颈椎原发性骨肿瘤的外科分期及其手术治疗

目的探讨颈椎原发性骨肿瘤的临床特点、外科分期、不同手术入路与术式的治疗效果。方法脊柱肿瘤的外科分期为4期。共观察45例病例,Ⅰ期10例,Ⅱ期11例,Ⅲ期9例,Ⅳ期15例。11例行囊内切除,18例包膜切除,15例广泛切除,1例仅单纯行后路固定。结果术后随访6个月～10年,平均3年,1例上颈椎肿瘤术后高位瘫痪,因呼吸衰竭死亡。余44例术后近期疗效均较满意,局部疼痛和神经症状改善或缓解,2例眩晕患者术后症状消失;1例恶性神经鞘瘤和1例软骨肉瘤患者分别于术后13、24个月发生全身多处转移而衰竭死亡;1例骨母细胞瘤、1例软骨肉瘤、1例骨巨细胞瘤术后1年局部复发。结论应根据颈椎肿瘤的部位、外科分期选择相应的手术入路和术式。肿瘤的性质、手术方式及术后综合治疗对患者的预后具有重要影响。     

Strategy for surgical treatment of intraductal papillary-mucinous tumors

The prognosis of malignant intraductal papillary mucinous tumors of the pancreas (IPMTs) should be considered more favorable than that of ordinary pancreatic ductal carcinoma. However, the preoperative diagnosis of malignancy is extremely difficult in IPMT. IPMT with a main pancreatic duct of less than 7 mm, or cystic lesion of less than 30 mm (branched type), or intramural nodule tumor of less than 4 mm, should be observed without performing surgery and followed carefully. The strategy for surgical treatment of IPMT is very important. Which procedure should be selected or performed? A radical operation should be performed with lymph node dissection if a preoperative diagnosis of malignancy is made. If cancer cannot be ruled out in an IPMT, a function-preserving procedure, such as pylorus-preserving pancreaticoduodenectomy, pancreatic head resection with second-portion duodenectomy, segmental resection, partial resection, or spleen-preserving distal pancreatectomy should be selected, and one of these procedures should be carried out with group I lymph node dissection. The greatest challenge in IPMT is making the diagnosis of benign or malignant and selecting the most appropriate treatment.     

原发性腹膜后肿瘤的诊断与外科治疗

目的 探讨原发性腹膜后肿瘤的诊断与外科治疗.方法 回顾性分析武汉大学中南医院2008年6月至2013年6月间手术治疗的39例原发性腹膜后肿瘤患者的临床资料.结果 39例中恶性肿瘤23例,良性肿瘤16例.16例良性肿瘤患者均获得完整切除,随访无复发患者.23例恶性肿瘤患者,手术完整切除17例,姑息性手术切除6例,其中,剖腹探查活检3例.肿瘤完全切除组中位生存时间为47个月,其1、3年生存率分别为100%、75.0%;姑息性切除组中位生存时间为15.3个月,其1、2年生存率分别为50.0%、33.3%.结论 影像学检查对原发性腹膜后肿瘤术前诊断和评估手术切除范围有着重要意义.手术切除是腹膜后肿瘤的最有效治疗方法,积极的外科治疗、争取完整切除可以延长患者生存期,降低复发率.     

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原发性腹膜后肿瘤在临床上并非少见。由于其位置深在 ,难以早期发现 ,因此诊断有一定困难 ,一旦确诊 ,往往肿瘤已较大 ,同时由于肿瘤常累及腹膜后血管、神经及脏器 ,如肾脏 ,输尿管等 ,致使手术难度增大 ,因而长期以来切除率较低。近年由于影像学的发展 ,手术技术特别是血管外科技术的提高 ,以及围手术期处理的进步 ,已使腹膜后肿瘤的切除率有较大提高。统计我院 1990～ 1999年间外科治疗原发性腹膜后肿瘤共 197例 ,其中行全切除 15 4例 ,占78 2 % [1] 。同时由于腹膜后肿瘤多数对放疗和化疗不敏感 ,手术切除仍是主要的治疗手段[2 ] 。因此 …     

Radiation for primary spine tumors

Malignant primary tumors of the spine present difficult management problems because of the complexities of en bloc resection and their chemoresistance and radioresistance. A combination of radiation techniques and advances in systemic therapy may ultimately provide improved local tumor control and cure for these treatment-resistant tumors.     

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。     

The results of surgical treatment of primary spinal tumors

A series of 72 primary spinal tumors including 57 malignant and 15 benign ones were treated surgically from the years 1961 to 1987. Neurologic complications developed in 52 patients, with paraplegia in 20, spastic paraparesis in 19, cauda damage in 11, and brachial plexus injury in two cases. The principles of the treatment were excision of the tumor, decompression of nervous elements, and stabilization of the spine. Surgical treatment was supplemented with radiotherapy or chemotherapy, or both. In the group of benign tumors, no deaths occurred and the clinical results were good. The results obtained in the group of malignant neoplasms were evaluated according to survival time and were analyzed separately for the dying and the surviving patients. In this group of 57 patients, 42 died, 17 dying within one year (three died from postoperative complications). In the remaining 25 patients surviving over one year, the mean survival time was four years and four months. Fifteen patients are alive, and their mean survival is five years and three months. The neurologic results in 39 patients surviving over six months were good in 92.3% of cases. Regression, or significant improvement of neurologic disturbances, was of considerable importance for the survival time. At the present time, surgical treatment combined with radiotherapy and chemotherapy is the most favorable method for the treatment of primary spinal tumors.     

原发性小肠肿瘤的临床诊断与外科治疗

尽管小肠占消化道总长度的70%,但小肠肿瘤的发生率仅占胃肠道肿瘤的1%～3%[1～5],且以小肠恶性肿瘤为多。良性肿瘤少见的原因可能是其生长缓慢、病程长、症状不典型而容易被忽略,待继发症状出现施行手术,甚至在尸解时才被发现[4～7]。我们回顾性分析1968年1月至2007年1月本院收治的186例小肠肿瘤的临床资料,探讨小肠肿瘤的临床病理特点,以期提高对本病的诊治水平。     

骶骨区神经源性肿瘤的手术治疗策略

目的:探讨骶部神经源性肿瘤恰当的手术入路及手术方法.方法:1998年7月～2006年7月,共收治48例骶骨神经源性肿瘤患者,手术时年龄17～75岁,平均47岁;男性18例,女性30例.良性肿瘤41例,其中神经鞘瘤19例,神经纤维瘤22例;恶性肿瘤7例,其中神经纤维肉瘤3例,恶性神经鞘瘤4例.肿瘤限于骶前、椎管内没有肿瘤者采用前方人路手术(7例),肿瘤限于椎管内或肿瘤出神经孔向前生长但低于S1平面者采用后方入路手术(22例),肿瘤出骶神经孔向前生长高于S1平面者采用前后路联合入路手术(19例).结果:41例良性肿瘤均行边缘性切除,1例死于围手术期失血性休克、DIC,其余40例中37例均保留至少一侧骶神经,3例因累及骶骨范围较大,出血较多,未能保留S2以下神经根.7例恶性肿瘤均行病灶内手术切除,术中均未能保留S2以下神经根.7例(14.9％)患者术后出现残腔内积血积液,其中4例皮瓣坏死,经手术清创,引流后愈合.5例(9.6％)术后出现不同程度的脑脊液漏,均经抬高床尾、抗生素等治疗后愈合.采用前方人路手术的患者1例出现腹膜后血肿;后方人路手术的患者中1例出现膀胱、直肠瘘;前后路联合人路手术的19例患者未发生严重并发症.术后随访20～96个月,平均47个月,良性肿瘤患者中3例神经鞘瘤术后复发;恶性肿瘤患者5例局部复发,3例术后出现肺转移,死亡5例,无瘤生存2例.结论:骶部神经源性肿瘤的切除可根据肿瘤生长的部位及大小来决定手术入路,巨大的骶前神经源性肿瘤适合经前路腹膜后切除,椎管内肿瘤必须从后路手术切除,累及椎管的巨大骶部神经源性肿瘤需经前后路联合入路手术切除.     

Instrumentation surgery for primary tumors of the spine

Summary We performed instrumentation surgery on ten patients with the following rare primary spinal tumors; three solitary plasmacytomas, an aneurysmal bone cyst, a chordoma, a giant-cell tumor, a hemangioma, a solitary bone cyst, a benign osteoblastoma, and a chondrosarcoma. These tumors were found in the cervical spine (one case), thoracic spine (five cases), lumbar spine (two cases), and sacrum (two cases). The patients consisted of five men and five women, and their average age was 43.1 years. Harrington instrumentation was used in six cases, Zielke instrumentation in two, a combination of both in one case, and a Kirshner wire in one. In two cases, iliolumbar fusion was performed with Harrington instrumentation, after total resection of the sacrum. Average duration of the follow-up period was 5 years. This report describes these rare cases and emphasizes the effectiveness of instrumentation surgery in the reconstruction of the spine after extensive surgery.

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Zusammenfassung Wir operierten 10 Patienten mit den folgenden seltenen Wirbelsäulentumoren: drei solitäre Plasmacytome, eine aneurysmale Knochenzyste, ein Chordom, einen Riesenzelltumor, ein Hämangiom, ein gutartiges Osteoblastom und ein Chondrosarkom. Diese Tumoren fanden sich in der Halswirbelsäule (ein Fall), in der Brustwirbelsäule (fünf Fälle), in der Lendenwirbelsäule (zwei Fälle) und im Sakrum (zwei Fälle). Es waren fünf männliche und fünf weibliche Patienten mit einem Durchschnittsalter von 43,1 Jahren. In sechs Fällen wurde Harrington-Instrumentation verwendet, in zwei Fällen Zielke-Instrumentation, eine Kombination von beiden in einem Fall und Kirschner-Draht für den letzten Fall. In zwei Fällen wurde nach totaler Resektion des Sakrum eine ilio-lumbale Verbindung mittels Harrington-Instrumentation durchgeführt. Die Fälle wurden durchschnittlich über fünf Jahre nachverfolgt. Der vorliegende Bericht beschreibt diese seltenen Fälle und betont die Wirksamkeit instrumenteller Chirurgie bei der Rekonstruktion der Wirbelsäule nach ausgedehnten Eingriffen.

     

骨盆原发恶性骨肿瘤的外科治疗

目的 评价不同切除重建方法治疗骨盆原发恶性骨肿瘤的疗效.方法 对1992年10月至2007年7月收治的、有完整随访资料的骨盆原发恶性骨肿瘤79例患者进行回顾性研究.其中低度恶性的Ⅰ B期肿瘤患者23例,高度恶性的ⅡB期肿瘤56例.根据术前诊断、治疗情况,采用不同的切除重建方法.术后按照Enneking外科边界的评定标准进行标本外科边界研究.随访时对患者进行MSTS功能评定.患者随访时间0～183个月,平均28.6个月,存活患者随访时间最短4个月.结果 本组患者保肢70例,其中无重建者42例,重建者28例;截肢9例.无重建患者术后MSTS功能评分2-30分,平均15分;重建患者术后MSTS功能评分5～29分,平均15分.术后局部复发25例,复发率31.6%.其中,低度恶性患者复发3例,复发率13.0%;高度恶性患者复发22例,复发率39.3%.低度与高度恶性患者复发率差异有统计学意义(P=0.023).保肢患者复发21例,复发率30.0%;截肢患者复发4例,复发率44.4%;二者差异无统计学意义(P=0.620).术后外科边界研究显示:包括囊内切除及边缘切除的边界不充分患者,局部复发率为38.1%;广泛切除边界充分患者局部复发率为6.3%,二者差异有统计学意义(P=0.014).术后发生远隔转移14例,其中复发后出现转移者12例,发生率48.0%,无复发出现转移者2例,发生率3.7%.二者差异有统计学意义(P=0.000).总生存率70.9%.结论 对于骨盆原发恶性肿瘤的外科治疗,确保广泛的外科边界是治疗成功的关键.如何选择、改进功能重建的方法是今后临床工作的重点`     

Surgical treatment of primary and secondary malignant tumors of the thoracic and lumbar spine

After considering conservative therapeutic measures, the authors opt for surgical treatment of primary or secondary spinal tumors if neurologic deficits occur or the structural stability of the spine is at risk. The majority of the tumors are located in the ventral section of the spine, i.e., in the vertebral body, and therefore the present authors mainly perform ventral tumor resection and spinal reconstruction (traction implant plus bone cement and ventral traction bracing with the DKS system). In cases with tumor spread over several segments and/or lumbosacral involvement the authors recommend combined ventral and dorsal procedures in order to achieve adequate stability of the vertebral body prosthesis.     

Surgical treatment of tumors of the spine

Indications for the surgical treatment of spinal tumors are intractable pain, spinal instability and deformity, and impending or present significant neurologic complications. The best results are obtained by thorough decompression, adequate correction of deformity, and proper stabilization of the spine. The decompressive laminectomy alone is rarely indicated for neoplastic diseases of the spine. In general, the principles of surgical treatment for spinal tumors are: anterior approach for the anterior lesion and posterior approach for the posterior lesion, a one-stage combined anterior and posterior approach for extensive lesions, and adequate stabilization with the use of various internal fixation devices, bone graft, or bone cement. The results of surgical treatments of 20 patients in this series based on these guidelines are satisfactory (7 excellent, 6 good, and 7 fair). None was rated as poor.