【摘要】：目的：探討單孔胸腔鏡模塊化肺癌根治術在肺癌外科治療中的安全性、可行性及手術切除效果。方法：回顧性分析我科自2015年3月至2015年12月間實施單孔胸腔鏡和三孔胸腔鏡模塊化肺癌根治的肺癌患者資料共334例,其中單孔胸腔鏡手術(單孔組)225例,三孔胸腔鏡手術(三孔組)109例。所有患者均按照模塊化肺癌根治的方法進行手術,即將解剖性肺葉／肺段切除±系統(tǒng)性淋巴結清掃劃分為五個模塊：①下縱隔第8、9組淋巴結模塊；②隆突下第7組淋巴結模塊；③右側上縱隔2R、4R組淋巴結模塊；④左側上縱隔4L～6組淋巴結模塊和⑤解剖性肺葉／肺段切除模塊。根據(jù)左側和右側肺部手術的不同技術路線依次進行各個模塊的操作完成全部手術。對比兩組患者的一般臨床特征、腫瘤特征和手術相關資料(包括術中胸膜粘連情況、手術時間、術中出血量、手術方式、淋巴結清掃枚數(shù)、中轉開胸情況等),比較兩組患者術后ICU治療時間、纖支鏡吸痰人數(shù)及人均吸痰次數(shù),分析兩組術后胸管引流時間、術后住院時間及術后并發(fā)癥發(fā)生率。根據(jù)患者術后不同TNM分期,在I期、II期和III期患者中分別對兩種術式的上述指標再次進行對比分析。結果：單孔組225例患者中共有男性126例,女性99例,三孔組109例中有男性66例,女性43例,兩組患者的一般臨床資料及腫瘤特征均無差異(P均0.05)。兩組無圍手術期死亡病例。單孔組共12例術中中轉增加操作孔或開胸手術,三孔組4例中轉開胸,兩組中轉率無統(tǒng)計學差異(P=0.504)。單孔組平均手術時間(144.9±16.0)min,較三孔組(135.1±13.9)min更長(P0.001),術中出血量(79.9±27.8)ml和三孔組(77.7±22.2)ml相比無統(tǒng)計學差異(P=0.463)；人均清掃淋巴結枚數(shù)方面單孔組為(17.4±3.0)枚,三孔組為(17.6±2.8)枚,兩組之間無統(tǒng)計學差異(P=0.580)。術后ICU治療時間[(24.2±9.6)h vs(25.4+7.9)h]和床邊纖支鏡吸痰率(24.9% vs 27.5%)兩組之間均無顯著差異(P=0.264,P=0.606),但單孔組吸痰人群中人均吸痰次數(shù)(1.4±0.6次)較三孔組(1.6±0.7次)更少(P=0.046),未發(fā)現(xiàn)兩組術后并發(fā)癥發(fā)生率有顯著區(qū)別(P均0.05)。單孔組術后胸管平均置管(4.4±1.3)天,顯著低于三孔組的(5.0±1.3)天(P0.001),術后住院時間單孔組亦較三孔組顯著縮短[(9.4±1.4)天vs(10.3±1.6)天,P0.001]。根據(jù)TNM分期在Ⅰ期、Ⅱ期和Ⅲ期患者中再次分別比較兩種術式的臨床應用情況,發(fā)現(xiàn)三個不同分期患者中,單孔胸腔鏡手術時間均較三孔胸腔鏡顯著延長[Ⅰ期：(140.2±11.6min vs 131.9±11.1)min, P＜0.001;Ⅱ期：(157.0±17.0) min vs (140.0±11.5) min, P=0.001;Ⅲ期：(158.8±21.1) min vs (141.6±19.8) min, P=0.004)],但術中出血量、手術方式、淋巴結清掃枚數(shù)及中轉率方面兩種術式之間均無顯著差異。在三個分期患者中,術后ICU治療時間、纖支鏡吸痰人數(shù)和術后并發(fā)癥發(fā)生率在兩種術式之間亦無明顯區(qū)別,但Ⅰ期患者術后纖支鏡吸痰人群的人均吸痰次數(shù)在單孔組(1.3±0.6)較三孔組(1.6±0.7)更少(P=0.045),在Ⅱ期和Ⅲ期患者中,兩種術式之間并無顯著區(qū)別(P--0.574,P=0.875)。在三個不同分期中,單孔術式術后胸管引流時間均較三孔術式更短[I期：(4.4±1.2)d vs(4.7±1.1)d,P=0.041：Ⅱ期：(4.6±2.0)d vs(5.8±1.6)d,P=0.050；Ⅲ期： (4.4±1.3)d vs(5.4±1.4)d,P=0.010]；Ⅰ期和Ⅲ期患者中,單孔術式術后住院時間亦顯著少于三孔組[Ⅰ期：(9.2±1.0)d vs(9.3±1.3)d,P=0.002;Ⅲ期：(10.0±1.9)d vs(11.6±1.9)d,P=0.004],而Ⅱ期患者中,兩種術式術后住院時間無顯著差別[Ⅱ期：(10.0±2.2)d vs(10.9±1.5)d,P=0.144]。結論：單孔胸腔鏡下模塊化肺癌根治術具有一定的臨床應用可行性,其手術切除效果和三孔胸腔鏡手術相似,不會增加患者術后并發(fā)癥風險且能促進其術后快速康復。目的：探討單孔胸腔鏡模塊化肺癌根治性切除對縱隔淋巴結的清掃效果,評估該手術方法在肺癌外科治療中的應用價值。方法：回顧性分析我科自2015年3月至2015年12月間實施單孔胸腔鏡或三孔胸腔鏡肺癌根治的非小細胞肺癌患者共311例,其中單孔胸腔鏡手術(單孔組)208例,三孔胸腔鏡手術(三孔組)103例。所有患者均按照模塊化肺癌根治的方法行解剖性肺葉/肺段切除+系統(tǒng)性淋巴結清掃。對比兩組患者的一般臨床特征、腫瘤特征和手術相關資料(包括手術時間、術中出血量、手術方式、術后胸管置管時間、術后住院時間及并發(fā)癥發(fā)生率等),比較兩組患者的淋巴結清掃總組數(shù)和總枚數(shù)、N2站淋巴結清掃的組數(shù)和枚數(shù)等,并分別對左、右兩側各N2站淋巴結的清掃情況進行統(tǒng)計和對比。分別在I期、II期和IIIa期患者中,再次比較兩種術式對縱隔淋巴結清掃的效果。結果：單孔組共有男性110例,女性98例,三孔組有男性61例,女性42例,兩組患者的一般臨床資料及腫瘤特征均無差異(P均0.05)。兩組均無圍手術期死亡病例,在手術方式上無差異,單孔組手術時間為(144.8±15.3)min,顯著長于三孔組[(135.1±13.9)min,P0.001],但術中出血量兩組無顯著差異。在淋巴結清掃方面,單孔組人均清掃胸腔內淋巴結(7.3±1.0)組,共(17.5±3.0)枚,三孔組人均清掃淋巴結(7.2±1.0)組,共(17.7±2.7)枚,在清掃的組數(shù)和枚數(shù)上兩種術式之間無統(tǒng)計學差異(P=0.208,P=0.596)。進一步對縱隔N2站淋巴結進行分析,單孔組人均清掃N2站淋巴結(4.3±0.7)組,共(8.6±1.1)枚,三孔組人均清掃N2站淋巴結(4.3±0.6)組,共(8.5±1.1)枚,兩種術式對縱隔淋巴結的清掃效果同樣相似(P--0.850,P=0.587)。在對左、右兩側各N2站淋巴結的清掃率及清掃枚數(shù)上,兩種術式間相比無統(tǒng)計學差異(P均0.05)。在Ⅰ期、Ⅱ期和Ⅲa期患者中,單孔胸腔鏡和三孔胸腔鏡手術在清掃的淋巴結組數(shù)、人均清掃枚數(shù)及對N2站淋巴結清掃的組數(shù)和人均清掃枚數(shù)上亦均無顯著差異(P均0.05)。單孔組術后胸管引流時間和住院時間分別為(4.4±1.3)天和(9.2±0.9)天,均較三孔組[(5.0±1.3)天, (9.8±2.0)天]更短且有顯著統(tǒng)計學差異(P均0.001),未發(fā)現(xiàn)兩組術后并發(fā)癥發(fā)生率存在顯著差異(P均0.05)。結論：單孔胸腔鏡下模塊化肺癌根治術能夠達到和傳統(tǒng)三孔胸腔鏡手術相同的淋巴結清掃效果,其在縱隔淋巴結清掃方面亦不遜色于三孔胸腔鏡手術,在肺癌根治性外科治療中具有一定的臨床應用價值。目的：探索使用雙16F胸管U型置管引流在單孔胸腔鏡肺癌根治術后胸腔引流中應用的可行性、安全性及引流效果。方法：分析我科自2014年9月至2015年2月間實施單孔胸腔鏡肺癌根治的非小細胞肺癌患者共88例,30F胸管引流組(粗胸管組)術后經切口留置1根30F胸管,16F胸管引流組(細胸管組)術后經切口留置2根16F胸管,并使其在胸腔內呈U型擺放(側位觀察)。對比兩組患者的一般臨床特征、腫瘤特征和手術資料和術后并發(fā)癥情況,比較兩組患者術后人均胸管引流總量、引流天數(shù)及術后住院天,以視覺模擬評分(visual analogue scale, VAS)法評估兩組患者術后第3、7天時疼痛的最小(VASmin-d3、d7)及最大(VASmin-d3、d7)值,對比兩組患者術后三月切口麻木發(fā)生率。結果：兩組患者的一般臨床資料及腫瘤特征均無差異(P均0.05)。兩組無圍手術期死亡病例,在手術方式、術中出血量及淋巴結清掃枚數(shù)上亦無差異(P均0.05),細胸管組胸管引流時間為(5.2±2.1)d,而粗胸管組術后平均胸管留置時間為(6.2±2.4)d,兩組相比具有統(tǒng)計學意義(P=0.044),但兩組在術后總引流量上并無差異[(1172.6±348.3)ml vs(1245.7±422.6)ml,P=0.138]；粗管組術后住院時間為(12.8±2.4)d,較細管組的(11.7±2.6)d更長(P=0.043)。細管組術后切口滲液率(2.2%)較粗管組(16.7%)顯著降低(P=0.025),在其他并發(fā)癥上兩組之間并無明顯統(tǒng)計學差異。細管組術后第3天和第7天的VASmin和粗管組相比無顯著差異(P均0.05),但細管組術后第3天和第7天的VASmax(3.77±0.75,2.02±039)均顯著低于粗管組(4.14±0.75,2.21±0.41),差異具有統(tǒng)計學意義(P=0.022,P=0.046)。術后三月細管組切口麻木發(fā)生率為19.6%,和粗管組(40.5%)相比具有顯著統(tǒng)計學意義(P=0.032)。結論：雙16F胸管U型置管能夠安全有效地用于單孔胸腔鏡肺癌根治術后胸腔引流管理,能夠縮短患者術后胸腔引流天數(shù)及術后住院天數(shù),并能減輕術后疼痛及術后切口麻木不適感,有助于患者術后快速康復。目的：本研究擬評估單孔胸腔鏡模塊化肺癌根治術對患者術后疼痛及短期生活質量的影響,進一步探討其臨床應用的價值。方法：選取2015年3月至2015年11月在我科行單孔胸腔鏡(單孔組)模塊化肺癌根治或三孔胸腔鏡(三孔組)肺癌根治術的非小細胞肺癌患者272例,其中單孔組176例,三孔組96例。對比兩組的臨床及手術資料,以視覺模擬評分(visual analogue scale, VAS)法評估兩組患者術后第3、7天時疼痛的最小(VASmin-d3、d7)及最大(VASmax-d3、 d7)值,肺癌治療功能性量表(Functional Assessment of Cancer Treatment-Lung， FACT-L)中文版v4.0評測兩組患者術前及術后三月的生活質量,對比兩組術后三月切口麻木發(fā)生率及患者對切口外觀的滿意度。結果：兩組患者的一般臨床資料無差異,均無圍手術期死亡病例,單孔組手術時間(144.3±15.50)min較三孔組(135.1±14.3)min更長(P0.001),但術后胸管置管時間和術后住院時間在單孔組[(4.4±1.2)d,(9.5±1.3)d]均明顯短于三孔組[(5.0±1.4)d, (10.2±1.6)d](P均0.001)；兩組患者術后VASmin-d3無顯著差異,但單孔組VASmin-d7及VASmax-d3、d7(1.41±0.26,3.74±0.54,2.39±0.51)均顯著低于三孔組(1.54±0.28,3.94±0.51,2.64±0.60)(P=0.003,P=0.003,P0.001)。FACT-L評分顯示術后三月單孔組患者功能狀態(tài)、情感狀態(tài)和整體生活質量得分(21.1±2.1,20.1±1.7,108.6±4.4)均顯著高于三孔組患者(20.2±1.9,19.3±1.7,106.8±4.2)(P=0.005,P=0.004,P=0.008),而生理狀態(tài)、社會/家庭狀態(tài)及肺癌相關癥狀評分兩組并無顯著差異。和三孔組相比,單孔組術后三月切口麻木發(fā)生率(25.6% vs 40.6%)更低(P=0.010),患者對切口的滿意度更高(77.8% vs 64.6%,P=0.018)。結論：和三孔胸腔鏡相比,單孔胸腔鏡模塊化肺癌根治術能夠減輕患者術后疼痛,改善術后短期生活質量,在肺癌的外科治療中有一定臨床應用價值。
[Abstract]:Objective: To evaluate the safety, feasibility and surgical outcome of single-hole thoracoscopic modular lung cancer radical surgery. Methods: A retrospective analysis of 334 lung cancer patients who underwent single-hole thoracoscopic and three-hole thoracoscopic modular lung cancer radical surgery from March 2015 to December 2015 was performed. All patients underwent modular lung cancer radical resection, i.e. dissected lobectomy / segmentectomy + systemic lymph node dissection, which was divided into five modules: (1) lower mediastinum lymph node module 8, 9; subcarina lymph node module 7; and (3) upper right lymph node module 3. Mediastinal 2R, 4R lymph node module; left upper mediastinum 4L ~ 6 lymph node module and_anatomical pulmonary lobectomy / segmentectomy module. According to the different technical routes of left and right lung surgery, each module was operated in turn to complete all the operations. Including intraoperative pleural adhesion, operation time, intraoperative bleeding, operation methods, lymph node dissection, conversion to thoracotomy, etc., the ICU treatment time, the number of fiberoptic bronchoscope sputum aspiration and the number of times per person were compared between the two groups, and the postoperative thoracic drainage time, postoperative hospitalization time and postoperative complications were analyzed. Results: There were 126 males and 99 females in 225 patients with single orifice group, 66 males and 43 females in 109 patients with three orifices group. There were no differences in general clinical data and tumor characteristics between the two groups (P 0.05). There was no perioperative mortality. There were 12 cases in the single-hole group and 4 cases in the three-hole group who were converted to open thoracotomy. There was no significant difference in the conversion rate between the two groups (P = 0.504). The average operation time in the single-hole group was (144.9 (+ 16.0) minutes, which was longer than that in the three-hole group (135.1 (+ 13.9) minutes (P 0.001). The intraoperative bleeding volume was (79.9 (+ 27.8) ml) and that in the three-hole group (77.7 (+ 22.2) ml). There was no significant difference between the two groups (P = 0.463); there was no significant difference in the number of lymph nodes per capita between the single-hole group (17.4 + 3.0) and the three-hole group (17.6 + 2.8) (P = 0.580). However, the average number of suctions per person in the single-hole group (1.4 + 0.6 times) was less than that in the three-hole group (1.6 + 0.7 times) (P = 0.046). No significant difference was found in the incidence of postoperative complications between the two groups (P = 0.05). The average postoperative chest tube placement time in the single-hole group (4.4 + 1.3 days) was significantly lower than that in the three-hole group (5.0 + 1.3 days) (P 0.001). According to the clinical application of TNM staging in stage I, stage II and stage III patients, it was found that the operation time of single-hole thoracoscopy was significantly longer than that of three-hole thoracoscopy in three different stages [stage I: (140.2 65 Phase II: 157.0 + 17.0 min vs (140.0 + 11.5) min, P = 0.001; Phase III: 158.8 + 21.1 min vs (141.6 + 19.8) min, P = 0.004), but there was no significant difference in the amount of bleeding, the number of lymph node dissections, and the rate of conversion between the two methods. There was no significant difference in the number of sputum aspirations and the incidence of postoperative complications between the two procedures, but the number of sputum aspirations per person in the single-hole group (1.3.6) was less than that in the three-hole group (1.6.7) (P = 0.045), and there was no significant difference between the two procedures in the second and third stages (P - 0.574, P = 0.875). In the middle, the time of thorthorthorthorthorthorthorthorthorthorthorthorthorthorthorthorthorthorthorthordrainwas shortethan that of three-hole operation [I stage: (4.4 1.2) days vs (4.4 ((4.4 1.2) days vs (4.7 (1.7 1.1 1) d, P = 0.041: 2 (P = 0.041: 0.041: I I stage: (4.6 (5.6 2.0) D vs (5.8 (5.8 1 1 1.8 1.6) 6) days (5 (5.8 0) D vs (9.3 + 1.3) d, P = 0.002; stage III: (10.0 + 1.9) D vs (11.6 + 1.9) d, P = 0.004). There was no significant difference in postoperative hospital stay between the two methods in stage II patients [stage II: (10.0 + 2.2) D vs (10.9 + 1.5) d, P = 0.144]. Objective: To investigate the effect of single-hole modular thoracoscopic radical resection of lung cancer on mediastinal lymph node dissection and evaluate the value of this method in the surgical treatment of lung cancer. A total of 311 patients with non-small cell lung cancer who underwent single-hole thoracoscopic or three-hole thoracoscopic radical resection of lung cancer were enrolled in this study. 208 patients underwent single-hole thoracoscopic surgery (single-hole group) and 103 underwent three-hole thoracoscopic surgery (three-hole group). The total number of lymph node dissection, the number of N2 lymph node dissection and the number of lymph node dissection were compared between the two groups. Results: There were 110 males, 98 females, 61 males and 42 females in the single foramen group and the three foramen group. The general clinical data and tumor characteristics of the two groups were compared. There was no significant difference between the two groups (P 0.05). There were no perioperative deaths and no significant difference in operative methods between the two groups. The operation time in the single-hole group was (144.8 (15.3) minutes, significantly longer than that in the three-hole group [(135.1 (13.9) minutes, P 0.001], but there was no significant difference in the amount of intraoperative bleeding between the two groups. There was no significant difference in the number and number of lymph node dissection between the two groups (P = 0.208, P = 0.596). Further analysis of mediastinal N2 lymph nodes, single-hole group (4.3 + 0.7) and three-hole group (8.6 + 1.1) were performed. There was no significant difference in the clearance rate and number of lymph nodes in the left and right N2 stations between the two methods (all P 0.05). In the patients of stage I, stage II and stage III, single-hole thoracoscopy and three-hole thoracoscopy had the same effect on mediastinal lymph nodes (P--0.850, P = 0.587). There was no significant difference in the number of lymph nodes dissected, the number of lymph nodes dissected per capita, the number of lymph nodes dissected at N2 station, and the number of lymph nodes dissected per capita (P There was no significant difference in the incidence of postoperative complications between the two groups (P 0.001). Conclusion: Single-hole thoracoscopic modular lung cancer radical resection can achieve the same effect of lymph node dissection as traditional three-hole thoracoscopic surgery, and it is not inferior to three-hole thoracoscopic surgery in mediastinal lymph node dissection. Objective: To explore the feasibility, safety and efficacy of double 16F thoracoscopic U-tube drainage in the treatment of non-small cell lung cancer after single-hole thoracoscopic lung cancer radical surgery. A total of 88 patients with cancer were enrolled. One 30F thoracic tube was retained through incision in the 30F thoracic drainage group (thick thoracic tube group) and two 16F thoracic tubes were retained through incision in the 16F thoracic tube drainage group (thin thoracic tube group). The general clinical features, tumor characteristics, surgical data and postoperative complications were compared between the two groups. The total amount of thoracic drainage, drainage days and hospitalization days per patient in both groups were assessed by visual analogue scale (VAS) to evaluate the minimal pain (VASmin-d3, d7) and maximal pain (VASmin-d3, d7) on the 3rd and 7th day after surgery. The incidence of incision numbness was compared between the two groups at 3 months after surgery. There was no difference between the two groups in terms of perioperative mortality, bleeding volume and number of lymph node dissection (P There was no significant difference in total drainage between the two groups (P = 0.044), but there was no significant difference in postoperative drainage between the two groups [(1172.6 + 348.3) ml vs (1245.7 + 422.6) ml, P = 0.138]; the hospitalization time in the tubule group was (12.8 + 2.4) d, longer than that in the tubule group (11.7 + 2.6) D (P = 0.043). The incision exudation rate in the tubule group (2.2%) was significantly lower than that in the tubule group (16.7%) and other complications (P = 0.025). There was no significant difference between the two groups. There was no significant difference in VASmin between the tubule group and the tubule group on the 3rd and 7th day after operation (P 0.05), but the VASmax (3.77.75, 2.02.039) in the tubule group was significantly lower than that in the tubule group on the 3rd and 7th day after operation (4.14.75, 2.21.41), the difference was statistically significant (P = 0.022, P = 0.046). The incidence of incision numbness in the tube group was 19.6%, which was significantly higher than that in the thick tube group (40.5%) (P = 0.032). Conclusion: Double 16F U-tube placement can be safely and effectively used for thoracic drainage management after single-hole thoracoscopic lung cancer radical surgery, which can shorten the days of thoracic drainage and hospitalization, and relieve postoperative pain and pain. Objective: To evaluate the effect of single-hole thoracoscopic modular lung cancer radical resection on postoperative pain and short-term quality of life, and to further explore its clinical value. Two hundred and seventy-two patients with non-small cell lung cancer who underwent modular lung cancer radical resection or three-hole thoracoscopy (three-hole group) were enrolled in this study. (VASmax-d3, d7) value and Chinese version of Functional Assessment of Cancer Treatment-Lung (FACT-L) v4.0 were used to evaluate the quality of life of the two groups before and after surgery in March. The incision numbness rate and the patients'satisfaction with the appearance of the incision were compared between the two groups. There was no perioperative mortality. The operation time of single-hole group was longer than that of three-hole group (P However, VASmin-d7 and VASmax-d3, D7 (1.41+0.26, 3.74+0.54, 2.39+0.51) were significantly lower in the single-hole group than those in the three-hole group (1.54+0.28, 3.94+0.51, 2.64+0.60) (P = 0.003, P = 0.003, P = 0.001). FACT-L scores showed functional status, emotional status and overall quality of life (21.1+2.1, 20.1 + 1.7, 108.4) in the single-hole group three months after surgery. It was significantly higher than that of the three-hole group (20.2 (+ 1.9), 19.3 (+ 1.7), 106.8 (+ 4.2)) (P = 0.005, P = 0.004, P = 0.008), and the physiological status, social / family status.
【學位授予單位】：華中科技大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R734.2

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