Results of simultaneous resection and plastic surgery of the esophagus with extra-cavitary cervical esophagostomy in esophageal cancer in its thoracic part

The work analyses the results of one-stage resection and plastics of the esophagus with a tube formed from the greater curvature of the stomach and creation of an ++extra-cavitary anastomosis on the neck in combined and surgical treatment of carcinoma of the thoracic esophagus in 279 patients. Various complications occurred in 181 (64.8%) patients. The mortality was 19.3% (16.8% among patients who underwent radical operation and 25.6% among those treated by a palliative operation). The number of complications in the groups of surgical and combined treatment was approximately equal. The results of 5-year survival were better in the group with combined treatment. Postponed + extra-cavitary anastomosis was formed in 65.2% of cases. One-stage resection and plastics of the esophagus with ++extra-cavitary anastomosis is an adequate operation from the oncological standpoint in the treatment of carcinoma of the thoracic esophagus. Its further perfection is necessary for improvement of the immediate and late-term results of treatment.     

Results of the treatment of patients with torsion of the sigmoid

The results of treatment of 204 patients with torsion of the sigmoid colon are analysed. Total postoperative mortality was 14.2%. Sixty-eight patients were subjected to palliative operations of the type of ++de-torsion or ++de-torsion in combination with mesosigmoplication and sigmopexy. In this group of patients, 20.5% underwent a second operation for a recurrence of the disease in different periods after the first operation. The mortality rate after palliative operations was 13.2%. Resection of the sigmoid colon with an end-to-end anastomosis was carried out in 87 patients. The postoperative mortality was 13.7%. There were no fatal outcomes among patients who were treated by radical operation carried out in a planned order of preliminary detorsion. In 11.7% of cases, sigmoid torsion was complicated by gangrene. Seven patients (29.1%) died in the postoperative period.     

Immediate resection in emergency large bowel surgery: a 7 year audit

In a consecutive series of 153 emergency admissions with large bowel disease during a 7 year period, 49 per cent were for colonic obstruction, 46 per cent for peritonitis and 5 per cent for miscellaneous conditions. Urgent operation was performed on 104 (68 per cent) patients. Of those operated upon, 82 (79 per cent) had a primary resection with a mortality rate of 12.2 per cent, intraperitoneal sepsis rate of 2.4 per cent and wound sepsis rate of 7.3 per cent. The median postoperative hospital stay was 21 days. An immediate anastomosis was performed in 46 (56 per cent) patients with a mortality rate of 8.7 per cent, anastomotic leak rate of 2.2 per cent, and wound sepsis rate of 8.7 per cent. The median postoperative hospital stay was 19 days. The mortality in patients presenting with large bowel emergencies is related to age and advanced malignant disease. Immediate resection is applicable in over 80 per cent of patients requiring urgent operation and morbidity can be low and treatment economical. Immediate anastomosis after proximal colonic resection is safe and the use of intra-operative colonic irrigation permits a primary anastomosis in selected patients after emergency resection of the distal colon.     

Complications of the Waterston-Cooley-Edwards anastomosis and their correction in radical surgery of the tetralogy of Fallot

The work is based on the analysis of complications of Waterston-Cooley-Edwards anastomosis which create tactical and technical difficulties in correction of Fallot's tetralogy. Rational methods for their correction are suggested. From January, 1982 to April, 1989 a total of 133 radical operations were carried out for Fallot's tetralogy in patients with Waterston-Cooley-Edwards anastomosis formed earlier; mortality was 6%. Negative sequelae of the anastomosis were found in 62 (46.6%) patients. These were: pathology of the right pulmonary artery in 33 (27%) patients, functional atresia of the outflow paths from the right ventricle in 11 (8.3%), acquired atresia of the valve of the pulmonary artery in 2 (1.5%), pulmonary hypertension in 12 (9%), and acquired cavopulmonary fistula in 1 (0.8%) patient. Despite the rather large number of complications, most of them were successfully removed in radical correction of the anomaly. The postoperative mortality in the group of patients without complications (5.6%) hardly differed from that among patients with unfavourable sequelae of the anastomosis (6.5%).     

Treatment of patients with cancer of the colon

Experience in the treatment of 317 patients with cancer of the colon is discussed. Surgery was conducted in 226 patients, 91 patients received combined treatment (operation and intravenous injection of radioactive colloidal gold). Postoperative mortality was 5.99%. The main cause of death was peritonitis (4.1%) due to incompetence of the anastomosis. Combined treatment of patients with stage III cancer of the colon improves somewhat the late-term results of management.     

Emergency surgical treatment of complicated acute diverticulitis

Twenty-five percent of patients undergoing surgery for acute complicated diverticulitis represent emergencies. This condition is currently treated by colonic resection with primary anastomosis with or without colostomy, or by a Hartmann operation. We report on our experience with 52 consecutive patients with generalized peritonitis (8 cases), peri- and paracolonic abscesses (19 cases), severe pelvic abscesses (12 cases) and multiple abscesses with visceral fistulas (13 cases). All patients had emergency surgery. In 50/52 patients (96.2%) we performed a colonic resection with primary anastomosis using a mechanical stapler and in 2/52 a Hartmann operation. The overall mortality rate was 5.8%. The morbidity rate was 22% with 9 anastomotic leakages. A diverting colostomy was constructed in 16 patients and opened in only 8 patients. In 4 cases a parastomal hernia occurred after late closure and reduction of the colostomy. This data suggest that colonic resection with primary anastomosis, even without colostomy, is a safe procedure for the emergency treatment of acute complicated diverticulitis.     

功能性单心室的外科治疗

目的 为了使更多的先天性心脏病患者得到纠治，回顾性总结手术治疗功能性单心室的临床经验。方法 手术纠治127例功能性单心室患者，年龄7个月－12岁，体重7．5－39kg，其中丰唐手术（Fontan operation)72例，半Fontan术3例，双向上腔静脉肺动脉吻合术51例，肺动脉环缩术1例。结果 早期Fontan术19例，死亡11例；改良Fontan术53例，死亡10例；半Fontan术死亡1例；双向上腔静脉肺动脉吻合术死亡4例；总手术死亡率20．5％。结论 功能性单心室必须早期得到纠治，控制肺动脉血流，预防严重缺氧。双向上腔静脉肺动脉吻合术能减少功能性单心室的容量负荷，保持足够的心排血量。改良Fontan术是功能性单心室的最佳手术方案。     

Experience with unilateral portalization of the adrenal and renal blood in chronic hepatitis]

An experience with treatment of 46 patients with chronic hepatitis and liver cirrhosis with the help of left-sided renoportal venous anastomosis is described. Unsuccessful therapeutic treatment is an indication to operation. In remote period after operation from 50 to 100% of clinical symptoms disappeared in 80% of the patients. Positive dynamics of the results of biochemical analyses and scanning of the liver was noted. The operation is not indicated in patients with formed cirrhosis, portal hypertension over 240 mm water column, decompensation of the liver functions.     

先天性食管闭锁的外科治疗

目的 总结32例先天性食管闭锁手术治疗经验。方法 手术均采用食管上盲端前壁肌层U形翻转，即经胸膜外入路充分游离食管上端及瘘管，近气管侧缝扎切断瘘管。用剪刀将远端食管前壁纵行剪开5min，吻合前距吻合口上方10min处行食管上下两端浆肌层缝合3针，然后距吻合口上方15～20min处将食管前壁肌层切开，从切开处向吻合口方向从两侧纵行切开肌层至吻合口约5mm，轻轻分离前壁肌瓣，形成U形向下翻转，缝合在食管远端浆肌层上。结果 32例中17例采用此方法未发生吻合口瘘，1例吻合口狭窄。2例成功行一期胃代食管术。结论 食管上盲端前壁肌瓣U形翻转能有效预防吻合口瘘及狭窄。Ⅰ、Ⅱ型食管闭锁采用一期胃代食管术，可避免二次手术。     

Damage control laparotomy

BACKGROUND: Damage Control Surgery (DCS) is well established in the management of trauma. This study assessed the results of DCS in the management of critically ill patients who had not had trauma. METHODS: This was a prospective series of patients treated by DCS. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth predictor equation (P-POSSUM) were used to predict the risk of death, which was compared with the observed mortality rate. RESULTS: Fourteen patients were studied. Nine had sepsis from gastrointestinal perforation. Eight of these underwent bowel resection without anastomosis or stoma formation at the initial laparotomy. Six patients later underwent bowel anastomosis and two had an end stoma formed at second laparotomy. A further three patients had a ruptured aortic aneurysm, one had a reactionary haemorrhage after elective aortic surgery, and one had a retroperitoneal bleed; all required haemostatic packing that was removed at second laparotomy. Mortality rates predicted by POSSUM and P-POSSUM scoring were 64.5 and 49.6 per cent respectively. One patient (7.1 per cent) died after operation, giving an observed mortality rate significantly lower than predicted (P = 0.002 and P = 0.038 versus values predicted by POSSUM and P-POSSUM, respectively). CONCLUSION: The use of DCS in the treatment of critically ill patients resulted in a lower mortality rate than that predicted by POSSUM or P-POSSUM. DCS should not be restricted to trauma.     

大肠癌并发急性肠梗阻的外科治疗的探讨

探讨大肠癌并发急性肠梗阻的外科治疗方法。方法回顾性分析我们收治的２３１例大肠癌并发急性肠梗阻病例，结合国内外文献，综合评价外科治疗方法。结果一期左半结肠切除吻合术的手术病死率为５．１％，吻合口瘘发生率为５．７％。结论对左半结肠癌、直肠癌并发急性梗阻病人进行综合判定，掌握好适应证，施行一期肿瘤切除吻合术是安全有效的。     

The role of cava-pulmonary (Glenn) anastomosis in the palliative treatment of congenital heart disease

The value of the cava-pulmonary anastomosis (Glenn procedure) was assessed by reviewing the entire experience with this procedure in 83 children at The Hospital for Sick Children, Toronto, from 1961 to 1980. The over-all operative mortality rate was 9.6%, but only 2% in the second half of the series. The average follow-up is 9.4 years per patient. The late mortality rate has been 20%. By actuarial analysis, 84% of survivors were alive 9 years after operation; 54% had adequate palliation and 46% had required further operation. Long-term palliation was significantly better when the anastomosis was performed after 5 years of age. A previous arterial pulmonary artery shunt had no effect on either patient or shunt survival. Patients with tricuspid atresia had a better long-term survival rate than, but similar shunt survival to, those children with transposition, single ventricle, or miscellaneous cardiac anomalies. Angiography in 36 survivors showed patent shunts in 35 and no arteriovenous fistulas. Clinical status was not related to superior vena caval pressure or angiographic findings, indicating that Glenn shunt failure is a functional problem. The procedure is most useful for patients over 5 years of age who have complex heart disease not amenable to total repair. It is also on appropriate initial procedure in young patients over 18 months of age for whom direct atrium--pulmonary artery anastomosis is proposed as the future definitive treatment.     

Present status of pharyngogastric anastomosis following pharyngolaryngo-oesophagectomy

Pharyngolaryngo-oesophagectomy with pharyngogastric anastomosis was described more than 25 years ago. Since then it has been employed for the treatment of cancers of the hypopharynx, cervical oesophagus and larynx. Results of recent reports showed a wide variability. Our previous report of 157 such operations gave a significant morbidity and overall hospital mortality rate of 31 per cent. In the 6-year period between 1980 and 1985, 91 patients underwent this operation. The morbidity and mortality rates gradually decreased to 30 and 5 per cent respectively. Changes in the indications for the operation resulted in a reduction in the number of procedures performed in recent years. Resection of the oesophagus for cancers of the pharyngolaryngeal region is indicated only when there is actual oesophageal involvement, and would be the prime indication of pharyngogastric anastomosis.     

Choledochoduodenostomy for choledocholithiasis. Indications and functional results

Choledochoduodenostomy in the prevention and treatment of patients with common bile duct stones has been frequently discussed during several years. The introduction of endoscopic sphincterotomy, with excellent results and low morbidity necessitate further examination of the indications for and the value of this procedure as an adjunct to choledocholithotomy. Twenty patients with a mean age of 73 years have been operated on with choledocholithotomy and subsequent choledochoduodenostomy. In 7 of the patients the anastomosis was performed at a primary operation, in 11 at a secondary and in 2 at a third operation. Seven of the patients had primary bile duct stones, while thirteen had multiple stones, either unextractable or with a doubtful clearance. There was no postoperative mortality and only one early complication, a pneumonia. Eighteen of the 20 patients are free of symptoms postoperatively and have normal liver function tests and verified open anastomoses. Two patients had recurrent postoperative cholangitis, one due to a stricture in the anastomosis, which was reoperated, and one due to multiple retained stones intrahepatically despite an open anastomosis. In conclusion choledochoduodenostomy is easy to perform with low morbidity even in old-aged, high-risk patients. It is a safe and effective method in the prevention of retained or recurrent stones.     

Surgical treatment of patients with damage and cicatricial stricture of biliary ducts

In 109 patients 106 reconstructive and 3 restorational operations were performed for iatrogenic damage and cicatricial structure of biliary ducts. Formation of biliobiliary anastomosis is effective in the treatment of the stricture restricted in length. The preference was given for hepaticoduodenostomy performance on the changeable transhepatic drain (in 60.4% of observations) or for the elaborated in the clinic method of operation application when high stricture was present or when the broad anastomosis formation was impossible. Application of optimal algorithm for surgical tactics had permitted to lower the mortality rate for 5-year period from 8.2 to 6.8%.     

Clinical signs, diagnosis and surgical treatment of extrahepatic biliary duct tumors]

Experience of surgical treatment of 271 patients the extrahepatic biliary ducts tumor for the 1992-1999 yrs period is presented. Indirect signs of extrahepatic biliary ducts tumor were revealed in 84% of observations. Depending on the tumor localization the trustworthiness of the endoscopic retrograde pancreatocholangiography method had constituted from 79.8 to 96.4%. Correct diagnosis was established before the operation in 94.3% of patients. Radical operation was done in 93 (34.3%) of patients, including 22 with proximal localization of tumor, 13--with central one, 10--distal, 48--terminal. Palliative operation was performed in 178 patients, in 76 of them biliodigestive anastomosis was done. Total postoperative mortality was 14.8%.     

Radical correction of Fallot's tetralogy following an earlier Blalock-Taussig anastomosis

Seventy-nine radical interventions for Fallot's tetralogy after a previously established Blalock-Taussig anastomosis were conducted at Bakulev Institute of Cardiovascular Surgery, AMS USSR, from 1983 to Dec. 1989. The average age at which the radical operation was undertaken was 10.1 +/- 0.4 years. The interval between the two operations ranged from 1 year to 12 years (7.0 +/- 0.2 year on average). Thrombosis of the anastomosis occurred in 2 (2.5%) patients. Development of pulmonary hypertension was not encountered. Complications like "functional atresia" of the right-ventricular outflow tract (5.1%) and acquired atresia of the valve of the pulmonary trunk (2.5%) were encountered when the interval between the two operations was more than 7 years, and developed mostly in patients with the anastomosis formed before the age of 2 years. In 70 (88.6%) patients the subclavian artery was ligated, in 6 the opening of the anastomosis was sutured through the lumen of the respective pulmonary trunk. Surgically significant constrictions of the branches of the pulmonary arteries were revealed in 10 (12.6%) patients, which called for plastic distension during radical correction. In 7 (8.8%) patients the operative interventions were limited to infundibulectomy. Transannular plastics was necessary in more than half of the patients (55.7%). A conduit containing a xenovalve was implanted between the right ventricle and the pulmonary trunk in one (1.3%) patients. Hospital mortality was 6.3% (5 patients died). With a proper surgical approach, complications of the Blalock-Taussig anastomosis produce no essential effect on the results of radical correction, which may be carried out with a mild degree of risk and a low mortality rate.     

Spontaneous small bowel perforations due to intestinal tuberculosis should not be repaired by simple closure

Intestinal tuberculosis is a major problem in many regions of the world. The incidence of it is rising in Western countries due to immigration from Third World countries and human immunodeficiency virus infection. The difference between the simple closure and resection and anastomosis was evaluated in this study. Retrospectively, 12 patients with intestinal tuberculosis diagnosed histopathologically among 50 patients with free intestinal perforations operated on between 1995 and 2003 at Turgut Ozal Medical Center were evaluated. Each patient underwent routine laboratory tests and radiologic studies. The most common symptoms of patients were abdominal pain, night sweats, and weight loss. Sites of perforation were ileum in 10 patients (multiple perforation in 4) and jejunum in 2 patients (both had multiple perforations). The perforation was closed by primary closure in 7 patients. Resection-anastomosis was performed in 5 patients. Leaks occurred in overall 3 of 7 patients with primary closure. Three of the 7 patients with leaks due to septicemia died. The mortality rate among all patients was 25%. Intestinal tuberculosis should be kept in mind as a cause in free intestinal perforations. Because of high mortality rate, the resection of the affected area and anastomosis may be the treatment of choice rather than primary closure.     

41例Ⅲ型先天性食管闭锁Ⅰ期手术治疗

目的 探讨先天性食管闭锁Ⅰ期根治手术治疗的效果.方法 1994年11月至2008年6月收治先天性食管闭锁113例,其中接受Ⅰ期根治术41例,均为Ⅲ型,其中B型38例,A型3例.手术治疗率36.28%(41/113例).手术先行胃造瘘术,后行食管闭锁根治术.结果 术后近、远期死亡6例,死亡率14.63%(6/41例).长期生存35例.2007年以后手术12例全部生存.术后常见并发症包括吻合口狭窄、吻合口瘘.吻合口狭窄行食管扩张术治愈.吻合口瘘5例,放弃治疗死亡2例,再次手术2例,保守治愈1例.结论 手术治疗先天性食管闭锁疗效肯定,吻合口瘘是死亡高风险因子,但不是决定因素.提高手术疗效的关键在于早诊早冶,加强围术期监护.