气管、隆突肿瘤外科治疗的技术探讨(附46例报告)

目的 总结气管、隆突肿瘤外科治疗经验,探讨其手术相关技术的合理应用.方法 回顾分析我科2001年2月至2008年10月手术治疗46例气管、隆突肿瘤的临床资料,其中恶性肿瘤29例,良性肿瘤17例;气管环形切除并对端吻合术33例,气管和隆突切除重建术12例,气管楔形切除1例,其中5例重度气管狭窄者在股动脉-股静脉部分体外循环辅助下完成麻醉和手术;43例采用多种带蒂的自体组织包埋气管吻合口.结果 气管切除长度2.0～6.5cm,平均3.2cm;无围手术期死亡,无气管吻合口瘘,临床治愈39例(84.8%);术后随访7个月～7年,死亡5例(10.9%),生存至今40例(87%),其中生存5年及以上者9例(20%).结论 外科手术是气管、隆突肿瘤的首选治疗方法 ;保障通气、合理术式和有效的吻合口包埋是手术成功和预防并发症的关键技术.     

原发性气管肿瘤的外科治疗

目的探讨原发性气管肿瘤外科治疗特点及预后,提高其诊治水平。方法回顾性分析1982年2月至2009年8月中南大学湘雅医院和湖南省肿瘤医院收治的38例原发性气管肿瘤患者的临床资料,其中男24例,女14例;年龄7～65岁。良性病变2例,腺样囊性癌13例,鳞癌11例,粘液表皮样癌5例,腺癌4例,其他组织类型3例。1例行开胸探查术,33例行肿瘤切除术和气道重建术,根据肿瘤生长特征行气管环形切除术＋端端吻合术或气管楔形切除术,1例在纤维支气管镜下行乳头状瘤切除术;另3例未行手术治疗。采用Kaplan-Meier法计算生存率,采用log-rank法比较不同气管肿瘤组织类型及行不同术式患者的生存率。结果行开胸探查术1例患者术后第3d死于呼吸衰竭,围术期病死率2.94%（1/34）,余33例术后康复出院。术后早期并发症发生率35.29%（12/34）,其中肺部感染6例、肺不张4例及声音嘶哑2例。随访6个月～15年,随访率97.29%（36/37）。3例未手术患者均在出院后6个月内死亡。33例患者术后1年、5年和10年生存率分别为88%[95%CI（0.77,0.99）]、47%[95%CI（0.29,0.66）]和41%[95%CI（0.21,0.61）]。腺样囊性癌及粘液表皮样癌术后生存率明显高于鳞癌及其他组织类型（χ2=17.581,P=0.001）。患者行气管楔形切除术与环形切除术后5年生存率分别为63%[95%CI（0.34,0.91）]和77%[95%CI（0.44,0.99）],其差异无统计学意义（χ2=0.021,P=0.886）。结论原发性气管肿瘤首选手术治疗,术后远期生存率与肿瘤组织类型有关     

体外膜肺氧合辅助下机器人气管肿瘤切除重建术1例北大核心CSCD

43岁男性患者,咳嗽、呼吸困难半个月。既往于外院确诊气管远段腺样囊性癌,并接受内镜下治疗,未能根治。入院后行气管镜及胸部CT检查示病变长约2 cm,下缘距离隆凸约2 cm,上缘距声带约8 cm。在体外膜肺氧合辅助下,行机器人辅助气管远段肿瘤切除+气管端端吻合术。术后顺利出院,随访未见气管吻合口狭窄或复发。     

电视硬质气管镜治疗原发性气管支气管肿瘤

目的总结电视硬质气管镜在原发性大气道肿瘤治疗方面的特点及体会。方法2002年9月～2009年10月,电视硬质气管镜手术治疗45例原发性气管支气管肿瘤。平均年龄54.4岁（18～80岁）。病变位于气管29例,隆突4例,左主支气管6例,右主支气管6例。全麻下经口置入电视硬质气管镜,根据病变情况决定治疗方式：窄蒂的良性肿瘤行内镜下完全切除;可切除的肿瘤,内镜下清除肿瘤后开胸行气管支气管部分切除吻合;不能切除的恶性肿瘤,内镜下气道疏通或放置支架。结果全组手术顺利,无死亡及严重并发症。良性病变11例,恶性病变34例。45例共进行49次手术,2例进行了2次手术,1例进行了3次手术。肿瘤根治性切除20次,气道疏通28次,支架放置1次。术后随访平均35.4月（1～83个月）,良性肿瘤中2例腺瘤术后复发,其余9例随访（57.0±22.0）月（5～83个月）无复发;恶性肿瘤中12例腺样囊性癌平均随访28.6月（1～71个月）无复发,其中8例未完全切除患者平均随访19.3月（1～48个月）,均存活;1例气管鳞癌根治性切除者术后随访60个月,存活。26例恶性肿瘤未完全切除者平均随访22.7月（8～41个月）,存活15例（其中复发2例）,死亡11例。结论电视硬质气管镜是原发性气管支气管肿瘤安全、可靠、有效的治疗方法。     

气管隆凸切除重建术在呼吸道肿瘤外科治疗中的应用

目的 总结气管隆凸切除重建术在呼吸道肿瘤患者中的手术治疗经验，探讨合理的手术方法及治疗措施。方法 回顾分析1996年1月～2004年6月，27例气管隆凸肿瘤患者的临床资料。结果 行气管肿瘤切除＋对端吻合8例；右全肺＋隆凸切除，气管与左主支气管对端吻合6例；左全肺＋隆凸切除，气管与右主支气管对端吻合3例；右上肺叶＋隆凸袖式切除，气管＋左主支气管＋右中间支气管“品”字吻合2例；隆凸切除，气管＋左主支气管＋右主支气管“品”字吻合3例；气管肿瘤及气管壁部分切除或刮除5例，其中体外循环辅助下完成手术2例。术后早期死亡3例，2例术后早期死于多器官衰竭，1例系胸腔感染、出血，术后21d死亡。半年以上随访，无死亡，无外科并发症。结论隆凸及气管手术比较复杂，手术难度大，选择合理的术式及麻醉方法，必要时应用体外循环技术，可以取得满意的疗效。     

隆突切除重建术五例

我院胸外科１９８２年１０月～１９９６年１０月共行隆突切除重建术５例，取得较好效果。报告如下。１．一般资料：本组５例皆为男性。年龄４８～７２岁，平均５２岁。５例全部为右原发性中心型支气管肺癌浸犯隆突，均为鳞状细胞癌。２．手术方式：右全肺隆突切除、气管左...     

甲状腺癌的外科治疗

目的 探讨甲状腺癌的外科手术治疗的方式和效果.方法 回顾性分析1990-2005年间上海市第八人民医院和江苏大学附属医院收治的126例甲状腺癌患者的临床资料.结果 126例甲状腺癌中,乳头状腺癌94例（74.6%）,其中有2例为桥本氏病合并甲瘤和甲状腺乳头状腺癌,1例还合并有甲亢,滤泡状腺癌20例（15.9%）,髓样癌5例（4.0%）,未分化癌4例（3.2%）,恶性淋巴瘤2例（1.6%）,鳞状细胞癌1例.126例中肿瘤直径小于1 cm的甲状腺微小癌（TMC）56例,均为乳头状腺癌.术后随访5年以上78例,1～5年36例,生活质量均为良好.未分化癌4例均于术后3～6个月死亡,2例髓样癌和1例鳞状细胞癌术后1年均因肺转移死于咯血.结论 早期诊断和治疗、规范手术切除范围可避免因漏诊再次手术,术后应早期尽量替代治疗.     

非计划性局部进展期肺癌扩大指征手术的回顾性分析

目的总结针对局部进展期非小细胞肺癌(LA-NSCLC)施行肺癌扩大指征手术的临床经验。方法回顾性分析2008年1月至2012年12月同济大学附属东方医院胸心外科非计划性实施肺癌扩大指征手术治疗的14例LA-NSCLC患者的临床资料,其中男9例、女5例,年龄30~67(59.5±6.1)岁。行胸壁切除与重建术2例主动脉切除及重建术1例肺癌上腔静脉切除重建术3例推体部分切除术1例左心房部分切除术1例肺上沟瘤外科治疗2例,袖形全肺切除或肺叶切除隆突成形术3例支气管肺动脉成形术1例。结果本组患者无围手术期死亡病例。术后病理诊断鳞癌7例,腺癌4例,鳞腺癌1例,腺样囊性癌2例。随访18.5(7~48)个月。全组患者中术后生存时间最长者超过4年;3例分别于术后7个月、11个月和17个月死于肿瘤远处转移;1例存活26个月,1例存活20个月,另1例术后3个月并发肺部感染死亡;4例已存活3年以上;另有3例术后随访至2013年9月,随访时间未满1年仍存活。结论肺癌扩大指征手术能使LA-NSCLC患者获得肺癌的完全性切除,其中相当部分患者术后可获良好的近远期效果,因此外科治疗依旧是肺癌治疗的基石对有条件手术者应力争手术治疗。     

体外循环下气管肿瘤切除术的护理配合

对27例气管肿瘤阻塞气道50%以上患者在体外循环(CPB)技术支持下行气管肿瘤切除术.结果 手术过程顺利,2例术后出现短暂的呼吸困难,经充分吸痰、吸氧后好转;27例无术后并发症.均临床痊愈出院.23例随访1～2年,3例气管腺样囊腺癌患者术后15个月左右复发,行支架置入术后出院.提示术前针对性的心理护理,熟练掌握手术步骤和各种器械的使用,医护密切配合是手术成功的重要环节.     

气管隆突切除及重建术治疗中心型支气管肺癌

本文报告１０例侵及气管隆突或距隆突０．３ｃｍ以内的中心型支气管肺癌行气管隆突切除及重建术，其中右上叶及隆突切除重建术３例，右全肺及隆突切除２例，左全肺及隆突切除４例，左上叶及隆突切除重建术１例，加部分左心房切除术３例。本组根治切除９例。姑息切除１例。术后并发症３例（３０％）。术后无癌生存６年１例，３年１例，２年１０月１例，２年６月３例，１年２例，半年１例；另１例于术后８月死于脑转移。重点讨论了手术适应证、手术方法、围手术期监护和处理。     

Experience with primary neoplasms of the trachea and carina

From 1963 to 1983, 44 patients presented with a primary tracheal neoplasm that was amenable to surgical treatment. Forty-two of the 44 tumors were malignant. Thirty-three patients were managed by resection and primary anastomosis. The following resections were done: trachea only, 12; trachea plus carina, 13; trachea plus cricoid cartilage, four; and trachea plus larynx, four. There were two operative deaths in these 33 patients. Prosthetic reconstruction with heavy-duty Marlex mesh was done in six patients. Three of the six died of erosion of the innominate artery during the postoperative period. In three patients with nonresectable tumors, a silicone-coated Montgomery T-tube provided transient but worthwhile palliation. In two patients with nonobstructive adenoid cystic carcinoma involving the subglottis, irradiation was chosen as the initial treatment, since resection would necessitate laryngectomy. Resection, including laryngectomy, may be required in the future. The following points are emphasized: (1) A majority of operable neoplasms can be resected through a cervical collar incision and median sternotomy. Median sternotomy is the optimal operative exposure in most neoplasms necessitating resection of the carina. (2) Partial resection of the cricoid with sparing of the recurrent laryngeal nerves and larynx is possible in some patients with primary malignant tumors involving the proximal trachea and subglottic region. (3) In patients with adenoid cystic carcinoma, resection may afford excellent, long-term palliation even when the resection is incomplete. Pulmonary metastases are common in patients with adenoid cystic tumors. However, they usually progress slowly, may remain asymptomatic for many years, and are not necessarily a contraindication to resection of the primary tumor even when they are synchronous. Our experience suggests that adjunctive radiotherapy is beneficial in patients with adenoid cystic carcinoma.     

Tracheal tumors: surgical management.

In a 15-year period, 63 patients with primary tracheal tumors were seen. Twenty-eight patients with primary tumors and 8 with secondary tumors of the trachea were treated by resection with single-stage reconstruction. There were 24 cylindrical resections of trachea, 2 lateral resections of trachea, and 10 carinal reconstructions. Thirty-five additional patients with primary tracheal tumors were managed by staged reconstruction, irradiation, or no treatment. The most common primary lesion was squamous cell carcinoma and the second, adenoid cystic carcinoma. Benign primary tumors and low-grade malignant tumors obtained excellent palliation and usually cure. Surgical removal of squamous cell carcinoma and adenoid cystic carcinoma, usually with adjunctive irradiation, provided good palliation or the probability of cure. Resection of selected secondary tumors provided long-term palliation.     

Primary tracheal tumors: experience with 14 resected patients.

OBJECTIVE: Primary tracheal tumors are rare. Management includes interventional endoscopy, surgery and radiotherapy. METHODS: Between 1987 and 1996, 14 patients treated by resection and reconstruction of the trachea and bifurcation for primary tracheal tumors were retrospectively analyzed. RESULTS: The most common histological finding was adenoid cystic carcinoma (n=7), followed by a squamous cell carcinoma (n=2), a mucoepidermoid carcinoma (n=2), a carcinoid tumor (n=1) and two benign tumors (xanthogranuloma, pleomorphic adenoma). Various reconstruction techniques were used and one prosthesis was implanted. Eight of the patients required preoperative Nd-YAG laser recanalisation. Six were treated by postoperative external beam radiotherapy, in three cases combined with endoluminal brachytherapy. Two major postoperative wound-healing impairment at the anastomosis occurred. Four minor wound-healing disorders were successfully treated by interventional endoscopy. Two patients died postoperatively with mediastinitis respectively with bilateral pneumonia. A local recurrence was observed in only two cases. At the last follow-up in January 1998, nine patients were still alive. We observed five long-term survivors (>6 years) with an adenoid cystic carcinoma or mucoepidermoid carcinoma. CONCLUSIONS: Extensive segmental resection of the trachea is the treatment of choice for primary malignant and occasionally for benign tracheal tumors. Interventional endoscopy is a part of modern tracheal surgery.     

Management of tracheal tumors

Since 1962, 110 primary tracheal tumors have been seen including 43 squamous cell carcinomas, 38 adenoid cystic, and 29 varied. Sixty-nine patients underwent resection of their primary tumors; an additional 33 patients with secondary tumors involving the trachea also underwent resection. Seventy-three of these 102 patients underwent primary reanastomosis. In 17, laryngotracheal resection was required; staged resections were done for the rest. Survival data indicate that benign tumors are cured by resection with reconstruction and that patients with squamous cell carcinoma, adenoid cystic carcinoma, and other types of malignant lesions obtained either long-term palliation or cure if surgical resection was possible. In patients with selected types of secondary tumors, resection and reconstruction provide prolonged palliation.     

Primary tracheal tumors: treatment and results

One hundred ninety-eight patients with primary tracheal tumors were evaluated in 26 years. One hundred forty-seven tumors were excised (74%): 132 (66%) by resection and primary reconstruction, seven by laryngotracheal resection or cervicomediastinal exenteration, and eight by staged procedures. Eleven more were explored. Forty-four squamous cell carcinomas were resected, 60 adenoid cystic, and 43 assorted tumors, benign and malignant. Eighty-two patients underwent tracheal resection with primary reconstruction, and 50 had carinal resection and reconstruction. Surgical mortality for resection with primary reconstruction was 5%, with one death after tracheal and six after carinal repair. Six patients had stenosis after tracheal or carinal resection; all underwent reresection successfully. Nearly all patients with squamous or adenoid cystic carcinoma were irradiated postoperatively. Twenty of 41 survivors of resection of squamous cell carcinoma are living free of disease (some for more than 25 years), 39 of 52 with adenoid cystic carcinoma (up to nearly 19 years), and 35 of 42 with other lesions (5 lost to follow-up). Comparison of length of survival of patients with squamous cell carcinoma and adenoid cystic carcinoma who are alive without disease with those who died with carcinoma supports surgical treatment (usually followed by irradiation). Positive lymph nodes or invasive disease at resection margins appear to have an adverse effect on cure of squamous cell carcinoma; such an effect is not demonstrable with adenoid cystic carcinoma.     

原发性气管肿瘤的外科治疗

目的 总结外科手术治疗原发性气管肿瘤的临床经验。方法 回顾性分析我科1968—2001年70例原发性气管肿瘤的外科治疗资料。结果 气管节段切除39例,隆凸切除13例,气管侧壁切除10例,肿瘤局部剔除5例,全肺切除1例,开胸探查2例。并发症发生率31％(22／70)。气管切除与重建术后30d内死亡率8％(4／52)。良性肿瘤14例,恶性肿瘤56例。其中腺样囊性癌和鳞癌是最常见的类型,分别为45％(25／56)和23％(13／56)。良性肿瘤随诊平均5．7年。恶性肿瘤切除术后5、10年生存率分别为64％(21／33)和54％(14／26)。结论 手术切除是治疗气管肿瘤最有效的方法。气管节段切除是治疗气管恶性肿瘤的主要术式,良性肿瘤可以考虑保守的术式。降低手术并发症是取得良好手术疗效的关键。     

22例原发性气管肿瘤的诊断与外科治疗

目的总结22例原发性气管肿瘤手术治疗的临床经验,以提高手术疗效。方法22例原发性气管肿瘤患者,其中良性肿瘤4例,恶性肿瘤18例。行气管对端吻合14例,隆凸重建4例,纤维支气管镜下摘除肿瘤1例,局部搔刮2例,气管修补1例。气管切除长度2．0～5．2cm,平均3．8cm。结果22例中确诊前有17例在门诊误诊,误诊率77．3％,大多数患者被误诊为支气管哮喘。术后30d内死亡1例,死于急性呼吸衰竭。发生并发症7例（31．8％）,分别为肺部感染4例,吻合口瘘1例,乳糜胸2例;远期并发症吻合口狭窄3例,经再次手术治疗,狭窄改善。随访20例,随访时间1个月～8年。4例良性肿瘤患者在随访期间均无瘤生存;16例恶性肿瘤患者术后随访满5年以上生存6例,因肿瘤脑、肝和骨远处转移死亡3例。结论手术切除是治疗气管肿瘤最有效的方法,气管节段切除是治疗气管恶性肿瘤的主要术式,良性肿瘤可以考虑保守术式,降低手术并发症是取得良好手术疗效的关键,掌握气管肿瘤的临床特点、提高对该病的认识是减少误诊的有效手段。     

Prosthetic reconstruction of the trachea and carina

We have performed prosthetic reconstruction of the trachea and carina in 12 patients since 1979. We used Neville's prosthesis in 7 patients and Katsura's prosthesis in 5 patients. Seven patients were operated on for lung cancer, 2 patients for adenoid cystic carcinoma of the trachea and the others for large cell carcinoma of the trachea, thyroid cancer and tuberculous granuloma, respectively. Prosthetic reconstruction of the trachea was performed in 4 patients. Carinal resection was performed in 8 patients: With right sleeve pneumonectomy in 4 patients, with right upper lobectomy in 2 patients and only carinal resection in 2 patients. Prosthetic reconstruction after the carinal resection was performed using 3 straight types, 1 curved type and 4 bifurcated types. With regard to the complications of the prosthetic reconstruction, dehiscence at the anastomotic site was seen in 5 patients, granulation in 4 patients, empyema in 3 patients, massive hemorrhage in 2 patients and migration of the prosthesis in 1 patient. Five patients survived more than 1 year. The longest survival time was 43 months. To prevent complications of the prosthetic reconstruction, we improved the anastomotic method, reinforced the anastomotic site with Marlex mesh and protected the surrounding vessels with Lyodura.     

24例隆凸气管主支气管肿瘤的外科治疗

总结１９８０－１９９４年２４例隆凸,气管,主支气管肿瘤病人手术治疗经验,方法,行气管、主支气管袖状切除对端合术１７例,隆凸切除重建术６例,气管纵行开窗刮除肿瘤减压术１例。结论：隆凸及气管手术比较复杂,手术难度大,但严和掌握的适应证,选择合理的术式及麻醉方法,可以取得满意的疗效。