胸外科手术后继发乳糜胸的防治

乳糜胸是一种罕见且严重的胸外科手术并发症,导致患者严重的营养消耗、生理紊乱和免疫抑制,了解乳糜漏的病理生理学是治疗原则的基础。保守治疗旨在通过营养干预减少乳糜的产生,并通过乳糜液引流控制症状,终点是淋巴管的自发闭合。手术干预的时机仍然存在争议,胸腔镜胸导管夹闭以及栓塞已成为开放手术的替代方案。采取何种处理方法应根据患者自生情况判断和决定,过度强调手术及不适当的保守治疗都不是临床的最佳选择。本文对胸外科术后继发乳糜胸的治疗及预防现状和新的进展进行了综述。     

A review of traumatic chylothorax

BackgroundTraumatic chylothorax is an extremely rare complication following thoracic trauma or surgery. The aetiology of traumatic chylothorax is dominated by iatrogenic causes, with a reported incidence of 0.5% to 3% following oesophageal surgery. The mortality from a chylothorax post oesophagectomy can be as high as 50%. Iatrogenic causes in total account for approximately 80% of traumatic causes. Non-iatrogenic traumatic chylothoraces are exceedingly uncommon. The complication rate in blunt thoracic trauma is said to be 0.2% to 3%, whilst in penetrating trauma, the incidence is 0.9% to 1.3%. If recognised late or managed poorly, this condition has devastating complications, including nutritional depletion, physiological derangements and immunological depression. This review revisits the anatomy of the thoracic duct, the physiology of chyle production and associated dynamics as well as the current management strategies available for traumatic chylothorax.MethodsA review of selected English literature from 1980 to 2015 was undertaken. Databases used included Pubmed, Cochrane and Science Direct. Publications of both traumatic and postoperative chylothorax were reviewed. The appropriate literature was analysed by comparing and contrasting content with particular emphasis on management issues. Keywords and phrases were used to achieve a streamlined and focused review of the topic.ConclusionChylothorax remains a rare complication of thoracic surgery and thoracic trauma. The potential complications can result in serious morbidity and can even be fatal. Understanding the pathophysiology of a chyle leak underpins the principles of management. The overall success of conservative management ranges from 20% to 80%. The timing of surgical intervention remains debatable. Benefits of early surgical intervention are clearly documented, resulting in a gradual shift toward early operative treatment with reports suggesting thoracic duct ligation yielding a 90% success rate. Technological advances such as thoracic duct embolisation, with a potential success rate of 90%, and thoracoscopic interventions are attractive alternatives to orthodox open surgery.     

Long‐term endoscopic management of upper tract urothelial carcinoma: 20‐year single‐centre experience

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Endoscopic management of small, low‐grade, non‐invasive upper tract urothelial cell carcinoma (UTUC) is a management option for selected groups of patients. However, the long‐term survival outcomes of endoscopically‐managed UTUC are uncertain because only four institutions have reported outcomes of more than 40 patients beyond 50 months of follow‐up. Moreover, there is significant variance in the degree of underlying UTUC pathology verification in some of these reports, which precludes an analysis of disease‐specific survival outcomes. The present study represents one of the largest endoscopically managed series of patients with UTUC, with a long‐term follow‐up. The degree of verification of underlying UTUC pathology is one of the highest, which allows a grade‐stratified analysis of different outcomes, including upper‐tract recurrence‐free survival, intravesical recurrence‐free survival, renal unit survival and disease‐specific survival. These outcomes provide further evidence suggesting that endoscopic management of highly selected, low‐grade UTUC can provide effective oncological control, as well as renal preservation, in experienced centres.

OBJECTIVE

• ? To report the long‐term outcomes of patients with upper tract urothelial cell carcinoma (UTUC) who were treated endoscopically (either via ureteroscopic ablation or percutaneous resection) at a single institution over a 20‐year period.

PATIENTS AND METHODS

• ? Departmental operation records were reviewed to identify patients who underwent endoscopic management of UTUC as their primary treatment.
• ? Outcomes were obtained via retrospective analysis of notes, electronic records and registry data.
• ? Survival outcomes, including overall survival (OS), UTUC‐specific survival (disease‐specific survival; DSS), upper‐tract recurrence‐free survival, intravesical recurrence‐free survival, renal unit survival and progression‐free survival, were estimated using Kaplan–Meier methods and grade‐stratified differences were analyzed using the log‐rank test.

RESULTS

• ? Between January 1991 and April 2011, 73 patients underwent endoscopic management of UTUC with a median age at diagnosis of 67.7 years.
• ? All patients underwent ureteroscopy and biopsy‐confirmation of pathology was obtained in 81% (n= 59) of the patients. In total, 14% (n= 10) of the patients underwent percutaneous resection.
• ? Median (range; mean) follow‐up was 54 (1–223; 62.8) months.
• ? Upper tract recurrence occurred in 68% (n= 50). Eventually, 19% (n= 14) of the patients proceeded to nephroureterectomy.
• ? The estimated OS and DSS were 69.7% and 88.9%, respectively, at 5 years, and 40.3% and 77.4%, respectively, at 10 years. The estimated mean and median OS times were 119 months and 107 months, respectively. The estimated mean DSS time was 190 months.

CONCLUSIONS

• ? The present study represents one of the largest reported series of endoscopically‐managed UTUC, with high pathological verification and long‐term follow‐up.
• ? Upper‐tract recurrence is common, which mandates regular ureteroscopic surveillance.
• ? However, in selected patients, this approach has a favourable DSS, with a relatively low nephroureterectomy rate, and therefore provides oncological control and renal preservation in patients more likely to die eventually from other causes.

     

Adult intussusception: A 15‐year retrospective review

Objective: Adult intussusception is an uncommon disease and is usually associated with malignancy. In many cases, diagnosis is made only in the theatre as a result of its non‐specific presentation and low index of suspicion. By reporting the present study, we would like to share our experience in managing this condition. Methodology: Patients with the diagnosis of intussusception admitted to Queen Elizabeth Hospital within the period 1996–2010 were included. Demographic data, presenting symptoms, and operative and pathological findings were collected and analysed. Results: There were 37 adult intussusceptions in the study period; 18 of them were female and 19 of them were male. The mean age of the patients was 67 years. More than 40% of the patients had subacute onset of the symptoms. Abdominal pain was the most common presenting symptom, present in 83.5% of the patients. Preoperative diagnosis was made in 62.2% of the cases and all of these received either preoperative computed tomography and/or ultrasonography. There were nine enteric and 28 colonic intussusceptions. A pathological lead‐point could be identified in 83.8%, and their size ranged from 2 cm to 8 cm. The malignant lead‐point was larger than the benign one lead‐point (4.74 vs 3.3, P = 0.021). Malignancy was found in 33.3% of the enteric lesions and 60.7% of the colonic lesions. respectively. Age older than 70 years was found to be an associated risk factor for malignancy (P = 0.022). Conclusion: Intussusception should be considered as one of the differential diagnoses, especially in elderly patients complaining of subacute abdominal pain. Computed tomography scan should be the imaging of choice. Oncological resection should be carried out without attempt of reduction if the patient is older than 70 years, having colonic intussusception and containing a large lead‐point.     

Whole‐body vibration for functional constipation: a single‐centre,single‐blinded,randomized controlled trial

Aim The aim of this trial was to determine whether whole‐body vibration (WBV) induced via a noninvasive oscillation platform could improve symptoms and health‐related quality of life (HRQOL) in patients with chronic functional constipation. Method A single‐blinded, randomized controlled trial was performed in a single hospital in Taiwan. Patients diagnosed with chronic functional constipation, as per the Rome III diagnostic criteria, were included and randomized to either the WBV treatment or no treatment (control) group. The treatment group received six 15‐min sessions of WBV therapy over a 2‐week period. Patients received vibrations of 2 mm in amplitude at a frequency of 12 Hz. The primary outcome was whether constipation symptoms improved, assessed by the constipation severity instrument (CSI) and the secondary outcome measure was whether there was an improvement in HRQOL. Results Whole‐body vibration therapy over a 2‐week period in patients with chronic functional constipation (n = 14) significantly reduced the total CSI and obstructive defaecation subscale scores compared with control (n = 13). However, WBV did not improve the pain and chronic inertia subscale scores of the CSI or HRQOL. Conclusion These findings suggest that low‐intensity WBV induced via a noninvasive oscillation platform may be an effective therapy for reducing symptom severity in patients with chronic functional constipation.     

Enterocutaneous fistula: a single‐centre experience

Background: Enterocutaneous fistulae (ECFs) present a difficult management problem and can cause significant morbidity. The aim of the study was to assess the outcome of these patients. Methods: A retrospective chart review of all patients with ECF managed at a tertiary centre between 1996 and 2006 was performed. Demographic, management and outcome data including ECF closure, morbidity and mortality were recorded. Results: A total of 33 patients (17 male) were identified with ECF (median age: 63 years, range: 27–84). The primary aetiology was Crohn's (30%), anastomotic leak (24%), iatrogenic (18%), mesh (6%), neoplasia (6%) and other (16%). Definitive surgery was undertaken in 21 (64%) at a median of 6.4 months (0.4–72 range) following presentation. Twenty percent of patients required emergency surgical intervention and 5 patients required preoperative total parenteral nutrition (TPN). Surgical management was formal resection and reanastomosis in all patients, with a mean operative time of 4.75 h (standard deviation = 1.8). The median hospital stay for the operative group was 19 days (7–85). Four patients required post‐operative TPN with one patient requiring home TPN. Fistula closure rate was 97% (operative group: 21 out of 21; non‐operative group: 11 out of 12). Mean follow‐up was 37.3 months (0.5–217). Six (19%) operative patients developed fistula recurrence. There were two deaths at 2 and 5 months (fistula aetiology malignant colonic fistula and radiation enteritis, respectively). Conclusion: Patients with ECF can be treated with low morbidity and low recurrence rate in a multidisciplinary setting. We believe that patients with ECF should be referred to specialist units for management.     

Liver retransplantation in children. A 21‐year single‐center experience*

In this study, the epidemiology and outcome of graft loss following primary pediatric liver transplantation (LT) were analysed, with the hypothesis that early retransplantation (reLT) might be associated with lower immunologic risks when compared with late reLT. Between March 1984 and December 2005, 745 liver grafts were transplanted to 638 children at Saint‐Luc University Hospital, Brussels. Among them, a total of 90 children (14%) underwent 107 reLT, and were categorized into two groups (early reLT, n = 58; late reLT, n = 32), according to the interval between either transplant procedures (< or >30 days). Ten‐year patient survival rate was 85% in recipients with a single LT, vs. 61% in recipients requiring reLT (P < 0.001). Ten‐year patient survival rates were 59% and 66% for early and late reLT, respectively (P = 0.423), the corresponding graft survival rates being 51% and 63% (P = 0.231). Along the successive eras, the rate of reLT decreased from 17% to 10%, whereas progressive improvement of outcome post‐reLT was observed. No recurrence of chronic rejection (CR) was observed after reLT for CR (0 of 19). Two children developed a positive cross‐match at reLT (two of 10, 20%), both retransplanted lately for CR secondary to immunosuppression withdrawal following a post‐transplant lymphoproliferative disease. In summary, the results presented could not evidence better results for late reLT when compared with early reLT. The former did not seem to be associated with higher immunologic risk, except for children having withdrawal of immunosuppression following the first graft.     

Papillary breast cancer: A retrospective single‐centre clinical study

Papillary carcinoma (PC) of the breast is a rare malignancy that accounts for 0.5%‐1% of breast cancers. PC remains an understudied cancer, and we still require further information on its behaviour, staging and management. In particular, a significant proportion of PC cases still undergo sentinel lymph node biopsy without clear empirical justification. In the present study, we provide a valuable cohort of 44 PC patients and examine the clinicopathological features and outcome of loco‐regional staging. Our results provide important insights into the behaviour of PC and suggest SLNB may be spared in this condition. Crucially, we show only one histologically confirmed PC case had evidence of nodal metastasis. In addition, up to 5 years postsurgery, no patient in our cohort died from their cancer. Together, our results support further work in the utility of SLNB in PC and highlight the favourable prognosis of this tumour. We propose SLNB should not be routinely indicated for patients with PC treated with breast conservation, and future studies should aim to incorporate prospective data to help inform optimal management of PC.