经内科胸腔镜胸膜病变活检对结核性胸膜炎的诊断价值  

The diagnostic value of pleural biopsy by medical thoracoscopy in tuberculous pleural effusions

作　　者：张芸 姜广路[3] 王冲 段鸿飞[1] 梁清涛[1] 李华[1] 杨扬[1] 郭超[1] 邵玲玲 陈效友 杨新婷[1] ZHANG Yun;JIANG Guang-lu;WANG Chong;DUAN Hong-fei;LIANG Qing-tao;LI Hua;YANG Yang;GUO Chao;SHAO Ling-ling;CHEN Xiao-you;YANG Xin-ting(不详;Beijing Chest Hospital,Capital Medical University,Beijing 101149,China)

机构地区：[1]首都医科大学附属北京胸科医院,101149 [2]首都医科大学附属北京地坛医院 [3]北京市结核病胸部肿瘤研究所

出　　处：《中国防痨杂志》2020年第11期1158-1164,共7页Chinese Journal of Antituberculosis

基　　金：北京市医院管理局“登峰”计划专项经费资助(DFL20181601);北京市科学技术委员会重点项目(D181100000418003,Z191100006619078);北京市卫生和计划生育委员会北京市卫生与健康科技成果和适宜技术推广项目(2018-TG-43)

摘　　要：目的评价经内科胸腔镜胸膜病变活检对结核性胸膜炎的诊断价值及安全性。方法2015年6月至2018年10月,首都医科大学附属北京胸科医院、首都医科大学附属北京朝阳医院、北京积水潭医院、卫生部北京医院等4家临床中心采用前瞻性多中心诊断试验方法,对参照入组标准顺序纳入的229例不明原因胸腔积液的入院患者行内科胸腔镜检查,并对活检留取胸膜病变组织标本行结核分枝杆菌GeneXpert MTB/RIF(简称“GeneXpert”)和BACTEC MGIT 960培养(简称“MGIT 960”)及常规病原学检测和病理学检查。结果229例患者经内科胸腔镜取胸膜活检组织行病理学和病原学检查结果显示,临床不能明确诊断者23例(10.0%),确诊者为206例(90.0%),其中129例(56.3%)确诊为结核性胸膜炎,77例(33.6%)诊断为其他原因所致的胸腔积液。胸膜活检组织经GeneXpert或MGIT 960检测结核感染的阳性率[分别为27.9%(64/229)和17.0%(39/229)]与病理学检测阳性率[(23.1%,53/229)]比较,差异无统计学意义(χ^2=1.32,P=0.251;χ^2=2.67,P=0.103);但GeneXpert+MGIT 960联合检测的阳性率[32.8%(75/229)]明显高于传统病理学检测(χ^2=5.25,P=0.022)。结核性胸膜炎患者的胸腔镜镜下特征性表现在纤维粘连带[70.5%(91/129)]、弥漫性粟粒结节状病灶[41.1%(53/129)]、纤维素沉积[40.3%(52/129)]等方面均明显高于其他原因胸腔积液者[分别为32.5%(25/77)、6.5%(5/77)、15.6%(12/77)],但散在多发结节状病灶[26.4%(34/129)]明显低于其他原因胸腔积液者[53.2%(41/77)](χ^2=28.41、28.52、24.42、15.06,P值均=0.000)。229例患者胸腔镜术后均未出现严重不良事件,224例(97.8%)有轻中度胸痛,口服止痛药2~3 d后可缓解;134例(58.5%)活检部位有少量出血,107(46.7%)例局部皮下气肿,均未给予特殊处理,拔管后2~3 d内吸收;仅2例患者术后出现脓胸,引流管留置14 d后行胸腔镜胸膜剥离术,随访6个月后均安全拔管。结论内科胸腔镜镜�Objective To evaluate the diagnostic value of pleural biopsy in tuberculous pleural effusions by medical thoracoscopy.Methods A total of 229 patients with undiagnosed pleural effusions in the four Beijing clinical centers including Beijing Chest Hospital,Beijing Chaoyang Hospital,Beijing Jishuitan Hospital and Beijing Hospital from Jun 2015 to Oct 2018 were enrolled as the subjects in this large sample and multi-central prospective clinical trial.All patients were given medical thoracoscopy and the pleural biopsy specimen were collected.A routine pathological examination of the pleural biopsy specimen was firstly conducted for each patient.Then,both GeneXpert MTB/RIF assay and BACTEC MGIT 960 liquid culture detentions were performed using the suspension of the other part of pleural specimen after grinding.Results Of the 229 patients,129 patients(56.3%)were confirmed with tuberculous pleurisy,77 patients(33.6%)were non-tuberculosis pleural effusion and 23(10.0%)patients were still undiagnosed by the medical thoracoscopy.In comparison with the routine pathological examination(23.1%,53/229),there was no significant difference in the positive rate of Mycobacterim tuberculosis infection detected by GeneXpert MTB/RIF(27.9%(64/229))or BACTEC MGIT 960 liquid culture(17.0%(39/229))(χ^2=1.32,P=0.251;χ^2=2.67,P=0.103).However,combined with the two detection methods,the positive rate of Mycobacterim tuberculosis infection(32.8%(75/229))was significantly superior to the routine pathological examination(χ^2=5.25,P=0.022).The appearances of fibrous adhesions(70.5%,91/129),diffuse miliary nodules(41.1%,53/129)and fibrinous exudate(40.3%,52/129)under the medical thoracoscopy were showed significantly higher in tuberculous pleurisy than that(32.5%(25/77),6.5%(5/77),15.6%(12/77))in non-tuberculosis pleural effusion.Moreover,the appearance of scattered multiple nodular lesions(26.4%,34/129)were markedly lower than that in non-tuberculosis pleural effusion(53.2%(41/77))(χ^2=28.41,28.52,24.42,15.06;Ps=0.000).Of the 229 patients,no

关 键 词：胸腔镜检查 结核 胸膜 活组织检查 诊断技术和方法 前瞻性研究 

分 类 号：R521.9[医药卫生—内科学]