气管、隆突及主支气管肿瘤的外科治疗体会

气管、隆突及主支气管肿瘤临床易误诊 ,外科治疗也存在一定困难度。 1988年 6月～ 1999年 12月我们收治原发性气管、隆突及主支气管肿瘤共 16例 ,对其中 13例施行了手术治疗 ,现将治疗体会报告如下。1　临床资料1 1　一般资料 :13例手术者男性 8例 ,女性 5例 ,年龄 2 5～ 6 3岁 ,平均年龄 5 1 5岁。良性肿瘤 2例 ,分别为腺泡细胞瘤和平滑肌瘤。恶性 11例 ,其中腺样囊性癌 5例 ,鳞癌 4例 ,腺癌 2例。1 2　病变部位及治疗方式 :气管肿瘤作气管袖状切除、端端吻合术 5例 ,其中颈段 2例 ,胸段 3例 ;隆突部肿瘤作全隆突切除重建术 2例 ,1例切除隆…     

肺癌侵及隆突的外科治疗

目的：总结分析肺癌侵及隆突外科治疗的手术适应证、技术方法及术后管理。方法：全组共36例，右肺中心型肺癌25例，右侧纵隔型肺癌2例，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：行右隆突令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：左隆突令肺切除9例。结果：全组围术期死亡4例(11．1％)，循环衰竭3例，呼吸衰竭l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：对于肺摇侵犯隆突和上腔静脉及双侧尢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，附加多学科的综合治疗，患者亦可获得良好的远期生存。     

气管隆突切除成形术治疗隆突部或侵犯隆突的恶性肿瘤4例体会

隆突切除成形术因其手术风险大,并发症高,目前在临床上尚未普及.自2004年2月至2007年3月本院共完成4例隆突切除成形术,现总结如下.     

气管、隆突与支气管成形术27例临床分析

本文报告气管、隆突及支气管成形术27例,其中气管、支气管肿瘤22例.外伤性支气管断裂4例,支气管内膜结核1例.术式包括气管环状切除、部分隆突切除、支气管肺袖状切除、外伤性气管食管痿二期手术保肺切食管以结肠代食管术.后者符合生理,部分隆突切除扩大了隆突成形术适应证.对各类手术适应证、特殊气管插管麻醉及手术技巧进行了讨论.     

左主干伴三支病变严重狭窄外科治疗体会

目的：探讨严重左主干狭窄伴三支血管病变严重狭窄患者的手术时机及方法选择。方法回顾分析2003年1月至2013年3月对严重左主干病变伴三支血管病变患者施行冠状动脉旁路移植术296例。其中体外循环冠状动脉旁路移植术（CCABG）276例,非体外循环冠状动脉旁路移植术（OPCAB）20例。60岁以上者172例（58.1％）。术前同时合并其他疾病患者246例（83.10％）,包括瓣膜病、高血压病、高血脂、糖尿病、陈旧性心肌梗死、室壁瘤、脑梗死等。冠状动脉旁路移植（3.85±0.6）支,左乳内动脉旁路移植281例（95.10％）。围术期使用主动脉内气囊反搏（IABP）32例。结果手术早期死亡7例（2.36％）,其中低心排综合征1例、心室纤颤2例、脑岀血1例、消化道岀血1例、肾功能衰竭1例、多脏器功能衰竭1例。术后并发症26例（8.78％）,其中低心排量综合征8例、心室纤颤4例、呼吸衰竭3例、多脏器功能衰竭3例、心包压塞2例、肾功能衰竭2例、消化道出血2例及脑岀血2例。212例（71.62％）患者随访2-84个月,3例死亡（1.01％）,2例与心脏病有关。结论严重左主干伴三支血管严重狭窄高危患者在体外循环下手术仍不失为一种安全有效的治疗方法,对左心功能低下者预先置入IABP可使CABG术的死亡率和并发症发生率均降低,改善了其预后。     

侵犯左心房的局部晚期非小细胞肺癌的外科治疗

目的 探讨侵犯左心房的局部晚期非小细胞肺癌的手术适应证、手术方式及术后处理。方法 回顾分析46例侵犯左心房的局部晚期非小细胞肺癌,其中40例在非体外循环下行左心房部分切除,另6例左心房受累范围广泛患者在体外循环支持下行左心房部分切除重建术;动脉插管部位分别为股动脉、降主动脉或升主动脉,静脉插管部位分别为肺动脉或上下腔静脉。结果 1例早期死亡于呼吸衰竭。1例急性肺水肿和3例心律失常均经保守治疗成功。1年、3年生存率分别为78．9％、43．0％。结论 体外或非体外循环方法均能安全有效地完成侵犯左心房的晚期肺癌的根治性切除,长期生存率尚需进一步观察。     

老年胰腺癌患者外科治疗的临床分析

目的 探讨老年胰腺癌患者的临床表现和治疗及预后。方法 收集1990－2000年上海华山医院胰腺癌中心180例经过手术治疗的老年胰腺癌患者,其中46例行Whipple手术,包括22例介入治疗后的区域性胰十二指肠切除术,观察术后并发症和30d内的死亡率。78例接受了姑息手术,54例仅做剖腹探查术。随访6个月到10年。结果 所有患者都成功地进行了手术。48例经外科根治性切除者的死亡率为6．2％,并发症率为20．8％,中位生存期为26个月;78例姑息手术者平均存活6个月,54例仅行剖腹探查术者平均生存期只有3个月。结论 外科治愈性手术治疗有助于延长老年胰腺癌患者的生存期,改善患者的生存质量。     

Surgical treatment of IIIb-T4 lung cancer invading left atrium and great vessels

Background IIIb-T4 non-small cell lung cancer （NSCLC） is commonly considered a contraindication to surgery, although chemo-radiotherapy also achieves a poor survival rate. We reviewed our experience with T4 NSCLC patients who underwent surgery to explore the indications and prognostic factors of surgical treatment of lung cancer invading the left atrium and great vessels. Methods We investigated a cohort of 105 patients, 79 men and 26 women, who underwent surgery from May 1996 to July 2008. Their pathological staging was T4No-2M0. The median age was 59 years, ranging from 36 to 75 years. Patients were grouped based on invading sites： tumors invading the left atrium （LA group）, tumors invading the superior vena cava （SVC group）, and tumors invading the intrapericardial pulmonary artery （PA group）. Patients were further characterized based upon the type of operation, complete resection and incomplete resection groups, and on the lymph node pathological status, No, N1 and N2 groups. We calculated the overall five-year survival rate. Results All patients received resection of primary lesions, with partial resection of the left atrium in the LA group （n=-25）, angioplasty of superior vena cava in the SVC group （n=-23） and intrapericardial ligation of the pulmonary artery in the PA group （n=57）. Complete resection was possible in 77 patients （73.3%）. The overall survival rate of the 105 patients was 41.0% at 5 years; 36.0% for the LA group, 34.8% for the SVC group and 45.6% for the PA group. Pathological N status significantly influenced the overall 5-year survival rate; 61.5% for No, 51.1% for the N1 and 11.8% for the N2 groups （N2 group versus No group, P 〈0.0001, N2 versus N1 group, P〈0.0001）. Surgical resection also influenced survival; 49.4% for the complete resection group and 17.9% for the incomplete resection group （P 〈0.0001）. Cox regression analysis demonstrated that pathological N status was a significant independent predictor of prognosis. Conclusions Pathological N status is a significant independent predictor for survival of patients with IIIb-T4 lung cancer invading the left atrium and great vessels. The completeness of resection has a significant influence on the overall 5-year survival rate. Surgery for T4 lung cancer may be effective in patients without mediastinal lymph node involvement.     

儿童外伤性后颅窝血肿的手术治疗

目的探讨儿童外伤性后颅窝血肿的临床特点、诊断、手术治疗方法及预后。方法回顾性分析18例行手术治疗的儿童外伤性后颅窝血肿患者的临床诊治资料。结果后颅窝硬膜外血肿14例,其中单侧血肿12例,双侧2例,血肿跨横窦2例;硬膜下血肿3例;小脑血肿1例。合并额颞部硬膜下血肿2例,合并额部硬膜下血肿2例。梗阻性脑积水6例,第四脑室环池受压移位7例,环池消失2例。术后死亡2例。术后6个月,16例患者获得随访,其预后按GOS分级:2分1例,3分3例,4分5例,5分7例。结论外伤性后颅窝硬膜外血肿病情危重,病情发展快,对有手术指征的病例,及时、合理的选择手术治疗是挽救患儿生命,改善预后的关键。     

Long-term clinical outcomes of patients with unprotected left main bifurcation lesions treated with 2-stent techniques

Background Currently available evidence suggests that outcomes are less favorable when left main (LM) bifurcation lesions are treated with 2-stent techniques compared with a single-stent technique.We aimed to evaluate the long-term outcomes of the 2-stent techniques for treating unprotected LM bifurcation lesions in Chinese patients.Methods We enrolled 301 consecutive patients treated with drug-eluting stents (DES) implantation using 2-stent techniques for unprotected LM bifurcation lesions (MEDINA 1,1,1,70.5％).The 2-stent techniques included crush technique,V stenting,T stenting,and Culottes stenting.After stenting,both vessels were redilated at a high pressure before final kissing balloon (FKB).Clinical and angiographic data were analyzed.The primary endpoints were major adverse cardiac events (MACE),whichincluded death,myocardial infarction,and target lesion revascularization.Results Immediate procedural success was obtained in all cases with a FKB success rate of 95.3％.Follow-up data were available for all patients.The overall incidence of angiographic in-stent restenosis (ISR) rate was 20.3％ and most ISRs were of the focal type.During long-term follow-up (mean duration,(54±22) months),the cumulative incidence of MACE was 11.0％,with 8 (2.7％) deaths,7 (2.3％) myocardial infarctions,and 18 (6.0％) repeated lesion revascularization.MACEs in high SYNTAX score terciles were significantly higher compared with those in low and intermediate SYNTAX score terciles (p=0.001).Conclusions Although percutaneous coronary intervention (PCI) with 2-stent technique for unprotected LM bifurcation lesions was accompanied with a slightly high incidence of ISR,the long-term clinical follow-up is acceptable.Technical modifications and stent innovations may further improve both the angiographic and clinical outcomes for patients with LM bifurcation disease treated by PCI.     

70岁以上老年胆石症56例的外科治疗

目的：探讨70岁以上老年人胆石症的临床特点、手术治疗方法及围手术期处理。方法：回顾性分析56例70岁以上胆石症患者的临床资料。结果：单纯胆囊切除38例（其中腹腔镜术11例）,胆囊切除、胆总管探查T管引流14例,胆总管空肠吻合内引流术2例,胆囊造瘘2期手术2例。结论：老年人胆石症的外科治疗必须完善围手术期处理,选择合适的手术时机和手术方式,尽量避免急诊手术以提高手术治愈率,减少并发症的发生。