ADENOCARCINOMA STOMACH A REVIEW OF 168 CASES

Medical records of 168 patients with gastric adenocarcinoma treated at Malignant Diseases Treatment Centre, Command Hospital (SC) Pune over a ten year period were analysed. Laparotomy was performed in 146 patients; in 82 patients a gastric resection was done, palliative gastrojejunostomy was done in 42 patients, while in 22 patients only a diagnostic biopsy was done. The resection was considered to be curative in 21 patients. Overall operative mortality was 12.3%. According to the international TNM Classification 16% patients were in Stage I, 13.7% in Stage II, 34.3% in Stage III and 35.8% in Stage IV. A significant correlation was found between five year survival rate and overall stage of disease as well as regional lymph node involvement (p < 0.001). Significantly better survival rates were seen in those who had curative resection as opposed to palliative resection (p < 0.01). Overall survival rate at five years in our patients was 8.3% this poor outcome was probably related to the advanced stage of disease at presentation.KEY WORDS: Gastric cancer, Adenocarcinoma stomach     

多层螺旋CT在肝静脉阻塞型布加综合征诊断和治疗中的应用

目的探讨肝静脉阻塞型Budd-Chiari综合征(BCS)多层螺旋CT动态增强规律及CT血管成像的诊断价值,评价多层螺旋CT检查对BCS治疗的指导意义。方法经血管造影证实的21例肝静脉阻塞型BCS患者,在DSA检查前2周内行肝脏多层螺旋CT动态增强扫描,并对其相关血管进行重建。病程短于3个月的有4例,3个月以上的17例。结果病程短于3个月的4例,CT平扫显示肝脏体积弥漫性增大,肝脏密度普遍降低;增强后表现为以肝门区和尾状叶为中心的斑片状强化,并随扫描时间延长强化范围扩大。病程3个月以上的17例,CT平扫显示肝脏形态异常,肝萎缩区或肝外周为低密度;增强后肝萎缩区及肝外周强化程度低,密度不均匀,其静脉引流血管闭塞,而静脉引流良好的区域强化均匀,其静脉引流至少有1支开通的肝静脉或扩张的副肝静脉。肝实质CT强化规律与肝静脉阻塞部位及肝内外侧支静脉形成密切相关。21例患者,共计42条肝静脉闭塞,其中肝左静脉9条,肝中静脉12条,肝右静脉16条,副肝静脉6条。横断面和CT血管成像显示肝静脉阻塞的正确率分别为61．9％和100％。结论多层螺旋CT动态增强扫描能够较准确地反映肝静脉阻塞型BCS肝内血流动力学变化,结合CTA可准确显示肝静脉阻塞部位、性质及肝内外侧支静脉,对指导BCS的治疗具有重要价值。     

Preliminary evaluation of magnetic resonance fresh blood imaging for diagnosis of Budd-Chiari syndrome

Background Budd-Chiari syndrome （BCS） is a rare disease with portal hypertension caused by the blockage of the hepatic vein and/or the inferior vena cava （IVC）. Angiography is the ＂golden standard＂ for diagnosis, but it is an invasive examination. To assess the diagnostic value of a fresh blood imaging （FBI） relative to BCS, we used a magnetic resonance angiography （MRA） with an FBI sequence for a preoperative evaluation of the BCS patients in this study. Methods Fifty patients who were suspected of having BCS after they had been checked by a B-ultrasound were studied. 2D and 3D FBI were performed on a 1.5T superconductive MR scanner. Original images were rebuilt using a maximal intensity projection （MIP） method on the console. Two doctors reviewed all images before they learned of the angiography results. We then compared the diagnoses obtained from the FBI and angiography results to evaluate the diagnostic value of the FBI. Results Forty-one patients were diagnosed as BCS and 9 as non-BCS based on an angiography. The FBI correctly diagnosed 38 patients, incorrectly diagnosed 1 patient, and missed diagnosis in 3 patients. Thus, the diagnostic sensitivity of the FBI is 93% （38/41）, the specificity is 89% （8/9） and the accuracy is 92% （46/50）. The FBI images of the 13 membranous stenoses of the IVC showed a sudden stenosis of the post-liver segment of the IVC. The Images of the 5 patients with a membranous obstruction of the IVC showed IVC thickening and an absence of blood signals in the post-hepatic segment of the IVC. The images of the 4 patients with the segmental thrombosis of the IVC showed abnormal and intermittent signals in the IVC. The images of the 6 patients with a simple hepatic vein obstruction showed obstructive hepatic veins. The images of the 6 patients with the stenosis of both the IVC and the hepatic veins showed the stenosis of the IVC, the thickening of the hepatic veins and the formation of a compensatory circulation within the liver. Lastly, the images of the 7 patients showed a combination of the IVC thrombosis with stenosis or with the obstruction of one or two hepatic veins. Conclusions An FBI can show a membranous stenosis, and an obstruction and thrombosis of the IVC. In addition, it can also demonstrate the thickening of the flexural hepatic vein and the development of intra-hepatic compensatory branches with slow blood flow. Thus, it can guide the puncturing and opening of the hepatic vein involved in an interventional therapy for BCS patients.     

肝移植术后缺血型胆道病变的预防和治疗

目的探讨原位肝移植术后缺血型胆道病变（ITBL）的发生原因及防治措施.方法回顾性研究从1999年2月至2004年8月间212例次原位肝移植患者的临床资料,总结原位肝移植术后发生ITBL的情况.结果共发生缺血型胆道病变14例（6.6%）,其中肝门部胆管病变5例,肝内外胆管多发病变6例,肝内胆管多发病变3例.供肝冷保存时间超过10 h,供受体ABO血型不符,术后肝动脉病变及原发病为重型乙型病毒性肝炎的ITBL发生率分别为9.8%（10/102）、22.2%（2/9）、40%（2/5）及14.6%（7/48）.14例患者采用内科保守、内镜、外科及再次肝移植治疗,7例治愈,4例病情改善,1例无效、1例死亡.治疗有效率为78.6%（11/14）,治愈率为50%（7/14）,与ITBL相关的病死率为7.1%（1/14）,与ITBL相关的移植物失功率为23%（3/14）.结论尽量避免供受体ABO血型不符和供肝冷保存时间过长,及时处理术后肝动脉病变是预防原位肝移植术后发生ITBL的有效措施.根据胆管树的病变情况选择合适的治疗方法,是原位肝移植术后ITBL患者获得良好疗效的关键.     

瓣膜替换或成形术同期行冠状动脉旁路移植术的临床分析

目的 分析７６例瓣膜替换或成形术同时行冠状动脉旁路移植术的危险因素,并介绍此类手术的成功经验。方法 行瓣膜替换或成形术同时行冠状动脉旁路移植术７６例。男６１例,女１５例,平均年龄５６岁,共移植旁血管１１７支,同时行主动脉瓣转换（ＡＶＲ）（１～３支桥）２５例,二尖瓣转换（ＭＶＲ）（１～４支桥）３１例（ＭＶＲ＋ＴＶＰ３例,ＭＶＲ＋ＡＶＰ２例）,双瓣转换（ＢＶＲ）（１～３支桥）１８例（ＢＶＲ＋ＴＲＰ２例     

严重肝外伤45例的治疗

目的总结严重肝外伤的治疗经验。方法回顾性分析1995年1月～2005年12月45例严重肝外伤病例行外科治疗的临床资料，包括损伤程度、手术方式、治疗效果及手术并发症。结果肝外伤Ⅲ级24例，Ⅳ级16例，Ⅴ级5例。行肝缝合修补术21例，大网膜填塞缝合4例，肝血肿清除3例，清创性肝切除14例，规则性肝切除3例。治愈38例，死亡7例，其中术中出血死亡1例，术后再出血死亡2例，术后多器官功能衰竭死亡4例。术后发生并发症17例（37．8％），并发多器官功能衰竭4例，术后再出血3例，胆漏3例，膈下脓肿3例。结论手术是治疗严重肝外伤的主要方法。术中彻底止血，充分引流，预防多发性器官功能衰竭（MOF），可降低严重肝外伤术后并发症和死亡率。     

The experience of a haematemesis and melaena unit: a review of the first 513 consecutive admissions.

This report is of the results of management in a haematemesis and melaena unit at Prince Henry's Hospital, Melbourne. The unit was established in October, 1972, in response to unpublished data for the decades 1950 to 1959 and 1960 to 1969, which showed a mortality of about 15%. In the 39 months to December, 1975, 513 patients were received into a semi-intensive care setting. The unit staff consisted of a group of four surgeons and four physicians working a weekly roster. Primary care and liaison were the responsibility of the gastroenterology registrar. The basic diagnostic measure taken was the routine early use of fibreoptic duodenoscopy. The unit was set up with an agreed policy of management of the common causes of haematemesis and melaena, and data were prospectively recorded in a form suitable for computer analysis in every case. Of the 513 admissions, 378 were of males and 135 were of females. Forty-five patients died, giving an overall admission mortality of 8-8. There were 143 admissions for bleeding duodenal ulceration, 102 for acute peptic ulceration, 47 for chronic gastriculceration, 43 for oesophageal varices, 33 for Mallory-Weiss syndrome and 45 for less common causes of upper gastrintestinal bleeding. In 100 cases the source of bleeding was not discovered. Of the 143 patients admitted for chronic duodenal ulcer, either patients died, giving a mortality of 5-6%; 72 patients underwent operation, with an operative mortality of 9-7%. Of the 47 admitted with bleeding gastric ulcer, nine died (19-1%), while 26 came to operation; the operative mortality was 26-9%. There were 102 admissions for acute peptic ulceration, with an overall mortality of 11-7% (12 patients); 16 patients came to operation, with an operative mortality of 43-7%. Eleven deaths occurred in the 43 patients admitted for bleeding oesophageal varices (25-6%), with 10 patients coming to operation; the operative mortality was 30-0%. An age of greater than 50 years and shock on admission were the most significant factors for poor prognosis in this group of patients.     

Acute and subacute fulminant hepatic failure: the role of liver transplantation

OBJECTIVES: To report the experience of the Australian National Liver Transplant Unit with patients with fulminant hepatic failure and to describe the role of liver transplantation. PATIENTS: Twenty-seven patients presented with acute or subacute fulminant hepatic failure during the period from January, 1986, to March, 1990. Twenty-two had acute and five had subacute fulminant hepatic failure. The causes were hepatitis B in 10 patients, presumed non-A, non-B (NANB) hepatitis in eight patients, drug-induced hepatic damage in five patients, and Wilson's disease in four patients. There were 13 males and 14 females. Ages were 2-43 years (mean, 23). Twenty patients (74%) were in grade IV encephalopathy on presentation. RESULTS: Six patients (22%) began to improve soon after admission and went on to full recovery. Spontaneous recovery was more frequent in patients with drug-induced hepatic damage (four patients [80%]) and was less frequent in those with hepatitis B (one patient [10%]) and NANB hepatitis (one patient [12%]). The other 21 patients (78%) were considered for orthotopic liver transplantation. Eight (30%) were judged to be unsuitable and went on to early death. Thirteen (48%) were suitable for transplantation. Of these five (19%) died before a liver donor became available and eight (30%) received liver grafts and went on to full recovery. Overall, 14 patients (52%) survived and 13 (48%) died. Patients with Wilson's disease (four [100%]) were most suitable for orthotopic liver transplantation whereas eight (44%) of those with hepatitis B or NANB hepatitis were unsuitable. Of the eight patients receiving liver grafts one had hepatitis B, three had NANB hepatitis and four had Wilson's disease. Five were in grade IV encephalopathy at the time of operation. The mean waiting time for transplantation was 6.4 days. Five patients received ABO blood group compatible grafts and three received ABO incompatible grafts. Of the latter group, two subsequently required secondary orthotopic liver transplantation with ABO compatible grafts. All eight patients who received transplants are alive and well 3-24 months after the operation. No patient has any neurological sequelae. CONCLUSIONS: Orthotopic liver transplantation is a preferred option for patients with fulminant hepatic failure whose condition is not responding to conservative management. ABO incompatible livers transplanted in emergency circumstances may prove life-saving either by functioning successfully or by providing time during which ABO compatible grafts become available.(ABSTRACT TRUNCATED AT 400 WORDS)     

Pneumonia in renal transplant patients.

Between January 1976 and March 1982, 28 episodes of pneumonia occurred in 26 renal transplant patients. The overall mortality rate was 46%. Of the 16 patients with nosocomial pneumonia 9 (56%) died, whereas of the 12 patients with community-acquired pneumonia 4 (33%) died. In all 9 cases of unknown cause the response to empiric treatment was prompt, whereas in 4 of the 10 cases of monomicrobial pneumonia and 8 of the 9 cases of polymicrobial pneumonia the patient died. Cytomegalovirus was the sole cause of the pneumonia in two patients and a contributing cause, along with aerobic gram-negative bacteria, in another five, four of whom also had a fungal infection. Two patients, both of whom survived, had nosocomial Legionnaires' disease.     

肝站区域血管阻断切除肝脏肿瘤63例报告

A new operative procedure for hepatic segmentectomy was performed by dissecting the hepatic hila to occlude blood vessels to and from hemihepatis, one lobe or one segment which bore hepatoma. Forty-three liver cancers with 33 of them in stage IV, 4 metastatic liver cancers and 16 hemangiomas were resected by this method. The types of hepatic segmentectomy consisted of monosegmentectomy, multisegmentectomy, peripheral and central segmentectomy, segmentectomy after hepatic arteria embolization and resegmentectomy for recurrent hepatic cellular carcinoma etc. The vascular occlusion lasted as long as 120 minutes for the right portal vein and 70 minutes for the left. Intravenous infusion of extract from Salive mliltiorrhiza before vascular occlusion could prevent hepatic cells from reperfusion injury. The mentioned maneuvers resulted in mild postoperative liver dysfunction, rapid recovery and hepatocytes regeneration. Two patients died within 30 days postoperatively, constituting an operative mortality of 3.1%.     

Rescue therapy with intravenous immunoglobulin in severe refractory dengue: A pilot study

BackgroundSevere dengue causes more than 22,000 deaths annually worldwide. Complicated dengue has high mortality of 44–72%. Disordered immune system with capillary leak and thrombocytopenia are hallmark of complicated dengue. Intravenous immunoglobulin (IV Ig) therapy has shown to be effective in complicated dengue in pediatric age group with refractory shock, but studies in adults are lacking. Its immunoresuscitative role is not yet fully explored in critically ill patients with severe dengue.MethodsThis is retrospective observational study of patients with complicated dengue fever who were administered IV Ig therapy in a tertiary care hospital of southern India from 01 Jan 2018 to 31 Dec 2019.ResultsA total of 999 patients with dengue were admitted; 754 (75.47%) were males, and 245 (24.53%) were females. A total of 402 (40.24%) patients presented with warning signs. Bleeding was seen in 121 patients (12.11%); 102 (10.21%) had shock; 29 (2.90%) had acute kidney injury and 24 (2.40%) had adult respiratory distress syndrome. Overall, four people died (mortality rate: 0.40%). IV Ig in the dose of 0.4 g/kg for 5 days was used in 13 critically ill patients where standard therapy failed, 9 patients with refractory shock (which included three with myocarditis with refractory shock), 2 with encephalitis, 2 in hemophagocytic lymphohistiocytosis. Two patients died, one with myocarditis with refractory shock and another with refractory shock.ConclusionIV Ig therapy in critically ill patients with complicated dengue can be used as a rescue therapy.     

脾静脉-颈内静脉转流术治疗重症布-加综合征

目的：探讨下腔静脉节段闭塞或狭窄并弥漫性肝静脉闭塞引起的重症布-加综合征的手术方式。方法：对38例重症布-加综合征患者采用脾切除，脾静脉-颈内静脉胸骨后转流术进行治疗。结果：围手术期死亡1例，病死率2.6%。2例发生切口感染，1例发生急性心功能衰竭，经药物治愈；余37例患者术后临床症状均有不同程度改善，对35例患者术后随访6-36个月，效果优者23例（65.7%)，患者临床无症状，腹水，胸腹壁曲张静脉及下肢肿胀消失，肝右肋下不能触及；良好者10例（28.5%)，胸胸壁曲张静脉基本消失，肝脏缩小；2例效果不佳（5.7%)。结论：脾静脉-颈内静脉转流术是治疗重症布-加综合征一种有效的手术方式。     

术中胆道镜在238例规则性肝段切除治疗肝胆管结石患者中的应用

目的探讨术中胆道镜在规则性肝段切除治疗肝胆管结石患者中的应用价值.方法回顾性分析2000年1月至2004年12月采用规则性肝段切除术联合术中胆道镜治疗238例肝胆管结石患者的临床资料及远期疗效.结果术后并发症发生率为16.0%(38/238),死亡率为2.1%(5/238),单纯肝段切除肝内胆管结石清除率为36.1%(86/238),应用术中胆道镜取石治疗后肝内胆管结石清除率提高至87.4%(208/238),结合术后胆道镜取石治疗后胆管结石清除率达98.3%(234/238).220例患者平均随访39个月,95.9%(211/220)获得优良疗效,其中84.5%(186/220)完全无症状,11.4%(25/220)偶有轻度胆管炎发作;4.1%(9/220)患者因反复发作严重胆道感染而需进一步手术处理.结论在规则性肝段切除治疗肝胆管结石患者术中,应用胆道镜不仅有助于术者选择正确的肝切除,而且作为辅助的治疗手段,能明显减少结石的残留率,从而有助于提高肝胆管结石患者的手术疗效.     

桥脑角区肿瘤的显微外科手术治疗

目的：提高显微外科手术切除小脑桥脑角区肿瘤的技巧,减少手术并发症,予病人术后良好的生存质量。方法：分析１９９４～１９９８年我科经显微外科手术切除小脑桥脑角区肿瘤４２例的经验。结果：全切除３１例（７３．８％）,次全切６例（１４．２％）,面神经保留２１例（５０％）,死亡例（４．７％）。结论：应用显微外科技术是改善小脑桥脑角区肿瘤手术效果,减少手术并发症的关键。     

冠状动脉旁路移植术治疗冠心病

目的 :为总结应用冠状动脉旁路移植术治疗冠心病的早期效果和经验。方法 :3例病人均采用正中开胸 ,低温体外循环下行冠状动脉旁路移植术 ,移植血管全部用自身大隐静脉。 2例搭 3支桥 ,1例搭 4支桥。结果 :术后 3例心绞痛症状完全消失 ,术后无严重并发症 ,无手术死亡。结论 :冠状动脉旁路移植术是治疗冠心病的一种安全有效的方法 ,近期临床效果满意     

30例伴糖尿病的冠心病患者行冠脉搭桥术的临床分析

目的探讨伴糖尿病的冠心病冠脉搭桥术(coronary artery bypass grafting,CABG)及围手术期处理.方法2000年1月～2003年6月,CABG治疗30例伴糖尿病的冠心病.结果术后发生低心排需要主动脉内气囊反搏(intra-aortic balloon pumping,IABP)2例.出现肾功能不全2例.脑血管意外长期昏迷1例,半年后死于肺部感染;术后多器官功能衰竭而死亡1例,全组死亡率为6.7%.胸部伤口感染3例,下肢伤口感染5例,占28.6%.术后出现心率失常9例,占32.1%.28例病人冠心病症状得到缓解或消失.结论伴糖尿病的冠心病的冠脉搭桥术,尽管手术死亡率及并发症稍偏高,但术前明确诊断及制订良好的手术方案,完善的围手术期处理,伴糖尿病的冠心病患者行冠脉搭桥术的治疗可取得良好效果.     

Surgical management of chronic occlusive disease of the aortic arch vessels and vertebral arteries.

Occlusive disease of the aortic arch vessels is relatively rare and often missed initially. Of 41 patients treated surgically for this condition over a 10-year period 38 had arteriosclerotic lesions, 2 had symptoms secondary to vasculitis (Takayasu's arteritis) and 1 had a radiation injury to a subclavian artery. In 22 cases the left subclavian artery was involved; the right subclavian and innominate arteries were the next most commonly affected. Only four vertebral stenoses were treated. Most patients presented with a combination of arm and hindbrain ischemia that was shown radiologically to be associated with a subclavian steal syndrome, but in some only isolated arm symptoms or severe vertigo alone was experienced. There was a difference in blood pressure between the arms of at least 20 mm Hg in 88% of the patients. The treatment for 28 patients was creation of a carotid-subclavian bypass, for 6 the placement of a bypass graft from the ascending aorta to the subclavian or carotid artery or both, for a 3 a subclavian endarterectomy and for 4 vertebral angioplasty. There were no operative deaths, and 90% of the grafts were patent 1 to 72 months later. however, only 30 (73%) of the patients were asymptomatic and 9 (22%) had improved.     

Oesophageal cancer treatment in North East Thames region, 1981: medical audit using Hospital Activity Analysis data

Figures from the Hospital Activity Analysis in the North East Thames region in 1981 were used to perform a medical audit on oesophageal cancer treatment. Four hundred and forty four patients were admitted with this diagnosis; 80 had been intubated without a thoracotomy or laparotomy, and 73 had had surgery (two thirds radical and one third palliative) with an overall operative mortality of 33%. Fifty five patients had had radiotherapy and 179 patients had no recorded operation or investigation. One hundred and seventy seven different consultants had looked after all these inpatients, most being general surgeons. Only five consultants had looked after 10 or more patients each year. From a calculated estimate of a total 286 patients in the region, 28% had palliative intubation and 25% had surgery; 20% of all the patients had radiotherapy either as a radical or palliative treatment, the remainder having no recorded therapeutic procedure. One hundred and eighty seven patients (66% of the calculated total) died in hospital. Investigation and treatment do not seem to be limited by lack of money, but money is being wasted by admitting patients for terminal care into acute hospital beds. It would be more humane for these patients to die at home or in a hospice if they wished.     

Hyperlipoproteinemia in occlusive cerebrovascular disease.

The distribution of occlusive atherosclerotic lesions in the aortocranial circulation as determined by arteriography was correlated with results of plasma lipid and lipoprotein determinations of patients with symptoms and signs of cerebrovascular disease. The incidence of hyperlipoproteinemia in the total study population was 31.8%. The frequency of hyperlipoproteinemia was signigicantly higher in patients with atherosclerotic lesions limited to extracranial (51%) and intracranial major vessels (44.2%) when compared to the total number of patients and patients with only intracranial small-vessel disease (P less than .05). Type IV hyperlipoproteinemia was the most common abnormality (extracranial group, 42% type IV, 9% type II; intracranial major-vessel group, 35.8% type IV, 8.4% type II). Patients with intracranial small-vessel disease had the lowest frequency of hyperlipoproteinemia (14.2%). The frequency of hypertension with or without hyperlipoproteinemia was higher in patients with intracranial small-vessel disease (P less than .01).     

视网膜母细胞瘤术后放射治疗—70例远期疗效分析

本文对70例经术后放射治疗的视网膜母细胞瘤,作了5—10年以上长期随访分析。随访率为98.6%。全组一、五、十年生存率分别为60.0%、51.4％、46.9%。病期早,视神经未受侵及手术与放疗间隔时间不超过一个月者预后好,且以术后照射4500—5500cGy疗效最佳。