ﻣﻘﺎﻳﺴﺔ ﻧﺘﺎﻳﺞ درﻣﺎن ﻃﺒﻲ ﺑﺎ درﻣﺎن ﺟﺮاﺣﻲ در ﮔﺮوﻫﻲ از ﺑﻴﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺑﺮوﻧﺸﻜﺘﺎزي

Results of the Surgical Treatment Versus Medical Treatment in a Group of Patients with Bronchiectasis

ﺯﻣﻴﻨﻪ ﻭ ﻫﺪﻑ: ﭘﻴﺸﺮﻓﺖ ﺩﺭ ﺩﺭﻣﺎﻥ ﻫﺎﻱ ﺁﻧﺘﻲ ﺑﻴﻮﺗﻴﻜﻲ، ﻭﺍﻛﺴﻴﻨﺎﺳﻴﻮﻥ ﻭ ﺑﻬﺪﺍﺷﺖ ﻋﻤﻮﻣﻲ ﺑﺎﻋﺚ ﺷﺪﻩ ﺍﺳﺖ ﻛﻪ ﺍﻣﺮﻭﺯﻩ ﻧﺴﺒﺖ ﺑﻪ ﮔﺬﺷﺘﻪ ﻣﻮﺍﺭﺩ ﺑﺴﻴﺎﺭ ﻛﻤﺘﺮﻱ ﺍﻋﻤﺎﻝ ﺟﺮﺍﺣﻲ ﺑﺮﺍﻱ ﺩﺭﻣﺎﻥ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ ﺻﻮﺭﺕ ﮔﻴﺮﺩ، ﺍﺯ ﻃﺮﻓﻲ ﺑﻪ ﻧﻈﺮ ﻣﻲ ﺭﺳﺪ ﻛﻪ ﺑﺎ ﭘﻴﺸﺮﻓﺖ ﻫﺎﻳﻲ ﻛﻪ ﺩﺭ ﺭﻭﺵ ﻫﺎﻱ ﺟﺮﺍﺣﻲ ﺭﻳﻪ ﺻﻮﺭﺕ ﮔﺮﻓﺘﻪ ﺍﺳﺖ، ﺍﻣﺮﻭﺯﻩ ﺑﺘﻮﺍﻥ ﺍﺯ ﺟﺮﺍﺣﻲ ﺩﺭ ﺩﺭﻣﺎﻥ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ ﻧﺘﺎﻳﺞ ﺑﻬﺘﺮﻱ ﺑﻪ ﺩﺳﺖ ﺁﻭﺭﺩ. ﺍﻳﻦ ﻣﻮﺿﻮﻉ ﻫﻢ ﺍﺯ ﻃﺮﻑ ﭘﺰﺷﻜﺎﻥ ﻣﻌﺎﻟﺞ ﻭ ﻫﻢ ﺍﺯ ﻃﺮﻑ ﺑﻴﻤﺎﺭﺍﻥ ﻣﻮﺭﺩ ﺗﻮﺟﻪ ﻛﺎﻓﻲ ﻗﺮﺍﺭ ﻧﮕﺮﻓﺘﻪ ﺍﺳﺖ. ﻟﺬﺍ ﻣﺎ ﺭﻭﺵ ﺩﺭﻣﺎﻥ ﻭ ﻧﺘﺎﻳﺞ ﺧﻮﺩ ﺭﺍ ﺩﺭ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ ﺍﺭﺍﺋﻪ ﻭ ﻣﻮﺭﺩ ﺗﺠﺰﻳﻪ ﻭ ﺗﺤﻠﻴﻞ ﻗﺮﺍﺭ ﻣﻲ ﺩﻫﻴﻢ. ﻣﻮﺍﺩ ﻭ ﺭﻭﺵ ﻫﺎ: ﻛﻠﻴﻪ ﺑﻴﻤﺎﺭﺍﻧﻲ ﻛﻪ ﺑﺮﺍﻱ ﺩﺭﻣﺎﻥ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ ﺩﺭ ﻃﻲ ﻣﺪﺕ 7/5 ﺳﺎﻝ ﻓﺮﻭﺭﺩﻳﻦ 1378 ﺗﺎ ﺷﻬﺮﻳﻮﺭ 1385 ﺑﻪ ﻣﺎ ﻣﻌﺮﻓﻲ ﺷﺪﻩ ﺨﺶ ﺟﺮﺍﺣﻲ ﺗﻮﺭﺍﻛﺲ ﺑﻴﻤﺎﺭﺳﺘﺎﻥ ﺩﻛﺘﺮ ﻣﺴﻴﺢ ﺩﺍﻧﺸﻮﺭﻱ ﺩﺭ ﺗﻬﺮﺍﻥ( ﻭ ﺑﺴﺘﺮﻱ ﺷﺪﻧﺪ ﻣﻮﺭﺩ ﺑﺮﺭﺳﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﺗﺸﺨﻴﺺ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ ﺑﺮﺍﺳﺎﺱ ﻋﻼﺋﻢ ﺑﺎﻟﻴﻨﻲ ﻭ ﺗﺄﻳﻴﺪ ﺳﻲ ﺗﻲ ﺍﺳﻜﻦ ﺑﻮﺩ. ﺍﻧﺘﺨﺎﺏ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻳﺎ ﻏﻴﺮ ﺟﺮﺍﺣﻲ ﺑﺮﺍﺳﺎﺱ ﻭﺟﻮﺩ ﺍﻧﺪﻳﻜﺎﺳﻴﻮﻥ ﻫﺎﻱ ﻣﻌﻤﻮﻝ ﺩﺭ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ، ﺷﺮﺍﻳﻂ ﻋﻤﻮﻣﻲ ﺑﻴﻤﺎﺭ ﻭ ﺍﻧﺘﺨﺎﺏ ﺧﻮﺩ ﺑﻴﻤﺎﺭ ﺻﻮﺭﺕ ﮔﺮﻓﺖ. ﭘﺎﺳﺦ ﺑﻪ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻭ ﻏﻴﺮ ﺟﺮﺍﺣﻲ ﺩﺭ ﺍﻳﻦ ﺑﻴﻤﺎﺭﺍﻥ ﺍﺯ ﻃﺮﻳﻖ ﻣﺮﺍﺟﻌﻪ ﺑﻪ ﭘﺮﻭﻧﺪﻩ ﺑﻴﻤﺎﺭ، ﻣﻌﺎﻳﻨﺎﺕ ﺑﺎﻟﻴﻨﻲ ﺩﺭ ﺩﺭﻣﺎﻧﮕﺎﻩ ﻭ ﻧﻴﺰ ﭘﺮﺳﺶ ﺗﻠﻔﻨﻲ ﺍﺭﺯﻳﺎﺑﻲ ﺷﺪﻩ ﻭ ﺩﺭ ﺳﻪ ﮔﺮﻭﻩ ﺧﻼﺻﻪ ﺷﺪ: ﺍـ ﺧﻮﺏ: ﺑﻴﻤﺎﺭﺍﻧﻲ ﺑﻮﺩﻧﺪ ﻛﻪ ﺩﺭ ﺁﻧﻬﺎ ﺑﻌﺪ ﺍﺯ ﺩﺭﻣﺎﻥ، ﺧﻠﻂ ﻭ ﺳﺎﻳﺮ ﻋﻼﺋﻢ ﺍﺻﻠﻲ ﺑﻄﻮﺭ ﻛﺎﻣﻞ ﺑﺮﻃﺮﻑ ﺷﺪﻩ، 2ـ ﺭﺿﺎﻳﺖ ﺑﺨﺶ: ﺑﻴﻤﺎﺭﺍﻧﻲ ﻛﻪ ﻋﻼﺋﻢ ﻓﻮﻕ ﺑﻪ ﻣﻘﺪﺍﺭ ﻗﺎﺑﻞ ﺗﻮﺟﻬﻲ ﻛﻤﺘﺮ ﺷﺪﻩ ﻭ ﺑﻴﻤﺎﺭ ﺍﺯ ﺩﺭﻣﺎﻥ ﺭﺍﺿﻲ ﺑﻮﺩ، 3ـ ﺑﺪ: ﺑﻴﻤﺎﺭﺍﻧﻲ ﻛﻪ ﻋﻼﺋﻢ ﺗﻐﻴﻴﺮ ﻭﺍﺿﺤﻲ ﻧﻜﺮﺩﻩ ﻭ ﺑﻴﻤﺎﺭ ﺍﺯ ﻧﺘﻴﺠﻪ ﺩﺭﻣﺎﻥ ﺭﺍﺿﻲ ﻧﺒﻮﺩ. ﺭﻭﺵ ﺟﺮﺍﺣﻲ ﻋﺒﺎﺭﺕ ﺑﻮﺩ ﺍﺯ ﺗﻮﺭﺍﻛﻮﺗﻮﻣﻲ ﭘﻮﺳﺘﺮﻭﻻﺗﺮﺍﻝ ﺗﺤﺖ ﻭﻧﺘﻴﻼﺳﻴﻮﻥ ﻳﻚ ﺭﻳﻪ ﺑﺎ ﺍﺳﺘﻔﺎﺩﻩ ﺍﺯ ﻟﻮﻟﻪ ﺩﺍﺑﻞ ﻟﻮﻣﻦ ﻭ ﺍﻧﺠﺎﻡ ﺭﺯﻛﺴﻴﻮﻥ ﻫﺎﻱ ﺁﻧﺎﺗﻮﻣﻴﻚ ﻟﻮﺑﺎﺭ ﻳﺎ ﺳﮕﻤﻨﺘﺎﻝ. ﺭﻭﺵ ﺩﺭﻣﺎﻥ ﻃﺒﻲ ﻋﺒﺎﺭﺕ ﺑﻮﺩ ﺍﺯ: ﻓﻴﺰﻳﻮﺗﺮﺍﭘﻲ، ﺁﻣﻮﺯﺵ ﺩﻓﻊ ﺧﻠﻂ، ﺗﺠﻮﻳﺰ ﺁﻧﺘﻲ ﺑﻴﻮﺗﻴﻚ، ﻭﺍﻛﺴﻴﻨﺎﺳﻴﻮﻥ ﺑﺮ ﻋﻠﻴﻪ ﺁﻧﻔﻮﻻﻧﺰﺍ ﻭ ﭘﻨﻮﻣﻮﻛﻮﻙ. ﻣﻄﺎﻟﻌﻪ ﺍﺯ ﻧﻮﻉ ﺗﻮﺻﻴﻔﻲ ﻭ ﺗﺤﻠﻴﻠﻲ ﺑﻮﺩﻩ، ﺍﻃﻼﻋﺎﺕ ﻭﺍﺭﺩ ﺑﺮﻧﺎﻣﻪ Access ﺷﺪﻩ ﻭ ﺑﺮﺭﺳﻲ ﺁﻣﺎﺭﻱ ﻧﻴﺰ ﺍﺯ ﻃﺮﻳﻖ ﻫﻤﺎﻥ ﺑﺮﻧﺎﻣﻪ ﻭ ﻧﺮﻡ ﺍﻓﺰﺍﺭ SPSS ﺍﻧﺠﺎﻡ ﺷﺪ. ﺑﺮﺍﻱ ﻣﻘﺎﻳﺴﺔ ﻛﻴﻔﻲ ﻧﺘﺎﻳﺞ ﺩﺭﻣﺎﻥ ﺍﺯ ﺁﺯﻣﻮﻥ ﻫﺎﻱ Fisher’s Exact Testﻭ Chi-Square ﺍﺳﺘﻔﺎﺩﻩ ﺷﺪ. ﻣﻴﺎﻧﮕﻴﻦ ﺯﻣﺎﻥ ﭘﻴﮕﻴﺮﻱ 35/9 ﻣﺎﻩ ﺑﻮﺩ )ﻣﺤﺪﻭﺩﻩ 1 -96 ﻣﺎﻩ(. ﻳﺎﻓﺘﻪ ﻫﺎ: ﺗﻌﺪﺍﺩ 83 ﺑﻴﻤﺎﺭ ﺑﺮﺭﺳﻲ ﺷﺪﻧﺪ48 ﺯﻥ، 35 ﻣﺮﺩ، ﻣﻴﺎﻧﮕﻴﻦ ﺳﻨﻲ 37/8 ﺳﺎﻝ ﺑﺎ ﻣﺤﺪﻭﺩﺓ ﺳﻨﻲ 8-71 ﺳﺎﻝ(. ﭼﻬﻞ ﺑﻴﻤﺎﺭ ﺗﺤﺖ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﻭ 43 ﺑﻴﻤـﺎﺭ ﺗﺤـﺖ ﺩﺭﻣﺎﻥ ﻃﺒﻲ ﻗﺮﺍﺭ ﮔﺮﻓﺘﻨﺪ. ﺩﺭ ﺑﻴﻤﺎﺭﺍﻥ ﺟﺮﺍﺣﻲ ﺷﺪﻩ ﻧﺘﺎﻳﺞ ﻋﺒﺎﺭﺕ ﺑﻮﺩ ﺍﺯ: ﺧﻮﺏ 16 ﻧﻔﺮ )55/2%(، ﺭﺿﺎﻳﺖ ﺑﺨﺶ 10 ﻧﻔﺮ )34/5%(، ﺑـﺪ2 ﻧﻔـﺮ )6/90 %(. ﻧﺘـﺎﻳﺞ ﺩﺭﻣـﺎﻥ ﻃﺒـﻲ ﻋﺒﺎﺭﺕ ﺑﻮﺩ ﺍﺯ: ﺧﻮﺏ 4 ﻧﻔﺮ )13/8%(، ﺭﺿﺎﻳﺖ ﺑﺨﺶ 11 ﻧﻔﺮ )37/9%(، ﺑﺪ 13 ﻧﻔﺮ )44/8%(. ﺩﺭ ﻫﺮ ﮔﺮﻭﻩ ﻳﻚ ﻣﻮﺭﺩ ﻣﺮﮒ ﺩﺭ ﻃﻲ ﻣﺪﺕ ﺩﺭﻣﺎﻥ ﺍﺗﻔﺎﻕ ﺍﻓﺘﺎﺩ. ﺩﺭ ﮔﺮﻭﻩ ﺩﺭﻣﺎﻥ ﻃﺒﻲ ﺩﺭ 14 ﺑﻴﻤﺎﺭ ﻭ ﺩﺭ ﮔﺮﻭﻩ ﺟﺮﺍﺣﻲ ﺷﺪﻩ ﺩﺭ 11 ﺑﻴﻤﺎﺭ ﺍﻣﻜﺎﻥ ﭘﻴﮕﻴﺮﻱ ﻛﺎﻣﻞ ﻧﺒﻮﺩ. ﻧﺘﺎﻳﺞ ﺧﻮﺏ ﺩﺭ ﺩﺭﻣﺎﻥ ﺟﺮﺍﺣﻲ ﺑﺎ ﺗﻔﺎﻭﺕ ﻣﻌﻨﻲ ﺩﺍﺭﻱ P=0.002)( ﺑﻬﺘﺮ ﻭ ﻧﺘﺎﻳﺞ ﺑﺪ ﻧﻴﺰ ﺑا ﺗﻔﺎﻭﺕ ﻣﻌﻨﻲ ﺩﺍﺭﻱ P=0.002)( ﻛﻤﺘﺮ ﺑﻮﺩ. ﻧﺘﻴﺠﻪ ﮔﻴـﺮﻱ: ﺩﺭ ﺻﻮﺭﺕ ﻭﺟﻮﺩ ﺷﺮﺍﻳﻂ ﻻﺯﻡ ﺑﺮﺍﻱ ﺍﻧﺠﺎﻡ، ﺟﺮﺍﺣﻲ ﺩﺭ ﺩﺭﻣﺎﻥ ﺑﺮﻭﻧﺸﻜﺘﺎﺯﻱ، ﺍﻳﻦ ﺷﻴﻮﺓ ﺩﺭﻣﺎﻧﻲ ﻧﺴﺒﺖ ﺑﻪ ﺍﺩﺍﻣﻪ ﺩﺭﻣﺎﻥ ﻃﺒﻲ ﻧﺘﺎﻳﺞ ﺑﻬﺘﺮﻱ ﺩﺍﺭﺩ.

Introduction & Objective: Due to the recent advancement in the fields of antibiotic therapy, vaccination, and general health, there is a decreasing number of surgical interventions for the treatment of bronchiectasis. Considering the favorable advances in the field of lung surgery these days, it seems that physicians as well as patients are not acquainted with the surgical methods and the outcome of the surgical treatment of bronchiectasis. Therefore, we present and analyze our results in the surgical treatment of bronchiectasis and compare the results with medical treatment during the same period. Materials & Methods: The study population consisted of all patients who were referred to us (Masih Daneshvari Hospital) and hospitalized for the surgical treatment of bronchiectasis during 7.5 years (March 1999 to September 2006). Surgical or non-surgical treatment was selected according to the usual indications for the treatment of bronchiectasis. Response to treatment was evaluated by referring to the patients' medical records, and outpatient visits. The results were attributed as: Good: Sputum production and other major signs completely disappeared; Satisfactory: Although the signs and symptoms had not totally disappeared, the patient was satisfied with the treatment results; Poor: No significant changes were detected in the major signs and symptoms. Technique of surgery was posterolateral thoracotomy under one lung ventilation, and performing lobar or segmental resections. Medical treatment included physiotherapy, antibiotic administration and vaccination against influenza and pneumonococcus. Statistical analysis was performed by using Access and SPSS software. Fisher’s exact test and Chi-Square tests were used for qualitative comparison of the results. Mean duration of follow up was 35.9 months (range 1-96 months). Results: Total number of 83 patients were studied (48 females, 35 males, mean age 37.8 yrs, range 8-71), 40 patients underwent surgery while 43 underwent medical treatment. The results of surgery were: good in 16 (55.2%), satisfactory in 10 (34.5%) and poor in 2 (6.9%) patients. The results of medical treatment were good in 4 (13.8 %), satisfactory in 11 (37.9 %), and poor in 13 (44.8%) patients. Good results were significantly better (P=0.002) and poor results were significantly worse (P=0.002) after surgical treatment. In each group, one death occurred during the treatment course. Fourteen patients in medical group and 11 patients in surgical group were lost from follow up. Conclusions: When indicated, surgical therapy offers advantages over medical therapy in the treatment of bronchiectasis.