胸腔镜诊治肺部微小结节29例报告

Video assisted thoracoscopic diagnosis and treatment of small pulmonary nodules: A report of 29 cases

目的探讨电视胸腔镜手术（video-assisted thoracoscopic surgery，VATS）在肺微小结节的诊断和治疗中的可行性。方法2000年5月～2005年6月对29例肺微小结节行VATS，术中明确结节所在位置、大小、性状以及与胸膜关系；对于肺实质内微小结节的探查全部依赖于手指的触诊定位，一般用食指即可，若定位有困难，可将切口适当延长至4cm左右，以2根手指协助定位。根据探查结果行结节所在肺组织的楔形切除，术中切除标本送快速冰冻病理学检查，如为良性，则术毕；如为恶性，进一步行VATS辅助小切口开胸肺叶切除联合纵隔淋巴结清扫术。结果全组患者手术顺利，无严重手术并发症和围手术期死亡。食指触诊定位微小结节，无一例延长切口。恶性病变11例（11／29，37．9％），良性病变18例（18／29，62．1％）。8例（57．1％）术前拟诊为恶性病变及3例术前拟诊为良性病变最终确诊为恶性病变。11例具有分叶、毛刺及胸膜皱缩等“恶性”影像学表现中仅6例（54．5％）确诊为恶性病变。21例单发结节恶性7例；8例多发结节良性和恶性各4例。18例良性行VATS肺楔形切除；11例肺癌中6例行根治性肺叶切除联合纵隔淋巴结清扫术，5例行姑息性肺楔形切除术。结论肺部微小结节诊断困难；VATS手术诊治肺部微小结节，技术成熟可行，疗效满意。

Objective To discuss the feasibility of video assisted thoracoscopic surgery （VATS） in the diagnosis and treatment of small pulmonary nodules. Methods A total of 29 patients with small pulmonary nodules was diagnosed and treated by VATS from May 2000 to June 2005. During the operation, the lesion was detected by forefinger palpation to determine the location, size, feature, and relation to the pleura. In case of difficult location, the incision was extended to 4 cm in length, and the lesion was examined and palpated with operator＇s two fingers. Pulmonary wedge resection was performed. Whether or not an open pulmonary lobectomy and mediastinal lymph node resection was required was determined according to pathological findings of intraoperative frozensection biopsy. Results All the operations were successfully accomplished and no complications or deaths occurred peri-operatively. The location of nodule was determined with single forefinger palpation and no extended incision was needed. There were 11 patients with malignant nodules （11/29, 37.9% ） and 18 benign nodules （18/29, 62.1% ）. A malignant nodule was confirmed eventually in 8 patients （57.1%） with suspected diagnosis of malignancy and in 3 patients with suspected diagnosis of benign lesions. Among 11 patients with ＂malignant＂ imaging signs, only 6 patients （54.5%） were at last confirmed to be malignant. Out of 21 patients with solitary pulmonary nodules, 7 were malignant ; out of 8 patients with multiple pulmonary nodules, 4 were confirmed to be malignant. Eighteen patients with benign nodules were treated with wedge resection under VATS. In the remaining 11 patients with malignant nodules, a radical resection of the tumor and a mediastinal lymph node resection was conducted in 6 patients and a palliative wedge resection was performed in 5 patients. Conclusions Small pulmonary nodules are difficult to get a confirmative diagnosis. VATS can be used for the diagnosis and treatment of small pulmonary nodules and obtain a satisfactory prognosis.