单向式全胸腔镜肺癌切除术的学习曲线分析

目的 分析单向式全胸腔镜肺癌切除术的学习曲线.方法 前瞻性收集2006年5月至2009年4月由两名医师完成的125例全胸腔镜肺癌切除术的临床资料.将手术病例按主刀医师分为A(n=24)、B(n=101)两组,并将B组按时间顺序根据患者例数分为B1(n=25)、B2(n=25)、B3(n=25)、B4(n=26)组.A组手术医师开展胸腔镜手术2年,B组手术医师开展胸腔镜手术5年.比较各组的手术时间、术中失血量、清扫淋巴结数目、中转开胸率、术后并发症发生率.结果 与B组比较,A组手术时间较长[(237±85)min比(187±43)min,P=0.013],而术中失血量、清扫淋巴结数目、中转开胸率、术后并发症发生率两组间差异无统计学意义(P＜0.05).A组与B1组比较也有相同结果.B组中从B1组到B4组手术时间逐渐缩短、术中失血量逐渐减少,但差异无统计学意义(P＜0.05).而B组中前50例(B1+B2)与后51例(B3+B4)比较术中失血量减少[(122±141)ml比(87±81),P=0.009].结论 在开展完全胸腔镜肺癌切除的早期阶段,手术时间会较长,这在腔镜手术经历较短的医生更明显,但并发症发生率无显著增加.完成50例全胸腔镜肺癌切除手术可作为评价熟练掌握该手术的指标.     

经口置入钉砧头技术用于全腔镜食管癌切除胸腔内胃食管吻合

目的 介绍一种通过经口置入钉砧头进行全腔镜食管切除胸腔内胃食管吻合的新技术.方法 2010年4月至6月,6例食管癌患者经口置入钉砧头进行全腔镜食管切除胸腔内胃食管吻合术.患者男性5例,女性1例;年龄38～69岁,平均55岁.病变位于贲门1例,食管下段4例,食管中段1例.病变平均长度4 cm.6例患者均采用腹腔镜胸腔镜联合食管癌切除胃食管胸腔内吻合术.手术分为两大步骤,首先采用腹腔镜游离胃和腹段食管,而后采用胸腔镜游离胸段食管并切除病变食管,应用经口置入钉砧头的方法进行胸腔内胃食管吻合术.结果 本组6例患者手术顺利,未发生术中并发症、中转开腹或开胸等情况.平均手术时间380 min,平均术中出血量300 ml,平均恢复进食时间为术后9 d.术后病理学检查示:食管鳞状细胞癌5例,食管小细胞癌1例,切缘和吻合口圈均阴性.pTNM分期:T2N0M0期3例,T2N1M0期1例,T3N0M0期2例.术后无吻合口和其他重大并发症.结论 本方法创伤小、恢复快,是一种较为安全可靠、操作简便的腔镜下胸腔内胃食管吻合方法.     

全胸腔镜肺叶切除手术操作流程及技巧的优化:北京大学人民医院经验

目的 总结北京大学人民医院全胸腔镜肺叶切除手术的操作流程和技巧的优化改进经验.方法 2006年9月至2010年8月连续开展全胸腔镜肺叶切除手术408例,男214例,女194例,平均年龄58.6岁.实体肿瘤平均最大径30.1 mm.手术采用双腔气管插管全身麻醉,健侧单肺通气.胸腔镜观察口选择第7或8肋间腋后线,长1.5 cm;辅助操作切口选择在肩胛下角线第7或8肋间,长1.5 cm;主操作口选择在第4或第5肋间腋前线,长约4 cm,无需放置开胸器,不牵开肋骨.全部操作过程完全在胸腔镜下完成.术者位于病人前侧,双手分别握持吸引器和电凝钩,在主操作口内进行操作;助手位于病人背侧,使用卵圆钳经辅助操作口帮助牵拉显露.基本操作顺序与传统开胸肺叶切除相同.肺癌病人均清扫纵隔淋巴结:肿瘤位于右侧,清扫2、4、3A、3P、7、8、9、10组淋巴结;左侧清扫3、5、6、7、8、9、10组淋巴结,必要时清扫第4组淋巴结.结果 全组手术顺利,围手术期死亡1例,无严重并发症发生.平均手术时间195 min,平均术中出血249 ml.术后病理良性疾病86例,恶性疾病322例.全组中转开胸35例,中转开胸率8.6%.术后轻微并发症48例,并发症发生率11.8%.术后平均带胸管时间7.9天,术后平均住院天数10.9天.结论 全胸腔镜肺叶切除手术操作难度较高,开展此项手术应具备5个方面条件:(1)较清晰的胸腔镜设备,(2)良好的术野显露,(3)熟练的镜下血管解剖分离技巧,(4)能将血管和支气管置入缝合切开器内,(5)纵隔淋巴结清扫技术.掌握正确的操作流程及一些关键技巧,可以缩短学习曲线.     

Transthoracoscopic needle biopsy for indeterminate lung nodules

Background: The usefulness of transthoracoscopic needle biopsy for preoperatively indeterminate intrapulmonary nodules was evaluated. Methods: Thoracoscopy was performed on 38 patients with pulmonary solitary nodules suspected to be primary lung carcinomas. When the nodule was localized by simple observation or tactile sensor, a biopsy specimen of the tumor was obtained by a biopsy needle introduced through a trocar. Results: The nodules were 7 to 55 mm in diameter. All were located in the peripheral region of the lung. Biopsy specimens were obtained even from 17 nodules with no associated pleural changes. By cytology, all the malignant tumors were precisely diagnosed, 29 as primary lung cancers and 3 as metastatic lung neoplasms. Five of the remaining six benign nodules were not precisely diagnosed. However, they were cytologically classified as class I. Conclusions: Transthoracoscopic needle biopsy is feasible for diagnosing small intrapulmonary nodules, particularly those of malignant neoplasms. As compared with thoracoscopic excisional biopsy, transthoracoscopic needle biopsy saves time and may reduce the possibility of tumor dissemination during the procedure. Received: 14 March 1997/Accepted: 31 May 1997     

Totally endoscopic Ivor Lewis esophagectomy

Esophagectomy is associated with significant risks of perioperative morbidity and mortality, as well as prolonged convalescence due to effects of the incisions used for conventional surgical access. Because the outcome of this procedure is palliative in the majority of patients, it is possible that laparoscopic techniques could improve initial postoperative outcomes and therefore make surgery more acceptable for patients with esophageal cancer. A new technique is described for Ivor Lewis esophagectomy, which incorporates a hand-assisted laparoscopic approach for gastric mobilization and a thoracoscopic approach for esophageal dissection and anastomosis. Initial experience in two patients has been encouraging, with postoperative hospital stay and convalescence shortened. Received: 17 December 1997/Accepted: 18 March 1998     

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas

Background: Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas. Methods: Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30–85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay. Results: All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58 ± 22 min for unilateral left splanchnicectomy and 93.5 ± 15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8–10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2–5). Conclusions: We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short. Received: 23 December 1999/Accepted: 6 January 2000/Online publication: 12 July 2000     

The thoracoscope as diagnostic tool for solid mediastinal masses

Background: Despite the accuracy of percutaneous biopsy of mediastinal masses under CT scan or sonographic control, there is still a need for surgical biopsy because of difficult location or because of insufficiency of the percutaneous biopsy, especially for those tumors requiring an immunological classification. Methods: The thoracoscopic approach to mediastinal masses is an alternative to the usual surgical biopsies performed through thoracotomy, sternotomy, or anterior mediastinotomy. The procedure is performed under general anesthesia and one-lung ventilation. Results: In a series of 47 cases, a histological diagnosis was obtained in 44 cases (93.6%). There was one hemorrhagic complication requiring thoracotomy (2.1%). The mean postoperative duration of stay was 3.2 days. Conclusions: Thoracoscopy is the method of choice in case of failure or contraindication of percutaneous biopsy. There is still a role for mediastinoscopy in treating paratracheal lymph nodes.     

Can we predict the failure of thoracostomy tube drainage in the treatment of pediatric parapneumonic collections?

Background/Purpose

Tube thoracostomy is a standard method of treating pediatric parapneumonic collections. Despite recent work denoting thoracoscopy as a superior method of treatment, few studies have looked at factors predictive of tube thoracostomy failure. We reviewed parapneumonic collections initially treated with tube thoracostomy to identify such factors.

Methods

Nontuberculous parapneumonic collections treated initially with tube thoracostomy over a 10-year period were reviewed. A “failed primary tube thoracostomy” was defined as the presence of worsening clinicoradiological signs requiring a further chest procedure (ie, thoracoscopy, thoracotomy, or second thoracostomy).

Results

Fifty-eight patients were identified. Forty-three percent failed primary tube thoracostomy. Within group F (failure group), 32% of patients had a concomitant medical condition (P < .001). Sixty percent of group F patients had duration of symptoms for more than 1 week compared with only 24% of group S (successful group) (P < .001).

Conclusions

Our results suggest that primary treatment of parapneumonic collections with tube thoracostomy is likely to be unsuccessful in patients who are symptomatic for more than a week or who have a concomitant medical condition.A more aggressive primary surgical intervention is suggested for this group.