73例70岁以上妇女妇科恶性肿瘤手术分析

[目的]探讨70岁以上妇科恶性肿瘤患者手术的耐受情况。[方法]收集浙江省肿瘤医院自1996年1月到2001年12月间,70岁以上妇科恶性肿瘤患者接受盆腔姑息性和根治性手术治疗73例,分析不同年龄及手术范围对术后恢复的影响。[结果]73例患者66例选择了根治性手术,7例接受姑息性手术。术后70~75岁组和>75岁组,其手术方式、平均住院时间、术前术后并发症等无明显差别。术中出血量、手术时间及并发症发生率均明显较姑息性手术组增加,12例严重并发症中,11例发生在根治性手术组。[结论]经过严密的术前准备、术后处理,70岁以上的老年妇女能够耐受根治性手术治疗。     

Current Concepts in the Surgical Management of Glioma Patients

The scientific basis for the surgical management of patients with glioma is rapidly evolving. The infiltrative nature of these cancers precludes a surgical cure, but despite this, cytoreductive surgery remains central to high-quality patient care. In addition to tissue sampling for accurate histopathological diagnosis and molecular genetic characterisation, clinical benefit from decompression of space-occupying lesions and microsurgical cytoreduction has been reported in patients with different grades of glioma. By integrating advanced surgical techniques with molecular genetic characterisation of the disease and targeted radiotherapy and chemotherapy, it is possible to construct a programme of personalised surgical therapy throughout the patient journey. The goal of therapeutic packages tailored to each patient is to optimise patient safety and clinical outcome and must be delivered in a multidisciplinary setting. Here we review the current concepts that underlie surgical subspecialisation in the management of patients with glioma.     

Intraoperative histologic assessment of surgical margins and lymph node metastasis in breast-conserving surgery

The diagnostic value of intraoperative histologic examination of frozen sections of surgical margins and axillary lymph nodes (AX) was investigated in 95 patients with breast cancer who underwent breast-conserving surgery. The periphery of the excised breast tissue was peeled like an orange and examined histologically by frozen section. The results were compared with examination by permanent section. Evaluation of surgical margins by frozen section resulted in a diagnostic accuracy of 87%, a sensitivity of 96%, and a specificity of 84%. Enlarged or hardened AXs were sampled from the axillary pad which was derived from a complete AX dissection. Histologic examination using frozen section was performed during surgery. After the operation, the remaining AXs were removed from the axillary pad by hand dissection and histologically examined on permanent section. A diagnostic accuracy of 97%, a sensitivity of 77%, and a specificity of 100% were achieved in the diagnosis of AX involvement on frozen section. It was therefore concluded that intraoperative histologic examination of frozen sections may be useful in the determination of involvement of the surgical margins and the AXs in patients with breast cancer. © 1995 Wiley-Liss, Inc.     

Perioperative measures to optimize margin clearance in breast conserving surgery

Margin status is one of the most important determinants of local recurrence following breast conserving surgery. The fact that up to 60% of patients undergoing breast conserving surgery require re-excision highlights the importance of optimizing margin clearance. In this review we summarize the following perioperative measures that aim to enhance margin clearance: (1) patient risk stratification, specifically risk factors and nomograms, (2) preoperative imaging, (3) intraoperative techniques including wire-guided localization, radioguided surgery, intraoperative ultrasound-guided resection, intraoperative specimen radiography, standardized cavity shaving, and ink-directed focal re-excision; (4) and intraoperative pathology assessment techniques, namely frozen section analysis and imprint cytology. Novel surgical techniques as well as emerging technologies are also reviewed. Effective treatment requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status.     

不同手术方式在结肠癌治疗中的效果分析和预后比较

目的 比较传统开腹手术和腹腔镜手术治疗结肠癌的疗效及预后.方法 回顾性分析92例结肠癌患者的临床资料,根据手术方式不同将患者分为腹腔镜组和传统开腹组,每组各46例.比较两组患者的术中和术后指标及预后情况.结果 腹腔镜组患者的手术切口长度明显短于传统开腹组,术中出血量明显少于传统开腹组,手术时间明显长于传统开腹组,差异均有统计学意义(P﹤0.001);腹腔镜组患者的术后体温恢复时间、开始进食时间和住院时间均明显短于传统开腹组(P﹤0.001).腹腔镜组患者的术后并发症总发生率低于传统开腹组(P﹤0.05);两组患者术后1年的局部复发率和远处转移率比较,差异均无统计学意义(P﹥0.05).结论 腹腔镜手术治疗结肠癌具有术中出血量少、创伤小、术后并发症发生率低等优点,且患者术后恢复时间短、速度快,预后效果良好,值得临床推广应用.     

开腹与后腹腔镜术式治疗肾上腺良性肿瘤的比较

目的 探讨开腹与后腹腔镜术式对肾上腺良性肿瘤患者围手术期临床指标、ICU转送率及并发症的影响。方法 选取120例肾上腺良性肿瘤患者为研究对象，以随机数字表法分为对照组和观察组，每组各60例；其中对照组患者采用开腹术式治疗，观察组患者则采用后腹腔镜术式治疗；比较两组患者的手术时间、术中失血量、肛门排气时间、术后引流量、术后拔管时间、住院时间、ICU转送率及并发症发生率。结果 观察组患者手术时间、肛门排气时间、术后拔管时间及住院时间均显著短于对照组（P＜0.05）；观察组患者术中失血量和术后引流量均显著少于对照组（P＜0.05）；两组患者ICU转送率比较差异无统计学意义（P＞0.05）；同时观察组患者术中和术后并发症发生率均显著低于对照组（P＜0.05）。结论 后腹腔镜术式治疗肾上腺良性肿瘤可有效减轻医源性损伤程度，促进术后早期康复，且有助于避免术中及术后出现并发症，其临床应用价值优于开腹术式。     

Appling the abdominal aortic-balloon occluding combine with blood pressure sensor of dorsal artery of foot to control bleeding during the pelvic and sacrum tumors surgery

BACKGROUND AND OBJECTIVES: To investigate the feasibilities of reducing intraoperative hemorrhage and improving the safety of pelvic and sacrum tumor surgery using sizing balloon occluding abdominal aorta. METHOD: From May 2001 to May 2007, 18 patients were diagnosed as sacrum or pelvic tumor and underwent surgery in our institution. Balloon catheters were placed via femoral artery to occlude the abdominal aorta of pelvic tumor and sacrum region undergoing the sacrum resection or half pelvis resection and replacement operation in 12 patients. A sizing balloon was used to occlude the abdominal aorta for 60 min in assisting with resection of pelvic and sacral tumors. RESULTS: After the abdominal aorta was occluded, much less intraoperative hemorrhage was found, and the average blood loss was only 280 ml (range 200-600 ml). This procedure assisted the surgeon in identifying clearly the surgical margin and neurovascular structure surrounded by the tumors. The blood pressure remained stable during the operation. And the function of the kidney, the pelvis organs and the lower extremities were normal. CONCLUSION: Intraoperative abdominal aorta occluding may effectively control intraoperative hemorrhage, thus assisting the surgeon in the complete and safe resection of pelvic and sacrum tumors.     

New developments in surgery of malignant gliomas

BACKGROUND: Malignant gliomas account for a high proportion of brain tumours. With new advances in neurooncology, the recurrence-free survival of patients with malignant gliomas has been substantially prolonged. It, however, remains dependent on the thoroughness of the surgical resection. The maximal tumour resection without additional postoperative deficit is the goal of surgery on patients with malignant gliomas. In order to minimize postoperative deficit, several pre- and intraoperative techniques have been developed. CONCLUSIONS: Several techniques used in malignant glioma surgery have been developed, including microsurgery, neuroendoscopy, stereotactic biopsy and brachytherapy. Imaging and functional techniques allowing for safer tumour resection have a special value. Imaging techniques allow for better preoperative visualization and choice of the approach, while functional techniques help us locate eloquent regions of the brain.     

达芬奇机器人手术、胸腔镜手术及开胸手术治疗早期肺癌的疗效对比

目的:比较达芬奇机器人、常规开胸、胸腔镜手术治疗早期肺癌的近期疗效。方法:早期肺癌手术患者118例,尊重自愿选择的原则分为开胸组52例、胸腔镜组43例及机器人组23例。三组基本资料无差异（P>0.05）,具有可比性。记录各组术前术后相关指标,并行统计学分析比较差异。结果:机器人组术中出血量、术后拔管时间、术后3天引流量、术后住院时间均明显低于开胸组（P<0.05）,术中出血量、清扫淋巴结个数与站数也明显优于胸腔镜组（P<0.05）,但手术费用明显高于其他二组（P<0.05）。结论:除手术费用高昂,机器人辅助手术较开胸手术、胸腔镜手术对于早期肺癌的近期疗效优势明显。     

Cavity shaving for invasive breast cancer conservative surgery: Reduced specimen volume and margin positive rates

IntroductionThe cavity shaving (CS) technique was described in breast conserving surgery to reduce the rate of reoperation avoiding the need for intraoperative margin analysis. This study assesses differences in the rates of involvement of the surgical margin (requiring further surgery) and volume of surgical specimens, depending on the use or not of this technique.Material and methodsA retrospective cohort study was conducted in patients with breast carcinoma who underwent breast conserving surgery between 2013 and 2019. They were divided into two groups depending on whether the cavity shaving technique was used or not. Primary outcomes of the study included presence of final margin involvement, requiring need for further surgery, and the volume of excised tissue comparing the study groups.ResultsA total of 202 cases were included: 92 in the control group and 110 in the cavity shaving group. Significant differences were found regarding involvement of the final margin (19.57% control group vs. 4.55% cavity shaving group; p = 0.010). The volume of additional surgical specimens were significantly greater in the traditional technique group than in the shaving technique (46.43 vs 13.32 cm³; p = 0.01) as was total specimen volume (143.40 vs 100.63 cm³; p = 0.022).ConclusionsCS can reduce the positive margin and re-excision rates without larger-volume resections and should therefore be considered a routine technique in BCS for early-stage breast cancer.     

Chronic preoperative pain and psychological robustness predict acute postoperative pain outcomes after surgery for breast cancer

Background:Few epidemiological studies have prospectively investigated preoperative and surgical risk factors for acute postoperative pain after surgery for breast cancer. We investigated demographic, psychological, pain-related and surgical risk factors in women undergoing resectional surgery for breast cancer.Methods:Primary outcomes were pain severity, at rest (PAR) and movement-evoked pain (MEP), in the first postoperative week.Results:In 338 women undergoing surgery, those with chronic preoperative pain were three times more likely to report moderate to severe MEP after breast cancer surgery (OR 3.18, 95% CI 1.45-6.99). Increased psychological 'robustness', a composite variable representing positive affect and dispositional optimism, was associated with lower intensity acute postoperative PAR (OR 0.63, 95% CI 0.48-0.82) and MEP (OR 0.71, 95% CI 0.54-0.93). Sentinel lymph node biopsy (SLNB) and intraoperative nerve division were associated with reduced postoperative pain. No relationship was found between preoperative neuropathic pain and acute pain outcomes; altered sensations and numbness postoperatively were more common after axillary sample or clearance compared with SLNB.Conclusion:Chronic preoperative pain, axillary surgery and psychological robustness significantly predicted acute pain outcomes after surgery for breast cancer. Preoperative identification and targeted intervention of subgroups at risk could enhance the recovery trajectory in cancer survivors.     

Neuronavigational guidance in craniofacial approaches for large (para)nasal tumors involving the anterior skull base and upper clival lesions

Objective

Due to the destruction of osseous landmarks of the skull base or paranasal sinuses, the anatomical orientation during surgery of frontobasal or clival tumors with (para)nasal extension is often challenging. In this relation computer assisted surgical (CAS) guidance might be a useful tool. Here, we explored the use of CAS in an interdisciplinary setting.

Methods

The surgical series consists of 13 patients who underwent a lateral rhinotomy combined with a subfrontal craniotomy in case of significant intracranial tumor extension. The procedures were planned and assisted by advanced CAS techniques with image fusion of CT and MRI. Tumors included carcinomas (one case associated with an olfactory groove meningioma), esthesioneuroblastoma, chordoma, chondrosarcoma and ganglioglioma.

Results

The application of CAS in the combined approaches was both safe and reliable for delineation of tumors and identification of vital structures hidden or encased by the tumors. There was no perioperative 30-day mortality; however two patients died 5 weeks and 5 months after craniofacial tumor resection due to worsening medical conditions. The most common perioperative morbidity was postoperative wound complication in two cases. Tumors were either removed completely, or subtotal resection was achieved allowing targeted postoperative radiotherapy.

Conclusion

Craniofacial approaches with intraoperative neuronavigational guidance in a multidisciplinary setting allow safe resection of large tumors of the upper clivus and the paranasal sinuses involving the anterior skull base. Complex skull base surgery with the involvement of bony structures appears to be an ideal field for advanced navigation techniques given the lack of intraoperative shift of relevant structures.     

腹腔镜与开腹Miles手术治疗低位直肠癌的临床研究

目的 对比分析腹腔镜与开腹Miles手术治疗低位直肠癌的疗效.方法 选择83例低位直肠癌患者,依据随机数字表法将患者分为腹腔镜组(n=42)和开腹组(n=41),观察记录两组患者的术中指标、术后恢复情况及术后并发症发生率.结果 腹腔镜组与开腹组患者的手术时间和淋巴结清扫数目比较,差异均无统计学意义(P﹥0.05);但腹腔镜组患者的术中出血量少于开腹组(P﹤0.05),胃肠道功能恢复时间、自主排尿时间、术后下床活动时间、术后住院时间、进食恢复时间均明显短于开腹组(P﹤0.01),并发症总发生率低于对照组(P﹤0.05).结论 腹腔镜Miles手术治疗低位直肠癌能达到开腹Miles手术的切除范围,且术中出血量少、创伤小、术后恢复快、住院时间短、术后并发症发生率低,值得临床推广应用.     

Comparison of laparoscopy and laparotomy for the management of early-stage ovarian cancer: surgical and oncological outcomes

Objective

To investigate the surgical and oncological outcomes of laparoscopic surgery compared with laparotomy for the treatment of early-stage ovarian cancer.

Methods

Data from patients who underwent surgical management for early-stage ovarian cancer between 2006 and 2012 were retrospectively reviewed. All patients presented with stage I or II disease, and underwent comprehensive staging surgery consisting of a total hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy, and peritoneal cytology.

Results

Seventy-seven patients who underwent laparoscopic surgery (24 patients) or laparotomy (53 patients) were identified. Surgery for none of the patients was converted from laparoscopy to laparotomy. The mean operation time was shorter and the estimated blood loss was lower in the laparoscopy group than in the laparotomy group, though the differences were not statistically significant (193 min vs. 224 min, p=0.127; 698 mL vs. 973 mL, p=0.127). There were no differences in the intraoperative or postoperative complications. During a mean follow-up period of 31 months, tumor recurrence occurred in 4 patients: 2 (8.3%) in the laparoscopy group and 2 (3.8%) in the laparotomy group. The mean disease-free survival was 59 months after laparoscopy and 66 months after laparotomy (p=0.367).

Conclusion

Laparoscopic surgery seems to be adequate and feasible for the treatment of early-stage ovarian cancer with comparable results to laparotomy in terms of the surgical outcomes and oncological safety.     

Adequacy of Intraoperative Nodal Staging during Surgical Resection of NSCLC: Influencing Factors and Its Relationship to Survival

IntroductionAdequate intraoperative lymph node sampling is a fundamental part of lung cancer surgery, but adherence to standards is not well known. This study sought to measure the adequacy of intraoperative lymph node sampling at a regional Thoracic Surgery Centre and a tertiary lung cancer center in the United Kingdom.MethodsThis retrospective study analyzed the pathological reports from NSCLC resections over the 4-year period 2011–2014. Adequacy of sampling was assessed against International Association for the Study of Lung Cancer recommendations of at least three mediastinal lymph node stations: station 7 in all patients, station 5 or 6 in left upper lobe tumors, and station 9 in lower lobe tumors. The influence of clinical variables (age, tumor T stage, type of surgery, and laterality) on adequacy of sampling and the effect of adequacy on overall survival were also assessed.ResultsA total of 1301 NSCLC resections were performed from January 11, 2011, to December 31, 2014. Adequate intraoperative lymph node sampling increased significantly from 14% (22 of 160) in 2011 to 53% (206 of 390) in 2014 (p = 0.001). Secondary analysis of clinical variables also revealed that patients with T1a or T4 tumors, those undergoing sublobar resections, those undergoing video-assisted thoracic surgery resections, and those undergoing left-sided resections have significantly higher rates of inadequate lymph node sampling. Overall, there was no statistically significant difference in survival between patients with adequate versus inadequate intraoperative lymph node sampling or when survival was stratified according to overall stage. There was worse survival in inadequate sampling for patients with pN2 disease than for patients with pN2 disease and adequate sampling.ConclusionThis study provides a much-needed benchmark of current thoracic surgical practice in lung cancer in the United Kingdom and important granularity to facilitate changes to improve adequacy of staging.     

Impact of contemporary therapy- concepts on surgical morbidity in breast cancer patients: A retrospective single center analysis of 829 patients

IntroductionMorbidity after breast cancer surgery remains low with revision surgery below 5%. This retrospective monocentric study investigates whether new methods like neoadjuvant chemotherapy (nCT), oncoplastic surgery (OPS) or intraoperative radiotherapy (IORT) affect overall morbidity. In addition, we sought to determine a possible effect of morbidity on oncologic outcome.MethodsClinical Data from all breast cancer cases, operated at the OnkoZert”- certified Breast Health Center of the “Sisters of Charity Hospital” in Linz between 2011 and 2014, were evaluated. Age (≤/>70), nCT, IORT, surgical technique and histological subtypes were analyzed concerning their impact on morbidity. Overall survival (OS) and disease-free survival (DFS) were assessed by Kaplan-Meier estimates.Results829 patients were included, 24% were older than 70y, 19% underwent oncoplasty, 5.5% immediate reconstruction, 17% of the invasive cancers were treated with nCT and 4.1% received IORT. One or more complications occurred in 83 patients (10%), while 62 patients (7.5%) underwent revision surgery. Univariate analysis showed that mastectomy and age >70 doubled the risk of surgical morbidity. Multivariate regression analysis identified age >70 as the only independent prognostic parameter for the occurrence of morbidity (OR: 2.42, 95% CI: 1.41–4.1, p = 0,00134). Morbidity was not associated with worse oncologic outcome in terms of OS or DFS.SummaryIn our patient collective, modern techniques such as nCT, OPS or IORT did not influence surgical morbidity rates. Those were only increased by patient's age. Additionally, surgical morbidity did not show any significant impact on OS and DFS.     

Surgical treatment of metastatic brain tumors

The most common structural neurologic complication of systemic cancer is brain metastasis. For the most part, treatment is palliative because the majority of patients ( 50%) have uncontrollable systemic cancer. However, for patients in whom the only metastasis is to the brain, death is more likely to result from the metastasis than from the systemic disease; hence, treatment of the metastasis is vitally important. Although radiotherapy is generally considered the preferred treatment, surgical removal of the mass, whether single or multiple, may be the most effective palliation, especially for tumors from radio-resistant diseases such as melanoma, kidney and colon cancer. We review the information regarding therapeutic decision-making; advances in surgical procedures, namely computer-assisted stereotactic and/or intraoperative ultrasound and mapping techniques; the efficacy of postoperative WBRT; complications and benefits of surgery; our experience with reoperation for recurrent metastatic brain tumors, the results of which indicate that reoperation for recurrent brain metastasis can prolong survival and improve quality of life for most individuals; our results comparing surgery versus radiosurgery, which show that patients who undergo surgical treatment live longer and have better tumor control than those treated with radiosurgery; and the patient's prognosis. The conclusion is that surgery should remain the treatment of choice whenever possible.     

Laparoscopic Roux-en-Y reconstruction using conventional linear stapler in robotic total gastrectomy for gastric cancer

BackgroundRobotic stapling devices have been designed to create staple formation equivalent to conventional laparoscopic stapling. In gastric cancer surgery, however, any advantages the robotic stapler has in maneuverability compared to standard laparoscopic stapling devices remain unclear [1]. We applied robotic-assisted laparoscopic stapling techniques during reconstruction after robotic total gastrectomy (RTG) for gastric cancers (GCs) as “fusion surgery”. Here, we outline our stapling technique and retrospectively evaluate surgical outcomes of laparoscopic staplers in patients undergoing RTG for GCs.MethodsThis is a single-center retrospective analysis of prospectively collected data. We performed robotic gastrectomy (RG) for GCs on 70 patients at the Wakayama Medical University Hospital (WMUH) between May 1, 2017 and July 31, 2019. RG was adopted for all patients with GCs in whom curative gastrectomy was applicable. All operations were performed by a single surgeon (T.O.). Of our 70 consecutive patients who underwent robotic gastrectomy for GCs, 22 underwent RTG with Roux-en-Y reconstruction using laparoscopic staplers. All RTG procedures were performed using the da Vinci Surgical System. The duodenum and abdominal esophagus were transected using a 45 mm long laparoscopic linear stapler. After total gastrectomy, we performed antecolic Roux-en-Y reconstruction. Jejunojejunostomy was completed under direct vision following retrieval of the stomach. In robotic view, an intracorporeal side-to-side esophagojejunostomy was constructed using a laparoscopic linear stapler [2]. The 22 patients were followed-up for at least 3 months. Follow-up data were obtained from the hospital database, including the patient background, tumor characteristics, and surgical data. Postoperative complications higher than Clavien–Dindo grade 2 were regarded as clinically significant postoperative complications [3].ResultsThe duration of operation and reconstruction were 385 min and 81 min, respectively. The median intraoperative bleeding was 45 ml. There were no conversions to conventional laparoscopy or open surgery in all patients. Of these 22 patients, one patient had postoperative pneumonia (Grade 2) and another developed postoperative intraabdominal bleeding (Grade 3a) [3]. No anastomosis-related complications developed in all patients.ConclusionsRegarding short-term surgical outcomes, robotic-assisted laparoscopic stapling techniques for reconstruction after RTG, “fusion surgery” are both feasible and safe for GCs. This study had several limitations. It was a retrospective study. Moreover, it was conducted at a single institution and the sample size was small (n = 22).     

Current status and future perspectives of fluorescence-guided surgery for cancer

Curative cancer surgery is dependent on the removal of all primary tumor and metastatic cancer cells. Preoperative imaging, intraoperative inspection and palpation, as well as pathological margin confirmation aid the surgeon, but these methods are lacking in sensitivity and can be highly subjective. Techniques in fluorescence-guided surgery (FGS) are emerging that selectively illuminate cancer cells, enhancing the distinction between tumors and surrounding tissues with the potential for single-cell sensitivity. FGS enhances tumor detection, surgical navigation, margin confirmation, and in some cases can be combined with therapeutic techniques to eliminate microscopic disease. In this review, we describe the preclinical developments and currently-used techniques for FGS.     

混合现实技术在肿瘤型假体置换手术中的应用研究

目的 探讨混合现实技术在骨肿瘤精准化治疗中行肿瘤型假体置换手术的临床应用价值。方法 回顾性分析2018年8月至2020年9月于中国医科大学附属盛京医院骨与软组织肿瘤科收治的符合选择标准的25例肢体骨肿瘤行肿瘤型假体置换手术患者的临床资料,其中男16例,女9例,年龄12～76(34.4±20.6)岁。按是否应用混合现实技术进行手术分为混合现实组11例和对照组14例,比较两组手术的手术时间、术中失血量、术后引流量、患者满意度及术后3个月美国骨骼肌肉系统肿瘤协会（MSTS）评分。结果 25例患者全部顺利完成手术,完整切除肿瘤组织,无血管神经副损伤。25例患者均获得定期随访,随访时间4～26(13.9±6.6)个月。两组病例手术时间差异无统计学意义（P>0.05）;术中失血量两组比较差异有统计学意义（P=0.033）;术后引流量两组比较差异有统计学意义（P=0.038）;患者满意度方面两组比较差异有统计学意义（P=0.025）;术后3个月MSTS评分两组比较差异有统计学意义（P=0.041）。结论 混合现实组在术中失血量、术后引流量、患者满意度及术后3个月MSTS评分方面优于对照组,混合...