非小细胞肺癌的外科治疗之全肺切除术  

Pneumonectomy for non-small cell lung cancer

作　　者：杨兴玲 王晓伟[1] 金海[1] Yang Xingling;Wang Xiaowei;Jin Hai(Department of Thoracic Surgery,Shanghai Changhai Hospital,Shanghai 200433,China)

机构地区：[1]上海长海医院胸外科,200433

出　　处：《中华胸心血管外科杂志》2020年第11期694-700,共7页Chinese Journal of Thoracic and Cardiovascular Surgery

摘　　要：全肺切除术是中央型肺癌的一种治疗手段,为了最大程度切除肿瘤组织需要切除一侧肺组织,其导致结果包括:(1)肺容积减少及肺通气换气量减少;(2)肺血管床减少及由此导致的肺动脉高压,右心室后负荷增加;(3)健侧肺门与纵隔移位及由此引起的肺通气,心脏血流动力学改变;(4)与局部血供不良,术后低氧,局部张力增高等危险因素相关的气管残端或气管支气管吻合口愈合不良,及可能出现的支气管胸膜瘘或气管支气管吻合口瘘。这导致全肺切除术相比较保留肺功能的肺切除术术后并发症风险有所增加。但并不意味着要退而求其次,放弃其在肺癌治疗中其他手术方式所不能比拟的肿瘤学治疗效益。术前精准评估患者肿瘤与淋巴结情况及手术可切除性、心肺功能,挑选出能够最大程度获益于该手术方式的患者;尽可能缩短手术时间以减少麻醉通气中造成的肺损伤,术中避免膈神经、喉返神经、迷走神经肺支等神经损伤,降低如支气管残端或气管支气管吻合口周围血供不良等引起残端或吻合口愈合的风险因素;优化术前、术中、术后管理中的气道管理、呼吸机管理、液体管理、疼痛管理、营养支持、心肺支持、自主咳嗽、早期活动等。可能会在规避风险的同时最大程度发挥一种手术方式本身在肿瘤学治疗中带来的效益。Pneumonectomy is mainly used for central primary bronchogenic carcinoma.In order to remove neoplastic tissue to the maximum,one side of the lung tissue needs to be resected.These results in an increased risk of postoperative complications in pneumonectomy compared to lung function preserved lung surgery.But this does not mean that it is the second best thing to abandon its oncology treatment benefits that are unmatched by other surgical methods in the treatment of lung cancer.We should not judge one surgical approach itself but to maxmize its therapeutic benefit through select suitable patients and practice strict perioperative planning.Preoperatively assess the patient's tumor and lymph node status and surgical resectability,cardiopulmonary function,and select the patients who can benefit the most from the operation;Reduce lung injury caused by anesthesia,avoid nerve damage such as phrenic nerve,recurrent laryngeal nerve,vagus nerve branch,etc.,reduce the risk factors of anastomotic healing such as blood supply around the anastomosis.Optimize airway management,ventilator management,fluid management,pain management,nutritional support,cardiopulmonary support,spontaneous cough,early activity and other factors in intraoperative and postoperative management.It may be possible to maximize the benifit of a surgical procedure in oncology treatment while avoiding risks.

关 键 词：支气管胸膜瘘 支气管残端 肺通气 肿瘤学 疼痛管理 肺癌治疗 肺血管床 膈神经 

分 类 号：R734.5[医药卫生—肿瘤]