Baba Mika, Nakagawa Masashi, Kuri Michioki, Taniguchi Hiroshi, Mammoto Tadanori, Kanbara Noriko, Sakai Toshiko, Kishi Yoshihiko
Department of Anesthesiology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511.
Masui. 2003 Jul;52(7):759-61.
We experienced perioperative management for excision of a huge sternal chondrosarcoma squeezing the heart. A 46-year-old woman could not sleep due to dyspnea for 6 months. Dyspnea increased in the right decubitus and disappeared in the left decubitus. This suggested that the heart was squeezing the tumor. MRI and echocardiography revealed no invasion to the heart. Surgical removal was proposed. Anesthesia was induced with propofol and fentanyl. As this tumor composed of bone-like tissue and was tightly connected with thoracic cage, we thought that the use of muscle relaxant at the induction of anesthesia would not cause cardiovascular collapse and ventilation insufficiency even if the tumor was huge. Vecuronium was administered to facilitate endotracheal intubation. Hemodynamic variables were stable and mask ventilation was uneventful. Anesthesia was maintained with propofol, sevoflurane, supplemental dose of fentanyl and epidural anesthesia. The tumor had invaded the myocardium and was successfully flaked off from the myocardium without using any assisted devices. The tumor was excised including thoracic wall (sternum and parts of 3rd to 12th ribs, 20 cm in diameter). Thoracoplasty was performed using Marlex Mesh. Muscle relaxant was reversed after the end of the operation. Respiration was stable without flail chest. Endotracheal tube was successfully removed in the operation room. The postoperative course was uneventful.
我们对一例挤压心脏的巨大胸骨软骨肉瘤切除手术进行了围手术期管理。一名46岁女性因呼吸困难6个月无法入睡。呼吸困难在右侧卧位时加重，在左侧卧位时消失。这提示心脏受到肿瘤挤压。磁共振成像（MRI）和超声心动图显示心脏未受侵犯。建议进行手术切除。采用丙泊酚和芬太尼诱导麻醉。由于该肿瘤由骨样组织构成且与胸廓紧密相连，我们认为即使肿瘤巨大，在麻醉诱导时使用肌肉松弛剂也不会导致心血管崩溃和通气不足。给予维库溴铵以利于气管插管。血流动力学变量稳定，面罩通气顺利。采用丙泊酚、七氟醚、追加剂量的芬太尼和硬膜外麻醉维持麻醉。肿瘤侵犯了心肌，在未使用任何辅助装置的情况下成功从心肌上剥离。包括胸壁（胸骨及第3至12肋部分，直径20厘米）在内切除肿瘤。使用Marlex网片进行胸廓成形术。术后结束时逆转肌肉松弛剂的作用。呼吸稳定，无连枷胸。在手术室成功拔除气管导管。术后病程顺利。
