胸腔镜两侧肋间观察孔肋弓下入路与经典剑突下入路行前纵隔肿瘤切除疗效比较的回顾性队列研究

Clinical efficacy of anterior mediastinal tumor resection by thoracoscopic subcostal approach versus classic subxiphoid approach:A retrospective cohort study

目的探讨胸腔镜下前纵隔肿瘤切除术中两种观察孔的临床疗效。方法回顾性纳入2016年10月—2024年1月联勤保障部队第910医院胸外科行胸腔镜前纵隔肿瘤切除患者,根据手术方式将患者分为两组:改良入路组(两侧肋间孔+肋弓下两孔),经典剑突下入路组(剑突下孔+肋弓下两孔)。比较两组患者围术期资料,以及重症肌无力(myasthenia gravis,MG)亚组术后肌无力改善情况。结果共纳入55例患者,其中男27例、女28例,平均年龄(49.4±15.1)岁。改良入路组23例,经典剑突下入路组32例。改良入路较经典剑突下入路手术时间更短[(129.0±20.5)min vs.(148.9±16.7)min,P<0.001],术中出血量更少[(63.0±16.6)mL vs.(75.0±10.8)mL,P<0.001],术后引流管拔除时间[(3.1±0.4)d vs.(3.9±0.6)d,P<0.001]和术后住院时间[(4.2±0.4)d vs.(5.0±0.6)d,P<0.001]更短,术中出现心脏循环功能异常比例更低[4(17.4%)vs.14(43.8%),P=0.040]。手术切除肿瘤最大直径[(4.5±1.7)cm vs.(4.0±0.9)cm,P=0.193]和术后引流液量[(396.4±121.5)mL vs.(399.9±161.3)mL,P=0.932]差异无统计学意义。改良入路组术中副损伤1例(心包损伤),经典剑突下入路组术中副损伤6例(膈肌损伤1例、肝挫伤1例、心包损伤4例);术后24 h、48 h和72 h疼痛评分差异无统计学意义(P>0.05)。改良入路组MG患者术后1年肌无力症状改善情况较经典剑突下入路组更好(完全稳定缓解率:77.8%vs.50.0%;有效率:100.0%vs.91.6%)。两组均无中转开胸,两组术后30 d均无手术相关再住院和死亡。结论改良入路组较经典剑突下入路组安全可控,具有更开阔的手术视野和更可靠彻底的切除范围。

Objective To explore the clinical efficacy of two procedures in thoracoscopic anterior mediastinal tumor resection.Methods A retrospective study was conducted on patients who underwent thoracoscopic anterior mediastinal tumor resection at the Department of Thoracic Surgery,the 910th Hospital of Joint Logistics Support Force from October 2016 to January 2024.Patients were divided into two groups according to the surgical approach:a modified approach group(bilateral intercostal ports+two subcostal ports)and a classic subxiphoid approach group(one subxiphoid port+two subcostal ports).Perioperative data and postoperative improvement of myasthenia gravis(MG)subgroup were compared between the two groups.Results A total of 55 patients were included,including 27 males and 28 females with a mean age of(49.4±15.1)years.There were 23 patients in the modified approach group and 32 patients in the classic subxiphoid approach group.The modified approach group had shorter operation time[(129.0±20.5)min vs.(148.9±16.7)min,P<0.001],less intraoperative blood loss[(63.0±16.6)mL vs.(75.0±10.8)mL,P<0.001],shorter postoperative drainage tube removal time[(3.1±0.4)d vs.(3.9±0.6)d,P<0.001]and shorter postoperative hospital stay[(4.2±0.4)d vs.(5.0±0.6)d,P<0.001),and lower proportion of intraoperative cardiac dysfunction[4(17.4%)vs.14(43.8%),P=0.040].There was no statistical difference in maximum diameter of tumor resected[(4.5±1.7)cm vs.(4.0±0.9)cm,P=0.193]and postoperative drainage volume[(396.4±121.5)mL vs.(399.9±161.3)mL,P=0.932].There was 1 patient of perioperative collateral injury in the modified approach group(pericardial injury),and 6 patients in the classic subxiphoid approach group(1 patient of diaphragm injury,1 patient of liver contusion,4 patients of pericardial injury).There was no statistical difference in pain scores at 24 h,48 h and 72 h after surgery(P>0.05).The postoperative improvement of MG symptoms in the modified approach group was better than that in the classic subxiphoid approach group at 1 year after surgery(complete stable remission rate:77.8%vs.50.0%;effective rate:100.0%vs.91.6%).No conversion to open chest surgery occurred in either group,and there were no postoperative rehospitalizations or deaths related to surgery within 30 days after surgery in both groups.Conclusion The modified approach is safe and controllable with more open surgical field and more reliable complete resection range than the classic subxiphoid approach group.