宫颈癌宫颈根治性切除联合腹腔镜下盆腔淋巴结清扫手术围术期护理

目的:探讨早期宫颈癌患者实施经阴道宫颈根治性切除联合腹腔镜下盆腔淋巴结清扫术手术护理方法。方法:回顾性分析62例早期宫颈癌患者实施经阴道宫颈根治性切除联合腹腔镜下盆腔淋巴结清扫术的临床资料,总结护理经验。结果:经过手术前准备和心理护理、手术中巡回护士和器械护士的配合、手术后随访等护理措施,62例患者手术顺利,手术时间3-3.5h,术中出血100-300ml,术后患者恢复良好,未出现严重并发症;术后随访除2例患者分别在手术后6个月、13个月复发进行进一步治疗外,其余60例患者均完全康复。结论:围手术期护理是手术成功、患者康复的重要保证。

前列腺癌盆腔淋巴结清扫:手术指征及清扫范围如何抉择?

盆腔淋巴结清扫术是判断前列腺癌患者有无淋巴结转移的"金标准",并可能具有一定治疗作用,但手术指证并未达成共识,临床分期、血清PSA水平、Gleason评分、穿刺阳性针数百分比等参数是决定是否手术的重要指标。与局部盆腔淋巴结清扫相比,扩大盆腔淋巴结清扫能够切除更多的淋巴组织,分期更准确,甚至能改善患者预后,因此被多数指南推荐。

结肠癌D3清扫术后腹腔乳糜漏的病因预防及治疗分析

目的总结结肠癌D3清扫术后腹腔乳糜漏的病因、治疗及预防经验。方法对628例行结肠癌D3清扫术后发生乳糜漏病例进行回顾性分析，比较不同术式（开腹组与腹腔镜组）、不同部位（右半结肠与左半结肠）乳糜漏的发生率。结果22例结肠癌患者（3．5％）术后发生乳糜漏，开腹组与腹腔镜组的发生率分别为2．8％（8／286）和4．O％（14／342），差异无统计学意义（P〉0．05）；右半结肠D3清扫术后腹腔乳糜漏发生率为7．8％（16／207），左半结肠D3术式乳糜漏发生率为1．4％（6／421），两组相比，差异具有统计学意义（P〈0．05），乳糜漏的发生与肿瘤的TNM分期无明显关系。21例患者经保守治疗（治疗方法包括禁食、肠外营养、静脉使用生长抑素、抗感染治疗和延缓拔除腹腔引流管），均获治愈，1例行腹腔淋巴管漏口结扎术并局部使用医用胶治愈，无复发及死亡病例。结论结肠癌D3清扫术开腹与腔镜在预防腹腔乳糜漏方面无明显差异，右半结肠D3术式是乳糜漏的高危因素，术后腹腔乳糜漏保守积极治疗有效。

结肠癌D3清扫术后乳糜漏的危险因素分析

目的研究结肠癌D3清扫术后腹腔乳糜漏的有关危险因素。方法回顾性分析行结肠癌D3清扫术后腹腔乳糜漏56例患者的临床资料做为实验组；并选取同期行相同手术未发生乳糜漏的769例患者作为对照组进行对比分析，对选取有可能影响乳糜漏的相关因素进行单因素分析与Logistic回归分析。结果所选的14个可能与乳糜漏相关的因素中，低蛋白血症、肿瘤部位、淋巴结清扫数目与术后发生乳糜漏有关，差异具有统计学意义（P〈0．05）；而年龄、性别、手术时间、手术方式、术中出血量、合并糖尿病、术前肠梗阻、术前行新辅助化疗、肿瘤大小、肿瘤浸润深度、淋巴结转移与术后乳糜漏无关（P〉0．05）。Logistic回归分析显示：低蛋白血症、淋巴结清扫数目和肿瘤部位是结肠癌D3清扫术后乳糜漏的独立危险因素。结论低蛋白血症、肿瘤部位和淋巴结清扫数目是结肠癌D3清扫术后乳糜漏的独立危险因素，术后腹腔乳糜漏积极保守治疗有效。

胸中段食管鳞癌Ivor-Lewis手术后肿瘤复发196例临床分析

背景与目的:近半数食管癌患者术后3年内出现肿瘤复发,但肿瘤复发的情况尚不完全清楚。本文旨在分析食管癌Ivor-Lewis手术后肿瘤复发的情况。方法:回顾性分析本院1997～2001年接受Ivor-Lewis手术及胸、腹二野淋巴结清扫治疗的196例胸中段食管鳞癌患者的临床资料,Logistic回归分析判定术后3年内肿瘤复发的危险因素。结果:3年内96例(48.9%)患者肿瘤复发,平均复发时间为12.2个月。局部-区域性复发52例(54.1%),其中41例(78.8%)有纵隔淋巴结转移,仅8例(15.3%)患者单纯颈淋巴结转移,血行转移(包括血行转移伴局部-区域性复发10例)44例(45.8%),以肝、骨和肺转移为主,占88.6%(39/44)。手术后辅助放疗组的患者局部-区域性复发率(23.3%)低于未放疗组者(41.3%)(P<0.05)。Logistic回归分析显示,T3期和N1状态是术后肿瘤复发的危险因素。结论:Ivor-Lewis手术后3年内约1/2的患者肿瘤复发,纵隔淋巴结、肝脏、骨和肺是主要的复发部位。手术后辅助放疗可以减少局部-区域性复发。

Prognosis in epithelial ovarian cancer: Clinical analysis of 287 pelvic and para-aortic lymphadenectomy

Objective: To evaluate the relationship between the pelvic and para-aortic lymphadenectomy and the prognosis of epithelial ovarian cancer. Methods: 287 patients suffering from primary epithelial ovarian cancer from 1995 to 2005 were analyzed retrospectively. Results: The 3-, 5-, 10-year survival with systematic lymphadenectomy (SL) were slightly higher than those without SL, but there were no statistically significance (P > 0.05). The 3-, 5-, 10-year survival of clinical stages without SL were lower than those with SL, but there were no significant difference either (P > 0.05). The 3-,5-, and 10-year survival rates with SL were higher than those without SL with no statistically differences (P > 0.05) among the subgroups such as absent, ≤ 2 cm and > 2 cm residual tumor. The survival rates of the groups without residual tumor and the group with ≤ 2 cm residual tumor were significantly higher than that of > 2 cm (P < 0.005). On multivariate analysis, patient staging (P = 0.01) and size of residual disease after primary cytoreductive surgery (P < 0.001 and = 0.002, respectively) retained prognostic significance. SL was not proved to be an independent prognostic factor (P = 0.69). Conclusion: Systematic pelvic and para-aortic lymphadenectomy can not improve and prolong the survival time significantly.

Comparative evaluation of surgical stress of different lymph node dissection for gastric cancer

Objective: To evaluate the effects of surgical trauma of open surgery on the patients with gastric carcinoma who underwent different lymph node dissection. Methods:Total 30 patients with gastric carcinoma were divided into three groups (D1, D2, and D3) according to the extent of lymph node dissection. Peripheral blood samples were taken to measure the levels of interleukin-6 (IL-6), interleukin-8 (IL-8), C-reactive protein (CRP) and polymorphonuclear elastase (PMNE). Ad- ditionally, leucocytes and lymphocytes counts in peripheral serum were also detected. Results: All the three groups showed a significant increase of the levels of IL-6, IL-8, CRP and PMNE after operation. There was no significant difference between D1 and D2 groups. When the comparison was made between D3 group and the other two groups, it showed higher concentration of IL-6, IL-8, CRP and PMNE in serum of D3 group. Leucocytes count showed no difference among the three groups. After operation, the patients in three groups had transient lymphocytes decrease on the second and third postoperative days, the lymphocytes count in D3 group was still lower while those in D1 and D2 groups began to increase. Conclusion: IL-6, IL-8, CRP and PMNE can be used to monitor surgical stress. Using these parameters, we found that extended lymph node dissec- tion of D3 group led to more postoperative stress than D1 and D2 groups.

Successful en bloc resection of primary hepatocellular carcinoma directly invading the stomach and pancreas

Multivisceral surgical resection for cure was successfully performed in a 70-year-old man suffering from a primary hepatocellular carcinoma(HCC)associated with direct invasion to the stomach and pancreas.The patient presented with gastric outlet obstruction,upper abdominal pain and a history of chronic liver disease due to hepatitis B virus(HBV)infection.Upper gastro-intestinal(GI)endoscopy revealed an infiltrating tumor protruding through the gastric wall and obliterating the lumen.Computer tomograghy(CT)and magnetic resonance imaging(MRI)scan demonstrated a 15-cm tumor in the left lateral segment of the liver with invasion to the stomach and pancreas.Alpha-foetoprotein (AFP)levels and liver function tests were normal.The patient underwent an en bloc left hepatectomy,total gastrectomy,distal pancreatectomy with splenectomy and radical lymphadenectomy.Pathology revealed a poorly differentiated,giant cell HCC involving the stom-ach and pancreas.Disease-free margins of resection were achieved.The patient's postoperative course was uneventful.Sixteen months after surgery,he has norecurrence or distal metastasis.Direct invasion of HCC into the GI tract is rarely encountered.Complete surgical resection should be considered in selected patients with an appropriate hepatic functional reserve.

Vagina vasorum dissection during D2 lymphadenectomy for gastric carcinoma

AIM: To explore the relationship between metastasis and vagina vasorum in the progress of gastric carcinoma and to find some facts and references for gastric surgeons. METHODS: One hundred and seven specimens of left or right gastric arteries (55 left and 52 right) were gathered from 59 patients undergoing radical gastrectomy for gastric carcinoma. All the frozen specimens were cut into 3 μm-thick sections and stained with hematoxylin-eosin (HE) and immunohistochemical method separately. Cytokeratin (CK) and mesothelial cells (MC) were stained with immunohistochemical method. Cancer cells inside vagina vasorum were detected and the structure of artery wall was observed under microscope. RESULTS: Metastatic cancer cells or tubercles were found inside vagina vasorum in some stage Ⅲ or Ⅳ specimens, but not in stageⅠor Ⅱ specimens. Tumor cells in vagina vasorum were CK positive in 26 specimens of 14 tumors. Among them, stage Ⅲ was found in 4 specimens of 2 tumors, and stage Ⅳ in 22 specimens of 12 tumors. None of these specimens was positive for MC. The positive rate of CK increased with TNM staging. Compared with the lower part, tumors in the upper and middle parts of stomach were more likely to metastasize into vagina vasorum. CONCLUSION: Vagina vasorum dissection should be performed during D2 lymphadenectomy for TNM stage Ⅲ or Ⅳ gastric carcinoma.

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.

Analysis of 6 Cases of Stromal Sarcoma of the Breast

OBJECTIVE To investigate the clinical and pathological characteristics, diagnosis and treatment of stromal sarcoma of the breast （SSB）. Methods： The clinical and pathological data of 6 patients with SSB treated between 1954 and 2007 were retrospectively analyzed. METHODS The clinical and pathological data of 6 patients with SSB treated between 1954 and 2007 were retrospectively analyzed. RESULTS All patients were female and one was menopausal. The median age of the patients was 39 years old （range, 20-55）. All cases had a history of a palpable mass. The tumor rapidly augmented in a short time period in 3 patients. One patient had discontinuous pain and 3 patients had masses located in the upper outer quadrant of the breast. The median tumor radius was 6.0 cm （range, 3-15 cm）. According to the AJCC breast cancer staging standard （6th edition）, 1 case was of stage ⅡA, 2 cases were of stage ⅡB, 2 cases were of stage ⅢB and one case couldn＇t be staged. Four patients were initially treated by excising the tumor and then undergoing mastectomy or modified radical mastectomy after recurrence. Radical mastectomy was suitable for those with pectoralis major muscle involvement. Two patients received simple mastectom）~ 2 patients underwent radical mastectomy and another 2 patients received modified radical mastectomy. After surgery, all patients were identified as SSB through pathology, with focal ossification in one case and mucinous degeneration in another one case. Four patients who underwent axillary lymph node dissection did not have lymph node metastases. Three patients received chemotherapy after surgery. After a median follow-up time of 36.5 months （8-204 months）, 4 patients had recurrence after local excision and 3 patients had recurrence more than 2 times with a median time to recurrence of 2.5 months （1 to 4 months） after surgery. One patient had lung metastases at 7 months after the initial surgery and the other 5 patients were alive without disease at the end of the follow-up period. CONCLUSION SSB is difficult to diagnose preoperatively and is characterized by its tendency to .recur locally. To obtain negative margins, wide local excision or mastectomy must be performed. Axillary lymph node dissection is not mandatory. The roles of adjuvant chemotherapy and radiotherapy have still been controversial.

Sentinel Lymph Node Identification in Endometrial Cancer

OBJECTIVE To evaluate the feasibility of intra-operativedetection of sentinel lymph nodes (SLN) in the patient withendometrial cancer (EC).METHODS Thirty-one patients with Stage Ⅰ and Ⅱ endometrialcancer, who underwent a hysterectomy and a lymphadenectomy,were enrolled in the study. At laparotomy, methylene blue dyetracer was injected into the subserosal myometrium of corpusuteri at multiple sites, and dye uptake into the lymphatic channelswas observed. The blue nodes which were identified as SLNs weretraced and excised. The other nodes were then removed. All of theexcised nodes were submitted for pathological hematoxylin andeosin (H&E) staining examination.RESULTS Failure of dye uptake occurred in 4 of the 31 cases(12.9%) because of spillage, and no lymphatic coloration wasobserved there. Lymphatic staining was clearly observable as bluedye diffused to the lymphatic channels of the uterine surface andthe infundibulopelvic ligaments in 27 (87.1%) cases. Concurrentcoloration in the pelvic lymphatic vessels was also observed in 22of the 27 patients. The SLNs were identified in 23 of the 27 (85.2%)cases with a lymphatic staining, with a total number of 90 SLNs,and a mean of 3.9 in each case (range, 1-10). Besides one SLN (1.1%)in the para-aortic area, the other 89 (98.9%) were in the nodes ofthe pelvis. The most dense locations of SLNs included obturator in38 (42.2%) and interiliac in 19 (21.1%) cases. In our group, pelviclymphadenectomy was conducted in 27 (87.1%) patients andpelvic nodal sampling in 4 (12.9%). Of the 31 cases, a concurrentabdominal para-aortic lymph node sampling was conducted in7. A total of 926 nodes were harvested, with an average of 39.8 ineach case (range, 14-55). Nodal metastases occurred in 3 patients(9.7%), 2 of them with SLN involvement and the other withoutSLN involvement. Adverse reactions or injury related to the studywas not found.CONCLUSION Application of methylene blue dye is feasible inan intra-operative SLN identification of endometrial cancer. Thetechnology is convenient, safe, and worth further investigation.

Radical resection of gastric carcinoma with pancreas and spleen preservation and functional cleaning of lymph nodes

OBJECTIVE: To study the clinical value of radical resection of gastric carcinoma with pancreas and spleen preservation (PSP) and functional cleaning of lymph nodes (LNs) of the spleen hillus and along the splenic artery. METHODS: Pancreas and spleen involvement was retrospectively reviewed among 439 cases of resectable carcinoma of the gastric cardia, gastric corpus and total stomach. During gastric surgery, 2 ml of methylene blue was injected into the subserosal space of the gastric cardia or corpus to observe the spread of lymphatic flow in 54 cases of gastric carcinoma. The metastatic rate of LNs in splenic hillus and along the trunk of the splenic artery (No10, No11), postoperative complications and survival rates were investigated in 63 gastric carcinoma patients that had received gastrectomy with pancreas and spleen preservation (PSP). These were compared with the pancreas preservation (PP) group and pancreas and spleen combined resection (PSR) group. RESULTS: Among these 439 cases, only 25 cases were observed with direct invasion to the pancreas (5.7%), and 10 cases with direct invasion to the spleen (2.3%). After pathological examination of the pancreatic body and tail, we found 22 cases with pancreas and spleen combined resection, 4 cases (18.2%, 4/22) with direct invasion of the capsule and 2 with invasion to the superficial parenchyma (9.1%, 2/22), without metastasis to the lymph nodes within the pancreas and spleen. The metastatic rate of No10, No11 lymph nodes were 17.5% (11/63) and 19.1% (12/63) in the PSP group, 20.8% (45/216) and 25% (54/216) in the PP group, and 20% (6/30) and 23.3% (7/30) in the PSR group. There were no statistically significant differences (P > 0.05). Injection of methylene blue into the subserosal space of the stomach did not diffuse into the spleen or pancreatic parenchyma. Postoperative complications, diabetes and mortality in PSP (0%, 0%, 0%) were lower than in PP (4.2%, 0.9%, 0.9%) or PSR (40%, 10%, 3.3%). The 5-year survival rate (5-YSR) and 10-YSR in PSP (57.5%, 52.0%) were higher than in PSR (37.5%, 30.0%). Those patients with stage II and III(a) treated by PSP, improved markedly. CONCLUSIONS: The surgical procedure of pancreas and spleen preservation for gastric cancer is a safe and organ function protected method. Postoperative complications were lower and survival rates were higher, the radicality was not reduced. These results indicate that PSP is preferred in patients with gastric carcinoma of stage II or III(a).

Secondary sentinel lymph node tracing technique: a new method for tracing lymph nodes in radical gastrectomy for advanced gastric cancer

Objective： To explore the feasibility and clinical value of secondary sentinel lymph node （SSLN） tracing technique in radical gastrectomy for advanced gastric cancer （AGC）. Methods： From January 2009 to June 2011,247 patients who suffered from gastric angle cancer with metastasis in No. 3 group lymph nodes were divided randomly into groups A and B. Methylthioninium chloride was injected into the peripheral tissue of the metastatic No. 3 group lymph nodes of 138 patients in group A before tumor resections. SSLNs were traced and individual lymphadenectomies were carried out based on the biopsy results of the SSLNs. Standard D2 radical gastrectomies were carried out directly on 109 patients in group B. Postoperative follow-up and survival analysis were carried out for patients in both groups. Results： SSLNs were found in 114 （82.6%） patients in group A. Ninety of those patients （78.9%） demonstrated existing metastasis in SSLNs. According to Kaplan-Meier＇s method, the postoperative 3-year cumulative survival rates were 63.5% and 47.5%, and the median survival time were 40 and 36 months for the patients of groups A and B, respectively （P〈0.05）. Conclusions： The SSLN tracing technique is feasible in radical gastrectomy for AGC. It gives surgeons important information about the terminal status of lymph node metastasis and provides some scientific basis for individual lymphadenectomy.