浅析甲状腺肿瘤的手术治疗方法

目的 探讨并分析甲状腺肿瘤的手术治疗方法。方法 22例甲状腺肿瘤患者,对其手术治疗方法及效果进行回顾性分析。结果 患者行单侧甲状腺手术17例,双侧甲状腺手术5例。所有患者手术均成功,22例患者中乳头状肿瘤14例、滤泡状腺肿瘤5例、未分化肿瘤2例、髓样肿瘤1例,手术时间1.4~2.5h,平均手术时间(1.6±0.4)h。患者在术后无甲状腺损伤、甲状腺危象及饮水呛咳等并发症出现。结论 甲状腺肿瘤是在临床中最常见的良性肿瘤之一,可引发甲亢的发生,并存在一定恶变的可能,应该尽早进行手术切除。

多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值

目的探讨多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值。方法 9例颅底肿瘤术前均行DynaCTA检查及MRI薄层(2 mm)增强扫描检查,将多组影像数据输入工作站,采用"双容积重建"技术进行脑血管及MRI的影像融合,通过静态及动态融合影像观察肿瘤与脑结构、血管及颅骨的毗邻关系,并对肿瘤的诊断、手术治疗及预防血管并发症进行分析。结果 9例均获得满意的影像融合、具有很好的空间一致性,在一张影像上可以清晰显示病变及其周围脑结构、血管及颅骨解剖关系,提高精准性诊断,并应用于指导治疗策略、设计手术划及预防并发症。9例均恢复满意出院。结论多模态影像融合对提高颅底肿瘤的诊断精准性、提高肿瘤全切除率、降低病死率和残疾率效果肯定,对血管损伤并发症治疗疗效肯定。

43例宫颈肌瘤的临床分析

目的探讨宫颈肌瘤的临床特征和诊治方法。方法回顾性分析我院43例宫颈肌瘤患者的临床资料。结果宫颈肌瘤主要表现为阴道出血、月经改变和阴道排液,其次为下腹部包块及直肠压迫症状。术前诊断率为88.4%,治疗以手术为主。结论宫颈肌瘤手术方式与肌瘤类型、大小及是否要求保留生育功能有关。掌握其手术要点可减少出血、损伤和感染,达到较为理想效果。

术后粘连性肠梗阻43例临床分析

目的探讨粘连性肠梗阻的诊断及治疗方法。方法回顾分析43例粘连性肠梗阻患者的临床特点及治疗效果。结果43例中急症手术治疗8例,保守治疗35例中,中转手术15例,所有患者均治愈,无并发症发生。结论部分粘连性肠梗阻患者经保守治疗症状可以缓解,部分需要手术治疗。对于有手术指征的粘连性肠梗阻,把握手术的时机和对术式做出正确的选择,才能达到最好的治疗效果。

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation(Part Ⅱ:Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be re- served for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotonin- ergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effec- tive in the treatment of patients with chronic constipa- tion. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coil who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treat- ment in dys-synergic defecation. Many surgical proce- dures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis

AIM: To determine patient and process of care factors associated with performance of timely laparoscopic cholecystectomy for acute cholecystitis. METHODS: A retrospective medical record review of 88 consecutive patients with acute cholecystitis was conducted. Data collected included demographic data, co-morbidities, symptoms and physical findings at presentation, laboratory and radiological investigations, length of stay, complications, and admission service (medical or surgical). Patients not undergoing cholecystectomy during this hospitalization were excluded from analysis. Hierarchical generalized linear models were constructed to assess the association of pre-operative diagnostic procedures, presenting signs, and admitting service with time to surgery.RESULTS: Seventy cases met inclusion and exclusion criteria, among which 12 were admitted to the medical service and 58 to the surgical service. Mean ± SD time to surgery was 39.3 ± 43 h, with 87% of operations performed within 72 h of hospital arrival. In the adjusted models, longer time to surgery was associated with number of diagnostic studies and endoscopic retrograde cholangio-pancreatography (ERCP, P = 0.01) as well with admission to medical service without adjustment for ERCP (P < 0.05). Patients undergoing both magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) scans experienced the longest waits for surgery. Patients admitted to the surgical versus medical service underwent surgery earlier (30.4 ± 34.9 vs 82.7 ± 55.1 h, P < 0.01), had less post-operative complications (12% vs 58%, P < 0.01), and shorter length of stay (4.3 ± 3.4 vs 8.1 ± 5.2 d, P < 0.01).CONCLUSION: Admission to the medical service and performance of numerous diagnostic procedures, ERCP, or MRCP combined with CT scan were associated with longer time to surgery. Expeditious performance of ERCP and MRCP and admission of medically stable patients with suspected cholecystitis to the surgical service to speed up time to surgery should be considered.

Preoperative localization and minimally invasive management of primary hyperparathyroidism concomitant with thyroid disease

The coexistence of thyroid diseases with primary hyperparathyroidism (PHPT) can present a challenge in the clinical diagnosis and management for these patients. This study aims to determine the frequency of coexisting thyroid gland lesions in a consecutive series patients with PHPT, and to analyze the clinical features, diagnosis and treatment of these patients. Twenty-two cases of a total of 52 PHPT patients who had synchronous thyroid and parathyroid pathology were surgically managed in this study. Thirteen patients had ipsilateral thyroid nodules, and 9 patients had thyroid nodules in contralateral or bilateral side. Seven patients underwent direct parathyroidectomy and hemithyroidectomy via a mini-incision (about 3 cm), while other 15 procedures were converted to Kocher incision. Seventeen nodular goiter (32.7%), 2 thyroiditis (3.8%), 2 thyroid adenoma (3.8%) and 1 thyroid carcinoma (1.9%) coexisting with parathyroid adenoma were pathologically diagnosed. The sensitivity of preoperative ultra-sonography (US) and methoxy-isobutyl-isonitrile (MIBI) scintigraphy for parathyroid lesions was 63.6% and 85.7%; and the overall positive predictive values for MIBI and US were 100% and 95.5% respectively. A high incidence of thyroid diseases that coexisted with PHPT in literatures was briefly reviewed. Our study illustrated the need for clinical awareness of concomitant PHPT and thyroid disease. A combination of US, computed tomography (CT) and MIBI scintigraphy would be recommended for preoperative localization of enlarged parathyroid adenoma and for evaluation of thyroid lesions. Synchronous treatment of asso-ciated thyroid abnormalities is desirable, and open minimally invasive surgical approach with additional resection of isolated ipsilateral thyroid nodules is possible in some of these patients.

Utility of fusion CT-PET in the diagnosis of small pancreatic carcinoma

Pancreatic carcinoma has a poor prognosis and early detection is essential for potentially curative resection. Despite the wide array of diagnostic tools, preoperative detection of small pancreatic carcinomas remains difficult. We report a case of small pancreatic carcinoma of the head of pancreas with indeterminate findings on US, ERCP, MRI and EUS which was successfully diagnosed via fusion CT-PET. This case illustrates the utility of CT-PET in the diagnosis of patients with small pancreatic carcinoma with equivocal findings on conventional diagnostic modalities.

Appendiceal mucocele: Case reports and review of current literature

The mucocele of the appendix is an uncommon disorder which is often asymptomatic but sometimes causes acute appendicitis-like symptoms. Sometimes, patients with mucocele can present with confusing symptoms. Preoperative suspicion and diagnosis of appendiceal mucocele are important. Ultrasonography and computed tomography are useful tools for the diagnosis of appendiceal mucocele. It may be also recognised by colonoscopy as a smooth submucosal lesion of the cecum. Optima management of the mucocele could be achieved through accurate preoperative diagnosis. Preoperative diagnosis is a major component for minimizing intra-operative and post-operative complications. We herein report five cases and discuss the diagnostic methods and surgical treatment.

Incidental gallbladder cancer during laparoscopic cholecystectomy:Managing an unexpected finding

AIM:To evaluate the impact of incidental gallbladder cancer on surgical experience.METHODS:Between 1998 and 2008 all cases of cholecystectomy at two divisions of general surgery,one university based and one at a public hospital,were retrospectively reviewed.Gallbladder pathology was diagnosed by history,physical examination,and laboratory and imaging studies [ultrasonography and computed tomography(CT)].Patients with gallbladder cancer(GBC) were further analyzed for demographic data,and type of operation,surgical morbidity and mortality,histopathological classification,and survival.Incidental GBC was compared with suspected or preoperatively diagnosed GBC.The primary endpoint was diseasefree survival(DFS).The secondary endpoint was the difference in DFS between patients previously treated with laparoscopic cholecystectomy and those who had oncological resection as first intervention.RESULTS:Nineteen patients(11 women and eight men) were found to have GBC.The male to female ratio was 1:1.4 and the mean age was 68 years(range:45-82 years).Preoperative diagnosis was made in 10 cases,and eight were diagnosed postoperatively.One was suspected intraoperatively and confirmed by frozen sections.The ratio between incidental and nonincidental cases was 9/19.The tumor node metastasis stage was:pTis(1),pT1a(2),pT1b(4),pT2(6),pT3(4),pT4(2);five cases with stageⅠa(T1 a-b);two with stageⅠb(T2 N0);one with stage Ⅱa(T3 N0);six with stage Ⅱb(T1-T3 N1);two with stage Ⅲ(T4 Nx Nx);and one with stage Ⅳ(Tx Nx Mx).Eighty-eight percent of the incidental cases were discovered at an early stage(≤Ⅱ).Preoperative diagnosis of the 19 patients with GBC was:GBC with liver invasion diagnosed by preoperative CT(nine cases),gallbladder abscess perforated into hepatic parenchyma and involving the transversal mesocolon and hepatic hilum(one case),porcelain gallbladder(one case),gallbladder adenoma(one case),and chronic cholelithiasis(eight cases).Every case,except one,with a T1b or more advanced invasion underwent Ⅳb + Ⅴ wedge liver resection and pericholedochic/hepatoduodenal lymphadenectomy.One patient with stage T1b GBC refused further surgery.Cases with Tis and T1a involvement were treated with cholecystectomy alone.One incidental case was diagnosed by intraoperative frozen section and treated with cholecystectomy alone.Six of the nine patients with incidental diagnosis reached 5-year DFS.One patient reached 38 mo survival despite a port-site recurrence 2 years after original surgery.Cases with non incidental diagnosis were more locally advanced and only two patients experienced 5-year DFS.CONCLUSION:Laparoscopic cholecystectomy does not affect survival if implemented properly.Reoperation should have two objectives:R0 resection and clearance of the lymph nodes.

Incidence of brain metastasis in patients with esophageal carcinoma

AIM:To determine the incidence of brain metastasis in a contemporary group of patients with carcinoma of the esophagus.METHODS:Retrospective analysis of 53 patients with esophageal carcinoma who received radiotherapy as a component of treatment between 1998 and 2007,including patient and tumor characteristics,and subsequent diagnosis of brain metastasis.The association between the histological type of esophageal cancer and the incidence of brain metastasis was assessed using Fisher's exact test.RESULTS:Forty-four of the fifty-three patients in this study had adenocarcinoma and nine had squamous cell carcinoma,ranging from stage ⅡA-ⅣB.Primary treatment was surgery with neoadjuvant chemoradiotherapy (trimodality therapy) in 19% of patients;chemoradiotherapy in 42%;and surgery and adjuvant radiotherapy in 7%.Twenty-five percent of patients inthis study received palliative radiotherapy.The overall incidence of brain metastasis in this cohort was 13%.Adenocarcinoma was the primary tumor histology in all of the patients who developed brain metastasis,representing an incidence of 16% in this subgroup.No patients with squamous cell carcinoma received trimodality therapy.The association between histology and brain metastasis was not statistically significant.CONCLUSION:The incidence of brain metastasis in this contemporary cohort of patients with esophageal carcinoma is higher than previously reported and was confined to those with adenocarcinoma.

DIAGNOSIS AND TREATMENT OF PULMONARY HAMARTOMA

From 1970 to 1997, 67 patients with pulmonary hamartoma were operated on in our hospital. There were 38 men and 29 women with a M/F ratio of 1. 3: 1. The mean age was 47 years (range 21 to 82 years). The peak incidence was 40 to 60 years. 39% Patients had pulmonary symptoms: hemoptysis, cough, phlegm and chest pain. All were solitary. 68. 7% tumors were located in right lung and 64. 2% in upper or middle lobe. 80. 6% hamartomas were less than 3 cm in transverse diameter. On chest films, the opacity was homogeneous in 79.1% cases, heterogeneous in 20.9% and calcifications in 9.0%. The vast majority of shadows were heterogeneous on CT films. Operation is the best treatment for hamartomas. Postoperative mortality was 1. 5%. There was none recurrences and canceration during the follow-up (mean 14 years).

LUMBAR SPINAL STENOSIS: A REVIEW OF BIOMECHANICAL STUDIES

Objective. To investigate the biomechanical aspects of etiology,pathology, clinical manifestation, diagnosis and surgical treatment of the lumbar spinal stenosis. Methods’ A series of biomechanical methods, such as three-dimensional finite element models. three-dimensional kinematic measurement, cadeveric evaluation, and imaging assessment was applied to correlate lumbar biomechanics and lumbar spinal stenosis. Surgery of lumbar spinal stenosis has been improved. Results. The stresses significantly concentrate on the posterolateral part of the annulus fibrosus of disc, the posterior surface of vertebral body, the pedicle, the interarticularis and the facet joints. This trend is intensified by disc degeneration and lumbar backward extension. Posterior element resection has a definite effect upon the biomechanical behavior of lumbar vertebrae. The improved operations proved satis- factory. Conclusion. Stress concentration in the lumbar vertebrae is of importance to the etiology of degenerative lumbar spinal stenosis, and disc degeneration is the initial key of this process. Then these will be aggravated by backward extension. Functional radiography and myelography are of assistance to the diagnosis o f the lumbar spinal stenosis. For the surgical treatment of the lumbar spinal stenosis, destruction of the posterior element should be avoid as far as possible based upon the thorough decompression. Maintaining the lumbar spine in flexion by fusion after decompression has been proved a useful method. When developmental spinal stenosis is combined with disc herniation, discectomy through laminotomy is recommend for decompression.

Iatrogenic bile duct injuries:Etiology,diagnosis and management

Iatrogenic bile duct injuries (IBDI) remain an important problem in gastrointestinal surgery. They are most frequently caused by laparoscopic cholecystectomy which is one of the commonest surgical procedures in the world. The early and proper diagnosis of IBDI is very important for surgeons and gastroenterologists, because unrecognized IBDI lead to serious complications such as biliary cirrhosis, hepatic failure and death. Laboratory and radiological investigations play an important role in the diagnosis of biliary injuries. There are many classifications of IBDI. The most popular and simple classification of IBDI is the Bismuth scale. Endoscopic techniques are recommended for initial treatment of IBDI. When endoscopic treatment is not effective, surgical management is considered. Different surgical reconstructions are performed in patients with IBDI. According to the literature, Roux- en-Y hepaticojejunostomy is the most frequent surgical reconstruction and recommended by most authors. In the opinion of some authors, a more physiological and equally effective type of reconstruction is end- to-end ductal anastomosis. Long term results are the most important in the assessment of the effectiveness of IBDI treatment. There are a few classifications for the long term results in patients treated for IBDI; the Terblanche scale, based on clinical biliary symptoms, is regarded as the most useful classification. Proper diagnosis and treatment of IBDI may avoid many serious complications and improve quality of life.

Intrapancreatic accessory spleen:A case report and review of the literature

Here,we report a case of intrapancreatic accessory spleen confirmed by pathologic diagnosis and discuss its differential diagnosis and surgical management with a review of the literature.

A case report of abdominal distention caused by herpes zoster

Gastrointestinal complications caused by herpes zoster are extremely rare. Here, we described a case of abdominal distention caused by herpes zoster. The patient was a 59-year-old female who suffered from unexplained paroxysmal and a burning pain on the right part of her waist and abdomen, accompanied by abdominal distention. Intestinal pseudo-obstruction was diagnosed by abdominal radiography. Distention of the right abdominal wall was still apparent after one month. In this report, we found that recovery from abdominal distention caused by herpes zoster is difficult and may require surgical intervention.

OVERVIEW FOR THE DIAGNOSIS AND TREATMENT OF GALLBLADDER CARCINOMA

Objective. To improve the recognition of diagnosis and treatment of gallbladder cancer. Methods. Retrospective analysis of 52 cases of gallbladder carcinoma in our hospital from 1988 to 1998. Results. Preoperative diagnostic rate was 90.3%, of which 12 cases (23%) were early stage of carcinoma. The total operation resection rate was 55.8%, for which only 17.8% were advance stage of carcinoma. Conclution.The early diagnosis is the key factor of increasing treatment successful rate. The following are the symptoms that raise our special attention to carcinoma of gallbladder: (1) Age over 50 have recurrent cholecystitis and with past history of gallstone; (2) Congenital malformation of bile duct; (3) Local thickening and irregularity of gallbladder wall; (4) Polypoid lesion larger than 1cm inside gallbladder; (5) Atrophic gallbladder; (6) Intraluminal stone of gallbladder does not move when change in body position; (7) Regional lymph node enlargement.

Oncological problems in pancreatic cancer surgery

Despite the development of more sophisticated diagnostic techniques, pancreatic carcinoma has not yet been detected in the early stage. Surgical resection provides the only chance for cure or long-term survival. The resection rate has increased due to recent advances in surgical techniques and the application of extensive surgery. However, the postoperative prognosis has been poor due to commonly occurring liver metastasis, local recurrence and peritoneal dissemination. Recent molecular-biological studies have clarified occult metastasis, micrometastasis and systemic disease in pancreatic cancer. Several oncological problems in pancreatic cancer surgery are discussed in the present review.

Appropriateness of indication and diagnostic yield of colonoscopy: First report based on the 2000 guidelines of the American Society for Gastrointestinal Endoscopy

AIM: To assess the appropriateness of referrals and to determine the diagnostic yield of colonoscopy according to the 2000 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE).METHODS: A total of 736 consecutive patients (415males, 321 females; mean age 43.6±16.6 years)undergoing colonoscopy during October 2001-March2002 Were prospectively enrolled in the study. The 2000ASGE guidelines were used to assess the appropriateness of the indications for the procedure. Diagnostic yield was defined as the ratio between significant findings detected on colonoscopy and the total number of procedures performed for that indication.RESULTS: The large majority (64%) of patients had colonoscopy for an indication that was considered'generally indicated'; it was 'generally not indicated' for20%, and it was 'not listed' for 16% in the guidelines.The diagnostic yield of colonoscopy was highest for the 'generally indicated' (38%) followed by 'not listed'(13%) and 'generally not indicated' (5%) categories.In the multivariable analysis, the diagnostic yield was independently associated with the appropriateness of indication that was 'generally indicated' (odds ratio=12.3) and referrals by gastroenterologist (odds ratio = 1.9).CONCLUSION: There is a high likelihood of inappropriate referrals for colonoscopy in an open-access endoscopy system. The diagnostic yield of the procedure is dependent on the appropriateness of indication and referring physician's specialty. Certain indications 'not listed' in the guidelines have an intermediate diagnostic yield and further studies are required to evaluate whether they should be included in future revisions of the ASGE guidelines.