从远期功能看乳腺癌手术保留胸肌的意义

近十余年来,由于人们对癌警惕性的提高,以及检查方法的进步,临床上所见乳腺癌的早期患者大为增多。对于局部表现为没有浸沾胸大肌筋膜的T_(1-3)N_(0-1a)乳腺浸润性癌,大都采用比Halsted根治术较为保守的(1)Auchincloss术,保留胸大、小肌,切除整个乳房并清除腋窝下部淋巴结;或(2)Patey氏术,仅保留胸大肌,将整个乳房、胸小肌及全部或大部腋窝淋巴结清除。     

保留中、下胸肌神经的Patey手术41例分析

目的 探讨保留中、下胸肌神经的乳腺癌改良根治术Ⅱ式（Patey术）的可行性,并观察手术效果.方法 回顾性分析2010年1月至2011年3月在第三军医大学西南医院乳腺外科行保留中、下胸肌神经Patey术治疗的41例乳腺癌患者的临床资料.结果 所有患者均顺利完成该手术.手术时间为72 ～107 min之间,平均时间为87 min；术中出血量在15 ～ 120ml之间,平均出血量为75 ml；腋窝淋巴结清扫数量在15～42枚之间,平均清扫23枚淋巴结；转移淋巴结数目在2～32枚之间,平均转移数为7.7枚.全组无皮瓣坏死、切口感染、术后出血等并发症,3例拔除引流管后出现皮下积液,再次置管行负压引流后痊愈.术后3个月随访,所有患者同侧胸大肌外形良好、患侧上肢活动自如.结论 保留中、下胸肌神经的Patey术对于术后胸大肌功能的恢复和胸廓形态的维持具有重要意义,是一种具有应用价值的手术方式.     

乳腺癌改良根治术腋窝清扫进路探讨

改良根治术有两类：Auchincloss术式（保留胸大、胸小肌），Patey术式（保留胸大肌、切除胸小肌）。按暴露腋南方法不同、有多种腋窝淋巴结清扫进路。常见的有：牵开胸大肌（或加胸小肌），劈开胸大肌、切断胸大肌止点，切断胸大肌起点[1]。但这一术式普遍存在腋窝完全暴露和胸前神经损伤等问题。我们从1996年起利用胸大肌锁骨部与胸肋部存在一自然解剖间隙为进路，完全暴露腋静脉及锁骨下静脉，可达到彻底清扫腋窝淋巴结和保护胸前神经的目的。材料和方法一、临床资料本组共4例，均为女性。年龄为40～48岁，平均44岁。按国际TNM分期为Ⅱ…     

经胸大肌清扫Ⅲ组淋巴结在乳腺癌改良根治术中的应用

目的 探讨经胸大肌间隙入路清扫Ⅲ组淋巴结在乳腺癌改良根治术中的应用及其临床意义.方法 观察组采用保留胸大小肌的乳腺癌改良根治术(Auchincloss手术),同时沿胸大肌肌间沟切开胸大肌,彻底清除Ⅲ组淋巴结(锁骨下淋巴结).对照组采用仅保留胸大肌、切除胸小肌的乳腺癌改良根治术(Patey手术).结果 与对照组比较,观察组能彻底清扫腋淋巴结,明显减少胸大肌萎缩率,提高术后生活质量.结论 经胸大肌清扫Ⅲ组淋巴结既保留胸大肌功能,又彻底清扫腋淋巴结,值得临床推广.     

乳癌改良根治术术式评介

一、乳癌改良根治术发展历史简要回顾1868年,Moore首先提出全乳房包括胸大肌筋膜切除加腋淋巴结切除术,作为根治性切除术治疗乳癌,这比Halsted1984年提出的乳癌根治术早27年。最早倡导作根治术而保留胸大肌的是Handley(1906),其后是Dusou(1938)、Patey(1948),开始并没有引起人们的注意.1948年Patey等报道其术式疗效后。这一段容较小的手术逐步为人们所接受.以后Handley等(1969)(2)、Payne等(1970和)Madden等(1965、1972)(3)相继有同类的报道,认为改良根治术与根治术效果可     

保留胸前神经的改良乳癌根治术——附3例报道

目的：探讨根治乳癌更为合理的术式。方法：对３例ⅡⅢ期的乳癌患者在行改良一式乳癌根治术的基础上，沿第２肋软骨上缘作胸大肌开窗清扫腋尖群淋巴结和胸肌间淋巴结。结果：本组术后经１年零３个月至２年零８个月的随访，均无肿瘤复发，术侧胸肌无萎缩，肩关节及上肢活动自如。结论：保留胸前神经的改良乳腺根治术既能彻底根治乳癌，又能使保留的胸肌有功能无萎缩，是一种比较理想的术式，适合于无胸大肌浸润的临床各期乳癌病例。     

国外乳腺癌改良根治术的概况

乳腺癌改良根治术主要有:(1)保存胸大肌、切除胸小肌(1948年Patey报告);(2)保存胸大、小肌(1951年Auchincloss和Madden先后报告),后者原则上不清除锁骨下组织,认为锁骨下淋巴结如有转移即使行传统根治术,预后亦不良。 深见等指出改良根治术的最大优点是保存胸大肌,使胸壁外形接近正常,不出现术后胸壁洗衣板     

乳腺癌Patey术两种腋淋巴结清扫径路的比较分析

[目的]探讨乳腺癌行Patey术时的腋清径路对分期准确性和功能保存的影响。[方法]对Patey手术83例，随机采用两种不同的腋清手术径路，比较两组的腋清标本病理检查情况及胸前神经的损伤情况。[结果]联合入路较单一入路清除的腋上组淋巴结总数多（P＜0.05)，胸前神经损伤较少。[结论]行Patey术时采用联合入路行腋清能提高乳腺癌分期准确性并减少胸大肌功能的损伤。     

乳腺癌根治术中发现胸小肌缺如、胸大肌发育不全1例

患者女性,46岁,天津自行车厂工人,汉族,已婚。因左乳腺大汗腺样癌,1988年1月20日住院,同年3月7日在针麻下行左乳腺癌根治术Ⅱ式。术中发现:1.保留的胸大肌锁骨束无异常,但切除的胸大肌为5cm直径,10cm长的圆柱形,第二前肋骨有肌肉附着处,而第三、四、五前肋骨均无肌肉附着,比正常人胸大肌小而少,发育不全。2.无胸小肌、肩肿骨喙突处无胸小肌附着,胸壁亦     

改良乳腺癌根治术保留胸前神经的方法及临床意义

目的：探讨在改良乳腺癌根治术中保留胸前神经的方法和临床意义.方法：将68例拟行改良乳腺癌根治术的患者随机分为两组,保留胸前神经组和不保留胸前神经组各34例.保留胸前神经组手术时分开胸大肌暴露并保留胸内、外侧神经,不保留胸前神经组则不保留胸内、外侧神经.其余手术操作相同.术后12个月用彩超测量胸大肌厚度,并与对侧比较.结果：保留胸前神经组无重度胸大肌萎缩,不保留胸前神经组重度萎缩26例（76.5%）.经统计学检验,保留胸前神经组重度胸大肌萎缩情况较不保留胸前神经组明显减少（P＜0.01）.结论：改良乳腺癌根治术中保留胸前神经能减少术后胸大肌萎缩.     

带蒂胸大肌肌皮瓣移植在头颈癌放疗后手术中的运用

目的:探讨头颈癌放疗后因肿瘤复发进行挽救性手术,带蒂胸大肌肌皮瓣修复手术切除后软组织缺损的可行性和价值。方法:7例头颈部恶性肿瘤进行了根治性放疗后局部复发或颈淋巴结转移,通过手术切除病灶,颈淋巴结清扫,同侧带蒂胸大肌肌皮瓣移植修复软组织缺损创面。结果:7例移植的带蒂胸大肌肌皮瓣全部成活,有2例出现切口裂开,愈合困难。结论:在头颈癌放疗后手术中,带蒂胸大肌肌皮瓣移植是修复手术切除后软组织缺损的有效方法。     

The preservation of minor pectoralis muscle in axillary dissection for breast cancer: functional and cosmetic evaluation.

We have evaluated, in two groups of 50 patients each submitted to axillary dissection for breast cancer (10 mastectomies and 90 conservative procedures), the advantage of the preservation of the minor pectoralis muscle. This muscle was preserved in one group and removed in the other. Whereas in the immediate postoperative period complications (shoulder pain, functional impairment, quantity or duration of serum drainage from the axilla) were the same in the two groups, at longer follow-up (more than 6 months after surgery) the patients whose pectoralis minor muscle was preserved showed a reduction in the incidence of partial atrophy and fibrosis of the pectoralis major muscle. Patients treated with conservation of the pectoralis minor muscle showed this atrophy in 6% of cases vs 54% observed in the other patients. This fact may be related to disruption of the pectoral nerves, which are in close contact with the pectoralis minor during their course from the brachial plexus to the pectoralis major muscle.     

高选择性肾动脉阻断在后腹腔镜下保留肾单位手术中的临床价值

目的:比较高选择性肾动脉阻断与肾动脉全阻断在后腹腔镜下保留肾单位手术中的临床疗效、安全性及对其术侧肾功能的影响。方法:选取拟行后腹腔镜下保留肾单位肾肿瘤患者56例,分为实验组和对照组。实验组29例,后腹腔镜下高选择性肾动脉阻断后行保留肾单位手术;对照组27例,后腹腔镜下完全肾动脉阻断后行保留肾单位手术。记录两组患者手术时间、肾动脉阻断时间、术中出血量,监测术前及术后即刻、1月、3月血清总肌酐值,并进一步ECT肾动态测定总肾及分肾肾小球滤过率（GFR）。结果:56例患者手术顺利完成,两组各有2例改后腹腔镜下肾脏根治性切除术。实验组手术时间、肾动脉阻断时间较对照组明显延长（P＜0.05）,实验组与对照组术中出血量无显著差异（P＞0.05）。两组患者术前血肌酐值无显著性差异（P＞0.05）,对照组术后即刻显著升高（P＜0.05）,术后1月、术后3月有所下降,在正常值范围,但仍高于术前水平（P＜0.05）;实验组术后即刻血肌酐显著升高（P＜0.05）,术后1月、3月降至术前水平（P＞0.05）,术后各时间节点实验组肌酐值均比对照组低（P＜0.05）。对照组术后即刻总肾及术侧GFR显著降低（P＜0.05）,1月、3月有所回升,但低于术前水平（P＜0.05）;实验组术后即刻总肾及术侧GFR降低（P＜0.05）,至1月、3月升至术前水平（P＞0.05）,术后实验组各时间节点总肾GFR及术侧GFR均比对照组高（P＜0.05）。术后随访1~3年,本组未见肿瘤局部复发、无远处转移,肾功能未出现异常。结论:后腹腔镜下保留肾单位手术肾动脉高选择性阻断较肾动脉全阻断术式手术时间有所延长,但术后对肾功能影响小、恢复快。     

改良带蒂胸大肌皮瓣修复头颈部晚期恶性肿瘤术后复杂缺损的临床应用

背景与目的：带蒂胸大肌皮瓣因为具有多种优点一直是头颈部组织缺损修复应用的经典组织瓣。当今,随着显微技术普及和提高,游离组织瓣逐步取代了带蒂组织瓣。然而,临床上并非所有病例均适宜接受游离组织瓣修复手术,邻近带蒂组织瓣更安全可靠。拟通过改进胸大肌皮瓣的制备及修复方法,探讨改良带蒂胸大肌皮瓣在修复头颈部晚期恶性肿瘤术后复杂缺损时的应用。方法：在皮瓣设计方案及制备方法等多方面改进胸大肌皮瓣,修复头颈部晚期恶性肿瘤术后复杂缺损患者51例。结果：51例改良胸大肌皮瓣全部存活,缺损区修复后外形和供区外形情况满意,缺损区功能得到良好的恢复,供区术后功能损伤最小化。结论：胸大肌皮瓣在设计及制备方法等多方面的改良,提高了对头颈部恶性肿瘤术后复杂缺损修复的范围及修复的距离,减少皮瓣坏死的概率,术后供区和受区外形、功能效果满意,目前仍然是头颈部恶性肿瘤术后缺损的重要修复手段之一。     

纳米羟基磷灰石／聚酰胺66修复肢体良性骨缺损的疗效观察

目的初步评估和分析纳米羟基磷灰石／聚酰胺66（nano—hydroxyapatitepolyamide66,n—HA／PA66）修复良性骨肿瘤术后骨缺损的疗效和安全性。方法2007年11月至2010年12月,应用n—HA／PA66骨填充材料修复114例良性骨肿瘤术后骨缺损,肿瘤刮除、灭活及人工骨植入70例,28例加用内固定,16例加用异体骨板和内固定。结果除10例失随访外,104例获得随访,随访时间3—33个月,平均8．2个月。伤口均I／甲愈合,无1例发生切口感染、非特异炎症反应和排斥反应;术前、术后的血常规、免疫、肝、肾功能检查均无明显异常。x线和CT检查示：术后1个月,病灶区密度逐渐升高,可见植骨周闸与自体骨结合处模糊,少量新生骨痂形成;术后3个月,病灶区从颗粒植骨周围间隙开始向中心融合成片,更多新生骨痂影融合;术后6个月,病灶区密度明显升高,病灶区大量新生骨痂形成。骨愈合时间为术后2—6个月,3个月时植骨愈合率65％,6个月为96．2％。结论n—HA／PA66骨填充材料的生物相容性良好,无明显排斥反应和非特异炎症反应,修复曩性良性骨肿瘤和瘤样病变效果良好。     

Transpectoral anterior approach to the axilla for lymph node dissection in association with mastectomy preserving both pectoral muscles and their neurovascular bundles

In Patey's mastectomy, which is still the most common operation for breast cancer, axillary node dissection (AND) is performed through the base of the axilla after retracting the pectoralis major muscle and excising the pectoralis minor muscle (some surgeons preserve the latter). This has the disadvantage of inadequate exposure of the axilla and the risk of damage to the neurovascular bundles supplying the pectoral muscles, which in the long run may lead to atrophy of these muscles. A transpectoral anterior approach to the axilla for AND in association with mastectomy was attempted in 115 cases to obviate the above-mentioned disadvantages. The approach included: 1) splitting of the pectoralis major between the clavicular and sternal fibers; 2) mobilization and swinging of the pectoralis minor into different directions by means of a sling to facilitate AND at selected levels. The major advantages of this approach were: 1) total preservation of both pectoral muscles with their neurovascular bundles maintained the normal anatomy and function of the shoulder; 2) the axilla was directly approached through the anterior wall instead of through the base; in this way the axillary contents were exposed almost at surface level; 3) the dissection plane could be limited to anterior to and below the axillary vein and the risk of postoperative lymphedema could thus be minimized; 4) change of position of the ipsilateral arm was not necessary; 5) the duration of surgery was reduced. Monoblock ablation of significant and suspected tissues, maintaining the normal anatomy and function of the shoulder, could be easily accomplished with this approach.     

Effect of a mixed solution of sodium hyaluronate and carboxymethyl cellulose on upper limb dysfunction after total mastectomy: a double-blind, randomized clinical trial

Restricted shoulder mobility is a major upper limb dysfunction related to lower quality of life and disability after breast cancer surgery. We hypothesized that sodium hyaluronate?Ccarboxymethyl cellulose (HA?CCMC) applied to the surface of the pectoralis major muscle after mastectomy would significantly reduce pain and improve range of motion (ROM) of the shoulder in breast cancer patients. We conducted a double-blind, randomized controlled study to evaluate the clinical efficacy and safety of HA?CCMC in the prevention of upper limb dysfunction after total mastectomy (TM). A total of 99 women with breast cancer were randomly assigned to one of two groups. In the HA?CCMC group (n?=?50), a mixed HA?CCMC was applied to the surface of the pectoralis major and serratus anterior muscle after TM. In the control group (n?=?49), TM was performed without the use of HA?CCMC. The primary outcomes were ROM of the shoulder and motion-related pain assessed using a numeric rating scale measured before surgery (T0) and 3 (T1) and 6?months (T2) after surgery. Secondary outcomes included disabilities of the arm, shoulder, and hand (DASH) and the pectoralis minor length test. Compared with the control group, the HA?CCMC group showed greater reductions in postoperative restriction of total shoulder ROM (sum of flexion and horizontal abduction) at 3?months (10.20°, P?=?0.004). Mean pain levels related to flexion and horizontal abduction were significantly lower in the HA?CCMC group (?1.32 and ?0.93, respectively, P?<?0.05). The DASH score was lower (?4.94; P?=?0.057) in the HA?CCMC group at T2. No adverse effect was observed in either group. These results provide evidence that HA?CCMC may provide pain relief and improve ROM of the shoulder without causing adverse effects. The effect on pectoralis tightness should be investigated in further studies.     

134例头颈部肿瘤手术后缺损修复

目的：分析4种皮瓣修复头颈部缺损的效果、功能、并发症和供区创伤的大小，以为不同的缺损选择不同的皮瓣。方法：134例头颈部肿瘤患者，均行联合根治术加胸大肌肌皮瓣、颈阔肌肌皮瓣、额瓣、前臂皮瓣修复。结果：胸大肌皮瓣全部存活96例，部分坏死21例，坏死≥1／25例，全部坏死2例，颈阔肌皮瓣全部存活2例，部分坏死1例，全部坏死1例，4例额瓣和2例前臂皮瓣全部存活。结论：口腔及颈部大面积缺损需要胸大肌肌皮瓣修复，对需要洞穿修复的，尤其是女性，应尽量避免用胸大肌折叠瓣，可用复合瓣。对一般的口腔缺损用前臂皮瓣修复最为合适。     

乳腺癌Auchincloss术中保护肋间臂神经、胸肌神经的意义

目的:探讨在乳腺癌Auchincloss术中保护肋间臂神经、胸肌神经的临床意义.方法:对2008年9月-2010年10月间的38例乳腺癌患者,在Auchincloss术中行腋淋巴结清扫时,注意游离并保护肋间臂神经、胸肌神经,随访观察术前、术后患者胸大肌功能、胸大肌外缘厚度、上臂内侧及腋部皮肤感觉功能的变化;腋窝淋巴结清扫的数量,对术中保护肋间臂神经、胸肌神经的价值进行评估.结果:38例患者中患侧上臂内侧及腋部皮肤感觉正常32例,感觉异常仅2例,占5.6%,4例腋窝淋巴结明显肿大与之黏连,放弃保留肋间臂神经;38例患者均成功保留胸肌神经,经术后随访观察,胸大肌功能均为5级,术后6个月复查B超,胸大肌外缘厚度与术前比较无明显差异.结论:在乳腺癌Auchincloss术中注意保护肋间臂神经、胸肌神经可有效避免术后上臂内侧皮肤感觉障碍及胸大肌萎缩,能明显改善患者术后生存质量,对手术疗效并无影响.