背景:先前切除同一肺叶后的完全肺叶切除术(CL)可能会并发严重的胸膜或肺门粘连。在这种情况下,从未评估过单通道电视辅助胸腔镜手术(U-VATS)的作用。
方法:数据来自两个意大利中心。2015年至2022年,122名患者(60名男性和62名女性,中位年龄67.7±8.913)在先前的肺部手术后至少4周接受了U-VATSCL。
结果:28例(22.9%)患者患有慢性阻塞性肺疾病(COPD),25例(20.4%)积极吸烟者。在队列中,初次手术使用U-VATS对103例(84.4%)患者进行,三门户-VATS在8个(6.6%),开胸11例(9.0%)。解剖节段切除术是46例(37.7%)患者的初始手术,肺门淋巴结清扫术16例(13.1%)。对110例(90.2%)患者进行CL,10例段切除术(8.2%),2例完成全肺切除术(1.6%)。再次操作时,38例(31.1%)患者出现中度胸膜粘连,2(1.6%)表现出强粘连。18例(14.8%)患者发现中度肺门粘连,11例(9.0%)发现强烈粘连。中位手术时间为203.93±74.4min。在四名(3.3%)患者中,进行PA录音。一名患者经历了术中出血,不需要转换为开胸手术。三名(2.5%)患者需要转换为开胸手术。术后中位引流时间和术后住院时间分别为5.67±4.44和5.52±2.66天,分别。术后并发症34例(27.9%)。30天死亡率为零。组织学是唯一对术中结果产生负面影响的因素(p=0.000)。在单变量分析中确定为对术后结果产生负面影响的因素是男性(p=0.003),年龄>60岁(p=0.003),COPD(p=0.014),先前开胸手术(p=0.000),先前的S2段切除术(p=0.001),先前的S8节段切除术(p=0.008),手术间隔>5周(p=0.005)。在多变量分析中,只有COPD证实其作为术后并发症的独立危险因素(HR:5.12,95%CI(1.07-24.50),p=0.04)。
结论:U-VATSCL在楔形切除术和解剖节段切除术后似乎是可行和安全的。
BACKGROUND: Completion lobectomy (CL) following a prior resection in the same lobe may be complicated by severe pleural or hilar adhesions. The role of uniportal video-assisted thoracoscopic surgery (U-VATS) has never been evaluated in this setting.
METHODS: Data were collected from two Italian centers. Between 2015 and 2022, 122 patients (60 men and 62 women, median age 67.7 ± 8.913) underwent U-VATS CL at least 4 weeks after previous lung surgery.
RESULTS: Twenty-eight (22.9%) patients were affected by chronic obstructive pulmonary disease (COPD) and twenty-five (20.4%) were active smokers. Among the cohort, the initial surgery was performed using U-VATS in 103 (84.4%) patients, triportal-VATS in 8 (6.6%), and thoracotomy in 11 (9.0%). Anatomical segmentectomy was the initial surgery in 46 (37.7%) patients, while hilar lymphadenectomy was performed in 16 (13.1%) cases. CL was performed on 110 (90.2%) patients, segmentectomy on 10 (8.2%), and completion pneumonectomy on 2 (1.6%). Upon reoperation, moderate pleural adhesions were observed in 38 (31.1%) patients, with 2 (1.6%) exhibiting strong adhesions. Moderate hilar adhesions were found in 18 (14.8%) patients and strong adhesions in 11 (9.0%). The median operative time was 203.93 ± 74.4 min. In four (3.3%) patients, PA taping was performed. One patient experienced intraoperative bleeding that did not require conversion to thoracotomy. Conversion to thoracotomy was necessary in three (2.5%) patients. The median postoperative drainage stay and postoperative hospital stay were 5.67 ± 4.44 and 5.52 ± 2.66 days, respectively. Postoperative complications occurred in 34 (27.9%) patients. Thirty-day mortality was null. Histology was the only factor found to negatively influence intraoperative outcomes (p = 0.000). Factors identified as negatively impacting postoperative outcomes at univariate analyses were male sex (p = 0.003), age > 60 years (p = 0.003), COPD (p = 0.014), previous thoracotomy (p = 0.000), previous S2 segmentectomy (p = 0.001), previous S8 segmentectomy (p = 0.008), and interval between operations > 5 weeks (p= 0.005). In multivariate analysis, only COPD confirmed its role as an independent risk factor for postoperative complications (HR: 5.12, 95% CI (1.07-24.50), p = 0.04).
CONCLUSIONS: U-VATS CL seems feasible and safe after wedge resection and anatomical segmentectomy.