目的 探讨单孔胸腔镜下前纵隔支气管囊肿切除的治疗效果。 方法 回顾性分析 2009 年 3 月至 2015 年 4 月我院 26 例前纵隔支气管囊肿患者的临床资料，其中男 17 例、女 9 例，平均年龄 32.4（25～51）岁。均行单孔胸腔镜手术治疗，分析其临床症状、影像学特点及手术疗效。 结果 本组 26 例患者平均手术时间 62.0（48～110）min，平均出血量 98.4（60～120）ml，术后平均住院时间 8.7（6～12）d。术后 25 例患者无手术并发症，1 例术后因不配合主动咳嗽，出现肺不张及胸腔积液，给予调整胸腔引流管，加强咳嗽后恢复良好。术后平均随访 9.6（1～18）个月，复查 CT 均无复发。 结论 前纵隔支气管囊肿难以根据影像学诊断，最终需术后病理检查确诊。单孔胸腔镜手术可作为治疗前纵隔支气管囊肿首选方法。
Objective To compare the differences in the application of ultrasound scalpel and coagulation hook in thoracoscopic anterior mediastinal tumor surgery and to analyze the respective advantages and indications of the two commonly used energy instruments. Methods The clinical data of 85 patients undergoing thoracoscopic anterior mediastinal tumor surgery in West China Hospital of Sichuan University between June and November in 2017 were prospectively analyzed. There were 45 males and 40 females at age of 50.45 (18–75) years. The patients were divided into three groups including a ultrasound scalpel group (59 patients), a coagulation hook group (17 patients) and a mixed group (9 patients) according to the using time of energy devices. The clinical effect among the three groups were compared. Results No significant difference was found among the three groups in operation time, blood loss, average duration of chest tube drainage or volume of drainage (P>0.05). No significant complications occurred in all groups during operation or after operation. The proportion of subxiphoid approach in the ultrasound scalpel group was higher than that in the other two groups (49/59vs. 7/17 vs. 5/9, P<0.01). The maximum diameter of the tumor (4.58±2.19 cmvs. 4.05±1.07 cm vs. 3.00±1.45 cm, P<0.05) and the resected tissue weight (103.67±74.78 gvs. 61.17±31.97 g vs. 61.86±34.13 g, P<0.05) were also significantly greater than that in the coagulation hook group or the mixed group. Conclusion Ultrasound scalpel has good safety and reliability in the thoracoscopic anterior mediastinal tumor surgery, and is more suitable for operation in a narrow space.
Objective To evaluate the clinical outcomes of harmonic scalpel in subxiphoid and subcostal arch approach for resection of anterior mediastinal lesion. Methods We retrospectively analyzed the clinical data of 217 patients with anterior mediastinal lesion at the Department of Thoracic Surgery of Tangdu Hospital of the Fourth Military Medical University from June 2015 to June 2017, among whom 162 underwent thoracoscopic surgery via subxiphoid and subcostal arch approach with harmonic scalpel (a harmonic scalpel group, 95 males and 67 females at an average age of 46.2±18.7 years ranging from 22 to 72 years) and 55 with Ligasure (a Ligasure group, 29 males and 26 females at an average age of 47.7±12.9 years ranging from 31 to 68 years). Operation time, intraoperative blood loss, intraoperative conversion rate, postoperative hospital stay, patients satisfaction score, patients pain score and postoperative complications were compared between both groups. Results All operations were accomplished successfully, and there was no death or conversion to thoracotomy. There was a statistical difference in operation time (58.6±34.8 min vs. 72.8±32.6 min, P=0.01), and intraoperative blood loss (36.2±18.7 ml vs. 41.9±12.9 ml, P=0.04). There was no statistical difference between the two groups in length of hospital stay (4.2±2.6 d vs. 4.5±1.9 d, P=0.36), pain score at postoperative day 1, 3 and 30 (8.3±0.9 vs. 8.5±0.6, P=0.13; 6.4±1.5 vs. 6.9±1.1, P=0.19; 1.3±0.7 vs. 1.4±0.9, P=0.40), patients’ satisfaction score (8.6±1.2 vs. 8.4±1.7, P=0.34), or incidence of postoperative complications (5.6% vs. 9.1%, P=0.35). Conclusion Harmonic scalpel plays an important role in resection of anterior mediastinal lesion via subxiphoid and subcostal arch approach. All tissues are separated and blood vessels are dissected only by the harmonic scalpel, so it is very important for us to handle the harmonic scalpel skillfully.
ObjectiveTo investigate the safety and feasibility of thoracoscopic surgery of anterior mediastinal tumors via subxiphoid approach under scissors position (SASP) and lateral thoracic approach under lateral position (LALP).MethodsClinical data of 69 patients who received anterior mediastinal tumor excision surgery in our hospital from June 2016 to November 2019 were retrospectively analyzed, including 32 males and 37 females with an average age of 46.38±11.52 years. The clinical effects of the two groups were compared.ResultsThere was no perioperative death or conversion to thoracotomy. There was no statistically significant difference between the two groups in the operative time (123.34±12.64 min vs. 125.05±17.02 min, P=0.642), intraoperative blood loss [50.00 (73.75) mL vs. 50.00 (80.00) mL, P=0.643], tumor diameter (2.75±0.57 cm vs. 2.89±0.45 cm, P=0.787) and total hospital expenses [32.70 (5.30) thousand yuan vs. 32.90 (4.80) thousand yuan, P=0.923]. However, the postoperative catheterization time [2.00 (1.00) d vs. 4.00 (1.50) d, P=0.000], postoperative drainage [260.00 (200.00) mL vs. 400.00 (225.00) mL, P=0.031], postoperative pain index [2.00 (1.00) points vs. 4.00 (2.00) points, P=0.000], postoperative analgesic time [1.50 (1.00) d vs. 3.00 (2.00) d, P=0.000], postoperative fever time [1.50 (1.00) d vs. 2.00 (1.00) d, P=0.000] in the SASP group were better than those in the LALP group.ConclusionThoracoscopic surgery via SASP is more suitable for the treatment of anterior mediastinal tumor with rapid postoperative recovery and reduced pain, and the postoperative curative effect is definite. However, there is a high requirement for the surgical experience and techniques. It can be promoted in the clinic.
ObjectiveTo investigate the safety and feasibility of laryngeal mask general anesthesia as a replacement of tracheal intubation general anesthesia in the "three-port" thoracoscopic thymectomy via subxiphoid and subcostal arch for thymoma patients without myasthenia.MethodsFrom January 2018 to June 2019, clinical data of patients with thymoma who underwent the novel "three-port" operation in our institution were analyzed retrospectively. The patients were divided into two groups according to the anesthesia methods, including a tracheal intubation general anesthesia group and a laryngeal mask general anesthesia group. There were 70 patients in the tracheal intubation general anesthesia group, including 42 males and 28 females, with an average age of 45.83±15.89 years. There were 39 patients in the laryngeal mask general anesthesia group, including 26 males and 13 females, with an average age of 43.31±15.64 years. The clinical data of the two groups were compared.ResultsThe baseline characteristics of the patients in the two groups were well balanced (P>0.05). No massive bleeding, conversion to thoracotomy, postoperative myasthenia or death occurred in those patients. No patient with laryngeal mask anesthesia had a conversion to tracheal intubation anesthesia during the operation. There was no significant difference in the operation time, intraoperative bleeding, intraoperative maximum partial pressure of CO2, lowest partial pressure of oxygen and anesthesia effect score between the two groups (P>0.05). There was also no statistical difference in postoperative aspiration, gastrointestinal discomfort, length of hospital stay, pain score and patient satisfaction degree between the two groups (P>0.05). However, the anesthesia time before operation and the time of awake after anesthesia in the laryngeal mask anesthesia group were significantly shorter than those in the tracheal intubation general anesthesia group (P<0.05), and the incidence of transient arrhythmia, laryngeal discomfort and hoarseness in the laryngeal mask general anesthesia group was significantly lower than that in the tracheal intubation general anesthesia group (P<0.05).ConclusionThe "three-port" thoracoscopic thymectomy via subxiphoid and subcostal arch under laryngeal mask general anesthesia is safe and feasible in the treatment of thymoma without myasthenia, and can be recommended routinely.
Objective To compare the safety and efficacy of the subxiphoid robot-assisted thoracoscopic surgery (SRATS) and intercostal robot-assisted thoracoscopic surgery (IRATS) for the treatment of anterior mediastinal tumors. Methods The clinical data of patients who received robot-assisted anterior mediastinal tumor resection in the same medical unit of the Department of Thoracic Surgery of Gansu Provincial Hospital from May 2020 to July 2022 were retrospectively collected. The patients were divided into a SRATS group and an IRATS group according to the surgical procedure. The perioperative data of patients were compared between the two groups. Results Finally 87 patients were collected, including 41 in the SRATS group (23 males and 18 females, mean age of 44.51±11.28 years) and 46 in the IRATS group (21 males and 25 females, mean age of 46.67±8.76 years). All 87 patients completed the surgery successfully. Compared with IRATS group, SRATS group had less intraoperative blood loss (24.41±6.67 mL vs. 37.93±9.23 mL, P=0.000), shorter postoperative catheterization time (1.73±0.59 d vs. 2.54±0.50 d, P=0.000), less postoperative drainage (94.46±34.08 mL vs. 116.72±24.90 mL, P=0.001), lower visual analogue score (VAS) on the first postoperative day (3.66±0.76 points vs. 4.15±0.84 points, P=0.005) and third postoperative day (2.41±0.59 points vs. 2.89±0.82 points, P=0.003), shorter postoperative hospital stay (4.12±0.81 d vs. 4.98±1.02 d, P=0.000) and lower hospitalization costs (45.1±6.5 thousand yuan vs. 48.6±6.8 thousand yuan, P=0.020). There was no significant difference in the operation time or the incidence of postoperative complications. Conclusion Both SRATS and IRATS have high safety and efficacy in the treatment of anterior mediastinal tumors. However, SRATS has less damage, which is more conducive to the rapid recovery of patients after surgery, and has a wide prospect of clinical application.
Objective To compare the safety and efficacy of the da Vinci robot and thoracoscopic subxiphoid approach for the treatment of anterior mediastinal tumors. Methods The clinical data of patients who underwent anterior mediastinal tumor resection through the subxiphoid approach admitted to the same medical group in the Department of Thoracic Surgery of the First Hospital of Lanzhou University between June 2020 and April 2022 were retrospectively analyzed. According to the surgery approach, the patients were divided into a robot-assisted thoracoscopic surgery (RATS) group and a video-assisted thoracoscopic surgery (VATS) group. The perioperative data and the incidence of postoperative complications were compared between the two groups. ResultsA total of 79 patients were enrolled. There were 41 patients in the RATS group, including 13 males and 28 females, with an average age of 45.61±14.99 years. There were 38 patients in the VATS group, including 14 males and 24 females, with an average age of 47.84±15.05 years. All patients completed the surgery successfully. Hospitalization cost and operative time were higher or longer in the RATS group than those in the VATS group, and the difference was statistically significant (P<0.05). Intraoperative bleeding, postoperative hospital stay, postoperative water and food intake time, postoperative off-bed activity time, white blood cell count, neutrophil percentage and visual analogue scale (VAS) score on the first postoperative day, white blood cell count and neutrophil percentage on the third postoperative day, duration of analgesic pump use, the number of voluntary compressions of the analgesic pump, and mediastinal drainage volume were all superior to those in the VATS group (P<0.05). The differences in VAS scores on the third postoperative day, duration of drainage tube retention and postoperative complication rates were not statistically different between the two groups (P>0.05). Conclusion RATS subxiphoid anterior mediastinum tumor resection is a safe and feasible surgical method with less injury and higher safety, which is conducive to rapid postoperative recovery and has wide clinical application prospects.
ObjectiveTo explore the clinical efficacy of two procedures in thoracoscopic anterior mediastinal tumor resection. MethodsA 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. ResultsA total of 55 patients were included, including 27 males and 28 females with a mean age of 47.5 (21-72) 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 myasthenia gravis 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. ConclusionThe modified approach is safe and controllable with more open surgical field and more reliable complete resection range than the classic subxiphoid approach group.
ObjectiveTo introduce an innovative technique, the "balance-shaped sternal elevation device" and its application in the subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for anterior mediastinal masses resection. MethodsPatients who underwent single-port thoracoscopic assisted anterior mediastinal tumor resection through the xiphoid process at the Department of Thoracic Surgery, West China Hospital, Sichuan University from May to June 2024 were included, and their clinical data were analyzed. ResultsA total of 7 patients were included, with 3 males and 4 females, aged 28-72 years. The diameter of the tumor was 1.9-17.0 cm. The operation time was 62-308 min, intraoperative blood loss was 5-100 mL, postoperative chest drainage tube retention time was 0-9 days, pain score on the 7th day after surgery was 0-2 points, and postoperative hospital stay was 3-12 days. All patients underwent successful and complete resection of the masses and thymus, with favorable postoperative recovery. ConclusionThe "balance-shaped sternal elevation device" effectively expands the retrosternal space, providing surgeons with satisfactory surgical views and operating space. This technique significantly enhances the efficacy and safety of minimally invasive surgery for anterior mediastinal masses, reduces trauma and postoperative pain, and accelerates patient recovery, demonstrating important clinical significance and application value.
Objective To systematically evaluate the difference in clinical outcomes between subxiphoid video-assisted thoracoscopic surgery (SVATS) and intercostal video-assisted thoracoscopic surgery (IVATS) for anterior mediastinal tumor resection. Methods Online databases including The Cochrane Library, PubMed, EMbase, Web of Science, Sinomed, CNKI, Wanfang from inception to December 19, 2022 were searched by two researchers independently for literature comparing the clinical efficacy of SVATS and IVATS in treating anterior mediastinal tumors. Two researchers independently screened literature and extracted relevant data. The quality of the included literature was evaluated using the Newcastle-Ottawa Scale (NOS). The meta-analysis was performed by RevMan 5.3. ResultsA total of 12 studies with 1 517 patients were enrolled. NOS score≥6 points. The results of meta-analysis showed that compared with the IVATS, SVATS had less blood loss (MD=−17.76, 95%CI −34.21 to −1.31, P=0.030), less total postoperative drainage volume (MD=−70.46, 95%CI −118.88 to −22.03, P=0.004), shorter duration of postoperative drainage tube retention (MD=−0.84, 95%CI −1.57 to −0.10, P=0.030), lower rate of postoperative lung infections (OR=0.33, 95%CI 0.16 to 0.70, P=0.004), lower postoperative 24 h VAS pain score (MD=−1.95, 95%CI −2.64 to −1.25, P＜0.001) and 72 h VAS pain score (MD=−1.76, 95%CI −2.55 to −0.97, P＜0.001), and shorter postoperative hospital stay (MD=−1.12, 95%CI −1.80 to −0.45, P=0.001). There was no statistical difference in the operation time, the incidence of postoperative complications, incidence of postoperative phrenic nerve palsy or incidence of postoperative arrhythmia (P＞0.05). ConclusionSVATS for the treatment of anterior mediastinal tumors has high safety. Compared with the IVATS, the patients have less intraoperative blood loss and postoperative drainage volume, lower risk of postoperative pulmonary infection, less postoperative short-term pain, and shorter postoperative catheter duration and hospital stay, which is more conducive to rapid postoperative recovery.