Ⅳ期卵巢癌使用EndoGIA外科吻合器横膈全层切除,继之使用Gore-tex移植重建横膈1例报道及文献回顾

Background. Previous studies have reported the results of fullthickness diaphragmatic resection for ovarian cancermetastatic to the diaphragm. Case. We present the first case of an extensive full- thickness diaphragmatic resection performed using the EndoGIA [US Surgical Corp., Norwalk, CT staple device followed by successful reconstruction using a Gore- tex (W.L. Gore and Associates, Inc., Newark, DE) graft. Conclusion. Full- thickness diaphragmatic resection using the EndoGIA stapling device is a safe and effectivemethod to completely remove extensive tumor during cytoreductive surgery. Use of the stapler expeditiously assists in removal of the specimen with minimal blood loss. In cases where large defects cannot be repaired primarily, a Gore- tex patch should be used.

整形外科经横直肌腹部肌皮瓣移植术后的乳腺癌患者行双侧输卵管切除术后的腹腔镜检查

Objective. The aim of this study was to describe the feasibility and outcome of laparoscopic risk-reducing salpingo-oophorectomy (RRSO) in patients with a history of breast cancer who previously had undergone a transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. Methods. We performed a retrospective review of patients with a history of breast cancer who had undergone laparoscopic RRSO between February 1995 and April 2002. Patients who had undergone TRAM flap reconstructive surgery were compared with patients who had undergone laparoscopic RRSO without prior reconstructive surgery. Results. We identified 102 patients with a history of breast cancer who were candidates for a laparoscopic RRSO during the study period. One hundred one of these patients underwent the procedure, including 10 patients with a history of TRAM flap breast reconstructive surgery. One patient did not undergo the procedure because she was noted to be hypotensive prior to the procedure from her bowel preparation. There were no differences between the groups with or without prior history of TRAM flap reconstruction with respect to body mass index, prior abdominal surgery, menopausal status, or preoperative ultrasound characteristics. Operatively, there was no difference between the groups with respect to estimated blood loss, hospital stay, and intraoperative and postoperative complication rates. The only noted difference between the two groups was the estimated operating time (TRAM group, 91 min; non-TRAM group, 70 min [P < 0.01]). Conclusions. Laparoscopic RRSO is safe and feasible in patients who have undergone a prior TRAM flap reconstruction.

卵巢上皮癌二探手术阳性患者预后因子的研究

Objective.: The objective of this study was to identify independent prognostic factors for survival in patients with epithelial ovarian cancer who had persistent disease identified at second look surgery. Methods.: We performed a retrospective chart review of all patients with epithelial ovarian cancer who had positive findings at second-look surgery between June 1991 and June 2002. All patients achieved a complete clinical remission after a prescribed course of primary therapy. Survival was determined from the time of second-look surgery until last follow-up or death. Results.: The study included a total of 262 patients, with a median age of 54 years(range, 22-80). Of the 262 patients, 166(63%) had died of disease. Records of initial(salvage) treatment after the positive second-look surgery were available for 243 patients. Therapies included the following: intraperitoneal(IP) cisplatin, 71(29%); IP cisplatin combined with a second drug, 53(22%); IP therapy other than cisplatin, 29(12%); intravenous(IV) chemotherapy, 50(21%); IP and IV therapy, 35(14%); and oral chemotherapy, 5(2%). Of the 13 potential prognostic factors analyzed, only 2 factors emerged that, when combined, were significant-residual disease after primary surgery and size of persistent disease found at second-look surgery. Patients with ≤1 cm residual disease after primary surgery and microscopic disease at second-look surgery had significantly improved survival. Conclusion.: In our analysis, the only prognostic factor for survival in patients with positive second-look procedures was a combination of residual disease after primary surgery and size of persistent disease identified at second-look surgery. No individual chemotherapy treatment imparted a survival advantage. Novel that therapeutic approaches are needed in this setting.

恶性肿瘤妇女腹腔镜手术后的皮下肿瘤种植

OBJECTIVE: To describe the incidence of clinically detected laparoscopy-related subcutaneous tumor implantation in women with malignant disease who were treated by a gynecologic oncology service. METHODS: We reviewed all cases of primary or metastatic malignancy who underwent a transperitoneal laparoscopy. Open laparoscopy technique was used in all cases with the Hasson trocar, usually placed near the umbilicus. A carbon dioxide pneumoperitoneum was used in all cases, with maximum intraabdominal pressure set at 15 mm Hg. All trocar sites more than 5 mm were closed at the fascia level. Identifying subcutaneous implantation was performed by a detailed review of all available medical records and by review of a prospectively maintained comprehensive complications database. RESULTS: In a 12-year period (July 1991 to July 2003), 2,593 laparoscopic procedures were performed,including 1,335 transperitoneal laparoscopies in 1,288 women with malignant disease. Malignant disease sites included adnexa/peritoneum (584), uterine corpus (355), uterine cervix (100), and other (249). There were no “isolated”trocar-related subcutaneous tumor implantations during the study period. Subcutaneous tumor implantations (n = 13, 0.97%) usually occurred with carcinomatosis, with synchronous metastases to other sites, and in the setting where the preceding laparoscopy was performed in the presence of advanced or recurrent abdominopelvic disease. CONCLUSION: Laparoscopy-related subcutaneous tumor implantation is rare (0.97%) in women undergoing transperitoneal laparoscopy with malignant disease. Subcutaneous implantation appears to occur in patients with known metastatic disease and is detected in the setting of synchronous advanced intraabdominal or pelvic metastasis and progression of carcinomatosis. The risk of subcutaneous tumor implantation should not be used as an argument against laparoscopy in the majority of women with gynecologic malignancies managed by gynecologic oncologists.

视频辅助胸腔镜手术对剖腹探查术前疑为晚期卵巢癌和中度至重度胸膜转移患者的益处

Objective. To analyze the findings and impact on the management of vi deo-assi sted thoracoscopic surgery (VATS) before planned abdominal exploration in patien ts with suspected advanced ovarian cancer and moderate to large pleural effusion s. Methods. We reviewed the charts of all patients with suspected advanced ovari an cancer and moderate to large pleural effusions who underwent VATS from 10/01 to 7/03. VATS was performed under double lumen endotracheal anesthesia. A 2-cm chest wall incision was made in the fifth intercostal space on the side of the e ffusion. The thoracoscope was introduced and biopsies of suspicious lesions were performed through the single incision. After VATS, all patients had a chest tub e placed through the incision, and those with malignant effusions underwent talc pleurodesis either intraoperatively or postoperatively. Results. Twelve patient s underwent VATS during the study period. Median operative time for VATS was 31 min (range: 20-49 min) with no complications attributable to the procedure. The median amount of pleural fluid drained was 1000 ml (range: 500-2000 ml). Solid , pleural-based tumor was found in six cases (50%), with nodules >1 cm noted i n four patients (33%) and nodules < 1 cm noted in two patients (17%). Of the s ix cases with no grossly visible pleural tumor, the pleural fluid was positive f or malignant cells in two patients (17%)-and negative in four patients (33%). Further initial patient management included the following: laparotomy with opti mal cytoreduction, 6 (50%); diagnostic laparoscopy, 3 (25%); and no abdominal exploration, 3 (25%). Final diagnosis of primary disease site was as follows: o vary, 9 (75%); fallopian tube, 1 (8%); endometrium, 1 (8%); and lymphoma, 1 ( 8%). Based on the findings duringVATS, laparotomy and attempted cytoreduction w ere avoided in four patients (33%), and the cytoreductive procedure was modifie d in one patient (8%). Conclusion. Fifty percent of patients with suspected adv anced ovarian cancer and moderate to large pleural effusions who underwent VATS had solid pleural-based tumor identified, and in 33%of cases the tumor nodules were >1 cm in diameter. VATS should be considered in these cases to delineate t he extent of disease, treat the effusion, and to potentially select patients for either intrathoracic cytoreduction or a neoadjuvant chemotherapy approach.

附件及腹膜癌症患者术中输血:对症状性静脉血栓及其生存率的影响

Objective. To determine whether perioperative packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions during ovarian, tubal, or peritoneal cancer surgery increase the risk of symptomatic postoperative venous thromboembolism (VTE) and adversely affect overall survival. Methods. We conducted a retrospective review of all cases of surgical exploration for resection of stage IIIC-IV adnexal/peritoneal cancer between November 1998 and May 2002 at Memorial Sloan-Kettering Cancer Center. Patients with a history of prior or active preoperative VTE were excluded. Routine intraoperative and postoperative VTE prophylaxis including lower extremity external pneumatic compression with or without postoperative subcutaneous heparin was utilized in all cases. Symptomatic postoperative VTE was diagnosed by lower extremity Doppler or computerized tomography (excluding cases with only ovarian vein thrombosis). Clinical parameters were examined by a logistic regression analysis to identify independent prognostic predictors of postoperative symptomatic VTE, which occurred within 30 days of surgery. Survival was calculated using the Kaplan-Meier method. Results. In all, 174 patients underwent exploratory surgery, and 6 (3.4%) were excluded due to active or prior history of VTE. Of the remaining 168 patients, 71 (42%) received at least one perioperative transfusion of PRBC or FFP. Postoperative VTE was documented in 5 of 46 (11%) patients who received a postoperative transfusion compared to 3 of 122 (2.5%) patients who did not (P = 0.04; odds ratio, 4.8); moreover, VTE was noted in 3:16 (19%)patients who received postoperative FFP compared to 5:152 (3.3%) patients who did not (P = 0.01, odds ratio of 6.78). Age, stage, body mass index, length of the operation, blood loss, presence of ascites, volume of ascites, residual disease status, preoperative hemoglobin level and coagulation profile were not associated with increased risk for VTE. When survival results were stratified by transfusion utilization and controlling for optimal debulking status, perioperative transfusions had no apparent effect on overall survival. Conclusion. In women with stage IIIC-V disease, postoperative blood product transfusions particularly FFP were associated with increased risk of DVT and PE, but transfusions had no impact on overall survival.

晚期上皮性卵巢癌患者肿瘤细胞减灭术后直肠乙状结肠切除和初期吻合的发病率

Studies from the colorectal literature have shown that factors associated with anastomotic leak after colorectal resection include long surgical time (>2 h), multiple blood transfusions, and short distance to the anal verge. The aim of this study was to assess the morbidity associated with en bloc resection of ovarian carcinoma with low anterior resection and anastomosis in patients undergoing primary cytoreductive surgery for advanced disease. Methods. We performed a retrospective chart review of all patients who had undergone primary cytoreduction for advanced epithelial ovarian cancer with rectosigmoid resection followed by low rectal anastomosis between January 1994 and June 2004. Patient characteristics, operative details, and postoperative complications were extracted from patients’ charts. Results. Seventy patients met the above criteria and form our study group. The median age was 59 years (range, 25- 82). There were 52 stage IIIC (74% ) and 18 stage IV (26% ) cancers. The median operating time was 315 min (range, 120- 750) and the median estimated blood loss was 1200 ml (range, 250- 8000), with 53 (76% ) patients requiring blood transfusion. Twenty-eight patients (40% ) underwent major upper abdominal procedures other than omentectomy, and 14 patients (20% ) underwent a second bowel resection. Twelve patients (17% ) underwent a protective ileostomy while the remainder (83% ) did not. Of the 58 patients with no ostomy, the only complications associated with the resection and anastomoses were a pelvic abscess in 3 patients (5% ) and an anastomotic leak requiring diverting colostomy in 1 patient (1.7% ). Of the 12 patients who had protective ileostomies, 3 (25% ) had complications related to their ileostomy short-bowel syndrome requiring early reversal, incarceration of the prolapsed loop requiring surgical correction, and prolapse corrected electively at the time of second-look surgery. Conclusions. In women undergoing primary cytoreductive surgery, the morbidity associated with en bloc resection of ovarian carcinoma with low rectosigmoid resection and anastomosis without protective ileostomy was acceptably low, with an anastomotic leak rate of less than 2% . Protective ileostomy is not always necessary and should be used selectively.