Trapdoor 手术在儿童颈胸交界处神经母细胞瘤中的应用

Surgical approach for cervicothoracic neuroblastomas in children via a Trapdoor incision

目的探讨Trapdoor手术治疗儿童颈胸交界处神经母细胞瘤的临床应用价值。方法收集浙江大学医学院附属儿童医院2018年1月至2021年10月经Trapdoor手术方式治疗的23例颈胸交界处神经母细胞瘤患儿的临床资料。其中男7例,女16例;肿瘤位于左侧19例,右侧4例;中位年龄为4岁4个月,年龄范围为6个月18 d~8岁7个月;手术时肿瘤最大径为(5.31±2.57)cm。根据国际神经母细胞瘤分期系统(ISSN分期):Ⅲ期10例,Ⅳ期13例。按照美国儿童肿瘤协作组(children's qncology group,COG)进行危险度分组:中危9例,高危14例。所有患儿均经前正中“C”型切口(锁骨上、胸骨正中及肋间切口),暴露锁骨后方及胸腔进行肿瘤切除,骨骼化颈胸大血管。记录手术相关指标及术后并发症,并随访所有患儿的复发、生存情况。结果所有病例均顺利完成手术且达到肉眼全切。手术时间为(3.81±1.64)h,术中出血(57.65±28.61)ml。26.1%(6/23)的患儿发生并发症。3例出现声音嘶哑,2例出现肺不张伴肺炎,2例出现肋骨骨折,1例出现乳糜漏,通过治疗均得到恢复,未出现因手术并发症而死亡的病例。术后复查增强CT影像均未见肿瘤残留。临床随访3个月至3年,共有17.4%(4/23)患儿出现病情进展或复发(2例为手术部位,另2例为转移灶),均为Ⅳ期高危组。3例患儿在随访期间死亡,其中2例死因为疾病进展,另1例为化疗骨髓抑制后严重感染。结论Trapdoor手术方式在术中视野暴露、手术完全切除方面具有优势,且并发症可控,是一种安全有效的手术方式,可作为治疗儿童颈胸交界处神经母细胞瘤的一种选择方法。

Objective To evaluate the clinical application value of Trapdoor incision for neuroblastomas at cervicothoracic junction in children.Methods From January 2018 to October 2021,clinical data were collected for 23 hospitalized children with neuroblastoma at cervical and thoracic junction.There were 7 boys and 16 girls.The involved side was left(n=19)and right(n=4).The median age was 4Y4M(6M18D⁃8Y7M).The maximal diameter of tumor was(5.31±2.57)cm.According to the International neuroblastoma staging System(ISSN),the clinical stages wereⅢ(n=10)andⅣ(n=13).According to the criteria of Children's Oncology Group(COG),the clinical risks were moderate(n=9)and high(n=14).The operative duration was(3.81±1.64)h and intraoperative bleeding(57.65±28.61)ml.Postoperative complications occurred(n=6,26.1%),including hoarseness(n=3),rib fracture(n=2),atelectasis(n=2)and chylous leakage(n=1).Gross total resection was performed through anterior C⁃notch(supraclavicular,median sternum&intercostal incision),exposing posterior clavicle and thoracic cavity and skeletonizing large cervical and thoracic vessels.Operation⁃related parameters and postoperative complications were recorded,and recurrence and survival followed up.Results Recovery was smooth without any mortality from surgical complications.Tumor residue was absent on postoperative enhanced computed tomography(CT).During a follow⁃up period of 3 months to 3 years,there was disease progression or recurrence(n=4).All of them were in high⁃risk group of stageⅣ.Among 3 deaths,the causes were disease progression(n=2)and infection,severe pneumonia and respiratory failure caused by bone marrow suppression after chemotherapy(n=1).The remainders survived.Conclusion Trapdoor surgical approach is ideal for neuroblastomas at cervicothoracic junction in children.It provides an excellent exposure for gross total resection with fewer perioperative complications.