Pettiford Brian L, Schuchert Matthew J, Santos Ricardo, Landreneau Rodney J
Heart, Lung, and Esophageal Surgery Institute, Department of Surgery, University of Pittsburgh Medical Center, Suite 715, Professional Office Building 1, UPMC Shadyside Medical Center, 5200 Centre Avenue, Pittsburgh, PA 15232, USA.
Thorac Surg Clin. 2007 May;17(2):175-90. doi: 10.1016/j.thorsurg.2007.03.002.
Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. This anatomic detail makes segmentectomy significantly more challenging than lobectomy. Several principles must be applied when performing segmental lung resection: (1) the surgeon should avoid dissection in a poorly developed fissure, (2) use the transected bronchus as the base of the segmental resection during the division of the lung parenchymal in the intersegmental plane, (3) consider the use of endostapler division of the pulmonary parenchyma to reduce the air leak complications related to "finger fracture" dissection of the intersegmental plane, and (4) consider the use of adjuvant iodine 125 brachytherapy as a means of reducing local recurrence following sublobar resection. Increasing evidence supports the use of anatomic segmentectomy in the treatment of primary lung cancer for appropriately selected patients. This resection approach seems most appropriate in the management of the small (<2 cm in diameter) peripheral stage I NSCLC in which a generous margin of resection can be obtained. Accurate intraoperative nodal staging is important to estimate the relative use of these approaches compared with more aggressive resection and to determine the need for adjuvant systemic therapy if metastatic lymphadenopathy is identified. Future investigations comparing the results of sublobar resection with lobectomy will more clearly define the role of segmentectomy among good-risk patients with clinical stage I NSCLC. At the present time, it seems that sublobar resection is an appropriate therapy for the management of stage I NSCLC identified in the elderly patient, those individuals with significant cardiopulmonary dysfunction, and for the management of peripheral solitary metastatic disease to the lung. Because the primary disadvantage of sublobar resection is that of local recurrence, intraoperative adjuvant iodine 125 brachytherapy may be considered to minimize this local recurrence risk.
肺段切除术需要对肺的三维支气管血管解剖结构有透彻的了解。这种解剖细节使得肺段切除术比肺叶切除术更具挑战性。在进行肺段切除时必须应用几个原则：（1）外科医生应避免在发育不良的裂口中进行解剖；（2）在肺实质段间平面的分割过程中，将切断的支气管作为肺段切除的基底；（3）考虑使用内镜缝合器分割肺实质，以减少与段间平面“手指骨折”解剖相关的漏气并发症；（4）考虑使用辅助碘125近距离放射治疗作为降低肺叶以下切除术后局部复发的一种手段。越来越多的证据支持对适当选择的患者采用解剖性肺段切除术治疗原发性肺癌。这种切除方法似乎最适合于治疗直径小于2cm的外周I期非小细胞肺癌，在此类手术中可获得足够的切缘。准确的术中淋巴结分期对于评估这些方法与更积极的切除相比的相对应用情况以及确定如果发现有转移淋巴结时是否需要辅助全身治疗很重要。未来比较肺叶以下切除与肺叶切除结果的研究将更清楚地界定肺段切除术在临床I期非小细胞肺癌低风险患者中的作用。目前，肺叶以下切除似乎是治疗老年患者、有明显心肺功能障碍的患者以及肺部外周孤立转移瘤的合适治疗方法。由于肺叶以下切除的主要缺点是局部复发，术中可考虑辅助碘125近距离放射治疗以尽量降低这种局部复发风险。
