无胸管单孔全胸腔镜手术在快速康复外科中的临床研究--单中心回顾性分析

Clinical study of uniportal thoracoscopic surgery without chest tube in rapid rehabilitation surgery-single center retrospective analysis

目的纳入接受单孔胸腔镜手术后不留置胸管与常规留置胸管的患者,比较两组术后气胸发生率、胸腔积液、肺不张、皮下气肿、切口渗液情况、数字评定量表(NRS)评分、术后平均住院日,从而对两组的安全性及有效性进行评估,以期对部分接受单孔胸腔镜术后不置胸管策略提供证据支持。方法回顾分析2019年1月1日至2020年11月1日粤北人民医院胸外科行全身麻醉双腔气管插管下胸科手术共1480例,筛选出单孔胸腔镜肺楔形切除、肺大泡切除及纵隔肿瘤切除患者112例,再次经过纳入排除标准筛选后共73例,分为无胸管组34例(术中经胸管排气水检测无漏气直接缝合切口,不放置引流管)和常规胸管组39例(术中在手术切口肋间留置22号胸腔引流管),对术中转多孔或中转开胸手术、术后并发症、疼痛评分、术后平均住院日进行分析。计量资料采用Wilcoxon秩和检验,计数资料采用χ^(2)检验。结果两组患者年龄、性别、病种分布比较,差异均无统计学意义(均P>0.05)。所有患者无术中中转开胸或多孔手术;两组患者手术时间、术中出血量、术后第2天NRS评分比较,差异均无统计学意义(均P>0.05);无胸管组和常规胸管组患者术后第1天NRS评分[2分:38.2%(13/34)比7.7%(3/39)、3分:52.9%(18/34)比56.4%(22/39)、4分:8.8%(3/34)比35.9%(14/39)]、术后住院时间[0 d:0.0%(0/34)比7.7(3/39)、1 d:38.2%(13/34)比15.4%(6/39)、2 d:58.8%(20/34)比48.7%(19/39)、3 d:2.9%(1/34)比17.9%(7/39)、4 d:0.0%(0/34)比10.3%(4/39)]比较,差异均有统计学意义(均P<0.05)。无胸管组并发症发生率为50.0%(17/34),与常规胸管组51.3%(20/39)比较,差异无统计学意义(χ^(2)=0.012,P=0.913)。结论无胸管单孔胸腔镜对于选择性肺楔形切除、肺大泡切除及纵隔肿瘤切除安全、可行,有助于术后快速康复,减轻患者疼痛及缩短术后住院时间。

Objective To compare the incidences of pneumothorax,pleural effusion,atelectasis,subcutaneous emphysema,and incision effusion,score of Numerical Rating Scale(NRS),and average postoperative hospital stay between the patients who underwent uniportal thoracoscopic surgery without chest tube indwelling and with conventional chest tube indwelling,so as to evaluate the safety and effectiveness of the two groups,and to provide evidence support for some patients who receive uniportal thoracoscopic surgery without chest tube.Methods From January 1,2019 to November 1,2020,a total of 1480 cases of thoracic surgery under general anesthesia and double-lumen endotracheal intubation in Yuebei People's Hospital were retrospectively analyzed,and 112 cases of uniportal thoracoscopic pulmonary wedge resection,pulmonary bulla resection,and mediastinal tumor resection were selected.After screening again,73 cases were divided into a tube-free group and a conventional chest tube group.In the 34 patients of the tube-free group,the incision was directly sutured without drainage tube indwelling after the chest tube exhaust water detection showed no air leakage during the operation;in the 39 patients of the conventional chest tube group,No.22 thoracic drainage tube was indwelled in the intercostal incision during the operation.The incidence of transferring to porous thoracoscopic surgery or thoracotomy,complications,pain score,and average postoperative hospital stay were analyzed.Wilcoxon rank sum test was used for the measurement data,andχ^(2) test was used for the count data.Results There were no statistically significant differences in the age,gender,and disease distribution between the two groups(all P>0.05).None of the patients in the two groups were transferred to porous thoracoscopic surgery or thoracotomy.There were no statistically significant differences in the operation time,intraoperative blood loss,and NRS score on the second day after the operation between the two groups(all P>0.05).There were statistically significant differences in the NRS score[2 points:38.2%(13/34)vs.7.7%(3/39),3 points:52.9%(18/34)vs.56.4%(22/39),4 points:8.8%(3/34)vs.35.9%(14/39)]on the first day after the operation and postoperative hospital stay[0 d:0.0%(0/34)vs.7.7(3/39),1 d:38.2%(13/34)vs.15.4%(6/39),2 d:58.8%(20/34)vs.48.7%(19/39),3 d:2.9%(1/34)vs.17.9%(7/39),4 d:0.0%(0/34)vs.10.3%(4/39)]between the tube-free group and the conventional chest tube group(both P<0.05).The incidence of complications in the tube-free group was 50.0%(17/34),without statistically significant difference compared with 51.3%(20/39)in the conventional chest tube group(χ^(2)=0.012,P=0.913).Conclusion Uniportal thoracoscopy without chest tube is safe and feasible for selective pulmonary wedge resection,pulmonary bullae resection,and mediastinal tumor resection,which is helpful for quick postoperative recovery,pain relief,and shortening hospital stay.