前上纵隔切开术的应用体会

Experience with anterior superior mediastinotomy

目的探讨侵入前上纵隔头颈肿瘤的手术方法。方法6例患者,其中颈段气管癌1例、甲状腺癌3例、鳃裂癌转移和气管瘘口复发癌各1例。采用切除胸骨柄和患侧1/3锁骨的方法,切开前上纵隔,切除肿瘤以及上纵隔淋巴结清扫术,2例颈动脉肿瘤受侵处同期植入125Ⅰ粒子组织间放疗。3例气管缺损分别应用前臂皮瓣、胸锁乳突肌骨膜瓣和气管端-端吻合修复,并应用胸大肌瓣充填前上纵隔。结果6例未发生术中严重并发症;随访3年以上。4例死亡,其中1例术后第4周因心脏病突发而死亡,3例分别在术后6个月、8个月和1年因感染引起颈动脉大出血或舌根部、气管局部复发而死亡。结论常规CT或MRI检查明确肿瘤范围制定手术方案,依据术中肿瘤切除后气管缺损范围采用不同方法整复,应用胸大肌肌瓣充填前上纵隔,保护大血管。同时2例颈动脉肿瘤受侵处术中植入125Ⅰ粒子组织间放疗,扩大手术适应证,提高了疗效。此手术方法术野暴露好,耳鼻咽喉头颈外科医生可独立完成,不失为减轻患者痛苦或延长生命的有效方法。

OBJECTIVE To discuss the methods to deal with tumor invading anterior superior mediastinum. METHODS Tumors were removed with superior mediastinum lymphadenectomy in 6 cases by sternal manubrectomy and removal of one third of the homolateral clavicle. 125 Ⅰ brachytherapy was done on the site where carotid artery was invaded by tumor. Pec toralis major flap was used to fill in the superior anterior mediastinum. Among the 6 cases, 1 was cervical trachea carcinoma, 3 were thyroid carcinoma, 1 was parotid carcinoma and 1 was stomal recurrent carcinoma. RESULTS None of the 6 cases had severe complications during operation. One died of cardiac infarction 4 weeks after operation. The rest cases were follow-up for 3 years. Three cases died at 6, 8,and 12 months after operation respectively. The causes of death were infection and tumor recurrence at tongue base or trachea. CONCLUSION The operative protocol should be made according to the extent of the tumor identified by routine CT and MRI scan. The methods for trachea reconstruction depend on the defect length of trachea after tumor resection. Pectoralis major flap was used to fill in the anterior mediastinum for protection of the blood vessel. This kind of operation provide satisfactory operation field exposure and can be done by ENT doctors. It is effective to alleviate patients from their suffering and prolong their life span.