两种消化道重建方式对Siewert Ⅱ、Ⅲ型食管胃结合部腺癌切除术患者预后的影响

目的:探讨两种消化道重建方式对Siewert Ⅱ、Ⅲ型食管胃结合部腺癌切除术患者预后的影响。方法:选择2018年8月-2020年10月荆州市第二人民医院收治的124例Siewert Ⅱ、Ⅲ型食管胃结合部腺癌切除术患者为研究对象,根据分层区组随机法将其分为观察组和对照组,每组62例。观察组进行空肠残胃-空肠双通道吻合,对照组进行食管残端单通道吻合。比较两组术后恢复指标以及各时间段体重、营养指标、胃肠消化功能,统计住院期间并发症发生情况。结果:两组手术时间、首次通气时间、术后肛门排气时间、消化道重建时间、住院时间比较,差异均无统计学意义(P>0.05)。经重复测量分析,两组单次进食量、胃泌素、胃蛋白酶原Ⅰ/Ⅱ的主体内效应、主体间效应比较,差异均有统计学意义(P<0.05)。两组术后2个月,单次进食量有所降低,但术后4、6个月均有所回升,术后2、4、6个月,两组胃泌素较术前均有所升高,胃蛋白酶原Ⅰ/Ⅱ均有所降低(P<0.05);观察组术后各时间段单次进食量、胃泌素均高于对照组,胃蛋白酶原Ⅰ/Ⅱ均低于对照组(P<0.05)。观察组术后6个月前白蛋白、白蛋白、总蛋白水平均高于对照组(P<0.05)。经重复测量分析,两组体重的主体内效应、主体间效应比较,差异均有统计学意义(P<0.05);两组术后2个月,体重均有所降低,但术后4、6个月体重均有所回升(P<0.05);而观察组术后各时间段体重均高于对照组(P<0.05)。观察组并发症发生率低于对照组,差异有统计学意义(P<0.05)。结论:对Siewert Ⅱ、Ⅲ型食管胃结合部腺癌切除术患者开展空肠残胃-空肠双通道吻合,能更好改善术后营养状况,且不影响残胃分泌功能,安全性较高。

胸腺癌切除术中反复室颤救治成功1例

背景:外科手术过程中并发室颤是一个急症,需要得到及时有效的处理,否则后果严重。胸腺癌切除术中发生室颤国内外文献鲜有报道。我们报道1例胸腺癌切除术中并发室颤的患者,最终得到了成功救治。方法:患者女性,59岁,主因间断发热2年入院,胸部CT显示前纵隔区可见一侵袭性肿瘤。患者于2012年3月8日在全麻下行手术治疗,肿瘤切除后,关胸前突发心室颤动,遂立即给予全面抢救。结果:患者于术后3周痊愈出院。结论:胸外科手术过程中室颤是一种紧急情况,需立即给予有效救治,经过积极治疗,多预后良好。

复发性鼻腔鼻窦眼眶颅底腺癌切除及皮瓣移植术后护理研究

探讨复发性鼻腔鼻窦眼眶颅底腺癌切除及皮瓣移植术后护理效果。方法 对复发性鼻腔鼻窦眼眶颅底腺癌切除及皮瓣移植术后的患者,术前给予心理疏导及锻炼指导,术后加强移植皮瓣、供皮区及伤口护理,提供有针对性的医疗治疗及护理措施。结果 患者鼻腔鼻窦眼眶颅底腺癌切除及皮瓣移植术后得到专业护理,在治疗过程中未出现护理并发症。结论 对复发性鼻腔鼻窦眼眶颅底腺癌切除及皮瓣移植术后患者采取有效、针对性的护理措施,可以帮助患者更好地康复。 。

50例肺腺癌切除术的治疗效果分析

就50例肺腺癌切除术的治疗效果进行分析。方法:选取我院2008年2月到2010年2月所收治的50例胃肠肿瘤患者为研究对象,I期24例(48%)患者均行肺叶切除术;Ⅱ期12例(24%)患者均行肺叶切除术;Ⅲ期10例(20%)患者均行全肺切除术,Ⅳ期4例(8%)患者均行全肺切除术或部分切除术。结果:基于术后病理报告来看,有24例(48%)患者出现淋巴结转移,有6例(12%)患者出现术后并发症,1例(2%)患者在术后30天内病死。经术后复查确诊,有19例(38%)患者出现血行转移,其中,肝器官血行转移的发生率为5.5%,肺器官血行转移的发生率为28.0%,脑器官血行转移的发生率为24.5%,骨器官血行转移的发生率为24.5%。结论:肺腺癌切除术具有一定的治疗效果,但为了有效提高患者的生存率,还需要结合采取化疗等多种治疗方法。

微创和开放肺癌切除术对肺腺癌患者围术期循环肿瘤细胞的影响

目的探讨微创和开放肺癌切除术对肺腺癌患者围术期循环肿瘤细胞的影响。方法选择行肺腺癌切除手术患者61例,根据手术方式分为微创肺腺癌切除术组(31例)和开放肺腺癌切除术组(30例),运用免疫磁珠富集法,流式细胞仪检测患者术前3日、术中和术后3日外周血CTCs(circuating tumor cells,CTCs)的含量,比较手术前后上述指标变化,并进行统计学分析。结果(1)61例肺腺癌患者中,术前3日CTCs检测35例(57.4%)为阳性。(2)61例肺腺癌患者外周血术中CTCs量(5.23±2.31)均高于术前CTCs量(3.43±1.98),术后CTCs量(9.46±3.86)均高于术中(5.23±2.31),差异均有统计学意义(P<0.001)。(3)微创肺腺癌切除术组术前CTCs量(3.42±2.03)和开放肺腺癌切除术组术前CTCs量(3.43±1.96),比较差异无统计学意义(P>0.05);微创肺腺癌切除术组术中CTCs量(5.06±2.35)和开放肺腺癌切除术组术中CTCs量(5.40±2.30),外周血CTCs的水平比较差异无统计学意义(P>0.05);但微创肺腺癌根治术组术后外周血CTCs量(7.58±2.92),显著低于开放手术组(11.40±3.78),差异有统计学意义(P<0.001)。结论微创手术有助于降低术后早期外周血中因手术播散的CTCs量,为术后患者的治疗效果的评估以及临床患者手术方式的选择提供参考。

Siewert Ⅱ/Ⅲ型食管胃结合部腺癌根治性切除术后并发症及其相关因素分析

目的分析Siewert Ⅱ/Ⅲ型食管胃结合部腺癌根治性切除术后并发症及相关危险因素的发生率,以预防术后并发症的发生。方法对该院2015年1月至2019年6月接受食管胃交界处腺癌根治性切除手术的346例Siewert Ⅱ/Ⅲ型食管胃结合部腺癌患者进行回顾性分析。探讨术后并发症的发生率,分析其危险因素,分析有无并发症人群临床状况的区别。结果 346例患者中78例(22.54%)发生了并发症。单因素分析显示,患者年龄、术前合并症、术前行辅助化疗、胃切除术方式、术后脉管癌栓形成、T分期、淋巴结转移数、Bormann分型、Siewert分型与食管胃结合部腺癌根治性切除术后并发症相关(P<0.05)。多因素回归分析显示,Bormann分型、术前合并症、近端胃切除术、术前行辅助化疗、T分期、年龄是术后并发症发生的独立危险因素(P<0.05)。结论 Siewert Ⅱ/Ⅲ型食管胃结合部腺癌根治性切除术患者的年龄,术前合并症,术前行辅助化疗,近端胃切除术,T2、T3、T4分期及Bormann Ⅲ型均可能引起术后并发症的发生。

Clinical value of serum CA19-9 levels in evaluating resectability of pancreatic carcinoma

AIM:To evaluate the clinical value of serum CA19-9 levels in predicting the respectability of pancreatic carcinoma according to receiver operating characteristic(ROC) curve analysis. METHODS:Serum CA19-9 levels were measured in 104 patients with pancreatic cancer which were possible to be resected according to the imaging. ROC curve was plotted for the CA19-9 levels. The point closest to the upper left-hand corner of the graph were chosen as the cut-off point. The sensitivity,specificity,positive and negative predictive values of CA19-9 at this cut-off point were calculated. RESULTS:Resectable pancreatic cancer was detected in 58(55.77%) patients and unresectable pancreatic cancer was detected in 46(44.23%) patients. The area under the ROC curve was 0.918 and 95% CI was 0.843-0.992. The CA19-9 level was 353.15 U/mL,and the sensitivity and specificity of CA19-9 at this cut-off point were 93.1% and 78.3%,respectively. The positive and negative predictive value was 84.38% and 90%,respectively. CONCLUSION:Preoperative serum CA19-9 level is a useful marker for further evaluating the resectability of pancreatic cancer. Obviously increased serum levels of CA19-9(> 353.15 U/mL) can be regarded as an ancillary parameter for unresectable pancreatic cancer.

Surgical outcome of adenosquamous carcinoma of the pancreas

Adenosquamous carcinoma is rare,accounting for 3%-4% of all pancreatic carcinoma cases. These tumors are characterized by the presence of variable proportions of mucin-producing glandular elements and squamous components,the latter of which should account for at least 30% of the tumor tissue. Recently,several reports have described cases of adenosquamous carcinoma of the pancreas. However,as the number of patients who undergo resection at a single institute is limited,large studies describing the clinicopathological features,therapeutic management,and surgical outcome for adenosquamous carcinoma of the pancreas are lacking. We performed a literature review of English articles retrieved from Medline using the keywords 'pancreas' and 'adenosquamous carcinoma'. Additional articles were obtained from references within the papers identif ied by the Medline search. Our subsequent review of the literature revealed that optimal adjuvant chemotherapy and/or radiotherapy regimens for adenosquamous carcinoma of the pancreas have not been established,and that curative surgical resection offers the only chance for long-term survival. Unfortunately,the prognosis of the 39 patients who underwent pancreatic resection for adenosquamous carcinoma was very poor,with a 3-year overall survival rate of 14.0% and a median survival time of 6.8 mo. Since the postoperative prognosis of adenosquamous carcinoma of the pancreas is currently worse than that of pancreatic adenocarcinoma,new adjuvant chemotherapies and/or radiation techniques should be investigated as they may prove indispensible to the improvement of surgical outcomes.

Advances in diagnosis, treatment and palliation of pancreatic carcinoma: 1990-2010

Several advances in genetics, diagnosis and palliation of pancreatic cancer (PC) have occurred in the last decades. A multidisciplinary approach to this disease is therefore recommended. PC is relatively common as it is the fourth leading cause of cancer related mortality. Most patients present with obstructive jaundice, epigastric or back pain, weight loss and anorexia. Despite improvements in diagnostic modalities, the majority of cases are still detected in advanced stages. The only curative treatment for PC remains surgical resection. No more than 20% of patients are candidates for surgery at the time of diagnosis and survival remains quite poor as adjuvant therapies are not very effective. A small percentage of patients with borderline non-resectable PC might benefit from neo-adjuvant chemoradiation therapy enabling them to undergo resection; however, randomized controlled studies are needed to prove the benefits of this strategy. Patients with unresectable PC benefit from palliative interventions such as biliary decompression and celiac plexus block. Further clinical trials to evaluate new chemo and radiation protocols as well as identification of genetic markers for PC are needed to improve the overall survival of patients affected by PC, as the current overall 5-year survival rate of patients affected by PC is still less than 5%. The aim of this article is to review the most recent high quality literature on this topic.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffu- sion. Additional researches are necessary to determine the best technique to improve the procedure results.

Primary leiomyosarcoma of the nipple-areola complex:Report of a case and review of literature

Primary leiomyosarcoma of the nipple-areola complex is extremely rare. Less than ten such cases have been reported in English literature so far. Herein we describe a 52-year-old female presenting with a 1.5 cm×1.1 cm×0.7 cm nodular lesion over her left nipple, and leiomyosarcoma was proved by pathological examination of the excised specimen. Positron emitted tomogram (PET) revealed no abnormal signal other than the primary site. Microscopically, this poorly circumscribed tumor was composed of interlacing bundles of smooth muscle cells with bizarre and pleomorphic nuclei, as well as prominent nucleoli. Its mitotic count was up to 7 mitoses per 10 high power fields (HPF). Immunohistochemical study of tumor cells revealed positive stain for α-smooth muscle actin and vimentin; and negative for cytokeratin, CD34 and S-100. Left simple mastectomy was undertaken and no residual mass lesion was noted on the resected specimen. Related literatures about the diagnosis and treatment for breast leiomyosarcoma will be presented here.

A survey of ampullectomy practices

AIM： To investigate the endoscopic ampullectomy practices of expert biliary endoscopists. METHODS： An anonymous expert biliary endoscopists practices. survey was mailed to 79 to assess ampullectomy RESULTS： Forty six （58%） biliary endoscopists returned the questionnaire. Of these, 63% were in academia and in practice for an average of 16.4 years （± 8.6）. Endoscopists performed an average of 1.1 （± 0.8） ampullectomies per month. Prior to ampullectomy, endoscopic ultrasound was ＂always＂ utilized by 67% of respondents vs ＂sometimes＂ in 31% of respondents. Empiric biliary sphincterotomy was not utilized uniformly, only 26% ＂always＂ and 37% ＂sometimes＂ performed it prior to resection. Fifty three percent reported ＂never＂ performing empiric pancreatic sphincterotomy prior to ampullectomy. Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy （OR = 10.9; P = 0.09）. Participants overwhelmingly favored ＂always＂ placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection （23%）. Argon plasma coagulation was the favored adjunct modality （83%） for removal of residual adenomatous tissue. Practitioners uniformly （100%） preferred follow-up examination to be within 6 mo postmpullectomy.CONCLUSION： Among biliary experts, there is less variation in ampultectomy practices than is reflected in the literature.

Cyclooxygenase-2 expression is associated with initiation of hepatocellular carcinoma, while prostaglandin receptor-1 expression predicts survival

AIM to determine whether cyclooxygenase-2(COX-2) and prostaglandin E1 receptor(EP1) contribute to disease and whether they help predict prognosis.METHODS We retrospectively reviewed the records of 116 patients with hepatocellular carcinoma(HCC) who underwent surgery between 2008 and 2011 at our hospital. Expression of COX-2 and EP1 receptor was examined by immunohistochemistry of formalin-fixed, paraffinembedded tissues using polyclonal antibodies. Possible associations between immunohistochemical scores and survival were determined.RESULTS Factors associated with poor overall survival(OS) were alpha-fetoprotein > 400 ng/m L, tumor size ≥ 5 cm, and high EP1 receptor expression, but not high COX-2 expression. Disease-free survival was not significantly different between patients with low or high levels of COX-2 or EP1. COX-2 immunoreactivity was significantly higher in well-differentiated HCC tissues(Edmondson grade Ⅰ-Ⅱ) than in poorly differentiated tissues(Edmondson grade Ⅲ-Ⅳ)(P = 0.003). EP1 receptor immunoreactivity was significantly higher in poorly differentiated tissue than in well-differentiated tissue(P = 0.001).CONCLUSION COX-2 expression appears to be linked to early HCC events(initiation), while EP1 receptor expression may participate in tumor progression and predict survival.

Pancreatic metastases from renal cell carcinoma:The state of the art

Pancreatic metastases are rare,with a reported incidence varying from 1.6%to 11%in autopsy studies of patients with advanced malignancy.In clinical series,the frequency of pancreatic metastases ranges from 2%to 5%of all pancreatic malignant tumors.However,the pancreas is an elective site for metastases from carcinoma of the kidney and this peculiarity has been reported by several studies.The epidemiology,clinical presentation,and treatment of pancreatic metastases from renal cell carcinoma are known from singleinstitution case reports and literature reviews.Thereis currently very limited experience with the surgical resection of isolated pancreatic metastasis,and the role of surgery in the management of these patients has not been clearly defined.In fact,for many years pancreatic resections were associated with high rates of morbidity and mortality,and metastatic disease to the pancreas was considered to be a terminal-stage condition.More recently,a significant reduction in the operative risk following major pancreatic surgery has been demonstrated,thus extending the indication for these operations to patients with metastatic disease.

Hepatoid adenocarcinoma in stomach:a case report

Objective:We reported a case with AFP produced gastric hepatoid adenocarcinoma.Methods:A male patient,77 year-old,was admitted to our hospital due to an unreasonable elevation of serum AFP.The tumors were revealed by PET-CT,but until the tumors were removed during the surgery,we did not recognize the primary lesion was the gastric cancer.Results:Radical distal gastrectomy was performed.The gastric lesion was confirmed by histology as a hepatic adenocarcinoma in its early stage.Conclusion:The rare etiology of the AFP elevation should be kept in mind in clinic,extrahepatic lesions should be excluded.

Standard Versus Extended Pancreaticoduodenectomy in Treating Adenocarcinoma of the Head of the Pancreas

Objectives To compare the postoperative complications and survival of standard pancreatoduodenectomy （SPD） and extended pancreatoduodenectomy （EPD） in patients with resectable adenocarcinoma of the head of the pancreas. Methods Between January 1994 and December 2011, 165 patients with biopsy-proven adenocardnoma of the pancreatic head were treated in West China Hospital, among whom 93 underwent SPD and 72 had EPD. Complications and survival after the surgery were analyzed retrospectively. Results The median operation time of the EPD group was longer compared with the SPD group （375 minutes vs. 310 minutes, P〈O.O1）, the volume of blood transfusion was larger （700 mL vs. 400 mL, P〈0.05）, while the median hospital stay （13.5 days vs. 12 days, P = 0.79） and the total complication rates were comparable （34.7% vs. 32.4%, P=0.93）. The total recurrence rates of the SPD and EPD groups were not significantly different （52.7% vs. 43.1%, P=0,83）. No significant differences were found between the SPD and EPD groups in 1-year （81.7% vs. 86.1%）, 3-year （38.7% vs. 43.1%）, 5-year （16.7% vs. 19.4%）, and median survivals （19.8 months vs. 23.2 months, P= 0.52）. Conclusion The postoperative complications and survival donot differ significantly between SPD and EPD.

The 10-Year Local Recurrence and Partial Breast Radiotherapy for Early Breast Cancer Treated by Conservative Surgery

To study the local recurrence and the role of whole breast radiotherapy for early breast cancer treated by conservative surgery. METHODS From April 1990 to December 2000, 49 patients with early primary breast cancer were treated by conservative surgery in our hospital. The cases were comprised of Stage 0, 1; Stage Ⅰ, 31; and Stage Ⅱa, 17. Forty cases underwent quadrantectomy plus axillary lymph node dissection, and the other 9 cases had lumpectomy alone. Irradiation, which was received by 39 patients, was administered by using low tangential half fields with 6 MV X-ray to decrease the pulmonary irradiative volume. The dose to the whole breast was 45 Gy/22 ～23f/4.5W, then a 15 Gy boost dose was delivered to the tumor bed by an electron beam. The other patients underwent an irradiated regional field according to postoperative pathology. RESULTS All patients were followed-up for 10 years or more. The 10- year local recurrence rates, distant metastasis rates and survival rates were 6.1%, 4.1% and 98.0% respectively. All of the 3 patients who had a local recurrence had infiltrative carcinomas and negative lymph nodes. The 10-year local recurrence rate was higher （2.6% vs. 20.0%） with nonpostoperative whole breast radootherapy, but the statistical difference was not marked because of the low number of cases. All of the recurrent lesions localized within 3 cm of the primary lesion. CONCLUSION Original recurrence of the tumor was the main type of local recurrence. Radiotherapy after conservative surgery is very essential. After conservative surgery it is feasible that irradiation can be delivered alone to the neighboring region of the tumor bed. Partial breast radiotherapy can substitute for whole breast radiotherapy.

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.

Ductal adenocarcinoma of the pancreatic head:A focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patients,and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer.Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques.Nevertheless,even in experienced hands,perioperative morbidity rates(delayed gastric emptying,pancreatic fistula etc.) are as high as 50%.Different strategies to reduce postoperative morbidity,such as different techniques of gastroenteric reconstruction(pancreatico-jejunostomy vs pancreatico-gastrostomy),intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome.The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct(< 3 mm).The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying,respectively.Currently,the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity,but without any positive impact on overall survival.However,there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

Five-year survival following a medial pancreatectomy for an invasive ductal carcinoma from the body of the pancreas

We report a rare case of a patient who survived for 5 years after undergoing a medial pancreatectomy for invasive ductal carcinoma originating from the body of the pancreas. A 63-year-old woman was diagnosed as a small cancer of the pancreatic body, and surgery was performed. Even though the tumor was a carcinoma, its small size prompted us to perform a medial pancreatectomy with regional lymph nodes dissection. Additional chemoradiation was performed and, five years after surgery, the patient is well with no signs of recurrence. Medial pancreatectomy for invasive ductal carcinoma has not ever been reported. Furthermore, long-term survival after a lumpectomy for invasive ductal carcinoma has never been reported in the literatures. The current case suggests that long-term survival in patients with invasive ductal carcinoma of the pancreas may be associated with the pathological or biological features of pancreatic carcinoma.