贲门癌切除术后残胃排空功能变化

目的 观察贲门癌术后残胃排空功能变化,探讨改善病人术后生活质量的方法。方法 用豆奶粉４０ｇ,水２００ｍＬ,加入１８．５ＭＢｑ＾９９Ｔｃ＾ｍ－ＤＴＰＡ,制成试验餐,于术后１８￣２０ｄ例行贲门癌近端胃次全切除患者,和５例健康人（Ｎ组）进行核素胃排空检查。     

CT findings of afferent loop syndrome after a subtotal gastrectomy with Roux-en-Y reconstruction

A rare case of combined afferent loop syndrome following Roux-en Y reconstruction and small bowel obstruction due to adhesions at the enteroenterostomy is presented. The CT findings of the obstruction of both the afferent and the efferent limbs are demonstrated, with emphasis on the characteristic CT features of afferent loop syndrome.     

Comparison of anterior and geometric mean liquid and solid gastric emptying rates in dogs and in patients after partial gastrectomy

OBJECTIVE: The purpose of this study was to determine if geometrical correction is necessary in the study of gastric emptying rate (GER) for liquids, using a low-energy radionuclide, such as 99mTc. Solid test meals were considered the reference. METHODS: Both solid and liquid GERs were investigated using regional analysis. Anterior data were compared with geometrically corrected values in 15 dogs and 9 partial gastrectomy patients. RESULTS: Anterior and geometrically corrected measurements differed significantly for solid food in the whole gastric region and in the antrum. Geometrically corrected values differed slightly from anterior data after partial gastrectomy. No difference was found for liquid food. Liquids redistributed much faster than solids within the stomach. CONCLUSION: Measurement of GER using a single-phase liquid meal does not require geometrical correction. This is due to the rapid intragastric redistribution of the liquid. Geometrical correction for solid food can be omitted only after partial gastrectomy.     

PSA bounce after prostate brachytherapy with or without neoadjuvant androgen deprivation

PurposeTo assess the impact of PSA bounce (PB) on biochemical failure (BF) and clinical failure (CF) in brachytherapy patients treated with or without neoadjuvant androgen deprivation (AD).Methods and MaterialsFrom 1987 to 2003, 691 patients with clinical stage T1–T3N0M0 prostate cancer were treated with external beam radiotherapy (EBRT) and high-dose-rate (HDR) brachytherapy boost (n = 407), HDR brachytherapy alone (n = 93), or permanent seed implant (n = 191). Three hundred seventeen patients (46%) received neoadjuvant/adjuvant AD with RT. BF was scored using 3 definitions (ASTRO—3 rises, nadir + 2 ng/ml, and threshold 3 ng/ml) based on current and absolute nadir (AN) methodologies. PB was defined as any increase in PSA followed by a decrease to the prior baseline or lower. The median followup was 4.0 years.ResultsForty-six patients (7%) experienced CF at 5 years. PB of ≥0.1, ≥1.0, and ≥2.0 ng/ml at any time after RT occurred in 330 (48%), 60 (9%), and 22 patients (3%) respectively. The use of an AN definition reduced the likelihood of scoring PB as BF across all levels. The patients receiving AD experienced significantly longer bounce duration. Bounce <1.0 ng/ml showed no association with CF. For bounce ≥1.0 ng/ml, 10% demonstrated CF vs. 6% without bounce of this amplitude (p = 0.27). Bounces ≥1.0 ng/ml were more likely to be scored as BFs for definitions based on current nadir (3 rises: 20% vs. 13%, nadir + 2: 43% vs. 11%, 3 at/after nadir: 57% vs. 12%) than those based on AN (3 rises: 8% vs. 10%, nadir + 2: 18% vs. 11%, 3 at/after nadir: 13% vs. 11%).ConclusionsBounces ≥1.0 ng/ml are rare after brachytherapy with or without neoadjuvant AD, occurring in less than 10% of patients. Low PBs have little impact on BF, but as PB amplitude increases, the BF rate increases. BF definitions based on AN are less sensitive to PB after brachytherapy.     

Chemoradiotherapy for patients with recurrent lymph-node metastasis or local recurrence of gastric cancer after curative gastrectomy

Objectives

Whether chemoradiotherapy (CRT) is clinically beneficial for the management of postoperative recurrence of advanced gastric cancer remains unclear. We retrospectively studied treatment outcomes in patients who had unresectable localized recurrence after surgery for advanced gastric cancer and evaluated the safety and efficacy of CRT.

Methods

The study group comprised 21 patients who received concurrent CRT for unresectable localized recurrence after undergoing R0 resection for stage II/III advanced gastric cancer. Localized recurrence was defined as a few or limited recurrent lesions.

Results

The recurrence pattern was anastomotic recurrence in 7 patients, abdominal lymph-node recurrence in 12, and anastomotic recurrence plus abdominal lymph-node recurrence in 2. The median total dose of radiotherapy was 48.6 Gy (range 39.6–56.0), and the CRT completion rate was 100 % (21 of 21 patients). CRT-related grade 3 or higher toxicity comprised neutropenia in 33.3 % of patients and anorexia in 9.5 %. The response rate was 61.9 % (complete response 38.1 %, partial response 23.8 %). The median overall survival was 35.0 months.

Conclusions

We conclude that CRT may become one treatment strategy for the management of unresectable localized recurrence after curative resection of advanced gastric cancer.

     

Volume change of segments II and III of the liver after gastrectomy in patients with gastric cancer

PURPOSE

We aimed to evaluate the relationship between gastrectomy and the volume of liver segments II and III in patients with gastric cancer.

METHODS

Computed tomography images of 54 patients who underwent curative gastrectomy for gastric adenocarcinoma were retrospectively evaluated by two blinded observers. Volumes of the total liver and segments II and III were measured. The difference between preoperative and postoperative volume measurements was compared.

RESULTS

Total liver volumes measured by both observers in the preoperative and postoperative scans were similar (P > 0.05). High correlation was found between both observers (preoperative r=0.99; postoperative r=0.98). Total liver volumes showed a mean reduction of 13.4% after gastrectomy (P = 0.977). The mean volume of segments II and III showed similar decrease in measurements of both observers (38.4% vs. 36.4%, P = 0.363); the correlation between the observers were high (preoperative r=0.97, P < 0.001; postoperative r=0.99, P < 0.001). Volume decrease in the rest of the liver was not different between the observers (8.2% vs. 9.1%, P = 0.388). Time had poor correlation with volume change of segments II and III and the total liver for each observer (observer 1, r_seg2/3=0.32, r_total=0.13; observer 2, r_seg2/3=0.37, r_total=0.16).

CONCLUSION

Segments II and III of the liver showed significant atrophy compared with the rest of the liver and the total liver after gastrectomy. Volume reduction had poor correlation with time.Gastric cancer is the fourth most common cancer among men and the sixth most common cancer among women. It is the third leading cause of cancer related deaths in both sexes worldwide (1). The life expectancy of the patients varies depending on the grade of the tumor, spread of the disease and the appropriate medical and surgical treatment. Many patients undergo surgery (2). In routine practice, contrast-enhanced computed tomography (CT) is used in order to understand the extent of the disease before the surgery. It is also the most important tool for follow up after the surgery (3).The deterioration of liver function tests after laparoscopic gastrectomy has been reported in a few studies (4, 5). In addition, there were several case reports indicating ischemia and infarct of the left lobe of the liver after laparoscopic gastrectomy due to prolonged Nathanson surgical retractor compression (6–10). In this study, we aimed to evaluate the relationship between open gastrectomy and the volume of the liver segments II and III.     

An integrated, self-expanding, Y-shaped, metallic stent for patients with complex obstruction after gastrojejunostomy (Billroth II): initial experience

Purpose

This paper reports our initial experience with an integrated, self-expandable, Y-shaped, metallic stent (SEMS) for patients with complex anastomotic obstructions after gastrojejunostomy (Billroth II).

Materials and methods

Eight consecutive patients with complex anastomotic obstructions involving the afferent and efferent loops after gastrojejunostomy (Billroth II) were treated with an integrated Y-shaped SEMS. The stents were placed in the anastomosis under fluoroscopy. Technical and clinical success; complications, including recurrent obstruction and stent migration; reintervention; and survival were assessed during follow-up.

Results

Y-shaped SEMS placement in the anastomotic areas was technically successful and well tolerated in all patients, with no procedure-related complications. Clinical success was observed in all patients 1?C7 days after the procedure. The improvement between pre- and postoperative gastric outlet obstruction scoring system (GOOSS) was statistically significant (p=0.01). During follow-up for 3.13±1.81 months, all stenoses were resolved without stent-related complications, and general physical examination of the eight patents showed improvement. Five patients continued with follow-up health care after the procedures; the remaining three died of causes unrelated to stent insertion. The mean and median survival periods were 3.92±0.81 months [95% confidence interval (CI) 2.34?C5.50] and 3.0±0.64 months (95% CI 1.74?C4.26), respectively.

Conclusions

Deployment of an integrated Y-shaped SEMS proved to be an expedient, simple, safe and minimally invasive procedure for treating complex anastomotic stenoses after gastrojejunostomy (Billroth II).     

Early Morbidity after Radiotherapy with or without Chemotherapy in Advanced Head and Neck Cancer

BACKGROUND: Data on early treatment-related morbidity after radiotherapy alone (RT; 217 patients) or combined with chemotherapy (RT + CT; 182 patients) of head and neck squamous cell carcinoma are analyzed. PATIENTS AND METHODS: The patients were treated between November 1985 and November 1996 in four Swiss centers that independently introduced combined-modality therapy in selected cases of head and neck cancer. RT schedules varied among the four centers, but within each institution all patients received the same dose-fractionation schedule irrespective of whether they had CT or not. The following early morbidity items were evaluated: skin, mucosa, larynx, salivary glands, dysphagia, weight loss, and toxic death. Toxicity was scored using the EORTC/RTOG scale. RESULTS: Although considerable variation was noted among the treatment schedules/centers, the main findings are as follows: (1) early morbidity was significantly enhanced after all five RT + CT schedules compared with RT alone; (2) typically, a third of the patients lost > 10% of their body weight during concurrent RT + CT as compared with 10% of the patients receiving RT alone; (3) at 12 weeks, the prevalence of grade 2 morbidity was 25-60% after RT + CT as compared with 4-20% after RT alone. CONCLUSION: A number of early morbidity items were found to be more prevalent and/or more severe after RT + CT than after RT alone.     

Pretreatment Proliferation and Local Control in Bladder Cancer after Radiotherapy with or without Concurrent Chemotherapy

PURPOSE: To investigate whether the addition of chemotherapy to radiotherapy (RT) is beneficial particularly in bladder tumors that possess the capacity for rapid proliferation. PATIENTS AND METHODS: The Ki-67 index was evaluated by immunohistochemistry on pretreatment biopsies from 136 patients treated by transurethral tumor resection (TURBT) and RT (n=50) or platin-based radiochemotherapy (RCT; n=86). Ki-67 expression was correlated with response to RT/RCT and long-term local control rates. The median follow-up was 43 months. RESULTS: The percentage of Ki-67-positive cells ranged from 1.5% to 89%. Complete response (CR) was observed in 100/131 patients (76%, five without restaging TURBT). A statistically significant association between high Ki-67 index (>or= median) and CR was noted for patients receiving RCT (93% vs. 66% for Ki-67 < median; p=0.001), but not for patients treated with RT alone (p=0.12). Long-term local control was 39% for patients treated with RT, and 44% for patients after RCT (p=0.49). Patients with high Ki-67 index did significantly better when subjected to combined RCT (55% vs. 33% with low Ki-67 index; p=0.006), whereas no difference between high and low Ki-67 status was observed in the RT group (39% each; p=0.57). On multivariate analysis, Ki-67 status was an independent predictor for local failure in the RCT group (risk ratio, 0.43; p=0.007). Disease-specific survival was significantly better after RCT (62%) as compared with RT (42%; p=0.03), however, the Ki-67 index was not related to this endpoint. CONCLUSION: Rapid proliferation is associated with improved local control, if patients are treated with concurrent RCT. The cytostatic effect of concurrent chemotherapy may effectively inhibit repopulation during fractionated RT.     

Muscle rehabilitation after arthroscopic meniscectomy with or without tourniquet control. A preliminary randomized study

Nineteen patients with isolated meniscus lesions were randomly assigned to operation with or without tourniquet. All patients underwent arthroscopic meniscectomy. Measurements of CK (creatinin-kinase), CK-B (isoenzymes MB of creatinin-kinase), LD (lactate dehydrogenase), ASAT (aspartate aminotransferase), and ALAT (alanine aminotransferase) were performed preoperatively and postoperatively over 6 days. The muscle torque was measured on a Cybex II isokinetic dynamometer preoperatively, 1 week and 4 weeks postoperatively. The mean CK level rose significantly in both groups, but did not pass the upper normal serum level. There was no effect on the other muscle enzymes. Quadriceps torque was significantly lowered in both groups 1 week after operation. Four weeks postoperatively, it was still lowered in the nontourniquet group, which also had a slower increase in torque between weeks 1 and 4 than the tourniquet groups. There was no effect from the operation on isometric or hamstrings torque. The slight rise in CK was similar to that seen after hard physical exercise. The decrease in muscle torque was, therefore, mostly due to pain inhibition. The slightly slower rehabilitation in the nontourniquet group may be caused by the technique of raising saline flow and pressure during the arthroscopy to control bleeding. This causes extravasation of fluid which may increase postoperative pain and stiffness.     

Surgery and Chemotherapy for Small Cell Lung Cancer in Stages I–II with or without Radiotherapy

PURPOSE: To analyze the effectiveness of surgery and chemotherapy with or without radiotherapy in the management of limited small cell lung cancer (LSCLC) in stages I and II. PATIENTS AND METHODS: 39 patients (median age 62 years) with LSCLC in stages pT1 or pT2 and pN0 or pN1 (stages IA-IIB) who had a tumor resection and systematic lymph node dissection were reviewed retrospectively. The median follow-up period was 29 months. 35 patients (90%) received a median of four cycles of a platinum-containing chemotherapy postoperatively. 16 patients (41%) received an adjuvant thoracic radiotherapy (TRT, median 50 Gy); 21 patients (54%) received a prophylactic cranial irradiation (PCI, median 30 Gy). RESULTS: The median overall survival for all patients was 47 months, resulting in actuarial 1-, 3-, and 5-year survival rates of 97%, 58%, and 49%, respectively. Distant metastases were found in 13 patients (33%) after a median of 16 months. Patients who received an adjuvant TRT showed a trend toward improved thoracic recurrence-free survival (p = 0.06) and improved overall survival (p = 0.07) compared to those treated with surgery and chemotherapy only. Brain metastasis-free survival (p = 0.01) and overall survival (p = 0.01) were improved significantly in patients who received a PCI. CONCLUSION: Surgical tumor resection may be considered for carefully selected patients. Adjuvant chemotherapy and PCI are recommended for all patients. Adjuvant TRT is currently used in patients with positive lymph nodes (pN1), because the probability of a subclinical involvement of the mediastinal lymphatic system appears to be increased in these patients.     

No difference in survivorship after unicompartmental knee arthroplasty with or without an intact anterior cruciate ligament

Purpose

Anterior cruciate ligament deficiency (ACLD) has been considered a contraindication for Oxford unicompartmental knee arthroplasty (UKA) because of the reported higher incidence of failure when implanted in ACLD knees. However, given the potential advantages of UKA over total knee arthroplasty (TKA), we have performed UKA in a limited number of patients with ACL deficiency and end-stage medial compartment osteoarthritis (OA) over the past 11 years. The primary aim of this study was to establish the clinical outcome of this cohort; the secondary aim was to compare both clinical and radiographic data with a matched cohort of ACL-intact (ACLI) patients who have undergone UKA for anteromedial OA.

Methods

This retrospective observational study describes the clinical and radiological outcome in 46 medial Oxford UKAs implanted in 42 consecutive patients with ACL deficiency and concomitant symptomatic medial compartment OA at mean follow-up of 5 years. It also compares the outcomes with a matched cohort of UKA patients with an intact ACL (ACLI group).

Results

At the time of last follow-up, there was no significant difference in clinical results or survivorship between the two groups in this study.

Conclusion

The successful short-term results of the ACLD group suggest ACL deficiency may not always be a contraindication to Oxford UKA as previously thought. Until long-term data is available, however, we maintain our recommendation that ACLD be considered a contraindication.

Level of evidence

III.     

Locoregional Failure 15 Years after Mastectomy in Women with One to Three Positive Axillary Nodes with or without Irradiation

BACKGROUND: There is insufficient evidence to suggest the routine use of postmastectomy radiotherapy (PMRT) in patients with one to three positive axillary nodes and T1/2 tumors. We have assessed the risk of locoregional recurrence (LRR) with or without RT in this group of patients, and focused on the results in subgroups defined by tumor size. PATIENTS AND METHODS: 249 women with T1/2 tumors and one to three positive nodes underwent mastectomy and axillary dissection between 1983 and 1987. Locoregional RT of 50 Gy was given to 175 patients. Chemotherapy or hormonal therapy was administered to 41 and 71 women, respectively. The median follow-up time of survivors was 189 months (range, 167-227 months). RESULTS: The rates of isolated LRR without or with RT were 16% (12/74) and 8% (14/175), respectively (p = 0.05), and the total (with or without distant relapse) LRR rates 23% and 12%, respectively (p = 0.03). 15-year overall survival amounted to 41% without RT and to 52% with RT (p = 0.2). The rates of isolated LRR for patients treated with chemotherapy or hormonal therapy only were 25% and 12%, respectively. In the absence of RT, age (> 45 vs = 45 years; p = 0.06), tumor size (T1 vs T2; p = 0.07), and extranodal invasion (ENI; absent vs present; p = 0.09) were related to the risk of developing an isolated LRR. On multivariate analysis, only tumor size (relative risk [RR], 3.92; 95% confidence interval [CI], 1.11-15.14) and age (RR, 3.37; 95% CI, 1.03-11.09) emerged as independent significant predictors, whereas ENI (RR, 1.50; 95% CI, 0.81-2.77) did not. In the T1 subgroup, the estimated 15-year isolated LRR rate was 9% (3/36) without and 9% (8/99) with RT (p = 0.9775). 15-year disease-free survival amounted to 62% and 57%, respectively (p = 0.5153). For patients without RT, according to the age groups (= 45 vs > 45 years), the 15-year rates of isolated LRR were 9% and 9%, respectively (p = 0.9910). In the T2 subgroup, the estimated 15-year isolated LRR rate was 30% (9/38) without and 10% (6/76) with RT (RR, 0.33; 95% CI, 0.12-0.92; p = 0.0244). 15-year disease-free survival amounted to 32% and 50%, respectively (p = 0.1213). For patients without RT, according to the age groups (< or = 45 vs > 45 years), the 15-year rates of isolated LRR were 57% and 16%, respectively (p = 0.0049). CONCLUSION: Patients with T1 tumor and one to three positive nodes are at low risk of isolated LRR either with or without RT. Patients with T2 tumor and one to three positive nodes are at high risk of isolated LRR without RT. Our findings support the routine use of PMRT in patients with T2 tumor, especially those aged < or = 45 years.     

Use of angiographic needles with or without stylets: pathologic assessment of vessel walls after puncture.

There is controversy as to whether angiographic needles without stylets produce more arterial damage than those with stylets. Iliac arteries from 15 fresh human cadavers were punctured 56 times with either an 18-gauge angiographic needle with a stylet or one without a stylet (28 punctures with each needle type). These puncture sites were serially sectioned and examined microscopically. Each needle tract was evaluated for margin irregularity, shape of puncture, and approximation of edges. No statistically significant differences in arterial wall changes were found. The authors' data suggest that the choice of beveled needle use in angiography can probably be made on a basis other than concern for differences in vessel wall damage secondary to the presence or absence of a stylet.     

Embolization of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms with use of cyanoacrylate with or without coils

Translumbar embolization was used to treat 11 type 2 endoleaks in nine patients with the liquid embolic agent n-butyl cyanoacrylate (NBCA). Nine of the embolizations were performed with a combination of stainless-steel coils and NBCAJ and the other two were performed with NBCA alone. There was complete occlusion on initial computed tomographic (CT) angiography in six of nine patients (66%), including the two cases treated with NBCA alone. Persistent endoleak on initial CT angiography occurred in three of nine patients (33%). Two of these patients underwent successful repeated embolization with NBCA. Aneurysm size remained unchanged in four patients (44%), decreased in four patients (44%), and increased in one patient (11%). No complications occurred. Initial results with the use of NBCA for endoleak embolization are encouraging.