电视胸腔镜与胸骨部分劈开行胸腺扩大切除治疗重症肌无力的随机对照研究

Comparison of Video-assisted Thoracoscopy and Partial Sternotomy for Extended Thymectomy in Myasthenia Gravis

目的探讨电视胸腔镜手术(video-assited thoracoscopic surgery,VATS)治疗重症肌无力(myasthenia gravis,MG)的价值。方法采用前瞻性随机对照研究分析2005年7月～2008年7月采用VATS和胸骨部分劈开行胸腺切除治疗54例MG,比较2组在手术时间、术中出血量、术后胸管放置时间、术后住院时间、术后发生重症肌无力危象及疗效等方面差异。结果VATS组26例手术顺利,1例因电凝钩伤及头臂静脉中转开胸。VATS组术中出血量(43.0±5.2)ml显著少于胸骨劈开组(117.6±17.2)ml(t=-21.196,P=0.000);VATS组手术时间(89.4±15.0)min显著短于胸骨劈开组(98.4±12.5)min(t=-2.377,P=0.021);VATS组术后放置胸管时间(2.2±1.6)d显著短于胸骨劈开组(4.2±1.3)d(t=-5.003,P=0.000);VATS组术后住院时间(7.0±1.2)d显著短于胸骨劈开组(11.0±2.5)d(t=-7.379,P=0.000)。胸骨劈开组发生肌无力危象3例,VATS组无一例发生,2组肌无力危象发生率无统计学差异(P=0.236);胸骨劈开组发生肺部感染9例,VATS组2例,2组有统计学差异(χ2=5.295,P=0.021)。54例随访6～24个月,平均18.6月,VATS组和胸骨劈开组有效率分别为80.8%(21/26)和85.2%(23/27),2组无统计学差异(Z=-0.126,P=0.899)。结论VATS下胸腺扩大切除在技术是安全可行的,具有创伤小,并发症少,疗效可靠等优点,具有良好临床应用前景。

Objective To explore the value of video-assisted thoracoscopic thymectomy in the treatment of myasthenia gravis. Methods A prospective randomized controlled study, fifty-four patients who were preoperatively confirmed to be MG from 2005 to 2008 were divided into VATS group （27 cases） and conventional thoracotomy group （27 cases）. Thymectomy and dissection of all fatty tissue anterior to the pericardium were performed in both the groups. The operation time, blood loss, chest drainage time, hospital stay and outcomes of the two groups were recorded and compared. Results In the VATS group, one patient was converted to open surgery because of electrocoagulation injury and brachiocephalic vein. Compared with the conventional group, the patients in the VATS group had fewer blood loss [（43.0 ±5.2） ml vs （117.6±17.2） ml, t = -21. 196, P=0.000], shorter operation and postoperative drainage time [（89.4±15.0） min vs （98.4±12.5） min, t= -2.377, P=0.021;and （2.2±1.6） d vs （4.2±1.3） d, t= -5.003, P=0.000,respectively],and shorter postoperative hospital stay [（7.0±1.2） d vs （11.0±2.5） d, t= -7.379, P =0. 000 ]. In the conventional group, 3 patients developed MG crisis and 9 had lung infection, while none of the VATS group developed the crisis, and 2 showed lung infection （ P = 0. 236 ; Χ^2 = 5. 295 ,P = 0. 021 ）. The 54 patients were followed up for 6 to 24 months with a mean of 18.6 months, during the period, the MG symptoms were improved in 80.8% （21/26）of the patients in VATS group and 85.2% （23/27） in conventional group （ Z = - 0. 126, P = 0. 899）. Conclusions Extended thymectomy by VATS is safe and feasible with the advantage of less invasion, less surgical trauma and pain, lower rate of complication, and good curative effect.