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中华胸部外科电子杂志

中华胸部外科电子杂志 ›› 2016, Vol. 03 ›› Issue (02) : 100 -106. doi: 10.3877/cma.j.issn.2095-8773.2016.02.007

所属专题： 专题评论； 文献；

论著

单肋间二孔法胸腔镜肺叶肺段切除术连续200例经验及慢性疼痛的评估
赵国芳1,†(), 杨明磊1, 徐湘1, 倪俊俊1, 董彩军1, 郑恩阔1, 曾招龙1, 李军芳1   
  1. 1. 315010　宁波市第二医院胸心外科
  • 收稿日期:2016-03-08 出版日期:2016-05-28
  • 通信作者: 赵国芳

Single-intercostal two-port video-assisted thoracoscopic lobectomy and segmentectomy: experience with 200 cases and assessment of chronic pain

Guofang Zhao1,†(), Minglei Yang1, Xiang Xu1, Junjun Ni1, Caijun Dong1, Enkuo Zheng1, Zhaolong Zeng1, Junfang Li1   

  1. 1. Department of Cardiothoracic Surgery, Ningbo No.2 Hospital, Ningbo University School of Medicine, Ningbo 315010, China
  • Received:2016-03-08 Published:2016-05-28
  • Corresponding author: Guofang Zhao
  • About author:
    Corresponding author: Zhao Guofang, Email:
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引用本文：

赵国芳, 杨明磊, 徐湘, 倪俊俊, 董彩军, 郑恩阔, 曾招龙, 李军芳. 单肋间二孔法胸腔镜肺叶肺段切除术连续200例经验及慢性疼痛的评估[J/OL]. 中华胸部外科电子杂志, 2016, 03(02): 100-106.

Guofang Zhao, Minglei Yang, Xiang Xu, Junjun Ni, Caijun Dong, Enkuo Zheng, Zhaolong Zeng, Junfang Li. Single-intercostal two-port video-assisted thoracoscopic lobectomy and segmentectomy: experience with 200 cases and assessment of chronic pain[J/OL]. Chinese Journal of Thoracic Surgery(Electronic Edition), 2016, 03(02): 100-106.

目的

描述单肋间二孔法胸腔镜(VATS)肺叶肺段切除术的方法并总结其经验，评估该手术方法对患者术后慢性疼痛的影响。

方法

2014年6月至2015年8月，连续有217例患者在宁波市第二医院胸心外科接受了单肋间二孔法VATS肺叶肺段切除术。2014年1月至6月，同一术者在该院连续完成了80例传统三孔法VATS肺叶和肺段切除术。收集并回顾性分析两组患者的临床数据，包括术后第6个月时患者慢性疼痛的数据。

结果

200例患者(其中肺癌173例，良性疾病27例)成功进行了单肋间二孔法VATS手术(其中肺叶切除141例，肺段切除59例)，17例患者因各种原因中转为三孔VATS或开放手术。200例行单肋间二孔法VATS手术的患者，平均手术时间(160.1 ± 56.1) min；平均淋巴结清扫数(10.5 ± 5.3)枚；术后平均住院时间(6.4 ± 2.9)d。其中46例患者出现并发症，1例患者在术后30 d内死亡。对比分析术后6个月随访成功的92例单肋间二孔组患者与71例三孔组患者，单肋间二孔组患者的慢性疼痛发生率和疼痛分值均明显低于三孔组[25.0% vs 43.7%，χ2＝6.300，P＝0.012；(2.3±0.8)分vs (3.6±1.6)分，t＝3.912，P<0.001]。

结论

单肋间二孔法VATS肺叶肺段切除术对大多数患者是安全、可行的。这项技术相比传统三孔法可显著降低患者术后慢性疼痛的发生率和疼痛分值。

关键词: 电视辅助胸腔镜手术, 肺叶切除术, 肺段切除术, 慢性疼痛
Objective

To describe the technique and outcomes for an initial series of 200 cases of lobectomy and segmentectomy using single-intercostal two-port video-assisted thoracoscopic surgery(VATS), and investigate the effect of this technique on postoperative chronic pain.

Methods

Between June 2014 and August 2015, 217 consecutive patients attempted lobectomy and segmentectomy using single-intercostal two-port VATS. Between January 2014 and June 2014, the same surgeon continuously completed 80 cases of lobectomy and segmentectomy using three-port approach. The clinical data of all these patients were retrospectively analyzed, including the data on chronic pain at the follow-up 6 months after operation.

Results

Among the 217 patients attempting lobectomy and segmentectomy using single-intercostal two-port VATS, 200 patients(173 cases of primary lung cancer and 27 cases of benign diseases) successfully completed the operation(141 cases of lobectomy and 59 cases of segmentectomy), and the other 17 patients transferred to three-port approach or open surgery due to various reasons. Of these 200 patients, the mean duration of surgery was (160.1 ± 56.1) min, the mean number of lymph node dissection was 10.5 ± 5.3, the mean duration of hospitalization after operation was (6.4 ± 2.9)d, complications occurred in 46 patients, and 1 patient died within 30 d after surgery. A total of 92 patients undergoing single-intercostal two-port VATS and 71 patients with three-port approach were successfully followed up 6 months after surgery, the prevalence of chronic pain and the mean chronic pain score of the former were significantly lower than that of the latter[25.0% vs 43.7%, χ2=6.300, P=0.012; (2.3±0.8) vs (3.6±1.6), t=3.912, P<0.001].

Conclusions

Lobectomy and segmentectomy using single-intercostal two-port VATS is safe and feasible for most patients. Compared with three-port approach, this technique significantly reduces the prevalence and score of chronic pain.

Key words: Video-assisted thoracoscopic surgery, Lobectomy, Lung segmentectomy, Chronic pain
图1 单肋间二孔法电视辅助胸腔镜手术。A：两个约2 cm的切口，位于同一肋间的腋前线和腋后线处。手术结束时，一根28F胸管经腋前线切口引入胸腔。B：术中采用的10 mm的30°角胸腔镜和常规胸腔镜手术器械。C：两个切口共同分担器械和镜子的进出，操作时器械、镜子与胸壁之间几乎垂直悬空。D：右肺上叶袖式切除术，用一根4-0滑线连续缝合作支气管重建术。
表1 单肋间二孔法组患者的基本资料(200例)
指标 数值
年龄(±s，岁) 56.76±11.23
性别[例数(%)] ?
? 男性 78 (39.0)
? 女性 122 (61.0)
吸烟史[例数(%)] ?
? 有 67 (33.5)
? 无 133 (65.5)
合并症[例数(%)] ?
? 慢性阻塞性肺病 10(5.0)
? 血管性疾病 55(27.5)
? 心脏病 24(12.0)
? 其他癌症 5(2.5)
? 其他疾病 51(25.5)
肺功能(±s，%) ?
? FEV1实测值/预计值 94.5±17.4 (33.6～143.5)
? DLCO实测值/预计值 79.8 ± 14.5 (35.5～115.9)
CT扫描肿瘤直径(±s，cm) 1.5±1.3 (0.6～ 6.0)
原发性肺癌[例(%)] 173 (86.5)
? 腺癌 159 (79.5)
? 鳞癌 11(5.5)
? 其他 3(1.5)
肺癌分期[例(%)] ?
? 0期 37 (18.5)
? Ⅰa期 105 (50.3)
? Ⅰb期 18 (9.0)
? Ⅱa期 5(2.5)
? Ⅱb期 4(2.0)
? Ⅲa期 4(2.0)
良性肺部疾病[例(%)] 27(13.5)
? 肺良性肿瘤 4(2.0)
? 肺曲菌球 4(2.0)
? 肺炎性假瘤或肉芽肿 11 (5.5)
? 肺支气管扩张 4 (2.0)
? 肺内淋巴结 4 (2.0)
表2 200例单肋间二孔法组患者手术方式及结果
指标 (±s)或[例数(%)]
手术切除类型[例数(%)] ?
? 右上肺叶切除术 43 (21.5)
? 右中肺叶切除术 21 (10.5)
? 右下肺叶切除术 30 (15.0)
? 左上肺叶切除术 24 (12.0)
? 左下肺叶切除术 23 (11.5)
? 肺段解剖性切除 59 (29.5)
手术时间(±s，min) 160.1±56.1
术中出血量(±s，ml) 93.3±72.6
淋巴结清扫数(±s，枚) 10.5±5.3*
淋巴结取样数(±s，枚) 4.5±1.4*
胸腔引流时间(±s，d) 3.4±2.3
术后住院时间(±s，d) 6.4±2.9
并发症[例数(%)] 46 (23.0)
? 肺漏气>5 d 18 (9.0)
? 肺不张 3 (1.5)
? 肺炎 8 (4.0)
? 切口不愈 11 (5.5)
? 心房颤动 3 (1.5)
? 哮喘 3 (1.5)
死亡[例(%)] 1 (0.5)
疼痛评分(±s，分) ?
? 术后当天疼痛分值 2.6±1.1
? 术后第3天疼痛分值 2.1±1.1
表3 术后第6个月单肋间二孔组和三孔组患者慢性疼痛和感觉异常的比较
指标 单肋间二孔组(92例) 传统三孔组(71例) 检验值 P值
年龄(±s年) 55.9±11.8 60.0±9.8 t＝2.422 0.115
性别[例(%)] ? ? χ2＝1.114 0.291
? 男性 39(42.4) 36(50.7) ? ?
? 女性 53(57.6) 35(49.3) ? ?
手术方法[例(%)] ? ? χ2＝3.178 0.075
? 肺叶切除 67(72.8) 60(84.5) ? ?
? 肺段切除 25(27.2) 11(15.5) ? ?
慢性疼痛患者[例(%)] 23(25.0) 31 (43.7) χ2＝6.300 0.012
慢性疼痛分值(±s，分) 2.3±0.8 3.6±1.6 χ2＝3.912 <0.001
感觉异常(不同于伤口疼痛)[例(%)] 34(37.0) 32(45.1) χ2＝1.095 0.295
? 麻木 6(6.5) 13(18.3) ? ?
? 触电感 3(3.3) 7(10.0) ? ?
? 瘙痒 15(16.3) 7(9.9) ? ?
? 胀感 10(10.9) 5(7.0) ? ?
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