胸腺腫瘤日間手術(shù)專家共識

也更容易產(chǎn)生麻醉相關(guān)藥物蓄積，影響術(shù)后快速康復(fù)[13]。因此腺腫瘤常伴發(fā)重癥肌無力(myastheniagravis,MG),患者多以肌無力為首發(fā)癥狀就醫(yī)。力危象發(fā)作風(fēng)險，這些因素均限制了針對合并MG的胸腺瘤的日間手術(shù)開展[14]。QMG評分是目前評價MG患者病情嚴重程度較為常用的量表。較高的QMG評分進一步影響患者的美國麻醉醫(yī)師協(xié)會(AmericanSocietyofAnesthesiologists,ASA)分級和圍手術(shù)期安全性。臨床發(fā)現(xiàn)，一些胸腺腫瘤患者在圍手術(shù)期才首共識3:推薦胸腺腫瘤日間手術(shù)前常規(guī)行胸部增強CT或胸部MRI檢查，用于胸腺腫瘤的鑒別診斷和侵襲性判斷。(3級推薦)胸腺腫瘤的鑒別診斷主要集中于前縱隔腫瘤及類腫瘤性病變，包括括胸腺增生與胸腺囊腫)、胸內(nèi)甲狀腺腫、淋巴瘤、生殖細胞腫瘤、淋巴結(jié)。常規(guī)胸部CT考慮為非侵襲性胸腺瘤者，與周邊重要結(jié)構(gòu)(如大血管、心包)無明顯侵犯，也未觀察到明顯的病灶胸膜播散及淋巴結(jié)增大；包含Masaoka-Koga分期為病灶未侵透包膜的I期病變，NSAIDs鎮(zhèn)痛。共識5:胸腺腫瘤日間手術(shù)推薦單腔氣管導(dǎo)管聯(lián)合人工氣胸，必要時輔助支氣管封堵器實現(xiàn)單肺通氣。(2級推薦)進行日間胸腺腫瘤手術(shù)時，若采用單側(cè)胸腔入路，術(shù)中需實施單肺通氣或通過CO?人工單肺通氣患者相似，僅術(shù)中呼氣末CO?水平更高[35]。單肺通氣下進行手術(shù)，推薦使用 DLT)相比，使用支氣管堵塞器的患者發(fā)生低氧血癥、聲音嘶啞、咽喉痛、支氣管/隆突損傷以及術(shù)后肺部并發(fā)癥的風(fēng)險更低[36-38]其重要理念即無氣管插管施行胸外科手術(shù)[39]。相較單腔氣管導(dǎo)管使用，無插管技術(shù)完全的術(shù)后快速康復(fù)效果[40]。建議有條件的胸外科中心在麻醉科的充分配合下積極開展共識6:胸腺腫瘤日間手術(shù)，經(jīng)單側(cè)胸腔或劍突下入路均是可行的，技術(shù)條件允許時，推薦首選劍突下入路。(1級推薦)共識7:機器人輔助胸腔鏡手術(shù)(robot-assistedthoracoscopicsurgery,RATS)與外情況(如大出血或需要中轉(zhuǎn)開胸等緊急情況)時可能不如傳統(tǒng)手術(shù)方式靈活便捷。因此，共識8:胸腺腫瘤日間手術(shù)推薦全胸腺切除，可不行淋巴結(jié)采樣或清掃。(4級推薦)分析報道，Masaoka-Koga于Masasoka-KogaⅡ期胸腺瘤患者，胸腺部分切除術(shù)后復(fù)發(fā)對2.9%,P<0.05)[52]。目前無法通過術(shù)前影像學(xué)檢查及術(shù)中評估來區(qū)分Masasoka-KogaI-Ⅱ期患者，且術(shù)中無法評估Masasoka-KogaⅡ期患者的腫瘤侵犯程度。對于胸腺腫瘤日間移率為0.5%,其中A型、AB型和B1型胸腺瘤未發(fā)現(xiàn)淋巴轉(zhuǎn)移，根據(jù)pT分期的T1淋巴結(jié)轉(zhuǎn)移率僅0.2%[53]。說明早期胸腺瘤的淋巴結(jié)轉(zhuǎn)移概率極低。近年來，胸腺瘤淋巴結(jié)轉(zhuǎn)移的樣或清掃，胸腺瘤淋巴結(jié)轉(zhuǎn)移發(fā)生率提高到2.1%[54]。有關(guān)胸腺瘤淋巴結(jié)轉(zhuǎn)移的研究程度喉返神經(jīng)損傷)的發(fā)生。有淋巴結(jié)轉(zhuǎn)移的患者往往表現(xiàn)為較高級別的胸腺瘤、更大的腫瘤體共識9:胸腺腫瘤日間手術(shù)不留置胸腔引流管是可行的，推薦術(shù)后常規(guī)留置不大于16號的胸腔引流管。(3級推薦)8]報道了70例因縱隔腫瘤行胸腔鏡手術(shù)的患者，其中未留置胸腔引流管組的術(shù)后并發(fā)癥發(fā)生比例并未增加，部分患者的術(shù)后疼痛和住院時間減少。秦等[55]的研究納入98例經(jīng)劍突建議胸腺腫瘤日間手術(shù)常規(guī)留置不大于16號的胸腔引流管，如術(shù)后胸腔引流液總量小于200ml,顏色較淡，引流管無漏氣，胸部正側(cè)位片提示雙肺復(fù)張良好時，可拔除胸共識10:應(yīng)嚴格把控出院指征，以提高胸腺腫瘤日間手術(shù)安全性。(2級推薦)級推薦)首選次選腫瘤及受侵組織、包含前縱隔脂肪腫瘤及受侵組織、包含前縱隔脂肪在內(nèi)的全胸腺切除常規(guī)留置細胸腔引流管不留置胸腔引流管可行出院指證：①生命體征平穩(wěn)，體溫③手術(shù)切口無明顯紅腫及滲出；④胸腔引流管已拔除；⑤患者可正常進食全病程管理RATS:機器人輔助胸腔鏡手術(shù)VATS:電視輔助胸腔鏡手術(shù)圖1胸腺腫瘤日間手術(shù)推薦管理模式2019:guidelinesfromtheAssociationofAnaesthetistsandtheBritishAssociationofDaySurgery[J].Anaesthesia,2019,74(6):778-792.doi:10.1111/anae.10/cma.j.issn.1671-0274.NationalClinicalResergery(2019)[J].ChinJGenSurg,2019,28(11):1322-1335.doi:10.3issn.1671-0274.2019.12.005.2023,28(6):541-545.doi:10.3969/j.issn.10MoQZ,MiuBL,LiuJJ,Researchprogressofpercutaneousnephrolithotomyinambulatorysurgerymode[J].JModUrol,2023,sn.1009-8291.2023.06.016.[4]國家老年疾病臨床醫(yī)學(xué)研究中心，中華醫(yī)學(xué)會運動醫(yī)療分會.關(guān)節(jié)鏡日間手術(shù)臨床實踐專家共識[J].中國內(nèi)鏡雜志，2020,26(6):1-7.doi:10.3969/j.issn.1007-1989.20ietyofSportsMedicine.Expertconsensfdaysurgery[J].ChinJEndosc,2020,肺癌雜志，2020,23(2):77-83.doi:10.3779/j.issn.1009-3thlungcanerbyoptimizeoperatingprocess[J].ChinJLungCancer,2020,23(2):[6]高陽，李曦哲，張?zhí)m軍，等.機器人胸外科日間手術(shù)熱點問題探討[J].中華醫(yī)學(xué)雜志，2021,101(29):2271-2275.doi:10.3760/l12137-20210510-01106.[7]國家老年疾病臨床醫(yī)學(xué)研究中心，”機器人胸外科日間手術(shù)臨床實踐專家共識”編寫組.機器人胸外科日間手術(shù)臨床實踐專家共識[J].中國內(nèi)鏡雜志，2021,27(8):10-20.GroupofExpertConsensusonTheClinicalPracticeofRobotic-assistedThoracicDaySurgery.Expertconsensusontheclinicalpracticeofrooracicdaysurgery[J].ChinJEnd[8]中國醫(yī)師協(xié)會腫瘤多學(xué)科診療專業(yè)委員會.中國胸腺上皮腫瘤臨床診療指南(2021版)[J].中華腫瘤雜志，2021,43(4):395-404.doi:10.3760/112152-20210313021Edition)[J].ChinJOncol,2021,43(4):395-404.ThoracOncol,2011,6(7):ff.atPathol,2021,28(5[11]WangH,WangM,XinN,etal.Effecstalthymectomy:am925003.doi:10.3389/fsurg.202[12]Corona-CruzJF,Lopez-SaucedoRA,Ramirez-TiradoLctionsoflargethymomas:importanceofenblocthymectomy[J].JThoracDis,2018,10(6):3473-3481.doi:10.21037/jtd.2018.05.101.WuWW,GaoPQ,WuWH,etal,Studyontheearlymediastinaltumorresectionviasubxiphoidapproach[Z].ProceedingsoftheChineseOncologyCongress.Chongqing,2019:3714-3715.tRevNeurother,2019,19(9):823-833.doi:[15]XuC,ZhangY,WangW,etal-1117.doi:10.1111/1759-7714[16]MasaokaA,MondenY,NakaharaK,etal.Follospecialreferencetotheirclinicalstages[J].Cancer,1981,48(11):2485-24doi:10.1002/1097-0142(19811201)48:11<2485::aid-cncr2820481123>3.0.co;2-r[18]AckmanJB,VerzosaS,KovachAE,etahyperplasia,andthymiccysts?[J].EurJRadiol,2015,84(3):524-533.doi:[19]TomiyamaN,MullerNL,EllisSJ,etal.Invasivea10.1097/00004728-2001[20]HarrisK,ElsayeghD,AzabB,etal.Thymomacllymeaningful?[J].WorldJSurgOn[21]KuriyamaS,ImaiK,reatveininvasionbythymicepithelialtumors:measurementtweenthetumorandneighboringstructures[J].EurRadiol,2022,32(3):1891-1[22]PriolaAM,Priola[23]TakahashiK,Al-JanabiNJ.Computedtomographyandgingofmediastinaltumors[J].JMagnResonImaging,2010,32(6):1325-1339.d[24]AbdelRazekAA,KhairyM,Nandclinicalstaging[J].Radiology,2014,273(1):268-275.doi[25]TravainiLL,PetraliaG,TrifiroG,etomography/computedtomograpymiclesiontreatmentplanning[J].LungCancer,2008,61(3):362-368.doi:10.1016/j.lungcan.2008.01.019.estheticsonpostoperativepulmonarycomplicaarandomizedclinicaltrial[J].AnesthAnalg,2021managementofpostoperativenauseaandvomiting[J].AnesthAnalg,2020,131(2):[28]DengW,JiangCW,Qkinvideo-assistedthoracicsurgery:comparingthreeconcentrationsoaine[J].FrontPharmacol,2[29]ThilenSR,WeigelWA,ToddMM,etal.2023AmericanSocietlogistspracticeguidelinesformonitoringandantagonismofneuromuscularblockade:areportbytheAmericanSocietyofAnestheforReversalofNeuromuscularBlockadeandPostos(STRONGER):amulticentermatchedcohortanalysis[J].Anestheinalcordinjuryafterzenker'sdiverdicalAssociation,andMinimageonsBranch,ChineseMediThoracCardiovascSurg,2018,25(11):921-928.doi:10.7507/1007-4848.201810[33]MakkadB,HeinkeTL,Sheritiveandintraoperativepainmanagementofthoracicsurgicalpatients[34]ZhaoM,JiangT,LiM,etal.Video-assistedth[35]PalaczynskiP,Misiol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