1、海南医学2023年2月第34卷第4期Hainan Med J,Feb.2023.Vol.34,No.4不同入路胸腔镜手术治疗前纵隔肿瘤的临床疗效对比研究刘鹏，郝登荣，彭彦才，席俊峰，张志斌，李伟伟榆林市第一医院胸心外科，陕西榆林719000【摘要】目的比较经剑突下入路胸腔镜与经侧胸入路胸腔镜前纵隔肿瘤切除术的临床治疗效果。方法选取2017年6月至2021年9月在榆林市第一医院拟实施前纵膈肿瘤切除术的患者86例，采用随机数表法分为观察组和对照组各43例。对照组患者予以经侧胸入路胸腔镜治疗，观察组患者予以经剑突下入路胸腔镜治疗。比较两组患者的手术相关指标(术中出血量、手术时间、拔管时间及住院时间)
2、；于手术前后，比较患者的炎症因子水平血清C-反应蛋白(CRP)、白细胞(WBC)和中性粒细胞比例；采用视觉模拟疼痛评分(VAS)评价两组患者术后不同时间的疼痛程度并记录两组患者的并发症发生情况；于术后随访6个月比较两组患者的复发率。结果观察组患者的术中出血量、拔管时间、住院时间分别为(63.477.22)mL、(3.491.03)d、(7.351.24)d，明显少(短)于对照组的(76.397.52)mL、(4.861.09)d、(9.571.37)d，差异均具有统计学意义(P0.05)；观察组患者术后1 d、3 d、5 d的VAS评分分别为(2.540.87)分、(2.010.50)分、(1
3、.370.31)分，明显低于对照组的(3.221.03)分、(2.950.62)分、(2.280.59)分，差异均有统计学意义(P0.05)；术后，观察组患者的CRP、WBC及中性粒细胞比例分别为(8.161.82)mg/L、(8.521.36)109/L、(61.255.33)%，明显低于对照组的(10.891.91)mg/L、(10.431.50)109/L、(70.135.40)%，差异均具有统计学意义(P0.05)；观察组患者的并发症发生率为6.98%，明显低于对照组的23.26%，差异均具有统计学意义(P0.05)。结论经剑突下入路胸腔镜用于前纵隔肿瘤切除术，不仅有助于缩短患者住院时
4、间、拔管时间，降低术中出血量、术后疼痛程度，而且能减轻炎症反应及减少并发症发生风险。【关键词】经剑突下入路；经侧胸入路；胸腔镜；前纵隔肿瘤切除术；疗效；预后【中图分类号】R738【文献标识码】A【文章编号】10036350（2023）04052005Comparative study on the clinical curative effect of thoracoscopic surgery through different approaches onanterior mediastinal tumor.LIU Peng,HAO Deng-rong,PENG Yan-cai,XI Jun
5、-feng,ZHANG Zhi-bin,LI Wei-wei.Department of Cardiothoracic Surgery,the First Hospital of Yulin,Yulin 719000,Shaanxi,CHINA【Abstract】ObjectiveTo compare the clinical curative effect of thoracoscopic anterior mediastinal tumor resec-tion through subxiphoid and lateral thoracic approaches.MethodsA tota
6、l of 86 patients undergoing elective anteriormediastinal tumor resection in the First Hospital of Yulin were enrolled between June 2017 and September 2021.Accord-ing to random number table method,they were divided into an observation group and a control group,with 43 patients ineach group.The patien
7、ts in the control group underwent thoracoscopy through lateral thoracic approach,while those inthe observation group underwent thoracoscopy through subxiphoid approach.The surgical related indexes(intraopera-tive blood loss,operation time,extubation time,length of hospital stay)and changes of inflam
8、matory factors serumC-reactive protein(CRP),white blood cell(WBC),neutrophil ratio before and after surgery were compared between thetwo groups.The postoperative pain degree was evaluated by Visual Analogue Scale(VAS).The occurrence of complica-tions in both groups was recorded.All the patients were
9、 followed up for 6 months after surgery to compare the recur-rence rate in the two groups.ResultsThe intraoperative blood loss,extubation time,and length of hospital stay in theobservation group were(63.477.22)mL,(3.491.03)d,and(7.351.24)d,significantly lower than(76.397.52)mL,(4.861.09)d,(9.571.37)
10、d in the control group(P0.05).At 1 d,3 d,and 5 d after surgery,VAS scores in observationgroup were(2.540.87)points,(2.010.50)points,and(1.370.31)points,significantly lower than(3.221.03)points,(2.950.62)points,(2.280.59)points in the control group(P0.05).After surgery,CRP,WBC,and neutrophils ratioin
11、 the observation group were(8.161.82)mg/L,(8.521.36)109/L,and(61.255.33)%,significantly lower than(10.891.91)mg/L,(10.431.50)109/L,(70.135.40)%in the control group(P0.05).The incidence of complications inthe observation group was significantly lower than that in the control group(6.98%vs 23.26%,P0.0
12、5)，具有可比性，见表1。本研究经医院伦理委员会审核批准。表1两组患者的一般资料比较例(%)，x-sTable 1Comparison of general data between the two groups n(%),x-s组别观察组对照组t/2值P值例数4343年龄(岁)47.713.4547.253.110.6490.518肿瘤直径2.850.462.740.511.0500.297男27(62.79)21(48.84)女16(37.21)22(51.16)1.6970.193胸腺瘤13(30.23)15(34.88)囊肿19(44.19)18(41.86)胸腺增生11(25.58)
13、10(23.26)性别疾病类型0.2180.8971.2手术方法1.2.1对照组该组患者予以经侧胸入路胸腔镜治疗。具体方法：患者采取平卧位，行全身麻醉后采用双腔气管插管，对手术部位常规消毒、铺巾。根据术前影像学肿瘤位置确定手术切口位置，通常在患者左侧或腋中线部位的第45肋骨间做一34 cm的切口作为操作孔，将切口保护套置入其中，然后将腹腔镜、手术相关器械置入胸腔，健侧单肺通气，利用胸腔镜及辅助器械探查胸腔后，使用超声刀或电凝钩将患者肿瘤组织与周围组织的黏性组织予以分离，剥除肿瘤物。仔细检查胸腔及手术创面无活动性出血或渗血后，利用生理盐水冲洗胸腔，将引流管放置在肋间切口处，逐层缝合切口。1.2.
14、2观察组该组患者予以经剑突下入路胸腔镜治疗。具体方法：患者采取仰卧位，将双腿分开呈现为“人”字形，于全身麻醉后进行单腔气管插管，对手术部位常规消毒，铺巾。主刀医生站于患者双腿之间，在剑突下做一1.5 cm的切口，依次剥开皮下组织，在剑突后方将周围皮下疏松组织钝性分离，使用食指将剑突及胸骨周围的组织分离后建立胸骨后隧道，并将其作为观察孔，将 30胸腔镜放置其中。于患者双侧锁骨中线及肋弓下缘处做一0.51 cm的切口作为操作孔，置入5 mm Trocar，放入手术器械，使用超声刀将胸骨后间隙及剑突周围结缔组织予以分离切断进入胸腔内，然后分离胸腔内黏连组织，观察肿瘤大小、位置及其与周围组织的关系。若
15、肿瘤直径较小且与周围组织无黏连，则直接使用超声刀予以分离；若肿瘤与周围组织有黏连，先观察肿瘤与周围血管、组织的关系，然后将肿瘤游离直至边界后将其切除。置入取物袋，将标本放入取物袋后取出标本，待对手术创面彻底止血后，置入胸骨后引流管，并逐层缝合手术切口。两组患者均由同一位医生进行手术操作。1.3观察指标与评价方法(1)手术相关指标：比较两组患者术中出血量、手术时间、拔管时间及住院时间；(2)疼痛程度：于术后1 d、3 d、5 d采用视觉模拟疼痛评分(Visual Analogue Scale，VAS)8评估患者术后疼痛程度，该量表总分为010分，分数越高说明疼痛越严重；(3)炎症因子：于术前1
16、d及术后1 d，抽取P0.05).ConclusionThoracoscopic anterior mediastinal tumor resection through subxiphoid approach is not only ben-eficial to shorten hospitalization time and extubation time,reduce intraoperative blood loss and alleviate postoperativepain,but also can relieve inflammation response and reduce the risk of complications.【Key words】Subxiphoid approach;Lateral thoracic approach;Thoracoscope;Anterior mediastinal tumor resec-tion;Curative effect;Prognosis521海南医学2023年2月第34卷第4期Hainan Med J,Feb.20
