直肠癌阴道后壁切除后子宫肌瓣即时修复10例

目的探讨直肠癌阴道后壁切除后的修复方法。方法采用地屿累及的阴道后壁一并切除，随时用子宫带蒂浆肌瓣修复有道后壁。结果１０例中除１例因子宫肌瓣血供不佳失败外，蓁效果满意。结论用带蒂子肌瓣修复阴道后壁，取材方便，手术简单易行，对直肠癌累及阴道后壁需切除阴道后壁才可选择此术式修复。     

直肠并阴道后壁切除与重建术

浙江省肿瘤医院大肠癌综合治疗科自1994年10月～1999年2月,行直肠并明道后壁切除与重建术15例,取得了良好的效果。该手术为直肠阴道隔恶性肿瘤、直肠癌累及阴道后壁或阴道后壁恶性肿瘤累及直肠的的治疗开创了一种新术式。l手术适应证直肠阴道隔恶性肿瘤末累及提肛肌及肛门括约肌者;直肠恶性肿瘤累及阴道后壁而仍能保留肛门者;阴道后壁恶性肿瘤累及直肠者。2手术方法直肠并阴道后壁（可包括子宫及其附件）切除后,用带血管蒂的回肠片修复阴道后壁,并将近端结肠拉下作结肠肛管吻合术。带蒂回肠片的制备和阴道后壁缺损的修复。将回肠末段…     

带蒂舌骨下肌群肌骨瓣修复分化型甲状腺癌术后气管部分缺损的临床应用

目的：探讨侵犯气管的分化型甲状腺癌术后，应用带蒂舌骨下肌群肌骨瓣修复的可行性。方法：对2006年1月至2010年12月共10例侵犯气管的分化型甲状腺癌行根治性切除术，受累气管窗式切除，应用带蒂舌骨下肌群肌骨瓣修复，术后辅助131Ⅰ治疗。结果：10例患者均术后3月拔除气管套管，拔管率100％，术后定期复查电子支气管镜，肌骨瓣均存活，重建气管腔壁上皮化，无明显狭窄；随访5年，远处转移死亡1例。结论：带蒂舌骨下肌群肌骨瓣有良好的血供，远期效果好，拔管率高，是分化型甲状腺癌气管部分切除后的理想修复组织。     

带蒂胸大肌皮瓣在头颈外科修复中的应用

目的探讨带蒂胸大肌复合组织瓣在头颈肿瘤切除后组织缺损一期修复的方法及适应证.方法采用带蒂胸大肌岛状复合组织瓣一期修复口腔癌7例,口咽癌、腮腺癌各1例.结果9例均获满意的外观和功能,2例皮瓣部分坏死,均经换药痊愈.结论带蒂胸大肌皮瓣可以满足颌面中部以下,口腔,颈部覆盖组织及衬里大面积缺损的修复,修复瓣成活率相对较高.     

带蒂胸大肌皮瓣在头颈外科修复中的应用

目的：探讨带蒂胸大肌复合组织瓣在头颈肿瘤切除后组织缺损一期修复的方法及适应证,方法：采用带蒂胸大肌岛状复合组织瓣一期修复口腔癌7例,口咽癌,腮腺癌各1例,结果：9例均获满意的外观和功能,2例皮瓣部分坏死,均经换药痊愈。结论：带蒂胸大肌皮瓣可以满足颌面中部以下,口腔,颈部覆盖组织及衬里大面积缺损的修复,修复瓣成活率相对较高。     

带血管蒂肌肉组织瓣在颅底肿瘤外科的应用

本文报道１３例晚期颅底部恶性肿瘤病例，应用带血管蒂肌肉组织瓣即刻修复根治性切除手术后的组织缺损，其中斜方肌组织瓣８例，胸大肌组织瓣３例，颞肌组织瓣２例，并对颅底部肿瘤术后组织缺损的修复和颅底肿瘤的综合治疗等问题进行讨论。     

带蒂胸大肌肌皮瓣移植在头颈癌放疗后手术中的运用

目的：探讨头颈癌放疗后因肿瘤复发进行挽救性手术，带蒂胸大肌肌皮瓣修复手术切除后软组织缺损的可行性和价值。方法：7例头颈部恶性肿瘤进行了根治性放疗后局部复发或颈淋巴结转移，通过手术切除病灶，颈淋巴结清扫，同侧带蒂胸大肌肌皮瓣移植修复软组织缺损创面。结果：7例移植的带蒂胸大肌肌皮瓣全部成活，有2例出现切口裂开，愈合困难。结论：在头颈癌放疗后手术中，带蒂胸大肌肌皮瓣移植是修复手术切除后软组织缺损的有效方法。     

肺癌心包内全肺切除术应用带蒂膈肌瓣修补心包缺损42例临床观察

目的探讨肺癌患者经心包内全肺切除术中应用自体带蒂膈肌瓣修补心包缺损。方法回顾性分析42例经心包内全肺切除术中应用自体带蒂膈肌瓣修补心包缺损患者的临床资料。结果42例患者术中无1例因心包切开引起不可逆性心律失常;心包修复后,心电图、心脏彩超无特殊改变,心功能良好。结论经心包内全肺切除术中应用自体带蒂膈肌瓣是修补心包缺损的理想材料,为心包内全肺切除提供了更满意的辅助条件。     

带蒂额肌帽状腱膜颅骨瓣修复前颅底的术后护理

目的：提高带蒂额肌帽状腱膜颅骨瓣修复前颅底的存活率，减少术后并发症。方法：对12例前颅底区病变的术后缺损行带蒂额肌帽状腱膜颅骨瓣修复，采取的护理措施有术后体位、神经系统、呼吸系统、创口出血、眼部、鼻部以及并发症的观察护理。结果：12例行带蒂额肌帽状腱膜颅骨瓣修复前颅底患者，全部痊愈出院。结论：带蒂额肌帽状腱膜颅骨瓣修复前颅底缺损手术，具有多学科性，在术后护理中必须融合神经外科、眼科、耳鼻咽喉科及额面整形的多学科知识，加强有效的多学科综合护理措施，才能保证手术的成功。     

直肠癌阴道壁部分切除阴道切口裂开的防治(附18例报告)

直肠癌阴道壁部分切除阴道切口裂开的防治（附１８例报告）邢金德张绍政＊孙黎明＊我院自１９８６～１９９６年行直肠癌根治中，其中有１８例侵及阴道后壁和侧后壁，行阴道后壁和侧后壁连同直肠整块切除Ⅰ期阴道缝合。现将本组病人阴道切口裂开感染的教训、防治报告如下...     

A case of local recurrence of rectal cancer in which trans-sacral resection and perineal reconstruction by femoral posterior flap were performed

A 54-year-old woman underwent abdomino-perineal resection for rectal cancer. Six months after surgery, perineal pain and the tumor marker increased. Local recurrence of the pelvic cavity and lung metastases were diagnosed by computed tomography (CT) and positoron emission tomography (PET) using 18F-fluorodeoxygulucose (FDG). Local perineal pain continued and there was no increase in the neoplastic lesion of the lung, so surgical treatment was performed. After partial resection of the lung, local resection of the gluteus maximus and posterior wall of the vagina was performed with the patient in the Jack-knife position. To fill the defect, a femoral posterior flap was made and the perineal defect was reconstructed.     

Curative laparoscopic surgery performed after neoadjuvant chemotherapy for locally advanced rectal cancer invading into the vagina

A 60-year-old woman with locally advanced rectal cancer, which had infiltrated into the vagina, was referred to our department in September 2010. She received 4 courses of neoadjuvant chemotherapy; the tumor size reduced, but the fistula was not closed. Because the tumor size had reduced, we performed a laparoscopic surgery. The laparoscopic surgery involved perineal proctectomy and resection of the posterior wall of the vagina, along with dissection of the bilateral lymph nodes. The efficacy of the neoadjuvant chemotherapy was judged as Grade 2. Neoadjuvant chemotherapy should be considered in patients with locally advanced lower rectal cancer with infiltration into other organs.     

A case of metastatic vaginal tumor of rectal cancer

The majority of vaginal metastases from extra-genital tumors are from colorectal cancer. A case of metastases to the vagina from a huge rectal carcinoma is described. A 55-year-old woman was admitted to the hospital because of a barium ileus after upper GI. Further examination revealed that she had a huge rectal carcinoma. Hartmann's operation combined with resection of the right ureter, posterior wall of the uterus and left ovary was performed. Postoperative chemoradiotherapy was performed with 60 Gy of irradiation to the small pelvis with 500 mg/day continuous infusion of 5-FU. After 18 months, she had genital bleeding. Digital examination revealed a vaginal tumor and metastasis of the rectal carcinoma to the vagina was confirmed histologically. Abdominoperineal resection of the rectum and vagina combined with simple total hysterectomy and bilateral salpingo-oophorectomy was performed. Thirty-three months after operation, there is no sign of recurrence.     

Combined laparoscopic and transperineal endoscopic total pelvic exenteration for the vaginal stump recurrence of cervical cancer

Total pelvic exenteration (TPE) is sometimes required for radical treatment of locally advanced or recurrent gynecologic cancer [1]. However, TPE with a transabdominal approach requires highly advanced techniques in the case of repeated surgery due to the effects of primary surgery and/or chemoradiotherapy, especially when a transabdominal approach is used. Recent technical advances in transanal/transperineal endoscopic surgery have proved beneficial for complicated surgery in the deep pelvis [2]. Here we introduce our surgical procedure for combined laparoscopic and transperineal endoscopic TPE (TpTPE) for pelvic recurrence of cervical cancer. A 42-year-old woman was diagnosed with vaginal stump recurrence of cervical cancer involving the rectum, bladder, and ureters following hysterectomy and pelvic lymph node dissection as primary surgery and chemotherapy/chemoradiotherapy for previous recurrences. We decided to perform TpTPE with a combined laparoscopic approach. The GelPOINT advanced access platform was fixed through a perineal skin incision around the tightly closed anus, external urethral orifice, and vagina. With sufficient pneumopelvic pressure (12 mmHg), TpTPE was performed under a good surgical view without any effect of the primary surgery. A ureterostomy and sigmoid colostomy were created and a right gracilis muscle flap was used to reconstruct the pelvic defect. The total operative time and estimated blood loss were 887 minutes and 497 mL, respectively. Histopathological examination revealed recurrent cervical cancer invading the rectum, bladder, and bilateral ureters with negative surgical margins. The postoperative course was uneventful except for paralytic ileus. The patient was discharged on postoperative day 18. TpTPE is a technically feasible and effective approach for locally advanced pelvic tumors.     

外阴广泛切除术后股薄肌肌皮瓣移植重建外阴的经验

目的:探讨减少外阴癌术后切口愈合困难、外阴严重变形、阴道狭窄等并发症的方法.方法:外阴广泛切除术后根据外阴缺损程度游离相应大小带有皮肤、皮下脂肪及供应血管、神经的股薄肌肌皮瓣,在肌皮瓣的供区及受区的皮下软组织内打通一条隧道,将游离好的肌皮瓣通过隧道扭转至外阴缺损区,肌皮瓣近端位于外阴前面耻骨联合处,远端位于外阴后面会阴处,将肌皮瓣与外阴切口的内外缘进行全层缝合.结果:12例患者移植后股薄肌肌皮瓣全部成活,Ⅰ期愈合9例,12例中9例可进行性生活,重建外阴丰满富有弹性,与正常外阴相似.结论:该方法可使外阴癌患者在手术切除肿瘤后获得外阴解剖外观及功能的恢复,缩短了术后康复时间,提高了生活质量,手术方法简单易行,可进行临床推广.     

Rectovaginal fistula following low circular stapled anastomosis in women with rectal cancer

Low anastomosis using a circular stapling instrument has become standard for performing a colorectal reconstruction following resection of a rectal cancer. Often these anastomoses are performed deep in the pelvis using a circular stapling instrument without clear visualization of the anastomotic site. In the female patient, unless an adequate stump of rectum is left above the circular staple line, there is danger that the side wall of the posterior aspect of the vagina can be included in the tissue rings (donuts) that are resected by the circular stapling instrument. This leaves the patient at high risk for late development of a rectovaginal fistula by vaginal mucosa being incorporated into the rectal wall. Maintenance of an adequate stump beyond the linear staple line and a vaginal examination prior to firing the circular stapler will prevent this problem. A patient is presented and the technical details for a safe low-low colorectal anastomosis are reviewed. © 1996 Wiley-Liss, Inc.     

On the use of margins for geometrical uncertainties around the rectum in radiotherapy planning.

BACKGROUND AND PURPOSE: To derive planning organ at risk volume (PRV) margins for the rectum and to analyse the impact of such margins on rectum dose volume histograms (DVHs). PATIENTS AND METHODS: Weekly repeat computer tomography (CT) scans of 19 bladder cancer patients acquired during a conformal radiotherapy course were registered with the corresponding planning CT scans. From these scans, the internal rectal motion was quantified, and the margins that had to be added to the rectum contour in the planning scan to encompass the observed span of rectum motion were determined. These margins were compared to the margins derived using a recent PRV margin recipe. To illustrate the impact of margins on rectum DVHs, the margins were applied in treatment plans of six prostate cancer patients. RESULTS: Altogether 141 CT scans were analysed. On average 24% of the repeat scan rectum volume was displaced outside the planning scan contours, and wall movements of up to 30 mm were observed. Margins of 16 mm anterior and 11 mm posterior encompassed all rectal motion except for the two most displaced rectum walls in each of these directions, in 89% of the patients. Using a recently published statistics-based recipe, margins of 6 mm anterior and 5 mm posterior accounted for the systematic rectum variation, i.e. the average wall position, in 90% of the patients. Adding anterior margin only caused consistent increases (up to 20%) in the fraction of the volume inside the high-dose region (40-70 Gy) compared to the DVH of rectum only. When using both anterior and posterior margins only small shifts (<5%) in the volume fractions were observed. CONCLUSIONS: Rectum PRV margins of 5-6 mm will encompass the systematic component of rectum motion, while margins up to 16 mm are required to also account for most of the random variation. Use of anterior margins only caused large shifts in the DVHs in the clinically significant dose range, while only minor shifts were seen when using both anterior and posterior margins.     

Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction

Vaginal defects from oncologic resection present a complex array of reconstructive challenges. Increased use of adjuvant radiation and chemotherapy demands uncomplicated wound healing. As patients are being diagnosed at earlier stages of disease and at younger ages, maintenance of sexual function and body image are fundamental goals. This review provides an algorithm approach to defect classification and flap reconstruction. Carefully appreciation of the specific defect facilitates flap choice. There are two basic defect types partial (Type I) and circumferential defects (Type II) 1. These defect types can be further subclassified. Type IA defects are partial and involve the anterior and/or lateral wall. Type IB defects are also partial, but involve the posterior vaginal wall. Type IIA defects are circumferential, involving the upper two-thirds of the vagina. Type IIB defects represent circumferential, total vaginal resection, most commonly following pelvic exenteration. Using this method of defect classification, three pedicled flaps can be used to successfully reconstruct the majority of defects: the Singapore (or pudendal thigh) flap, the rectus flap, and the gracilis flap. With appropriate flap choice and a multidisciplinary approach to patient care, rapid wound healing, restoration of the pelvic floor, and re-establishment of sexual function may be most reliably achieved.     

A case of thyroid cancer involving the trachea: treatment by partial tracheal resection and repair with a latissimus dorsi musculocutaneous flap

A 65 year-old man had undergone left thyroidectomy for thyroid cancer. The cancer had directly invaded the cervical esophagus and trachea and the patient was referred to our hospital for radical resection and reconstruction. Cervical computed tomography showed a mass at the left-posterior wall of the trachea. Cervical esophagectomy, resection of the left half of the trachea (6 x 3 cm) including seven rings and cervical lymph node dissection were performed. The tracheal defect was covered by a latissimus dorsi musculocutaneous flap. The patient did not lose vocal function and remains alive and well 3 years after surgery without any evidence of recurrence. Latissimus dorsi muscle flap coverage of tracheal defects seems to be a useful technique in the combined resection of the trachea.     

Prospective speech outcome study in patients with soft palate reconstruction in tonsillar cancer

For advanced stage tonsil cancer, extensive resection of the soft palate is unavoidable. The purpose of this study is to report on the speech outcome according to the various types of defects and reconstruction techniques. This prospective study was performed on 53 patients of tonsil cancer. The postoperative speech function was evaluated for three factors: nasalance, speech intelligibility, and velopharyngeal insufficiency. Four reconstruction methods used for the soft palate defect: local flap, patch method, Gehanno method, and Denude method. Univariate analysis showed that the Denuded reconstruction technique, more than one-half of the soft palate resection, and T stage was significantly associated for nasalance, speech intelligibility, and velopharyngeal insufficiency. Multivariate analysis showed that the Denuded reconstruction technique (for patients with extensive soft palate and posterior pharyngeal wall defect) was the most significant variable. When the defect of tonsil cancer is extensive, especially when it extends to the posterior pharyngeal wall, a reconstruction method that can reduce the velopharyngeal cross-sectional area efficiently, such as the Gehanno method, is preferred.