Thoracic surgery is a discipline with a wide spectrum of diseases, high difficulty and high risk of operation, and rapid development of diagnosis and treatment technology. An excellent thoracic surgeon not only needs to master solid theoretical knowledge and excellent clinical skills but also needs to have strong psychological quality and the ability to integrate across disciplines. Therefore, the training period for thoracic surgeons is long and difficult, and standardized and systematic training is particularly important. This article briefly describes the characteristics of the training system for thoracic surgeons and discusses the current challenges faced by the training of thoracic surgeons in China. We hope that it can be used as a reference for the training of thoracic surgeons in China and promote the improvement of the quality of thoracic surgeon training.

食管癌(esophageal cancer,EC)是常见的癌症之一,组织病理类型分为食管鳞状细胞癌和食管腺癌.因确诊晚,并缺乏有效的治疗手段,EC成为世界范围的公共健康问题之一.与常规的肿瘤活检不同,液态活检因损伤性小,可作为传统活检的补充甚至替代方法.尤其是细胞游离DNA(cell-free DNA,cf DNA),在癌症临床管理中已表现出应用前景.cf DNA已成为非侵入性癌症诊断和监测的有效循环分子标志物.虽然很多研究报道了cf DNA在各种癌症中的临床应用,但对其在EC中的作用尚缺乏了解.因此,我们就这一主题进行了综述,并讨论了其在EC诊断和监测中的优势及局限性.

小细胞肺癌(SCLC)是肺癌的一种重要组织学类型,其主要的治疗方案是化疗、放疗、靶向治疗、免疫治疗等,但是当患者从上述辅助治疗方案中的生存获益达到瓶颈时,手术治疗给一些中晚期SCLC患者带来了生存获益,这不同于以往研究中认为的手术治疗多适用于早期SCLC.因此,手术治疗在SCLC治疗中的作用引起学者们的广范关注.本文旨在总结归纳手术治疗在SCLC治疗中的研究进展.

现行的国内外非小细胞肺癌诊疗指南均推荐,在保证切缘阴性的情况下,可以为局部晚期肺癌患者实施全肺切除手术,从而为该类人群带来临床治愈的机会(5年生存率为10.8％～66.0％).但该术式相关的围手术期并发症发生率(3.4％～54.0％)和病死率(3.0％～26.0％)均较高,成为限制其临床广泛开展的重要原因之一.本文将对可耐受全肺切除手术患者选择、围手术期并发症和死亡预防、综合治疗策略制订和胸腔镜下全肺切除手术实践现状进行系统性综述,旨在帮助胸外科医生在临床实践中能够更加安全地开展全肺切除手术,最终达到改善局部晚期肺癌患者长期生存的目的 .

Objective:To investigate the expression of lncRNA GPC3-AS1 in non-small cell lung cancer (NSCLC) and its effects on the proliferation, migration and invasion of A549 cells.Methods:qPCR was used to detect the expression of lncRNA GPC3-AS1 in non-small cell lung cancer tissues and cells. Then, lncRNA GPC3-AS1 siRNA and its control siRNA were transferred into A549 cells. qPCR was used to detect the change in lncRNA GPC3-AS1 expression; MTT assay was used to examine the cell proliferation; scratch test was used to measure the cell migration; Transwell assay was used to measure cell invasion, and Western blotting was used to detect the expression of PI3K/Akt signaling pathway proteins in cells.Results:Compared with NSCLC-adjacent tissues and human lung epithelial cells BEAS-2B, the expression of lncRNA GPC3-AS1 in NSCLC tissues and HCC827, H1650, and A549 cells was significantly increased ( P<0.05) . The expression of lncRNA GPC3-AS1 in NSCLC tissues was not related to gender, age, pathology and differentiation, but was significantly related to TNM staging, tumor size, and lymph node metastasis ( P<0.05) . Compared with the silenced control group, the expression of lncRNA GPC3-AS1 in A549 cells in the GPC3-AS1-silenced group was significantly reduced ( P<0.05) , and the ability of cell proliferation, migration and invasion was also significantly reduced ( P<0.05) . The expressions of PI3K/Akt signaling pathway proteins p-PI3K, p-Akt and its downstream proteins Cyclin D1 and P70S6K in the cells of GPC3-AS1-silenced group and inhibitor group were significantly lower than those in the silenced control group and the control group ( P<0.05) . Conclusion:LncRNA GPC3-AS1 is highly expressed in NSCLC. Silencing LncRNA GPC3-AS1 can inhibit the proliferation, migration and invasion of NSCLC cells. The mechanism may be related to inhibition of PI3K/Akt signaling pathway.

肺癌一直是严重危害国民健康的恶性肿瘤之一,肺叶切除术一直是治疗早期肺癌的经典术式.随着外科手术技术的不断进展和微创外科技术的飞速发展,越来越多的早期肺癌被发现并接受有效治疗,肺段切除术不仅可以完整地切除肿瘤组织,还可以保护患者的肺功能,逐渐受到研究者的关注,但同时由于缺乏充分的循证医学证据支持,这项新技术的开展和推广也受到了一些质疑.本文对肺癌肺段切除术的应用基础、技术难点、操作方法及存在的争议进行介绍和总结.

食管胃交界部腺癌(adenocarcinoma of esopha-gogastric junction,EGJ)在国内传统上常常称为贲门癌.因其解剖位置的特殊性,虽然在肿瘤的命名、手术入路、消化道重建方式及淋巴结清扫范围等方面达成了诸多共识,但一直以来也存在较多争议.我们通过分析各学会最新的指南与分期系统,结合最新文献,探讨目前 EGJ外科治疗中的争议与共识.

[目的]探讨食管癌根治术后颈部吻合口瘘的独立危险因素.[方法]回顾性分析930例接受食管癌根治术并行颈部吻合患者的临床病理资料.详细记录患者各项围术期指标,分析患者发生颈部吻合口瘘的危险因素.[结果]患者颈部吻合口瘘的发生率为16.1％(150/930),颈部吻合口瘘相关死亡率为0.6％.单因素分析结果显示,一秒用力呼气容积与用力肺活量比值、一氧化碳弥散量占预计值比值、胸部手术史、腹部疾病史、慢性阻塞性肺疾病、外周血管疾病史、胰岛素使用、美国麻醉医师协会(ASA)分级、降主动脉钙化、腹腔干钙化、肝动脉钙化、术后使用呼吸机、二次开胸、呼吸衰竭、术后声嘶均与食管癌术后发生颈部吻合口瘘相关(P＜0.05).多因素Logistic分析结果显示一氧化碳弥散量占预计值比值、腹部疾病史、外周血管疾病史、降主动脉钙化以及术后使用呼吸机为食管癌术后发生颈部吻合口瘘的独立危险因素(P＜0.05).[结论]食管癌根治术后颈部吻合口瘘的发生和多种因素密切相关,关注这些因素并做好围术期管理,可减少颈部吻合口瘘发生,避免出现严重的术后并发症.

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH(2)O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre-and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.

Methyltransferase like 3 (METTL3) was incipiently known as a methyltransferase which was responsible for N6-methyladenosine (m6A) methylation. METTL3 can promote the expression of several crucial oncoproteins and its high expression enhanced proliferation, survival, and invasion of human lung cancer cells. However, how METTL3 was regulated is seldom understood in non-small-cell lung carcinoma (NSCLC). In the present study, miR-33a was suspicious to target to the 3'-untranslated region (3'UTR) of METTL3 mRNA via in silico prediction. Besides, the expressions of METTL3 were higher in NSCLC tissues than those in adjacent tissues, and METTL3 expressions were positively related to the expressions of miR-33a in NSCLC tissues which confirmed by quantitative real-time polymerase chain reaction (qRT-PCR). MiR-33a can directly target to the 3'UTR of METTL3 mRNA which examined by luciferase reporter gene assay. Moreover, we found that miR-33a can reduce the expression of METTL3 at both mRNA and protein levels using reverse transcription-polymerase chain reaction (RT-PCR) and Western blot analysis. Functionally, miR-33a can reduce the proliferation of A549 and NCI-H460 cells. Conversely, inhibition of miR-33a by anti-miR-33a can rescue that using 4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2-H-tetrazolium bromide (MTT) and 5-ethynyl-2-deoxyuridine (EdU) assay. Similarly, miR-33a can reduce cellular anchorage-independent growth of A549 cells. Additionally, the negative influences of miR-33a on the downstream genes of METTL3 were examined by Western blot analysis. Thus, we concluded that miR-33a can attenuate NSCLC cells proliferation via targeting to the 3'UTR of METTL3 mRNA. Our findings provide new insights into the mechanism of METTL3 regulation by micro RNA, and supports METTL3 as a therapeutic target in NSCLC.

Objective To analyze the profile of inpatients treated in the department of thoracic surgery of cancer hos-pital, and to investigate the influential factors concerning patients had a hospital stay time of over 30 d. Method Clinical profiles of 12 423 patients discharged from cancer hospital (CAMS) between 2010 and 2013 were collected. Of all those patients, 396 who had extended hospital stay>30 d were analyzed through multivariate Logistic regression analysis.Re-sult A predominant proportion of patients thathad>30 days of hospital stay were aged between 50~80(85.61%), and suf-fered from esophageal or esophagogastric junction tumors (73.23%), and pulmonary tumors (25.00%). Postoperative com-plication wasthe primary cause for extended hospital stay, followed byessential tests delay, consultation of complex preop-erative complications, non-surgical day delay, medical disputes and referral difficulties. Respiratory failure, pulmonary in-fection, thoracic air leakage, anastotomic leakage, poor wound healing, chylothorax, pleural effusion or empyema, compli-cations of unexpected reoperation were independentrisk factors that may contribute to extended hospital stay (P<0.01). Conclusion Postoperative complication takes a major part inextended hospital stay. The postoperative complications of esophageal or esophagogastric junction tumors, as well as essential tests delay should also be addressed accordingly. The shortening of average hospital stay relies on the improving of perioperative medical quality, and the amelioration of col-laborative efficiency among different departments.

Objective To investigate the effect of different surgical options on the short-and long-term outcomes of patients with esophageal gastrointestinal stromal tumors (E-GIST). Method The clinical and treatment characteristics of 28 consecutive E-GIST patients were retrospectively reviewed. Result All the patients underwent curative surgery, including endoscopic submucosal dissection (ESD, n=4), enucleation (n=13), esophagectomy (n=11). Patients in the esophagectomy group had the largest tumors (P<0.001), the longest mean operative time (P<0.001), and the mean post-operative hospital stay in this group was prolonged (P=0.001), while the incidences of perioperative complications of the three groups were similar (P=0.096). After a median follow-up of 48 months (range 3-156 months), two patients who underwent esophagectomy experienced recurrence, one patient developed liver metastasis, one patient had local re-currence and liver metastasis. Conclusion Surgical resection remains mainstay for the treatment of E-GIST, ESD and enucleation are the preferred surgical options.

目的 探讨恶性胸膜间皮瘤(MPM)的临床特征及预后因素.方法 回顾性分析1990年1月至2013年12月闯收治的151例MPM患者的临床资料,并分析其预后因素.结果 患者中位年龄52岁(16 ～ 78岁),有石棉接触史4例(2.6％).最常见的首发临床表现为胸痛(64例,42.4％).根据侵犯范围分为局限型(43例,28.5％)和弥漫型(108例,71.5％).治疗方式包括单纯手术23例(15.3％),单纯化疗63例(41.7％),手术+辅助治疗57例(37.7％),化疗+放疗8例(5.3％).随访到133例患者,中位随访时间13.0个月(0.3～158个月),中位生存时间19.0个月(95％ CI为11.5 ～26.5).1、2、3及5年总生存率分别为60.0％、44.6％、36.0％和28.3％.单因素分析结果显示,性别(P =0.048)、侵犯范围(P=0.005)、肿瘤分期(P =0.002)与预后相关.多因素分析结果显示,性别(P=0.013)和肿瘤分期(P =0.001)是影响预后的独立因素.结论 恶性胸膜间皮瘤预后差,手术、化疗、放疗及综合治疗的疗效均欠佳.性别及肿瘤分期是影响预后的独立因素.

OBJECTIVE To compare the short-term outcomes and pulmonary function loss between thoracoscopic anatomical partial-lobectomy and thoracoscopic lobectomy on the patients with pT1aN0M0 peripheral non-small cell lung cancer. METHODS The clinical data of 191 patients with pT1aN0M0 peripheral non-small cell lung cancer received thoracoscopic anatomical pneumonectomy between January 2013 and July 2013 in Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences was analyze retrospectively. There were 71 patients underwent thoracoscopic anatomical partial-lobectomy and 120 patients underwent thoracoscopic lobectomy. Demographic features, operation time, blood loss, number of dissected lymph nodes, chest tube duration, drainage volume, postoperative hospital stay, postoperative complications, two-year progress and pulmonary function loss of FEV1% (percentage of the predicted forced expiratory volume in 1 second) at 6 months were retrospectively reviewed and compared by t test, rank-sum test, χ² test and Fisher exact test. RESULTS There were no significant differences in operation time, blood loss, number of dissected lymph nodes, chest tube duration, drainage volume, postoperative hospital stay, and postoperative complication rate (P > 0.05). The two-year progress rate between two groups did not differ significantly either (1.4% vs. 1.7%, χ² = 0.000, P = 1.000). Pulmonary function loss of FEV1% at 6 months was significantly smaller in thoracoscopic anatomical partial lobectomy group than thoracoscopic lobectomy group (14% ± 4% vs. 16% ± 4%, t = 2.408, P = 0.017). CONCLUSIONS Thoracoscopic anatomical partial-lobectomy is safe and feasible for patients with pT1aN0M0 peripheral non-small cell lung cancer. It could achieve equal short-term effect and reserve more pulmonary function compared with thoracoscopic lobectomy.

Objective To investigate the safety and feasibility of combined thoracoscopic and laparoscopic minimally invasive surgery for esophageal cancer patients administered with neoadjuvant therapy. Method The records of esophageal cancer patients who received neoadjuvant therapy in our hospital between January 2012 and December 2013 were retrospectively analyzed, and the surgery duration, intraoperative bleeding, lymph node clearance, postoperative drainage and perioperative complications between conventional three-incision esophagectomy and the combined thoraco-scopic and laparoscopic minimally invasive surgery were compared. Result For conventional three-incision esophagecto-my group ( Conv. group, 18 cases) and minimally invasive surgery group ( MIS group, 17 cases) , there was no statis-tical difference in post-operative drainage and lymph node clearance ( P>0. 05);while operation duration and intra-oper-ative bleeding were statistically different, MIS took longer time in operation, with less intra-operative bleeding. No differences were seen in other postoperative observations ( P>0. 05 ) . The major postoperative complications included dyspnea and anastomotic leak, and there were no death reports. Conclusion Combined thoracoscopic and laparoscopic minimally invasive surgery is safe and feasible for esophageal cancer patients with neoadjuvant therapy and it is worthy of further research and popularization.

[目的]通过对北京市3所三级甲等医院肺癌手术分级管理进行回顾性调研分析,为进一步完善肿瘤外科手术分级管理制度提供依据。[方法]随机抽取2004～2005年肺癌手术病例1297例进行术者职称与手术等级分析,并收集专家评定肺癌手术分级和手术准入资质等意见。[结果]1297例肺癌手术术者为主任医师占58.52%,副主任医师占41.17%,主治医师占0.31%;肺癌手术主要采用肺叶切除术,该术式术者职称从高到低比例分别为54.24%、45.39%和0.37%。综合医院手术定级标准略高于专科医院。[结论]医院应完善手术分级管理制度,科学研究手术级别,加强术者资质准入和实行手术权限审批,实现医院管理科学化、规范化、精细化。

电视胸腔镜手术为目前主要的胸腔微创手术之一,时于早期非小细胞肺癌的治疗,主要适用于临床Ⅰ期患者,随着技术的熟练,已有部分医师开始尝试将此技术用于中晚期患者.而最新的机器人系统(达芬奇)也已开始临床的实际应用.

Objective To investigate the clinic-pathologic characteristics and the prognostic factors in the patients with lung adenosquamous carcinoma. Methods The data of 361 patients operated for lung adenosquamous carcinoma were retrospectively analyzed as to the prognostic factors through comparison of survival rates by the actuarial method.A prognostic multivariable analysis was performed,after the variables related to prognosis were seeded with prognostic univariate analyses in the 24 non-repeating possible prognostic variables which including sex,age,symptom,course of disease,location,the type of X-ray film,margin of tumor,lobulation,attenuation,operation,the pleural collapse,the invading of pleural or thoracic wall found grossly in operation,the kind of resection,the size,the kind of dissecting lymph node,the degree of lymph metastasis(the numbers of positive lymph nodes/the numbers of lymph nodes resected),histological differentiation,the invading of pleural or thoracic wall were confirmed pathologically,UICC pathologic TNM staging,T item and N item in TNM staging,postoperative chemotherapy or radiotherapy,and postoperative recurrence and metastasis. Results The overall survival rate at 5,10 year was 29.1% and 15.4% respectively in the cases underwent complete resection.According to the result of Cox prognostic multivariate analysis,postoperative recurrence and metastasis,UICC pathologic TNM staging and the kind of resection were the most important prognostic variables. Conclusion The lung adenosquamous carcinoma is a highly aggressive virulent non-small lung cancer with a dissatisfactory result by single surgical treatment.

随着医改方案的启动,卫生行政管理部门已将医院绩效考核管理工作纳入医院管理年的要求之中.在新医改条件下,医院临床科室绩效评价和管理机制的建立已成为医院管理的难点问题[1].临床科室作为医院管理的重要组成部分,建立和完善其绩效管理对于提高医院的核心竞争力,实现医院的战略目标具有至关重要的意义[2].

Objective To evaluate the applicability of single-stage surgical treatment of synchronous bilateral multiple lung cancer.Methods One patient diagnosed as synchronous bilateral multiple lung cancer received single-stage surgery was reported,literatures were reviewed to discuss the indication and multidisplinary management of synchronous bilateral multiple lung cancer.Results One patient diagnosed as synchronous bilateral multiple lung cancer received single-stage surgery including lobectomy of left lower lobe and wedge resection of right upper lobe.Pathology report showed adenosquamous carcinoma of left lung and adenocarcinoma of right lung.The patient suffered respiratory failure and recovered after mechanical ventilation.The patient received four cycles of chemotherapy.The patient was diseases-free after 26 months of follow up.Conclusion Single-stage surgical treatment of synchronous bilateral multiple lung cancer plus adjuvant therapy may yielded satisfactory result in selected patients.