肺癌的手術治療 Surgery for Lung Cancer 曾宇鼎醫師 臺大醫院雲林分院胸腔外科主治醫師
肺癌 : 近年來台灣癌症死亡原因之第一名 肺癌 肝癌 大腸癌 資料來源 : 行政院衛生署
非小細胞肺癌 : 約佔所有肺癌之 85-90% 外科手術之角色 : 根除性切除 : 提供早期肺癌病患最佳根治及存活機會確定診斷與分期症狀解除
肺癌手術簡介 : 肺臟切除不再重生 楔狀切除術 肺葉切除術 雙肺葉切除術 全肺切除術
肺癌手術後肺活量短期減少 40-70%; 長期減少 10-40%, 如何減少短期傷害?
肺癌手術及麻醉之進展趨勢 : 肺癌手術及麻醉之風險 : 老年病患居多, 心肺功能不佳術前及術後須追加治療, 惡化身體狀況切除肺臟及胸壁肌肉, 嚴重影響肺功能全身麻醉及插管使用呼吸器之併發症肺癌手術及麻醉進展趨勢 : 減少胸壁創傷 : 胸腔鏡手術減少肺實質切除 : 肺節切除術及楔狀切除術減少麻醉創傷 : 免插氣管內管之胸腔鏡手術
胸腔鏡肺葉切除術 : 優點 胸腔鏡肺葉切除術後之肺功能影響較小 胸腔鏡手術引發較少之發炎反應, 對免疫功能較好 胸腔鏡肺葉切除術後長期生活品質較好 1. Kaseda S. Ann Thoracic Surg, 2000 2. Leaver HA. Eur J Clin Investi, 2000 3. Sugiura H. Surg Laparo Endo, 1999
VATS vs. Thoracotomy? 台大醫院肺癌手術經驗 (1997-2010) (n=616) (n=301) Courtesy from Dr. Kuo SW
肺葉切除術 : 胸腔鏡或開胸手術? 目前胸腔鏡肺葉切除術已經有許多醫學中心使用於肺癌之手術治療. 安全性 : 與開胸手術類似, 甚至更好 腫瘤學方面考量 (JCO 2009 meta-analysis): 局部復發率沒有差別 遠處轉移率較低 5 年死亡率較低 Yan TD. J Clin Oncol 2009.
B. 如何減少肺實質切除? Lobectomy or less? Lobectomy Sublobar resection 1. Wedge resection 2. Setmentectomy
62 歲女性, 胸部電腦斷層發現 0.7 公分結節, 是否一定要接受肺葉切除?
VATS sublobar resection for lung cancer 包括楔狀切除 (wedge resection) 或肺節切除 (segmentectomy) 局部復發率可能稍高, 但長期存活率和肺葉切除術類似 楔狀切除或肺節切除之適應症 : 腫瘤小於 2 公分, 特別是 Bronchioloalveolar cell carcinoma (BAC) 之前曾接受肺臟手術 年齡大或心肺功能差之病患 Bilfinger TV. Curr Opin Pulm Med 2008
Sublobar resection for lung cancer Wedge resection 肺葉切除術 Lobectomy Segmentectomy
術後 6 日出院, 日常生活不受 影響 Post-op CXR
傳統胸腔鏡手術之麻醉 C. 如何減少麻醉創傷? General anesthesia with muscle paralysis Endotracheal intubation with one lung ventilation -> 醫師輕鬆, 病患危險增加 : Increased risk of pneumonia Impaired cardiac performance Barotrauma by ventilator Pulmonary atelectasis Intubation-related complication
Double-lumen Endotracheal Tube Left-sided tube 16
Double lumen endotracheal tube- 長又粗, 不適合東方女性 Carlens tube, Since 1949
30 y/o female with IDDM and uremia Complicated with right empyema Before Double-lumen intubation Courtesy from Dr. Hsu HH CPR for Tension pneumomediastinum after Double lumen intubation
免插氣管內管胸腔鏡手術 Non-intubated (Awake) VATS 免氣管插管胸腔鏡 (nonintubated VATS) 手術之優點 無插管之併發症心血管之功能較不受影響 Improved myocardial blood flow Improved LV function Reduced heart rate and arrhythmia 術後肺功能恢復較好 Intact cough ability immediate after op Improved post-op lung function COPD 術後發作之比例較低 Decreased bronchospasm Decreased respiratory complications Mineo TC. Eur J Cardiothorac Surg. 2007
病患自主呼吸, 如何讓手術之肺 臟塌陷? Open pneumothorax
近代 Nonintubated thoracic surgery 之創始 : 针灸传奇 尼克松参观针灸麻醉开胸术 原美国总统尼克松参观针灸麻醉开胸手术 : 据著名的胸外科专家辛育龄讲 上世纪 70 年代, 中美关系出现了缓和,1972 年尼克松访华, 在访问期间, 他们特意提出要参观针灸麻醉, 因为他觉得这实在不可思议的魔术
Nonintubated VATS 手術現況 : 肋膜腔疾病之診斷及治療 : Pleural biopsy (199?) Spontaneous pneumothorax, empyema (1998) 周邊楔型肺臟切除 : Resection of pulmonary nodules (2004) Resection of solitary metastasis (2007) Lung volume reduction surgery (2006) 肺葉切除 : 目前只有本團隊研究報告 (2011) Mineo TC. Eur J Cardiothorac Surg. 2007
Nonintubated VATS 需克服之困難 : 肺功能不良病患, 使用單肺自主呼吸可能引發血中二氧化碳濃度過高, 甚至呼吸衰竭手術時肺臟及縱隔腔位移支氣管受刺激, 引發咳嗽反應側躺開刀姿勢, 要再插 double lumen tube 困難 Mineo TC. Eur J Cardiothorac Surg. 2007
Nonintubated VATS 在台灣或台大醫院是否可行? 台灣手術室麻醉現況 : 麻醉醫師只有在插管及拔管時會出現一位麻醉科醫師須同時照顧數位病患 麻醉安全第一守則 : 建立安全及穩固的呼吸道放倒病患及氣管插管是最好的選擇 胸腔手術不插氣管內管 : 自找麻煩! 發神經了?
前兩例 Nonintubated needlescopic VATS 切除肺節結 76 歲女性, 大腸癌術後 左下肺 1 公分腫瘤 59 歲男性, 胸腺癌術後復發
Ann Thorac Surg. 2012 Apr;93(4):1049-54
46 patients with peripheral lung nodules (2008-2011)
Nonintubated needlescopic VATS Safe and feasible 100% diagnostic rate, satisfactory scars and less wound pain Easy conversion to standard VATS if major pulmonary resection is required An attractive method for diagnosis of small peripheral lung nodules.
Bilateral nonintubated VATS 58 y/o female, Sjogren s syndrome Final pathology: 1. Left: BAC 2. Right: benign nodule Tsai TM, et al. J Thorac Cardiovasc Surg, revision
Non-intubated VATS segmentectomy for high risk patients: 81 y/o male, COPD, LLL sq. ca FEV1.0: 1.02L, 44.6% % FEV1.0: 47.9% Pre-op CXR Post-op CXR Final pathology: T2aN0M0 Postoperative stay: 4 days
81 y/o female, RLL adenocarcinoma FEV1.0: 0.77L, 74.5%; %FEV1.0: 58.8% Non-intubated VATS wedge resection Post-op stay: 5 days
Non-intubated thoracoscopic lobectomy: The NTUH experience
Chen JS et al. Ann Surg 2011
Patients and methods Study design: Retrospective chart review with historical control Study group (2009/8-2010/6): 30 lung cancer patients underwent non-intubated thoracoscopic lobectomy Control group (2008/8-2009/7): 30 lung cancer patients with the same selection criteria underwent intubated thoracoscopic lobectomy using single-lung ventilation
Selection criteria for thoracoscopic lobectomy Inclusion criteria: Stage I or II peripheral NSCLC Tumor size < 6 cm Without evidence of chest wall, diaphragm or main bronchus involvement Exclusion criteria: ASA score > 3 Bleeding disorders Unfavorable airway or spinal anatomy
32 y/o female, adenocarcinoma Clinical staging: ct1bn0-1m0
Table 5. Difference in Anesthesia methods Between Published data Study group NTUH, 2011 Anesthesia Epidural IV sedation + Vagal block Pompeo 2004, 2008, 2010 Epidural + IV sedation Rocco 2010** Epidural + Local IV sedation Katlic 2010 Local + IV sedation Elia 2005 Intercostal block Pleural + + +* + +* Bullectomy or bulloplasty Wedge resection Mediastinal manipulation + + - - - + + + + - + ± - ± - Lobectomy + - - - - *Theoretically feasible **Confined to case report
Nonintubated VATS: 台大經驗 (2009-2012) A total of 258 patients underwent 259 VATS Needlescopic VATS wedge resection: 47 cases Conventional VATS wedge resection: 100 cases VATS segmentectomy: 8 cases VATS lobectomy: 104 cases (including benign and malignant diseases) Conversion to intubated general anesthesia: 14 cases (6%) No mortality
並非沒有風險 Conversion to general anesthesia Timing: Severe and dense adhesions Poor oxygenation Significant mediastinal movement Uncontrollable bleeding (Emergent) Method: Seal the wound with a chest tube to re-expand the lung Rotate the operation table Single lumen endo-tube insertion +/- bronchoscopy, followed by blocker.
Take home message for non-intubated VATS: 1. Cooperation between surgeons and anesthesiologists 2. Risk/benefit analysis before the operation Chen JS, Ann Surg 2011
免氣管插管之胸腔鏡手術結論 可使用於診斷及治療良性及惡性肺疾病可進行楔狀切除術 肺節切除術 肺葉切除術可雙側手術免氣管插管之胸腔鏡肺葉切除術手術成果類似插管麻醉之肺葉切除術安全性腫瘤考量需與麻醉醫師充分溝通配合
肺癌手術的未來 : 未來的世界是老年人的世界 體力不好 心臟不好 呼吸功能不好 手術併發症比例高 不僅開刀方式要微創, 麻醉方式也要微創 縮小傷口 :Needlescopic VATS 減少切除範圍 :Lobectomy to segmentectomy 微創麻醉 :Non-intubated VATS General anesthesia with endotracheal intubation 決不是每一台胸腔手術的必然選擇