韓舟

兩種不同的微創(chuàng)方法運(yùn)用于非小細(xì)胞肺癌肺葉切除的臨床分析

韓舟

目的研究全胸腔鏡下肺葉切除術(shù)與小切口開胸手術(shù)對(duì)非小細(xì)胞肺癌的療效及安全性。方法選取我院2013年10月至2016年5月診斷為非小細(xì)胞肺癌并行肺葉切除手術(shù)治療的患者 142例，根據(jù)隨機(jī)數(shù)表法將患者平分為對(duì)照組(n=71)和實(shí)驗(yàn)組(n=71),實(shí)驗(yàn)組采取全胸腔鏡下肺葉切除術(shù)，對(duì)照組采取小切口開胸術(shù)，對(duì)比兩組術(shù)后的療效及并發(fā)癥。結(jié)果實(shí)驗(yàn)組手術(shù)時(shí)長(zhǎng)為(181.37±20.61)min，明顯低于對(duì)照組的(217.29±30.69)min(t=5.291，P<0.001)；實(shí)驗(yàn)組手術(shù)失血量為(263.26±60.27)mL，明顯低于對(duì)照組的(420.26±119.27)mL(t=3.871，P=0.004)；實(shí)驗(yàn)組引流量為(174.92±120.89)mL，明顯低于對(duì)照組的(318.29±30.26)mL(t=2.589，P=0.027)；實(shí)驗(yàn)組引流時(shí)間為(4.65±1.70)d，明顯低于對(duì)照組的(8.27±2.91)d(t=3.026，P=0.012)；實(shí)驗(yàn)組住院時(shí)長(zhǎng)為(8.33±1.90)d，明顯低于對(duì)照組的(11.28±3.28)d(t=2.218，P=0.032)。2組清掃的淋巴結(jié)數(shù)及淋巴結(jié)轉(zhuǎn)移數(shù)差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；實(shí)驗(yàn)組肺部感染、肺不張、心律失常、應(yīng)激性潰瘍及其他并發(fā)癥的比例分別為2.82%、4.23%、1.41%、0%、1.41%，而對(duì)照組肺部感染、肺不張、心律失常、應(yīng)激性潰瘍及其他并發(fā)癥的比例分別為2.82%、5.64%、4.23%、1.41%和2.82%，差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)；實(shí)驗(yàn)組患者術(shù)后2小時(shí)VAS得分為(29.27±3.29)分，顯著低于對(duì)照組的(58.60±3.69)分，差異有統(tǒng)計(jì)學(xué)意義(t=4.281，P=0.008)；實(shí)驗(yàn)組患者術(shù)后24小時(shí)和術(shù)后48小時(shí)的VAS得分與對(duì)照組的得分差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論全胸腔鏡下肺葉切除術(shù)比小切口開胸術(shù)療效更好，安全性更高，值得在臨床中推薦。

非小細(xì)胞肺癌；全胸腔鏡；小切口開胸術(shù)；微創(chuàng)

臨床最常見的肺癌類型為非小細(xì)胞肺癌，其發(fā)病率在肺癌中高達(dá)85%，其中高齡患者占50%以上[1]。隨著現(xiàn)代醫(yī)學(xué)技術(shù)的進(jìn)步，肺癌的診斷方式更多且準(zhǔn)確率更高，而Ⅰ、Ⅱ和ⅢA期患者的治療主要途徑為手術(shù)切除[2]。目前非小細(xì)胞肺癌行微創(chuàng)手術(shù)治療有很好的發(fā)展前景。現(xiàn)比較傳統(tǒng)小切口開胸手術(shù)與全胸腔鏡下肺葉切除兩種微創(chuàng)方法對(duì)非小細(xì)胞肺癌的臨床效果，為選擇非小細(xì)胞肺癌微創(chuàng)手術(shù)方式提供一定參考價(jià)值，先報(bào)道如下。

資料與方法

一、一般資料

選取我院2013年10月至2016年5月診斷為非小細(xì)胞肺癌并行肺葉切除手術(shù)治療的患者 142例，其中男性74例，女性68例，平均年齡為(59.27±4.29)歲，平均病程為(4.7±1.9)月。根據(jù)隨機(jī)數(shù)表法將患者平分為對(duì)照組和實(shí)驗(yàn)組，其中對(duì)照組采取開胸手術(shù)，男性39例，女性32例，平均年齡為(60.02±3.23)歲，平均病程為(4.6±2.0)月，中央型30例，周圍型41例；實(shí)驗(yàn)組采取胸腔鏡下肺葉切除，男性35例，女性36例，平均年齡為(58.38±4.02)歲，平均病程為(4.7±2.5)月，中央型32例，周圍型39例。兩組一般資料差異無(wú)統(tǒng)計(jì)學(xué)意義(P<0.05)，研究經(jīng)院倫理協(xié)會(huì)批準(zhǔn)，實(shí)驗(yàn)患者均自愿簽署知情同意書。

二、納入與排除標(biāo)準(zhǔn)

納入標(biāo)準(zhǔn)：① 符合中華醫(yī)學(xué)會(huì)非小細(xì)胞肺癌診斷標(biāo)準(zhǔn)，CT及胸部X檢查結(jié)果一致[3]；② 均伴隨低熱、咳血。排除標(biāo)準(zhǔn)：① 近半年內(nèi)存在放療史或化療史；② CT掃描結(jié)果顯示存在遠(yuǎn)處轉(zhuǎn)移；③ 存在出血性疾病或結(jié)締組織疾病[4]。

三、方法

手術(shù)方法。術(shù)前完整詢問患者病史及治療史，進(jìn)行常規(guī)生化檢查及血?dú)夥治?。?duì)照組采取予小切口開胸術(shù)，雙腔氣管插管全麻和硬膜外麻醉處理[5]，健側(cè)臥位后于外側(cè)作一長(zhǎng)度約15cm的切口，進(jìn)行肺癌組織切除于淋巴結(jié)清掃。實(shí)驗(yàn)組給予全胸腔鏡下肺葉切除術(shù)，給予雙腔氣管插管全身麻醉，健側(cè)側(cè)臥，于腋中線7-8肋間選取穿刺點(diǎn)，再分別于第4肋間腋前線處和第7肋間處作一長(zhǎng)度約為4cm和1.5cm的切口為操作口，在胸腔鏡下行肺葉切除及淋巴結(jié)清掃[6-7]。

四、觀察指標(biāo)

比較2組術(shù)中出血量、引流量、引流時(shí)間、手術(shù)時(shí)長(zhǎng)及住院時(shí)長(zhǎng)。觀察并記錄2組患者的并發(fā)癥，如呼吸衰竭、肺部感染等。采用視覺模擬評(píng)分法(Visual analogue scale，VAS)[8]給予術(shù)后疼痛評(píng)分，共10分，得分越高表示疼痛越劇烈。

五、統(tǒng)計(jì)學(xué)方法

將本組研究數(shù)據(jù)錄入SPSS 19.0行數(shù)據(jù)分析，計(jì)數(shù)資料行χ2檢驗(yàn)或確切概率法，計(jì)量資料用(±s)表示，組間比較采用兩樣本t檢驗(yàn)，如結(jié)果提示P<0.05，差異存在統(tǒng)計(jì)學(xué)意義。

結(jié) 果

一、實(shí)驗(yàn)組手術(shù)時(shí)長(zhǎng)為(181.37±20.61)min，明顯低于對(duì)照組的(217.29±30.69)min，差異有統(tǒng)計(jì)學(xué)意義(t=5.291，P<0.001)；實(shí)驗(yàn)組手術(shù)失血量為(263.26±60.27)mL，明顯低于對(duì)照組的(420.26±119.27)mL，差異有統(tǒng)計(jì)學(xué)意義(t=3.871，P=0.004)；實(shí)驗(yàn)組引流量為(174.92±120.89)mL，明顯低于對(duì)照組的(318.29±30.26)mL，差異有統(tǒng)計(jì)學(xué)意義(t=2.589，P=0.027)；實(shí)驗(yàn)組引流時(shí)間為(4.65±1.70)d，明顯低于對(duì)照組的(8.27±2.91)d，差異有統(tǒng)計(jì)學(xué)意義(t=3.026，P=0.012)；實(shí)驗(yàn)組住院時(shí)長(zhǎng)為(8.33±1.90)d，明顯低于對(duì)照組的(11.28±3.28)d，差異有統(tǒng)計(jì)學(xué)意義(t=2.218，P=0.032)。(見表1)。

表1 對(duì)比2組臨床療效

二、2組清掃的淋巴結(jié)數(shù)及淋巴結(jié)轉(zhuǎn)移數(shù)差異無(wú)統(tǒng)計(jì)學(xué)意義，P>0.05，(見表2)。

表2 對(duì)比兩組淋巴清掃效果(n)

三、實(shí)驗(yàn)組肺部感染、肺不張、心律失常、應(yīng)激性潰瘍及其他并發(fā)癥的比例分別為2.82%、4.23%、1.41%、0%、1.41%，而對(duì)照組肺部感染、肺不張、心律失常、應(yīng)激性潰瘍及其他并發(fā)癥的比例分別為2.82%、5.64%、4.23%、1.41%和2.82%，差異無(wú)統(tǒng)計(jì)學(xué)意義，P>0.05，(見表3)。

四、實(shí)驗(yàn)組患者術(shù)后2小時(shí)VAS得分為(29.27±3.29)分，顯著低于對(duì)照組的(58.60±3.69)分，差異有統(tǒng)計(jì)學(xué)意義(t=4.281，P=0.008)；實(shí)驗(yàn)組患者術(shù)后24小時(shí)VAS得分為(68.27±9.89)分，略高于對(duì)照組的(66.82±9.26)分，差異無(wú)統(tǒng)計(jì)學(xué)意義(t=0.721，P=0.172)；實(shí)驗(yàn)組患者術(shù)后48小時(shí)VAS得分為(158.73±6.19)分，略低于對(duì)照組的(162.29±5.84)分，差異無(wú)統(tǒng)計(jì)學(xué)意義(t=0.528，P=0.264)。(見表4)。

表3 2組術(shù)后并發(fā)癥比較[n，χ2]

表4 2組術(shù)后VAS評(píng)分比較

討 論

在現(xiàn)代生活環(huán)境因素的影響下，非小細(xì)胞肺癌發(fā)生率不斷提高，而臨床對(duì)非小細(xì)胞肺癌的診斷技術(shù)及治療水平也相應(yīng)提高，非小細(xì)胞肺癌患者選擇外科手術(shù)治療的比例不斷上升[9]。我國(guó)相關(guān)研究人員表明，全胸腔鏡下在進(jìn)行肺葉切除的同時(shí)可有效完成淋巴結(jié)的清掃，其手術(shù)療效及安全性可與開胸手術(shù)媲美[10]。而在本研究數(shù)據(jù)表明實(shí)驗(yàn)組和對(duì)照組清掃的淋巴結(jié)數(shù)及淋巴結(jié)轉(zhuǎn)移數(shù)差異無(wú)統(tǒng)計(jì)學(xué)意義，表明微創(chuàng)開胸手術(shù)與全胸腔鏡下在進(jìn)行肺葉切除術(shù)的成功率相差無(wú)幾。實(shí)驗(yàn)中出現(xiàn)4例全胸腔鏡轉(zhuǎn)開胸患者，分析原因后發(fā)現(xiàn)均為淋巴結(jié)干擾導(dǎo)致，非小細(xì)胞肺癌可導(dǎo)致淋巴結(jié)腫大，與血管和氣管發(fā)生黏連，剝離血管、氣管嚴(yán)重增加手術(shù)難度，迫使手術(shù)方式轉(zhuǎn)變?yōu)殚_胸手術(shù)[11-12]。國(guó)外研究表明[13]，行全胸腔鏡肺葉切除治療患者中轉(zhuǎn)開胸的原因主要為淋巴結(jié)干擾，其比例高達(dá)71%，由此可見淋巴結(jié)干擾是影響全胸腔鏡肺葉切除術(shù)的重要原因之一。

本組數(shù)據(jù)表明，實(shí)驗(yàn)組手術(shù)時(shí)長(zhǎng)、失血量明顯低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義，猜測(cè)與手術(shù)視野過窄相關(guān)，從而提高操作難度，導(dǎo)致失血量過多。實(shí)驗(yàn)組引流量和引流時(shí)間均明顯低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義。表明全胸腔鏡下的手術(shù)治療方式給患者帶來(lái)的損傷更低，有利于縮短手術(shù)時(shí)間，利于患者術(shù)后恢復(fù)。實(shí)驗(yàn)組住院時(shí)長(zhǎng)為(8.33±1.90)d，明顯低于對(duì)照組的(11.28±3.28)d，差異有統(tǒng)計(jì)學(xué)意義。進(jìn)一步說明全胸腔鏡下的手術(shù)治療方式更利于患者恢復(fù)，縮短患者住院時(shí)間同時(shí)可減少患者住院費(fèi)用。對(duì)比兩組的并發(fā)癥可得，實(shí)驗(yàn)組肺部感染、肺不張、心律失常、應(yīng)激性潰瘍及其他并發(fā)癥的比例分別為2.82%、4.23%、1.41%、0%、1.41%，而對(duì)照組肺部感染、肺不張、心律失常、應(yīng)激性潰瘍及其他并發(fā)癥的比例分別為2.82%、5.64%、4.23%、1.41%和2.82%，差異無(wú)統(tǒng)計(jì)學(xué)意義，與微創(chuàng)開胸手術(shù)對(duì)比，不僅取得更好的療效，同時(shí)安全性也更優(yōu)，降低術(shù)后并發(fā)癥的風(fēng)險(xiǎn)。國(guó)外學(xué)者認(rèn)為，主要是全胸腔鏡下的肺葉切除術(shù)的失血量較少，切口更小導(dǎo)致[14-15]。同時(shí)胸腔鏡的技術(shù)支持下可更清晰看到肺部深部組織，可更高效得切除肺葉及淋巴結(jié)清掃，能大大節(jié)約手術(shù)時(shí)間，從而減少引流量及引流時(shí)間。國(guó)內(nèi)學(xué)者研究發(fā)現(xiàn)[16]，在尸檢上首先驗(yàn)證了胸腔鏡下淋巴結(jié)清掃的效果，另一些學(xué)者的研究均證實(shí)胸腔鏡下系統(tǒng)縱隔淋巴結(jié)清掃不遜于開胸手術(shù)，可以達(dá)到肺癌診療規(guī)范的要求?？偨Y(jié)多例手術(shù)經(jīng)驗(yàn)可得，正常肺組織阻斷通氣之后很快即會(huì)萎陷，這樣可以為胸腔鏡操作創(chuàng)造足夠的空間，但是大腫瘤往往會(huì)使鏡下操作空間明顯減小，反復(fù)翻動(dòng)，無(wú)法將腫瘤所在肺葉置于某個(gè)相對(duì)固定而又有利于操作的位置將大大增加手術(shù)難度，多次翻動(dòng)反而容易造成腫瘤擴(kuò)散。同時(shí)大腫瘤可導(dǎo)致阻塞性肺炎而引起淋巴結(jié)反應(yīng)性增生，處理淋巴結(jié)時(shí)應(yīng)分離淋巴結(jié)包膜，減少術(shù)中出血，或先在隆突下位置夾閉并切斷供應(yīng)這些淋巴結(jié)的支氣管動(dòng)脈，可以使手術(shù)野更加干凈。肺血管出血是影響手術(shù)安全性的重要因素[17]，對(duì)于肺血管的解剖性游離和骨骼化被認(rèn)為是增加手術(shù)安全性的有效方式。此外外科手術(shù)團(tuán)隊(duì)的配合和熟練技巧是保障手術(shù)安全的最大因素，根據(jù)手術(shù)設(shè)計(jì)不同的器械，術(shù)中，扶鏡者應(yīng)充分靈活運(yùn)用 30 度胸腔鏡為術(shù)者準(zhǔn)確完整顯露手術(shù)野，保持鏡像清晰，為內(nèi)鏡下切割縫合提供良好的觀察角度。

綜上所述，全胸腔鏡下肺葉切除術(shù)較微創(chuàng)開胸術(shù)所需手術(shù)時(shí)間更短，引流量更低，在療效更佳的同時(shí)還能保證其安全性，并縮短患者術(shù)后住院時(shí)間，但臨床應(yīng)進(jìn)一步判斷患者是否適合進(jìn)行全胸腔鏡下肺葉切除術(shù)，避免轉(zhuǎn)開胸術(shù)的發(fā)生率[18]。

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Clinicanalysisoftwominimallyinvasivemethodinlobectomyofnonsmallcelllungcancer

HANZhou

DepartmentofThoracicSurgery,theFirstPeople’sHospitalofZhumadian,Zhumadian,Henan463000,China

ObjectiveTo study the efficacy and safety of lobectomy in thoracoscopic and small incision thoracotomy on minimally invasive surgical treatment for non small cell lung cancer.Methods142 patients with non-small cell lung cancer

lung lobectomy from October 2013 to May 2016 in our hospital were randomly divided into the control group (n=71) and the experimental group (n=71). The experimental group adopted thoracoscopic lobectomy while the control group adopted small incision thoracotomy. The efficacy and complications of the two groups were compared.ResultsThe operation time of the experimental group was (181.37±20.61) min, which was significantly lower than that of the control group (217.29±30.69) min (t=5.291,P<0.001). The amount of blood loss in the experimental group was (263.26±60.27) mL, which was significantly lower than that of the control group (420.26±119.27) mL (t=3.871,P=0.004). The experimental group induced flow rate was (174.92±120.89) mL, significantly lower than that of the control group (318.29±30.26) mL (t=2.589,P=0.027). The drainage time of the experimental group was (4.65±1.70) d, which was significantly lower than that of the control group (8.27±2.91) d (t=3.026,P=0.012). The length of stay in the experimental group was (8.33±1.90) d, which was significantly lower than that of the control group (11.28±3.28) d (t=2.218,P=0.032). There was no significant difference in the number of lymph nodes and lymph node metastasis between the two groups (P>0.05). The incidence of pulmonary infection, atelectasis, arrhythmia, stress ulcer and other complications were 2.82%, 4.23%, 1.41%, 0%, 1,41% in the experimental group, and 2.82%, 5.64%, 4.23%, 1.41% and 2.82% in the control group (P>0.05). The VAS score of 2 hours after operation in the experimental group was (29.27±3.29), which was significantly lower than that of the control group (58.60±3.69) (t=4.281,P=0.008). There was no significant difference in VAS scores between the experimental group and the control group at 24 hours and 48 hours after the operation (P>0.05).ConclusionThe curative effect of thoracoscopic lobectomy is better than small incision thoracotomy, with higher safety, which is worthy to be recommended in clinical practice.

non small cell lung cancer; total thoracoscopy; small incision thoracotomy; minimally invasive

2017-04-05]

10.3969/j.issn.1009-6663.2017.11.031

463000 河南 駐馬店，駐馬店市第一人民醫(yī)院心胸外科