胸腔镜肺癌肺切除术后患者住院时间延长(>7天)的病因分析——附115例报道

Analysis of Prolonged Hospitalizations(Longer than 7 days): 115 Lung Cancer Patients after Video Assistant Thoracic Surgery(VATS)

背景与目的胸腔镜手术已是我科肺癌肺切除手术的主要方式,其特点是创伤小、恢复快,术后7天以内出院患者近90%,但术后并发症仍时有发生;我们对胸腔镜肺癌肺切除术后住院时间>7天的患者进行分析,旨在总结并发症的种类及危险因素,提高患者的术后安全性。方法数据来源为北京肿瘤医院胸外一科前瞻性肺癌数据库,选取2010年1月-2014年12月行胸腔镜肺癌肺切除手术,且住院时间>7天的患者,调查其并发症种类,并按照改良Clavien分级将其分为轻度及重度并发症,分析临床因素与并发症程度之间的关系。结果术后住院时间>7天者共115例,占同期手术比例为10.3%(115/1,112)。全组患者轻度并发症81例,占同期手术(1,112例)比例和术后住院时间延长者比例分别为7.3%和70.4%,重度并发症34例,分别为3.1%和29.6%;因并发症死亡者2例,分别为0.18%和1.7%;术后最常见者为漏气超过5日20例,分别为1.8%和17.4%,肺不张19例,分别为1.7%和16.5%,肺部感染18例,分别为1.6%和15.7%;罕见并发症中支气管胸膜瘘4例(0.36%和3.5%),但危险高,其中2例因并发急性呼吸窘迫综合征(acute respiratory distresssyndrome,ARDS)围手术期死亡;临床因素中仅低肺功能(FEV1%<70%)可能是造成术后严重并发症的因素(45.8%vs 23.6%,P=0.038);轻度并发症组与重度并发症组5年无疾病生存率(52.2%vs51.9%,P=0.894)及5年总生存率(64.0%vs 53.5%,P=0.673)均无显著差异。结论术后持续漏气、肺不张及肺部感染等并发症是延长胸腔镜肺癌术后住院时间的主要原因,而支气管胸膜瘘是最凶险的并发症;术前低肺功能患者更易出现术后严重并发症,但并发症严重程度并不会影响远期预后。

Background and objective Tnoracoscopic surgery has gradually become the major procedure for lung cancer surgery in our department. Its characteristics are minimal trauma and quick recovery, which make approximately 90% of patients discharge from the hospital after surgery. However, the postoperative complications still happen now and then. We analyzed the patients who had been hospitalized for longer than 7 days after thoracoscopic lung cancer surger, aiming to summarize the types and risk factors of complications, and improve postoperative safety of patients. Methods The data were come from the prospective database of Thoracic Surgery Unit One in Peking Cancer Hospital, and patients that underwent thoracoscopic pulmonary surgery between Jan. 2010 and Dec. 2014 with length of stay more than 7 days were included in the study. The classifications of the complications were investigated and graded as mild or severe complications according to modified Claviengrading, the relationship between clinical factors and degrees of complications was also analyzed. Results The hospitalization of 115 cases were longer than 7 days after surgery, accounting for 10.3 % （115 / 1,112 ） of the whole patients that underwent surgery during the same period. Eighty-one cases had mild complications, accounting for 7.3% （81/1,112）of the whole cases that underwent surgery during the same period and 70.4% （81/115 ） of the cases with prolonged length of stay; the proportions of severe complications in both groups were 3.1% （34/1,112） and 29.6% （34/115）, respectively; and the proportions of complications that caused perioperative deaths were 0.18% （2/1112） and 1.7% （2/115）, respectively. Among all the postoperative complications, the most common was air leakage for more than 5 days after surgery, with a total of 20 cases （1.8% and 17.4%）. The other common complications were： atelectasis （19 cases, 1.7% and 16.5%）, pulmonary infection （18 cases, 1.6% and 15.7%）, etc. The less common complications was bronchopleural fistula （4 cases, 0.36% and 3.5%） with very high risk, and 2 cases died perioperatively due to the combination of acute respiratory distresssyndrome （ARDS）. In the clinical factors, only preoperative low pulmonary function （FEV1%〈70%） was the potential risk factor for postoperative severe complications （45.8% vs 23.6%, P=0.038）. There was no significant difference either regarding the 5 year disease free survival or the 5 year overall survival between mild complication group and severe complication group, with 5 year DFS being 52.2% and 51.9%, respectively （P=0.894）, and 5 year overall survival being 64.0% and 53.5%, respectively （P=0.673）. Conclusion Continuous postoperative air leakage, atelectasis and pulmonary infections were the major causes for prolonged hospitalization after thoracoscopic surgery for lung cancer, and bronchopleural fistula was the most perilous complications. Patients with low preoperative pulmonary function were more likely to have severe postoperative complication, however, this would not influence the long term survival of the patients.