胸腺上皮肿瘤是前纵隔最常见的原发性肿瘤,以胸腺瘤较为多见,在我国居民中发生率较低。胸腺瘤生长速度缓慢,但具有潜在侵袭性,容易浸润周围组织和器官,部分合并重症肌无力(MG),故对于可手术切除的此类疾病,胸腺切除术常作为首选治疗措施。标准术式为胸腺扩大切除术,即对胸腺与其周边脂肪组织行完整切除处理。应用较为广泛的手术方法包括机器人辅助胸腔镜手术(RATS)、电视辅助胸腔镜手术(VATS)与胸骨正中切开术。随着微创技术的发展成熟,微创手术逐渐占主导地位。有充足的研究证明与传统胸骨正中切开术相比,微创胸腺切除术治疗早期胸腺瘤的短期效果更好,但对于理想手术方式及入路无统一意见。
Thymic epithelial tumor is the most common primary tumor in the anterior mediastinum. Thy-moma is more common, and the incidence is low among Chinese residents. Thymomas grow slowly, but are potentially invasive and easily infiltrate surrounding tissues and organs, partly with myas-thenia gravis (MG). Therefore, for surgical resection of such diseases, thymectomy is often used as the preferred treatment. The standard surgical procedure is extended thymectomy, that is, com-plete resection of the thymus and surrounding adipose tissue. The widely used surgical methods in-clude robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS) and median sternotomy. With the development of minimally invasive technology, minimally invasive surgery has gradually dominated. Ample studies have shown that compared with traditional me-dian sternotomy, minimally invasive thymectomy has a better short-term effect in the treatment of early thymoma, but there is no consensus on the ideal surgical method and approach.
胸腺切除术,电视胸腔镜手术,机器人辅助胸腔镜手术,剑突下入路,研究进展, Thymectomy Video-Assisted Thoracoscopic Surgery Robot-Assisted Thoracoscopic Surgery Subxiphoid Approach Research Progress摘要
Thymic epithelial tumor is the most common primary tumor in the anterior mediastinum. Thymoma is more common, and the incidence is low among Chinese residents. Thymomas grow slowly, but are potentially invasive and easily infiltrate surrounding tissues and organs, partly with myasthenia gravis (MG). Therefore, for surgical resection of such diseases, thymectomy is often used as the preferred treatment. The standard surgical procedure is extended thymectomy, that is, complete resection of the thymus and surrounding adipose tissue. The widely used surgical methods include robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS) and median sternotomy. With the development of minimally invasive technology, minimally invasive surgery has gradually dominated. Ample studies have shown that compared with traditional median sternotomy, minimally invasive thymectomy has a better short-term effect in the treatment of early thymoma, but there is no consensus on the ideal surgical method and approach.
大量研究报道 [29] [30] 表明小切口胸腺切除术优点明显,与胸骨正中切开胸腺切除术相比,横断胸骨行胸腺切除手术时间短[(71.1 ± 14.4) min vs (110.0 ± 11.7) min]、术中出血量少[(56.4 ± 15.7) ml vs (100.1 ± 11.3) ml]、胸腔引流时间短[(1.7 ± 0.4) d vs (3.1 ± 0.6) d]、引流量少[(87.6 ± 23.9) ml vs (99.9 ± 11.2) ml]、术后住院时间短[(8.6 ± 1.1) d vs (12.2 ± 3.0) d]、肺部感染发生率低[0% (0/568) vs 3.1% (2/65)]、MCAT发生率低[8.8% (50/568) vs 16.9% (11/65)],以上统计指标均具有统计学差异(p < 0.05);肋间小切口创伤小、疼痛轻、手术简便,平均手术时间65 min,平均引流量低于100 ml,术后1~3天可拔出引流管。随着胸腔镜、机器人微创手术发展,此术式具有破坏胸骨与胸廓稳定性、适用范围局限等劣势,临床选用率明显下降。
VATS:近年来,随着胸腔镜仪器和技术的进展,自1993年Sugarbaker [32] 将胸腔镜技术应用于胸腺手术至今已有近30年历史,VATS已被广泛接受为传统胸骨正中切开术治疗MG和早期胸腺瘤的微创替代方案 [33] [34],目前除了一些巨大胸腺肿瘤、浸润纵隔大血管等情况外,绝大多数的胸腺切除术可通过VATS完成。当术前影像学检查发现大的胸腺瘤时,采用胸骨正中切口或开胸手术时会更容易,因为此时选择VATS存在技术上的困难。但是目前对于可以进行VATS的合适胸腺瘤大小尚未达成共识:有研究认为胸腺瘤直径 < 5 cm适合VATS [35] [36],也有研究认为肿瘤直径 < 8 cm皆适用VATS [37],而Manoly等 [38] 则认为只要肿瘤不突破包膜就不应把肿瘤直径作为VATS的限制条件。Odaka等 [39] 做的一项胸腺瘤 ≥ 5 cm行VATS与开胸手术比较的研究,结果表明两组手术时间相仿,但在出血量(125 ml VS 300 ml; p = 0.0002)、术后住院时间(5 d VS 14 d; p < 0.0001),并发症[(6/38) VS (14/25); p = 0.0008)]方面,VATS组优于开胸手术组,差异具有统计学意义,证明肿瘤大小不应该作为胸腺瘤VATS的考量因素。但是受限于狭窄的纵隔空间,肿瘤直径过大,会进一步缩小操作空间,完整切除肿瘤便存在困难,并且难以处理术中突发事件。
孙玉慧,范 坤,刘 傲,彭 垒,矫文捷. 胸腺切除术不同手术方式及入路的研究进展Research Progress of Different Surgical Methods and Approaches of Thymectomy[J]. 临床医学进展, 2023, 13(01): 406-414. https://doi.org/10.12677/ACM.2023.131062
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