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。

A clinical analysis on subxiphoid and intercostal video-assisted thoracoscopic extended thymectomy

ObjectiveTo explore the clinical characteristics of video-assisted thoracoscopic (VATS) extended thymectomy via subxiphoid and intercostal approaches. MethodsClinical data of consecutive VATS extended thymectomy performed between Jan. 2015 and Dec. 2018 in Department of Thoracic Surgery of Xuzhou Central Hospital was retrospectively analyzed. The patients were divided into intercostal multiple VATS (MVATS) group, subxiphoid MVATS group and subxiphoid uniportal VATS (UVATS) group. The operation-related parameters were compared respectively among the groups. ResultsThere were 5 cases in the intercostal group and 7 cases in the subxiphoid groups suffered from myasthenia gravies (MG) before surgery. There was no short-term mortality, or conversion to thoracotomy. Three patients in subxiphoid UVATS group converted to subxiphoid MVATS. Besides, as compared with the subxiphoid MVATS and UVATS group, the patients of intercostal MVATS group revealed shorter operation time (64.0±15.1) min vs (71.4±18.1) min vs (87.4±18.7) min, P< 0.05], shorter chest tube drainage (1.5±0.7) d vs (2.3±1.1) d vs (2.9±1.3) d, P< 0.05], smaller drainage volume (131.4±66.5) ml vs (169.9±110.6) ml vs (231.5±111.9) ml, P<0.05], shorter postoperative stay (1.9±1.1) d vs (3.1±2.0) d vs (3.7±2.8) d, P< 0.05], but higher pain score on the first postoperative day (4.2±1.3) vs (3.7±1.1) vs (3.5±1.2), P<0.05]. In addition, subxiphoid UVATS group reported two cases of MG crisis after surgery. Besides, incomplete resection of anterior mediastinal fat tissue was found in 1 case in the subxiphoid MVATS group and 5 cases in the UVATS group, as shown by computered tomography after surgery. ConclusionsSubxiphoid VATS extended thymectomy is feasible, but it does not indicate significant advantages as compared with intercostal MVATS approach.