THE TREATMENT OF CHYLOTHORAX

Objectives. To understand and grasp the diagnosis and treatment of chylothorax caused by various reasons. Method. The treatment results of 31 cases of chylothorax in PUMC hospital from 1963 ～ 1997 were retrospectively analyzed. Results. Among 31 cases, 18 underwent surgery, 14 of 18 were cured, 2 died. In the 13 treated conservatively, 2 were cured, 3 died. Eleven cases were congenital, iatrogenic and traumatic chylothorax, 8 of them received surgical treatment and 6 of 8 were cured. The spontaneous chylothorax of unknown cause were 10 cases, 7 were treated by smgeiy and 6 were cured. Conclusion. Surgical intervention should be aggressively recommended for the traumatic, congenital, and iatro-genic chylothorax. The definite reason must be found out for the spontaneous chylothorax, corresponding management will be given according to the reason. Surgical ligation of the thoracic duct will contribute good result for the chyloflm-rax of unknown cause, but combination of multiple treatment measures will be neccssmy for a successful management.     

Circumferential decompression via the posterior approach for the surgical treatment of multilevel thoracic ossification of the posterioJ longitudinal ligaments： a single institution comparative study

Background The treatment strategies for multilevel thoracic ossification of the posterior longitudinal ligaments （T-OPLL） were rarely reported. The aim of this study was to investigate the clinical outcomes and complications of circumferential decompression for multilevel T-OPLL and compare two different methods in the management of the OPLL （resection or floating）. Methods Data of sequentially treated patients who received surgical treatment for thoracic spinal stenosis caused by multilevel T-OPLL from January 2005 to February 2012 were retrospectively reviewed. Based on the surgical approaches applied, the patients were divided into two groups. Group A consisted the patients who received posterior decompression and group B consisted the patients who received circumferential decompression via the posterior approach. Group B was further divided into two subgroups： subgroup 1 （the resection group） where the OPLL was completely resected and subgroup 2 （the floating group） where the OPLL was floated. Results A total of 49 patients were included in the study. Fourteen patients with single posterior decompression were included in group A and 35 patients who received circumferential decompression were included in group B. In group B, 29 patients had complete resection of the ossified posterior longitudinal ligaments, while the other six underwent a flotation procedure. The follow-up data were available in 39 patients. Mean JOA scores improved from 5.4 ± 1.8 to 7.5 ± 2.8 in group A and from 3.7 ± 1.8 to 7.9 ± 2.4 in group B. The main complications included cerebrospinal fluid （CSF） leakage and postoperative neurelogic deterioration （ND）. Twenty-three of the 25 cases with postoperative CSF leakage achieved a complete recovery at the last follow-up and 12 of the 15 cases with ND achieved some neurological improvement at the last follow-up. Conclusions Circumferential decompression via the posterior approach is an effective surgical method for thoracic spinal stenosis caused by multilevel OPLL     

SURGICAL TREATMENT OF MALIGNANTESOPHAGEAL TUMORS IN PUMC HOSPITAL

To study how to prolong the postoperative survival time of the patients with malignant esophageal tumors. The clinical data of 1098 patients with malignant esophageal tumors from 1961 to 1992 were retrospectively analyzed.The deletion of fragile histnmine triplet (FHIT) gene (a tumor suppressor gene) in 30 fresh esophageal samples obtained in 1996 was detected with PCR and RT-PCR method. The resectability was raised gradually and the operatire morbidity and mortality decreased year by year, but there was no significant improvement on the postoperative 5-year survival rate. Delayed diagnosis and irradical resection influenced the long-term survival. The deletion of cDNA of FHIT gene was 64. 2% in esophageal cancer and 20% in the resected margin of the cancer. We believe that high-grade atypical hyperphsia in esophageal epithelium and deletion of FHIT gene in esophageal cancer and its resected margin are pathological and molecular markers for early diagnosis of esophageal cancer respectively,and the latter may be one of the molecular markers for the resection. Early diagnosis and treatment, radical.resection, and postoperative nutritional support are very important for the improvement of the postoperative survival time of the patients.     

SURGICAL TREATMENT OF RECURRENT SYMPTOMS AFTER CURATIVE RADIOTHERAPY FOR ESOPHAGEAL CARCINOMA

This article presents the clinical results of sur- gical treatment of symptom recurrence after cura. tive radiotherapy for esophageal carcinoma in 54 patients. The overall resectability rate was 75.9T。 and the resection mortality rate 21.OTo. Pneumonia, anastomotic leakage, and empyema were the three major complications, occurring in 26.8'lo, 17.1%, and 17.1% of the cases. Pneumonia was the main cause of postoperative death. The 5-year survival rate was 26.1% after surgical resection and 30.4e70 after radio therapy. These results compare favorably with those achieved by radiotherapy alone and may strengthen the rationale for combined preoperative irradiation and surgery in esophageal carcinoma. Whenever re currence is suspected or severe stricture occurs after curative radiotherapy, surgery is necessary for localized lesions and should be done if the patient's general condition is satisfactory and there is no sign of distant metastasis.     

Apoxesis of primary tracheal tumor. A clinical analysis of 23 cases.

During a 17-year period, 23 patients with primary tracheal tumors underwent surgical treatment in the Department of Thoracic Surgery, PUMC Hospital (11 cases of benign tumor of the trachea, 12 cases of low malignancies). Fourteen times of apoxesis were performed in 11 patients with benign tumors who were followed up for an average of 6.3 years. Fifteen operations were performed in 12 cases including local resection of the tracheal wall and tumor in 4, and curettage of tumor plus electric cauterization on the basis in 10. Eight of 9 patients with adenoid cystic carcinoma received postoperative adjuvant irradiation, with a 5-year postoperative survival rate of 75% (6/8) and 3 cases survived over ten years. The desirability of apoxesis and local resection of tracheal tumor is discussed. The authors suggest that these two surgical patterns can be regarded as a simple and effective treatment for patients with primary tracheal tumors.

     

Treatment for 63 cases of the elderly with choledocholith by duodenoscope

Objective To explore the effect of duodenoscope in the treatment for the elderly cases.Method Retrospective analysis of the treatment by duodenoscope for 63 elderly patients (all aged over 80 years old) with high risk choledocholith from Jan 2006 to Dec 2010.Results All of the 63 cases obtained a success in the endoscopic operation.The operative time was within 15~60 min.Endoscopic stone extraction was performed on 21 cases,bile duct plastic stent in 35,of them 2 cases had the second operation because their stones were too big.In 2 cases of 9 who suffered from acute obstructive suppurative cholangitis (AOSC),plastic stents were placed.In the rest 7 cases,nasobiliary drainages (NBD) were inserted,on 4 of the 7 cases,stone extraction were performed 5-7 days later,in 3 of the 7 cases,stents were inserted for the second time,of the 3 cases,2 were found blood oozing on the surface of wound after EST (endoscopic sphicterectomy),the bleeding was stopped by local spray of noradrenaline,no hematorrhea or perforation occurred.Postoperative choledochitis was found in 1 case,to whom anti inflammatory therapy was applied.Pancreatitis was found in 3 cases,blood amylase increasing in 12,who were cured with fast,pancreatic secretion inhibition and anti inflammatory drugs.One patient died of acute left heart failure (ALHF),no death from the bile duct diseases or concerned were found.Conclusion Although many basal diseases of the elderly increase the risks in the endoscopic treatment,it proves to be practical for it has less complications,high security and definite curative results.     

Circumferential decompression via the posterior approach for the surgical treatment of multilevel thoracic ossification of the posterior longitudinal ligaments: a single institution comparative study

Background The treatment strategies for multilevel thoracic ossification of the posterior longitudinal ligaments (T-OPLL) were rarely reported. The aim of this study was to investigate the clinical outcomes and complications of circumferential decompression for multilevel T-OPLL and compare two different methods in the management of the OPLL (resection or floating).

Methods Data of sequentially treated patients who received surgical treatment for thoracic spinal stenosis caused by multilevel T-OPLL from January 2005 to February 2012 were retrospectively reviewed. Based on the surgical approaches applied, the patients were divided into two groups. Group A consisted the patients who received posterior decompression and group B consisted the patients who received circumferential decompression via the posterior approach. Group B was further divided into two subgroups: subgroup 1 (the resection group) where the OPLL was completely resected and subgroup 2 (the floating group) where the OPLL was floated.

Results A total of 49 patients were included in the study. Fourteen patients with single posterior decompression were included in group A and 35 patients who received circumferential decompression were included in group B. In group B, 29 patients had complete resection of the ossified posterior longitudinal ligaments, while the other six underwent a flotation procedure. The follow-up data were available in 39 patients. Mean JOA scores improved from 5.4 ± 1.8 to 7.5 ± 2.8 in group A and from 3.7 ± 1.8 to 7.9 ± 2.4 in group B. The main complications included cerebrospinal fluid (CSF) leakage and postoperative neurologic deterioration (ND). Twenty-three of the 25 cases with postoperative CSF leakage achieved a complete recovery at the last follow-up and 12 of the 15 cases with ND achieved some neurological improvement at the last follow-up.

Conclusions Circumferential decompression via the posterior approach is an effective surgical method for thoracic spinal stenosis caused by multilevel OPLL of the thoracic spine. Patients who receive complete resection of the ossified posterior longitudinal ligaments may have better recovery rate than the “floating” group.

     

Treatment of esophageal rupture or perforation

<正>Esophageal rupture or perforation is a serious emergent disease.Without accurate diagnosis and effective treatment in time,it’s life-threatening.Esophageal rupture or perforation can be caused by:iatrogenic endoscopy examination and treatment,ligation and sclerotherapy of esophageal variceal,dilation of esophageal stricture,operative injury and so on; Spontaneous perforations; foreign body ingestion; trauma; tumor; calculus and ulcer of esophagus and so on.The key-point for the treatment of this disease lies in early diagnosis and accurate effective treatment.     

Surgical treatment for scoliosis extending to main thoracic spine by keyvertebral-screws technique （KVST）

Objective ：To introduce a key-vertebral-screws technique （KVST） in the surgical treatment of scoliosis extending to main thoracic levels, and to find the role of fulcrum bending in predicting the result of surgical treatment for scoliosis by this technique. Methods： Seventeen consecutive patients with scoliosis extending to main thoracic spine, who underwent pure posterior fusion without anterior or posterior release by KVST between January 2004 and July 2005 were evaluated for fulcrum bending flexibility, surgical correction rate, fulcrum bending correction index （FBCI） in main thoracic curves. Universal Spine System （USS） instrumentation was used in 15 cases, Monarch in another 2 cases. The severity of the curves was measured by Cobb＇s method using RadWork 6.0 software. Preoperative standing AP radiographs, preoperative fulcrum bending anterioposterior （AP） radiographs, postoperative standing AP radiographs, and most recent follow-up standing AP radiographs for spine were measured and recorded. All the data were analyzed with two-sample paired t-test by Origin 7.0 software. Results： Infection and neurological complications were not noted. No major complications were found. Just one case had some axial back pain, which got a full recovery from physiotherapy for 2 weeks. In the X-ray, there was an average correction of 71.5 % of the fused main thoracic curves, which had no significant lose of correction in final follow-up. For the whole fused main thoracic curves, the fulcrum bending flexibility were lower to operation correction rate （P=0. 013）. The average FBCI was 123%. From the data, the more rigid curves （especially fulcrum bending flexibility 〈50%）, the more correction rate operation could get, compared with fulcrum bending flexibility. Conclusion： （1） KVST is a good method in the surgical treatment of thoracic scoliosis, which can get satisfying result with lower medical cost. （2） Fulcrum bending flexibility is lower than operative correction rate by KVST in main     

Surgical intervention for advanced valvular heart disease in 227 cases

Background Although the results of surgical treatment in cardiac valve disease continue to improve, the postoperative mortality rate and the rate of complications in patients with advanced valvular heart disease (AVHD) are still very high. We did this retrospective study to summarize the surgical experience of heart valve replacement for patients with AVHD and discuss effective ways to improve the surgical outcome.Methods From January 1994 to October 2003, surgical procedures of heart valve replacement were performed on 227 (136 men and 91 women) patients with AVHD in our Department of Cardiothoracic Surgery. The clinical data of all patients were collected and analysed. Patients’ age ranged from 10 years to 77 years. In preoperative cardiac function grading, 157 cases were NYHA III and 70 cases NYHA IV. Fifty-one patients had had cardiac operations. The ultrasonic cardiac graphs showed that 145 patients suffered from moderate or severe pulmonary hypertension and 73 had combined giant left ventricle. Mitral valve replacement was performed in 32 cases, aortic valve replacement in 90, tricuspid valve replacement in 1, combined mitral and aortic replacement in 103 and combined mitral and tricuspid replacement in 1. Nineteen patients also received surgical corrections for other minor abnormalities during the operations. A logistic model was established to evaluate the influence of perioperative factors on the mortality rate. Results The operative mortality rate was 13.2% (30/227). The main causes of death included multiple organ dysfunction syndrome (MODS), low cardiac output syndrome and ventricular fibrillation. From the results of the binary noncounterpart multivariate logistic regression, the following statistically significant factors were found to influence the operative mortality rate: redo operation, age ≥55 years, preoperative NYHA cardiac function grading, extracorporeal circulation time ≥120 minutes and postoperative usage of GIK (glucose, insulin and potassium) solution. All factors were risk ones except postoperative application of GIK. The Hosmer-Lemeshow goodness of fit coefficient of this model was 0.976. Conclusions The risk factors associated with postoperative mortality rate in the patients with AVHD were redo operation, age ≥55 years, preoperative NYHA cardiac function grading and extracorporeal circulation time ≥120 minutes. Postoperative usage of GIK acted as a kind of metabolic therapy and will improve the recovery for patients with AVHD. Active perioperative management and care will play a very important role in reducing the operative risk and improving the short term outcome of surgical treatment for the patients with AVHD.     

食管癌手术后乳糜胸的外科治疗：附12例报告

本文报告１２例食管癌切除术后并发乳糜胸的外科治疗。４例保守治疗，８例行胸导管结扎术，除１例同时合并吻合口瘘死亡外，均治愈。本文着重讨论了食管癌手术后乳糜胸发生的因素、治疗原则和预防性胸导管结扎术的作用，并认为食管癌手术后乳糜胸的外科治疗应取积极态度。     

肺癌术后乳糜胸诊治分析

目的:探讨肺癌术后并发乳糜胸的发生率、病因、临床表现、诊断及治疗。方法:回顾性分析5例肺癌术后并发乳糜胸患者的临床资料。结果:2例患者行保守治疗,3例患者沿原切口开胸行胸导管结扎术,均治愈。结论:应根据患者的病情来决定是采用保守疗法还是采用开胸结扎胸导管的方法。     

食管癌术后乳糜胸治疗及预防

目的： 讨论食管癌术后乳糜胸的治疗及预防。方法：１９９０ 年７ 月～１９９８ 年１２ 月分别对４ 例术后乳糜胸及１６７ 例食管癌术中行低位结扎胸导管术。结果：４ 例乳糜胸全部治愈,１６７ 例均未并发乳糜胸。结论： 预防性结扎胸导管术可有效降低乳糜胸发生率     

食道癌术中结扎胸导管预防乳糜胸

目的 术中预防性结扎胸导管防止乳糜胸的发生.方法 收治2582例病人,A组:不结扎胸导管.B组:分离后结扎胸导管.C组:大块组织缝扎胸导管.结果 B组和C组乳糜胸的发生率与A组相比有差异(P＜0.01),C组乳糜胸的发生率低于B组,但无统计学差异(P＜0.05).结论 术中预防性结扎胸导管对减少食管癌术后乳糜胸的发生有明显作用.     

46例食管癌及贲门癌手术并发症分析

目的探讨食管癌及贲门癌常见手术并发症及预防方法。方法分析我院自2004年～2008年46例食管癌及贲门癌行根治手术后的并发症及其与手术方法的关系。结果在46例食管癌及贲门癌中,全部并发症为9例,包括乳糜胸及吻合口瘘、吻合口狭窄等,全部并发症经过治疗后治愈。结论采用左侧开胸胃、食管吻合根治食管癌及贲门癌手术中,缩短手术时间、加强无菌操作及预防性结扎胸导管有利于预防术后并发症的发生。     

食管癌手术后乳糜胸的治疗(附44例报告)

目的 探讨食管癌术后乳糜胸的有效治疗方法。方法 回顾分析食管癌术后并发乳糜胸的手术与非手术治疗结果。结果 4126例食管癌术后发生乳糜胸44例，发生率1．07％(44／4126)，非手术治疗13例，手术治疗31例，术后死亡1例，余均治愈。结论 膈上水平胸导管结扎对治疗和预防食管癌手术后乳糜胸简便易行，疗效确切。     

食管肿瘤术后乳糜胸

目的探讨食管肿瘤术后乳糜胸的诊断、治疗和预防。方法采用回顾性总结法，对１０例食管肿瘤术后乳糜胸的临床诊治进行分析。结果首次将乳糜胸划分为即发型和迟发型两种临床类型并给予相应治疗。结论即发型乳糜胸应采用早期低位胸导管结扎术，迟发型乳糜胸手术和非手术治疗均有效。预防乳糜胸的关键是手术中对主动脉弓后及上下部位的仔细操作。     

食管癌术后乳糜胸的诊断和治疗

目的　探讨食管癌术后并发乳糜胸的诊断和治疗 ,重点讨论治疗方法。方法　回顾本院 1989～2 0 0 3年间的 112 0例食管癌手术病例 ,对其中发生乳糜胸并发症的 16例病例进行分析。结果　 16例患者中 ,采用保守治疗 11例 ,采用手术治疗 5例 ,其中 1例经过 2次手术结扎胸导管而痊愈。本组无死亡病例。结论　食管癌术后并发乳糜胸的患者 ,大多数可以通过保守治疗而痊愈 ,只有少部分需要手术治疗。关键在于手术适应证的掌握及手术时机、术式的选择。     

食管癌术后并发乳糜胸的原因及治疗

目的：探讨食管癌术后并发乳糜的原因及治疗方法.方法：分析13例食管癌术后发生乳糜胸者的手术过程及术后引流量等相关指标.结果：本组13例中12例行主动脉弓上吻合,1例主动脉下吻合.术后病理均为鳞状细胞癌;其中T12例,T23例,T3 8例;N08例,N15例,M013例.术后引流量320～1530ml/天,平均560ml/天,白蛋白总用量30～210g,血浆总用量1000～8000ml;9例行二次开胸胸导管结扎术治疗,两次手术间隔时间9～21天.4例保守治疗,胸腔注射重组人血白介素Ⅱ等.全部病例均治愈.结论：肿瘤外侵处,主动脉弓后和弓上部位胸导管易受损伤,此为产生乳糜胸的主要原因,手术部位的良好显露在一定程度上可避免胸导管损伤.胸腔引流量平均在500ml/d以上,保守治疗1w无好转者,应考虑手术治疗.     

食管癌术后乳糜胸的治疗

目的:探讨食管癌术后乳糜胸的防治方法。方法:回顾性分析17例食管癌术后并发乳糜胸患者的临床资料。结果:1 651例食管癌术后发生乳糜胸17例,发生率1.03%(17/1651),非手术治疗6例,手术治疗11例,均痊愈出院。结论:食管癌术后乳糜胸应本着预防为主,综合治疗的原则,膈上水平胸导管结扎对治疗和预防食管癌术后乳糜胸疗效确切。