肺结核病胸腔镜肺叶切除术中非计划开胸手术原因初步分析

Clinical study of intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy in pulmonary tuberculosis

目的探讨胸腔镜下肺叶切除治疗肺结核术中非计划中转开胸的原因,分析胸腔镜手术中转开胸对手术安全性的影响。方法回顾性分析2015年1月-2018年6月因肺结核进行肺叶切除手术的113例患者资料,年龄(39.55±14.20)岁。胸腔镜组49例,开胸组64例。其中开胸组再分为胸腔镜中转开胸组14例,计划开胸组50例。记录中转开胸组中转原因;对比胸腔镜组与开胸组之间,计划开胸组与胸腔镜中转开胸组之间的手术时间、术中出血量、术后引流量、术后拔管时间、术后住院时间、术后并发症等指标。结果胸腔镜手术中转开胸率22.2%(14/63),其中主动中转的比率71.4%(10/14);不可控紧急开胸7.1%(1/14);意外发生控制性开胸21.4%(3/14)。中转开胸原因:血管损伤因素21.4%(3/14);解剖因素42.9%(6/14);淋巴结因素28.6%(4/14);技术因素7.1%(1/14)。胸腔镜组与开胸组对比:在手术时间(207.14±65.56 VS 265.63±93.99min,t=3.717,P<0.001),术中出血量(400(100,1600)VS 800(200,3400)mL,Z=-4.908,P<0.001),术后引流量(800(125,2175)VS 1227.5(410,3250)mL,Z=-3.955,P<0.001),术后拔管时间(5(2,19)VS 7(2,26)d,Z=-3.662,P<0.001),术后住院时间(13.08±4.39 VS 19.13±7.72d,t=5.252,P<0.001),胸腔镜组要优于开胸组。两组患者术后并发症发生率(11 VS 16,χ^2=0.099,P=0.753)差异无统计学意义。计划开胸组与胸腔镜中转开胸组对比:在手术时间(253.80±89.14 VS 307.86±101.99min,t=1.944,P=0.056),术中出血量(400(100,1600)VS 875(500,3300)mL,Z=-1.916,P=0.055),术后引流量(800(125,2175)VS 1077.5(670,1980)mL,Z=-0.365,P=0.715),术后拔管时间(5(2,19)VS 6(3,22)d,Z=-1.023,P=0.306),术后住院时间(13.08±4.39VS15.86±5.19d,t=0.175,P=0.073),术后并发症(11 VS 4,χ^2=0.122,P=0.486)方面,两组无明显差异。结论肺结核患者进行胸腔镜手术可明显受益。肺门淋巴结粘连及胸腔粘连解剖困难是胸腔镜下肺叶切除治疗肺结核中转开胸的主要原因。虽然手术中中转开胸的比例较高,但相比计划开胸手术,中转开胸并没有增加围手术期的风险。

Objective To discuss the causes of non-planned conversion to thoracotomy in VATS lobectomy for pulmonary tuberculosis and analyze the influence of non-planned conversion to thoracotomy on surgical safety.Methods The data of 113 patients who underwent lobectomy due to tuberculosis from January 2015 to June 2018 were retrospectively analyzed,and their average age was 39.55±14.20 years old.There were 49 cases in the thoracoscopic group and 64 cases in the thoracotomy group,and among them,the thoracotomy group was divided into the non-planned conversion to thoracotomy group(14 cases)and the planned thoracotomy group(50 cases).The cause of conversion to thoracotomy was recorded.The operative time,intraoperative blood loss,postoperative drainage volume,postoperative extubation time,postoperative hospitalization time,postoperative complications and other indicators were compared among the groups.Results During thoracoscopic surgery,the rate of conversion to thoracotomy was 22.2%(14/63).The rate of elected to open with anticipation of difficulties was 71.4%(10/14).The rate of controlled and opened following difficulty was 21.4%(3/14)and the rate of uncontrolled open with emergency was 7.1% (1/14). Reasons for conversion to thoracotomy included vascular injury (21.4%, 3/14), anatomy (42.9%, 6/14), lymph nodes (28.6%, 4/14), and technical (7.1%, 1/14). Compared to the thoracotomy group, the VATS group had shorter operation time (207.14±65.56 VS 265.63±93.99min, t=3.717, P< 0.001), less amount of intraoperative blood loss [400 (100, 1600) VS 800 (200, 3400) ml, Z=-4.908, P< 0.001], less postoperative drainage [800 (125, 2175) VS 1227.5 (410, 3250) mL, Z=-3.955, P< 0.001], less extubation time [5 (2, 19) VS 7 (2, 26) d, Z=-3.662, P< 0.001] and shorter hospital stay (13.08±4.39 VS 19.13±7.72d, t=5.252, P< 0.001). There was no statistical difference in postoperative complications (11 VS 16, χ^2=0.099, P =0.753) between the two groups. At the same times, there was no statistical difference in operation time (253.80±89.14 VS 307.86±101.99min, t=1.944, P =0.056), amount of intraoperative blood loss [400 (100, 1600) VS 875 (500, 3300) mL, Z=-1.916, P =0.055], the postoperative drainage [800 (125, 2175) VS 1077.5 (670, 1980) mL, Z=-0.365, P =0.715], extubation time [5 (2,19) VS 6 (3, 22) d, Z=-1.023, P =0.306], hospital stay (13.08±4.39 VS 15.86±5.19d, t=0.175, P =0.073) and postoperative complications (11 VS 4, χ^2=0.122, P =0.486) between the non-planned conversion to thoracotomy group and the planned thoracotomy group. Conclusion Patients with tuberculosis can benefit significantly from video-assisted thoracoscopic surgery. The difficulty in dissection of hilar lymph node adhesion and thoracic adhesion is the main reason when pulmonary resection under video-assisted thoracoscopic is converted to thoracotomy for tuberculosis. Although a higher proportion of patients are converted to thoracotomy during the operation, there is no increase in perioperative risk compared with planned thoracotomy.