经剑突下与经肋间单孔胸腔镜胸腺切除术倾向性评分匹配对比研究

Subxiphoid versus lateral intercostal uniportal thoracoscopic thymectomy:a propensity score matching study

目的对比分析经剑突下与经肋间单孔胸腔镜胸腺切除术的优势及安全性。方法纳入2014年10月至2019年12月期间在同济大学附属上海肺科医院胸外科行单孔胸腔镜全胸腺切除术治疗的308例胸腺上皮性肿瘤患者。术前均经影像学临床诊断为胸腺上皮性肿瘤,临床分期MasaokaⅠ-Ⅱ期,不合并肌无力症状。按照手术入路方式分为剑突下单孔胸腔镜胸腺切除术组(剑突组)和肋间单孔胸腔镜胸腺切除术组(肋间组),其中剑突组77例,男40例,女37例,年龄32~80岁,平均(58.0±11.8)岁;肋间组231例,男114例,女117例,年龄25~78岁,平均(54.8±11.4)岁。通过倾向性评分匹配法,对两组基线资料进行匹配,对比分析两组术后短期和长期疼痛指标。结果全组无死亡,所有患者均顺利完成全胸腺切除术,无中转开胸。经过倾向性评分匹配,共62对患者匹配成功,匹配后两组在性别、年龄、体质量指数、肺功能、合并症、病灶直径、病理类型、Masaoka分期、术中出血量、术后胸腔引流量、术后住院时间等方面差异均无统计学意义(P>0.05)。剑突组术后第1天疼痛视觉模拟评分、术后额外追加镇痛次数、术后疼痛持续时间≥3个月的患者比例均低于肋间组,差异均有统计学意义(P<0.05)。1例剑突组患者术后出现肌无力症状,机械通气时间延长;其他均未出现严重围手术期并发症。结论剑突下单孔胸腔镜全胸腺切除术安全可行。相比肋间入路而言,剑突下入路具有不损伤肋间神经、术后疼痛(短期和长期)更轻的优势。

Objective To investigate the advantages and safety of subxiphoid uniportal thoracoscopic thymectomy.Methods From October 2014 to December 2019,a total of 308 patients diagnosed with early stage thymic epithelial tumor underwent uniportal thoracoscopic thymectomy were included.Subxiphoid group including 40 males and 37 females,aged 32-80 years old,mean age(58.0±11.8)years old.Intercostal group including 114 males and 117 females,aged 25-78 years old,mean age(54.8±11.4)years old.Short-term and long-term postoperative pain scores was compared in a propensity score matching analysis.Results Propensity score analysis revealed that 62 patients treated with the subxiphoid approach and 62 patients treated with the lateral intercostal approach had the same baseline characteristics.There were no significant differences in lesion size,stage,pathological type,intraoperative blood loss,postoperative drainage volume and postoperative hospital stay between the two groups(P>0.05).Compared with those in the intercostal group,patients in the subxiphoid group yielded lower pain scores on the first day after operation and less patients with postoperative pain lasting more than 3 months.Patients required for additional analgesic therapy in subxiphoid group was less than intercostal group.One patient in subxiphoid group developed myasthenia after operation,which prolonged the duration of mechanical ventilation.No serious perioperative complications and death occurred in other patients.Conclusion Subxiphoid uniportal thoracoscopic thymectomy is safe and feasible,it has the advantages of no injury to intercostal nerve and less short-term and long-term postoperative pain compared with intercostal approach.