经后腹膜腹腔镜清除结核性腰大肌脓肿的临床应用  

Clinical application of retroperitoneoscopic surgery for psoas abscess with thoracolumbar tuberculosis

作　　者：张智发[1] 杨晓清[1] 杨全中[1] 胡凡琦 张少甫[1] 张雪松[1] 

机构地区：[1]解放军总医院骨科,北京100853

出　　处：《中华腔镜外科杂志（电子版）》2016年第2期89-92,共4页Chinese Journal of Laparoscopic Surgery(Electronic Edition)

摘　　要：目的探讨经后腹膜入路运用腹腔镜清除结核性腰大肌脓肿的微创治疗的有效性及可行性。方法回顾性分析2010年1月至2014年1月纳入研究的35例行经后腹膜入路运用腹腔镜清除结核性腰大肌脓肿患者的微创治疗情况。纳入研究的所有患者无明显神经功能障碍,不合并严重的脊柱畸形,所有患者术前均进行抗结核治疗至少2周。脊柱结核性腰大肌脓肿诊断依据为临床症状及体征、化验指标、病变部位的CT及MRI检查、试验性抗结核药物治疗有效。对35例胸腰段脊柱结核合并腰大肌脓肿患者,进行经腹膜后入路腹腔镜下脓肿清除、脓苔壁刮除、局部抗结核药灌洗。术中留病理标本进行抗酸杆菌染色、结核杆菌培养,病理结核杆菌培养证实所有患者均为结核性腰大肌脓肿。术后继续进行局部抗结核药物灌洗及全身抗结核治疗,监测血细胞沉降率,定期复查胸腰段X线及MRI。结果所有患者术后发热及腰背痛等临床症状明显缓解,术后1周、3个月复查时血细胞沉降率分别为(27.0±11.0)mm/h、(18.0±7.0)mm/h,与术前血细胞沉降率[(65.5±30.8)mm/h]比较,差异有统计学意义(P<0.05)。随访期至少12个月[(21±9)个月],随访期间1例脓肿复发,1例窦道形成,其他患者未见脓肿复发及其他重大并发症。结论经后腹膜入路运用腹腔镜清除结核性腰大肌脓肿可以彻底清除腰大肌脓肿及脓肿苔壁,配合局部及全身的抗结核化疗可以迅速遏制脊柱结核病情发展及腰大肌脓肿复发;与开放病灶清除术相比,手术时间、术中出血量、复发率、全身化疗时间均有明显的优势。对于不合并严重脊柱畸形和神经症状的脊柱结核腰大肌脓肿患者,应该首选后腹膜入路运用腹腔镜清除结核性腰大肌脓肿。Objective To investigate efficacy and feasibility of minimally invasive retroperitoneoscopic surgery( MIS) for psoas abscess( PA) with thoracolumbar tuberculosis. Methods Since Jan. 2010 to Jan. 2014,retrospectively,35 patients of the diagnosis of PA with thoracolumbar tuberculosis received the debridement of psoas abscesses and cavity walls of abscesses by the retroperitoneoscopic technique( MIS) in combination with anti-tuberculosis chemotherapy. Inclusion criteria: psoas abscess with thoracolumbar tuberculosis without severe neural deficit and obvious spinal deformity after the total evaluation of X-ray and physical examination. For all the suspected patients preoperatively,the diagnoses of PA associated with tuberculous thoracolumbar spondylitis were made on the evidences of clinical symptoms such as mild fever,night-sweats,weight loss and laboratory examinations as well as examinations such as X-ray,computed tomography( CT),and magnetic resonance imaging( MRI).The diagnoses of tuberculosis-induced PA were confirmed by pathological examination,acid-fast stain and / or culture of mycobacterium tuberculosis. All the patients took at least 2 weeks experimental anti-tuberculosis therapy preoperatively. ESR and x-ray,MRI were examined in the follow-up. Results Immediately relief in clinical symptoms and signs and amelioration in imaging and laboratory examinations were obviously observed in all the patients. One week and three months postoperative,ESR was( 27. 0 ± 11. 0) mm / h、( 18. 0 ± 7. 0) mm/h respectively. Statistical analysis demonstrated that there was significant difference between pre-and postoperative ESR [( 65. 5 ± 30. 8) mm / h]( P < 0. 05). The first patient of MIS in our group had a recurrent abscess in the follow-up of 9 months postoperative due to dissemination of tuberculous abscess. One patients developed a sinus after operation. The follow-up had proceeded for at least 12 months[( 21 ± 9) months]. No complication was observed during the follow-up postoperatively. Conclusions The retroperi

关 键 词：脊柱结核 腰大肌脓肿 腹腔镜后腹膜入路 微创手术 脓肿腔壁清除 

分 类 号：R687.3[医药卫生—骨科学]