胸部肿瘤侵及心脏大血管的外科治疗研究
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摘要
目的：探讨胸部肿瘤侵及心脏(包括心包)及大血管的外科治疗手术经验,对手术病例的选择、整个围手术期的准备及术后并发症的防治,术中麻醉、手术入路、切除方式的决断等外科经验进行分析研究。
方法：回顾分析2001-2008年54例侵犯心脏(包括心包)及大血管的胸部肿瘤临床资料。Ⅰ.切口：胸骨正中劈开切口20例,其中伴颈领小切口1例,右后外侧切口15例,左后外侧切口14例,右腋中线4-5肋间切口1例,左前外侧切口2例,右前外侧切口1例,右胸上腹正中两切口1例；Ⅱ.麻醉：气管插管静吸复合全身麻醉54例,并连续硬膜外麻醉40例,体外循环(CPB)1例；Ⅲ.术式：全组病例行肿瘤并部分心包切除36例,并心房大血管切除成形或重建置换19例、并肺动脉袖式切除成形12例、并单侧膈神经切除9例、并部分肺切除8例、并单侧全肺切除5例、切除主动脉外膜5例、隆突成形重建2例、切除单侧迷走神经2例、体外循环下切除1例、52例均完全切除肿瘤,2例残端阳性,其中1例因肿瘤对双侧膈神经均侵犯,只能切除一侧,另一侧少许肿瘤残留。
结果：全组病例手术顺利,平均手术时间192分钟、平均手术出血量302ml、上腔静脉平均阻断时间25-35分钟、引流管平均放置时间3.89天、每天平均引流量230.95ml(除外1例术后第1日活动性出血再手术,其后出现严重低蛋白血症平均每日约800ml者)。标本大小(最大径)为3cm-15cm；术后保留气管插管、呼吸机辅助呼吸6例,平均使用1.5天(除外1例因重症肌无力危象呼吸机辅助11天者)；术后平均住院时间16天；术后并发症：胸腔积液10例(18.52%)、心律失常10例(18.52%)、肺部感染5例(9.26%)、胸内活动性出血2例(3.70%)、并肺不张1例(1.85%)、深静脉血栓1例(1.85%)、重度低蛋白血症1例(1.85%)、死亡1例(肺栓塞)(1.85%)；切口Ⅱ/甲愈合。随访6-96个月,纵隔肿瘤组1年生存率85.19%(23/27),3年生存率62.50%(10/16),5年生存率57.14%(4/7),其中1例6年,2例8年,均为恶性胸腺瘤。肺癌组：1年生存率72.00%(18/25),3年生存率50.00%(10/20),5年生存率33.33%(3/9),局部复发1例。食管癌组1例：生存3年5个月。
结论：对于侵犯心脏和大血管的胸部肿瘤经合理的手术选择、理想的术中处理及术后治疗,不但能根治切除肿瘤,也能为进一步放化疗提供机会,从而提高患者的生存时间、生存质量。
Objective:To discuss the experience of surgical treatment for thoracic tumor invading the heart (include pericardium) or great vessels. To analyze and research the experience include the case selection of surgery, the preparation during perioperative period, the management of postoperative complications and intraoperative anesthesia, and the surgical approachs, decisions of resection type and extent etc.
Methods:A retrospective analysis of 54 cases of thoracic tumor invading the heart (include pericardium) or great vessels. I.Incision:20 cases of mid-sternal incision combined with 1 case of the small collar incision,15 cases of right chest posterolateral incision,14 cases of left chest postero-lateral incision,2 cases of left anterior outboard incision,1 case of right anterior outboard incision,1 case of right midaxillary line incision between 4th and 5th costa,1 case of two incisions of right chest and upper middle abdomen.Ⅱ.Anesthesia:54 cases of intravenous inhalational anesthesia,40 cases combined with the continuous epidural anesthesia,1 case of cardiopulmonary bypass (CPB).Ⅲ. Surgical approachs:All cases received tumor resection. Among them, there are 36 cases of partial pericardiectomy, 19 cases of partial atrium and major vessels reconstruction,11 cases of sleeve lobectomy combined with sleeve pulmonary artery resection,9 cases of unilateral phrenectomy,8 cases of partial lung resection,5 cases of total resection pneumonectomy,5 cases of the aortic adventitia resection,2 cases of the tracheal carina reconstruction and plasty,1 case of unilateral vagectomy,1 case of CPB.52 cases were performed by radical tumor resection, and 2 cases of stump-positive, one has no option but to unilateral phrenectomy and the other lateral residual tumor because that bilateral phrenic nerve are invaded by tumor.
Results:All the patients underwent the operation successfully, the average operation duration was 192 minutes, mean operative blood loss was 302 ml, the average time of superior vena cava occlusion was 25-35 minutes, the average time with drainage tubes was 3.89 days, the average amount of drainage daily was 230.95 ml (Except that one case of postoperative active hemorrhage underwent reoperation and combined with severe hypopro-teinemia, the average amount of drainage daily was 800 ml). Specimens size (maximum diameter) was 3cm-15cm. The average time of tracheal intubation and assist breathing with ventilator of 6 cases were 1.5 days (Except that 1 case myasthenia gravis of assist breathing with ventilator, the time was 11 days). The median postoperative stay was 16 days. Complications:Pleural effusion in 10 patients (18.52%), arrhythmia in 10 patients (18.52%), pulmonary infection in 5 cases (9.26%), chest active hemorrhage in 2 cases (3.70%), and atelectasis in 1 case (1.85%), deep vein thrombosis in 1 case (1.85%), severe hypoproteinemia in 1 case (1.85%), Death (pulmonary embolism) in 1 case (1.85%). Incision II/A healed. Follow-up 6 to 96 months, the mediastinal tumor group:1-year survival rate of 85.19%(23/27),3-year survival rate of 62.50%(10/16),5-year survival rate of 57.14%(4/7).1 case survival time was 6 years and 2 cases survival time were 8 years, which all were malignant thymoma. Lung Cancer Group:1-year survival rate of 72.00%(18/25),3-year survival rate of 50.00%(10/20),5-year survival rate of 33.33%(3/9). Local recurrence in 1 case.1 case of esophageal cancer:Survived 3 years and 5 months.
Conclusion:The proper selection of operation and intraoperative treatment for tumor invading the heart or great vessels not only can be performed to radical resection but also provide more chances to radiotherapy or chemotherapy, so it is benefit for improving living quality and survival time of patients.
方法：回顾分析2001-2008年54例侵犯心脏(包括心包)及大血管的胸部肿瘤临床资料。Ⅰ.切口：胸骨正中劈开切口20例,其中伴颈领小切口1例,右后外侧切口15例,左后外侧切口14例,右腋中线4-5肋间切口1例,左前外侧切口2例,右前外侧切口1例,右胸上腹正中两切口1例；Ⅱ.麻醉：气管插管静吸复合全身麻醉54例,并连续硬膜外麻醉40例,体外循环(CPB)1例；Ⅲ.术式：全组病例行肿瘤并部分心包切除36例,并心房大血管切除成形或重建置换19例、并肺动脉袖式切除成形12例、并单侧膈神经切除9例、并部分肺切除8例、并单侧全肺切除5例、切除主动脉外膜5例、隆突成形重建2例、切除单侧迷走神经2例、体外循环下切除1例、52例均完全切除肿瘤,2例残端阳性,其中1例因肿瘤对双侧膈神经均侵犯,只能切除一侧,另一侧少许肿瘤残留。
结果：全组病例手术顺利,平均手术时间192分钟、平均手术出血量302ml、上腔静脉平均阻断时间25-35分钟、引流管平均放置时间3.89天、每天平均引流量230.95ml(除外1例术后第1日活动性出血再手术,其后出现严重低蛋白血症平均每日约800ml者)。标本大小(最大径)为3cm-15cm；术后保留气管插管、呼吸机辅助呼吸6例,平均使用1.5天(除外1例因重症肌无力危象呼吸机辅助11天者)；术后平均住院时间16天；术后并发症：胸腔积液10例(18.52%)、心律失常10例(18.52%)、肺部感染5例(9.26%)、胸内活动性出血2例(3.70%)、并肺不张1例(1.85%)、深静脉血栓1例(1.85%)、重度低蛋白血症1例(1.85%)、死亡1例(肺栓塞)(1.85%)；切口Ⅱ/甲愈合。随访6-96个月,纵隔肿瘤组1年生存率85.19%(23/27),3年生存率62.50%(10/16),5年生存率57.14%(4/7),其中1例6年,2例8年,均为恶性胸腺瘤。肺癌组：1年生存率72.00%(18/25),3年生存率50.00%(10/20),5年生存率33.33%(3/9),局部复发1例。食管癌组1例：生存3年5个月。
结论：对于侵犯心脏和大血管的胸部肿瘤经合理的手术选择、理想的术中处理及术后治疗,不但能根治切除肿瘤,也能为进一步放化疗提供机会,从而提高患者的生存时间、生存质量。
Objective:To discuss the experience of surgical treatment for thoracic tumor invading the heart (include pericardium) or great vessels. To analyze and research the experience include the case selection of surgery, the preparation during perioperative period, the management of postoperative complications and intraoperative anesthesia, and the surgical approachs, decisions of resection type and extent etc.
Methods:A retrospective analysis of 54 cases of thoracic tumor invading the heart (include pericardium) or great vessels. I.Incision:20 cases of mid-sternal incision combined with 1 case of the small collar incision,15 cases of right chest posterolateral incision,14 cases of left chest postero-lateral incision,2 cases of left anterior outboard incision,1 case of right anterior outboard incision,1 case of right midaxillary line incision between 4th and 5th costa,1 case of two incisions of right chest and upper middle abdomen.Ⅱ.Anesthesia:54 cases of intravenous inhalational anesthesia,40 cases combined with the continuous epidural anesthesia,1 case of cardiopulmonary bypass (CPB).Ⅲ. Surgical approachs:All cases received tumor resection. Among them, there are 36 cases of partial pericardiectomy, 19 cases of partial atrium and major vessels reconstruction,11 cases of sleeve lobectomy combined with sleeve pulmonary artery resection,9 cases of unilateral phrenectomy,8 cases of partial lung resection,5 cases of total resection pneumonectomy,5 cases of the aortic adventitia resection,2 cases of the tracheal carina reconstruction and plasty,1 case of unilateral vagectomy,1 case of CPB.52 cases were performed by radical tumor resection, and 2 cases of stump-positive, one has no option but to unilateral phrenectomy and the other lateral residual tumor because that bilateral phrenic nerve are invaded by tumor.
Results:All the patients underwent the operation successfully, the average operation duration was 192 minutes, mean operative blood loss was 302 ml, the average time of superior vena cava occlusion was 25-35 minutes, the average time with drainage tubes was 3.89 days, the average amount of drainage daily was 230.95 ml (Except that one case of postoperative active hemorrhage underwent reoperation and combined with severe hypopro-teinemia, the average amount of drainage daily was 800 ml). Specimens size (maximum diameter) was 3cm-15cm. The average time of tracheal intubation and assist breathing with ventilator of 6 cases were 1.5 days (Except that 1 case myasthenia gravis of assist breathing with ventilator, the time was 11 days). The median postoperative stay was 16 days. Complications:Pleural effusion in 10 patients (18.52%), arrhythmia in 10 patients (18.52%), pulmonary infection in 5 cases (9.26%), chest active hemorrhage in 2 cases (3.70%), and atelectasis in 1 case (1.85%), deep vein thrombosis in 1 case (1.85%), severe hypoproteinemia in 1 case (1.85%), Death (pulmonary embolism) in 1 case (1.85%). Incision II/A healed. Follow-up 6 to 96 months, the mediastinal tumor group:1-year survival rate of 85.19%(23/27),3-year survival rate of 62.50%(10/16),5-year survival rate of 57.14%(4/7).1 case survival time was 6 years and 2 cases survival time were 8 years, which all were malignant thymoma. Lung Cancer Group:1-year survival rate of 72.00%(18/25),3-year survival rate of 50.00%(10/20),5-year survival rate of 33.33%(3/9). Local recurrence in 1 case.1 case of esophageal cancer:Survived 3 years and 5 months.
Conclusion:The proper selection of operation and intraoperative treatment for tumor invading the heart or great vessels not only can be performed to radical resection but also provide more chances to radiotherapy or chemotherapy, so it is benefit for improving living quality and survival time of patients.
引文
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7.陈克能,顾振东,熊宏超.外侵性前纵隔肿瘤扩大切除及腔静脉成形术的诊治经验.中华医学杂志.2004年1月2日第84卷第1期：35-37.
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1.周清华,刘伦旭,刘斌等.肺切除合并心脏大血管切除重建治疗晚期肺癌.中国肺癌杂志.2001,Dec vol.4.no.6：403-406
2. Stanford W, ty DB. The role of venography and surgery in the management of patients with superior vena cava obstruction. Ann Thorac Surg.1986.41(2):158-163
3. Benumof JL,fery DD. esthesia for thoracic surgery北京：科学出版社.2000：1683-1697
4.杭燕南,庄心良,蒋豪,等.当代麻醉学.上海：上海科技出版社,2002：5082-5091
5.刘斌,潘莉,王雄等.肺切除合并上腔静脉切除人造血管置换术治疗上腔静脉综合征的麻醉处理.中国肺癌杂志2003年12月第6卷第6期：492-494
6. Vaporciyan AA,Rice D, Correa AM,et al.Resection of advanced thoracic malignancies requiring cardiopulmonary bypass.Eur J Cardiothorac Surg,2002, 22(1):47-52
7.陈克能,顾振东,熊宏超.外侵性前纵隔肿瘤扩大切除及腔静脉成形术的诊治经验.中华医学杂志.2004年1月2日第84卷第1期：35-37.
8. Fukuse T,W ada H,Hitomi S, et al. Extended operation for non-small cell lung cancer invading great vessels and left atrium.Eur J Cardiothorac Surg,1997, 11(4):664-669
9.赵风瑞,葛炳生,辛育龄等.肺外科中血管或心房阻断及成形术的应用.中华胸心血管外科杂志1992年第8卷第3期：168-170
10.黄孝迈,秦文瀚,孙玉鹗.胸部外科及胸腺肿瘤[A].黄孝迈,秦文瀚.孙E鹗.现代胸外科学[c].2版.1997：591-604
11.彭丽君,乔贵宾.体外循环在局部晚期胸部恶性肿瘤外科治疗中的应用进展.中国胸心血管外科临床杂志2007年6月第14卷第3期：221-224
12.彭向红,冯奉仪.周立强.恶性胸腺瘤化疗研究进展[J].国外医学肿瘤学分册.1999,26(3)：176-178
13. Graeber GM, Tamim W. Current status of the diagnosis and treatment of thymoma.Semin Thorac Cardiovasc Surg,2000,12:268-277
14. Puntnam JB Jr,Lammcrmeier DE.Colon R.et al.Predicted pulmonary function and survival after pneumonectomy for primary lung cancer. Ann Thorac Surg 1990; 49: 909
15.Page A.Nakhle G,Mercier C,et al. Surgical treatment of bronchogenic carcinoma: the importance of staging in evaluating late survival Can J Surg 1987:30;96
16.黄国俊,毛友生,张德超.局部晚期非小细胞肺癌侵及纵隔器官扩大手术治疗的评价.中华肿瘤杂志,2005.27(1)：59-61
17.张德超,毛友生,黄国俊.中国肺癌外科治疗概况与进展.中国肺癌杂志2005年12月第8卷第6期：557-562