“精准医疗”理念下单孔VATS肺癌根治术的发展现状、应用细节和展望

单孔电视胸腔镜手术（uni-portal uideo-assisted thoracic surgery, Uni-VATS）的推广,是近年微创胸外科最重大的进展之一。随着腔镜下成像设备、切割缝合器械及电分离器械的改进,单孔VATS的应用范围已从最初的肺组织活检术逐渐扩大到解剖性肺叶/段切除、全肺切除、支气管/血管袖式吻合。多中心大量报道已证实：单孔VATS行肺叶切除安全、可行,清扫纵隔淋巴结的组数及总数均不低于传统多孔VATS,在疼痛、创伤及术后恢复方面也有积极的结果。虽然暂未得到多中心、大样本的临床数据如5年生存率,但有序地逐步开展单孔VATS仍是微创胸外科未来发展的重要方向。本文将围绕单孔VATS的原理及具体操作细节,结合肺癌根治术的基本操作理念进行讨论及综述,以期为单孔VATS的有序、规范化开展提出思考和探索。     

无管化麻醉在胸科手术中的应用研究进展

电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）是目前治疗肺癌最常用的微创外科方式,但在提高患者舒适度和促进快速康复方面仍有待改进。一种新的无管化电视胸腔镜手术（tubeless VATS）正在逐渐发展,可以避免给患者使用气管插管、中心静脉导管、硬膜外导管、胸腔引流管和导尿管。Tubeless VATS结合当前最先进、创伤最小的麻醉、视频辅助外科和围术期护理方法,可确保手术的安全性和可行性,并且能够使患者在术后实现早期进食、下床和出院,使胸科日间手术成为可能。Tubeless VATS在肺癌手术乃至胸外科手术中的应用,见证了胸腔镜手术从微创到超微创的发展,使患者从快速康复外科治疗中最大获益。      

单操作孔胸腔镜下微创治疗纵隔肿瘤22例体会

目的：分析单操作孔胸腔镜下微创治疗纵隔肿瘤的临床效果.方法：对22例行胸腔镜手术的纵隔肿瘤患者相关资料进行回顾分析.结果：22例均完全在胸腔镜下完成手术,16例在单孔操作下完成,6例因游离困难加开副操作孔,手术时间30-1 10min,平均65min;术中出血30-200ml,平均100ml;术后胸管引流时间2-4天,平均3天;术后住院时间5-8天,平均6.5天.均顺利恢复出院,无术后出血、气胸、感染、肺不张等并发症.随访1-20个月,未有局部复发.结论：单操作孔胸腔镜下切除纵隔肿瘤可达到双操作孔的手术效果,进一步减少手术创伤,加快术后恢复,可在临床上加以推广应用.     

肺癌外科手术切口的演变与发展趋势

微创、安全以及无瘤原则,是影响肺癌外科手术切口选择的最重要因素。近年来,随着微创技术的进步,逐步出现了单操作孔电视辅助胸腔镜手术（video-assisted thoracic surgery, VATS）、单孔VATS、机器人辅助胸腔镜切除术（robotic-assisted thoracoscopic resection, ARTS）、剑突下单孔VATS、双侧同期VATS肺切除术、跨纵隔单侧进胸双侧肺切除术等新兴入路,特别是单孔VATS,目前在国内外开展已呈燎原之势。本文回顾了肺癌手术切口演变趋势,并对近年来,肺癌外科手术切口的发展趋势予以总结。     

早期非小细胞肺癌外科治疗进展

 外科手术是早期肺癌治疗的首选。肺癌的标准术式是肺叶切除加淋巴结清扫。但淋巴结清扫对肺癌的治疗作用尚存争议。近年来以胸腔镜为代表的微创胸外科技术在临床广泛开展,胸腔镜肺叶切除的安全性已得到认可,但用于肺癌的外科治疗是否能达到如同开胸手术一样的功效,尚未达成共识。医学影像技术进步使更多的早期肺癌得以被发现,对于直径小于2 cm的周围型肺癌,肺段切除或楔形切除能否取代肺叶切除成为此类型肺癌的标准手术方式,还有待新的证据出现。     

Surgical Management of Lung Cancer: History,Evolution, and Modern Advances

Purpose of Review

Although surgery for lung cancer was not common before the early twentieth century, it has enjoyed remarkable progress since then both in type of resection and technical approach. This has been coupled with significant technological advances. Here, we will review the history and evolution of this relatively new field of surgery.

Recent Findings

The gold standard of the extent of resection for lung cancer evolved from pneumonectomy to lobectomy to even sublobar resection for select situations. In addition, major advances have occurred in the technical aspect of the surgical procedure. The incisional approach has evolved from rib spreading thoracotomy to thoracoscopic surgery with the latter showing significant improvement in short-term outcomes over open thoracotomy. However, standard video-assisted thoracoscopic surgery or VATS is associated with visual and mechanical limitations, including lack of depth perception and rigid straight instruments. This makes it appropriate only for early-stage peripheral and small tumors. Most of the limitations of VATS can be overcome with the more recently introduced robotic-assisted thoracic surgery (RATS). RATS utilizes wristed instruments that are introduced in the chest through 8-mm ports and can mimic the movements of the human hand. In addition, magnified, three-dimensional and high definition imaging gives the surgeon an image of the lung unlike any other modality. This has allowed surgeons to perform advanced resections such as pneumonectomy or sleeve resection in a minimally invasive fashion. In addition, RATS has become a platform for the addition of other technical enhancements such as incorporating a near infra-red light source into the camera allowing identification of autoflourescent agents, such as indocyanin green. This has allowed localization of small nodules for resection and identification of tissue planes for sublobar resection. However, new technologies also require investments in time and money.

Summary

Thoracic surgery for lung cancer has evolved to include advanced minimally invasive techniques including video-assisted and robotic-assisted thoracoscopy. RATS in particular may enable surgeons to perform more advanced procedures in a minimally invasive fashion. It is hoped that the higher costs of new surgical technology may be offset by the potential for improved patient outcomes and resultant socioeconomic benefits.

     

加速康复外科联合单孔胸腔镜在肺癌手术中的应用价值

加速康复外科(enhanced recovery after surgery，ERAS)是指在围术期采用一系列具有循证医学证据的优化处理措施，以减轻患者心理和生理的创伤和应激反应，减少术后并发症，缩短住院时间，降低医疗费用，促进患者快速康复。随着胸外科微创技术的不断发展，单孔胸腔镜应运而生，大量临床实践证明在保证肺癌根治性及安全、可行的前提下，单孔胸腔镜肺癌手术在疼痛、创伤等方面具有显著优势。为进一步探讨加速康复外科联合单孔胸腔镜在肺癌手术中的应用价值，现综述如下。     

电视胸腔镜辅助下小切口肺癌手术的临床研究

背景与目的：在世界范围内，胸腔镜下行肺叶切除术治疗肺癌的相关经验正在逐渐积累。很多医学中心可在胸腔镜下完成解剖学上彻底的肺叶切除和淋巴结清扫。一些胸外科医师关注该类手术方式治疗肺癌的安全性、益处和根治性。我们的研究旨在探讨电视胸腔镜辅助小切口根治性肺癌切除的可行性。方法：电视胸腔镜辅助小切口下实施肺叶切除合并淋巴结清扫治疗原发性非小细胞肺癌32例，运用常规开胸手术器械及胸腔镜用器械切除肺叶，结合特殊的淋巴结摘除钳完成淋巴结清扫，并与同期40例肺癌常规开胸手术进行比较研究。结果：胸腔镜组32例肺癌手术顺利，出血少，均无输血，无严重并发症，术后恢复快。与常规组比较在手术时间、术后拔管时间和淋巴结清扫数量、范围无显著差异；术中出血量、术后住院天数胸腔镜组明显优于常规组。结论：电视胸腔镜辅助小切口下肺癌手术安全可行，创伤小，符合肺癌手术原则，长期疗效有待随访观察。     

Robotics — The answer to the Achilles’ heel of VATS pulmonary resection

During the past decade,robotic surgical systems have been increasingly utilized to perform highly complex surgical procedures.In fact,the robotic-assisted approach to the treatment of many gynecological and urological surgical procedures has become the standard-of-care.The use of robotic surgical system in thoracic surgery is in its early development.Video-assisted thoracoscopic surgery(VATS)     

单孔与单操作孔电视辅助胸腔镜手术治疗ⅠA期非小细胞肺癌的临床对比研究

目的 对比研究单孔与单操作孔电视辅助胸腔镜手术治疗ⅠA期非小细胞肺癌(Non-small cell lung cancer,NSCLC)的临床效果。方法 统计哈尔滨医科大学附属肿瘤医院自2015年1月—2015年11月收治的行胸腔镜手术的ⅠA期NSCLC患者的病例资料共81例,其中行单操作孔胸腔镜下肺癌根治术患者51例(对照组),行单孔胸腔镜下肺癌根治术患者30例(观察组),对比两组患者的临床疗效的差异。结果 观察组在切口长度、手术时间、术中失血量、淋巴结清扫个数、术后24h胸引量、胸引管留置时间、住院时间、术后并发症发生率等方面分别为(4.27±0.29)cm、(208.80±61.12)min、(92.33±73.75)mL、(15.62±5.12)个、(401.70±53.31)mL、(6.30±3.01)d、(19.03±5.85)d、13.33%,对照组分别为(3.86±0.23)cm、(184.30±51.36)min、(84.90±80.98)mL、(15.84±5.66)个、(398.00±52.73)mL、(6.10±3.25)d、(18.69±6.81)d、25.49%,观察组与对照组差异不具有统计学意义(P＞0.05)。术后采用视觉模拟评分(VAS)评估患者疼痛,观察组(2.32±0.94)分,对照组为(4.18±0.95)分,观察组疼痛明显减轻(P＜0.05)。结论 单孔胸腔镜手术创伤小,术后患者疼痛明显减轻,单孔胸腔镜手术值得推广。     

放射性核素胶体32p在胸壁小切口胸腔镜治疗Ⅱ期肺癌中的应用

Objective: To study the feasibility of radionuclide colloid ³²p used for the treatment of stage II lung cancer by video enhanced minimal access muscle sparing thoracotomy (VEMAST). Methods: Video assisted thoracoscopic surgery (VATS) was carried out under general anesthesia. A double lumen endobronchial tube was intubated into trachea. One lung ventilation of the healthy side was done during operation. An incision of 8-10 cm long was made along the 4^th or 5^th intercostals. The lobectomy could be performed under VATS. Radionuclide colloid ³²p was injected locally into the area where surgical cleaning of lymph node around was considered to be unsatisfactory or desection of the tumor was not completed. Results: The operation with VEMAST was successful in 29 patients. A conventional lobectomy by thoracotomy had to be done due to unusual bleeding from the pulmonary artery involved during VEMAST in one case and the procedure was interrupted because the pulmonary artery cloud not be separated from the tumor in another patient. There was no dead case or the patient who had any severe complication or adverse response to the radiant. Conclusion: Radionuclide therapy was performed to the treatment of stage II lung cancer with VEMAST in case that surgical resection was considered not to be satisfactory. Minithoractomy assisted with VATS lobectomy and radionuclide colloid ³²p therapy is a safe and effective technique for some selected stage II lung cancer.     

Long-term survival ofearly-stage non-small cell lung cancer patients who underwent robotic procedure：a propensity score-matched study

Background:In the past decade, many researchers focused on to robot?assisted surgery. However, on long?term outcomes for patients with early?stage non–small cell lung cancer (NSCLC), whether the robotic procedure is superior to video?assisted thoracic surgery (VATS) and thoracotomy is unclear. Nonetheless, in the article titled “Long?term survival based on the surgical approach to lobectomy for clinical stage I non–small cell lung cancer: comparison of robotic, video assisted thoracic surgery, and thoracotomy lobectomy” by Yang etal. that was recently published in Annals of Surgery, the authors provided convincing evidence that the robotic procedure results in similar long?term survival as compared with VATS and thoracotomy. Minimally invasive procedures typically result in shorter lengths of hospital stay, and the robotic procedure in particular results in superior lymph node assessment.
Main body:Our propensity score?matched study generated high?quality data. Based on our ifndings, we see prom?ise in expanding patient access to robotic lung resections. In this study, propensity score matching minimized the bias involved between groups. Nevertheless, due to its retrospective nature, bias may still exist. Currently, the concept of rapid rehabilitation is widely accepted, and it is very diffcult to set up a randomized controlled trial to compare robotic, VATS, and thoracotomy procedures for the treatment of NSCLC. Therefore, to overcome this limitation and to minimize bias, the best approach is to use a registry and prospectively collected, propensity score?matched data.
Conclusions:Robotic lung resections result in similar long?term survival as compared with VATS and thoracotomy. Robot?assisted and VATS procedures are associated with short lengths of hospital stay, and the robotic procedure in particular results in superior lymph node assessment. Considering the alarming increase in the incidence of lung can?cer in China, a nationwide database of prospectively collected data available for clinical research would be especially important.     

胸腔镜手术治疗肺癌的现状及趋势

胸腔镜手术治疗肺癌较传统开胸术具有技术和临床上的优势,安全可靠,能够达到根治性的目的,并且创伤小、疼痛轻,围术期并发症发生率低,有助于患者康复以及生活质量的提高。机器人手术、单孔胸腔镜手术及术前定位技术等新的进展都是胸腔镜手术的发展趋势。     

电视胸腔镜手术治疗肺癌的进展

随着医疗技术进步、胸部微创手术不断发展，电视胸腔镜手术（VATS）因治疗肺癌具有创伤小、切口小、疼痛较轻、恢复快等优点而在临床广泛应用，其治疗有效性已经获得医师与患者认可，成为诊疗肺癌主要手段之一。     

全胸腔镜肺癌根治术在治疗高龄患者中的价值

目的探讨全胸腔镜肺叶切除及纵隔淋巴结清扫术在治疗高龄非小细胞肺癌(non-small cell lungcancer,NSCLC)患者中的价值。方法 回顾分析225例接受该术式的NSCLC患者的临床资料,对比38例高龄(≥70岁)与随机抽取的57例非高龄(<70岁)患者的手术创伤、术后恢复、术后并发症及早期预后。结果 两组患者在手术创伤、术后恢复方面无差异;高龄组患者术后心血管并发症发生率高于非高龄组(23.7%vs 1.8%,P=0.001),其余并发症没有增多;术后生存分析两组无差异。结论 该术式治疗高龄NSCLC患者安全可行且疗效良好。     

单操作孔电视胸腔根治术治疗早期肺癌的效果分析

目的 观察单操作孔电视胸腔根治术治疗早期肺癌的效果.方法 60例早期肺癌患者根据不同的手术方法分成进行肋间切口的开放组、双操作孔胸腔镜手术的双孔组、单操作孔胸腔镜手术的单孔组,分别对3组患者的肺功能、并发症例数和手术情况进行比较,采取统计分析.结果 单孔组、双孔组和开放组肺感染(χ2=6.234,P=0.044)和肺不张(χ2=5.089,P=0.079)的发生率比较,具有统计学差异;3组患者在住院总时间(F=3.252,P=0.046)、卧床时间(F=4.033,P=0.023)、手术时间(F=7.817,P=0.001)、术后引流量(F=3.495,P=0.037)、术中出血量(F=3.204,P=0.048)以及NRS评分(F=3.590,P=0.034)方面的比较,均具有统计学差异;3组患者的PEF(F=3.495,P=0.037)和FEV1/FVC%(F=3.353,P=0.042)之间的比较,具有统计学差异.结论 单操作孔电视胸腔根治术能有效改善肺功能、促进术后恢复、减小手术创伤、减少术后并发症,是有效治疗早期肺癌且安全的手术方法.     

电视胸腔镜与开胸肺癌切除淋巴结清扫的对比研究

目的：探讨电视胸腔镜肺癌切除术淋巴结清扫的彻底性和完全性。方法：50例准备常规开胸切除的肺癌患者先采用电视胸腔镜行肺叶切除＋纵隔淋巴结清扫术,随后再接受同组医师的开胸肺门纵隔淋巴结清扫。对开胸后清扫的淋巴结单独标注、计数后送组织病理学检查。结果：50例胸腔镜肺癌切除淋巴结清扫术后,开胸重新清扫淋巴结数共48枚,每例0枚～3枚,平均0．96枚。病理检查全部未查见癌细胞转移。结论：电视胸腔镜肺癌切除淋巴结清扫是彻底的、完全的。     

胸腔镜与传统开胸手术对肺癌患者T淋巴细胞亚群和NK细胞的影响

目的:比较两种手术方法对肺癌患者免疫功能的影响进而从免疫学角度探讨肺癌胸腔镜手术的临床意义。方法:收集我院胸外科自2016年01月至2016年10月I期或IIa期肺癌患者共60例,随机分为开胸组（TTS组）和胸腔镜组（VATS组）各30例,应用流式细胞仪动态监测两组术前及术后外周血T淋巴细胞亚群和NK细胞水平,比较两组间免疫指标和临床指标。结果:VATS组与TTS组在年龄、性别、病理分期、病理类型、肿瘤最大直径、手术时间及术后拔管时间方面,差异无统计学意义（P>0.05）,而在术中出血量、术后下床时间及疼痛评分方面,VATS组明显优于TTS组（P<0.05）。VATS组与TTS组术前1天T淋巴细胞亚群和NK细胞水平差异无统计学意义（P>0.05）。术后第1天TTS组的CD3+T、CD4+T/CD8+T比值、NK细胞较VATS组下降更明显（P<0.05）。术后第3天、第5天,VATS组CD3+T、CD4+T、CD4+T/CD8+T比值,较TTS组上升更明显（P<0.05）。结论:术中出血量、术后下床时间、术后疼痛与肺癌术后免疫功能变化相关,胸腔镜手术比传统开胸手术对机体免疫系统影响更小,且术后免疫功能恢复更好。     

Chest radiographic findings following video-assisted thoracoscopic lung volume reduction surgery for emphysema

Surgical reduction of lung volume is being investigated as a promising alternative in the treatment of selected patients with severe debilitating emphysema. Following bilateral video-assisted thoracoscopic surgical resection (VATS) of emphysematous lung tissue, patients show improvements in exercise tolerance, dyspnoea, increases in oxygenation, decreased airway obstruction and enhanced quality of life. The postoperative findings in the first 24 patients who underwent bilateral VATS volume reduction are described. Pneumothoraces developed in all patients, often with unusual shapes related to the surgical sutures. Perihilar, pulmonary and paramediastinal pulmonary parenchymal opacities were seen in approximately half of the patients, representing areas of pulmonary contusion, atelectasis and/or haemorrhage associated with the staple lines. The purpose of the present study is to describe the immediate postoperative chest radiographic appearances and to familiarize radiologists with the surgical procedure.