胸、腹腔镜联合食管癌手术的临床分析

目的:探讨胸腹腔镜联合手术治疗食管癌的可行性和疗效,并总结相关临床经验。方法:2010年3月至2010年8月采用胸腔镜联合腹腔镜施行7例食管癌切除术,肿瘤均位于食管中上段,行胃体游离并经食管床上提胃体(管状胃)行食管胃颈部吻合术。结果:所有患者均顺利完成腔镜手术,无中转开胸病例,手术时间平均260min,术中平均出血200ml。平均清扫淋巴结12.8枚。术后下床活动时间平均3d,术后平均住院12d。术后1例发生吻合口漏,无其他并发症发生。患者均康复出院,术后随访2～8个月,均恢复良好。结论:胸、腹腔镜联合食管切除术较常规食管癌手术患者创伤小,术后康复快,且淋巴结清扫彻底,值得临床推广。     

后腹腔镜手术治疗肾上腺囊肿42例报告

目的:总结后腹腔镜手术治疗肾上腺囊肿的手术经验及疗效。方法:回顾分析2004年12月至2011年3月为42例肾上腺囊肿患者行后腹腔镜手术的临床资料。患者平均(45.6±10.8)岁,囊肿直径平均(6.8±3.1)cm。其中单纯囊肿切除术29例,合并肾上腺部分切除术11例,合并肾上腺全切除术2例。结果:42例手术均获成功,无一例中转开放手术,围手术期无严重并发症发生。手术时间平均(58.5±22.4)min,术中出血量平均(37.5±27.1)ml,术后平均住院(6.0±1.8)d,平均随访(45±28.5)个月,患者不适症状消失或明显缓解,术后肾上腺功能正常,无局部复发。结论:腹腔镜手术治疗肾上腺囊肿安全、有效,具有患者创伤小、康复快等优点,可作为治疗肾上腺囊肿的首选方法。     

腹腔镜手术治疗胃间叶源性肿瘤的临床研究

目的:探讨腹腔镜手术治疗胃间叶源性肿瘤的临床应用价值。方法:回顾性分析2008年3月至2010年10月间接受腹腔镜手术的35例胃间叶源性肿瘤病人的临床资料,包括手术方式、手术时间、术中出血量、术后住院时间、并发症、术后病理及随访结果等。结果:所有手术均在腹腔镜下完成,其中使用内镜下线型切割闭合器行腹腔镜胃部分切除术27例,腹腔镜辅助远端胃大部切除术4例,腹腔镜辅助近端胃大部切除术4例。8例手术采用术中胃镜的双镜治疗。无一例中转开腹手术。中位手术时间90(60~160)min,术中平均出血量(42.1±23.6)(10~200)mL,肿瘤平均大小(35.4±13.5)(10~62)mm,肿瘤切缘术中冷冻及术后石蜡病理均为阴性。术后病理胃间质瘤26例、胃神经鞘瘤5例、胃平滑肌瘤2例、胃脉管瘤1例、胃纤维母/肌纤维母细胞瘤1例。术后平均住院时间(6.3±1.3)(4~10)d,无术后并发症。术后中位随访时间22(12~43)个月,所有病人均无肿瘤复发及远处转移。结论:腹腔镜手术切除胃间叶源性肿瘤是安全、微创、有效的,应作为此类肿瘤治疗的首选方法。     

腹腔镜在小肠出血诊治中的临床应用

目的:评价腹腔镜在小肠出血诊治中的临床应用价值。方法:回顾性分析2003年9月至2007年6月行腹腔镜诊治的55例小肠出血患者的临床资料,并对手术时间、术中失血、切口长度、术后排气时间、术后住院天数、并发症、术后病理和随访结果进行统计学分析。结果:腹腔镜探查不仅明确了所有患者小肠出血的原因,而且同时实施了相应的腹腔镜手术,其中包括7例完全腹腔镜下小肠肿瘤局部切除术;10例腹腔镜下小肠憩室切除术;37例腹腔镜辅助下小肠肠段切除术;1例腹腔镜辅助下右半结肠切除术。腹腔镜平均手术时间(70.0±28.6)min,术中平均失血(13.5±10.2)ml,平均切口长度(3.4±1.3)cm,平均术后排气时间为(2.2±0.8)d,术后平均住院(7.8±2.9)d。2例(3.6%)术后分别出现吻合口糜烂出血和束带粘连性小肠梗阻。术后随访29(5~50)个月,无复发病例。结论:腹腔镜技术在小肠出血诊治中具有良好效果,腹腔镜小肠手术是一种安全、有效的微创手术方法,值得临床推广应用。     

腹腔镜小肠切除术的临床应用

目的探讨腹腔镜小肠切除术的治疗价值。方法总结分析1993年3月至2000年12月施行的腹腔镜小肠切除术31例患者的临床资料。结果术式包括:腹腔镜辅助下小肠切除术25例;全腹腔镜下小肠切除术6例。25例腹腔镜辅助下小肠切除术平均手术时间(101.9±32.8)min;术中平均出血(65.3±28.5)ml;平均住院(5.5±1.6)d。6例全腹腔镜下小肠切除术平均手术时间(97.2±28.1)min;术中平均出血(59.6±22.1)ml;平均住院(5.1±1.3)d。两组各指标比较,差异均无显著性意义(P>0.05)。所有患者均在术后48d内恢复胃肠功能,并开始下床活动。仅3例术后使用止痛剂。全组手术无病灶遗漏,也无并发症、中转开腹和手术死亡发生。结论腹腔镜小肠切除术具有良好的治疗效果,器械的更新和经验的积累将使这项技术日臻完善。     

腹腔镜辅助远端胃次全切除术

目的探讨腹腔镜外科技术在胃切除手术的应用价值。方法对15例腹腔镜辅助胃手术患者的临床资料和随访情况进行回顾性分析。结果腹腔镜辅助远端胃大部分切除术13例(其中胃癌D1根治术3例、胃十二指肠溃疡手术10例),进展期胃癌腹腔镜探查术2例。无中转开腹,无手术死亡。术中皮下气肿1例、发生率6.67%(1/15),平均手术时间245.6±35min,平均出血量110±45ml,辅助切口平均长6.5±1cm,平均术后住院日10±2.5d。术后吻合口输出襻梗阻1例、发生率7.69%(1/13)。全组13例患者术后随访2～26个月,未出现远期并发症,其中3例胃癌患者未发现远处转移病灶,其trocar穿刺孔及腹壁切口无肿瘤种植。结论只要严格掌握手术适应证,正确应用腹腔镜技术,腹腔镜辅助远端胃大部分切除术是安全、可行的。     

腹腔镜胃楔形切除术治疗胃底部间质瘤

目的:总结腹腔镜胃底楔形切除术治疗胃底部间质瘤的可行性及其临床应用价值。方法:采用4孔法。手术主要步骤为肿瘤定位、网膜游离、胃底和脾上极分离、食管贲门连接处(esophagocardiac junction,ECJ)显露以及用内视镜切割吻合器楔形切除胃底间质瘤。结果:79例手术均获成功,手术时间平均为(60.1±6.6)min;术中平均出血(56.2±6.7)ml。无病灶遗漏,也无并发症和手术中转。术后平均住院(4.6±0.5)d。78.5%病人于术后36 h内恢复胃肠功能,并开始进食和下床活动。结论:腹腔镜胃腔外胃底楔形切除术对胃底,尤其是对后壁近ECJ黏膜下肿瘤的治疗是安全、简便和有益的,可以避免腹腔污染、脾脏损伤以及术后食管狭窄的发生;同时,胃的切除范围也不受限。     

后腹腔镜下肾脏肿瘤铥激光部分切除术10例报告

目的 探讨后腹腔镜下铥激光在肾脏肿瘤部分切除术中的操作要点和临床应用价值.方法 对10例肾脏肿瘤患者采用后腹腔镜下肾脏肿瘤铥激光部分切除术进行治疗,肿瘤直径(3.10 ±0.70)cm,均位于肾脏的一侧或突出于肾脏表面.术前检查临床分期均为T1aNoMo期.对10例肾脏肿瘤患者均采用后腹腔镜下肾脏肿瘤铥激光切除术进行治疗.结果 10例患者手术均成功,未中转开放手术.手术平均时间(105.14±19.63) min.术中未阻断肾血管;术中平均出血量(112.63±20.21)mL,未输血.术后无大出血、感染、继发性出血、漏尿等并发症.术后住院时间为7d.术后病理结果1例为肾乳头状细胞癌,9例为肾透明细胞癌,术后随访6个月至1年内均未见肿瘤复发及转移.结论 后腹腔镜下肾脏肿瘤铥激光切除术具有创伤小、恢复快、术中止血快、切除精确、视野清晰等优点,可能将成为一种新的安全可行的微创治疗方法.     

腹腔镜Hill修补术治疗胃食管反流病20例疗效分析

目的 探讨腹腔镜Hill修补术治疗胃食管反流病的临床价值。方法 回顾性分析2019年1-10月海军军医大学第二附属医院普外三科收治的行经腹腔镜Hill修补术治疗的20例GERD病人的临床资料,随访观察临床疗效。结果 术中测压提示Hill修补缝合后LESP显著高于缝合前水平（t=42.845,P<0.001）。20例病人术后6周复查,反流症状均明显改善,胃食管交界区阀瓣形态均较为良好,24 h食管pH监测无一例出现异常酸反流。Hill修补术后平均下食管括约肌静息压为（29.4±1.90）mmHg,显著高于术前平均水平（t=37.014,P<0.001）。结论 腹腔镜Hill手术可提高下食管括约肌静息压及重建胃食管交界区阀瓣结构,对GERD病人抗反流效果显著。     

腹腔镜胃基质瘤切除术：附32例报告

目的:探讨腹腔镜胃基质瘤切除术的临床应用价值。方法:回顾性总结32例采用腹腔镜方法治疗胃基质肿瘤患者的临床资料。肿瘤直径1.5~5.5 (平均2.6) cm。手术方式主要为腹腔镜下胃肿瘤切除术、腹腔镜辅助和手助腹腔镜下胃肿瘤切除术。结果:32例均手术均顺利完成。平均手术时间75min，术中平均出血50mL。术后疼痛轻微，术后排便、排气时间平均为34h，术后平均住院天数为7.5d。术后病理证实25例为良性基质瘤， 7例为低度恶性基质瘤。随访8~30个月未见复发。结论:腹腔镜下胃基质瘤切除术是一种安全、有效的微创手术方法，值得临床推广应用。     

Laparoscopic Transgastric Resection of Gastric Submucosal Tumors Located Near the Esophagogastric Junction

Background

Laparoscopic wedge resection is widely accepted as a choice of treatment for gastric submucosal tumors (SMTs). But it cannot easily be applied to tumors located near the esophagogastric junction (EGJ) due to the high risk of causing deformity or stenosis in the gastric inlet. We evaluated our laparoscopic transgastric surgical technique for gastric SMTs located near the EGJ and clinical outcomes.

Methods

Twelve consecutive patients with gastric intraluminal SMTs located 3 cm or less from the EGJ underwent laparoscopic transgastric resection at our institution from June 2010 to November 2012. The clinicopathological results of these 12 cases were analyzed.

Results

Laparoscopic transgastric resection was successfully performed on all the patients. The mean operation time was 125?±?25 min (range, 85–160 min) and the mean blood loss was 53?±?32 mL (range, 10–120 mL). There was no death in our series. One patient experienced a postoperative complication of upper gastrointestinal tract bleeding due to the errhysis along the staple line treated with an endoscopic hemostatic clip. The mean postoperative length of hospital stay was 5.1?±?1.2 days (range, 3–7 days). All patients received complete resection with a negative margin. Histopathologic diagnoses were gastrointestinal stromal tumor in seven cases, leiomyoma in four, and heterotopic pancreas in one. There was no tumor recurrence or evidence of stenosis of the EGJ during a mean follow-up of 15.3?±?9.6 months (range, 1–30 months).

Conclusions

Laparoscopic transgastric resection is simple, safe, and effective for gastric intraluminal SMTs located near the EGJ.     

Short- and Long-Term Outcomes of Endoscope-Assisted Laparoscopic Wedge Resection for Gastric Submucosal Tumors Adjacent to Esophagogastric Junction

Background

Laparoscopic wedge resection (LWR) is used to treat gastric submucosal tumors (SMTs). However, LWR can injure the cardia if tumors are near the esophagogastric junction (EGJ), resulting in gastric stenosis. This study’s purpose was to summarize our experience with endoscope-assisted LWR for gastric SMTs within 3 cm of the EGJ and to verify the procedure’s feasibility and safety.

Methods

Data from 91 consecutive patients with gastric SMTs within 3 cm of the EGJ who underwent endoscope-assisted LWR at our hospital from 2007 to 2017 were obtained from a prospectively maintained database. The clinicopathological results, perioperative data, and long-term follow-up data were analyzed.

Results

All patients successfully underwent endoscope-assisted LWR. The mean distance from tumor to EGJ was 2.43 ± 0.80 cm. Eighty-two patients underwent laparoscopic exogastric wedge resection (LEWR) and nine underwent laparoscopic transgastric wedge resection (LTWR). Mean operative time was 112.4 ± 48.8 min; mean blood loss was 36.8 ± 53.5 ml. Mean time to first flatus was 2.04 ± 0.68 days. Mean time to liquid intake was 2.53 ± 0.85 days. Mean postoperative hospital stay was 4.97 ± 1.80 days. Three patients (3.3%) had postoperative complications, all Clavien–Dindo grade I. The mean maximum tumor diameter was 3.00 ± 1.96 cm (range 0.5–10). LTWR was used more often than LEWR for SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ. The mean follow-up time was 36.86 ± 29.73 months (range 3–126). There was no stenosis of EGJ or tumor recurrence. Sixteen patients (17.6%) complained of upper gastrointestinal symptoms during the follow-up, which were all relieved by usage of acid suppressive medications.

Conclusions

Endoscope-assisted LWR is safe, feasible, and effective for gastric SMTs near the EGJ. LTWR is preferable to LEWR for gastric SMTs in the posterior wall, those with intraluminal growth, and those closer to the EGJ.

     

Tailored-approach of laparoscopic wedge resection for treatment of submucosal tumor near the esophagogastric junction

Background Laparoscopic wedge resection (LWR) of the stomach cannot easily be applied to tumors that are located near the esophagogastric junction (EGJ). To define the tailored approach for this type of tumors, we evaluated our laparoscopic surgical technique and clinical outcomes. Methods We successfully performed 10 LWRs for patients with submucosal tumor (SMT) located 3 cm or less from the esophagogastric junction. A presumptive diagnosis of gastrointestinal stromal tumor (GIST) was made in all the cases, based on endoscopic and radiologic examinations. The patient demographics, perioperative parameters and outcomes of 10 patients were assessed. Results Neither intraoperative complications nor conversion to open surgery was required, and we were able to perform complete tumor excision with negative surgical margins for all the patients. The laparoscopic approaches of resection included the transgastric method (n = 5) and the exogastric method (n = 5). The mean operation time was 92.5 minutes (range 60–125 minutes). No blood transfusion was given for all cases in the perioperative period. The patients’ oral intake was restored on the third postoperative day. The hospital stay ranged from three to seven days (mean: 4.9 days). Pathologic analysis of the resected specimens showed six GISTs, three leiomyomas, and one lipoma. Conclusions Laparoscopic resection of gastric SMTs located near the EGJ is a feasible and safe procedure. The laparoscopic approaches to this area should be tailored, based on the location, size and expanding pattern of the tumor. This work was supported partly by the Catholic Cancer Center     

Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection

BACKGROUND: Laparoscopic wedge resections are increasingly applied for gastric submucosal tumors such as gastrointestinal stromal tumor (GIST). Despite this, no defined strategy exists to guide the surgeon in choosing the appropriate laparoscopic technique for an individual case on the basis of tumor characteristics such as location or size. This study aimed to introduce a laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection that is applicable for submucosal tumor resection independent of tumor location and size. METHODS: Seven patients underwent LECS for the resection of gastric submucosal tumors. Both mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection via intraluminal endoscopy. Subsequently, the seromusclar layer was laparoscopically dissected on the exact three-fourths cut line around the tumor. The submucosal tumor then was exteriorized to the abdominal cavity and dissected with a standard endoscopic stapling device. RESULTS: In all cases, the LECS procedure was successful for dissecting out the gastric submucosal tumor. In four of seven cases, the tumor was located in the upper gastric portion near the esophagogastric junction. The remaining three tumors were in the posterior gastric wall. In two cases, the tumors were more than 5 cm in diameter, and one was a GIST of the remnant stomach. The mean operation time was 169 +/- 17 min, and the estimated blood loss was 7 +/- 2 ml. The postoperative course was uneventful in all cases. CONCLUSIONS: The LECS procedure for dissection of gastric submucosal tumors such as GIST may be performed safely with reasonable operation times, less bleeding, and adequate cut lines. In addition, the success of the procedure does not depend on the tumor location such as the vicinity of the esophagogastric junction or pyloric ring.     

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内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)作为一种治疗早期胃癌新技术,同样适用于治疗食管胃结合部(esophagogastric junction,EGJ)的浅表癌。ESD治疗食管胃结合部腺癌(adenocarcinoma of the esophagogastric junction,AEG)及EGJ处癌前病变,与外科剖腹手术及内镜黏膜切除术(endoscopic mucosal resection,EMR)等内镜治疗方法相比,具有明显优势。但ESD治疗EGJ处病变,手术难度较高,手术时间更长,手术并发症发生率更高,对操作者的技术要求较高。     

Laparoscopic intragastric stapled resection of gastric submucosal tumors located near the esophagogastric junction

BACKGROUND: Laparoscopic resection cannot be applied easily to tumors located near the esophagogastric junction or the pyloric ring. We evaluated our laparoscopic intragastric surgical technique for gastric submucosal tumors located near the esophagogastric junction and the results of a clinical study. MATERIALS AND METHODS: We performed our technique in six patients: one man and five woman with a mean age of 61 years. Using the laparoscopic procedure, after inflation of the stomach, we inserted two or three balloon-type ports into the stomach through the abdominal wall. RESULTS: A stapled resection of gastric submucosal tumors using a laparoscopic linear stapler was performed successfully in all the patients. Without exception, stapled resections were successfully performed. The mean operation time was 168 min, and the blood loss was minimal There were no intra- or postoperative complications. The mean postoperative hospital stay was 9.8 days. The mean maximal diameter size of the resected specimens was 2.4 cm. Histopathologic diagnoses were gastrointestinal stromal tumors in five cases and enterogenous cyst in one. There were no recurrences during a mean follow-up period of 27 +/- 11.6 months. CONCLUSION: Although we need to evaluate the long-term outcomes, our procedure is considered technically feasible, safe, and useful for the resection of gastric submucosal tumors located near the esophagogastric junction.     

食管胃交界部固有肌层来源黏膜下肿瘤内镜下切除方法的选择与评价

目的评价以内镜黏膜下剥离术（ESD）为基础的各种内镜切除技术在食管胃交界部（EGJ）固有肌层来源黏膜下肿瘤（SMT）治疗中的临床价值和适应证的选择。方法回顾性分析复旦大学附属中山医院内镜中心所有接受内镜下切除治疗的患者资料库．筛选出2007年3月至2011年6月间经内镜下超声或CT证实固有肌层来源的EGJ处SMT患者143例。详细记录患者的临床病理资料、内镜切除方法、完整切除率、并发症发生率及术后随访资料。结果143例患者中男74例,女69例,平均年龄49．1岁。135例（94-4％）病变成功完成内镜下整块切除,其中接受内镜黏膜下挖除术126例,无腹腔镜辅助的内镜全层切除术6例,内镜经黏膜下隧道肿瘤切除术3例：另外8例肿瘤于内镜下部分切除后,基底部尼龙绳套扎。肿瘤平均直径为17．6mm．平均手术时间45．1min．平均出血量50．0ml。术中穿孔6例,贲门黏膜撕裂1例。均通过内镜下处理及保守治疗好转。术后病理示,平滑肌瘤121例,胃肠间质瘤20例。颗粒细胞瘤1例．肌间脂肪瘤1例。术后经3。48个月的随访,未见局部复发和远处转移病例。结论在EGJ固有肌层来源SMT治疗中．各种内镜切除方法均安全有效．临床医师需根据肿瘤的临床特征具体选择．     

Laparoscopic resection of gastrointestinal mesenchymal tumors located in the upper stomach

Background: The treatment strategy for a gastrointestinal mesenchymal tumor located close to the esophagogastric junction remains controversial. The authors evaluate the criteria indicating that a gastrointestinal mesenchymal tumor is suitable for laparoscopic resection and assess the surgical techniques on the basis of clinical outcomes.Methods: The criteria specified a tumor more than 2 cm in diameter or a tendency for it to increase in size during the follow-up period. For eight patients in whom the tumor was located within 3 cm of the esophagogastric junction, an intragastric laparoscopic approach was used, whereas for seven patients in whom the tumor was further from the esophagogastric junction, an exogastric approach was used.Results: In all 15 cases, the laparoscopic resection was successful, with no complications. The intragastric group had a mean maximal tumor size of 2.9 cm, a mean operation time of 168 min, and a mean postoperative hospital stay of 8.8 days, whereas these values in the exogastric group, were respectively, 3.9 cm, 121 min (p = 0.0442), and 9.6 days. There were no recurrences in either group during the follow-up period.Conclusion: The good clinical outcomes suggest hat the criteria used as an indication for laparoscopic resection and the surgical techniques applied were appropriate for the resection of gastrointestinal mesenchymal tumors.     

内镜下切除技术对食管胃连接部胃肠间质瘤的治疗价值

目的评价以内镜黏膜下剥离术（ESD）为基础的内镜下切除术在食管胃连接部（EGJ）胃肠间质瘤（GIST）治疗中的安全性及有效性。方法收集复旦大学附属中山医院内镜中心所有接受ESD治疗的患者资料．筛选出2007年11月至2011年6月间经病理证实的EGJ处GIST患者20例．总结并分析其临床病理及术后随访资料。结果20例EGJ处GIST均起源于固有肌层,其中男性11例,女性9例,年龄29～67（平均54．1）岁,病灶直径8-20（平均14．8）mm。所有病例均成功完成内镜切除手术．其中15例接受了内镜黏膜下挖除术．4例接受了无腹腔镜辅助的内镜全层切除术。1例接受了内镜经黏膜下隧道肿瘤切除术。手术时间15-90（平均47．8）min,术中出血量5-200ml,病灶的完整切除率为100％。术中穿孔4例,气腹3例,气胸1例,贲门黏膜撕裂1例,均通过内镜下处理及保守治疗恢复。20例患者术后均接受了3-36（平均13-2）个月的随访,无局部复发和远处转移病例。结论在EGJ处GIST的治疗中,以ESD为基础的内镜下切除技术是一种安全和有效的治疗手段。     

Submucosal tunneling endoscopic resection for submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a feasibility study (with videos)

Background

The esophagogastric junction (EGJ) is a difficult location for endoscopic resection due to its narrow lumen and sharp angle. Potential increased risks of perforation and mediastinal infection exist, especially for submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. We previously demonstrated the safety and efficacy of submucosal tunneling endoscopic resection (STER) for upper gastrointestinal SMTs, but the feasibility of STER for the removal of SMTs at the EGJ requires systematic investigation. The aim of the investigation was to evaluate the clinical impact of STER on the removal of SMTs at the EGJ.

Methods

A prospective study was carried out which included a consecutive cohort of 57 patients who underwent STER for 57 SMTs of the EGJ originating from the MP layer between July 2010 and August 2012 in a single academic medical center. Adverse events, en bloc resection rate, and local recurrence were evaluated.

Results

The average maximum diameter of the lesions was 21.5 mm (range 6–35 mm). The en bloc resection rate was 100 % (57/57). No delayed hemorrhage or severe adverse events occurred in any of the 57 patients following STER. No local recurrence and distant metastasis occurred during 24 months’ follow-up. Less subcutaneous emphysema and pneumomediastinum absorption time (p = 0.005) occurred with CO₂ versus air insufflations.

Conclusions

Our study showed that STER was safe and effective, provided accurate histopathologic evaluation, and was curative for SMTs of the deep MP layers at the EGJ. CO₂ gas insufflation is recommended.