体外循环辅助下胸部局部晚期肿瘤切除术

目的探讨体外循环（CPB）辅助下局部晚期胸部肿瘤切除术的可行性及手术治疗的危险性,总结治疗经验。方法回顾性分析2006年8月至2007年8月在我科行体外循环辅助下肿瘤切除术3例患者的临床资料,其中男2例,女1例;平均年龄为31岁（14～43岁）。术前评估均属侵犯心脏、大血管的胸部晚期肿瘤;其中2例行肿瘤完全切除（R0）,1例行姑息性切除（R2）。结果无住院死亡。平均CPB时间101min,平均住ICU时间3d,平均住院时间15d;2例术后并发心房颤动、轻度心力衰竭,1例并发肺水肿,均经积极治疗好转出院。术后分别随访14个月、8个月和5个月,生存2例,死亡1例,死于脑转移。结论体外循环技术扩大了局部晚期胸部恶性肿瘤（T4期或Ⅳ期）手术的适应证,在能够接受手术风险的基础上给患者带来了希望。     

体外循环下局部晚期肺癌扩大切除的手术配合

对9例局部晚期肺癌患者在体外循环（CPB）技术支持下施行肿瘤扩大切除术。结果手术过程均顺利，1例术后18h并发呼吸衰竭死亡；8例无术后并发症，均临床痊愈出院。随访1～12个月，1例因脑转移而死亡，其余7例仍存活。提示局部晚期肺癌侵犯心脏大血管时，CPB可降低外科手术的危险性，扩大手术的适应证；充分的术前准备和熟练的手术配合是保证手术顺利完成的重要环节。     

体外循环在局部晚期肺癌外科治疗中的应用

近年来，虽然国内外均有将体外循环(cardiopulmonary bypass，CPB)用于局部晚期肺癌手术的报道，但对此存在不同观点，有些问题值得进一步探讨。现将我科CPB辅助下的肺癌切除治疗结果及经验体会报告如下。     

体外循环下局部晚期肺癌扩大切除的手术配合

对9例局部晚期肺癌患者在体外循环(CPB)技术支持下施行肿瘤扩大切除术.结果 手术过程均顺利,1例术后18 h并发呼吸衰竭死亡;8例无术后并发症,均临床痊愈出院.随访1～12个月,1例因脑转移而死亡,其余7例仍存活.提示局部晚期肺癌侵犯心脏大血管时,CPB可降低外科手术的危险性,扩大手术的适应证;充分的术前准备和熟练的手术配合是保证手术顺利完成的重要环节.     

转化手术在局部晚期不可切除非小细胞肺癌治疗中的作用

肺癌是我国发病率和死亡率最高的恶性肿瘤，严重威胁着我国人民群众的生命健康。局部晚期不可切除非小细胞肺癌异质性高、预后差，同步放化疗后度伐利尤单抗巩固治疗是其主要治疗模式。近年来，随着靶向治疗及免疫治疗的进展，肺癌的治疗格局发生改变，一部分原来不可切除的局部晚期或晚期非小细胞肺癌经综合治疗后降期转化为可手术根治性切除，这种外科治疗策略称为转化手术。随着综合治疗模式的进展，其未来或在胸外科中占有越来越高的比重。本文就局部晚期不可切除非小细胞肺癌的治疗模式及转化手术进行综述。     

原发性肝癌合并肝静脉/下腔静脉癌栓的综合治疗策略

原发性肝癌是一种常见的恶性肿瘤。早期肝癌适合行手术切除、局部消融、肝移植等根治性治疗, 预后相对较好。然而, 晚期肝癌常伴有肝静脉和下腔静脉癌栓, 治疗后复发、转移率高, 预后差。合并肝静脉和下腔静脉癌栓的晚期肝癌患者, 我国指南推荐包括局部治疗、系统治疗、手术切除等综合治疗模式。本文重点回顾了近十年来原发性肝癌合并肝静脉及下腔静脉癌栓在诊断、分型与治疗方面的进展。     

晚期恶性肿瘤患者的护理关怀

我国现有癌症患者700多万，每年新增200万以上，其中50％为晚期肿瘤，伴随出血、厌食、呕吐、疼痛等并发症的发生，长期手术和放化疗治疗使患者本人遭受极大的身心损害和经济负担的压迫，且随时可能发生死亡。本文统计了我院20年来各科收治的恶性肿瘤患者1774例，其中晚期恶性肿瘤826例，现对其治疗情况及晚期护理情况做一总结。     

胃癌外科综合治疗的若干进展与展望

胃癌是国内、外常见恶性肿瘤，手术仍是治疗胃癌的主要方法。一系列临床研究改变了传统胃癌手术理念，避免盲目扩大手术切除范围。腹腔镜手术治疗早期和局部进展期胃癌的疗效并不劣于开腹手术。胃癌微创手术发展的关键是把握合理的手术指征，建立手术技术培训系统，以及优化成本与效益。理性认识胃癌扩大术脏器切除与保留脏器功能的关系。注重局部进展期胃癌围术期治疗的全程管理。并提倡晚期胃癌的术前转化治疗。对广泛转移晚期胃癌的姑息性切除术应慎之又慎，建议综合治疗，旨在延长病人生命。     

腹腔镜淋巴结清扫能否达到宫颈癌根治术的要求

腹腔镜手术作为一种微创手术,具有住院时间短、创伤少、恢复快等特点,对肿瘤患者,更有助于术后其他辅助治疗的进行.腹腔镜手术自1990年开始用于妇科恶性肿瘤的治疗,此后无论是手术技巧还是仪器设备均有了很大的改进,目前许多复杂的妇科恶性肿瘤手术均可在腹腔镜下完成,并且并发症和中转开腹率均明显下降,而恶性肿瘤的复发率并未增加.许多妇科恶性肿瘤的手术分期均包括盆腔和腹主动脉旁淋巴结清扫术均可行腹腔镜手术,腹腔镜可以发现淋巴转移、对患者的治疗及预后均有重要作用.对于早期子宫颈癌和局部晚期子宫颈癌患者,淋巴结清扫术既可达到治疗目的,又可为制定进一步治疗方案提供依据.因此,腹腔镜淋巴结清扫术在治疗早期子宫颈癌患者中起非常重要的作用.     

综合治疗对中低位直肠癌功能保护的意义

结直肠癌是世界上最常见的恶性肿瘤之一，居恶性肿瘤发病率的第3位。西方化生活方式和饮食习惯使中国结直肠癌的发病率呈逐年上升的趋势，且40岁以下年轻人占30％以上，因此。在中国关注结直肠癌、尤其低位直肠癌的治疗状况非常有意义。尽管手术切除仍是直肠癌最重要的治疗手段，但淋巴结阳性和肿瘤侵犯浆膜者很容易发生肝、肺等远处转移，其局部复发率也很高；晚期患者的局部复发率为4％～40％，     

同种异体原位肝移植15例报告

目的 总结临床肝移植的经验。方法 对１０例晚期肝硬变、２例肝内胆管扩张症、１例肝内胆管结石、１例布－加氏综合征、１例胆管细胞癌患者施行了原位肝移植。结果 １５例患者术后移植肝活力恢复良好；死亡３例，１例死于肿瘤转移，２例死于感染，余１２例存活良好，已有３例存活超过１年。结论 完善的手术技术及正确的围手术期处理是肝移植成功的关键。     

Cardiopulmonary bypass technique for treatment of renal cell carcinoma extending into the vena cava.

Cardiopulmonary bypass (CPB) is a unique technique used widely for renal cell carcinoma patients showing inferior vena cava invasion. We used a modification of CPB technique for 2 patients. These patients were managed with CPB without cross clamping and so without cold potassium cardioplegia. The primary tumor was a renal cell carcinoma propagating into the inferior vena cava and going into the right atrium as a thrombus in both patients. As a surgical procedure the urology team did nephrectomy and then with our clinical techniques we used CPB to cool the patients to 20 degrees C and decreased the flow to 500 ml/min/m2. The heart went into spontaneous ventricular fibrillation without using cross clamping and cardioplegia. Then we did atrial and inferior vena caval thrombectomy in a bloodless and visible operation field within a safe time interval. The aim of using this technique is to prevent myocardial injury and to protect the brain from hypoxia by using this low flow technique. This method can be used safely for the management of renal cell carcinomas and for some retroperitoneal malignancies associated with vena caval and atrial involvement.     

Resection of advanced thoracic malignancies requiring cardiopulmonary bypass.

OBJECTIVES: Patients with malignancies involving cardiac structures have limited therapeutic options and significant risk of mortality. The decision to offer radical palliative or curative resection must be made only after consideration of the substantial surgical risks. The purpose of this retrospective study was to determine the feasibility and benefits of resection with cardiopulmonary bypass (CPB) of metastatic or non-cardiac primary malignancies extending directly into or metastasizing to the heart in select patients. Our results were examined to assess the risks and benefits of such radical therapy. METHODS: We retrospectively reviewed patient charts and identified all patients with malignancies involving the cardiac chamber or great vessels (excluding renal carcinomas with caval extension) or with substantial cardiac compression who had undergone resection with CPB at The University of Texas M.D. Anderson Cancer Center between January 1995 and July 2000. We evaluated demographic data, symptomatology, tumor characteristics, and outcomes. RESULTS: Nineteen patients (six males and 13 females; median age of patients, 47 years; age range, 17-67 years) were included in the study. Eleven patients underwent surgery with curative intent, and eight underwent surgery with palliative intent. Seventeen patients had tumors that required CPB because their tumors directly involved the heart and/or great vessels (nine sarcomas, seven epithelial carcinomas, and one unclassified), and two patients (both with sarcomas) required CPB to relieve tumor tamponade. The technique included CPB (n=5), CPB with diastolic arrest (n=12), and CPB with hypothermic circulatory arrest (n=2). Five patients underwent concomitant pneumonectomy, and three underwent lobectomy. Two patients (11%) died in the hospital after resection with palliative intent. Of the 11 patients who underwent resection with curative intent, ten (91%) had complete resections. The median time in the intensive care unit was 5.3 days (range, 0-37 days) and the median length of hospital stay was 17.2 days (range, 0-107 days). Major complications occurred in 11 patients (58%); the most common major complications were pneumonia (n=7 patients), mediastinal hematoma (n=4 patients), and acute respiratory distress syndrome (n=2 patients). The median follow-up duration was 27 months. The overall 1- and 2-year survival rates were 65 and 45%, respectively. CONCLUSIONS: Extensive thoracic tumors involving cardiac structures can be resected with acceptable risk. When resection was performed with curative intent, excellent 1- and 2-year cumulative survival rates were achieved. Although resection with palliative intent was associated with greater mortality rates, some patients survived for 1 and 2 years. The use of CPB in selected patients with thoracic malignancies should be considered, especially when complete resection can be achieved.     

Repair of lesions of the descending thoracic aorta with the TDMAC-heparin shunt

Utilizing a heparinized tridodecylmethylammonium chloride (TDMAC) shunt makes it possible to treat various surgical diseases of the descending thoracic aorta without cardiopulmonary bypass. Since the initial report by Gott and associates on the use of the heparinized shunt, few subsequent clinical trials have appeared in the literature. Six patients with Type III dissecting thoracic aneurysm, acquired and congenital coarctation of the aorta, saccular arteriosclerotic aneurysm, and transection of the descending thoracic aorta were operated upon by means of this technique. Only one patient had more than 500 ml. of chest tube drainage in the first 8 hours postoperatively. There were no instances of paraplegia, renal failure, or death. This technique is also recommended for repair of innominate artery aneurysms, endarterectomy of the innominate or subclavian artery, arch aneurysm, penetrating injuries of the thoracic aorta, and proximal abdominal aneurysms. Surgical indications, operative management, and postoperative follow-up are discussed.     

Surgical treatment of acute traumatic rupture of the thoracic aorta a timing reappraisal?

OBJECTIVE: To report our experience with surgery of thoracic aortic rupture due to blunt trauma. METHODS: Between October 1976 and October 1999, 50 patients suffering from acute rupture of the thoracic aorta due to blunt trauma were operated on. On admission, 22 patients (44%) presented with hypovolemic shock and all but five (90%) sustained major associated injuries. Thirty-one patients (62%) underwent immediate operation for aortic repair, whereas the procedure was delayed from 6 to 60 days in ten patients because of late diagnosis or coexisting life-threatening lesions thought to largely worsen the operative risk. In 48 patients, the aortic repair was carried out with the aid of cardiopulmonary bypass (CPB) in order to maintain the distal perfusion and to prevent spinal cord injury. An inert 'Gott' shunt and the 'clamp-and-sew' technique were used in one patient each. RESULTS: The hospital mortality amounts to 18% (nine patients). Four patients (8%) died intraoperatively and five patients (10%) died in the postoperative course. In five patients (10%) death was caused by cerebral or pulmonary hemorrhage, possibly worsened by systemic heparinization during CPB. One case of postoperative paraplegia (2%) was observed in a patient operated on with the aid of CPB. There was neither aortic rupture nor sudden death in the group of patients in whom the surgical procedure was delayed. CONCLUSIONS: The immediate outcome of patients suffering from acute traumatic aortic rupture strongly depends on the associated injuries. In some cases, the emergency aortic repair must be favorably delayed because of the necessity of life-sustaining measures and management of major coexisting injuries, which could be worsened by the use of CPB. Conversely, the risk of paraplegia is significantly reduced by the use of CPB and distal perfusion during the time of aortic cross-clamping.     

Medical education and surgical residency program for general thoracic surgery

We introduced medical education for general thoracic surgery to medical students and a new surgical residency program to instruct residents who aspire to become general thoracic surgeons. It is important to understand the etiology of thoracic diseases, methods of diagnosis for tumorous lesions, anatomy of the interior thorax, surgical therapies and indications for thoracic diseases, and management of perioperative periods in the medical education of general thoracic surgery. According to the new residency program, a surgical resident must complete a super rotating system that consists of the subjects of internal medicine, general surgery, emergency and critical care medicine, anesthesiology, pediatrics, gynecology, and local healthcare for several months each in the first two years. On the other hand, a surgical residency program includes core surgical residencies to train clinical patient-care oriented surgeons and advanced residencies in such areas as thoracic surgery, cardiovascular surgery, pediatric surgery, and digestive organ surgery. Residents who want to become general thoracic surgeons must complete 350 cases of general surgery including at least 120 cases for an operator in the first 4 or more years in core programs. After passing the board for general surgery, they can advance to a subspecialty program for thoracic surgery in the final 3 or more years to pass the board for general thoracic surgery. It is essential to train the general thoracic surgeons who empathize with patients with thoracic diseases and can contribute to overcoming thoracic diseases by practicing evidence- or science-based medicine.     

Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass.

OBJECTIVE: Complete resection of advanced pulmonary malignancies infiltrating the heart or the great vessels may require the application of cardiopulmonary bypass (CPB). Extracorporal circulation, however, is known to cause lung injury and may be harmful especially in pneumonectomies. METHODS: Over a period of 10 years extended pulmonary resections requiring cardiopulmonary bypass were analyzed in a retrospective study. RESULTS: From August 1993 to August 2003, 13 patients underwent an extended pulmonary resection for curative indications, requiring support by CPB. Underlying diseases were sarcomas (n=8), non-small cell lung carcinomas (n=3), and others (n=2). Pneumonectomies were performed in nine and lobectomies in four cases. In the majority of cases, several cardiac structures, predominantly the left atrium (n=9), were affected. In four patients (31%), the indication for a CPB-supported procedure was not electively planned, but made intraoperatively. Complete en-bloc resection (R0) was achieved in 12 of 13 cases (92%). The 30-day mortality rate was 15% (n=2). Major complications observed were acute lung injury (n=4), right heart failure (n=1), and multi-organ failure (n=1). The cumulative survival at 1, 3, and 5 years in patients presenting with sarcomas was 62.5% compared to 33%, 0%, and 0%, respectively, in patients with non-small cell carcinoma (n=3). CONCLUSIONS: Our results encourage the application of CPB in extended pulmonary resections to achieve complete resections. In carefully selected patients, especially those with sarcomas, the radical surgical procedure associated with increased pulmonary complications allows for significantly prolonged survival and quality of life.     

Laser Therapy in Pulmonary Medicine

In this review, the different laser applications for diseases in the thoracic cavity are presented. The different laser types, Nd-YAG, CO₂, diode lasers and photodynamic therapy (PDT) and their indications are presented. The indications for endobronchial laser vary from benign disorders like granuloma to the more frequent ablation of endobronchial tumours. The promising use of treatment with PDT in early stage lung cancer and its adjuvant role in surgical resection of pleural malignancies is discussed. Emphasis is given to the data obtained so far for the different laser applications. Paper received 4 March 1997; accepted in final form 10 November 1997.     

Recent advances in the management of thoracic surgical infections

Current management of infections in thoracic surgery is reviewed. The selection of patients for the use of antibiotics prophylactically, the diagnosis and treatment of pulmonary infection in immunosuppressed patients, indications for operation in patients with fungal infections, bronchiectasis, lung abscess, and empyema, and the management of mediastinitis after sternotomy and of postpneumonectomy space infections is described.     

An expanding role for cardiopulmonary bypass in trauma.

OBJECTIVES: To analyze experience at the McGill University Health Centre with cardiopulmonary bypass (CPB) in trauma, complemented by a review of the literature to define its role globally and outline indications for its expanded use in trauma management. DATA SOURCES: All available published English-language articles from peer reviewed journals, located using the MEDLINE database. Chapters from relevant, current textbooks were also utilized. STUDY SELECTION: Nine relevant case reports, original articles or reviews pertaining to the use of CPB in trauma. DATA EXTRACTION: Original data as well as authors' opinions pertinent to the application of CPB to trauma were extracted, incorporated and appropriately referenced in our review. DATA SYNTHESIS: Overall mortality in the selected series of CPB used in the trauma setting was 44.4%. Four of 5 survivors had CPB instituted early (first procedure in operative management) whereas 3 of 4 deaths involved late institution of CPB. CONCLUSIONS: Although CPB has traditionally been used in the setting of cardiac trauma alone, a better understanding of its potential benefit in noncardiac injuries will likely make for improved outcomes in the increasingly diverse number of severely injured patients seen in trauma centres today. Further studies by other trauma centres will allow for standardized indications for the use of CPB in trauma.