肺小结节胸腔镜术前的CT引导定位技术进展

随着低剂量CT和电视辅助胸腔镜手术的广泛运用,肺小结节的检出和早期干预越来越普遍。术前对小结节的定位对于手术成功至关重要,目前已有多种术前定位技术,CT引导是一种简单且成功率较高的定位方式,本文将主要从钩丝系统、微弹簧圈系统、医用胶定位和医用染料定位等方面详细介绍。     

肺小结节胸腔镜术前医用胶定位的应用价值

目的 研究肺小结节(SPN)胸腔镜术前医用胶定位的应用价值.方法 同顾分析41例孤立性SPN胸腔镜术前定位病例资料,包括医用胶定位组22例,Hook-wire定位组19例.统计医用胶定位的定位效果、并发症、衔接期时间以及肺楔形切除所用时间,并将两组结果进行对比分析.结果 两组病例定位均取得成功;医用胶组的气胸发生率(18.2％)、肺出血发生率(9.1％)、胸痛发生率(4.5％)均低于Hook-wire组,其中肺出血发生率与Hook-wire组比较差异有统计学意义(P＜0.01);医用胶组无并发症率(63.6％)高于Hook-wire组(21.1％),差异有统计学意义(P＜0.05);衔接期时间医用胶组(16.32±8.83)h长于Hook-wire组(3.29±4.21)h,差异有统计学意义(P＜0.01);作楔形切除所用时间医用胶组(21.14±7.01) min与Hook-wire组(18.58±5.22) min差异无统计学意义(P＞0.05).结论 SPN胸腔镜术前医用胶定位安全可靠、效果良好,与Hook-wire定位比较并发症发生率更低,并可获得更长的衔接期,具有较高的应用价值.     

肺小结节胸腔镜切除术前定位方法的应用进展

随着低剂量CT(low-dose computed tomography, LDCT)在肺癌筛查运用中的日益普遍,越来越多的肺结节被检出,鉴别其良恶性显得尤为重要,电视胸腔镜手术（video-assisted thoracoscopic surgery,VATS）由于具有创伤小、恢复快等优势,在临床中应用较为广泛,成为肺小结节诊断及治疗的重要手段。VATS术前对肺小结节进行精确定位是手术成功的关键环节,近年来一系列术前辅助定位技术应运而生,包括CT引导、术中超声引导、近红外成像技术及支气管镜下引导。通过在影像系统引导下注入液体材料或金属材料标记,包括亚甲蓝、医用胶、对比剂、带钩金属丝、弹簧圈及肺结节定位针,以方便外科医生能够在术中精准定位病灶并予以切除。然而最佳的定位技术尚无统一标准,本文综述了近年来肺小结节VATS术前定位的各种技术手段,并对各种方法的优点及不足进行分析及总结。     

肺结节定位针对周围型浅表非实性肺小结节VATS术前CT引导下精准定位的临床应用

目的:探讨肺结节定位针在电视胸腔镜手术(VATS)下对周围型浅表非实性肺小结节术前CT引导下定位的有效性及安全性。方法:回顾性收集2020年4月-2021年3月60例患者共60个周围型浅表非实性肺小结节进行VATS术前CT引导下肺结节定位针定位的病例资料,统计肺结节定位针的定位成功率、定位时间、并发症。结果:60例周围型浅表非实性肺小结节患者VATS术前CT引导下采用肺结节定位针的定位成功率为100%,胸腔镜下周围型浅表非实性肺结节切除率为100%,结节定位时间平均为(14.15±3.12)分钟,气胸发生率为16.67%,肺出血发生率为13.33%。结论:CT引导下肺结节定位针对周围型浅表非实性肺小结节的定位成功率高、时间效率高、并发症轻微,可辅助VATS精准、快速、有效地对周围型浅表非实性肺小结节行肺楔形切除术,值得临床推广应用。     

CT引导下微弹簧圈定位在肺小结节胸腔镜术中的临床应用

目的 探讨电视胸腔镜手术(VATS)前CT引导下微弹簧圈定位肺小结节(SPN)对精准切除病灶的临床价值.方法 回顾性分析2014年6月至2016年5月,90例行VATS切除孤立性SPN患者的资料.其中45例患者术前行微弹簧圈定位(A组),45例患者未行术前定位(B组).统计分析两组VATS肺叶楔形切除时间、转开胸手术率、术后住院时间,以及微弹簧圈定位病灶的成功率、并发症等,评价术前微弹簧圈定位病灶的安全性及其对VATS术的增益价值.结果 A组VATS术成功率100％;SPN病灶定位成功率95.6％,术后出现气胸5例、肺表面出血6例、弹簧圈脱落2例等并发症.B组VATS手术成功率84.4％,中转开胸率15.6％.A组VATS手术时间(17.7±2.8) min、术后住院时间(6.2±1.7)d及中转开胸0例明显低于B组,差异具有统计学意义(P＜0.05).结论 CT引导下微弹簧圈定位,可辅助VATS快速、精确切除肺内小病灶,能有效降低中转开胸率、缩短VATS手术时间及术后住院时间.     

同步法Hook-wire多针定位在多发肺结节胸腔镜切除术中的应用

【摘要】 目的 探讨运用Hook- wire多针同步穿刺同侧肺多发结节进行电视胸腔镜手术（video- assisted thoracic surgery,VATS）前定位的安全性和可行性。方法 回顾性分析2016年4月至2020年6月使用同步法Hook- wire多针穿刺进行胸腔镜术前定位的52例同侧肺多发性结节患者资料。记录定位成功率、定位时间、CT扫描次数及手术完整切除率,评估定位方法的可行性;记录气胸、肺内出血等穿刺相关并发症发生率,评估定位方法安全性。 结果 52例患者共定位105枚结节,定位成功率100%,平均定位用时（9.98±1.02） min,CT扫描次数（3.17±0.38）次。VATS术中验证无定位针脱钩发生,病灶完整切除率100%。定位后气胸发生率30.8%（16/52例）,均为无症状少量气胸,肺内出血发生率9.5%（10/105枚）,均为无症状肺内少量出血。 结论 同步法Hook- wire多针定位同侧肺多发结节,避免了穿刺过程中气胸对结节精准定位的干扰,定位成功率高,安全可行。     

肺结节术前CT定位在胸腔镜中的应用价值

目的 探讨术前CT引导下定位针定位指导在胸腔镜手术中精准切除肺结节的临床价值。方法 选取经胸腔镜术前行CT定位的肺结节患者100例（实验组）,另选取同期未行CT引导下定位而直接胸腔镜切除的患者100例（对照组）,并统计穿刺成功率、病理结果、穿刺并发症等情况;对比胸腔镜手术时间、术后并发症等指标,分析可能影响并发症发生的相关危险因素。结果 实验组（130枚结节）定位成功率为100%,未发现定位针脱钩或移位。9例（9.0%）穿刺针道附近轻微出血;15例（15.0%）穿刺部位胸膜下出现少量气胸。结节与胸膜的距离、穿刺气胸的发生率差异有统计学意义（P<0.01）。实验组均无中转开胸手术,对照组中转开胸手术的约为6.0%,两组精准切除率、切除结节所需时间、术后住院时间等差异均有统计学意义（P<0.05）,两组手术后并发症差异无统计学意义（P>0.05）。结论肺结节术前CT定位可以指导胸腔镜有效、精准、安全切除肺结节,缩短手术时间,降低并发症,因此对胸腔镜手术具有较高的增益意义。     

CT引导下经皮穿刺Hook-wire定位肺磨玻璃结节的安全性及有效性研究

目的 探讨电视辅助胸腔镜手术(VATS)前使用Hook-wire定位肺磨玻璃结节(GGO)的安全性及有效性.方法 回顾性分析60例患者的临床资料及Hook-wire定位、VATS相关数据,采用决策树、单因素及多因素Logistic回归分析寻找显著影响因素及相关因素.结果 Hook-wire定位成功率98.3％(59/6...     

C臂CT在肺小结节胸腔镜切除术前定位中的应用

目的 探讨C臂CT在肺小结节胸腔镜术前定位中的应用价值.方法 回顾性分析2011年1月至2015年12月51例患者51个孤立性肺结节(SPN)于电视胸腔镜肺叶切除(VATS)术前行C臂CT引导下Hook-wire定位技术,并统计该技术的成功率、定位时间、并发症、VATS转开胸手术率,以及SPN平均大小,距脏层胸膜距离、病理学结果.结果 C臂CT引导下Hook-wire定位成功率100％,平均定位时间16 min,无症状气胸发生率7.8％,无症状出血率21.6％,1例(2.0％)发生脱落,SPN平均大小10.7 mm,距脏层平均距离25.3 mm,穿刺距离(皮肤至肺结节的距离)66.7 mm,恶性SPN占60.8％.结论 C臂CT引导下Hook-wire肺小结节定位准确、安全、快速,是一种高效的引导方式,具有临床应用价值.     

The probability of malignancy in small pulmonary nodules coexisting with potentially operable lung cancer detected by CT

The aim of this study was to assess the probability of malignancy in one or two small nodules 1 cm or less coexisting with potentially operable lung cancer (coexisting small nodules). The preoperative helical CT scans of 223 patients with lung cancer were retrospectively reviewed. The probability of malignancy of coexisting small nodules was evaluated based on nodule size, location, and clinical stage of the primary lung cancers. Seventy-one coexisting small nodules were found on conventional CT in 58 (26%) of 223 patients, and 14 (6%) patients had malignant nodules. Eighteen (25%) of such nodules were malignant. The probability of malignancy was not significantly different between two groups of nodules larger and smaller than 0.5 cm (p=0.1). The probability of malignancy of such nodules within primary tumor lobe was significantly higher than that in the other lobes (p<0.01). Metastatic nodules were significantly fewer in clinical stage-IA patients than in the patients with the other stage (p<0.01); however, four (57%) of seven synchronous lung cancers were located in the non-primary tumor lobes in the clinical stage-I patients. Malignant coexisting small nodules are not infrequent, and such nodules in the non-primary tumor lobes should be carefully diagnosed.     

CT-guided needle localization of lung nodules for thoracoscopic resection

We used CT to guide positioning of hookwires within 19 lung nodules in order to localize them prior to thoracocschic surgery. Both Hawkins III and Kopans-type needles with internal hookwires were employed. Nodule diameter ranged between 0.7 and 4 cm (mean 1.7 cm), and depth from the site of entry of the needle into the pleural surface ranged from 0.5 to 8 cm. Needles were advanced using a technique identical to that for CT-guided biopsy, and localization proved successful in 18 of 19 cases. During surgery, dislodgement of the guidewire occurred in 5 cases, probably due to traction manoeuvers on it. In all these cases the hook of the wire had been opened within the nodule. No dislodgement occurred in patients in whom the needle had been advanced beyond the nodule and the hook allowed to open in the pulmonary parenchyma deep to it. Severe complications did not occur: there was moderate pleuritic pain in 16 cases and asymptomatic pneumothorax in 13 patients. Computer-tomography-guided needle localization of lung nodules is a safe and relatively easy procedure that allows thoracoscopic surgery of lesions which otherwise might be impossible to locate and resect. Correspondence to: L. E. Derchi     

自体血在肺小结节术前CT引导下定位中应用的初步探讨

目的探讨自体血在肺小结节术前CT引导下定位的应用价值。 方法收集中国科学技术大学附属第一医院胸外科2018年9月至2019年6月间肺内小结节采用自体血CT引导下经皮穿刺辅助定位的患者共30例，定位结节36枚，术前24 h内完成定位后进行手术，统计分析定位效果、并发症、病理资料及手术方案等相关资料。 结果CT显示结节直径4～17 mm，平均（9.22±3.51）mm。病灶与胸膜垂直距离0～20 mm，平均（6.97±5.73）mm。穿刺胸膜进针点与病灶间距离1～36 mm，平均（10.97±7.70）mm。定位成功率93.3%。从确定穿刺路径至定位完成平均操作时间为（13.38±6.09）min。穿刺后出现中等量气胸1例、少量气胸1例、少量血气胸1例、少量血胸1例，肺内血肿形成2例，均未予以特殊处理，总体并发症发生率20%。36枚结节中手术方式采用楔形切除26例（72.2%），肺段切除5例（13.9%），肺叶切除5例（13.9%）。病理结果诊断为恶性结节28例，良性结节8例。 结论自体血用于外周胸膜下肺小结节术前CT引导定位安全有效，副作用小，是一种理想的定位材料。     

全胸腔镜与开胸肺叶切除术对NSCLC患者围术期的影响比较

目的通过对比Ⅰ期和除T3N0M0外的Ⅱ期非小细胞肺癌（NSCLC）患者行全胸腔镜（c-VTAS）或传统后外侧开胸（CPT）肺叶切除术的白细胞计数（WBC-C）、超敏反应C蛋白（hs-CRP）的含量及临床相关指标,比较两种术式对患者围术期的影响。方法连续选取拟行肺叶切除术的Ⅰ期及除T3N0M0外的Ⅱ期NSCLC患者67例,分为c-VTAS组34例,CPT组33例。检测两组患者术前、术后外周血中WBC-C和hs-CRP的水平,收集相关临床指标,并进行统计分析。结果术后两组患者WBC-C及hs-CRP水平较术前升高（P〈0.01）;术后c-VATS组WBC-C及hs-CRP水平明显低于CPT组（P〈0.01）。两组无死亡、严重并发症及二次手术病例;c-VATS组术中出血量、开始下床活动时间、疼痛评分低于CPT组（P〈0.01）;两组手术时间、清扫淋巴结组数和个数、引流量、引流时间、住院天数、并发症无统计学差异（P〉0.05）;术后两组肿瘤病理分期总体有升级趋势,出现了Ⅲ期病例。结论 c-VTAS肺叶切除对患者围术期影响小,具有安全、淋巴结清扫彻底及微创的优点。     

Computer-aided diagnosis of lung cancer and pulmonary embolism in computed tomography-a review

Computer-aided detection (CADe) and computer-aided diagnosis (CADx) have been important areas of research in the last two decades. Significant progress has been made in the area of breast cancer detection, and CAD techniques are being developed in many other areas. Recent advances in multidetector row computed tomography have made it an increasingly common modality for imaging of lung diseases. A thoracic examination using thin-section computed tomography contains hundreds of images. Detection of lung cancer and pulmonary embolism on computed tomographic (CT) examinations are demanding tasks for radiologists because they have to search for abnormalities in a large number of images, and the lesions can be subtle. If successfully developed, CAD can be a useful second opinion to radiologists in thoracic CT interpretation. In this review, we summarize the studies that have been reported in these areas, discuss some challenges in the development of CAD, and identify areas that deserve particular attention in future research.     

单孔法与三孔法胸腔镜肺大疱切除术疗效比较

目的：比较单孔法与三孔法电视胸腔镜手术治疗肺大疱的临床疗效。方法回顾性分析本院行肺大疱106例电视胸腔镜手术治疗情况,其中行单孔法切除术51例称单孔法组,行三孔法切除术55例称三孔法组,对两组的手术时间、切口总长度、术中出血量、术后胸管引流总量、胸管留置时间、术后住院时间、住院费用、术后疼痛程度等指标进行对比。结果所有患者均手术成功,两组手术时间、术中出血量比较差异无统计学意义;单孔法组较三孔法组手术切口总长度小[（4．1±0．4）cm vs（4．9±0．5） cm],术后胸管引流总量减少[（186±79）ml vs（219±80）ml],胸管留置时间缩短[（2．3±1．6） d vs（2．9±1．6）d],术后疼痛程度比对照组轻,差异均具有统计学意义（P＜0．05）。结论与传统的三孔法相比,单孔法有利于减轻疼痛、提高患者生活质量。     

Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery

The aim of our study was to evaluate the role of ultrasonography in the localization of pulmonary nodules during video-assisted thoracic surgery (VATS). Ultrasonography was performed in 35 patients for the localization of pulmonary nodules during VATS. Indication for VATS was excisional biopsy of undetermined nodules in 22 patients, single or multiple metastasectomy in 12 patients and resection of primitive pulmonary cancer in 1 patient with reduced pulmonary reserve. A laparoscopic probe with flexible head and multi-frequency transducer (5–7.5 MHz) was used. Intraoperative ultrasonography localized 37 of 40 nodules preoperatively detected by CT and/or by positron emission tomography in 35 patients. Furthermore, ultrasonography localized two nodules not visualized at spiral CT. Eighteen nodules were not visible or palpable at thoracoscopic examination and were found by intraoperative sonography only. In 6 patients in whom thoracotomy was performed, manual palpation did not reveal more lesions than ultrasonography. In our experience, ultrasonography was very helpful when lesions were not visible or palpable during thoracoscopy, showing high sensitivity (92.5%) in finding pulmonary nodules. Since it is not possible to determine preoperatively whether a localization technique will be necessary during the operation or not, and ultrasonography is a non-invasive technique, we think that, at present, this technique can be considered as the first-instance localization technique during thoracoscopic resection of pulmonary nodules.