【作者】 杨斌；

【导师】 杨占泉；

【作者基本信息】 吉林大学 ， 耳鼻咽喉科学， 2006， 博士

【摘要】 本文深入研究了颈胸交界处的解剖层次,包括颈部的颈根部及胸部的上纵隔,不仅熟知颈胸解剖分界线上区的动静脉,臂丛神经的上中下干及胸导管在肌肉覆盖下密集交错的走行和毗邻关系,还深入研究颈胸解剖分界线下区的胸膜顶、肺尖、上腔静脉其及属支、主动脉弓及其分支,尤其是锁骨下动静脉的解剖方位与特点。在熟知颈胸交界处这一区域应用解剖的基础上,总结作者采用颈胸联合进路治疗跨锁骨和胸骨肿瘤18例的临床经验,指出应根据颈胸交界处肿瘤的原发部位、侵袭范围和病理特点,选择跨锁骨肿瘤、跨胸骨肿瘤和跨锁骨及胸骨肿瘤的颈胸联合进路手术方式;明确了锁骨切除或离断移位的指征及胸骨正中部分或全劈开的手术指征;术中需要注意的要点,以及手术的并发症及预后。通过本研究我们总结了颈胸交界处的解剖层次、采用不同方式的颈胸联合进路手术的指征,术中要点以及手术的并发症,将过去耳鼻咽喉科、胸外科、神经外科独立操作无法进行根治性切除的颈胸交界处肿瘤的治疗进行系统化及理论化,为颈胸交界处肿瘤外科治疗手术入路的选择提供了理论依据,使得以往不能进行根治性切除的颈根部肿瘤可以达到根治性切除,为耳鼻咽喉科的完善和发展做出了贡献。更多还原

【Abstract】 With progress of basic research and clinical research, the headand neck surgery have made a lot of improvement in many aspects, butthe reports about the surgical treatment of cervicothoracic tumorsare few. In recent years, literature reports about the surgicaltreatment of cervicothoracic tumors is increasing, but it isrestricted to sporadic reports, not given a deep research. It is theimportant mark in the realm of that cervicothoracic tumors aretreated with cervicothoracic approach operation.Cervicothoracic tumors across the border of neck and chest havethe unique clinical and pathological characteristics, theseobjective existing diseases, just like the skull bottom diseases tobe same, have caused doctors of otolaryngology and thoracic surgeryenormous interest and attention. Surgical treatment ofcervicothoracic junction diseases can be a challenging issue, asevidenced by diverse reports in the literature from practitionersof many different surgical specialties, including neurological;orthopedic;ear, nose, and throat;and cervicothoracic surgeons.Access to this region is complicated by the presence of major vascularelements as well as important visceral and soft-tissue structures.Therefore it appears especially important and has enormous practicalsignificance that we are familiar with the application anatomy ofthis region and design corresponding operation incision accordingto the disease characteristic.Based on these reasons we first study the anatomy of thecervicothoracic junction, including the neck root and superiormediastinum, not only knowing very well about the artery and vein,brachial plexus and the thoracic duct crowded under the muscle coverand their adjacent relations above the border line of thecervicothoracic junction, but also being familiar with cupula ofpleura, the lung apex, superior vena cava and its branches, the archof the aorta and its branches under the border line of thecervicothoracic junction, especially the anatomy position and thecharacteristic of the subclavian artery and vein. On the basis ofknowing the application anatomy of cervicothoracic junction verywell, we performed surgery in 18 patients with cervicothoracicapproach to treat the transclavicular tumors and the transmanubriatumors, benign 13 patients, malignant 5 patients, including totalclaviculectomy 8 patients, partial claviculectomy 4 patients,sternotomy 6 patients. Benign tumor include giant cystlymphangioma2 patients, hemangioma 1 patients, neurilemoma 3 patients,neurofibroma 1 patients, retrostenal goitor 5 patients. Malignanttumor include unknown reason metastasis cancer 4 patients, neck rootand superior mediastinum thyroid papillary carcinoma 1 patients.According to the tumor location, the extent of involvement andthe pathology characteristic, we choose three different surgerymethods, including transclavicular approach, transmanubrialapproach and cervicothoracic approach.To the transclavicular tumor, according to the scope of the tumorinvolvenment to subclavical and to the neck and chest important bloodvessel and nerve, we decide to choose the total or partialclaviculotomy and the dividing clavical technique in order to fullyexpose disease area and to excise from the top downward or from thebottom upward. The indication of claviculectomy and the dividingclavical technique: 1st, the malignant tumor has invaded the clavicle;2nd, the tumor transgress the clavicle, if not excise or not divideand shift the clavicle, the tumor excision is difficult or dangerors;3rd, in the operation the subclavian artery and vein hemorrhage orthe pleural and lung damage needs urgent operation.Along the occipital triangle vertically and the clavicle levelhorizontally we make the big L-shape incision, its convergencevertically and horizontally maintain obtuse angle. Cutting open skin,hypoderm and platysma, turning over the skin to expose the shallowstructure of the neck front side and flank side, excising orinterrupting and shifting clavicle, and cutting off thesternocleidomastoid and inferior belly of omohyoid from the neckroot , after lifting these structures we expose the deep structureof the neck front side and flank side, meantime we can look straightthe disease scope of subclavical and upclavical and the extend oftumor involvenment to the neck and chest important blood vessel andnerve. When excision tumor, we must pay attention to protect thepleural membrane, the lung apex and the blood vessel, such as commoncarotid artery of brachiocephalic trunk, subclavian artery and vein,thyroid gland and neck traversing vein. The recognition andprotection of vagus nerve, diaphragm and brachial plexus , it is veryimportant to decide the surgery success or failure and to reducedisease complication. Operateing on the left side clavicle, we shouldcarefully observe whether there are the thoracic duct damage and thechyle fistula occurrence. In the operation if we find pneumothoraxbecause of the pleural damage, we should fast place the chest cavitydrainage tube. Any hemorrhage must be adopted accurate measurementsto stop bleeding, especially the damage of common catotid andsubclavian artery and vein, not only the bad risk also lethalfrequently.The transmanubria tumors not only include the tumor in the lowerpart the neck which already invade the retrosternal mediastinum, alsohas the mediastinum tumor which develope upward to the neck. Thesurgery indication of transmanubrial approach or sternocotomy refersto the size and nature of primary chest cavity tumor and the invasionmediastinum tumor. Regarding certain cysts, the thyroid gland tumorand the lymphangioma and so on, sometimes we may use the finger toenter into the mediastinum , make the blunt separation along the tumorcapsula, at the same time clip on both sides of the tumor by theinstrument and raise slowly, with joint forces take out the wholetumor from the neck incise. But the more big or malignant growth tumor,because the blood circulation is rich or we doubts there has theneighbor tissue adhesion or metastasis, operation blindly is noteffective and dangerous. Usually we advocate transmanubrial approachor sternocotomy in order to expose the mediastinum disease and itsanatomy structure. In the operation we must avoid damaging therecurrent laryngeal nerve, artery and vein, trachea, esophagus,pleural and thoracic duct and so on, in case causing the seriouscomplication. Transclavimanubrial tumor is rare in clinic, becausethe lesion scope is generally broad, we must synthesize the aboveway to carry on the surgery.Because there are a number of objective existence diseases in thecervicothoracic junction and the tumor has the invading mutuallybiological characteristic, it has already provided the new clinicaland basic research platform for multi-disciplinary doctor, such asthoracic, osteo, radiography and otolaryngology department and soon. Benign tumor in the area around cervicothoracic junction anatomyborder, mostly origining from the nerve, blood vessel or fiberstructure, dystopia thyroid gland and so on, is found mostly in 30years old or above male. In the young child many are congenital, suchas cyst and lymphangioma. In benign tumor operation has goodlong-term curative effect. 13 patients in this group was made a from1 to 8 years follow-up, there has not an example to recur. The headand neck lymphangioma, although Sichel and so on injected the OK-432hardening therapy locally to have satisfaction effect, but it isadvocated the surgical treatment as to the giant neck-chest typewhich is reported in this article, if it recurs we use hardeningtherapy locally secondly. In the malignant tumor the unknown reasonsuperior clavicle metastasis squamous tumor is common, in this groupof 5 patients, after the multi-spots radiography, ultrasonic,endoscopy examination, cell pathological inspection, we has notdiscovered the primary site in 4 patients. Most scholars advocateapprehensive therapy at present primarily operation, and think theprognosis of 81. 1% squamous cancer is favorable. Second is thethyroid cancer, the papillary carcinoma and the follicular carcinomaare most frequent in clinic. If it is discovered early and the lesionscope is limit, after the operation and the supplement chemotherapy,generally its prognosis is favorable.The common operation complications include hemorrhage,pneumothorax, neurotrosis, chyle fistula and infection. In order toavoid the blood vessel, the pleural membrane and the nerve damage,the surgeon needs to be familiar with the anatomy structure in thecervicothoracic junction. We must be pay attention to stop bleedingaccurately during operation, to some malignant tumor if excision hasthe hemorrhage risk, it should be given palliative operation. Afterthe operation supplement radiotherapy and chemotherapy may used. Thepneumothorax from pleural damage must promptly be treated by suturingthe pleural membrane or the chest cavity drainage. During theoperation carrying out the strict aseptic operation and reducingunessential operation, we drain the incise, treat the complicationearly and use anti-infection therapy after operation.Through this study we summarize the anatomy structure in thecervicothoracic junction, indications of the differentcervicothoracic approach, the main point during opetation as wellas the operation complication. We make it systematization andtheorization to treat the cervicothoracic tumor with differentcervicothoracic approaches, this has provided theory basis for thetreatment of cervicothoracic junction tumor.更多还原