Surgery for stage IV gastric cancer

BACKGROUND: Surgical treatment for stage IV gastric cancer is controversial. METHODS: We analyzed the surgical experience with advanced gastric carcinoma in a tertiary referral center in Mexico City from 1995 through 2000. We analyzed surgical morbidity, mortality, and factors associated with prognosis. Survival was analyzed with the Kaplan-Meier method, and the curves were compared with the log-rank test. Significance was assigned at P <0.05. RESULTS: Seventy-six cases were identified. Mean patient age was 56 +/- 14.5 years. Thirty-nine patients (51.3%) were women. Patients were grouped according to surgical procedure: group 1 underwent resection (40 patients), group 2 underwent bypass procedures (10 patients), and group 3 underwent either celiotomy and biopsy alone or jejunostomy placement (26 patients). Twenty patients (26%) developed operative complications, but most were minor. There was no difference in morbidity between surgical groups and no difference according to patient's age. Operative mortality was 2.6%. Good palliation of symptoms was significantly more common in group 1 patients (82%) than in group 2 patients (60%) (P = 0.0001). Median survival was 8 months (95% confidence interval 4 to 12) for the entire cohort and 13, 5, and 3 months for groups 1, 2, and 3, respectively (P = 0.00001 for group 1 vs groups 2 and 3). CONCLUSIONS: Surgical resection for stage IV gastric cancer can be done with low operative mortality and acceptable morbidity rates, and it provides patients with good symptomatic relief. Advanced patient age is not a contraindication for surgical treatment.     

Surgical treatment of pulmonary metastases from colon and rectal cancer

We retrospectively studied the surgical treatment for pulmonary metastases from colon and rectal cancer. A total of 24 patients (9 males and 15 females; mean age 61 years) underwent 29 thoracotomies for metastatic colon carcinoma, while 22 patients (16 males and 6 females; mean age 63 years) underwent 29 thoracotomies for metastatic rectal cancer. The median interval between the primary procedure and lung resection for metastases was 26 months in the patients with colon carcinoma and 32 months in the patients with rectal cancer. In the patients with colon carcinoma, 16 underwent wedge resection or segmentectomy (including 4 video-assisted procedures) and 13 (54%) underwent lobectomy or pneumonectomy. In the patients with rectal cancer, 15 underwent wedge or segmentectomy (including 1 video-assisted procedure), 13 (59%) underwent lobectomy or pneumonectomy, and 1 underwent exploratory thoracotomy. All procedures except exploratory thoracotomy were curative operations. There was no mortality. Overall 5-year survival was 56% (n=46). Five-year survival was 65% for patients with colon metastases (n=24) and 45% for patients with rectal metastases (n=22), and there was no significant difference. Recurrent sites were 4 lungs (36%), 4 livers (36%), 1 bone, 1 uterus, and 1 peritoneum in patients with colon carcimoma, and 10 lungs (43%), 5 brains (22%), 3 livers (13%), 1 bone, and 1 vagina in patients with rectal cancer. Pulmonary resection for metastases from colon carcinoma may have better prognosis than that from rectal cancer. However, further investigation may be required to obtain convincing conclusions.     

Surgery of rare malignant lung tumours

4023 operations on account of primary bronchopulmonary cancer were performed in the period of 1963--2006 years. Rare malignant tumors (carcinoid, adenocystic cancer, sarcoma, large cell carcinoma etc.) were diagnosed in 379 (9,1%) cases. 275 patients of those had bronchpulmonary carcinoid; adenocystic cancer was diagnosed in 26 patients; 67 had various types of non-epithelial malignant tumors and 11 had a large cell carcinoma. All patients were operated on, morphological verification was obtained in all cases. The surgical tactics in patients with rare malignant tumours should be the same as for non-small cell lung--lobectomy of pneumonectomy with lyphadenectomy. The long term follow-up results witness the advisability of surgical treatment.     

Stereotactic management of craniopharyngiomas

Eleven patients with craniopharyngiomas underwent 13 stereotactic procedures (intracavitary irradiation, n = 7; radiosurgery, n = 6). Nine patients (82%) had recurrent tumors after prior surgery (median, 2 operations). The median patient age was 50 years (range, 6-63 years). At a median follow-up of 38 months (range, 24-102 months), no patient had progression of the treated tumor component. Two patients developed new cysts, so the actuarial 2- and 4-year progression-free survival rates were 91 and 73%, respectively. Visual function improved in 3 patients, remained stable in 6 patients, and worsened in 1 patient. Two patients (both without prior surgery) not having diabetes insipidus pre-operatively continued to have normal posterior pituitary function. Stereotactic techniques should be considered for patients with craniopharyngiomas, especially those who have failed prior surgical resection.     

Surgical Treatment of Cancer of the Thoracic Esophagus in Association With a Major Pulmonary Operation

Background: Pulmonary complications have been a major cause of mortality after operations for cancer of the thoracic esophagus. Although the risk involved in esophagectomy associated with a major pulmonary operation is expected to be high, it has seldom been evaluated on the basis of clinical experience.

Study Design: Of 408 patients who underwent esophagectomy, 8 had previously undergone major pulmonary operation (7 for tuberculosis and 1 for pulmonary cancer) and 10 underwent concurrent major pulmonary resection (7 for pulmonary invasion of esophageal cancer, 2 for synchronous pulmonary cancer, 1 for extensive bronchiectasia). All patients underwent systematic lymph node dissection for esophageal cancer, except one patient with mucosal cancer. To prevent postoperative complications, the operative approach and dissection procedures for esophageal cancer were modified according to the associated pulmonary operation and the extent of cancer invasion. All thoracotomies for esophagectomy were performed on the same side as the major pulmonary operation. Additional median sternotomy was performed when necessary. In the most recent 8 patients who underwent major pulmonary resection concurrent with esophagectomy, the bronchial stump was covered with a pedicle flap.

Results: Of the 18 patients who underwent pulmonary operation, postoperative complications developed in 13 of the 18 object patients, but none was fatal. The 3-year survival rate was 45%. All deaths were caused by esophageal cancer or another cancer.

Conclusions: Aggressive esophagectomy associated with major pulmonary operation is not contraindicated in patients with fair risk conditions. The operative procedures for esophagectomy should be appropriately modified to minimize the effect of the associated pulmonary operation. Special care should be taken with respect to the approach for mediastinal dissection and closure of the bronchial stump.     

Bronchoplastic procedures and pulmonary artery reconstruction in the treatment of bronchogenic cancer

Nineteen patients with primary bronchogenic carcinoma underwent bronchoplastic procedures (six wedge and 13 sleeve resections) between 1970 and 1982. In six of them lobectomy was combined with sleeve resection and reconstruction of the pulmonary artery: In one a synthetic prosthesis was inserted. Twelve patients had squamous cell carcinoma, five adenocarcinoma, and two large cell carcinoma. No operative deaths were observed, and the 5 year survival rate is 28.1%. One patient had an early bronchial fistula and two patients had bronchial stenosis (one suture granulation and one local recurrence). No patient with resection of the pulmonary artery had vascular complications. Survival rates on the basis of nodal involvement indicate 50% survival at 5 years without nodal metastasis (11 cases) versus 9.7% with nodal involvement (eight cases) (p less than 0.05). Bronchoplastic procedures, even if accompanied by segmental resection of the pulmonary artery, can be performed safely with long-term results comparable to those following major pulmonary resections.     

Simultaneous cardiac and thoracic operations

BACKGROUND: Optimal surgical strategy in patients with combined disease of heart (mainly ischemic heart disease or critical valve disease) and other thoracic organs (mainly pulmonary carcinoma) is still controversial. METHODS: From 1997 to 2004, 13 simultaneous cardiac and thoracic operations were performed in 13 patients. Most of them were necessary for combinations of symptomatic coronary artery disease (CAD) and bronchogenic carcinoma (BCA). Patient characteristics: 11 patients showed CAD, mean preoperative LVEF was 44 %. Surgical procedure: Surgical exposure was performed via sternotomy in 10 patients, the rest of the patients underwent thoracotomy. Seven patients were operated on cardiopulmonary bypass, the others underwent an off-pump procedure. Eleven patients underwent CABG, mean number of anastomoses were 2.1 (range 1-4), two patients underwent aortic valve replacement. One patient underwent radical removal of pulmonary adenocarcinoma with local expansion into the left atrium. For the lung cancer lobectomy was necessary in 8, pneumectomy in 1, extirpation of multiple metastases in 1, resection of the trachea in 1 patient. Histological diagnosis was epidermoid carcinoma in 6, adenocarcinoma in 3, undifferentiated carcinoma in 1, metastasis of Grawitz tumor in 1, pneumoconiosis in 1 patient. RESULTS: No patient died in hospital. One patient had to be re-explored for bleeding. Mean blood loss, duration of intubation and length of hospital stay were not different from other patients who underwent cardiac operation only. CONCLUSION: In accordance with the majority of the data published in the literature, combined procedures did not negatively influence hospital morbidity and mortality. Simultaneous operations eliminate the necessity of a second operation and do not delay the postoperative oncological therapy. Long-term results are primarily determined by histological diagnosis and by the extent of the tumor.     

Fluorescence bronchoscopy for selection of surgical procedure in patients with early staged endobronchial carcinoma

BACKGROUND: It is sometimes difficult to determine the extent of resection in patients with endobronchial carcinoma because preoperative white-light bronchoscopic (WLB) examination is not sensitive enough to examine the extent fully. Light-Induced Fluorescence Endoscopy (LIFE) is recognized as a useful modality for the diagnosis of early staged bronchial carcinoma, but there have been no reports of its significance in surgical treatment. We have studied the influence of LIFE upon the selection of surgical procedures or other treatments in patients with endobronchial carcinoma preoperatively. METHODS: Conventional WLB and LIFE were performed within 7 days of operation. Biopsy specimens were taken from the marginal regions of the areas that were suspicious for malignancy on LIFE examination and WLB. We decided the resection line before operation and kept the resected central margin 1 cm apart from the area revealed as suspicious by LIFE. RESULTS: From January 1999 to March 2003, 75 patients underwent LIFE. LIFE was performed to decide the surgical procedures for 12 patients (16.0%). Surgical therapy was performed in 8 (66.7%). LIFE findings dramatically changed the surgical procedures for 3 patients, lobectomy changed to sleeve lobectomy in 2 and laser therapy to segmentectomy in 1. LIFE revealed larger abnormal areas of bronchial cancer compared to WLB in 7 (58.3%). Conversely, WLB overestimated the extent of abnormal area in 1 (8.3%). WLB revealed the same cancer area as LIFE in 4. In all patients, the resected bronchial margins were cancer free intraoperatively and postoperatively. CONCLUSION: LIFE can be more sensitive than WLB and be more beneficial for judging the extent of neoplastic bronchial changes for some patients. LIFE may be a useful modality for the preoperative selection of surgical procedures, especially whether sleeve resection is needed or not, for some centrally located superficial endobronchial carcinoma.     

Surgical outcome of tracheobronchial reconstruction for lung cancer

We retrospectively evaluated the surgical outcome after sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction for lung cancer. From 1993 to 2008, 46 patients with primary lung cancer underwent these surgical procedures. Seventeen patients (37%) received induction therapy, 15 received chemotherapy, while chemoradiotherapy or radiotherapy alone were received by one patient each. Sleeve lobectomy without carinal resection was performed in 41 patients. Carinal resection with 2 sleeve pneumonectomies was performed in 5 patients. There were no operative deaths. Bronchopleural fistula occurred in one patient, who required completion pneumonectomy. One patient presented local mucosal necrosis in the anastomotic site and was managed conservatively. Two patients had bronchial strictures as late complications and successfully dilated by a balloon using bronchoscopy. Overall 5-year and 10-year survival rates were 54% and 48%, respectively. No recurrence developed at any anastomotic site. The results showed that sleeve lobectomy and pneumonectomy with tracheobronchial reconstruction can be performed with low mortality and bronchial anastomotic complication rates. As well, local control of the tumor was satisfactory.     

非恶性食管-气管/支气管瘘的外科治疗

目的探讨非恶性食管-气管/支气管瘘的临床特点和处理方法。方法回顾性分析2002年1月至2011年10月北京协和医院收治12例非恶性食管-气管/支气管瘘患者的临床资料,其中男6例,女6例;平均年龄49.8(32～72)岁。食管气管瘘7例,食管支气管瘘1例,食管癌术后胸胃支气管瘘2例,食管憩室支气管瘘2例。右侧开胸入路9例,左侧开胸3例。行食管瘘、气管瘘修补7例;食管瘘、支气管瘘修补1例;胸胃瘘、支气管瘘修补术2例;食管下段、左肺下叶切除,食管胃弓下吻合术1例;左肺下叶切除,食管憩室瘘修补术1例。结果全部患者均顺利恢复,无手术合并症或死亡,7～10 d恢复经口进食。术后3个月～1年内复查纤维支气管镜及上消化道造影,无气管支气管狭窄,无食管狭窄,不必采用支架或扩张治疗。术后随诊3个月～10年,均恢复良好。结论食管-气管/支气管瘘排除恶性病因,明确瘘口位置,术前给予充分营养支持,手术Ⅰ期修补瘘口,可以获得良好的治疗效果。     

Pulmonary resection combined with cardiac operations

Surgical management of patients with concomitant critical cardiac disease and resectable lung lesions is controversial. During a 7-year period (1982 to 1988), 21 patients underwent combined cardiac and pulmonary operations. Patients had cardiac symptoms only; the lung lesions were found on preoperative chest roentgenograms. The pathological diagnosis was established in only 2 of the patients before operation. All underwent concurrent pulmonary resection during cardiac operations requiring extracorporeal circulation. The pulmonary operations included 17 wedge resections and four lobectomies. The final diagnoses in 8 patients with stage I non-small cell lung cancer included epidermoid carcinoma (4), adenocarcinoma (3), and bronchoalveolar carcinoma (1). Postoperatively, 1 patient required a permanent pacemaker and 1 patient died. The actuarial survival at 5 years for all patients who underwent combined procedures was 95%. The 5-year survival for the 8 patients with lung cancer was 88% compared with 100% for those with benign pulmonary pathology (p = 0.172). This experience suggests that combining pulmonary resection with cardiac operations is safe and offers a favorable prognosis to a select group of patients.     

Colorectal intervention as part of surgery for patients with gynaecological malignancy

OBJECTIVE: This study was conducted to determine the indications for and outcome of colorectal intervention in patients with advanced gynaecological malignancy. METHODS: Between January 1999 and June 2004, 27 gynaecological cancer patients underwent 36 colorectal intervention performed by general surgeons. The 36 operations were associated with 14 (39%) primary surgical procedures, 9 (25%) second-look laparotomies, and 13 (36%) procedures for recurrence or palliation. RESULTS: The mean age was 56 years (range 32-83 years). The majority of operations were performed in patients with ovarian (67%), endometrial (18%) and cervical (15%) malignancy. The primary indications for colorectal resection was tumour cytoreduction in 56% of the 36 operations. Other indications included repair of iatrogenic bowel injuries (n = 9, 25%), resection for multiple iatrogenic enterotomies (n = 4, 11%), and bowel obstruction (n = 3, 8%). The most frequently performed bowel operation was rectosigmoid resection with end-to-end anastomosis (n = 19, 53%). Colostomy was performed in 14% of the rectosigmoid resections at primary surgery. Small-bowel resection was required in 31% of the 36 operations. Postoperative complications included wound complications (14%), pulmonary infections (8%), cardiac complications (6%) and intra-abdominal abscess (6%). There was a single surgical mortality (3%). CONCLUSION: Colorectal intervention is frequently indicated during operations for advanced gynaecological malignancy, and they are associated with a significant rate of postoperative complications. Specialists operating on gynaecological malignancy should have the technical skills necessary to perform these procedures.     

Evaluations of bronchoplasty and pulmonary artery reconstruction for bronchogenic carcinoma.

OBJECTIVE: To evaluate the surgical results of bronchovascular reconstruction and the prognostic factors for lung cancer. METHODS: From 1976 to 1995, 78 patients with a mean age of 55.1 years (range 26-69 years) underwent bronchoplasty for non-small-cell lung cancer (NSCLC) including pulmonary artery (PA) reconstruction in 21 patients. There were 47 right upper lobectomies (60.3%), 24 left upper lobectomies (30.8%), and seven other atypical types of operations (8.9%). The bronchoplasty was a full sleeve in 71 patients, and a bronchial wedge resection in seven. Thirteen PA tangential resections and eight PA sleeve resections were performed. Tissue diagnosis was squamous cell carcinoma in 56 patients, adenocarcinoma in six, adenosquamous carcinoma in ten, neuroendocrine carcinoma in two and others in four. No patient had a microscopically positive bronchial resection margin. The follow up is complete for all patients. Seventy-five patients were statistically analyzed using STATA software. The survival rate was calculated with life table method. Comparisons of the difference of survival rates between groups were made according to the log-rank test. RESULTS: The operative mortality rate (30 days) was 3.8% (3/78). The prolonged atelectasis necessitating repeated bronchoscopy was the most common major complication which occurred in 12 patients (16%). Tumor recurrence around the anastomotic site confirmed by bronchoscopic biopsy was observed in four patients. The overall survival at 5 and 10 years was 48.9 and 38.8%, respectively. The 5- and 10-year survival for patients with stage I disease were 66.1 and 57.5%, and for patients with stage II were 62.8 and 44.2%, respectively. The 3- and 5-year survivals for patients with stage III were 11.1 and 0%, respectively (P = 0.0000). The 5-year survival rates for those with N0 tumor (n = 36) were 63.3%, 53.6% for those with N1 (n = 26), and with no survivors for N2 (n = 13), respectively (P = 0.0000). The 5- and 10- year survival rates with bronchoplasty (n = 54) were 55.0 and 47.8%, and 33.3 and 16.7% with bronchovascular reconstruction (n = 21), respectively (P = 0.0033). Multivariate analysis showed that long-term results were influenced chiefly by nodal stage among five factors of pT, pN, bronchoplasty with or without PA reconstruction, cell types, and postoperative adjuvants (P = 0.004). CONCLUSIONS: Any type of lobectomy with bronchial reconstruction is an adequate cancer operation for both compromised and uncompromised patients especially in patients with stages I and II lung cancer with reasonably good results. Sleeve lobectomy with PA reconstruction may finally be indicated in patients considered compromised because of cardiac or respiratory impairment contraindicating pneumonectomy.     

Surgery for intrathoracic recurrence of non-small cell lung cancer

In this study, we defined a solitary lung nodle in the same histology which could be traced its' origin from carcinoma in situ or was found over than two years' follow up as a second primary lung cancer. These cases were excluded. Eighteen cases underwent second surgery for intrathoracic recurrence. Fourteen cases were male and four cases were female. Their ages ranged from 23 to 75 (average 59.6) years. The histology were adenocarcinoma in 9 cases, squamouscarcinoma in 7, adenosquamous carcinoma in 1, large cell carcinoma in 1. The initial surgical procedures were lobectomy in 17, partial resection in 1. The initial stage were I in 13, II in 2, IIIA in 1. Pulmonary recurrence were found in 10, bronchial stump recurrence were found in 4, pulmonary hilus lymph node recurrence were found in 2, mediastinal lymph node recurrence were found in 2, pulmonary stump recurrence was found in 1. The second surgical procedures were completion pneumonectomy in 7, completion lobectomy in 1, lobectomy with segmentectomy in 1, segmentectomy or partial resection in 7, mediastinal dissection in 2. The overall 5-year survival rate of the patients with recurrence after reoperation was 31.8%. An aggressive surgical approach for recurrent lung cancer should be recommended.     

支气管袖式肺叶切除肺动脉成形术治疗中心型肺癌

目的 总结支气管袖式肺叶切除、肺动脉成形术治疗中心型肺癌的临床经验.方法 回顾分析1989年5月至2009年5月收治的52例中心型肺癌患者,其中38例行支气管环状切除成形及支气管袖式肺叶切除术;12例行支气管肺动脉双袖式肺叶切除术;2例行气管隆突及半隆突切除重建合并肺叶切除术.结果 本组术后死亡1例,发生手术并发症5例...     

Long-term results after recurrence of completely resected primary lung cancer

The recurrence rate of complete surgical resection and the long-term results following recurrence have rarely been reported. Whether patients with recurrence could be cured is still unknown. Patients who underwent complete surgical resection for lung cancer from 1981 to 1999 (n=945) and were followed-up for more than 5 years were retrospectively reviewed. Recurrent diseases were treated by chemotherapy and/or radiotherapy when surgical treatment was not indicated. Postoperative 5-year survival in 585 patients (62%) without recurrence and in 360 patients (38%) with recurrent diseases were 84 and 27%, respectively. The recurrence rates of stage I patients (n=164), stage II (n=55), stage III (n=127) and stage IV (n=13) were 26, 52, 68 and 93%, respectively. The 5-year survival rates of these patients were 36, 23, 19 and 7%, respectively. The period between the operation and the first recurrence was approximately 2 (0-9) years and the patients with recurrence died in about 1 (0-9) year. Four patients actually survived more than 10 years after the first recurrence. The recurrence rate after complete surgical resection of lung cancer was 38% in all and it increased along with the advanced pathological stages.     

Pediatric renovascular hypertension: 132 primary and 30 secondary operations in 97 children

PURPOSE: This study was undertaken to characterize the contemporary surgical treatment of pediatric renovascular hypertension. METHODS: A retrospective analysis was conducted of the clinical data of 97 consecutive pediatric patients (39 girls, 58 boys), aged from 3 months to 17 years, who underwent operation at the University of Michigan from 1963 to 2006. All but one patient had refractory hypertension not responsive to contemporary medical therapy. Developmental renal artery stenoses accounted for 80% of the renal artery disease, with inflammatory and other ill-defined stenoses encountered less frequently. Splanchnic arterial occlusive lesions affected 24% and abdominal aortic coarctations, 33%. RESULTS: Primary renal artery operations were undertaken 132 times. Procedures included resection beyond the stenosis and implantation into the aorta in 49, renal artery in 7, or superior mesenteric artery in 3; aortorenal and iliorenal bypasses with vein or iliac artery grafts in 40; focal arterioplasty in 10; resection with reanastomosis in 4; operative dilation in 4; splenorenal bypass in 2; and primary nephrectomy in 13 when arterial reconstructions proved impossible. Bilateral renal operations were done in 34 children, and 17 underwent celiac or superior mesenteric arterial reconstructions, including 15 at the time of the renal operation. Thirty patients underwent abdominal aortic reconstructions with patch aortoplasty (n = 19) or thoracoabdominal bypass (n = 11). Twenty-five of the aortic procedures were performed coincidently with the renal operations. Thirty secondary renal artery procedures were done in 19 patients, including nine nephrectomies. Hypertension was cured in 68 children (70%), improved in 26 (27%), and was unchanged in three (3%). Follow-up averaged 4.2 years. No patients required dialysis, and there were no operative deaths. CONCLUSION: Contemporary surgical treatment of pediatric renovascular hypertension emphasizes direct aortic implantation of the normal renal artery beyond its stenosis and single-staged concomitant splanchnic and aortic reconstructions when necessary. Benefits accompany carefully executed operative procedures in 97% of these children.     

Surgical treatment of malignant mediastinal neurogenic tumors in children.

INTRODUCTION: The aim of this study was to identify the role of surgical resection in the treatment of malignant mediastinal neurogenic tumors in children. MATERIALS AND METHODS: Thirty-eight consecutive children, who underwent surgical resection of a malignant mediastinal neurogenic tumor between 1986 and 2004, were included in this study. The tumor cell types were neuroblastoma in 23 patients (60.5%), ganglioneuroblastoma in 14 (36.8%), and malignant neuroepithelioma in 1 (2.6%). Surgery was performed for curative resection in localized tumors and salvage resection of residual mediastinal masses after chemotherapy in stage IV tumors. Of the 16 patients (42.1%) who underwent salvage resection, 14 had neuroblastoma and 2 ganglioneuroblastoma. RESULTS: Mean patient age was 3.4+/-3.0 years (1 month-13 years) and 26 patients (68.4%) were symptomatic at presentation. Adjacent structure invasion was found in eight patients (21.1%), invasion of chest wall in four, heart and vena cava in two, lung in one, and chest wall and lung in one. Complete gross resection was possible in 30 patients (78.9%) and there was no surgical mortality. Surgical morbidity occurred in 10 patients (26.3%) and Horner's syndrome was the most frequent complication (n=7). The 5-year survival was 95.2% for a localized tumor and 52.5% for a stage IV tumor (p=0.004). The significant risk factors of long-term survival were adjacent structure invasion (p=0.002) and a stage IV tumor (p=0.002) by multivariate Cox regression analysis. CONCLUSIONS: Surgical resection of localized malignant mediastinal neurogenic tumor in children showed good long-term survival, and salvage operations after chemotherapy showed acceptable long-term survival.     

残胃癌外科治疗临床分析及再认识

目的分析残胃癌的外科治疗及其临床病理特征,对当前残胃癌外科治疗进行再认识。方法回顾性总结我院2004年1月至2011年3月期间经内镜和病理学检查诊断为残胃癌并行外科治疗的26例患者的临床资料,其中首次疾病为良性的残胃癌(RGCB)者14例,胃癌根治术后残胃癌(RGCC)者12例,对其临床发病、HP感染、手术方式、组织病理学特点及预后因素进行分析。结果 RGCB距第1次胃切除术后的发病时间为15～44年(中位时间为26.3年),RGCC距第1次胃切除术后的发病时间为1~10.5年(中位时间为4.0年),两者间差异有统计学意义(P<0.05)。病理检测残胃癌的HP感染率为73.1%(19/26),其中RGCB的HP感染率为71.4%(10/14),RGCC的HP感染率为75.0%(9/12),两者间差异无统计学意义(P>0.05)。26例患者均再次进行了手术治疗,其残胃癌手术根治率为46.2%(12/26),其中RGCB根治切除率为57.1%(8/14),RGCC根治切除率为33.3%(4/12),两者间差异无统计学意义(P>0.05)。在行根治性切除的12例患者中胃周淋巴结转移以小弯淋巴结转移率最高(83.3%,10/12),其次为空肠系膜淋巴结(33.3%,4/12)和脾门淋巴结(33.3%,4/12)。26例残胃癌术后病理分期:Ⅰ期3例,Ⅱ期2例,Ⅲ期14例,Ⅳ期7例。18例手术切除者术后病理报告提示有13例(72.2%)发生淋巴结转移;明确肿瘤侵犯胰腺或横结肠或脾脏者13例(50.0%);8例有腹膜转移(30.8%),其中RGCB的腹膜转移率为14.3%(2/14),明显低于RGCC的腹膜转移率(50.0%,6/12),P<0.05。全组病例累积1年总体生存率为54.5%,3年生存率为38.5%,生存时间为2～61个月(中位生存时间12个月)。生存分析结果表明,肿瘤的病理分期与是否接受根治性手术为残胃癌患者生存的影响因素(P<0.01),而患者年龄、性别、第1次疾病、病理分化程度以及HP感染均不是影响预后的相关因素(P>0.05);是否接受根治性手术为影响生存的独立预后因素(P<0.05)。结论早期诊断和根治手术是改善残胃癌患者预后的关键因素,腹腔镜探查可减少不必要的外科手术创伤。胃癌术后残胃癌与良性疾病后残胃癌在临床特点上不同,临床处理仍需区别对待。     

The first open-heart repairs of ventricular septal defect, atrioventricular communis, and tetralogy of Fallot using extracorporeal circulation by cross-circulation: a 30-year follow-up

From March 26, 1954, to July 19, 1955, 45 patients with major cardiac malformations not previously correctable underwent open repair utilizing cross-circulation between patient and donor without donor deaths. All operations were carried out at normothermia with lowered flow rates based on azygos flow studies. Twenty-seven patients, more than half of them infants, had ventricular septal defects closed. There were 8 hospital deaths, and there have been only 2 late deaths in 30 years. Fourteen (87.5%) of 16 who underwent recatheterization have closed defects. The 17 30-year-survivors are all in New York Heart Association Functional Class I. Five patients 4 months to 10 years old were operated on for atrioventricular canal (complete form). All had intractable failure, and 4 had pulmonary hypertension. Two of the 3 hospital deaths were due to heart block. The long-term survivor, a 15-month-old infant at the time of operation (severe pulmonary hypertension, 90/50 mm Hg), underwent repair 31 years ago and is now married with 3 children. Recatheterization disclosed normal pulmonary pressure (20/4 mm Hg), no shunts, and mild mitral regurgitation. Ten cyanotic tetrads 13 months to 14 years old were operated on with 5 hospital deaths. Of the 3 late deaths, 1 was accidental at 17 years, 1 occurred suddenly at home 13 years after operation in infancy for atresia, and the third occurred at reoperation 10 years later. The 2 remaining patients (1 the first patient operated on) are in excellent health. The surgical methods used and the physiological advantages of cross-circulation (temporary placenta) that made these results possible at a time when surgical knowledge was primitive are described.