隆凸合并心脏大血管切除重建术治疗局部晚期中心型支气管肺癌

背景与目的 迄今，同时侵犯隆凸和心脏大血管的局部晚期非小细胞肺癌仍被视为外科手术治疗的禁忌证。本研究的目的是总结我院施行隆凸合并心脏大血管切除重建术治疗84例侵犯隆凸和心脏大血管的局部晚期非小细胞肺癌的临床经验。方法 1988年3月～2004年12月，对84例同时侵犯隆凸和心脏大血管的局部晚期中心型非小细胞肺癌施行隆凸合并心脏大血管切除重建术。本组隆凸、心脏大血管切除重建术式包括：（1）隆凸切除重建合并右肺动脉袖状切除重建袖式右肺上叶切除术（气管-左主支气管-右中间支气管重建）9例；（2）袖式右全肺切除合并上腔静脉切除人造血管重建加部分左心房切除重建术3例；（3）隆凸切除合并左肺动脉袖状切除重建袖式左上叶切除加部分左心房切除重建术3例；（4）隆凸切除合并部分左心房切除重建和右肺动脉袖状切除重建袖式右上叶切除术（左主支气管-气管端端吻合，右中间支气管-气管端侧吻合）10例；（5）隆凸切除合并左肺动脉袖状切除成形左上叶切除术9例；（6）隆凸切除合并左肺动脉袖状切除成形左上叶切除＋主动脉弓鞘膜切除6例；（7）隆凸切除合并右肺动脉袖状切除成形右中上叶切除术3例；（8）隆凸切除合并左肺动脉袖状切除成形左上叶切除、主动脉弓鞘膜切除＋部分左心房切除重建术8例；（9）隆凸切除合并右肺动脉袖状切除成形右上叶切除加部分左心房切除重建术4例；（10）袖式左全肺切除（气管-右主支气管端端吻合）合并部分左心房切除重建术3例；（11）隆凸切除合并右肺动脉袖状切除成形右中上叶切除加上腔静脉切除人造血管重建术23例；（12）袖式右全肺切除（左主支气管-气管端端吻合）合并部分左心房切除术1例；（13）隆凸切除合并右肺动脉袖状切除成形右中上叶切除加部分左心房切除重建术1例；（14）隆凸切除合并右肺动脉袖状成形右中上叶切除加右肺下静脉袖状切除和右肺下静脉-左心房端侧吻合术1例。结果 本组手术死亡2例，死亡率为2．38％。发生手术并发症32例次，发生率为38．10％。术后1、3、5和10年生存率分别为81．34％、59．47％、31．73％和24．06％。结论 （1）施行隆凸合并心脏大血管切除重建术在技术上是可行的；（2）隆凸切除合并心脏大血管切除重建术为主的多学科综合治疗能明显提高局部晚期非小细胞肺癌患者的生存率，改善患者预后和生活质量。

Carinal resection and reconstruction combined with heart and great vessel plasty in the treatment of locally advanced non-small cell lung cancer

Background and objective Up to now, locally advanced non-small cell lung cancer simutaneously involving carina, heart and great vessels is still regarded as contraindication for surgical treatment. However, the prognosis is very poor in these patients treated with chemotherapy and/or chemoradiotherapy. The aim of this study is to summarize the clinical experiences of carinoplasty combined with heart and great vessel plasty in the treatment of 84 patients with locally advanced non-small cell lung cancer involving carina, heart and great vessels or both in our hospital. Methods From March, 1988 to December, 2004, carinal resection and reconstruction combined with heart, great vessel plasty was performed in 84 patients with locally advanced non-small cell lung cancer involving carina, heart and great vessels simutaneously. The operative procedures in this series included as follows: (1) Right upper sleeve lobectomy combined with carinal resection and reconstruction, and right pulmonary artery sleeve angioplasty in 9 patients; (2) Right sleeve pneumonectomy combined with partial resection and reconstruction of left atrium, and superior vena cava resection and Gortex grafts in 3 cases; (3) Left upper sleeve lobectomy combined with carinoplasty, left pulmonary artery sleeve angioplasty and partial resection and reconstruction of left atrium in 3 cases; (4) Right upper sleeve lobectomy combined with carinoplasty, right pulmonary artery sleeve angioplasty and partial resection and reconstruction of left atrium in 10 cases; (5) Left upper sleeve lobectomy combined with carinoplasty and left pulmonary artery angioplasty in 9 cases; (6) Left upper sleeve lobectomy combined with carinoplasty, left pulmonary artery sleeve angioplasty and resection of the aorta arch sheath in 6 cases; (7) Right upper-middle sleeve lobectomy combined with carinoplasty and right pulmonary artery sleeve angioplasty in 3 cases; (8) Left upper sleeve lobectomy combined with carinoplasty, left pulmonary artery angioplasty, resection of the aorta arch sheath and partial resection and reconstruction of left artium in 8 cases; (9) Right upper sleeve lobectomy combined with carinoplasty, right pulmonary artery angioplasty and partial resection and reconstruction of left atrium in 4 cases; (10) Left sleeve pneumonectomy combined with partial resection and reconstruction of left atrium in 3 cases; (11) Right upper-middle sleeve lobectomy combined with carinoplasty, right pulmonary artery angioplasty and superior vena cava resection and reconstruction with Gortex grafts in 23 casese; (12) Right sleeve pneumonectomy combined with partial resection and reconstruction of left atrium in 1 case; (13) Right upper-middle sleeve lobectomy combined with carinoplasty, right pulmonary artery angioplasty and partial resection and reconstruction of left atrium in 1 case; (14) Right upper-middle sleeve lobectomy combined with carinoplasty, right pulmonary artery angioplasty and right inferior pulmonary vein sleeve resection and reconstruction in 1 case. Results There were two operative death in this series. The operative mordality was 2.38%. A total of 32 patients had operative complications. The incidence of operative complications was 38.10%. The 1-, 3-, 5-and 10-year survival rate was 81.34%, 59.47%, 31.73% and 24.06% respectively. Conclusion (1) It is feasible in technique that carinal resection and reconstruction combined with heart, great vessel plasty in the treatment of locally advanced non-small cell lung cancer involving carina, heart and great vessels simutaneously; (2) Multiple modality therapy based on carinal resection and reconstruction combined with heart and great vessel plasty can remarkably increase the survival rate, and improve the prognosis and quality of life in patients with locally advanced non-small cell lung cancer involving carina, heart and great vessels.