Thoracoscopic sleeve resection—the better approach?
Editorial

胸腔镜袖式切除术——更好的方法？

Calvin S.H. Ng

Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China

Correspondence to: Calvin S.H. Ng, BSc (Hons) MBBS (Hons) MD, FRCSEd (CTh). Associate Professor, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, N.T. Hong Kong SAR, China. Email: calvinng@surgery.cuhk.edu.hk.

Submitted Jul 04, 2014. Accepted for publication Jul 06, 2014.

doi: 10.3978/j.issn.2072-1439.2014.07.28

既往只有最富冒险精神和最有才能的胸外科医生才敢于挑战胸腔镜袖式肺叶切除手术。随着胸腔镜技术能力的提高、更多的知识传播和技巧交流、以及设备的改进，越来越多的医疗中心能够实施胸腔镜袖式肺叶切除术。中国的何建行教授领衔的团队素以胸腔镜技术创新和卓越而闻名，最近他们报道了关于支气管袖式切除的经验[1]。在49名患者中，20例(41%) 接受了胸腔镜支气管袖式肺叶切除术，其中有一名患者需要行半隆凸重建的右上肺叶袖式切除。他们采用的是三孔胸腔镜技术，切口在前胸壁，胸腔镜观察孔在低位。在早期的一半病例中，采用的是改良的间断吻合技术，即以4-0聚丙烯线关闭支气管后壁膜部，然后以4-0单股可吸收线行交替的“8”字缝合前壁软骨。在随后的病例中采用了连续缝合技术缝合支气管的后壁和前壁。吻合口无需采用覆盖和加固措施，没有发现吻合口漏的发生。基于无围术期死亡和优良的近期效果，这项研究似乎进一步支持了在有丰富胸腔镜经验的中心开展胸腔镜袖式肺叶切除术的安全性和有效性。除此之外，这项研究也体现了胸腔镜下支气管吻合技术的演变历程，即传统上基于安全性考虑而十分强调采用的间断缝合[2]近年来越来越多地被更为便捷的连续缝合技术所取代[1,3,4]。显然，连续缝合技术可以减少缝线的缠绕使得操作更流畅；但是，间断缝合的支持者们则一直强调其潜在的优势在于支气管吻合部位缺血程度更轻以及技术的安全性。这两种胸腔镜袖式肺叶切除术的吻合方法之间的临床效果似乎难以进行有效的比较，这是由于其样本容量较小、患者的异质性以及各术式内的技术差异，例如吻合口大小、针距宽度，等等。对于外科医生来说，培训时所接受的手术技术往往最为得心应手，同时效果也是最好的，这在胸外科或者说在胸腔镜外科更是如此。所以外科医生理应选择他所最熟悉的支气管吻合技术。

温故而求新

尽管迄今尚无比较胸腔镜袖式肺叶切除对比胸腔镜全肺切除的疗效的随机对照试验，然而学者们公认后一种术式具有更高的围术期死亡率和并发症，包括胸腔感染、支气管胸膜瘘、房颤和呼吸衰竭等[5]。并且在胸腔镜全肺切除术后，右心室负荷和压力等临床指标往往更为严重。因此，尽管胸腔镜全肺切除术后的疗效也在不断提高[6,7]，越来越多的学者支持胸腔镜袖式肺叶切除成为适合病例的术式选择之一，因为它能够保留更多的肺功能，并降低并发症和死亡率。

目前也没有比较胸腔镜和开放的袖式肺叶切除术的前瞻性研究。然而我们知道与其他开放手术相比，胸腔镜肺切除术已被证实能够减少炎症反应[8]、更好地保护免疫功能[9,10]、减少术后局部的血管生成状况[11]、减少肺功能的损失[12]、减轻术后疼痛以及肩部的功能障碍[13]。更为重要的是，通过胸腔镜技术减小手术创伤对于患者的长期生存能够产生积极有益的作用。在数项关于早期肺癌患者的研究中，胸腔镜肺叶切除与开放手术相比显示出了少许的五年期的生存优势 [14,15]。有意思的是，类似的生存优势也在其他恶性肿瘤中被发现，例如腹腔镜对比开放的结肠癌手术[15]。另一项常常被忽略的优点是胸腔镜手术所带来的更快的术后康复使得进展期的肺癌患者尽早接受辅助治疗并且耐受程度更高 [16]。今后需要进一步的研究来确定胸腔镜对比开放的袖式肺叶切除手术是否也存在类似的优势。

新视野

从胸腔镜辅助小切口开胸的杂交手术[18]，到两孔的胸腔镜技术[19], 再到最新的单孔胸腔镜技术[20]，包括胸腔镜袖式肺叶切除术在内的整个微创胸外科正处于日新月异般的飞速进步中[17]。随着胸外科医生越来越多地通过更少更微小的切口进行外科手术，胸腔镜袖式肺叶切除技术的挑战便来自于否能够获得良好的视野、能否合理使用腔镜器材进行组织操作，从而降低支气管吻合的难度。成角度、双关节、细操作杆的专业化胸腔镜手术器材的不断改进显著地提高了人机工程学效果，并且减少了器材置入微小手术切口时的阻碍[21]。近期的另一个进步是可变视角的广角胸腔镜的发明，它通过可弯曲的镜头或可旋转的棱镜设计可以实现最大120度的视角。这些胸腔镜器材改善了外科医生的视野和灵活度，即便是其活动和位置受限制于单一小切口的情况下[22]。既往支气管吻合时困难的腔内打结任务现在可以通过使用“腔镜打结”装置大大简化，例如TK Ti-KNOT® (LSI Solutions, Rochester, USA), 它通过钛合金装置可以十分方便地拉紧缝线并予以固定 [23]。此外，快速发展的倒钩缝线技术可能将很快免除体内打结的必要。将来会出现腔镜手术用的机械臂，它能够在胸腔内展开、识别组织、自动精密缝合[24]。在那之前，我们血肉之躯的人类医生仍要为实现技术的卓越而孜孜以求，并且时常需要与最新最好的器材装备相知相伴。

Acknowledgements

Disclosure: The author declares no conflict of interest.

References

  1. Xu X, Chen H, Yin W, et al. Thoracoscopic Half Carina Resection and Bronchial Sleeve Resection for Central Lung Cancer. Surg Innov 2014;21:481-6. [PubMed]
  2. Mahtabifard A, Fuller CB, McKenna RJ Jr. Video-assisted thoracic surgery sleeve lobectomy: a case series. Ann Thorac Surg 2008;85:S729-32. [PubMed]
  3. Yu D, Han Y, Zhou S, et al. Video-assisted thoracic bronchial sleeve lobectomy with bronchoplasty for treatment of lung cancer confined to a single lung lobe: a case series of Chinese patients. J Cardiothorac Surg 2014;9:67. [PubMed]
  4. Yang R, Shao F, Cao H, et al. Bronchial anastomosis using complete continuous suture in video-assisted thoracic surgery sleeve lobectomy. J Thorac Dis 2013;5:S321-2. [PubMed]
  5. Ng CS, Wan S, Lee TW, et al. Post-pneumonectomy empyema: current management strategies. ANZ J Surg 2005;75:597-602. [PubMed]
  6. Nwogu CE, Yendamuri S, Demmy TL. Does thoracoscopic pneumonectomy for lung cancer affect survival? Ann Thorac Surg 2010;89:S2102-6. [PubMed]
  7. Lau KK, Ng CS, Wan IY, et al. Video-assisted thoracoscopic pneumonectomy is safe and may have benefits over open pneumonectomy. European Society of Thoracic Surgeons (ESTS), 21st European Conference on General Thoracic Surgery, Birmingham, UK. 2013;17:abstract F108.
  8. Yim AP, Wan S, Lee TW, et al. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg 2000;70:243-7. [PubMed]
  9. Ng CS, Lee TW, Wan S, et al. Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer. J Invest Surg 2005;18:81-8. [PubMed]
  10. Ng CS, Wan S, Hui CW, et al. Video-assisted thoracic surgery lobectomy for lung cancer is associated with less immunochemokine disturbances than thoracotomy. Eur J Cardiothorac Surg 2007;31:83-7. [PubMed]
  11. Ng CS, Wan S, Wong RH, et al. Angiogenic response to major lung resection for non-small cell lung cancer with video-assisted thoracic surgical and open access. ScientificWorldJournal 2012;2012:636754.
  12. Garzon JC, Ng CS, Sihoe AD, et al. Video-assisted thoracic surgery pulmonary resection for lung cancer in patients with poor lung function. Ann Thorac Surg 2006;81:1996-2003. [PubMed]
  13. Li WW, Lee RL, Lee TW, et al. The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy. Eur J Cardiothorac Surg 2003;23:390-6. [PubMed]
  14. Ng CS, Wan S, Hui CW, et al. Video-assisted thoracic surgery for early stage lung cancer - can short-term immunological advantages improve long-term survival? Ann Thorac Cardiovasc Surg 2006;12:308-12. [PubMed]
  15. Ng CS, Whelan RL, Lacy AM, et al. Is minimal access surgery for cancer associated with immunologic benefits? World J Surg 2005;29:975-81. [PubMed]
  16. Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007;83:1245-9; discussion 1250. [PubMed]
  17. Ng CS, Lau KK, Gonzalez-Rivas D, et al. Evolution in surgical approach and techniques for lung cancer. Thorax 2013;68:681. [PubMed]
  18. He J, Shao W, Cao C, et al. Long-term outcome of hybrid surgical approach of video-assisted minithoracotomy sleeve lobectomy for non-small-cell lung cancer. Surg Endosc 2011;25:2509-15. [PubMed]
  19. Jiao W, Zhao Y, Huang T, et al. Two-port approach for fully thoracoscopic right upper lobe sleeve lobectomy. J Cardiothorac Surg 2013;8:99. [PubMed]
  20. Gonzalez-Rivas D, Fernandez R, Fieira E, et al. Uniportal video-assisted thoracoscopic bronchial sleeve lobectomy: first report. J Thorac Cardiovasc Surg 2013;145:1676-7. [PubMed]
  21. Ng CS, Wong RH, Lau RW, et al. Minimizing chest wall trauma in single-port video-assisted thoracic surgery. J Thorac Cardiovasc Surg 2014;147:1095-6. [PubMed]
  22. Ng CS, Wong RH, Lau RW, et al. Single Port Video-Assisted Thoracic Surgery: Advancing Scope Technology. Eur J Cardiothorac Surg 2014. [Epub ahead of print]. [PubMed]
  23. Demmy TL. Thoracoscopic Left Upper Lobe Sleeve Lobectomy for Inflammatory Myofibroblastic Tumor. 94th Annual Meeting American Association for Thoracic Surgery (AATS), April 26-30, 2014, Toronto, Canada. [video presentation].
  24. Ng CS, Rocco G, Wong RH, et al. Uniportal and single-incision video-assisted thoracic surgery: the state of the art. Interact Cardiovasc Thorac Surg 2014. [Epub ahead of print]. [PubMed]

(译者：汪灏)

（本译文仅供学术交流，实际内容请以英文原文为准。）

Cite this article as: Ng CS. Thoracoscopic sleeve resection—the better approach? J Thorac Dis 2014;6(9):1164-1166. doi: 10.3978/j.issn.2072-1439.2014.07.28

Article Options

Download Citation

Share