全胸腔镜手术在肺部局灶性磨玻璃影结节诊疗中的应用

Complete Video-assisted Thoracoscopic Surgery for the Diagnosis and Treatment of Focal Ground-glass Opacity

目的探讨全胸腔镜手术在局灶性磨玻璃影(focal ground-glass opacity,fGGO)诊断与治疗中的价值。方法2007年5月～2011年5月对46例术前未确诊的fGGO行全胸腔镜手术。病变位于外周,先完成VATS下的楔形切除,在术中冰冻的基础上行解剖性肺叶切除及系统性淋巴结清扫。若病变靠近肺门,不易行楔形切除,则直接行肺叶切除,根据术中冰冻结果是否行淋巴结清扫。结果 46例均顺利完成手术,手术时间98～117 min,平均107.5 min;术后住院时间3～5 d;切口总长度5～6 cm,术后疼痛轻;术后自控镇痛1～2.5 d(平均1.5 d)。术后病理良性8例:结核球6例,真菌病2例。恶性肿瘤38例:其中3例为PET/CT诊为良性;支气管肺泡癌14例,腺癌11例,含有支气管肺泡癌成分的腺癌11例,大细胞肺癌2例。fGGO恶性率为82.6%(38/46),其中支气管肺泡癌比例最高,为36.8%(14/38)。术后并发症3例(6.5%,3/46):2例肺不张,经对症治疗治愈;1例胸腔持续漏气11 d,自愈。术中确诊的38例行淋巴结清扫,共切除淋巴结394枚(每例9～15枚,平均12枚/例),淋巴结转移7枚,全部为N1淋巴结。结论全胸腔镜手术治疗fGGO安全、有效。

Objective To explore complete video-assisted thoracoscopic surgery（VATS） for the diagnosis and treatment of focal ground-glass opacity （fGGO）. Methods From May 2007 to May 2011, we performed complete VATS on 46 patients with preoperatively undiagnosed fGGO. VATS wedge resection was carried out for peripheral lesions, and then, based on intraoperative fast frozen section,anatomical lobectomy and systematic lymph node dissection were followed. For the lesions in the centre, for which wedge resection was not appropriate, we performed lobectomy immediately, and then systematic lymph node dissection if it was necessary shown by fast frozen section. Results The procedure was completed in all the 46 patients within a mean of 107.5 min （98 - 117 min）. The postoperative hospital stay was 3 - 5 days. The length of surgical incision was 5 - 6 cm. Postoperative pain was mild in all the patients, and self-controlled analgesia ranged from 1 to 2.5 days （ mean, 1.5 days）. Postoperative pathology showed benign lesions in 8 cases including 6 cases of tuberculoma and 2 cases of fungal disease, and malignancy in the other 38 cases （3 of them had been diagnosed as benign lesions by PET/CT） including 14 cases of bronchioloalveolar carcinoma, l 1 cases of adenocarcinoma, 11 cases of adenocarcinoma mixed with bronchioloalveolar carcinoma, and 2 cases of large cell lung cancer. The rate of malignancy was 82.6% （38/46） , of which bronchioloalveolar carcinoma accounted for 36.8% （ 14/38 ）. Three patients developed postoperative complications （6.5 % , 3/46） , including atelectasis in 2 cases, who were cured by symptomatic treatments; and continuous chest leak for 11 days in 1 case, who was cured spontaneously. Lymph node dissection was performed on 38 patients who were diagnosed intraoperatively; totally 394 lymph nodes were resected （9 -15 per case with a mean of 12 per case）. Metastasis was detected in seven lymph nodes; all of them were in stage Nr. Conclusion Complete VATS is a superior approach for patients with fGGO.