支气管袖状肺叶切除术治疗中央型肺癌的临床研究
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摘要
目的：探讨支气管袖状肺叶切除术的技术特点及临床运用价值。
方法：对江西省肿瘤医院胸外科自1991年11月至2004年12月期间,经支气管袖状肺叶切除术治疗的中央型肺癌病例共129例进行回顾性分析。其中,41例行右上支气管袖状肺叶切除术；5例肿块累及了右肺动脉干,行右上支气管肺动脉双袖状切除术；3例上腔静脉受侵犯,行右上支气管袖状肺叶切除+上腔静脉侧切成形术；1例侵犯了食管,行右上支气管袖状肺叶切除+食管肌层部分切除术；6例行右下支气管袖状肺叶切除术；11例行右中间支气管袖状肺叶切除术；7例肿瘤累及了隆突,行右上支气管袖状肺叶切除+隆突重建成形术；36例行左上支气管袖状肺叶切除术；1例侵犯了左心房,行左上支气管袖状肺叶切除+左心房部分切除术；3例肿瘤累及了隆突,行左上支气管袖状肺叶切除+隆突重建成形术；15例行左下支气管袖状肺叶切除术。术后化疗77例,放疗19例。
结果：本组无手术死亡病例,术中心跳骤停1例,经胸内心脏按压,静脉注射肾上腺素及阿托品等抢救后复苏。术后发生肺不张6例,心律失常4例,吻合口瘘1例,支气管胸膜瘘1例,肺部感染2例。经积极残对症治疗,均痊愈出院。术后病理诊断：鳞癌85例,腺癌19例,小细胞癌9例,大细胞癌2例,混合性癌9例,肺泡细胞癌2例,其它类型癌3例,支气管切缘阳性12例。病理分期(采用UICC2009年TNM分期标准)：Ⅱ期30例,Ⅱ期20例,Ⅲa期71例,Ⅲb期8例。术后随访103例,随访率79.8%。生存期限最长达216个月,最短4个月,中位生存期38.4个月。1年、3年和5年生存率分别为89.7%、56.6%和37.9%。
结论：(1)支气管袖状肺叶切除术治疗中心型肺癌能最大限度地保留正常肺组织,保护肺功能,提高了中央型肺癌的治愈率以及术后生活质量。(2)支气管袖状肺叶切除术使一些肿瘤侵及主支气管、隆凸、支气管开口、肺动脉的中心型肺癌且肺功能较差的病人有了手术的可能、扩大了手术指征、拓展了手术治疗范围。(3)降低了全肺切除率。(4)术后并发症发生率在可接受范围内。因此,支气管袖状肺叶切除术是治疗中央型肺癌安全有效的术式。
Objective:Research into the bronchial sleeve lobectomy's(BSL) technical characteristics and the clinical value.
Methods:Analyzing retrospectively 129 central lung cases underwent bronchial sleeve lobectomy(BSL) treament, during the period from November 1991 to December 2004 in Thoracic Surgery, Jiangxi Province Tumour Hospital. Among them, there were 41 cases underwent upper-right bronchial sleeve lobectomy(BSL);5 cases underwent upper pulmonary artery and upper-right bronchial sleeve lobectomy(BSL); 3 cases underwent superior vena cava sidecut plasty and upper-right bronchial sleeve lobectomy (BSL); 1 cases underwent partial mastectomy oesophagus musclar layer and upper-right bronchial sleeve lobectomy(BSL); 6 cases underwent inferior-right bronchial sleeve lobectomy(BSL); 11 cases underwent midst -right bronchial sleeve lobectomy(BSL); 7 cases underwent carina reconstruction plasty and upper-right bronchial sleeve lobectomy(BSL); 36 cases underwent upper-left bronchial sleeve lobectomy(BSL); 1 cases underwent left atrium sidecut and upper-left bronchial sleeve lobectomy(BSL); 7 cases underwent carina reconstruction plasty and upper-left bronchial sleeve lobectomy(BSL); 15 cases underwent inferior-right bronchial sleeve lobectomy(BSL). Postoperative chemotherapy 77 cases, postoperative radiotherapy 19 cases.
Results:In the operations there was no case of death,1 case of intraoperative cardiac,which get recovered after emergency rescues by intrathoracic cardiac massage an intravenous adrenaline and atropine,6 cases of atelectasis,4 cases of arrhythmia, 1 case of anastomotic fistula,2 cases of pulmonary infection. After active treament, all patients got recovery and left hospital. Their postoperative pathologic diagnoses were lung cancer, including squamous cell carcinoma 85 cases;adenocarcinoma 19 cases;small cell carcinoma 9 cases;large cell carcinoma 2 cases; mixed carcinoma 9 cases, alveolar cell carcinoma 2 cases, other cancer types 3 cases. Pathologic stage (take UICC2009 years TNM staging as standard):stageⅠ,30 cases;stageⅡ20 cases; stageⅢa,75 cases; stageⅢb,8 cases; 12 cases of bronchial the cut edge positive. Among the 103 survivals investigated postoperatively, the longest survival time is 216 months, the shortest 4 months,median survival time 38.4 months and the survial rate of 1 year、3 years and 5 years were respectively 90.2%、59.2% and 36.9%.
Conclusion:(1)The treatment of bronchus sleeve(BSL) resection in central central lung cancer cases can mostly save normal lung organization, protect its function and increase the cure rate as well as improve lifte quality. And it may be desirable implement operation for the sort of weak pulmonary function patients.It also expand the operation indicatio and the range of operation treament. (2) Bronchial sleeve lobectomy(BSL) treatment provides chances of operation for patients with tumor invaded into main bronchus, carina,bronchus aperture, pulmonary artery,et.al central lung cancer and patients with weak lung function. Reduce the ablation rate of pnenmonectomy. (3)It's postoperative cardiovascular complications, operative mortality and recurernce rate less than pnenmonectomy. But,5-year survival have an advantage over pnenmonectomy.So the treatment of bronchial sleeve resection is safe for central lung cancer, and it's the best choice for clinic. (4)Early detection,early diagnosis and early treatment remain the best therapy of central lung cancer to improve the curtive effect.
方法：对江西省肿瘤医院胸外科自1991年11月至2004年12月期间,经支气管袖状肺叶切除术治疗的中央型肺癌病例共129例进行回顾性分析。其中,41例行右上支气管袖状肺叶切除术；5例肿块累及了右肺动脉干,行右上支气管肺动脉双袖状切除术；3例上腔静脉受侵犯,行右上支气管袖状肺叶切除+上腔静脉侧切成形术；1例侵犯了食管,行右上支气管袖状肺叶切除+食管肌层部分切除术；6例行右下支气管袖状肺叶切除术；11例行右中间支气管袖状肺叶切除术；7例肿瘤累及了隆突,行右上支气管袖状肺叶切除+隆突重建成形术；36例行左上支气管袖状肺叶切除术；1例侵犯了左心房,行左上支气管袖状肺叶切除+左心房部分切除术；3例肿瘤累及了隆突,行左上支气管袖状肺叶切除+隆突重建成形术；15例行左下支气管袖状肺叶切除术。术后化疗77例,放疗19例。
结果：本组无手术死亡病例,术中心跳骤停1例,经胸内心脏按压,静脉注射肾上腺素及阿托品等抢救后复苏。术后发生肺不张6例,心律失常4例,吻合口瘘1例,支气管胸膜瘘1例,肺部感染2例。经积极残对症治疗,均痊愈出院。术后病理诊断：鳞癌85例,腺癌19例,小细胞癌9例,大细胞癌2例,混合性癌9例,肺泡细胞癌2例,其它类型癌3例,支气管切缘阳性12例。病理分期(采用UICC2009年TNM分期标准)：Ⅱ期30例,Ⅱ期20例,Ⅲa期71例,Ⅲb期8例。术后随访103例,随访率79.8%。生存期限最长达216个月,最短4个月,中位生存期38.4个月。1年、3年和5年生存率分别为89.7%、56.6%和37.9%。
结论：(1)支气管袖状肺叶切除术治疗中心型肺癌能最大限度地保留正常肺组织,保护肺功能,提高了中央型肺癌的治愈率以及术后生活质量。(2)支气管袖状肺叶切除术使一些肿瘤侵及主支气管、隆凸、支气管开口、肺动脉的中心型肺癌且肺功能较差的病人有了手术的可能、扩大了手术指征、拓展了手术治疗范围。(3)降低了全肺切除率。(4)术后并发症发生率在可接受范围内。因此,支气管袖状肺叶切除术是治疗中央型肺癌安全有效的术式。
Objective:Research into the bronchial sleeve lobectomy's(BSL) technical characteristics and the clinical value.
Methods:Analyzing retrospectively 129 central lung cases underwent bronchial sleeve lobectomy(BSL) treament, during the period from November 1991 to December 2004 in Thoracic Surgery, Jiangxi Province Tumour Hospital. Among them, there were 41 cases underwent upper-right bronchial sleeve lobectomy(BSL);5 cases underwent upper pulmonary artery and upper-right bronchial sleeve lobectomy(BSL); 3 cases underwent superior vena cava sidecut plasty and upper-right bronchial sleeve lobectomy (BSL); 1 cases underwent partial mastectomy oesophagus musclar layer and upper-right bronchial sleeve lobectomy(BSL); 6 cases underwent inferior-right bronchial sleeve lobectomy(BSL); 11 cases underwent midst -right bronchial sleeve lobectomy(BSL); 7 cases underwent carina reconstruction plasty and upper-right bronchial sleeve lobectomy(BSL); 36 cases underwent upper-left bronchial sleeve lobectomy(BSL); 1 cases underwent left atrium sidecut and upper-left bronchial sleeve lobectomy(BSL); 7 cases underwent carina reconstruction plasty and upper-left bronchial sleeve lobectomy(BSL); 15 cases underwent inferior-right bronchial sleeve lobectomy(BSL). Postoperative chemotherapy 77 cases, postoperative radiotherapy 19 cases.
Results:In the operations there was no case of death,1 case of intraoperative cardiac,which get recovered after emergency rescues by intrathoracic cardiac massage an intravenous adrenaline and atropine,6 cases of atelectasis,4 cases of arrhythmia, 1 case of anastomotic fistula,2 cases of pulmonary infection. After active treament, all patients got recovery and left hospital. Their postoperative pathologic diagnoses were lung cancer, including squamous cell carcinoma 85 cases;adenocarcinoma 19 cases;small cell carcinoma 9 cases;large cell carcinoma 2 cases; mixed carcinoma 9 cases, alveolar cell carcinoma 2 cases, other cancer types 3 cases. Pathologic stage (take UICC2009 years TNM staging as standard):stageⅠ,30 cases;stageⅡ20 cases; stageⅢa,75 cases; stageⅢb,8 cases; 12 cases of bronchial the cut edge positive. Among the 103 survivals investigated postoperatively, the longest survival time is 216 months, the shortest 4 months,median survival time 38.4 months and the survial rate of 1 year、3 years and 5 years were respectively 90.2%、59.2% and 36.9%.
Conclusion:(1)The treatment of bronchus sleeve(BSL) resection in central central lung cancer cases can mostly save normal lung organization, protect its function and increase the cure rate as well as improve lifte quality. And it may be desirable implement operation for the sort of weak pulmonary function patients.It also expand the operation indicatio and the range of operation treament. (2) Bronchial sleeve lobectomy(BSL) treatment provides chances of operation for patients with tumor invaded into main bronchus, carina,bronchus aperture, pulmonary artery,et.al central lung cancer and patients with weak lung function. Reduce the ablation rate of pnenmonectomy. (3)It's postoperative cardiovascular complications, operative mortality and recurernce rate less than pnenmonectomy. But,5-year survival have an advantage over pnenmonectomy.So the treatment of bronchial sleeve resection is safe for central lung cancer, and it's the best choice for clinic. (4)Early detection,early diagnosis and early treatment remain the best therapy of central lung cancer to improve the curtive effect.
引文
[1]Parking, D.M., F. Bray, and J. Ferlay, Globe career statistics,2002. [J]CA Cancer J Clin, 2005.55:p.74-108.
[2]Price, T., Conserving reserving resection of the bronchial tree [J]JR coll Surg Edinb,1956. 1. p.169.
[3]Pearson, F.G., Thoracic surgery. [C]2nd ed. ed.2002, New York; Edinburgh:Churchill Livingstone, xxv,1942 p.
[4]Tedder, M., et al., Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. [J]Ann Thorac Surg,1992.54(2):p.387-91.
[5]王长利,et al.,肺癌袖状切除术与全肺切除术疗效比较分析.[J]中国肺癌杂志,2006.9(1).
[6]Xie, M.R., et al., [Safety and long-term outcome of sleeve lobectomy for non-small cell lung cancer]. [J]Ai Zheng,2009.28(8):p.868-71.
[7]Detterbeck, F.C., et al., Diagnosis and treament of lung cancer. [D]Philadelphia:W.B. Saunders Company,2001:p.134.
[8]Ibrahim M, et al., Bronchial and pulmonary arterial Sleeve resection [J]Muhimedia Mannual of Cardiovascular Surgery,2005.67:17.
[9]吴一龙,肺癌手术规范的儿个问题.J中国癌症杂志,2003.13(5)：p.416-22.
[10]茅乃权,et al.,袖状肺叶切除术后肺通气功能的研究.[J]广西医学,2004.26(5).
[11]End, A., et al., Bronchoplastic procedures in malignant and nonmalignant disease: multivariable analysis of 144 cases. [J]J Thorac Cardiovasc Surg,2000.120(1):p.119-27.
[12]Okada, M., et al., Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. [J]J Thorac Cardiovasc Surg,2000.119(4 Pt 1): p.814-9.
[13]Gezer, S., et al., Sleeve resections for squamous cell carcinoma of the lung. [J]Heart Lung Circ,2010.19(9):p.549-54.
[14]Schirren, J., et al., Prospective study on perioperative risks and functional results in bronchial and bronchovascular sleeve resections. [J]Thorac Cardiovasc Surg,2009.57(1):p. 35-41.
[15]Martin-Ucar, A.E., et al., Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery. [J]Eur J Cardiothorac Surg,2002.21(4):p. 601-5.
[16]Gomez-Caro, A., et al., Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients:an audit of an aggressive policy of pneumonectomy avoidance. [J]Eur J Cardiothorac Surg,2011.39(3):p. 352-9.
[17]Barnett,S.,et a1.,Long-term survival of 42 patients with resected N2 non-small-cell lung cancer: the impact of 2-(18)F-fluoro-2-deoxy-D-glucose positron emission tomogram mediastinal staging.[J]Eur J Cardiothorac Surg,2011.39(1):p.96-101.
[18]张晓明,et al.,肺叶袖状切除术治疗中心型肺癌的体会.[J]中国现代医学杂志,2009.08.vol.19 No.15：p.2394-2395.
[19]黄邵洪,肺癌肺叶袖状切除术的安全性和有效性.[J]中国肿瘤临床,2005.32(5).
[20]刘岩,气管及支气管成形术中两种缝合方法的比较.[J]广东医学,2007.28(2).
[21]石远凯,肺癌诊断治疗学.[M]人民卫生出版社,2008:p.204.
[22]Jan,w.,et al.,Residual disease at the bronchial stump after curative resection for lung career[J]Eur J Cardiothorac Surg,2007.32:p.29.
[23]张克,肺叶袖状切除、肺动脉成形术治疗支气管肺癌疗效观察.[J]中国误诊学杂志,2005.5(6).
[24]Deslauriers,J.,et a1.,Sleeve lobectomy versus pneumonectomy for lung cancer:a comparative analysis of Survival and sites or recurrences.[J]Ann Thorac Surg,2004.77(4): p.1152-6；discussion 1156.
[1]Parking, D.M., F. Bray, and J. Ferlay, Globe carcer statistics,2002. [J]CA Cancer J Clin,2005. 55:p.74-108.
[2]Price, T., Conserving reserving resection of the bronchial tree [J]J R coll Surg Edinb,1956.1: p.169.
[3]Pearson, F.G., Thoracic surgery. [C]2nd ed. ed.2002, New York; Edinburgh:Churchill Livingstone, ⅹⅹⅴ,1942 p.
[4]Tedder, M., et al., Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. [J]Ann Thorac Surg,1992.54(2):p.387-91.
[5]王长利,et al.,肺癌袖状切除术与全肺切除术疗效比较分析.[J]中国肺癌杂志,2006.9(1).
[6]Xie, M.R., et al., [Safety and long-term outcome of sleeve lobectomy for non-small cell lung cancer]. [J]Ai Zheng,2009.28(8):p.868-71.
[7]Detterbeck, F.C., et al., Diagnosis and treament of lung cancer. [D]Philadelphia: W.B.Saunders Company,2001:p.134.
[8]Ibrahim M, et al., Bronchial and pulmonary arterial S2eeve resection Muhimedia Mannual of Cardiovascular [J]Surgery,2005.67:17.
[9]吴一龙,肺癌手术规范的儿个问题.[J]中国癌症杂志,2003.13(5)：p.416-22.
[10]茅乃权,et al.,袖状肺叶切除术后肺通气功能的研究.[J]广西医学,2004.26(5).
[11]End, A., et al., Bronchoplastic procedures in malignant and nonmalignant disease: multivariable analysis of 144 cases. [J]J Thorac Cardiovasc Surg,2000.120(1):p.119-27.
[12]Okada, M., et al., Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. [J]J Thorac Cardiovasc Surg,2000.119(4 Pt 1): p.814-9.
[13]Gezer, S., et al., Sleeve resections for squamous cell carcinoma of the lung. [J]Heart Lung Circ,2010.19(9):p.549-54.
[14]Schirren, J., et al., Prospective study on perioperative risks and functional results in bronchial and bronchovascular sleeve resections. [J]Thorac Cardiovasc Surg,2009.57(1):p.35-41.
[15]Martin-Ucar, A.E., et al., Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery. Eur J Cardiothorac Surg,2002.21(4):p. 601-5.
[16]Gomez-Caro, A., et al., Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients:an audit of an aggressive policy of pneumonectomy avoidance. [J]Eur J Cardiothorac Surg,2011.39(3):p. 352-9.
[17]Barnett, S., et al., Long-term survival of 42 patients with resected N2 non-small-cell lung cancer:the impact of 2-(18)F-fluoro-2-deoxy-D-glucose positron emission tomogram mediastinal staging. [J]Eur J Cardiothorac Surg,2011.39(1):p.96-101.
[18]张晓明,et al.,肺叶袖状切除术治疗中心型肺癌的体会.中国现代医学杂志,2009.08.vol.19 No.15：p.2394-2395.
[19]黄邵洪,肺癌肺叶袖状切除术的安全性和有效性.[J]中国肿瘤临床,2005.32(5).
[20]刘岩,气管及支气管成形术中两种缝合方法的比较.[J]广东医学,2007.28(2).
[21]石远凯,肺癌诊断治疗学.[M]人民卫生出版社,2008：p.204.
[22]Jan, W., et al., Residual disease at the bronchial stump after curative resection for lung career [J]Eur J Cardiothorac Surg,2007.32:p.29.
[23]张克,肺叶袖状切除、肺动脉成形术治疗支气管肺癌疗效观察.[J]中国误诊学杂志,2005.5(6).
[24]Deslauriers, J., et al., Sleeve lobectomy versus pneumonectomy for lung cancer:a comparative analysis of survival and sites or recurrences. [J]Ann Thorac Surg,2004.77(4):p. 1152-6; discussion 1156.
[25]Mouroux, J., et al., [Thoracic surgery:the major surgical procedures]. [J]J Radiol,2009. 90(7-8 Pt 2):p.980-90.
[26]Mehran, R.J., et al., Survival related to nodal status after sleeve resection for lung cancer. [J]J Thorac Cardiovasc Surg,1994.107(2):p.576-82; discussion 582-3.
[27]Okada, M., et al., Operative approach for multiple primary lung carcinomas. [J]J Thorac Cardiovasc Surg,1998.115(4):p.836-40.
[2]Price, T., Conserving reserving resection of the bronchial tree [J]JR coll Surg Edinb,1956. 1. p.169.
[3]Pearson, F.G., Thoracic surgery. [C]2nd ed. ed.2002, New York; Edinburgh:Churchill Livingstone, xxv,1942 p.
[4]Tedder, M., et al., Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. [J]Ann Thorac Surg,1992.54(2):p.387-91.
[5]王长利,et al.,肺癌袖状切除术与全肺切除术疗效比较分析.[J]中国肺癌杂志,2006.9(1).
[6]Xie, M.R., et al., [Safety and long-term outcome of sleeve lobectomy for non-small cell lung cancer]. [J]Ai Zheng,2009.28(8):p.868-71.
[7]Detterbeck, F.C., et al., Diagnosis and treament of lung cancer. [D]Philadelphia:W.B. Saunders Company,2001:p.134.
[8]Ibrahim M, et al., Bronchial and pulmonary arterial Sleeve resection [J]Muhimedia Mannual of Cardiovascular Surgery,2005.67:17.
[9]吴一龙,肺癌手术规范的儿个问题.J中国癌症杂志,2003.13(5)：p.416-22.
[10]茅乃权,et al.,袖状肺叶切除术后肺通气功能的研究.[J]广西医学,2004.26(5).
[11]End, A., et al., Bronchoplastic procedures in malignant and nonmalignant disease: multivariable analysis of 144 cases. [J]J Thorac Cardiovasc Surg,2000.120(1):p.119-27.
[12]Okada, M., et al., Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. [J]J Thorac Cardiovasc Surg,2000.119(4 Pt 1): p.814-9.
[13]Gezer, S., et al., Sleeve resections for squamous cell carcinoma of the lung. [J]Heart Lung Circ,2010.19(9):p.549-54.
[14]Schirren, J., et al., Prospective study on perioperative risks and functional results in bronchial and bronchovascular sleeve resections. [J]Thorac Cardiovasc Surg,2009.57(1):p. 35-41.
[15]Martin-Ucar, A.E., et al., Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery. [J]Eur J Cardiothorac Surg,2002.21(4):p. 601-5.
[16]Gomez-Caro, A., et al., Determining the appropriate sleeve lobectomy versus pneumonectomy ratio in central non-small cell lung cancer patients:an audit of an aggressive policy of pneumonectomy avoidance. [J]Eur J Cardiothorac Surg,2011.39(3):p. 352-9.
[17]Barnett,S.,et a1.,Long-term survival of 42 patients with resected N2 non-small-cell lung cancer: the impact of 2-(18)F-fluoro-2-deoxy-D-glucose positron emission tomogram mediastinal staging.[J]Eur J Cardiothorac Surg,2011.39(1):p.96-101.
[18]张晓明,et al.,肺叶袖状切除术治疗中心型肺癌的体会.[J]中国现代医学杂志,2009.08.vol.19 No.15：p.2394-2395.
[19]黄邵洪,肺癌肺叶袖状切除术的安全性和有效性.[J]中国肿瘤临床,2005.32(5).
[20]刘岩,气管及支气管成形术中两种缝合方法的比较.[J]广东医学,2007.28(2).
[21]石远凯,肺癌诊断治疗学.[M]人民卫生出版社,2008:p.204.
[22]Jan,w.,et al.,Residual disease at the bronchial stump after curative resection for lung career[J]Eur J Cardiothorac Surg,2007.32:p.29.
[23]张克,肺叶袖状切除、肺动脉成形术治疗支气管肺癌疗效观察.[J]中国误诊学杂志,2005.5(6).
[24]Deslauriers,J.,et a1.,Sleeve lobectomy versus pneumonectomy for lung cancer:a comparative analysis of Survival and sites or recurrences.[J]Ann Thorac Surg,2004.77(4): p.1152-6；discussion 1156.
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