Homma Takahiro, Shimada Yoshifumi, Tanabe Keitaro, Akemoto Yushi, Ojima Toshihiro, Yamamoto Yutaka, Kitamura Naoya, Yoshimura Naoki
Department of General Thoracic and Cardiovascular Surgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan; Division of Thoracic Surgery, Joetsu General Hospital, Niigata, Japan.
Department of General Thoracic and Cardiovascular Surgery, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan.
Ann Palliat Med. 2021 Mar;10(3):2849-2858. doi: 10.21037/apm-20-1729. Epub 2021 Feb 5.
Whether challenging video-assisted thoracoscopic surgery (VATS) is a minimal invasive surgery remains controversial. This study aimed to analyze causes of challenging conventional multiple-port VATS (CVATS) and conversion to thoracotomy and postoperative pain to provide indications for VATS.
This was a two-center retrospective study. Challenging VATS was defined as CVATS with operation time ≥5 hours and it was converted to thoracotomy. This study included patients who were admitted to Joetsu General Hospital (Joetsu, Niigata, Japan) and Toyama University Hospital (Toyama, Japan) for elective CVATS between April 2013 and March 2019. The exclusion criteria were as follows: a planned thoracotomy, uniportal VATS, robot-assisted thoracoscopic surgery, and simultaneous resection of extrathoracic organs.
A total of 911 (91.6%) patients underwent CVATS. Of these cases, 876 (96.2%) were suitable VATS cases. On the contrary, 35 cases (3.8%) were recognized as challenging VATS. In 21 (2.3%) cases, VATS took ≥5 hours, and 14 (1.5%) VATS cases were converted to thoracotomy. The causes were severe adhesions (62.9%), air leak (45.7%), body position changes (22.9%), large tumor (14.3%), bronchoplasty or angioplasty (8.6%), and bleeding (2.9%). The minimum diameter of large tumors was 61.4 mm (53-67 mm). In 15 (71.4%) patients, VATS took ≥5 hours, and 10 (71.4%) patients who were converted to thoracotomy developed postoperative neuropathic pain.
In this study, VATS ≥5 hours and conversion from VATS to thoracotomy were complicated by postoperative neuropathic pain. In case of bronchoplasty, angioplasty, and large tumor with minimum diameter ≥5 cm, a thoracotomy approach would be appropriate depending on the skill and experience of the surgeon. In cases of local or vascular sheath adhesion, if operation progress is delayed, it may be necessary to set a time limit and decide to convert to thoracotomy, considering patient's safety first.
具有挑战性的电视辅助胸腔镜手术（VATS）是否属于微创手术仍存在争议。本研究旨在分析具有挑战性的传统多端口VATS（CVATS）、中转开胸的原因以及术后疼痛情况，为VATS提供指征。
这是一项两中心回顾性研究。具有挑战性的VATS定义为手术时间≥5小时的CVATS且中转开胸。本研究纳入了2013年4月至2019年3月期间因择期CVATS入住新潟县上越市立综合医院（上越、新潟、日本）和富山大学医院（富山、日本）的患者。排除标准如下：计划开胸手术、单孔VATS、机器人辅助胸腔镜手术以及同期切除胸外器官。
共有911例（91.6%）患者接受了CVATS。其中，876例（96.2%）为合适的VATS病例。相反，35例（3.8%）被认为是具有挑战性的VATS。21例（2.3%）病例中，VATS手术时间≥5小时，14例（1.5%）VATS病例中转开胸。原因包括严重粘连（62.9%）、漏气（45.7%）、体位改变（22.9%）、大肿瘤（14.3%）、支气管成形术或血管成形术（8.6%）以及出血（2.9%）。大肿瘤的最小直径为61.4毫米（53 - 67毫米）。15例（71.4%）患者VATS手术时间≥5小时，10例（71.4%）中转开胸的患者出现了术后神经性疼痛。
在本研究中，VATS手术时间≥5小时以及从VATS中转开胸均伴有术后神经性疼痛。对于支气管成形术、血管成形术以及最小直径≥5厘米的大肿瘤病例，根据外科医生的技术和经验，开胸手术可能更为合适。对于局部或血管鞘粘连的病例，如果手术进展延迟，考虑到患者安全，可能有必要设定时间限制并决定中转开胸。
