Combined resection of the aorta for an esophageal carcinoma invading the aorta through a right transthoracic approach

The prognosis of esophageal carcinoma invading the thoracic aorta has been extremely poor, as it has been either not resected or only palliatively resected. In recent years a remarkable improvement in survival has been achieved in advanced esophageal carcinoma through an aggressive dissection of the upper mediastinal lymph nodes. This implied that resection only of the aorta without lymph node dissection in these patients was not adequate for curability. Although a resection of the aorta would seem to be performed more easily through a left thoracotomy than through a right thoracotomy, the upper mediastinal lymph node dissection was unsatisfactory through a left thoracotomy. Therefore, we performed combined resection of the aorta using a temporary aorta-aorta bypass together with upper mediastinal lymph node dissection through a right thoracotomy for four patients with the esophageal carcinoma invading the thoracic aorta. This operative procedure was performed safely, and had the advantage that full observation on the extent of the carcinoma was attained together with subsequent radical lymph node dissection in the same field through only the right thoracic approach. This operation may provide a possibility for cure to patients with an esophageal carcinoma invading the aorta, who would otherwise receive only palliative treatment.     

Combined resection of the descending aorta under a simple temporary bypass for advanced lung cancer invading the aorta

Three patients with advanced lung cancer invading the descending aorta underwent concomitant resection under a simple temporary bypass using thin-wall metallic cannulas. In each case, invasion to the descending aorta was suspected by CT and MRI. In case 1, resection of adventitia of the aorta was performed under a temporary bypass between the left subculavian artery and the descending aorta. In case 2 and 3, tubular resection and reconstruction of the aorta were carried out under a temporary bypass between proximal site of descending aorta from involved level and distal site. Complete resections of tumors were performed in all cases. During and after operation, vital signs were stable and no ischemic disorder of lower limbs and abdominal organs were observed. Case 1 died 7 months postoperatively because of recurrence in small intestine. Case 2 and 3 are alive at present, 21 and 5 months postoperatively, respectively. This procedure has advantages of safety, simplicity, and low invasiveness, in the cases the left subcuravian artery or the descending aorta is available for proximal site of the temporary bypass.     

Venous bypass for surgical resection of renal carcinoma invading the vena cava: a new approach

A new technique is described which facilitates the surgical removal of renal carcinoma from the inferior vena cava. The use of cardiopulmonary bypass with or without cardiac arrest has been advocated but with this procedure only the inferior vena cava is bypassed, using femoral and right atrial cannulation, assisted by a closed system electromagnetic centrifugal pump. In appropriate cases this less complex technique allows prolonged access to the inferior vena cava whilst providing equal protection from pulmonary embolisation and tumour dissemination; it also reduces morbidity, operating time, difficulty and cost when compared with cardiopulmonary bypass.     

Combined resection of respiratory tract for thoracic esophageal carcinoma]

Thirty seven patients with thoracic esophageal carcinoma underwent esophagectomy combined with resection of respiratory tract. In 5 patients who received resection with the trachea or bronchus, 1 patient survived more than two years. His status of lymph node metastasis was n2 positive, and surgical margin was free of cancer. These findings show that negative surgical margin and certain lymph-adenectomy are required to obtain good prognosis. A half of 32 patients who received combined resection of the lung had no invasion into the lung tissue pathologically. Five-year survival rate of 32 patients was 22.9%. We concluded that combined resection of the lung was safe procedure and showed satisfactory outcome.     

Surgical resection for T4 lung cancer invading thoracic aorta

The prognosis of the lung cancer patients with aortic invasion is thought to be very poor in general. Thoracic aorta resection and reconstruction was performed in 6 patients, aortic arch in 2, descending aorta in 4. An intraoperative and a postoperative major complication occurred in each 1 patient. Five patients survived more than 1 year after operation, and 1 of them has been living without relapse for more than 5 years. Pulmonary resection with the involved aorta can be done safely using cardiopulmonary bypass, with encouraging long-term survivals in patients without N2 or N3 nodal metastasis.     

The right upper lobe pulmonary resection performed through the transcervical approach.

OBJECTIVE: Preliminary report: presentation of the new technique of transcervical right upper lobectomy with transcervical extended mediastinal lymphadenectomy (TEMLA) for NSCLC. METHODS: Two patients underwent the operation that was performed through the collar incision, with elevation of the sternal manubrium with the mechanical sternal retractor. TEMLA and bilateral mediastinal lymph node excision (stations 1, 2R, 4R, 2L, 4L, 3A, 3P, 7 and 8) and bilateral supraclavicular lymph node excision were performed (frozen section analysis: all nodes negative). The mediastinal pleura was opened and the following structures were dissected in the open fashion with standard surgical instruments and divided with the use of endostaplers: the azygos vein, the upper trunk of the right pulmonary artery, the branch of the superior pulmonary vein to the upper lobe, the upper lobe bronchus, the segment 2 artery, the posterior part of the oblique fissure and the horizontal fissure. The operation was performed with the use of one videothoracoscopic (VTS) port for insertion of 5mm, 30 degree VTS camera for intraoperative control and for single thoracic drain for the postoperative period. RESULTS: The operative times were 250 and 270 min, respectively; intraoperative blood loss was 110 and 100ml, respectively. There were no intraoperative complications. The postoperative course was remarkably smooth. The final pathologic report: large cell carcinoma pT2N0M0 and squamous cell carcinoma pT2N0M0, no metastatic changes of 51 and 41 mediastinal and intrapulmonary (stations 10, 11 and 12) and supraclavicular nodes, respectively. CONCLUSIONS: This preliminary report indicates possible advantages of the transcervical right upper lobe pulmonary resection including: (1) extremely radical, minimal invasive procedure with no need for utility thoracotomy; (2) dissection performed with standard surgical instruments in the open fashion.     

Anterior approach for major right hepatic resection for large hepatocellular carcinoma

OBJECTIVE: To report the surgical and long-term outcomes of major right hepatic resection for large hepatocellular carcinoma (HCC) using the anterior approach compared with the conventional approach. SUMMARY BACKGROUND DATA: Great difficulty can be encountered during major right hepatic resection for large HCC using the conventional approach. Forceful retraction during mobilization of the tumor might result in serious complications, including dissemination of cancer cells, iatrogenic tumor rupture, and excessive bleeding, leading to unfavorable surgical and long-term outcomes. METHODS: In patients who had large HCC at the right lobe of liver and underwent major hepatic resection, the technique of anterior approach was used. After hilar control of the inflow blood vessels and without prior mobilization of the right lobe of liver and the tumor, parenchymal transection was performed using an ultrasonic dissector from the anterior surface of the liver until the anterior surface of the inferior vena cava was exposed. All venous tributaries, including the right hepatic vein, were controlled before the right lobe of liver was mobilized. Surgical and long-term outcomes were analyzed retrospectively and compared with patients who underwent surgery using the conventional approach. RESULTS: From 1989 to 1997, the anterior approach was used for major right hepatic resection in 54 patients with HCC of 5 cm or more in diameter. When compared with the 106 patients with similar clinical parameters who underwent hepatic resection using the conventional approach during the same period, the patients in the anterior approach group had significantly less intraoperative blood loss and blood transfusion, a lower hospital death rate, a lower incidence of pulmonary metastases, and a better median disease-free survival and median overall cumulative survival. CONCLUSION: The anterior approach is the preferred technique for major right hepatic resection for large HCC because it resulted in improved surgical and survival outcomes compared with the conventional approach.     

Primary leiomyosarcoma of the inferior vena cava invading the right atrium: a technique for intraluminal biopsy through a transvenous approach

Leiomyosarcoma of inferior vena cava (IVC) is a very rare tumor constituting less than 1% of all malignant tumors. However, it is the most common malignant primary IVC tumor. We report a case of primary leiomyosarcoma involving the entire IVC and extending into the right atrium. We also describe a simple endovascular technique that can be used to biopsy IVC masses through a transvenous approach. Our technique can be used as an alternative to percutaneous biopsy which carries a risk of bleeding when transgressing the IVC wall with a biopsy needle. To our knowledge, the use of this technique to biopsy IVC masses has not been described in literature.     

Combined resection of the thoracic aorta associated with subtotal esophagectomy for carcinoma of the esophagus

With recent advances in surgical techniques and post-operative care, surgical treatment of esophageal cancer has been safely performed. Nevertheless, prognoses of such cases in which the cancer is invading the ajacent aorta and when only an incomplete resection was performed are very poor. The following case in which annular resection of the thoracic aorta combined with subtotal esophagectomy was performed and an aorto-aortic bypass graft was replaced was reported. A 70 year old man came to our hospital, complaining of difficulty in swallowing. The upper GI series showed a 8 cm long filling defect in the middle esophagus. Computed tomography suggested that the tumor was directly invading the aorta. The patient underwent two staged procedure operations. During the first operation, the left chest was opened, and a side-to-end bypass graft was replaced to detour around the tumor bearing aorta with 20 mm phi Dacron Double Velour graft. The aorta was then transected. The second operation was performed through the right thoracotomy. During the operation, the thoracic esophagus and the tumor bearing aorta were resected en bloc. The patient died of hepatic failure and right pyothorax 4 months after the first operation.     

Combined radiofrequency ablation and myxoma resection through a port access approach

Myxomas are common cardiac tumors that are traditionally managed by complete excision through a median sternotomy approach with the use of cardiopulmonary bypass. We discuss a patient with left atrial myxoma and chronic atrial fibrillation who underwent surgical excision and combined irrigated radiofrequency ablation for atrial fibrillation through a Port Access approach. Minimally invasive operations constitute an expanding field for the treatment of many cardiac diseases and may be an alternative for the treatment of this pathology because of less surgical trauma and cosmetic superiority. In this case, both excision of the myxoma and radiofrequency ablation were feasible through this minimally invasive approach. The combination of direct and endoscopic views enabled both procedures to be performed safely and efficiently.     

Pulmonary complications after esophageal cancer surgery through right thoracic approach

In order to investigate the effect of preoperative pulmonary function exerted on the postoperative pulmonary complications, postoperative chest X-ray films were consecutively studied in terms of abnormal shadows in the lung up to the 30th postoperative day (p.o.d.) in a series of 60 patients with intrathoracic esophageal cancer. Patients were divided into 3 groups according to their preoperative % VC and FEV1.0%; patients with % VC greater than or equal to 100% and FEV1.0% greater than or equal to 80% were stratified as group A, those with % VC greater than or equal to 80% and FEV1.0% greater than or equal to 70% excluding group A as group B, and those with % VC less than 80% or FEV1.0% less than 70% as group C. Patients with pyothorax secondary to anastomotic leakage, and/or ARDS due to proven septicemia were excluded. Abnormal shadows on the chest X-ray were observed in 68.3% of all the patients after surgery. The positive ratios for those shadows were not statistically different among the three groups. Before 3rd p.o.d., preoperative pulmonary function did not correlate with the positive ratio for abnormal shadows of each group. After 5th p.o.d., however, the positive ratios in group C were higher than those in group A and B up to 14th p.o.d. (p less than 0.05). Approximately seventy per cent of all abnormal shadows started within 3 days after the operation. Abnormal shadows first appeared on the upper lung fields more frequently in group C than in group A + B (p less than 0.01). The abnormal shadows on the right lower lung field appeared significantly later than those on the right upper lung field (p less than 0.05). In group C, major abnormal shadows were found in 71.4%, which were higher than those in group A and B (p less than 0.05). The abnormal shadows in group C persisted for a period of 14 days, which was longer than those in group A and B (p less than 0.05). In conclusion, preoperative pulmonary function exerts much influence on the progress and continuity of abnormal shadows in the lung after 5th p.o.d. in patients with esophageal cancer.     

Modified trap-door thoracotomy for mediastinal metastasis of thyroid carcinoma invading the right brachiocephalic vein.

The patient was a 65-year-old female with metastasis of thyroid papillary carcinoma at the right upper mediastinum. The tumor, which invaded almost the entire length of the right brachiocephalic vein, was resected via a modified trap-door thoracotomy. The modification was the additional resection of the first rib from inside the thorax, which provided a sufficient exposure from the distal side of the brachiocephalic and subclavian vein. Because the subclavian and internal jugular veins could be clamped under this thoracotomy, the entire right brachiocephalic vein could be reconstructed by graft without excessive difficulty. Modified trap-door thoracotomy is a useful approach in the resection of malignancies which invade the brachiocephalic and subclavian vein.     

结肠癌联合胰十二指肠切除术

目的探讨结肠癌患者实施联合胰十二指肠切除术(PD)的必要性和方法。方法总结1994年1月至2002年12月间1750例结直肠癌患者中5例横结肠癌患者(0.3%)行联合PD术的临床资料。结果结肠癌联合PD术的5例患者(其中1例加肠系膜上静脉部分切除吻合)均无手术死亡。1例术后并发胰瘘和切口感染,但均康复出院。3例术后半年因肿瘤复发死亡,2例随访至今45个月和72个月仍无瘤生存。结论结肠癌侵犯胰十二指肠较少见。结肠癌联合胰十二指肠切除手术是安全的,能为部分患者提供长期生存的机会。     

Endoscopic oesophagectomy through a right thoracoscopic approach.

A technique of subtotal endoscopic oesophagectomy through the right thoracoscopic approach is described. It has been used in five patients, four with cancer and one with benign motility disorder. The operative blood loss during the endoscopic dissection stage was unmeasurable in four patients and amounted to 300 ml in one. The mean (range) duration of the endoscopic dissection was 3.3 (3.0-4.0) h and of the total procedure was 5.5 (4.5-7.5) h. After the operation, the mean (range) duration of stay in the intensive care unit was 19.5 (16-26) h. From the time of the operation, the mean (range) hospital stay was 11 (8-18) days. One patient developed left vocal cord palsy which prolonged this.     

Ascending aorta-to-descending aorta bypass via right thoracotomy for the re-coarctation of the aorta: an alternative surgical approach for re-coarctation

Surgical treatment of aortic coarctation is performed with low postoperative complication rates. However, some patients may require additional surgical interventions due to stenosis or re-coarctation of the aorta, and ascending-to-descending aortic bypass via right thoracotomy is a valid alternative approach in the adult population group. Risk of massive intraoperative bleeding due to adhesions at the previous left thoracotomy site and the risk of spinal cord ischemia due to aortic cross-clamping or injury to the recurrent laryngeal nerve may be avoided with right thoracotomy in such cases. In this report, we present an adult patient with re-coarctation of the aorta who was successfully treated by extra-anatomic ascending-to-descending aortic bypass via right thoracotomy without cardiopulmonary bypass.