电视胸腔镜治疗后纵隔神经源性肿瘤

Experience of VATs for posterior mediastinal neurogenic tumors

目的利用电视胸腔镜切除后纵隔神经源性肿瘤，探讨该技术的操作特点。方法2001年5月至2011年6月利用电视胸腔镜切除后纵隔神经源性肿瘤58例中男36例，女22例。平均年龄38．7岁。实体瘤平均最大径为4．9cm。术前合并神经系统或肺部症状16例，无症状体检发现42例。病变位于左侧24例，右侧33例，双侧1例。手术通过3个切口完成，多采用包膜内剥除的方法，较大之滋养血管采用钛夹或Hem-o-lock夹闭；肿瘤来源神经者分别在瘤体两端正常神经束部位钛夹夹闭后剪断。如肿瘤巨大、粘连严重或出血时，延长前胸壁切口长约6-10cm，转为开胸手术治疗。结果全组手术顺利，无围手术期死亡。手术时间127．2min，术中出血206．4ml，术中术后输血3例，术后胸腔闭式引流时间2．72天，住院5．19天。53例在全腔镜下完成手术，中转开胸5例。术后并发症7例，其中Homer综合征4例。术后病理亦神经鞘瘤25例，神经纤维瘤23例，神经节细胞瘤8例，副神经节细胞瘤1例，恶性副神经节细胞瘤1例。术后随访44．9个月，未见肿瘤复发。结论利用胸腔镜治疗后纵隔神经源性肿瘤是一种安全、有效的手术方式，但需严格把握适应证并熟练掌握胸腔镜手术技巧。包膜内肿瘤切除是保障手术安全、减少手术并发症的重要手段。肿瘤直径超过6cm时手术风险明显增加。胸膜顶肿瘤也是该类手术的难点之一。

Objective To review the experience of video-assisted thoracoscopic resection for posterior mediastinal neurogenic tumors, to investigate the technical features and difficulties of thoracoscopic approach. Methods From May 2001 to June 2011, 58 patients underwent thoracoscopic resection of posterior mediastinal tumors in our institution, including 36 males and 22 females. The average age of the patients was 38.7 years. The average tumor size was 4.9 cm. 16 patients bad neurogenic or pulmonary symptoms at the time of diagnosis, while the other 42 were asymptomic. 24 lesions were located in the left side, 33 lesions in the right side, 1 lesion in bilateral sides. All procedures generally required 3 ports, and intracapsular enueleation was preferred, supplying vessels were ligated by hemoclips or Hem-o-lock clips; the nerves of origin were cut off at both edges of the tumor. For bulky tumor, dense adhesion, and massive bleeding, open conversions were performed by extending the incision anteriorly to 6-10 cm. Results All procedures were successfully performed without death event occurring. The average operating time was 127.2 rain. The average intraoperative blood loss was 206.4 ml. 3 cases requied blood transfusion. The average chest tube duration was 2.72 days. The average postoperative stay was 5.19 days. 53 procedures were performed entirely under thoracoscopy to achieve gross-total resection. Conversions to an open procedure were necessitated in 5 patients （8.6%）. 7 patients experienced post-operative complications, with 4 Homer syndromes. There were 25 neurilemomas, 23 neurofibromas, 8 ganglioneuromas, 1 paraganglioma, and 1 malignant paraganglioma. No local recurrence was seen after an average follow-up of 44.9 months. Conclusion Video-assisted thoraeoscopic removes of the posterior mediastinal tumors are safe, reliable and minimally invasive for selected patients with mastered throcoscopic skills, intracapsular enucleation is a safe procedure with reduced risk, while tumors larger than 6era and located in the apex are with increased risk.