Chronic myelogenous leukemia: management of splenectomy in a high-risk population.

Splenectomies have been performed on 58 patients with chronic myelogenous leukemia (CML) during the last 16 years. For the 27 patients operated upon during the first 12 years, the operative mortality was 26%. Four patients also had to be re-explored for bleeding and three required drainage of subphrenic abscesses.There has been no operative mortality in the 31 patients operated using a standardized procedure during the last four years but two had to be re-explored for bleeding and one required drainage of a subphrenic abscess. The operative risks for leukemic patients are infection, perhaps related to granulocyte abnormalities and hemorrhage in patients with thrombocytopenia or qualitative platelet abnormalities. When the splenectomy in patients with CML is timed with the patient's chemotherapy cycle, the use of local antibiotics and platelet concentrates should permit a safe operation. Survival rates were not comprised even when the patients had their splenectomy during CML-blast crisis.     

心脏黏液瘤36例手术治疗的回顾性分析

目的 总结心脏黏液瘤的外科治疗经验.方法 36例心脏黏液瘤患者(左心房黏液瘤32例,右心房黏液瘤3例,左心室黏液瘤1例)均在低温体外循环下接受黏液瘤摘除术,1例同时行三尖瓣成形术,1例同时行二尖瓣成形术.结果 全组无围手术期死亡病例,随访18(2 ～36)个月,无一例术后复发和远处种植转移.结论 心脏黏液瘤手术疗效好,确诊后应立即手术.     

Intraoperative Endoscopy in the Management of Patients with Colorectal Disease

Preoperative colonoscopy is recommended in the evaluation of patients with lower gastrointestinal malignancies. The purpose of this study was to investigate the indications and impact on patient management in patients undergoing intraoperative endoscopy. This is a retrospective review of patient charts from February 1972 to July 1994 of 69 intraoperative endoscopic procedures performed in 54 patients during 54 operative sessions. The results of intraoperative endoscopy affected patient management in 29 of the 54 operative sessions (54%). This included 9 cases (17%) in which the planned surgical procedure was altered. There were no complications related to the endoscopies and 99% were completed successfully. Intraoperative endoscopy can provide important information that can alter the surgical management of patients with colorectal disease. This technique should be considered when intraoperative palpation fails to identify synchronous lesions identified on preoperative studies or in cases where the preoperative study is suboptimal.     

食管癌和贲门癌切除术严重并发症的防治(附1238例分析)

目的：探讨食管、贲门癌切除术后严重并发症的预防和处理。方法：１９８３年４月至１９９５年６月间连续手术切除治疗食管癌，贲门癌１２３８例。其中食管癌５６３例，贲门癌６７５例。食管癌经左胸切除弓上吻合９３例，弓下吻合４５例；经上腹、右胸后外侧二切口切除３３８例；经右胸后外侧、上腹和左颈三切口切除８１例；食管内翻拔脱术５例，单一右胸切除１例。贲门癌经左胸切除３３３例，经腹切除２９９例，经胸腹斜切口切除４３例。结果：术后有１１４例发生并发症，４１例为肺部并发症，占３６％，发生率最高，术后无吻合口瘘发生，无术后３０日死亡及住院死亡。结论：笔者认为：降低手术死亡率的重点是预防吻合口瘘，根据不同的病变部位选择恰当的手术径路，以便获得充分的手术暴露，吻合方法和技术是关键，食管粘膜延长法食管胃定点一层吻合术能可靠地预防瘘的发生。此外要及时有效地处理术后并发症，发生呼吸衰竭要尽早作气管切开。     

Pancreatic resection in a large tertiary care community-based hospital: building a successful pancreatic surgery program

Pancreatic resection can be performed safely in the community-based hospital setting only when appropriate systems are in place for patient selection and preoperative, operative, and postoperative care. Pancreatic surgery cannot be performed optimally without considerable investment in, and coordination of, multiple departments. Delivery of high-quality pancreatic cancer care demands a rigorous assessment of the hospital structure and the processes through which this care is delivered; however, when a hospital makes the considerable effort to establish the necessary systems required for delivery of quality pancreatic cancer care, the community and hospital will benefit substantially.     

An alternative approach to nonpalpable breast biopsies

Traditionally, when a negative specimen radiograph is obtained during biopsy of a nonpalpable breast lesion, immediate re-excision is performed in an attempt to successfully remove the lesion. Based on a retrospective study of the biopsy results of 792 nonpalpable breast lesions, the authors suggest delaying the re-excision, despite a negative specimen x-ray, until postoperative mammography confirms the persistence of the lesion. Utilization of this approach was associated with a comparably low incidence of missed lesions (3%) and had the added advantages of preserving breast tissue and decreasing operative time.     

胃大部切除术后食管癌的外科治疗(30例残胃食管吻合术)

自１９８９年６月至１９９６年６月对３０例胃大部切除术后食管癌采用经左胸切除，后充分游离残胃脾胰体尾并将其移入左胸内行残胃食管弓下、弓上或颈部吻合，取得良好效果。术后并发症５例（１６．６％）。其中吻合口瘘１例，非手术治愈，脓胸２例，心律失常频发室早、房早各１例，无手术死亡。作者认为本手术方法操作方便，手术时间短，除颈部吻合外通常一个切口一个吻合口即能完成手术，通过对残胃充分游离一般能上提２０～２５ｃｍ，使吻合无张力，同时食管切除长度达无瘤残留，同时还保留了残胃，有利于消化功能，是一种有实用意义的手术方式。     

Open cervical lymph node biopsy for head and neck cancers: any benefit?

Introduction

Partial glossectomy is the main treatment for tongue carcinoma. The resection of the tongue, which is a very vascularised tissue, requires a good hemostasis. The advantage of the harmonic scalpel is in combining sectioning and hemostasis in one single instrument, allowing a bloodless dissection of soft tissue. The aim of this prospective study was to evaluate the benefits and risks when using a harmonic scalpel in partial glossectomy.

Subjects and Methods

In this prospective study conducted in a university hospital from march 2004 to Decemeber 2008, eighteen consecutive patients underwent a partial glossectomy with the use of harmonic scalpel. Results were compared with previous surgical procedures performed between September 2000 and February 2004 by monopolar hemostasis by our team (n = 12) when the harmonic scalpel was not available.

Results

All 18 patients underwent partial glossectomy with the harmonic scalpel as the only instrument of section and hemostasis. The median blood loss was of 0 mL. The median operative time was 29 minutes (16 minutes less than partial glossectomies performed with conventional hemostasis. P < .001). No operative complications occurred. Two post-operative bleedings (5 days and 7 days after the glossectomy) occurred necessitating a new surgery to ligate the lingual artery. The margins of the resection were acceptable and no recurrence appeared.

Conclusion

The harmonic scalpel makes it fast and easy to perform a partial glossectomy with no bleeding. Ligation of the lingual artery (when it is visualized during the dissection) should be performed because of the frequency (more than 10% in our series) and because of the potential gravity of a lingual post-operative bleeding.     

Optimal surgery for advanced gastric cancer

Locoregional control remains a major problem after surgery, although a curative resection is still the only treatment to offer a cure for patients with gastric cancer. Despite the results of major randomized trials, the extent of nodal dissection continues to be debated. If there is a survival benefit to be gained by extended lymphadenectomy, added operative mortality should be eliminated. A pancreas and spleen-preserving D2 lymphadenectomy provides superior staging information and may provide a survival benefit while avoiding its excess morbidity. Splenectomy during gastric resection for tumors not adjacent to or invading the spleen increases morbidity and mortality without improving survival. Therefore, splenectomy should not be performed unless there is direct tumor extension. The Maruyama Index and nomograms that predict disease-specific survival may help to discriminate between patients with a high risk of relapse and select those patients who will be most likely to benefit from tailored multimodality treatment. There is growing evidence that gastric cancer surgery should be performed in high-volume centers with experienced specialists to reduce morbidity and operative mortality and to achieve better survival results.     

Percutaneous silastic catheter insertion in patients with thrombocytopenia

A retrospective analysis of 33 patients with malignancy and thrombocytopenia of less than 100,000/microliter who underwent percutaneous Silastic (Evermed) catheter insertion is presented. Thirty-seven catheter insertions were performed in these patients during a 2-year period. The insertion technique includes intraoperative platelet transfusion for patients with platelet counts of less than 50,000/microliter, the use of general anesthesia for infants and children, and intravenous sedation with local anesthesia in adults. Minimizing the dissection required for the subcutaneous catheter tunnel is achieved with a modified shunt-tunneling device. The majority of catheters were placed by the subclavian approach. Fifty-nine percent of the procedures took place when the platelet count was less than or equal to 30,000/microliter. There was no mortality related to the procedure. Four complications directly related to the technique (arterial puncture, 3; cervical hematoma, 1) and eight related to the catheter occurred without serious sequelae. With appropriate precautions, percutaneous placement of Silastic catheters can be performed safely in patients with thrombocytopenia. This technique produces less tissue injury than operative venotomy, may be performed more rapidly, obviates sacrifice of the vein that is used and, consequentially, allows for multiple subsequent insertions via the same vein.     

余肺切除治疗肺癌临床分析

目的 探讨余肺切除治疗肺癌的手术适应症、手术技巧及预后。方法 32例肺癌行余肺切除，采用Kaplan-Meier法计算5年生存率，与同期165例标准全肺切除肺癌5年生存率比较（χ^2检验）。结果 全组无手术死亡病例，7例（21．9％）术后出现并发症，5年生存率为21．9％，与同期标准全肺切除肺癌25．7％的5年生存率比较无显著性差异（P＞0．05）。结论 余肺切除治疗肺癌的适应症包括复发性肺癌、二次原发肺癌及良性病变肺切除后原发肺癌。尽管余肺切除手术操作复杂，但其5年生存率可达到标准全肺切除的水平。     

Gastrostomy and oesophagoplasty with a flap from the greater curvature of the stomach as stages of surgical and combined treatment of cancer of the thoracic oesophagus

Four-hundred fifty-eight patients with cancer of the oesophagus were subjected to revisional laparotomy. Metastases into subphrenic lymph nodes were registered in 24% of the cases with a tumor in the bronchial segment; 42% with tumor in the subbronchial segment; 48% with tumor in the retropericardial segment; 71% with tumors in the sub-, intra-, and supraphrenic segments of the oesophagus. In 345 cases, laparotomy was followed by tube gastrostomy (Beck—Carrel method) with two operative deaths. Fifty-six patients in good condition with a small tumor in the middle part of the oesophagus (≤5 cm) without any abdominal metastases were subjected to primary oesophagoplasty: a 30–32-cm tube was formed out of the greater curvature of the stomach and placed retrosternally; gastrostomy was performed on the level of the thyroid cartilage (without any operative deaths). In two weeks, extirpation of the thoracic part of the oesophagus (with preoperative irradiation) was performed on patients with no abdominal metastases. Then the patients with primary oesophagoplasty were subjected to oesophago-gastrostomy of the neck. From six to 12 months following the combined treatment, the gastrostomy tube of 45 patients was lengthened to 30–32 cm and used for retrosternal oesophagoplasty (six operative deaths). Oesophagoplasty was performed on 14 patients during the extirpation of the oesophagus (six operative deaths).     

Evaluation of computed tomography in the detection of pulmonary metastases: a prospective study.

Conventional linear x-ray tomography is often used to search for pulmonary metastases but tends to underestimate extent of disease when compared with operative findings. In a prospective study, operative findings were correlated with computed axial tomography and conventional linear tomography performed on 25 patients with a history of extrathoracic malignancy and pulmonary nodules. Computed tomography detected 69 nodules of which 31 proved to be metastases. Conventional linear tomography detected 38 nodules of which 25 were metastases. Of the 54 resected nodules measuring greater than 3 mm, computed tomography detected 42; whereas conventional tomography detected 32. Only six of the 31 additional nodules (20%) detected by computed tomography and not by conventional tomography proved to be metastases. These results suggest that computed tomography is more sensitive than conventional tomography in detecting small pulmonary nodules; however, there is diminished specificity in identifying metastatic nodules.     

Cervical anastomosis of the stomach transposed through the esophageal bed--report of 536 cases

Cervical anastomosis of the stomach transposed through the esophageal bed after subtotal resection of esophagus was performed in 536 patients with esophageal cancer during the past 15 years. It comprised 41.2% of all esophagotomy. This operation can be used for lesion at every segment of the esophagus except carcinoma of gastric cardia. Its advantages are: 1. The lesions can be radically resected; 2. The distance of transposition is short; 3. The patient's position need not be changed during the whole course of the operation, and the operative trauma is smaller than the conventional method with three incisions; 4. The stomach lying in the esophageal bed is more physiological; and 5. The procedure of cervical anastomosis is easy and safe. The authors recommend that the cervical anastomosis be adopted instead of anastomosis above the arch of aorta, and be performed through the esophageal bed.     

Efficacy of PET/CT in the accurate evaluation of primary colorectal carcinoma.

AIM: This study was performed to assess in the accurate evaluation of primary colorectal carcinoma using PET/CT. METHODS: One hundred patients with primary colorectal carcinoma were evaluated during 2004. All patients underwent PET/CT when their preoperative serum carcinoembryonic antigen was >or=10 ng/mL or when CT showed equivocal findings. The appropriateness of PET/CT-induced changes was noted by subsequent operative findings and follow-up. RESULTS: PET/CT more detected 15 intra-abdominal metastatic lesions than abdomino-pelvic CT scan. PET/CT showed true negative findings in 13 patients and false positive or negative findings in 10. Due to PET/CT results, management plans were altered in 27 patients; 9 had inter-modality changes, 10 received more extensive surgery, and 8 avoided unnecessary procedures. CONCLUSIONS: PET/CT altered management plan in 24% of patients with primary colorectal carcinoma in correct direction. These findings suggest that PET/CT should be considered a part of standard work up for preoperative evaluation in a subset of patients with colorectal carcinoma.     

Routine nasal packing follwoing nasal surgery—Is it necessary?

The practice of routine nasal packing after nasal surgery is usually customary and not evidence based. Post operative complications, while uncoumon, are sometimes pack related. A retrospective analysis of 110 patients who underwent a variety of nasal operations was performed to determine the incidence of complications when nasal packs were not routinely inserted 9 cases (8.2%) [6 out of these were revision surgeries] needed nasal packing for haemostasis at the end of surgery. 4 cases (3.6%) required to be packed in the immediate post operative period. One patient who required nasal packing developed a unilateral adhesion. No patient developed septal hematoma. The need for routine nasal packing is not supported. Packing should be indicated where there continuous bleeding at     

Evidence and interdisciplinary consensus-based German guidelines: surgical treatment and radiotherapy of melanoma

The primary treatment of a melanoma is surgical excision. An excisional biopsy is preferred, and safety margins of 1 cm for tumor thickness up to 2 mm and 2 cm for higher tumor thickness should be applied either at primary excision or in a two-step procedure. When dealing with facial, acral or anogenital melanomas, micrographic control of the surgical margins may be preferable to allow reduced safety margins and conservation of tissue. The sentinel lymph node biopsy should be performed in patients whose primary melanoma is thicker than 1.0 mm and this operation should be performed in centers where both the operative and nuclear medicine teams are experienced. In clinically identified lymph node metastases, radical lymph node dissection is considered standard therapy. If distant metastases involve just one internal organ and operative removal is feasible, then surgery should be seen as therapy of choice. Radiation therapy for the primary treatment of melanoma is indicated only in those cases in which surgery is impossible or not reasonable. In regional lymph nodes, radiation therapy is usually recommended when excision is not complete (R1 resection) or if the nodes are inoperable. In distant metastases, radiation therapy is particularly indicated in bone metastases, brain metastases and soft tissue metastases.     

Transsternal thoracotomy for bilateral pulmonary metastasis.

Advances in the surgical treatment of primary malignancies and the recent chemotherapy have led to an expansion of the surgical treatment of metastatic lung tumors. However, multiple pulmonary metastases are often found and may affect both lungs. It is difficult to reach tumors in the posterior parts of the lung when using a common midsternal approach, especially lesions located in the left lower lobe. We performed transsternal simultaneous bilateral thoracotomy on 10 patients with bilateral lung tumors (9 bilateral metastatic pulmonary tumors and 1 bilateral primary lung cancer). This procedure provides a wide operative field and is an effective method of thoracotomy for patients with bilateral lung tumors. In future, this method should be more actively performed for patients in whom it is indicated.     

儿童晚期肾母细胞瘤的术前化疗分析

目的探讨术前化疗对肿瘤较大或有远处转移的肾母细胞瘤的手术帮助和手术时机的选择。方法回顾性分析16例肾母细胞瘤的诊治过程。Ⅱ期10例,Ⅲ期5例,Ⅳ期1例。16例患儿术前均经影像学检查及穿刺活栓明确诊断。所有病例均予术前化疗后行手术治疗。结果5例瘤肾根治性切除,1例手术过程中发生肿瘤破裂,术后病理检查有镜下残留。在术前化疗后2～3周手术13例,2例因术前化疗后肿瘤坏死彻底未获得术后病理分型,术后化疗方案制定依据术前细针穿刺结果。结论术前化疗可以使肿瘤体积变小,减少肿瘤破溃,改善瘤体对毗邻器官浸润程度,使外科手术变得容易。     

直肠癌误诊72例报告

目的 :探讨晚期直肠癌误诊病例的诊断与治疗。方法 :回顾性分析研究 1990～ 1999年我院收治的 72例直肠癌误诊病例临床资料。结果 :本组 72例 ,术前均误诊 ,全部病例均经手术治疗。其中Miles手术 53例 ,腹前切除 14例 ,乙状结肠造口 5例。在术前、术中、术后均采取了辅助化疗。结论 :提高直肠癌的诊断正确率是提高直肠癌患者远期生存率的关键。手术治疗的原则是根治第一 ,保肛第二 ;骶前出血是重要的手术并发症 ;术前、术中、术后化疗可提高手术疗效。