背景:与开放方法相比,微创食管切除术(MIE)在降低肺部并发症方面具有优势。(1)然而,肺部并发症仍然是食管癌手术切除后最常见的并发症。(2,3)这一前景的目标,随机化,控制,临床试验旨在观察低潮气量(VT)能否进一步减少MIE术后肺部并发症.
方法:在2011年6月至2012年7月期间,共有101例接受MIE的患者在胸腔镜食管切除术期间接受了左肺通气。所有患者在胸腔镜食管癌切除术期间均接受左肺通气。患者被随机分配到低VT(5mL/kg+5cmH2O呼气末正压)保留通气(PV)组(n=53)和常规VT(8mL/kg)控制通气(CV)组(n=48)。在插管时和手术后18小时从通气肺收集肺泡灌洗液,用于分析白细胞介素(IL)-1β,IL-6和IL-8水平。临床特征,包括病人的人口统计,操作功能,和氧合指数的变化,进行记录和分析。确定肺部并发症并进行统计学比较。
结果:两组患者的临床特征和手术特点具有可比性。IL-1β,两组术前肺泡灌洗液中IL-6和IL-8的表达相似。在MIE后18小时,PV组的IL表达明显低于CV组(IL-1β,25.42±31.01vs94.96±118.24pg/mL;IL-6,30.86±75.78vs92.99±72.90pg/mL;IL-8,258.75±188.24vs403.95±151.44pg/mL;所有P<0.05)。CV组术后18小时氧合指数低于PV组(292.85±28.74vs326.35±34.43;P=.046)。观察18例肺部并发症,更频繁地发生在通风侧(右,6例;左,12例)。所有患者均通过保守治疗治愈,无严重后遗症。PV组肺部并发症发生率低于CV组(9.43%vs27.08%;P=.021)。
结论:术中单肺通气导致的肺损伤可能是MIE术后肺部并发症的原因。低VT通气可以减少通气相关的肺部炎症,从而减少MIE后的肺部并发症。进一步研究,基于更大的人口数量,需要确认这些发现。
BACKGROUND: Minimally invasive esophagectomy (MIE) has been advantageous for lowering pulmonary complications compared with open approaches.(1) However, pulmonary complications remain the most common morbidity after surgical resection of esophageal cancer.(2,3) The aim of this prospective, randomized, controlled, clinical
trial was designed to see whether low tidal volume (VT) could further minimize pulmonary complications after MIE.
METHODS: Between June 2011 and July 2012, a total of 101 patients who underwent MIE received left-lung ventilation during thoracoscopic esophagectomy. All patients received left-lung ventilation during thoracoscopic esophagectomy. Patients were randomly assigned to a low VT (5 mL/kg + 5 cm H2O positive end-expiratory pressure) preserved ventilation (PV) group (n = 53) and a conventional VT (8 mL/kg) controlled ventilation (
CV) group (n = 48) in the thoracic stage. Alveolar lavage fluid was harvested from the ventilated lung at intubation and at 18 hours after surgery for analysis of interleukin (IL)-1ß, IL-6, and IL-8 levels. Clinical characteristics, including patient demographics, operation features, and changes in oxygenation index, were recorded and analyzed. Pulmonary complications were identified and statistically compared between the 2 groups.
RESULTS: The clinical characteristics and operation features were comparable between the 2 groups. IL-1ß, IL-6, and IL-8 expressions in preoperative alveolar lavage fluid were similar between the 2 groups. Significantly lower IL expressions were observed in the PV group than those in the
CV group at 18 hours after MIE (IL-1ß, 25.42 ± 31.01 vs 94.96 ± 118.24 pg/mL; IL-6, 30.86 ± 75.78 vs 92.99 ± 72.90 pg/mL; IL-8, 258.75 ± 188.24 vs 403.95 ± 151.44 pg/mL; all P < .05). The 18-hour postoperative oxygenation index was lower in the
CV group than that in the PV group (292.85 ± 28.74 vs 326.35 ± 34.43; P = .046). Pulmonary complications were observed in 18 cases of our series, occurring more frequently on the ventilation side (right, 6 cases; and left, 12 cases). All patients were cured by conservative therapy without severe sequelae. The occurrence of pulmonary complications in the PV group was lower than that in the
CV group (9.43% vs 27.08%; P = .021).
CONCLUSIONS: Lung injury due to intraoperative single-lung ventilation may contribute to pulmonary complications after MIE. Low VT ventilation could decrease ventilation-associated lung inflammation, thus minimizing pulmonary complications after MIE. Further studies, based on a larger volume of populations, are required to confirm these findings.