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山东大学学报 (医学版) ›› 2022, Vol. 60 ›› Issue (11): 44-53.doi: 10.6040/j.issn.1671-7554.0.2022.0960

• 胸外科肺癌、食管癌微创诊治和加速康复专题 • 上一篇    下一篇

解剖性部分肺叶切除术及围术期加速康复外科的临床综合应用

彭岳1,2,刘雷1,3,李原1,别凤龙1,周博伦1,李润泽1,冀瑛2,白广宇1,谭锋维1,高禹舜1,牟巨伟1,薛奇1,邱斌1,*(),高树庚1,*()   

  1. 1. 国家癌症中心 国家肿瘤临床医学研究中心 中国医学科学院北京协和医学院肿瘤医院胸外科, 北京 100021
    2. 首都医科大学附属北京朝阳医院 北京市呼吸疫病研究所胸外科, 北京 100020
    3. 河北省承德市中心医院/承德医学院第二临床学院, 河北 承德 067000
  • 收稿日期:2022-08-11 出版日期:2022-11-01 发布日期:2022-11-04
  • 通讯作者: 邱斌,高树庚 E-mail:drqiubin@aliyun.com;gaoshugeng@cicams.ac.cn
  • 基金资助:
    国家重点研发计划(2021YFC2500900);国家自然科学基金(82273129);中国医学科学院医学与健康科技创新工程(2021-I2M-1-015);中央保健专项资金(2022ZD17);院所科研课题(LC2019L01)

Comprehensive application of anatomical partial lobectomy and enhanced recovery after surgery

Yue PENG1,2,Lei LIU1,3,Yuan LI1,Fenglong BIE1,Bolun ZHOU1,Runze LI1,Ying JI2,Guangyu BAI1,Fengwei TAN1,Yushun GAO1,Juwei MU1,Qi XUE1,Bin QIU1,*(),Shugeng GAO1,*()   

  1. 1. Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
    2. Department of Thoracic Surgery, Beijing Institute of Respiratory Medicine and Beijing Chao-yang Hospital, Capital Medical University, Beijing 100020, China
    3. Chengde Central Hospital, The Second Clinical College of Chengde Medical University, Chengde 067000, Hebei, China
  • Received:2022-08-11 Online:2022-11-01 Published:2022-11-04
  • Contact: Bin QIU,Shugeng GAO E-mail:drqiubin@aliyun.com;gaoshugeng@cicams.ac.cn

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摘要：

目的: 总结分析解剖性部分肺叶切除术(APL)以及围术期加速康复外科(ERAS)的统筹应用经验，以期为肺癌外科微创治疗的综合管理提供临床参考与理论支持。方法: 回顾性分析中国医学科学院肿瘤医院胸外科肺癌数据库2013年11月1日至2021年10月31日接受APL手术的6 449例患者的临床病理学资料以及围手术期数据，包括性别、年龄、吸烟史、手术方式、病理、术后住院日等指标。以2014—2018年作为经验积累阶段，2019—2021年作为技术成熟阶段。比较两阶段在手术量、良性结节占比、术后平均住院日、术后住院日超7 d的差异。结果: 纳入患者6 449例，其中男2 094例，女4 355例。分期完成两侧肺部手术88台，同期完成双侧手术8台，共完成APL手术6 493台。技术成熟阶段较经验积累阶段的年度月均手术量增加、良性结节占比减少、术后平均住院日缩短、术后住院日超7 d占比减少(P＜0.05)。通过结合ERAS理念优化本中心APL围术期管理细节，成功使得患者术后平均住院日从6.98 d显著降至3.96 d。术后住院日超7 d患者占比由23.80%降至2.87%，多因素Logistic回归分析结果显示性别、年龄、手术术式、手术阶段是APL术后住院日超7 d的独立危险因素。结论: ERAS能够优化APL围术期管理流程，加速患者术后康复。而APL手术可以在保证肿瘤学原则的前提下，为患者保留更多的健康肺组织，实现手术切除范围、手术创伤的最小化，为ERAS理念能够更好地在肺癌根治手术中应用推广提供了必要的临床实践基础。

关键词: 加速康复, 解剖性部分肺叶切除术, 胸腔镜, 肺癌, 肺结节

Abstract:

Objective: To summarize the application of anatomical partial lobectomy (APL) and enhanced recovery after surgery (ERAS) in order to provide clinical reference and theoretical support for the comprehensive management of minimally invasive surgical treatment of lung cancer. Methods: The clinicopathological and perioperative data of 6, 449 patients who underwent APL during Nov. 1, 2013 and Oct. 31, 2021 were retrospectively collected, including gender, age, smoking history, surgical method, pathology, postoperative hospital stay and other indicators. The period from 2014 to 2018 was regarded as the experience accumulation stage, and the period from 2019 to 2021 the technology maturity stage. The number of surgery, percentage of benign nodules, average postoperative hospital stay, and percentage of postoperative hospital stay over 7 days were compared between the two stages. Results: Of the 6, 449 patients, 2, 094 were males and 4, 355 were females. Among them, 88 bilateral lung surgeries were performed in stages, and 8 bilateral surgeries were performed simultaneously, and altogether 6, 493 APL surgeries were performed. Compared with the experience accumulation stage, in the technology maturity stage, the annual average monthly number of operations increased, the percentage of benign nodules decreased, the average postoperative hospital stay shortened, and the percentage of postoperative hospital stay longer than 7 days decreased (P < 0.05). With the application of ERAS from 2014 to 2021, the average annual postoperative hospital stay for APL gradually decreased from 6.98 days to 3.96 days. The percentage of patients with postoperative hospital stay exceeding 7 days decreased from 23.80% to 2.87%. The results of multivariate Logistic regression analysis showed that gender, age, surgical procedure, and surgical stage were independent risk factors for postoperative hospital stay more than 7 days after APL. Conclusion: ERAS can optimize the perioperative management of APL and accelerate postoperative recovery of patients. APL can be performed on the premise of oncology principles, preserve more healthy lung tissue, minimize the scope of surgical resection and surgical trauma, so that the concept of ERAS can be better applied and promoted in radical surgery for lung cancer.

Key words: Enhanced recovery after surgery, Anatomical partial lobectomy, Thoracoscopy, Lung cancer, Pulmonary nodules

中图分类号: 

  • R734.2

图1

结节位于右肺上叶前段(RS3) A：横断位(肺窗)；B：横断位(纵隔窗)；C：矢状位(肺窗)；D：冠状位(肺窗)。"

图2

术前右上肺三维重建规划手术区域 A：右上肺支气管、血管三维重建图像；B：等比例3D打印模型；C：RS3结节安全切缘球(黄)；D：拟切除范围规划(RS3扩大切除)。"

图3

解剖性部分肺叶切除术(RS3扩大切除术) A：清扫10区淋巴结送冰冻病理；B：结扎V3a和V3b+c静脉；C：离断A3动脉；D：离断V1b静脉，暴露B3支气管；E：利用膨胀萎陷法显露切割平面；F：电刀标记切割平面；G：电刀劈开切割平面；H：切割闭合器离断肺组织；I：移除目标肺组织。"

图4

APL术后第1天(POD1)和术后第3天(POD3)胸部正位片"

表1

6 493台次解剖性部分肺叶切除术患者的临床病理学特征"

项目 例数(%)
性别
  男 2 094(32.25)
  女 4 399(67.75)
年龄(岁)
  ≤60 4 322(66.56)
  ＞60 2 171(33.44)
吸烟史
  有 1 170(18.02)
  无 5 323(81.98)
病理类型
  良性 458(7.05)
  转移瘤 110(1.69)
  浸润前病变 1 016(15.65)
  腺癌 4 800(73.93)
  鳞状细胞癌 62(0.95)
  小细胞肺癌 10(0.15)
  其他 37(0.57)
手术方式
  APL±楔形等 6 279(96.70)
  肺叶+APL 214(3.30)
手术阶段
  2014~2018年 1 854(28.55)
  2019~2021年 4 639(71.45)

图5

APL年手术台次趋势(A)及肺良性结节占比趋势(B)"

图6

解剖性部分肺叶切除术后住院日 A：术后年平均住院日变化趋势；B：术后住院日超7 d占比趋势。"

表2

APL术后住院日超7d的单因素分析"

项目 术后住院日[ n(%)] χ2 P
≤7 d ＞7 d
性别
  男 1 972(94.17) 122(5.83) 18.418 ＜0.001
  女 4 244(96.48) 155(3.52)
年龄(岁)
  ≤60 4 171(96.51) 151(3.49) 18.881 ＜0.001
  ＞60 2 045(94.20) 126(5.80)
吸烟史
  有 1 101(94.10) 69(5.90) 9.299 0.002
  无 5 115(96.09) 208(3.91)
手术术式
  APL±楔形等 6 018(95.84) 261(4.16) 5.585 0.018
  肺叶+APL 198(92.52) 16(7.48)
手术阶段
  2014~2018年 1 686(90.94) 168(9.06) 146.107 ＜0.001
  2019~2021年 4 530(97.65) 109(2.35)

表3

APL术后住院日超7 d的多因素Logistic回归分析"

项目 B 标准误 Wald P OR 95%CI
性别 0.540 0.155 12.083 0.001 1.715 1.265~2.325
年龄 0.455 0.127 12.815 0.000 1.576 1.228~2.021
吸烟史 -0.123 0.181 0.462 0.497 0.884 0.621~1.260
手术术式 0.626 0.275 5.175 0.023 1.871 1.091~3.209
手术阶段 -1.419 0.127 124.716 0.000 0.242 0.189~0.310
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