The significance of preoperative cervical thoracic enhancement CT and CTA in the selection of different tumor surgical methods at the base of the neck to minimize complications
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摘要: 目的 探讨术前颈胸增强CT和CT血管造影(CTA)在颈根部不同肿瘤手术方式选择中的意义, 评估手术安全性, 选择合适的手术入路, 最大限度减少并发症。方法 回顾性分析51例累及颈根部肿物手术患者的临床资料, 其中良性病变24例, 恶性肿瘤27例。术前均行增强CT和(或)CTA检查, 了解肿瘤和(或)复发灶或转移灶与颈根的无名动静脉、颈内动静脉、锁骨动静脉、甲状颈干以及椎动脉的关系, 根据术前增强CT和(或)CTA分别采用单纯颈部切口入路、内镜辅助下颈部切口入路、颈胸联合(胸锁关节切除, 部分锁骨、胸骨柄切除或胸骨正中裂开)入路切除肿瘤。结果 患者随访6个月~10年, 24例良性病变全部完整切除; 27例恶性肿瘤中25例完整切除, 2例姑息减瘤切除, 无术中死亡病例。本组27例恶性肿瘤中术后出现声嘶2例; 永久性甲状旁腺机能减退1例, 术后1年死于并发症; 锁骨下动脉损伤和锁骨下静脉破裂各1例, 术中予以修复; 乳糜漏2例, 术后及时负压吸引和加压后痊愈; 胸膜顶损伤1例, 术中予以修补; 臂丛神经和膈神经损伤各1例。1例胸骨正中裂开后纵隔感染, 经3个月治疗后痊愈。结论 对不同性质、不同类型的颈胸交界处肿瘤应根据术前颈胸增强CT和CTA选择合适的手术入路以充分暴露肿瘤, 解剖并保护重要神经血管的同时也可及时有效处理术中并发症, 安全切除颈根部肿瘤。Abstract: Objective To explore the significance of preoperative cervical thoracic enhancement CT and CTA in the selection of different tumor surgical methods at the base of the neck to minimize complications.Methods Analysing the clinical data of 51 patients who had cervical root tumor surgery, including 24 benign lesions and 27 malignant tumors. Enhanced CT and/or CTA examinations were used before surgery to understand the relationship between tumors and/ or recurrent or metastatic lesions and the unnamed arteriovenous, internal jugular arteriovenous, clavicular arteriovenous, thyroid neck, and cone arteries of the cervical root. According to the preoperative enhanced CT and/or CTA, the tumor was removed by a simple neck incision approach or an endoscopic assisted neck incision approach or a combined neck and chest approach.Results The patients were followed up for 6 months to 10 years. All 24 benign lesions were completely removed. Twenty-seven cases of malignant tumors were completely resected, 2 cases were palliative and cytoreductive, and no death occurred during the operation; There were 2 cases of hoarseness in 27 cases of malignant tumors in this group; 1 case of permanent hypoparathyroidism, died of complications 1 year after surgery; 1 case of subclavian artery injury and 1 case of subclavian vein rupture, repaired during operation; 2 cases of chylous leakage were cured after timely negative pressure suction and compression; 1 case of pleural trauma was repaired during the operation; 1 case of brachial plexus nerve and sacral nerve injury. One case had mediastinal infection after median dehiscence of the sternum was cured after 3 months of treatment.Conclusion For different nature and different types of tumors at the neck-thoracic junction, appropriate surgical approaches should be selected according to preoperative enhanced CT and CTA to fully expose the tumors. While effectively protecting important neurovasculature, timely and effective treatment of intraoperative complications, so that it is feasible to safely remove part of the cervical root tumor.
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Key words:
- computed tomography /
- angiography /
- head and neck neoplasms /
- cervical root
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图 1 单一颈部切口入路切除胸骨后巨大甲状腺肿 1a：CT示胸骨后巨大甲状腺肿；1b：CTA示胸骨后巨大甲状腺肿；1c：胸骨后巨大甲状腺肿自颈部切除； 图 2 单一颈部切口入路切除上纵隔-畸胎瘤 2a：CT示上纵隔-畸胎瘤；2b：上纵隔-畸胎瘤切除后术中所见；图 3 下咽癌术后放疗后颈部复发侵犯甲状颈干分支CTA评估血管关系后仍可行手术治疗 3a：CT示下咽癌术后放疗后颈部复发累及颈根部；3b：CTA示甲状颈干分支侵犯、椎动脉未受累；3c：术中示甲状颈干分支侵犯、椎动脉未受累； 图 4 单一颈部切口入路切除气管造口复发癌，皮瓣修补 4a：气管造口复发癌；4b：CT示气管造口复发癌与颈部重要血管有筋膜间隙；4c：气管造口复发癌术后； 图 5 甲状腺癌侵犯甲状颈干分支，CTA评估血管关系后仍可行手术治疗 5a：CT示甲状腺癌侵犯颈根部；5b：CTA示甲状颈干分支侵犯、椎动脉未受累；5c：术中示甲状颈干分支侵犯、椎动脉未受累； 图 6 年龄较大且基础疾病多的患者术后气管缺损较大直接行气管造瘘 6a：CT示甲状腺癌侵犯颈段气管；6b：甲状腺癌侵犯颈段气管术中所见； 图 7 颈段气管鳞状细胞癌，与周围组织粘连紧密，行胸骨劈开入路切除肿瘤 7a：CT示颈段气管鳞状细胞癌；7b：胸骨劈开暴露颈段气管鳞状细胞癌； 图 8 甲状腺癌伴颈根部、上纵隔转移，行胸骨劈开入路切除肿瘤 8a：CT示甲状腺癌侵犯颈根部及上纵隔；8b：胸骨劈开暴露侵犯颈根部、上纵隔甲状腺癌。
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