胸腺切除术不同手术方式及入路的研究进展
Research Progress of Different Surgical Methods and Approaches of Thymectomy
摘要: 胸腺上皮肿瘤是前纵隔最常见的原发性肿瘤，以胸腺瘤较为多见，在我国居民中发生率较低。胸腺瘤生长速度缓慢，但具有潜在侵袭性，容易浸润周围组织和器官，部分合并重症肌无力(MG)，故对于可手术切除的此类疾病，胸腺切除术常作为首选治疗措施。标准术式为胸腺扩大切除术，即对胸腺与其周边脂肪组织行完整切除处理。应用较为广泛的手术方法包括机器人辅助胸腔镜手术(RATS)、电视辅助胸腔镜手术(VATS)与胸骨正中切开术。随着微创技术的发展成熟，微创手术逐渐占主导地位。有充足的研究证明与传统胸骨正中切开术相比，微创胸腺切除术治疗早期胸腺瘤的短期效果更好，但对于理想手术方式及入路无统一意见。
Abstract: Thymic epithelial tumor is the most common primary tumor in the anterior mediastinum. Thy-moma is more common, and the incidence is low among Chinese residents. Thymomas grow slowly, but are potentially invasive and easily infiltrate surrounding tissues and organs, partly with myas-thenia gravis (MG). Therefore, for surgical resection of such diseases, thymectomy is often used as the preferred treatment. The standard surgical procedure is extended thymectomy, that is, com-plete resection of the thymus and surrounding adipose tissue. The widely used surgical methods in-clude robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS) and median sternotomy. With the development of minimally invasive technology, minimally invasive surgery has gradually dominated. Ample studies have shown that compared with traditional me-dian sternotomy, minimally invasive thymectomy has a better short-term effect in the treatment of early thymoma, but there is no consensus on the ideal surgical method and approach.
文章引用：孙玉慧, 范坤, 刘傲, 彭垒, 矫文捷. 胸腺切除术不同手术方式及入路的研究进展[J]. 临床医学进展, 2023, 13(1): 406-414. https://doi.org/10.12677/ACM.2023.131062

参考文献

[1] 何博, 吴蔚, 谭德立, 等. 经剑突肋缘下与经肋间胸腔镜手术治疗前纵隔肿瘤的疗效对比[J]. 局解手术学杂志, 2020, 29(10): 812-817.
[2] 中国医师协会医学机器人医师分会胸外科专业委员会筹备组, 谭群友, 陶绍霖, 等. 机器人辅助纵隔肿瘤手术中国专家共识(2019版) [J]. 中国胸心血管外科临床杂志, 2020, 27(2): 117-125.
[3] 张家豪, 张亚杰, 李鹤成. 机器人在胸腺瘤手术中的技术与临床应用[J]. 中华胸部外科电子杂志, 2020, 7(4): 252-256.
[4] Wu, N., Tüzün, E., Cheng, Y., et al. (2021) Central Role of T Follicular Helper Cells in Myasthenia Gravis. Nöro Psikiyatri Arşivi, 58, 68-72. [Google Scholar] [CrossRef] [PubMed]
[5] 崔博宙, 阮哲, 徐拓, 等. 重症肌无力患者胸腺切除术后发生肌无力危象的相关风险因素分析[J]. 空军军医大学学报, 2022, 43(9): 963-966+972.
[6] Wolfe, G.I., Kaminski, H.J., Aban, I.B., et al. (2016) Randomized Trial of Thymectomy in Myas-thenia Gravis. New England Journal of Medicine, 376, 511-522. [Google Scholar] [CrossRef] 
[7] Alhaidar, M.K., Abumurad, S., Soliven, B. and Rezania, K. (2022) Current Treatment of Myasthenia Gravis. Journal of Clinical Medicine, 11, Article No. 1597. [Google Scholar] [CrossRef] [PubMed]
[8] Wolfe, G.I., Kaminski, H.J., Aban, I.B., et al. (2019) Long-Term Effect of Thymectomy plus Prednisone versus Prednisone Alone in Patients with Non-Thymomatous Myasthenia Gravis: 2-Year Extension of the MGTX Randomised Trial. The Lancet Neurology, 18, 259-268. [Google Scholar] [CrossRef] 
[9] Kaufman, A.J., Palatt, J., Sivak, M., et al. (2016) Thymec-tomy for Myasthenia Gravis: Complete Stable Remission and Associated Prognostic Factors in Over 1000 Cases. Semi-nars in Thoracic and Cardiovascular Surgery, 28, 561-568. [Google Scholar] [CrossRef] [PubMed]
[10] 袁东风, 谷志涛, 梁光辉, 等. 胸腺瘤合并重症肌无力患者预后的临床研究[J]. 中国肺癌杂志, 2018, 21(1): 1-7.
[11] Wei, Y., Gu, Z, Shen, Y., et al. (2016) Preoperative In-duction Therapy for Locally Advanced Thymic Tumors: A Retrospective Analysis Using the ChART Database. Journal of Thoracic Disease, 8, 665-672. [Google Scholar] [CrossRef] [PubMed]
[12] 中国医师协会肿瘤多学科诊疗专业委员会. 中国胸腺上皮肿瘤临床诊疗指南(2021版) [J]. 中华肿瘤杂志, 2021, 43(4): 395-404.
[13] Tassi, V., Vannucci, J., Ceccarelli, S., et al. (2019) Stage-Related Outcome for Thymic Epithelial Tumours. BMC Surgery, 18, Article No. 114. [Google Scholar] [CrossRef] [PubMed]
[14] Li, J.F., Hui, B.-G., Li, X., et al. (2018) Video-Assisted Thoracic Surgery for Thymoma: Long-Term Follow-up Results and Prognostic Factors—Single-Center Experience of 150 Cases. Journal of Thoracic Disease, 10, 291-297. [Google Scholar] [CrossRef] [PubMed]
[15] Margaritora, S., Cesario, A., Cusumano, G., et al. (2009) Thir-ty-Five-Year Follow-up Analysis of Clinical and Pathologic Outcomes of Thymoma Surgery. The Annals of Thoracic Surgery, 89, 245-252. [Google Scholar] [CrossRef] [PubMed]
[16] Chiappetta, M., Zanfrini, E., Giraldi, L., et al. (2019) Prog-nostic Factors after Treatment for Iterative Thymoma Recurrences: A Multicentric Experience. Lung Cancer, 138, 27-34. [Google Scholar] [CrossRef] [PubMed]
[17] Narm, K.S., Lee, C.Y., Do, Y.W., et al. (2016) Limited Thy-mectomy as a Potential Alternative Treatment Option for Early-Stage Thymoma: A Multi-Institutional Propensi-ty-Matched Study. Lung Cancer, 101, 22-27. [Google Scholar] [CrossRef] [PubMed]
[18] 康云腾, 许世广, 刘博, 等. 纵隔肿物合并重症肌无力的外科治疗: 达芬奇机器人、胸腔镜与胸骨正中切口手术对比研究[J]. 中国胸心血管外科临床杂志, 2018, 25(12): 1027-1031.
[19] Ambrogi, V. and Mineo, T.C. (2012) Active Ectopic Thymus Predicts Poor Outcome after Thymec-tomy in Class III Myasthenia Gravis. The Journal of Thoracic and Cardiovascular Surgery, 143, 601-606. [Google Scholar] [CrossRef] [PubMed]
[20] 周一凡, 钟永泷. 胸腔镜胸腺切除术的进展[J]. 中国微创外科杂志, 2018, 18(2): 166-168+180.
[21] 汪灏, 谷志涛, 丁建勇, 等. 胸腔镜与开放手术治疗临床早期胸腺恶性肿瘤的围手术期效果及长期生存率的比较[J]. 中国肺癌杂志, 2016, 19(7): 453-458.
[22] Goldstein, S.D. and Yang, S.C. (2010) Assessment of Robotic Thymectomy Using the Myasthenia Gravis Foundation of America Guidelines. The Annals of Thoracic Surgery, 89, 1080-1086. [Google Scholar] [CrossRef] [PubMed]
[23] Alfred, B. (1944) Thymectomy in the Treatment of Myasthe-nia Gravis: Report of Twenty Cases. Journal of Thoracic Surgery, 13, 316-339. [Google Scholar] [CrossRef] 
[24] 徐惟, 许世广, 刁玉刚, 王述民. 机器人完全不插管全胸腺切除术安全专家共识[J]. 中国胸心血管外科临床杂志, 2022, 29(12): 1554-1561.
[25] 赵子聪, 洪志鹏. 外科胸腔镜的发展现状[J]. 中华肺部疾病杂志(电子版), 2018, 11(5): 618-620.
[26] 崔文鹏, 马捷, 景雅帆. 微创外科在胸腺瘤切除的应用及研究进展[J]. 中国现代医生, 2016, 54(3): 161-164.
[27] Khicha, S.G., Kaiser, L.R. and Shrager, J.B. (2008) Extended Transcervical Thymectomy in the Treatment of Myasthenia Gravis. Annals of the New York Academy of Sciences, 1132, 336-343. [Google Scholar] [CrossRef] [PubMed]
[28] 舒涵, 梅宏, 许川, 等. 前上纵隔肿瘤外科治疗研究进展[J]. 中国实用医药, 2021, 16(25): 20620-9.
[29] 崔新征, 方华, 杨鲲鹏, 等. 横断胸骨第2肋间小切口与胸骨正中切口行胸腺切除治疗重症肌无力的对比研究[J]. 中国微创外科杂志, 2010, 10(6): 492-495.
[30] 陈锋夏, 杨作衡, 汤鹏, 等. 肋间小切口胸膜外切除前纵隔肿瘤[J]. 中国现代医学杂志, 2002, 12(13): 94-95.
[31] Burt, B.M., Yao, X., Shrager, J., et al. (2017) Determinants of Complete Resection of Thy-moma by Minimally Invasive and Open Thymectomy: Analysis of an International Registry. Journal of Thoracic Oncol-ogy, 12, 129-136. [Google Scholar] [CrossRef] [PubMed]
[32] Sugarbaker, D.J. (1933) Thoracoscopy in the Management of Ante-rior Mediastinal Masses. The Annals of Thoracic Surgery, 56, 653-656. [Google Scholar] [CrossRef] 
[33] Numanami, H., Yano, M., Yamaji, M., et al. (2018) Thoraco-scopic Thymectomy Using a Subxiphoid Approach for Anterior Mediastinal Tumors. Annals of Thoracic and Cardio-vascular Surgery, 24, 65-72. [Google Scholar] [CrossRef] [PubMed]
[34] Raza, A. and Woo, E. (2016) Video-Assisted Thoracoscopic Surgery versus Sternotomy in Thymectomy for Thymoma and Myasthenia Gravis. Annals of Cardiothoracic Surgery, 5, 33-37.
[35] Tagawa, T., Yamasaki, N., Tsuchiya, T., et al. (2014) Thoracoscopic versus Transsternal Resection for Early Stage Thymoma: Long-Term Outcomes. Surgery Today, 44, 2275-2280. [Google Scholar] [CrossRef] [PubMed]
[36] Ye, B., Tantai, J.-C., Ge, X.-X., et al. (2014) Surgical Techniques for Early-Stage Thymoma: Video-Assisted Thoracoscopic Thymectomy versus Transsternal Thymectomy. The Journal of Thoracic and Cardiovascular Surgery, 147, 1599-1603. [Google Scholar] [CrossRef] [PubMed]
[37] Jurado, J., Javidfar, J., Newmark, A., et al. (2012) Minimally Invasive Thymectomy and Open Thymectomy: Outcome Analysis of 263 Patients. The Annals of Thoracic Surgery, 94, 974-982. [Google Scholar] [CrossRef] [PubMed]
[38] Manoly, I., Whistance, R.N., Sreekumar, R., et al. (2014) Early and Mid-Term Outcomes of Trans-Sternal and Video-Assisted Thoracoscopic Surgery for Thymoma. European Journal of Cardio-Thoracic Surgery, 45, e187-e193. [Google Scholar] [CrossRef] [PubMed]
[39] Odaka, M., Tsukamoto, Y., Shibasaki, T., et al. (2017) Thoracoscopic Thymectomy Is a Feasible and Less Invasive Alternative for the Surgical Treatment of Large Thymomas. Interactive CardioVascular and Thoracic Surgery, 25, 103-108. [Google Scholar] [CrossRef] [PubMed]
[40] 黄佳, 罗清泉, 谭强. 机器人外科手术系统辅助胸腔镜胸腺瘤切除手术一例[J]. 上海医学, 2010, 33(11): 1072.
[41] 蒋彬, 康珀铭, 陶绍霖, 等. 机器人与胸腔镜手术治疗前纵隔肿物的近期疗效对比[J]. 第三军医大学学报, 2019, 41(16): 1578-1582.
[42] Kang, C.H., Na, K.J., Park, S., Park, I.K. and Kim, Y.T. (2021) Long-Term Outcomes of Robotic Thymectomy in Patients with Thymic epithelial Tumors. The Annals of Thoracic Surgery, 112, 430-435. [Google Scholar] [CrossRef] [PubMed]
[43] Su, K.W., Luketich, J.D. and Sarkaria, I.S. (2022) Robot-ic-Assisted Minimally Invasive Thymectomy for Myasthenia Gravis with Thymoma. JTCVS Techniques, 13, 270-274. [Google Scholar] [CrossRef] [PubMed]
[44] Fiorelli, A., Mazzella, A., Cascone, R., et al. (2016) Bilateral Tho-racoscopic Extended Thymectomy versus Sternotomy. Asian Cardiovascular and Thoracic Annals, 24, 555-561. [Google Scholar] [CrossRef] [PubMed]
[45] Caronia, F.P., Fiorelli, A., Arrigo, E., et al. (2016) Bilateral Sin-gle-Port Thoracoscopic Extended Thymectomy for Management of Thymoma and Myasthenia Gravis: Case Report. Journal of Cardiothoracic Surgery, 11, Article No. 153. [Google Scholar] [CrossRef] [PubMed]
[46] Zieliński, M., Czajkowski, W., Gwozdz, P., et al. (2013) Resection of Thymomas with Use of the New Minimally-Invasive Tech-nique of extended Thymectomy Performed through the Subxiphoid-Right Video-Thoracoscopic Approach with Double Elevation of the Sternum. European Journal of Cardio-Thoracic Surgery, 44, e113-e119. [Google Scholar] [CrossRef] [PubMed]
[47] 卢强, 李小飞, 赵晋波, 等. “三孔式”经剑突肋缘下胸腺切除治疗重症肌无力[J]. 中华胸部外科电子杂志, 2016, 3(2): 95-09.
[48] Suda, T. (2016) Uniportal Subxiphoid Video-Assisted Thoracoscopic Thymectomy. Journal of Visualized Surgery, 2, Article No. 123. [Google Scholar] [CrossRef] [PubMed]
[49] Zhang, L., Li, M., Jiang, F., et al. (2019) Subxiphoid versus Lateral Intercostal Approaches Thoracoscopic Thymectomy for Non-Myasthenic Early-Stage Thymoma: A Propensity Score-Matched Analysis. International Journal of Surgery, 67, 13-17. [Google Scholar] [CrossRef] [PubMed]
[50] Cao, P., Hu, S., Qu, W., et al. (2022) Subxiphoid-Subcostal Tho-racoscopic Thymectomy for Seropositive Myasthenia Offers Equivalent Remission Rates and Potentially Faster Recovery. Interactive Cardiovascular and Thoracic Surgery, 34, 576-583. [Google Scholar] [CrossRef] [PubMed]
[51] Lu, Q., Zhao, J., Wang, J., et al. (2018) Subxiphoid and Subcostal Arch “Three Ports” Thoracoscopic Extended Thymectomy for Myasthenia Gravis. Journal of Thoracic Disease, 10, 1711-1720. [Google Scholar] [CrossRef] [PubMed]
[52] 张淼, 武文斌, 杨敦鹏, 等. 剑突下单孔胸腔镜胸腺扩大切除术的学习曲线分析[J]. 中华胸部外科电子杂志, 2019, 6(3): 146-151.
[53] Jiang, J.-H., Gao, J., Zhang, Y., et al. (2020) Modified Subxiphoid Thoracoscopic Thymectomy for Locally Invasive Thymoma. The Annals of Thoracic Surgery, 112, 1095-1100. [Google Scholar] [CrossRef] [PubMed]
[54] Song, N., Li, Q., Aramini, B., et al. (2022) Double Sternal Elevation Subxiphoid versus Uniportal Thoracoscopic Thymectomy Associated with Superior Clearance for Stage I-II Thymic Epithelial Tumors: Subxiphoid Thymectomy Compared with VATS. Surgery, 172, 371-378. [Google Scholar] [CrossRef] [PubMed]
[55] 朱铁源, 范国华, 王土生, 黄杰. 颈部切口联合胸腔镜技术在颈纵隔良性肿瘤切除中的应用[J]. 临床外科杂志, 2019, 27(2): 149-151.
[56] Brichkov, I., Chiba, S., Lagmay, V., et al. (2017) Simultaneous Unilateral Anterior Thoracoscopy with Transcervical Thyroidectomy for the Resection of Large Mediastinal Thyroid Goiter. Journal of Thoracic Disease, 9, 2484-2490. [Google Scholar] [CrossRef] [PubMed]
[57] Zieliński, M., Kużdżał, J., Szlubowski, A. and Soja, J. (2004) Trans-cervical-Subxiphoid-Videothoracoscopic “Maximal” Thymectomy—Operative Technique and Early Results. The Annals of Thoracic Surgery, 78, 404-409. [Google Scholar] [CrossRef] [PubMed]

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