膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌的疗效评价

目的：评价膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌的疗效.方法：对17例膀胱非尿路上皮癌患者行根治性膀胱全切,盆腔淋巴结清扫;然后取一段肠管缝制成新膀胱,分别与输尿管和尿道残端吻合,实现原位尿流改道.结果：手术均获成功,手术时间172～380 min,平均310 min.16例获得随访,平均随访67个月（1～16年）.6例因肿瘤复发或转移于5年内死亡,2例死于非肿瘤因素,1例仍在随访,7例存活已达5年.结论：根治性膀胱全切原位尿流改道术治疗膀胱非尿路上皮癌,具有较好的治疗效果,能明显改善患者生活质量.     

Trimodality Therapy for Bladder Conservation in Treatment of Invasive Bladder Cancer

During the past 25 years, prospective clinical trials have established that bladder preservation therapy for select patients with muscle-invasive bladder cancer is a safe and effective alternative to an immediate cystectomy. Cisplatin-based chemoradiation is the most well-studied and accepted component of trimodality therapy; however, other systemic agents have recently been shown effective in combination with radiation therapy, increasing the range of options to allow for better personalization of care. In this review, the most recent advances in the field of bladder-preserving trimodality therapy are presented, and future directions for improving the outcomes are outlined.     

Tumours of Oddi: Diagnosis and Surgical Treatment

A retrospective review of 56 patients operated upon for tumours of Oddi was performed in order to determine optimal diagnostic and therapeutic procedures. Common presenting symptoms were jaundice (86%) and anemia (21%). Mean size of the tumour was 2.3 cm. Five tumours were benign and 51 were malignant. According to the classification of Martin, five were grade I: 10 grade II; 18 grade III; and 18 grade IV. Forty-seven patients underwent resection of the tumour: three local excisions for small benign tumors, six ampullectomies (followed in three by a Whipples’ procedure for recurrence) and 41 Whipples’ procedures. The hospital mortality was 5.3%, minor complications appeared in 21%. The overall five years survival was 41%. It was 75% in grade I, 50% in grade II, 40% in grade III and 10% in grade IV. The patients who received ampullectomies were alive with a follow-up of one, two and three years. All patients operated upon for a benign tumour were alive except one who died of cardiac failure. Ultrasonography and duodenoscopy are the most useful tests for the diagnosis of tumours of Oddi. Prognosis depends on the degree of infiltration of the duodenal wall and the presence of positive lymph nodes. Whipples’ procedure is best but ampullectomy can be used in elderly or poor risk patients. Malignant tumours of the ampullary region are infrequent and reported to constitute betwee 0.02 and five percent of all cancers of the digestive tract. With wider application of endoscopic techniques, there has been an increasing interest in this group of tumours during recent years. In the literature tumours of Oddi are usually reported in the group of periampullary tumours, including tumours of the ampulla itself, duodenal wall surrounding the ampulla, the distal part of the common bile duct and head of the pancreas. We have wanted to distinguish specifically the tumours of the ampulla of Vater and have adopted the term tumour of Oddi introduced by Marchal and Hureau.The sphincter of Oddi exactly delineates the junction between the bile duct, pancreatic duct and duodenum. We wanted to avoid using the anatomic term ampulla of Vater, since this structure rarely appears as an ampulla. This then excludes tumours in the head of pancreas, common bile duct above ths phincter of Oddi and tumours of the duodenal wall adjacent to the papilla. These tumours seem to behave differently from other pancreatic tumours, as they carry a different prognosis and need special attention. We have therefore reviewed retrospectively 56 patients with tumours of Oddi with special reference to diagnosis, histopathologic examination and surgical therapy.     

Improving Transurethral Resection of Bladder Tumour: The Gold Standard for Diagnosis and Treatment of Bladder Tumours

Transurethral resection of bladder tumour (TURB) remains the gold standard for management of bladder cancer, but there is evidence of a high rate of tumour recurrence after primary resection, and of variation between institutions. Surgical accuracy is paramount to the safety and efficacy of TURB, but technical and procedural considerations may also have an impact on outcomes. A second resection may improve staging and tumour removal, particularly where the primary procedure was affected by multiple tumours, large tumour bulk, bleeding during resection, bladder perforation, patient habitus, or anaesthetic risk, or if the patient has high-risk bladder tumour, T1 tumour, multiple high-grade Ta tumours, or carcinoma in situ. The piecemeal resection achieved by standard TURB may contribute to tumour recurrence, and technical modifications are being developed to provide en bloc tumour resection. The authors are refining an en bloc method using a knife electrode. Modifications to the resectoscope are also under investigation, and there are encouraging results from studies of alternative energy sources.These modifications of TURB equipment and techniques offer exciting possibilities for improving outcomes in bladder cancer. A move towards en bloc rather than piecemeal resection may help to reduce recurrence rates.     

尿流改道及膀胱重建在膀胱癌手术治疗中的进展

尿流改道及膀胱重建在膀胱癌手术治疗中的应用日益广泛,但由于各种手术方式各有利弊,在临床应用中尚未找到一种真正完美理想的术式.本文就尿流改道及膀胱重建在膀胱癌手术治疗方面的临床进展作一综述.     

Results of Surgical Treatment After Neoadjuvant Chemotherapy for Stage III Non-Small Cell Lung Cancer

BACKGROUND: The potential benefits of an approach combining neoadjuvant chemotherapy and surgery in stage IIIA and IIIB NSCLC have to be weighed against a potential increase in postoperative complications. We evaluated the results in terms of postoperative complications and survival in patients with stage III NSCLC who underwent complete surgical treatment after neoadjuvant chemotherapy with two regimens: mitomycin, vinblastine, and cisplatin (MPV) versus gemcitabine and cisplatin (GC). METHODS: From March 1991 to September 2005, 110 patients with stage III NSCLC (86 stage IIIA and 24 stage IIIB) underwent complete surgical treatment after neoadjuvant chemotherapy. Ninety-two patients were men and 18 were women, with a mean age of 59 (range, 39-80) years. The neoadjuvant chemotherapy regimen was MPV in 72 patients and GC in 38. RESULTS: The overall response (>50%) to chemotherapy was 84%. Postoperative mortality and morbidity were 1.8% and 20%, respectively. Overall 5-year survival was 46%. Minor response to neoadjuvant chemotherapy (<50%) and residual nodal N2 involvement in stage IIIA had an adverse impact on survival (p < 0.05). CONCLUSIONS: Favorable long-term survival was observed after neoadjuvant chemotherapy with MPV and GC regimens in stage IIIA and IIIB NSCLC, with relatively low postoperative mortality and morbidity. Caution should be taken when offering surgical treatment to patients with minor response to induction chemotherapy and residual N2 disease in view of the significantly reduced survival.     

在微创外科时代对肝内胆管结石外科治疗的再认识

自从20世纪90年代以来，国内肝内胆管结石的相对发病率有所下降；同时，随着影像诊断技术的进步，当前对肝内胆管结石患者已能做出准确的手术前诊断和结石在肝脏中的定位，对肝脏的伴随改变亦能达到清楚的认识。我国肝内胆管结石病的模式，当前趋向是症状趋于轻型化、范围趋于局限化、病程趋于早期化。因此，在肝内胆管结石外科治疗上，亦从以往的对症治疗到当前和今后的彻底性治疗，更多地采用微创外科手段以治愈肝内胆管结石和预防结石再发已成为治疗的重点。早期的肝内胆管结石多是局限于肝内某一个亚肝段或肝段的局限性病变，感染较轻，在病灶以外的肝内胆管系统和肝实质多较正常，亦较少合并肝外胆管结石。所以说早期的肝内胆管结石只是局部的肝内胆管病变，因而外科治疗应是彻底切除病灶，以求达到治愈目的，并恢复胆道系统的生理功能。     

Minimally Invasive Surgical Treatment of Sigmoidal Esophagus in Achalasia

Background  The appropriate surgical intervention for sigmoidal esophagus in the setting of achalasia remains controversial. The objective of this study is to review our experience with minimally invasive myotomy (MIM) and minimally invasive esophagectomy (MIE) in the treatment of these patients. Methods  We reviewed the records of 30 patients (19 men, 11 women); mean age 59.1 years (range 25–83 years) who underwent MIM (n = 24) or MIE (n = 6). Primary variables included perioperative and long-term outcomes. Univariate and multivariate analyses were performed to identify clinical variables predictive of myotomy failure. Results  The operative mortality was zero and median hospital stay was 2 days (MIM) and 7 days (MIE). On follow-up (mean 30.5 months), nine (37.5%) patients undergoing primary MIM had failure requiring redo myotomy (n = 1) or esophagectomy (n = 8). Univariate analysis showed that previous myotomy and duration of symptoms were significant predictors of failure of MIM, with patient age trending toward significance. Multivariate analysis showed age and longer symptom duration to be significant. Conclusions  MIM affords symptomatic improvement in many patients. Age and symptom duration may be preoperative indicators of MIM failure. MIE offers similar symptom relief but is associated with a longer hospital stay. Further prospective studies are required to define the optimum treatment algorithm in the management of these patients. The Society for Surgery of the Alimentary Tract 48th Annual Meeting, Washington DC, May 19–23, 2007.     

Surgical Treatment Results of Burn-Related Oesophageal Strictures

Background

Post-burn oesophageal stricture is a late complication, which may require surgical intervention. The aim of the study was to compare gastric and colonic conduits and to evaluate the safety, efficacy and complications of these techniques.

Methods

Retrospective analysis of all patients treated for burn-related oesophageal strictures between 1989 and 2013. Oesophagectomy was performed via laparotomy and right thoracotomy, and/or cervical incision.

Results

Forty-six patients, including 29 men, aged 17–67 years (mean: 41 years), had burn-related oesophageal strictures. The post-operative follow-up period ranged between 3 months and 30 years. Colonic transposition was used in 23 patients. In 21 patients, the oesophageal substitute was introduced through the posterior mediastinum, and in two patients the retrosternal route was used. Gastric conduit in was used in 21 patients and jejunal interposition in one patient. One patient underwent segmental oesophageal resection with end-to-end anastomosis. One patient had necrosis of the colonic conduit with anastomotic leakage, two patients had oesophago-colonic anastomosis leakage, five developed anastomotic stenosis, and two had respiratory insufficiency. Among patients with a gastric conduit, anastomotic leakage occurred in four, cervical anastomotic stenosis occurred in two, and respiratory insufficiency occurred in three, and one patient had impaired gastric emptying that required surgical re-intervention. Operative mortality was three patients (6.5%).

Conclusions

The use of colonic and gastric conduit is an effective and safe method for restoring the continuity of the gastrointestinal tract, with an acceptable rate of post-operative complications. Patients who undergo oesophageal resection for post-burn stricture require post-operative systematic endoscopic control.

     

Endometriosis Involving the Diaphragm: A Patient-Tailored Minimally Invasive Surgical Treatment

Background

Diaphragmatic endometriosis is a rare presentation of endometriosis and no standardized technique for surgical treatment is available so far. We aim to verify and describe feasibility, safety and post-operative outcomes of patients affected by diaphragmatic endometriosis treated with a minimally invasive video-assisted thoracic approach.

Methods

We prospectively collected data of all patients we operated on at our Institution for diaphragmatic endometriosis between 2015 and 2019. We included all patients with a previous histological diagnosis of pelvic or abdominal endometriosis who have complained chronic thoracic pain or who had two or more episodes of pneumothorax with or without radiological evidence of pleural and diaphragmatic endometriosis.

Results

During the study period, we operated on 22 patients, 20 on the right side, one on the left side and one bilaterally. Indication for surgery was based on symptoms and/or radiological evidence of diaphragmatic disease. Diaphragm was resected and reconstructed according to intraoperative findings; in 11 cases, an additional mesh was used to reinforce the suture. According to our experience with VATS, we shift from an open approach to a uniportal VATS technique.

Conclusions

Surgery for diaphragmatic endometriosis can be safely performed using a minimally invasive VATS approach, which is feasible and safe even when more extensive diaphragmatic resections are required, and it allows a lower post-operative pain compared to the open approach. Moreover, uniportal VATS approach guarantees similar outcomes with better cosmetic results.

     

Long-term Results of Surgical Treatment of Hydatid Disease

Background-Aims: non-radical surgery is the preferred method of treatment of hydatid liver disease, and is associated with low mortality and recurrence rate. The purpose of the study is the retrospective analysis of the outcome of patients who were treated surgically in a single institution.

Material and methods: between 1987 and 2005, 59 patients, mean age 58.2 ± 15.9 (13–83) years, underwent surgery for liver hydatid disease. The patients were reassessed with physical examination, serological tests and radiological examination for the evaluation of the recurrence rate.

Results: most cysts were solitary, the more frequently affecting the right lobe of the liver. Radical surgery was possible in four cases (6.8%) that were classified as PNM stage I. Partial cystectomy and omentoplasty was performed in 37 patients (62.7%) and external drainage with partial cystectomy in 18 patients (30.5%). The hospital morbidity was 27.2% and was found to be related to ASA class (p = 0.019). Hospital mortality was 5.1%. The median follow-up time was 94 (1–228) months and 45 out of 59 patients (76.3%) were reassessed, but no recurrence was recorded. There was no significant difference in morbidity, mortality, and hospital stay between partial cystectomy combined with external drainage or omentoplasty (p > 0.05).

Conclusions: PNM staging seems to be a reliable tool in selecting patients with liver hydatid disease for non-radical or radical surgery. Omentoplasty is an easy and effective surgical method for the treatment of hepatic echinococcosis but is not different than partial cystectomy and external drainage in regard to morbidity, mortality, and recurrence.     

Minimally Invasive Surgical Treatment of Hepatocellular Carcinoma: Long-Term Outcome

Background  

Laparoscopic liver resection for hepatocellular carcinoma (HCC) is still a matter of debate because of the uncertainty of the long-term results and the fear of compromising the oncological resection. Published findings on survival and outcome after laparoscopic liver resection for HCC are scarce still. The aim of the present study was to report the perioperative and long-term outcome of minimally invasive surgical treatment of HCC.