中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

肺癌患者胸腔镜下肺叶切除术中转开胸危险因素分析

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目的 分析肺癌患者胸腔镜下肺叶切除术中转开胸的原因、危险因素和近期临床效果。 方法 回顾性分析 2011 年 3 月至 2015 年 11 月计划行胸腔镜下肺叶切除术肺癌患者 423 例的临床资料,男 252 例、女 171 例,中位年龄 60(24~83)岁。根据术中是否中转开胸分为中转开胸组(45 例)和胸腔镜组(VATS 组,378 例),对比两组临床资料,评估两组术后近期手术效果并分析中转开胸的可能因素。 结果 导致中转开胸最常见因素为肺门及叶裂间淋巴结与周围血管和支气管紧密粘连,有 15(33.3%)例;其次是袖状肺叶切除术,有 11(24.4%)例;血管意外损伤致不可控出血有 8 例,肿瘤侵犯或外侵周围组织有 5 例,支气管暴露困难有 3 例,致密胸膜粘连有 2 例,肺叶裂不全有 1 例。与 VATS 组相比,中转开胸组整体并发症发生率(P=0.030)、手术时间(P<0.001)、术中失血量(P<0.001)高于或长于 VATS 组。单因素分析发现肺切除类型、肺癌解剖学部位、胸部 CT 淋巴结情况和肺一氧化碳弥散量(DLCO)低与中转开胸有关。多因素 logistic 回归分析提示袖状肺叶切除(OR=5.675,95%CI 2.310~13.944,P<0.001)、胸部 CT 显示肺门淋巴结增大(OR=3.732,95%CI 1.347~10.341,P=0.011)、DLCO≤5.16 mmol/(min·kPa)(OR=3.665,95%CI1.868~7.190,P<0.001)为中转开胸的独立危险因素。 结论 VATS 中转开胸没有增加死亡率,是降低手术风险的一项措施。术者对具有中转开胸高风险的肺癌患者进行手术方式预选时应慎重。微创术中如有必要中转开胸,必须及时作出决定,以降低术后近期不良后果。

Objective To explore the risk factors and short-term clinical effect of conversion to open thoracotomy during thoracoscopic lobectomy for lung cancer patients. Methods We retrospectively analyzed the clinical data of 423 lung cancer patients who were scheduled for thoracoscopic lobectomy between March 2011 and November 2015.There were 252 males and 171 females at median age of 60 (24-83) years. According to the patients who were and were not converted to thoracotomy, they were divided into a conversion group (378 patients) and a video-assisted thoracic surgery group (a VATS group, 45 patients). Then, clinical data of two groups were compared, and the risk factors and short-term clinical effect of unplanned conversions to thoracotomy were analyzed. Results Lymph nodes of hilar or/and interlobar fissure closely adhered to adjacent vessels and bronchi was the most common cause of unexpected conversions to thoracotomy in 15 patients (33.3%), followed by sleeve lobectomy in 11(24.4%) patients, uncontrolled hemorrhage caused by intraoperative vessel injury in 8 patients, tumor invasion or extension in 5 patients, difficulty of exposing bronchi in 3 patients, close adhesion of pleural in 2 patients, incomplete interlobar fissure in 1 patient. Conversion did translate into higher overall postoperative complication rate (P=0.030), longer operation time (P<0.001), more intraoperative blood loss (P<0.001). In the univariable analysis, the type of operation, the anatomical site of lung cancer, the lymph node enlargement of hilar in CT and the low diffusion capacity for carbon monoxide (DLCO) were related to conversion. Logistic regression analysis showed that the independent risk factors for conversion were sleeve lobectomy (OR=5.675, 95%CI 2.310–13.944, P<0.001), the lymph node enlargement of hilar in CT (OR=3.732, 95%CI 1.347–10.341, P=0.011) and DLCO≤5.16 mmol/(min·kPa)(OR=3.665, 95%CI 1.868–7.190, P<0.001). Conclusions Conversion to open thoracotomy during video-assisted thoracic surgery lobectomy for lung cancer does not increase mortality, and it is a measure of reducing the risk of surgery. Therefore, with high-risk patients who may conversion to thoracotomy, the surgeon should be careful selection for VATS candidate. And, if necessary, the decision to convert must be made promptly to reduce short-term adverse outcome.

关键词: 电视胸腔镜手术; 中转开胸; 肺叶切除术; 独立危险因素

Key words: Video-assisted thoracic surgery; conversion to thoracotomy; lobectomy; independent risk factor

引用本文: 李华伟, 王海艳, 张临友. 肺癌患者胸腔镜下肺叶切除术中转开胸危险因素分析. 中国胸心血管外科临床杂志, 2017, 24(12): 962-969. doi: 10.7507/1007-4848.201609064 复制

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