Preliminary results of cytotoxic monoclonal antibody treatment in pancreatic adenocarcinomas and biliary tract carcinomas

Fifteen patients with biliopancreatic carcinoma were treated by monoclonal antibodies (12 pancreatic adenocarcinomas, 3 bile duct carcinomas). In 7 cases, a tumor resection was associated with immunotherapy: 5 partial pancreatic resections for stage III and IV disease, according to Hermreck's classification, and 2 biliary resections (Whipple resection for distal duct tumor, biliary and liver resection for proximal bile duct tumor). We use the 17-1.A antibody, an IgG-2a murine monoclonal antibody, either isolated (6 cases) or in association with other monoclonal antibodies (4 cases) or gamma IFN (5 cases). All of these patients underwent leukapheresis. Response to 17-1.A therapy was evaluated by laboratory tests (CA 19-9) and by morphological investigations (US, CT, radioimmunolocalization scanning). The median survival of patients with unresectable pancreatic carcinoma (7 cases), was 7.4 months. For pancreatic adenocarcinoma, treated by resection associated with immunotherapy (5 cases), the median survival was 21 months. Monoclonal antibody therapy was effective in a third of evaluated pancreatic adenocarcinomas (4 clear objective responses) but only transiently except in one patient still alive after 57 months. The low rate of therapeutic responses may been attributed to inadequate doses and the development of human anti-murine antibodies.     

Factors influencing survival after resection for periampullary neoplasms

BACKGROUND: The purpose of this study was to determine predictors of survival after resection for periampullary neoplasms. METHODS: Over a 15-year period, 208 patients underwent laparotomy for periampullary neoplasms. Data were analyzed to assess predictors of survival. RESULTS: Pathologic examination showed pancreatic cancer (n = 136; 65%), ampullary cancer (n = 28; 13%), distal common bile duct cancer (n = 10; 5%), duodenal cancer (n = 4; 2%), neuroendocrine tumor (n = 11; 5%), cystadenocarcinoma (n = 4; 2%), cystadenoma (n = 5; 2%), and other (n = 10; 5%). A total of 129 patients underwent pancreatic resection (71 Whipples, 35 total pancreatectomies, 21 distal pancreatectomies, and 2 partial pancreatectomies) whereas 79 patients were found to be unresectable and underwent palliative bypass and/or biopsy. Median survival was 20.4 months for resectable patients versus 4.5 months for unresectable patients (P<0.001). Of the 129 resected patients, factors significantly (P<0.05) favoring long-term survival on univariate analysis included well-differentiated histology, common bile duct or ampullary adenocarcinoma, early stage, tumor diameter <2 cm, negative margins, and absence of lymph node metastases, perineural, or vascular invasion. Age, sex, race, and type of procedure had no influence on survival. On multivariate analysis, only tumor differentiation appeared independently related to survival. Using Kendall's tau analysis, tumor type and grade correlated significantly with all other predictors. CONCLUSIONS: Of all variables studied, tumor type and poor tumor differentiation in periampullary neoplasms appear to be markers that predict a constellation of other adverse findings.     

根治性经尿道电汽化术切除侵犯肌层膀胱肿瘤的疗效评估

目的评估根治性经尿道膀胱肿瘤电汽化术(根治性TUVBT)治疗膀胱肿瘤的中长期疗效. 方法已侵犯肌层的膀胱肿瘤患者39例.采用根治性TUVBT治疗14例,获随访12例,时间34～66个月,平均44.6个月.参照根治性经尿道膀胱肿瘤电切术的手术原则,汽化切除肿瘤至膀胱壁外脂肪层.采用膀胱部分切除术治疗25例,获随访22例,时间30～96个月,平均50.7个月.两组术后常规10-羟基喜树碱膀胱灌注化疗2年. 结果根治性TUVBT组术后肿瘤复发率33.3%(4/12);膀胱部分切除术组复发率31.8%(7/22),死亡率4.5%(1/22).两组比较,差异无显著性意义(P>0.05). 结论对已侵犯肌层的膀胱肿瘤,根治性TUVBT可作为外科治疗的一种选择,尤其适用于年老体弱或不愿意接受根治性膀胱全切术或开放手术者.     

Nonvestibular schwannomas of the brain: a 7-year experience

OBJECTIVE: Nonvestibular schwannomas are uncommon tumors of the brain. Trigeminal nerve schwannomas are the most common of this group, followed by glossopharyngeal, vagal, facial, accessory, hypoglossal, oculomotor, trochlear, and abducens nerve schwannomas, in descending order of frequency. We present a series of nonvestibular schwannomas that were surgically treated during a 7-year period. METHODS: Forty-six patients with schwannomas of Cranial Nerves V (26 cases), VII (7 cases), IX, X, and XI (9 cases), XII (3 cases), and III (1 case) were microsurgically treated by the senior author (LNS) during a 7-year period, from 1993 to 2000. The clinical presentations, operative approaches, complications, and results were studied. RESULTS: Forty-five patients underwent gross total tumor resection in the first operation. One patient who had undergone subtotal tumor resection in the initial operation experienced a large recurrence after 4 years, and gross total tumor resection was achieved in the second operation. There were no postoperative deaths. Postoperative morbidity consisted of cerebrospinal fluid leaks for 5 patients (3 patients required a second operation to repair the leak, and 2 patients responded to lumbar drain placement), meningitis for 3 patients (2 cases were aseptic and 1 involved bacterial meningitis, which resolved with antibiotic therapy), vasospasm requiring angioplasty for 1 patient, temporary hemiparesis for 2 patients (who experienced good recoveries), and permanent hemiparesis for 1 patient. New cranial nerve deficits were observed for 24% of patients but were usually partial. The mean follow-up period was 33.3 months (range, 0.2-93 mo). No patient experienced tumor recurrence after complete tumor removal. The patient who experienced regrowth of the tumor did not exhibit recurrence after the second operation. The Karnofsky Performance Scale scores at the latest follow-up examination were 80 or more for 45 patients (98%) and 70 for 1 patient. CONCLUSION: Nonvestibular schwannomas can be treated via microsurgical excision, with excellent functional results. Recurrence is rare after total tumor excision, although much longer follow-up monitoring is required.     

胆管内乳头状黏液性肿瘤21例临床分析

目的 探讨胆管内乳头状黏液性肿瘤（intraductal papillary mucinous neoplasm of the bile tract， IPMN-B）的临床特点及诊治方法。方法 回顾性分析郴州市第一人民医院2012年1月至2019年6月收治 的21例IPMN-B患者临床资料。结果 21例患者中男4例，女17例，平均年龄（63.0±7.5）岁。临床表现： 腹痛19例，黄疸10例，畏寒发热7例；既往有胆道手术史13例；合并胆管结石14例。患者CA19-9阳性率 38.1%（8/21）， CEA阳性率28.6%（6/21）；术前诊断率33.3%（7/21）。肿瘤位置：位于左肝19例，右肝及胆 总管各1例。手术方式：肝部分切除+胆道探查术18例，肿瘤活检+胆道探查术2例，胰十二指肠切除术1例。 术后病理诊断：腺癌11例，腺瘤10例。本组死亡4例，其中1例因术后1个月并发肝功能衰竭死亡； 2例术 后病情进展，分别于术后8个月及10个月死亡； 1例术后2年复发并发消化道出血死亡。术后复发3例，其 中1例再次手术，2例保守治疗，其余患者顺利康复。结论 IPMN-B患者以老年女性为主，多数合并有胆 道手术史、胆管结石，好发于左肝，术前诊断率低，手术切除是主要治疗手段，预后较好。     

Does the intraoperative peritoneal lavage cytology add prognostic information in patients with potentially curative gastric resection?

Peritoneal recurrence is the foremost pattern of failure after potentially curative resection for gastric cancer. Our aim was to evaluate the prognostic value of intraperitoneal free cancer cells (IFCCs) in peritoneal lavage of patients who underwent potentially curative resection for gastric carcinoma. Two hundred twenty patients with gastric cancer stage I, II, or III were prospectively evaluated with peritoneal lavage and cytologic examination. Aspirated fluid from the abdominal cavity was centrifuged and subjected to Papanicolaou staining. The mean age was 60.9 years (range, 21–89 years), and 63.6% were men. IFCCs were detected in 6.8% of the patients; suspicious in 2.7%, and negative in 84.5%. No judgment could be given in 5.9% of the cases. Invasion of the gastric serosa (pT3) was observed in all positive cytology patients. Patients with IFCCs had a mean survival time of 10.5 months, while those with negative IFCC had a mean survival time of 61 months (P = 0.00001). There was no correlation between the presence of IFCCs and tumor size, histology, pN, or tumor site. Our conclusions are that (1) positive cytology indicates a poor prognosis in patients who underwent potentially curative gastric resection and (2) peritoneal lavage cytology improves staging in assessing these patients and may alter their therapeutic approach.     

成人先天性胆管囊状扩张症的临床分析

目的:探讨成人先天性胆管囊状扩张症的诊断及治疗。方法:回顾性分析1996年1月—2012年5月收治的53例成人先天性胆管囊状扩张症患者的临床资料。结果:53例患者均行手术治疗,Ia,Ib,Ic型39例和II型4例行囊肿完整切除、肝总管空肠Roux-en-Y吻合术,另3例Ia型行囊肿大部分切除、肝总管空肠Roux-en-Y吻合术;IVa型1例行肝左外叶切除、囊肿完整切除、胆管成形、肝总管空肠Roux-en-Y吻合术,另1例行囊肿完整切除、肝总管空肠Roux-en-Y吻合术;V型1例行左肝内胆管囊肿切除术;2例癌变患者,其中1例行癌变囊肿切除、局部转移淋巴结清扫术,1例行囊肿切除、左肝内胆管肿瘤切除术。53例手术患者中获随访42例,随访时间为6个月至3年,良性患者情况良好;2例癌变患者,1例术后生存26个月,死于肿瘤复发,多系统器官功能衰竭,1例术后26个月肿瘤复发,肝转移,再次手术行左半肝切除、S5(第V段肝脏)切除、肝肠吻合术,术后2个月出现肿瘤进展,死于多系统器官功能衰竭。结论:成人先天性胆管囊状扩张症的手术方式选择与治疗效果密切相关,不同的临床分型应选择不同的手术方式。     

Long-term survival after curative resection for pancreatic ductal adenocarcinoma. Clinicopathologic analysis of 5-year survivors.

OBJECTIVE: The authors reviewed the clinicopathologic characteristics of patients who underwent resection with curative intent for ductal adenocarcinoma of the pancreas between 1983 and 1989. SUMMARY BACKGROUND DATA: Recent studies have demonstrated a reduction in the morbidity and mortality of pancreatic resection and improvement in the actuarial 5-year survival for patients with resected ductal adenocarcinoma. METHODS: Resection with curative intent was performed on 118 of 684 patients (17%) with pancreatic cancer admitted to the authors' institution. Clinical, demographic, treatment, and pathologic variables were analyzed. The original material for all cases was reviewed; nonductal cancers were excluded. RESULTS: The head of the gland was the predominant tumor site (n = 102), followed by the body (n = 9), and tail (n = 7). Seventy-two percent of the patients underwent pancreaticoduodenectomies, 15% underwent total pancreatectomies, 10% underwent distal pancreatectomies, and 3% underwent distal subtotal pancreatectomies. Operative mortality was 3.4%. Median survival was 14.3 months after resection compared with 4.9 months if patients did not undergo resection (p < 0.0001). Twelve patients survived 5 years after surgery (10.2% overall actual 5-year survival rate). Three of the tumors were well differentiated, five were moderately differentiated, and four were poorly differentiated. Extrapancreatic invasion occurred in nine cases (75%), and perineural invasion was present in ten cases (83%). Five tumors exhibited invasion of duodenum, ampulla of Vater, and/or common bile duct, and an additional tumor invaded the portal vein. Lymph node involvement by carcinoma was noted in five cases (42%). Six patients remain alive without evidence of disease at a median follow-up of 101 months (range, 82-133 months). Five patients died of recurrent or metastatic pancreatic cancer at 60, 61, 62, 64, and 64 months, respectively. One patient died at 84 months of metastatic lung cancer without evidence of recurrent pancreatic disease. CONCLUSIONS: This paper emphasizes the grim prognosis of pancreatic ductal adenocarcinoma. Five-year survival cannot be equated to cure. Although pancreatectomy offers the only chance for long-term survival, it should be considered as the best palliative procedure currently available for the majority of patients. This emphasizes the need for the development of novel and effective adjuvant therapies for this disease.     

Gastroduodenostomy after gastric resection for cancer.

Gastrojejunostomy after resection for gastric cancer has been associated with a variety of complications, including bile reflux gastritis, marginal ulcers, and afferent loop syndrome. Gastroduodenostomy, although more physiologic, has not been recommended because of the fear of obstruction due to tumor recurrence. A review of 62 patients with gastric adenocarcinoma who underwent gastric resection from 1986 to 1996 was performed. Of the 62 patients, 52 (83%) underwent subtotal gastric resection and 10 (17%) underwent total gastrectomy with Roux-en-Y reconstruction due to tumor location. Forty-seven (90%) of the 52 patients underwent gastroduodenostomy, and 5 (10%) of these patients underwent gastrojejunostomy due to operative findings of excessive tumor burden or the inability to create a safe tension-free anastomosis. Patients who underwent gastroduodenostomies were followed for a period of 6 months to 5 years and had a median survival of 2.5 years. Two (4.2%) of the 47 patients obstructed due to tumor recurrence at 2 and 4 years postoperatively. One patient (2%) had symptomatic bile reflux gastritis, which was treated conservatively without reoperation. There were no incidences of marginal ulcers. In conclusion, gastroduodenostomy should be considered for patients undergoing resection for gastric cancer due to its physiological benefits and acceptable rate of obstruction.     

肝细胞肝癌经肝动脉化疗栓塞联合索拉非尼降期后二期切除的初步报告

目的探讨不可一期切除肝细胞肝癌(hepatocellular carcinoma,HCC)经导管肝动脉化疗栓塞(transcatheter hepatic arterial chemoembolization,TACE)联合索拉非尼(Sorafenib)降期治疗后,二期再行根治性切除的可行性。方法回顾性分析2010年3月至2015年1月在南方医科大学南方医院肝胆外科经TACE及口服分子靶向药物索拉非尼治疗、成功降期后再行二期切除的21例HCC病人的临床资料。该组病人平均年龄45.5岁(20~67岁),肝切除手术后持续服用索拉非尼。结果该组病人经TACE联合口服索拉非尼成功降期,降期治疗所需时间平均为52.3 d。降期后实施左、右半肝切除分别为5例和3例,扩大左半肝切除1例,扩大右半肝切除1例,肝脏区段切除11例。术中平均出血量为356.3 ml(150~1 200 ml),平均手术时间为243.3 min(145~365 min)。经过12~62个月随访(中位随访时间为30.1个月),1、2、3年的无瘤存活率分别为76.2%、52.4%、43.6%,复发后病人再次接受TACE、放疗、射频消融等综合治疗者5例,接受再次手术切除的病人3例,1、2、3年总生存率分别为85.7%、71.4%、57.1%。结论 TACE联合口服索拉非尼全身治疗,可使部分初期不可切除肝癌成功降期,降期后接受外科根治性切除手术,初步效果令人鼓舞。     

Carcinoma of the distal and middle bile duct: surgical results, prognostic factors, and long-term follow-up

BACKGROUND/PURPOSE: Carcinoma of the distal bile duct is associated with poor prognosis. Surgical resection remains the only potentially curative treatment. We conducted a retrospective study to identify prognostic factors determining longterm survival. METHODS: From 1990 to 2006, 95 patients with distal and/or middle bile duct carcinoma had resections. Fifty-four patients underwent pylorus-preserving pancreaticoduodenectomy (57%) and 41 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (43%). Nine patients underwent pancreaticoduodenectomy including portal vein resection (9%). RESULTS: Overall 1-, 3-, and 5-year survival rates were 60%, 36%, and 29%, respectively. Five-year survival after R0 resection was 34%, and after R1 resection it was 0%. Four patients died during their hospital stay (4%). Multivariate analysis showed negative resection margins (P = 0.040), lymphatic vessel invasion (P = 0.036), and portal vein infiltration (P = 0.027) as strong predictors for survival, whereas the location of the tumor (distal bile duct vs middle bile duct) and lymph node status were not identified as independent prognostic factors. CONCLUSIONS: Five-year survival depends strongly on negative resection margins, independent of nodal status. Portal vein resections in patients with portal vein involvement fail to ameliorate long-term survival. Primary tumor site--middle bile duct or distal bile duct--did not determine prognosis.     

87例意外胆囊癌多中心诊疗分析

目的 分析多中心意外胆囊癌（IGBC）病例治疗现状,探讨IGBC的诊断与治疗要点。方法回顾性分析2013年1月至2020年6月上海市浦东新区6家医院收治的87例IGBC患者临床资料,男27例（31.03%）,女60例（68.97%）;年龄34～89岁,平均68岁。术前诊断为胆囊结石伴胆囊炎67例,其中合并胆总管结石9例;胆囊息肉4例;胆囊腺肌症5例;胆囊结石合并胆囊息肉8例;慢性胆囊炎2例。术前87例患者均行B超检查;26例行CT检查,其中6例发现胆囊壁局部或不规则增厚;术前行肿瘤标志物检测52例,CA199升高7例（67～238 kU/L）。结果 同期6家医院行腹腔镜胆囊切除术（LC）16 411例,IGBC占比0.53%;同期胆囊癌根治术219例,IGBC占比39.73%。87例IGBC中,急诊LC 25例（28.74%）,择期LC62例（71.26%）;术中冰冻病理发现IGBC 70例,术后常规病理发现IGBC 17例;行胆囊癌根治术65例,未行根治术22例。术后病理检查,Tis期15例,T1期20例,T2期28例,T3期22例,T4期2例。45例获得随访,随访时间3～96个月,中位时间26个月。T分期越早,生存期越长（P=0.01039）,根治性手术明显改善患者的生存期（P=0.00423）。结论 意外胆囊癌应从胆囊良性疾病的规范化诊治角度入手防治,才能减少其发生;根治手术能提高意外胆囊癌患者术后的生存期。     

肝部分切除联合肝十二指肠韧带骨骼化治疗肝门部胆管癌

目的 总结应用肝部分切除联合肝十二指肠骨骼化治疗肝门部胆管癌的临床经验。方法回顾1999年1月～2001年12月手术治疗67例肝门胆管癌的临床资料。结果67例患者中65例手术切除,49例根治性切除(22例肝十二指肠韧带骨骼化切除,27例联合部分肝切除)。根据Bismuth分型,Ⅰ、Ⅱ型行骨骼化切除,Ⅲa型行右半肝加右尾叶切除,Ⅲb型行左半肝加左尾叶切除,Ⅳ型中行右半肝加全尾叶3例切除,左半肝加全尾叶9例切除,方叶切除者2例。2例外院曾行部分肿瘤切除加肝门胆管空肠吻合术者,我们再次行左半肝加全尾叶切除加右肝管空肠吻合术根治肿瘤。8例患者行肿瘤部分切除加肝内胆管支撑加肝门胆管空肠吻合。13例患者行门静脉部分切除,27例患者切除肝动脉。24例患者术后无并发症发生,加例发生了严重并发症。后者中14例经治疗后康复,余6例患者术后7、12、14、42、57、89d死于肝功能衰竭、心源性休克、腹内大出血、消化道大出血。术后30d病死率4、5％,根治性手术后患者中位生存期16个月(1个月～41个月),姑息治疗者为7个月(1个月～16个月)。结论 肝部分切除联合肝十二指肠韧带骨骼化可用以根治肝门部胆管癌,尾叶切除可提高根治性切除率。     

Gallbladder Cancer with Duodenal Infiltration: Is it still resectable?

Objective To assess the resectability and the long-term survival in patients of gallbladder cancer with duodenal involvement. Background Duodenal infiltration in patients of carcinoma gallbladder is generally regarded as a sign of advanced disease and an indicator of unresectable disease. Methods A total of 252 patients of gallbladder cancer (GBC) who underwent surgery over a 5-year period were studied for duodenal involvement. Patients with duodenal infiltration on per-operative assessment were analyzed for resectability, postoperative morbidity, mortality and disease free survival. Results Forty-three patients were detected to have duodenal infiltration on per-operative assessment out of which 17 had unresectable disease (39.54%), whereas the remaining 26 patients underwent R0 resection (61.9%). Of these, nine underwent distal gastrectomy with resection of the first part of the duodenum (34.62%), 16 underwent duodenal sleeve resection (61.54%), and in one patient pancreatoduodenectomy (HPD) (3.85%) was performed. With regard to the extent of liver resection, two underwent extended right hepatectomy, whereas the remaining 24 underwent segment IVB and V resection. Bile duct and adjacent viscera were resected when involved. Of the resected patients, eight underwent bile duct excision, seven had colonic resection, and three had vascular resection and reconstruction. The postoperative morbidity and mortality was 15 (34.9%) and three (6.97%), respectively, in the resected group of patients. The overall actual survival in the resected group was a mean of 15.87 months, median of 14 months (range 3 to 56 months). Conclusion Duodenal infiltration is neither an indicator of unresectability nor an indication to perform Hepato-pancreatoduodenectomy (HPD). In most of these patients, an oncologically adequate R0 resection can be performed with either a duodenal sleeve resection or distal gastrectomy with resection of the first part of the duodenum.     

Management strategies in resection for hilar cholangiocarcinoma.

Between 1960 and 1990, resection was performed in 23 of 122 patients who underwent surgical treatment for hilar cholangiocarcinoma. Local excision of the lesion alone was performed in 10 cases (43%). Hepatic resection for tumor extending to the secondary bile ducts or hepatic parenchyma was performed in 13 cases (57%): extended right hepatectomy (3), right hepatectomy (1), extended left hepatectomy (6), left hepatectomy (2), and left lobectectomy (1). In three other cases, resection by total hepatectomy and liver transplantation was performed, but these were not included in the analysis of results for resection. Significant operative complications occurred in only two cases (8.7%), and the operative mortality rate was zero. In four cases, complete excision of the tumor could not be achieved macroscopically (macroscopic curative resection rate 19/122; 15.6%). In nine cases, the margins of the resected specimens were free from tumor on histologic examination (microscopic curative resection rate, 9/122; 7.4%). In 10 cases, the resection margins were found to contain tumor on histologic examination. The overall survival rate was 87% at 1 year, 63% at 2 years, and 25% at 3 years (median survival, 24 months). The survival and freedom from recurrence rates for patients with free resection margins was superior to that for patients with involved resection margins or residual macroscopic disease. A potentially curative resection, with histologically negative margins and no recurrence to date, was achieved in seven patients using the following procedures: local excision for two type I lesions; left hepatectomy plus excision of segment 1 for two type IIIb lesions and one type IV lesion; right hepatectomy and right hepatectomy plus excision of segment 1 for two type IIIa lesions. These results indicate that improved survival in hilar cholangiocarcinoma can be achieved by resection, with minimal morbidity and zero mortality rates, if histologically free resection margins are obtained. To achieve this, we recommend the following procedures for each type of lesion, based on our experience and on anatomic considerations: local excision for type I; local excision plus resection of segment 1 for type II; local excision, resection of segment 1, and right or left hepatectomy for types IIIa and b; hepatectomy plus liver transplantation for type IV.     

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。     

肝门部胆管癌192例外科治疗及疗效分析

目的 探讨肝门部胆管癌的诊断方法和外科治疗的疗效。方法 对１９８４年至１９９９年收治的１９２例肝门部胆管癌的临床特点,诊断,手术方式和随访结果进行回顾分析。结果 本组ＭＲＣＰ对肝门部肿物显示率１００％（４４／４４）。１５３例行手术治疗,其中探查术１０例,内、外引流术８８例,均于术后３－１５个月死亡。切除术５３例,全肝切除原位肝移植术２例。手术切除率为３６.０％（５５／１５３）,行根治性切除３８例,中位生存期为３１个月,姑息性切除１７例,中位生存期为１３个月。结论 ＭＲＣＰ可以确定肝门部胆管癌病变部位及范围。术中胆道切断端应行冰冻病理检查。经根治切除术可显著延长患者生存期和改善生存质量。对于ＢismuthⅢ型、Ⅳ型无肝外转移者,行全肝切除、肝移植术不失为一种有效的治疗方法。     

Leiomyosarcoma of the inferior vena cava: experience in 22 cases

From 1979 to 2004, 22 patients were seen with leiomyosarcomas of the inferior vena cava (IVC). Twenty were treated surgically. Involvement of the IVC included the infrarenal segment in 3 cases, the suprarenal and/or retrohepatic segment in 13, and the suprahepatic segment in 4. Nineteen patients underwent wide tumor resection followed by ligation of the IVC in 5 cases, replacement with a PTFE prosthesis in 13, and cavoplasty in 1. An intracardiac tumor extension was resected during hypothermic circulatory arrest in 1 patient. Vascular exclusion of the liver was used in 5 cases and simple clamping of the IVC in 13 cases. There were 1 intraoperative death due to cardiac failure and 3 postoperative deaths due to multiple organ failure, liver failure, and duodenal fistula after treatment of a bleeding ulcer. Fifteen of the 16 surviving patients underwent adjuvant chemotherapy associated with radiation therapy in 4 cases. One patient was lost from follow-up at 10 months. Four patients including one with metastasis are still alive with a mean follow-up of 18.3 months. Eleven patients died after a mean follow-up period of 43.7 months due to local recurrence and/or distant metastasis in 9 cases and complications of chemotherapy in 2. The 3- and 5-year mean actuarial survival rates in patients who underwent resection were 52.0% and 34.8%, respectively. Leiomyosarcoma of the IVC is a serious disease. Although surgical resection combined with chemotherapy is usually not curative, it can achieve reasonably long-term survival. We recommend aggressive operative management using the latest vascular surgery and oncology techniques.     

Surgical approach to bismuth Type I and II hilar cholangiocarcinomas: audit of 54 consecutive cases

OBJECTIVE: To clarify the optimal surgical strategy for Bismuth type I and II hilar cholangiocarcinomas. SUMMARY BACKGROUND DATA: Local or hilar resections is often performed for Bismuth type I and II tumors; however, reported outcomes have been unsatisfactory with a high recurrence and low survival rate. To improve survival, some authors have recommended right hepatectomy. However, the clinical value of this approach has not been validated. METHODS: Records of 54 consecutive patients who underwent resection of a Bismuth type I or II hilar cholangiocarcinoma were analyzed retrospectively. Through 1996, bile duct resection or the smallest necessary hepatic segmentectomy was performed. Beginning in 1997, choice of resection was based on the cholangiographic tumor type. For nodular or infiltrating tumor, right hepatectomy was indicated; for papillary tumor, bile duct resection with or without limited hepatectomy was chosen. RESULTS: Right hepatectomy was performed in 5 (20.8%) of 24 patients through 1996 and was done in 22 (73.3%) of 30 patients from 1997 (P = 0.0003). In patients without pM1 disease, R0 resection was achieved more frequently in the later period than in the earlier period (23 of 24 = 95.8% vs. 13 of 21 = 61.9%, P = 0.0073), which lead to better survival (5-year survival, 44.3% vs. 25.0%, P = 0.0495). In the 31 patients with nodular or infiltrating tumor, who tolerated surgery and did not have pM1 disease, survival was better in the 18 patients who underwent right hepatectomy than in those who did not (5-year survival, 62.9% vs. 23.1%, P = 0.0030). In cases of papillary tumor, bile duct resection with or without limited hepatectomy was sufficient to improve long-term survival. CONCLUSIONS: The surgical approach to Bismuth type I and II hilar cholangiocarcinomas should be determined according to cholangiographic tumor type. For nodular and infiltrating tumors, right hepatectomy is essential; for papillary tumor, bile duct resection with or without limited hepatectomy is adequate.     

Urgent indications for surgery in primary or secondary cardiac neoplasm

Ten patients underwent resection of primary or secondary cardiac tumor. Two-dimensional transthoracic echocardiography per se accurately located the endoluminal cardiac mass in nine patients, and transesophageal echocardiography demonstrated a right atrial tumor in the tenth case. The indications for urgent surgery included prior embolic events (3 cases), syncopal attacks (2) or echocardiographic evidence of a multilobulated mass (2 cases). The operative strategy was standardized for atrial tumors, but for malignant myocardial neoplasm both the anatomic site and the extent of tumor growth determined the surgical procedure. Histologic examination showed myxoma in seven cases, fibroma in one and metastases of malignant melanoma in two cases. The course after resection of endoluminal benign tumor was uneventful apart from transient atrial fibrillation in four cases. Follow-up echocardiography (after 4-28 months) showed no recurrent growth. In both cases of intracardiac metastases there was recurrence within 6 to 8 months after resection of the growth.