原发性肺和纵隔恶性纤维组织细胞瘤（附3例报告及文献复习）

我院自１９８６年１月至１９９３年８月分别收治了２例原发肺和１例原发纵隔恶性纤维组织细胞瘤，通过手术广泛切除及术后放疗、化疗及免疫治疗，分别随访３年、１年及半年，患者仍健在。作者复习１９８３年以后的国内文献，收集到２ｌ例肺、１例纵隔恶性纤维组织细胞瘤，结合我院３例，就本病的发病、病理、临床表现、诊断及鉴别诊断，治疗及预后作简要讨论。     

后纵隔巨大淋巴结增生误诊为食管平滑肌瘤2例

后纵隔巨大淋巴结增生误诊为食管平滑肌瘤２例范士志，蒋耀光，王如文，牛会军我科自１９９４年７月～１９９５年８月收治２例酷似食管平滑肌瘤的后纵隔巨大淋巴结增生，结合文献复习，报告如下。１临床资料例１女性，２１岁，学生。间隙性吞咽困难６个月，消瘦伴胸部疼痛...     

电视纵隔镜在胸部疾病诊断与治疗中的应用

目的探讨电视纵隔镜在胸部疾病诊断和治疗中的应用价值，总结其临床经验。方法对2006年3月至2007年5月开展的47例电视纵隔镜手术资料进行回顾性分析，其中经颈部纵隔镜手术38例，左胸纵隔镜手术8例，右胸纵隔镜手术1例。结果本组手术时间10～100min，平均44．2min；术中出血5～200ml，平均33．5ml。肺癌术前分期12例，纵隔淋巴结病理检查阴性4例，阳性8例，均与开胸手术后检查结果相符，其敏感性、特异性、准确性均为100％。纵隔疑难疾病诊断31例，经过纵隔镜手术后30例（96．8％）明确诊断，其中恶性肿瘤16例，分别为纵隔转移性肿瘤8例、纵隔淋巴瘤3例，恶性纤维组织细胞瘤、食管鳞状细胞癌、促纤维组织增生性小圆细胞肿瘤、胸腺类癌、淋巴上皮癌各1例；良性疾病14例，分别为结节病8例、慢性淋巴结炎4例、纵隔淋巴结结核2例。纵隔镜辅助纵隔或肺部病变切除4例，均顺利完成手术。本组手术无死亡及严重并发症发生，均治愈出院。结论电视纵隔镜手术安全、可靠，可作为纵隔疑难疾病诊断和鉴别诊断的有效方法以及肺癌术前分期的金标准。     

继发性纵隔脓肿的诊断与治疗

目的探讨多种原因导致的继发性纵隔脓肿的诊断和综合治疗方法。方法回顾性分析1988年12月至2007年11月中国医科大学附属第一医院收治的23例继发性纵隔脓肿的临床资料,男18例,女5例;年龄13个月~76岁,平均年龄40.9岁。致病原因：食管穿孔或破裂14例（外伤致食管破裂7例、医源性食管破裂6例、自发性食管破裂1例）,咽部脓肿5例,口底蜂窝组织炎2例,气管断裂2例。采取以外科手术治疗为主,辅以抗感染和营养支持治疗。行食管破裂修补术10例次,空肠或胃造瘘术6例次,脓胸纤维板剥脱术4例次,经颈部切口上纵隔引流术15例次,胸腔闭式引流术7例次,肺叶部分切除术2例次,心包引流术1例次,牙周和颌下切开引流术1例次。结果住院死亡5例,病死率21.7%（5/23）,死于中毒性休克4例,静脉大出血1例。出院时完全治愈或病情稳定18例。随访16例,随访时间6~18个月,随访期间生存患者生活质量提高,死于脑血管意外1例;失访2例。结论继发性纵隔脓肿病情发展迅速,且病死率高,应早期诊断,充分的外科引流、合理使用抗生素和营养支持是治疗的关键。     

纵隔肿瘤及囊肿的外科治疗

纵隔肿瘤及囊肿的外科治疗王伟姚松朝张章渝贝亚军我院自１９７８年１０月～１９９５年１２月共收治纵隔肿瘤８６例，均经手术和病理证实，现报告如下。１临床资料本组男性４９例，女性３７例。年龄５～６５岁，平均３４．７岁，男女＝１．３２１。病理类型见附表。附表８...     

纵隔神经源性肿瘤92例临床病理分析

纵隔神经源性肿瘤９２例临床病理分析张逊，严嘉顺，陈东鸿，姚计方，王增林，陈宇我们自１９６５年１月至１９９３年６月，手术治疗各类纵隔肿瘤４０７例，其中神经源性肿瘤９２例，占２２．６％。现对后者进行临床病理分析如下：临床资料本组男４９例，女４３例。年龄１...     

纵隔肿瘤的电视胸腔镜诊断和治疗

作者总结了近三年来的电视胸腔镜纵隔瘤手术２８例,其中２２例施行纵隔瘤切除。包括纵隔囊肿９例,畸胎瘤５例,神经原肿瘤５例,胸腺瘤、迷走甲状腺肿和脂肪瘤各１例;６例纵隔瘤取材或穿刺明确诊断。上述手术病例获得转好近期手术效果。作者认为胸腔镜作为一种新的诊断和治疗方法,对某些纵隔疾病比传统开胸手术具有更多的优点。     

张力性纵隔气肿16例急诊处理体会

目的探讨张力性纵隔气肿的诊断及急诊治疗经验。方法16例外伤致张力性纵隔气肿患者,均经临床和影像学检查确诊。急诊行床旁纵隔切开减压引流术。结果本组有1例死于腹腔脏器大出血,其余15例治愈,未发生胸腔感染及纵隔感染。随访4个月～2年,全组无纵隔气肿复发。结论张力性纵隔气肿要积极减压治疗,采取前纵隔切开置管引流排气,患者症状缓解快,排气充分,是一种良好的治疗方法。对于有气胸的纵隔气肿,首先行胸腔闭式引流,然后视纵隔气肿消退与否采取是否引流排气。     

电视纵隔镜手术治疗早期食管癌89例报告

目的探讨电视纵隔镜在食管癌切除手术中的应用。方法2005年10月～2009年2月,对89例早期食管癌行常规电视纵隔镜下食管癌切除术。术中使用电视纵隔镜游离食管,经腹部切口游离胃,切除食管后,将食管残端与胃底做颈部吻合。结果1例术中发生出血,中转开胸;余88例顺利完成手术。无围手术期死亡病例。86例随访1～38个月,其中6个月16例,7～12个月9例,13～18个月21例,24个月40例,中位随访时间为17个月。死亡8例,生存时间8～29个月(平均17.8月),其中5例因肿瘤复发死亡,3例死亡原因不明。结论电视纵隔镜下食管癌切除术是一种安全、有效的术式,尤其适用于心、肺功能较差的早期食管癌患者。     

创伤性纵隔血肿的特点及处理

目的 探讨创伤性纵隔血肿的临床特征、诊断方法和治疗。方法 对１２例纵隔血肿病例进行了总结，对其临床表现、治疗方法、疗效和预后进行了分析。结果 ４８６例胸部创伤患者中发生纵隔血肿１２例，占胸部创伤的２．５％。根据病情进行开胸手术及Ｂ型超声波定位引导下血肿空刺治愈１１例，死亡１例。结论 严重胸部创伤时，即使无明显临床症状，亦应考虑纵隔血肿的存在，并给予必要的检查，积极治疗，效果满意。     

胸腹腔镜食管癌根治术与传统开放手术的疗效及对肺功能影响的对比研究

目的 比较胸腹腔镜食管癌根治术与传统开放手术的疗效及对肺功能的影响。方法 按照手术方式不同将116例食管癌患者分为2组,各58例。腔镜组采用胸腹腔镜联合食管癌根治术,开放组采用传统开放手术。对比2组患者手术治疗指标、并发症情况及对肺功能的影响。结果 2组手术时间、清扫淋巴结数和术后并发症发生率差异均无统计学意义(P0.05);腔镜组术中出血量、创口直径、第1天引流量、留置胸管时间、术后住院时间均显著低于开放组,差异有统计学意义(P0.05);术后2组FEV1差异有统计学意义(P0.05),且腔镜组较为明显;2组FEV1/FVC、Pa O2差异均有统计学意义(P0.05)。结论 胸腹腔镜食管癌根治术较传统开胸手术,出血量少、创口直径小,术后住院时间短且对肺功能无明显影响,疗效优于传统开放性手术。     

Functional Outcome After Surgical Treatment of Esophageal Perforation

Background. The functional results after treatment of intrathoracic esophageal perforations have been poorly documented.

Methods. A retrospective review of 42 patients who underwent treatment of intrathoracic esophageal perforation associated with benign esophageal disease was performed.

Results. Of 42 patients treated for esophageal perforation, 25 underwent primary repair, 15 underwent esophagectomy and reconstruction, 1 underwent cervical esophagostomy and drainage followed by esophageal resection, and 1 had drainage alone followed by primary repair. Among the patients treated with primary repair, at least one additional operation was required in 13 patients. Of the 15 patients treated with esophagectomy and reconstruction, none required further operative treatment. Follow-up averaged 3.7 years, and of the 36 survivors available for follow-up, 18 (50%) required at least one esophageal dilation postoperatively, and 3 (8.3%) have required regular dilations. Subjectively, 19 of 36 patients (53%) indicate that their swallowing is better than before perforation, it was the same in 12 (33%), and worse in 4 (11%).

Conclusions. In conclusion, approximately one third of patients surviving primary repair of esophageal perforations have continued difficulty with swallowing, which often requires esophageal dilations or esophageal reconstructive procedures, or a combination of both. Optimal long-term results are achieved when primary repair is performed in patients with motor disorders or a “normal” esophagus. Esophagectomy is a better option in those patients with strictures or diffuse esophageal disease.     

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.     

Spectrum of esophageal motility disorders: implications for diagnosis and treatment

BACKGROUND: The named primary esophageal motility disorders (PEMDs) are achalasia, diffuse esophageal spasm (DES), nutcracker esophagus (NE), and hypertensive lower esophageal sphincter (HTN-LES). Although the diagnosis and treatment of achalasia are well defined, such is not the case with the other disorders. HYPOTHESIS: (1) Symptoms do not reliably distinguish PEMDs from gastroesophageal reflux disease; (2) esophageal function tests are essential to this distinction and to identifying the type of PEMD; (3) minimally invasive surgery is effective for each condition; and (4) the laparoscopic approach is better than the thoracoscopic approach. DESIGN: University hospital tertiary care center. SETTING: Retrospective review of a prospectively collected database.Patients and METHODS: A diagnosis of PEMD was established in 397 patients by esophagogram, endoscopy, manometry, and pH monitoring. There were 305 patients (77%) with achalasia, 49 patients (12%) with DES, 41 patients (10%) with NE, and 2 patients (1%) with HTN-LES. Two hundred eight patients (52%) underwent a myotomy by either a thoracoscopic or a laparoscopic approach. RESULTS: Ninety-nine patients (25%) had a diagnosis of gastroesophageal reflux disease at the time of referral and had been treated with acid-suppressing medications. In achalasia and DES, a thoracoscopic or laparoscopic myotomy relieved dysphagia and chest pain in more than 80% of the patients. In contrast, in NE the results were less predictable, and the operation most often failed to relieve symptoms. CONCLUSIONS: These results show that (1) symptoms were unreliable in distinguishing gastroesophageal reflux disease from PEMDs; (2) esophageal function tests were essential to diagnose PEMD and to define its type; (3) the laparoscopic approach was better than the thoracoscopic approach; (4) a laparoscopic Heller myotomy is the treatment of choice for achalasia, DES, and HTN-LES; and (5) a predictably good treatment for NE is still elusive, and the results of surgery were disappointing.     

Esophageal Gunshot Injuries

During a 15-year period from August 1964 to August 1979, 48 patients with gunshot wound of the esophagus (24 of the cervical, 17 of the thoracic, and seven of the abdominal) were treated at Grady Memorial Hospital. In the majority of the patients, the initial history, physical findings, and chest roentgenograms were nondiagnostic for esophageal injury. Esophageal perforation was mainly suspected because the bullet tract was in close proximity to the esophagus or the bullet had traversed the mediastinum. The diagnosis of esophageal perforation was made by esophagography (29 patients), at the time of emergency surgical exploration for suspected other organ injuries (17 patients), or by esophagoscopy (one patient). All but one patient were treated surgically. The surgical procedure most commonly used was primary repair of the esophageal wound with wide drainage of the mediastinum. Thirty-eight (79.2%) of the 48 patients survived, 21 (87.5%) of the 24 patients with cervical, 11 (64.7%) of the 17 patients with thoracic, and six (85.7%) of the seven patients with abdominal esophageal wounds. Ten patients died, three with cervical wound, six with thoracic wound, and one with abdominal esophageal wound. Three patients died intraoperatively from major bleeding and the remaining seven died from the esophageal and/or other associated injuries, four to eight days after surgery. None of the seven patients who underwent primary repair with wide drainage and plication of the suture line with pleural flap or other tissue, died or developed leak at the suture line. This study suggests that the physical and roentgenographic findings in patients with esophageal injury are often nondiagnostic and frequently are masked by coincidental injury to other organs. Hence, a high index of suspicion is required for the diagnosis of esophageal injury from gunshot wounds and esophagography should be performed as soon as the patient's condition is stable in all patients who present with a missile wound in close proximity to the esophagus or traversing the mediastinum. All patients with perforation of the esophagus from bullet wounds should be operated upon as soon as possible after the diagnosis is made. Wide drainage of the mediastinum and primary repair of the esophageal wound and plication of the suture line with parietal pleura or gastric fundus provide the best possible results.     

Showing no increase of C-reactive protein and developing non-bacterial median chest wound dehiscence after coronary artery bypass grafting

A 72-year-old male underwent coronary artery bypass grafting for 3 vessels disease. After the operation, the peak C-reactive protein (CRP) level was 0.85 mg/dl and CRP levels stayed very low. Forty days after the operation the patient developed a progressive median chest wound dehiscence but the bacterial cultures were negative. In spite of conventional therapies such as debridement of necrotic tissue or irrigation, the wound granulation was underdeveloped. After 6 months an epidermis had developed to cover the wound.     

The influence of thoracotomy and laparotomy on the chest wall movement

The influence of thoracotomy and laparotomy on the chest wall movement was examined using newly produced 6-channeled linear magnetometer. Two groups (one is the group of the patients who had undergone thoracotomy and laparotomy for esophageal cancer and the other is the group of the patients who had undergone laparotomy) were examined 2 to 8 weeks after operation. The chest wall movement was restricted analward at the operative wound of the chest wall. The other points had no remarkable restriction. From the view point of the chest wall movement this study shows thoracotomy and laparotomy at the same time and only laparotomy had almost the same influence.     

电视胸腔镜在食管疾病诊断与治疗中的应用

电视胸腔镜手术(VATS)作为一种微创技术应用于食管疾病的诊断和治疗已10年左右,其优点为减少术后早期和长期胸痛,减少术后呼吸道并发症,符合美学要求.VATS食管癌分期主要是评估食管癌外侵和转移情况,有助于选择合适的治疗方案.VATS治疗食管癌主要应用于早期食管癌切除,但由于手术部位多,操作较繁杂,应用受到一定的限制;而对食管良性疾病,如平滑肌瘤、贲门失弛缓症等在有条件的医疗中心已成为首选的手术方案.     

食管破裂诊断及外科手术方式的选择——附36例临床分析

目的探讨食管破裂的诊断与手术方式。方法 1980-01—2012-06间共收治36例食管破裂与穿孔患者。保守治疗2例,手术治疗34例。单纯食管破裂修补术、食管破裂修补加肋间肌瓣、膈肌瓣、带蒂大网膜覆盖破裂口8例;破裂食管切除、Ⅰ期食管胃胸内或颈部吻合术3例;纵膈引流、胸腔引流或食管"T"管引流加空肠造瘘6例;食管旷置或颈部食管造瘘,加纵膈、胸腔引流及空肠造瘘,Ⅱ期消化道重建2例,其中1例为经胸骨后管状胃与颈部食管吻合;颈部食管旁切开引流术及食管支架置入术各1例。贲门失弛缓症、食管癌、食管癌术后吻合口狭窄扩张或支架置入时破裂5例:姑息性食管癌切除、吻合口狭窄部切除再游离胃行颈部吻合术4例,食管破裂修补术加破裂食管对侧Heller手术1例。合并多发性肋骨骨折肺深部裂伤、脾破裂胃破裂、车祸胸部贯通伤伴胸壁皮肤Ⅱ度烧伤各1例:行肺裂伤修补,胸腹联合切口行脾切除胃破裂修补术加胃空肠造瘘,1例伤后6d,确诊食管破裂,行食管破裂修补及肋间肌瓣加固。1例食管异物40 d,致食管-主动脉瘘(AEF),左心转流下阻断主动脉,修补主动脉破口,切除胸段食管行颈部食管胃吻合,获成功。食管胸中段化学性烧伤致穿孔1例,I期行胸段食管切除食管胃颈部吻合术。食管破裂修补术后再瘘3例:行胸腔廓清、上下胸腔引流及空肠造瘘。结果治愈27例,其中3例并吻合口狭窄,经扩张后好转。死亡9例。结论选择合理方式治疗食管破裂至关重要。要综合考虑食管破裂的原因、部位、时间、大小、原发疾病、并发症、纵隔及胸腔感染情况。     

胸部刀刺伤剖胸探查的指征和手术策略

目的探讨胸部刀刺伤剖胸探查的指征和手术策略。 方法回顾性分析上海交通大学附属第六人民医院胸外科2006年1月至2017年12月经剖胸探查救治的80例胸部刀刺伤患者的临床资料。 结果80例胸部刀刺伤患者中单纯胸部刀刺伤36例，合并腹部损伤16例，合并四肢损伤21例，颈根部损伤7例；平均损伤严重度评分(ISS)16.42分。所有患者行急诊剖胸探查术，治愈76例(95%)，死亡4例(5%)，死亡原因为心脏破裂、失血性休克、弥散性血管性凝血(DIC)。 结论进行性的血气胸、通气障碍、心脏压塞是急诊剖胸探查的重要指征，合理把握手术指征、选择手术路径是救治胸部刀刺伤的关键。