Department of Thoracic Surgery, Henan Provincial Chest Hospital, Chest Hospital of Zhengzhou University, Zhengzhou, 450000, China.
Updates Surg. 2024 Oct;76(6):2321-2327. doi: 10.1007/s13304-024-01826-2. Epub 2024 Apr 4.
Video-assisted thoracic surgery (VATS) has been widely used in lung cancer treatment. However, VATS left upper lobectomy (LUL) is complex due to the intricate branching pattern of the left pulmonary artery (PA). Nevertheless, VATS right upper lobectomy can be simplified through a bronchus-first and simultaneous vessel stapling technique. In this study, the learning curve was obtained while ensuring favorable oncological outcomes using bronchus-first method for VATS LUL. First, retrospective data of 148 consecutive patients who underwent VATS LUL (bronchus-first method) for non-small cell lung cancer (NSCLC) from March 2018 to October 2020 were analyzed. The learning curve was then assessed via cumulative sum (CUSUM) analysis. Moreover, data at different stages of the learning curve, including operation time, blood loss, postoperative hospital stay, lymph node harvested, thoracotomy conversion, postoperative complications, endoscopic stapler consumptions, and 3 year overall survival, were recorded. The learning curve was best modeled as the equation: y = - 7.78 + 2.05x-2.23 × 10x + 6.43 × 10x, with a good-to-fit test R = 0.97. The surgeon entered the proficient stage (59th case-148th case) after consecutive operations of 58 cases (learning stage, 1st case-58th case). Notably, more lymph nodes were harvested in the proficient stage than in the learning stage (17.69 ± 1.47 vs. 15.53 ± 1.43, P < 0.01). Compared with the learning stage, the proficient stage was associated with shorter operation time (114.28 ± 8.56 min vs. 126.81 ± 7.30 min, P < 0.01), fewer blood loss (44.22 ± 7.75 mL vs. 57.41 ± 22.98 mL, P < 0.01), shorter postoperative hospital stay (6.02 ± 0.99 d vs. 7.22 ± 1.34 d, P < 0.01), and fewer endoscopic stapler consumptions (5.89 ± 0.64 vs. 6.53 ± 0.50, P < 0.01). However, thoracotomy conversion (4/90 vs. 5/58, P = 0.32), postoperative complications (10/90 vs. 11/58, P = 0.23) and 3 year overall survival (62.2% vs. 50.8%, log-rank test, P = 0.11) showed no significant difference between the two stages. The surgeon with former single-direction VATS lobectomy experience can master bronchus-first VATS LUL after attending to 58 cases.
视频辅助胸腔镜手术（VATS）已广泛应用于肺癌的治疗。然而，由于左肺动（PA）脉的复杂分支模式，VATS 左上肺叶切除术（LUL）较为复杂。但是，通过支气管优先和同时血管结扎技术，VATS 右上肺叶切除术可以得到简化。在这项研究中，我们使用支气管优先法对非小细胞肺癌（NSCLC）患者进行 VATS LUL ，同时确保了良好的肿瘤学结果，从而获得了学习曲线。首先，分析了 2018 年 3 月至 2020 年 10 月间 148 例连续接受 VATS LUL（支气管优先法）的非小细胞肺癌患者的回顾性数据。然后通过累积和（CUSUM）分析评估了学习曲线。此外，记录了不同学习阶段的手术时间、出血量、术后住院时间、淋巴结采集量、开胸术转换、术后并发症、内镜吻合器消耗以及 3 年总生存率。学习曲线最好用方程表示：y=-7.78+2.05x-2.23×10x+6.43×10x，拟合度良好，R=0.97。连续手术 58 例（学习阶段，第 1 例-第 58 例）后，外科医生进入熟练阶段（第 59 例-第 148 例）。值得注意的是，熟练阶段采集的淋巴结比学习阶段多（17.69±1.47 vs. 15.53±1.43，P<0.01）。与学习阶段相比，熟练阶段的手术时间更短（114.28±8.56 min vs. 126.81±7.30 min，P<0.01），出血量更少（44.22±7.75 mL vs. 57.41±22.98 mL，P<0.01），术后住院时间更短（6.02±0.99 d vs. 7.22±1.34 d，P<0.01），内镜吻合器消耗更少（5.89±0.64 vs. 6.53±0.50，P<0.01）。但是，开胸术转换（4/90 例 vs. 5/58 例，P=0.32）、术后并发症（10/90 例 vs. 11/58 例，P=0.23）和 3 年总生存率（62.2% vs. 50.8%，log-rank 检验，P=0.11）在两个阶段之间无显著差异。具有单一方向 VATS 肺叶切除术经验的外科医生在完成 58 例手术后，可以掌握支气管优先 VATS LUL。
