颈椎旁神经源性肿瘤手术入路的探讨

背景与目的：颈椎旁神经源性肿瘤多起源于脊神经背根，与颈动脉三角区的颈总动脉，颈内静脉，迷走神经及椎动脉等重要血管神经相互毗邻。其特殊的解剖位置使得手术难度增加，手术进路的选择也就显得尤为重要。本文旨存探讨颈侧手术入路对颈椎旁神经源性肿瘤切除的可行性及其治疗效果。方法：回顾性分析经颈侧入路于术治疗的从1971～2006年我院29例颈椎旁神经源性肿瘤患者的临床资料。结果：本组病例中，良性肿瘤20例，占70．37％（19／27），恶性肿瘤9例，占29．63％（8／27）。本组29例病例中，经颈侧进路切除肿瘤28例，经颈项部切门进路枕部下横切口1例。27例肿瘤全切除的病例中，经颈侧切口进路肿瘤全切除26例，其中胸锁乳突肌前缘切口12例，胸锁乳突肌后缘切口7例，颈胸切口1例，下颌角下做横切口4例，锁上弧形切口2例；经颈项部进路切除肿瘤1例。经颈侧进路肿瘤全切除26例．大部分切除2例，肿瘤全切除率为92．85％（26／28）；在肿瘤全切除病例中，有3例局部复发，1例局部复发伴双肺转移。肿瘤全切除病例的局部复发率为14．81％（4／27）。结论：颈椎旁肿瘤经颈侧切口进路手术具有术野暴露清楚，肿瘤全切除率较高等优点，应为颈椎旁肿瘤切除手术切口进路的首选。     

食管癌手术径路的比较分析

目的：选择一种比较理想的食管癌手术径路,方法：1958年-1997年的40年间945例胸吵段食管癌病例,分为5组,分别采用：（1）左胸后外侧切口食管癌切除,食管胃胸内弓上吻合。（2）右胸前外侧切口加上腹正中切口食管癌切除。胃经食管床胸顶吻合。（3）右胸前外侧切口加上腹正中切口,颈部切口食管癌切除,胃经食管床左颈或右颈吻合。（4）右胸后外侧切口加上腹正中切口,颈部切口食管癌切除,胃经食管床颈部吻合。（5）右胸后外侧切口经胸游高分子食管,食管癌切除,经膈肌食管裂孔游离胃,胸顶食管胃吻合,用SAS医用统计软件列联表方法分析切除率,并发症,死亡率,五年生存率之间的相关性。结果：右胸后外侧切口径路切除率较左胸后外侧切口和右胸前外侧切口径路高,生存率之间也存在明显差异。5组切除率和五年生存率分别为84.19%和29.00%,81.69%和28.57%,83.65%和26.19%,90.74%和34.70%,93.67%和39.74%。结论：右胸后外侧切口径路可作为胸中段食管癌的常规手术径路。     

胸腺囊肿(附16例报告)

目的：探讨胸腺囊肿的诊断、治疗。方法：天津市医科大学附属肿瘤医院1960年1月至2007年6月共收治胸腺囊肿16例，其中男5例，女11例；年龄22～78岁，平均44.6岁；病期2天－2年，平均99．8天。术前胸片、CT、MRI检查诊断：胸腺囊肿1例，皮样囊肿1例，14例诊断前纵隔肿瘤（前上纵隔肿瘤12例，前中纵隔肿瘤2例）。结果：16例均行手术治疗，其中15倒完整切除：胸骨柄上颈横切口3例，胸骨正中切口3例，左腋径第二肋间切口1例，右后外切口5例，左后切口3例。1例右纵隔胸腺囊肿与心包及上腔静脉粘连，未能全切除，病理检查：肿瘤有完整包膜，囊肿，内含暗红色液体，多为单层。病理诊断为胸腺囊肿，无手术并发症，随访4个月～10年，患者完全生存。结论：胸腺囊肿为纵隔良性肿瘤，易误诊，但囊肿必须有朐腺组织才能确诊，手术切除可治疗。     

胸腔巨大肿物伴椎管内肿物

患者胸闷、憋气5年，加重1年；上腹胀、发现“左下肺”肿物1年余入院。入院后胸部CT、MRI发现：左下胸腔椎管内来源巨大肿物，考虑神经源性肿瘤，伴左侧胸腔积液；胸腔内肿物穿刺病理提示：孤立性纤维瘤。行左胸后外侧切口＋背部纵切口手术切除肿物。术后病理显示：孤立性纤维瘤。孤立性纤维瘤发生部位广泛，几乎囊括躯体所有的解剖部位，临床上常无症状，随着肿瘤的增大，会出现相应部位的压迫症状。手术可以治愈绝大部分病例。     

40例纵隔肿瘤再次手术的经验

纵隔肿瘤占肿瘤发病率的5%,以胸腺瘤为最多,畸胎瘤和神经源性肿瘤次之犤1犦。纵隔肿瘤一经发现,均应采取积极的手术治疗。手术能否将肿瘤彻底切除的关键因素是手术切口的选择。总结我院1980年1月～2001年12月间,纵隔肿瘤再次外科手术的病例40例,报告如下。1材料与方法40例纵隔肿瘤患者,占同期纵隔肿瘤的5%,其中男性35例,女性5例,恶性胸腺瘤24例,恶性畸胎瘤8例,神经源性肿瘤8例。1.1再次外科手术的切口胸后外切口13例,经胸骨正中切口19例,前胸切口合并胸骨横断5例,前胸切口合并胸骨上部劈开3例。术中失血最多达10000ml,最少为600ml,平均为380…     

食管贲门癌419例手术治疗临床分析

 目的 探讨食管贲门癌的手术径路、切除范围、淋巴结清扫及手术疗效。方法 手术治疗食管贲门癌419例，经左胸后外侧切口394例，右胸前外侧及上腹正中切口4例，右胸前外侧、上腹正中及左颈部三切口19例，左颈部及上腹正中非开胸食管内拨脱2例，均清扫术野淋巴结。结果 本组病例发生并发症56例，其中吻合口瘘16例，吻合口狭窄7例，心血管并发症11例，肺部并发症7例，切口感染及其他15例，除3例心血管并发症于术后48 h内死亡，1例乳糜胸于术后第9天死亡外，余无手术死亡及住院死亡。结论 严格掌握手术适应证，合理选择手术径路，注意术中缜密操作及改进吻合方法，对提高切除率、减少并发症大为有益。     

喉及颈胸段气管切除无名动脉下方纵隔气管造口术在气管外科中的应用

目的：探讨与研究低位胸段气管纵隔造口术的适应征、手术技术难点以及在气管外科治疗中的价值。方法：对１例肿瘤长度５．６ｃｍ的颈胸段气管癌患者设计采用了前上胸壁大块切除、右胸大肌皮瓣的建立与转移,带血管蒂大网膜经胸骨后间隙填塞气管造口周围以及低位胸段气管造口端转至无名动脉下方等多种手术步骤,最终完成喉及颈胸段气管切除,无名动脉下方纵隔气管造口术。结果：切口基本一期愈合,手术获得成功。随访一年,未出现无名     

胸段食管癌手术径路的个体化选择

目的　探讨胸段食管癌手术径路选择个体化的意义。方法　回顾性研究２００７年１月至２００９年１月共４５６例胸段食管癌根治患者的临床资料,分析不同手术径路对肿瘤根治性与术后并发症的影响。结果　全部患者均顺利完成食管癌根治术,其中左胸后外侧开胸＋左颈部切口（Ⅰ组）２６８例,单纯左胸后外侧开胸（Ⅱ组）４２例,右胸后外侧开胸＋上腹部正中切口（Ⅲ组）９４例,右胸前外侧开胸＋上腹部正中切口＋颈部切口（Ⅳ组）５２例。胸上段癌５９例中,Ⅳ组４３例,Ⅰ组１６例（临床分期Ｔ_１-２Ｎ_０Ｍ_０）;中段癌３１６例中,Ⅰ组２３１例,Ⅲ组７６例,Ⅳ组９例;下段癌８１例中,Ⅰ组２１例,Ⅱ组４２例,Ⅲ组１８例。全组食管上切端残留癌５例。全组清扫淋巴结８１４１枚,平均每例（１７.８５±８.９４）枚,检出有淋巴结转移１８６例,共７５８枚,淋巴结转移率４０.８％（１８６／４５６）,转移度９.３％（７５８／８１４１）。全组发生并发症共８０例,其中吻合口瘘１２例,胸胃瘘４例,肺部并发症２１例。Ⅳ组并发症发生率最高,为３６.５％,与其他３组比较差异均有统计学意义。结论　胸段食管癌手术径路的个体化选择策略有助于提高肿瘤切除率与根治率。手术创伤的控制是降低术后并发症和提高生存质量的有效手段。     

非开胸食管内翻拔脱术治疗颈段及上胸段食管癌：附45例报告

本文报告了我科非开胸食管内翻拔脱术治疗颈段及上胸段食管癌45例.其中颈段食管癌22例,上胸段23例;病变位于颈段者采用左侧颈部切口,位于上胸段者行颈胸骨部分劈开切口.术后发生颈部吻合口瘘7例,声嘶5例,全组元手术死亡.文中还就手术方法、体会及吻合口瘘的预防进行了讨论.     

改良Ivor—Lewis术式在食管癌手术中的应用体会

目的：应用改良Ivor-Lewis术式治疗食管癌。方法：1995年2月至1999年9月我院对86例食管癌病人应用右胸前外侧、上腹部正中切口切除胸段食管癌。同时采用机械方法经胸内进行食管、胃颈部吻合（颈段食管胃吻合）。结果：86例中无手术死亡。无吻合口瘘、狭窄,无乳糜胸发生。2例发生脓胸,经引流、抗感染治愈,1例病理检查切缘阳性,术后补充较好。胃排空障碍4例,经保守治愈。结论：改良Ivor-Lewis对食管中下段癌是较理想的术式。     

Intrapericardial isolation of the inferior vena cava through a transdiaphragmatic pericardial window for tumor resection without sternotomy or thoracotomy.

AIMS: The prognosis for patients with advanced tumors invading the inferior vena cava (IVC) is dismal and surgical treatments for these tumors are challenging. A surgical approach that avoids sternotomy and thoracotomy for tumors invading the IVC even to the level of the hepatocaval junction would be extremely helpful. METHODS: The intrapericardial IVC was isolated via a transdiaphragmatic pericardial window using a transabdominal approach. Hepatectomy was then applied via an anterior approach until the IVC was seen. Total hepatic vascular exclusion was achieved by clamping the portal triad, intrapericardial IVC and infrahepatic IVC. We removed the primary tumor, the liver portion involved and the tumor thrombi, with segmental resection of the IVC. Vascular continuity was reestablished using a 20-mm-diameter polytetrafluoroethylene graft. RESULTS: Four patients with tumors invading the IVC were treated with this method. All underwent gross en-bloc tumor resections and all survived. CONCLUSION: This method for the resection of IVC tumors could avoid emboli dislodging from the tumor thrombi, prevent the complications of sternotomy, cardiopulmonary bypass and shorten operative times.     

Results of surgical treatment of pulmonary metastases

From 1970 to 1993, 155 thoracotomies for metastatic lung tumors were performed on 113 patients in the Department of Surgery, Kanazawa University School of Medicine. Overall 30-day mortality amounted to 0.9% (1/113). The cumulative 3- and 5-year survival rates were 39.4% and 29.1%, respectively. The overall median survival was 24 months. The 5-year survival rate for carcinoma was 37.2% and for sarcoma it was 14.5% (P < 0.01). The other significant predictors of better long-term survival with metastatic lung tumors were solitary lesions, disease-free interval (DFI) > 24 months, and tumor size ≤ 20 mm in diameter. There was no significant difference in survival based on the method of pulmonary resection. Repeat thoracotomy for recurrent metastases was performed in 27 patients, whose 5-year survival rate after the first lung resection was 35.5%. For bilateral pulmonary metastases, we recently performed simultaneous bilateral thoracotomy via median sternotomy on 25 patients and transsternal simultaneous bilateral thoracotomy on 8 patients. The latter procedure provides a wide operative field and better survival. We conclude that resection of metastatic lung tumors is safe and effective, and that repeat thoracotomy is warranted in selected patients with recurrent pulmonary metastases. © 1995 Wiley-Liss, Inc.     

142例食管癌合并肺功能不全患者的围手术期治疗

目的:总结食管癌合并肺功能不全患者围手术期治疗的经验。方法:2010年7月-2013年10月,收集我院对食管癌合并肺功能不全行食管癌根治术患者142例,其中男86例,女56例,年龄46-75岁,平均年龄62.4岁。术前经严格禁烟,净化呼吸道,并给予雾化化痰、解痉、呼吸功能锻炼改善肺功能,术前合并肺部感染者,给予抗感染直至感染控制及呼吸道症状消失。经右胸前外侧切口、上腹部正中切口手术82例,左后外侧切口食管癌根治术36例,颈、胸、腹联合三切口手术24例,术后予以预防感染、解痉化痰保持呼吸道通畅、抑制抗炎介质释放、营养支持和氧气支持治疗,部分患者予以纤维支气管镜吸痰。结果:142例患者均顺利出院,无1例手术死亡,其中术后发生肺部感染12例,颈部吻合口瘘1例。142例均获随访,随访时间1-6个月,平均4.2个月。术后均恢复良好,经复查无手术相关并发症。结论:严格的围手术期处理对于提高肺功能不全食管癌患者手术成功具有重要意义。     

Surgical Treatment of Retrosternal Goitre

This study aims to evaluate surgical approaches to the management of retrosternal goitre. Between 2004 and 2014, 35 patients (eight males; mean age 67.4 ± 10.9 years) with retrosternal goitre (mainly right-sided in 9, left-sided in 14 and bilateral in 12) underwent surgery. A palpable neck mass was found in 11 (31.4%), stridor in 10 (28.6%) and thyrotoxicosis in 4 (11.4%) cases. 4 (11.4%) patients were asymptomatic. Tracheal compression was detected radiologically in 27 (77.2%) patients with deviation in 18 (51.4%). A collar incision was performed in 34 patients, 6 (17.1%) of whom required additional sternotomy, 1 (2.9%) was assisted by an anterior mediastinotomy. 1 (2.9%) had a right lateral thoracotomy. There was no operative mortality. Transient vocal changes occurred in 3 (8.6%) patients, recurrent laryngeal nerve palsy in 3, atrial fibrillation in 2, and wound complications in 2 (5.7%). Hospital stay ranged from 2 to 12 days (5.5 ± 2.0). Multinodular goitre was found in 33 patients, diffuse goitre in 1 and ectopic thyroid in 1. The average vertical length of goitres in the collar incision group was 7.6 cm compared to 10.6 cm in the sternotomy group. The average weight of specimens was 156.3 g in patients with collar incisions and 307.5 g in the sternotomy group. Removal of retrosternal goitre is more commonly performed via a cervical collar incision with mandatory availability of sternotomy. Radiological measurement of craniocaudal length may predict the risk of sternotomy. Surgical outcomes are not affected by surgical approach.     

非开胸上段食管癌直视下切除38例报告

 本文报告非开胸直视下切除上段食管癌38例.男性27例,女性11例.年龄36～79岁.肿瘤长度l.0～7.ocm.肿瘤下缘均在主动脉弓上缘以上.手术并发症发生10.5%,无手术死亡.手术采用颈部扩大切口或纵劈上部胸骨入路直视下游离肿瘤,正常中下段食管内翻剥脱,食管胃或咽胃颈部吻合.此种手术避免了开胸、创伤小、操作简单且效果好,值得推广运用.     

Iodine125 interstitial brachytherapy in the treatment of carcinoma of the lung.

In a prospective study, 14 patients with primary non-oat cell lung carcinoma were treated with intraoperative Iodine125 (I125) implantation of the lung tumor via lateral thoracotomy or median sternotomy. Staging mediastinal node dissection was performed in each case. Patients were selected when wedge or segmental resections were not technically feasible, such that lobectomy or completion pneumonectomy would have been required or pulmonary function studies were poor. Doses ranged from 8,000 cGy at the periphery to 20,000 cGy at the center. With a minimum 12 month follow-up, mean and median survivals were 16.7 and 15.1 months, respectively. Local control was achieved in 10 of 14 patients (71%) with all local failures occurring in pathologic stage III patients. When separated according to tumor size, local control was obtained in six of seven tumors of less than 3 cm and four of five tumors of 3-5 cm. Both cases with masses greater than 5 cm failed locally. There was one operative mortality and two postoperative complications. All other patients were discharged within one week of surgery. There was no radiation pneumonitis. I125 lung brachytherapy is an excellent alternative treatment for T1 and T2 tumors when medical conditions preclude curative resection.     

单纯后路横切口治疗骶骨肿瘤的临床疗效分析

目的:探讨骶骨后路横切口治疗骶骨肿瘤的疗效。方法:收集2013-2019年通过手术治疗的骶骨肿瘤患者20例,其中男16例,女4例, 年龄18～76岁,其中ASIA分级E级的有12例,ASIA分级D级的有8例,按手术切口不同,将患者分为后入路横切口组及后入路倒“Y”型切口组,记录患者手术出血量、手术时间、术后患者恢复情况等资料进行对比。结果:16例患者行后入路横行切口,手术时间为（173.9±65.69）min,术中出血量为（1 493.75±1 261.46）mL,其中1例患者出现切口愈合差的情况。4例患者行后入路倒“Y”型切口,手术时间为(285±116.19)min,术中出血量为(4 250±759.39)mL,其中2例患者出现切口愈合不良,所有患者均获得完整的病理报道和随访。结论:骶骨后入路横切口可以在完整切除肿瘤同时,做到出血量少,手术时间短,感染率低的临床疗效。     

食管癌外科治疗体会

［目的］探讨外科治疗食管癌的经验。［方法］自１９８８年至１９９８年对１００例食管癌施行切除术,其中上段８例,中段７２例,下段２０例,手术入路计经左颈、右胸、腹部三切口１８例,右胸、腹部二切口４９例,右胸后外侧单切口５例,左后外侧单切口 ２８例,切除食管后均作食管胃一层间断吻合重建消化道。［结果］住院死亡４例,死亡率为４％,术后发生吻合口瘘２例。术后５年生存率为３７．２％（１６／４３）。［结论］食管癌的手术入路应取决于病灶的所在部位;主张一层食管胃吻合术重建消化道;为了提高食管癌术后的生存率,必须作广泛的食管切除及彻底的淋巴结清扫。     

Mediastinal tracheostomy during esophagectomy for cervicothoracic esophageal carcinoma invading the proximal trachea

A total of 16 patients with carcinoma in the cervicothoracic esophagus underwent pharyngolaryngoesophagectomy with construction of a mediastinal tracheostoma. Among them, seven patients underwent transhiatal esophagectomy without thoracotomy, four proximal esophagectomy by cervicotomy and sternal split, and five cervical and thoracic esophagectomy and lymphadenectomy by cervicotomy and right thoracotomy. Free jejunal transfer was performed to reconstruct the esophagus in five patients, and the stomachs were used in ten. One patient died of pneumonia 27 days after surgery, and two of arterial blowout. Plastic and reconstructive surgery techniques were introduced to protect large vessels and cover the wound. The postoperative 30-day mortality was 6.3% and the total operative mortality was 18.8%. Median survival was 327 days. Mediastinal tracheostomy is safely applicable today for patients with esophageal carcinoma invading the proximal trachea, allowing them to achieve safe respiration and to enjoy meals. © Wiley-Liss, Inc.     

Pull-Through Esophagectomy Without Thoracotomy

Twenty patients with carcinoma of the hypopharynx, esophagusand thyroid underwent pull-through esophagectomy. Seventeenof them received combined resection of the larynx and trachea.Dissection of the lymph nodes at the upper mediastinum was performedin 11 patients by sternotomy. Seven patients received mediastinaltracheostomy after combined resection of the trachea and thelarynx. Pull-through esophagectomy was followed by pharyngogastrostomywithout thoracotomy via the posterior mediastinum. This techniqueis described in detail. Because there is no thoracotomy andligation of the esophageal vessels is ensured, no pulmonarycomplications and no massive mediastinal hemorrhages occurred.There were no operative deaths. This operation offers excellentpalliation and little morbidity. Moreover, the use of sternotomyand mediastinal tracheostomy for pull-through esophagectomymade it possible to dissect the upper mediastinal lymph nodes,and we could resect the affected trachea with certainty.