探讨非血管重建颈动脉切除术在头颈外科中的应用

Application of resection of tumor and carotid artery without artery reconstruction to head and neck surgeries

摘要:

目的：探讨进一步提高固着于颈动脉肿瘤的手术成功率，扩大外科治疗范围。方法：采用数字减影脑血管造影（DSA）和经颅多普勒 （TCD）术前诊断和评估脑血流侧支循环状态，对固着于颈动脉的12例颈动脉体瘤和2例颈部转移癌施行非血管重建的肿瘤合并颈动脉切除术。结果：全组病例经颈动脉体外压迫训练30 d后，TCD检测显示前、后交通动脉开放良好，患侧大脑前动脉（ACA）和大脑中动脉（MCA）平均血流速均达到（40～56）cm/s和（50～64）cm/s；DSA显示ACA完全显影，MCA大部分显影提示训练达标。术后病理报告显示颈动脉体瘤12例，甲状腺乳头状癌转移1例，口底鳞癌转移1例。所有患者随诊4～15年，其中2例转移癌患者分别在术后2年死于肿瘤复发，其余患者未见肿瘤复发，无1例手术死亡或脑血管并发症。结论：DSA和（或）TCD在颈动脉切除术的术前诊断和评估脑血流侧支循环代偿能力起决定性作用，准确的术前评估，严格操作步骤是手术成功的关键。

Abstract:

Objective:To promote the operative successful rate and enlarge the operative range for tumors fixed to carotid artery. Methods:After preoperative evaluation of cerebral collateral circulation with digital subtraction angiography (DSA) and trans-cranial Doppler test (TCD), resection of tumor and carotid artery without artery reconstruction was applied to 14 patients with tumor fixed to carotid artery. Of them, 12 suffered from carotid body tumor and 2 from metastatic carcinoma of the neck. Results:After extracorporeal carotid pressure training with pediatric stermalretractor device (PSRD) for 30 days, TCD displayed excellent opening to anterior communication artery (AcoA) and posterior communication artery (PcoA) in all cases. The average cerebral perfusion flow rates of anterior cerebral artery (ACA) and middle cerebral artery (MCA) in the involved side were 40-56cm/s and 50-64cm/s respectively. Meanwhile, DSA displayed total and partial image development of ACA and MCA, which was considered to be eligible for surgery. Postoperative pathological examinations confirmed carotid body tumor in 12 cases, metastatic carcinoma from thyroid gland in one, and from mouth floor in another case. No intraoperative death and severe CNS complications occurred. Followup of the 14 patients for 4 to 15 years revealed that 2 cases of them died from tumor recurrence 2 years after operation. Conclusions:DSA and TCD play an essential role in the preoperative diagnosis and evaluation of compensatory ability of cerebral collateral circulations. Successful operation bases on precise preoperative evaluation, proper choice of surgical approach and procedure.