胸腹腔镜联合治疗食管胃交界部肿瘤术后并发症的护理

目的探讨胸腹腔镜联合治疗食管胃交界部肿瘤术后并发症的护理。方法回顾性分析10例胸腹腔镜下联合治疗食管胃交界部肿瘤患者的临床资料,其中术后并发心律失常2例,肺部感染、肺不张2例,吻合口瘘2例,胸部皮下气肿1例,腹腔内出血1例,腹部穿刺孔出血1例。对不同的并发症采取相应的治疗、护理措施。结果经对症治疗、护理,2例心律失常患者72h内均得到纠正;2例肺部感染、肺不张患者经复查胸片证实肺部感染消失,肺复张良好;2例吻合口瘘瘘口均在术后1个月左右愈合;胸部皮下气肿1例经调整胸腔闭式引流后好转,1周后皮下气肿消失;1例腹部穿刺孔出血床旁局麻下成功止血;1例内出血患者开腹行止血术成功止血。结论胸腹腔镜联合治疗食管胃交界部肿瘤手术复杂,并发症发生率高,护理过程中应密切观察患者病情变化,早期发现、早期预防,以减少并发症的发生。     

胃食管反流病的腹腔镜外科治疗

目的:探讨腹腔镜手术治疗胃食管反流病的临床效果.方法:回顾性分析2008年1月—2011年9月对33例胃食管反流病患者行腹腔镜食管裂孔疝修补和胃底折叠术的临床资料.腹腔镜单纯胃底折叠术5例(Toupet式),腹腔镜食管裂孔疝修补加胃底折叠术25例(Nissen式3例,Toupet式22例),腹腔镜单纯食管裂孔疝修补术3例.结果:全组患者手术均获成功,手术时间90～185 min.术后平均住院6d.无中转开腹及死亡病例,无术后严重并发症.术后随访1～24个月,32例临床症状完全消失,1例明显好转.结论:对于胃食管反流性疾病,腹腔镜食管裂孔疝修补和胃底折叠术是一种微创、安全、有效的治疗方法.     

胃食管交界区黏膜下肿瘤腹腔镜手术体会(附5例报告并文献复习)

目的:探讨腹腔镜胃局部切除术治疗胃食管交界区黏膜下肿瘤的可行性。方法:回顾性分析2005年3月至2008年3月5例行腹腔镜手术的胃食管交界区黏膜下肿瘤患者的手术方式设计,术后定期随访。结果:平均手术时间(108±19.5)min,术中平均出血(65±11.7)ml;5例手术均获成功,无病灶遗漏,无贲门狭窄、腹腔感染、脾脏损伤、胃漏等并发症和中转手术;术后随访均未见肿瘤复发。结论:腹腔镜胃局部切除术治疗胃食管交界区黏膜下肿瘤安全、有效。     

腹腔镜手术治疗食管裂孔疝及胃食管反流性疾病的临床体会

目的:探讨腹腔镜手术治疗食管裂孔疝及胃食管反流性疾病的临床疗效及安全性。方法:回顾分析2009年1月至2012年11月36例食管裂孔疝及胃食管反流性疾病患者的临床资料,20例行腹腔镜手术(腹腔镜组),16例行开腹手术(开腹组)。观察两组患者手术时间、术中出血量、术后住院时间、术后抗生素使用时间、术后胃肠道功能恢复时间及术后并发症。结果:腹腔镜组手术时间、术中出血量、术后住院时间、术后抗生素使用时间、术后胃肠道功能恢复时间及术后并发症发生率均显著优于开腹组(P<0.05)。结论:腹腔镜手术治疗食管裂孔疝及胃食管反流性疾病安全、可靠,具有广阔的临床应用前景。     

Nursing care of patients developing complications after surgical removal of carcinoma of the esophagogastric junction under thoracoscopy and laparoscopy

目的 探讨胸腹腔镜联合治疗食管胃交界部肿瘤术后并发症的护理.方法 回顾性分析10例胸腹腔镜下联合治疗食管胃交界部肿瘤患者的临床资料,其中术后并发心律失常2例,肺部感染、肺不张2例,吻合口瘘2例,胸部皮下气肿1例,腹腔内出血1例,腹部穿刺孔出血1例.对不同的并发症采取相应的治疗、护理措施.结果 经对症治疗、护理,2例心律失常患者72 h内均得到纠正;2例肺部感染、肺不张患者经复查胸片证实肺部感染消失,肺复张良好;2例吻合口瘘瘘口均在术后1个月左右愈合;胸部皮下气肿1例经调整胸腔闭式引流后好转,1周后皮下气肿消失;1例腹部穿刺孔出血床旁局麻下成功止血;1例内出血患者开腹行止血术成功止血.结论 胸腹腔镜联合治疗食管胃交界部肿瘤手术复杂,并发症发生率高,护理过程中应密切观察患者病情变化,早期发现、早期预防,以减少并发症的发生.     

腹腔镜胃底折叠术治疗胃食管反流病

目的探讨腹腔镜胃底折叠术治疗胃食管反流病的临床效果。方法2008年1月-2011年11月对40例胃食管反流病行腹腔镜胃底折叠术。腹腔镜单纯胃底折叠术7例（Toupt式）,腹腔镜食管裂孔疝修补加胃底折叠术33例（Nissen式5例,Toupet式28例）。结果手术均获成功,无中转开腹及死亡病例,无术后严重并发症。手术时间75～215min,平均112min;术中出血量10-350ml,平均52ml;术后住院5—10d,平均7d。40例术后随访1—24个月,平均16个月,34例临床症状完全消失,6例症状明显好转。结论腹腔镜胃底折叠术治疗胃食管反流病疗效满意。     

腹腔镜经膈肌裂孔近端胃切除治疗食管胃交界部腺癌98例

目的探讨腹腔镜经膈肌裂孔近端胃切除治疗食管胃交界部腺癌（AEG）的安全性及近期临床效果。方法回顾2008年8月至2011年5月接受腹腔镜经膈肌裂孔近端胃切除术治疗的98例AEG患者的临床资料,分析手术时间、术中出血情况、食管切除长度、淋巴结清扫情况及术后近期并发症。结果腹腔镜下完成近侧胃切除术96例,中转开腹2例（联合脾切除术1例,联合脾脏、胰尾切除术1例）。手术时间（224．1±33．7）min;术中出血（69．4±26．1）ml;切除食管长度（4．0±0．6）cm;术后病检切缘均无癌残留;获取淋巴结（16．4±5．7）枚／例。术中损伤胸膜14例,损伤脾脏3例;术后吻合口瘘1例,无吻合口狭窄、术后出血、切口（包括穿刺孔）感染及围手术期死亡病例。随访时间3～30个月,术后1个月和3个月反流性疾病问卷表评分分别为（9．9±4．4）和（9．3±4．3）,无切口（包括穿刺孔）癌种植,随访期间死亡5例。结论腹腔镜经膈肌裂孔近侧胃切除治疗AEG安全可行．近期临床效果较好。     

腹腔镜辅助远端胃次全切除术

目的探讨腹腔镜外科技术在胃切除手术的应用价值。方法对15例腹腔镜辅助胃手术患者的临床资料和随访情况进行回顾性分析。结果腹腔镜辅助远端胃大部分切除术13例(其中胃癌D1根治术3例、胃十二指肠溃疡手术10例),进展期胃癌腹腔镜探查术2例。无中转开腹,无手术死亡。术中皮下气肿1例、发生率6.67%(1/15),平均手术时间245.6±35min,平均出血量110±45ml,辅助切口平均长6.5±1cm,平均术后住院日10±2.5d。术后吻合口输出襻梗阻1例、发生率7.69%(1/13)。全组13例患者术后随访2～26个月,未出现远期并发症,其中3例胃癌患者未发现远处转移病灶,其trocar穿刺孔及腹壁切口无肿瘤种植。结论只要严格掌握手术适应证,正确应用腹腔镜技术,腹腔镜辅助远端胃大部分切除术是安全、可行的。     

腹腔镜食管裂孔疝修补联合胃底折叠术治疗胃食管反流病合并食管裂孔疝

目的：探讨腹腔镜下行食管裂孔疝修补联合胃底折叠术治疗胃食管反流病合并食管裂孔疝的临床疗效和安全性。 方法：回顾性分析2012年1月—2014年2月在我院进行食管裂孔疝修补联合胃底折叠术的58例胃食管反流病合并食管裂孔疝患者临床资料,其中36例在腹腔镜下行食管裂孔疝修补联合胃底折叠术（观察组）,22例患者行开腹手术（对照组）。观察并比较两组患者手术时间、术中出血量、术后住院时间、术后胃肠道功能恢复时间及术后并发症发生情况,手术前及手术后4个月进行反流性疾病问卷（RDQ）调查结果。 结果：观察组手术时间、术后住院时间、术后胃肠道功能恢复时间均明显短于对照组（均P<0.05）;观察组术中出血量及术后并发症发生情况均明显优于对照组（P<0.05）;两组患者RDQ评分显示术后4个月症状均有不同程度的改善,观察组患者症状改善程度优于对照组患者（均P<0.05）。 结论：腹腔镜下行食管裂孔疝修补联合胃底折叠术治疗胃食管反流病合并食管裂孔疝,疗效显著,安全性好,可积极应用于临床上胃食管反流病合并食管裂孔疝的治疗。     

腹腔镜Roux-en-Y改道术治疗胃食管术后顽固性胃食管反流的初步经验

目的:探讨腹腔镜Roux-en-Y改道术治疗治疗胃食管术后顽固性胃食管反流及其呼吸道症状的方法与疗效.方法:分析腹腔镜Roux-en-Y空肠改道术治疗5例此类患者的手术史、临床表现、Roux-en-Y改道方法和随访12～22个月的疗效.结果:所有的患者均行40 cm空肠的Roux-en-Y改道术,无手术死亡和术后并发症.4例患者反流症状和呼吸道症状消失,1例患者症状明显改善,所有患者均停用抗反流药物.结论:腹腔镜Roux-en-Y空肠改道术可有效控制食管切除或胃大部切除手术后的顽固性反流及由其引起的消化和呼吸道症状.     

HER2 Assessment in Upper Gastrointestinal Tract Adenocarcinoma: A Practical,Algorithmic Approach

Gastric and gastroesophageal junction adenocarcinomas constitute a major health problem. For localized disease, adjuvant treatment is multidisciplinary and usually includes a combination of surgery, radiation and chemotherapy. Recently, trastuzumab (Herceptin) has been approved for the treatment of metastatic upper gastrointestinal (GI) tract (gastric, esophageal, and gastroesophageal) adenocarcinomas. The purpose of this review is to provide pathologists with practical guidance in HER2 assessment of upper GI tract adenocarcinomas in order to accurately identify patients eligible for trastuzumab therapy.     

Measurement of gastric pH in ambulatory esophageal pH monitoring

Background  Ambulatory esophageal pH monitoring is the method used most widely to quantify gastroesophageal reflux. The degree of gastroesophageal reflux may potentially be underestimated if the resting gastric pH is high. Normal subjects and symptomatic patients undergoing 24-h pH monitoring were studied to determine whether a relationship exists between resting gastric pH and the degree of esophageal acid exposure. Methods  Normal volunteers (n = 54) and symptomatic patients without prior gastric surgery and off medication (n = 1,582) were studied. Gastric pH was measured by advancing the pH catheter into the stomach before positioning the electrode in the esophagus. The normal range of gastric pH was defined from the normal subjects, and the patients then were classified as having either normal gastric pH or hypochlorhydria. Esophageal acid exposure was compared between the two groups. Results  The normal range for gastric pH was 0.3–2.9. The median age of the 1,582 patients was 51 years, and their median gastric pH was 1.7. Abnormal esophageal acid exposure was found in 797 patients (50.3%). Hypochlorhydria (resting gastric pH >2.9) was detected in 176 patients (11%). There was an inverse relationship between gastric pH and esophageal acid exposure (r = −0.13). For the patients with positive 24-h pH test results, the major effect of gastric pH was that the hypochlorhydric patients tended to have more reflux in the supine position than those with normal gastric pH. Conclusion  There is an inverse, dose-dependent relationship between gastric pH and esophageal acid exposure. Negative 24-h esophageal pH test results for a patient with hypochlorhydria may prompt a search for nonacid reflux as the explanation for the patient’s symptoms. Presented orally at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Annual Meeting, Pennsylvania Convention Center, Philadelphia, PA, USA, 9–12 April, 2008.     

In a Setting of Esophageal Replacement,Total Gastric Pull-Up has Fewer Complications than Partial Gastric Pull-Up

AimThe main indications for an esophageal replacement (ER) are unresolved complex esophageal atresia (EA) and caustic strictures (CS). The use of different organs for replacement has been described. When the stomach is chosen, there are two ways to do a gastric pull-up: a partial (PGP) or a total pull-up (TGP). Few studies have been published comparing the different techniques. The aim of this study was to compare the outcomes of patients who underwent ER by PGP or by TGT.MethodsThe medical records of all patients who underwent gastric pull-up for ER in the last 18 years at the National Pediatric Hospital Prof. Dr. Juan P. Garrahan were reviewed. The study is comparative, retro-prospective and longitudinal. Patients were divided in two groups according to the ER technique (PGP or TGP). We compared the following outcomes: duration of the operation, days of hospitalization in the intensive care unit (ICU), days of total hospitalization, time to initiation of oral feedings and rate of anastomosis dehiscence, incidence of anastomotic stenosis, need for re-operations, incidence of gastroesophageal reflux disease (GERD), incidence of tracheo-esophageal fistulas (TEF), incidence of dumping syndrome, incidence of gastric necrosis and mortality.ResultsThere were 92 patients included in the study: 70 in the PGP group (76%) and 26 in the TGP group (24%). The two groups were demographically equivalent. Patients in the TGP group had a statistically significant lower incidence of anastomotic dehiscence (22,7% versus 54,3%; p = 0.01) and dumping syndrome (13,6% versus 37,1%; p = 0.038). Patients in the TGP had lower incidence of anastomotic stenosis, although the difference was not statistically significant. There were no statistically significant differences between the groups in terms of duration of the operation, postoperative days in the ICU, time to oral feedings, GERD, TEF or overall hospital stay. There were no cases of gastric necrosis. There were 3 deaths in the PGP group and one in the TGP group.ConclusionsWe observed benefits in the TGP group versus the PGP approach in terms of anastomotic dehiscence and dumping syndrome, as well as a trend toward a lower incidence of anastomotic stenosis. Based on this experience, we recommend the TGP approach for patients who need an esophageal replacement by a gastric pull-up.Levels of evidenceAccording to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.     

Minimally invasive esophagectomy is safe in patients with previous gastric bypass

BackgroundThe prevalence of morbid obesity in the United States has been steadily increasing, and there is an established relationship between obesity and the risk of developing certain cancers. Patients who have undergone prior gastric bypass (GB) and present with newly diagnosed esophageal cancer represent a new and challenging cohort for surgical resection of their disease. We present our case series of consecutive patients with previous GB who underwent minimally invasive esophagectomy (MIE).MethodsRetrospective review of consecutive patients with a history of GB who underwent a MIE for esophageal cancer between July 2010 and August 2012.ResultsFive patients were identified with a mean age of 57 years. Mean follow-up was 9.1 months. Four patients had undergone laparoscopic GB, and 1 patient had an open GB. Two patients received neoadjuvant chemoradiation therapy for locally advanced disease. Minimally invasive procedures were thoracoscopic/laparoscopic esophagectomy with cervical anastomosis in 4 patients and colonic interposition in 1 patient. Mean operative time was 6 hours and 52 minutes. Median length of stay was 7 days. There was no mortality. Postoperative complications occurred in 3 patients and included pneumonia/respiratory failure, recurrent laryngeal nerve injury, and pyloric stenosis. All patients are alive and disease free at last follow-up.ConclusionsMinimally invasive esophagectomy after prior GB is well tolerated, is technically feasible, and has acceptable oncologic and perioperative outcomes. We conclude that precise endoscopic evaluation before bariatric surgery in patients with gastroesophageal reflux disease is essential, as is the necessity for continuing postsurgical surveillance in patients with known Barrett’s esophagitis and for early evaluation in patients who develop new symptoms of gastroesophageal reflux disease after bariatric surgery.     

Evaluation of gastroesophageal function and mechanisms underlying gastroesophageal reflux in infants and adults born with esophageal atresia

Purpose

To evaluate the mechanisms underlying gastroesophageal reflux (GER) following esophageal atresia (EA) repair and gastroesophageal function in infants and adults born with EA.

Methods

Ten consecutive infants born with EA as well as 10 randomly selected adult EA patients were studied during their first postoperative follow-up visit and a purposely planned visit, respectively. A ¹³C-octanoate breath test and esophageal pH–impedance–manometry study were performed. Mechanisms underlying GER and esophageal function were evaluated.

Results

Transient lower esophageal sphincter relaxation (TLESR) was the most common mechanism underlying GER in infants and adults (66% and 62%, respectively). In 66% of all GER episodes, no clearing mechanism was initiated. On EFT, normal motility patterns were seen in six patients (four infants, two adults). One of these adults had normal motility overall (> 80% of swallows). Most swallows (78.8%) were accompanied by abnormal motility patterns. Despite this observation, impedance showed normal bolus transit in 40.9% of swallows. Gastric emptying was delayed in 57.1% of infants and 22.2% of adults.

Conclusions

TLESR is the main mechanism underlying GER events in patients with EA. Most infants and adults have impaired motility, delayed bolus clearance, and delayed gastric emptying. However, normal motility patterns were seen in a minority of patients.     

Comparison of laparoscopically assisted and open radical distal gastrectomy with extended lymphadenectomy for gastric cancer management

Background The feasibility and safety of laparoscopically assisted gastrectomy with extended lymphadenectomy for advanced gastric cancer has rarely been studied. This study aimed to investigate the feasibility, safety, and cancer clearance of laparoscopically assisted distal gastrectomy with D2 lymphadenectomy. Methods Of the 44 patients with distal gastric cancer who underwent radical distal gastrectomy from March 2004 to May 2005, 35 were treated with D2/D2⁺ lymphadenectomy. These patients were compared with 58 patients who, during the same period, underwent a conventional open radical distal gastrectomy. Results The mean total number of retrieved lymph nodes (30.11 ± 16.97) and the mean tumor margin were comparable with those in the open group. The mean operative time for laparoscopically assisted distal gastrectomy was significantly longer than for open surgery (282.84 ± 32.81 min vs 223.75 ± 23.25 min). The patients in the laparoscopic surgery group had less blood loss, shorter times of analgesic injection, and a faster recovery. The rates of complications were comparable between two groups. Conclusions Although laparoscopically assisted radical gastrectomy with D2 lymphadenectomy is more time consuming than open surgery, it is a safe, feasible procedure that achieves cancer clearance similar to open surgery and leads to a quick postoperative recovery.     

食管癌切除术后双相胃排空

目的：进一步研究食管癌工除术后病人固体和液体两种实验餐的胃排空。方法：对１０例食管癌切除术后病人用＾９９ｍＴｃ和＾１１１Ｉｎ分别标定液体和固体实验餐进行胃排空闪烁照相,并与７名下沉人作对比,共检查１２０分钟。结果：病人组液体和固体食物排空率分别为２８．０８％和０,较正常人延迟（８２．０３％和３０．５２％）,差异有显著性（Ｐ〈０．０１）。结论：有因素影响术后胃排空,以迷走神经切除为最主要原因。     

Conversion of laparoscopic Roux-en-Y gastric bypass

BACKGROUND: To determine the incidence and causes of conversion from a laparoscopic to an open gastric bypass for morbid obesity, we reviewed the experience of our bariatric center. METHODS: We performed a retrospective review of the records of consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at our center. RESULTS: In all, 1,236 consecutive patients with body mass indes (BMI) from 35 to 82 were approached laparoscopically. In 97%, bypasses were completed laparoscopically and in 3% (40 patients), a conversion was required to complete the procedure. Older age and male sex were greater in the converted group, whereas BMI was not different nor was the proportion of super obese patients. The cause of conversion was technical in 80%, bleeding in 10%, and a massive liver in 10%. CONCLUSIONS: Our risk of conversion was generally low, but increased in older patients and males. In 33% of patients, conversions could have been avoided with technical lessons learned by experience.     

Sporadic gastric carcinoid tumor laparoscopically resected: a case report.

Sporadic gastric carcinoid tumors are relatively infrequent malignancies of the stomach. Tumors measuring less than 1 cm can sometimes be safely removed endoscopically; however, larger neoplasias require surgical ablation. The present case report represents a gastric carcinoid tumor laparoscopically resected in a patient with a history of hematemesis. The tumor was first marked endoscopically with India ink, which facilitated subsequent localization of the area to be resected. Laparoscopic resection of the mass was without complication, and the pathology study confirmed the preoperative diagnosis and negativity of the margins. In patients who present with masses that are not amended for endoscopic resection, sporadic gastric carcinoid tumors can be resected laparoscopically.     

Laparoscopic management of gastric diverticula.

Gastric diverticular are rare and usually are diagnosed incidentally on radiographic examination. Surgical treatment, consisting of simple excision or inversion of the diverticulum, has been reserved for patients with proven symptoms or complications. These procedures have typically required laparotomy, but with the development of advanced endoscopic techniques, a minimally invasive approach may be appropriate. The authors report two cases of gastric diverticula managed laparoscopically and review the literature related to this entity. Between 1993 and 1996, two patients were evaluated for dyspepsia-like gastrointestinal complaints. Both patients were found to have a gastric diverticulum on a contrast study, and one diverticulum was also seen on upper endoscopy. Laparoscopic resection was undertaken in both cases. Flexible gastroscopy was performed intraoperatively to help localize the diverticulum, which was resected with an endoscopic stapling device. Nissen fundoplication was performed in conjunction with the diverticulectomy in the second patient for gastroesophageal reflux. Both procedures were completed laparoscopically without complications. The postoperative course was uneventful in both patients. At long-term follow-up, the patients are asymptomatic. This experience indicates that laparoscopic resection of symptomatic gastric diverticula is a feasible alternative to laparotomy. A prospective analysis to verify the safety and efficacy of this procedure should be done.