Staging laparoscopy for potentially resectable noncolorectal,nonneuroendocrine liver metastases

Background Carefully selected patients with noncolorectal, nonneuroendocrine (NCNN) liver metastases may benefit from hepatic resection. The incidence of occult unresectable disease and the possible benefits of staging laparoscopy in these patients are not known. Methods From December 1997 to July 2000, staging laparoscopy was performed in 30 consecutive patients with NCNN metastases before planned open exploration and resection. Demographies, extent of preoperative imaging, operative and postoperative findings, and factors associated with laparoscopic identification of unresectable disease were analyzed. Results Twenty-four patients (80%) had a complete laparoscopic examination, and 23 had laparoscopic ultrasonography. All patients underwent preoperative computed tomography or magnetic resonance imaging, and 21 (70%) patients had 2 or more preoperative radiological studies. Overall, nine patients had unresectable disease, six of whom were identified by laparoscopy. Of the remaining 24 patients believed to have resectable disease at laparoscopy, 21 went on to a potentially curative procedure. Laparoscopy did not identify irresectability because of vascular involvement in three patients. Laparoscopy added a median of 30 minutes of operative time to those patients going on to laparotomy. Conclusions Laparoscopy identified the majority of patients with occult unresectable disease, improved resectability, and should be routine in patients being considered for potentially curative hepatic resection. Presented in part at the 54th Annual Meeting of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

腹腔镜超声在腹腔镜肝胆手术中的应用

目的探讨腹腔镜超声在腹腔镜肝胆手术中的应用价值。方法腹腔镜下肝切除、肝囊肿开窗及复杂胆囊切除等手术156例,手术中应用腹腔镜超声进行辅助检查,了解手术解剖入路结构及肿瘤分期。结果在19例肝切除及39例肝囊肿开窗手术中,腹腔镜超声在手术中标示重要肝内及肝外管道的走向及指导切除,在15例复杂胆囊切除中指导精确定位及进一步辨别可疑恶性占位。结论腹腔镜超声能够在腹腔镜肝胆外科手术中进行准确定位、指导治疗,对解决腹腔镜手术中外科医生触觉反馈减弱问题,提高手术效果有一定临床价值。     

Staging Anal Cancer: Prospective Comparison of Transanal Endoscopic Ultrasound and Magnetic Resonance Imaging

Purpose  The staging of anal cancer is extremely important for therapy and prognosis. Transanal endoscopic ultrasound and magnetic resonance imaging are routinely applied. The aim of this prospective comparative study is to evaluate whether tumor staging is concordant between these techniques. Methods  Forty-five anal cancer patients underwent endoscopic ultrasound and magnetic resonance imaging. Histological confirmation was obtained in all patients. The two test methods were compared with the kappa concordance index and sensitivity for the initial method of tumor detection was calculated. For six patients who were operated upon because of tumor progression, the results were evaluated against the histological tumor stage. Results  High concordance was found in the assessment of tumor size and nodal status (kappa index 0.63 and 0.77). Cancer patients were correctly identified with 100% sensitivity (45/45) by endoscopic ultrasound and with 88.9% (40/45) sensitivity by magnetic resonance imaging. In the six operated patients, T stage was correctly assessed in four of six patients by endoscopic ultrasound and in three of six patients by magnetic resonance imaging. Conclusion  The results of endoscopic ultrasound strongly coincide with those of magnetic resonance imaging. Endoscopic ultrasound may be superior to magnetic resonance imaging for detection of small superficial tumors. However, magnetic resonance imaging is needed for N staging.     

腹腔镜超声在胰腺壶腹部肿瘤分期诊断和治疗中的价值

目的 评价腹腔镜超声技术(LapUS)在胰腺和壶腹部癌肿分期诊断和治疗中的临床应用价值。方法 自1996年12月～1999年12月连续对46例怀疑胰腺和壶腹部肿瘤病人进行腹腔镜和腹腔镜超声分期诊断。并与术前影像学检查、手术中发现及术后标本病理学检查进行前瞻对比研究。着重检查肿瘤范围、周围血管侵犯、周围淋巴结转移、浆膜浸润和肝、邻近脏器转移;对可疑病变和肿大的淋巴结进行腹腔镜超声引导下穿刺活检。判断肿瘤切除性。结果 46例病人中。LapUS发现肿块性病灶44例,2例阻塞性黄疸确诊为壶腹部结石嵌顿排除肿瘤。44例肿块性病变中41例为恶性肿瘤,3例为炎性病变,肿瘤诊断正确率为93．2％。本组未发生腹腔镜和腹腔镜超声检查有关并发症。结论腹腔镜和腹腔镜超声检查应列为重要的分期诊断工具,剖腹探查前常规应用可明显提高诊断正确率、完善肿瘤分期诊断和可切除性判断。可避免不必要的剖腹探查术。在微创外科诊治中具有重要的临床应用价值。     

Comparing Surgical Outcomes in Obese Women Undergoing Laparotomy,Laparoscopy, or Laparotomy With Panniculectomy for the Staging of Uterine Malignancy

Background Limiting surgical morbidity while maintaining staging adequacy is a primary concern in obese patients with uterine malignancy. The goal of this study was to compare the surgical adequacy and postoperative morbidity of three surgical approaches to staging the disease of obese women with uterine cancer. Methods The records of all patients with a body mass index (BMI) of ≥35 undergoing primary surgery for uterine corpus cancer at our institution from January 1993 to May 2006 were reviewed. Patients were assigned to three groups on the basis of planned surgical approach—standard laparotomy, laparoscopy, or laparotomy with panniculectomy. Standard statistical tests appropriate to group size were used to compare the three groups. Results In all, 206 patients with a BMI of ≥35 were grouped as follows: laparotomy, 154 patients; laparoscopy, 25 patients; and laparotomy with panniculectomy, 27 patients. Median BMI was 41 (range, 35–84). Regional lymph nodes were removed in 45% of the laparotomy patients, 40% of the laparoscopy patients, and 70% of the panniculectomy patients (P = .04). Compared with laparotomy, both laparoscopy and panniculectomy yielded higher median pelvic and total lymph node counts (P = .001). Operative time was shortest after standard laparotomy, and blood loss was greatest after panniculectomy. The incidence of all incisional complications was lower for panniculectomy (11%) and laparoscopy (8%) compared with standard laparotomy (35%) (P = .002). On multivariate analysis, a significantly lower risk of total incisional complications was seen for patients undergoing panniculectomy (risk ratio, .25; 95% confidence interval, .071–.88) and laparoscopy (risk ratio, .19; 95% confidence interval, .04–.94). Conclusions Both laparoscopic staging and panniculectomy in a standardized fashion were associated with an improved lymph node count and a lower rate of incisional complications than laparotomy alone. Although definitive conclusions are limited by low patient numbers, the substantial decrease in wound complications suggests that these two approaches should be considered for obese patients undergoing uterine cancer staging. Presented in part at the Society of Gynecologic Oncologists Winter Meeting; Beaver Creek, CO; February 1–3, 2007.     

转化医学时代的肝胆外科

转化医学是一种新兴的医学研究模式,其内涵包括有效地将医学基础研究的最新成果转化为可用的临床医学技术和产品,并把临床医疗中的实际问题反馈到实验室开展研究的双向过程,即“从实验室到病房” 和“从病房到实验室” 的双向研究。肝胆外科与转化医学是医学科学的尖端领域。近年来肝胆外科领域研究成果的临床转化应用得到世界各国科学家的共同关注,政府领导的相关法律、法规已开始制订。肝胆外科的进步离不开转化医学的贡献。在不远的将来,中国有望在肝胆外科与转化医学领域走在世界前列。中国外科界应放眼世界,集世界发展之大成,加快转化医学理念的传播与深入,努力改进技术理念并提升疗效。     

Evaluation of the role of laparoscopic ultrasonography in the staging of oesophagogastric cancers

Introduction  The role of laparoscopic ultrasound (LUS) during staging laparoscopy for pancreatic cancers is established but remains debatable in evaluating oesophagogastric cancers. Methods  A retrospective consecutive case series consisting of patients undergoing staging laparoscopy in two centres (centre A and B) was carried out over a 5-year period (2000–2005). Patients in centre B underwent LUS following laparoscopic assessment using a 7.5-MHz probe. Staging laparoscopy in both centres was performed using a standardised three-port protocol using a 30° laparoscope. All suspicious lesions were sent for histological assessment for confirmation of malignancy. Results  There were 201 patients in centre A (83 gastric, 138 lower oesophageal/junctional cancers) and 119 patients in centre B (51 and 68, respectively). There were no differences between the two centres for patient demographics and tumour site. There was no difference between the two centres for the detection of metastatic disease using laparoscopic assessment alone (A 13% versus B 20%, p = 0.12). However, there was a significant difference (13% versus 28%, p = 0.001) with the additional use of LUS in centre B. The findings in the additional 8% (n = 9) were para-aortic lymphadenopathy (n = 5), liver metastasis (n = 3) and local extension (n = 1). Five had gastric and four lower oesophageal/junctional cancers. The negative predictive value was 6.4% for centre A and 4.5% for centre B. Conclusion  The addition of LUS increased the detection rate of metastasis by 8% but there was little impact on the false-negative rate. LUS is useful in detecting metastatic lymphadenopathy beyond the limits of curative resection and liver metastasis.     

腹腔镜超声影像技术在腹内恶性肿瘤诊治中的价值

应用腹腔镜超声技术(LapUS)对30例怀疑为腹内恶性肿瘤患者进行分期诊断和术中应用,探讨了LapUS对腹内恶性肿瘤分期诊断和治疗中的价值。结果表明,LapUS对腹内肿瘤诊断正确率达96.7％(29/30),12例避免了不必要的剖腹探查术(占40％)。LapUS对腹内恶性肿瘤准确定位、准确分期能提供非常有价值的信息,可判断恶性肿瘤能否切除,减少了不必要的剖腹探查并能指导手术方式和切除范围。     

The Current Role of Staging Laparoscopy in Oesophagogastric Cancer

Introduction

Oesophagogastric cancers are known to spread rapidly to locoregional lymph nodes and by transcoelomic spread to the peritoneal cavity. Staging laparoscopy combined with peritoneal cytology can detect advanced disease that may not be apparent on other staging investigations. The aim of this study was to determine the current value of staging laparoscopy and peritoneal cytology in light of the ubiquitous use of computed tomography in all oesophagogastric cancers and the addition of positron emission tomography in oesophageal cancer.

Methods

All patients undergoing staging laparoscopy for distal oesophageal or gastric cancer between March 2007 and August 2013 were identified from a prospectively maintained database. Demographic details, preoperative staging, staging laparoscopy findings, cytology and histopathology results were analysed.

Results

A total of 317 patients were identified: 159 (50.1%) had gastric adenocarcinoma, 136 (43.0%) oesophageal adenocarcinoma and 22 (6.9%) oesophageal squamous carcinoma. Staging laparoscopy revealed macroscopic metastases in 36 patients (22.6%) with gastric adenocarcinoma and 16 patients (11.8%) with oesophageal adenocarcinoma. Positive peritoneal cytology in the absence of macroscopic peritoneal metastases was identified in a further five patients with gastric adenocarcinoma and six patients with oesophageal adenocarcinoma. There was no significant difference in survival between patients with macroscopic peritoneal disease and those with positive peritoneal cytology (p=0.219).

Conclusions

Staging laparoscopy and peritoneal cytology should be performed routinely in the staging of distal oesophageal and gastric cancers where other investigations indicate resectability. Currently, in our opinion, patients with positive peritoneal cytology should not be treated with curative intent.     

腹腔镜肝切除术27例报告

目的探讨腹腔镜肝切除术的可行性。方法采用腹腔镜多功能手术解剖器(LPMOD)刮吸断肝技术行完全腹腔镜下肝切除术27例。包括规则性肝切除13例(其中Ⅱ、Ⅲ段切除3例,Ⅴ段切除1例,Ⅵ段切除7例,Ⅴ、Ⅵ段切除1例,Ⅴ、Ⅵ、Ⅶ、Ⅷ段切除1例),局部切除14例。结果全部顺利完成手术,无中转开腹。手术时间35~360 min,(178.0±78.4)min,术中出血35~1200 ml,(451.7±332.6)ml,术后住院时间2~14 d,(8.4±3.0)d,无严重并发症发生。术后病理:肝海绵状血管瘤15例,肝局灶性增生2例,肝细胞性肝癌伴肝硬化6例,肝胆管结石伴胆管增生2例,肝(血肿)纤维化1例,肝血管平滑肌脂肪瘤1例。27例术后随访1~26个月,(7.9±7.4)月,复查肝B超或CT,无血管瘤复发、肝癌复发及穿刺口种植、肝内胆管结石残留。结论在经过选择的病例中,采用LPMOD行腹腔镜肝切除术是可行的。     

腹腔镜在胃癌根治术的应用进展

近年来有关早期胃癌的微创治疗进展很快，并已取得国内外的共识。对进展期胃癌应用腹腔镜行胃癌根治术尽管已经取得了较好的临床效果，但仍尚待前瞻性多中心临床随机对照研究。从应用前景看，随着术者技术的完善、观念的改变、经验的积累、手术器械的不断改进，腹腔镜胃癌根治术必将在胃癌手术中扮演越来越重要的角色。     

Role of staging laparoscopy in gastric malignancies - our institutional experience

AIM: To investigate the value of staging laparoscopy with laparoscopic ultrasound (LUS) and peritoneal lavage cytology in patients with newly-diagnosed gastric tumours in our department.METHODS: Retrospective review of prospectively-collected data was conducted in all patients with newly-diagnosed gastric tumours on oesophagogastroduode-noscopy between December 2003 and July 2008. All the patients had a pretreatment histological diagnosis and were discussed at the hospital multidisciplinary tumour board meeting for their definitive management. Computed tomography scan was performed in all patients as a part of standard preoperative staging work up. Staging laparoscopy was subsequently performed in selected patients and staging by both modalities was compared.RESULTS: Twenty seven patients were included. Majority of patients had cardio-oesophageal junction adenocarcinoma. Thirteen patients (48%) were up-staged following staging laparoscopy and one patient was downstaged (3.7%). None of the patients had procedure-related complications. None of the patients with metastasis detected at laparoscopy underwent laparotomy. Gastrectomy after staging laparoscopy was performed in 13 patients (9R0 resections, 3 R1 resections and 1 R2 resection). Only one patient did not have gastrectomy at laparotomy because of extensive local invasion. Three patients were subjected to neoadjuvant therapy following laparoscopy but only one patient subsequently underwent gastrectomy. CONCLUSION: In this small series reflecting our institutional experience, staging laparoscopy appears to be safe and more accurate in detecting peritoneal and omental metastases as compared to conventional imaging. Peritoneal cytology provided additional prognostic information although there appeared to be a high false negative rate.     

腹腔镜超声在腹腔镜肝切除术中的应用

目的:探讨腹腔镜超声在腹腔镜肝切除术中的应用价值。方法:用腹腔镜行肝切除术24例,其中肝血管瘤17例,原发性肝癌7例。术中常规应用腹腔镜超声检查了解肿瘤与周围组织的解剖关系,确定肿瘤分期和手术解剖入路。结果:13例行全腹腔镜肝切除术,9例行手助腹腔镜肝切除术。术中超声检查后中转开腹2例。手术平均出血量230ml,术后无并发症发生。结论:腹腔镜超声在腹腔镜肝切除术中能够确定肿瘤位置、临床分期并指导手术入路,提高了肝切除术的安全性,减少了手术并发症。     

腹腔镜在中低位直肠癌手术中的应用

目的通过比较腹腔镜与开腹中低位直肠癌手术的临床疗效,探讨腹腔镜中低位直肠癌手术的临床价值。方法回顾性分析2010年1月~2012年1月我科收治的82例中低位直肠癌患者的临床资料,其中42例行腹腔镜手术(腹腔镜组),40例行开腹手术(开腹组),比较两组手术时间、术中出血量、淋巴结清扫范围、肿块距下切缘距离、切除肠管长度、胃肠功能恢复时间、术后住院时间及并发症发生率等指标。结果两组出血量、淋巴结清扫数目、肿块距下切缘距离、切除肠管长度、并发症发生率比较,差异均无统计学意义(P0.05);两组手术时间、胃肠功能恢复时间、术后住院时间比较,差异均有统计学意义(P0.05)。结论腹腔镜下中低位直肠癌切除术是可行和安全有效的,与开腹手术对比有较多优点,值得在临床进一步推广应用。     

Impact of Regional Lymph Node Evaluation in Staging Patients With Periampullary Tumors

Background Two distinct lymph nodes reproducibly assessed by computed tomography for the evaluation of periampullary tumors are the common bile duct (CBD) node and the gastroduodenal artery (GDA) node. We examined whether radiographical enlargement of either lymph node predicts tumor resectability, nodal metastasis, or patient survival. Methods Ninety-four consecutive patients underwent attempted curative resection of periampullary tumors between September 2001 and June 2003. A single radiologist recorded in a retrospective, blinded fashion the short- and long-axis measurements of the CBD and GDA nodes. Results Sixty-one percent (n = 57) of tumors were resectable by pancreaticoduodenectomy. Overall, actual 6-, 12-, and 18-month survival was 87%, 68%, and 63%, respectively. Enlarged radiographical nodal size by either axis was not associated with the presence of metastasis to these lymph nodes or with reduced overall patient survival. Only a CBD node short-axis size >10 mm predicted unresectability (odds ratio, 3.2; P = .036). Liver metastasis and/or carcinomatosis were present in 43% of unresectable patients, and this was associated with decreased survival at both 1 year (25% vs. 77%; P < .001) and 18 months (19% vs. 72%; P <.001). A pathologic diagnosis of metastasis to the GDA node, but not the CBD node, was associated with a similarly decreased survival (1 year: 33% vs. 78%, P = .028; 18 months: 22% vs. 70%, P = .023). Conclusions For presumed periampullary malignancy, a CBD node short-axis size >10 mm predicts tumor unresectability. Metastatic disease to the GDA node, particularly for pancreatic adenocarcinoma, portends a poor prognosis equivalent to that of hepatic or peritoneal spread. Given these findings, radiographical CBD lymph node measurements may guide selection for performing laparoscopic staging with or without ultrasonography in conjunction with GDA nodal biopsy in patients with periampullary malignancy. Presented in part at the annual meetings of the American Hepato-Pancreatico-Biliary Association on April 15, 2005 and The Pancreas Club on May 15, 2005.     

腹腔镜肾上腺肿瘤切除术75例报告

目的探讨腹腔镜下肾上腺肿瘤切除的方法和临床应用价值.方法1999年1月～2004年6月75例患者行腹腔镜肾上腺肿瘤切除术,其中采用经腹腔途径51例和经腹膜后途径24例.结果手术时间平均为(170.16±33.81)min,术中的出血量平均为(70.82±37.15)ml.术后平均住院时间为(5.87±1.01)d.中转开放手术2例(2.67%).发生并发症4例(5.33%),分别为膈肌损伤、胰腺损伤、肠道损伤、皮下血肿各1例.结论腹腔镜下行肾上腺肿瘤切除术具有创伤小,术中出血少,术后恢复快等优点,已经成为现代治疗肾上腺肿瘤的金标准.     

The Role of Laparoscopy in the Management of Groin Hernia

Introduction:

The advantage of using minimally invasive techniques over open techniques in the repair of groin hernias is still debated. Despite its more widespread use, an apparent dichotomy exists. While some surgeons continue to believe that no advantage is gained using the laparoscopic technique, others argue laparoscopic hernia repair (LHR) offers a quicker recovery with the use of a tensionfree repair.

Methods:

A mailing to the general surgeon members of the Society of Laparoendoscopic Surgeons, an international multidisciplinary laparoendoscopic society, was performed (mailing size=l680).

Results:

Nine hundred and ninety-three surgeons responded (60%). Across all demographic variables, 60% of respondents performed approximately 27% of their hernia repairs laparoscopically (40% of respondents did not perform LHR). Surgeon age less than 45 was the only demographic characteristic that predicted the likelihood to perform LHR (p<0.0001) and the percentage of hernias repaired laparoscopically (p<0.005). Most respondents felt that the presence of bilateral hernias (73%) or a recurrent hernia (74%) were indications for LHR. Eighty-nine percent of respondents felt that LHR would still be performed 20 years from now. Surgeons expressed concerns regarding increased cost, the need for more anesthesia, and a lack of long-term follow-up for LHR.

Conclusions:

Only surgeon age predicted the likelihood of a surgeon performing LHR or the percentage of hernias that would be repaired laparoscopically.     

The Prognostic Effect of Clinical Staging in Pancreatic Adenocarcinoma

Background The importance of pancreatic cancer staging is uncertain. The aim of this report was to evaluate the accuracy of combined standard imaging techniques in predicting the pathologic stage and to evaluate the prognostic effect of clinical staging to identify patient groups in which laparoscopy and laparotomy could be beneficial.Methods Fifty-four patients were included in this analysis. The techniques used for clinical staging were endoscopic retrograde cholangiopancreatography, abdominal computed tomographic scan, and ultrasonography. All patients underwent both clinical and surgical/pathologic staging. A comparison was performed between presurgical stage and surgical/pathologic stage. The prognostic effect of different factors on survival was evaluated with both univariate (log-rank) and multivariate (Cox) analysis.Results Sensitivity and specificity for vascular involvement were 73.9% and 96.3%, respectively. Sensitivity and specificity for nodal involvement were 63.6% and 95.4%, respectively. A total of 33.3% of patients showed a higher than expected pathologic stage, and 3.7% showed a lower than expected pathologic stage, by comparing clinical and pathologic evaluation. A highly significant correlation was observed between clinical T stage (P = .0067) and tumor diameter (P = .0037) and patient survival. Maximal prognostic differentiation was observed by dividing patients into two groups based on imaging results: group A (favorable prognosis) and group B (unfavorable prognosis). The median survival was 25.1 and 8.0 months for group A and B, respectively. Five-year survival was 20.1% and 0%, respectively (multivariate analysis: P = .0007).Conclusions Integrated standard imaging studies achieved reasonable diagnostic accuracy in our analysis. A single classification based on clinical stage and tumor diameter evaluated by imaging predicts prognosis in patients with pancreatic carcinoma.     

后腹腔镜治疗复杂性肾囊肿14例报告

目的探讨后腹腔镜治疗复杂性肾囊肿的疗效。方法 2006年1月～2010年12月后腹腔镜治疗复杂性肾囊肿14例,常规于腋后线第12肋缘下、腋中线髂嵴上、腋前线肋缘下做穿刺点,建立工作通道。根据术前影像学资料,寻找并游离出囊肿,电刀切开囊壁,吸净囊内液体并观察其形状,扩大囊壁口,检查囊腔内病变,距肾实质边缘约0.5 cm处切除囊壁,止血,生理盐水冲洗创面并置负压引流管。囊壁常规送病理检查。结果 13例手术成功,1例肾上极旁囊肿与膈肌粘连明显,术中损伤膈肌致气胸,中转开放手术。手术时间50～80 min,平均65 min;出血量60～180 ml,平均75 ml。术后24～48 h下床活动。术后2～4 d拔除引流管和导尿管。住院3～10 d,平均6 d。14例随访6～12个月,平均9.5月,症状缓解,无复发。结论后腹腔镜治疗复杂性肾囊肿疗效满意,但对于术前诊断不明,特别是有恶变倾向的肾囊肿,仍以开放手术为宜。