获得性自身免疫性重症肌无力的外科治疗进展（附三篇病例报告）
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摘要
目的 评价胸骨肿瘤扩大切除加自体髂骨植骨胸骨成形术的手术效果；方法8例胸骨肿瘤的病人均行胸骨肿瘤扩大切除，并同期行自体髂骨植骨胸骨成形术；结果8例病人中除1例切口有少量渗液外，其他均无并发症；术后随访半年以上，恢复良好，呼吸功能正常。讨论 胸骨肿瘤扩大切除加自体髂骨植骨胸骨成形术能够有效的防止术后胸壁软化，重建胸壁的稳定性。
Objective To evaluate the method of expanded sternal excision with self-iliac bone grafting to reconstruct the sternum; Method Eight patients with sternal tumor underwent expanded sternal excision, and had reconstruction of the sternum with self-iliac bone in one stage; Result No further complications were found postoperatively, except for one patient who had little exudation in the incision. All patients followed up for more than half year recovered well and had normal respiratory function; Discussion Expanded sternal excision with self-iliac bone grafting was effective in preventing chest intenerating postoperatively and restoring the stability of
thorax.
Objective To evaluate the method of expanded sternal excision with self-iliac bone grafting to reconstruct the sternum; Method Eight patients with sternal tumor underwent expanded sternal excision, and had reconstruction of the sternum with self-iliac bone in one stage; Result No further complications were found postoperatively, except for one patient who had little exudation in the incision. All patients followed up for more than half year recovered well and had normal respiratory function; Discussion Expanded sternal excision with self-iliac bone grafting was effective in preventing chest intenerating postoperatively and restoring the stability of
thorax.
引文
1． Cooper JD, et al. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg. 1988; 45: 242
2． Blalock A, et al. Myasthenia gravis and tumors of the thymus: Report of a case in which tumor was removed. Ann Surg. 1939; 110: 554
3． Kirchner T, Schalke B, et al. Immounol histological patterns of non-neoplastic changes in the thymusin myasthenia gravis. Virchows Archiv B. 1986; 52: 237-257
4． Blalock A: Thymectomy in the treatment of myasthenia gravis: Report of twenty cases. J Thorac Surg. 1944; 13:316
5． Levinson AZ, Zweiman B, et al. Pokeweed mitogen-induced immunoglobulin secretory responses to thymic B cells in myasthenia gravis: selective secretion of IgG vs IgM cannot be explained by helper functions of thymic T cells. Clin Immunol Immunopathol. 1990; 57: myasthenia gravis 211-217
6． Spuler S, Marx A, Et al. Myogenesis in thymic transplants in the severe combined immunodeficient mouse model of myasthenia gravis. Ann J Pathol. 1994; 145:766-770
7． 蒋光亮，赵雍凡．胸腺切除治疗重症肌无力31例报告．中国胸心血管外科杂志．1996; 3(4) : 199-200
8． Anglo E Paletto, et al. Thymectomy in the treatment of myasthenia gravis: Results in 320 patients. Int Surg. 1982; 67: 13
9． Jaretzki A, et al. "Maximal" thymectomy for myasthenia gravis: results. J Thorac Cardiovasc Surg. 1988; 95: 747
10． Masaoka A, Yamakawa Y, et al. Extended thymectomy for myasthenia gravis patients: a 20-year review. Ann Thorac Surg. 1996; 62: 852-859
11． Dalakas MC, et al. Identification of human thymic epithelial cells with antibodies to thymusin alpha 1 in myasthenia gravis. Ann-N-Y-Acad-Sci. 1981; 31(4) : 377477-377485
12． Muldder DG, et al. Thymectomy for myasthenia gravis: recent observations and comparisons with past experience. Ann Thorac Surg. 1989; 48: 551
13． Miller JI, et al. Median T sternotomy incision for thymectomy for myasthenia gravis. Ann Thorac Surg. 1981; 34: 473
14． Heiser JC, et al. Thymectomy for myasthenia gravis: a changing perspective. Arch Surg. 1982; 117: 533
15． Givel JC. Surgery of the thymus. Berlin: Spring-Verlag. 1990: 243-290
16． Sugarbaker Dj. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg. 1993; 56: 653-656
17.Yim AP, Kay RL, Ho JK. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest. 1995; 108:1440-1443
18.Mack M J, Landreneau R J, Yim AP, et al. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg.1996;112:1352-1360
19.Ruckert JC, Gellert K, Muller JM. Operative technique for thoracoscopic thymectomy. Surg Endosc. 1999; 13:943-946
20．王如文，蒋耀光．电视胸腔镜手术131例临床观察．第三军医大学学报．2001；23(5)：524-525
21.Kido T, Hazama K, Inoue Y, et al. Resection of anterior mediastinal masses through an infrastemal approach. Ann Thorac Surg. 1999; 67: 943-946
22.Akihiko U, Shuji S, Hiroyuki M, et al. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: Surgical results in 23 patients. Ann Thorac Surg. 2001; 72:1902-1905
23．杨任民．血浆交换疗法在神经系统与肌肉疾病中的应用。中华神经精神科杂志．1988；2：134
24.Buckingham JM, et al. The value of thymectomy in myasthenia gravis: A computer-asisted matched study. Ann Surg. 1976:184
25． Genkins G, et al. Studies in myasthenia gravis: Early thymectomy electrophysiologic and pathologic correlations. The American Journai of Mebicin. 1975; 58: 517
26． Angelos E Papatestas, et al. Transcervical thymectomy in myasthenia gravis surgery. Gynecology-obstetrics. 1975; 140: 535
27． Orkin FK, et al. Predicting respiratory failure following thymectomy. Myasthenia gravis pathopysiology and management. 1983; 377: 862
28． Grecey DR, et al. Postoperative respiratory care after transsternal thymectomy in myasthenia gravis: three years experience in 53 patients. Chest. 1984; 86: 67
29． Bolooki H, Schwartzman RJ. Hight dose steroids for perioperative management of patients with myasthenia gravis undergoing thymectomy: a preliminary report. J Thorac Cardiovasc Surg 1978; 75: 754
30． Donald G Muldder, et al. Thymectomy for myasthenia gravis. The American Journal of Surgery. 1983; 43: 348
31． Warren Olanow M.D, et al. A prospective study of thymectomy and serum acetylcholine receptor antibodies in myasthenia gravis. Annals of Surgery. 1982; 196: 113
32． Perlo VP, et al. Myasthenia gravis: evaluation of treatment in 1355 patients. Neurology. 1966; 16: 431
33.Nakamura H, Fukuda M, Suzuki Y, et al. The long-term results of thymectomy for myasthenia gravis. Kyobu Geka. 1995; 48:184-189
34．许贤豪．重症肌无力治疗的进展。中华精神神经科杂志．1987；(20)5：331
35.Nakamure H, Taniguchi Y, Suzuki Y, et al. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg 1996; 11:12-14
36．吕传真，沈定国，秦知九，等．骨骼肌疾病．上海：上海科学技术出版社．1987：238
37．姚亚其，陈志明，庞烈文，等．胸腺切除治疗重症肌无力的远期疗效．中华外科杂志．1999；37(6)：353-354
38．陆轩，毛履琰．胸腺切除治疗重症肌无力远期疗效及影响因素的分析．中华外科杂志．1999；37(3)：160-161
39.Joseph W Rubin, et al. Factor affecting responses to thymectomy for myasthenia gravis. Thorac Cardiovasc Surg. 1981; 82:702
40．蒋耀光，范士志，陈建明，等．胸腺切除治疗重症肌无力远期疗效分析．中华外科杂志．1993；31：765-767
41．邵孟平，毛履琰，吕传真．胸腺切除后血清乙酰胆碱受体抗体改变与疗效关系．中华胸心血管外科杂志．1995；11：12-14
42.Jaretzki A, Penn AS, Younger S, et al. Maximal thymectomy for myasthenia gravis. J Thorac Cardiovasc Surg. 1988; 95:747-749
43.Otto TJ, Strugalska H. Surgical treatment for myasthenia gravis. Thorax.1987; 42:199
44.First WH, Thirumalai S, Doehring CB, et al. Thymectomy for myasthenia gravis patient: factors influencing outcome. Ann Thorac Surg. 1994; 57:334-336
45．曾涟乾，等．胸腺摘除及前纵隔脂肪清扫术治疗重症肌无力．中华胸心血管外科杂志．1991；7：99
2． Blalock A, et al. Myasthenia gravis and tumors of the thymus: Report of a case in which tumor was removed. Ann Surg. 1939; 110: 554
3． Kirchner T, Schalke B, et al. Immounol histological patterns of non-neoplastic changes in the thymusin myasthenia gravis. Virchows Archiv B. 1986; 52: 237-257
4． Blalock A: Thymectomy in the treatment of myasthenia gravis: Report of twenty cases. J Thorac Surg. 1944; 13:316
5． Levinson AZ, Zweiman B, et al. Pokeweed mitogen-induced immunoglobulin secretory responses to thymic B cells in myasthenia gravis: selective secretion of IgG vs IgM cannot be explained by helper functions of thymic T cells. Clin Immunol Immunopathol. 1990; 57: myasthenia gravis 211-217
6． Spuler S, Marx A, Et al. Myogenesis in thymic transplants in the severe combined immunodeficient mouse model of myasthenia gravis. Ann J Pathol. 1994; 145:766-770
7． 蒋光亮，赵雍凡．胸腺切除治疗重症肌无力31例报告．中国胸心血管外科杂志．1996; 3(4) : 199-200
8． Anglo E Paletto, et al. Thymectomy in the treatment of myasthenia gravis: Results in 320 patients. Int Surg. 1982; 67: 13
9． Jaretzki A, et al. "Maximal" thymectomy for myasthenia gravis: results. J Thorac Cardiovasc Surg. 1988; 95: 747
10． Masaoka A, Yamakawa Y, et al. Extended thymectomy for myasthenia gravis patients: a 20-year review. Ann Thorac Surg. 1996; 62: 852-859
11． Dalakas MC, et al. Identification of human thymic epithelial cells with antibodies to thymusin alpha 1 in myasthenia gravis. Ann-N-Y-Acad-Sci. 1981; 31(4) : 377477-377485
12． Muldder DG, et al. Thymectomy for myasthenia gravis: recent observations and comparisons with past experience. Ann Thorac Surg. 1989; 48: 551
13． Miller JI, et al. Median T sternotomy incision for thymectomy for myasthenia gravis. Ann Thorac Surg. 1981; 34: 473
14． Heiser JC, et al. Thymectomy for myasthenia gravis: a changing perspective. Arch Surg. 1982; 117: 533
15． Givel JC. Surgery of the thymus. Berlin: Spring-Verlag. 1990: 243-290
16． Sugarbaker Dj. Thoracoscopy in the management of anterior mediastinal masses. Ann Thorac Surg. 1993; 56: 653-656
17.Yim AP, Kay RL, Ho JK. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest. 1995; 108:1440-1443
18.Mack M J, Landreneau R J, Yim AP, et al. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg.1996;112:1352-1360
19.Ruckert JC, Gellert K, Muller JM. Operative technique for thoracoscopic thymectomy. Surg Endosc. 1999; 13:943-946
20．王如文，蒋耀光．电视胸腔镜手术131例临床观察．第三军医大学学报．2001；23(5)：524-525
21.Kido T, Hazama K, Inoue Y, et al. Resection of anterior mediastinal masses through an infrastemal approach. Ann Thorac Surg. 1999; 67: 943-946
22.Akihiko U, Shuji S, Hiroyuki M, et al. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: Surgical results in 23 patients. Ann Thorac Surg. 2001; 72:1902-1905
23．杨任民．血浆交换疗法在神经系统与肌肉疾病中的应用。中华神经精神科杂志．1988；2：134
24.Buckingham JM, et al. The value of thymectomy in myasthenia gravis: A computer-asisted matched study. Ann Surg. 1976:184
25． Genkins G, et al. Studies in myasthenia gravis: Early thymectomy electrophysiologic and pathologic correlations. The American Journai of Mebicin. 1975; 58: 517
26． Angelos E Papatestas, et al. Transcervical thymectomy in myasthenia gravis surgery. Gynecology-obstetrics. 1975; 140: 535
27． Orkin FK, et al. Predicting respiratory failure following thymectomy. Myasthenia gravis pathopysiology and management. 1983; 377: 862
28． Grecey DR, et al. Postoperative respiratory care after transsternal thymectomy in myasthenia gravis: three years experience in 53 patients. Chest. 1984; 86: 67
29． Bolooki H, Schwartzman RJ. Hight dose steroids for perioperative management of patients with myasthenia gravis undergoing thymectomy: a preliminary report. J Thorac Cardiovasc Surg 1978; 75: 754
30． Donald G Muldder, et al. Thymectomy for myasthenia gravis. The American Journal of Surgery. 1983; 43: 348
31． Warren Olanow M.D, et al. A prospective study of thymectomy and serum acetylcholine receptor antibodies in myasthenia gravis. Annals of Surgery. 1982; 196: 113
32． Perlo VP, et al. Myasthenia gravis: evaluation of treatment in 1355 patients. Neurology. 1966; 16: 431
33.Nakamura H, Fukuda M, Suzuki Y, et al. The long-term results of thymectomy for myasthenia gravis. Kyobu Geka. 1995; 48:184-189
34．许贤豪．重症肌无力治疗的进展。中华精神神经科杂志．1987；(20)5：331
35.Nakamure H, Taniguchi Y, Suzuki Y, et al. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg 1996; 11:12-14
36．吕传真，沈定国，秦知九，等．骨骼肌疾病．上海：上海科学技术出版社．1987：238
37．姚亚其，陈志明，庞烈文，等．胸腺切除治疗重症肌无力的远期疗效．中华外科杂志．1999；37(6)：353-354
38．陆轩，毛履琰．胸腺切除治疗重症肌无力远期疗效及影响因素的分析．中华外科杂志．1999；37(3)：160-161
39.Joseph W Rubin, et al. Factor affecting responses to thymectomy for myasthenia gravis. Thorac Cardiovasc Surg. 1981; 82:702
40．蒋耀光，范士志，陈建明，等．胸腺切除治疗重症肌无力远期疗效分析．中华外科杂志．1993；31：765-767
41．邵孟平，毛履琰，吕传真．胸腺切除后血清乙酰胆碱受体抗体改变与疗效关系．中华胸心血管外科杂志．1995；11：12-14
42.Jaretzki A, Penn AS, Younger S, et al. Maximal thymectomy for myasthenia gravis. J Thorac Cardiovasc Surg. 1988; 95:747-749
43.Otto TJ, Strugalska H. Surgical treatment for myasthenia gravis. Thorax.1987; 42:199
44.First WH, Thirumalai S, Doehring CB, et al. Thymectomy for myasthenia gravis patient: factors influencing outcome. Ann Thorac Surg. 1994; 57:334-336
45．曾涟乾，等．胸腺摘除及前纵隔脂肪清扫术治疗重症肌无力．中华胸心血管外科杂志．1991；7：99