重症肌无力合并前纵隔肿物患者手术入路选择研究

Selection of surgical approach in patients with myasthenia gravis complicated by anterior mediastinal mass

目的通过正中开胸入路、肋间胸腔镜入路及剑突下胸腔镜入路三种手术入路的对比,为重症肌无力合并前纵隔肿物患者术前手术入路的选择提供依据。方法选取2013年10月至2019年12月胸腺外科手术切除前纵隔肿物的重症肌无力患者186例,依据手术入路的不同,分为3组:正中开胸入路组62例,肋间胸腔镜入路组55例,剑突下胸腔镜入路组69例。比较患者术前[年龄、性别、病程、肌无力危象既往史、术前激素冲击、术前免疫球蛋白冲击、临床分型(Osserman)等基本临床资料],术中(手术时间、术中出血量、肿物最大直径、肿物侵及部位),术后(病理类型、Masaoka分期、呼吸机使用时间、监护室住院天数、第1天引流量、引流管留置时间、住院时间、肌无力近期缓解率、肌无力危象发生率)各方面,分析3组之间差异。结果三种手术入路在年龄、性别、病程、肌无力危象既往史、术前激素冲击、术前免疫球蛋白冲击、临床分型(Osserman)、术后病理类型、术后肌无力近期缓解率等方面差异无统计学意义(P>0.05);在手术时间、术中出血量、呼吸机使用时间、监护室住院天数、术后第1天引流量、引流管留置时间、术后住院时间、肌无力危象发生率方面,剑突下胸腔镜入路组明显优于正中开胸入路组和肋间胸腔镜入路组(P<0.05)。在术后Masaoka分期、肿物最大直径方面,正中开胸入路组较剑突下胸腔镜入路组、肋间胸腔镜入路组更具有优势(P<0.05)。结论剑突下胸腔镜入路在肿物直径较小及Masaoka分期较早的重症肌无力患者手术时间更短、出血量更少、术后恢复更快,较肋间胸腔镜入路和正中开胸入路更显优越性;而肿物直径较大及Masaoka分期较晚的患者,行正中开胸入路是重症肌无力合并前纵隔肿物的更佳选择。

Objective To compare the three surgical approaches of midline thoracotomy,intercostal thoracoscopy and subxiphoid thoracoscopy,so as to provide basis for the selection of surgical approach in patients with myasthenia gravis complicated by anterior mediastinal mass.Methods A total of 186 patients with myasthenia gravis who underwent surgical resection of anterior mediastinal masses were enrolled.According to different surgical approaches,who were divided into three groups:central approach group(n=62),intercostal thoracoscopic approach group(n=55),and subxiphoid thoracoscopic approach group(n=69).The basic data including preoperative age,gender,course of disease,previous history of myasenia crisis,preoperative hormone shock,preoperative immunoglobulin shock,clinical classification(Osserman),intraoperative time,intraoperative blood loss,maximum diameter of tumor,site of tumor invasion,postoperative:pathological types,Masaoka stage,breathing machine use time and hospital days,muscle weakness status,remission rate,incidence of myasthenia crisis were observed and compared among the three groups.Results There were no significant differences in patient’s age and gender,course of disease,history of muscle weakness crisis,preoperative hormone shock,preoperative immunoglobulin shock,clinical type(Osserman),postoperative pathological type,and short-term remission rate of muscle weakness status among the three group(P>0.05).However the intraoperative blood loss,duration of ventilator use,length of stay in the intensive care unit,postoperative drainage volume on day 1,indwintering time of drainage tube,postoperative hospital stay,incidence of muscular weakness crisis in subxiphoid thoracoscopic approach group were superior to those in the other two groups(P<0.05).Moreover the postoperative Masaoka stage and the maximum diameter of the tumor in entral approach group were superior to those in the other two groups(P<0.05).Conclusion In myasthenia gravis patients with small tumor diameter and early Masaoka stage,the operative time is shorter,the amount of bleeding is less,and the postoperative recovery is faster,and subxiphoid thoracoscopic approach was superior to intercoastal thoracoscopic approach and central approach.For the patients with larger mass diameter and later Masaoka stage,central approach thoracotomy is a better choice.