胸部肿瘤切除并血管置换术围术期护理

胸部肿瘤侵犯上腔静脉和无名静脉表明原发肿瘤已属晚期，远期预后极差：手术根治切除难度大，技术要求高；以往曾被认为是外科手术的禁忌证。随着血管外科技术在胸部肿瘤外科治疗中的应用，使部分肿瘤侵犯上腔静脉和（或）无名静脉的患者得到了根治性手术治疗。     

胸部肿瘤切除并血管置换术的护理

报告了31例晚期胸部肿瘤侵犯上腔静脉和无名静脉患者行胸部肿瘤切除并血管置换术围术期护理。术前做好患者的心理护理，呼吸道准备，输液护理；术后密切观察病情变化，加强呼吸、循环监护，配合做好抗凝治疗，是确保手术成功的关键。本组术后因心力衰竭、呼吸衰竭死亡2例。其余患者均恢复良好。     

复杂纵隔肿瘤的外科治疗

目的探讨各类复杂纵隔肿瘤的外科治疗方法及特点。方法对13例复杂纵隔肿瘤患者的外科治疗方法进行回顾性分析。结果取颈部低位领状(和胸骨半劈开)切口切除巨大胸骨后甲状腺肿6例;3例合并上腔静脉综合征患者分别行纵隔肿瘤切除、人工血管置换或自体心包修补术;再次手术完整切除纵隔肿瘤2例;手术治疗因肿瘤反复破溃引起纵隔感染、冻结2例。结论一些复杂纵隔肿瘤的手术难度及危险性较大,应根据不同情况,采取适当术式,以达到理想的治疗效果。     

上腔静脉回流无阻断人工血管置换术在肺癌侵犯上腔静脉患者中的临床疗效

目的:探讨上腔静脉回流无阻断人工血管置换术在肺癌侵犯上腔静脉患者中的临床疗效.方法:选择我院心胸外科2005年4月至2013年4月收治的3例肺癌侵犯上腔静脉的患者,实施了肺叶/全肺切除+纵隔淋巴结清扫+上腔静脉完全切除及人工血管置换术.3例经相关检查,明确肿瘤情况并排除远处转移,确诊前未接受抗肿瘤治疗.结果:所有患者无术中及围术期死亡,术后无脑水肿、人工血管血栓形成、大出血等严重并发症.1例术后7个月死于化疗期并发症;1例于术后13个月后出现脑转移,并于脑转移后25个月死于肿瘤转移(生存38个月);1例患者术后至今48个月,全身状况良好,影像学检查未发现复发证据.结论:肺癌侵犯上腔静脉可能不是手术的禁忌证,选择合适的患者进行上腔静脉完全切除及人工血管置换术可能使部分患者获得治愈的机会     

肺癌侵及隆突的外科治疗

目的：总结肺癌侵及隆突的外科治疗，研究分析其手术适应证、技术方法及术后管理。方法：全组病例共36例，右肺中心型肺癌25例，右侧纵隔型肺癌2例，其中侵及上腔静脉及无名静脉6例；左侧中心型肺癌9例；手术方式：行右隆突全肺或肺叶切除隆突重建术27例，6例同时行受侵上腔静脉及无名静脉切除人工血管置换；左隆突全肺切除9例。结果：全组无手术死亡，术后早期死亡4例（11．1％），循环衰竭3例，呼吸衰竭1例；1年生存率80．6％（29／36），3年生存率47．4％（9／19），5年生存率33．3％（3／9）。结论：对于肺癌侵犯隆突和上腔静脉及双侧无名静脉通过切除原发病变和部分受侵器官可达到临床根治之目的，辅于多学科的综合治疗，患者亦可获得良好的远期生存。     

累及上腔静脉的肺癌外科治疗效果探析

目的探析肺癌累及上腔静脉的外科治疗效果。方法将我院2008年5月至2010年5月经手术治疗的肺癌累及上腔静脉患者30例作为研究对象,将其临床资料进行回顾性分析,记录患者上腔静脉压力及阻断时间的测量结果;上腔静脉置换患者给予膨体聚四氟乙烯人工血管治疗;运用4-0Prolene无创伤滑线进行缝合;观察术后患者吻合口出血等情况。结果上腔静脉置换19例患者中,未阻断的患者有5例,上腔静脉阻断患者的阻断时间为10～32 min。阻断患者的上腔静脉压力在术前测定为30 KPa,术中最高压力为40 KPa。整个围术期及手术中未出现死亡现象;12例患者术后出现肺炎、肺不张、心功能不全、心律失常等并发症。结论治疗过程中,减少上腔静脉阻断时间可避免患者出现脑水肿;选择适宜的人工血管,运用无创伤滑线连续外翻缝合,可有效控制出血、血管栓塞的症状。     

人工血管置换上腔静脉在肺癌外科治疗中的应用

目的　探讨上腔静脉切除行人工血管置换在晚期肺癌外科治疗中的作用、技术方法及其预后。方法　全组共２６ 例,右侧中心型肺癌２１ 例、周围型肺癌５ 例。行肺癌原发病变、转移淋巴结及受侵及的上腔静脉切除,采用人工血管置换切除的上腔静脉。术后口服小剂量抗凝剂短期治疗,并进行长期的随访与观察。结果　全组无术中及术后早期死亡,无术后近期及远期上腔静脉及无名静脉梗阻症状的发生。随访２３ 例,１、３、５ 年生存率分别为８５％ （２２／２６） 、３９％ （７／１８） 、３６％ （４／１１） 。结论　人工血管置换受侵及的上腔静脉使部分晚期肺癌获得根治性切除,扩大了肺癌外科手术适应证,提高了晚期肺癌患者的生存率,可在晚期肺癌的外科治疗中推荐应用。     

大隐静脉与腋静脉吻合治疗上腔静脉阻塞综合征一例

患者,男,29岁。体检:面部暗红,颈粗脸肿,颈静脉和胸壁表浅静脉怒张,双上肢轻度肿胀。呼吸费力,R19次/分,P80次/分,Bp120/70mmHg;心肺无异常;胸透和胸部平片(一),两肺和纵隔断层摄片,气管和支气管未见狭窄和阻塞,两上纵隔未见增宽和块影。自左锁骨下静脉注射造影剂行上腔静脉造影,见左锁骨下静脉、颈静脉及半奇静脉显影,无名静脉及上腔静脉未见显影。诊断为上腔静脉阻塞综合征.1985年5月在全麻下行右侧大隐静脉与右腋静脉端侧吻合术。病人仰卧位,常规消毒皮肤;沿右大隐静脉走向自卵圆窝至内踝前方切开右下肢的皮肤和皮下组织,电灼止血;分离大隐静脉主干及其分支,除旋髂浅静脉、     

用自体组织替换上腔静脉的实验研究

本文评价用心包和自体静脉辅以动-静脉瘘来替换上腔静脉的效果。用体重25～40公斤的犬,以硫苯妥钠麻醉并作气管插管,用氟烷维持麻醉。由第三肋间进胸显露上腔静脉并结扎奇静脉。术中对血管注意无损伤性操作原则。自体组织管柱和上腔静脉的吻合采用6-0或7-0聚四氟乙烯聚酯纤维线作连续外翻缝合。较精细的缝合用放大镜帮助。动物分成11组:第一组仅作单侧横断上腔静脉后缝合,以观察缝线的影响;第二组于两端横断上腔静脉后立即重新缝合,以观察切断营养血管后的影响。其余各组上腔静脉从右锁骨下静脉分叉至进入右房处全部切除,用心包做成的血管或颈外静脉代替上腔静脉。这些组织切下后立即浸于肝素生理盐水溶液中(每毫升含20单位肝素)。相应各     

三度房室传导阻滞合并双奇静脉畸形植入永久起搏器一例

本例患者为老年女性,三度房室传导阻滞合并肺栓塞,行永久起搏器植入术。经左锁骨下静脉途径导丝不能进入上腔静脉,造影显示无名静脉闭塞,永存左上腔静脉、奇静脉畸形。血管走行：左锁骨下静脉—永存左上腔静脉—左奇静脉—奇静脉环—右奇静脉—右上腔静脉。改右锁骨下静脉途径植入心室主动导线,植入永久起搏器。     

胸腔镜辅助小切口手术治疗老年人胸部肿瘤

目的 探讨胸腔镜辅助小切口手术治疗老年人胸部肿瘤的手术方法及应用价值。方法 应用胸腔镜辅助小切口手术治疗老年人胸部肿瘤356例，其中肺癌228例，肺部良性肿瘤23例，食管癌62例，纵隔肿瘤39例，胸膜肿瘤4例。结果 全组无手术死亡，食管癌手术时间3．5～4．5h，平均4．0h；其他手术时间0．5～3．5h平均2．0h。术中延长手术切口至12cm 23例，占6．5％，均为中央型肺癌患者，需作支气管或肺血管成形。开胸时间5～12min，平均8min；关胸时间15～30min，平均23min。开胸过程出血量少于30ml，切口均Ⅰ期愈合。胸腔引流时间2～7d，平均2．5d、住院天数5～19d，平均11．2d。结论 胸腔镜辅助小切口手术治疗老年胸部肿瘤具有创伤小、恢复快、出血少，对心肺功能影响小，开关胸时间短，术后并发症少，手术适应证更广等优点。     

Successful Treatment of Chylothorax and Chylopericardium by Radiotherapy in Lung Cancer

A 58-year-old man was diagnosed with stage IVB lung adenocarcinoma in the right upper lobe and underwent systemic chemotherapy. Seven months after the diagnosis, large left pleural and pericardial effusion was detected. The patient developed both chylothorax and chylopericardium following superior vena cava (SVC) obstruction with mediastinal lymphadenopathy caused by lung carcinoma. Since conservative treatment of the chyle leakage was ineffective, we administered radiotherapy to treat the SVC obstruction and mediastinal lymphadenopathy. After radiotherapy, the chylothorax and chylopericardium gradually resolved, and no further chyle leaks were identified on follow-up computed tomography. This case indicates that radiotherapy can be used to ameliorate lung cancer-related chylothorax and chylopericardium.     

A case of adenosquamous carcinoma with unknown origin and with superior vena cava syndrome as the first symptom]

This report is concerning a case of adenosquamous carcinoma having unknown origin and showing SVC syndrome as the first symptom. A 44 year-old man was admitted to our hospital because of facial edema at the beginning of April 1990. He was diagnosed as having a mediastinal tumor of the SVC syndrome type. Resection of the SVC tumor and part of the pericardium was performed on June 20, 1990. The operation had extraordinary findings. Lymph nodes adhering to tumor invaded the adjacent right side of the trachea and were situated in a rosette-like form. Furthermore, a part of the tumor stemmed into the lumen of the superior vena cava causing complete obstruction. The pathological diagnosis of the SVC tumor was adenosquamous carcinoma, however, no clinical examinations could identify its original matrix. Mediastinal tumors of unknown origin are reported as about 1% of all mediastinal tumors, and are responsible for 0.68% of all carcinomas in the mediastinum. This was one experience of a rare case of mediastinal tumor having unknown origin and showing SVC syndrome as the first symptom.     

Extended resection of T4 lung cancer with invasion of the aorta: is it justified?

BACKGROUND: We report our 10-year experience of performing surgical resection of T4 lung cancer invading the thoracic aorta. PATIENTS AND METHODS: From 1994 to 2004, sixteen patients with T4 primary lung cancer with local invasion of the thoracic aorta underwent tumor resection. Surgical resection included 8 pneumonectomies and 8 lobectomies. The histologic type was squamous cell carcinoma in 7 patients, adenocarcinoma in 7, large cell carcinoma in 1, and small cell carcinoma in 1. Complete resection of the tumor with mediastinal lymph node dissection was achieved in 8 patients (50 %), while the resection was incomplete in the other 8 cases. RESULTS: The overall cumulative survival of the 16 patients at 3 and 5 years was 34.7 % and 17.4 %, respectively. The survival of the patients in the complete resection group was found to be 36.5 % at 5 years, with 2 patients surviving more than 5 years without a recurrence, which was significantly better than that of the incomplete resection group ( p = 0.005). CONCLUSIONS: Extended aortic resection with primary lung cancer is complex and possibly high risk, but can achieve long-term survival in selected patients. Surgical resection should be considered as a treatment option for T4 lung cancer for this T4 subcategory.     

Surgical management of mediastinal tumor invading the heart and large blood vessels

Background Surgical removal plays an irreplaceable important role in mediastinal tumor therapy. With advances of anesthesia, cardiopulmonary bypass and vascular surgery technology, even tumor invading the heart and great vessels can also be removed. Patients get good results after radical surgery. Methods Review The perioperative treatment was reviewed for 36 patients with complicated mediastinal tumor involving the heart and great vessels from February 1997 to March 2014. Out of them, 2 patients underwent extracorporeal circulation; one patient underwent superior vena cava and left innominate vein replacement besides the resection of mediastinal tumor; one did superior vena cava replacement, 3 patients received partial right atrial resection, 5 did superior vena cava angioplasty, 4 did innominate vein resection, 5 did innominate vein angioplasty, 10 did partial excision and repair of pericardium, 8 did pulmonary wedge resection successfully,and 2 did lobectomy. Results All 36 procedures were completed with no perioperative death. Clinical outcome was satisfactory. Conclusions Surgical management for complicated mediastinal tumor invading the heart and great vessels is difficult and risky. Therefore, comprehensive perioperative preparation and appropriate surgical procedures are indispensable for a successful surgery and desirable therapeutic effect.     

电视胸腔镜辅以胸部小切口手术40例

对４０例胸部疾病患者行电视胸腔镜辅以胸部小切口手术（ＶＡＭＴ），其中肺癌１７例，肺周围型病灶１０例，食管癌８例，食管平滑肌瘤、贲门失弛症、食管憩室、纵隔肿瘤、急性脓胸各１例；ＶＡＭＴ探查时间为２０￣３０分钟，ＶＡＭＴ手术时间为４０￣１５０分钟，小切口长５￣８ｃｍ；无手术死亡者。本文对ＶＡＭＴ的手术适应症、小切口设计及其临床价值进行了讨论。     

Mediastinal hydatid disease: an unusual presentation

Hydatid disease is a significant health problem in endemic areas. While occurrence of the cysts in the liver and lung is common, mediastinal localisation is extremely rare. We report the case of a 35-year-old male who presented with a painless swelling on the right side of the neck and features of superior vena caval obstruction. Chest radiography and computed tomography (CT) suggested a cyst in the right upper lobe, extending into the right supraclavicular region as well as another cyst in the left lung. Thoracotomy revealed that the right-sided cyst was actually mediastinal in location and had herniated through the thoracic inlet compressing the superior vena cava (SVC). Both cysts were removed in two separate operations and symptoms of SVC compression subsided after removal of the right-sided cyst. Histopathology was consistent with a hydatid disease.     

电视胸腔镜手术治疗胸部肿瘤患者86例分析

目的 分析电视胸腔镜手术(Video Assisted Thoracoscopic Surgery,VATS)在胸部肿瘤治疗中的效果.方法 通过回顾分析2010年2月～2011年6月,来我院就诊并行电视胸腔镜手术的86例罹患胸部肿瘤的患者的临床资料,探讨VATS的治疗效果.结果 本组行全胸腔镜手术80例,术中转胸腔镜辅助小切口手术6例,无手术死亡病例.本组患者中肺楔形切除32例,肺叶切除42例,纵隔肿瘤9例,胸膜活检加肺固定术3例.手术持续时间平均89 min,术中平均失血量149 ml,均未输血,术后仅8例出现并发症,患者术后平均住院时间为8 d.结论 电视胸腔镜手术在治疗胸部肿瘤时具有创伤小、痛苦轻、并发症少、恢复快等优点,具有较高的临床推广价值;一次性缝合材料配合完全性肺叶切除可达到开胸手术相同的治疗效果,但仍需继续积累相关手术经验.     

Causes and management of intraoperative complications in robot-assisted anatomical pulmonary resection for lung cancer

BackgroundTo perform safe robot-assisted anatomical lung resections, the details of intraoperative complications need to be shared among thoracic surgeons. However, only limited data are available.MethodsThis retrospective, single-institutional study evaluated 134 patients who underwent robot-assisted anatomical lung resection. We examined the causes, management, and outcomes of all intraoperative complications.ResultsOf the 134 eligible patients, 118 (88%) underwent lobectomy and 16 (12%) underwent segmentectomy. Intraoperative complications occurred in 17 (12.7%) patients. These complications included pulmonary artery (PA) injuries in seven patients, pulmonary vein (PV) injuries in three, azygos vein (AV) injury in one, superior vena cava (SVC) injury in one, bronchial injuries in three, and lung injuries in four. Most PA injuries were at a distal side and controlled by pressure, fibrin sealant, or stapling of the proximal side. In the three PV injuries, right upper PV was sandwiched by robotic instruments, V6 was punctured by the tip of the Maryland bipolar forceps, and the distal side of V2t was injured during tunneling of a minor interlobar fissure. These were controlled the same way as the PA injuries. The AV injury occurred during hilar lymph node (LN) dissection and was controlled by suturing. The SVC injury was caused by interference of the robotic forceps and the suction tube outside the field of view during upper mediastinal LN dissection. The injury was controlled by continuous pressure while layering polyglycolic acid sheets and fibrin glue. In the three bronchial injuries, B10 was injured during subcarinal LN dissection, right main bronchus was injured during upper bronchus dissection and the stapling failure of the bronchus occurred by strong traction. They were all repaired by suturing. All lung parenchymal injuries were caused by manipulation of robotic instruments outside the field of view. The lung injuries were repaired by suturing with pledgets. No cases were converted to thoracotomy. The 30-day mortality rate was 0.7%. The cause of mortality was pneumonia.ConclusionsIn robot-assisted anatomical pulmonary resection for lung cancer, most major intraoperative complications can be safely managed robotically without conversion to thoracotomy.