两孔、三孔胸腔镜与开放肺叶切除治疗肺癌的对比研究

目的：分析两孔胸腔镜肺叶切除及系统性淋巴结清扫手术治疗肺癌的临床效果。方法回顾性分析2013年6月～2014年4月我科单一术者两孔胸腔镜肺叶切除术治疗肺癌47例（两孔组）,同期三孔法胸腔镜手术61例（三孔组）,以及2007～2010年传统开胸手术49例（开放组）的资料。比较3组手术时间、术中出血量、输血量、术中清扫淋巴结数目、站数、术后前3天引流量、胸腔引流时间、术后住院时间及并发症的发生情况等。结果两孔组手术均顺利完成,无需副操作孔或中转开胸。两孔组与三孔组比较,在手术时间、术中出血量、胸腔引流时间、引流量、术后住院时间、并发症等方面差异均无显著性（P＞0．05）;与开放组比较,两孔组术中出血少[（154．0±107．5）ml vs．（254．7±192．2）ml,P＝0．007],术后住院时间短[（8．5±1．9）d vs．（10．9±2．4）d,P＝0．000],输血患者比例小（1／47 vs．8／49,P＝0．017）。3组在淋巴结清扫总数目和站数、N2组淋巴结清扫数目和站数、病理阳性淋巴结数目等方面均无统计学差异（P＞0．05）。结论两孔胸腔镜肺叶切除手术能够达到三孔胸腔镜手术的治疗效果,并且能避免多余切口对胸壁肌肉、肋间神经或血管的损伤,进一步降低手术创伤,是安全有效的肺癌根治性手术方式之一。     

胸腔镜肺叶切除术治疗I期肺癌

目的：探讨胸腔镜肺叶切除术的疗效。方法：对30例术前诊断为I期肺癌的患行胸腔镜肺叶切除术，男19例，女11例，年龄36岁－78岁，平均63．1岁。结果：无手术死亡。2例（6．67％）术后输血，发生并发症4例（13．3％）。随访时间12月－45月，平均28．7月，生存率83．3％（25／30），其中I期患生存率为90．9％（20／22）。结论：对于I期肺癌，胸腔镜肺叶切除术长期疗效与常规开胸手术相仿，而且具有安全性高，手术创伤小，术后恢复快等优点。     

两孔法胸腔镜手术治疗原发性周围型肺癌的初步探讨

目的探讨两孔法电视辅助胸腔镜手术（VATS）治疗原发性周围型肺癌的手术操作方法和临床应用价值。方法 2009年10月～2011年2月,开展两孔法VATS治疗早期原发性周围型肺癌32例,腋中线第7肋骨上缘2.5～3 cm切口为观察孔兼副操作孔,腋前线第5肋骨上缘2.5 cm切口为主操作孔,均行肺叶切除加纵隔淋巴结廓清。右肺上叶8例,右肺中叶4例,右肺下叶7例,左肺上叶6例,左肺下叶7例。结果手术过程顺利,中转开胸1例（因转移淋巴结侵及肺动脉分离时出血）,无严重手术并发症,无围手术期死亡。32例手术时间70～260 min,平均102 min。术中出血量50～300 ml,平均160 ml。每例清除淋巴结6～14枚,平均8.2枚。术后住院时间5～9 d,平均6.7 d。TNM分期：Ⅰa期7例,Ⅰb期7例,Ⅱa期10例,Ⅱb期5例,Ⅲa期3例。结论两孔法VATS治疗原发性周围型肺癌,手术操作方法安全、可靠,值得临床推广。     

胸腔镜辅助小切口肺叶切除术治疗早期肺癌

目的探讨胸腔镜根治性肺癌切除的可行性. 方法 2000年1月～2003年6月我们应用胸腔镜辅助小切口对31例早期肺癌行肺叶切除淋巴结扩清术,其中右肺上叶8例,中叶4例,下叶5例,左肺上叶8例,下叶6例,29例根治性切除. 结果全组均行肺叶切除.手术时间2～4 h,平均2.5 h.术中出血量50～150 ml,均未输血.切除淋巴结5～12枚,平均8枚.术后胸腔闭式引流平均3 d(1.5～28 d),术后住院平均7.5 d(5～30 d).无手术死亡及并发症发生.29例随访2～40个月,1例术后6个月因心肌梗塞死亡,2例分别于术后6、15个月出现脑、肝、肺等远处转移. 结论胸腔镜辅助小切口对较早期肺癌行根治性手术治疗可行.     

518例早期肺癌的电视胸腔镜肺叶切除术

目的 探讨采用电视胸腔镜手术(VATS)治疗早期肺癌的理论依据和实践规范,分析影响预后的相关因素.方法 1997年5月至2009年10月,518例早期肺癌患者行VATS肺叶切除术中男297例,女221例;平均年龄(58.9±10.6)岁.结果 术后并发症和手术死亡分别为10.8％和0.4％.患者年龄(P=0.0300,OR=2.0148,95％ CI 1.0700～3.7940)和手术时间(P =0.0007,OR=1.0086,95％ CI 1.0036～1.0136)是影响术后并发症发生率的独立危险因素.1、3、5年总生存率为98％、81％、66％,术后病理分期(P=0.0036,OR=1.6071,95％ CI 1.1677 ～2.2118)是惟一的影响因素.结论VATS肺叶切除术是治疗早期肺癌的一种安全手术方式.对于高龄患者应慎重;手术时间不宜过长;合理处理意外状况、必要时应果断中转开胸有助于降低手术风险.     

两孔法与三孔法胸腔镜肺大疱切除术的临床对比分析

目的探讨胸腔镜两孔法手术切除肺大疱的临床应用价值。方法采用胸腔镜治疗肺大疱,2011年4～12月常规三孔法手术43例,2012年4～10月两孔法手术40例,比较2组手术时间、术中出血、术后1日疼痛评分、术后胸腔引流液量、拔管时间、住院时间。结果2组均无中转开胸、术中输血、胸腔感染等。两孔组手术时间（48．0±18．8）min,术中失血（12．9±8．2）ml,三孔组分别为（51．8±19．4）min、（14．3±7．5）ml,2组差异无显著性（P〉0．05）。两孔组术后1日疼痛评分（VAS）低[（2．1±1．0）分vs．（3．4±1．6）分,t=-4．926,P=0．000],术后胸腔引流液总量少[（270．6±192．3）ml vs．（360．2±210．5）ml,t=-2．020,P=0．046],引流管拔管时间早[（3．2±1．5）d vs．（4．7±1．9）d,t=-3．946,P=0．000],住院时间短[（5．8±2．0）d vs．（7．1±1．9）d,t=-3．099,P=0．003]。术后6个月复发率2组差异无显著性[0．4％（1／24）vs ．0％（0／31）,P=0．436]。结论两孔法胸腔镜手术治疗自发性气胸安全可行,利于患者恢复,可以作为优先选择。     

全胸腔镜下肺叶切除术治疗48例肺癌患者体会

目的比较全胸腔镜肺叶切除术与开胸肺叶切除术治疗肺癌的效果。方法将96例肺癌患者按照手术方式分为全胸腔镜组和对照组,各48例。分别实施全胸腔镜下肺叶切除术和传统开胸肺叶切除术。比较2组的手术时间、术后拔管时间、术后住院时间及术后并发症发生率等指标。结果全胸腔镜组手术时间长于对照组,术中出血量、术后拔管时间、并发症发生率及住院时间短或少于对照组,差异均有统计学意义(P0.05)。结论全胸腔镜肺叶切除术治疗肺癌,创伤小、住院时间短、术后并发症少。     

全胸腔镜肺叶切除术治疗早期肺癌的临床疗效

目的:评价完全胸腔镜下肺叶切除治疗早期肺癌的疗效。方法:回顾性分析全腔镜下肺叶切除55例Ⅰ期肺癌及开胸肺叶切除30例Ⅰ期肺癌患者的资料,比较两组手术时间、术中出血量、术后胸管留置时间、淋巴结清扫数目、术后疼痛、术后住院时间、术后并发症等指标的差异。结果:两组患者均无围手术期死亡。胸腔镜组平均手术时间95 min,术中平均出血80 m L,术后平均带管时间4.2 d,平均淋巴结清扫数目12.0枚,术后疼痛疼痛评分3~6分,平均4分;术后平均住院时间9 d,术后并发症发生率8.5%。开胸组平均手术时间85 min,术中平均出血130 m L,术后平均带管时间5.5 d,平均淋巴结清扫数目13.2枚,术后疼痛疼痛评分5~9分,平均6分;术后平均住院时间12 d。胸腔镜手术术中出血量、术后拔管时间、术后疼痛及术后住院时间、术后并发症发生率方面优于传统开胸手术。结论:全腔镜肺叶切除治疗早期肺癌安全可行,值得临床推广应用。     

单向四孔法全胸腔镜肺叶切除术治疗非小细胞肺癌的临床研究

目的探讨单向4孔法全胸腔镜肺叶切除术治疗非小细胞肺癌的可行性、安全性。方法回顾性分析2007年1月至2010年12月上海市胸科医院采用单向式全胸腔镜肺叶切除治疗428例非小细胞肺癌患者的临床资料,其中男186例,女242例;年龄33～78岁。术前临床诊断为早期非小细胞肺癌。428例中行右肺上叶切除134例,右肺中叶切除48例,右肺下叶切除98例,右肺中下叶切除4例,左肺上叶切除72例,左肺下叶切除72例。将428例患者按手术方式分为单向3孔法组(300例)和单向4孔法组(128例);比较两组的临床效果。结果412例在全胸腔镜下完成肺叶切除术,16例中转常规开胸手术(中转开胸比率3.7%)。平均手术时间132.1(120～180)min,平均手术切口长度3.7(3～5)cm,平均术中出血量150.0(50～800)ml;两组患者平均拔管时间、术中出血量、术后住院时间差异均无统计学意义,但4孔法组较3孔法组手术时间缩短,且差异有统计学意义(P<0.05)。16例中转开胸患者接受术中输血。死亡5例,于术后1个月内分别死于严重肺部感染、肺栓塞和急性脑梗死。术后病理诊断:鳞状细胞癌52例,腺癌340例,腺鳞癌20例,低分化癌8例,大细胞癌6例,类癌2例。术后出现持续肺漏气4例,脓胸2例,肺部感染4例,心律失常26例,肺栓塞2例,乳糜胸2例,急性脑梗死2例。3年总生存率为83.6%(358/428)。结论单向式4孔法全胸腔镜肺叶切除术治疗非小细胞肺癌的有效性和安全性满意,符合肺癌手术的治疗规范。单向4孔法还能大大提高手术流畅程度和淋巴结清扫程度。     

比较全胸腔镜与开胸肺叶切除术治疗早期肺癌的效果

目的比较全胸腔镜与开胸肺叶切除术治疗早期肺癌的效果。方法选取2016-03-2018-07间在滑县人民医院就诊的76例早期肺癌患者,随机分为2组,每组38例。对照组采用开胸肺叶切除术,观察组予全胸腔镜肺叶切除术。结果观察组术中出血量、术后引流时间、VAS评分,以及住院时间均小于(短于)对照组,差异有统计学意义(P<0.05)。观察组并发症发生率低于对照组,差异有统计学意义(P<0.05)。结论与开胸肺叶切除术比较,全胸腔镜肺叶切除术出血量少,术后疼痛轻,并发症少,有利于术后恢复。     

Compromised video-assisted thoracoscopic segmental resection for high-risk patients with stage I lung cancer near the lung hilum

We performed a video-assisted thoracoscopic segmental resection without doing a mini-thoracotomy in two patients (one octogenarian and one with poor lung function) with early stage (T1-2N0) lung cancer located at the lung hilum who required preservation of their cardiopulmonary function. After 2 years of follow-up, both patients are alive without recurrence. We describe the cases and the method used for the video-assisted thoracoscopic segmental resection using an endoscopic stapler.     

Very long-term outcomes of video-assisted thoracoscopic surgery for lung cancer

Background  The most critical parameter in the evaluation of the feasibility of video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer is long-term outcome. In this study, patients in whom more than 5 years had elapsed since they had undergone VATS lobectomy for lung cancer were identified, and the 5-year survival rate and frequency of recurrence were evaluated as the long-term outcomes; in addition, the frequency of perioperative complications were also evaluated as the short-term outcomes. Methods  The stage, histology, perioperative complications, recurrence, and survival data were carefully reviewed in 198 patients who underwent VATS lobectomy for lung cancer between 1998 and 2002. Results  Median postoperative follow-up period was 72.1 months. Of the 198 patients, 138 and 30 were diagnosed as having p-stage IA and IB disease, respectively, while the remaining 30 patients had more advanced disease. Perioperative complications were observed in 20 patients (10.1%), however, there were no perioperative mortalities. Recurrence was observed in 26 patients (13.1%): of these, 11 patients showed local recurrence, including malignant pleural effusion and mediastinal lymph node recurrence, and 16 patients showed distant metastasis, the lung being the commonest site of metastasis; six patients had both local recurrence and distant metastasis. During the study period, there were 26 deaths (13.1%), of which 17 were due to lung cancer and 9 were due to other causes. The 5-year overall survival rates of the patients with p-stage IA and IB disease were 93.5% and 81.6%, respectively. Conclusion  VATS lobectomy for the treatment of lung cancer is as feasible and safe as open lobectomy in terms of both very long- and short-term outcomes.     

小切口电视胸腔镜辅助与传统开胸肺癌根治术的比较

目的探讨小切口电视胸腔镜辅助肺癌根治术的临床价值。方法2005年1月～2006年6月收治49例I、Ⅱ期非小细胞肺癌,22例在小切口(腋前线肋间6～8cm)辅助电视胸腔镜下行肺叶切除术及肺门纵隔淋巴结清扫(VATS组),27例在常规开胸手术下完成肺叶切除术及淋巴结清扫(传统开胸组),比较2种术式肺功能和C反应蛋白(C reactiveprotein,CRP)的变化。结果胸腔镜组2例为方便安全地处理肺门血管将小切口扩大至12～15cm。2组患者术后血清CRP浓度明显升高,第1天达到峰值,胸腔镜组CRP术后1d(56.1±10.9)mg/L,显著低于传统开胸组(73.8±15.1)mg/L(t=-4.603,P=0.000)。2组术后肺功能每分钟通气量相对值(minute ventilation volume,MV)、1秒用力呼气容积相对值(forced expiratory volume in one second,FEV1)下降,术后1周时胸腔镜组MV为(95.6±16.4)L,显著高于传统开胸组(81.9±12.7)L(t=3.296,P=0.002),胸腔镜组FEV1为(57.1±5.7)%,显著高于传统开胸组(51.4±6.9)%(t=3.105,P=0.003)。结论与常规开胸肺癌根治术相比,小切口电视胸腔镜辅助肺叶切除术适合于早中期肺癌,疗效确切,可明显减少病人的手术创伤,可以作为非小细胞型肺癌的一种常规的治疗手段。     

Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer

 Open in a separate windowOBJECTIVESAlthough video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection.METHODSMonocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: ‘early discharge’ (within 72 postoperative hours) and ‘routine discharge’ (at >72 postoperative hours).RESULTSA total of 660 patients with a median age of 66.5 years (interquartile range 60–73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien–Dindo III–IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4–10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m² [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17).CONCLUSIONSAge, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.     

Intraoperative conversion during video-assisted thoracoscopy resection for lung cancer does not alter survival

 Open in a separate windowOBJECTIVESThe aim of this study was to assess the long-term outcomes of patients treated by anatomical pulmonary resection with the video-assisted thoracoscopic surgery (VATS) approach, VATS requiring intraoperative conversion to thoracotomy or an upfront open thoracotomy for lung cancer surgery. METHODSWe performed a retrospective single-centre study that included consecutive patients between January 2011 and December 2018 treated either by VATS (with or without intraoperative conversion) or open thoracotomy for non-small-cell lung cancer (NSCLC). Patients treated for a benign or metastatic condition, stage IV disease, multiple primary lung cancer or by resection, such as pneumonectomies or angioplastic/bronchoplastic/chest wall resections, were excluded.RESULTSAmong 1431 patients, 846 were included: 439 who underwent full-VATS, 94 who underwent VATS-conversion (21 emergent, 73 non-emergent) and 313 treated with upfront open thoracotomy. The median follow-up was 37 months. There were no statistical differences in stage-specific overall survival between the full-VATS, VATS-conversion, and open thoracotomy groups, with 5-year OS for stage I NSCLC of 76%, 72.3% and 69.4%, respectively (P = 0.47). There was a difference in disease-free survival for stage I NSCLC, with 71%, 60.2% and 53%, respectively at 5 years (P = 0.013). Fewer complications occurred in the full-VATS group (pneumonia, arrhythmia, length of stay), but complication rates were similar between the VATS-conversion and thoracotomy groups.CONCLUSIONSVATS resection for NSCLC with intraoperative conversion does not appear to alter the long-term oncological outcome relative to full-VATS or open upfront thoracotomy. Postoperative complications were higher than for full-VATS and comparable to those for thoracotomy. VATS should be favoured when possible.     

Video-assisted thoracoscopic major pulmonary resections: technical aspects,personal series of 259 patients,and review of the literature

Background Although more than 10 years have passed since the first video-assisted thoracoscopic lobectomies, these procedures have not gained widespread acceptance. We discuss the technical aspects and major problems associated with these operations, focusing on their present status and future perspectives. The results of our clinical series are presented and the relevant literature is reviewed. Methods From October 1991 to June 2003, 344 patients were submitted to surgery for an intended video major pulmonary resection. Results Of the 344 patients, seven (2.0%) were deemed inoperable at video exploration; 78 (23.1%) required conversion, either for technical reasons (n = 3), anatomical problems (n = 49), oncological conditions (n = 20), or intraoperative complications (n = 6). We carried out 253 video-assisted lobectomies and six pneumonectomies (209 for primary lung tumor, 43 for benign disease, and seven for metastases). There were no intraoperative deaths. Two patients died postoperatively. Complications occurred in 20 patients (7.7%). Global survival at 3 and 5 years was 83.24% (±6.9) and 68.87% (±9.7), respectively. Patients with T1 N0 cancer had a better survival rate at 3 and 5 years (87.13 ± 8.3% and 75.12 ± 12.2%) than those with T2 N0 cancer (78.49 ± 11.2% and 61.2 ± 15%). Conclusions Based on our experience and a review of the literature, we conclude that video-assisted thoracoscopic lobectomies offer less postoperative pain, a more rapid recovery, and better cosmetic results than their conventional counterpart. The results at 3- and 5-year follow-up for cancer are attractive. However, because no randomized study has yet proved these benefits definitively, further studies are still needed. The video for this paper is available at     

Treatment of pulmonary sequestration by video-assisted thoracic surgery (VATS)

Pulmonary sequestration is a rare malformation of the respiratory tract that accounts for 0.15–6.4% of all congenital lung anomalies. Treatment requires resection of the lesion, provided that there is no technical contraindication. The lession should first be evaluated using video thoracoscopy and then resected whenever possible by video-assisted thoracic surgery (VATS). We report a case of extralobar pulmonary sequestration in a 48-year-old woman. She underwent lobectomy by VATS and achieved an excellent outcome.     

282例全电视胸腔镜下肺叶切除术的围术期护理体会

目的总结完全胸腔镜下行单向式肺叶切除术围手术期的护理经验,探讨胸腔镜肺叶切除术后并发症的护理方法,减少并发症的发生。方法回顾性分析2010年1月至2011年12月282例肺癌患者行胸腔镜单向式肺叶切除术的临床资料。对上述282例行该手术的患者均加强术前宣教,指导有效咳嗽和深呼吸锻炼,做好呼吸道护理,加强生命体征及引流管观察等。结果全部患者均治愈出院,住院期间无护理并发症发生。结论电视胸腔镜肺叶切除术具有创伤小,痛苦轻,恢复快等优点,通过正确的护理干预措施,加强围手术期护理,严密观察病情变化,可减少护理并发症发生,促进术后恢复。