原发性肝癌病人的护理详解医学幻灯片

转移背阔肌肌皮瓣修复术在局部晚期乳腺癌手术中的应用,.,Contents,局部晚期乳腺癌定义,局部晚期乳腺癌治疗现状,背阔肌解剖学,背阔肌肌皮瓣修复术手术要点,注意事项及临床体会,.,局部晚期乳腺癌治疗现状？,.,Impact of progression during neoadjuvant chemotherapy on surgical management of breast cancer.,METHODS: We reviewed clinicopathological data on patients who received NCT for stage I-III breast cancer from 1994 to 2007. Chemotherapy regimens were anthracycline-and/or taxane-based as determined by the treating medical oncologist. RESULTS: Of 1,928 patients who received NCT, 1,762 (91%) had a partial or complete response, 107 (6%) had stable disease (SD), and 59 (3%) progressed (PD) while receiving at least one regimen. Of the patients with progressive disease, 40 (68%) patients underwent mastectomy, 12 (20%) underwent BCT, and 7 (12%) did not undergo surgery. In patients who underwent mastectomy, only three (8%) were BCT candidates before progression. Overall, disease progression changed the operative plan in 11 (0.5%) patients: 3 developed distant metastasis, 2 developed clinical lymphadenopathy, 3 required mastectomy instead of BCT, 2 became inoperable, and 1 required flap closure.CONCLUSIONS: Disease progression while receiving NCT is infrequent (3%), but early identification may allow for change to other, potentially beneficial, therapeutic interventions. Patients with breast cancer who receive NCT should be evaluated frequently for response to therapy. Overall, progression during NCT changes the surgical management in a small proportion of patients.,Caudle AS et al. Ann Surg Oncol. 2011 Apr;18(4):932-8.,.,转移背阔肌肌皮瓣修复术适应症及禁忌症,适应症：乳房切除术后皮肤缺损乳腺癌根治术后自体组织乳房重建保乳术后局部畸形放疗后胸壁溃疡,禁忌症开胸术后背阔肌被切断胸背血管受损者上胸壁大面积皮肤缺损者,.,背阔肌的解剖学基础,.,背阔肌解剖学,位于肩胛骨下方，三角形发于T7T12、腰骶椎和最下面34根肋骨，止于肱骨结节间沟供血来源于胸背动脉和内乳动脉及肋间动脉的穿支神经支配为胸背神经功能：使肱骨内旋，上臂的内收和外展,.,背阔肌肌皮瓣的应用,历史：Baudet (1976) 首先进行了游离移植的报道。以后临床广泛应用，成为最常用的游离皮瓣之一 皮瓣特点：血管分布恒定，蒂部管径在1.52.0mm。血管蒂长：68cm易于剥离和切取供区范围大：68cmX 1215cm供区不遗留明显的功能障碍皮瓣血运丰富可形成单纯的肌瓣可用于进行肌肉功能的重建 应用范围：带蒂移植：胸部、上肢的组织缺损，屈肘功能重建，乳房再造等游离移植：头、面、颈、四肢、躯干等部位均可应用,.,1,术前先描画出手术切口全麻下，先仰卧位，行乳腺癌改良根治或根治术乳房切口彻底止血后用湿大纱布覆盖并用无菌手术膜隔离,.,2,再取侧卧位，在背阔肌表面按预先设计的梭形切口逐层切开沿背阔肌前缘切取背阔肌并向后方延续，注意保护前锯肌及大圆肌注意保护血管蒂把肌皮瓣经皮下隧道轻送到乳房创面,.,3,再改为仰卧位，将转移的肌皮瓣缝合固定于前胸壁切口并关闭皮肤切口切口轻度加压包扎引流管负压吸引,.,手术技巧及注意事项,.,1.体位,1.先仰卧位；2.侧卧位；3.最后仰卧位,.,2.保护胸背血管蒂,胸背血管,胸外侧血管,.,5.慎防误切大圆肌及前锯肌,误切上述二肌肉会引起肩关节内收功能障碍,.,临床体会,.,