应用单侧肺循环阻断术治疗局部晚期非小细胞肺癌

Previously blocking both pulmonary artery and veins for surgical treatment of advanced non-small cell lung cancer

目的探讨单侧肺循环短暂阻断术(同期阻断肺动脉、肺静脉)治疗累及肺血管的局部晚期非小细胞肺癌(NSCLC)的应用价值。方法30例侵犯肺动脉的局部晚期NSCLC,开胸后探查见肺动脉干受侵,在心包内或心包外游离出患侧肺动脉干根部和上、下肺静脉,放置血管阻断钳同时阻断三支血管以防止肺动脉和左心房血液逆行倒灌出血。在患侧肺循环无血状态下切除病肺和受肺癌侵犯的部分肺动脉。行肺动脉成形或吻合后,开放阻断的肺动脉干和保留肺静脉,恢复其肺循环。20头杂种猪随机分成单侧肺循环阻断组和单纯肺动脉阻断组(每组各10头),分别阻断单侧肺循环或单纯肺动脉60min,再灌注240min后,取肺组织进行光镜、电镜检测缺血再灌注损伤情况,然后饲养7d,再次获取的肺组织进行光镜、电镜检测缺血再灌注损伤情况。结果30例侵犯肺动脉的局部晚期NSCLC切除率为100%,均保留了健康有功能的上叶肺或下叶肺,避免了全肺切除。肺动脉、肺静脉阻断的时间分别为(48±7.5)min(18～72min)和(33±6.8)min(16～66min)。术中平均出血量(248±34)ml(172～412ml),5例双袖切的患者术后因痰阻塞支气管引起肺不张,其中1例出现心律失常,经对症处理后好转。动物实验的结果提示:单纯肺动脉阻断组和单侧肺循环阻断组两种术式均使保留肺产生缺血再灌注损伤;肺血管阻断至少在一定时限内(本组为60min)保留肺产生缺血再灌注损伤是可逆的(本组为术后7d)。结论单侧肺循环阻断术为不能耐受全肺切除的局部晚期NSCLC患者保留健康肺,提供了一种安全、简捷的新手术方法。

Objective To investigate the feasibility of previously blocking both pulmonary artery and veins for surgical treatment of advanced non-small cell lung cancer （ NSCLC ） to preserve the normal function of pulmonary tissue. Methods Firstly, the relation of the pulmonary artery, the lung neoplasm and the enlarged mediastinal lymph nodes was observed. If the hilum of lung remained freezing stably, the pericardium was opened and the pulmonary artery, the upper and lower lobe pulmonary veins were divided. Then those three vessels were blocked to prevent the blood flow from the pulmonary artery or refluence of the left atrium. When the pulmonary circulation was stopped, bloodless lobectomy and pulmonary artery angioplasty and/or anastomosis were performed. Then the blockers were removed, and pulmonary circulation was recovered. Twenty hybrid swine were divided randomly into two groups ： 10 hybrid swine were assigned to the group of the lung circulation blocked and another 10 hybrid swine were assigned to the group of the pulmonary artery blocked. The experimental method was blocking the unilateral lung circulation or the pulmonary artery for 60 minutes,and then reperfusing for 240 minutes,detected the lung tissues into the level of reperfusion injury by light microscope and electron microscope, and then breeded the swine for 7 days, and detected the lung tissue into the level of reperfusion injury by light microscope and electron microscope again. Results All 30 patients suffer from advanced NSCLC, whose the hila of lung remained freezing stably, received complete resection of the tumor. The normal function of pulmonary tissue in the 30 patients was preserved, and the pneumonectomy did not need to perform. The time of blocking pulmonary artery was （48 ±7. 5 ） minutes （ 18 - 72 minutes）, vessels was 33 ± 6. 8 minutes （ 16 - 66 minutes）. The average amount of bleeding was 248 ± 34 ml（ 172 - 412 ml） during operation. All 30 patients have recovered well. The results of experiments indicated that the group of the lung circulation blocked and the group of the pulmonary artery blocked both have reperfusion injury, and the reperfusion injury is reversible in 60 minutes. Conclusions Previously blocking both pulmonary artery and veins for surgical treatment of advanced NSCLC is an innovation in surgical technique,which makes the operation safely and easily. This technique provides a chance to some patients, whose cardio-pulmonary function is too poor to tolerate pneumonectomy, to receive surgical treatments. Also,this technique widens the surgical indications for patients suffering from lung cancer.