上纵隔暴露术在颈部晚期癌手术中的应用

目的 研究累及颈根部和上纵隔区域的颈部晚期肿瘤根治性手术的方法。方法 1992～1999年对18例颈部晚期癌行不同方式的上纵隔暴露术和肿瘤根治性切除术。其中晚期气管造口复发癌10例，晚期复发甲状腺癌2例，晚期颈段气管癌2例，锁骨上巨大转移癌4例。根据肿瘤的部位和侵及范围行单纯胸骨柄切除10例，切除一侧胸锁关节和锁骨内侧1／2者4例，切除胸骨柄和双侧锁骨内侧1／3者4例。其中1例锁骨上窝肿瘤因其侵犯左侧锁骨下动脉而实行了锁骨下动脉部分节段性切除加肿瘤全切除和人工血管锁骨下动脉重建术。对10例气管造口复发癌在肿瘤切除后以胸大肌肌皮瓣修复局部大块组织缺损，覆盖并保护下颈部和上纵隔大血管。结果 通过上纵隔暴露与清扫术，16例患者的肿瘤得以完整切除。2例因肿瘤在上纵隔内过度向后下延伸而行大部分切除术，其中1例在分离肿瘤时术中发生气胸。术后2例发生咽瘘，其中1例因伤口感染发生右侧颈总动脉假性动脉瘤，均经及时处理后治愈。1例于术后2个月发生无名动脉出血死亡。术后1年、2年和3年生存率分别为72．2％(13／18)、22．2％(4／18)和11．1％(2／18)。结论 上纵隔暴露术对切除累及上纵隔的颈部晚期癌是一种必要、安全和可靠的手术路径。

Superior mediastinum exposure in the removal of the advanced cancers in the lower neck regions]

OBJECTIVE: In order to achieve the radical removal of advanced cancers involving the lower neck regions. METHODS: Upon the thorough evaluation of tumors with different imaging methods, several kinds of superior mediastinum exposure were carried out in a series of 18 patients with advanced neck cancer of various kinds. There were 10 cases of stomal recurrence, 2 cases of recurrent thyroid carcinomas, 2 cases of advanced carcinomas in the cervical trachea, and 4 cases of metastatic carcinomas in the supraclavicular region. According to the site and extension of tumor invasion, simple manubrium resection were performed in 10 cases, resection of the medial half of the clavicle was adopted in 4 cases and resection of the manubrium and the medial 1/3 of both clavicles were used in 4 cases. Pectoralis major myocutaneous flaps were raised to reconstruct the defects resulting from tumor ablations. RESULTS: Radical removal of tumors was achieved in 16 cases. Minor complications occurred in 3 cases including one case of intraoperative pneumothorax and 2 cases of postoperative pharyngeal fistula. One patient developed aneurysm in the right common carotid artery after radical neck dissection and wound infection. One patient died of eruption of the innominate artery due to the major vessel injury caused by the tracheostomy tube two months after the operation. Results from postoperative follow-up demonstrated that one-year, two-year and three-year postoperative survival rate was 72.2% (13/18), 22.2% (4/18) and 11.1% (2/18), respectively, in this series. CONCLUSION: Superior mediastinum exposure is a necessary and reliable surgical approach in the removal of advanced tumors involving the lower neck and superior mediastinum.