Extrapleural pneumonectomy for malignant pleural mesothelioma

Standard treatment for malignant pleural mesothelioma (MPM) has not been proved yet. However, it has been recognized that extrapleural pneumonectomy (EPP) is a treatment of choice for epithelial MPM when combined with adjuvant therapies though EPP may frequently cause fetal complications. We report 5 cases of MPM with EPP, including 1 with good prognosis. Sixteen patients with MPM were admitted to our hospital between 1988 and 2003. Five patients underwent EPP, among which 4 were male and 1 female with ages from 46 to 61 years old. Histologically, 3 of them were epithelial and 2 were biphasic. Those with biphasic experienced acute respiratory failure and empyema, and died 81 days and 8 months after the surgery respectively. Among those with epithelial MPM, 2 are alive with no recurrence at 129 and 29 months after the surgery, and the other, followed by postoperative radiotherapy, died at 12 months. More cases with EPP or randomized controlled trials regarding EPP are necessary to evaluate efficacy of EPP for MPM.     

Surgically debulked malignant pleural mesothelioma: Results and prognostic factors

Background: We analyzed morbidity and mortality, sites of recurrence, and possible prognostic factors in 95 (78 male, 17 female) patients with MPM on phase I–III trials since 1990. A debulking resection to a requisite, residual tumor thickness of ≤ 5 mm was required for inclusion. Methods: Preoperative tumor volumes were determined by three-dimensional reconstruction of chest computerized tomograms. Pleurectomy (n=39) or extrapleural pneumonectomy (EPP; n=39) was performed. Seventeen patients could not be debulked. Preoperative EPP platelet counts (404,000) and mean tumor volume (491 cm³) were greater than that seen for pleurectomy (344,000, 114 cm³). Results: Median survival for all patients was 11.2 months, with that for pleurectomy 14.5 months, that for EPP 9.4 months, and that for unresectable patients 5.0 months. Arrhythmia (n=14; 15%) was the most common complication, and there were two deaths related to surgery (2.0%). Tumor volume of >100 ml, biphasic histology, male sex, and elevated platelet count were associated with decreased survival (p<0.05). Both EPP and pleurectomy had equivalent recurrence rates (27 of 39 [69%] and 31 of 39 [79%], respectively); however, 17 of 27 EPP recurrences as opposed to 28 of 31 pleurectomy recurrences were locoregional (p₂=0.013). Conclusions: Debulking resections for MPM can be performed with low operative mortality. Size and platelet count are important preoperative prognostic parameters for MPM. Patients with poor prognostic indicators should probably enter nonsurgical, innovative trials where toxicity or response to therapy can be evaluated. Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

Right extrapleural pneumonectomy for malignant mesothelioma via median sternotomy or thoracotomy? Short- and long-term results.

OBJECTIVE: To examine the short- and long-term results of right extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma (MM) via median sternotomy or thoracotomy. METHODS: We analysed the results of EPP in consecutive patients with early stage MM undergoing a radical surgery protocol for MM over a 7-year period. Initially thoracotomy, but later median sternotomy, was the incision of choice for right-sided tumours. The effects of the change of approach on perioperative course and survival were analysed. RESULTS: EPP was performed in 105 patients (50 left thoracotomy, 22 right thoracotomy, 28 sternotomy, 5 combined sternotomy and right thoracotomy). Operation time was faster with median sternotomy than right thoracotomy (p=0.008). Right thoracotomy was associated with higher epidural infusion volume in the first 3 days than median sternotomy (p<0.001). There were fewer postoperative complications in the sternotomy group (p=0.05). There were no differences in pathological stage, completeness of resection or duration of postoperative stay. Median survival following left thoracotomy, right thoracotomy and median sternotomy was 18.3, 8.5 and 17.7 months, respectively (p=0.02). Planned neoadjuvant or adjuvant chemotherapy was more common following median sternotomy than right thoracotomy (p=0.01). However, compared with the left thoracotomy and sternotomy groups, right EPP performed via thoracotomy was an independent predictor of poor prognosis (hazard ratio 2.3 (95% confidence intervals, CI 1.3-4.1), p=0.02). No wound complications or tumour recurrence have been observed following median sternotomy. CONCLUSIONS: Median sternotomy should be considered as an alternative approach to thoracotomy for right EPP.     

Complications of laparoscopic cholecystectomy in HIV and AIDS patients

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS).One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy.In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group.Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.     

Delayed hemorrhage following resection of an arteriovenous malformation in the brain

OBJECT: Between 1989 and 2002 the authors treated 416 cases of angiographically confirmed arteriovenous malformations (AVMs) of the brain. METHODS: Three hundred fifty-five patients underwent resection of an AVM; 2% died and 12% experienced a permanent morbidity (1.7% experienced a deterioration of modified Rankin Scale [mRS] score of 3-5). Patient outcomes in this series were based on the Spetzler-Martin grade. For patients with Grade I and II AVMs the rate of permanent morbidity was 1% and the rate of mortality was 0.5%. For patients with Grade III AVMs the morbidity rate was 18.9% (2.7% experienced a deterioration of mRS score of 3-5) and the mortality rate was 2.7%. For patients with Grade IV and V AVMs the morbidity rate was 25.6% (5.1% experienced a deterioration of mRS score of 3-5) and the mortality rate was 7.7%. No patient with a Spetzler-Martin Grade I or II lesion had a worsened outcome due to delayed hemorrhage, whereas 3.6% of patients with a Grade III and 12.8% of patients with Grade IV and V AVMs experienced delayed hemorrhage that led to a permanent downgrade in function. With the introduction of an aggressive postoperative blood pressure protocol (for AVMs with grades > II and sizes > 3.5 cm in diameter) the incidence of delayed postoperative hemorrhage leading to mortality or permanent morbidity decreased from 4.4 to 1%. This difference was significant. Neither case selection nor complications other than delayed hemorrhage changed between these two periods. CONCLUSIONS: In selected cases an aggressive postoperative blood pressure protocol is likely to reduce delayed hemorrhage following AVM resection.     

Infectious complications after hepatic resection

The purpose of this study was to assess the characteristics of surgical infections after hepatic resection (HR) to identify factors accounting for increased postoperative mortality. Advances in operative technique and care have decreased morbidity and mortality after HR. However, infections after HR continue to be a major contributor to postoperative morbidity and mortality. All HR done during a 7-year period were analyzed and compared to our prospective surgical infection database. Factors contributing to infectious complications and mortality were identified. HR (n = 207) were performed with an overall mortality of 5.8 per cent. Nine patients (3.3%) had 18 infections; 6 (60%) had multiple infection sites, most commonly the peritoneum, blood, or wound. Three infected patients died. Lung and line infections occurred in 2 (67%) infection-related deaths. No single comorbidity increased postoperative infection risk, but an average of 6.7 comorbid conditions were present. All infection-related deaths were associated with ventilator-dependence. All infection-related deaths occurred after resection of a mean of four segments. Additional procedures at the time of HR, operative drains, or transfusion requirements did not impact infectious complications or mortality. Methicillin-resistant Staphylococcus sp. was isolated in all infection-related deaths. The mean time from HR to initiation of treatment was 8 days for infection survivors and 13.3 days for infection-related deaths. Infectious mortality after HR remains significant. Contributing risk factors are advanced age, multiple comorbid conditions, and extent of HR. Ventilator-dependence and delays in antibiotic therapy were associated with infectious mortality. Although gram-negative enteric infections were more common, abdominal, lung, and line infections with gram-positive cocci had higher associated mortality; especially when antibiotic resistant strains were present.     

Surgical experience with pancreatic and periampullary cancer

Between 1940 and 1978, 179 patients underwent pancreatic resection (64 total, 102 Whipple, 13 distal) at the Presbyterian Hospital, predominantly for carcinoma of the pancreas and periampullary area. With respect to operative morbidity and mortality and survival, these patients have been compared with 141 patients subjected to pancreatic biopsy only, and with 172 by-passed for palliation. Likewise, total pancreatectomy has been compared to pancreaticoduodenectomy (Whipple) in terms of safety and efficacy. The overall major postoperative complication rate for pancreatic resection was 36%, in contrast with 13.5% for biopsy only and 16.8% for by-pass. Of the resected cases with major complications postoperatively, roughly half died, a mortality of 17.9%. Patients who underwent Whipple resections fared significantly better than did those having total pancreatectomies; the postoperative mortality following 102 Whipples was 14.7%, as compared with 23.4% for total pancreatectomies. Intra-abdominal sepsis accounted for most of the postoperative deaths; nine pancreatic and four biliary leaks or fistulae followed Whipple resections. The later complications were of interest; 18 patients undergoing biliary-en-teric by-pass procedures later developed gastroduodenal obstruction, 15 of whom required reoperation, and in 18 survivors of pancreatic resection, upper gastrointestinal hemorrhage (mostly from marginal ulcers) developed, necessitating surgery in seven. Brittle diabetes was a problem in nine patients following pancreatectomy. Survival rates were discouraging in all categories. For ductal carcinoma of the pancreas, median survival for biopsy only was two months, for by-pass six months, for total pancreatectomy nine months, and for Whipple resection 14 months. There were three five-year survivors following resection, a rate of 4.5%. Five-year survival rates following resection for ampullary, common duct, duodenal, and islet cell cancer were 27.8, 33.3, 27.3, and 37.5%, respectively.

It is concluded that survival after resection for ductal pancreatic cancer is so rare as to be considered more a biologic aberration than a result of radical surgery. Despite theoretical advantages of total pancreatectomy over Whipple resections, our experience would suggest that the latter can be carried out with lower morbidity and mortality, and with equal chance for cure. Resection for pancreatic cancer should not be abandoned, but rather undertaken with greater selectivity. Operative morbidity and mortality can probably be improved additionally by preoperative transhepatic biliary decompression, and later complications reduced by including vagotomy with gastric resection at the time of pancreatectomy and by performing prophylactic gastroenterostomies in conjunction with by-pass procedures.

     

The role of video assisted thoracoscopic pleurectomy/decortication in the therapeutic management of malignant pleural mesothelioma.

OBJECTIVE: Extrapleural pneumonectomy (EPP) has high mortality and morbidity; radical pleurectomy decortication (P/D) carries less mortality but still significant morbidity. This surgery is not suitable for many patients with malignant pleural mesothelioma (MPM) for whom video assisted thoracic surgery (VATS) offers a minimally invasive alternative. We aimed to assess the role of VATS decortication for MPM. METHODS: Over a 9-year period 208 patients underwent therapeutic surgery for MPM in our unit. One hundred and twelve of the patients underwent EPP, 29 had a P/D and 67 had VATS decortication. Sixty-three of the 208 patients (EPP n=13, P/D n=8 and VATS decortication n=42) were 65 years of age or older at the time of the operation (57 males and 6 females, age 70 (65-80) years). In this group we analyzed perioperative morbidity and mortality and long-term survival data using the Kaplan-Meier method. RESULTS: Postoperative stay and 30-day mortality was significantly lower for VATS P/D than for EPP (14.3 days vs 36.6 days, p<0.05 and mortality 7.1% vs 23%, respectively). There was no significant difference in the overall mean survival between the two groups (11.5 months for EPP and 14 months for VATS P/D, p=0.6). CONCLUSION: VATS decortication should be considered in the therapeutic strategy for MPM.     

Relief of tracheal compression by aortopexy

We have performed aortopexy in 12 children with tracheal compression. Six infants had compression secondary to a vascular anomaly (group 1), and the other 6 had previous repair of esophageal atresia (group 2). Eleven of the 12 children are alive after a mean follow-up of 36 months. In group 1, 1 patient died and 3 patients (50%) experienced recurrent respiratory distress. Five infants sustained a major postoperative complication, and the average postoperative hospital stay was 25 days. In group 2, however, aortopexy was uniformly successful. There were no deaths, no postoperative complications, and no cases of postoperative respiratory distress, and the mean postoperative hospital stay was only 10 days. For children with reflex apnea after repair of esophageal atresia, aortopexy is lifesaving and can be performed with minimal morbidity and mortality. Great caution is indicated in children with tracheal compression from other causes.     

Completion pneumonectomy: current indications, complications, and results

OBJECTIVE: Completion pneumonectomy is reported to be associated with high morbidity and mortality, especially when done in patients with benign disease. We review our 9 years of experience with this operation to evaluate the postoperative outcome and long-term results of various indications. METHODS: Between January 1990 and December 1998, 66 consecutive patients underwent completion pneumonectomy (6.8% of all pneumonectomies), and their cases were retrospectively reviewed. The indication was benign disease in 17 patients and malignant disease in 49 patients. In patients with malignant indications there were 14 local recurrences, 4 second primary tumors, 5 metastatic diseases, and 26 indications because of incomplete initial resection. RESULTS: There were no intraoperative deaths, and the postoperative mortality rate was 7.6%. Complications were encountered in 32 (53%) patients, without any significant difference between benign indication (71%) and malignant indication (47%; P =.0923). Bronchopleural fistula was encountered in 5 (7.6%) patients, and empyema was encountered in 7 (11%) patients. The actuarial 5-year survival was 57% for all patients, 65% for those with benign indications, and 54% for those with malignant indications (60% for local recurrence, 50% for second primary tumor, and 56% for incomplete resection), without any difference between benign and malignant indications (P =.9478). CONCLUSIONS: Completion pneumonectomy can be performed with acceptable mortality and morbidity, even in patients with benign disease. Patients with preoperative infection can be managed with bronchial stump covering and adequate postoperative drainage. Although complications are common, they can successfully be managed with a proper understanding of them.     

WHIPPLE'S PROCEDURE: IS IT JUSTIFIED?

Debate continues as to the appropriateness of the Whipple procedure. This retrospective review confirms that it is a worthwhile operation when done by experienced surgeons on suitable patients. Meticulous intra-operative technique must be followed by judicious postoperative care. in this series of 27 Whipple operations major morbidity occurred in 26% of cases. Leakage from the pancreatic anastomosis was infrequent (11%). Various anastomotic techniques were used, depending on the findings at operation. There were no peri-operative deaths and five-year actuarial survival is 63%.     

Effect of Preoperative Biliary Decompression on Pancreaticoduodenectomy-Associated Morbidity in 300 Consecutive Patients

OBJECTIVE: To examine the relationship between preoperative biliary drainage and the morbidity and mortality associated with pancreaticoduodenectomy. SUMMARY BACKGROUND DATA: Recent reports have suggested that preoperative biliary drainage increases the perioperative morbidity and mortality rates of pancreaticoduodenectomy. METHODS: Peri-operative morbidity and mortality were evaluated in 300 consecutive patients who underwent pancreaticoduodenectomy. Univariate and multivariate logistic regression analyses were done to evaluate the relationship between preoperative biliary decompression and the following end points: any complication, any major complication, infectious complications, intraabdominal abscess, pancreaticojejunal anastomotic leak, wound infection, and postoperative death. RESULTS: Preoperative prosthetic biliary drainage was performed in 172 patients (57%) (stent group), 35 patients (12%) underwent surgical biliary bypass performed during prereferral laparotomy, and the remaining 93 patients (31%) (no-stent group) did not undergo any form of preoperative biliary decompression. The overall surgical death rate was 1% (four patients); the number of deaths was too small for multivariate analysis. By multivariate logistic regression, no differences were found between the stent and no-stent groups in the incidence of all complications, major complications, infectious complications, intraabdominal abscess, or pancreaticojejunal anastomotic leak. Wound infections were more common in the stent group than the no-stent group. CONCLUSIONS: Preoperative biliary decompression increases the risk for postoperative wound infections after pancreaticoduodenectomy. However, there was no increase in the risk of major postoperative complications or death associated with preoperative stent placement. Patients with extrahepatic biliary obstruction do not necessarily require immediate laparotomy to undergo pancreaticoduodenectomy with acceptable morbidity and mortality rates; such patients can be treated by endoscopic biliary drainage without concern for increased major complications and death associated with subsequent pancreaticoduodenectomy.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from grastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

Thoracoscopy-assisted Heller myotomy for the treatment of achalasia: results of a minimally invasive technique

BACKGROUND: Several surgical methods have been described to treat achalasia with a recent trend toward utilizing minimally invasive techniques to perform a myotomy. Since 1998 our institution has utilized a minimally invasive thoracoscopy-assisted technique (ThAM) that allows a myotomy to be performed under direct visualization. METHODS: From 1992 to 2002, 57 patients underwent transthoracic Heller myotomy at our institution. Thirty-eight patients (67%) who underwent ThAM were reviewed and compared with 19 (33%) who previously underwent myotomy through a standard open left thoracotomy (OM). RESULTS: There were no operative deaths in the ThAM group (n = 38) and 4 patients (11%) experienced minor morbidity. Four ThAM patients required conversion to open thoracotomy and 2 were lost to follow-up. Of the remaining 32 patients, 29 have improved postoperative dysphagia scores after a mean follow-up of 17 months. Only 4 patients have required further endoscopic or surgical intervention. Compared with the OM group, ThAM patients experienced significantly shorter average surgery time (97 versus 139 minutes), less blood loss (80 versus 155 mL), less postoperative narcotic requirement (8 versus 20 days), and shorter recovery to normal activity (20 versus 73 days). CONCLUSIONS: Thoracoscopy-assisted myotomy results in excellent relief of dysphagia in the short term and would be expected to have long-term results similar to OM. Shorter operating and recovery times as compared with OM without the need for an antireflux procedure makes ThAM an attractive minimally invasive technique.     

Postoperative epidural morphine is safe on surgical wards

The use of epidural morphine for postoperative analgesia outside of intensive care units remains controversial. In this report our anesthesiology-based acute pain service documents experience with 1,106 consecutive postoperative patients treated with epidural morphine on regular surgical wards. This experience involved 4,343 total patient days of care and 11,089 individual epidural morphine injections. On a 0-10 verbal analog scale, patient-reported median pain scores at rest and with coughing or ambulation were 1 (inter-quartile range 3) and 4 (interquartile range 4), respectively. The incidence of side effects requiring medication were as follows: pruritus 24%, nausea 29%, and respiratory depression 0.2%. There were no deaths, neurologic injuries, or infections associated with the technique. Migration of epidural catheters into the subarachnoid space and into epidural veins each occurred twice. Overall, 1,051 of the 1,106 patients (95%) experienced none of the following problems: catheter obstruction, premature dislodgement, painful injections, catheter migration, infection, or respiratory depression. We conclude that postoperative pain can be safely and effectively treated with epidural morphine on surgical wards.     

Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection

BACKGROUND: Recent studies have demonstrated a reduction in hospital stay and postoperative complications in elderly patients undergoing laparoscopy-assisted colectomy, and have attributed the shorter stays and reduced morbidity to the laparoscopic approach. We questioned whether the improved outcomes in these studies were a result of the laparoscopic procedure alone or a result of early postoperative feeding and early hospital discharge. We hypothesized that early feeding in elderly patients undergoing open colorectal resection results in a short hospital stay and favorably affects postoperative morbidity. STUDY DESIGN: Patients aged 70 years and older who were undergoing elective open colon resection were placed on an early postoperative feeding protocol. The early feeding protocol consisted of clear liquids on postoperative day 2, regular diet on postoperative day 3, and discharge to home as tolerated. The main outcomes measurements included early feeding tolerance, hospital stay, postoperative morbidity, and requirement for postoperative assisted care. RESULTS: There were 87 study patients (42 men and 45 women, mean age 77 years). The most common operation was right hemicolectomy (53%). Overall 78 of 87 patients (89.6%) tolerated early feeding. Five patients (5.7%) initially tolerated a diet but required readmission for ileus. Nine patients (10.4%) did not tolerate early feeding initially. The mean hospital stay for all patients was 3.9 days. There were 15 postoperative complications in 13 patients (14.9%), the most common of which was urinary retention. There were no deaths, anastomotic leaks, abscesses, or pneumonia. Only 3 of 86 patients (3.5%) who were previously independent required assisted care after colectomy. CONCLUSIONS: In elderly patients undergoing elective open colon resection, early feeding results in a short hospital stay and low postoperative morbidity. These results are comparable to those reported for laparoscopy-assisted colectomy.     

Aortocoronary bypass following unsuccessful PTCA: experience in 100 consecutive patients

This study reviews the experience in a community hospital with aortocoronary bypass in 100 consecutive patients following failed percutaneous transluminal coronary angioplasty (PTCA) in terms of timing of intervention, morbidity, and mortality. Patients undergoing operation within 24 hours of PTCA are defined as the urgent group (68%) and those with intervention at greater than 24 hours, the elective group (32%). Mean interval from PTCA to operation was 43.5 days; among patients with apparently initially successful PTCA and hospital discharge, mean interval to operation was 138 days. Complete revascularization was carried out in all patients using standard techniques. Although the difference was not statistically significant, patients in the urgent group required intraaortic balloon pump support and inotropic infusions more often and experienced greater postoperative blood loss. Significant increases in the use of lidocaine and blood products were noted in the urgent group. The rates of major complications were 54.4% in the urgent group and 18.8% in the elective group. Mortality was 4.4% in the urgent group and 3.1% in the elective group (not significant); all deaths were cardiac related. There were no late deaths among survivors followed for 3 months to 4 years; 86% were in Functional Class I. We conclude that PTCA is a reasonable approach for some patients with ischemic heart disease. However, mandatory urgent aortocoronary bypass in these patients carries an increased morbidity and mortality, and patients should be selected with care.     

Standard Roux-en-Y gastroieiunostomv vs. “Uncut” Roux-en-Y gastrojejunostoki: A matched cohort study

Roux-en-Y gastrojejunostomy is a common method of reconstruction after subtotal gastrectomy. Maintaining myoneural continuity has been proposed to decrease the incidence of Roux stasis syndrome, with an “uncut” Roux-en-Y reconstruction. The aim of our study was to compare the clinical results in patients who have undergone uncut Roux-en-Y gastrojejunostomy with those in patients who have undergone a standard Roux-en-Y gastrojejunostomy. Eleven patients underwent gastrectomy and uncut Roux-en-Y gastrojejunostomy and were compared with a cohort of 14 patients who underwent gastrectomy and standard Roux-en-Y gastrojejunostomy. Patients were contacted and charts were reviewed for Visick grade, early and late morbidity and mortality, and incidence of staple line dehiscence. Early postoperative morbidity was 18% in patients undergoing uncut Roux gastrojejunostomy and 28% in patients under-going standard Roux reconstruction. There were no early postoperative deaths in either group. In the patients undergoing the uncut Roux procedure, no cases of staple line dehiscence were detected clinically (mean follow-up 9 months, range 1 to 48 months). Visick grade improved following the uncut Roux procedure, but changed little after standard Roux reconstruction. Uncut Roux-en-Y gastrojejunostomy can be performed safely with improvement in symptoms. The uncut Roux procedure may provide an alternative for reconstructive gastric surgery. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

肺癌再切除术的外科疗效分析

目的 通过对60例肺癌再切除手术患者进行回顾性分析，探讨其手术特征、并发症和生存率。方法 自1980年1月至2000年10月，对60例肺癌患者实施肺癌再切除手术，余肺肺癌复发36例，第2次原发性肺癌24例。应用生命表法计算1年、3年、5年生存率。结果 全组无手术及围术期死亡，术后发生并发症26例（43．3％），涉及呼吸系统症状的21例（35％），非呼吸系统5例（8．3％），其中支气管胸膜瘘4例（6．7％），脓胸6例（10％）。随访至2000年10月，术后1年、3年、5年生存率分别为80％、68．3％和38．3％。结论 只有患者条件许可，对肺癌再切除手术应积极主动的态度。     

Extrapleural pneumonectomy or pleurectomy/decortication for malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is associated with a very poor prognosis. Unlike other solid tumors, any type of planned surgery for MPM would be cytoreductive rather than radical. There are two types of surgery for MPM. Extrapleural pneumonectomy (EPP) involves en bloc resection of the lung, pleura, pericardium, and diaphragm. Pleurectomy/decortication (P/D) is a lung-sparing surgery that removes only parietal/visceral pleura. In comparison with EPP, P/D is theoretically less radical but is associated with less perioperative mortality/morbidity and less postoperative deterioration of cardiopulmonary function. It still remains unclear which surgical technique is superior in terms of the risk/benefit ratio. In this context, selection between EPP and P/D has been a matter to debate.