2021年 · 第101卷第33期

In recent years, low-dose chest CT has been used to effectively screen pulmonary ground glass nodules, which has improved the detection rate of small pulmonary nodules, promoted the early detection, early diagnosis and treatment of lung malignant tumors, and effectively improved the clinical treatment effect of lung cancer. At present, surgery is still the first choice for early lung cancer treatment, but there is still some controversy for multiple nodules, especially for thoracoscopic surgery of multiple nodules in both lungs. This literature describes a novel approach, a combination of electromagnetic navigation bronchoscopy (ENB) -guided microwave ablation and video-assisted thoracoscopic surgery for the treatment of multiple high-risk pulmonary nodules in patients. This paper describes a patient who received two simultaneous treatments for multiple pulmonary nodules located in different lobes. First, the patient completes ENB, and the doctor delivers the positionable electromagnetic probe to the nodule of the right upper lobe according to the navigation route and indwelling the catheter, quickly diagnoses the right upper lobe lesion as adenocarcinoma in situ, and guides the microwave antenna to the distal end of the lesion through the working channel for microwave ablation treatment; Further thoracoscopic wedge resection of left upper lobe and lower lobe and lingual segment resection were performed. The lesions in the left upper and lower lobes were adenocarcinoma in situ, and the lesions in the left lingual segment were chronic inflammation.

With the increase of the detection rate of pulmonary nodules, thoracoscopic wedge resection is a reliable way to detect some small nodules. If the small nodules cannot be located, thoracoscopic surgery may convert to thoracotomy. A total of 39 image-guided thoracoscopic surgeries (iVATS) from April 2016 to November 2019 were included in this study. Study reports experience with simultaneous localization and thoracoscopic resection of non-palpable undiagnosed pulmonary nodules. The inclusion criteria were: small lesions (<1 cm), deep (>1 cm from the surface), subsolid or located within a dystrophic area. Conical beam CT was used for scanning and intraoperative marking with positioning hooks and coils. The size of the localized nodule was (12 ± 6) mm, and the distance from the deep edge of the lesion to the pleural surface was (24 ± 9) mm. A total of 20 positioning hooks and 19 coils were used for localization. Of these, 36 patients were successfully positioned (92.3%), 37 wedge resections were completed thoracoscopically, of which 2 (5%) were converted to thoracotomy, 9 patients with intraoperative diagnosis of lung cancer underwent lobectomy (7 thoracoscopic and 2 thoracotomy), the time of iVATS positioning was (30±13) min, and the postoperative hospital stay was 4 (3,5) d. These results suggest that iVATS appears feasible to reduce the conversion rate of thoracotomy in thoracoscopic surgery.

The treatment of adult spinal deformity (ASD) mainly aims to relieve symptoms, improve spinal function, reestablish stability and restore spinal balance. With the development of posterior spinal orthopedic instruments and the need to preserve spinal motor segments, spinal doctors are increasingly adopting the surgical strategy of selective posterior segmental fusion. Although good clinical results can be achieved, the occurrence of proximal junctional kyphosis (PJK) of postoperative fusion segments has gradually become one of the hot research topics in this field. PJK is a common complication after ASD surgery, mainly manifested by the decline of neurological function, worsening of spinal deformity and spinal instability, which requires reoperation. The incidence of PJK after ASD surgery can be as high as 69.4%. PJK was first proposed by Professor Lowe in 1994. Professor Kim et al. defined it as the Cobb angle in the sagittal plane of the proximal junction area after operation, that is, the angle (PJA) between the proximal fusion inferior vertebral endplate and the upper endplate of the proximal second vertebral body>10° and increased by 10° compared with that before operation. There are many studies on the mechanism of PJK after ADS, but the exact mechanism is not fully understood.

Small pulmonary nodules are located by CT in the radiology department and then go to the operating room for surgical resection. The stepwise method presents great risks, such as pneumothorax, hemothorax, and detachment of positioning hooks. Theoretically, these problems can be circumvented by simultaneous positioning and thoracoscopic surgery (VATS) in a composite operating room equipped with a suitable positioning system. This study included 12 patients with solitary pulmonary nodules who underwent image-guided thoracoscopic surgery (iVATS) from October 2016 to January 2017, and analyzed the feasibility of simultaneous localization followed by thoracoscopic surgery. The solitary pulmonary nodule observed in the study was 5.5 (4,6) mm in size and its distance from the pleural surface was 11.7 (6.0, 11.3) mm. All lesions were visible on intraoperative C-arm cone beam computed tomography images, 10 patients were successfully localized and complete thoracoscopic resection was successfully performed, the time required for localization was 45.5 (36, 60) min, whereas radiation exposure (expressed by skin absorbed dose) was 223.2 (180.3, 321.3) mGy. Focal localization failed in 2 cases due to pneumothorax caused by acupuncture, in which case practical thoracotomy was required to identify solitary pulmonary nodules. There were no surgical deaths and postoperative hospital stay was 4 (3.8, 4.0) d. This study shows that simultaneous positioning followed by thoracoscopic surgery can reduce the complications of this method. However, in the future, it is necessary to further apply other composite operating rooms with different equipment for comparison, and at the same time, it is necessary to further compare with thoracoscopic surgery after step-by-step positioning.