直肠癌术后局部复发的外科治疗

目的探讨直肠癌术后复发再手术的价值。方法对直肠癌术后局部复发接受再手术治疗的62例患者的临床资料进行回顾性分析。结果62例中有32例(51.6%)获根治性切除,其中16例行联合脏器切除;6例获姑息性肿块切除手术;单纯造口11例;单纯剖腹探查13例。术后超过5年局部复发者其肿瘤切除率为100%(11/11);术后2年内复发者切除率为62.9%(22/35);术后超过2年、但在5年以内局部复发者,肿瘤切除率为31.3%(5/16);差异有统计学意义(χ2=13.07,P<0.01)。单纯局部复发者肿瘤切除率为80.0%(32/40);局部复发伴有附近脏器侵犯者肿瘤切除率为27.3%(6/22);差异有统计学意义(P<0.01)。首次术式为Dixon根治术者,再手术的肿瘤切除率为61.9%(26/42);首次术式为Miles根治术者,再手术的肿瘤切除率为30.0%(6/20);两组的肿瘤切除率比较,差异有统计学意义(P<0.01)。获根治性切除病例术后1、3、5年生存率分别为90.6%、59.4%和18.8%;姑息性手术及其他治疗者生存时间为2-24个月,中位生存期为15个月;差异有统计学意义(P<0.01)。结论直肠癌患者术后复发再手术可以延长生存期。     

贲门癌术后吻合口复发的再手术治疗

目的探讨贲门癌术后吻合口复发外科再治疗的手术指征及术式选择.方法对23例贲门癌术后吻合口复发,再手术患者的临床资料进行回顾性分析.结果本组患者的手术切除率、手术并发症发生率及手术病死率分别为69.6%、17.4%和8.7%,胸、腹腔粘连率为87.0%.肿瘤切除患者平均术后存活15.0个月,明显长于未切除患者的4.1个月(P＜0.05).无淋巴结转移患者术后存活21.3个月,虽较有淋巴结转移患者的10.2个月长,但差异无显著性意义(P＞0.05).根治性切除和姑息性切除患者的术后生存期分别为15.8个月和13.3个月,差异无显著性意义(P＞0.05).结论由于胸、腹腔的广泛粘连及二次手术后的消化道重建,贲门癌术后吻合口复发再手术有一定难度,手术风险较大,加之贲门癌患者本身预后较差,因此应严格把握手术指征.术式选择应根据患者病变的分期、分级等具体情况而定.     

残胃复发癌的再手术治疗

目的探讨残胃局部复发癌再手术治疗的临床意义。方法回顾性分析我院 1986～2 0 0 1年间收治的 5 1例残胃局部复发癌的临床资料。结果本组 5 1例中 ,复发局限于残胃者 31例 ,伴有转移的复发 2 0例。行根治性切除术 2 7例 ( 5 3% ) ,其中 16例行联合脏器切除术 ;行姑息性残胃全切术 3例 ,胃肠吻合、造口术 15例 ;单纯剖腹探查术 6例。 30例切除术后病理检查报告 :吻合口周围复发 10例 ,残胃复发癌 2 0例。根治性切除组术后 1、3、5年生存率分别为 88%、5 8%、19%。姑息性手术及综合治疗组的生存时间为 6～ 2 4个月 ,中位生存期为 16个月 ;单纯剖腹探查及腹腔化疗组均于 2～ 7个月内死亡。结论残胃局部复发癌以残胃、吻合口局部复发为主 ,具有较高的切除率 ,应积极行再手术治疗     

直肠癌根治术后局部复发再手术35例分析

目的探讨直肠癌根治术后局部复发再手术的适应证及手术方法。方法对上海交通大学医学院附属新华医院普通外科1998年1月至2002年12月间收治的35例直肠癌根治术后局部复发的患者进行再手术治疗,并对其疗效进行回顾性分析。结果本组患者根治性切除19例（54.3％）,姑息性切除11例,剖腹探查或单纯造瘘5例。根治性手术、姑息性手术及未切除患者的5年生存率分别为35．3％、18．2％和0,中位生存期分别为45个月、22个月和9个月。结论 对于局部复发性直肠癌,积极再手术能有效延长患者的生存期和提高生存率。     

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目的　探讨肝门部胆管癌不同外科治疗方法间的疗效差异。方法　回顾总结 1997～ 2 0 0 2年手术治疗的 63例肝门部胆管癌的临床资料。结果　 63例中手术切除 2 8例 ,切除率 44 4% ,其中根治性切除率为5 7 1%。切除组中 14例合并肝切除 ,其中 11例为根治切除。根治切除组与姑息切除组的平均生存期分别为 2 9个月和 12个月 ( P<0 0 5 )。切除组与引流组疗效差异有显著意义 ( P <0 0 5 )。结论　肝门部胆管癌应争取手术切除 ,合理的联合肝叶切除能提高根治性切除率 ,改善预后     

Clinical experience of reoperation for 35 cases of recurrent colon cancer

目的 探讨结肠癌术后复发的病因及再手术治疗.方法 对2000年1月至2011年1月诊治的35例结肠癌术后复发再手术病例进行回顾性分析.结果 35例结肠癌再手术病因:吻合口复发6例,肠管多处复发12例,腹腔内复发10例,混合型复发7例.围手术期无死亡病例.吻合口复发及手术区域复发病人得到根治性切除;腹腔、盆腔种植转移复发因复发病灶与腹壁、盆腔粘连紧密而作回肠结肠吻合短路解除梗阻.术后出现并发症5例,其中切口感染3例,切口裂开1例,肺部感染1例.术后随访31例,随访率88.6％,随访时间6～60个月.非根治性切除病人生存期4～30个月,中位生存期7.4个月.根治性切除病人生存期9～42个月,中位生存期22.6个月;3年生存率为44.7％.结论 结肠癌术后复发行根治性手术治疗可显著提高病人中位生存期和生存率.     

复发性胃癌的再次手术治疗

目的评估复发性胃癌再次手术治疗的临床价值。方法回顾性分析我院1990年1月至2003年6月收治的58例复发性胃癌再次手术病例的临床病理及生存资料。结果全组病例多为术后定期胃镜检查发现复发,其中41例发生于2年之内。全组再次手术切除40例,再次手术后第1、3、5年生存率分别为70.7%、29.2%和10.3%;其中相对根治性切除者23例(根治性切除组),平均生存39个月,术后第1、3、5年生存率分别为100%、56.5%和26.1%;姑息性切除者17例(姑息性切除组),平均生存23个月,术后第1、3、5年生存率分别为94.1%、17.6%和0。而未能切除者18例(未切除组)均于1年内死亡。3组术后生存率比较,差异有显著性意义(P<0.01)。结论术后定期纤维胃镜检查有助于复发性胃癌的早期诊断和提高手术切除率。选择身体素质相对较好、复发癌肿较局限的患者采取积极的再次手术治疗,可延长患者生存时间,提高其生活质量。     

结肠癌术后复发再手术31例体会

目的总结结肠癌术后复发再手术的体会。方法收集2009-12—2014-12间郑州市第三人民医院收治的31例结肠癌术后复发患者,回顾性分析其临床资料。结果 31例患者中,腹腔内复发9例,吻合口复发5例,肠管多处复发11例,混合型复发6例。随访时间7～62个月,失访2例,随访率为93. 55%。术后发生并发症4例(12. 90%),其中肺部感染1例(3. 23%)、切口感染2例(6. 45%)、切口裂开1例(3. 23%),无死亡病例。非根治性手术患者生存期为5～32个月,中位生存期为9. 6个月。根治性切除手术患者生存期为10～43个月,中位生存期为23. 5个月,3 a生存率为45. 66%。结论结肠癌术后复发患者再手术,可使其中位生存期和生存率明显提高。     

手术切除治疗肝门部胆管癌

目的 总结肝门部胆管癌手术治疗的经验.方法 回顾性分析本院9年因肝门部胆管癌行手术切除的83例病人的临床资料和随访结果.结果 83例手术切除病人中行根治性切除（R0）31例,非根治切除52例（R1,R2）,术后出现并发症29例,死亡5例.根治性切除组中位生存期21.5个月,1、3、5年生存率分别为79.6%,43.3%和25.9%,明显优于非根治性切除组（P＜0.05），近5年本院根治性切除率达44.8%,中位生存期18.7个月,疗效明显提高（P＜0.05），结论 加强围手术期处理、术中行切缘冰冻病理检查、联合肝切除等可提高肝门部胆管癌根治性切除率、减少并发症和死亡率;根治性切除可更好延长病人生存期,使手术治疗肝门部胆管癌获得良好的疗效.     

103例肝门部胆管癌的外科手术切除治疗

目的总结103例肝门部胆管癌采用手术切除治疗的经验。方法回顾性分析10年来行手术切除的肝门部胆管癌103例患者的临床资料和随访结果。结果本组行根治性（‰）切除43例,根治性切除率为41．7％,非根治性（R,,R2）切除60例（58．3％）,术后发生并发症34例,手术死亡8例。根治性切除组中位生存期29．9个月,1、3、5年生存率分别为69．6％、42．0％、20．9％,明显优于非根治性切除组34．1％、10．2％、0（P＜0．05）。本组近5年术前减黄治疗42例,合并肝切除达53．8％,根治性切除率达45．7％,中位生存期24．7个月,疗效明显提高（P＜0．05）。结论肝门部胆管癌作根治性手术切除能更好延长患者生存期,使手术治疗获得良好的疗效。随着近年来加强围手术期处理、术中行切缘冰冻病理检查、联合肝切除等提高了肝门部胆管癌根治性切除率。     

Preoperative chemotherapy and radiation therapy for stage IIIa carcinoma of the lung.

Thirty-six patients with stage IIIa histologically proven non-small cell carcinoma (T3 N2 or T2 N2) underwent concomitant radiation therapy and chemotherapy before pulmonary resection. The therapy consisted of two cycles of continuous infusion of cis-platinum, 25 mg.m-2.day-1 (days 1 through 4) every 4 weeks and concomitant irradiation, 55 Gy, of the tumor and mediastinum. Two to 3 weeks after treatment, the patients were reevaluated for thoracotomy and pulmonary resection. Five patients were found to have unresectable lesions. Thirty-one patients had complete resection, 27 by radical pneumonectomy and 4 by radical lobectomy, giving a resectability rate of 86%. Complete sterilization of lung tumor and mediastinal nodes proven histologically was achieved in 10 patients (28%) and 17 patients (47%). The 3-year survival rate is 61.7% for patients who had resection. Median follow-up is 27 months (range, 6 to 61 months). The preliminary study indicates that preoperative cis-platinum and concomitant radiation therapy is tolerated, appears to increase resectability, and may improve survival in patients with stage IIIa lung cancer.     

Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer

OBJECTIVE: The present study was undertaken to demonstrate that limited pulmonary resection for peripheral small-sized lung cancer yields outcomes not inferior to those of lobectomy. METHODS: During the 9-year period from 1992 to 2000, patients with cT1 N0 M0 peripheral non-small cell lung cancer whose maximum tumor diameter was 2 cm or less on diagnostic imaging and in whom lobectomy was determined to be feasible were treated with limited resection if the patient consented to the procedure and with lobectomy if consent to limited resection was not obtained. The survival and clinical outcome of the patients whose tumors were postoperatively staged as pT1 N0 M0 were compared between the limited resection group (n = 74) and the lobectomy group (n = 159). RESULTS: The limited resection group consisted of 60 patients treated with segmentectomy and 14 patients treated with wedge resection. Among patients followed up for a mean period of 52 months after the operation, neither the 3-year nor 5-year survivals differed significantly between the limited resection group (3-year survival, 94.0%; 5-year survival, 89.1%) and the lobectomy group (3-year survival, 97.0%; 5-year survival, 90.1%). Postoperative tumor recurrence was noted in 5 patients after limited resection and in 9 patients after lobectomy, and the difference in the incidence of postoperative recurrence between the 2 groups was not significant. CONCLUSIONS: The results of this study indicate that in patients with peripheral T1 N0 M0 non-small cell lung cancer whose maximum tumor diameter was 2 cm or less, the outcome of limited pulmonary resection is comparable with that of pulmonary lobectomy.     

Combined thoracic aortic or upper digestive tract resection for lung cancer and malignant mediastinal tumor

Objective: We studied possible indications and combined resection in patients with lung cancer and mediastinal tumors requiring combined thoracic aortic or upper digestive tract resection.Methods: Ten patients with lung cancer and malignant mediastinal tumors (9 men and 1 woman aged 39 to 72 years; mean: 60.5) underwent combined aortic or upper digestive tract resection.Results: Fiv — 3 with primary lung cancer, 1 with thymic cancer, and 1 with liposarcoma —, underwent combined aortic resection. In 2 each, lung cancer and malignant mediastinal tumor had infiltrated the thoracic aorta. The remaining case of lung cancer was complicated by aortic aneurysm in the distal arch. Cardiopulmonary bypass was conducted in 4, and selective cerebral perfusion in 2. Three patients are alive after 11, 22, and 61 months without disease recurrence. Those undergoing combined upper digestive tract resection all had lung cancer, with 4 having tumors infiltrating the esophagus or corpus ventriculi. The remaining patient had both lung and esophageal cancer. The patient treated with combined corpus ventriculi resection has survived 24 months and the patient treated with combined esophageal resection has survived 12 months without disease recurrence. The 1-year survival rate was 60%, 2-year 23%, and 3-year 23%. Prognosis was generally poor with the longest survival 13 months with N2 lung cancer.Conclusions: In combined resection due to malignant mediastinal tumor, T4N0-1 lung cancer, or diseases such as aortic aneurysm, prognosis can be expected to improve. Despite the often poor prognosis in T4N2 lung cancer, surgical intervention may be indicated to avoid complications due to tumor invasion and to lengthen survival and improve quality of life.     

Sleeve lobectomy for bronchogenic cancers: factors affecting survival

BACKGROUND: Sleeve lobectomy is a parenchyma-sparing procedure that is particularly valuable in patients with cardiac or pulmonary contraindications to pneumonectomy. The purpose of this study is to report our experience with sleeve lobectomy for bronchogenic cancer and to investigate factors associated with long-term survival. METHODS: Between January 1981 and June 2001, 169 patients underwent sleeve lobectomy for non-small-cell lung cancer (n = 139) or carcinoid tumor (n = 30), including 61 with a preoperative contraindication to pneumonectomy. Mean age was 59 +/- 14 years (range, 19 to 82 years). Vascular sleeve resection was performed in 11 patients. The remaining bronchial stump contained microscopic disease in 7 patients. RESULTS: Major bronchial anastomotic complications occurred in 6 (3.6%) patients: one was fatal postoperatively, three required reoperation, and two were managed conservatively. In the non-small-cell lung cancer group, operative mortality was 2.9% (4 of 139), and overall 5-year and 10-year survival rates were 52% and 28%, respectively. Six patients experienced local recurrence after complete resection. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0 or N1 versus N2; p = 0.01) and microscopic invasion of the bronchial stump (p = 0.02). In the carcinoid tumor group, there were no operative deaths, and overall 5-year and 10-year survival rates were 100% and 92%, respectively. CONCLUSIONS: Sleeve lobectomy achieves local tumor control and is associated with low mortality and bronchial anastomotic complication rates. Long-term survival is excellent for carcinoid tumors. For patients with non-small-cell lung cancer, N2 disease or incomplete resection is associated with a worse prognosis; outcome is not affected by presence of a preoperative contraindication to pneumonectomy.     

肺及部分左心房切除术治疗中心型肺癌

为探讨肺及部分左心房切除术在治疗侵及左心房的ＩＩｂ期肺癌的效果。对１９８３年２月至１９９４年１０月期间诊断为侵及左心房的ＩＩＩｂ期肺癌病人分为手术组２６例、探查组１４例。两组于围术期均行强化化疗和术后放、化疗。结果本组无手术死亡，探查组生存２～７个月，平均１３４天；切除组除５例术后１０～５８个月死于癌转移外，余２１例无癌生存６～８５个月。作者认为，肺叶或全肺切除并部分左心房切除能明显延长侵及左心房的ＩＩｂ期肺癌的生存时间。     

新辅助放化疗在局部进展期低位直肠癌中的疗效

目的探讨新辅助放化疗对局部进展期低位直肠癌的治疗效果。方法2001年5月至2005年8月共收治105例局部进展期（T3、T4期）低位直肠癌患者,术前给予中等剂量放疗40—46Gy,分次剂量2Gy／d,每周5d,共4—5周完成放疗;放疗开始同时给予卡培他滨1250mg·m^-2·d^-1,分2次I=I服,持续服用至手术。放疗结束后休息6周进行手术,手术均按直肠系膜全切除操作规范进行。结果全组105例患者均按计划完成预定的放化疗。其中36例出现各种不良反应,但Ⅲ级不良反应仅见2例手足综合征。13例患者放化疗后经复查后提示肿瘤消失未行手术。其余92例患者则施行了根治性手术,其中低位前切除术71例,结肠肛管吻合术（Parks术）17例,腹会阴切除术4例,全组总保肛率为96．2％。术后标本病理检查显示11例未见癌细胞及阳性淋巴结。肿瘤TNM分期为TON0者24例,T2N0者23例,BNo者43例,T4N0者2例,T2N1者5例,T3N1者8例;按Dworak肿瘤消退分级,TGR05例,TGR129例,TGR247例,TGR324例。全组共有82例（78．1％）达到降期。全组无手术死亡,术后出现3例直肠阴道漏,2例吻合口漏。所有患者均获随访,随访时间为16—67个月。随访期间肺转移4例,肝转移2例,局部复发4例,其中3例死亡。全组病死率为2．9％,3年无瘤生存率为82．8％,3年总生存率为96．5％。结论新辅助放化疗可有效达到肿瘤降期的目的,提高了局部进展期低位直肠癌的根切率和保肛率,进一步降低了局部复发率和总复发率,并明显提高了无瘤生存率和总生存率。     

Limited resection for non-small cell lung cancer: observed local control with implantation of I-125 brachytherapy seeds

BACKGROUND: Limited resection for lung cancer has been associated with a relatively high incidence of local recurrence. This retrospective study evaluates the impact of implanting radioactive iodine-125 (125I) seeds along the resection margin in these patients. METHODS: Thirty-three patients with lung cancer who were not candidates for lobectomy or pneumonectomy underwent a limited resection of 35 primary non-small cell lung cancers. 125I brachytherapy seeds were implanted along the resection margin to reduce the risk of local recurrence. Survival using the Kaplan-Meier method and sites of recurrence were documented. Follow-up ranged from 20 to 98 months (median, 51 months). RESULTS: The 5-year survival was 47% for all patients. For patients with T1N0 tumors, it was 67%, and for patients with T2N0 tumors, it was 39%. However, the cancer-specific survivals were 77% and 53% for patients with T1N0 and T2N0 tumors, respectfully. Ten patients experienced recurrence, with two local (at the resection margin) and six regional recurrences (five mediastinum, one chest wall). Both local recurrences and one regional recurrence occurred in the 19 patients with T1N0 tumors. CONCLUSIONS: 125I seed implantation along the resected margin for compromised patients undergoing limited resection of lung cancer results in a relatively low incidence of local recurrence and may prolong survival.     

Radical pancreatectomy for pancreatic cancer in the elderly. Is it safe and justified?

Surgical resection provides the only potential cure for pancreatic cancer, yet resection in patients 70 years of age and older remains controversial because of presumed increased morbidity and mortality. Our aim was to determine the operative results in patients 70 years of age or older undergoing potentially curative radical pancreatic resection for pancreatic cancer from 1982 through 1987. Of 206 consecutive patients explored for potential resection, 42 patients (mean age, 75 years) had potentially curative procedures, including radical pancreaticoduodenectomy in 23 patients, total pancreatectomy in 8 patients, and distal pancreatectomy in 11 patients. Ductal adenocarcinoma was the most frequently encountered neoplasm (69%), but cystadenocarcinoma and islet cell carcinoma accounted for 12% and 7%, respectively. The overall operative mortality rate was 9%, while surgical morbidity was 28%, and medical morbidity was 12%. Overall median survival was 19 months, and 5-year survival was 4%. Despite the low overall incidence of resectability and postoperative cure rate for pancreatic carcinoma, exploration for potential curative resection should not necessarily be withheld for healthy, selected patients who are older than 70 years. Morbidity and mortality rates, although slightly greater than for patients who are older than 70 years, are acceptable.     

Aggressive surgical resection for hilar cholangiocarcinoma

BACKGROUND: Surgical treatment of hilar cholangiocarcinoma remains a great challenge to surgeons because of its low resectability, poor survival, and high operative mortality and morbidity. METHODS: The medical and pathological records of 36 patients with a preoperative diagnosis of 'resectable' hilar cholangiocarcinoma operated on by us between January 1998 and December 2002 were studied. The clinical presentations, operative records, and pathology results were retrospectively reviewed. RESULTS: Twenty-six patients (72%) underwent resection with curative intent. Apart from resection of the extrahepatic biliary tree and porta hepatis lymph node dissection, 85% received concomitant en-bloc liver resection and 4% received ex situ liver resection and auto-transplantation. The margin of resection was negative (R0 resection) in 73% of patients, and microscopically positive (R1 resection) in the remaining 27%. The 30-day hospital mortality was 7.6%. Of the patients, 42% had major postoperative complications. The median survival was 20 months, with the longest survival 75 months. The 1-, 3- and 5-year actuarial overall survival rate after resection with curative intent was 77%, 31%, and 12%, respectively. The 1-, 3-, and 5-year actuarial overall survival after R0 resection was 84%, 42%, and 16%, respectively. Tumour recurrence occurred in 58% of patients. CONCLUSIONS: Aggressive surgery increases the resectability of hilar cholangiocarcinoma. R0 resection provides the only chance of long-term survival of these patients.     

腹腔镜结直肠癌根治术疗效分析

目的 探讨腹腔镜结直肠癌根治术的疗效.方法 比较2000年9月至2004年12月福建医科大学附属协和医院收治的99例腹腔镜结直肠癌根治术(腹腔镜组)患者和198例开腹结直肠癌根治术(开腹组)患者局部复发及生存情况的差异.两组各随访时间段的局部复发率、生存率计算采用寿命表法,局部复发率及生存率的比较采用Wilcoxon(Gehan)检验或X2检验及Fisher确切概率法,复发间隔时间、生存时间的比较均采用非参数Wilcoxan秩和检验.结果 腹腔镜组2、3年局部复发率均为3.0%,总的局部复发率3.0%(3/99);开腹组2、3年局部复发率分别为2.6%和4.0%,总的局部复发率为3.5%(7/198),两组局部复发率比较差异无统计学意义(χ2=0.002,P>0.05).两组局部复发的患者中位生存时间分别为15个月(7～24个月)和11个月(2～28个月),差异无统计学意义(U-15.500,P>0.05).两组局部复发的患者1年生存率分别为33.3%和42.9%,2年生存率分别为0和42.9%,差异无统计学意义(χ2=0.120,P>0.05).结论 腹腔镜结直肠癌根治术与开腹结直肠癌根治术有同样的疗效,且安全可行,不会增加肿瘤的复发率.