Hirata Tomomi, Koizumi Kiyoshi, Tanaka Shigeo
Department of Surgery II, Nippon Medical School, Tokyo, Japan.
Jpn J Thorac Cardiovasc Surg. 2003 May;51(5):178-85. doi: 10.1007/s11748-003-0028-1.
Extended bilateral mediastinal lymphadenectomy (ND3alpha) through median sternotomy for lung cancer has been reported to show longer survival compared to that after ipsilateral mediastinal lymphadenectomy (ND2a) through posterolateral thoracotomy for node-positive lung cancer. However, a high incidence of morbidity or mortality has also been found. The present prospective study was conducted to clarify the influence of this procedure on the hemodynamics as one of the factors influencing postoperative course.
Between December 1999 and January 2001, at the Nippon Medical School Hospital, 10 patients underwent pulmonary resection with ND2a through a posterolateral thoracotomy, while another 10 patients underwent pulmonary resection with ND3alpha through median sternotomy. Changes in the hemodynamics were evaluated preoperatively and at 6, 12, 24 and 48 hours postoperatively.
Those who underwent ND3alpha showed higher peripheral vascular resistance for 24 hours postoperatively resulting from the longer surgery and increased blood loss, than those who underwent ND2a. The pulmonary capillary wedge pressure was elevated in those who underwent ND3alpha comparing to that in those who underwent ND2a. Stroke index decreased in patients who underwent NDalpha comparing to that in those who underwent ND2a. Even though the right ventricular ejection fraction showed minimal change, both the ventricular stroke work indices were depressed at 48 hours postoperatively in patient who underwent ND3alpha.
ND3alpha was concluded to have affected the cardiopulmonary circulation, compared to ND2a, and to be more invasive than ND2a. To perform ND3alpha, preoperative patient selection is an important factor to archive the advantage of increased survival by this procedure.
据报道，与经后外侧开胸行同侧纵隔淋巴结清扫术（ND2a）治疗淋巴结阳性肺癌相比，经正中胸骨切开术行扩大双侧纵隔淋巴结清扫术（ND3α）治疗肺癌的患者生存期更长。然而，也发现该手术的发病率或死亡率较高。本前瞻性研究旨在阐明该手术对血流动力学的影响，这是影响术后病程的因素之一。
1999年12月至2001年1月期间，在日本医科大学医院，10例患者经后外侧开胸行ND2a肺切除术，另外10例患者经正中胸骨切开术行ND3α肺切除术。术前及术后6、12、24和48小时评估血流动力学变化。
与接受ND2a手术的患者相比，接受ND3α手术的患者术后24小时外周血管阻力较高，这是由于手术时间较长和失血量增加所致。与接受ND2a手术的患者相比，接受ND3α手术的患者肺毛细血管楔压升高。与接受ND2a手术的患者相比，接受NDα手术的患者每搏指数降低。尽管右心室射血分数变化极小，但接受ND3α手术的患者术后48小时心室每搏功指数均降低。
与ND2a相比，ND3α对心肺循环有影响，且比ND2a的侵袭性更大。要进行ND3α手术，术前患者选择是通过该手术获得生存获益的重要因素。
