【摘要】：背景和目的:可手術局部晚期(Ⅲa-N2期)非小細胞肺癌新輔助化療后病變情況較早期肺癌更為復雜,常規(guī)需采用開胸手術,該類患者能否施行胸腔鏡手術?在技術上和安全性上是否可行?較傳統(tǒng)開胸手術是否有優(yōu)勢?目前國內(nèi)外仍存在廣泛爭議。本研究通過對臨床分期Ⅲa-N2期非小細胞肺癌新輔助化療后胸腔鏡手術與開胸手術的前瞻性隨機對照研究,探討臨床分期Ⅲa-N2期非小細胞肺癌新輔助化療后行胸腔鏡肺葉切除術的安全性和可行性,并總結手術經(jīng)驗。方法:本研究選擇2012年6月~2016年6月初診臨床分期Ⅲa-N2期已行新輔助化療并擬行肺葉切除術的非小細胞肺癌患者40例,隨機分兩組:研究組20例行胸腔鏡肺葉切除+系統(tǒng)性淋巴結清掃術;對照組20例行傳統(tǒng)開胸肺葉切除+系統(tǒng)性淋巴結清掃術。比較兩組手術時間、術中出血量、引流管留置時間、淋巴結清掃數(shù)目、術后并發(fā)癥、術后住院天數(shù)、術后VAS疼痛評分。結果:研究組有17例完成胸腔鏡肺葉切除術,1例(1/20,5%)行胸腔鏡探查術,中轉(zhuǎn)行開胸肺葉切除術2例(2/20,10%);傳統(tǒng)開胸組20例均順利完成肺葉切除術。兩組患者無圍手術期死亡。兩組手術時間:研究組165.47±30.54分,對照組152.53±35.65分。術中出血:研究組187.35±90.93m L,對照組210.29±98.02mL。胸管留置時間:研究組5.42±2.49天,對照組5.35±3.18天。淋巴結清掃數(shù)目:研究組9.59±2.32個,對照組9.47±2.03個。術后并發(fā)癥:研究組2例(11.8%),對照組6例(30.0%)。術后住院天數(shù):研究組7.35±2.03天,對照組10.12±2.32天。兩組患者手術時間、術中出血量、引流管留置時間、淋巴結清掃數(shù)目差異無統(tǒng)計學意義(P0.05);研究組術后并發(fā)癥發(fā)生率及VAS疼痛評分更低、住院天數(shù)更短,差異有統(tǒng)計學意義(P0.05)。結論:臨床分期Ⅲa-N2期非小細胞肺癌新輔助化療后行胸腔鏡肺葉切除手術治療是安全的、可行的,較傳統(tǒng)開胸手術具有一定的微創(chuàng)優(yōu)勢。臨床分期Ⅲa-N2期非小細胞肺癌患者新輔助化療后胸腔鏡手術,應在化療后進行精確的療效評估和手術可行性評估,選擇合適的病例施行,化療療效較好、無明顯腫大融合并侵犯肺門縱膈結構淋巴結者可以選擇胸腔鏡手術。術前肺內(nèi)N1淋巴結是否包繞粘連肺內(nèi)支氣管血管的準確評估也是能否選擇胸腔鏡手術的關鍵技術點�？v膈淋巴結清掃應采用enbloc切除技術即整塊切除技術,應避免淋巴結采樣。
[Abstract]:BACKGROUND & OBJECTIVE: The patients with advanced non-small cell lung cancer (NSCLC) with advanced non-small cell lung cancer (NSCLC) with advanced non-small cell lung cancer are more complicated than the early stage of lung cancer. Is technically and safely possible? Is there an advantage over the traditional thoracotomy? There are still a wide range of disputes at home and abroad. The purpose of this study was to investigate the safety and feasibility of a new adjuvant chemotherapy for non-small cell lung cancer in stage 鈪-N2 non-small cell lung cancer after neoadjuvant chemotherapy, and to evaluate the safety and feasibility of thoracoscopic pulmonary lobectomy after neoadjuvant chemotherapy in stage 鈪-N2 non-small cell lung cancer. And summarize the experience of the operation. Methods:40 patients with non-small cell lung cancer who received neoadjuvant chemotherapy in stage 鈪-N2 and non-small cell lung cancer with pulmonary lobectomy were selected from June 2012 to June 2016, and two groups were randomly divided into two groups:20 patients in the study group and 20 patients with systematic lymph node dissection; In the control group,20 cases of conventional thoracotomy + systematic lymph node dissection were performed. The operative time, the intraoperative blood loss, the indwelling time of the drainage tube, the number of lymph node dissection, the postoperative complications, the number of postoperative hospital stay and the VAS pain score were compared. Results: In the study group,17 cases underwent thoracoscopic lobectomy, one case (1/20,5%) underwent thoracoscopic exploration, and 2 cases (2/20,10%) of transthoracic and pulmonary lobectomy were performed in the study group, and 20 cases of the traditional thoracotomy group successfully completed the lobectomy. There were no perioperative deaths in both groups. The operation time of the two groups was 165.47 and 30.54 in the study group, and the control group was 152.53 to 35.65. Intraoperative bleeding: Study group 187.35-90.93 m L, control group 210.29-98.02 mL. The indwelling time of the chest tube: 5.42 to 2.49 days in the study group and 5.35 to 3.18 days in the control group. The number of lymph node dissection: 9.59 to 2.32 in the study group and 9.47 to 2.03 in the control group. Postoperative complications were 2 (11.8%) in the study group and 6 in the control group (30.0%). Post-operative hospitalization days: Study group 7.35-2.03 days, control group 10.12-2.32 days. The operative time of the two groups, the intraoperative blood loss, the time of the indwelling time of the drainage tube and the number of lymph node dissection were not significant (P0.05); the incidence of postoperative complications and the VAS pain score of the study group were lower, and the number of hospitalized days was shorter and the difference was statistically significant (P0.05). Conclusion: The clinical stage 鈪-N2 stage non-small cell lung cancer is safe and feasible after neoadjuvant chemotherapy for non-small cell lung cancer. In the patients with non-small cell lung cancer in stage 鈪-N2 of clinical stage, the patients with non-small cell lung cancer were treated with video-assisted thoracoscopic surgery. Video-assisted thoracoscopic surgery can be selected for patients with non-obvious enlargement and invasion of the mediastinal lymph nodes of the hilar. It is also possible to select the key technology points of video-assisted thoracoscopic surgery. For mediastinal lymph node dissection, the enbloc resection technique, i.e., one-piece resection technique, should be used to avoid lymph node sampling.
【學位授予單位】：南昌大學
【學位級別】：碩士
【學位授予年份】：2018
【分類號】：R734.2

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