经剑突入路胸腔镜胸腺扩大切除治疗重症肌无力的临床分析CSCD

目的探讨结合肋缘下切口的剑突入路胸腔镜胸腺扩大切除治疗重症肌无力的手术安全性与临床疗效。方法回顾性分析2015年10月至2016年4月期间我院心胸外科收治的23例重症肌无力合并胸腺疾病患者的临床资料。其中男8例、女15例,年龄11~70(40.70±17.31)岁。所有患者采用经剑突入路胸腔镜胸腺扩大切除手术。结果所有手术均成功,无中转开胸或延长手术切口长度患者。患者切口长度平均(2.76±0.40)cm,手术时间平均(138.4±35.4)min,术中出血量平均(35.2±28.6)ml,术后呼吸机辅助时间平均(13.40±9.84)h,采用延迟拔管1例,术后并发症2例,其中少量胸腔积液1例、肺炎1例。术后疼痛视觉模拟(VAS)评分平均2.77分。结论剑突入路胸腔镜胸腺扩大切除技术是安全可行的手术方式,具有容易操作、清扫彻底、手术创伤小、恢复快、美容效果好等优点,值得深入研究及进一步推广。     

机器人辅助经剑突下胸腺(扩大)切除手术的临床应用

目的探讨机器人辅助经剑突下胸腺(扩大)切除手术治疗重症肌无力和胸腺肿瘤的初步经验。方法纳入我院2016年8月至2017年8月胸腺肿瘤和重症肌无力患者62例,其中男34例、女28例,平均年龄(38±11)岁;行机器人辅助经剑突下胸腺切除手术。所有患者均使用4孔完成手术,镜孔位于剑突下方,双侧锁骨中线肋缘下为1#和2#臂操作孔,3#臂操作孔位于腋前线第5或第6肋间隙,胸腺肿瘤患者行全胸腺切除,重症肌无力患者行胸腺扩大切除。结果所有患者均顺利完成手术,平均手术时间(116.0±34.0)min,术中平均出血量(5.6±4.3)ml,术后平均住院时间(4.0±2.2)d。无术中大出血、中转开胸、围手术期死亡及并发症发生。结论机器人辅助经剑突下胸腺(扩大)切除手术安全可行,值得临床推广应用。     

经剑突入路胸腔镜胸腺扩大切除治疗重症肌无力的临床分析

目的探讨结合肋缘下切口的剑突入路胸腔镜胸腺扩大切除治疗重症肌无力的手术安全性与临床疗效。方法回顾性分析2015年10月至2016年4月期间我院心胸外科收治的23例重症肌无力合并胸腺疾病患者的临床资料。其中男8例、女15例,年龄11~70(40.70±17.31)岁。所有患者采用经剑突入路胸腔镜胸腺扩大切除手术。结果所有手术均成功,无中转开胸或延长手术切口长度患者。患者切口长度平均(2.76±0.40)cm,手术时间平均(138.4±35.4)min,术中出血量平均(35.2±28.6)ml,术后呼吸机辅助时间平均(13.40±9.84)h,采用延迟拔管1例,术后并发症2例,其中少量胸腔积液1例、肺炎1例。术后疼痛视觉模拟(VAS)评分平均2.77分。结论剑突入路胸腔镜胸腺扩大切除技术是安全可行的手术方式,具有容易操作、清扫彻底、手术创伤小、恢复快、美容效果好等优点,值得深入研究及进一步推广。     

胸腔镜剑突肋缘下及纵劈胸骨胸腺扩大切除术治疗重症肌无力合并胸腺瘤临床疗效的倾向性评分匹配研究

目的 分析胸腔镜剑突肋缘下及纵劈胸骨胸腺扩大切除术治疗重症肌无力合并胸腺瘤的临床疗效、安全性及可行性。方法 回顾性分析2011年12月—2021年12月在空军军医大学唐都医院胸外科同一诊疗组行手术治疗的重症肌无力合并胸腺瘤患者的临床资料，按照手术入路分为胸腔镜剑突肋缘下胸腺扩大切除术组（胸腔镜组）和纵劈胸骨胸腺扩大切除术组（纵劈组）。比较两组患者的临床资料。结果 共纳入456例患者，其中纵劈组51例，男30例、女21例，年龄23～66(49.5±11.8)岁；胸腔镜组405患者经倾向性评分匹配后纳入51例患者，男28例、女23例，年龄26～70(47.2±12.2)岁。两组均顺利完成手术，胸腔镜组无术中转开胸。胸腔镜组在手术时间、术中出血量、胸腔引流时间、术后住院时间、患者满意度评分、疼痛评分、并发症方面优于纵劈组（P<0.05）。两组在术中淋巴结清扫站数、术中淋巴结清扫枚数、术后肌无力缓解情况方面差异无统计学意义（P>0.05）。结论 对于重症肌无力合并胸腺瘤患者，胸腔镜剑突肋缘下胸腺扩大切除术的手术彻底性、安全性不亚于纵劈胸骨术式，但其更加微创化，是一种有效的手术方式。     

胸腔镜剑突肋缘下与单侧胸腔镜胸腺扩大切除术治疗重症肌无力疗效对比的倾向性评分匹配分析

目的通过倾向性评分匹配,对比分析胸腔镜剑突肋缘下及单侧胸腔镜胸腺扩大切除术在治疗合并胸腺异常重症肌无力患者的临床效果,探讨并评价胸腔镜剑突肋缘下胸腺扩大切除术的临床疗效。方法回顾性分析2011年12月至2018年12月于空军军医大学唐都医院胸外科同一诊疗组接受手术治疗612例重症肌无力患者的临床资料。按照手术入路将患者分为胸腔镜剑突肋缘下胸腺扩大切除术组(剑突组,520例)和单侧胸腔镜胸腺扩大切除术组(单侧组,92例)。经倾向性评分匹配,剑突组获得与单侧组术前基线资料差异无统计学意义的92例患者,其中剑突组男52例、女40例,年龄26~70(50.2±10.3)岁;单侧组男47例、女45例,年龄20~73(51.5±12.1)岁。对比分析两组患者的手术时间、术中出血量、胸腔引流时间、术后住院时间、脂肪清扫彻底性、术后肌无力缓解情况、患者满意情况、疼痛情况及并发症等指标。结果两组均顺利完成手术,均无中转开胸。剑突组、单侧组在手术时间[(46.2±19.5)min vs.(53.4±23.5)min]、胸腔引流时间[0 d vs.(3.4±1.2)d]、术后住院时间[(2.9±1.9)d vs.(3.6±1.7)d]、患者满意度评分[(7.9±2.1)分vs.(6.7±1.2)分]等方面差异均有统计学意义(P均<0.05)。两组在术中出血量[(52.2±12.7)mL vs.(51.2±10.3)mL]、脂肪清扫彻底性(8.1±0.6 vs.7.9±0.9)、术后肌无力缓解率(89.1%vs.85.9%)、总体并发症发生率(10.9%vs.6.5%)方面差异均无统计学意义(P均>0.05)。结论对于合并胸腺异常的重症肌无力患者,胸腔镜剑突肋缘下胸腺扩大切除术是一种更有效的手术方式。     

胸腔镜胸腺切除术剑突下入路与侧胸入路的病例对照研究

目的探讨经胸腔镜胸腺切除剑突下入路治疗重症肌无力的安全性和疗效。方法回顾性分析2014年1月至2016年7月在复旦大学附属华山医院胸外科行胸腔镜下扩大胸腺切除85例患者的临床资料,对比经剑突下入路胸腺切除(subxiphoid approach video-assisted thymectomy,SXVT)与侧胸入路胸腺切除(traditional unilateral approach video-assisted thymectomy,TVAT)的手术时间、术中失血量、术后引流时间、疼痛指数及生活质量等数据。结果全组无围手术期死亡,无中转开胸,术后无患者出现肌无力危象。两组患者在切除标本大小、术中失血量、引流时间、术后引流量、术后住院时间及重症肌无力改善率等方面差异无统计学意义(P0.05)。SXVT组患手术时间明显短于TVAT组、术后胸痛情况优于TVAT组(P0.05)。结论胸腔镜经剑突下胸腺切除安全可行,具有手术时间短、术后胸痛症状轻、术后疗效确切等优点,值得推广。     

经剑突下胸腔镜技术在胸腺瘤切除术中的应用

目的探讨经剑突下胸腔镜技术在胸腺瘤切除术中的应用价值。方法回顾性分析2015年6月~2017年5月15例胸腺瘤采用经剑突下途径行胸腺瘤切除手术的临床资料,其中男6例,女9例,年龄(48.5±5.4)岁,合并重症肌无力6例(眼肌型5例,轻度全身型1例)。结果 15例均顺利完成手术,无中转开胸。手术时间(95±15)min,术中出血量(50±10)ml,术后住院时间(4.2±1.5)d,术后胸腔引流管留置时间(1.5±1.0)d。无术后出血二次开胸手术等并发症。术后病理诊断胸腺瘤A型8例,AB型5例,B1型1例,B2型1例。15例术后随访(6.5±2.5)月,无胸腺瘤复发。合并重症肌无力6例按照Monden标准,肌无力症状消失5例,肌无力改善1例。结论经剑突下途径行胸腔镜胸腺瘤切除手术有效、可行。     

剑突下与肋间入路胸腔镜胸腺扩大切除术的临床体会

目的探讨经剑突下入路与肋间入路胸腔镜(video-assisted thoracoscopic surgery, VATS)胸腺扩大切除术的特点。 方法回顾性分析2015年1月至2018年12月徐州市中心医院胸外科VATS胸腺扩大切除术的病例资料113例,依据术式不同分为经肋间多孔VATS (multiple-port VATS,MVATS)组46例(肋间MVATS组)、剑突下MVATS组40例与剑突下单孔VATS (uniportal VATS,UVATS)组27例(剑突下UVATS组)。比较手术相关参数的差异。 结果肋间入路组5例、剑突下入路组7例术前合并重症肌无力(myasthenia gravis, MG)。患者无中转开胸手术或死亡。剑突下UVATS组3例中转剑突下MVATS。肋间MVATS组与剑突下MVATS组、剑突下UVATS组比较,手术时间短[(64.0±15.1) min比(71.4±18.1) min比(87.4±18.7) min, P<0.05],胸腔引流时间短[(1.5±0.7) d比(2.3±1.1) d比(2.9±1.3) d, P< 0.05]、胸腔引流量少[(131.4±66.5) ml比(169.9±110.6) ml比(231.5±111.9) ml, P< 0.05]、术后住院时间短[(1.9±1.1) d比(3.1±2.0) d比(3.7±2.8) d, P< 0.05],而术后1 d视觉模拟评分高[(4.2±1.3)分比(3.7±1.1)分比(3.5±1.2)分,P< 0.05]。剑突下UVATS组2例术后出现MG危象。CT提示剑突下MVATS组1例、剑突下UVATS组5例术后前纵隔脂肪影残留。 结论剑突下入路VATS胸腺扩大切除术是可行的,但与肋间入路MVATS比较无显著优势。     

电视胸腔镜经右胸前侧径路胸腺切除治疗重症肌无力

目的　探讨电视胸腔镜手术 (VATS)胸腺切除治疗重症肌无力的效果。　方法　 10例重症肌无力患者采用 VATS经右胸前侧径路行胸腺切除及纵隔脂肪清扫 (VATS组 ) ,并与 2 0例胸骨劈开胸腺切除 (胸骨劈开组 )相对照。　结果　 VATS组中 9例顺利完成手术 ,1例因电凝钩伤及头臂静脉干而中转开胸止血 ;全组无术后死亡及危象发生 ;手术时间、术后住院时间均较胸骨劈开组明显缩短。　结论　 VATS经右胸前侧径路行完全胸腺切除是可行的 ,且具有创伤小、恢复快等优点 ,可在临床进一步应用。     

电视胸腔镜治疗胸腺瘤和重症肌无力

目的　探讨电视胸腔镜治疗胸腺肿瘤和重症肌无力 (MG)的手术方法和可行性。方法　1996年 3月至 2 0 0 2年 12月 ,2 2例病人行胸腺瘤和 (或 )重症肌无力胸腔镜手术治疗。其中男 16例 ,女 6例 ;年龄 14～ 77岁 ,平均 44 1岁。行胸腺全切 12例 ,合并MG者行胸腺扩大切除 10例。结果　所有手术均在胸腔镜下完成 ,无中转开胸者。 3例MG病例术后需短暂呼吸机辅助通气 ( <2 4h) ,二次气管插管1例 ,余无严重并发症 ,无手术死亡。平均手术时间 10 8min ,平均胸腔引流 2d ,平均术后住院 4 5d。结论　胸腔镜治疗Ⅰ期胸腺瘤较开胸手术具有创伤小、恢复快等显著优势 ,且符合该类肿瘤的外科治疗原则 ;胸腔镜胸腺扩大切除治疗重症肌无力在技术上是可行的。     

喉罩与气管插管麻醉下“三孔式”非肌无力胸腺瘤切除术的对比研究

目的探讨喉罩全身麻醉(全麻)代替气管插管全麻用于经剑突、肋缘下"三孔式"前纵隔病变切除术治疗不合并肌无力的胸腺瘤患者的安全性和可行性。方法纳入我科2018年1月至2019年6月连续收治的行"三孔式"前纵隔病变切除术治疗不合并肌无力的胸腺瘤患者109例。根据麻醉方式不同,将患者分为气管插管全麻组和喉罩全麻组。气管插管全麻组患者共70例,其中男42例、女28例,平均年龄(45.83±15.89)岁;喉罩全麻组患者共39例,其中男26例、女13例,平均年龄(43.31±15.64)岁。比较两组患者的临床资料。结果两组患者基线特征差异无统计学意义(P>0.05)。所有患者均未出现大出血、中转为开胸、术后并发肌无力、死亡等情况。喉罩全麻组患者术中无中转为气管插管全麻者。两组患者在手术时间、术中出血量、术中最高CO2分压、最低氧分压值、麻醉效果评分等方面差异无统计学意义(P>0.05)。两组患者在术后误吸、胃肠道不适、住院时间、疼痛评分、患者满意度等方面差异无统计学意义(P>0.05)。但喉罩全麻组患者手术前麻醉所用时间、麻醉清醒所用时间均明显短于气管插管全麻组患者(P<0.05),而且喉罩全麻组患者术中一过性心律失常、术后咽喉部不适及声音嘶哑发生率均明显低于气管插管组患者(P<0.05)。结论在喉罩全麻下行经剑突、肋缘"三孔式"前纵隔病变切除术治疗不合并肌无力胸腺瘤患者是安全、可行的,可尝试常规推荐使用。     

Placement of a permanent epicardial pacemaker in children using a subcostal approach.

BACKGROUND: Previously described techniques for epicardial pacemakers in children have generally included either a left thoracotomy approach or a subxiphoid incision. METHODS: We have recently used a single left subcostal incision for placement of both the epicardial electrodes and the pacemaker generator. We report our initial experience with this technique in 8 patients. The mean age was 4 years (range, 4 months to 12 years). The smallest patient weighed 4,100 g. RESULTS: The subcostal approach was successful in 7 patients. One patient with a narrow costal margin operated on early in our experience required conversion to a thoracotomy. The pacing thresholds were uniformly excellent in all patients. There have been no associated complications. CONCLUSIONS: Placement of epicardial leads using a left subcostal incision avoids a thoracotomy, is simpler than a subxiphoid approach, and results in acceptable thresholds with minimal morbidity.     

Trans-sternal thymectomy in myasthenia gravis

Between 1986 and 1989 27 patients with myasthenia gravis underwent radical thymectomy: 24 patients without and two patients with thymoma through a trans-sternal incision, another with thymomatous myasthenia through a left-sided thoracotomy. The patients were staged according to the modified Ossermann classification. The results were evaluated prospectively according to the Disability Status Scale of Oosterhuis. During a mean follow up of 22.4 months, 21 patients (77%) benefited from the operation with complete remission achieved in 9 (33%) and significant improvement noted in 12 (44%). There were no operative deaths and no hospital morbidity. The mean operation time was 88 minutes, the mean postoperative hospital stay 10.5 days. These results support the recommendation for radical trans-sternal thymectomy in the treatment of patients with myasthenia gravis as a safe procedure.     

胸腔镜手术切除胸腺瘤治疗重症肌无力

目的探讨胸腔镜手术治疗胸腺瘤伴重症肌无力的可行性。方法2005年7月-2006年2月，采用电视胸腔镜在双腔气管插管静脉复合麻醉下行胸腺、胸腺瘤切除术10例，胸腺瘤最大6cm×4cm×3cm。于腋中线第5肋间做1cm胸腔镜口，腋前线与锁骨中线中点第4肋间做3cm主操作孔，腋前线第6肋间做1．5cm辅助操作孔。术中沿胸廓内动脉与锁骨下动脉分叉下方、胸廓内动脉内侧，剪开纵隔胸膜暴露同侧胸腺及部分对侧胸腺；沿上腔静脉或膈神经前方剪开胸膜，暴露同侧胸腺下极，自下而上游离同侧胸腺，沿头臂干静脉前方解剖、结扎胸腺静脉，同法游离对侧并切除。术后全部进行4000cGy放疗。结果手术时间70—130rain，平均110min。术中出血〈100ml。术后Masaoka分期Ⅰ期7例，Ⅱ期3例。术后无死亡，未出现心肺并发症和重症肌无力危象。术后1周重症肌无力症状缓解。10例随访8—15个月，平均13．0月，均无复发、转移，重症肌无力症状无明显加重。结论采用胸腔镜手术切除Ⅰ期或部分Ⅱ期胸腺瘤技术上是可行的，创伤小，术后并发症少，且不影响美观。     

"Maximal" thymectomy for myasthenia gravis. Results

Thymectomy has been shown to be effective in the treatment of myasthenia gravis. The logical goal of operation has been complete removal of the thymus, but there has been controversy about the surgical technique and its relation to results. Surgical-anatomic studies have shown gross and microscopic thymus widely distributed in the neck and mediastinum. We believe that an en bloc transcervical-transsternal "maximal" thymectomy is required to remove all thymic tissue predictably. Ninety-five patients with generalized myasthenia gravis underwent "maximal" thymectomy consecutively between 1977 and 1985 and were evaluated 6 months to 89 months after operation. In Group A (N = 72), myasthenia gravis without thymoma, the uncorrected data revealed that 96% (69) had benefited from operation: 79% (57) had no symptoms; 46% (33) were in remission; 33% (24) were symptom free when receiving minimal doses of pyridostigmine; and none were worse. Life table analysis yielded a remission rate of 81% at 89 months. In group B (N = 8), myasthenia gravis without thymoma for which patients underwent reexploration for incapacitating weakness after earlier transcervical or transsternal operations, residual thymus was found in all. One patient was in remission, two were symptom free when receiving medication, one was unchanged, and none were worse. In group C (N 15), myasthenia gravis and thymoma, two patients were in remission and nine were symptom free when receiving medication. Two patients in this group died 2 and 4 years postoperatively in crisis. Response to thymectomy in group A was greater in patients with mild myasthenia gravis and may have been better in patients who had symptoms for less than 60 months preoperatively, but the response did not depend on age, sex, presence or absence of thymic hyperplasia or involution, or titers of acetylcholine receptor antibodies. The response to thymectomy in group B was striking but slower than in group A, perhaps because symptoms were more severe and of longer duration. The response in group C was also less good than in group A and proportionately fewer benefited. These results support the recommendation for thymectomy in the treatment of patients with generalized myasthenia gravis and indicate the desirability of a maximal procedure. For persistent or recurrent severe symptoms after previous transcervical or submaximal transsternal resections, reoperation by this technique is also recommended.     

Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy for juvenile myasthenia gravis

Background/Purpose

Myasthenia gravis is an autoimmune disease that usually responds positively to treatment with thymectomy. Various approaches via video-assisted thoracic thymectomy as a substitute for conventional sternotomy have been reported. We reported a less invasive technique for thymectomy in pediatric groups.

Methods

Four adolescents with juvenile myasthenia gravis all underwent hybrid combination of small subxiphoid incision and thoracoscopic thymectomy at our institute. Clinical characteristics and surgical outcome were consecutively collected.

Results

In these 4 patients, 2 presented with Osserman class III and 2 with class IIb. The mean operative time was 180 minutes. There was no conversion to sternotomy, and there was only minimal blood loss. Follow-up duration was 3 to 64 months. Postoperatively, 1 patient had complete remission and 3 patients had improvement in clinical symptoms.

Conclusion

Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy may be an effective alternative with low surgical invasiveness for treating juvenile myasthenia gravis.     

Needlescopic video-assisted wedge resection combined with the subcostal trans-diaphragmatic approach for undetermined peripheral pulmonary nodules

Background

Reduced mortality from lung cancer by computed tomography (CT) screening facilitates the use of video-assisted thoracic surgery (VATS) lung wedge resection to obtain a definite diagnosis and to treat tiny nodules. The authors evaluated their initial experience using novel needlescopic VATS wedge resection combined with the subcostal trans-diaphragmatic (SCTD) approach for managing undetermined peripheral pulmonary nodules.

Methods

Between 2009 and 2012, 35 patients who had 36 operations underwent needlescopic VATS wedge pulmonary resection with the SCTD approach. Preoperative percutaneous CT-guided marking of the nodule was performed. Two 3-mm miniports were placed in the thorax for the thoracoscopic camera and minigrasper. Just anterior to the 10th rib, a 2-cm subcostal incision was made, and a 12- or 15-mm port was placed trans-diaphragmatically into the chest cavity. Wedge resection of the lung was performed with endostaplers introduced through a subcostal port.

Results

The median tumor size was 1.1 cm. Localization of the tumor was widely distributed. The mean operation time was 51 min, and the mean blood loss was 4.2 mL. No patients required conversion to thoracotomy, and one patient required conversion to conventional VATS. Additional thoracic ports were placed in five patients, and the needlescopic incision was extended to 15 mm in one patient. The median duration of chest drainage was 1 day. Additional analgesia was not required for 22 patients and was used for less than 1 day for three patients, less than 2 days for seven patients, and less than 3 days for seven patients. The pathologic diagnosis of the nodules was malignant for 28 patients and benign for 8 patients. On postoperative day 7 or at admission, 34 patients were free of postoperative neuralgia.

Conclusions

Needlescopic VATS wedge pulmonary resection combined with the SCTD approach is both safe and feasible and offers the specific advantages of minimal invasiveness and good cosmetic outcomes.     

"Maximal" thymectomy for myasthenia gravis. Surgical anatomy and operative technique

Removal of all thymic tissue is the goal of surgical treatment of myasthenia gravis. In this report we describe an operation that predictably achieves that goal in most patients. The results of surgical-anatomic studies in 50 consecutive specimens obtained by this technique indicate that an en bloc transcervical-transsternal "maximal" thymectomy is required to ensure removal of all available thymus in all patients. This procedure is recommended for all patients undergoing thymectomy in the treatment of myasthenia gravis with or without thymoma and in the treatment of thymoma with or without myasthenia gravis.