盆腔淋巴结计数的应用解剖学研究及其临床意义

目的 探讨根治性膀胱全切术中盆腔不同清扫范围内淋巴结的清扫数目作为衡量盆腔淋巴结清扫(PLND)手术质量标准的可行性。方法 在19具成人尸体标本上模拟行超扩大PLND术,并将范围分为标准、扩大、超扩大3级及10个解剖区域,对每个区域淋巴结分别清扫及计数。计算超扩大、扩大和标准清扫解剖区域之内清除的淋巴结总数目及其变异系数(CV)。结果 超扩大PLND术产生的淋巴结数目29~72个,平均(46.1±12.5)个;扩大清扫为23~69个,平均(41.3±10.8)个;标准清扫为18~39个,平均(28.9±7.2)个;CV分别为27.2%、26.2%与25.1%。结论 盆腔各解剖区域淋巴结数目存在较大的个体差异。在根治性膀胱切除术中,应用最低淋巴结计数作为衡量PLND手术质量标准的合理性和可行性需进一步探讨。     

腹腔镜下精准解剖定位行前列腺癌或膀胱癌根治术降低术后苏醒延迟发生风险

目的 探讨腹腔镜下前列腺癌或膀胱癌根治术术后苏醒延迟的危险因素,为临床早期防治提供信息.方法 选择2016年9月～2019年1月期间于南通市第二人民医院行腹腔镜下前列腺癌或膀胱癌根治术治疗的327例患者作为观察对象,对患者的临床资料、手术资料进行收集,统计术后苏醒延迟发生率,经Logistic回归分析法分析苏醒延迟的危...     

腹腔镜下全膀胱切除术治疗膀胱癌12例

目的 探讨膀胱癌患者使用腹腔镜下全膀胱切除术的临床应用效果.方法 回顾分析了2003年8月～2008年9月之间12例行腹腔镜下全膀胱切除术的膀胱癌患者的临床资料.结果 手术时间为(280 + 48)分钟,术中出血(260 + 28.6)ml;无严重并发症发生,到目前为止,在全部12例患者中,有两例死亡.其中一位患者因合并有宫颈癌转移而只存活了14个月,另一位患者由于多处于扩散30个月后死亡,其余患者目前仍然健康活着.结论 腹腔镜下全膀胱切除术创伤小、出血较少,对患者免疫功能影响较小,并且能够遵循根治肿瘤的原则,彻底切除淋巴结,在应用上更具价值.     

超声引导下腹横平面阻滞与切口局部浸润对腹腔镜膀胱癌根治术患者快速恢复的影响

目的在加速康复外科(ERAS)的背景下,探讨超声引导下腹横肌平面(US-TAP)阻滞与局部伤口浸润(LA)对腹腔镜膀胱癌根治术患者快速恢复的影响。方法将择期行腹腔镜膀胱癌根治术的70例患者随机分为:对照组(C组,n=35):局部伤口浸润联合静脉镇痛;研究组(S组,n=35):超声引导下TAP阻滞联合静脉镇痛,该组患者在超声引导下行双侧TAP阻滞,每侧注射0.35%罗哌卡因20 mL(共40 mL)。所有患者围术期均采用加速康复外科(ERAS)方案,术毕两组患者均使用舒芬太尼静脉自控镇痛泵。观察并记录两组患者不同时间点静息及运动的视觉模拟疼痛(VAS)评分及术后快速康复指标;同时记录两组患者24 h阿片类药物消耗量、术后首次静脉镇痛(PCIA)按压时间、24 h内PCIA有效按压次数、患者镇痛满意度评分及不良反应(恶心、呕吐、切口感染和皮肤瘙痒)的发生情况。结果 S组患者术后24和48 h的静息和运动VAS疼痛评分较对照组显著降低(P0.05),首次肠道排气时间、首次下地时间及出院时间明显缩短(P0.01);S组术后首次PCIA按压时间明显迟于C组,PCIA有效按压次数明显少于C组,24 h舒芬太尼消耗总量、恶心呕吐的发生率明显低于C组(P0.05),两组在切口感染和皮肤瘙痒方面意义无统计学差异。结论与局部伤口浸润联合静脉镇痛相比,超声引导下TAP阻滞联合静脉镇痛更有利于腹腔镜膀胱癌根治患者术后早期活动,促进快速康复,并可缩短住院时间。     

胃间质瘤的腹腔镜手术治疗及临床疗效分析

目的:探讨腹腔镜手术治疗胃间质瘤的可行性及安全性。方法:回顾分析解放军总医院肿瘤外科2010年3月~2014年9月期间经腹腔镜手术治疗的50例胃间质瘤患者的临床资料。结果:平均手术时间为(105.7±59.0)min,术中出血为(50±53.9)mL;术后进食清流食时间为(4.6±1.8)d,术后平均住院时间为(8.7±6.2)d,无手术死亡病例。肿瘤直径为1.0~16.0 cm,平均直径5.6 cm。CD34阳性者45例(90.0%),CD117阳性者42例(84.0%),S-100阳性者5例(10.0%)。中位随访23.3(1~55)个月,1例术后12个月发现肝转移,无再次手术及死亡病例。结论:对于局部可切除胃间质瘤,腹腔镜手术是一种安全、有效的治疗方式,肿瘤大小并不是手术绝对禁忌症。     

经尿道膀胱肿瘤电切术后正负性情绪对肌层浸润性膀胱癌患者预后的影响

目的:探讨经尿道膀胱肿瘤电切术后正负性情绪对肌层浸润性膀胱癌患者预后的影响。方法:选取我院2016年6月至2017年6月期间收治的90例肌层浸润性膀胱癌患者作为研究对象,术后1周进行正负情绪评定,采取一般资料调查问卷,1年后,对患者的生存情况采取电话随访,运用Log-rank检验及Cox回归分析对影响患者的预后因素进行分析。结果:肌层浸润性膀胱癌患者1年的生存率为80.00%,家庭人均月收入、居住地、病理级别、复发瘤分期均是影响患者预后的主要因素,具有统计学意义(χ~2=11.347,13.611,9.938,7.280;P0.05),性别及年龄、文化程度、工作情况均无统计学意义;采用多元逐步Cox回归分析患者术后正性情绪、负性情绪,结果显示:术后正性情绪(0.753;95%CI=0.642～0.864)是患者的有利因素,术后负性情绪(1.165;95%CI=1.123～1.210)是危险因素;经过校正后,正性情绪(0.847;95%CI=0.736～0.958)仍然影响肌层浸润性膀胱癌患者的预后,而负性情绪(1.035;95%CI=0.998～1.072)对预后的影响不再显著。结论:应用经尿道膀胱肿瘤电切术对患者疗效较好,术后情绪影响肌层浸润性膀胱癌预后,其中正性情绪比负性情绪对患者预后的影响更加重要。     

探讨延续性护理在膀胱癌术后膀胱灌注化疗中的应用效果

目的探讨延续性护理在膀胱癌术后膀胱灌注化疗中的应用效果。方法本次选取研究对象为2016年10月至2018年03月在我院收治的70例膀胱癌术后膀胱灌注化疗患者,随机分为对照组和观察组,每组各35例。对照组给予常规护理干预,观察组于对照组基础上给予延续性护理干预,对两组患者的SF-36生活质量评分及治疗依从性进行观察及评估。结果观察组35例膀胱癌术后膀胱灌注化疗患者的生活质量评分(躯体健康70.36±5.65分、心理健康72.02±5.78分、社会功能70.42±5.70分、精力75.65±6.02分)高于对照组数据(P0.05)。观察组35例膀胱癌术后膀胱灌注化疗患者的治疗依从性97.14%(34/35),高于对照组数据71.43%(25/35)(P0.05)。结论于膀胱癌术后膀胱灌注化疗中应用延续性护理干预具有较高的临床价值,能够在提高治疗依从性的基础上改善生活质量,值得应用及推广。     

腹腔镜病灶切除术治疗子宫肌瘤的疗效分析

目的:分析腹腔镜病灶切除术应用于子宫肌瘤治疗的效果及安全性.方法:选取2020年5月至2022年5月收治的86例子宫肌瘤患者,随机分组,对照组(43例)行开腹手术治疗,研究组(43例)行腹腔镜病灶切除术治疗,比较两组术后1个月的临床疗效及随访安全性.结果:与对照组比较,研究组手术时间、肛门排气时间及住院时间更短,术中出血量更少,总有效率更高,术后疼痛视觉模拟评分法(Visual analogue scale,VAS)评分、并发症发生率及复发率均更低(P<0.05).结论:子宫肌瘤患者应用腹腔镜病灶切除术治疗,可减轻术中创伤,缓解患者术后疼痛,缩短术后恢复时间,有利于减少并发症及复发.     

23例腹腔镜下阴式全子宫切除术的护理经验体会

目的 总结腹腔镜辅助下阴式全子宫切除术(LAVH)的护理经验.方法 收集我院2013年11月～2014年11月共23例行腹腔镜辅助下阴式全子宫切除术患者的临床及护理资料.结果 本组23例患者均成功行腹腔镜辅助下阴式子宫切除术,其中:子宫肌瘤9例(39.1％),子宫腺肌病9例(39.1％),子宫脱垂2例(8.7％),功能性子宫出血2例(8.7％),宫颈重度不典型增生1例(4.4％);平均年龄47.1岁,手术时间(101.3±45.7)min,术中出血(82.5±57.5)ml,住院时间(12.75±4.83)d,术后低热发生率73.9％,无严重并发症的发生.结论 腹腔镜辅助下阴式全子宫切除术具有手术创伤小,术后恢复快等优点,优质的护理对于手术成功及术后恢复具有重要的意义.     

舒芬太尼注射液联合丙泊酚维持麻醉对膀胱癌腹腔镜根治术患者恢复质量、应激反应及血流动力学指标的影响

目的:研究舒芬太尼联合丙泊酚维持麻醉对膀胱癌腹腔镜根治术患者恢复质量、血流动力学指标及应激反应的影响.方法:选取我科109例膀胱癌腹腔镜根治术患者作为研究对象,以抽签法分组.对照组54例给予瑞芬太尼注射液联合丙泊酚维持麻醉,观察组55例给予舒芬太尼注射液联合丙泊酚维持麻醉.观察两组患者恢复质量、血流动力学、应激反应.结果:观察组定向力恢复时间、唤醒时间、拔管时间均小于对照组(P<0.05);观察者插管时及拔管时,心率、平均动脉压均大于对照组(P<0.05);观察组患者麻醉后、麻醉后24h的葡萄糖、白细胞介素-6、C反应蛋白均小于对照组(P<0.05).结论:舒芬太尼注射液联合丙泊酚能够稳定血流动力学指标,改善应激反应,提高术后恢复质量.     

Characteristics of pelvic lymph node metastases in prostatic adenocarcinoma: a study of 83 cases

Pelvic lymph node dissection (PLND) is currently the most accurate staging modality for lymph node metastases in prostate adenocarcinoma. There is no consensus on the optimal sampling method of PLND specimens among pathologists. This study analyzed the effectiveness of the submission of entire adipose tissue in 451 cases and its impact on total lymph node yield and detection of positive lymph nodes. The sizes of metastatic foci and positive lymph nodes in 83 cases were also studied. Submission of entire adipose tissue increased the lymph node yield and positive lymph node detection by 36.7 % and 1.99 %, respectively. Three cases had positive lymph nodes exclusively in adipose tissue. Of the patients examined, 68% had the largest positive lymph node, <1 cm. In conclusion, it was noted that metastases from prostate cancer were frequently small and seen within small lymph nodes. Submission of entire adipose tissue substantially increased the lymph node yield, but its impact on the detection of additional positive lymph nodes was low. Submission of the entire adipose tissue may be considered as an option in patients with high-risk factors for lymph node metastases.     

Sentinel node evaluation in prostate cancer

Sentinel lymph node (SLN) based pelvic lymph node dissection (PLND) in prostate cancer (PCa) is appealing over the time, cost and morbidity classically attributed to conventional PLND during radical prostatectomy. The initial report of feasibility of the SLN concept in prostate cancer was nearly 20 years ago. However, PLND based on the SLN concept, either SLN biopsy of a single node or targeted SLN dissection of multiple nodes, is still considered investigational in PCa. To better appreciate the challenges, and potential solutions, associated with SLN-based PLND in PCa, this review will discuss the rationale behind PLND in PCa and evaluate current SLN efforts in the most commonly diagnosed malignancy in men in the US.     

“镂空法”在胸腔镜食管癌根治术中清扫喉返神经旁淋巴结的应用价值

目的 探讨在胸腔镜食管癌根治术中采用“镂空法”行喉返神经旁淋巴结清扫的临床应用价值。方法 回顾性队列研究。纳入2017年1月—2020年6月厦门大学附属第一医院胸外科178例T1~T3期食管癌患者临床资料,其中男105例、女73例,年龄41~78岁。178例患者均采用微创McKeown食管癌切除术治疗,根据术中喉返神经淋巴结的清扫方式不同分为两组:采用传统方法100例纳入传统组,采用 “镂空法”78例纳入镂空组。比较两组患者术中出血量、手术时间、喉返神经旁淋巴结清扫数、术后喉返神经损伤发生率及损伤程度、术后胸腔引流量、食管吻合口瘘及肺部相关并发症。结果 两组患者年龄、性别、肿瘤病灶部位及临床分期等基线资料比较,差异均无统计学意义(P值均＞0.05)。镂空组喉返神经旁淋巴结清扫数目左侧为(5.28±1.77)枚、右侧为(3.33±1.36)枚,传统组喉返神经旁淋巴结清扫数目左侧为(1.79±0.96)枚、右侧为(1.05±0.88)枚;同侧组间比较,镂空组均多于传统组,差异均有统计学意义(t=15.710、12.841,P值均＜0.01)。镂空组78例中,喉返神经损伤共3例(3.85%),其中轻度损伤2例(2.56%)、中度损伤1例(1.28%);传统组100例中, 喉返神经损伤12例(12.00%),其中轻度损伤8例(8.00%)、中度损伤4例(4.00%);镂空组喉返神经损伤的发生率及损伤程度低于传统组,但组间比较差异均无统计学意义(χ²=3.775, Z=-1.936, P值均＞0.05)。 镂空组肺部感染7例(8.97%)、传统组为20例(20.00%),差异有统计学意义(χ²=4.140,P＜0.05)。两组术中出血量、手术时间、术后胸腔引流量及食管吻合口瘘发生率比较,差异均无统计学差异(P值均＞0.05)。结论 在胸腔镜食管癌切除术中采用“镂空法”清扫喉返神经旁淋巴结是安全、可行的,在增加喉返神经旁淋巴结清扫数目的同时不增加喉返神经损伤的发生率。     

颈中央区淋巴结数目及分布的临床解剖学研究

目的　探讨颈中央区淋巴结的数目及分布规律。 方法　回顾分析2013年6月-2016年6月在我科行中央区淋巴结清扫术的甲状腺乳头状癌患者的临床资料。统计分析颈部中央区及各亚区淋巴结的数目。 结果　双侧中央区淋巴结(9.86±3.36) 枚（4~20枚）。左侧中央区淋巴结(6.24±2.23) 枚（2~14枚）。右侧中央区淋巴结(7.77±2.79) 枚（2~15枚）。喉前区淋巴结(1.29±0.75) 枚（0~4枚）,气管前区(2.62±1.26) 枚（0~7枚）,左侧气管旁区(2.38±1.34) 枚（0~6枚）,右侧气管旁区(3.97±1.97) 枚（0~10枚）。四个亚区淋巴结比例分别为：12.69%,24.47%,24.15%,38.47%。其中右侧气管旁区的两个亚区右侧喉返神经外侧区(1.35±1.27) 枚（0~6枚）,右侧喉返神经内侧区(2.64±1.75) 枚（0~9枚）。 结论　本研究报道颈中央区淋巴结的数目及分布结果,可为外科医生在行颈中央区淋巴结清扫术时提供解剖学依据。     

Correlation between retroperitoneal lymph node size and presence of metastases in nonseminomatous germ cell tumors

Eighty-five patients had staging laparoscopic retroperitoneal lymph node dissection (L-RPLND) for nonseminomatous germ cell tumors at our institution. The largest lymph node size was measured and presence or absence of metastatic disease was determined. A total of 1139 lymph nodes have been removed and in 27 (31.8%) patients, metastases in one or more lymph nodes were detected. There were 338 (29.7%) hilar, 259 (22.7%) paraaortic, 221 (19.4%) interaortocaval, 171 (15%) paracaval, 133 (11.7%) preaortic and 17 (1.5%) precaval lymph nodes. The total number of lymph nodes with metastases was 74 (6.5%), and 1065 (93.5%) nodes did not have any metastases. The average size of a lymph node with metastases was 1.05 (0.3-3), and without metastases it was 0.55 (0.1-2.5) cm, (p<0.001). If we use > 1 cm size of a lymph node as a "cut-off" value for enlargement and presence of metastases, 60% of metastatic lymph nodes would be missed since they were all ≤ 1 cm. Our results have shown that decreasing size of lymph nodes which are considered positive from > 1 cm to 0.7 -0.8 cm can be recommended, with specificity and sensitivity equal 70%.     

The extent of agreement between frozen and paraffin block data from axillary samples in patients with early-stage breast cancer

IntroductionPatients with early-stage breast cancer currently undergo sentinel lymph node dissection to evaluate the axillary region. Frozen tissue blocks are evaluated intra operatively and paraffin-embedded samples are studied postoperatively. We explored whether sentinel lymph node dissection adequately reflected axillary involvement (as revealed by the paraffin blocks) in patients with early-stage breast cancer; we sought to avoid axillary dissection.MethodsThe agreement/non-agreement rates between the results of axillary ultrasonography and biopsy, sentinel lymph node and axillary dissections, and frozen and paraffin block results, were retrospectively analyzed for 200 patients with early-stage breast cancer. The positive predictive values and accuracies were recorded in those who were positive on both ultrasonography and biopsy. The negative predictive values were calculated for doubly negative cases.ResultsThe frozen and paraffin block results disagreed in 19 (9.5 %) cases and agreed in 181 (90.5 %). The frozen block and dissection results differed in five of 38 patients who underwent axillary dissection (AD) (one patient did not undergo AD); the results were in agreement in 32. Of the 19 block-disagreement cases, 16 were in the non-neoadjuvant chemotherapy (NAC) group and three in the NAC treatment group. Clinically, the negative predictive values of the frozen and paraffin block data were 80 % in patients lacking axillary involvement.ConclusionParaffin block evaluations only (thus, without frozen block examinations) of early-stage breast cancer lymph nodes seem to be sufficient to guide treatment. Also, a thorough clinical examination (with ultrasonography and axillary biopsy) reduces the dissection rate and the associated functional impairments.     

The value of ultrasound in the assessment of cervical and abdominal lymph node metastases and selecting surgical strategy in patients with squamous cell carcinoma of the thoracic esophagus treated with neoadjuvant therapy

PurposeTo establish the role of ultrasound (US) in the assessment of cervical and abdominal lymph node metastases and its impact on making decision about surgical strategy in patients with squamous cell carcinoma of the thoracic esophagus.Material/MethodsThe results of US lymph node assessment before and after a neoadjuvant treatment in 83 patients were compared with the results of histopathological evaluation of lymph nodes harvested during surgery (transthoracic esophagectomy and 2-field extended or 3-field lymph node dissection). A diagnostic value of cervical and abdominal US in terms of sensitivity, specificity, positive and negative predictive value after a neoadjuvant treatment were determined.ResultsThe sensitivity, specificity, positive and negative predictive value of the US assessment of cervical lymph node metastases were 100%, 96%, 81% and 100%, respectively. The sensitivity, specificity, positive and negative predictive value of the US assessment of abdominal lymph node metastases were 82%, 94%, 91.5% and 87%, respectively.ConclusionsThe high sensitivity and specificity of cervical US make this investigational method sufficient in the assessment of cervical nodal involvement. In esophageal cancer patients with negative cervical lymph nodes on US, three-field lymph node dissection could be avoided. In patients with positive cervical lymph nodes on US one should consider to extend lymph node dissection about lymph nodes of the neck to achieve a curative resection. In patients with negative abdominal US this investigation should be supplemented by more detailed diagnostic methods.     

两孔法腹腔镜辅助右半结肠癌完整系膜切除术技术要点及短期疗效

目的　探讨两孔法腹腔镜辅助完整结肠系膜切除术治疗右半结肠癌的手术要点及短期疗效。 方法　回顾分析广东省人民医院胃肠外科2019年3月至2019年12月两孔法腹腔镜辅助完整结肠系膜切除术治疗右半结肠癌17例患者的临床资料,评估手术指标和疗效。 结果　本组患者手术切口长度（5.6±3.1）cm、手术时间（126.0±27.8）min、术中出血量（21.2±14.9）mL、清扫淋巴结（33.8 ± 11.2）枚,阳性淋巴结75%分位数为1枚（0 ~ 9枚）。术后首次排气时间（1.5±0.6）d,首次进流质饮食时间（1.3 ± 0.6）d,首次进半流质饮食时间为（4.1±2.3）d,术后并发症5例（淋巴漏3例、腹腔出血1例、肺部感染1例）,术后平均住院时间（7.9±4.5）d。 结论　两孔法腹腔镜辅助完整结肠系膜切除术治疗右半结肠癌安全可行,术中淋巴结清扫时应注意避免损伤胃-结肠静脉干。     

Does open biopsy before mastectomy affect the prevalence of so-called axillary lymph node micrometastases detected immunohistochemically

OBJECTIVE: To determine the effect of a previous open biopsy on the presence of immunohistochemically detected micrometastases, particularly single cells, in axillary lymph nodes in patients with "node-negative" invasive breast carcinoma. METHODS: Node-negative breast cancer patients were divided into group 1 (diagnostic frozen-section biopsy with immediate mastectomy and axillary dissection) and group 2 (open surgical biopsy with temporally delayed mastectomy and axillary dissection). Archival slides of lymph nodes were examined and new sections stained with hematoxylin-eosin and immunohistochemically with a cytokeratin cocktail to detect micrometastases. RESULTS: Four (12%) of 33 patients had unequivocal lymph node metastases on additional hematoxylin-eosin sections (3 cases) or review of original material (1 case). Immunohistochemical analysis contributed additional data in only 1 group 2 patient. In this case a single strongly keratin-positive sinus-based cell was detected in 1 lymph node. CONCLUSION: The study suggests that previous surgical biopsy of the breast does not increase the incidence of immunohistochemically detected keratin positive cells in axillary lymph nodes.