CT三维重建肺血管支气管辅助单孔胸腔镜肺叶切除术的学习曲线分析

doi:10.3760/cma.j.cn101202-20190211-00050

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摘要目的探讨CT三维重建肺叶血管、支气管影像解剖辅助单孔胸腔镜 (U-VATS) 肺叶切除术治疗可切除肺癌的学习曲线。方法回顾性分析2017年1月—2019年1月在徐州市中心医院由同一治疗组开展的59例经肋间U-VATS肺叶切除治疗的肺癌患者资料。其中男32例,女27例;年龄34～81(62.8±9.5)岁。依据手术的时间顺序分为A组(15例)、B组(15例)、C组(15例) 和D组 (14例)。术前应用OsiriX软件将患者薄层CT数据进行支气管、肺血管三维成像 (3D-CTBA),观察拟切除肺叶的动脉、静脉与支气管的分支数量、走行情况,并模拟肺叶切除。根据术前模拟的切除计划,行U-VATS肺叶切除与肺门、纵隔系统性淋巴结清扫术。分析患者手术时间、术中出血量、淋巴结清扫范围、胸腔引流管留置时间与总引流量、并发症发生率、术后第14天疼痛视觉模拟评分(VAS)与术后住院时间等参数。依据手术时间与术中出血量绘制学习曲线,并应用累积求和法(CUSUM)分析跨越学习曲线需要的最低手术操作例数。结果 3D-CTBA显示,本组59例中,12例 (20.3%) 有肺动、静脉分支与支气管走行变异。1例支气管动脉损伤、出血,无中转开胸或死亡病例。各组术中出血、淋巴结清扫站数和个数、更改术式的比例、并发症率、胸腔引流管留置时间、术后住院时间等差异均无统计学意义(P值均＞0.05)。A、B、C、D 4组手术时间分别为(130.7±17.7)min、(103.7±11.1)min、(87.7±5.9)min、(88.9±6.3)min,住院时间分别为(4.5±3.0)d、(3.8±2.2)d、(2.5±1.0)d、(2.5±0.8)d;4组间比较差异均有统计学意义(F=45.807、3.530,P值均＜0.05),其中C、D组患者手术时间明显少于A、B组(P值均＜0.05),而C、D组之间差异无统计学意义(P＞0.05)。全组患者均获随访,随访时间6～30个月,平均22个月。随访期间患者无肿瘤复发或转移。以手术时间、术中出血量为指标绘制学习曲线,散点图拟合模型方程:Ŷ_手术时间=127.7+0.8X-0.1X²+1.4e^-3X³,R²=0.705;Ŷ_出血量=84.6 - 2.5logX,R²=0.019。CUSUM拟合模型方程:Ŷ_{手术时间cusum}=37.2+2.3X-0.2X²+2.8e^-3X³,R²=0.701;Ŷ_{出血量cusum}=19.3-2.8X+9.5e^-2X²-9.1e^-4X³,R²=0.090。学习曲线评价结果提示,经过约30例的临床实践后,出血量趋于稳定,手术时间达到低点且趋于稳定。结论 3D-CTBA辅助U-VATS肺叶切除术的学习曲线约30例。利用3D-CTBA精准的术前切除模拟,可能有助于降低血管损伤风险,缩短手术时间,帮助培训医师缩短学习曲线。

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	王其斌

关键词 ：胸外科手术,电视辅助, 肺切除术, 支气管, 肺动脉, 肺静脉, 成像,三维

Abstract：Objective To explore the learning curve of lobectomy by uniportal video-assisted thoracoscopic surgery (U-VATS) assisted with three-dimensional computed tomography (3D-CT) reconstruction of the pulmonary vessels and bronchus for resectable lung cancer.Methods A retrospective cohort study was conducted. The data of 59 lung cancer patients undergoing intercostal U-VATS lobectomy by the same surgeon team in Xuzhou Central Hospital between January 2017 and January 2019 were retrospectively reviewed. This study consisted of 32 male and 27 female patients with the age of 34-81 (62.8±9.5) years. The patients were divided into subgroups of A (15 cases), B (15 cases), C (15 cases) and D (14 cases) according to the order of surgery. Preoperative 3D-CT bronchography and angiography (3D-CTBA) were performed by OsiriX software using thin-slice CT data for each patient, with the aim to observe the numbers and drainage of pulmonary arteries, veins, and bronchus branches, followed by lobectomy simulation. Then, U-VATS lobectomy and systemic lymphadenectomy of hilar and mediastinum were performed according to the previous surgical plan. The operative time, intraoperative blood loss, stations and numbers of dissected lymph nodes, rate of transfer to multi-port VATS or thoracotomy, chest tube duration and total drainage volume, complication rate, visual analog scale (VAS) of pain on the 14th postoperative day, and hospital stay were compared, respectively. Cumulative sum (CUSUM) analysis of the operation time and blood loss was utilized to verify the number of operation cases needed for the stabilization of the learning curve.Results The 3D-CTBA indicated 12 cases (20.3%, 12/59) had variation in pulmonary arteries, veins or bronchus. No thoracotomy, massive hemorrhage, or mortality was observed in this cohort. One case in group B reported an injury of bronchial artery. These groups indicated similar intraoperative blood loss, stations and numbers of harvested lymph nodes, conversion rate of surgical approaches, complications, chest drainage duration, and postoperative hospital stay (all P values>0.05, respectively). The operation time of the group A, B, C, D was (130.7±17.7) min, (103.7±11.1) min, (87.7±5.9) min, (88.9±6.3) min, respectively. Meanwhile, the postoperative hospital stays of these subgroups was (4.5±3.0) d, (3.8±2.2) d, (2.5±1.0) d, (2.5±0.8) d, respectively. The differences of these parameters between the four groups were statistically significant (F=45.807、3.530, all P values＜0.05). The operation time of group C and D was significantly shorter than that of group A and B (P＜0.05), whereas there was no significant difference between group C and D(P＞0.05). All the patients were followed up for 6-30 (average, 22) months. During the follow-up, there were no recurrence or metastasis of the tumor during the radiological exams. The learning curve was drawn with the operation time and intraoperative blood loss as indicators, and the fitting formula of the scatter plot were as follows: Ŷ_{operation time}=127.7+0.8X-0.1X²+1.4e^-3X³, R²=0.705; Ŷ_{blood loss}=84.6 - 2.5logX, R²=0.019. Accordingly, the CUSUM fitting formulae were as follows: Ŷ_{operation time cusum}=37.2+2.3X-0.2X²+2.8e^-3X³, R²=0.701; Ŷ_{blood loss cusum}=19.3-2.8X+9.5e^-2X²-9.1e^-4X³, R²=0.090.Conclusions The learning curve of U-VATS lobectomy assisted with 3D-CTBA is about 30 cases. Preoperative resection simulation using 3D-CTBA might be helpful to reduce the risk of vascular injury, shorten the operation time and the learning curve of the doctors.

Key words： Thoracic surgery, video-assisted Pneumonectomy Bronchus Pulmonary artery Pulmonary veins Imaging, three-dimensional

收稿日期: 2019-02-11

通讯作者: 王其斌,Email:340324925@qq.com

引用本文:

张淼, 武文斌, 杨敦鹏, 张辉, 胡正群, 刘冬, 李敏, 王其斌. CT三维重建肺血管支气管辅助单孔胸腔镜肺叶切除术的学习曲线分析[J]. 中华解剖与临床杂志, 2020, 25(4): 393-400.
Zhang Miao, Wu Wenbin, Yang Dunpeng, Zhang Hui, Hu Zhengqun, Liu Dong, Li Min, Wang Qibin. The learning curve of uniportal video-assisted thoracoscopic lobectomy assisted with the three-dimensional CT reconstruction of the pulmonary vessels and bronchus. Chinese Journal of Anatomy and Clinics, 2020, 25(4): 393-400.

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http://www.cjac.com.cn/CN/10.3760/cma.j.cn101202-20190211-00050 或 http://www.cjac.com.cn/CN/Y2020/V25/I4/393

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