare the safety and curative effect of video-assisted thoracoscopic surgery (VATS) and traditional thoracotomy in treatment of traumatic hemothorax. Methods The clinical data of 91 patients with hemothorax (received VATS) and 131 patients (received thoracotomy) in the Second Affiliated Hospital of PLA Air Force Military Medical University from January 2012 to December 2018 were retrospectively case-control analyzed. The curative effects between the two groups were compared by propensity score matching (PSM) method, and the risk factors of complications were predicted with multivariate logistic analysis. Results The total incidence of complications in the 222 patients was 22.1%. One patient died in thoracotomy group, whereas no patient died in VATS group. Before PSM, the numbers of fractured ribs, proportions of ribs fixation surgery and blunt injuries were lower (P<0.001) with lower incidence of complications (P=0.008) and shorter hospital length of stay (LOS) (P<0.001) in VATS group than those in thoracotomy group. After 1:1 PSM, 120 patients (60 patients in each group) were selected for further statistical analysis, and no significant difference was then identified between the two groups in the rate of complications and the hospital LOS (P>0.05). Significant statistical differences existed between the two groups in postoperative volume of drainage (P=0.006), drainage time (P=0.008), as well as postoperative hospital LOS (P=0.022) and ICU length of stay (P=0.010). Multivariate logistic analysis showed that the operation mode was not the independent risk factor for postoperative complications of traumatic hemothorax operation (OR=0.848, P=0.755). Conclusions VATS is safe and effective for hemodynamically stable patients with traumatic hemothorax since it can avoid the huge trauma of traditional thoracotomy,accelerate postoperative recovery of patients and shorten their postoperative hospital stay.

, correspAuthors=Yong Han, authorNote=null, correspAuthorsNote=
*E-mail:
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目的 比较电视胸腔镜手术(VATS)与传统开胸手术治疗创伤性血胸的疗效。方法 采用回顾性病例对照研究方法分析2012年1月—2018年12月在空军军医大学第二附属医院接受VATS(n=91)或开胸手术(n=131)治疗的创伤性血胸患者的临床资料。采用倾向评分匹配的方法对两组患者的术后情况进行对比分析，并采用多因素logistic回归分析术后并发症的危险因素。结果 所有患者的总并发症发生率为22.1%。开胸手术组死亡1例，VATS组无死亡病例。在匹配前，VATS组的肋骨骨折数目(P<0.001)、术中行肋骨固定手术的比例(P<0.001)及钝性伤比例(P=0.001)较开胸手术组低，且并发症发生率低(P=0.008)，总住院时间短(P<0.001)。经1:1倾向评分匹配后，共成功匹配VATS组及开胸手术组各60例。倾向性匹配后，VATS组与开胸手术组的并发症发生率及总住院时间差异无统计学意义(P>0.05)。两组的术后引流量(P=0.006)、引流时间(P=0.008)、术后住院时间(P=0.022)及ICU时间(P=0.010)差异有统计学意义。多因素logistic回归分析显示，手术方式不是创伤性血胸术后并发症的独立危险因素(OR=0.848，P=0.755)。结论 对于血流动力学稳定的创伤性血胸而言，应用VATS是安全有效的，可在避免传统开胸手术巨大创伤的同时，加快患者术后恢复、缩短术后住院时间。

, correspAuthors=韩勇, authorNote=null, correspAuthorsNote=
韩勇，E-mail：
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辛少伟，医学硕士，主治医师，主要从事胸部损伤及胸部肿瘤方面的研究

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辛少伟，医学硕士，主治医师，主要从事胸部损伤及胸部肿瘤方面的研究

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辛少伟，医学硕士，主治医师，主要从事胸部损伤及胸部肿瘤方面的研究

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Langenbecks Arch Surg, 2013, 398(4): 515-523., articleTitle=Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1208862372282896796, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, xref=1, ext=[AuthorCompanyExt(id=1208862372291285406, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, companyId=1208862372282896796, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1Department of Thoracic Surgery, the 962 Hospital of Joint Service Support Force, Harbin 150000, China), AuthorCompanyExt(id=1208862372295479710, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, companyId=1208862372282896796, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1解放军联勤保障部队第962医院胸外科，哈尔滨 150000)]), AuthorCompany(id=1208862372358394275, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, xref=2, ext=[AuthorCompanyExt(id=1208862372366782884, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, companyId=1208862372358394275, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2Department of Thoracic Surgery, the Second Affiliated Hospital of Air Force Military Medical University, Xi’an 710038, China), AuthorCompanyExt(id=1208862372370977189, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, companyId=1208862372358394275, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2空军军医大学第二附属医院胸外科，西安 710038)])], figs=[ArticleFig(id=1208862375885804092, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=EN, label=Fig.1, caption=The equalization of the baseline data of patients with traumatic hemothorax between the two groups before and after PSM, figureFileSmall=PcghtegEbR3xW4rxukkpow==, figureFileBig=cLwqJSlDQM2VWx9V3sV6OQ==, tableContent=null), ArticleFig(id=1208862375986467392, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=CN, label=图1, caption=两组创伤性血胸患者基线数据PSM前后的均衡性, figureFileSmall=PcghtegEbR3xW4rxukkpow==, figureFileBig=cLwqJSlDQM2VWx9V3sV6OQ==, tableContent=null), ArticleFig(id=1208862376342983257, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=EN, label=Tab.1, caption=

Comparison of preoperative clinical baseline data between the two groups of patients with traumatic hemothorax

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=91)开胸手术组(n=131)P
年龄(岁，$\bar{x}±s$)45.4±14.947.8±13.60.212
性别[例(%)]  0.036
 男72(79.1)117(89.3)
 女19(20.9)14(10.7)
损伤类型[例(%)]0.001
 钝性伤65(71.4)116(88.6)
 穿透伤26(28.6)15(11.4)
术前基础疾病[例(%)]
 糖尿病2(2.2)3(2.3)1.000
 慢性阻塞性肺疾病3(3.3)4(3.1)1.000
 心脏疾病5(5.5)17(13.0)0.066
 脑血管疾病2(2.2)10(7.6)0.129
简明损伤定级(AIS)($\bar{x}±s$)3.30±0.463.31±0.470.796
损伤严重度评分(ISS)(分，$\bar{x}±s$)14.31±5.1314.79±4.390.197
格拉斯哥评分(GCS)(分，$\bar{x}±s$)14.81±0.3914.82±0.390.946
肋骨骨折数目(根，$\bar{x}±s$)4.25±3.316.30±2.90<0.001
气胸[例(%)]  0.324
 是77(84.6)104(79.4)
 否14(15.4)27(20.6)
双侧血胸[例(%)]  0.329
 是4(4.4)10(7.6)
 否87(95.6)121(92.4)
血胸量(ml, $\bar{x}±s$)596.37±358.05500.38±313.940.036
受伤至手术时间(d, $\bar{x}±s$)3.40±2.223.53±2.140.640
), ArticleFig(id=1208862376468812381, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=CN, label=表1, caption=

两组创伤性血胸患者术前临床基线资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=91)开胸手术组(n=131)P
年龄(岁，$\bar{x}±s$)45.4±14.947.8±13.60.212
性别[例(%)]  0.036
 男72(79.1)117(89.3)
 女19(20.9)14(10.7)
损伤类型[例(%)]0.001
 钝性伤65(71.4)116(88.6)
 穿透伤26(28.6)15(11.4)
术前基础疾病[例(%)]
 糖尿病2(2.2)3(2.3)1.000
 慢性阻塞性肺疾病3(3.3)4(3.1)1.000
 心脏疾病5(5.5)17(13.0)0.066
 脑血管疾病2(2.2)10(7.6)0.129
简明损伤定级(AIS)($\bar{x}±s$)3.30±0.463.31±0.470.796
损伤严重度评分(ISS)(分，$\bar{x}±s$)14.31±5.1314.79±4.390.197
格拉斯哥评分(GCS)(分，$\bar{x}±s$)14.81±0.3914.82±0.390.946
肋骨骨折数目(根，$\bar{x}±s$)4.25±3.316.30±2.90<0.001
气胸[例(%)]  0.324
 是77(84.6)104(79.4)
 否14(15.4)27(20.6)
双侧血胸[例(%)]  0.329
 是4(4.4)10(7.6)
 否87(95.6)121(92.4)
血胸量(ml, $\bar{x}±s$)596.37±358.05500.38±313.940.036
受伤至手术时间(d, $\bar{x}±s$)3.40±2.223.53±2.140.640
), ArticleFig(id=1208862376598835810, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=EN, label=Tab.2, caption=

Comparison of intraoperative and postoperative clinical data between the two groups of patients with traumatic hemothorax

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=91)开胸手术组(n=131)P
肺实质及肋间血管出血[例(%)]  0.822
 是32(35.2)48(36.6)
 否59(64.8)83(63.4)
肋骨骨折复位内固定[例(%)]  <0.001
 是50(54.9)115(87.8)
 否41(45.1)16(12.2)
手术持续时间(min, $\bar{x}±s$)103.68±41.44144.16±51.06<0.001
术后胸腔总引流量(ml, $\bar{x}±s$)603.19±354.78978.41±691.91<0.001
术后引流时间(d, $\bar{x}±s$)5.73±1.907.79±3.82<0.001
ICU时间(d, $\bar{x}±s$)1.62±0.922.56±2.02<0.001
总住院时间(d, $\bar{x}±s$)10.21±2.9413.38±6.00<0.001
术后住院时间(d, $\bar{x}±s$)8.14±2.4211.31±5.98<0.001
并发症[例(%)]  0.008
 是12(13.2)37(28.2)
 否79(86.8)94(71.8) 
), ArticleFig(id=1208862376716276329, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=CN, label=表2, caption=

两组创伤性血胸患者术中及术后临床资料的比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=91)开胸手术组(n=131)P
肺实质及肋间血管出血[例(%)]  0.822
 是32(35.2)48(36.6)
 否59(64.8)83(63.4)
肋骨骨折复位内固定[例(%)]  <0.001
 是50(54.9)115(87.8)
 否41(45.1)16(12.2)
手术持续时间(min, $\bar{x}±s$)103.68±41.44144.16±51.06<0.001
术后胸腔总引流量(ml, $\bar{x}±s$)603.19±354.78978.41±691.91<0.001
术后引流时间(d, $\bar{x}±s$)5.73±1.907.79±3.82<0.001
ICU时间(d, $\bar{x}±s$)1.62±0.922.56±2.02<0.001
总住院时间(d, $\bar{x}±s$)10.21±2.9413.38±6.00<0.001
术后住院时间(d, $\bar{x}±s$)8.14±2.4211.31±5.98<0.001
并发症[例(%)]  0.008
 是12(13.2)37(28.2)
 否79(86.8)94(71.8) 
), ArticleFig(id=1208862376812745325, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=EN, label=Tab.3, caption=

Comparison of the baseline data of patients with traumatic hemothorax between the two groups after PSM

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=60)开胸手术组(n=60)P
年龄(岁，$\bar{x}±s$)45.62±15.7146.32±14.430.799
性别[例(%)]  1.000
 男50(83.3)50(83.3)
 女10(16.7)10(16.7)
损伤类型[例(%)]1.000
 钝性伤46(76.7)46(76.7)
 穿透伤14(23.3)14(23.3)
术前基础疾病[例(%)]
 糖尿病1(1.7)1(1.7)1.000
 慢性阻塞性肺疾病2(3.3)2(3.3)1.000
 心脏疾病5(8.3)4(6.7)1.000
 脑血管疾病2(3.3)2(3.3)1.000
简明损伤定级(AIS)($\bar{x}±s$)3.32±0.473.30±0.460.844
损伤严重度评分(ISS)(分，$\bar{x}±s$)14.32±5.0314.30±03.850.545
格拉斯哥评分(GCS)(分，$\bar{x}±s$)14.78±0.4214.83±0.380.488
肋骨骨折数目(根，$\bar{x}±s$)4.98±3.475.12±3.200.733
气胸[例(%)]  0.817
 是48(80.0)49(81.7)
 否12(20.0)11(28.3)
双侧血胸[例(%)]  1.000
 是2(3.3)3(5.0)
 否58(96.7)57(95.0)
血胸量(ml, $\bar{x}±s$)594.17±335.36596.67±366.950.694
受伤至手术时间(d, $\bar{x}±s$)3.45±2.163.70±2.310.646
肺实质及肋间血管出血[例(%)]  1.000
 是22(36.7)22(36.7)
 否38(63.3)38(63.3)
肋骨骨折复位内固定[例(%)]  0.540
 是42(70.0)45(75.0)
 否18(30.0)15(25.0) 
), ArticleFig(id=1208862376955351669, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=CN, label=表3, caption=

两组创伤性血胸患者病例PSM后基线数据比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=60)开胸手术组(n=60)P
年龄(岁，$\bar{x}±s$)45.62±15.7146.32±14.430.799
性别[例(%)]  1.000
 男50(83.3)50(83.3)
 女10(16.7)10(16.7)
损伤类型[例(%)]1.000
 钝性伤46(76.7)46(76.7)
 穿透伤14(23.3)14(23.3)
术前基础疾病[例(%)]
 糖尿病1(1.7)1(1.7)1.000
 慢性阻塞性肺疾病2(3.3)2(3.3)1.000
 心脏疾病5(8.3)4(6.7)1.000
 脑血管疾病2(3.3)2(3.3)1.000
简明损伤定级(AIS)($\bar{x}±s$)3.32±0.473.30±0.460.844
损伤严重度评分(ISS)(分，$\bar{x}±s$)14.32±5.0314.30±03.850.545
格拉斯哥评分(GCS)(分，$\bar{x}±s$)14.78±0.4214.83±0.380.488
肋骨骨折数目(根，$\bar{x}±s$)4.98±3.475.12±3.200.733
气胸[例(%)]  0.817
 是48(80.0)49(81.7)
 否12(20.0)11(28.3)
双侧血胸[例(%)]  1.000
 是2(3.3)3(5.0)
 否58(96.7)57(95.0)
血胸量(ml, $\bar{x}±s$)594.17±335.36596.67±366.950.694
受伤至手术时间(d, $\bar{x}±s$)3.45±2.163.70±2.310.646
肺实质及肋间血管出血[例(%)]  1.000
 是22(36.7)22(36.7)
 否38(63.3)38(63.3)
肋骨骨折复位内固定[例(%)]  0.540
 是42(70.0)45(75.0)
 否18(30.0)15(25.0) 
), ArticleFig(id=1208862378175894138, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=EN, label=Tab.4, caption=

Comparison of intraoperative and postoperative clinical data of patients with traumatic hemothorax between the two groups after PSM

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=60)开胸手术组(n=60)P
手术持续时间(min, $\bar{x}±s$)105.33±43.10136.92±51.94<0.001
术后胸腔总引流量(ml,$\bar{x}±s$)612.17±374.50857.53±526.610.006
术后引流时间(d, $\bar{x}±s$)5.73±1.957.02±2.970.008
ICU时间(d, $\bar{x}±s$)1.53±0.792.40±2.040.010
总住院时间(d, $\bar{x}±s$)10.47±2.8812.42±5.710.076
术后住院时间(d, $\bar{x}±s$)8.32±2.3510.37±5.510.022
并发症[例(%)]  0.624
 是9(15.0)11(18.3)
 否51(85.0)49(81.7) 
), ArticleFig(id=1208862378272363138, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=CN, label=表4, caption=

两组创伤性血胸患者PSM后术中及术后临床资料比较

, figureFileSmall=null, figureFileBig=null, tableContent=
指标VATS组(n=60)开胸手术组(n=60)P
手术持续时间(min, $\bar{x}±s$)105.33±43.10136.92±51.94<0.001
术后胸腔总引流量(ml,$\bar{x}±s$)612.17±374.50857.53±526.610.006
术后引流时间(d, $\bar{x}±s$)5.73±1.957.02±2.970.008
ICU时间(d, $\bar{x}±s$)1.53±0.792.40±2.040.010
总住院时间(d, $\bar{x}±s$)10.47±2.8812.42±5.710.076
术后住院时间(d, $\bar{x}±s$)8.32±2.3510.37±5.510.022
并发症[例(%)]  0.624
 是9(15.0)11(18.3)
 否51(85.0)49(81.7) 
), ArticleFig(id=1208862378368832136, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=EN, label=Tab.5, caption=

Multivariate logistic analysis of postoperative complications of traumatic hemothorax surgery

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变量PSM前PSM后
OR95%CIPOR95%CIP
手术方式0.5340.244~1.1710.1170.7960.296~2.1430.651
性别0.3520.097~1.2740.1125.3060.631~44.6550.125
损伤类型1.2280.215~7.0240.8171.6780.162~17.4180.665
血胸量1.0000.999~1.0010.3391.0000.998~1.0010.724
肋骨骨折数目1.0110.859~1.1910.8941.0550.830~1.3420.661
肋骨骨折内固定2.6620.549~12.9100.2242.2160.261~18.8260.466
受伤至手术时间0.9000.757~1.0700.2320.9470.726~1.2340.685
), ArticleFig(id=1208862378486272654, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1208862371175600488, language=CN, label=表5, caption=

创伤性血胸患者手术后并发症的多因素logistic回归分析

, figureFileSmall=null, figureFileBig=null, tableContent=
变量PSM前PSM后
OR95%CIPOR95%CIP
手术方式0.5340.244~1.1710.1170.7960.296~2.1430.651
性别0.3520.097~1.2740.1125.3060.631~44.6550.125
损伤类型1.2280.215~7.0240.8171.6780.162~17.4180.665
血胸量1.0000.999~1.0010.3391.0000.998~1.0010.724
肋骨骨折数目1.0110.859~1.1910.8941.0550.830~1.3420.661
肋骨骨折内固定2.6620.549~12.9100.2242.2160.261~18.8260.466
受伤至手术时间0.9000.757~1.0700.2320.9470.726~1.2340.685
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电视胸腔镜与传统开胸手术治疗创伤性血胸的疗效比较：一项倾向评分匹配研究
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辛少伟 1 , 熊延路 2 , 乔天运 2 , 韩勇 2, *
解放军医学杂志 | 临床研究 2021,46(9): 940-945
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解放军医学杂志 | 临床研究 2021, 46(9): 940-945
电视胸腔镜与传统开胸手术治疗创伤性血胸的疗效比较：一项倾向评分匹配研究
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辛少伟1, 熊延路2, 乔天运2, 韩勇2, *
作者信息
  • 1解放军联勤保障部队第962医院胸外科，哈尔滨 150000
  • 2空军军医大学第二附属医院胸外科，西安 710038

    • 辛少伟，医学硕士，主治医师，主要从事胸部损伤及胸部肿瘤方面的研究

通讯作者:

韩勇，E-mail：
Comparison of video-assisted thoracoscopy and traditional thoracotomy in treatment of traumatic hemothorax: A propensity score matching study
Shao-Wei Xin1, Yan-Lu Xiong2, Tian-Yun Qiao2, Yong Han2, *
Affiliations
  • 1Department of Thoracic Surgery, the 962 Hospital of Joint Service Support Force, Harbin 150000, China
  • 2Department of Thoracic Surgery, the Second Affiliated Hospital of Air Force Military Medical University, Xi’an 710038, China
出版时间: 2021-09-28 doi: 10.11855/j.issn.0577-7402.2021.09.16
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摘要
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目的 比较电视胸腔镜手术(VATS)与传统开胸手术治疗创伤性血胸的疗效。方法 采用回顾性病例对照研究方法分析2012年1月—2018年12月在空军军医大学第二附属医院接受VATS(n=91)或开胸手术(n=131)治疗的创伤性血胸患者的临床资料。采用倾向评分匹配的方法对两组患者的术后情况进行对比分析，并采用多因素logistic回归分析术后并发症的危险因素。结果 所有患者的总并发症发生率为22.1%。开胸手术组死亡1例，VATS组无死亡病例。在匹配前，VATS组的肋骨骨折数目(P<0.001)、术中行肋骨固定手术的比例(P<0.001)及钝性伤比例(P=0.001)较开胸手术组低，且并发症发生率低(P=0.008)，总住院时间短(P<0.001)。经1:1倾向评分匹配后，共成功匹配VATS组及开胸手术组各60例。倾向性匹配后，VATS组与开胸手术组的并发症发生率及总住院时间差异无统计学意义(P>0.05)。两组的术后引流量(P=0.006)、引流时间(P=0.008)、术后住院时间(P=0.022)及ICU时间(P=0.010)差异有统计学意义。多因素logistic回归分析显示，手术方式不是创伤性血胸术后并发症的独立危险因素(OR=0.848，P=0.755)。结论 对于血流动力学稳定的创伤性血胸而言，应用VATS是安全有效的，可在避免传统开胸手术巨大创伤的同时，加快患者术后恢复、缩短术后住院时间。

创伤性血胸  /  电视胸腔镜手术  /  开胸手术  /  术后并发症

Objective To compare the safety and curative effect of video-assisted thoracoscopic surgery (VATS) and traditional thoracotomy in treatment of traumatic hemothorax. Methods The clinical data of 91 patients with hemothorax (received VATS) and 131 patients (received thoracotomy) in the Second Affiliated Hospital of PLA Air Force Military Medical University from January 2012 to December 2018 were retrospectively case-control analyzed. The curative effects between the two groups were compared by propensity score matching (PSM) method, and the risk factors of complications were predicted with multivariate logistic analysis. Results The total incidence of complications in the 222 patients was 22.1%. One patient died in thoracotomy group, whereas no patient died in VATS group. Before PSM, the numbers of fractured ribs, proportions of ribs fixation surgery and blunt injuries were lower (P<0.001) with lower incidence of complications (P=0.008) and shorter hospital length of stay (LOS) (P<0.001) in VATS group than those in thoracotomy group. After 1:1 PSM, 120 patients (60 patients in each group) were selected for further statistical analysis, and no significant difference was then identified between the two groups in the rate of complications and the hospital LOS (P>0.05). Significant statistical differences existed between the two groups in postoperative volume of drainage (P=0.006), drainage time (P=0.008), as well as postoperative hospital LOS (P=0.022) and ICU length of stay (P=0.010). Multivariate logistic analysis showed that the operation mode was not the independent risk factor for postoperative complications of traumatic hemothorax operation (OR=0.848, P=0.755). Conclusions VATS is safe and effective for hemodynamically stable patients with traumatic hemothorax since it can avoid the huge trauma of traditional thoracotomy,accelerate postoperative recovery of patients and shorten their postoperative hospital stay.

trauma hemothorax  /  video-assisted thoracoscopic surgery  /  thoracotomy  /  postoperative complications
辛少伟, 熊延路, 乔天运, 韩勇. 电视胸腔镜与传统开胸手术治疗创伤性血胸的疗效比较：一项倾向评分匹配研究. 解放军医学杂志, 2021 , 46 (9) : 940 -945 . DOI: 10.11855/j.issn.0577-7402.2021.09.16
Shao-Wei Xin, Yan-Lu Xiong, Tian-Yun Qiao, Yong Han. Comparison of video-assisted thoracoscopy and traditional thoracotomy in treatment of traumatic hemothorax: A propensity score matching study[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (9) : 940 -945 . DOI: 10.11855/j.issn.0577-7402.2021.09.16
正文
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创伤是导致青年人死亡最主要的因素，胸部创伤约占所有创伤性死亡的1/4[1-3]。其中，创伤性血胸为胸部创伤的常见损伤[3-5]。创伤性血胸如果得不到及时正确的救治，患者的病死率将明显增高。手术是治疗创伤性血胸的重要手段，但其适应证和适用范围仍存在争议[6-9]。传统的外科手术一般特指开胸手术，较大的手术创伤使其广泛应用受到了限制。电视胸腔镜手术(video-assisted thoracoscopy，VATS)从20世纪90年代开始成熟并逐渐应用于包括胸部创伤在内的各种胸部疾病的治疗，具有切口小、术后恢复快、疼痛轻等优势，且在治疗创伤性血胸方面的安全性及有效性也被越来越多的研究所证实[10-14]，但是目前比较VATS与开胸手术治疗创伤性血胸的研究较少。为此，本研究使用倾向评分匹配(propensity score matching，PSM)的方式探讨了VATS与开胸手术治疗创伤性血胸疗效的差异。
1 资料与方法
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1.1 临床资料
选取空军军医大学第二附属医院胸外科自2012年1月1日—2018年12月31日连续收治的1217例胸部损伤病例中符合标准的222例创伤性血胸病例进行回顾性分析。其中VATS组91例，开胸手术组131例。创伤性血胸由胸部CT检查进行诊断。创伤性血胸手术治疗的指征为：(1)评估血胸量或首次引流量≥1000 ml；(2)血胸引流量≥200 ml并持续3 h以上；(3)血胸伴明显肺裂伤；(4)血胸伴多发肋骨骨折(有明显骨折移位)；(5)开放性血胸或血气胸。选择VATS还是传统开胸手术基于术者经验、手术习惯及患者诉求进行综合评估。纳入标准为：(1)因创伤性血胸行VATS治疗或传统开胸手术；(2)年龄>15岁。排除标准为：(1)合并心脏大血管损伤、气管或支气管断裂、食管破裂等；(2)合并严重颅脑损伤、腹腔脏器损伤或四肢损伤等；(3)凝血功能障碍；(4)双侧创伤性血胸同期手术者；(5)临床资料不完整或依从性差、未完成整个临床治疗过程；(6)因创伤性凝固性血胸或脓胸而手术者；(7)脏器功能不全(呼吸衰竭、心肝肾衰竭)者；(8)既往胸膜炎病史，胸膜腔广泛粘连者。本研究经空军军医大学第二附属医院伦理委员会批准。
1.2 方法
1.2.1 手术方法
(1)VATS组：手术均在全身麻醉和气管插管下进行。VATS设备采用德国史托斯(STORZ)胸腔镜系统及常规配套器械，以手术侧腋中线第7肋间胸壁约1.5 cm切口作为观察孔置入30°角胸腔镜，并利用镜头角度全面探查胸腔内损伤情况。钝性伤时标准的VATS操作口选在手术侧腋前线第3或4肋间隙，做1.5~2.5 cm切口；穿透性损伤通常可通过原有伤口进行手术，也可选择标准切口。进入胸腔后，首先用吸引器迅速吸尽胸腔内的积血及血凝块，再次探查胸腔内损伤情况。胸膜出血点可采用电凝止血，肋间血管出血时如电凝止血不满意可采用缝扎止血或钛夹夹闭；对于肺裂伤出血采用3-0或4-0 Prolene线缝合或用内镜切割闭合器切除毁损的肺组织。若多根多处骨折伴有明显骨折移位或骨折断端刺伤肺组织，可同时对骨折的肋骨行复位内固定。彻底止血后用500~1000 ml温无菌生理盐水冲洗胸腔，嘱麻醉医师用呼吸机鼓肺无漏气后逐层关胸，从观察孔留置胸腔引流管一根并连接水封瓶。(2)开胸手术组：麻醉方式同VATS组。通常选择手术侧第5或6肋间隙做标准后外侧切口，也可根据不同的损伤部位灵活选择开胸切口。胸腔内止血、处理及留置胸腔引流管与VATS组一致。
1.2.2 围术期管理
入院后所有患者均行胸部CT检查，评估胸部损伤情况及血胸量，对于血胸量≥500 ml或因合并气胸肺压缩>30%的患者术前行胸腔闭式引流以保证安全。血胸量通过胸部CT扫描评估，并由公式V=d2×L计算得出，V为血胸量(单位：cm3，等同于ml)，d为CT层面上血胸最大深径，L为血胸在CT上的头尾长度[15]。术前均给予二代头孢抗生素预防感染。术后所有患者均进入ICU病房观察，如患者自主呼吸恢复、生命体征平稳、无出血倾向，可转回普通病房治疗。每天对胸腔引流管的引流量进行记录。胸腔引流管的拔除指征为：24 h内胸管引流量<100 ml，无明显气泡溢出，复查胸部CT显示无明显胸腔积液及气体残留。
1.2.3 数据收集、结果评定及指标分析
收集并比较两组患者的术前指标，如年龄、性别、基础疾病、简明损伤定级(AIS)、损伤严重度评分(ISS)、格拉斯哥评分(GCS)、损伤类型、气胸及血胸情况、肋骨骨折数目、受伤至手术时间等；术中及术后指标，如手术情况(手术持续时间、出血来源、有无行肋骨骨折复位内固定)、ICU时间、术后引流时间、术后胸腔引流管总引流量、总住院时间、术后住院时间及并发症情况[包括残留血胸(retained hemothorax，RH)、气胸、严重肺不张、切口感染、脓胸、出血、呼吸衰竭等]。并将年龄、性别、损伤类型、基础疾病、AIS、ISS、GCS、肋骨骨折数量、气胸、血胸量、双侧血胸、出血来源、肋骨骨折复位内固定、受伤至手术时间等基线数据进行1:1 PSM后，对比两组的治疗效果。
1.3 统计学处理
采用STATA 15.0软件进行统计分析。符合正态分布的计量资料以$\bar{x}±s$表示，两组间比较采用独立样本t检验；计数资料或等级资料以例(%)表示，组间比较采用χ2检验。对两组患者进行1:1 PSM后对比两组的治疗效果，并通过多因素logistic回归分析术后并发症的危险因素。P<0.05为差异有统计学意义。
2 结果
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2.1 PSM前结果
2.1.1 两组患者术前基线指标的比较
两组患者在年龄、AIS、ISS、GCS、气胸、双侧血胸、术前基础疾病、受伤至手术时间等方面差异无统计学意义(P>0.05)；开胸手术组中男性比例及钝性伤比例高于VATS组(分别为89.3% vs. 79.1%，88.6% vs.71.4%)，肋骨骨折数目明显多于VATS组[(6.30±2.90)根 vs. (4.25±3.31)根]，而血胸量少于VATS组[(500.38±313.94) ml vs. (596.37±358.05) ml]，差异均有统计学意义(P<0.05)(表1)。
2.1.2 两组病例术中及术后指标
VATS组的手术持续时间、ICU时间、术后引流时间、总住院时间及术后住院时间均较开胸手术组短，差异有统计学意义(P<0.001)；VATS组较开胸手术组术中进行肋骨骨折复位内固定的比例低，差异有统计学意义(54.9% vs. 87.8%，P<0.001)；VATS组术后胸腔总引流量明显少于开胸手术组，差异有统计学意义[(603.19±354.78) ml vs. (978.41±691.91) ml，P<0.001]；两组的肺实质及肋间血管出血比例(即出血来源)相似，差异无统计学意义(P=0.822)。222例中有49例(22.1%)出现术后并发症，其中开胸手术组37例(28.2%)，VATS组12例(13.2%)。开胸手术组并发症发生率高于VATS组(P=0.008)，且有多个病例出现两种及以上并发症，多个病例需通过两次及以上干预才得到治愈。其中，5例术后出现2种并发症，1例出现3种并发症，5例术后因RH实施了2次胸腔闭式引流，1例术后因RH实施了3次胸腔闭式引流，2例因开胸手术后胸腔内出血行二次手术，1例因开胸术后呼吸衰竭死于入院后第4天。而VATS组中术后并发症均经一次处置治愈，仅1例因VATS下肋膈角处肋间血管出血无法缝合而中转开胸手术(P=0.008)(表2)。
2.2 PSM后结果
2.2.1 PSM结果
对VATS组及开胸手术组病例进行1:1 PSM后，VATS组60例与开胸手术组60例成功配对，配对后两组病例在损伤类型、血胸量、单双侧血胸、气胸、基础疾病(慢性阻塞性肺疾病、糖尿病、脑血管疾病、心脏疾病)、GCS、出血来源、AIS、受伤至手术时间、ISS、年龄、性别、肋骨骨折数目、肋骨骨折复位内固定等基线数据方面均衡，差异无统计学意义(P>0.05)(图1、表3)。
2.2.2 两组患者术中及术后指标比较
VATS与开胸手术组在总住院时间[(10.47±2.88) d vs.(12.42±5.71) d，P=0.076]及术后并发症发生率(15.0%vs. 18.3%，P=0.624)比较差异无统计学意义；VATS组的手术持续时间、术后引流时间、ICU时间、术后住院时间较开胸手术组短，术后胸腔总引流量也少，差异均有统计学意义(P<0.05)(表4)。
2.3 多因素分析结果
多因素logistic回归分析结果显示，无论PSM前后，手术方式、性别、损伤类型、血胸量、肋骨骨折数目、肋骨骨折复位内固定及受伤至手术时间均与术后并发症无明显相关性(P>0.05，表5)。
3 讨论
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本研究两组患者在PSM前，VATS的术后并发症发生率明显低于开胸手术组；PSM后，虽然两组并发症发生率差异无统计学意义，但开胸手术组中有5例因合并2种及2种以上并发症须进行多次处置，即开胸手术组的并发症严重程度较VATS组更重。传统上，开胸手术用于大量血胸或进行性出血的紧急救治，但因对创伤患者实施临床试验的难度及伦理问题，其治疗标准未得到高级别RCT研究的证实，而是根据专家意见制定的[9,15]。血胸量大小是创伤性血胸治疗方式选择的考虑因素之一，但手术的选择更应该根据患者的损伤情况、生命体征及身体状况综合考虑[3,15-17]。开胸手术因其自身创伤大的缺点，除急诊抢救或治疗脓胸、纤维胸外，不宜广泛应用于创伤性血胸的治疗[9,14,18]。VATS可弥补开胸手术的不足，在早期应用中具有潜在的优势。VATS治疗创伤性血胸不仅可清除胸腔内积血，还可早期明确诊断、处理胸腔内损伤，并预防RH的发生[19]。
本研究中80例(36.0%)因肺裂伤或肋间血管出血而进行了修补、结扎，181例钝性损伤所致的创伤性血胸病例中165例(91.2%)进行了肋骨骨折复位内固定。创伤性血胸的发生率随肋骨骨折数量的增多而逐渐增高，更多的肋骨骨折数目提示更严重的胸腔内损伤[20-21]。本研究发现，在PSM前开胸手术组钝性损伤患者和肋骨骨折数目更多，这可能是导致其术后并发症更多的原因之一。处理血胸的同时对肺裂伤进行修补或对骨折的肋骨进行复位内固定可明显缩短住院时间并减少术后并发症的发生[12,22-23]。与开胸手术相比，VATS下进行肋骨骨折复位内固定及肺修补具有切口定位清晰、切口小、术后疼痛轻等优点[22]。也有研究认为，VATS应用于肋骨骨折合并血胸的老年人更具有优势，不仅可改善患者的肺功能，减轻疼痛，还可减少术后并发症[24]。
手术医师可根据自己的习惯选择单孔、单操作孔或传统三孔胸腔镜手术，胸腔镜的30°镜头较开胸手术更有利于观察胸壁、胸膜顶及膈肌角周围的损伤。对于穿透性损伤，VATS还可通过原有伤道进行手术，能进一步避免二次创伤[25]。Ben-Nun等[26]发现，胸部创伤中1/3的出血来源于损伤的胸壁和肺实质，与本研究结果相似，肺实质损伤或肋间血管出血者占36.0%(80/222)。大多数由肺损伤、肋间血管和胸膜壁层损伤引起的出血可通过VATS进行有效处理。对于VATS难以控制的出血，不能盲目处理，应及时转为开胸手术。本研究中有1例出血位置为肋膈角处的肋间血管，因角度及器械问题导致通过VATS无法缝合而中转为开胸手术。此问题可通过优化切口位置及改良器械避免。
VATS在创伤性血胸的治疗中具有许多优点，如术后疼痛轻、恢复快、总医疗费用低等[14,27]。一项包含18项研究的系统评价结果表明，早期使用胸腔镜治疗创伤性血胸可降低脓胸发生率、缩短住院时间及降低医疗费用[28]。另一项荟萃分析也发现，VATS的治疗效果明显优于开胸手术，引流时间及住院时间短，且术中出血和输血少[14]。对于血流动力学稳定的患者，不管损伤机制是什么，无论是钝性伤、枪弹伤、刀刺伤、交通事故伤、跌倒伤还是击打伤，在开胸手术前先进行VATS探查是安全的[19]。在PSM前，本研究中VATS组无一例出现脓胸或行二次手术，而开胸手术组术后出现3例脓胸，还有2例因术后出血行二次手术。在PSM前后，VATS组的ICU时间、引流时间、术后住院时间均短于开胸手术组，术后胸腔总引流量也较少，提示通过VATS治疗创伤性血胸更有利于术后恢复。为了进一步探讨两种治疗方式对创伤性血胸的治疗效果，本研究对PSM前后的数据分别进行了多因素分析，包括手术方式在内的指标均与术后并发症无明显相关性，进一步说明VATS对血流动力学稳定的创伤性血胸的治疗效果与传统开胸手术相当。
综上所述，对于血流动力学稳定的创伤性血胸而言，应用VATS是安全有效的，可在避免传统开胸手术巨大创伤的同时，加快患者术后恢复、缩短术后住院时间。
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doi: 10.11855/j.issn.0577-7402.2021.09.16
  • 接收时间：2021-05-26
  • 首发时间：2025-12-19
  • 出版时间：2021-09-28
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  • 收稿日期：2021-05-26
  • 修回日期：2021-06-29
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    1解放军联勤保障部队第962医院胸外科，哈尔滨 150000
    2空军军医大学第二附属医院胸外科，西安 710038

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2种不同金属材料的力学参数
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species		 占总种数比例
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total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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