巨大前列腺增生症前列腺前被膜∧形切除术(附23例报告)

我院自1988年2月～1998年2月共收治巨大前列腺增生症23例,均采用前列腺被膜∧形切除术,效果满意,现报道如下。1 临床资料1.1 一般资料 本组23例,年龄65～92岁,平均74岁,进行性排尿困难14例,急性尿潴留9例,有导尿史19例,其中保留尿管12例,改做膀胱造瘘5例,伴有血尿7例,...

Predictive value of D-dimer for portal vein thrombosis after portal hypertension surgery in hepatitis B virus-related cirrhosis

AIM: To evaluate the predictive value of D-dimer as a predictive indicator of portal vein thrombosis (PVT) after portal hypertension surgery in hepatitis B virus-related cirrhosis. METHODS: A prospective study was carried out in 52 patients who had undergone surgery for portal hypertension in hepatitis B virus-related cirrhosis. Changes in perioperative dynamic D-dimer were observed. The sensitivity, specifi city, positive predictive values and negative predictive values of D-dimer were calculated, and ROC curves were analyzed. RESULTS: The D-dimer levels in the group developing postoperative PVT was signifi cantly higher than those in the group not developing PVT (P = 0.001), and the ROC semi-quantitative and qualitative analysis of D-dimer showed a moderate predictive value in PVT (semi- quantitative value Az = 0.794, P = 0.000; qualitative analysis: Az = 0.739, P = 0.001). CONCLUSION: Dynamic monitoring of D-dimer levels in patients with portal hypertension after surgery can help early diagnosis of PVT, as in cases where the D-dimer levels steadily increase and exceed 16 μg/mL, the possibility of PVT is very high.

Surgical anatomy of innervation of the gallbladder in humans and Suncus murinus with special reference to morphological understanding of gallstone formation after gastrectomy

AIM： To clarify the innervation of human gallbladder,with special reference to morphological understanding of gallstone formation after gastrectomy.METHODS： The liver, gallbladder and surrounding structures were immersed in a 10 mg/L solution of alizarin red S in ethanol to stain the peripheral nerves in cadavers （n = 10）. Innervation in the areas was completely dissected under a binocular microscope. Similarly,innervation in the same areas of 10 Suncus murinus （S. murinus） was examined employing whole mount immunohistochemistry.RESULTS： Innervation of the gallbladder occurred predominantly through two routes. One was from the anterior hepatic plexus, the innervation occurred along the cystic arteries and duct. Invariably this route passed through the hepatoduodenal ligament. The other route was from the posterior hepatic plexus, the innervation occurred along the cystic duct ventrally. This route also passed through the hepatoduodenal ligament dorsally.Similar results were obtained in S. murinus.CONCLUSION： The route from the anterior hepatic plexus via the cystic artery and/or duct is crucial for preserving gallbladder innervation. Lymph node dissection specifically in the hepatoduodenal ligament may affect the incidence of gallstones after gastrectomy.Furthermore, the route from the posterior hepatic plexus via the common bile duct and the cystic duct to the gallbladder should not be disregarded. Preservation of the plexus may attenuate the incidence of gallstone formation after gastrectomy.

Bleeding duodenal hemangioma: Morphological changes and endoscopic mucosal resection

Recently, the development of endoscopic procedures has increased the availability of minimally invasive treatments; however, there have been few case reports of duodenal hemangioma treated by endoscopic mucosal resection. The present report describes a case of duodenal hemangioma that showed various endoscopic changes over time and was treated by endoscopic mucosal resection. An 80-year-old woman presented with tarry stools and a loss of appetite. An examination of her blood revealed severe anemia, and her hemoglobin level was 4.2 g/dL. An emergency upper gastrointestinal endoscopy was performed. A red, protrusive, semipedunculated tumor (approximately 20 mm in diameter) with spontaneous bleeding on its surface was found in the superior duodenal angle. Given the semipedunculated appearance of the tumor, it was suspected to be an epithelial tumor with a differential diagnosis of hyperplastic polyp. The biopsy results suggested a telangiectatic hemangioma. Because this lesion was considered to be responsible for her anemia, endoscopic mucosal resection was performed for diagnostic and treatment purposes after informed consent was obtained. A histopathological examination of the resected specimen revealed dilated and proliferated capillary lumens of various sizes, which confirmed the final diagnosis of duodenal hemangioma. Neither anemia nor tumor recurrence has been observed since the endoscopic mucosal resection (approximately 1 year). Duodenal hemangiomas can be treated endoscopically provided that sufficient consideration is given to all of the possible treatment strategies. Interestingly, duodenal hemangiomas show morphological changes that are influenced by various factors, such as mechanical stimuli.

Is delayed gastric emptying so terrible after pylorus-preserving pancreaticoduodenectomy? Prevention and management

AIM： To explore some operative techniques to prevent the occurrence of delayed gastric emptying （DGE） alter pylorus-preserving pancreaticoduodenectomy （PPPD）.METHODS： One hundred and eighty-six patients in a single medical center who accepted PPPD were retrospectively studied. The incidence of DGE was investigated and the influence of some operative techniques on the prevention of DGE was analyzed.RESULTS： During the operative process of PPPD, the methods of detached drainage of pancreatic fluid and bile and gastric fistulization were used. Postoperatively, six patients suffered DGE among the 186 cases; the incidence was 3.23% （6/186）. One of them was complicated with intraabdominal infection at the same time, and two with pancreatic leakage.CONCLUSION： Appropriate maneuvers during operation are essential to avoid postoperative DGE in PPPD. The occurrence of DGE is avoidable. It should not be used as an argument to advocate hemigastrectomy in PPPD.

A special recurrent pattern in small hepatocellular carcinoma after treatment:Bile duct tumor thrombus formation

AIM:To investigate the clinicopathologic features of bile duct tumor thrombus(BDTT) occurrence after treatment of primary small hepatocellular carcinoma(sHCC) .METHODS:A total of 423 patients with primary sHCC admitted to our hospital underwent surgical resection or local ablation.During follow-up,only six patients were hospitalized due to obstructive jaundice,which occurred 5-76 mo after initial treatment.The clinicopathologic features of these six patients were reviewed.RESULTS:Six patients underwent hepatic resection(n=5) or radio-frequency ablation(n=1) due to primary sHCC.Five cases had an R1 resection margin,and one case had an ablative margin less than 5.0 mm.No vascular infiltration,microsatellites or bile duct/canaliculus affection was noted in the initial resected specimens.During the follow-up,imaging studies revealed a macroscopic BDTT extending to the common bile duct in all six patients.Four patients had a concomitant intrahepatic recurrent tumor.Surgical re-resection of intrahepatic recurrent tumors and removal of BDTTs(n=4) ,BDTT removal through choledochotomy(n= 1) ,and conservative treatment(n=1) was performed.Microscopic portal vein invasion was noted in three of the four resected specimens.All six patients died,with a mean survival of 11 mo after BDTT removal or conservative treatment.CONCLUSION:BDTT occurrence is a rare,special recurrent pattern of primary sHCC.Patients with BDTTs extending to the common bile duct usually have an unfavorable prognosis even following aggressive surgery.Insufficient resection or ablative margins against primary sHCC may be a risk factor for BDTT development.

A rare case of duodenal duplication treated surgically

Duodenal duplication,a rare congenital malformation,can also be observed in adulthood.Although it can be cystic or tubular,communicating or non-communicating,cystic and non-communicating forms are the most common.Several complications,such as obstruction,bleeding,perforation and pancreatitis,may result.Optimal treatment is total excision,although endoscopic procedures have also been described in appropriate cases.If total excision is not possible,subtotal excision and internal derivation can be performed.The 38-year-old woman presented here had occasional attacks of abdominal pain and obstruction,and we considered the diagnosis of duodenal duplication by abdominal computerized tomography.As we confirmed the diagnosis with operative findings and histopathological signs,we treated her with subtotal excision and intraduodenal cystoduodenostomy.

Resection and primary anastomosis with or without modified blow-hole colostomy for sigmoid volvulus

AIM: To evaluate the efficacy of resection and primary anastomosis (RPA) and RPA with modified blow-hole colostomy for sigmoid volvulus. METHODS: From March 2000 to September 2007, 77 patients with acute sigmoid volvulus were treated. A total of 47 patients underwent RPA or RPA with modified blow-hole colostomy. Twenty-five patients received RPA (Group A), and the remaining 22 patients had RPA with modified blow-hole colostomy (Group B). The clinical course and postoperative complications of the two groups were compared. RESULTS: The mean hospital stay, wound infection and mortality did not differ significantly between the groups. Superficial wound infection rate was higher in group A (32% vs 9.1%). Anastomotic leakage was observed only in group A, with a rate of 6.3%. The difference was numerically impressive but was statistically not significant. CONCLUSION: RPA with modified blow-hole colostomy provides satisfactory results. It is easy to perform and may become a method of choice in patients with sigmoid volvulus. Further studies are required to further establish its role in the treatment of sigmoid volvulus.

Advances in diagnosis,treatment and palliation of cholangiocarcinoma:1990-2009

Several advances in diagnosis,treatment and palliation of cholangiocarcinoma(CC)have occurred in the last decades.A multidisciplinary approach to this disease is therefore recommended.CC is a relatively rare tumor and the main risk factors are:chronic inflammation, genetic predisposition and congenital abnormalities of the biliary tree.While the incidence of intra-hepatic CC is increasing,the incidence of extra-hepatic CC is trending down.The only curative treatment for CC is surgical resection with negative margins.Liver transplantation has been proposed only for selected patients with hilar CC that cannot be resected who have no metastatic disease after a period of neoadjuvant chemo-radiation therapy.Magnetic resonance imaging/magnetic resonance cholangiopancreatography,positron emission tomography scan,endoscopic ultrasound and computed tomography scans are the most frequently used modalities for diagnosis and tumor staging.Adjuvant therapy,palliative chemotherapy and radiotherapy have been relatively ineffective for inoperable CC.For most of these patients biliary stenting provides effective palliation.Photodynamic therapy is an emerging palliative treatment that seems to provide pain relief,improve biliary patency and increase survival. The clinical utility of other emerging therapies such as transarterial chemoembolization,hepatic arterial chemoinfusion and high intensity intraductal ultrasound needs further study.

Impact of early or delayed elective resection in complicated diverticulitis

AIM： To investigate the outcomes of early and delayed elective resection after initial antibiotic treatment in patients with complicated diverticulitis. METHODS： The study, a non-randomized comparison of the two approaches, included 421 consecutive patients who underwent surgical resection for complicated sigmoid diverticulitis （Hinchey classification I - II ） at the Department of Surgery, University Medical Center Hamburg-Eppendorf between 2004 and 2009. The operating procedure, duration of hospital and intensive care unit stay, outcome, complications and socioeconomic costs were analyzed, with comparison made between the early and delayed elective resection strategies. RESULTS： The severity of the diverticulitis and American Society of Anesthesiologists score were comparable for the two groups. Patients who underwent delayed elective resection had a shorter hospital stay and operating time, and the rate of successfully completed laparoscopic resections was higher （80% vs 75%）. Eight patients who were scheduled for delayed elective resection required urgent surgery because of complications of the diverticulitis, which resulted in a high rate of morbidity. Analysis of the socioeconomic effects showed that hospitalization costs were significantly higher for delayed elective resection compared with early elec- tive resection （9296 ± 694 vs 8423 ± 968 ; P = 0.001）. Delayed elective resection showed a trend toward lower complications, and the operation appeared simpler to perform than early elective resection. Nevertheless, delayed elective resection carries a risk of complications occurring during the period of 6-8 wk that could necessitate an urgent resection with its consequent high morbidity, which counterbalanced many of the advantages.

Deep venous thrombosis after gastrectomy for gastric carcinoma:A case report

The treatment of gastric carcinoma consists of neoadjuvant chemoradiation,partial gastrectomy,subtotal gastrectomy,total gastrectomy,extended resection,and postoperative chemotherapy.Currently,gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma.Postoperative complications are common after total gastrectomy including hemorrhage,anastomotic leakage,f istula,and obstruction.However,deep venous thrombosis(DVT) is an uncommon complication after gastrectomy for gastric carcinoma.We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma.The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring.The patient recovered well after treatment and was symptom-free during a 3-mo follow-up.We conclude that correct diagnosis and treatment of DVT are crucial.

Breast-conserving surgery and combined therapy for women breast cancer: a report of 216 cases

Objective： To explore the therapeutic effect and associated techniques of breast-conserving therapy on patients with clinical stage Ⅰ and stage Ⅱ breast cancer. Methods： 216 female patients with breast cancer underwent breast-conserving therapy from December 1993 to October 2004. Their data were analyzed retrospectively. The breast-conserving therapy consisted of lumpectomy or quadrant removal of the breast, postoperative radiotherapy, chemotherapy and endocrine therapy. Of them, 209 patients underwent axillary lymph node dissection. Results： There were no operative complications. 216 patients were followed-up 3 to 147 months, the medial follow-up time was 78 months. The local recurrence rate was 1.85%. Two patients died and one of them was not related with breast cancer. Presence or absence of fibrosis, shape of breast, asymmetry, pigmentation and handle were taken into consideration for cosmetic evaluation by the patients and experienced breast surgeon. Breasts were scored cosmetically as excellent and good in 199 patients, the rate of satisfactory was 92.13%. Conclusion： Breast-conserving therapy for early breast cancer is e safe end effective therapy. It has less trauma end less complications and can also raise the quality of life in the patients. But we must obey the strict indications and reasonable techniques.

Treatment of comminuted trochanteric fractures and non-union of trochanteric osteotomy in revision total hip arthroplasty

Objective: To explore the clinical efficacy of the treatment of comminuted trochanteric fractures and trochanteric osteotomy non union in revision total hip arthroplasty with tension band fixation. Methods: A retrospective review of 295 revision total hip operations performed between 1992 and 1998 was undertaken. Twenty hips of 19 patients with comminuted fractures or nonunion of the greater trochanter were stabilized with tension band technique. Multiple 2.0 mm k wires and tension band wires were placed through the intact cortex distally and the abductor tendon proximally in the pattern "8". Results: The average follow up was 30 months. The Harris Hip Score improved on average from 45 preoperatively to 89 at follow up. Sixteen hips with intra operative trochanteric fracture through osteolytic bone and four hips with symptomatic trochanteric nonunion were approached with tension band fixation. Perioperative loss of fixation in one patient required a repeated surgery. The same fixation at the second operation achieved an uneventful healing. Two patients had a 2 cm proximal migration of one K wire without loss of bony fixation. The trochanteric fractures healed with no further proximal wire migration. One patient had loss of fixation with trochanteric escape at 6 weeks post operatively. The patient has abductor weakness with Trendleburg limp but without pain. On average, radiographic examination showed that healing occurred at 16.6 weeks postoperatively. Six patients developed grade 1 heterotopic ossification and two patients grade 3. All were asymptomatic. None of the 19 patients experienced a dislocation during the follow up. Conclusions: Tension band fixation for greater trochanter can enhance the success rate of revision total hip arthroplasty without a deficient abductor mechanism.