胸部肿瘤上腔静脉重建术中脑氧代谢的变化对手术策略选择的指导意义

The Guiding Significance of the Choice of Surgical Strategy of Intraoperative Oxygen Metabolism during Superior Vena Cava Reconstruction for Thoracic Neoplasm

目的:探讨侵犯上腔静脉的胸部肿瘤手术中手术策略的选择对上腔静脉阻断期间脑氧代谢的影响。方法:总结我院31例胸部肿瘤侵犯上腔静脉合并上腔静脉阻塞及不合并上腔静脉阻塞患者上腔静脉重建术中,直接阻断上腔静脉或旁路分流患者血液动力学改变、脑氧代谢及乳酸改变的情况。结果:上腔静脉阻塞患者术前上腔静脉压力、脑氧摄取率、乳酸水平明显高于不合并上腔静脉阻塞者(24.0 ±8.9 &11.0 ±2.5;36 ±12 &29 ±1O;5.75 ±2.36 &3.54 ±0.88),而在直接阻断上腔静脉进行重建过程中,上腔静脉压力未见明显升高,脑氧摄取率、静脉乳酸水平无改变,上腔静脉重建开放后腔静脉压力、脑氧摄取率、静动脉乳酸差值明显下降(24.0 ±8.9 &14.6.0 ±6.3;36 ±12 &26 ±12;0.51 ±1.23 &0.28 ±1.21);未合并上腔静脉阻塞者在进行旁路分流后血液动力学、脑氧代谢率、脑静脉乳酸水平无明显改变。结论:合并上腔静脉阻塞患者在上腔静脉重建过程中直接阻断上腔静脉进行肿瘤切除、腔静脉重建是安全的,未合并上腔静脉阻塞者进行上腔静脉至心房的旁路分流是必要的。

Objective: To discuss the effects of the change of oxygen metabolism of the choice of surgical strategy during the superior vena cava reconstruction of thoracic neoplasm. Method: 31 patients underwent superior vena cava replacement from 2006 to 2013. The superior vena cava was totally obstructed in 12 patients and was partially involved in 19 patients. During the SVC replacement, the SVC were directly clamped in the SVCOS patients, and bypassed through the temporary SVC to right atrial bypass graft. The hemodynamic indexes, jagular oxygen index, and blood lactate were monitored during the operation. Results: SVC pressure, was significantly higher in the SVCO pa-tients before the operation than the non-SVCO patients (24.0 ±8.9 mmHg &11.0 ±2.5 mmHg), and decreased significantly after SVC reconstruction (24.0 ±8.9 mmHg &14.6.0 ±6.3 mmHg). The ce-rebral oxygen extraction rate, venous-arterial oxygen content difference and the jagular vein blood lactate level were significantly higher in the SVCOS patients comparing with no SVCO patients (36 ±12 &29 ±1O;0.51 ±1.23 &0 ±0.21;5.75 ±2.36 &3.54 ±0.88), and decreased significantly after SVC replacement (36 ±12 &26 ±12;0.51 ±1.23 &0.28 ±1.21;5.75 ±2.36 &3.86 ±1.75). The he-modynamic indexes and oxygen metabolism indexes were stable during the direct clamp of SVCO patients and bypass procedure of non-SVCO patients. Conclusion: The direct clamp of SVC for SVCO patients was safe and the efficacious bypass between SVC and right atrium was essential for non- SVCO patients during the SVC replacement of thoracic neoplasm.