侵及胸廓上口大血管的纵隔肿瘤的外科治疗

目的　探讨侵及胸廓上口大血管的纵隔肿瘤的外科治疗经验。方法　回顾分析 11例侵及胸廓上口大血管的纵隔肿瘤患者的临床资料 ,全组患者均行纵隔肿瘤切除 ,其中 2例于麻醉诱导前辅以股 -股转流并行体外循环 ,2例辅以颈静脉、股静脉 -股动脉转流并行体外循环。同期行上腔静脉重建 2例 ,成形 2例 ,左无名静脉成形 3例 ,右无名静脉成形 1例 ,无名动脉、左颈总动脉、左锁骨下动脉人造血管置换各 1例。结果　全组病例无手术死亡。术后随访 2～ 7年 ,3例于 2～ 4年后死于癌瘤复发 ,6例无瘤健康生存 ,均未出现血管栓塞。结论　侵及胸廓上口的大血管纵隔肿瘤宜积极手术治疗 ,麻醉诱导前辅以股 -股转流或颈、股 -股转流。同期作血管成形或重建。术后小剂量抗凝治疗     

术前3D-CTBA重建指导上腔静脉置换术3例

2017年1月至2018年6月3例纵隔肿瘤伴上腔静脉阻塞综合征患者行全上腔静脉置换术,根据3D-CTBA重建影像技术进行术前手术规划,确定上腔静脉、左无名静脉、右无名静脉的形态、直径、受累范围和纵隔病灶的大小、部位。充分术前准备,麻醉干预。按照3D-CTBA重建结果,术中精准分离肿瘤周围组织,切除被侵组织肿瘤病灶和受累的上腔静脉、左无名静脉、右无名静脉部分。完整切除纵隔肿瘤,应用合适材料(人工血管、自体心包)行上腔静脉、左无名静脉、右无名静脉血管吻合重建。平均病灶直径7.5 cm,平均手术时间306 min,平均术中出血183 ml。术后病理诊断侵袭性胸腺瘤2例,胸腺癌1例。3例患者上腔静脉梗阻症状均得到改善,无围手术期死亡,随访至今均生存。     

上腔静脉和无名静脉的切除及重建治疗纵隔肿瘤

目的　探讨分析纵隔肿瘤根治性切除 ,重建上腔静脉和无名静脉的手术意义及技术方法。　方法　回顾性分析北京协和医院 2 0 0 1～ 2 0 0 3年 11例纵隔肿瘤引起上腔静脉综合征患者的治疗及预后。根治性切除肿瘤 9例 ,其中 2例行心包修补静脉壁成形术 ,7例人工血管置换重建上腔静脉和无名静脉 ;2例部分切除。术中对左、右无名静脉分次阻断 ,单侧阻断时间 2 2 .15± 6 .2 9min,手术出血量 1342 .86± 6 92 .4 8ml。　结果　侵袭性恶性胸腺瘤 4例 ,胸腺癌5例 ,纵隔小细胞癌 2例。术后早期患者静脉梗阻症状即改善 ,无神经系统并发症 ,1例死于肺部感染 ,其余 10例全部健在 ,存活时间已达 6～ 30个月。　结论　上腔静脉和无名静脉的重建可以有效地消除上腔静脉综合征 ,其手术是安全的 ;但应注意病变的范围 ,争取根治性切除是提高生存率的关键。     

胸部肿瘤侵及大血管时的手术处理

目的 总结64例胸部肿瘤浸润大血管手术时的处理经验，分析上腔静脉（SVC）手术技术及指征以及肺动脉袖状切除的适应证。方法 回顾性分析1991年1月至1999年6月64例胸内大血管受到肿瘤浸润患者的手术经验。受侵血管包括肺动脉根部和（或）肺动脉干、上静脉和（或）下肺静脉根部、SVC和（或）无名静脉。结果 24例接受了不同类型的SVC手术，包括左及右无名静脉分别与右心房人工血管搭桥术1例、左无名静脉与右心房人工血管搭桥4例、右无名静脉与右心房搭桥3例、奇青脉切除并SVC部分切除11例、单纯SVC部分切除5例。SVC置换或搭桥除1例应用涤纶血管者外，其余均是Gore-Tex人工血管，5例部分切除者使用了缝合器，41例肺动脉部分或袖状切除（肺动脉袖状并支气管袖状成形4例）、左心房部分切除13例，应用肺血管阻断或临时架桥术，所有手术均成功进行，无手术死亡，无严重并发症。SVC切除后生存时间最长者已达15年，为1例恶性畸胎瘤患者，肺癌切除SVC、无名静脉搭桥患者术后生存最长者已达5年。结论 大血管包括SVC及肺血管阻断与成形技术以及SVC置换术，是根治性切除浸润大血管的胸部肿瘤的关键性技术，正确及时地应用可以提高根治性切除率和安全性，减少探查率。     

非体外循环下上腔静脉置换术的麻醉处理

右上肺癌和上纵隔肿瘤往往累及上腔静脉(SVC)及左右无名静脉。行肿瘤切除和SVC置换可达到根治性肿瘤切除或解除SVC阻塞的目的。我院成功开展了2例SVC置换手术,均在非体外循环情况下阻断SVC完成肿瘤切除及SVC移植术。     

上腔静脉阻塞综合征非体外循环下血管置换术的麻醉管理

上腔静脉阻塞综合征多由于右肺上叶癌或右上纵隔肿瘤肿块较大时压迫上腔静脉（SVC）及左右无名静脉所致。使用体外循环或非体外循环方法行肿瘤切除和SVC置换既可切除肿瘤又可解除SVC的阻塞，但是非体外循环下上腔静脉置换术的麻醉具有一定的挑战性。笔者于2000～2005年为9例在非体外循环下阻断SVC行肿瘤切除及SVC移植术的上腔静脉患者成功地进行了麻醉，现报告如下。     

保持下腔静脉通畅的全肝血流阻断切肝术

目的探讨保持下腔静脉通畅的全肝血流阻断切肝术（THVEPC）的应用价值。方法对25例位于第二肝门区肿瘤施行第一肝门＋左、中、右肝静脉阻断切肝术，保持下腔静脉血流畅通，11例病人同时行肝短静脉结扎。结果25例病人中原发性肝癌17例、转移性肝癌1例、肝母细胞瘤2例、肝巨大血管瘤5例。肿瘤直径14．7cm（5～43cm）。肿瘤侵犯2根主肝静脉16例，侵犯3根主肝静脉9例。行右三叶切除7例，右半肝切除3例，中肝叶切除6例，Ⅷ段切除3例，左三叶切除4例，尾状叶切除2例。共结扎肝静脉16根，血管带阻断20根，血管夹或心耳钳阻断18根。切断1根主肝静脉14例，切断2根主肝静脉11例。平均第一肝门阻断时间25．5min（15～42min），平均肝静脉阻断时间16．4min（5～28min）。平均术中出血量820ml（100～6000ml）。行肝静脉修补4例。结论保持下腔静脉通畅的全肝血流阻断切肝术既能达到无血切肝的目的，又避免了下腔静脉阻断所引起全身血流动力学紊乱，是一种更符合生理的新技术。     

肿瘤侵犯上腔静脉的外科治疗

目的探讨上腔静脉综合征(SVCS)的手术方法,总结外科诊治经验。方法 2008年10月至2014年7月福建医科大学附属协和医院胸外科采用全上腔静脉人造血管置换或心包补片修补成形术成功治疗恶性肿瘤侵犯上腔静脉导致的SVCS患者11例,其中恶性纵隔肿瘤8例,淋巴瘤2例,肺癌1例。9例患者采用全上腔静脉人造血管置换;2例患者行上腔静脉部分切除,自体心包补片重建术。结果全组无手术死亡病例,术后患者上腔静脉梗阻症状均明显改善。全组患者术后随访8~68个月,除1例肺癌患者存活18个月后死于肿瘤复发转移,其余10例患者均无肿瘤复发,生活质量良好,术后生存时间为8个月至5年。结论采用手术扩大切除肿瘤及受侵的上腔静脉系统并行血管重建,能在短期内显著缓解SVCS的临床症状,提高生存质量,效果确切。     

纵隔小细胞癌致上腔静脉综合征1例

我们成功治疗1例纵隔小细胞神经内分泌癌致上腔静脉综合征病人,结合文献资料报道如下. 资料和方法47岁男病人,头颈部及双上肢肿胀伴胸闷1月余.查体见面颈部肿胀,结膜充血,双侧颈静脉怒张.胸部CT示纵隔肿瘤压迫上腔静脉(图1).2007年5月经胸部正中切口探查,见肿瘤位于左、右无名静脉汇合处及上腔静脉后方,与右上肺动脉、奇静脉及心包粘连,突入升主动脉与气管之间,包绕上腔静脉左后壁约2/3周(图2).     

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原发性腹膜后肿瘤常侵及下腔静脉,手术难度和风险集中在如何阻断肿瘤上下的下腔静脉,控制出血[1-4]。笔者施行了2例累及下腔静脉的右侧腹膜后的巨大肿瘤切除手术,发现如不预先结扎切断腔静脉后方曲张的腰静脉,单纯阻断腔静脉不能控制出血。报告如下。     

Thymic carcinoma with tumor thrombus into the superior vena cava

Tumor thrombus into the vena cava have been reported in cases with renal cell carcinoma, thyroid tumor and in those with thymoma. These tumors are frequently invasive and continuous from the main tumor that shows direct vessel wall invasion. Here, we report a case of thymic carcinoma with superior vena cava syndrome, which was caused by a tumor thrombus in the superior vena cava without vessel wall invasion. The main mediastinal tumor did not show innominate vein invasion, and the superior vena cava syndrome was a result of separate tumor thrombus that was free of vessel wall invasion. The tumor thrombus could be removed through a simple venotomy. To prevent stenosis in the superior vena cava and the left innominate vein, we used a pericardial patch to close the venotomy site.     

A long-term survival case of thymic squamous cell carcinoma, performed complete extirpation with vascular reconstruction of the superior vena cava.

A 59-year-old woman who complained of anterior chest pain exhibited an abnormal shadow on chest X ray and was admitted to our hospital. The chest X ray showed a demarcated tumor at the anterosuperior mediastinum and she was diagnosed as having a mediastinal tumor. After the midsternotomy was performed, the mediastinal tumor derived from the thymic tissues was discovered to have invaded the right upper lung, pericardium and superior vena cava. After excising the tumor, anastomosis between the right brachiocephalic vein and superior vena cava, followed by that between the left brachiocephalic vein and right cardiac auricle was performed using expanded polytetrafluoroethylene-ringed vascular grafts (phi 10 mm) for reconstruction. The tumor was diagnosed as a thymic carcinoma (squamous cell carcinoma) pathologically. After surgery, she was treated by cobalt irradiation. One month and again 3 months after the operation, venography showed patency. The patient has not demonstrated recurrence for 9 years and 6 months.     

A long term survival case of thymic squamous cell carcinoma, performed complete extirpation with vascular reconstruction of the superior vena cava

A 59-year-old woman who complained of anterior chest pain exhibited an abnormal shadow on chest X ray and was admitted to our hospital. The chest X ray showed a demarcated tumor at the anterosuperior mediastinum and she was diagnosed as having a mediastinal tumor. After the midsternotomy was performed, the mediastinal tumor derived from the thymic tissues was discovered to have invaded the right upper lung, pericardium and superior vena cava. After excising the tumor, anastomosis between the right brachiocephalic vein and superior vena cava, followed by that between the left brachiocephalic vein and right cardiac auricle was performed using expanded polytetrafluoroethylene-ringed vascular grafts (? 10 mm) for reconstruction. The tumor was diagnosed as a thymic carcinoma (squamous cell carcinoma) pathologically. After surgery, she was treated by cobalt irradiation. One month and again 3 months after the operation, venography showed patency. The patient has not demonstrated recurrence for 9 years and 6 months.     

Thymic carcinoma with vascular resection

Thymic carcinomas are rare neplasm. The standard treatment for advanced thymic carcinoma has not yet been established, and the prognosis is poor. We report 3 cases of thymic carcinoma involving major vessely. Case 1:The aortic arch and the innominate vein were involved. Case 2:The left brachiocephalic vein was involved. Case 3:Tumor invaded to superior vena cava. Complete resection of the tumor was possible with vascular reconstruction.     

Surgical treatment of stage III and IV thymoma

During past 15 years, 39 cases of thymoma were underwent surgical intervention. In these cases, invasive type, so called stage III and IV in Masaoka's classification were 19 cases. This report documents the results of extended operation in 19 patients treated for malignant thymoma. All patients had neoplasm which invaded adjacent structures; superior vena cava, pericardium, and lung. Eight patients had disseminated lesions in the pleural or pericardial cavities. All patients were underwent surgical exploration through median sternotomy (18 patients) or left thoracotomy (1 patient). Our surgical management to malignant thymoma is to have complete resection, even if tumor invades the great veins. Of 8 patients, superior vena cava and left innominate vein were resected with tumor and reconstructed with ringed PTFE. Mediastinal pleura and pericardium should be widely opened and intrapericardial or intrapleural disseminated lesions should be removed as far as possible. Malignant thymoma could be resected completely applying technique of vascular surgery. Good results were expected when tumor was resected with invading adjacent structures completely. Reoperation to the recurrent tumor is also important.     

Long-term graft patency after replacement of the brachiocephalic veins combined with resection of mediastinal tumors

OBJECTIVE: We sought to investigate the correlation between type of vascular reconstruction and long-term graft patency after replacement of brachiocephalic veins combined with resection of mediastinal malignancies. METHODS: Eighteen patients underwent surgical resection of tumors and the superior vena cava with concomitant vascular reconstruction using ringed polytetrafluoroethylene grafts. Graft patency was verified by means of venography or contrast-enhanced computed tomography at time points ranging from 3 to 77 months (median, 33 months) postoperatively. RESULTS: Seven patients underwent sole reconstruction of the right brachiocephalic vein, with occlusion observed in only 1 patient. In 6 patients who underwent reconstruction of the bilateral brachiocephalic veins with 2 separate grafts, the grafts remained patent in 2, whereas 4 patients experienced occlusion of one of the two grafts yet remained asymptomatic. Both patients who underwent reconstruction with a Y graft experienced left brachiocephalic vein graft occlusion. In the 3 patients who underwent reconstruction of a left brachiocephalic vein, the graft became occluded, and superior vena cava syndrome developed in 2 of these patients. CONCLUSION: When replacing the superior vena cava, reconstruction of a left brachiocephalic vein alone results in a significant rate of occlusion and development of superior vena cava syndrome. Thus we advocate sole right brachiocephalic vein reconstruction or bilateral brachiocephalic vein reconstruction in this setting, and separate reconstruction of the veins is preferable to use of a Y graft.     

Aneurysm of the superior mediastinal veins

A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine. (J VASC SURG 1995;21:505-9.)     

A case report of superior vena cava reconstruction using a heparin-coated temporary bypass tube

A 56-year-old woman with stage IIIB (c-T1N3M0) small cell lung cancer was treated with combination chemotherapy (CAVE). After five cycles of chemotherapy a surgical resection was performed. As mediastinal lymph nodes (#2, 3, 3a) had invaded to the superior vena cava, a heparin-coated tube was inserted into the left innominate vein and the right auricular appendage as a temporary bypass. Advantages of a heparin-coated tube for the temporary SVC bypass are as follows. 1) simple operative procedure. 2) enough flexibility to be kept out of the operative field. 3) no need for anticoagulants, consequently less bleeding resulted.     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。