非体外循环下上腔静脉置换术的麻醉处理

右上肺癌和上纵隔肿瘤往往累及上腔静脉(SVC)及左右无名静脉。行肿瘤切除和SVC置换可达到根治性肿瘤切除或解除SVC阻塞的目的。我院成功开展了2例SVC置换手术,均在非体外循环情况下阻断SVC完成肿瘤切除及SVC移植术。     

血管重建在原发性纵隔肿瘤中的临床应用

目的总结血管重建在原发性纵隔肿瘤中的应用经验和疗效。方法经外科手术治疗并血管重建的原发性纵隔肿瘤76例,22例（28.9%）单纯侵及上腔静脉;16例（21.1%）侵及单纯左或右无名静脉;34例（44.7%）侵及上腔静脉和左或右无名静脉;有4例（5.3%）单纯侵及主动脉外膜。行完整切除70例,部分切除6例;行血管置换46例,血管成形30例。结果全组病人无一例围术期死亡。上腔静脉阻断时间为（10-30）min,平均（18.0±5.3）min。左或右无名静脉单侧阻断时间为（11-25）min,平均（16.5±4.2）min。全组病人均获随访,时间为12-26个月,术后生活质量满意。结论纵隔肿瘤侵及上腔静脉及其属支大血管的病人,如全身无系统功能严重受损应积极手术治疗,可选用血管置换或血管成形术。     

上腔静脉和无名静脉的切除及重建治疗纵隔肿瘤

目的　探讨分析纵隔肿瘤根治性切除 ,重建上腔静脉和无名静脉的手术意义及技术方法。　方法　回顾性分析北京协和医院 2 0 0 1～ 2 0 0 3年 11例纵隔肿瘤引起上腔静脉综合征患者的治疗及预后。根治性切除肿瘤 9例 ,其中 2例行心包修补静脉壁成形术 ,7例人工血管置换重建上腔静脉和无名静脉 ;2例部分切除。术中对左、右无名静脉分次阻断 ,单侧阻断时间 2 2 .15± 6 .2 9min,手术出血量 1342 .86± 6 92 .4 8ml。　结果　侵袭性恶性胸腺瘤 4例 ,胸腺癌5例 ,纵隔小细胞癌 2例。术后早期患者静脉梗阻症状即改善 ,无神经系统并发症 ,1例死于肺部感染 ,其余 10例全部健在 ,存活时间已达 6～ 30个月。　结论　上腔静脉和无名静脉的重建可以有效地消除上腔静脉综合征 ,其手术是安全的 ;但应注意病变的范围 ,争取根治性切除是提高生存率的关键。     

体外循环在胸部肿瘤手术中的应用价值

目的探讨体外循环技术在胸部肿瘤手术中的应用及价值，为难治性胸部肿瘤手术方法提供依据。方法对6例胸部肿瘤患者（右肺中心性肺癌1例、左肺中心性肺癌1例、气管肿瘤2例、食管癌1例、纵隔肿瘤1例）采用不同的体外循环方法进行麻醉或手术切除，行右全肺切除＋部分心包切除＋部分左心房切除1例，气管肿瘤切除、端端吻合2例，食管癌切除＋胸降主动脉部分切除＋人工血管修补1例，左全肺切除＋部分左心房切除1例，纵隔肿瘤切除先Gor Tex16mm人工血管施行左无名静脉-右心耳吻合＋Gor Tex12mm人工血管施行右无名静脉-上腔静脉吻合1例。结果6例患者均手术顺利，术后恢复良好，康复出院。随访3个月～5年，1例肺癌患者术后10个月死于肺部转移，其余患者生存良好，生活质量高，采用胸部X线片、胸部CT和超声心动图等检查均无复发。结论对侵及部分肺血管和心脏的胸部肿瘤患者，以及气管肿瘤不能常规进行麻醉的患者，应用体外循环技术可明显提高手术切除几率，增加手术安全性，提高患者的生活质量和延长生存期。     

上腔静脉阻塞综合征非体外循环下血管置换术的麻醉管理

上腔静脉阻塞综合征多由于右肺上叶癌或右上纵隔肿瘤肿块较大时压迫上腔静脉（SVC）及左右无名静脉所致。使用体外循环或非体外循环方法行肿瘤切除和SVC置换既可切除肿瘤又可解除SVC的阻塞，但是非体外循环下上腔静脉置换术的麻醉具有一定的挑战性。笔者于2000～2005年为9例在非体外循环下阻断SVC行肿瘤切除及SVC移植术的上腔静脉患者成功地进行了麻醉，现报告如下。     

腹膜后肿瘤累及大血管的外科处理

对侵及大血管的腹膜后肿瘤，外科医生常因惧怕术中分破被肿瘤浸润或包裹的大血管致无法控制的大出血，而放弃对肿瘤的完整切除。因此，腹膜后肿瘤侵犯血管是肿瘤切除不彻底的重要原因，这方面国内外尚缺乏系统指南，根据我们多年来的经验，联合切除受累大血管（加或不加血管移植）是处理这类肿瘤的重要方法。我院曾分析近年25例腹膜后肿瘤累及大血管手术的病例，     

肠系膜上血管或门静脉受压性胰头部恶性肿瘤根治性胰十二指肠切除术的技巧

目的 探讨肠系膜上血管或门静脉受压性胰头部恶性肿瘤的根治性胰十二指肠切除技巧.方法 在2005年3月至2007年3月,术前采用多排螺旋CT薄层扫描和血管重建技术评估56例肠系膜上血管或门静脉受压性胰头部恶性肿瘤患者的邻近血管是否受侵犯和肿瘤的可切除性;术中运用预置肠系膜上静脉、门静脉、脾静脉三阻断带或四阻断带(附加肠系膜下静脉),以及肠系膜上静脉与肠系膜上动脉交叉牵引下完整切除胰腺钩突部的方法,顺利地完成了56例根治性胰十二指肠切除.结果 术前判断胰腺肿瘤是否侵犯血管和可切除性的准确率分别为98%和100%.56例患者中,37例行三阻断和2例行四阻断后用5-0无创血管缝合线缝合肠系膜上静脉出血点;1例行肠系膜上静脉部分切除修补;手术时间5～8 h;出血量200～600 ml.无术中及术后大出血和胰瘘发生.随访至今,2例患者因肝脏多发性肿瘤转移,分别于术后7个月和9个月死亡.其他54例至今存活良好.结论 术前多排螺旋CT薄层扫描、血管重建技术可较准确地判断胰腺肿瘤是否侵犯血管和是否可根治性切除;采用三阻断或四阻断和肠系膜上血管交叉牵引方法可较顺利地完成肠系膜上血管或门静脉受压性胰头部恶性肿瘤的根治性胰十二指肠切除.     

肝静脉阻断技术在肝切除术中的应用(附105例报道)

目的探讨肝静脉阻断技术在复杂肝脏肿瘤切除术中防止肝静脉破裂大出血及空气栓塞的作用。方法对105例肝脏肿瘤手术切除患者施行了1根以上主肝静脉阻断。所有肿瘤均位于第二肝门并侵犯或压迫1根以上主肝静脉。肝静脉阻断方法采用绕线结扎、血管带阻断或血管夹及心耳钳夹闭法。结果105例中无一例肝静脉分离破裂。施行半肝全血流阻断41例（右侧27例，左侧14例），交替半肝全血流阻断4例，第一肝门阻断加部分肝静脉阻断45例，第一肝门阻断加全部肝静脉阻断（不阻断下腔静脉的全肝血流阻断）15例。其中46例同时行第三肝门分离。105例肿瘤顺利切除。结论肝静脉阻断技术是一种安全、有效的血流阻断技术。不阻断下腔静脉的全肝血流阻断术既能控制术中出血，又能保证全身血流动力学稳定。     

肝静脉阻断技术在肝切除术中的应用

目的 探讨肝静脉阻断技术在复杂肝脏肿瘤切除术中防止肝静脉破裂大出血及空气栓塞的作用。方法 对71例肝脏肿瘤手术切除病例施行了1根以上主肝静脉阻断。所有肿瘤均位于第二肝门并侵犯或压迫1根以上主肝静脉。肝静脉阻断方法采用绕线结扎、血管带阻断或血管夹及心耳钳夹闭法。结果 71例中无1例肝静脉分离破裂，行肝静脉结扎28例，血管带阻断26例，血管夹阻断17例；阻断右肝静脉34例，右肝静脉＋中肝静脉2例，左、中肝静脉共干24例，左、中肝静脉分干2例，左、中、右三干9例。施行半肝全血流阻断35例（右侧24例，左侧11例）。交替半肝全肝血流阻断4例，第一肝门阻断加部分肝静脉阻断23例。第一肝门阻断加全部肝静脉阻断（不阻断下腔静脉的全肝血流阻断）9例。71例肝肿瘤均顺利切除。结论 肝静脉阻断技术是一种安全、有效的血流阻断技术。不阻断下腔静脉的全肝血流阻断术既能控制术中出血，又能保证全身血流动力学稳定。     

间歇性肝门阻断下肝腔静脉结合部肝肿瘤的手术切除及疗效观察

目的 探讨肝腔静脉结合部肝肿瘤手术切除的方法和疗效。方法 在间歇性肝门阻断下行肝切除术，部分病例预置肝下下腔静脉（IVC）阻断带；切肝先易后难，最后处理肝静脉根部；全组68例患者术后随访观察患者生存期。结果 68例肝腔静脉结合部肝肿瘤均在间歇性肝门阻断下得到成功切除，全组无手术死亡，术中因皆得到妥善处理；切除的68例肝肿瘤中65例为原发性肝癌，术后1、2、3和4年生存率分别为64.11％、52.82%、44.90%和36.98%，其中肿瘤有包膜者术后生态率显著高于无包膜者。结论 肝腔静脉结合部肝肿瘤可在简单的间歇性地门阻断下获得安全切除，不必常规作复杂的全肝血流阻断；对该部位边界清楚的原发性肝癌应积极争取手术切除。     

Surgical Treatment of Partial Anomalous Pulmonary Venous Connection of the Left Lung (It-PAPVC)

Between January 1981 and December 1983, 4 patients, aged 6 to 50 years, with It-PAPVC were operated upon at the Kokura Memorial Hospital, by a new technique of anastomosis between the left anomalous PV and the left auricular appendage. One patient, a 9-year-old male, had unilateral anomalous pulmonary venous connection of the entire left lung to the innominate vein. The other three patients had partial anomalous pulmonary venous connection from the left upper lobe to the innominate vein. Two patients has pulmonary valvular stenosis, and the other two had ASD. All patients were operated upon through a midsternal incision. After cardiopulmonary bypass was established, the anomalous vein was divided as high as was reachable. The present operative method involved the use of an oval pericardial gusset extending from the left auricular appendage into the split anomalous vein so as to obtain a wide anastomotic orifice. Other associated congenital anomalies were simultaneously corrected. All patients had uneventful recovery and at postoperative cardiac catheterization and angiography, the anastomosis between the pulmonary vein and the left auricular appendage was widely patent.     

Surgical strategy for invasive pulmonary and mediastinal tumors requiring superior vena cava reconstruction

During the past 16 years, 22 patients were operated on concomitantly with superior vena cava (SVC) reconstruction in our university hospital. Among them, 19 patients had anterior mediastinal tumor and 3 advanced lung cancer. They were 13 males and 9 females, ranging in age from 16 to 70 (mean, 51.4) years. Severe SVC syndrome was found in 10 cases of them. The anterior mediastinal tumors consisted of invasive thymoma in 10 cases, thymic Hodgkin's disease in 2, seminoma in 2, and thymic cancer, thymic carcinoid, thyroid cancer, metastasis of chondrosarcoma and yolk sac tumor in each one. Regarding SVC reconstruction, anatomical bypass was performed in 18 cases, in addition to a radical resection of the tumor. The left innominate vein was reconstructed in 5, the right innominate vein including SVC in 4 and bilateral veins in 9. Extra-anatomical bypass was performed in 4 cases with unresectable tumors because of severe SVC syndrome. Subclavian-femoral vein bypass was performed in one and internal jugular-femoral vein bypass in 3. In anatomical bypass, 7 cases have been alive now though 11 died, and graft patency rate was 82% in the right and 38% in the left. All 4 cases with extraanatomical bypass showed improvement of SVC syndrome, but died one to seven months postoperatively. In conclusions, radical operation with reconstruction of SVC was effective to long-term survival and improvement of SVC syndrome. Extraanatomical bypass improved postoperative quality of life remarkably.     

Superior vena cava obstruction: bypass using spiral vein graft.

BACKGROUND: Previous midterm experience with the composite spiral saphenous vein graft to bypass the obstructed superior vena cava (SVC) has been favorable. This study looks at the long-term results in patients followed for up to 23 years. METHODS: Sixteen patients aged 17 to 68 years had operation for obstruction of the SVC with SVC syndrome caused by benign disease. Eleven patients had fibrosing mediastinitis with or without caseous necrosis, 4 had thrombosis caused by a catheter or a pacemaker electrode, and 1 had spontaneous thrombosis. All operations were performed using a composite spiral vein graft constructed from the patient's own saphenous vein. Graft diameter ranged from 9.5 to 15.0 mm. Ten grafts were from the left innominate vein, and six grafts were from the right or left internal jugular vein. The grafts were placed to the right atrial appendage in all patients except 1. Follow-up extends from 1 month to 23 years 8 months (mean follow-up, 10.9 years). RESULTS: Fourteen of 16 grafts remain patent for up to 23 years, and all patients but 1 are free from SVC syndrome. One patient required revision of the graft for thrombosis 4 days after operation. Two grafts closed during the first year after operation: one because of recurrence of spontaneous venous thrombosis and the other because of aggressive fibrosing mediastinitis requiring operation for graft revision three times over a 12-year period prior to death. CONCLUSIONS: These data demonstrate that a spiral vein bypass graft for treatment of the obstructed SVC relieves SVC syndrome and has excellent long-term patency.     

A case report of superior vena cava reconstruction using a heparin-coated temporary bypass tube

A 56-year-old woman with stage IIIB (c-T1N3M0) small cell lung cancer was treated with combination chemotherapy (CAVE). After five cycles of chemotherapy a surgical resection was performed. As mediastinal lymph nodes (#2, 3, 3a) had invaded to the superior vena cava, a heparin-coated tube was inserted into the left innominate vein and the right auricular appendage as a temporary bypass. Advantages of a heparin-coated tube for the temporary SVC bypass are as follows. 1) simple operative procedure. 2) enough flexibility to be kept out of the operative field. 3) no need for anticoagulants, consequently less bleeding resulted.     

侵及胸廓上口大血管的纵隔肿瘤的外科治疗

目的　探讨侵及胸廓上口大血管的纵隔肿瘤的外科治疗经验。方法　回顾分析 11例侵及胸廓上口大血管的纵隔肿瘤患者的临床资料 ,全组患者均行纵隔肿瘤切除 ,其中 2例于麻醉诱导前辅以股 -股转流并行体外循环 ,2例辅以颈静脉、股静脉 -股动脉转流并行体外循环。同期行上腔静脉重建 2例 ,成形 2例 ,左无名静脉成形 3例 ,右无名静脉成形 1例 ,无名动脉、左颈总动脉、左锁骨下动脉人造血管置换各 1例。结果　全组病例无手术死亡。术后随访 2～ 7年 ,3例于 2～ 4年后死于癌瘤复发 ,6例无瘤健康生存 ,均未出现血管栓塞。结论　侵及胸廓上口的大血管纵隔肿瘤宜积极手术治疗 ,麻醉诱导前辅以股 -股转流或颈、股 -股转流。同期作血管成形或重建。术后小剂量抗凝治疗     

Superior vena cava reconstruction combined with resection of mediastinal-pulmonary malignant tumors

From 1988 to 1997, we experienced 5 cases of the superior vena cava (SVC) replacement with expanded polytetrafluoroethylene (ePTFE) grafts combined with resection of mediastinal or pulmonary malignant tumors. Two patients had lung cancer and three had invasive thymoma. Resection and reconstruction of the superior vena cava (SVC) were performed by application of a bypass graft between the innominate vein and the right atrium in two cases and a temporary bypass using a heparin-coated tube in three cases. Except in one patient who died of acute respiratory failure, no complication or occlusive symptom were observed postoperatively. Two patients remain healthy for 5 years 4 months and 2 years 7 months after operation. Three died 9 years, 5 months, and 110 days after operation respectively. In conclusion, ePTFE graft replacement or patch angioplasty of the SVC should be part of planning and execution of radical excision with curative intent of mediastinal or pulmonary malignant tumors.     

Transcaval invasion of right atrium by thymoma: resection via transient cava-pulmonary shunt

Transcaval extension of the thymoma to the right atrium has very rarely been reported, and cardiopulmonary bypass is recommended for successful resection. An invasive thymoma with intravascular invasion of the superior vena cava, and the left innominate vein extending into the right atrium was presented. Intra-atrial extension was resected through a transient external shunt from the inferior vena cava to the main pulmonary artery. We discussed the feasibility of this surgical technique and possible advantages of cardiopulmonary bypass avoidance.     

Triple reconstruction of pulmonary artery, superior vena cava and bronchus for lung cancer

We report on a case of a complete resection for bronchogenic carcinoma necessitating right upper sleeve lobectomy with prosthetic replacement of right pulmonary artery (PA) and superior vena cava (SVC). A 74-year-old male with squamous cell carcinoma had a tumor which extended to the right main bronchus, right PA and SVC. After reconstruction of the SVC with a ringed polytetrafluoroethylene (PTFE) graft between the left brachiocephalic vein (BCV) and right atrial auricle, the tumor was completely resected en bloc. Bronchial anastomosis followed by the prosthetic reconstructions of PA and SVC between the right BCV and the origin of SVC were performed. Pathological staging was t4n2m0 (stage IIIB). The postoperative course was uneventful and the patient discharged from the hospital on the 29th postoperative day. He has been doing well without recurrence and keeping a good graft patency for more than 3 years.     

Partial anomalous pulmonary venous drainage to the high superior vena cava; repair by direct anastomosis between the superior vena cava and the right atrial appendage; report of a case

A 10-year-old boy with partial anomalous pulmonary venous connection to the high superior vena cava (SVC) underwent surgical repair by Williams method. The SVC was divided above the orifice of the anomalous pulmonary vein. The proximal end of the SVC was closed and the distal end of the SVC was anastomosed to the right atrial appendage (RAA). The anomalous pulmonary vein was rerouted to the left atrium via the SVC and the surgically enlarged central type atrial septal defect (ASD). The postoperative course was uneventful except transient sinus bradycardia and catheter study showed no stenosis of the SVC and the RAA.     

Reconstruction of nonconfluent pulmonary artery using the retroaortic innominate vein for a single ventricle

The innominate vein usually courses anterior to the aortic arch, where it joins the right brachiocephalic vein to form the superior caval vein. A retroaortic innominate vein is an uncommon finding in patients with congenital heart disease. We report a patient with a single ventricle, single atrium, pulmonary atresia, nonconfluent pulmonary artery, persistent left superior caval vein, absent inferior caval vein (azygos connection), right aortic arch, and retroaortic innominate vein. His innominate vein took an anomalous course. The right brachiocephalic vein crossed from right to left underneath the aortic arch and formed a left superior caval vein with the left brachiocephalic vein and the azygos vein. We reconstructed the nonconfluent pulmonary artery using the retroaortic innominate vein and then performed a total cavopulmonary shunt when he was 32 months of age. Thereafter, a total cavopulmonary connection was carried out at age 42 months.