目的

探讨剑突下单孔胸腔镜（UVATS）胸腺扩大切除术的学习曲线特点。

方法

回顾性分析2015年1月—2019年1月在徐州市中心医院同一术者连续开展的胸腺切除并前纵隔脂肪清扫术的病例资料。依据手术先后分为剑突下UVATS-A 组（n ＝15）、UVATS-B 组（n ＝15）和UVATS-C组（n＝15）。记录各组患者的手术时间、术中出血量、中转多孔胸腔镜或开胸率、术后胸腔置管时间与总引流量、并发症、疼痛评分和住院时间的差异，与经肋间入路多孔胸腔镜胸腺扩大切除术患者（MVATS组，n＝46）进行比较。术后肺CT 扫描分析前纵隔脂肪切除是否彻底。

结果

各组患者年龄、性别构成比、体重指数、肿瘤直径等比较差异均无统计学意义（P＞0 .05）。 MVATS 组5 例、UVATS-A 组2 例、UVATS-B 组4 例合并重症肌无力（MG）。无中转开胸手术或死亡病例。 UVATS-A 组2 例、UVATS-B组1 例中转剑突下三孔VATS。MVATS 组患者手术时间、术后胸管引流时间、术后住院时间均显著短于UVATS-A 、UVATS-B 组（P＜0 .05），但与UVATS-C 组比较无统计学差异（P＞0 .05）；MVATS 组患者术后第1、3 天的疼痛评分与UVATS-A、UVATS-B 组比较均无统计学差异（P＞0 .05），但显著大于UVATS-C 组（P＜0 .05）。各组术中出血量、术后胸管引流量、手术并发症等比较均无统计学差异（P＞0 .05）。 UVATS-B 组2 例术后出现MG 危象，予血浆置换后缓解。术后CT 扫描提示UVATS-A组3 例、UVATS-B 组2 例前纵隔少量脂肪影残留。

结论

剑突下UVATS 胸腺扩大切除术学习曲线至少需要累积30 例，其近期临床参数与肋间MVATS 比较无显著优势。

Objective

To explore the characteristics of learning curve of subxiphoid uniportal video-assisted thoracoscopic (UVATS) extended thymectomy .

Methods

Clinical data of consecutive cases undergoing VATS thymectomy and fat tissue dissection by the same surgeon in Xuzhou Central Hospital between January 2015 and January 2019 was retrospectively analyzed . The patients were divided into subxiphoid UVATS-A (15 cases) ,UVATS-B (15 cases) and UVATS-C (15 cases) groups according to the date of surgery .The operation time ,blood loss ,the incidence of conversion to multiport VATS or thoracotomy ,postoperative chest tube duration and total drainage volume ,complications ,pain scale ,and postoperative hospital stay were recorded ,which were compared with those using intercostal multiport VATS procedure (MVATS group , 46 cases) . Computed tomography was conducted after surgery to evaluate whether the fat tissue in anterior mediastinum was resected radically .

Results

Significant difference was not indicated among the groups in terms of age ,gender ,body weight index ,diameter of the tumors ( P＞0 .05) .There were 5 cases in the MVATS group ,2 cases in the UVATSA group ,and 4 cases in the UVATS-B group indicated myasthenia gravis (MG) before surgery .There was no short-term mortality , or conversion to thoracotomy . One patient in UVATS-A group and 2 patients in UVATS-B group converted to subxiphoid MVATS .Besides ,the operation time ,chest tube drainage duration and postoperative hospital stay of the patients in MVATS group was significantly shorter than that of UVATS-A and UVATS-B group ( P＜0 .05 , respectively) , but not UVATS-C group ( P＞0 .05) . The pain score on 1d and 3d after surgery of the patients in MVATS group were similar to that of UVATS-A and UVATS-B groups ( P＞0 .05 ,respectively) ,but they were higher than that of UVATS-C group ( P＜ 0 .05 , respectively) . However , these groups indicated similar intraoperative blood loss , postoperative chest drainage volume , and complications ( P＞ 0 .05 ,respectively) . The UVATS-B group reported 2 cases of MG crisis after surgery , and they recovered after plasma exchange.Incomplete resection of anterior mediastinal fat tissue was found in 3 cases in UVATS-A group and 2 cases in UVATS-B group ,as shown by CT images .

Conclusions

The learning curve of subxiphoid UVATS extended thymectomy should based on at least 30 cases ,and this approach does not indicate obvious advantages regarding short-term clinical parameters as compared with intercostal MVATS .