中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

纵隔肿物合并重症肌无力的外科治疗:达芬奇机器人、胸腔镜与胸骨正中切口手术对比研究

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目的 对比纵隔肿物合并重症肌无力的外科治疗方法。 方法 回顾性分析 2010 年 1 月至 2017 年 12 月我院分别通过达芬奇机器人、胸腔镜或胸骨正中切口行全胸腺切除、纵隔脂肪清除术 53 例患者的临床资料,其中男 29 例、女 24 例,年龄 17~73 岁。根据手术方式将患者分为三组:A 组(机器人组,n=22),B 组(胸腔镜组,n=12)和 C 组(胸骨正中切口组,n=19)。对比三组患者性别分布、年龄、术中失血量、手术时间、术后拔管时间、术后住院时间、重症肌无力 Osserman 分型和术后肌无力缓解率等方面。 结果 所有患者均无围手术期死亡。其中 C 组 1 例患者术后出现肌无力危象,积极治疗后好转;B 组 1 例患者因术中损伤左侧无名静脉而中转开胸。与 B 组及 C 组相比,A 组手术时间短、术中失血量少、术后第 1 d 引流量较少,拔管时间短,术后住院时间 A 组短于 C 组,且差异均有统计学意义,术后肌无力缓解率 A 组(88.9%)要高于 B 组(75.0%)和 C 组(76.9%),但差异无统计学意义。 结论 因为机器人的独特的微创优势,在本研究数据中,应用达芬奇机器人行纵隔肿物扩大切除术的重症肌无力合并胸腺肿物患者,无论是从围手术期的一些指标还是术后短期肌无力缓解率来看均优于其余两组。虽然数据还需要远期效果及大量配对试验证实。但不可否认的是,机器人手术一定是未来微创外科的发展趋势。

Objective To compare three surgical treatments for mediastinal masses with myasthenia gravis. Methods Retrospective analysis was performed on the clinical data of 53 patients who underwent extended thymectomy between January 2010 and December 2017. There were 29 males and 24 females, aged 17–73 years. Patients were divided into three groups according to the surgical methods: a Group A (video assisted thoracoscopic surgery approach with the da Vinci robotic system, n=22); Group B (video assisted thoracoscopic surgery, n=12), Group C (open accession by total median sternotomy, n=19). The gender distribution, intraoperative blood loss, operating time, postoperative extubation time, postoperative hospital stay, Osserman classification of myasthenia gravis, postoperative myasthenic remission rate and etc were compared in patients of different groups. Results No perioperative death was observed in 53 patients. One patient in the C group suffered from postoperative myasthenia gravis crisis and improved after active treatment. One patient of VATS thoracoscopy transitted to open accession due to the intraoperative injury of the left brachiocephalic vein. Compared with the group B and group C, group A had shorter operation time, less intraoperative blood loss, less drainage on the first postoperative day, and fewer days of extubation. Postoperative days of hospital stay were less in group A than that in group C. The postoperative myasthenia gravis remission rate was higher in the group A than that in the other two groups, but there was no significant statistical difference. Conclusion Because of the robot’s unique minimally invasive advantage, in this study, patients with myasthenia gravis treated with Da Vinci robots and thymectomy are better than the remaining two groups regardless of perioperative outcomes or myasthenia gravis remission rate. The recent results are better than the remaining two groups, but the data also needs long-term results and a large of number matching experiments to confirm. However, it is undeniable that robotic surgery must be the future of the minimally invasive surgery.

关键词: 重症肌无力; 胸腺扩大切除术; 机器人手术; 胸腔镜; 胸骨正中切口

Key words: Myasthenia gravis; thymectomy; sternotomy; robotic surgery; thoracoscopy

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