Appraisal of resection and end-to-end anastomosis for repair of coarctation of the aorta in infancy: preference for resection

Between 1973 and 1987, 70 consecutive infants under-went repair of coarctation of the aorta. Age at operation was 80.0 +/- 77 days (mean +/- standard deviation); mean weight was 3.0 +/- 0.5 kg. Isolated coarctation was present in 25 patients (group 1); in 19 patients coarctation existed in association with ventricular septal defect (group 2); and in 26 patients coarctation was associated with major intracardiac defects (group 3). Subclavian flap angioplasty was performed in 19 patients and resection and end-to-end anastomosis in 51 patients. Hospital mortality was not significantly different between subclavian flap angioplasty (11%) and resection and end-to-end anastomosis (24%). Freedom from reintervention for recoarctation after 5 years was 87% in the subclavian flap angioplasty group and 95% in the group having resection and end-to-end anastomosis. Actuarial survival at 5 years was 100% for group 1, 73% for group 2, and 28% for group 3. In the subclavian flap angioplasty group, we observed detrimental effects of the sacrifice of the left subclavian artery: 1 patient had a 2.5-cm shortening of the left upper arm, and 5 others complained of claudication in the left upper limb during strenuous exercise. As no major advantage in terms of mortality and recoarctation to either technique of coarctation repair was found, and as subclavian flap angioplasty carries the possible disadvantage of late contracture of isthmic ductal tissue and possible detrimental effects on the left upper limb, resection and end-to-end anastomosis is recommended.     

Choice of the method in the surgical treatment of cancer of the thoracic part of the esophagus

The optimal approaches to the choice of the surgical treatment of carcinoma of the thoracic esophagus are discussed from analysis of 425 operations. Louis' operation providing for a convenient approach for a rather high resection of the esophagus with one-stage esophagogastric anastomosis is recommended in localization of the tumor in the inferior third of the esophagus. Garlock's operation is indicated only in low localization of the carcinoma (diaphragmatic and supradiaphragmatic segments). In carcinoma of the middle third of the esophagus Dobromyslov-Torek's operation is indicated only for elderly and debilitated patients; in the remaining cases a one-stage intervention (Louis' operation) is recommended. An original modification of esophagogastric anastomosis is suggested.     

早期低位直肠癌经腹肛门拖出切除双吻合器吻合的临床应用

目的 总结分析早期低位直肠癌经腹肛门拖出切除双吻合器吻合I临床应用的经验体会.方法 对2001年5月至2008年3月25例早期低位直肠癌采用经腹直肠游离,远端直肠腔内翻转经肛门拖出、直视下切除,双吻合器吻合.其中男性17例,女性8例,平均年龄45岁(26～57岁).肿瘤下缘距齿线的平均距离为(3.2 ±0.5)cm(2.0～4.5 cm),肿瘤平均最大直径为(2.8±0.8)cm(2.0～3.5 cm).结果 肿瘤下缘距切缘的平均距离为(1. 5±0.4)cm(1.1～2.2 cm),切缘肿瘤均阴性.吻合口位于齿状线以上18例,距离0.3～2.1 cm[(1.7±0.2)cm],7例吻合口位于齿状线以下0.1～0.5 cm(平均0.3 cm).一例术后吻合口漏,保守治疗愈合.术后随访6～62个月(平均32个月),局部复发1例(4.0%),远处肝脏转移3例(12.0%);肺部转移2例(8.0%).轻度大便失禁7例.结论 对于早期低位早期直肠癌的切除,与经腹在盆腔内离断相比,将直肠经肛门翻出在直视下离断可以更准确地把握切断的位置,既保证安全的切除距离,又尽可能地多保留远端直肠,保留控便功能.     

经腹肛直肠拉出切除吻合术的应用(附70例报告)

在70例中低位直肠癌行保留肛门的直肠癌根治术患者中,肿瘤下缘距肛缘5～8cm,术后吻合口距齿线0～3cm,认为癌肿距肛缘≥5cm,肿瘤分化程度较高、无远处转移及周围浸润,行保肛手术是可行的。术中应充分游离乙状结肠及降结肠中下段,注意保证血运,直肠分离至尽量低位,将直肠及乙状结肠拉出于肛门外边切边缘,或切断后拉出吻合,注意斜口吻合。强调术中病理检查及吻合口缝合技术的重要性,提出并发症的预防措施。     

腹腔镜全胃切除术后食管空肠侧侧吻合术12例

目的总结腹腔镜全胃切除术后食管空肠重建的方法。方法总结分析自2006年2．10月间对12例胃癌患者采用腹腔镜直线切割器成功施行食管空肠侧侧吻合术的临床资料。结果全组患者吻合过程均顺利，手术时间（247．0±13．1）min，其中吻合耗时（43．5±10．4）min，术中出血量（107．5±44．9）ml，吻合121距肿瘤近端距离（3．4±1．2）cm，残端均无癌残留。无手术死亡及吻合口瘘发生，术后短期随访无吻合口狭窄。结论腹腔镜食管空肠侧侧吻合法是腹腔镜全胃切除后一种简单、安全、经济的消化道重建吻合方式。     

Partial median sternotomy: anterior approach to the upper thoracic esophagus

Based upon experience with cervicothoracic esophageal carcinomas in which resection of the manubrium, adjacent clavicles, and ribs has facilitated exposure of the tumor, it has been found that a partial upper sternal split (without resection) provides access to the upper thoracic esophagus to the level of the carina. With a knowledge of the anatomic relationships of the esophagus in this area, this direct anterior approach has been used for both benign and selected malignant diseases involving the upper thoracic esophagus. A partial median sternotomy has been used in 11 patients with the following esophageal pathology: upper- and/or middle-third malignancy (six), benign upper-third stricture (three), perforation of upper-third esophagogastric anastomotic stricture (one), and cricopharyngeal achalasia in association with a chronic cervical compression fracture that prevented extension of the neck (one). The following operations were performed: blunt esophagectomy with cervical esophagogastric anastomosis (six), segmental esophageal resection with primary anastomosis (three), drainage of perforation (one), and extended cervical esophagomyotomy (one). A chylothorax developed in one patient with carcinoma, the only major postoperative complication in this group. Transient hoarseness occurred in two patients. Careful evaluation of the patient with upper thoracic esophageal pathology, focusing on the type, extent, and location of the abnormality relative to the level of the carina, as well as the habitus of the patient, often indicates that a partial sternotomy can be utilized to facilitate the operation.     

Diagnosis and surgical treatment of reflux esophagitis]

Operations were performed on 192 patients with reflux esophagitis, 23 of them had peptic stricture of the esophagus. Esophago-fundoplication was the main operation. Nissen's (106), Tupe (47), Belsi's (3), Dor's (5), and atypical methods were applied. Whenever indicated it was supplemented by crurorhaphy, SPV, pylorotomy, correction of the duodenal junction, etc. Resection of the esophagus (19) was performed with one-stage esophagoplasty by means of the stomach through a left thoracoabdominal approach (14), the whole stomach passed through the posterior mediastinum from an abdomino-cervical approach (2) and the whole stomach with Lewis' intrathoracic anastomosis (3). Distal gastric resection was carried out in 6 and other operations in 3 patients. The mortality was 1%. Reoperations were performed in 5 patients. The results were good in 81.2% of cases. The tactics is individualized according to the presence or absence of a stricture, its length, and localization of the upper border.     

Anastomotic complications after esophagectomy for cancer. A comparison of neck and chest anastomoses.

Leakage, tumor recurrence, and stricture formation at the anastomosis are serious problems after esophagectomy for cancer of the esophagus or cardia. Because the prevalence of these postoperative complications may be affected by whether an anastomosis is made in the neck or in the chest, a comparison was made between anastomoses made at these two sites. During a period of some 7 years, we studied prospectively 411 patients who underwent resection for cancer of the esophagus or cardia and, after immediate reconstruction, had an anastomosis made in the neck or chest. The anastomotic leak rate for the neck anastomosis group was 4.3% and for the chest anastomosis group, 3.7% (p = not significant). The difference between leak rates of anastomoses fashioned by hand-sewn (5.0%) or stapled (3.0%) techniques was also not significant. The median upper resection margins in the neck and chest anastomosis groups were 4.5 cm and 3.5 cm, respectively. The corresponding rates of anastomotic tumor recurrence were 6.1% and 8.1% (p = not significant). The prevalence of benign stricture formation was significantly higher in the chest anastomosis group (19.2%) than in the neck anastomosis group (9.0%) (p = 0.002). This difference was a reflection of a significantly increased prevalence of stricture formation when an anastomosis was made by the stapler technique than with the hand-sewn method, and whereas most of the anastomoses in the neck were hand sewn (90%) the majority of those in the chest were stapled (80%). There were thus no statistically significant differences between the sites in terms of anastomotic leak and tumor recurrence rates, and the higher stricture rate in the chest anastomosis group was the result of more stapled anastomoses.     

食管破裂诊断及外科手术方式的选择——附36例临床分析

目的探讨食管破裂的诊断与手术方式。方法 1980-01—2012-06间共收治36例食管破裂与穿孔患者。保守治疗2例,手术治疗34例。单纯食管破裂修补术、食管破裂修补加肋间肌瓣、膈肌瓣、带蒂大网膜覆盖破裂口8例;破裂食管切除、Ⅰ期食管胃胸内或颈部吻合术3例;纵膈引流、胸腔引流或食管"T"管引流加空肠造瘘6例;食管旷置或颈部食管造瘘,加纵膈、胸腔引流及空肠造瘘,Ⅱ期消化道重建2例,其中1例为经胸骨后管状胃与颈部食管吻合;颈部食管旁切开引流术及食管支架置入术各1例。贲门失弛缓症、食管癌、食管癌术后吻合口狭窄扩张或支架置入时破裂5例:姑息性食管癌切除、吻合口狭窄部切除再游离胃行颈部吻合术4例,食管破裂修补术加破裂食管对侧Heller手术1例。合并多发性肋骨骨折肺深部裂伤、脾破裂胃破裂、车祸胸部贯通伤伴胸壁皮肤Ⅱ度烧伤各1例:行肺裂伤修补,胸腹联合切口行脾切除胃破裂修补术加胃空肠造瘘,1例伤后6d,确诊食管破裂,行食管破裂修补及肋间肌瓣加固。1例食管异物40 d,致食管-主动脉瘘(AEF),左心转流下阻断主动脉,修补主动脉破口,切除胸段食管行颈部食管胃吻合,获成功。食管胸中段化学性烧伤致穿孔1例,I期行胸段食管切除食管胃颈部吻合术。食管破裂修补术后再瘘3例:行胸腔廓清、上下胸腔引流及空肠造瘘。结果治愈27例,其中3例并吻合口狭窄,经扩张后好转。死亡9例。结论选择合理方式治疗食管破裂至关重要。要综合考虑食管破裂的原因、部位、时间、大小、原发疾病、并发症、纵隔及胸腔感染情况。     

Results of simultaneous resection and plastic surgery of the esophagus with extra-cavitary cervical esophagostomy in esophageal cancer in its thoracic part

The work analyses the results of one-stage resection and plastics of the esophagus with a tube formed from the greater curvature of the stomach and creation of an ++extra-cavitary anastomosis on the neck in combined and surgical treatment of carcinoma of the thoracic esophagus in 279 patients. Various complications occurred in 181 (64.8%) patients. The mortality was 19.3% (16.8% among patients who underwent radical operation and 25.6% among those treated by a palliative operation). The number of complications in the groups of surgical and combined treatment was approximately equal. The results of 5-year survival were better in the group with combined treatment. Postponed + extra-cavitary anastomosis was formed in 65.2% of cases. One-stage resection and plastics of the esophagus with ++extra-cavitary anastomosis is an adequate operation from the oncological standpoint in the treatment of carcinoma of the thoracic esophagus. Its further perfection is necessary for improvement of the immediate and late-term results of treatment.     

Magnetic resonance imaging predicts sphincter invasion of low rectal cancer and influences selection of operation

BACKGROUND: With the development of numerous sphincter-saving surgical techniques in the last 2 decades, the indication for abdominoperineal resection in radical-elective operations has been markedly reduced. The preoperative assessment of the extent of local tumor growth is essential for the planning of the optimal surgical procedure. Magnetic resonance imaging (MRI) proved to be a reliable method for local staging of low rectal carcinoma. The objective of this study was to determine the frequency of sphincter invasion in an unselected population with low rectal cancer. METHODS: From 1997 to 1999, 40 patients with histologically verified adenocarcinoma of the lower rectum (+/-5 cm above the linea dentata) without evidence of metastases underwent a MRI with a body coil (no anal endocoil). The MRI results were compared with the operative situs and with pathohistologic findings. RESULTS: An infiltration of the sphincter ani internus was observed in 11 cases (28%), and a combined infiltration of the sphincter ani internus and externus was found in 2 patients (5%). The median distance of the lower tumor edge to the upper border of the anal canal was 2.0 cm (range, 0-4.5 cm). No infiltration of the external sphincter was observed in patients with cancers above the anal canal. Nine patients (22%) were treated with intersphincteric resection and coloanal anastomosis, 12 (30%) with ultralow resection, and 11 (28%) with low anterior resection of the rectum in conjunction with coloanal anastomosis or a stapled anastomosis. Eight (17%) of the patients were treated with abdominoperineal resection. CONCLUSION: An infiltration of the internal sphincter occurs only in 28% of low rectal cancers; an infiltration of the external anal sphincter is extremely rare and occurred only in patients with cancers located in the anal canal. Pelvic MRI offers a precise preoperative visualization of sphincter infiltration in patients with low rectal cancers and is therefore a valuable tool for planning of rectal surgery.     

Increased brain tumor resection using fluorescence image guidance in a preclinical model

BACKGROUND AND OBJECTIVES: Fluorescence image-guided brain tumor resection is thought to assist neurosurgeons by visualizing those tumor margins that merge imperceptibly into normal brain tissue and, hence, are difficult to identify. We compared resection completeness and residual tumor, determined by histopathology, after white light resection (WLR) using an operating microscope versus additional fluorescence guided resection (FGR). STUDY DESIGN/MATERIALS AND METHODS: We employed an intracranial VX2 tumor in a preclinical rabbit model and a fluorescence imaging/spectroscopy system, exciting and detecting the fluorescence of protoporphyrin IX (PpIX) induced endogenously by administering 5-aminolevulinic acid (ALA) at 4 hours before surgery. RESULTS: Using FGR in addition to WLR significantly increased resection completeness by a factor 1.4 from 68+/-38 to 98+/-3.5%, and decreased the amount of residual tumor post-resection by a factor 16 from 32+/-38 to 2.0+/-3.5% of the initial tumor volume. CONCLUSIONS: Additional FGR increased completeness of resection and enabled more consistent resections between cases.     

Resection for advanced cancer of the thoracic esophagus: cervical or thoracic anastomosis? Late results of a prospective randomized study.

During a 2 1/2-year period, 60 consecutive patients with cancer of the thoracic esophagus were randomized to undergo a cervical or thoracic anastomosis. The tumors were staged postoperatively (stage I, n = 2; stage II, n = 19; stage III, n = 9; and stage IV, n = 30) and were almost equally distributed between the two groups. The upper limit of three tumors was above the convexity of the aortic arch. The esophageal specimens were studied with regard to measurements of the tumor and of the resected esophagus. The microscopic aspects were evaluated by serial sections after vital staining. The prevalence of ignored plurifocal cancers, of submucosal infiltrations, and of distant areas of dysplasia in both groups was confirmed. Malignant invasions of esophageal sections were more frequent in patients undergoing thoracic anastomosis (10 versus 3), and diseased upper mediastinal lymph nodes were more frequent in those undergoing cervical anastomosis (17 versus 7). Mortality was equally divided between the two groups. Respiratory complications and recurrent laryngeal trauma were more frequent in patients having cervical anastomosis. Long-term survivors had stage N0 disease, with a healthy esophageal section. Even though subtotal esophagectomy reduces the prevalence of microscopic esophageal wall invasion above the tumor and allows more complete unilateral exploration and resection of invaded lymph nodes, it offers no significant benefit concerning survival of patients with advanced cancer and malignant lymphadenopathy.     

Laparoscopy-assisted D2 subtotal gastrectomy in early gastric cancer

The purpose of this study is to prove the safety and efficacy of laparoscopy-assisted subtotal gastrectomy and D2 lymph node dissection using 4 ports and an EEA stapler with a Billroth I anastomosis. From 1999 to 2001, 20 patients with EGC located in the distal stomach underwent laparoscopy-assisted Billroth I gastrectomy (LABIG). A 4-port-technique was performed for omentectomy, vascular ligation, and D2 lymph node dissection. A mini-incision was created between the two ports in the epigastric area and a gastroduodenal anastomosis with an EEA stapler and a distal resection was performed. The mean operating time was 261.8 (170-410) minutes. There was one postoperative complication without any intraoperative transfusions or perioperative mortality. The number of harvested nodes was 31.9 +/- 11.4. Mean distance from the lesion to the margin of resection was 5.3 +/- 2.2 cm proximally and 4.0 +/- 2.0 cm distally. On average, oral liquids were started at the 4.7th (3rd-8th) postoperative day. LABIG is a safe and effective way of performing D2 gastrectomy in terms of morbidity and oncological principles. A randomized controlled clinical study to compare long-term survival and quality of life is warranted.     

A case of lung cancer underwent carinal resection with right upper lobectomy and carinal reconstruction with double-barreled anastomosis

A 70-year-old male complaining cough was admitted to our hospital. Bronchoscopic examination revealed a tumor mass which occluded the orifice of the right upper lobe. Chest computed tomographic (CT) scans gave the image of tumor invasion at the carina. The pathological diagnosis of the tumor was squamous cell carcinoma. Operation was accomplished by right posterolateral thoracotomy approach through the fifth rib bed. The carinal resection with right upper lobectomy was followed by a double-barreled anastomosis of the right intermediate trunk and left main-stem bronchus into the carina. The operation was successfully performed and was considered curative. The length of resected airway measured 4.0 cm from tracheal line of resection to the divided the right intermediate trunk. Reinforcement of the anastomosis was not performed in this case. No postoperative complication occurred but mild ischemia of the anastomosis. The patient died of recurrent tumor in a year and 2 months after operation.     

The cricoid cartilage and the esophagus are not aligned in close to half of adult patients

PURPOSE: To determine the frequency and degree of lateral displacement of the esophagus relative to the cricoid cartilage ("cricoid") using computed tomography (CT) images of normal necks. METHODS: Fifty-one cervical CT scans of clinically normal patients were reviewed retrospectively. Esophageal diameter, distance between the midline of the cricoid and the midline of the esophagus, and distance between the lateral border of the cricoid and the lateral border of the esophagus were measured. RESULTS: Lateral esophageal displacement was observed in 49% (25/51) of CT images. When present, the mean length of displaced esophagus relative to the midline of the cricoid was 3.3 mm +/- SD 1.3 mm. Of those with lateral displacement, 64% had esophageal displacement beyond the lateral border of the cricoid (mean 3.2 mm +/- SD 1.2 mm). There is a relatively normal distribution of the grouped measures of percentage of esophageal diameter that is displaced. Of those with displacement, 48% had over 15% of the total width of the esophagus displaced laterally and 20% had over 20% of the esophageal width displaced laterally. CONCLUSION: There is a 49% frequency of some degree of lateral displacement of the esophagus relative to the cricoid.     

Results of colo-anal anastomosis in deep-seated tumors of the rectum

Colo-anal anastomosis as surgical procedure for low rectal tumors was analysed in regard of complication rate, functional and oncological results. The sensibility of the method particularly in tumors near the anal sphincters, was assessed by means of a new radiological procedure (lateral distant view). From 1982 to 1985 colo-anal anastomosis was performed in 30 patients with rectal carcinoma. All tumors were within reach of the palpating finger. Tumor distance from the anal verge was measured endoscopically (6.4 +/- 1.5 cm) and radiologically (9.3 +/- 1.7 cm) (x +/- SD). The complication rate was comparable to that after anterior resection with conventional anastomosis. Inspite of problems with high frequency in the first months after surgery, all patients were satisfied with the functional result of the operation. Frequency decreased within a year to 4 stools/day. At present a reliable evaluation of the oncological results cannot yet be established.     

Shrinkage of the esophagus after resection for carcinoma.

The purpose of this study was to document and quantitate the degree of shrinkage of resection margins of the esophagus following extirpation for carcinoma. Measurements were made at operation before the esophagus was removed (in-situ), when the removed specimen had been stretched maximally (stretched), with the specimen lying free (contracted), and after fixation (fixed). After resection, there was substantial shrinkage of the margins, and the upper margins underwent a greater degree of shrinkage than the lower margins, with the tumor changing little in length. In the contracted state before fixation, the upper and lower margins were reduced to 44% and 54% of their in-situ lengths, respectively; after fixation, they were 32% and 39%, respectively. Even after maximal stretching, only 73% of the upper and 89% of the lower in-situ resection margins were restored. The overall shrinkage for the whole specimen after fixation was 50%. It is concluded that there is considerable shrinkage of the resection margins in the esophagus from the time of operation to fixation, and this accounts for the discrepancy claimed by surgeons and pathologists regarding the length of the margins. This finding has relevance in the extrapolation of surgical resection margins from pathological specimens.     

Y Roux anastomosis of small intestine in gastrectomy and esophagectomy

A clutch-like method of esophagojejunal anastomosis on the excluded by the Roux method loop of the small intestine was worked out in experiments on 80 corpses of humans. It was found that the anastomosis should be made at a distance of 3.2 +/- 0.48 cm (two diameters of the patient's esophagus) from the tightly sutured part of the small intestine. In the clinic there were no cases of incompetence of the anastomosis sutures in 86 gastric cancer patients aged from 31 to 71 years (81 gastrectomies and 5 extirpations of the gastric stump). Two patients died (2.3%). The follow-up of the patients during 1-10 years after operation has found that mild reflux-esophagitis developed in 6.1% of the patients, average degree--in 2.04%. No cicatricial strictures of the anastomosis were revealed. The method was used in 6 patients in gastroplasty after Kupriyanov-Zakharov. The dumping syndrome of mild degree developed in 23.6%, average--in 2.7% of the patients. The anastomosis can be used in gastrectomy as a method of choice in extirpation of the gastric stump.     

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目的　探讨治疗贲门癌的手术新入路及吻合方法。方法　广东省揭阳市人民医院普通外科 1997年1月至 2 0 0 3年 7月经腹切开膈肌脚入路 ,行胃浆肌瓣覆盖 食管胃黏膜吻合 10 3例。结果　全组病例无死亡、无吻合口瘘 ,亦无食管切缘癌残留。术后并发症发生率 4 82 %。结论　经腹切开膈肌脚 ,行胃浆肌瓣覆盖 食管胃黏膜吻合术 ,操作在腹腔进行 ,创伤及生理干扰较小 ;能有效地预防吻合口漏 ;既能切除足够的食管 ,又能扩大淋巴结的清除范围 ,适用于浸润食管长度 <2cm的贲门癌的手术治疗。