胸部肿瘤侵及大血管时的手术处理

摘要

目的总结64例胸部肿瘤浸润大血管手术时的处理经验，分析上腔静脉（SVC）手术技术及指征以及肺动脉袖状切除的适应证。方法回顾性分析1991年1月到1999年6月64例胸内大血管受到肿瘤浸润患者的手术经验。受侵血管包括肺动脉根部和（或）肺动脉干、上肺静脉和（或）下肺静脉根部、SVC和（或）无名静脉。结果 24例接受了不同类型的SVC手术，包括左及右无名静脉分别与右心房人工血管搭桥术1例、左无名静脉与右心房人工血管搭桥4例、右无名静脉与右心房搭桥3例、奇静脉切除并SVC部分切除11例、单纯SVC部分切除5例。SVC置换或搭桥除1例应用涤纶血管者外，其余均是Gore-Tex人工血管。5例部分切除者使用了缝合器。41例肺动脉部分或袖状切除（肺动脉袖状并支气管袖状成形4例）、左心房部分切除13例。应用肺血管阻断或临时架桥术，所有手术均成功进行，无手术死亡，无严重并发症。SVC切除后生存时间最长者已达l5年，为1例恶性畸胎瘤患者。肺癌切除SVC、无名静脉搭桥患者术后生存最长者已达5年。结论大血管包括SVC及肺血管阻断与成形技术以及SVC置换术，是根治性切除浸润大血管的胸部肿瘤的关键性技术，正确及时地应用可以提高根治性切除率和安全性，减少探查率。%Objectives　To summarize the experience in surgical treatment great vessel invasion by chest tumor, analyze techniques and indications for the management of the superior vena cava (SVC) and the indications for sleeve resection of the pulmonary artery.　Methods　64 patients with great vessels involved by malignant disease who had been treated successfully from January 1991 to June 1999 were analysed retrospectively. The invaded vessels were as follows: the root and /or the trunk of the pulmonary artery, the root of the superior and/or inferior pulmonary vein,and SVC and/or tho innominate vein.　Results　24 patients were subjected to SVC procedures including resection and one patient to two bypasses (between left and right innominate vein and right appendage), 7 to one bypass (left innominate to right appendage in 4 patients, right innominate to right appendage in 3), 11 to partial resection of SVC together with azygous vein , and 5 to partial resection of SVC. Gore-Tex artificial vessel was used for SVC replacement or bypass in all patients except one. Partial resection was done by stapler in 5 patients. Sleeve or partial resection of the pulmonary artery (sleeve resection of the pulmonary artery together with sleeve bronchoplasty in 4 patients) was performed in 41 patients and partial left atrium resection in 13 patients. With vessel control or temporary bypass, all procedures were successfull without operative death and major complications. The longest survival of SVC resection in patient with malignant teratoma was 15 years. For patients with lung cancer the longest survival of SVC surgery was 5 years.　Conclusions　Vasocontrol and vasoplasty of SVC and pulmonary vessels and replacement of SVC are the key techniques for radical resection of chest tumor invading the great vessels. Their correct use could enhance the possibility of radical resection and operative safety, and decrease the exploratory rate.