[A Programmed Procedure of Prosthetic Reconstruction of the Superior Vena Cava â©for Thoracic Tumors via Median Thoracotomy].

: 背景与目的 上腔静脉系统受累是局部晚期胸部肿瘤较常见的一种情况，手术可能获益，但风险极高。本研究针对正中开胸入路，提出一种程序化的手术方案，旨在优化流程，使得这一类以往认为风险极高的手术能够更加安全地实施。方法 35例胸部疾患累及上腔静脉系统，经正中开胸进行人工血管置换的患者资料，分期检查明确为局部晚期。包括肺部肿瘤16例，纵隔肿瘤19例。手术方法采用从左至右的单向推进，先游离左无名静脉起始部，阻断后切断，掀起瘤体，打开心包，用人工血管桥接左无名静脉和右心耳。游离上腔静脉近心端未受侵部分后，向尾侧牵拉肿瘤，剪开右侧纵隔胸膜，结扎切断右侧乳内血管，可以充分显露右无名静脉。向左上方牵拉瘤体，于肺门上方结扎切断奇静脉，此时可以阻断右无名静脉和上腔静脉，切除中间受侵的血管，以人工血管行右无名静脉-上腔静脉桥接，完成受侵的上腔静脉系统全部替换。结果 全组病例均顺利完成手术。术后并发症包括：心律失常6例，低氧血症5例，肌无力危象1例，心脏疝1例，真菌感染2例。2例患者死亡，死亡率5.12%，分别死于心梗和肺部感染。其余33例顺利出院。平均术后住院日15 d。在10例术前出现上腔静脉综合征的患者中，除2例术中即出现人工血管内血栓形成的患者，其余8例症状均明显改善。结论 上腔静脉人工血管置换手术经程序化的处理，规范治疗的细节，在手术操作过程中可降低手术风险，本组病例手术能够安全实施的实践也支持这一点。. METHODS: A total of 35 patients with thoracic disease involved superior vena cava underwent prosthetic vascular reconstruction via median thoracotomy. All patients were confirmed locally advanced without distant metastasis including 16 pulmonary neoplasm and 19 mediastinal disease. The operations proceed from left to right with one direction manner. The initial part of the left innominate vein was dissected, then cut off, so as to lift tumor, the pericardium was opened, and the left innominate vein and the right artrium were bridged with prosthetic vascular. The proximal end of the superior vena cava which not invaded was dissected and the tumor was pulled to the caudal side, the right mediastinal pleura was opened and the right inner mammary vascular was ligated and the right innominate vein was fully revealed. Stretch the tumor to left top, cut azygos vein on above the hilum, then block the right innominate vein and superior vena cava, removed involved part of blood vessels, the right innominate vein and superior vena cava was connected with prosthetic vascular. With these procedures the superior vena cava was reconstructed completely. RESULTS: The operation was completed successfully in all cases. Postoperative complications included 6 cases with arrhythmia, 5 cases with hypoxemia, 1 case with myasthenia crisis, 1 case with cardiac hernia, and 2 cases with fungal infection. 2 patients died of myocardial infarction and lung infection respectively with a mortality rate of 5.12%. The remaining 33 cases were discharged successfully. The average postoperative hospital stay was 15 days. Of the 10 patients with superior vena cava syndrome preoperatively, 8 patients had symptoms relief except 2 cases with intraoperative intravascular thrombosis. CONCLUSIONS: We recommended the programmed procedure of prosthetic reconstruction of the superior vena cava, standardize the details of treatment, and minimize the risk during operation. The safe surgical procedures of this group of cases confirm this practice.