Controversies in biliary tract surgery

There are many controversies regarding the surgical management of calculous gallbladder disease. Newer data in the surgical literature and competing medical treatments compound this confusion. In this guest lecture the author reviews current data and provides an update in seven controversial areas: the timing of operation in acute cholecystitis, the management of the diabetic patient with gallstones, the treatment of the patient with asymptomatic gallstones, the medical treatment of gallstones, the use and abuse of operative cholangiography, the management of the patient with gallstone pancreatitis and management of the patient with acalculous cholecystopathy.     

快速康复外科在食管癌治疗中的应用

过去的10年间，快速康复外科治疗在很多外科领域都得到了应用。快速康复外科的应用可以使患者更快地恢复从而缩短住院时间，在增加患者满意度的同时减少了治疗费用。本文通过相关文献复习并结合我们的临床实践，探讨食管癌快速康复外科的具体措施及其临床应用价值。     

Computerized tomography in the surgery of esophageal cancer

Preoperative X-ray computerized tomography (CT) was performed in 60 patients with carcinoma of the esophagus at the All-Union Oncology Research Centre, USSR AMS in 1986-1989. The method is evaluated on the basis of comparison with the operative findings in determining the depth of invasion of the esophageal wall and adjoining structures by the tumor, metastatic involvement of the lymph nodes below the diaphragm, and metastases in the liver. Informativeness of X-ray CT proved to be highest in patients in whom the tumor had not spread beyond the esophageal wall. It was established that the method possesses high resolving possibilities in identification of enlarged lymph nodes in the abdominal cavity. Small metastases in the liver, measuring 0.5 to 2 cm in diameter, cannot be revealed by the method in some cases. The data gained by means of X-ray CT allows tactics of the surgical intervention to be determined and the late-term results to be predicted.     

Radical surgery with mini-thoracolaparotomy for esophageal cancer

In our institute, radical esophagectomy through mini-thoracolaparotomy has been performed as a less-invasive surgery for esophageal cancer since 1996. We describe the indications for and operative procedures of mini-thoracolaparotomy. Next we report the preliminary results of a prospective randomized trial that compared mini-thoracolaparotomy with conventional thoracolaparotomy in 30 patients without neoadjuvant therapy. There were no differences between the two groups in operative time, bleeding volume, and number of dissected lymph nodes. Thoracolaparotomy was effective in decreasing the quantity of morphinerequired in the ICU and shortening hospitalization after surgery. Thoracolaparotomy was effective in preventing a decrease in and early recovery of postoperative vital capacity. In clinical data on radical esophagectomy performed through a right thoracotomy and reconstruction with a stomach tube from 1996 to 2000, the 5-year survival rate of 63 patients in the thoracolaparotomy group (67.6%) did not differ from that of 124 patients in the conventional surgery group (49.9%).     

Methodological aspects of surgery of esophageal cancer

Based on many years of clinical experiences including more than 400 patients operated on for carcinoma of the thoracic portion of the esophagus the author describes the methodological aspects of the succession of operation stages and rational modes of mobilization of the malignant area guided by the principles of observation of the maximum degree of ablastic character of the intervention and getting higher radicalism of it.     

Sentinel node navigation surgery for esophageal cancer

Although sentinel node (SN) biopsy has been utilized to predict regional lymph node metastasis in patients with melanoma and breast cancer, the validity of the SN hypothesis is still controversial in regard to esophageal cancer. SN mapping for esophageal cancer is relatively complicated compared to that for gastric cancer, and the number of early-stage esophageal cancers is limited. Therefore, only a few studies have demonstrated the feasibility and validity of the SN concept for esophageal cancer. Nevertheless, our preliminary studies showed that SN mapping may be feasible in patients with early-stage esophageal cancer. Transthoracic extended esophagectomy with three-field radical lymph node dissection has been recognized as a curative procedure for thoracic esophageal cancer in Japan. However, uniform application of this highly invasive procedure might increase the morbidity and markedly reduce quality of life (QOL) after surgery. Although further accumulation of evidence based on multicenter clinical trials using standard protocol is required, SN mapping would provide significant information on individualized selective lymphadenectomy, which might reduce the morbidity and retain the patients' QOL.