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全胸腔镜下纵隔良性肿瘤切除术22例

电视纵隔镜诊断不明性质的纵隔或肺部病变

摘要： 目的 探讨电视纵隔镜检查在不明原因纵隔或肺部病变诊断中的可靠性和安全性。 方法 2003年10月至2008年5月我科收治61例不明性质的纵隔或肺部疾病患者，男43例，女18例；年龄16～71岁，平均年龄47岁。采用单腔气管内插管全身麻醉，行电视纵隔镜活检术，经颈入路57例，经胸骨旁入路4例。 结果 术中损伤无名动脉1例，中转开胸止血并活检；另60例均获得满意病理学标本，确切诊断率为100%，敏感性为100%，特异性为100%。病理诊断：纵隔原发性恶性肿瘤9例，纵隔良性肿瘤1 例，淋巴瘤 2例，结核32例，纵隔淋巴结转移12 例，淋巴结反应性增生4例。术后切口愈合不良3例；围术期死亡1例。 结论 电视纵隔镜检查术是一种创伤小、有效的诊断性检查方法，但对伴有上腔静脉综合征患者应重视手术风险。

VideoAssisted Thoracoscopic Surgery for Posterior Mediastinal Tumors

Abstract: Objective To discuss the security, effectiveness and risk factors of videoassisted thoracoscopic surgery for posterior mediastinal tumors. Methods We retrospectively analyzed the data of 59 patients including 36 men and 23 women who underwent thoracoscopic resection of posterior mediastinal tumors in People’s Hospital of Peking University from May 2001 to July 2009. Their age ranged from 6 to 73 years old with an average age of 40.6 years old. The average maximum diameter of the tumors was 4.86 cm. All procedures were performed under general anesthesia and tumors were cut out with three ports. The anterior port was extended to 6 to 10 cm when conversion to thoracotomy was needed. After mediastinal pleura were opened, the tumor was stripped out along the outside of peplos and the vascular pedicle nerves were managed respectively. Results All surgeries were carried out successfully. The surgical duration, perioperative blood loss, postoperative chest tube duration and postoperative stay in hospital were respectively 45-300 min(125.80±57.40 min), 10-1 000 ml(168.10±157.70 ml), 1-10 d(2.50±1.74 d), and 2-14 d(5.24±2.24 d). There were 6 cases of conversion to open thoracotomy with a conversion rate of 10.2%. Postoperative pathology showed that there were 46 cases of neurogenic tumors, 10 cases of cyst, 2 cases of teratoma, and 1 case of lipoma. Follow-up was done on 51 cases for a period of 7-108 months(55.0±24.0 months) and 8(13.6%) cases were missed out during the period. No recurrence or death occurred during the followup. Logistic multivariable analysis showed that maximum diameter of the tumor ≥6 cm was the independent risk factor for extending operative time (OR=1.932，P=0.004), increasing perioperative blood loss (OR=2.267，P=0.002), increasing conversion rate to thoracotomy (OR=3.123，P=0.004) and increasing postoperative complication rate (OR=1.778，P=0.013). Conclusion Videoassisted thoracoscopic surgery for posterior mediastinal tumor is safe and effective. Maximum diameter of the tumor ≥6 cm is an independent risk factor for increasing operation difficulty and risk.

电视纵隔镜在胸部疾病诊断与治疗中的应用

摘要: 　目的　探讨电视纵隔镜在胸部疾病诊断和治疗中的应用价值, 总结其临床经验。　方法　对2006 年3 月至2007 年5 月开展的47 例电视纵隔镜手术资料进行回顾性分析, 其中经颈部纵隔镜手术38 例, 左胸纵隔镜手术8 例,右胸纵隔镜手术1 例。　结果　本组手术时间10～ 100m in, 平均44. 2min; 术中出血5～ 200ml, 平均33. 5ml 。肺癌术前分期12 例, 纵隔淋巴结病理检查阴性4 例, 阳性8 例, 均与开胸手术后检查结果相符, 其敏感性、特异性、准确性均为100%。纵隔疑难疾病诊断31 例, 经过纵隔镜手术后30 例(96. 8%) 明确诊断, 其中恶性肿瘤16 例, 分别为纵隔转移性肿瘤8 例、纵隔淋巴瘤3 例, 恶性纤维组织细胞瘤、食管鳞状细胞癌、促纤维组织增生性小圆细胞肿瘤、胸腺类癌、淋巴上皮癌各1 例; 良性疾病14 例, 分别为结节病8 例、慢性淋巴结炎4 例、纵隔淋巴结结核2 例。纵隔镜辅助纵隔或肺部病变切除4 例, 均顺利完成手术。本组手术无死亡及严重并发症发生, 均治愈出院。　结论　电视纵隔镜手术安全、可靠,可作为纵隔疑难疾病诊断和鉴别诊断的有效方法以及肺癌术前分期的金标准。

体外循环在胸部肿瘤手术中的应用价值

目的 探讨体外循环技术在胸部肿瘤手术中的应用及价值，为难治性胸部肿瘤手术方法提供依据。 方法 对6例胸部肿瘤患者(右肺中心性肺癌1例、左肺中心性肺癌1例、气管肿瘤2例、食管癌1例、纵隔肿瘤1例)采用不同的体外循环方法进行麻醉或手术切除，行右全肺切除＋部分心包切除＋部分左心房切除1例，气管肿瘤切除、端端吻合2例，食管癌切除＋胸降主动脉部分切除＋人工血管修补1例，左全肺切除＋部分左心房切除1例，纵隔肿瘤切除先Gor Tex16mm人工血管施行左无名静脉-右心耳吻合＋Gor Tex12mm人工血管施行右无名静脉-上腔静脉吻合1例。 结果 6例患者均手术顺利，术后恢复良好，康复出院。随访3个月～5年，1例肺癌患者术后10个月死于肺部转移，其余患者生存良好，生活质量高，采用胸部X线片、胸部CT和超声心动图等检查均无复发。 结论 对侵及部分肺血管和心脏的胸部肿瘤患者，以及气管肿瘤不能常规进行麻醉的患者，应用体外循环技术可明显提高手术切除几率，增加手术安全性，提高患者的生活质量和延长生存期。

原发性纵隔肿瘤的外科治疗

目的总结原发性纵隔肿瘤的外科治疗经验。方法回顾性分析我院1986年6月～2004年12月122例原发性纵隔肿瘤患者的临床资料，肿瘤全部切除107例，肿瘤大部分切除6例，单纯探查活检9例，手术切除率为92．6％（113／122）。结果手术死亡2例，术后94例患者获得随访，随访3个月～18年。除1例良性胸腺瘤切除术后7个月肿瘤复发外，其余良性纵隔肿瘤患者术后均预后良好。2例年轻的胸腺癌患者分别在术后3个月和5个月死于癌肿复发及其引起的各种并发症。结论原发性纵隔肿瘤不论良性还是恶性，只要无明确的远处转移和呼吸循环系统功能不全，允许胸部探查者均应及早手术，争取摘除肿瘤。

Extended Resection and Reconstruction of Superior Vena Cava and Innominate Vein for Mediastinal Tumor

ObjectiveTo report the effect and experience of the extended resection and reconstruction of superior vena cava(SVC) and innominate vein for invasive mediastinal tumors.MethodsA retrospective study of 11 patients who underwent extended resection and grafts of SVC and innominate vein for invasive mediastinal tumor in Peking Union Medical College Hospital from 2001 to 2003 was performed. Radical resection was performed in 9 cases, among which SVC and left innominate vein were reconstructed with pericardium patch in 2, with prostheses(ringed GoreTex) interposed in 7.The other 2 patients who had incomplete resection also underwent prostheses interposition for SVC reconstruction. During operation, SVC and left innominate vein were clamped in turn,to avoid total interruption of blood return, clamping time for each site was 22.15±6.29 min. The volume of blood loss was 1 342.86± 692.48ml during operation.ResultsThe tumor included 4 invasive thymoma, 5 thymic cancer, 2 primary mediastinal small cell carcinoma. The patency was good in the grafts with external ring support and no SVC symptoms were observed in all cases postoperatively. One patient died of respiratory infection two weeks after operation, others are alive till now. The longest patent and functional graft is 30 months postoperatively.ConclusionSVC and innominate vein reconstruction by prostheses interposition can effectively eradicate the SVC syndrome. Clamping SVC needs careful study. Attention to the invasive extention of tumor should be made to avoid palliative operation,because complete resection is most important for long term survival.

巨大纵隔肿瘤的外科治疗

目的回顾性总结28例巨大纵隔肿瘤的诊断要点及外科治疗经验。方法28例巨大纵隔肿瘤患者在全身麻醉双腔气管内插管下行手术治疗,完整切除肿瘤23例,大部分切除5例;同期行肺楔形切除术2例,肺叶切除术1例,部分心包切除术5例,上腔静脉成形术1例。结果无手术死亡患者,术中发生复张性肺水肿2例,失血性休克6例,损伤上腔静脉1例;术后发生心律失常3例,肺部感染4例,经治疗均恢复良好。结论巨大纵隔肿瘤手术治疗效果良好,麻醉时体位及手术切口的选择、术中仔细操作可提高手术的安全性及切除率,预防和治疗术中创面渗血及复张性肺水肿可进一步提高疗效。

巨大纵隔肿瘤的外科治疗

目的 回顾性总结15例巨大纵隔肿瘤的临床经验,探讨其外科治疗及预后. 方法 15例巨大纵隔肿瘤患者中经右胸切口7例,胸骨正中切口5例,左胸切口3例;其中2例术中运用体外循环,2例行血管成形术.结果 患者全部治愈出院,辅以放疗、化疗,预后良好. 结论 巨大纵隔肿瘤的外科治疗困难,手术切口、术中操作技术、肿瘤有无外侵对肿瘤切除起主要作用,体外循环的运用有助于肿瘤的完整切除.

Multislice Spiral CT Features and Pathologic Basis of Cavernous Hemangioma in Mediastinum

ObjectiveTo discuss multislice spiral CT (MSCT) features and pathologic basis of the cavernous hemangioma of mediastinum, and further improve the diagnostic accuracy with CT. MethodsWe collected 4 cases of cavernous hemangioma in mediastinum from November 2008 to November 2013. All patients underwent MSCT examination of plain scan and enhanced-contrast scan. The CT manifestations of cavernous hemangioma in mediastinum were observed. The correlation of the CT imaging findings with pathology features was analyzed retrospectively. ResultsTwo of the 4 lesions were located in the anterior mediastinum and the other 2 in the posterior mediastinum. On plain scan, 2 lesions showed homogeneous density, and 2 had heterogeneous density. Vessels could be observed in all lesions on enhanced-contrast CT imaging. ConclusionCavernous hemangioma in mediastinum is often located in the anterior and posterior mediastinum. Calcification and vessels in lesions are its imaging characteristics. Multislice spiral enhanced CT can accurately reflect the characteristics and pathological basis, providing more important information for diagnosis.