Neoadjuvant chemotherapy in advanced stomach cancer--a case of complete response

In the treatment of gastric cancer R0 surgical resection is the only hope for cure. Unfortunately most patients are first seen when they are in an advanced stage, when the possibility of R0 resection is very poor. In these cases administration of other therapies is justified. In the last decade neoadjuvant combination chemotherapy had been introduced with promising results. ECF neoadjuvant chemotherapy has 60% response rate in irresectable cases. We report about a patient with locally advanced gastric cancer treated with neoadjuvant ECF chemotherapy. The patient reacted with complete response, so following chemotherapy R0 resection could be carried out. We describe different therapies used for patients with locally advanced gastric cancer. Neoadjuvant chemotherapy is a recommended therapeutic modality in locally advanced gastric cancer, because it may have the effect of irresectable disease becoming resectable.     

Langzeitergebnisse nach laparoskopischer Resektion colorectaler Carcinome

BACKGROUND: Laparoscopic techniques are currently used for curative resection of colorectal cancer although long-term results from controlled clinical trials are not available yet that prove laparoscopic procedures are adequate. METHODS: All patients who under-went a curative resection of a colorectal tumor from 1995 to 1997 were included in a prospective cohort study to evaluate the short- and long-term results. RESULTS: Laparoscopic colorectal resections were accomplished in 68 patients. In only 3 patients was an adenoma (stage 0) found, and 10 patients had multiple liver metastases at the time of palliative resection. An oncological resection was performed in 55 patients. The average age was 62.8 +/- 14.6 years (29 female and 26 male patients). Eleven right colectomies, 1 left colectomy, 21 sigmoid resections, 16 proctosigmoidectomies and 6 abdominoperineal resections were carried out. Two patients (3.6%) were lost during follow-up. The median follow-up was 27.1 months (range 9.1-45.1 months). No port-site metastases were found. Two patients who are still alive after sigmoid resection suffered from a recurrence. The first patient underwent only limited lymphadenectomy because of synchronous malignant lymphoma. The second patient developed bilateral lung metastases. Only one patient died during the follow-up period because of myocardial infarction. CONCLUSION: Although the follow-up is short, it seems that the recurrence rate is low. Controlled multicenter clinical trials are currently performed to evaluate whether laparoscopic surgery is really adequate to treat colorectal cancer.     

Bloqueio lobar seletivo com um bloqueador Coopdech combinado com um tubo endotraqueal de duplo lúmen para ressecção de metástases pulmonares com laser

In recent years, laser resection of lung metastases has been established as the standard procedure worldwide. To avoid airway fire, it is necessary to collapse the surgical lung. The selective lobar bronchial blockade is a technique that allows one‐lung ventilation while the operated lobe is collapsed in patients with previous pulmonary resection requiring subsequent resection or with limited pulmonary reserve. We report a clinical case about our experience of a selective lobar bronchial blockade technique with a bronchial blocker (Coopdech endobronchial blocker) that was employed successfully with a double‐lumen endotracheal tube in a patient with previous contralateral pulmonary resection who was scheduled for atypical resections of pulmonary metastases by laser. We selectively blocked the right intermediate bronchus for management of hypoxemia during one‐lung ventilation. This technique provided adequate ventilation and oxygenation during surgery, avoiding the need of two‐lung ventilation during lung metastases resection by laser.

Laparoscopic abdominoperineal resection for rectal cancer in a patient with situs inversus totalis

Situs inversus totalis (SIT) is a very rare condition. Laparoscopic surgery in a patient with SIT is difficult because the surgeon's dexterity is compromised during the procedure, and the patient's anatomy is the mirror image of normal. We present a SIT patient who underwent laparoscopic abdominoperineal resection for rectal cancer. The detailed operative procedures and trocar placement considerations are described.     

Treatment of iatrogenic injury of membranous trachea with intercostal muscle flap

Iatrogenic injuries of the membranous trachea are rare but potentially lethal, and most commonly require surgical treatment. Such injuries occur intraoperatively during specific thoracic surgery procedures or are associated with endotracheal anesthesia. Special technical difficulties in managing them surgically are encountered when lacerations are in proximity to the rigid rings of the trachea because of the lack of membranous tissue distal to the tear. We describe our technique used in a patient with such an iatrogenic tracheal injury during resection of invasive lung carcinoma.     

Anesthetic management of simultaneous coronary artery bypass grafting and cardiac pheochromocytoma resection under cardiopulmonary bypass

We experienced simultaneous coronary artery bypass grafting and cardiac pheochromocytoma resection under cardiopulmonary bypass in a 79-year-old woman with atherosclerotic angina. During manipulation of the tumor under cardiopulmonary bypass, the serum norepinephrine concentration increased to over seventy times the normal limit, and there was a 25-mmHg rise in mean arterial pressure. Cardiopulmonary bypass has been recommended for the resection of cardiac pheochromocytoma to isolate the heart from the systemic circulation, and thus prevent massive catecholamine release when handling the tumor. However, the serum catecholamine concentration surged in our patient during tumor manipulation under cardiopulmonary bypass, probably because of the reperfused blood from the operating field. We suggest that cardiopulmonary bypass be performed for the anesthetic management of cardiac pheochromocytoma resection, because excessive hypertension can be avoided during cardiopulmonary bypass, even if the catecholamine concentration increases excessively when handling the tumor.     

Surgical Treatment of Superior Sulcus Tumors

Purpose To access the clinical outcome of patients with superior sulcus tumor.Methods We reviewed the records of 16 patients who underwent surgery for a superior sulcus tumor between 1988 and 2003, focusing on the type of surgery.Results All 16 patients underwent en bloc lung and chest wall resection, which was done as pneumonectomy in 1 patient and lobectomy in 15. Complete resection was achieved in 11 patients, but incomplete resection was done in 5 patients because microscopic examination revealed positive surgical margins. Eight patients underwent partial vertebrectomy and 1 patient had combined resection of the subclavian artery. There was no postoperative mortality. All patients received pre- or postoperative adjuvant therapy, or both. The overall 5-year survival rate was 31.0%. The 5-year survival rate was higher after complete resection than after incomplete resection (59.3% vs 0%, P = 0.08). Patients who underwent complete resection for vertebral invasion and those who did not had 5-year survival rates of 66.7% and 0%, respectively (P = 0.17). Patients who underwent preoperative induction therapy followed by complete resection and those who did not had 5-year survival rates of 80% and 0%, respectively (P = 0.009).Conclusion Although superior sulcus tumors are still complex, preoperative induction therapy followed by complete resection seemed effective for prolonging survival.     

Management of unsuspected gallbladder carcinoma discovered during or following laparoscopic cholecystectomy

Laparoscopic cholecystectomy (LC) is widely used in the treatment of symptomatic cholelithiasis. Gallbladder carcinoma (GBC) discovered during or after LC presents a management problem because of the difficulty of intraoperative staging. We conducted a retrospective, 8-year review of 10 patients with GBC discovered during or after LC. Of 3050 patients undergoing LC for cholelithiasis, 10 (0.3%) had GBC. The histological diagnoses of the 10 GBC patients included well-differentiated adenocarcinomas (n = 5), papillary adenocarcinomas (n = 2), moderately differentiated adenocarcinomas (n = 2), and poorly differentiated adenocarcinoma (n = 1). Of these patients, four had TNM classified T1 tumors, three had T2 tumors, one had T2N0M0 tumor, one had T2N1M0 tumor, and one had T3N0M0 tumor. In three of them (T2N0M0, T2N1M0, and T3N0M0), the procedure was converted to open cholecystectomy, wedge resection of liver bed tissue in segment 5, and lymph node dissection after frozen-section biopsy of the laparoscopically removed gallbladder revealed GBC. Patients were closely followed at regular intervals until death or May 2000. The median follow-up period was 24.5 months. One patient died of carcinomatosis 6 months after undergoing the open procedure. The remaining nine patients did not have any recurrence during the follow-up period. No patient had a port site recurrence of GBC. Based on our limited experience, early GBC (T1a or T1s) can successfully be managed by simple cholecystectomy, either by LC or the open method.     

Plastic surgery of the thoracic wall (malformations and tumors) using a sliding splint-stapler]

Chest wall instability, created surgically by correction of a chest deformity (funnel chest or, more rarely, pigeon chest) or by resection of a tumour of the chest wall, is serious as it can jeopardize the immediate vital prognosis because of paradoxical respiration and, in the long term, the functional and aesthetic prognosis due to progressive impaction of the unstable segment of the wall. The polyvalent and adaptable material which we have developed (sliding splint-staple) and which we also use in thoracic traumatology (thoracic flaps), has allowed us to perform audacious corrections for deformities or wide resections for tumours since 1980. We have used this material on 13 occasions for contention after sternochrondroplasty, with an excellent result in each case both in terms of the immediate stability and in terms of the aesthetic result. The sliding splint-staples, generally two, are placed in staggered positions behind the sternum (11 cases--funnel chest) or in front of the sternum (2 cases--pigeon chest). The material is left in place for at least one year. We have used this material on 8 occasions after various tumour resections: 3 times after subtotal resection of the sternochrondral breastplate and 5 times after lateral or anterolateral resection removing at least 2 ribs.     

Occlusion of surgical opening of the ventricular system with fibrinogen-coated collagen fleece: a case collection study

Background  

Implantation of 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU) wafer for malignant glioma is not recommended in the case of surgical opening of the ventricular system during microsurgical tumor resection because the wafer material may dislocate from the resection cavity into the ventricular system and cause obstructive hydrocephalus. TachoSil is an adhesive collagen fleece used in different surgical disciplines that provides an air- and liquid-tight seal closing communications between the ventricular system and the resection cavity after tumor removal.     

The use of cardiopulmonary bypass and extracorporeal membrane oxygenation for support during removal of two teratomas and hydrops fetalis

The removal of massive tissue tumors often leads to rapid blood loss and decreased lung compliance because of large volume shifts. Cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) have both been used as a means of support during resection of saccrococcygeal teratomas. Hydrops fetalis is the accumulation of fluid in extravascular spaces and body cavities. This leads to edema and sometimes hypoxia. ECMO has been used for support during treatment of hydrops fetalis. This patient was diagnosed, via sonogram, at 30 weeks gestation to have two teratomas and hydrops fetalis. Because of the risk of hemorrhage and poor lung compliance during removal of these types of tumors, CPB and ECMO were used. This support allowed for successful removal of the tumors. Following removal of the tumors, the patient failed to wean from CPB because of the severity of hydrops. The patient remained on extracorporeal support for treatment of hydrops fetalis. This report describes the perfusion techniques used for support during the removal of teratomas and the treatment of hydrops fetalis.     

Resection and reconstruction of sternnum

In case of sternal resection, it is necessary to preserve bone material indispensable for the stability of the anterior chest wall and air tightness of the thoracic cavity, and the support of the chest wall integrity must be restored by some means. Various techniques have been applied to the reconstruction of the chest wall following resection. During the last 10 yers, we have performed reconstructive operation for 6 cases of the chest wall following resection of the sternum in recurrent cases of breast cancer or invaded case of primary breast cancer. In these patients, the chest wall was reconstructed using a rib-latissimus dorsi osteomyocutaneolus flap or a latissimus dorsi myocutaneous flap. The sternum was totally resected in 3 cases, and in all 3 cases, reconstructed using a rib-latissimus dorsi osteomyocutaneous flap. Although postoperative pulmonary function decreased, all cases could be relieved from endotracheal intubation within 17 hours aftr operation, and had no problems in activities of daily living or occurrence of chest flailing or paradoxical movement of the chest. An artificial material (expanded polytetrafluoroethlene patch) was used in only one patient for the reconstruction of the osseous thorax, but this case developed infection during postoperative chemotherapy. After this experience, we used only biological materials for the reconstruction of the chest wall and postoperatively performed radiotherapy and/or chemotherapy on all cases. We have observed no flap infection or detachment since then. One characteristic of using the latissimus dorsi myocutaneous flap is that it is easily elevated and rarely causes serious postoperative esthetic or functional problems. The flap is also easily utilized to reinforce the osseous thorax because ribs immediately below the latissimus dorsi muscle are readily mobilized as a pedicle graft. Reconstruction of the chest wall following resection of the sternum, described in this report, allowed us to perform radiotherapy and/or chemotherapy without serious postoperative complications on the cases relapsing after treatment of breast cance. The 2-year survival rate is 50% and one of these cases survived up to 10 years after resection of the sternum. Thus we prefer to perform resection of the sternum for sternal recurrence of breast cancerif there are no metastatic lesions in other organs.     

Endovascular treatment for facial arteriovenous malformations using new particles: report of two cases

Facial arteriovenous malformations (FAVM) are difficult to treat because of their highly vascular networks. Intravascular treatment using liquid material to occlude the FAVM occasionally results in skin necrosis after embolization. The use of particulate materials to obliterate the nidus often fails to obtain a permanent cure due to arterial recanalization. We report two patients with FAVM who were successfully treated with endovascular embolization using a new type of particulate material. One patient was treated with embolization only, the other was treated with embolization followed by surgical resection. Both patients showed clinical and angiographic improvement. Intravascular treatment using particles with a smooth surface and optimal size is safe and effective in the treatment of patients with FAVM.     

Surgical Treatment of a Superior Sulcus Tumor in a Patient with Idiopathic Thrombocytopenic Purpura: Report of a Case

We herein report a resection of a superior sulcus tumor in a patient with idiopathic thrombocytopenic purpura. A resection of the left upper lobe of the lung, left subclavian artery, and left first to third ribs, as well as a reconstruction of the left subclavian artery, were performed. Postoperative hemorrhaging was controlled due to preoperative high-dose intravenous immunoglobulin therapy and a platelet transfusion both during and following surgery. The resected tumor was diagnosed to be a pulmonary pleomorphic carcinoma, which was pathologically determined to be T3N0M0-Stage 2B. The patient remained in good condition for 20 months following the surgery; however, he eventually died due to bone metastases.     

Prosthetic rehabilitation after craniofacial surgery

We report our experience during the last 6 years with 20 patients fitted with prosthesis (19 patients with osseointegration of screw, 1 patient with primarily gluing method) for camouflage of congenital or acquired (trauma, tumor resection) defects of the ear, nose, or eye. Out of a total of 53 extra-oral implants fitted, 3 were lost in the orbital area due to loosening 6 months after radiation treatment. Another three implants were removed at the request of an 80-year-old patient who preferred a prosthesis retained by spectacles because of recurring infection around one of the implants. On average, 43 months (range, 7 months to 8 years) after completion of the prosthesis, 85% of the patients assessed the result as excellent, 15% as good, 0% as fair, and 0% as poor. The ENT surgeon and the prosthesis designer were slightly more critical (ENT surgeon-95% good or excellent and 5% fair, prosthesis designer-90% good or excellent, 10% fair).     

Early complications of gastric resection.

Analyzing the patient material of 506 patients with gastric resection, authors deal with the early complication of resection, its diagnosis and treatment. They review the complications, their frequency and mortality in their own material. After operations made for tumour, complications occurred more frequently than after interventions because of ulcer. Total mortality was 10.2%. In order to reduce mortality they call attention to the possible prevention of complications and their careful management.     

Prosthetic Rehabilitation After Craniofacial Surgery

We report our experience during the last 6 years with 20 patients fitted with prosthesis (19 patients with osseointegration of screw, 1 patient with primarily gluing method) for camouflage of congenital or acquired (trauma, tumor resection) defects of the ear, nose, or eye. Out of a total of 53 extra-oral implants fitted, 3 were lost in the orbital area due to loosening 6 months after radiation treatment. Another three implants were removed at the request of an 80-year-old patient who preferred a prosthesis retained by spectacles because of recurring infection around one of the implants. On average, 43 months (range, 7 months to 8 years) after completion of the prosthesis, 85% of the patients assessed the result as excellent, 15% as good, 0% as fair, and 0% as poor. The ENT surgeon and the prosthesis designer were slightly more critical (ENT surgeon—95% good or excellent and 5% fair, prosthesis designer—90% good or excellent, 10% fair).     

Viszeralarterienrekonstruktionen mit Homografts bei Resektionen des Pankreas

BACKGROUND: At present, surgical treatment with R(0) resection offers the only chance of cure for patients suffering from pancreatic cancer. Carcinomas of the pancreas are frequently diagnosed at an inoperable stage because of local tumor progression by vessel wall infiltration. In a small series of patients, efforts have been made to increase curative resection rates for advanced pancreatic cancer by excision and reconstruction of the involved visceral arteries. Whether this provides clinical benefit remains uncertain. METHODS: Since 2001 we have been employing "en bloc" tumor resection for advanced pancreatic carcinomas with extended infiltration of visceral vessels. Technical experience was gained previously by performing portal vein resection as well as arterial excision and reconstruction by direct anastomosis in the presence of malignant wall infiltration. A total of ten patients underwent vascular reconstruction by arterial homograft interposition. In six of ten cases, combined extended reconstructions of the hepatic and superior mesenteric arteries were performed. One patient died during the perioperative course due to fulminant bleeding. One patient developed severe diarrhea. During a 3- to 18-month follow-up, one case of liver metastasis and one case of local tumor recurrence were documented. CONCLUSIONS: In selective cases, operability and R(0) resection can be achieved in advanced pancreatic cancer by performing extended resection procedures with vascular reconstruction using arterial homografts. Vascular substitution of visceral arteries can be conducted without ischemic disturbances of the small bowel and liver. Only a few perioperative complications were observed.     

Oromandibular reconstruction for oncological purposes

The authors compared different vascularized bone grafts in 15 patients with different oncological diagnoses that were treated with hemimandibulectomy in 9 patients, total mandibulectomy in 1 patient, resection of the mandible involving the anterior arch and the symphysis in 3 patients, 1 patient who underwent a segmental mandibular resection, and 1 patient in whom the entire hemimandible was reconstructed because of mandibular hypoplasia diagnosed during the resection of a parotid neoplasm. The flaps used included fibular free flaps in 11 patients, iliac crest in 3 patients, and a radial forearm osteocutaneous flap in 1 patient. Two patients had major complications and 1 patient experienced recurrence of the primary tumor. The fibular free flap was the preferred method in this series due to the size of the defect, which in most patients did not require extensive soft-tissue reconstruction, and due to the nature of the bone defect involving the symphysis and condyle in 9 patients. The different vascularized bone grafts provided adequate osseous and soft tissue for oromandibular reconstruction.