Dmitrii Sekhniaidze, Diego Gonzalez-Rivas, Pavel Kononets, Alejandro Garcia, Vladimir Shneider, Malik Agasiev, Ivan Ganzhara
European Journal of Cardio-Thoracic Surgery, ezaa120, https://doi.org/10.1093/ejcts/ezaa120
Published: 05 July 2020
AbstractObjectives: Important benefits in uniportal video-assisted thoracoscopic surgery (VATS) for lung cancer have recently been achieved. However, the use of this technique for complex sleeve procedures is limited. We describe the technical aspects of and patient outcomes following carinal resections using uniportal VATS.背景：目前單孔胸腔鏡輔助下肺癌手術已取得較好的臨床獲益。但其在複雜袖狀切除術中應用較少。本研究展示了單孔VATS應用於隆突切除術的手術技巧和患者長期預後。
Methods: Since 2015, 16 sleeve carinal resections, including 11 right pneumonectomies, 4 right upper lobectomies and 1 lung-sparing carinal resection, have been performed at the Regional Clinic Hospital, Tyumen, Russia.方法：自2015年起於俄羅斯秋明地區中心醫院共進行了16例袖狀隆突切除重建手術，包括11例右側全肺切除術，4例右上葉切除術和1例保留肺組織的隆突重建切除術。
Results: The mean surgical time was 215.9 ± 67.2 min (range 125-340 min). The mean blood loss volume was 256.3 ± 284.5 ml (range 50-1200 ml). There was 1 case of conversion to thoracotomy. The crate was 25%, and the mortality rate was 0%. The median overall survival was 38.6 ± 3.5 months.結果：平均手術時長為215.9± 67.2 （125-340 min）。平均失血量為256.3 ± 284.5 ml (50-1200 ml)。其中1例患者中轉開胸。術後併發症發生率25%，病死率0%。中位OS為38.6 ± 3.5個月。
Conclusions: The use of uniportal VATS for carinal resections in certain patients allows for radical resections with low rates of morbidity and mortality.結論：在部分患者中使用單孔胸腔鏡進行隆突切除術可達到根治性切除，併發症和病死率較低。
Keywords: Advanced video-assisted thoracoscopic surgery resections; Carinal resections; Lung cancer surgical outcomes; Uniportal video-assisted thoracoscopic surgery.
—討論—
單孔隆突重建難度確實是高不少，從既往國內報導的結果來看，作者單孔確實做的比較快，當然這種比較沒什麼意義。看大咖炫技的同時，一切為了患者的安全。
有趣的是這裡的病例都是右側，個人覺得可以借著作者的思路思考一下左側的種種。N2如何治療更需要深思。
如果想了解更多可以翻看這個連結：https://link.springer.com/chapter/10.1007/978-981-13-2604-2_29
目錄
INTRODUCTION
PATIENTS AND METHODS
Surgical technique
Optimal surgical field exposure
Nodes first technique
Anastomosis
Covering
RESULTS
DISCUSSION
CONCLUSION
INTRODUCTION
Carinal resection is arguably the most challenging procedure in general thoracic surgery and is completed at only a few centres worldwide, likely because of its technical complexity and limited patient benefit. However, good survival results can be expected in patients with pN0- or pN1-stage lung cancer, so these surgical approaches are effective options if performed by experienced surgeons.眾所周知隆突切除術是普胸外科最具挑戰性的手術，僅在全球少數幾個中心能夠順利進行，可能是由於其技術復髮型和有限的患者獲益。然而在pN0-N1期肺癌中可能有較好的預後，因此經驗豐富的外科醫師開展這一手術是一種有效的治療方式。
Today, video-assisted thoracoscopic surgery (VATS) has been widely applied to treat lung cancer. However, guidelines for the treatment of non-small-cell lung cancer only recommend VATS for stage 1 tumours but not for more locally advanced cancers. A few reports from Eastern countries have described the use of VATS for carinal resections, but few describe the use of uniportal VATS (UVATS) in such procedures. Although the use of VATS and UVATS for carinal resections is reportedly both practical and safe, their utility is limited, with no survival data available. We describe the technical aspects and patient outcomes for carinal resections using UVATS at our hospital since 2015.目前VATS廣泛應用於肺癌的治療。但非小細胞肺癌診療指南僅推薦對I期腫瘤行VATS手術，在進展期腫瘤未作推薦。來自東亞國家的部分報導提到了VATS在隆突切除術中的應用，但幾無在術中應用UVATS. 雖然研究顯示VATS和UVATS在隆突切除術中安全可行，其應用範圍仍較小，尚無遠期生存數據。本研究對本中心自2015年來的UVATS隆突切除術的手術技巧和患者預後進行匯總分析。
PATIENTS AND METHODS
From 2015 to 2018, 16 patients with tumours of the right main bronchus and carina received radical resections at the Regional Clinic Hospital, Tyumen, Russia. All 16 surgeries were performed using UVATS. A central lung tumour requiring carinal resection to enable radical resection was an indicator for minimally invasive carinal resection. Tumour invasion did not extend >2 cm from the lower trachea or 1.5 cm from the opposite main bronchus. The main contraindication for a carinal resection using VATS was a tumour size of >8 cm. In our opinion, lung resection can be performed by UVATS with any tumour size.自2015-2018年，俄羅斯秋明地區中心醫院共進行了16例右主支氣管及隆突根治性手術。所有患者均為UVATS。一例中央型肺癌需行隆突切除術以確保R0切除。腫瘤於氣管下段侵襲範圍＜2 cm或對側主支氣管＜1.5 cm。使用VATS進行隆突切除術的主要禁忌症是腫瘤大小> 8 cm。我們認為，任何大小的腫瘤均可行UVATS肺切除手術。
Surgical technique
All procedures were performed following oncological principles: tumour-free margins were confirmed by intraoperative frozen section, *en bloc* resection and systematic lymphadenectomy.所有手術均遵循腫瘤學原則：通過術中冰凍確定腫瘤切緣陰性、完整整塊切除及系統性淋巴結清掃。
Management of anaesthesiology was comparable to that for open resection. Initially, intubation was performed using a double lumen tube. Once the resection was completed, a high-frequency jet ventilation catheter was inserted into the left main bronchus with the patient positioned in the left lateral decubitus position.麻醉管理於開放切除術並無二致。手術開始時實用雙腔氣管插管。切除完成後，將高頻噴射通氣導管插入左主支氣管，患者取左外側臥位。
All procedures were performed using UVATS with an incision made in the 4th or 5th intercostal space at the right midaxillary line.所有病例均通過右側腋中線第4-5肋間行UVATS。
All margins were confirmed to be tumour free by frozen section prior to anastomosis.所有切緣吻合前均通過病理證實切緣陰性。
Optimal surgical field exposure
The creation of adequate exposure of the surgical field under direct visual control is necessary for the safe execution of all stages of the procedure. After creating a single port between 4 and 6 cm in length, a wound protector was placed to provide optimal exposure. Before dissecting the lung hilum, all adhesions were divided. The azygos vein was transected using vascular clips or ligatures. To create the optimal exposure of the paratracheal space, we fixed the stumps of the azygos vein to the mediastinal and costal pleurae with sutures (Fig. [1]).在鏡頭直視下，建立手術視野的充分暴露暴露是安全進行手術每一步所必備的。為充分暴露，建立好4-6cm長的切口後需在切口防止切口保護套。進行肺門清掃前，需分離粘連。奇靜脈實用血管夾或結紮切斷。為了暴露好氣管旁間隙，我們用縫合線將奇靜脈的殘端固定在縱隔和肋胸膜上（圖1）。
Figure 1:
Optimal surgical exposure: (1) posterior stump of the azygos vein; (2) paratracheal tissue; (3) superior vena cava; (4) anterior stump of the azygos vein; and (5) anterior mediastinum.
In cases of sleeve right upper lobectomies and lung-sparing resections, a vascular tourniquet was used on the pulmonary artery, to provided more space for manipulation during reconstruction (Fig. 2).在一例右肺上葉袖式切除及保留肺組織切除術中，在肺動脈上使用血管止血帶，以提供更多的重建空間。（圖2）
Figure 2:
Optimal surgical exposure: (1) lung; (2) bronchus intermedius; (3) left main bronchus; (4) trachea; (5) anterior stump of azygos vein; (6) right pulmonary artery; and (7) tourniquet.
Nodes first technique
After the division of all adhesions and optimal exposure of the surgical field, a systematic mediastinal lymphadenectomy (the nodes first technique) was performed. During lymphadenectomy, all structures of the mediastinum and the lung hilum were exposed and the ability to perform radical resection was confirmed. Mediastinal lymphadenectomy included removing the hilar (#10), subcarinal (#7) and right paratracheal (#2R and #4R) lymph nodes. When removing a block of nodes, it is important to preserve the blood supply to the tracheal wall and main bronchi for optimal healing of the tracheobronchial anastomosis.分離粘連和手術野充分暴露後，進行系統性淋巴結清掃術（淋巴結先行）。在淋巴結清掃術中，暴露縱隔各結構和肺門，並對是否可以行根治性手術進行確認。縱隔淋巴結清掃術包括肺門（10）、隆突下（7）和有支氣管旁淋巴結（2R、4R）。清掃大塊淋巴結時，最重要的是保證氣管壁、主支氣管血供和氣管支氣管吻合後的理想癒合。
The mediastinal pleura was opened along the vagus nerve. And the block of subcarinal lymph nodes was separated from the wall of the oesophagus. In this case, it was necessary to ensure that the active branch of the energy device scalpel did not contact the wall of the oesophagus and the membrane of the bronchi. A nasogastric tube was not used as it would prevent adequate visualization during UVATS subcarinal lymph node dissection. The middle chest oesophagus was partially mobilized from the main bronchi and moved posteriorly for better visualization of the subcarinal space. As a result, the branches of the bronchial artery could be isolated and clipped, creating additional conditions for working in a 『dry』 surgical field.沿迷走神經打開縱膈胸膜。將隆突下淋巴結從食管壁逐步分離。進行這一操作時，必須確保能量設備的簡短未接觸到食管壁和支氣管膜部。通常不下鼻胃管，因其可能妨礙到UVATS隆突下淋巴結清掃時各組織的骨骼化。胸中段食管可從主支氣管部分游離並移向後方，確保隆突下區域的充分暴露。因此支氣管動脈的分支需要游離後結紮，為「幹(淨）」的手術野創造有利條件。
Then, right paratracheal lymph node dissection was performed. The mediastinal pleura was dissected in the cranial direction along the border of the superior vena cava (along the phrenic nerve) and the right vagus nerve. After cutting the azygos vein and exposure, lymph node dissection was straightforward. The lower semicircle of the brachiocephalic artery was the upper point of the dissection.隨後進行右側氣管旁淋巴結的清掃。沿著上腔靜脈和右側迷走神經（或膈神經）的方向自下而上打開縱膈胸膜。結紮切斷奇靜脈並充分暴露後進行淋巴結清掃。胸腔內頭臂幹弓下為清掃的最高點。
Mediastinal lymphadenectomy performed during the first stage of the surgery allowed free access to the mobilized bronchial structures and permitted visual assessment of the border of the tumour when evaluating the possibility of resection. In addition, after dissecting the lymph nodes, all structures of the lung hilum and trachea become mobile, resulting in safer intersection.在手術的第一階段進行的縱隔淋巴結清掃術，有助於接近並游離支氣管，並在評估切除的可能性時能夠視覺評估腫瘤的邊界。此外，清掃淋巴結後，肺門和氣管的多數結構均已游離，從而使手術更加安全。
Anastomosis
Two types of anastomotic reconstructions were used. The first was relatively simple, consisting of an end-to-end, tracheobronchial anastomosis with sleeve carinal pneumonectomy. The second type was double-barrel reconstruction and was required for sleeve carinal right upper lobectomy and sleeve carinal lung-sparing resection.實用兩種吻合重建方法。第一種相對簡單，包括端端氣管支氣管吻合及袖狀隆突肺切除術。第二種為隆突切除後雙側支氣管隆突重建、需要進行袖狀右上葉切除術和袖狀保留肺組織切除術。
After carinal resection, a mismatch of stump diameter often occurred. This could be overcome using telescopic techniques invaginating the smaller diameter into the larger.隆突切除後，氣管支氣管殘端直徑不完全匹配。可以通過使用縮縫技術將直徑較小的支氣管插入直徑較大者來解決。
When performing tracheobronchial suturing using UVATS, it was very important to position the camera in the posterior part of the incision, so that both hands were visible beneath the camera. Then, the same principle was applied as for an open anterior thoracotomy: the surgeon had a direct view of their hands. The dimensions of the reconstruction were important to consider when planning the use of only a single incision [[7]].當使用UVATS進行氣管支氣管縫合時，將鏡頭置於切緣後方十分重要，因兩操作臂均在視野內。然後，採用與開放式前胸切開術相同的原理：外科醫生可以直接看到他們的操作臂。當計劃僅使用單孔手術時，重建的尺寸非常重要。
A single tracheobronchial anastomosis was always performed in an end-to-end fashion using a running suture. Monofilament suture material (both non-absorbable and absorbable) such as Prolene 3/0 and polydioxanone sutures 3/0 with 2 needles (Ethicon, Somerville, NJ, USA) were typically used. The running suture began at the left cartilage–membranous junction of the trachea and the bronchus. The suture first joined the left side wall of the trachea to the left side wall of the left main bronchus. Then, the cartilaginous and membranous sections were sutured continuously with both ends of the thread directed towards each other and tied on the right wall of the tracheobronchial anastomosis (Fig. [3] and Video 1).單氣管支氣管吻合術常採用連續縫合以端端吻合的方式進行。通常使用單絲縫合線材料（不可吸收和可吸收的），例如Prolene 3/0和帶有兩個針的聚二惡烷酮縫合線3/0（Ethicon，Somerville，NJ，USA）。縫合起始于于氣管和支氣管的左軟骨-膜連接處。然後，連續縫合軟骨和氣管膜部，使線的兩端彼此相對並在氣管支氣管右側壁上進行打結（圖3）。
Figure 3:
End-to-end tracheobronchial anastomosis: (1) posterior stump of the azygos vein; (2) trachea; (3) left main bronchus; and (4) oesophagus.
The double-barrel tracheobronchial reconstruction is technically more difficult. It involves the reimplantation of the left main bronchus and the bronchus intermedius to the trachea with construction of a neo-carina. Anastomosis began from the left wall of the trachea and the left main bronchus. Cartilaginous and membranous regions were sequentially joined using a continuous suture. Next, a neo-carina between the medial walls of the left main bronchus and the intermediate bronchi (or the right main bronchus in the case of lung sparing) was created using interrupted sutures (Fig. [4]).雙側氣管支氣管重建在技術上更加困難。它涉及到左主支氣管和中間支氣管再植入到氣管中，並涉及新隆突的重建。重建需要先從氣管左側壁和左主支氣管開始。使用連續縫合將軟骨和氣管膜部連續縫合。隨後，使用間斷縫合在左主支氣管和中間段支氣管（或在保留肺的情況下為右主支氣管）之間形成一個新隆突（圖4）。
Figure 4:
Double-barrel carinal reconstruction: (1) right main bronchus; (2) trachea; (3) left main bronchus; and (4) suction.
Then, a continuous suture was used between the trachea and the bronchus intermedius as for single tracheobronchial anastomosis.隨後與單支氣管支氣管吻合術一致，在氣管和中間支氣管之間使用連續縫合。
Covering
The anastomosis was always covered to prevent leakage. In cases of a short and limited resection without tension or risk of leakage, a mediastinal flap could be used. In this case, a flap of mediastinal pleura and fat was mobilized with an energy device from the anterior mediastinum and attached to the anastomosis with separate sutures.常使用組織覆蓋術以防支氣管胸膜瘻。如果切除範圍短且沒有張力或滲漏的危險，可以使用縱隔脂肪瓣。在這種情況下，用能量裝置從縱隔前部游離縱隔胸膜和縱隔內脂肪瓣，並用單根的縫合線將其附著在吻合處。
In cases of a high risk of anastomotic leakage, the diaphragm was used to cover the anastomosis. A flap was cut so that the lower diaphragmatic vessels maintained vascularity (Fig. 5).在瘻風險較高的病例中，使用膈肌包裹吻合口。游離肌瓣並保持膈肌血供（圖5）。
Figure 5:
Diaphragmatic flap cutting scheme (bird view): (1) heart; (2) diaphragmatic flap; (3) inferior vena cava; (4) oesophagus; and (5) descending aorta.
Any part of the diaphragm that was sufficiently wide and long enough could be used. After cutting the flap, the defect in the diaphragm was closed with a continuous suture. In all cases, we prepared the flap so that the apical section extended 2–4 cm higher than the tracheobronchial anastomosis.足夠長度和寬度的肌瓣均可使用。切除肌瓣後，用連續的縫合線縫合膈肌的缺損。所有的病例中我們均游離好肌瓣使之尖端高於氣管支氣管吻合口2-4cm。
The flap was fixed with 4 U-shaped relaxation sutures around the ipsilateral semicircle of the tracheobronchial anastomosis. The first suture was passed through the para-aortic fascia at the level of the tracheobronchial anastomosis. The lower and front sutures were passed through the medial wall of the contralateral main bronchus and the anterior wall of the anastomosis. The upper suture was passed through all layers of the lateral tracheal wall. Finally, the tracheobronchial anastomosis was tightly wrapped (Fig. [6] and Video [2]).肌瓣用氣管支氣管吻合的同側半圓周圍的4個U形鬆弛縫合固定。第一針縫合在氣管支氣管吻合處穿過主動脈旁筋膜。下縫線和前縫線穿過對側主支氣管的內壁和吻合口前壁。上縫線需穿過氣管側壁全層。最終將氣管支氣管吻合口緊密包裹（圖6，視頻2）。
Figure 6:
Diaphragmatic flap fixation: (1) oesophagus; (2) trachea; (3) superior vena cava; (4) anterior stump of the azygos vein; and (5) diaphragmatic flap.
Video 1: End-to-end tracheobronchial anastomosis.
Video 2: Diaphragmatic flap fixation.
Statistical analysis
All statistical tests were performed using IBM SPSS Statistics 20.0 for Windows (USA). Measurement data were shown as the mean (standard deviation). For the survival analysis, we used the Kaplan–Meier method and compared by the log-rank test.所有的統計學檢驗均使用IBM SPSS 20.0進行。可測量數據以均數（標準差）呈現。生存分析使用K-M法，其對比使用log-rank檢驗進行。
RESULTS
The mean age of the patients (15 men, 1 woman) was 59 ± 4.0 years (range 54–69 years). All tumours were diagnosed as pathologically malignant using a fibre bronchoscope prior to surgery. Seven (40%) patients in our study were subjected to neoadjuvant chemotherapy (via tumour board decision). The mean number of neoadjuvant chemotherapy courses was 3.8 ± 1.1 courses (range 3–6 courses) (Table [1]).患者（15例男性，1例女性）的平均年齡為59 ± 4.0歲（54-69歲）。術前均經細支氣管鏡病理證實為惡性腫瘤。7例（40%）患者接受了新輔助化療（經MDT決定）。進行新輔助治療平均為3.8 ± 1.1個周期（3-6周期）（表1）。
Table 1:
Patient characteristics
VariablesAgeGenderSmoking history (years)FEV1 (%)FVC (%)VC (%)HistologyNeoadjuvant chemotherapyClinical stageCase 1 55 Male 40 60 75 87 SC 0 T3N0M0 Case 2 55 Male 48 74 77 99 SC 0 T3N0M0 Case 3 60 Male 38 72 80 80 SC 0 T3N0M0 Case 4 61 Female 0 72 88 88 CR 6 EC T4N0M0 Case 5 69 Male 50 64 100 123 SC 0 T3N0M0 Case 6 65 Male 50 48 44 64 SC 4 EP T3N0M0 Case 7 57 Male 42 78 66 92 SC 0 T3N0M0 Case 8 57 Male 40 88 75 86 SC 3 EP T2N2M0 Case 9 61 Male 40 54 50 51 SC 4 EP T4N0M0 Case 10 60 Male 40 79 61 79 SC 3 EP T4N1M0 Case 11 55 Male 40 80 84 84 SC 0 T4N0M0 Case 12 59 Male 40 48 66 75 ADC 0 T2N0M0 Case 13 54 Male 35 62 86 88 SC 4 GC T4N2M0 Case 14 57 Male 38 88 78 101 SC 0 T3N0M0 Case 15 62 Male 40 50 70 86 ADC 3 GC T3N2M0 Case 16 57 Male 45 88 78 101 SC 0 T3N0M0ADC: adenocarcinoma; CR: carcinoid tumour; EC: etoposide + carboplatin; EP: etoposide + paclitaxel; FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity; GC: gemzar + cisplatin; SC: squamous cell carcinoma; VC: vital capacity.
Four patients were considered at high risk for anastomotic fistula formation due to a positive water probe test at the end of the anastomosis, high anastomotic tension after extended pneumonectomy and >4 courses of chemotherapy. These patients all underwent diaphragmoplasty of the tracheobronchial anastomosis.4例患者因擴大全肺切除術後吻合口張力過高、化療＞4個周期、吻合術後經水封檢驗為吻合口瘻高風險患者。這些患者均接受了氣管支氣管吻合術膈肌肌瓣成形術。
General perioperative data are presented in Table [2]. The most common surgical procedure performed in this study was sleeve carinal pneumonectomy (69%). In addition, 4 (25%) sleeve carinal right upper lobectomies and 1 (6%) lung-sparing sleeve carinal resection were performed. The mean surgical time was 215.9 ± 67.2 min (range 125–340 min), and the mean blood loss volume was 256.3 ± 284.5 ml (range 50–1200 ml). There was 1 case of conversion to thoracotomy due to uncontrolled bleeding. We registered postoperative complications in 4 cases (25%), 1 case of pneumonia and 3 cases requiring surgery. In 1 case, chylothorax was observed on postoperative day 15 after sleeve pneumonectomy, which required repeat UVATS, debridement and clipping of the thoracic duct. One case of postoperative haemothorax was observed on postoperative day 4, requiring repeat UVATS and debridement. In 1 case, anastomotic leakage was observed on postoperative day 3, which required emergency thoracotomy, suturing of the defect of the anastomosis, and diaphragmoplasty. After the surgical correction of these complications, no other postoperative complications were observed. There was no postoperative mortality. The median survival was 38.6 ± 3.5 months.患者圍術期數據見表2.本研究中最常使用的手術為袖式隆突肺切除術（69%）。此外還包括4（25%）例袖狀右上葉切除術和1例（6%）保留肺組織的袖狀隆突切除術。平均手術時間為256.3 ± 284.5 ml (50–1200 ml)。，平均失血量256.3 ± 284.5 ml (50–1200 ml)。1例因無法控制的出血而中轉開胸。4例（25%）患者出現術後併發症，2例為術後肺炎，3例需行手術。在1例患者中，在進行袖狀肺切除術後的第15天後出現乳糜胸，需要二次UVATS清創術和胸導管結紮。1例因術後第4天血胸，需要二次UVATS和清創術。另1例患者因術後3天觀察到吻合口漏，這需要緊急開胸，縫合吻合口瘻和進行膈肌肌瓣成形術。這些患者二次手術處理併發症後，未觀察到其他術後併發症。圍術期病死率為0，中位生存時間為38.6 ± 3.5個月。
Table 2:
Perioperative data
VariableProcedureOperation timeBlood lossDuration of thoracic drainage (days)Pathological stageAdjuvant chemotherapyFollow-up duration (months)Recurrence-free duration (months)StatusCase 1 SPE 190 1200 5 T3N2M0 0 12 6 Died Case 2 SPE 150 100 7 T4N0M0 5 EC 24 14 Died Case 3 SPE 125 100 5 T4N2M0 6 EP 30 26 Died Case 4 LSSCR 280 250 6 T4N0M0 0 EC 37 37 Alive Case 5 SPE 140 50 7 T3N0M0 6 EP 36 36 Alive Case 6 SPE 235 100 3 T3N0M0 0 24 24 Alive Case 7 SCRUL 340 250 7 T3N0M0 3 EP 23 23 Alive Case 8 SPE 175 600 2 T2N2M0 1 EP 19 10 Died Case 9 SPE 245 350 9 T4N0M0 4 EP 28 26 Alive Case 10 SPE 220 200 15 T4N1M0 6 EP 18 18 Alive Case 11 SCRUL 305 200 9 T3N2M0 1 EP 12 12 Alive Case 12 SPE 130 200 3 T4N2M0 0 6 6 Alive Case 13 SPE 220 150 4 T4N0M0 3 EP 46 46 Alive Case 14 SCRUL 310 100 6 T3N0M0 0 47 47 Alive Case 15 SPE 220 150 4 T4N0M0 3 EP 43 43 Alive Case 16 SCRUL 270 100 6 T3N0M0 0 44 44 AliveEC: etoposide + carboplatin; EP: etoposide + paclitaxel; LSSCR: lung-sparing sleeve carinal resection; SCRUL: sleeve carinal right upper lobectomy; SPE: sleeve pneumonectomy.
Survival analysis was dependent on the stage of the tumour. Of the 16 study patients, 6 had stage N1–2 tumours and a median overall survival of 22.0 ± 4.7 months; the median overall survival of the remaining 10 patients without metastases to the mediastinal lymph nodes was higher 44.4 ± 2.4 months (*P* = 0.003).長期生存結果取決於腫瘤的分期。研究納入的16例患者中，6例患者為N1-2，其中位OS為22.0 ± 4.7個月；其餘10例無縱隔淋巴結轉移的患者的中位OS更高為44.4 ± 2.4個月（p=0.003）。
There were 5 cases of cancer recurrence. In all cases, these were distant metastases that caused death.
Adjuvant chemotherapy was administered to 10 patients (60%). The mean number of adjuvant chemotherapy courses was 3.8 ± 1.9 courses (range 1–6).5例患者出現腫瘤復發。所有病例均為遠處轉移致死。
10例（60%）患者接受了術後輔助化療。平均輔助化療周期為3.8 ± 1.9 （1-6）。
DISCUSSION
The rapid development of minimally invasive technologies over the past 25 years has allowed for the performance of very complex procedures such as bronchovascular resection and carinal resection. The advent of UVATS has accelerated this evolution. The first UVATS lobectomy was reported in 2011, and the first UVATS carinal resection was performed in 2016.微創手術在過去25年間的飛速發展使得開展高難度複雜手術如支氣管血管切除術、隆突切除術等成為可能。UVATS的出現加快了這一進程。第一例UVATS肺葉切除術於2011年進行，第一例UVATS隆突切除術於2016年開展。
In the series of patients presented above, there was no mortality during the postoperative period. In addition, the percentage of postoperative complications was acceptable. Good postoperative performance is largely due to the careful selection of relatively young patients. Although one can perform any procedure using UVATS, there is some restriction on the number of instruments inserted into the wound. To overcome this limitation, we used various retraction sutures and tourniquets, which were completely located in the pleural cavity and did not hinder the actions of the surgeon.在上述一系列患者中，無手術後死亡。此外，術後併發症率也在合理範圍內。良好的術後表現在很大程度上是由於精心選擇了相對年輕的患者。儘管可以使用UVATS進行任何手術，但是插入切口的手術器械數量還是受到限制。為克服這一限制，我們使用了多種牽拉線和止血帶，完全位於胸腔且不妨礙外科醫生的動作。
We also used the nodes first technique, a systematic mediastinal lymphatic dissection. Via lymphadenectomy, we determine the degree of resection of the lung parenchyma (with carinal lobectomy), confirmed the possibility of performing radical resection and prepared all anatomical structures for resection.同時我們也採用了系統性淋巴結清掃，淋巴結清掃先行的策略。通過淋巴結清掃術，可以判斷肺組織切除的範圍（即隆突伴肺切除術），證實R0切除的可行性，為切除游離好各解剖結構。
We prefer to perform anastomosis using a continuous suture, which has been shown to be safe and practical for bronchial anastomoses.考慮到支氣管吻合的安全性和可行性，術中更傾向採用連續縫合進行吻合。
A continuous seam improves visibility and provides more space for manipulation by the surgeon.連續縫合有助於視野並為術者提供更大的操作空間。
In a large series of sleeve carinal resections, Porhanov *et al.* reported a high frequency of anastomotic problems and related mortality.在更多袖狀隆突切除術報導中，Porhanov等報導了更高的吻合口併發症和吻合口相關死亡。（。。。起碼考慮一下時代局限性吧）
A diaphragmatic flap is one of the most reliable materials for covering an anastomosis, as its axis vessels are well marked and provide good circulation. The diaphragm has a strong, bilateral, serous cover that guarantees mechanical strength and integrity, and it cannot be stratified or torn. Its dimensions and form are varied, and the flap can reach the tracheobronchial anastomosis easily. The diaphragm is also thin, elastic and flat, so it can be modelled to yield a dense, airtight and leak-proof cover. The flap should be fixed to normal tissues beyond the area of the anastomosis so that destructive inflammation cannot spread to the site of the sutures. In our series, 4 patients underwent diaphragmoplasty of the tracheobronchial anastomosis without any leakage during the subsequent postoperative period.膈肌肌瓣是覆蓋吻合術的最可靠的材料之一，因為其供應血管標記清晰，可提供良好的循環。膈肌有堅固的雙側髒層胸膜蓋，可確保機械強度和完整性，並且難以分層或撕裂。其尺寸和形式各不相同，肌瓣可以很容易地達到氣管支氣管吻合口。膈肌薄、有彈性且平整，因此可以對其進行修剪以產生緻密，氣密和防漏的包裹物。肌瓣應固定在吻合口以外的正常組織上，以免損傷性炎症擴散到吻合口縫線處。在本研究中，有4例患者在隨後的手術期間接受了氣管支氣管吻合術膈肌肌瓣成形術，手術後無滲漏。
Many researchers have described the dependence of postoperative survival on the stage of the tumour. In our series, we observed significant differences in survival depending on metastasis to the mediastinal lymph nodes. The procedures described here are accompanied by less trauma and an acceptable number of complications. These advantages allow us to further use and develop this method for complex procedures such as carinal resection.多數研究人員表明術後生存與腫瘤生存直接相關。本研究中，有無縱隔淋巴結轉移的患者有明顯的生存差異。本研究採用的術式創傷更小，併發症也可接受。這些優點使我們可以進一步使用發展這一術式進行複雜的手術，例如隆突手術。
CONCLUSION
In conclusion, UVATS carinal resection is safe and practical for use in certain patients and results in acceptable postoperative outcomes. Further research is needed to evaluate long-term outcomes for these patients.總之，UVATS隆突手術在部分患者中安全可行，有較好的圍術期結果。未來需研究評估此類患者的長期預後。
Conflict of interest: none declared.
Author contributionsDmitrii Sekhniaidze: Writing—original draft; Writing—review & editing.
Diego Gonzalez-Rivas: Conceptualization; Investigation; Methodology.
Pavel Kononets: Writing—original draft.
Alejandro Garcia: Resources; Writing—original draft.
Vladimir Shneider: Methodology; Supervision.
Malik Agasiev: Data curation; Formal analysis.
Ivan Ganzhara: Data curation; Formal analysis.
Presented at the 7th Asian single port VATS symposium, Nagoya, Japan, 24–25 May 2019.