目的 探讨术前辅助定位联合CT三维重建技术在以肺结节为中心的单孔胸腔镜联合亚段/肺段切除术中的临床应用.方法 回顾性分析2019年12月—2021年10月于首都医科大学宣武医院行联合亚段/肺段切除术30例患者的临床资料,其中男19例、女11例,平均年龄56.4(32.0～71.0)岁.术前应用CT引导下注射定位胶辅助定位肺结节,用Mimics 21.0软件三维重建技术做手术规划,术中根据定位胶的位置和CT三维重建图像行胸腔镜联合亚段/肺段切除术.结果 全组患者均顺利完成手术,无中转开胸或肺叶切除.平均肿瘤直径(11.6±3.5)mm,平均结节距离脏层胸膜(13.6±5.6)mm,平均实际切缘宽度(25.0±6.5)mm,平均手术时间(110.2±23.8)min,平均淋巴结清扫站数(6.5±2.4)站,平均术中出血量(50.8±20.3)mL,平均胸腔引流管留置时间(3.2±1.1)d,平均术后住院时间(4.5±1.7)d.术后并发症包括皮下气肿1例、心房颤动1例、痰中带血1例.结论 术前CT引导下注射医用胶辅助定位联合CT三维重建技术,在以肺结节为中心的单孔胸腔镜联合亚段/肺段切除术中安全可行,既保证了手术切缘,又最大限度地保留了肺组织,达到解剖学切除的目的.

目的 分析细支气管腺瘤(bronchiolar adenoma,BA)患者的影像学表现和病理学特征.方法 回顾性分析首都医科大学宣武医院2019年1月-2020年9月接受手术治疗的11例BA患者的临床资料,其中男5例、女6例,年龄40～73(62.40±10.50)岁.分析术前胸部CT的影像学特征、术中快速冰冻病理诊断情况、术后病理分型、细胞生长方式、细胞核增殖指数Ki-67等.结果 平均术前观察时间(381.10±278.28)d,影像学病变最大径5～27(10.27±6.34)mm.表现为不规则形态的异质性磨玻璃样病变8例(72.7％),纯磨玻璃样病变3例(27.3％);有血管征象10例(90.9％),空泡征8例(72.7％),支气管征1例(9.1％),胸膜征3例(27.3％),毛刺/分叶征9例(81.8％).术式包括亚肺叶切除10例和肺叶切除1例.术中冰冻病理明确诊断为BA的有5例(45.5％).术后病理分型包括8例远端型BA和3例近端型BA,病灶最大径为4～20(8.18±5.06)mm.8例(72.7％)病灶在显微镜下可观察到特征性的双层细胞结构,10例(90.9％)病变组织显示甲状腺转录因子1表达;9例(81.8％)病灶显示NapsinA腔内细胞表达;病灶组织Ki-67指数为1％～5％(3.22％±1.72％).结论 病理学特征及影像学表现明确了 BA是肿瘤性病变的前提,但对BA是良性或惰性肿瘤的认定,还需要更多的临床资料及分子病理学研究证据.

目的 分析全身型重症肌无力(MG)患者胸腺切除术后肌无力危象(POMC)的影响因素.方法 回顾性分析2018 年1 月至2022 年6 月于首都医科大学宣武医院胸外科接受胸腺切除术的116 例全身型MG患者的临床资料,根据术后是否出现POMC分为POMC组38 例和非POMC组78 例.对其临床特点进行单因素和多因素分析,确定POMC的影响因素.结果 POMC组的机械通气时间、住ICU时间显著长于非POMC组(P＜0.001).POMC组和非POMC组在改良Osserman分型、合并胸腺瘤、手术方式、用力肺活量(FVC)、第一秒用力呼气容积(FEV1)以及血清白蛋白与球蛋白比值(AGR)等方面比较差异均有统计学意义(P＜0.05).多因素logistic回归分析结果显示,Osserman分型、FVC、FEV1 以及AGR是POMC发生的影响因素(P＜0.05).结论 术前Osserman分型、FVC、FEV1 以及AGR是全身型MG患者发生POMC的影响因素,可为临床工作提供参考.

目的 探索在胸部薄层CT(thin-section CT,TSCT)表现为肺纯磨玻璃结节(pure ground-glass opacity,p-GGO)患者的影像学特征对术后病理预判的可能性.方法 对笔者医院2019年1月 ～2020年6月行胸腔镜手术治疗的451例p-GGO患者的临床资料进行回顾性分析,依据TSCT扫描所表现的p-GGO内部特征将p-GGO分为Ⅰ型p-GGO和Ⅱ型p-GGO.结果 451例患者中包括Ⅰ型p-GGO 188例(41.7％),Ⅱ型p-GGO 263例(58.3％).与Ⅱ型p-GGO比较,Ⅰ型p-GGO病变最大径度(8.86±5.10mm vs 11.24±5.80mm,F=8.247,P=0.004)、径度增大和密度增高的平均时间(30.50±14.30个月vs 9.74±16.40个月,F=6.945,P=0.009)、边缘分叶或毛刺征(P=0.000)、胸膜征(P=0.001)、血管征(P=0.009)等影像学表现的差异有统计学意义.Ⅰ型p-GGO组中的浸润前期病变例数(n=123)明显多于Ⅱ型p-GGO组(n=63),而微浸润期病变例数(20例vs 86例)和浸润期病变例数(17例vs 86例)明显少于Ⅱ型p-GGO组(P=0.000),且Ⅱ型p-GGO组中有更多的病例发生局部浸润(P=0.000).结论 p-GGO在TSCT所表现的内部特征有助于对早期肺癌病理特性的预判.

目的 分析老年肺部磨玻璃影(ground-glass opacity,GGO)患者的影像学特征及病理结果.方法 对首都医科大学宣武医院2017年1月至2019年12月手术治疗的281例年龄大于60岁的老年GGO患者的影像学表现和术后病理结果进行回顾性研究.结果 GGO最大径均值为(13.3±7.5)mm.Ⅰ型GGO病例97例(34.5％),Ⅱ型GGO病例119例(42.3％),Ⅲ型和Ⅳ型病例分别为51例(18.1％)和14例(5.0％).术后病理报告:30例(10.7％)为良性病变,75例(26.7％)浸润前期病变,65例(23.1％)微浸润腺癌,111例(39.5％)浸润期肺癌.对GGO影像学特征与术后病理结果的相关性分析表明,依据GGO影像学特征所进行的GGO分型与术后病理结果存在显著相关性(r=0.365,P<0.01);GGO分型与肺癌病理亚型存在可能的关联(P<0.05,r=0.276),且与肺癌发生STAS(P<0.05,r=0.175)和胸膜浸润(P<0.01,r=0.236)存在显著相关性.结论 老年患者的GGO影像学分型与术后肿瘤性质、肿瘤细胞的浸润程度密切相关.

目的 研究磨玻璃结节(GGN)预测非小细胞肺癌(NSCLC)浸润的情况.方法 回顾性选择2014年1月至2019年6月经手术切除病理证实为GGN型NSCLC患者244例,分析其CT特征和病理检查结果,评估GGN与NSCLC浸润的关联性.结果 244例GGN病理检查为腺癌,其中原位腺癌(AIS)44例,微浸润腺癌(MIA)53例,浸润性腺癌(IA)147例.9例支气管充气征GGN病理结果全部为IA.2例存在淋巴结转移.AIS组、MIA组和IA组在密度、分叶、毛刺、空泡征、支气管充气征、胸膜牵拉征、血管集束征,以及实性成分大小、实性成分比例和结节最大径方面比较差异有统计学意义(P<0.05).受试者工作特征(ROC)曲线分析结果显示,结节最大径、实性成分大小、实性成分比例具有预测NSCLC是否浸润的价值,其中以结节最大径的诊断效能最佳.结论 GGN大小可用于预测NSCLC是否浸润.

目的 分析单孔胸腔镜治疗老年肺磨玻璃结节(ground-glass opacity,GGO)患者的临床资料及病理结果.方法 对笔者医院2017年1月～2019年12月行单孔胸腔镜手术治疗、年龄>60岁的老年GGO患者281例的临床资料进行回顾性研究.结果 281患者的平均年龄为67.00±5.30岁,其中男性患者83例(29.5％),女性患者198例(70.5％).190例(67.6％)伴有高血压、糖尿病、吸烟、冠心病、COPD等.胸部CT扫描发现,GGO最大径均值为13.31±7.50mm.平均观察时间为13.48±23.30个月.术式为肺叶切除术88例(31.3％)、亚肺叶切除术193例(68.7％).手术平均用时为162.61±63.50min,平均术中出血量为53.68±29.60ml.51例(17.6％)术后出现心脑血管、肝功能损害等术后并发症,无围术期死亡病例.术后病理报告:30例(10.7％)为良性GGO病变、75例(26.7％)为浸润前期病变、65例(23.1％)为微浸润腺癌、111例(39.5％)为浸润期肺腺癌.平均住院日为10.93±3.60天.男性患者(P=0.024)、肺叶切除术式(P=0.000)、影像学表现为Ⅲ ～Ⅳ型GGO的患者(P=0.036)、浸润期病变患者(P=0.009)是超过平均住院日的主要因素.结论 具备Ⅱ型GGO以上特征或最大径10mm以上的GGO是预判老年早期肺癌的重要影像学特征.单孔胸腔镜下的亚肺叶切除是治疗以GGO为影像学表现的老年早期肺癌患者首选的治疗手段.

通过对建国以来分阶段开展的3次国人死亡原因的回顾调查和国家癌症中心最新发布的我国癌症数据报告的分析,可以看到恶性肿瘤是影响我国人民生命健康的重要疾病,肺癌是首要的危险因素;同时也看到我国政府在不同发展时期应对恶性肿瘤所制定的一系列防控策略的科学性和有效性,明确把"早诊早治"作为防治肺癌等恶性肿瘤的重要策略.我国的肺癌外科在建国后进入了一个新的发展时期,学术水平和技术能力在20世纪90年代已接近或达到国际水平,部分领域已经处于国际领先水平.胸部螺旋CT扫描的应用使早期肺癌诊断成为可能;液体活检联合常规血清肿瘤标志物检测有助于提高早期肺癌的正确诊断率;胸腔镜技术的应用是胸外科领域发展的里程碑,也使早期肺癌患者的微创外科治疗成为现实.在提高早期肺癌患者生存率的同时,提高了患者生存质量.

Lung cancer is a leading cause of cancer mortality worldwide. As the incidence of lung cancer increases in recent years, the number of patients diagnosed with synchronous multiple primary lung cancers (SMPLC) is also rising. SMPLC diagnosis is often made based on the clinical course, imaging findings, and histologic and molecular features. Standard lobectomy is the main therapeutic modality for SMPLC. Because maximum retention of lung function is essential, sublobectomy is also a commonly used surgical strategy when appropriate. The question is how to optimize the sequence of lobectomy and sublobectomy for patients with SMPLC. Thoracoscope lobectomy for the primary lesion plus sublobectomy for the secondary lesions is the most commonly used approach. Here we present a case of SMPLC with sublobectomy followed by lobectomy.

目的 分析20～30mm磨玻璃肺结节(GGO)的影像学征象及病理特征.方法 对笔者医院2017年1月 ～2019年12月手术治疗的29例20～30mm磨玻璃肺结节患者的影像学特征和术后病理结果等进行回顾性研究.结果 在29例患者中,男性13例,女性16例.平均年龄为64.7岁(49～78岁).随访观察时间4～2190天,平均随访观察时间为261.76天.病变最大径21～30mm,平均病变最大径为24.7mm.形态规则的GGO为21例(72.40％),分叶状21例(72.7％),胸膜牵拉16例(55.2％),血管征象18例(62.1％).术式包括亚肺叶切除3例、肺叶切除术26例.术后病理报告硬化性血管瘤1例,微浸润癌7例、浸润腺癌21例,其中腺泡为主型、贴壁为主型和乳头状生长为主型分别为7例(29.17％)、15例(62.5％)和2例(8.33％),这3种亚型的ki-67值分别为11.86％、8.53％ 和12.50％;发现肿瘤细胞累及脏层胸膜4例(19.05％),肺泡内浸润4例(19.05％),脉管浸润2例(9.52％).结论 GGO的形态、边缘征象、内部征象、PETCT所反映的病灶代谢征象和动态观察征象,与肿瘤细胞的ki-67值的关系更为密切.应该考虑把20～30mm GGO的最大径纳入TNM分期中"T"分期.

OBJECTIVES:To retrospectively analyze the clinical results of the treatment of pulmonary multifocal adenocarcinoma presenting as ground glass opacity (GGO) by surgery and thermal ablation. METHODS:87 GGO-type pulmonary adenocarcinomas of 48 patients (14 males and 34 females; mean age: 59.7 years old ±9.9, range: 33-79 years old) had been treated from March 2015 to March 2019. Treatment means included 43 wedge resections, 7 segmentectomy, 17 lobectomies, and 20 thermal ablations. The indication selected for treatment means, safety, and local tumor progression rate were evaluated. RESULTS:No operation-related death occurred in all patients. 42 times of surgery were performed and 67 carcinomas were resected in 42 patients. 23 times of single-port Video-assisted thoracoscopic surgery (VATS), 8 times of two-port VATS and 11 times of three-port VATS were performed in total. There were 2 cases of air leak (exceeding 1 week), 1 case of chylothorax and 1 case of massive pleural effusion. Time duration of surgery was between 60 and 300mins (mean: 167mins). Intra-operative blood loss was between 5 and 300 ​mL (mean: 44 ​mL). Time of chest drainage was between 2 and 23d (mean 4.9d). Chest drainage volume was between 14 and 4633 ​mL (mean: 872 ​mL). Post-operation LOS (length of stay) was between 3 and 25d (mean: 6.2d). 15 times of thermal ablation were performed (1 case of air leak) and 20 carcinomas were ablated in 14 patients. The ablation time was between 30 and 120min (mean: 43min); post-operation LOS was between 1 and 10d (mean: 3.5d). During the mean follow-up period (16 months ​± ​13) (range: 5-60 months), no local tumor progression occurred. CONCLUSIONS:Surgery and thermal ablation are safe and effective options for the treatment of pulmonary multifocal GGO-type adenocarcinoma.

目的 分析重症肌无力术后发生肌无力危象的影响因素.方法 回顾性分析2006年6月至2019年6月首都医科大学宣武医院胸外科65例重症肌无力术后发生肌无力危象患者的临床资料,其中男31例(47.7％)、女34例(52.3％),年龄15～ 78(45.7±17.8)岁.分析患者的手术方式、手术时间、病理类型等与术后发生肌无力危象的关系.结果 手术时间、病理类型是术后肌无力危象的影响因素.Osserman分型的受试者工作特征曲线下面积(AUC)为0.676,临界值为ⅡB型,灵敏度37.5％,特异性90.5％,约登指数0.280.Masaoka分期的AUC为0.682,临界值为Ⅱ期,灵敏度62.5％,特异性66.7％,约登指数0.292.出血量的AUC为0.658,临界值为90 mL,灵敏度87.5％,特异性69.6％,约登指数0.304.结论 术前Osserman分型、病理类型、手术时间、出血量是发生术后肌无力危象的影响因素,因此充分的术前准备、快捷仔细的术中操作和积极的术后处理可减少术后肌无力危象的发生.

目的 探讨CT引导下注射医用胶在肺小结节胸腔镜术前定位中的临床应用价值.方法 回顾性分析2018年5月～2019年5月54例肺小结节胸腔镜术前定位的临床资料.其中多发结节11例(2枚8例,3枚3例),单发结节43例.结果 54例均准确定位.多发结节穿刺操作时间(19.8±5.1)min,气胸发生率18.2％(2/11),胸痛发生率18.2％(2/11),刺激性干咳发生率27.3％(3/11);单发结节穿刺操作时间(12.1±3.3)min,气胸发生率14.0％(6/43),胸痛发生率16.3％(7/43),刺激性干咳发生率20.9％(9/43).无术后并发症.结论 在操作熟练和合理规划定位顺序的基础上,使用医用胶对肺结节术前CT定位安全、可行.

目的 探讨叶酸受体循环肿瘤细胞检测在亚厘米孤立性肺结节(solitary pulmonary nodule,SPN)临床诊断和外科治疗策略的应用.方法 对笔者医院2017年9月～ 2018年6月期间56例术前叶酸受体循环肿瘤细胞检测阳性的亚厘米SPN病历进行回顾性分析.所有患者术前均行2次以上胸部CT扫描,随访观察时间1～6个月(平均4.2个月).52例患者行术前病变定位.术式包括胸腔镜肺叶切除术7例,亚肺叶切除49例,包括肺楔形切除术41例,肺段切除术8例.结果 术前胸部CT肺窗测定,病变直径≤5mm 22例,6～9mm 34例.实性结节9例,半实性结节36例,纯磨玻璃样病变11例.术后病理证实恶性结节54例(96.4％),良性结节2例(3.6％).均为原发肺恶性肿瘤,包括非典型性腺瘤样增生(AAH)5例,原位腺癌(AIS) 22例,微浸润腺癌(MIA)21例,贴壁生长为主的浸润腺癌(LPA)4例,肺鳞癌1例,类癌1例.结论 亚厘米SPN影像学静态特征相对缺乏,需要通过随访观察确定诊疗策略.叶酸受体循环肿瘤细胞检测有助于弥补亚厘米SPN在影像学特征相对缺乏的不足,有希望成为提高早期肺癌诊断率的新辅助手段.

目的 评价数字化胸腔引流系统在胸腔镜下肺结节楔形切除术中的应用价值.方法 回顾性分析2017年5～12月胸腔镜下肺结节楔形切除术34例资料,术后应用数字化胸腔引流系统(数字组)和传统胸腔引流贮液瓶(传统组)各17例.2组性别、年龄、病灶最大径和良恶性无明显统计学差异.比较2组引流时间与术后住院时间.结果 34例手术过程顺利,术后均未出现肺炎、肺不张及心血管意外等并发症,顺利出院.与传统组相比,数字组引流时间短[中位数2(1～5)d vs.3(2～6)d,Z=-2.126,P=0.033],术后住院时间短[3(2～6)d vs.5(2～8)d,Z=-2.056,P=0.040].结论 数字化胸腔引流系统可实时观测术后恢复与漏气情况,对缩短引流时间和术后住院时间具有积极意义.

Objective To assess the long-term results and relevant influencing factors of extended thymectomy and medicine-alone treatment of non-thymomatous myasthenia gravis (MG) patients. Methods We retrospectively analyzed the clinical data of 174 patients with non-thymomatous MG diagnosed and treated in our department from December 2009 to April 2017, including 81 males and 93 females, aged 13-88 (47.1±17.8) years. According to the different treatment methods, the patients were divided into two groups: an operation group (91 patients receiving extended thymectomy) and a medicine-alone group (83 patients receiving medical therapy alone). The efficacy was evaluated according to the Myasthenia Gravis Foundation of America (MGFA). Survival curves of the patients were plotted using the Kaplan-Meier method to evaluate the remission rate and survival rate. Cox regression analysis was used to assess the influencing factors of the outcomes. Results The patients were followed up for 3 to 94 (39.1±26.9) months. As a result, 29 patients (31.9％) achieved complete remission in the surgery group and 13 patients (15.7％) were completely relieved in the medicine-alone group (P=0.014). Further analysis showed that treatment pattern (P=0.018) and MG type (P=0.021) were the main factors related to the efficacy. Conclusion For patients with non-thymomatous MG, extended thymectomy is superior to the medicine-alone in terms of complete remission rate and the postoperative immunosuppression ratio.

目前恶性肿瘤的发病率逐年增长,已成为本市居民的首要死因.当肿瘤患者就诊于专科医生处后需要回归社区时,大部分社区缺少与肿瘤专科的衔接,或仅关注对专科疾病病情的衔接,忽视或极少关注肿瘤患者的生存质量的评估.致使肿瘤患者在治疗或康复期间生存质量评估的缺失.此种状况在某种程度上严重影响肿瘤患者原发疾病的康复和生活质量.主要从生存质量的概念、评价方法 、社区影响因素及干预措施等方面介绍社区肿瘤患者生存质量研究现状,以期为全科医生的社区临床实践提供依据.

目的 探讨2μm铥激光肺切除术中肺断面漏气的处理.方法 回顾性分析我科2016年1月～2018年6月应用2μm铥激光行电视胸腔镜下肺结节切除48例资料,在气道压力30 cm H2 O条件下,采用Macchiarini分级标准,0～2级漏气40例,未予特殊处理;3级漏气(大量成簇状堆积气泡)8例,2例未予处理,6例缝合修补.结果 0～2级漏气40例,术后胸管引流时间17～31 h,平均28.0 h;3级漏气8例,除1例未缝合者持续漏气带管16 d外,术后胸管引流时间25～61 h,平均45.2 h.结论 在2μm铥激光肺切除术中,0～2级漏气可不予特殊处理,3级漏气需要积极手术修补.

Objective The aim of the present study was to evaluate the clinical application of 2 μm thulium laser in pulmonary nodules resection under VATS.Methods 61 patients,undergoing thoracoscopic resection of pulmonary nodules in thoracic department of Xuanwu Hospital,were identified between January and December of 2016.Of those,30 underwent 2μm thulium laser dissection and 31 were treated with standard technique by using staplers.In terms of clinical characteristics,including gender,age and smoking history,there is no significant difference between the laser group and the stapler group,but the lesion size was slightly larger in the stapler group compared with the laser group.The lesions of the two groups were almost evenly distributed on the five lobes.Results All the procedures were performed successfully under VATS.The intraoperative evaluation of air leaks demonstrated that less than or equal to 2 grade air leaks were observed in 28 cases in the laser group and in 30 cases in the stapler group.Grade 3 air leaks requiring a rescue treatment were observed in 2 cases in the laser group and in 1 case in the stapler group.There were no significant differences in the postoperative hospital stay and total hospital stay between two groups.Chest tube duration was lower in the laser group compared with the stapler group even if it was not statistically significant (2.71 vs 3.55 days).Hospitalization costs was significantly lower for the laser group.Conclusion The use of 2um thulium laser to prevent intra-and postoperative air leaks and bleeding is effective and makes patients recover quickly,which allows a minimally invasive,accurate and safe application during thoracoscopic resection of pulmonary nodules.

Objective To evaluate the short-term outcomes of video-assisted thoracoscopic surgery ( VATS) of segmentectomy in the treatment of pathological stage ⅠA non-small cell lung cancer ( NSCLC) in patients above sixty years old . Methods Clinical data of 64 patients with pathological stage ⅠA NSCLC who underwent VATS segmentectomy ( n=32) and VATS lobectomy ( n=32) from June 2011 to December 2014 in our hospital were retrospectively analyzed .The operation time , blood loss , number of dissected lymph nodes (including N1 and N2), chest tube duration, postoperative hospital stay, morbidity of postoperative complications and follow-up after operation were compared between the two groups .Results There were no significant differences in blood loss [ 100 (20-900) ml vs.150 (50-500) ml, Z=-1.509, P=0.131], morbidity of postoperative complications [6.3%(2/32) vs. 9.4%(3/32),χ2 =0.000, P=1.000], chest tube duration [(5.4 ±1.2) d vs.(5.5 ±1.1) d, t=0.218, P=0.828], and postoperative hospital stay [(6.4 ±1.2) d vs.(6.5 ±1.1) d, t=0.218, P=0.828] between the segmentectomy group and the lobectomy group.The operation time of VATS segmentectomy was significantly shorter than that of VATS lobectomy [(136.8 ±65.2) min vs.(189.2 ±74.2) min, t=2.999, P=0.004].The total number of dissected lymph nodes of VATS segmentectomy was less than that of VATS lobectomy [6.5 (3-45) vs.12 (4-30), Z=-4.750, P=0.000].There were significant differences in the segmentectomy group and the lobectomy group in the number of N 1 lymph nodes [3 (2-9) vs.5 (2 -11), Z=-3.294, P=0.001] and N2 lymph nodes [3.5 (0-36) vs.8.5 (1-29), Z=-4.814, P=0.000], respectively.There were no recurrence and metastasis during follow-ups for 12 -42 months (median, 18 months) in 32 cases of segmentectomy and for 12 -19 months (median, 16 months) in 32 cases of lobectomy. Conclusions VATS segmentectomy is a choice in treatment of pathological stage ⅠA NSCLC in patients above sixty years old .The short-term outcomes are not worse than VATS lobectomy .