高龄胃癌患者的临床特点及围手术期处理

目的：探讨高龄胃癌患者的临床表现、治疗特点及其对术后并发症的影响,以及高龄胃癌患者的围手术期处理。
方法：回顾性分析手术治疗的101例高龄胃癌患者的临床资料,着重分析术前合并症与术后并发症的治疗。
结果：大于70岁的高龄胃癌患者（高龄组）有临床表现多无特异性、病变部位及范围不同、术前合并症多等临床特点。高龄组术前合并症发生率为49.5%(50例),对照组（小于70岁的胃癌患者）为21.3%,两组差异有统计学意义(P<0.05);高龄组术后并发症发生率为18.8%,对照组为15.2%,但两组无统计学差异(P>0.05);高龄组胃癌手术切除98例(97.0%),其中根治性切除87例(86.1%)。
结论：高龄胃癌患者术前合并症较多,术后并发症发生率也较高。加强此类患者的围手术期处理,对减少术后并发症,提高生存率和生活质量有重要意义。     

Abdominal aortic aneurysm surgery: Survival and quality of life in patients requiring prolonged postoperative intensive therapy

The goal of this study was to identify patients who need longer care in the ICU (more than 48 hours) following abdominal aortic aneurysm (AAA) surgery and to evaluate the influence of perioperative complications on short- and long-term survival and quality of life. AAA surgery was performed in 553 patients, 51 (9%) of whom died within the first 48 hours. Of the 502 patients who survived for more than 48 hours, 109 required ICU therapy for more than 48 hours, whereas 393 patients were in the ICU for less than 48 hours. The incidence of preoperative risk factors was similar for the two groups. The cumulated survival rates for the two groups were 68% and 92% at 1 months, 52% and 88% at 1 year, and 60% and 33% at 6 years, respectively. This significant difference was primarily related to renal, pulmonary, and cardiac complications. However, assessment of the most severe complications and risk factors combined failed to permit identification of patients in whom the perioperative survival rate was 0%. Even 20% of patients with multiorgan failure survived for 6 months. Of those patients who needed ICU therapy for more than 48 hours, 41 (38%) were alive at the end of 1988. In response to a questionnaire, 78% stated that their quality of life had improved or was unchanged after surgery and had resumed working. These data justify a therapeutically aggressive approach, including ICU therapy following AAA surgery, despite failure of one or more organ systems.     

Preliminary results of concurrent methotrexate,cisplatin and radiation treatment for locally advanced urothelial cancers

Ten patients with invasive bladder cancer and one with locally advanced renal pelvic cancer were treated with concurrent methotrexate, cisplatin and radiotherapy. Methotrexate 30 mg/m² was administered intravenously on the day of the initiation of radiotherapy and cisplatin 70 mg/m² on the second day. The number of chemotherapy cycles delivered was 1 in 7 patients and 2 in 4. The median dose of radiation was 50 Gy. Of 11 patients, 7 (64%) achieved a partial response and 4 had no change in disease. The median duration of response was 16 months for patients with a partial response. Six patients with a partial response (55%) are alive for a median of 22.5 months and 2 of 4 with no change are alive for 4 and 15 months, respectively. Leukopenia less than 3000 cell/mm³ was observed in 4 (36%) and thrombocytopenia less than 100,000 cells/mm³ in 3 (27%). Local control could be achieved safely with concurrent methotrexate, cisplatin and radiation therapy in patients with locally advanced urothelial cancer who were unsuitable for surgery.     

Transoral robotic surgery and transoral laser microsurgery for oropharyngeal squamous cell cancer

The aim of our study was to compare transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) for primary resection of oropharyngeal squamous cell cancer (OPSCC). This was a retrospective chart analysis of 33 patients with OPSCC treated at one academic medical center with either TORS (n = 17) or TLM (n = 16) between July 2008 and December 2010. Six patients in the TLM group and seven patients in the TORS group had primary cancer of the tonsil; the remaining patients had base of tongue cancer. Two patients in the TORS group had Stage I or II disease; the other 31 patients had Stage III [1/16 (6 %) TLM; 5/17 (29 %) TORS] or Stage IV cancer [15/16 (94 %) TLM; 10/17 (59 %) TORS]. The intervention was transoral surgery for OPSCC, and the main outcome measures were perioperative variables and functional outcomes. Mean operative time was 170 versus 115 min for TLM and TORS, respectively (p = 0.057). One patient, in the TLM group, required a temporary tracheostomy. Perioperative feeding tubes were placed in 6/16 (38 %) patients who underwent TLM and in 4/17 (24 %) patients who underwent TORS (p = 0.465). At a median follow-up of 14.5 months, the average MD Anderson Dysphagia Inventory score was 65.2 for TLM and 70.8 for TORS (p = 0.431). All TORS procedures were performed with a single oral retractor, while multiple laryngoscopes were required in 9/16 (56 %) TLM cases (p = 0.0003). The mean number of total specimens were 6.2 for TORS and 13.6 for TLM (p = 0.002). These results demonstrate that TLM and TORS have comparable perioperative variables with no significant differences in functional outcomes. For a subset of patients, TORS reduced the spatial complexity of surgery, suggested by the decreased need for multiple laryngoscopes, fewer specimens, and shorter operative times, while larger tumors were more amenable to TLM.     

Alterations in Pulmonary Function Following Pneumonectomy for Bronchogenic Carcinoma

Twenty-one patients who underwent pneumonectomy for bronchogenic carcinoma at the Nashville Veterans Administration Hospital from November, 1977, to March, 1980, were evaluated with standard pulmonary function tests preoperatively and postoperatively. Twelve patients had Stage I disease, 4 patients had Stage II, and 5 patients had Stage III disease. The interval between the operative procedure and postoperative testing ranged from 2 to 33 months (mean, 12.4 months).Mean functional loss of pulmonary capacity after pneumonectomy was based on analysis of preoperative and postoperative forced vital capacity (FVC) and initial-second forced expiratory volume (FEV₁) indices. The mean functional loss as expressed by FVC was 41.5% after right pneumonectomy and 34.0% after left pneumonectomy. The mean functional loss as expressed by FEV₁ was 40.2% after right pneumonectomy and 38.3% after left pneumonectomy.The postoperative functional status of each patient was classified according to the New York Heart Association criteria. Nineteen of the 21 patients were in Class I or II preoperatively. Postoperatively, 10 patients were in Class I or II and 11 in Class III or IV. The results indicate that a postoperative FVC less than 2.5 liters and FEV₁ less than 1.5 liters are not compatible with active life.     

Randomized clinical trial of preoperative and postoperative adjuvant chemotherapy with cisplatin, vindesine, and bleomycin for carcinoma of the esophagus

Thirty-nine patients with potentially resectable cancer of the middle or lower esophagus who had not previously been treated were randomly assigned to receive either immediate operation (n = 20) or operation plus preoperative and postoperative therapy with cisplatin, vindesine, and bleomycin (n = 19). Patients were stratified by tumor size and location and by sex, with no significant differences appearing between the two treatment groups. Median follow-up for both groups was 30 months. The preoperative response rate to chemotherapy was 47%. The postoperative complication rate for patients in the operation-only group was 47%; it was 29% for patients receiving chemotherapy. The overall resectability rates were similar for the two groups. Patients responding to chemotherapy preoperatively had significantly prolonged survival (median greater than 20 months) when compared with either nonresponders (median 6.2 months) or patients receiving only operation (median 8.6 months). A highly significant correlation was noted between a weight loss of less than 10% and response to chemotherapy, which suggested that responses occurred in patients with less advanced disease. We conclude that preoperative and postoperative cisplatin, vindesine, and bleomycin chemotherapy has acceptable toxicity and does not increase the incidence of postoperative complications. The natural history of epidermoid carcinoma of the esophagus is altered and overall survival is prolonged for patients responding to preoperative chemotherapy. Potential responding patients can be identified by the degree of preoperative weight loss.     

Combined chemotherapy of irinotecan and low-dose cisplatin (I/low-P) against metastatic biliary tract cancer

There is no established or effective standard therapy for metastatic biliary tract cancer, resulting in poor prognosis. Recently, we performed combination chemotherapy of irinotecan and low-dose cisplatin (I/low-P) for three consecutive patients with metastatic biliary tract cancer. The regimen of I/low-P therapy consisted of irinotecan (60 mg/m²) and low-dose cisplatin (6 mg/m²), administered by intravenous infusion weekly or biweekly. Of the three patients, two showed a partial response, with durations of more than 20 months, and 2 months, respectively, while the third patient had stable disease for 3 months. One patient, who had jaundice, had grade 3 thrombocytopenia, but the other patients did not have any severe toxicities. Survival times were more than 20 months, 10 months, and 13 months, respectively. These outcomes suggest that I/low-P therapy is safe and may be worth trying as a first-line chemotherapy for patients with metastatic biliary tract cancer.     

Causes of the Increased Stroke Rate after Carotid Endarterectomy in Patients with Previous Strokes

n = 183) were compared to those who were either asymptomatic or experienced only transient ischemic attacks (TIAs) preoperatively (n= 423). Of the 183 patients who had suffered preoperative strokes, eight patients who experienced perioperative strokes after endarterectomy were compared with 175 who successfully underwent surgery. Patients with a prior stroke had an increased perioperative stroke rate (4.4% versus 1.2%, p= 0.01). They had a significantly higher incidence of hypertension (62.6% versus 47.9%, p < 0.001), cardiac disease (54.7% versus 40.7%, p= 0.001), and positive smoking history (52% versus 40.6%, p= 0.01) than did the asymptomatic/TIA patients. The presence of contralateral total occlusion was also significantly increased (22% versus 10.3%, p < 0.001). Although not statistically significant due to the overall small number of patients who sustained perioperative strokes, the preoperative stroke patients who sustained perioperative strokes had a higher incidence of hypertension (87.5% versus 61.5%) and contralateral total occlusion (37.5% versus 21.3%) than did those who successfully underwent surgery. Patients with both a prior stroke and contralateral total occlusion had a 7.5% perioperative stroke rate. Patients with both a prior stroke and hypertension had a 6.1% perioperative stroke rate. The perioperative strokes in patients with prior strokes were not related to the severity of the prior stroke, the interval between the stroke and surgery, the use of a shunt, or the type of anesthesia employed. Patients who have sustained preoperative strokes have a higher incidence of significant medical illnesses and overall cerebrovascular disease. Hypertension and total occlusion of the contralateral carotid artery appear to be particularly poor prognostic indicators of outcome after endarterectomy in these patients. Patients who have sustained preoperative strokes may be more likely to display clinical neurologic symptoms in response to any form of cerebral ischemia. In this higher risk subgroup, intraoperative and surgeon-dependent factors appear to play less of a role.     

Very long-term outcomes of video-assisted thoracoscopic surgery for lung cancer

Background  The most critical parameter in the evaluation of the feasibility of video-assisted thoracoscopic surgery (VATS) lobectomy for lung cancer is long-term outcome. In this study, patients in whom more than 5 years had elapsed since they had undergone VATS lobectomy for lung cancer were identified, and the 5-year survival rate and frequency of recurrence were evaluated as the long-term outcomes; in addition, the frequency of perioperative complications were also evaluated as the short-term outcomes. Methods  The stage, histology, perioperative complications, recurrence, and survival data were carefully reviewed in 198 patients who underwent VATS lobectomy for lung cancer between 1998 and 2002. Results  Median postoperative follow-up period was 72.1 months. Of the 198 patients, 138 and 30 were diagnosed as having p-stage IA and IB disease, respectively, while the remaining 30 patients had more advanced disease. Perioperative complications were observed in 20 patients (10.1%), however, there were no perioperative mortalities. Recurrence was observed in 26 patients (13.1%): of these, 11 patients showed local recurrence, including malignant pleural effusion and mediastinal lymph node recurrence, and 16 patients showed distant metastasis, the lung being the commonest site of metastasis; six patients had both local recurrence and distant metastasis. During the study period, there were 26 deaths (13.1%), of which 17 were due to lung cancer and 9 were due to other causes. The 5-year overall survival rates of the patients with p-stage IA and IB disease were 93.5% and 81.6%, respectively. Conclusion  VATS lobectomy for the treatment of lung cancer is as feasible and safe as open lobectomy in terms of both very long- and short-term outcomes.     

Attenuation of the Systemic Inflammatory Response and Infectious Complications After Gastrectomy with Preoperative Oral Arginine and ω-3 Fatty Acids Supplemented Immunonutrition

Background  Past trials have shown perioperative immunonutrition to improve the outcome for patients with gastric cancer. The present study was designed to evaluate the effect of preoperative oral immunonutrition on cellular immunity, the duration of the systemic inflammatory response syndrome (SIRS), and detailed postoperative complications in patients with gastric cancer. Methods  Sixty patients with gastric cancer were randomly assigned to two groups: one group received immune-enhanced formulas supplemented with arginine and ω-3 fatty acids (immune-enhancing diet (ID) group, n = 30); the other received standard formulas (conventional diet (CD) group, n = 30) for 7 days before the operation. These groups were well matched in terms of age, sex, operations, cancer stages, and intraoperative variables. The postoperative outcome was evaluated based on clinical variables, including postoperative infectious complications, noninfectious complications, and SIRS duration. In addition, the perioperative state of cellular immunity was evaluated and compared between the two groups. Results  The incidence of postoperative infectious complications in the ID group (6%) was significantly (p < 0.05) lower than that of the CD group (28%). The duration of SIRS in the ID group (0.77 ± 0.9 days) was significantly (p < 0.05) shorter than that in the CD group (1.34 ± 1.45 days). The postoperative lymphocyte and CD4⁺T-cell counts significantly decreased (p < 0.05) in both groups. However, the number of CD4⁺T-cells on preoperative day 1 and postoperative day 7 was significantly (p < 0.05) higher in the ID group than in the CD group. Conclusions  Preoperative oral immune-enhanced formulas supplemented with arginine and ω-3 fatty acids enhanced the immune status of the patients, reduced the duration of SIRS, and decreased the incidence of postoperative infectious complications. CD4⁺T-cell immunity likely played an important role in the modulation of the postoperative immune and inflammatory response after gastrectomy.     

Pancreaticoduodenectomy after placement of endobiliary metal stents

Contemporary treatment programs for patients with potentially resectable pancreatic cancer often involve preoperative therapy. When the duration of preoperative therapy exceeds 2 months, the risk of plastic endobiliary stent occlusion increases. Metal stents have much better patency but may complicate subsequent pancreaticoduodenectomy (PD). We evaluated rates of perioperative morbidity, mortality, and stent complications in 272 consecutive patients who underwent PD at our institution from May 2001 to November 2004. Of these 272 patients, 29 (11%) underwent PD after placement of a metal stent, 141 underwent PD after placement of a plastic stent, 10 had PD after biliary bypass without stenting, and 92 had PD without any form of biliary decompression. No differences were found between the Metal Stent group and all other patients in median operative time, intraoperative blood loss, or length of hospital stay. No perioperative deaths occurred in the Metal Stent group versus 3 (1.2%) deaths in the other 243 patients. The incidence of major perioperative complications was similar between the two groups, including the rates of pancreatic fistula, intra-abdominal abscess, and wound infection. Furthermore, there were no differences in the perioperative morbidity or mortality rates between patients who underwent preoperative biliary decompression with a stent of any kind (metal or plastic) and those patients who underwent no biliary decompression at all. Metal stent-related complications occurred in 2 (7%) of 29 patients during a median preoperative interval of 4.1 months; in contrast, 75 (45%) of the 166 patients who had had plastic stents experienced complications, including 98 stent occlusions, during a median preoperative interval of 3.9 months (P < 0.001). We conclude that the use of expandable metal stents does not increase PD-associated perioperative morbidity or mortality, and as such an expandable metal stent is our preferred method of biliary decompression in patients with symptomatic malignant distal bile duct obstruction in whom surgery is not anticipated, or in whom there is a significant delay in the time to surgery. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). Supported by the Lockton Fund for Pancreatic Cancer Research, The University of Texas M. D. Anderson Cancer Center, Houston, Texas.     

Prognostic Effect of Perioperative Change of Serum Carcinoembryonic Antigen Level: A Useful Tool for Detection of Systemic Recurrence in Rectal Cancer

Background The prognosis of patients even with the same stage of rectal cancer varies widely. We analyzed the capability of perioperative change of serum carcinoembryonic antigen (CEA) level for predicting recurrence and survival in rectal cancer patients. Methods We reviewed 631 patients who underwent potentially curative resection for stage II or III rectal cancer. Patients were categorized into three groups according to their serum CEA concentrations on the seventh day before and on the seventh day after surgery: group A, normal CEA level (≤5 ng/mL) in both periods; group B, increased preoperative and normal postoperative CEA; and group C, continuously increased CEA in both periods. The prognostic relevance of the CEA group was investigated by analyses of recurrence patterns and survival. Results Stage III patients showed higher systemic recurrence (P = .001) and worse 5-year survival rates (P < .0001) for group C than for groups A and B. On multivariate analysis, the CEA group was a significant predictor for recurrence (P < .001; relative risk, 2.740; 95% confidence interval, 1.677–4.476) and survival (P = .001; relative risk, 2.174; 95% confidence interval, 1.556–3.308). Conclusions The perioperative serum CEA change was a useful prognostic indicator to predict for systemic recurrence and survival in stage III rectal cancer patients.     

Perioperative complications of pelvic lymphadenectomy and radical retropubic prostatectomy for Stages C and D1 prostate cancer

The complications experienced by 205 consecutive patients who underwent bilateral pelvic lymphadenectomy and radical retropubic prostatectomy for surgical Stages C and D1 prostate cancer were analyzed. One hundred five patients had pathologic Stage C disease, and 100 patients had pathologic Stage D1 disease. Seven patients had thromboembolic complications. Wound or pelvic hematomas developed in 6 patients. Only two lymphoceles were detected. Rectal injuries occurred in 6 patients, of whom 4 required colostomies. The overall incidence of perioperative complications was 17 per cent. There was one postoperative death.     

Primary laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ-cell testis tumor

Introductionthis report is intended to retrospectively assess cancer control and morbidity of primary laparoscopic reproperitoneal lymphadenectomy (L-RPLND) in patients with clinical Stage I non seminomatous germ cell tumour (NSGCT).Materials and methodsone hundred and sixty-four patients with clinical Stage I NSGCT underwent primary diagnostic LRPLND between 1993 and 2006. Patients were operated unilaterally limiting the dissection to templates. Kaplan Meier curves were generated estimating time to recurrence.Resultsof the 164 patients, 82 (48%) had embryonal components and 35 (20%) lymphovascular invasion in the orchiectomy specimen. The median (IQR) age, operative time, length of hospital stay, blood loss and number of lymph nodes retrieved was 28 years (24-33), 135 minutes. (120- 180), 48 hours (24-48), 50 cc (20-100) and 14 (10-18) nodes, respectively. All patients had negative serum markers preoperatively.Presence of lymph node metastasis was identified in 32 (19.5%) patients. Follow-up was available in 15 of these. Fourteen received adjuvant chemotherapy and 2 of them had recurrence at 3 and 64 months. Absence of lymph node metastasis was diagnosed in 132 (80.5%) patients. Follow-up was available in 80 of these. Among them 7 recurred (5 retroperitoneum, 2 lung), one of them 33 months after L-RPLND. Median follow-up for patients without recurrence was 14 months (IQR:4-35). The cumulative 3-year recurrence free rate was 82% (95%CI: 64-91). Seventeen (10%) of 164 patients had intra or perioperative complications.Conclusionsthis is the largest series of L-RPLND performed in a single institution. Both morbidity and oncologic safety of this technique needs to be prospectively evaluated in randomized trials.     

Relations Among Circulating Monocytes,Dendritic Cells,and Bacterial Translocation in Patients With Intestinal Obstruction

Background Little evidence is available regarding the relations among circulating monocytes, dendritic cells (DCs), and bacterial translocation (BT) in patients with intestinal obstruction. Methods We investigated alterations in DCs in mesenteric lymph nodes (MLNs), circulating immune cells (white blood cell, lymphocyte, and monocyte counts), and BT to MLNs in 21 patients undergoing abdominal surgery because of intestinal obstruction. We also examined whether BT correlated with the development of perioperative systemic inflammatory response syndrome (SIRS) and postoperative septic complications. Results BT subsequent to intestinal obstruction was observed in 7 (33%) patients. Preoperative circulating immune cell counts were significantly lower in BT-positive patients than those in BT-negative patients. The presence of preoperative SIRS was also significantly related to BT-positive status. A preoperative monocyte count <290/mm³ was the best predictive factor for BT in MLNs during intestinal obstruction: sensitivity 85.7%; specificity 92.3%; positive and negative predictive values 85.7% and 92.9%, respectively. The area under the receiver operating characteristic curve was 0.944. The expression of S-100 protein-positive DCs in MLNs significantly increased in BT-positive patients. Conclusions A significant inverse correlation was observed between the circulating monocyte count and the ratio of DCs among all cells in MLNs (r ² = 0.259). Postoperative septic complications were 3.3 times more common in BT-positive patients than in BT-negative patients. A significant increase in the expression of DCs in MLNs was observed in patients with BT subsequent to intestinal obstruction. Our findings suggested that a low monocyte count (<290 /mm³) and the presence of preoperative SIRS might be useful factors for predicting BT in patients with intestinal obstruction.     

Timing of chemotherapy and survival in patients with resectable gastric adenocarcinoma

AIM: To evaluate the timing of chemotherapy in gastric cancer by comparing survival outcomes in treatment groups.METHODS: Patients with surgically resected gastric adenocarcinoma from 1988 to 2006 were identified from the Los Angeles County Cancer Surveillance Program. To evaluate the population most likely to receive and/or benefit from adjunct chemotherapy, inclusion criteria consisted of Stage II or III gastric cancer patients > 18 years of age who underwent curative-intent surgical resection. Patients were categorized into three groups according to the receipt of chemotherapy: (1) no chemotherapy; (2) preoperative chemotherapy; or (3) postoperative chemotherapy. Clinical and pathologic characteristics were compared across the different treatment arms.RESULTS: Of 1518 patients with surgically resected gastric cancer, 327 (21.5%) received perioperative chemotherapy. The majority of these 327 patients were male (68%) with a mean age of 61.5 years; and they were significantly younger than non-chemotherapy patients (mean age, 70.7; P < 0.001). Most patients had tumors frequently located in the distal stomach (34.5%). Preoperative chemotherapy was administered to 11.3% of patients (n = 37) and postoperative therapy to 88.7% of patients (n = 290). An overall survival benefit according to timing of chemotherapy was not observed on univariate or multivariate analysis. Similar results were observed with stage-specific survival analyses (5-year overall survival: Stage II, 25% vs 30%, respectively; Stage III, 14% vs 11%, respectively). Therefore, our results do not identify a survival advantage for specific timing of chemotherapy in locally advanced gastric cancer.CONCLUSION: This study supports the implementation of a randomized trial comparing the timing of perioperative therapy in patients with locally advanced gastric cancer.     

Thymidylate synthase was associated with patient prognosis and the response to adjuvant therapy in bladder cancer

OBJECTIVE

To investigate the expression of thymidylate synthase (TS), a key enzyme in DNA synthesis that is over‐expressed in several cancer cells, in bladder cancer and its association with patient prognosis and the response to adjuvant therapy.

PATIENTS AND METHODS

In all, 67 bladder tissue specimens were obtained from patients who had undergone transurethral resection (TUR). TS expression in bladder cancer and normal bladder tissue was analysed by immunohistochemistry.

RESULTS

Of the 67 bladder tissue specimens, 47 (70%) and 10 (15%) had positive expression for TS in cancer and normal tissues, respectively. TS expression was greater in patients with Grade 3 (16/17, 94%) than in Grade 1 and 2 (31/50, 64%; P = 0.002). It was also greater in Stage T1 (14/14) than in Stage Ta (33/53, 62%; P = 0.001). Furthermore, patients with negative TS expression had a longer postoperative recurrence‐free survival (RFS) than those with positive expression during the 5 year follow‐up (P = 0.028). In the patients with positive TS‐expressing tumours, adjuvant therapy significantly improved RFS (P < 0.001).

CONCLUSIONS

High TS expression might be a marker of poor prognosis for patients with bladder cancer. In addition, patients with high TS expression might also be benefit from adjuvant therapy.     

Perioperative complications of anterior cervical decompression with fusion in patients with ossification of the posterior longitudinal ligament: a retrospective, multi-institutional study

BackgroundAnterior decompression with fusion (ADF) for patients with cervical ossification of the posterior longitudinal ligament (OPLL) is reportedly associated with a higher incidence of complications than is laminoplasty. However, the frequency of perioperative complications associated with ADF for cervical OPLL has not been fully established. The purpose of this study was to investigate the incidence of perioperative complications, especially neurological complications, following ADF performed to relieve compressive cervical myelopathy due to cervical OPLL.MethodsStudy participants comprised 150 patients who had undergone ADF for cervical OPLL at 27 institutions between 2005 and 2008. Perioperative—especially neurological—complications occurring within 2 weeks after ADF were analyzed. Preoperative imaging findings, including Cobb angle, between C2 and C7 and occupying ratio of OPLL were investigated. Multivariate analysis with logistic regression was performed to identify independent risk factors for neurological complications.ResultThree patients (2.0 %) showed deterioration of lower-extremity function after ADF. One of the three patients had not regained their preoperative level of function 6 months after surgery. Upper-extremity paresis occurred in 20 patients (13.3 %), five of whom had not returned to preoperative levels 6 months after surgery. Patients with upper-extremity paresis showed significantly higher occupying ratios of OPLL, greater blood loss, longer operation times, fusion of more segments, and higher rates of cerebrospinal fluid leakage than those without paresis. Independent risk factors for upper-extremity paresis were a high occupying ratio of OPLL and large blood loss during surgery.ConclusionsThe incidences of deterioration in upper- and lower-extremity functions were 13.3 % and 2.0 %, respectively. Patients with a high occupying ratio of OPLL are at higher risk of developing neurological deterioration.     

Factors Affecting Perioperative Mortality and Wound-Related Complications Following Major Lower Extremity Amputations

Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.Presented at the 33rd Annual Symposium: Society for Clinical Vascular Surgery, Coral Gables, FL, March 2005.     

放射性125I粒子植入治疗癌痛

目的探讨放射性~(125)I粒子植入治疗癌痛的有效性。方法收集33例肿瘤患者,采用CT引导放射性~(125)I粒子植入术对引起患者疼痛的责任病灶进行治疗。术前利用放射性粒子源植入治疗计划系统(TPS)制定粒子植入计划,术中实时调整手术方案,术后即刻利用TPS进行植入后验证。对所有患者随访6个月,采用CT扫描评价肿瘤局部控制率。采用视觉模拟评分法(VAS)于术前及术后3天、1个月对患者进行疼痛评估,比较VAS评分的变化。分析术中及术后手术相关并发症。结果对33例患者均成功完成手术,患者第2、4、6个月局部控制率分别为27.27%(9/33)、72.72%(24/33)、84.85%(28/33)。33例患者术后VAS评分均有不同程度改善,术后3天VAS评分3.80±1.25,术后1个月为2.25±1.00,二者差异有统计学意义(t=3.53,P0.05)。手术相关并发症主要为疼痛、发热、软组织肿胀、气胸、局部出血。结论对肿瘤患者癌痛责任病灶行放射性~(125)I粒子植入,可有效缓解疼痛,是一种安全、有效的方法。