部分左心房切除的扩大切除术在局部晚期肺癌16例手术中的应用临床观察

目前 探讨左心房部分切除的肺扩大切除术治疗局部晚期肺癌的手术方法及临床疗效。方法 2001年12月至2006年12月,16例肿瘤累及左心房的局部晚期肺癌患者施行肺叶或全肺切除时,同时切除部分左心房。其中左肺下叶切除6例,左全肺切除4例,右肺中下叶切除3例,右肺下叶切除3例。结果 16例患者均顺利完成手术,无手术死亡及术中并发症。术后有2例发生心律失常,2例并发肺炎。平均存活时间36个月,术后1、3、5年生存率分别为75%（12/16）、43.75%（7/16）、25％（4/16）。结论 肺切除加部分左心房切除的扩大切除术治疗局部晚期肺癌,术后配以放化疗,具有较好的临床疗效,能明显提高其生存质量并延长生存时间。     

肺切除加部分左心房切除在局部晚期肺癌手术中的应用(附16例报告)

目前 探讨左心房部分切除的肺扩大切除术治疗局部晚期肺癌的手术方法及临床疗效.方法 2001年12月至2006年12月,16例肿瘤累及左心房的局部晚期肺癌患者施行肺叶或全肺切除时,同时切除部分左心房.其中左肺下叶切除6例,左全肺切除4例,右肺中下叶切除3例,右肺下叶切除3例.结果 16例患者均顺利完成手术,无手术死亡及术中并发症.术后有2例发生心律失常,2例并发肺炎.平均存活时间36个月,术后1、3、5年生存率分别为75%(12/16)、43.75%(7/16)、25%(4/16).结论 肺切除加部分左心房切除的扩大切除术治疗局部晚期肺癌,术后配以放化疗,具有较好的临床疗效,能明显提高其生存质量并延长生存时间.     

侵犯心脏大血管局部晚期肺癌的外科治疗

目的总结侵犯大血管和左心房的局部晚期非小细胞肺癌的外科治疗经验。方法回顾性分析我科2005年2月至2009年11月期间对32例局部晚期(T4N0M0、T4N1M0、T4N2M0)非小细胞肺癌患者(男27例,女5例;年龄48~73岁,中位年龄58岁)采用原发肿瘤加部分心房或大血管切除治疗的临床资料。侵犯上腔静脉和无名静脉5例,肺动脉干4例,左心房23例。行左全肺及左心房部分切除13例,左全肺及肺动脉干部分切除4例,右全肺及左心房部分切除9例(其中2例在体外循环辅助下进行),右肺中下叶及部分左心房切除1例,右肺上叶及上腔静脉部分切除人工血管置换3例,上腔静脉修补2例。结果本组32例患者无手术死亡,手术完全切除16例。术后仅有3例发生心律失常。肿瘤病理类型:鳞癌25例,腺癌5例,大细胞癌2例。术后pTNM分期:T4N0M03例,T4N1M011例,T4N2M018例。所有患者术后随访6个月~5年,中位生存时间15个月;T4N0M0、T4N1M0患者的中位生存时间为19个月,T4N2M0患者的中位生存时间为10个月。1例患者无瘤生存5年。结论侵及心房大血管的局部晚期肺癌(Ⅲb期)采用扩大切除术能提高根治性手术切除率,改善患者生活质量,提高局部晚期肺癌患者的生存率。     

单侧肺循环短暂阻断术在局限性T4期肺癌外科治疗中的应用

目的 探讨同期阻断肺动脉、肺静脉的单侧肺循环短暂阻断术在局限性T4期肺癌外科治疗中的应用价值。方法 开胸后首先探查肺癌、转移淋巴结与肺血管的关系，如果肺动脉干受侵，在心包内或心包外游离出患侧肺动脉干根部和上、下肺静脉，放置血管阻断钳同时阻断，防止肺动脉和左心房血液逆行倒灌出血。在患侧肺循环无血状态下切除病肺和受肺癌侵犯的部分肺动脉。行肺动脉成形或吻合后，开放阻断的肺动脉干和保留肺静脉，恢复肺循环。结果 肺动脉、肺静脉分别阻断（46．0±2．5）min和（35．0±1．5）min。20例侵犯肺动脉的局限性T4期肺癌切除率为100％，均保留了健康有功能的上叶肺或下叶肺，避免了全肺切除。术中平均出血量256ml。3例双袖切的病人术后出现因痰阻塞支气管的肺不张，经吸痰后治愈。3例出现心律失常，经对症处理后好转。结论 同期阻断肺动脉、肺静脉的肺循环短暂阻断术，为不能耐受全肺切除的局限期T4期肺癌病人保留了健康肺组织，提供了一种安全、简捷的新手术方法。     

心包内全肺加左心房部分切除术治疗中心型肺癌

目的:探讨心包内全肺加左心房部分切除术治疗中心型肺癌的优点。采用双腔气管插管麻醉是手术成功的前提条件,处理肺血管是术中最危险和最重要的关键步骤。方法:用直角钳从近心端处钝性分离,不可硬行分离;如发现肺静脉内有癌栓或肿瘤直接侵及左心房壁,用两把无损伤血管钳夹闭左心房壁,既可安全处理肺静脉,又可避免静脉内癌栓脱落造成血行播散;切除部分左心房壁,近侧断端用4/Oprolene线连续往返缝合。无损伤血管钳钳夹左心房壁后应稳妥固定在胸壁上,以防突然牵拉意外致心房破裂大出血。结果:心包内处理血管的全肺切降术可提高肺癌切除率,改善生活质量,提高5年生存率;死亡率和重要并发症发生率与标准全肺切除术相比差异无显著性,生存率与标准全肺切除术亦相近,但明显优于单纯探查术。结论:采用心包内全肺加左心房部分切除术,以求彻底切除肿瘤组织,对中晚期中心型肺癌浸润肺血管根部、心包和左心房的病人,不失为一种比较积极和有效的治疗方法。     

局部肺循环临时阻断在复杂肺切除术中的应用

目的探讨局部肺循环临时阻断在复杂肺切除术中的应用价值和技术细节。方法接受局部肺循环临时阻断条件下的肺切除手术24例,12例接受支气管、肺动脉、静脉联合成形术,其中4例为支气管肺动脉“双袖”成形术;10例肺动脉成形或同时联合肺静脉成形（其中1例联合左心房成形术）;2例单纯肺动脉、静脉阻断切除肺叶或全肺。在“双袖”成形术中采用左房血反流氧合残肺。结果术后30 d内死亡2例,死亡原因分别为右全肺切除术后呼吸衰竭和肺动脉成形术后急性肺动脉栓塞。4例接受“双袖”成形术的患者术后均产生不同程度的残肺水肿,术后14-18 d完全恢复。发生脓胸1例（4.2%）,肺炎6例（25.0%）,漏气3例（12.5%）。Ⅰ-Ⅱ期肺癌患者中位生存期为36个月,ⅢA期患者中位生存期为18个月。结论局部肺循环临时阻断在复杂肺切除术中的应用能降低术中风险,简化操作程序,达到最大限度保留健康肺组织和最大限度切除癌肿的目的,有临床实用价值。     

肺及部分左心房切除术治疗中心型肺癌

为探讨肺及部分左心房切除术在治疗侵及左心房的ＩＩｂ期肺癌的效果。对１９８３年２月至１９９４年１０月期间诊断为侵及左心房的ＩＩＩｂ期肺癌病人分为手术组２６例、探查组１４例。两组于围术期均行强化化疗和术后放、化疗。结果本组无手术死亡，探查组生存２～７个月，平均１３４天；切除组除５例术后１０～５８个月死于癌转移外，余２１例无癌生存６～８５个月。作者认为，肺叶或全肺切除并部分左心房切除能明显延长侵及左心房的ＩＩｂ期肺癌的生存时间。     

应用自体肺重植技术治疗上叶中心型肺癌

目的 探讨应用自体肺重植技术治疗上叶中心型肺癌的可行性。方法 ２例作双袖状右上叶中联合肺叶切除，因主支气管或肺动脉切除过长，吻龛和力过大，遂切断我脉，肺短时间离体后作下叶重植，将下肺静脉移植在上肺静脉残端。２例左上叶肺癌部分侵及斜裂，无法进行双袖状肺叶切除术，作全肺切除后，在器械台上行肿瘤切针修剪后的下叶肺组织重植。结果 随访至２０００年２月，２例病人已分别无瘤存活３３和２０个月，生活质量良好。１     

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。     

肺癌余肺切除术后的观察及护理

余肺切除术即完成式肺叶切除术,是将同侧经过手术切除的残余肺组织切除的手术,是治疗肺癌复发转移及第二原发癌的主要方法。手术难度大,术后并发症发生率高,患者在手术前心理和病理生理问题很严重,因此手术前后的护理很重要。2000年1月~2005年12月我们对6例肺癌术后复发再次行余肺切除术患者进行护理,取得满意效果,现将护理体会报告如下。1临床资料本组6例,男5例,女1例,年龄49~70岁。首次行左肺上叶切除术2例,左肺下叶切除术2例,右肺中叶切除术1例,右肺下叶切除术1例。两次手术时间间隔17~86个月。2.4术侧胸腔引流管护理:余肺切除术后,术侧…     

Surgical Treatment of Lung Cancer Invading the Left Atrium or Base of the Pulmonary Vein

Background  The purpose of the present study was to explore the efficacy of an extended operation for locally advanced non-small cell lung cancer invading the left atrium and intrapericardial pulmonary vein. Methods  From January 2000 to January 2006, lobectomy or pneumonectomy combined with extended resection of the left atrium was carried out in 46 patients. The operations included left lower lobectomy in 6 cases, left pneumonectomy in 14 cases, right middle and lower lobectomy in 8 cases, right lower lobectomy in 2 cases, and right pneumonectomy in 16 cases; these cases accounted for 4.9% of the lung cancer patients who underwent surgical treatment in the Changzheng Hospital, Second Military Medical University, during the study period. Results  There were no surgery-related deaths, and the overall 1-, 3-, and 5-year survival rates were 71.77%, 37.79%, and 22.04%, respectively; the 1-, 3-, and 5-year survival rates of patients with no lymph node involvement (N0) were 77.16%, 43.40%, and 28.94%, respectively; the 1-, 3-, and 5-year survival rates of N1 patients were 75.94%, 41.88%, and 27.92%, respectively; the 1- and 3-year survival rates of N2 patients were 53.85% and 17.95%, respectively. Conclusions  Surgical treatment of T4 lung cancer invading the left atrium or the base of the pulmonary vein is feasible, particularly in N0 and N1 patients with a ≤3 cm maximum diameter of primary lung cancer. It can improve the quality of life and increase long-term survival. Surgical management should be considered in selected lung cancer patients.     

Advanced lung cancer invading the left atrium wall treated with pneumonectomy and combined resection of the left atrium using stapling devices: report of two cases.

In chest surgery, stapling devices are primarily used to close bronchi. However, they are also used for dissection and suturing between lung lobes, resection and plication of lung tissue (including bullae), combined resection of the superior vena cava, closure of the pulmonary great vessels, closure of the left atrium following combined resection of the left atrium, and so on. We recently treated two cases of advanced lung cancer, which had invaded the left atrial wall, with pneumonectomy and combined resection of the left atrium using stapling devices, and obtained favorable results. For combined resection of the left atrium, it is safer to use stapling devices than vascular clamps, since the latter involve the risk of dislocation during use. Furthermore, since stapling devices require no margin for suturing, the left atrium can be resected at a point sufficiently distant from the cancer, thus allowing for highly radical resection. Stapling devices are also useful because they can be manipulated even within narrow operative fields. When dealing with lung cancer requiring combined resection of the left atrium, pneumonectomy is needed in most cases. When performing surgery for these cases, it is essential to first close and divide the bronchi and pulmonary arteries and veins as far as possible so that adequate adherence around the left atrium can be developed and the entire lung can be lifted up, followed by resection of the left atrium with a stapling device applied to the left atrium without any tension.     

Pulmonary resection after pneumonectomy

Patients who have a lung cancer in the residual lung after pneumonectomy should not be automatically excluded for surgical consideration. These patients should be carefully staged and evaluated physiologically. The most important initial differentiation is to distinguish a true second primary lung cancer from metastatic recurrent lung cancer. Meticulous staging with chest CT, PET, brain MRI, and mediastinoscopy should be able to successfully exclude metastatic disease, multifocal disease, or locally advanced tumors. Only patients who have stage I disease are candidates for this type of extended resection. Ideally, these patients should have small peripheral tumors that can be encompassed with a low-volume wedge resection. More extended resections, such as segmentectomy or right middle lobectomy, may be considered in some patients but seem to bear a higher operative morbidity and mortality. The need for an upper or lower lobectomy after contralateral pneumonectomy is probably an absolute contraindication to surgical resection. To tolerate pulmonary resection after pneumonectomy, and to obtain the desired survival benefit, patients should have a good to excellent performance status, no serious comorbidities, and a ppoFEV1 greater than 1.0 L/second. In these highly selected patients, pulmonary resection after pneumonectomy can be accomplished with an acceptable operative morbidity and mortality and, in true cases of metachronous second primary lung cancers, may achieve a 5-year survival rate of up to 50%.     

隆凸部位原发性肺癌的手术治疗

作者对１３例涉及隆凸部位的中心型肺癌行切除治疗。鳞癌１１例,腺癌２例Ｔ３Ｎ２Ｍ０３例,Ｔ４Ｎ２Ｍ０１０例。根治手术１０例,姑息手术３例。右全肺切除隆凸全切除３例。右全肺切除隆凸部分切除６例,左全肺切除隆凸部分切除１例,右上中叶切除隆凸部分切除下叶隆凸部位吻合３例。无手术并发症及手术死亡。３年治愈率５４％,５年治愈率３０％,１例已存活８年。该类患者如纵隔淋巴结无广泛转移,局部病灶允许切除,手术效果仍较满意。作者对术中血管、支气管隆凸部的处理提出了自己的经验。     

Superior vena cava reconstruction via a posterolateral thoracotomy without venous occlusion for locally advanced lung cancer: Report of a case

We performed a right upper lobectomy with prosthetic replacement of the superior vena cava (SVC) through a posterolateral thoracotomy in a 65-year-old man undergoing complete resection of a locally advanced non-small-cell lung cancer with invasion of the SVC. Instead of using a vascular shunt, the right atrium and a right brachiocephalic vein (BCV) were anastomosed using a ringed polytetrafluoroethylene (PTFE) graft. During the anastomosis, vascular flow was maintained through the left BCV. By using this technique, SVC resection and reconstruction during lung cancer surgery can be safely performed through a posterolateral thoracotomy without blood flow interruption.     

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。     

Extended Bronchoplasty Anastomosed between the Left Main and the Superior Segmental Bronchi for Locally Advanced Left Upper Lobe Lung Cancer with Invasion of the Basal Segment

We report a case of extended bronchoplasty in which anastomosis between the left main and the superior segmental bronchi with resection of the left upper lobe and basal segment was required to avoid pneumonectomy for locally advanced lung cancer. The main tumor located at the left upper lobe invaded the basal segment, and involved both the basal pulmonary artery and left secondary carina. Regarding anastomosis, the bronchi were cut in a deep wedge shape and a wall flap was made by part of the lower lobar bronchus. The patient’s postoperative course was uneventful and he has been alive without recurrence for more than 3 years after surgery.