Surgically treated primary malignant tumor of small bowel:A clinical analysis

AIM:To evaluate the clinical presentation,treatment and survival of patients with primary malignant tumor of small bowel(PMTSB).METHODS:Clinicopathologic data about 141 surgically treated PMTSB patients(91 males and 50 females) at the median age of 53.5 years(range 23-79 years) were retrospectively analyzed.RESULTS:The most common initial clinical features of the patients were intermittent abdominal discomfort or vague abdominal pain(67.4%),abdominal mass(31.2%),bowel obstruction(24.1%),hemotochezia(21.3%),jaundice(16.3%),fever(14.2%),coexistence of bowel perforation and peritonitis(5.7%),coexistence of gastrointestinal bleeding and shock(5.0%),and intraabdominal bleeding(1.4%).Ileum was the most common site of tumor(44.7%),followed by jejunum(30.5%)and duodenum(24.8%).PMTSB had a nonspecific clinical presentation.Segmental bowel resection(n=81)was the most common surgical procedure,followed by right hemicolectomy(n=15),pancreaticoduodenectomy(n=10),and others(n=19).Twenty-seven adenocarcinoma patients and 13 malignant lymphoma patients received adjuvant chemotherapy with 5-fluorouracil and cyclophosphamide,adriamycin,vincristine and prednisone,respectively.Information about 120 patients was obtained during the follow-up.The median survival time of PMTSB patients was 20.3 mo.The 1-,3-and 5-year survival rate was 75.0%(90/120),40.0%(48/120)and 20.8%(25/120),respectively.Adenocarcinoma was found in 73.7%(42/57),21.1%(12/57)and 15.8%(9/57)of the patients,respec-tively.Gastrointestinal stromal tumor was observed in 80.0%(20/25),72.0%(18/25)and 36.0%(9/25)of the patients,respectively.Carcinoid was detected in 100.0%(15/15),80.0%(12/15)and 46.7%(7/15)of the patients,respectively.Malignant lymphoma was demonstrated in 69.2%(9/13),30.8%(4/13)and 0%(0/13)of the patients,respectively.CONCLUSION:En bloc resection is the principal therapy for most PMTSB and chemotherapy is the important treatment modality for malignant lymphoma and other malignant tumors of small bowel which cannot be radically removed.

Evaluation of surgical procedure selection based on intraoperative free portal pressure measurement in patients with portal hypertension

BACKGROUND: Various surgical procedures can be used to treat liver cirrhosis and portal hypertension. How to select the most appropriate procedure for patients with portal hypertension has become a difficult problem. This study aimed to analyze the relationship between the value of intraoperative free portal pressure (FPP) and postoperative complications, and to explore the significance of intraoperative FPP measurement with respect to surgical procedure selection. METHODS: The clinical data of 187 patients with portal hypertension who received pericardial devascularization and proximal splenorenal shunt combined with devascularization (combined operation) at the Department of General Surgery in our hospital from January 2001 to September 2008 were retrospectively analyzed. Among the patients who received pericardial devascularization, those with a postoperative FPP >= 22 mmHg were included in a high-pressure group (n=68), and those with FPP <22 mmHg were in a low-pressure group (n=49). Seventy patients who received the combined operation comprised a combined group. The intraoperative FPP measurement changes at different times, and the incidence of postoperative complications in the three groups of patients were compared. RESULTS. The postoperative FPP value in the high-pressure group was 27.5 +/- 2.3 mmHg, which was significantly higher than that of the low-pressure (20.9 +/- 1.8 mmHg) or combined groups (21.7 +/- 2.5 mmHg). The rebleeding rate in the high-pressure group was significantly higher than that in the low-pressure and combined groups. The incidence rates of postoperative hepatic encephalopathy and liver failure were not statistically different among the three groups. The mortality due to rebleeding in the low-pressure and combined groups (0.84%) was significantly lower than that of the high-pressure group. CONCLUSIONS: The study demonstrates that FPP is a critical measurement for surgical procedure selection in patients with portal hypertension. A FPP value >= 22 mmHg after splenectomy and devascularization alone is an important indicator that an additional proximal splenorenal shunt needs to be performed. (Hepatobiliary Pancreat Dis Int 2010; 9: 269-274)

Pancreatic duct stones in patients with chronic pancreatitis:surgical outcomes

BACKGROUND: Pancreatic duct stone (PDS) is a common complication of chronic pancreatitis. Surgery is a common therapeutic option for PDS. In this study we assessed the surgical procedures for PDS in patients with chronic pancreatitis at our hospital. METHOD: Between January 2004 and September 2009, medical records from 35 patients diagnosed with PDS associated with chronic pancreatitis were retrospectively reviewed and the patients were followed up for up to 67 months. RESULTS: The 35 patients underwent ultrasonography, computed tomography, or both, with an overall accuracy rate of 85.7%. Of these patients, 31 underwent the modified Puestow procedure, 2 underwent the Whipple procedure, 1 underwent simple stone removal by duct incision, and 1 underwent pancreatic abscess drainage. Of the 35 patients, 28 were followed up for 4-67 months. There was no postoperative death before discharge or during follow-up. After the modified Puestow procedure, abdominal pain was reduced in patients with complete or incomplete stone clearance (P>0.05). Steatorrhea and diabetes mellitus developed in several patients during a long-term follow-up. CONCLUSIONS: Surgery, especially the modified Puestow procedure, is effective and safe for patients with PDS associated with chronic pancreatitis. Decompression of intraductal pressure rather than complete clearance of all stones predicts postoperative outcome.

Indications and surgical treatment of chronic pancreatitis

BACKGROUND: Some patients with chronic pancreatitis (CP) may require surgery mainly because of intractable pain, suspicion of malignancy, or complications related to CP. This study aimed to analyze the efficacy of surgical treatment for patients with CP in terms of pain relief, control of local complications, and pancreatic endocrine/exocrine function. METHODS: Twenty-six patients with CP were treated surgically at our hospital from June 1985 to November 2005. The clinical data of these patients were analyzed retrospectively. RESULTS: The follow-up time ranged from 8 to 130 months with a median of 60.6 months. No patients were lost to follow-up. All patients had improvement of clinical symptoms such as abdominal pain, steatorrhea and weight loss, to some degree, especially pain relief in patients with good dilation and high pressure of the main pancreatic duct. The endocrine and exocrine functions were not alleviated in all patients, otherwise the impaired glucose tolerance was improved in 8 (30.8%), 15 (57.7%) maintained the same body weight, one (3.8%) had an acute attack of CP, and 2 (7.7%) developed pancreatic carcinoma in the 16th and 28th month postoperatively and died within 3 years after operation for CP. The 1-, 3-, 5-year pain-free rates of CP patients were 96.2% (25/26), 88.5% (23/26) and 84.6% (22/26), respectively. CONCLUSIONS: In selected patients with CP, surgical treatment is a safe procedure and can effectively relieve pain and control local complications; also, it is helpful to improve the quality of life for patients with pancreatitis, and to control the development of this disease.

Recurrent lithiasis after surgical treatment of elderly patients with choledocholithiasis

BACKGROUND: The recurrence rates of choledocholithiasis depend on the type of the disease. This study was undertaken to examine recurrent lithiasis after surgical treatment of elderly patients with choledocholithiasis, especially with primary common bile duct stones, and thereby to determine the best treatment modality for choledocholithiasis in the elderly. METHODS: The recurrence rates of choledocholithiasis were calculated from the records of 193 outpatients who had been treated from January 1993 to January 2005 and monitored for periods ranging from I to 12 years (mean 6.7 years). The patients were divided into 3 groups: 81 who had undergone choledocholithotomy and T-tube drainage, 41 who had had choledochoduodenostomy. and 71 patients who had received choledochojejunostomy. RESULTS: Since the 41 choledochoduodenostomy cases had only one recurrence of choledocholithiasis, the recurrence rate was analyzed for the remaining 152 cases, which were divided into two groups: group A with recurrent lithiasis (13 cases), and group B without recurrence (139 cases). The recurrence was found in 7 patients after choledocholithotomy and T-tube drainage (7/81, 8.6%), and in 6 patients after choledochojejunostomy (6/71, 8.5%). The recurrence rates for these procedures were higher than for choledochoduodenostomy (1/41, 2.4%, P<0.05). Moreover, stones recurred in 4 of the 11 patients with primary bile duct stones who underwent choledocholithotomy an T-tube drainage (4/11, 36.4%), and in 5 of the 34 patients who had choledochojejunostomy (5/34, 14.7%). The recurrence rates for these procedures were higher than for choledochoduodenostomy (1/39, 2.6%, P<0.05). The diameter of the common bile duct was more dilated in group A (14.6 +/- 3.9 mm) than in group B (10.8 +/- 4.5 turn, P<0.05). Primary bile duct stones were found in 9 cases of group A (69.2%), and in 36 cases of group B (25.9%, P<0.01). CONCLUSION: Choledochoduodenostomy should be recommended for elderly patients with primary bile duct stones to prevent postoperative recurrent lithiasis.

Diagnosis and surgical treatment of hepatic hilar cholangiocarcinoma

BACKGROUND: Hepatic hilar cholangiocarcinoma can be diagnosed early with the progress in diagnostic imaging, and thus the rate of resection of the tumor has increased markedly. To assess the effectiveness of resection, we reviewed 185 cases of hepatic hilar cholangiocarcinoma diagnosed and treated at our hospital. METHODS: The clinical data of 185 patients with hepatic hilar cholangiocarcinoma who had been treated surgically from 1972 to 2006 were retrospectively analyzed. RESULTS: The records of the 185 patients were divided into first stage (1972-1986) or second stage (1987-2006) according to the incidence of the tumor and its resection rate. Primary symptoms included upper abdominal discomfort or pain, anorexia, tiredness, weight loss and progressive jaundice. Ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) were first line methods for atraumatic diagnosis. If the patients displayed intrahepatic bile duct dilatation or were diagnosed as suffering from extrahepatic obstructive jaundice, percutaneous transhepatic cholangiography (PTC), MRCP or endoscopic retrograde cholangiopancreatography (ERCP) should be used. In this series, 87 patients underwent resection of the tumor (47.0%). Of the 87 patients, 43 received radical resection and 44 palliative resection. Fifteen patients underwent resection in the first stage and 72 in the second stage. A total of 74 patients were followed up after the resection. The median survival time of the radical resection group was 37 months and that of the palliative resection group was 17 months (P<0.001). The other 62 patients receiving no resection died within 1.5 years. CONCLUSIONS: Once patients are diagnosed with hepatic hilar cholangiocarcinoma, they should undergo exploratory laparotomy. Resection is the most effective method for the treatment of hepatic hilar cholangiocarcinoma.

Microsurgical reconstruction of hepatic artery in living donor liver transplantation:experiences and lessons

BACKGROUND: Hepatic artery (HA) reconstruction is one of the key steps for living donor liver transplantation (LDLT). The incidence of HA thrombosis has been reduced by the introduction of nucrosurgical techniques under a high resolution microscope or loupe. METHODS: We report our experience in 101 cases of HA reconstruction in LDLTs using the graft-artery-undamp and posterior-wall-first technique. The reconstructions were completed by either a plastic surgeon or a transplant surgeon. RESULTS: The rate of HA thrombosis was 2% (2/101). The risk factors for failed procedures appeared to be reduced by participation of the transplant surgeon compared with the plastic surgeon. For a graft with duplicate arteries, we considered no branches should be discarded even with a positive clamping test. CONCLUSIONS: HA reconstruction without clamping the graft artery is a feasible and simplified technique, which can be mastered by transplant surgeons with considerable microsurgical training.

Surgical procedure determination based ontumor-node-metastasis staging of gallbladder cancer

AIM To compare survival and recurrence in hepatocellularcarcinoma （HCC） patients who did or did notreceive adjuvant transarterial chemoembolization（TACE）.METHODS： A consecutive sample of 229 patients whounderwent curative resection between March 2007and March 2010 in our hospital was included. Of these229 patients, 91 （39.7%） underwent curative resectionfollowed by adjuvant TACE and 138 （60.3%） underwentcurative resection alone. In order to minimize confoundsdue to baseline differences between the twopatient groups, comparisons were conducted betweenpropensity score-matched patients. Survival data andrecurrence rates were compared using the Kaplan-Meier method. Independent predictors of overall survivaland recurrence were identified using Cox proportionalhazard regression.RESULTS： Among 61 pairs of propensity scorematchedpatients, the 1-, 2-, and 3-year overall survivalrates were 95.1%, 86.7%, and 76.4% in the TACEgroup and 86.9%, 78.5%, and 73.2% in the controlgroup, respectively. At the same time, the TACE andcontrol groups also showed similar recurrence rates at1 year （13.4% vs 24.8%）, 2 years （30.6% vs 32.1%）,and 3 years （40.1% vs 34.0%）. Multivariate Coxregression identified serum alpha-fetoprotein level ≥400 ng/mL and tumor size 〉 5 cm as independent riskfactors of mortality （P 〈 0.05）.CONCLUSION： As postoperative adjuvant TACE doesnot improve overall survival or reduce recurrence inHCC patients, further study is needed to clarify itsclinical benefit.

Etiology and surgical treatment of hilar bile duct strictures

Objective To improve curative effects in treatment of hilar bile duct strictures. Methods The clinical data of 76 patients with hilar bile duct strictures treated in our hospital from 1990 to 2000 were analyzed. The diagnosis was determined by cholangitis of 3 chief signs: increase in ALP and 7-GGT, intra-and extra hepatic bile duct dilatation showed by BUS and CT and confirmation by PTC and/or ERCP. The site of strictures was classified according to Bismuth standard. Results Amongst the 76 patients, 60. 5% suffered from injurious strictures, including Bismuth Ⅰ in 13%, Bismuth Ⅱ in 39%, Bismuth Ⅲ in 19. 4% and Bismuth Ⅳ in 28. 2%. Inflammatory strictures were found in 28 patients, including LHD in 13(46.4%) ,RHD in 10(35.7%) and CHD in 5 (17. 9 % ). The percentages of patients with strictures due to Mirizzy syndrome, choledo-cyst and sclerosing cholangitis were 9. 2 % , 3. 9 % and 2.6%, respectively. Repair with umbilical vein was performed in 9. 2% and that with high-level choledochojejuostomy

Treatment for long-term poorly closed incisions after hepatobiliary surgery

BACKGROUND: Effective measures are lacking to treat long-term poorly closed incisions after hepatobiliary surgery, including chronic sinus tract and keloid. This study aimed to introduce the treatment experiences with the abdominal wall and costal margin complications after hepatobiliary surgery, and to investigate the method for prevention of this kind of complication. METHODS: We retrospectively studied 26 patients with complications of abdominal wall and costal margin after hepatobiliary surgery, who had been admitted to our hospital since 1998. The 26 patients were classified according to complications into 3 groups: chronic ulcer with costal chondritis (5 patients), single chronic ulcer (3), and keloid (18). According to the symptoms of patients, treatments given included focal removal regional flap transfer restoration and focal removal dermatoplasty combined with glucocorticoid injection, anti-scar medication, external application of silicone gel film, and pressure therapy after surgery to inhibit recurrence. RESULTS: Satisfactory results were observed in the 26 patients after the treatments. Focal and regional ache and itching disappeared, and 2-3-year follow-up revealed no recurrence. CONCLUSIONS: Attention should be paid to patients with complications of abdominal wall and costal margin after hepatobiliary surgery. Combined treatment or mainly operations produce satisfactory result.

Surgical treatment of cicatricial esophageal stenosis in infants

Objective To review the results of surgical management of cicatricial esophageal stenosis secondary to chemical burn. Methods Retrospective study was carried out on 30 children ( male 20, female 10 ) with esophagageal cicatricial stenosis. The mean age was 29 months (17 to 60 months) and body weight ranged from 5 to 20 kilograms. One child ingested pesticide whereas the remaining ingested acidic of caustic solutions. There children had complete obliteration of cervical esophagus, 5 had near-complete obliteration and the remaining showed stringy esophageal outline on barium meal study. Five children developed stridor and inspiratory dyspnea. Six children had previous gastrostomy. All patients underwent retrosternal colonic replacement based on left ascending colonic artery. Results Post-operatively, one patient developed anastomotic leakage and one anastomotic stenosis. One patient underwent a post-operative tracheostomy. There was no mortality. All patients were followed-up for 4-20 years with normal

Parenteral administration of branch-chain amino acids enrichment in critically ill surgical patients

To investigate the effect of the infusion of BCAA-enriched parenteral nutrition in critical patients on nutritional status and clinical outcome.Methods 40 critical patients who met the criteria were enrolled in a prospective,randomly and single-blind-controlled study,and received total parenteral nutrition.TPN was infused to the patients in both groups with equal calorie and equal nitrogen by central vein.Meanwhile,plasma amino acid patterns and nitrogen balance were assayed.Results After 6 days treatment of parenteral nutrition,plasma concentrations of valine(P=0.008),leucine(P=0.02) and isoleucine(P=0.01) in research group increased more obviously than that in control group,so did the plasma concentrations of arginine(P=0.007).No positive introgen balance was obtained after 6 days’ treatment of parenteral nutrition in the two groups.APACHEⅡ scores of research group decreased more obviously than that of control group,but length of stay and mortality rate show no significant differences between the two groups.Conclusion The formula of amino acid enriched BCAA may normalize the levels of serum amino acids,reduce the proteolysis,and increase the synthesis of protein.A further study with large sample is improtant to evaluate the effect of BCAA on clinical outcome in critically ill patients.5 refs.

THORACIC AND CARDIOVASCULAR SURGERY--Upper respiratory tract, lung： Clinical analysis of pulmonary mucosal resection in the treatment of multi-drug resistant pulmonary tuberculosis in 56 cases

2009216 Relation of inositol 1,4,5-trisphosphate with calcium metabolism in rats with severe acute pancreatitis.SHI Chengxian(石承先),et al.Dept Live Bili Pancre Surg,Guizhou Prov Hosp,Guiyang 550002.World Chin J Digestol,2009;17(6):598-601.

Surgical treatment of degenerative scoliosis

Objective To investigate the techniques of posterior lumbar interbody fusion and pedicle screws in the treatment of degenerative scoliosis and evaluate their clinical significance. Methods Twenty five patients with degenerative scoliosis were treated operatively during 1997 -2002. Among the 25 pateints,13 pateints were treated with Brantigan I/F carbon cages in 28 intervertebral spaces,7 patients were treated with Prospace cages in 15 spaces, 1 patient was treated with CONTACT cages in 2 spaces. The correcting effects, complications and follow-up results were analyzed retrospectively. Results The average correction rate of scoliosis was 59 % and the rate of pain relief was 88 %. There were a case of pseudoarthritis and a case of embolism. During follow-up, correction rate and height of dics spaces were not lost nor shift of interbody cages. Conclusion Posterior pedicle screws combined with interbody fusion is a safe and effective treatment for degenerative scoliosis. 5 refs, 2 figs.

Clinical use of left ventricular assist in coronary artery surgery.

Objective To review the experience of using left ventricular assist (LVAD) in coronary artery bypass grafting (CABG). Methods The data of 1 704 CABG cases were analyzed. 25 patients required LVAD after CABG (1. 5% ,25/1704). Results About 78% of 25 patients were weaned off LVAD, and 48% of them were discharged. IABP was used in 88% of patients. The major complications were MOF,lung disease,renal insufficiency/ failure, arrhythmia, coapulopathy, and infection. The causes of death were MOF, pump failure, renal failure, venticular fibrillation, respiratory failure, bleeding. Conclusion LVAD is a very useful tool in salvaging left ventricular failure. LVAD should be used as early as possible. Before weaning, trials should be madeat decreasing flow rates. 11 refs,2 tabs.

Congenital coronary artery flstnlae in adults: diagnosis and surgical treatment

Objective To summarize the clinical characteristics, diagnosis and surgical treatment results of congenital coronary artery fistulas (CAF) in adults. Methods Fourteen patients (8 men,6 women) ,aged from 18 to 60 years with a mean of 32 ±12 years, underwent surgical correction of CAF between March 1985 and April 2002. Eleven of the 14 patients (78. 57% ) were symptomatic. The diagnosis of CAF was made by echocardiography or angiocardioraphy preoperatiely. The fistulae originated from the right, left and double coronary arteries in 10 (71%),3(21%) and 1(7%) patient (s),respectively. The fistulae drained into the right ventricle (8 patients), left ventricle (4),right atrium (1) and pulmonary artery (1), respectively. The diameter of fistulae ranged from 0.30 tol.80 cm with a mean of (1.16±0.49)cm.There were 6 CAF patients associated with coronary artery aneurysms and 4 CAF patients with other coexisting cardiac defects. The distal fistulae were closed in 10 patients with cardiopulmonary bypass (CPB)

Transit time flow measurement in cormary surgery

Objective To review the experience of using the transit time flow measurement (TTFM) in coronary artery bypass grafting (CABG). Methods From Sept. 2001 to May, 2002,90 cases underwent CABG. Among them, 40 cases with off-pump beating heart (OPCAB) and 50 with conventional coronary bypass grafting. All graft patency were verified intraoperatinlly with TTFM. The flow value of left internal mammary artery (LIMA) in 30 cases was also detected by the same way before grafting to left anterior descending (LAD). Results There was no operative death and severe complications. The mean flow value of LIMA in 30 cases was (42. 9 ± 33. 0) ml/min. The actual blood flow value, measured simultaneously by exsanguination was (37.4 ± 28. 8)ml/ min. Excel-lent correlation was demonstrated. The mean pulsatility index value (PI) was 1. 00 ± 0. 04. The flow curve showed both diastolic and systolic filling. The mean flow value of LIMA to LAD.saphenous vein graft (SVG) or radial artery (RA) to circumflex coronary artery (LCX)

THORACIC AND CARDIOVASCULAR SURGERY

5.1 Pleura,pleural cavity,mediastinum,diaphragm207101 The clinical study on thymoma associated with pure red cell aplasia:report of five cases/Zhang Xiaofeng(张晓峰,Dept Thorac Surg,1st Affil Hosp, China Med Univ,Shenyang 110001)…∥Chin J Thorac Cardiovasc Surg.-2006,22(5).-305～307Objective To present the clinic characteristics of thymoma associated with pure red cell aplasia.Methods Between 1979 and 2004,5 patients with thymoma associated with pure red cell aplasia were surgically treated.Results The age of the patients ranged from 43 to 68 years,mean age 54.6 years.The incidence of thymoma associated with pure red cell aplasia was 2.7% (5/185) in the contemporary series.All five patients underwent radical operation.The early results of thymomectomy were excellent,4 cases are longterm survivals,and recurrence of PRCA was found in one patient 2 months after operation and died 31 months later.Conclusion Thymoma associated with PRCA is a rare autoimmune disease.Surgery for thymoma is still top priority in the selection of treatment.Incretion and immunosuppressor may be considered for postoperative persistent PRCA cases.