肝硬化合并胆石症的手术治疗

目的: 探讨肝硬化合并胆石症患者的手术风险及预后 。方法: 对我院1994~2000年间收治的42例肝硬化合并胆石症患者的临床资料进行回顾分析 。结果: 42例肝硬化合并胆石症患者中,肝功能ChildA级19例,ChildB级18例,ChildC级5例。急诊手术15例,择期手术27例。术中出血量1000ml以上13例。术后出现并发症22例,其中ChildA级6例(占31.6%),B级12例(占66.7%),C级4例(占80.0%)。治愈29例,死亡6例,术后胆道残余结石7例 。结论: Child分级适用于肝硬化患者胆道手术风险的评估。术中出血和术后肝功能衰竭是影响预后的主要因素。     

Prognostic factors of cirrhotic patients in extra-hepatic surgery

BACKGROUND: The surgical approach to a cirrhotic patient is conditioned by a number of variables depending on the emergency and kind of the intervention. It is also related to the evolutionary stage of the liver pathology (evaluated following Child-Pugh score). The present study will explore the physiopathologic mechanisms which should be correlated with the preoperative risk factors responsible for the variation of morbidity and mortality of the hepatopathic patient addressed to an extrahepatic surgical intervention. METHODS: This study includes a retrospective analysis (from 1992 to 1999) of 40 patients with cirrhosis (80% HCV correlated cirrhosis, 15.5% alcoholic cirrhosis, 2.5% cryptogenic cirrhosis), who underwent such procedures as: colon resection (5), gastrectomy (4), hernioplasty (11), cholecystectomy (14), ulcorraphy (3), laparotomy (3). Patients with hepatic resection and portal shunt are excluded from this study. A pre- and postoperative evaluation of ascites, PT, APTT, albumin, bilirubin and protein value, number of leukocytes and Child-Pugh score was performed on all patients. Their follow-up was 30 days. RESULTS: The presence of tensive ascites, low albumin value, PT, APTT, together with the emergency of the operation, proved to be significant (p<0.001), in correlation with a mortality of 7.1% in Child's class A, of 23% in class B, and of 84% in class C. CONCLUSIONS: Cirrhotic patients undergoing elective or emergency surgery can incur significant preoperative risks and postoperative complications, increasing their mortality rate. An accurate preoperative predictive factor is Child's class.     

Emergency portasystemic shunting in cirrhotics with bleeding varices--a comparison of portacaval and mesocaval shunts

Despite the best conservative measures available for the control of major variceal hemorrhage, some patients either continue to bleed, or rebleed early, and require emergency surgery. One hundred patients with cirrhosis and uncontrolled bleeding were treated with emergency portasystemic shunts between 1968 and 1983. Fifty eight patients had end-to-side portacaval shunts and 42 had Dacron interposition mesocaval shunts. Both groups were comparable with respect to age, sex and prevalence of alcoholism. There was an increased severity of liver disease as assessed by Child's class in the mesocaval group of patients. Overall in-hospital mortality was 31% with no significant difference demonstrated between the mesocaval group (28%) and the portacaval group (33%), nor between alcoholic cirrhotics (34%) and non-alcoholic cirrhotics (21%). Mortality rates based on severity of liver disease were: Child's A (1/6) 17%, Child's B (9/48) 19%, and Child's C (21/46) 46%. There was a statistically significant difference between Child's A & B and Child's C (p less than 0.01). Four patients were lost to follow-up. No significant differences were found in 5 year survival by life table analysis comparing portacaval (39%) vs. mesocaval (28%) groups or alcoholic cirrhotics (36%) vs. non-alcoholic cirrhotics (29%). Encephalopathy in survivors was absent in 46%, mild in 28% and severe in 26% of patients. There was no significant difference in encephalopathy rates following portacaval or mesocaval shunting. Neither operation was clearly superior and choice of operation can be made on the basis of technical and anatomical factors and surgeon experience. Emergency shunting remains a useful option for patients with variceal bleeding refractory to other more conservative therapy, and is associated with acceptable early mortality and long term survival rates.     

Clinical outcome of epithelial tumors of the thymus

OBJECTIVE AND METHODS: We retrospectively reviewed treatment and clinical outcome of thymic epithelial tumors of 64 patients over a 20-year period. Clinical staging of the tumor was done by according to Masaoka classification. Histological diagnosis of the tumors was done by according to the second edition of the WHO histologic classification system for thymic epithelial tumors. Survival rate was calculated after Kaplan-Meire method. RESULTS: Median age of patients was 53.7 years (ranged from 16 to 81). There were 30 men and 34 women. Eighteen patients had auto-immuno diseases. Sixty-two patients underwent surgery. In 57 patients resection was complete (extended thymo-thymectomy), but in the other five incomplete. The operative approach was median sternotomy in 51 patients and video-assisted thoracoscopic surgery in 6. Stage II to IV patients had postoperative mediastinal irradiation. Stage III to IV patients had postoperative cisplatin (CDDP) based chemotherapy. Inoperable patients were treated by chemo-radiotherapy. There were 42 stage I, 7 stage II, 11 stage III, 3 stage IV a, 1 stage IV b. The 5-year/10-year survival rates were 93%/89%, 71%/71%, 68.5%/--in patients with stage I, II and III. There were 5 type A tumors, 8 type AB tumors, 11 type B1 tumors, 11 type B2 tumors, 9 type B3 tumors, 11 type C tumors, the respect 5-year survival rates were 100%, 100%, 87.5%, 60%, 85.7% and 90%. Masaoka stage II to IV patients classified in B2, B3 and C type except one case. CONCLUSION: Histologic type B2, B3 and C tumors may reflect the invasive nature. Masaoka staging system and the WHO histologic classification may help the assessment and treatment of patients with thymic epithelial tumor.     

Primary surgery as treatment for early squamous cell carcinoma of the tonsil

BACKGROUND: The management of tonsil carcinoma has gradually evolved such that the literature is replete with outcome summaries of this disease treated with primary RT and chemotherapy. Recently there have been no reports of patient outcomes with primary surgical therapy. Nonsurgical treatment is warranted when tumors are unresectable or if the patient refuses surgery. Our policy has been to treat operable squamous cell carcinoma (SCCA) of the tonsil with surgery. The decision to use adjuvant therapy is based on the surgical and histologic findings. We herein report our results with this treatment protocol. METHODS: A retrospective review of 162 patients with SCCA of the tonsil was performed. Eighty-four patients were treated with surgery, which was followed by RT and/or chemotherapy if histologic signs of aggressive behavior were identified. Patients were followed 2 to 15 years after treatment. RESULTS: Of the 9 patients with stage I disease, 89% are without evidence of recurrent disease and 91% of patients with stage II tonsil cancers are also disease free. The survival rates for stage III and stage IV cancer patients are 79 and 52%, respectively. CONCLUSION: Our data suggest that patients with early tonsil cancer can be effectively treated with surgery. Surgery allows pathologic staging so that patients with advanced tumors can be treated with adjuvant therapy.     

Minimally invasive devascularization for variceal bleeding that could not be controlled with sclerotherapy

The appropriate therapy for continued bleeding despite sclerotherapy remains controversial. This study evaluates a devascularization procedure performed without the risks of major surgery and general anesthesia. Fifty consecutive patients, each with an endoscopically proven variceal hemorrhage that was uncontrollable with sclerotherapy, were treated with minimally invasive devascularization. The procedure was performed in three stages. First, the portal pressure was sharply reduced by angiographic embolization of the midsplenic artery. Then the esophagogastric variceal network was thrombosed by means of a catheter introduced during laparotomy, which created a portoazygos disconnection. Finally, the left gastric and left gastroepiploic arteries were embolized, which completed devascularization of the proximal stomach. According to the Child classification, 16 patients were in class B and 34 were in class C. All Child's class B patients (16/16) and 71% (24/34) of Child's class C patients survived hospitalization. One-year survival was 94% (15/16) for Child's class B and 62% (21/34) for Child's class C patients. Rebleeding occurred in 63% (25/40) of the discharged patients but caused the death of only seven. In conclusion, the 20% initial hospital mortality for these difficult patients was significantly better than that reported for emergency surgery, and the rate of rebleeding was comparable to that seen with other nonshunting therapies.     

Primary ovarian cancer

Sixty-six patients with primary ovarian cancer were treated at National Taiwan University Hospital from 1981 to 1985. About 21% of the patients were in stage I, 18% in stage II, 50% in stage III and 11% in stage IV. The distribution of histologic types included 73% epithelial, 15% germ cell, 9% gonadal stroma, and 3% of non-specific mesenchymal origin. The ages at diagnosis ranged from 8 to 83 years. Peak incidence was noted between 50-59 years. Mean ages for epithelial, non-epithelial, and germ cell ovarian cancers were 52, 29, and 22 years, respectively. Most (47%) of the patients were treated by surgery plus chemotherapy. Complete surgical removal of the tumor mass was done for all 14 patients with stage I ovarian cancer. Bilateral salpingo-oophorectomy plus total abdominal hysterectomy was performed in 67% of stage II, 40% of stage III, and no stage IV case. The rates of occult bilaterality in the contralateral ovary for stage I to IV were 0%, 25%, 29% and 100%, respectively. Survival in ovarian cancer is a function of clinical stage and histologic type. The 2-year survival rates for stage I to stage IV were 71%, 67%, 33%, and 0%, respectively. The 2-year survival rate was 78% for non-epithelial ovarian cancer, and 26% for epithelial ovarian cancer.     

Restorative operations in atherosclerotic lesions of the arteries of the lower extremities and severe ischemia]

The results of surgical treatment of patients with atherosclerotic occlusion of the lower extremities arteries have been analysed. In 29 of 45 patients with severe ischemia of the lower extremities regional circulation disorders of stage III and in 16 patients of stage IV (gangrene) were found. The preservation of the peripheral vascular bed served as an indication for operation. The effect of the surgery was assessed on the basis of the analysis of immediate and late results. The authors believe that an adequately performed restorative operation allows to obtain good late results in 70% of patients operated upon in stage III and in 50% of those operated upon in stage IV of regional circulation disorders.     

Transabdominal suture of bleeding gastro-oesophageal varices in cryptogenic cirrhosis of the liver.

Emergency transabdominal suture of gastro-oesophageal varices was performed when conventional conservative measures including oesophageal tamponade failed to control bleeding in 60 of 167 patients with cryptogenic cirrhosis and bleeding varices. The immediate mortality for the whole series was 29-9 per cent. Surgery performed in this selected manner carried an immediate mortality of 40 per cent. The transabdominal approach detected and treated 19 (31-7 per cent) patients who had concomitant bleeding from extra-oesophageal sources. Ageing and sex (male) affect the immediate prognosis adversely. Using a modification of Child's classification of hepatic dysfunction, a direct relationship between hepatic dysfunction and mortality was found, reaching 100 per cent in those with grade C (severe) dysfunction, irrespective of whether or not surgery had been performed. Bleeding was successfully arrested in 96-7 per cent of cases and recurrence of bleeding was acceptably low in the first 6 months of surgery but not after.     

Management of gastric variceal haemorrhage

From March 1979 to April 1988 nine patients with hepatic cirrhosis have presented with acute variceal haemorrhage from gastric varices. Of six patients who underwent emergency laparotomy those with modified Child's grade C (n = 3) died within 30 days of surgery. Six patients have been followed for 2 years or longer. In the three patients who underwent under-running of gastric varices alone, two patients developed oesophageal varices at 3 and 14 months, respectively, and in the third patient gastric varices recurred 3 years after surgery. In the remaining three patients, additional left gastric vein ligation was not associated with recurrence of gastric varices or the development of oesophageal varices.     

A retrospective review of transcatheter hepatic arterial embolisation for ruptured hepatocellular carcinoma

BACKGROUND: Hepatocellular carcinoma (HCC) is a disease with a high prevalence in South East Asia. It is not uncommon to encounter rupture of the tumour in an emergency situation. Operative measures in this situation are often associated with high mortality rates. Transcatheter arterial embolisation (TAE) appears to be an effective alternative to surgery and is increasingly used by many centres. In this study, we have reviewed the outcome of our patients after receiving TAE and tried to identify prognostic indicator(s). PATIENTS AND METHODS: From 1996 to 2000, we had retrospectively reviewed the outcome of 31 patients who had undergone TAE for rupture of HCC and compared their survival with respect to different prognostic indicators. RESULTS: The were 31 patients with a mean age of 53 years. At the time of rupture, 19 patients had Child's A, 5 Child's B and 7 of Child's C disease. The most common presentation was abdominal pain (14 patients). Bleeding was successfully arrested in all 31 patients. The most common complication was fever (13 patients). The overall mean survival was 126 days. Eight patients died within 30 days of admission, the major cause of death was liver failure, which occurred in 6 patients. In addition, we had also postulated several prognostic indicators for patients' survival. The results showed that only those with a bilirubin level below 50 umol/L and who presented with shock had a poor outcome. CONCLUSION: TAE should be considered in the initial management of patients with ruptured HCC. It is effective in arresting tumour bleeding and allows the patient to have subsequent definitive management.     

Colorectal cancer surgery. Analysis of risk factors in relation to incidence of morbidity and mortality

The aim of the study was to investigate risk factors in relation to the incidence of morbidity and mortality in surgery for colorectal cancer. Between 1986-2005, 328 patients underwent colorectal cancer surgery, 308 of whom (93.9%) in elective and 20 (6.1%) in emergency surgery. Radical resection was performed in 276 (84.2%) and palliative surgery in 52 (15.8%) patients. Bivariate statistical analysis was used for morbidity and mortality factors and multivariate analysis was performed in order to find independent variables (age, gender, ASA grade, elective or emergency surgery, tumour excision, cancer stage according to Dukes) associated with dependent variable interactions. Differences were considered statistically significant for p values < 0.05. The incidences of mortality and morbidity were 0.91% and 20.1%, respectively. In our study we observed a leakage incidence of 2.74% (9/328). In emergency surgery we found morbidity and mortality rates of 20% and 10%, respectively. Age and advanced cancer stage influenced results but were not found to be statistically significant. 18.3% of patients (60/328) were ASA I, 32% (105/328) ASA II, 39.6% (130/328) ASA III and 10.1% (33/328) ASA IV. Among the independent variables observed in the multivariate analysis, ASA grade was found to be the only positive predictive factor correlated with morbidity. Logistic regression showed an exponential increase in operative risk: odds ratio (OR) 2.9 in ASA I vs ASA II, OR 4.2 in ASA I vs ASA Ill, OR 10.3 in ASA I vs ASA IV (95% confidence interval). As regards the mortality rate, none of the independent variables were found to be statistically significant risk factors (p < 0.05).     

Short term outcome after emergency and elective surgery for colon cancer

Objective  Emergency presentation of colon cancer is common and associated with high mortality and morbidity following surgical treatment. The purpose of this study was to evaluate postoperative mortality and complications in a consecutive and population based series.
Method  All patients with adenocarcinoma of the colon diagnosed between 1993 and 2007 were registered prospectively. Postoperative mortality and complication rates in elective and emergency patients were compared. Logistic regression analysis was used to identify independent risk factors for postoperative complications.
Results  In the study period 1129 patients were admitted, of whom 279 (25%) presented as an emergency. A total of 999 (89%) patients underwent surgical treatment; 924 patients (82%) had a major resection. The mortality rate was 3.5% after elective and 10% after emergency operation with resection ( P  < 0.01), and the complication rate was 24% and 38% ( P  < 0.01), respectively. In patients with left-sided obstruction, the mortality rate after Hartmann's procedure was 19% compared to 3% after resection with primary anastomosis ( P  < 0.01). Multivariate analyses demonstrated that emergency operation, increasing age, advanced tumour stage and ASA class IV were independent risk factors for postoperative mortality.
Conclusion  Emergency operation for colon cancer was associated with high rates of complications and mortality, indicating that immediate surgery should be avoided if possible. Decompression of left sided obstruction with a stent seems promising, whereas no conclusion can be made with regard to optimal procedure if stent placement fails; in this study Hartmann's procedure was associated with high mortality and morbidity.     

Beneficial Effect of Partial Portal Decompression Using the Inferior Mesenteric Vein for Intractable Gastroesophageal Variceal Bleeding in Patients With Liver Cirrhosis

BACKGROUND: Use of the inferior mesenteric vein (IMV) for partial portal decompression has not been recommended as a first-line option for intractable gastroesophageal variceal bleeding because of the thin diameter of the vein. Although these indications remain relevant, few reports have compared partial portal decompression using the IMV with other therapies. We propose that partial portal decompression using the IMV is a useful alternative treatment for intractable variceal bleeding. METHODS: We performed partial portal decompression using the IMV in eight patients with intractable variceal bleeding that had been uncontrolled using medical and endoscopic therapies. All patients were classified into Child's class B or C. The surgical data, morbidity, and mortality were assessed. RESULTS: Mean portal venous pressure significantly decreased from 26.9 +/- 2.0 mmHg before the surgery to 19.8 +/- 3.9 mmHg after the surgery. The operative mortality rate was 0%. The mean duration of hospital stay was 25.5 +/- 13.3 days. Although one patient experienced recurrent bleeding, shunt patency was well maintained in all patients during the follow-up period (mean 28.9 +/- 14.1 months). Six patients are still alive and well without ascites or hepatic encephalopathy. Two of the Child's class C patients who underwent emergency shunt died owing to hepatic decompensation. CONCLUSION: Partial portal decompression using the IMV can be a safe, effective way to treat intractable variceal bleeding in patients with liver cirrhosis. However, use of the shunt procedure may have the most survival benefits for cirrhotic patients with preserved liver function.     

Preoperative Wilms tumor rupture in children

Purpose

According to the guidelines of International Society of Pediatric Oncology (SIOP) and National Wilms Tumor Study (NWTS), Wilms tumor with preoperative rupture should be classified as at least stage III. Few clinical reports can be found about preoperative Wilms tumor rupture. The purpose of this study was to investigate our experience on the diagnosis, treatment and prognosis of preoperative Wilms tumor rupture.

Methods

Patients with Wilms tumor who underwent treatment according to the NWTS or SIOP protocol from January 2008 to September 2017 in Beijing Children’s Hospital were reviewed retrospectively. The clinical signs of preoperative tumor rupture were acute abdominal pain, and/or fall of hemoglobin. The radiologic signs of preoperative tumor rupture are as follows: (1) retroperitoneal and/or intraperitoneal effusion; (2) acute hemorrhage located in the sub-capsular and/or perirenal space; (3) tumor fracture communicating with peritoneal effusion; (4) bloody ascites. Patients with clinical and radiologic signs of preoperative tumor rupture were selected. Patients having radiologic signs without clinical symptoms were also selected. The clinical data, treatments and outcomes were analyzed. Meanwhile, patients without preoperative Wilms tumor rupture during the same period were collected and analyzed.

Results

565 Patients with Wilms tumor were registered in our hospital. Of these patients, 45 patients were diagnosed with preoperative ruptured Wilms tumor. All preoperative rupture were confirmed at surgery. Spontaneous tumor rupture occurred in 41 patients, the other 4 patients had traumatic history. Of the 45 patients, 41 were classified as stage III, 3 patients with pulmonary metastases were classified as stage IV, and one patient with bilateral tumors were classified as stage V. Of these patients with preoperative tumor rupture at stage III, 30 patients had clinical and radiologic signs of tumor rupture, the other 11 patients had radiologic signs without clinical symptoms. Among the 41 patients at stage III, 13 patients had immediate surgery without preoperative chemotherapy (immediate group), and 28 patients had delayed surgery after preoperative chemotherapy (delayed group). In immediate group, 12 patients had localized rupture, 1 patient underwent emergency surgery because of continuous bleeding. In delayed group, 4 had inferior vena cava tumor embolus (1 thrombus extended to inferior vena cava behind the liver, three thrombi got to the right atrium), 4 crossed the midline with large tumors, 20 had extensive rupture without localization. In immediate group, tumor recurrence and metastasis developed in 2 patients, and no death occurred. In the delayed group, tumor recurrence and metastasis developed in 8 patients, and 7 patients died. During the same period, 41 patients were classified as stage III without preoperative rupture. In the non-ruptured group, tumor recurrence and metastasis developed in 3 patients, and 4 patients died. The median survival time in the ruptured group (both immediate group and delayed group) and non-ruptured group were (85.1 ± 7.5) and (110.3 ± 5.6) months, and the 3-year cumulative survival rates were 75.1% and 89.6%, respectively. The overall survival rate between the ruptured and non-ruptured groups showed no statistic difference (P = 0.256). However, there was significant difference in recurrence or metastasis rate between the ruptured and non-ruptured groups (24.4% vs 7.3%; P = 0.031).

Conclusion

Contrast-enhanced computed tomography (CT) and ultrasonography (US) are of major value in the diagnosis of preoperative tumor rupture, and immediate surgery or delayed surgery are available therapeutic methods. The treatment plan was based on patients’ general conditions, tumor size, position and impairment degree of tumor rupture, extent of invasion and experience of a multidisciplinary team (including surgeon and anesthesiologists). In our experience, for ruptured preoperative tumor diagnosed with stage III, the criteria for immediate surgery are as follows: tumor not acrossing the midline, tumor without inferior vena cava thrombus, localized rupture, being capable of complete resection. Selection criteria for delayed surgery after preoperative chemotherapy are as follows: large tumors, long inferior vena cava tumor thrombus, tumors infiltrating to surrounding organs, unlocalized rupture, tumors can not being resected completely. Additionally, patients with preoperative Wilms tumor rupture had an increased risk of postoperative recurrence or metastasis.

     

Impact of Intraoperative Blood Loss on Long-Term Survival after Lung Cancer Resection

Purpose: The purpose of this study was to clarify relationships between intraoperative blood loss (IBL) and long-term postsurgical survival in lung cancer patients.Methods: We retrospectively analyzed 1336 patients undergoing surgery: lobectomy in 1016, sublobar resection in 174, pneumonectomy in 106, and combined resection with adjacent organs in 40. The lobectomy group was stratified further by pathologic stages; overall survival difference was examined according to amount of IBL.Results: Volume of IBL differed significantly according to surgical procedure when all patients were included. Within the lobectomy group, IBL differed significantly between gender, pathologic stage, histologic type (adenocarcinoma vs. non-adenocarcinoma), and year of operation (1983 to 2002 vs. 2003 to 2012). After stratification by pathologic stage, survival differed with IBL for stages IB to IIIB. Multivariate analysis identified gender, patients age (<69 vs. ≥69), pathologic stage (IA to IIB vs. IIIA to IV), year of operation, histologic type, and IBL as significant predictors of survival.Conclusion: Since degree of IBL is an independent predictor of overall survival after lung cancer resection, IBL should be minimized carefully during surgery.     

The key role of time in predicting progression-free survival in patients with renal cell carcinoma treated with partial or radical nephrectomy: Conditional survival analysis

IntroductionIn surgically treated patients with renal cell carcinoma (RCC), the progression-free survival (PFS) rate may significantly change according to the progression-free postoperative period. To test this hypothesis, we set to evaluate the conditional PFS rate in surgically treated patients with RCC.MethodsWe evaluated 1,454 patients with RCC, surgically treated between 1987 and 2010, at a single institution. Cumulative survival estimates were used to generate conditional PFS rates. Separate Cox regression models were fitted to predict clinical-progression risk in patients who were progression free from 1 to 10 years after surgery.ResultsDuring the immediate postoperative period, the 5-year PFS rate was 88%, and it increased to 92%, 94%, and 97% in patients who remained progression free at, respectively, 1, 5, and 10 years after surgery. At multivariable analyses, where patients with stage I disease were considered as a reference, the highest clinical-progression risk was observed at the eighth postoperative year in patients with stage II disease (hazard ratio [HR]: 2.9) and during the immediate postoperative period in patients with stage III to IV disease (HR: 5.5). In comparison with patients with grade I disease, the highest clinical-progression risk was observed at the fourth (as well as eighth) postoperative year in patients with grade II disease (HR: 5.7), sixth postoperative year in patients with grade III disease (HR: 7.2), and during the immediate postoperative period in patients with grade IV disease (HR: 8.5).ConclusionsThe postoperative progression-free period has an important effect on the subsequent clinical-progression risk. This aspect should be considered along with tumor characteristics to plan the most cost-effective follow-up scheme for surgically treated patients with RCC.     

Surgical treatment of renal artery dissection in 25 patients: indications and results

OBJECTIVE: Results of surgical revascularization in 25 patients with renal artery dissection (RAD) over 14 years, with mean follow-up of 55.3 months (range, 10-111 months), were analyzed. Indications for surgery were renovascular hypertension and preservation or improvement of kidney function. PATIENTS AND METHODS: Two patients (both 20 years of age) underwent emergency surgery after severe trauma; 23 patients (mean age, 41 years) underwent elective surgery in a chronic stage of disease. Preoperative, postoperative, and follow-up examinations included duplex ultrasound scanning, determination of serum creatinine and urea concentrations, and evaluation of blood pressure control. All long-term patients underwent digital subtraction angiography preoperatively and postoperatively. All histologic specimens of resected renal arteries were re-evaluated by two independent pathologists. RESULTS: Histologic re-evaluation confirmed the traumatic origin in 2 patients who underwent emergency surgery and 1 who underwent elective surgery. Renal artery dissection developed spontaneously, with no histologic signs of trauma or fibromuscular dysplasia, in 22 patients. In 17 revascularized kidneys (61%) a kidney infarction had already developed preoperatively, and the kidneys were diminished in size or function. Results of revascularization and improvement of hypertension depended on preoperative extent of renal infarction. Hypertension resolved or improved in 86% of patients without preoperative kidney damage, but in only 38% with preoperatively damaged kidneys. Kidney function was preserved in 23 of 28 revascularized kidneys (82%). During follow-up, late renal artery occlusion developed in 3 kidneys. CONCLUSIONS: Renal artery dissection can be effectively treated with surgical revascularization. Primary nephrectomy should be considered only in patients with a large ischemic kidney infarction, with significant deterioration of kidney function, to effectively cure or improve severe renovascular hypertension.     

Current controversies and trends in stage IV rectal cancer

Almost one-third of patients with rectal cancer present with stage IV disease, with the liver being the most common site of distant metastasis. Long-term survival depends on the ability to safely resect all disease (primary and secondary) with negative margins in a multidisciplinary management setting. Unlike stage IV colon cancer where chemotherapy and surgery are the only two options for management, patients with stage IV rectal cancer are candidates for chemoradiotherapy for optimum local control of the primary, in addition to surgery and chemotherapy. There are no standard guidelines for the exact sequence of management in stage IV rectal cancer. While there are still questions regarding proper treatment, for the best results treatment plans should be individualized and formulated in a comprehensive multidisciplinary setting.     

Reimplantation of freeze-treated bone in immediate reconstruction of the mandible

Surgical defects encountered with corrective surgery of the mandibular complex have been repaired most successfully with autogenous composite bone grafts. Their use belies inherent consequences associated with distant donor sites. Presented here are the experiences and results in two patients whose reconstructions consisted of immediate replacement of the resected mandibular segment after its devitalization with cryogenic freezing treatments. Such treated, autologous bone provides an ideal anatomic graft, nondistinct antigenicity, and immediate restoration of form and function. Monitoring of neoosteogenesis was performed with sequential panographic, nuclear, and histologic studies that documented clinical and histologic repair.