Relationship of postoperative complications to the surgical approach in treating cancer of the proximal portion of the stomach]

The authors have analyzed the interrelationship between postoperative complications and surgical approach in the treatment of carcinoma of the proximal portion of the stomach. The radical operations were carried out upon 140 patients; in 93 of them the transperitoneal approach was applied and in 47-the transpleural one. It has been found that in the transpleural approach the insufficiency of anastomosis sutures and postoperative pancreatitis occur much more seldom, and bronchopulmonary complications rate the first. Such complications are not infrequent after the transperitoneal approach either. The disorders of bronchial permeability constitute the main cause in the occurrence of these complications.     

Aorto-Y-bifurcation graft: Dacron versus PTFE. Preliminary results of a randomized prospective study

A randomized prospective study comparing PTFE-Y and Dacron-Y-grafts with regard to function rate, morphology, hemodynamic differences along the proximal anastomosis and body of the graft, complications and quality of material was performed. Between March 1983 and February 1987, 112 patients were admitted to the study. Randomization including the criteria of age, sex, indication to operation (chronic occlusive disease, aneurysm) run-off, diabetes, nicotine consumption and operative approach (transperitoneal, retroextraperitoneal) followed the methods of adaptive randomization developed by Pocock and Simon and was well balanced. Function rate and complications as well as morphological alterations showed no significant differences in either group. During a mean observation period of 24 months, Group I yielded a 97% and Group II a 95% function rate (Kaplan-Meier). In all patients but one in each group with limb graft occlusions (n = 5) function was regained by successful thrombectomy and profundaplasty. With respect to Doppler ultrasound differences in flow pattern, in four patients with enlarged proximal side-end anastomosis and adequate--not to large--incision is recommended performing the proximal anastomosis.     

腹腔镜治疗肾囊肿16例

目的 探讨腹腔镜手术治疗单纯性肾囊肿疗效。方法 采用经腹腔和经腹膜后腹腔镜技术对16例单纯性肾囊肿行囊肿去顶术,并回顾分析比较20例开放性肾囊肿去顶术。结果 经腹腔途径手术时间与开放手术无显著性差异(P>0.05),经腹膜后途径手术时间显著长于开放手术(P<0.05),腹腔镜手术患者的术中失血量、术后并发症及术后住院时间均显著少于开放手术(P<0.01)。结论 腹腔镜肾囊肿去顶术具有创伤小、术后并发症少及康复快等优点,治疗单纯性肾囊肿的疗效明显优于开放性手术。     

经肾周脂肪囊内入路后腹腔镜肾上腺手术初步探讨

目的探讨经肾周脂肪囊内入路后腹腔镜肾上腺手术的安全性和可行性。 方法2015年1月1日至2018年12月30日,临沂市人民医院共收治252例肾上腺肿瘤患者。其中行经腹腔入路腹腔镜肾上腺手术115例(经腹腔组),行经肾周脂肪囊内入路后腹腔镜肾上腺手术137例(经脂肪囊内组)。经肾周脂肪囊内入路后腹腔镜肾上腺手术方法：手术常规建立腹膜后空间,打开肾筋膜后直接经肾脏中上极与肾周脂肪囊之间的无血管层面分离、解剖肾上腺,行肾上腺全切术或部分切除术。分析、比较两组患者的手术时间、术中出血量、术后住院时间等临床资料。 结果经腹腔入路腹腔镜肾上腺手术115例及经肾周脂肪囊内入路后腹腔镜肾上腺手术137例均顺利完成,无一例中转开放手术。经腹腔入路腹腔镜肾上腺手术平均手术时间(52.7±19.7)min,平均术中出血量(33.1±23.2)ml,平均术后住院时间(3.5±0.9)d。经肾周脂肪囊内入路后腹腔镜肾上腺手术平均手术时间(54.4±22.7)min,平均术中出血量(31.8±21.4)ml,平均术后住院时间(2.8±0.4)d。两组比较,手术时间、术中出血量无统计学差异,经肾周脂肪囊内入路后腹腔镜肾上腺手术组术后住院时间缩短,差异有统计学意义。 结论经肾周脂肪囊内入路后腹腔镜肾上腺手术解剖肾上腺操作简便,患者术后康复较快,是安全可行的手术方式。     

Tactical and technical principles of the surgical treatment of stomach ulcer

On the basis of surgical treatment of 3230 patients with the ulcer disease, of them 582 operated on for an ulcer localized in the stomach, the authors have formulated the indications for the performance of operation in these patients, substantiated the principles of choice of its method. The use of different types of operative interventions permitted to establish that in 98.5% of the patients, it was technically possible to preserve passage through the duodenum in comparatively low lethality (0.86%). A new method for formation of gastroduodenal anastomosis is described. The long-term results of the use of selective proximal vagotomy in gastric ulcer are studied.     

Surgical policy in false aneurysm of proximal anastomosis secondary to reconstruction of aortofemoral segment

The results of surgical treatment of 10 patients with a false aneurysm of the proximal anastomosis are analyzed. An average time for development of a false aneurysm made up 57.2 months. Fluorlon-lavsan vascular woven prosthesis of Russian produce was used in primary reconstruction. Bacteriological examination of operation material was carried out in 9 patients. 8 cases revealed the growth: of Staph. aureus (4) epidermal staphylococcus flora (3) and Proteus vulg. (1). The authors suggest that surgical treatment of patients with false aneurysms of the proximal anastomosis should consist in resection of the aneurysms and revascularization of the extremities from the proximal segment of the aorta with partial or total removal of the old vascular prosthesis. The application of this method in 7 patients allowed to avoid the repeated development of false aneurysms during a mean follow up period of 4.1 years.     

机器人食管裂孔疝修补联合胰腺中段切除、端端吻合术

目的探讨利用机器人手术系统的优势联合进行食管裂孔疝无张力修补与胰腺中段切除、端端吻合术的可行性。 方法优化胰腺中段切除的微创手术入路,利用机器人先行食管裂孔疝的疝内容物的松解复位、缩小裂孔、安放固定补片与胃底折叠术,随后继续进行胰腺中段切除,在近、远两端胰管内置入8号管后行胰腺端端吻合术。 结果避免二次手术与减少手术操作孔数,术后患者恢复良好。复查CT显示胃底复位良好,胰腺肿瘤已切除,胰腺端端吻合处对位良好、支架管在位;术后病理提示近、远端切缘净。 结论经文献检索,本病例报告是国内首例机器人经腹食管裂孔疝无张力修补、胃底折叠术联合胰腺中段切除、胰管成形、端端吻合术。本病例利用机器人联合手术治疗的成功有助于将来可能进行的多疾病联合手术治疗提供经验与思路。     

New approach to the splenic vessels

The transperitoneal approach is used systematically for an arterial or a venous splenorenal anastomosis. However, this approach is associated with high morbidity and mortality rates. Because of our anatomical and surgical findings we have used the retroperitoneal approach to the splenic hilus by means of the lumbar region. The first splenorenal arterial anastomosis with this approach was done in 1972. The approach has proved to be less aggressive since it avoids the danger of damaging the pancreas, it is a more direct approach to the splenic vessels and it provides better exposure and facilitates the anastomosis. In addition, the loss or infection of ascitic fluid in cirrhotic patients is avoided with this approach, as well as intraoperative hemorrhaging caused by the great surplus circulation. There has been neither mortality nor complications in the 13 cases of arterial and venous splenorenal anastomoses that we have done with this method.     

Comparative description of approaches in surgical treatment of aneurysms of descending thoracic aorta

Surgical treatment of patients with thoracic and thoracoabdominal aortic aneurysms is one of the most difficult and topical problems of up-to-date cardio-vascular surgery. Right choice of surgical approach is important condition for effective surgery. This study is dedicated to comparative evaluation and definition of clear indication for choice of surgical approach in reconstruction of thoracic aneurysms. It is concluded that thoracotomy through 3(rd) intercost is preferable in isolated lesion of isthmus and proximal part of descending aorta. Approach through 5(th) intercost is not recommended in this localization of aneurysm. Prosthesis of all descending thoracic aorta (from arch to diaphragm) must be performed through double left-sided thoracotomy with single skin incision (left-sided double thoracotomy through 3(rd) and 6(th) intercosts from single S-type skin incision). This approach always permits to perform surgical reconstruction of distal part of aortic arch, isthmus and all descending aorta, forms optimal conditions for creation of proximal and distal anastomosis.     

Comparison of lumbar flank approach and transperitoneal approach for radical nephrectomy

A retrospective analysis based on Robson's tumor stage classification was performed on 56 patients with renal cell carcinoma who had undergone radical nephrectomy through a lumbar flank approach and 35 who had through a transperitoneal approach. The 5-year survival rates of patients with nephrectomy through the lumbar approach for Robson's stage 1, stage 2 and stage 3 were, respectively, 93.1, 70.4 and 60.0%. In comparison, the respective 5-year survival rates of patients with nephrectomy through the transperitoneal approach for Robson's stage 1, stage 2 and stage 3 were 90.5, 72.2 and 25.0%. As a result, there was no significant difference in survival rates between the two surgical procedures for any of the three Robson's stages. It is further suggested that the lumbar flank approach for radical nephrectomy does not result in poorer prognosis than does the transperitoneal approach, though transperitoneal and thoracoabdominal approaches have been generally recommended.     

Clinical signs, diagnosis and surgical treatment of extrahepatic biliary duct tumors]

Experience of surgical treatment of 271 patients the extrahepatic biliary ducts tumor for the 1992-1999 yrs period is presented. Indirect signs of extrahepatic biliary ducts tumor were revealed in 84% of observations. Depending on the tumor localization the trustworthiness of the endoscopic retrograde pancreatocholangiography method had constituted from 79.8 to 96.4%. Correct diagnosis was established before the operation in 94.3% of patients. Radical operation was done in 93 (34.3%) of patients, including 22 with proximal localization of tumor, 13--with central one, 10--distal, 48--terminal. Palliative operation was performed in 178 patients, in 76 of them biliodigestive anastomosis was done. Total postoperative mortality was 14.8%.     

Retroperitoneal Aortobifemoral Bypass by a Combination of Horseshoe Kidney and Aortoiliac Occlusive Disease with Stent Thrombosis

Bilateral aorto-profunda femoris bypass with Dacron bifurcation graft was performed by a patient with aortoiliac occlusive disease (AIOD) and horseshoe kidney (HSK) who had undergone stenting of the right common iliac artery and of the left superficial femoral artery with subsequent stent thrombosis as well as significant subrenal aortic stenosis. As endovascular treatment was not feasible and surgical treatment by means of transperitoneal incision would be associated with high risk of damage to the HSK, the operation was successfully accomplished through left pararectal retroperitoneal approach.     

食管胃结合部腺癌手术方式的选择

目的探讨食管胃结合部腺癌（AEG）合理的手术方式。方法检索2004年1月至2013年12月第三军医大学西南医院实施手术治疗的AEG病例资料,按年份分析AEG的发病趋势,AEG3种亚型的构成比,Siewert分型与手术路径、切除范围、消化道重建方式的关系,以及机械吻合器和腹腔镜技术介入后AEG手术方式的变化情况。结果共纳入AEG患者563例,男443例,女120例;年龄15～91岁,平均年龄59岁。AEG在所有胃腺癌中所占比例约为25．897％（563／2174）。2004—2013年,AEG在当年胃腺癌中所占比例分别为18．89％（27／143）、14．81％（20／135）、17．06％（29／170）、14．21％（28／197）、19．78％（36／182）、33．64％（72／214）、31．17％（72／231）、29．31％（85／290）、30．42％（87／286）、37．15％（107／288）。SiewertI型AEG患者52例（9．24％）、Ⅱ型424例（75．31％）、11I型87例（15．45％）。手术路径：52例SiewertI型AEG患者均采用经胸路径;424例SiewertU型AEG患者中,采用经胸路径45例（10．61％）、经胸腹联合路径12例（2．83％）、经腹路径367例（86．56％）;87例Siewert111型AEG患者均采用经腹路径。切除范围：52例SiewertI型AEG患者均行食管下段及近端胃切除;424例Siewert1I型AEG患者中,行近端胃切除167例（39．39％0）、全胃切除257例（含残胃癌27例,60．61％）;87例SiewertⅢ型AEG患者均行全胃切除。消化道重建方式：52例SiewertI型AEG患者均行经胸食管胃吻合;424例SiewertII型AEG患者中,行食管胃吻合62例（14．62~70）,保留远端残胃的双通道吻合55例（12．97％）,食管空肠Roux-en-Y吻合248例（58．49％0）、食管空肠Braun吻合59例（13．92％）;87例Siewert111型AEG患者中,行食管空肠Roux-en-Y吻合61例（70．11％）、食管空肠Braun吻合26例（29．89％）。食管胃吻合、食管空肠吻合基本采用机械吻合器完成。自2005年起,腹腔镜技术介入AEG手术,腹腔镜下实施SiewertII型AEG手术239例、SiewertⅢ型AEG手术59例。结论SiewertI型AEG主要采用经胸路径,Siewert1I、11I型AEG手术路径由经胸路径向经腹路径转移,全胃切除比例上升,但尚未形成标准的手术方式。AEG手术方式应从手术的安全性、根治的彻底性、术后生命质量、手术的简约性以及腹腔镜技术的熟练程度等进行合理选择。     

A 1-stage surgical treatment for postherniorrhaphy neuropathic pain: triple neurectomy and proximal end implantation without mobilization of the cord

BACKGROUND: The recommended surgical treatment for chronic neuropathic pain after herniorrhaphy has been a 2-stage operation including: (1) ilioinguinal and iliohypogastric neurectomies through an inguinal approach and (2) genital nerve neurectomy through a flank approach. HYPOTHESIS: A 1-stage surgical procedure resecting all 3 nerves from an anterior approach avoids a second operation through the flank and successfully treats chronic neuralgia. SETTING: A private practice dedicated to abdominal wall hernia surgery in general community hospitals. PATIENTS: Between 1995 and 2001, 49 patients underwent triple neurectomies with proximal end implantation to treat chronic postherniorrhaphy neuralgia. INTERVENTION: Triple neurectomy of the ilioinguinal, iliohypogastric, and genital nerves performed under local anesthesia with implantation of their proximal ends and without mobilization of the spermatic cord. RESULTS: Two patients (4%) reported no improvement. Eighty percent of patients recovered completely, and 16% had transient insignificant pain with no functional impairment. These results are comparable to the results of the 2-stage operation. CONCLUSIONS: Simultaneous neurectomy of the ilioinguinal, iliohypogastric, and genital nerves without mobilization of the spermatic cord is an effective 1-stage procedure to treat postherniorrhaphy neuralgia. It is performed under local anesthesia and avoids testicular complications. Proximal end implantation of the nerves prevents adherence of the cut ends to the aponeurotic structure of the groin, which can result in recurrence of the pain.     

Total aortic arch replacement through the L-incision approach

BACKGROUND: Even though the median sternotomy is the standard approach for surgery involving the aortic arch, access to the site of distal anastomosis is problematic when the aortic pathology involves the distal arch. We recently developed an "L-incision" approach (a combination of a left anterior thoracotomy and upper half median sternotomy) for total arch replacement. METHODS: We reviewed our surgical technique and operative results for 11 patients who underwent total aortic arch replacement through the L-incision between July 1999 and July 2000. With a patient in a left anterolateral position, a left anterior thoracotomy was performed through the fourth to sixth intercostal space. An upper half median sternotomy followed. Operative exposure was enhanced with spring retractors. The proximal anastomosis (between the four branched graft and ascending aorta) was accomplished first. Upon completion of the proximal anastomosis, the heart was reperfused from one branch of the graft. The three arch vessels were subsequently reconstructed under deep hypothermia and retrograde cerebral perfusion. Antegrade cerebral perfusion was accomplished through the graft as the distal anastomosis (between the graft and descending thoracic aorta) was performed. RESULTS: No early operative deaths were observed. One patient sustained a permanent neurologic deficit. A transient recurrent laryngeal nerve palsy lasting 1 month occurred in 1 patient. No patient required reoperations for bleeding, nor did any patient develop a postoperative phrenic nerve palsy, aspiration pneumonia, or renal dysfunction. CONCLUSIONS: The L-incision allows extensive replacement of the aortic arch and is associated with a low incidence of postoperative bleeding and respiratory insufficiency.     

经腹腔与腹膜后行腹腔镜肾癌根治术的比较

目的:比较经腹腔和腹膜后方式行腹腔镜肾癌根治术的优缺点。方法:随机将60例肾癌患者分别经腹腔或腹膜后方式行腹腔镜下肾癌根治术,比较两组术中、术后的情况。结果:与经腹腔方式比较,腹膜后方式处理肾动脉平均时间、处理肾静脉平均时间、总的手术平均时间较短。但经腹膜和腹膜后方式在估计出血量、术后住院时间、术中并发症和术后并发症发生率上无明显差异。结论:腹腔镜下经腹腔或腹膜后方式行肾癌根治术均有效,但后者在处理肾门和总的手术时间方面更快。     

腹腔镜前列腺癌根治术36例报告

目的探讨腹腔镜前列腺癌根治术(laparoscopic radical prostatectomy,LRP)的可行性和手术技巧。方法2005年3月～2008年12月,行LRP36例。平均年龄64岁(51～73岁),术前病理检查均证实为前列腺癌。T111例,T225例。21例参照Montsouris方法行经腹腔途径LRP,15例行经腹膜外途径LRP。结果平均手术时间265min(155～480min),平均出血量455ml(170～2500ml)。中转开放手术3例,其中2例为阴茎背静脉复合体出血,1例为直肠损伤。术后病理报告切缘阳性2例。术后尿管留置10～30d,平均14d,无真性尿失禁发生。术后漏尿6例,尿道狭窄2例。术后平均随访15.5月(2～44个月),穿刺孔皮下种植转移1例,余35例无复发转移。术后1个月前列腺特异抗原(PSA)0～5.85ng/ml。结论LRP治疗局限性前列腺癌安全有效。熟练掌握盆腔解剖,预先处理阴茎背静脉复合体,熟练掌握膀胱颈重建和镜下吻合技术是成功完成手术的关键。     

Ruptured abdominal aortic aneurysms

Eighty two aortic replacements of ruptured abdominal aortic aneurysms have been performed during the last 6 years. There were 72 male and 10 female patients, and the average age was 71.33 years. Hemorrhagic shock on the admission was observed in 45 patients, and 13 have been operated urgently without any diagnostic procedures. The transperitoneal approach have been used for the operation. Two aorto duodenal and one aorto caval fistulas, have been found. Only exploration (three patients died immediately after laparotomy and 6 after cross clamping) has been done in 9 cases, and the aortic replacement in 70 cases (27 with tubular, and 43 with bifurcated graft). In 3 cases and axillobifemoral bypass had to be done. During the operation eleven patients died, and 30 in postoperative period, during the period between one and 40 days. Total intrahospital mortality rate was 50%, compared with 3.5% for 250 electively operated patients with abdominal aortic aneurysms in same period. In postoperative period the most important cause of death was multiple organs failures. Statistically significant greater mortality rate (p > 0.01%) was found in cases of late operative treatment, hemorrhagic shock, intra-operational bleeding, ruptured front wall, suprarenal cross clamping and in patients older than 75 year. In complicated cases such as juxtarenal aneurysm, 3 sutures parachute technique for proximal anastomosis, a temporary transection of the left renal vein, and intraaortal balloon occlusive catheter for proximal bleeding control are recommended.     

COMPARISON OF 3 SURGICAL APPROACHES TO LAPAROSCOPIC ADRENALECTOMY: A NONRANDOMIZED, BACKGROUND MATCHED ANALYSIS

PURPOSE: To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches. MATERIALS AND METHODS: From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40. RESULTS: To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive. CONCLUSIONS: Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.     

Retroperitoneal aortofemoral bypass using a reversed L-shaped prosthesis

An extraperitoneal approach for aortofemoral bypass has proven superior to the transperitoneal approach. The incision starts at the tip of the eleventh rib and extends obliquely downward to 2 inches above the femoral point, where it turns further downward over the femoral artery. This approach is especially suitable for a reversed L-shaped prosthesis which extends from the aorta directly to the left femoral artery and crosses the abdomen subcutaneously to the right groin, where an anastomosis is made with the right femoral artery. The operation is simple and rapid. Morbidity is reduced and recovery is accelerated. The same incision is used to perform aortoiliac endarterectomy. Fifteen patients with occlusive disease and twenty-one with aneurysms received reversed L-shaped prostheses through an extraperitoneal approach. The procedure was superior to that involving a transperitoneal approach to the aorta and the reversed L-shaped graft was superior to the Y graft for replacement of the iliac arteries.