胸腔镜下肺癌根治术在老年肺癌患者中的应用

<正>早期非小细胞肺癌的治疗往往是以手术为主的综合治疗。采用后外侧切口径路进行肺叶切除联合纵隔淋巴结清扫已成为标准的肺癌手术方式。由于后外侧切口具有手术视野暴露好,可以满足不同肺叶肺癌手术需要等优点已经成为最常选用的手术切口。但其手术切口过长,创伤巨大,必须切断背阔肌及前锯肌,出血较多,术后恢复慢,尤其是术后疼痛剧烈,易导致心血管、呼吸系统等并发症的发生也使得许多患者难以接受,尤其是很大一部分老年人,特别是心肺功能欠佳的患者在     

胸腔镜在肺癌中的应用进展

手术是非小细胞性肺癌治疗的主要手段,传统开胸手术损伤大,并发症多,微创手术在达到传统开胸手术同样治疗效果的同时,具有创伤小,术中和术后并发症少的优点。胸腔镜为微创手术在心胸外科的应用提供了一个可行的路径,胸腔镜在周围型、中央型肺癌切除及淋巴结清扫中均能有效去除病灶,减少并发症发生,是目前临床上极具前景的一门新技术。     

Ⅰ期肺癌患者VATS与常规后外侧切口下肺癌根治术的淋巴结清扫效果对比

目的通过比较电视胸腔镜(video-assisted thoracoscopic surgery,VATS)下肺癌根治术与常规开胸肺癌根治术的淋巴结清扫情况,探讨电视胸腔镜应用于Ⅰ期肺癌根治中淋巴结清扫的有效性。方法将2012年2月至2015年3月期间在本院临床确诊为Ⅰ期非小细胞肺癌并接受肺癌根治手术的98例患者作为研究对象。根据术式的不同分为电视腔镜组(n=49)和常规开胸组(n=49),两组均进行淋巴结清扫。比较两组手术的安全性与有效性。结果两组患者均顺利完成手术,电视腔镜组清除淋巴结(13.3±4.0)枚,常规开胸组(14.2±4.8)枚,两组比较差异无统计学意义(t=-1.562,P=0.231)。其中N1阳性淋巴结,电视腔镜组(1.1±0.6)枚,常规开胸组(1.1±0.8)枚,差异无统计学意义(t=-1.321,P=1.231)。N2阳性淋巴结,电视腔镜组(0.1±0.7)枚,常规开胸组(0.2±0.4)枚,差异无统计学意义(t=0.000,P=1.000)。清扫淋巴结手术时长,电视腔镜组(38.2±9.1)min,常规开胸组(24.5±6.8)min,差异有统计学意义(t=5.213,P=0.000)。电视胸腔镜组患者手术切口、手术时间、术中出血量、住院时间及并发症的发生率,明显低于传统开胸组(P0.05)。在术后引流总量等比较,常规开胸组和电视胸腔镜组差异无统计学意义(P0.05)。结论电视胸腔镜肺叶切除术治疗早期非小细胞肺癌安全、可靠。     

全胸腔镜肺叶切除联合淋巴结清扫术治疗老年非小细胞肺癌的疗效

目的探讨全胸腔镜肺叶切除联合淋巴结清扫术治疗老年非小细胞肺癌(NSCLC)患者的临床效果。方法收集该院2011年6月至2013年6月住院治疗的老年NSCLC患者100例,按照随机数字表法分为观察组和对照组各50例,观察组给予全胸腔镜肺叶切除联合淋巴结清扫术,对照组给予开胸手术同样联合淋巴结清扫术,观察两组手术基本情况、治疗效果、术后并发症等。结果观察组的手术时间长于对照组(P<0.05);而术中出血量、术后住院时间、术后引流量、清扫淋巴结组数、术后下床活动时间等均小于对照组(P<0.05);清扫淋巴结个数在两组之间差异无统计学意义(P>0.05);观察组术后疼痛评分(VAS)评分低于对照组(P>0.05);两组围术期死亡率以及随访1年死亡率比较差异无统计学意义(P<0.05);观察组1年疾病复发率低于对照组(P<0.05)。两组术后并发症发生率比较差异显著(P<0.05)。结论全胸腔镜肺叶切除联合淋巴结清扫术治疗老年NSCLC术中出血量、术后疾病复发率以及术后并发症发生率较低,值得临床上采纳使用。     

胸腔镜肺癌根治术治疗高龄非小细胞肺癌36例

<正>外科手术是治疗非小细胞肺癌患者的首选方式,而高龄患者往往因为基础疾病较多、心肺功能欠佳而耐受不了开胸手术,术后也常因手术创伤过大出现并发症较多、恢复慢等问题,所以大部分高龄患者选择放弃外科手术治疗〔1,2〕。胸腔镜手术具有微创、并发症少、恢复快等特点,目前胸腔镜肺癌根治术已经成为治疗非小细胞肺癌患者的主要术式之一,但高龄患者能否适合还没有定论。本文拟探讨胸腔镜肺癌根治术对高龄非小细胞肺癌患者的治疗意义。     

完全胸腔镜技术在肺动脉瓣狭窄手术治疗中的应用

目的 探讨完全胸腔镜技术矫正肺动脉瓣狭窄(Pulmonary valvular stenosis,PS)的手术方法、安全性和有效性及优越性.方法 分析2014年1月～2018年12月在空军军医大学第一附属医院(西京医院)行完全胸腔镜下PS松解术患者的临床资料.共计102例患者,男性52例,女性50例.体外循环下经右心房...     

胸腔镜在非小细胞肺癌TNM分期的临床应用

目的 探讨胸腔镜在非小细胞肺癌TNM分期的临床应用.方法 本组61例手术前诊断的非小细胞肺癌,3例患者术前诊断Ⅳ期,选择化疗.其余58例应用电视胸腔镜(VATS)进行胸腔内淋巴结活检并术中送冰冻病理,进行术中分期,相应采取胸腔镜手术,胸腔镜辅助小切口肺叶切除,胸腔镜辅助开胸手术.对病理类型、淋巴结清除总数、淋巴结病理阳性数、术前术后TNM分期等指标进行观察和分析.结果 58例行VATS手术检查:胸腔镜微创手术2例;VATS小切口肺叶切除34例;VATS辅助全肺切除18例;VATS辅助袖式切除4例.术中共活检淋巴结数目139枚,病理阳性数目39枚.术前术后的TNM分期存在显著性差异(P＜0.01).结论 术前胸腔镜胸内淋巴结活检,可进行术中分期,能正确选择治疗对策.在肺癌的诊断治疗中是一种更准确的补充手段.     

胸腔镜下行肺癌根治术治疗肺癌80例分析

目的探讨胸腔镜下行肺癌根治术在治疗肺癌中的效果。方法分析入住我院的80例肺癌患者的临床资料,本组患者均经电视胸腔镜(VATS)辅助下的小切口行肿瘤切除并系统纵膈淋巴结清扫术,并对病理类型、病理分级、淋巴结转移频度以及随访6年之内的生存时间、手术前后患者的生存质量等方面进行观察、分析。结果本组80例肺癌患者,一共清理淋巴结688个区1054枚淋巴结,每位患者平均为(12.31±2.67)枚;胸腔镜下肺癌根治术与传统治疗方法的术后患者生存率不存在统计学差异(P>0.05);胸腔镜下肺癌患者在手术前后的生存质量存在显著的统计学差异(P<0.01)。结论胸腔镜下行肺癌根治术是一种安全、有效地治疗肺癌的方法。     

全胸腔镜肺叶切除术在早期肺癌的治疗

目的探讨全胸腔镜肺叶切除术在早期肺癌治疗中的临床疗效。方法选取盛京医院早期肺癌的患者,将其随机划分为观察组（31例）与对照组（31例）,其中对照组采用传统的开胸肺叶切除术治疗方法,观察组采用全胸腔镜肺叶切除术治疗方法,对二者的疗效及手术情况。结果观察组出现术后并发症1例,总有效率为80.6%;对照组出现术后并发症4例,总有效率达到58.1%,两组疗效及术后并发症发生率比较存在差异显著（P〈0.05）,具有统计学意义。结论全胸腔镜肺叶切除术在早期肺癌治疗中的临床疗效显著,与传统的开胸肺叶切除术治疗方法相比,可更好地缓解临床症状,能够有效进行淋巴结清扫,减少转移和复发,安全可靠。     

全胸腔镜下肺叶切除的临床应用

目的 探讨全胸腔镜肺叶切除术的临床价值.方法 全胸腔镜下行肺叶切除127例.其中右肺上叶19例,右肺中叶12例,右肺下叶17例,右肺中下叶7例,左肺上叶44例,左肺下叶28例;对94例原发性肺癌患者并同期施行纵隔淋巴结清扫.结果 全组手术均顺利完成.结论 全胸腔镜肺叶切除术疗效可靠、技术可行,安全、微创、恢复迅速,适用于早期周围型肺癌和需要施行肺叶切除的良性肺部疾病,但需要娴熟的内镜下处理血管和清扫淋巴结等关键技术.     

Single-port video-assisted thoracoscopic surgery for lung cancer

In 2004, novel results using pulmonary wedge resection executed through single-port video-assisted thoracoscopic surgery (VATS) was first described. Since that time, single-port VATS has been advocated for the treatment of a spectrum of thoracic diseases, especially lung cancer. Lung cancer remains one of the top three cancer-related deaths in Taiwan, and surgical resection remains the “gold standard” for early-stage lung cancer. Anatomical resections (including pneumonectomy, lobectomy, and segmentectomy) remain the primary types of lung cancer surgery, regardless of whether conventional open thoracotomy, or 4/3/2-ports VATS are used. In the past three years, several pioneers have reported their early experiences with single-port VATS lobectomy, segmentectomy, and pneumonectomy for lung cancer. Our goal was to appraise their findings and review the role of single-port VATS in the treatment of lung cancer. In addition, the current concept of mini-invasive surgery involves not only smaller resections (requiring only a few incisions), but also sub-lobar resection as segmentectomy. Therefore, our review will also address these issues.     

Robot-assisted vs. video-assisted thoracoscopic surgery in lung cancer

BackgroundThe major advantages of robot-assisted surgery are the fine field of view provided by the high-precision three-dimensional (3D) images and the good operability provided by the robotic arms that enables precise movements. A growing number of retrospective studies have compared robotic-assisted thoracoscopic surgery (RATS) with video-assisted thoracoscopic surgery (VATS), but the number of cases is limited and the results are contradictory.MethodsWe studied the medical records of primary lung cancer patients who underwent lobectomy with lymph node dissection between 2017 and 2020. Four hundred and eleven patients fulfilled the inclusion criteria in this study (RATS: 103; VATS: 308). We compared the perioperative factors and postoperative results of the VATS and RATS groups. Further, we adjusted background factors using propensity score matching (PSM) then compared the results of 200 patients (100 patients in each group). In this study, we matched interlobar fissure completeness, which affects operative difficulty and operative time; however, this has been superficially compared in previous studies.ResultsAfter PSM, a significant difference was observed in the intraoperative blood loss (RATS: 53.3 mL, VATS: 120.3 mL, P=0.04). The rates of surgical complications were comparable between the groups (10.0% vs. 13.0%, P=0.66) with similar mean operation times (RATS: 215.0 min, VATS: 210.1 min, P=0.57). The mean postoperative stay in the RATS group was shorter than that in the VATS group (10.0 vs. 11.5 days, P=0.04).ConclusionsInitial experience of RATS had no obvious drawbacks when compared with that of VATS on propensity-matched analysis.     

The safety and feasibility of three-dimension single-port video-assisted thoracoscopic surgery for the treatment of early-stage lung cancer

BackgroundVideo-assisted thoracoscopic surgery (VATS) has been widely used in the lung resections. Reports regarding three-dimension (3D) single-port VATS are very limited. The purpose of this study is to evaluate the perioperative outcomes of 3D single-port VATS in a single medical center.MethodsTotally 523 clinical stage I lung cancer patients underwent surgical resection through VATS operation between September 2016 and October 2017 in our single institution were retrospectively collected and 374 were enrolled. The comparison between 3D single-port VATS and conventional VATS (c-VATS), single-port VATS was conducted focusing on intraoperative and postoperative outcomes. Continuous and categorical variables were analyzed through SPSS software.ResultsThe 3D singe-port VATS demonstrated no significant difference neither on the intraoperative outcomes including the operative time and the intraoperative blood loss nor the postoperative outcomes including the length of drainage duration and postoperative complications when against c-VATS and single-port VATS. Besides, 3D singe-port VATS elucidated comparable ability of lymph node dissection with c-VATS in subgroup analysis (P=0.192), both of which were better than single-port VATS group (P<0.001). What’s more, the rate of conversion as well as hospital stays of 3D single-port group were also comparable. In subgroup analysis, 3D singe-port VATS also elucidated its safety and feasibility when dealing with routine thoracic surgeries including lobectomy and segmentectomy.Conclusions3D single-port VATS, integrating the advantages of single-port VATS and three-dimensional vision of 3D VATS, is a safe and feasible technique and is promising for next-generation thoracoscopic surgery.     

True video-assisted thoracic surgery for early-stage non-small cell lung cancer

Since its inception, minimally invasive surgery has made a dramatic impact on all branches of surgery. Video-assisted thoracic surgery (VATS) lobectomy for early-stage non-small cell lung cancer (NSCLC) was first described in the early 1990s and has since become popular in a number of tertiary referral centers. Proponents of this relatively new procedure cite a number of potentially favorable perioperative outcomes, possibly due to reduced surgical trauma and stress. However, a significant proportion of the cardiothoracic community remains skeptical, as there is still a paucity of robust clinical data on long-term survival and recurrence rates.The definition of 'true' VATS has also been under scrutiny, with a number of previous studies being considered 'mini-thoracotomy lobectomy' rather than VATS lobectomy. We hereby examine the literature on true VATS lobectomy, with a particular focus on comparative studies that directly compared VATS lobectomy with conventional open lobectomy.     

Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis

Background

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive alternative to conventional surgery (CS). We aimed to estimate the short-term cost-effectiveness of VATS vs. CS for clinical stage I non-small cell lung cancer (NSCLC-c-stage-I) patients from the payer’s perspective (National Health Insurance).

Methods

We identified NSCLC-c-stage-I patients diagnosed and received surgery within 2007-2009 through a comprehensive population-based database containing cancer and death registries, and reimbursement data. The duration of interest was 1 year. We included potential confounding covariables through literature searching and our own experience, and used a propensity score to construct a 1:1 population for adjustment.

Results

Our study population constituted 966 patients. The mean hospital stay [days, standard deviation (SD)] were 14.4 [7] and 16.1 (7.7) for VATS and CS respectively (P=0.002). The mean cost (2013 USD) and survival (year) was $22,316 vs. $21,976 and 0.98 vs. 0.974 for VATS vs. CS. The probability for VATS to be cost-effective (i.e., positive net benefit) was 0.49 & 0.56 at willingness-to-pay (WTP) 50,000 & 100,000 USD/life-year, respectively.

Conclusions

We provide the first empirical evidence that when compared to CS, VATS was potentially cost-effective in the short term (1 year) within the common WTP levels in Taiwan.     

Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy

Background

To explore the effectiveness of video-assisted thoracoscopic surgery (VATS) bronchial sleeve resection and reconstruction.

Methods

The clinical data of patients who had received VATS bronchial sleeve lobectomy in our center from January 2008 to February 2015 were retrospectively analyzed.

Results

Totally 118 patients (105 men and 13 women) received the VATS bronchial sleeve lobectomy. The procedures included sleeve resection of right upper lobe (n=59), right middle lobe (n=7), right lower lobe (n=8), left upper lobe (n=34), and left lower lobe (n=10). The lesions were confirmed to be squamous cell carcinoma (n=68), adenocarcinoma (n=16), mucoepidermoid carcinoma (n=8), adenosquamous carcinoma (n=7), large cell carcinoma (n=1), carcinoids (n=5), and others (n=13; including small cell carcinoma, pleomorphic carcinoma, and inflammatory myofibroblastic tumor). Operations lasted 118–223 min [mean ± standard deviations (SD): 124.00±31.75 min]. The length of removed bronchus was 1.50–2.00 cm (mean ± SD: 1.75±0.26 cm). The duration of bronchial anastomosis (from the first puncture to the completion of knotting) was 15–42 min (mean ± SD: 30.20±7.97 min). The number of dissected lymph node stations (at least three mediastinal lymph node stations, including station 7) was 5–9 stations (mean ± SD: 6.50±1.18 min). The number of dissected lymph nodes was 10–46 (mean ± SD: 26.00±10.48). The intraoperative blood loss was 20–400 mL (mean ± SD: 71.00±43.95 mL), and no blood transfusion was performed. All patients were observed in intensive care unit (ICU) for 1 day. Postoperative drainage was performed for 3–8 days (mean ± SD: 5.00±1.49 days). Postoperative hospital stay was 3–8 days (mean ± SD: 5.10±2.07 days).

Conclusions

VATS bronchial sleeve resection and reconstruction is a safe and feasible technique.     

Video-assisted mediastinoscopic resection compared with video-assisted thoracoscopic surgery in patients with esophageal cancer

Objective

The purpose of this study was to explore the indications of radical vedio-assisted mediastinoscopic resection for esophageal cancer.

Methods

The data of 109 patients with T1 esophageal cancer who underwent video-assisted mediastinoscopic resection (VAMS group) in Third Affiliated Hospital of Soochow University Hospital from December 2005 to December 2011 were collected in the study for comparison with the 58 patients with T1 esophageal cancer who underwent video-assisted thoracoscopic surgery (VATS group) in Zhongshan Hospital, Fudan University. The perioperative safety and survival were compared between the two groups.

Results

All operations were successful in both groups. One perioperative death was noted in the VATS group. The incidences of post-operative complications were not significantly different between these two groups, whereas the VAMS group was favorable in terms of operative time (P<0.001) and blood loss (P<0.001), and a significantly larger number of chest lymph nodes were dissected in the VATS group compared with the VAMS group (P<0.001). Long-term follow-up showed that the overall survival was not significantly different between these two groups (P=0.876).

Conclusions

T1N0M0 esophageal cancer can be as the indication of VAMS radical resection. VAMS radical resection can be considered as the preferred option for patients with poor pulmonary and cardiac function or a history of pleural disease.     

Uniportal complete video-assisted thoracoscopic surgery lobectomy with partial pulmonary arterioplasty for lung cancer with calcified lymph node

Now, more and more complete video-assisted thoracoscopic surgery (cVATS) surgeons are capable of performing lobectomy by uniportal approach. However, concerns regarding the safety of uniportal procedures for complex cases such as neoadjuvant chemotherapy, bronchial sleeves or vascular reconstructions still remains. As experience with uniportal VATS has increased, its application toward more technically demanding operations has also expanded. This article describes a uniportal cVATS left upper lobectomy with partial pulmonary arterioplasty for lung cancer with calcified lymph nodes. In order to reduce the risk of bleeding, we looped the left main pulmonary artery and applied two-stage maneuvering for left upper lobe (LUL) bronchus, cut the bronchus at the distal end and close the stump using a stapler at the end, which are conducive to maximal safety.     

Uniportal video-assisted thoracoscopic surgery right upper lobectomy with systematic lymphadenectomy in a semiprone position

A 53-year-old male smoker was referred to our hospital with an enlarged lesion in the right upper lung. Computed tomography (CT) showed a 1.5 cm solid lesion with pleural indentation in the right upper lobe adjacent to the oblique fissure. The preoperative clinical diagnosis was stage I primary lung cancer. Uniportal video-assisted thoracoscopic surgery (VATS) right upper lobectomy in a semiprone position was performed in this case. Frozen section examination confirmed the diagnosis of lung adenocarcinoma, and systematic lymphadenectomy was then performed. A chest tube was placed at the posterior part of the incision through the dorsal thoracic cavity to the apex. The postoperative pathologic diagnosis was T2aN0M0 adenocarcinoma.     

Comparative study of systematic thoracoscopic lymphadenectomy and conventional thoracotomy in resectable non-small cell lung cancer

Objective

To assess the feasibility and safety of the video-assisted thoracoscopy surgery (VATS) systematic lymph node dissection in resectable non-small cell lung cancer (NSCLC).

Methods

The clinical data of patients with NSCLC who underwent VATS or thoracotomy combined with lobectomy and systematic lymphadenectomy from January 2001 to January 2008 were retrospectively analyzed to identify their demographic parameters, number of dissected lymph nodes and postoperative complications.

Results

A total of 5,620 patients were enrolled in this study, with 2,703 in the VATS group, including 1,742 men (64.4%), and 961 women (35.6%), aged 59.5±10.9 years; and 2,917 in the thoracotomy group, including 2,163 men (74.2%), and 754 women (25.8%), aged 58.5±10.4 years. Comparing the VATS with the thoracotomy groups, the mean operative time was 146 vs. 157 min, with a significant difference (P<0.001); and the average blood loss was 162 vs. 267 mL, with a significant difference (P<0.001). Comparing the two groups of patients data, the number of lymph node dissection: 18.03 in the VATS group and 15.07 in the thoracotomy group on average, with a significant difference (P<0.001); postoperative drainage time: 4.5 days in the VATS group and 6.37 days in the thoracotomy group on average, with a significant difference (P<0.001); postoperative hospital stay: 6.5 days in the VATS group and 8.37 days in the thoracotomy group on average, with a significant difference (P<0.001); proportion of postoperative chylothorax: 0.2% (4/2,579) in the VATS group and 0.4% (10/2,799) in the thoracotomy group, without significant difference (P>0.05).

Conclusions

For patients with resectable NSCLC, VATS systematic lymph node dissection is safe and effective with fewer postoperative complications, and significantly faster postoperative recovery compared with traditional open chest surgery.