双侧同期颈清扫术治疗甲状腺癌6例

本文报告对 6例甲状腺癌双侧颈淋巴结转移的患者行双侧同期颈清扫术的结果。对手术适应症进行了讨论 ,认为正确掌握手术适应症 ,将不会增加术中意外损伤及术后并发症的发生率 ,并认为术中应首先清扫颈淋巴结转移较轻且估计可行保留颈内静脉清扫术的一侧。     

双侧同期颈清扫术治疗甲状腺癌6例

本报告对6例甲状腺癌双侧颈淋巴结转移的患行双侧同期颈清扫术的结果。对手术适应症进行了讨论,认为正确掌握手术适应症,将不会增加术中意外损伤及术后并发症的发生率,并认为术中应首先清扫颈淋巴结转移较轻且估计可行保留颈内静脉清扫术的一侧。     

甲状腺癌双侧同期颈淋巴结清扫手术的临床应用

目的探讨甲状腺癌双侧同期颈淋巴结清扫术的可行性及合理性。方法对19例甲状腺癌双侧同期颈淋巴结清扫术的手术操作技巧及并发症的诊治进行回顾性分析。结果19例均有不同程度的颜面部水肿及眼结膜充血水肿,占100.0%;5例出现头痛,占26.3%;2例出现术后声嘶,占10.5%;2例术后出现饮水呛嗽,占10.5%;1例术后出现淋巴导管瘘,占5.3%;2例出现术后甲状旁腺低功能的临床表现,占10.5%;所有病例均未出现皮瓣坏死、感染及明显的皮下积血积液,无手术相关死亡病例。结论只要有颈淋巴结清扫术的手术适应证及采用正确的手术操作方式,就不会增加术中损伤及术后并发症的发生率,且术中应首先清扫颈淋巴结转移较轻微的一侧颈部或是估计颈内静脉可保留的一侧颈部。     

口腔癌及口咽癌的功能性颈淋巴结清扫

:〔目的〕对口腔癌及口咽癌功能性颈淋巴结清扫术的效果进行评价。〔方法〕对近10年我院所行功能性颈淋巴结清扫术的病例作了回顾性研究,并与同期所行根治性颈淋巴结清扫术的病例作了比较分析。〔结果〕两组病人在手术时间及并发症方面较为接近,在复发率和生存率方面也无明显差异。〔结论〕功能性颈淋巴结清扫术对于口腔癌和口咽癌是一种有效的颈部处理方法,其效果与根治性颈淋巴结清扫术类似,而其良好的肩部功能更易为人们所接受。     

口腔癌及口咽癌的功能性颈淋巴结清扫

〔目的〕对口腔癌及中咽癌功能性颈淋巴结清扫术的效果进行评价。〔方法〕对近１０年我院所行功能性颈淋巴结清扫术的病例作了回顾性研究，并与同期所行根治性颈淋巴结清扫术的病例作发比较分析。〔结果〕两组病人在手术时间及并发症方面较为接近，在揽发率和生存率方面也无明显差异。〔结论〕功能性颈淋巴结清扫术对于口腔癌和口咽癌是一种有效的颈部处理方法，其效果与根治性颈淋巴结清扫术类似，而其良好的肩部功能更易为们所接受     

序贯三切口及选择性淋巴结清扫治疗食管癌1162例临床效果分析

目的 探讨食管癌外科治疗的手术方式、淋巴结清扫范围、术后综合治疗模式.方法 对1998年1月至2007年12月间收治的不同部位的食管癌1162例采用序贯的腹、胸、颈三切口的手术径路行食管肿瘤切除,应用术前影像、超声定位下穿刺细胞学检查和术中颈部淋巴结抽样活组织快速病理检查三步筛选方法行选择性一期三野淋巴结清扫,一期规范胸腹二野清扫和二期第三野颈部淋巴结清扫.同时,术后积极实施综合治疗.观察总的临床疗效和长期生存.结果 1162例食管癌手术中,手术切除率100％.根治性切除97.6％（1134/1162）.围手术期并发症发生率16.4％（191/1162）,吻合口瘘发生率为0.6％（7/1162）,术后30 d内死亡5例.全组淋巴结转移率52.6 ％（611/1162）,淋巴结转移度12.1％（3 092/25 564）.全组实施一期三野淋巴结清扫348例,阳性准确率为94.8％（330/348）,实施一期二野清扫814例,实施二期第三野颈部淋巴结清扫89例.三野清扫术后并发症明显高于二野清扫（23.6％比13.4％）（χ^2=18.37,P＜ 0.001）,但两者的1、3、5年生存率差异无统计学意义（P＞0.05）.一期三野清扫和二期第三野清扫患者1、3、5年生存率差异亦无统计学意义（P＞0.05）.但不同的淋巴结转移程度预后差异有统计学意义（χ^2=35.57,P＜ 0.001）,不同的分期决定着患者的预后.本组术后综合治疗实施率为87.2％,手术加术后综合治疗者总的1、3、5年生存率分别为92.1％、69.2％、49.6％.结论 序贯三切口切除食管肿瘤及应用三步筛选法选择性淋巴结清扫具有根治彻底、术后并发症少、患者生存质量高、长期生存率较好等优点,是食管癌外科治疗值得临床广泛应用的一种方法.术后积极的综合治疗是今后食管癌治疗的发展方向.     

宫颈癌术前放疗37例报道

目的探讨Ⅰb~Ⅱb期宫颈癌术前放疗的优势及放疗后的手术适应症。方法37例Ⅰb~Ⅱb期宫颈癌接受术前放疗后行广泛性子宫切除加盆腔淋巴结清扫术。结果全组病人均能如期按手术规范完成手术,术中未发生不可控制的大出血,无输尿管、膀胱、直肠等损伤发生。术后常见并发症发生率低。结论Ⅰb~Ⅱb期宫颈癌经术前放疗,降低了手术难度,并使Ⅱb期病人具有手术机会,且不增加术中术后并发症的发生。     

中低位直肠癌腹腔镜与开放全系膜切除合并侧方淋巴结清扫围手术期临床分析北大核心CSCD

目的比较中低位直肠癌患者在腹腔镜与开放全直肠系膜切除术(TME)基础上行侧方淋巴结清扫的围手术期临床结果,以探讨腹腔镜盆腔淋巴结清扫术的可行性及安全性。方法对浙江省肿瘤医院同期16例腹腔镜及55例开放侧方淋巴结清扫术患者临床资料进行回顾性分析,比较了两组间围手术期手术时间、术中出血量、侧方淋巴结清扫数目、术后并发症及术后住院时间。结果腹腔镜组与开放组患者基础临床特征相似。两组患者均无围手术期死亡。腹腔镜组患者无中转开腹手术。腹腔镜组比开放组手术时间显著延长(218.6±71.6 min vs.181.3±57.9 min,P=0.035)、术中出血量显著减少(190.6±80.1 ml vs.344.9±295.2 ml,P=0.044)。腹腔镜组与开放组清扫的侧方淋巴结数目(9.8±6.1枚vs.11.0±9.7枚,P=0.642)、侧方淋巴结转移阳性率(25.0%vs.34.5%,P=0.556)、术后并发症发生率(25.0%vs.20.0%,P=0.666)、术后住院时间(10.9±3.5天vs.13.8±7.1天,P=0.125)差异均无统计学意义。侧方淋巴结转移与肿瘤低分化(P=0.001)、阳性脉管瘤栓(P=0.011)和神经侵犯(P=0.002)相关,但与术前是否行放化疗(P=0.479)及肿瘤大小(P=0.907)无关。结论腹腔镜直肠癌全系膜切除术基础上的侧方淋巴结清扫是安全可行的,并能达到和传统开放手术同样的围手术期临床效果。     

胸腔镜辅助小切口下肺切除术清扫纵隔及肺门淋巴结的临床研究

背景与目的：近20年来,胸腔镜下行肺切除术治疗肺肿瘤的相关经验在世界范围内迅速积累.很多医学中心可在胸腔镜下完成解剖学上彻底的肺叶切除和淋巴结清扫.本研究旨在评价胸腔镜下肺切除术清扫纵隔及肺门淋巴结的安全性和可行性.方法：2006年8-9月,选取我院行胸腔镜辅助小切口下肺叶切除手术9例,观察手术时间、死亡率、并发症发生率及淋巴结清扫情况.结果：全组患者无围手术期死亡及严重围手术期并发症,共清扫100枚淋巴结,手术历时1.5～3 h,平均2.3 h;平均淋巴结清扫时间15.0 min.结论：小切口辅助胸腔镜下肺切除淋巴结清扫术在不增加手术难度及手术时间的同时,为肺叶或全肺切除术的淋巴结清扫提供了一种可供选择的方法.     

新手术径路治疗食管癌的临床研究

目的　探索新手术径路治疗食管癌对手术切除率、根治性、术后并发症及生存质量和生存率的影响。方法　 1992年 1月～ 1997年 12月采用新手术径路 (左上腹直肌 /右胸后外侧或右颈部切口 )次全食管切除 ,颈部或右胸顶食管胃吻合术治疗食管癌 15 0例 (治疗组 ) ,同期以 16 0例 (对照组 )应用常规手术方法左胸后外侧或加左颈部切口治疗食管癌 ,作对照比较。结果　新手术径路切除率提高到 99.3% ,对腹、胸、颈三区的淋巴结清扫的彻底性提高。术后无吻合口瘘发生 ,术后并发症下降为 11.4% ,且术后生活质量提高 ,1、3、5年生存率较对照组高。结论　正确应用新手术径路治疗不同部位食管癌 ,可明显提高手术切除率 ,提高手术的根治彻底性 ,降低围手术期并发症 ,延长远期生存率。     

A study of a regional lymph node metastasis in a well-differentiated thyroid carcinoma

Forty-eight patients with a well-differentiated thyroid cancer that occupied unilateral lobe were given, a modified radical neck dissection (unilateral or bilateral). After an examination of their lymph nodes, a retrospective analysis showed that the metastasis extended to the lateral cervical lymph node on the ipsilateral neck in 43.8% of all cases, and to at least the paratracheal lymph node on the contralateral neck in 27.2% of all cases. Therefore a bilateral modified radical neck dissection is needed surgical treatment for such patients.     

Simultaneous bilateral radical neck dissection following high-level radiation therapy

Twenty-two patients with advanced cancer in the area of the head and neck were treated by combining major curative radiation (5000-8000 rads) and a composite operation including excision of the primary lesion and bilateral radical neck dissection. The mortality and morbidity of combining these two treatment methods was quite acceptable and did not exceed mortality and complication rates for this type of operation done without prior radiation.     

Bilateral radical neck dissection: results in 193 cases

BACKGROUND AND OBJECTIVES: Indications of simultaneous bilateral radical neck dissection remains controversial. The main objectives of this analysis were to study: a) the frequency of postoperative complications, b) the patterns of metastatic lymph nodes in the surgical specimen, c) the predictive factors of neck recurrences, d) the prognostic factors related to overall survival. METHODS: A retrospective review of results in 193 consecutive patients submitted to a simultaneous bilateral radical neck dissection from 1960-1990. RESULTS: Postoperative complications occurred in 60.8% of the cases. The most frequent ones were: fistula, wound infection, flap dehiscence and necrosis. There were four postoperative deaths (2.7%). The lymph nodes most frequently involved were of the upper jugular and upper accessory groups. Only patients with lip and paranasal sinus tumors never presented metastatic nodes at Levels IV and V. Tumor recurrences were more common at the ipsilateral neck (13.5%) or at distant sites (12.4%). The predictive factors of neck recurrences were: age, N stage, ipsilateral metastasis at Level II, and contralateral metastasis at Levels II and IV. The overall 5-year survival rates for the two age groups, that is, younger than 40 and older than 40 years of age, were respectively, of 8.5% and 35.6% (P = 0.0296). There were no survivals among the group of patients with neck lymph nodes staged as N3 or Nx. The overall 5-year survival rates were significantly influenced by contralateral metastatic lymph nodes at any level. The results of multivariate analysis using the Cox regression technique, showed that Level II ipsilateral metastatic lymph nodes, Levels II and IV contralateral metastatic lymph nodes, and age were the independent predictors of the risk of death. CONCLUSIONS: This study demonstrates that simultaneous bilateral neck dissection has a high morbidity and should be contraindicated as an elective procedure. Further studies with selective neck dissections are warranted.     

颈清扫术在声门上型喉癌治疗中的作用

目的 探讨颈清扫术在声门上型喉癌治疗中的作用.方法 总结448例声门上型喉癌患者的临床治疗及生存情况,其中T12例,T2175例,T3 140例,T4 131例.N+173例,占声门上型喉癌的38.6％.采用喉部分切除术173例,喉全切除术275例.同期颈清扫术396例(88.4％)(单侧168例,双侧228例).223例N0病例行改良全颈清扫术,173例N+病例行经典全颈清扫术,52例N0患者未行颈清扫术.结果 直接法统计其3年生存率为75.2％(337/448),5年生存率为52.2％(234/448).N0患者3年生存率为78.9％ (217/275),5年生存率为69.8％(192/275).N+患者3年生存率为69.4％ (120/173),5年生存率为24.3％(42/173),二者比较差异均有统计学意义(P＜0.05,P＜0.01).Ⅰ、Ⅱ期123例,Ⅲ、Ⅳ期325例,5年生存率分别为76.4％ (94/123)及43.1％(140/325),二者差异有统计学意义(P＜0.01).在颈部转移二次住院手术的44例中,其5年生存率仅为34.1％(15/44).结论 喉癌早期病例疗效明显好于晚期病例.声门上型喉癌N0时同期行必要的择区性颈清扫术是提高疗效的重要措施.     

Surgical management of the neck in squamous cell carcinoma of the floor of the mouth

Nodal involvement in squamous cell carcinoma considerably lowers survival rate. Despite its importance, neck management has still not been adequately explored. The Authors have retrospectively reviewed the records of 112 cases. Unilateral N+ were treated with a homolateral therapeutic and a controlateral prophylactic neck dissection; bilateral N+ were treated with a bilateral therapeutic neck dissection. On first observation the majority of cases (66.1%) were T1–2. N+ patients accounted for 45.5%. Among N− patients, 21.3% of occult nodal metastases were observed. The 5-year survival rate was 52.7%. With N+ lesions, a radical neck dissection should be performed; the dissection should be performed bilaterally. With N− lesions a prophylactic modified radical neck dissection is recommended in T2–4 lesions.     

Squamous cell carcinoma of the head and neck treated with radiation therapy: the role of neck dissection for clinically positive neck nodes

This is an analysis of 161 patients with squamous cell carcinoma of the head and neck treated with irradiation to the primary site and neck followed by a neck dissection(s) for clinically positive neck nodes. Patients were treated between October 1964 and December 1982; there was a minimum 2-year follow-up. Fifty-two patients were deleted from analysis of neck disease control because they died of intercurrent disease or cancer less than 2 years from treatment with the neck continuously disease-free. All patients are included in the analysis of complications. Neck disease control rate was the same for radiation plus neck dissection or radiation therapy alone for solitary nodes less than 3 cm. As the size and number of nodes increased, there was a higher rate of neck disease control for combined treatment as compared with irradiation alone. The neck disease control rate, size for size, was lower for patients with fixed nodes and for those with residual tumor in the pathologic specimen. There was no difference in neck disease control as a function of the interval between irradiation and neck dissection. For nodes less than or equal to 6 cm, a minimum node dose of 5000 rad appeared to be sufficient for control, whereas for nodes greater than 6 cm, at least 6000 rad appeared to be required for optimal control. Fixed nodes required a higher dose compared to mobile masses. The incidence of postoperative complications was increased with maximum subcutaneous doses of greater than or equal to 6000 rad. There was also an increased incidence of postoperative complications for patients undergoing simultaneous, as compared with staged, bilateral neck dissection.     

Head and neck cancers--significance of salvage operation

The crude and determinate 5 year survivals out of 264 cases were 28.4% and 34.6% respectively. There were 136 cases in which the recurrence located at the primary site only. Whereas surgery performed on 81 cases resulted in the determinal survival rate of 58.0%, radiation therapy for 42 cases could attained only 19.5% survival. Cryotherapy were performed on 4 localized recurrent lesions and all but one which died of other cause are living well for more than 5 years. In 58 cases, the recurrence appeared only in neck nodes. Determinate 5 year survival rate of 64.7% could be obtained out of 40 cases treated by radical neck dissection. Only 7.1% of cases treated otherwise survived more than 5 years. Results of treatment were poor in the 39 cases in which both the primary and neck nodes were involved by recurrences. Only one case survived more than 5 years which had undergone composite operation. Introduction of composite operation simultaneously combined with reconstruction extended the indication of radical therapy. Seventy-eight cases which would have been the candidate for palliative treatment underwent this type of surgery, and 41.0% of them survived more than 5 years. It is noteworthy that radical treatment is still reserved for many recurrent cases of head and neck carcinoma. And salvage operation, if indicated, promises the best results among various methods of treatment.     

Simultaneous bilateral neck dissection

The presence of bilateral cervical nodal metastases secondary to intraoral, laryngeal and hypopharyngeal carcinoma was once thought to make the condition inoperable and “incurable”. It was also stated that the mortality from bilateral neck dissection would most likely exceed the number of patients cured by this procedure. We have a number of patients who had and tolerated it well, with a few surviving even for three and five years. We wish to report the morbidity, mortality and cure rate with simultaneous bilateral neck dissection in patients who had this procedure. From January 1960 to December 1975, 61 simultaneous bilateral neck dissections were performed as a part of oral, laryngeal or hypopharyngeal resections. Fifty-three patients had a classical bilateral radical neck dissection while in six patients one of the internal jugular veins and in two patients both of these veins were preserved. Six out of 61 (9%) patients had received radiation therapy previously. Nodal clearance was done in all the patients. Six out of 61 (8%) patients died within one month, three of whom never regained consciousness and died within 48 hours of the procedure. Sixty-three percent (39/55) of patients developed immediate postoperative facial swelling and wound infection. Thirty-six percent (22/55) had orocutaneous fistulae; of these, 11% (7/55) had carotid artery blowouts. Sixteen percent (10/55) of patients had significant pulmonary complication. The percentage of patients who were free of disease at 6 months, 1 year, 1 1/2 years, 3 years, and 5 years following the procedure was 54% (26/48), 37% (18/48), 29% (14/48), 20% (10/48) and 12.5% (6/48), respectively. It appears from the present study that although bilateral neck dissection has a high postoperative morbidity and mortality rate, it can effectively control the disease in a significant number of patients with a 20% three-year and 12.5% five-year cure rate.     

改良根治性颈清在甲状腺癌中的应用

在甲状腺癌的治疗中,改良根治性颈清术比传统根治性颈清术能保瘤较多的功能,又不影响肿瘤的根治,它适用于甲状腺髓样癌,分化性甲状腺癌及部分甲状腺微小癌, 而对未分化癌是否有必要尚有争议。     

腔镜辅助下行分化型甲状腺癌功能性颈淋巴结清扫术（附7例）

目的：研究腔镜辅助下行分化型甲状腺癌颈淋巴结清扫术的可行性,探索手术治疗分化型甲状腺癌的新方法。方法：为7名分化型甲状腺癌患者行腔镜辅助下功能性颈淋巴结清扫术,其中4例为甲状腺癌联合根治术。就手术的清扫范围、手术时长、术中失血量、术后病理结果、并发症、患者满意度等多方面进行分析。结果：全部病例手术顺利,清扫范围可以达到传统开放式手术范围。整体手术时长平均214分钟,平均失血量约137ml。病理显示颈部各区清扫组织均可见数目不等的淋巴结,并有部分癌转移。伤口愈合良好,无并发症,患者满意度100%。结论：在腔镜辅助下行颈淋巴结清扫术是安全可行的,较完全腔镜式和传统开放式手术,在美容、微创、疗效三方面互有补裨,相得益彰。该技术可用于分化型甲状腺癌的手术治疗。