肺中叶病变的外科治疗

５８例肺中叶病变行外科治疗，其中恶性病变３０例，良性病变２８例（１８％），术后并发症４例（７％），无手术死亡和术后近期死亡，强调下列情况应尽早手术治疗；（１）中叶急性病变。（２）中叶病变、尤其叶不张，不能外恶性、（３）中叶良性病变致中叶不张，内科治疗１个月无效者。对中叶病变的病因诊断、手术切除范围及术中应注意的环节，作了较详细的讨论。     

中叶病变的外科治疗

１１０例肺中叶病变行外科治疗，包括原发和继发性肺癌、低度恶性肿瘤４６例，良性肿瘤１２例，良性病变５２例。胸部Ｘ线表现：典型中叶不张者不足１／３，１／３以上病例为肺门团块影或浸润影。纤维支气管镜检查对中叶恶性肿瘤诊断的假阴性达３０％。单纯中叶切除为６０％，中叶合并其他叶切除３０％，开胸探查和右全肺切除各３例。术后并发症中，５５％为感染，胸内出血１６％。无手术死亡和术后近期死亡。强调中叶病种复杂，需综合分析方可做出诊断；对肺门团块、浸润影和中叶不张术前应充分估计和准备；耐心细致的手术操作可减少并发症；４０岁以上原因不明的中叶不张，应首先除外恶性肿瘤，内科治疗不能复张且有腔内器质性梗阻者应尽早手术探查。     

原发性中叶肺癌的诊断与治疗

中叶病变多因肺部感染所致，中叶肺癌发生率低而易误诊。为探讨中叶肺癌早期诊断和以手术为主综合治疗效果，总结１１年间手术治疗３９例中叶肺癌（占同期肺癌手术总例数的５．１％）。手术切除３４例（８７．１８％），开胸探查５例。手术方式以中叶切除和双肺叶切除为多。２３例术后辅以化疗或加免疫治疗。随访率为９２．３％。２３例术后化疗和免疫治疗者其１、３、５年生存率分别为８６．９５％、４３．４８％、３０．４３％。术后未作辅助治疗的１３例其１、３、５年生存率分别为６９．２３％、３０．７７％、１５．３８％。二组生存率相比有显著差异（Ｐ＜０．０５）。本组中晚期肺癌占多数，病理类型以腺癌居多。影响生存率的因素为病理分期、组织学和纵隔淋巴结转移。     

51例肺中叶病变的诊断及外科治疗

目的:探讨肺中叶病变的诊断及外科治疗方法.方法:51例肺中叶病变良性9例(17.7%),恶性42例(82.3%),术前诊断明确率24.5%.单纯中叶切除占72.5%,合并其他肺叶切除19.6%,肺楔形切除占3.9%,全肺切除3.9%.结果:术后并发症4例(占7.8%).结论:下列情况应及早手术治疗: 中叶恶性病变;中叶病变,尤其中叶不张,不能除外恶性;中叶良性病变致中叶不张,内科治疗2～3周无效者.     

中央型肝癌的手术切除

目的探讨中央型肝癌手术切除的方法和疗效。方法回顾分析1988—2005年在我所行手术切除的257例中央型肝癌的临床资料及随访结果。按手术切除的方式将患者分为半肝切除（包括扩大半肝，n=19）和肝中叶切除（包括部分及扩大肝中叶，n=238）两组，比较手术情况及预后的差异。结果257例中央型肝癌患者术后1、3、5年生存率及无瘤生存率分别为73．4％、55．6％、41．2％和83．8％、73．8％、63．4％。Cox多因素分析提示，肿瘤大小、包膜及微血管侵犯是影响患者预后的相关因素。两种手术方式对手术时间、术后并发症、围手术期死亡、生存率及无瘤生存率的影响差异无统计学意义（P〉0．05）。结论手术切除是治疗中央型肝癌的有效手段，而对于合并有肝硬化的中央型肝癌，肝中叶切除术（包括部分及扩大肝中叶）则是首选的治疗方法。     

老年人上消化道大出血的临床特征与治疗体会

目的：探讨老年人上消化道大出血的特点和治疗应注意的问题。方法：对１１６例老年人上消化道大出血行胃镜及手术探查，发现出血病因１０１例，原因不明１５例。结果：８０例行急诊手术，治愈６８例（８５％），死亡１２例（１５％）；择期手术３３例，治愈３０例（９０．９％），死亡３例（９．１％）；３例胃粘膜病变行非手术治愈。术后出现并发症３５例（３０．９％）。结论：老年人上消化道大出血，不易非手术止血；若非手术和内镜下不能止血，应果断采取手术治疗，术前应注意防治休克和并存的心肺肾等器官的病变，以提高抢救的成功率。     

外科治疗合并华支睾吸虫感染的胆道疾病125例

目的 探讨外科治疗合并华枝睾吸虫感染的胆道疾病特点。方法 回顾1997年1月至2001年12月手术或内镜治疗的合并华枝睾吸虫感染的胆道疾病125例，良性病变107例（85．6％），恶性病变18例（14．4％），合并重症胆管炎（ACST）21例（16．8％），合并梗阻性黄疸63例（50．4％），急诊手术42例（33．6％）。手术方式以胆囊切除，胆总管探查和内镜下十二指肠乳头括约肌切开术（EST）为主。结果 良性病变中1例死于术后ACST，5例结石复发2次手术。恶性病变中围手术期死亡3例，生存期3个月至2年。结论 不仅华支睾吸虫本身可引起胆道外科疾病，而且引起一系列合并症，外科治疗时应同时注意对吸虫病的处理。     

腹腔镜术治疗中叶突出前列腺癌20例报告

目的：介绍腹腔镜术治疗中叶突出前列腺癌的临床经验。方法：采用腹腔镜下前列腺癌根治术治疗中叶突进膀胱三角区的前列腺癌患者20例，其中8例中叶突出2cm以内的患者直接贴腺体切开膀胱后壁；12例中叶突出超过2cm的患者先横行切开中叶表面黏膜，潜行分离并剥出中叶后再行横断膀胱后壁。结果：20例手术均获得成功，平均手术时间135rain，术中出血量350ml，1例直肠前壁损伤，平均留置尿管15．7天，术后1年控尿率90％。结论：腹腔镜下前列腺癌根治术适用于中叶突出的前列腺癌，但术中有效地处理中叶是关键。     

对38例门静脉高压症食管曲张静脉破裂大出血治疗的回顾

讨论１９８２年１月至１９９１年１２月收治的门静脉高压症食管曲张静脉破裂大呕血３８例的治疗．急症手术２１例，术后死亡９例（４２．８％）；择期手术１７例，死亡１例（５．９％）．术式为脾切除、贲门周围血管离断术．全部病例均经病理诊断为肝炎后肝硬变．治疗体会：１．大呕血或内窥镜检查视野不清．可因血液误吸致窒息，主张先行三腔二囊管压迫止血．２．大出血期间及术后病人应常规吸氧．３．非手术治疗４８ｈ无效或止血后短期内再出血者应及早手术．４．护肝期间避免过量补给胶体或全血，以免再出血，择期手术前２ｄ根据情况适量用心得安或镇静剂．５．５０ａ以上病例手术死亡率明显增高（７０．１％）。     

原发性感染性心内膜炎的外科治疗（附102例报告）

回顾性分析原发性感染性心内膜炎１０２例，其中主动脉瓣病变７１例，二尖瓣病变１６例，主动脉瓣与二尖瓣联合病变６例，三尖瓣病变５例，肺动脉瓣病变４例。按照病人术前心功能状态，分为：（１）急性心功能不全组（２５例）；（２）慢性心功能不全组（７７例）。施行主动脉瓣替换术７１例，二尖瓣替换术１６例，双瓣替换术６例，三尖瓣修复成形术５例，肺动脉瓣成形术４例。术后早期死亡９例（８．８％）。９３例生存者随访时间３个月～１６年，平均随访时间４．３年。晚期死亡６例，其中２例为人工瓣膜心内膜炎，复发率为２％。作者对手术时机与手术方式的选择作了讨论，并介绍了围术期处理的经验。     

Isolated middle lobe atelectasis: aetiology, pathogenesis, and treatment of the so-called middle lobe syndrome.

Isolated atelectasis of the middle lobe has been known for many years as the "middle lobe syndrome". Several clinical studies have shown that it may bae caused by malignant tumours. A 10-year study of 135 patients with isolated middle lobe atelectasis is presented. Fifty-eight patients (43%) had malignant tumours. Of 38 who had a thoracotomy, lung resection was possible in 25. In 20 patients regional or systemic dissemination of the tumour had been diagnosed before operation. Seventy-seven patients had benign diseases, of which 74 were non-specific infections. Bronchography was performed in 46 of these cases, and all had abnormal findings in the middle lobe, eight revealing definite bronchiectasis. In three cases tuberculosis was found. In 16 cases the benign diagnosis was established at thoracotomy. Only three patients out of 58 with malignant tumours lived more than five years. Atelectasis of the middle lobe is always a sign of potential malignancy especially in patients with a previously normal chest radiograph.     

Thoracoscopic resection of 85 pulmonary lesions.

Advances in endoscopic surgical equipment and laser technology have expanded the role of thoracoscopy to include thoracoscopic pulmonary resection. Eighty-five thoracoscopic pulmonary resections were performed on 61 consecutive patients with small lesions (less than 3 cm) in the outer third of the lung. Patients with preoperative histologic evidence of bronchogenic carcinoma were excluded unless there was impairment of cardiopulmonary function, advanced age, or concomitant extrathoracic malignancy. These thoracoscopic pulmonary resections were accomplished with the neodymium:yttrium-aluminum garnet laser (31), endoscopic stapler (29), or both (25). The mean diameter of the lesions was 1.3 cm (range, 0.4 to 2.7 cm). There has been one late death (38th postoperative day) unrelated to the operation. Morbidity consisted of postoperative atelectasis (2), pneumonia (2), bleeding requiring transfusion (1), and bronchopleural fistula of greater than 7 days duration (3). There were no wound problems. The mean period of chest tube drainage was 3.3 +/- 3.0 days. Mean postoperative stay was 5.7 +/- 4.9 days. The pathologic diagnosis was benign disease in 28 patients (interstitial fibrosis/pneumonitis, 15; radiation fibrosis, 1; sclerosing hemangioma, 1; rheumatoid nodules, 1; granuloma, 2; nocardia, 1; infarct, 1; hamartoma, 4; scar, 1; cytomegalovirus pneumonia, 1), metastatic malignancy in 20 patients, and bronchogenic carcinoma in 13 patients. Five patients found at thoracoscopic pulmonary resection to have bronchogenic cancer had adequate pulmonary function and therefore underwent formal segmentectomy (3) or lobectomy (2). Thoracoscopic pulmonary resection was the only operation performed on patients with benign disease, patients with metastatic lesions, and selected patients with limited stage bronchogenic carcinoma at increased risk for thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Impact of counterclockwise rotation of the right middle lobe following right upper lobectomy

Open in a separate window OBJECTIVESFollowing right upper lobectomy, the right middle lobe may shift towards the apex and rotate in a counterclockwise direction with respect to the hilum. This study aimed to investigate the incidence and clinical impact of middle lobe rotation in patients undergoing right upper lobectomy.METHODSFrom January 2014 to November 2018, 82 patients underwent right upper lobectomy at our institution for lung cancer using a surgical stapler to divide the minor fissure. Postoperative computed tomography scans evaluated the counterclockwise rotation of the middle lobe, in which the staple lines placed on the minor fissure were in contact with the major fissure of the right lower lobe (120° counterclockwise rotation). Clinicoradiological factors were evaluated and compared between patients with and without middle lobe rotation. We also reviewed surgical videos in patients with middle lobe rotation to evaluate the position of the middle lobe at the end of surgery.RESULTSNine patients had a middle lobe rotation (11%), where 1 patient required surgical derotation. Patients with middle lobe rotation were significantly associated with more frequent right middle lobe atelectasis and severe postoperative complications compared with those without rotation. A surgical video review detected potential middle lobe rotation at the end of the surgery.CONCLUSIONSMiddle lobe rotation without torsion following right upper lobectomy is not rare, and it is associated with adverse postoperative courses. Careful positioning of the right middle lobe at the end of surgery is warranted to improve postoperative outcomes.     

Duodenal-preserving resection of the head of the pancreas and pancreatic head resection with second-portion duodenectomy for benign lesions,low-grade malignancies,and early carcinoma involving the periampullary region

HYPOTHESIS: Duodenal-preserving resection of the head of the pancreas (DPRHP) and pancreas head resection with segmental duodenectomy (PHRSD) can be alternatives to standard pancreaticoduodenectomy for benign periampullary lesions. DESIGN: Retrospective analysis of patients requiring surgery for benign and borderline malignant tumors of the periampullary region. SETTING: Tertiary care referral center. PATIENTS: Duodenal-preserving resection of the head of the pancreas (n = 8) and PHRSD (n = 7) were performed in 15 patients with a preoperative diagnosis of benign and borderline malignant tumors of the periampullary region (ie, 11 pancreas head lesions [2 intraductal papillary mucinous tumors, 4 serous cystadenomas, 2 insulinomas, 1 epidermal cyst, 1 metastatic renal cell carcinoma, 1 nonfunctioning islet cell tumor/parapaillary] and 4 duodenal lesions [3 adenomas and 1 adenocarcinoma]). MAIN OUTCOME MEASURES: Surgical factors (operation time and blood loss), postoperative complication, postoperative pancreatic insufficiency (eg, development of diabetes mellitus and steatorrhea or elevated stool elastase values), weight change, and recurrence of disease. RESULTS: No differences were noted in the mean operation time and estimated blood loss between the 2 procedures. Major postoperative complication constituted the following: bile duct stricture (n = 1) in DPRHP and delayed gastric emptying (n = 1) and postoperative bleeding (n = 1) in PHRSD. Newly developed diabetes mellitus occurred in 1 patient. Exocrine pancreatic insufficiency (steatorrhea) was observed in 1 patient after PHRSD. Patients with early duodenal carcinoma and intraductal papillary mucinous tumors with a borderline malignancy are still alive without evidence of recurrence. There was no hospital or long-term mortality. CONCLUSIONS: Duodenal-preserving resection of the head of the pancreas is recommended first for a benign or low-grade, early malignant pancreatic head lesion; PHRSD can be an option for a lesion of the ampullary-parapapillary duodenal area as well as the pancreatic head. Duodenal-preserving resection of the head of the pancreas can be converted to PHRSD if ischemia of the second portion of the duodenum occurs. We found benign periampullary lesions could be conservatively treated with DPRHP and PHRSD, which could substitute for classic pancreaticoduodenectomy.     

Relationships Between Divisions of the Middle Bronchus and Vascularization Patterns in the Middle Lung Lobe

In 100 right human lungs the main bronchus, the pulmonary artery and the pulmonary vein were injected with 65% methyl methacrylate and then digested in sulphuric acid. The resulting specimens were studied to observe the divisions of the middle lobe bronchus and the types of arterial and venous vascularization of this lobe. The lobe was always entered by one lobar bronchus, which usually divided into two segmental bronchi. In 53% of the middle lobes with this bronchial pattern there was one artery. When the lobar bronchus divided into three branches, at least two arteries entered the lobe in almost all cases. Complete consistency between the pattern of bronchial division and that of arterial vascularization of the middle lobe was found in almost two-thirds of cases. Associations between patterns of bronchial division and of venous drainage from the middle lobe were found in slightly more than half of the cases.     

Hepatic angiomyolipoma: Two case reports of caudate-based lesions and review of the literature

Two case reports of hepatic angiomyolipoma, both originating in the caudate lobe, are reported with a review of the literature. The liver is the second most common site of angiomyolipoma, an uncommon benign tumor of mixed mesenchymal origin. It is commonly diagnosed following abdominal pain or as an asymptomatic mass discovered on abdominal ultrasound or computed tomography scan. Of 74 cases reported, the lesions ranged from 0.3 to 36 cm in diameter and are noted between the first and eighth decade, with predominant female predilection. The right lobe is the most common site, with lesions arising in the caudate lobe comprising only five cases. The natural history of the hepatic lesion is unknown. Malignant invasion or metastatic disease has not been documented. Hepatic and renal angiomyolipoma can occur concurrently (13 of 60 cases), although the majority are not biopsy proven. Multicentric hepatic disease occurs. The correlation between tuberous sclerosis and hepatic angiomyolipoma is not confirmed histologically and occurs rarely. These lesions have a characteristic radiographic appearance due to high fat content. Histologically, angiomyolipoma are characterized by an admixture of adipose tissue, blood vessels, and smooth muscle cells. These lesions cannot reliably be differentiated from a malignant lesion based on clinical history, radiologic examination, and/or pathologic interpretation. If clinical suspicion for malignancy is low, then careful observation with serial radiologic follow-up is performed. The treatment for a symptomatic or suspicious lesion is resection, if feasible. Liver transplantation may be considered for large or centrally located lesions not amenable to resection. (Liver Transpl Surg 1997 Jan;3(1):46-53)     

磁共振诊断肾移植后合并脑后部可逆性脑病综合征四例

目的 探讨磁共振成像(MRI)在肾移植术后合并脑后部可逆性脑病综合征(PRES)诊断中的应用.方法 4例患者,均为女性,平均年龄为41.7岁,肾移植后使用环孢素A(或他克莫司)、霉酚酸酯和糖皮质激素预防排斥反应,其中1例于术后第2天采用抗淋巴细胞球蛋白.PRES的起病时间为术后4～17 d,平均为10 d,患者均于起病后2 d内进行MRI检查.结果 MRI结果提示,PRES病变累及顶叶4例,枕叶3例,额叶2例,小脑2例,桥脑1例,基底节区1例,病变占位效应均不明显.顶枕叶、额叶病变位于皮层下白质,其中1例累及皮质,为双侧大致对称性分布的斑片状影.病变区T1WI呈低、等信号,T2WI及冠状位液体衰减反转恢复(FLAIR)像呈高信号.3例磁共振扩散加权成像(DWI)呈等信号,1例呈略低信号;4例表观扩散系数(ADC)图均表现为高信号,其中1例病变周边DWI表现为高信号,ADC图为等信号.结论 肾移植术后合并RPES的MRI表现较具特征性,特别是DWI及ADC图,有助于疾病的早期诊断.     

A study of high-resolution computed tomography (HRCT) findings of resected small pulmonary nodules 2 cm or less in diameter with reference to the malignant nature

To identify the characteristics of peripheral small lung mass lesions on high-resolution computed tomography (HRCT) and discriminate between malignant and benign, 223 mass lesions 2 cm or less resected surgically were evaluated about following points. 1) Density : 90.7% of lesions with mixed solid and ground-glass opacity (GGO) components were adenocarcinomas. Pure GGO lesions without scale-down between several months were all adenocarcinomas or atypical adenomatous hyperplasia (AAH). Thereby, patients with these findings are good candidates for surgical resection. 2) Spicular or pleural indentation :75.2% (88 of 117 cases) of adenocarcinomas and all squamous cell carcinomas (18 cases) showed these findings, but 26.6% (41 of 154 cases) of positive cases were benign lesion (non-specific inflammation, mycobacterisis, and so on). Accordingly, they are not peculiar to malignancy. 3) Satellite lesion : all lesions with this one showed benign, therefore it was thought that this finding could exclude malignant lesion. Thus, recognition of certain characteristics at HRCT can be helpful in discrimination between small malignant mass and benign mass.     

Caudate lobectomy: tumor location, topographic classification, and technique using right- and left-sided approaches to the liver

BACKGROUND: Resection of the caudate lobe (involving segments I [dorsal sector] and/or IX [right paracaval region]) often presents a technical challenge. It is difficult to perform because of its deep location and adjacency to the major hepatic vessels (ie, the left and middle hepatic veins). METHODS: A literature review was performed based on a Medline search to identify articles on caudate lobectomy published from 1990 to 2005. This article describes the right and left-sided approaches to the liver for caudate resection according to caudate lobe tumor location and topographic classification. RESULTS: The results of 377 lobectomies were analyzed in this review. The left-sided approach to the liver was used in 55 (14.58%), the right-sided approach in 24 (6.36%), and both approaches in 298 (79.04%) caudate lobectomies. Primary benign and malign liver tumors, as well as secondary liver tumors, were resected. CONCLUSIONS: Access to and resection of the caudate lobe should be determined on the basis of tumor location and hepatic function. The left or right approach to the caudate lobe can be recommended for local resection of tumor located at Spiegel's portion or process portion. Approaches to caudate lobectomy are therefore largely dependent on size and location of the lesion, type of associated resection, and presence of scarring from previous resection.