Agostini Paula, Lugg Sebastian T, Adams Kerry, Vartsaba Nelia, Kalkat Maninder S, Rajesh Pala B, Steyn Richard S, Naidu Babu, Rushton Alison, Bishay Ehab
Department of Thoracic Surgery, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, UK.
School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK.
Interact Cardiovasc Thorac Surg. 2017 Jun 1;24(6):931-937. doi: 10.1093/icvts/ivx002.
: Video-assisted thoracoscopic surgical (VATS) lobectomy is increasingly used for curative intent lung cancer surgery compared to open thoracotomy due to its minimally invasive approach and associated benefits. However, the effects of the VATS approach on postoperative pulmonary complications (PPC), rehabilitation and physiotherapy requirements are unclear; our study aimed to use propensity score matching to investigate this.
Between January 2012 and January 2016 all consecutive patients undergoing lobectomy via thoracotomy or VATS were prospectively observed. Exclusion criteria included VATS converted to thoracotomy, re-do thoracotomy, sleeve/bilobectomy and tumour size >7 cm diameter (T3/T4). All patients received physiotherapy assessment on postoperative day 1 (POD1), and subsequent treatment as deemed appropriate. PPC frequency was measured daily using the Melbourne Group Scale. Postoperative length of stay (LOS), high dependency unit (HDU) LOS, intensive therapy unit (ITU) admission and in-hospital mortality were observed. Propensity score matching (PSM) was performed using previous PPC risk factors (age, ASA score, body mass index, chronic obstructive pulmonary disease, current smoking) and lung cancer staging.
Over 4 years 736 patients underwent lobectomy with 524 remaining after exclusions; 252 (48%) thoracotomy and 272 (52%) VATS cases. PSM produced 215 matched pairs. VATS approach was associated with less PPC (7.4% vs 18.6%; P < 0.001), shorter median LOS (4 days vs 6; P < 0.001), and a shorter median HDU LOS (1 day vs 2; P = 0.002). Patients undergoing VATS required less physiotherapy contacts (3 vs 6; P < 0.001) and reduced therapy time (80 min vs 140; P < 0.001). More patients mobilized on POD1 (84% vs 81%; P = 0.018), and significantly less physiotherapy to treat sputum retention and lung expansion was required ( P < 0.05).
This study demonstrates that patients undergoing VATS lobectomy developed less PPC and had improved associated outcomes compared to thoracotomy. Patients were more mobile earlier, and required half the physiotherapy resources having fewer pulmonary and mobility issues.
与开胸手术相比，电视辅助胸腔镜手术（VATS）肺叶切除术因其微创方法及相关益处，越来越多地用于肺癌根治性手术。然而，VATS手术方式对术后肺部并发症（PPC）、康复及物理治疗需求的影响尚不清楚；我们的研究旨在使用倾向评分匹配法对此进行调查。
2012年1月至2016年1月期间，对所有连续接受开胸手术或VATS肺叶切除术的患者进行前瞻性观察。排除标准包括VATS中转开胸、再次开胸、袖状/双肺叶切除术以及肿瘤直径>7 cm（T3/T4）。所有患者在术后第1天（POD1）接受物理治疗评估，并根据情况进行后续治疗。使用墨尔本组量表每日测量PPC发生频率。观察术后住院时间（LOS）、高依赖病房（HDU）住院时间、重症监护病房（ITU）收治情况及院内死亡率。使用先前的PPC危险因素（年龄、美国麻醉医师协会评分、体重指数、慢性阻塞性肺疾病、当前吸烟情况）和肺癌分期进行倾向评分匹配（PSM）。
4年间，736例患者接受了肺叶切除术，排除后剩余524例；252例（48%）开胸手术和272例（52%）VATS手术病例。PSM产生了215对匹配病例。VATS手术方式与较少的PPC相关（7.4%对18.6%；P<0.001），中位LOS较短（4天对6天；P<0.001），中位HDU住院时间较短（1天对2天；P = 0.002）。接受VATS手术的患者需要的物理治疗接触次数较少（3次对6次；P<0.001），治疗时间缩短（80分钟对140分钟；P<0.001）。更多患者在POD1时能够活动（84%对81%；P = 0.018），治疗痰液潴留和肺扩张所需的物理治疗显著减少（P<0.05）。
本研究表明，与开胸手术相比，接受VATS肺叶切除术的患者发生的PPC较少，相关结局得到改善。患者更早能够活动，并需要一半的物理治疗资源，肺部和活动问题较少。
