胰腺囊性肿瘤13例临床分析

目的总结胰腺囊性肿瘤(pancreatic cystic neoplasms,PCN)的诊断与治疗体会。方法回顾性分析手术治疗的13例PCN的临床资料。结果术前B超确诊率为61.5%(8/13),CT确诊率为84.6%(11/13),肿瘤切除率为84.0(11/13),术后发生胰漏、切口感染各2例,腹腔感染1例。10例平均随访3.6年,3例死亡,其余均无复发。结论PCN术前定位困难,主要依靠影像学检查与胰腺假性囊肿鉴别。外科手术是PCN的主要治疗手段。     

Laparoscopic Pancreatic Resection: The Past,Present, and Future

Since the early 1990s, laparoscopic techniques have been applied to a growing number of pancreatic surgeries. Laparoscopic pancreatic resections have been performed in patients with a variety of diseases including chronic pancreatitis, pancreatic trauma, congenital hyperinsulinism, and neoplasms of the pancreas; e.g., insulinoma, mucinous cystic neoplasm, intraductal papillary mucinous neoplasm, etc. Laparoscopic pancreatic resections with an en bloc lymph node dissection have also been performed for invasive carcinomas. The long-term results after laparoscopic resections for invasive pancreatic cancer, however, are still not well defined. Laparoscopic distal pancreatectomies with or without spleen preservation may benefit patients with reduced postoperative pain, shorter hospital stay, a quicker recovery to normal activity, and better cosmetic appearances based on retrospective analyses of collective series and case reports. Prospective randomized controlled trials are needed to validate these benefits. In contrast, laparoscopic proximal pancreatectomies with or without duodenum preservation remain controversial. Although a laparoscopic pancreaticoduodenectomy and laparoscopic duodenum-preserving pancreatic head resection are technically feasible, laparoscopic reconstruction after proximal pancreatectomies is not yet generally practicable but limited to personal experiences by highly skilled endoscopic surgeons. To justify the performance of laparoscopic proximal pancreatectomies, it is mandatory to demonstrate the potential clinical benefits and safety of these complicated procedures.     

Laparoscopic Medial-to-lateral Approach for the Curative Resection of Right-Sided Colon Cancer

INTRODUCTION: Our previous randomized clinical trial comparing the laparoscopic medial-to-lateral dissection with the more classic lateral-to-medial approach for resection of rectosigmoid cancer showed that the medial approach reduces the operative time and the postoperative proinflammatory response. Besides the oncologic advantages of an early vessel division and a "no-touch" dissection, we feel that the longer the lateral abdominal wall attachments of the colon are preserved, the better the exposure and the easier the dissection. Encouraged by the above-mentioned positive findings, we therefore further conduct this phase II clinical trial to examine the feasibility and surgical outcomes regarding the utilization of this medial-to-lateral laparoscopic dissection approach for the curative resection of right-sided colon cancer. METHODS: A total of 104 patients (from December 2000 to January, 2005) with advanced right-sided colon cancer (TNM stage II: n = 56; stage III: n = 48) requiring a curative right hemicolectomy were subjected to the laparoscopic medial-to-lateral approach that included initial exploration and ligation of ileocolic, right colic, and middle colic vessels in no-touch isolation fashion, subsequent medial-to-lateral extension of retroperitoneal dissection along Gerota fascia, opening of lesser sac by transection of gastrocolic ligament, and the final mobilization of hepatic flexure and lateral attachments of ascending colon (Fig. 1). This study was approved by the institutional review committee of National Taiwan University Hospital. The surgical details were shown in the video. Postoperatively, adjuvant chemotherapy with Mayo Clinic Regimen was given in patients with stage III diseases. The functional recovery and surgical outcomes were prospectively evaluated. RESULTS: The laparoscopic medial-to-lateral approach for a curative right hemicolectomy can be preformed with acceptable operation time (192.6 +/- 32.8 min, mean +/- standard deviation) and little blood loss (48.4 +/- 14.4 ml) through a small wound (6.0 +/- 0.8 cm). The number of dissected lymph node was 16.0 +/- 2.8. The operative complications represented 5.7% of all cases, including anastomotic leakage in two cases (1.9%) and wound infection in four cases (3.8%). The patients have quick functional recovery, as evaluated by the length of postoperative ileus (60.0 +/- 12.0 h), hospitalization (9.0 +/- 1.5 days) and degree of postoperative pain (4.0 +/- 0.5, visual analogue scale). Besides the expenses covered by the National Bureau of Health Insurance in Taiwan, the patient had to pay an extra-expenses of NT$ 25,000.0 +/- 2,800.0 (1.0 US$ = 32.0 NT$). During the follow-up periods (median: 30 months, range 6-55 months), recurrence of tumor developed in 6 (10.7%) of stage II and 10 (20.8%) of stage III patients, with liver metastasis in six patients, lung metastasis in 4, liver and lung metastasis in 1, intraperitoneal recurrence in 2, bone metastasis in 1, brain metastasis in 1, and port-site recurrence in 1. CONCLUSIONS: By medial-to-lateral dissection method, the laparoscopic right hemicolectomy can be performed with technical efficiency, short convalescence, and acceptable short-term oncologic results. We therefore encourage the use of this approach for patients requiring a curative laparoscopic right hemicolectomy.     

Laparoscopic Colonic Resection for Rectosigmoid Colonic Tumours: A Retrospective Analysis and Comparison with Open Resection

Laparoscopic approach for treatment of colorectal malignancy is gaining acceptance gradually; however the benefits of laparoscopic surgery in colonic and rectal tumours is still open to debate. This study aims at a retrospective analysis of operative and short term outcome of patients with rectosigmoid tumours. A retrospective analysis of operative, postoperative and short-term outcome of 62 patients who underwent laparoscopic colorectal resection for cancer of rectosigmoid region were compared with a same number of parameters-matched patients who underwent open colorectal resection. Blood transfusion requirement was significantly more in the open group compared to the laparoscopy group (38.7% versus 6.4%, p = 0.001). ICU stay was less in the laparoscopy group (p = <0.05) and they were started on oral liquid diet earlier (p = 0.013). The number of the lymph nodes retrieved, positive distal margin and radial involvement were similar in both groups. The hospital stay was significantly shorter in laparoscopy group (8.4 versus 13.8 days, p < 0.05). Radical operation for rectosigmoid tumors is technically feasible with laparoscopic surgery. Laparoscopic approach is associated with less blood loss, transfusion and significantly less ICU stay. Laparoscopic group recovers early and needs less hospital stay     

Laparoscopic Resection of Solitary Adrenal Metastasis from Lung Carcinoma: A Case Report

Background and Objectives:

Patients with adrenal metastases from bronchogenic carcinoma are considered incurable and any surgical treatment is usually excluded. A review of the few cases of adrenalectomy for metastases from lung cancer that have been reported in the literature shows that good results can be achieved in selected patients. We propose a laparoscopic approach to perform the adrenalectomy in these patients.

Methods:

A right laparoscopic adrenalectomy for metastasis from lung adenocarcinoma was performed. The right adrenal was resected using the anterior transperitoneal laparoscopic approach.

Results:

The tumor was resected in total. The operating time was two hours. One year after surgery the patient remains well.

Conclusions:

The current indications for laparoscopic adrenalectomy can include the removal of small metastatic adrenal lesions in selected cases.     

Laparoscopic Resection of a Retroperitoneal Liposarcoma: A Case Report and Review of the Literature

Here, we describe a case of a retroperitoneal liposarcoma successfully managed by laparoscopic surgery. A 72-year-old man underwent abnormal hypertension screening using computed tomography (CT), which revealed a low-density mass measuring 7 cm in diameter in the retroperitoneal space. We diagnosed the mass as a liposarcoma before the operation. The mass was resected laparoscopically. No perioperative complications were encountered, and the patient was discharged on the fourth postoperative day. The pathologic diagnosis was well-differentiated liposarcoma, indicating complete surgical resection. Thus, we conclude that a laparoscopic approach for the patients with retroperitoneal tumors, including liposarcomas, is safe, feasible, and minimally invasive, even if there is a possibility of the tumor being malignant.     

Pancreatic neuroendocrine tumor with splenic vein tumor thrombus: A case report

INTRODUCTION

Pancreatic neuroendocrine tumors (PNET) are rare, often indolent malignancies. PNET are classified as functional or nonfunctional based on the secretion of hormones without a negative feedback loop; the latter account for up to 60% of PNET. Although PNET are associated with a better prognosis compared to pancreatic adenocarcinomas, they are often diagnosed in advanced stages, making them a significant source of morbidity for patients. Here we present a rare case of venous tumor thrombus arising from a nonfunctional PNET.

PRESENTATION OF CASE

A 44-year-old woman was referred for evaluation and treatment of a possible tail of pancreas PNET discovered during work-up for a 9 year history of intermittent subcostal pain. Previous endoscopic ultrasound with fine needle aspiration revealed a 3.5 cm × 3 cm mass, with cytological diagnosis of neuroendocrine tumor. Patient was scheduled for laparoscopic distal pancreatectomy. During surgery the mass was found to encase the splenic vein leading the surgeon to perform an en bloc distal pancreatectomy and splenectomy. Pathologic analysis revealed a 1.8 cm × 5 cm tumor thrombus lodged in the splenic vein.

DISCUSSION

Nonfunctional PNET usually present in advanced stages and can be associated with venous tumor thrombi. Preoperative imaging may not accurately predict the presence of venous tumor thrombi.

CONCLUSION

En bloc resection of primary tumor, involved organs and thrombus is the recommended treatment option and often results in long term survival. New multi-modality strategies are needed for detection of venous involvement in nonfunctional PNET to better assist with preoperative planning and counseling.     

Laparoscopic Spleen-Preserving Pancreatic Tail Resection for an Intrapancreatic Accessory Spleen Mimicking a Nonfunctioning Endocrine Tumor: Report of a Case

Laparoscopic surgery is now performed for several pancreatic disorders, such as benign tumors of the pancreatic body or tail, which are a good indication for laparoscopic resection. However, the risk of pancreatic fistula after distal pancreatectomy, performed laparoscopically or by open surgery, is a topic of debate. We report the case of a 61-year-old man in whom a routine follow-up computed tomography (CT) scan showed a solid, well-defined mass, 1.5cm in diameter, in the pancreatic tail. The mass was homogeneously enhanced from the early phase to the super-delayed phase on enhanced CT. We suspected a nonfunctioning endocrine tumor of the pancreas, and surgery was performed laparoscopically. After dissecting the pancreatic tail away from the splenic hilum and the splenic vessels, it was resected using only a linear stapler. The histological diagnosis was an intrapancreatic accessory spleen. The patient was discharged on postoperative day 14, but was readmitted 6 days later because of a pancreatic fistula, which was treated by CT-guided percutaneous drainage.     

A Propensity Score-Based Analysis of Laparoscopic Liver Resection for Liver Malignancies in Elderly Patients

Purpose: Laparoscopic liver resection is safe, feasible and associated with less blood loss, shorter hospital stays and fewer postoperative complications in the working age patients with malignant liver tumors. However, it is still unclear if the elderly patients with malignant liver tumors would also benefit from that approach as the younger patients. So, the aim of the study was to compare the clinical outcomes of laparoscopic versus open liver resection for malignant liver tumors in elderly patients. Materials and Methods: Between March 2009 and July 2016, all elderly patients (≥70 years old) who underwent laparoscopic (n = 40) and open (n = 202) liver resection for malignant liver tumors were included. A one to one propensity score matching analysis was performed, based on 6 covariates, to decrease the selection bias. Results: There was no significant difference between the laparoscopic and open liver resection groups regarding the patient characteristics and tumor features. The operative time was comparable between both groups (Laparoscopic group 259 min vs Open group 308 min, p = .86), while patients who underwent laparoscopic liver resection had lower intraoperative blood loss (30 ml vs 517 ml, p < .0001), shorter hospital stays (10 days vs 23 days, p < .0001), and less overall morbidity (15% vs 38%, p = .04). The one-, three-, and five-year survival for patients with hepatocellular carcinoma was comparable between both groups (Laparoscopic group 96%, 74%, 47%, vs Open group 94%, 71%, 48%, p = .82), whereas The one-, three-, and five-year recurrence-free survival for patients with hepatocellular carcinoma was significantly higher in the laparoscopic group (88%, 60%, 60% vs 54%, 25%, 19%, p = .019). Conclusions: Laparoscopic approach for minor liver resection in elderly patients is safe and feasible with less blood loss, a shorter hospital stay, less postoperative complications and a better oncological outcome.     

Survival after Resection of Pancreatic Adenocarcinoma: Results from a Single Institution over Three Decades

Background  

Randomized trials have demonstrated a benefit associated with adjuvant therapy for pancreatic cancer, and retrospective studies have demonstrated improvements in postoperative mortality. The purpose of this study was to evaluate whether these improvements could be identified in a cohort of patients who underwent resection for pancreatic cancer at a single institution over three decades.     

肝脏肿瘤的微创治疗——从腹腔镜到机器人

目的探讨完全腹腔镜、手助式腹腔镜及机器人三种微创手术方式在肝脏切除术中的可行性、安全性及适用范围。方法回顾性分析上海交通大学医学院附属瑞金医院普外科自2004年9月至20l2年1月期间完成的微创肝脏切除术(minimally invasive liver resection,MILR)128例患者的临床资料,根据手术方式分为完全腹腔镜肝脏切除术(pure laparoscopic resection,PLR)组、手助式腹腔镜肝脏切除术(hand-assisted laparoscopicresection,HALR)组及机器人辅助肝脏切除术(robotic liver resection,RLR)组,分别观察3组患者术中与术后恢复情况并进行对比分析。结果 PLR组82例,中转开腹3例,手术时间为(145.4±54.4)min(40～290 min)、术中出血量为(249.3±255.7)ml(30～1 500 ml),术后并发腹腔感染3例,胆瘘5例,经保守治疗后痊愈,无围手术期死亡,术后住院时间为(7.1±3.8)d(2～34 d)。HALR组35例,中转开腹3例,手术时间为(182.7±59.2)min(60～300 min)、术中出血量为(754.3±785.2)ml(50～3 000 ml),术后并发腹腔感染1例,胆瘘2例,切口感染2例,经保守治疗后痊愈,无二次手术,术后住院时间为(15.4±3.7)d(12～30 d)。RLR组11例,中转开腹2例,手术时间为(129.5±33.5)min(120～200 min)、术中出血量为(424.5±657.5)ml(50～5 000 ml),术后并发腹腔感染1例,胆瘘1例,经保守治疗后痊愈,术后住院时间为(6.4±1.6)d(5～9 d)。3组中,RLR组手术时间最短(P=0.001),术后住院时间最短(P=0.000),PLR组术中出血量最少(P=0.000),其差异均有统计学意义。结论肝脏肿瘤微创切除术安全、可行,临床工作中,需要根据不同的病例选择不同的手术方式。机器人辅助肝脏切除术为肝脏肿瘤的微创治疗带来了新的突破。     

Middle Segment Pancreatectomy: A Useful Tool in the Management of Pancreatic Neoplasms

Small, benign, or low-grade malignant tumors located in the neck of the pancreas are usually treated with enucleation. However, if enucleation is too risky because of possible damage of the main pancreatic duct, standard pancreatic resections are performed. Such operations can lead to impaired long-term exocrine–endocrine function. Middle segment pancreatectomy consists of a limited resection of the midportion of the pancreas and can be performed in selected patients affected by tumors of the pancreatic neck. Middle segment pancreatectomy is a safe and feasible procedure for treating tumors of the pancreatic neck; in experienced hands it is associated with no mortality but with high morbidity, even if the rate of “clinical” pancreatic fistula is about 20%. Moreover, it allows a surgeon to preserve pancreatic parenchyma and consequently long-term endocrine and exocrine pancreatic function.     

Laparoscopic Resection of an Ileal Lipoma: Report of a Case

A 63-year-old woman was admitted to our hospital for investigation of upper abdominal pain and vomiting. Ultrasonography (US) showed a hyperechoic mass in the right lower abdomen, and computed tomography (CT) showed a low-density mass and intestinal invagination. Thus, we made a diagnosis of intestinal lipoma with intussusception and performed laparoscopic partial resection of the ileum, including the tumor. The resected specimen contained a round tumor, 25 × 22 × 20 mm, which was identified as an intestinal lipoma histopathologically. Our experience supports earlier reports that US and CT are effective tools in the diagnosis of bowel lipoma. Laparoscopic surgery is the treatment of choice for benign tumors of the small intestine because it is minimally invasive, with cosmetic, physical, and economic benefits.     

Laparoscopic Wedge Resection for Gastrointestinal Stromal Tumors of the Stomach: Initial Experience

PURPOSE: Surgery for gastrointestinal stromal tumors (GIST) of the stomach is now frequently performed using a laparoscopic approach. We investigated the feasibility and effectiveness of laparoscopy in the management of GIST of the stomach. METHODS: We reviewed the records of 12 consecutive patients who underwent laparoscopic surgery for GIST between April 2000 and April 2004, and compared their short-term outcomes with those of patients who underwent open surgery. All laparoscopic wedge resections were done using stapling devices and 3-4 trocars, often with the aid of intraoperative gastroscopy. We examined all patients preoperatively using various diagnostic modalities, including endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA). A laparoscopic approach was not indicated if the tumor was located near the cardia or pylorus or if it was >=5 cm in diameter. RESULTS: A specific diagnosis of GIST was obtained preoperatively by EUS-FNA in 10 of the 12 patients. The median diameter of the lesion was 2.7 cm (range, 1.5-4.8 cm). Although intraoperative complications were encountered in two patients, conversion to open surgery was not required, and we were able to perform complete tumor excision with negative surgical margins in all patients. The median operative time was 100 min (range, 65-180 min), similar to that for open surgery. First flatus was passed earlier, and the interval to resuming oral intake was shorter than after open surgery. No major postoperative complications such as leakage developed, and the median postoperative hospital stay was 7 days (range, 5-12 days). All diagnoses made by EUS-FNA were confirmed by immunohisto-pathological evaluation of resected specimens. CONCLUSION: Laparoscopic wedge resection is a feasible treatment option for GISTs of the stomach if the lesion is <5 cm in diameter.     

腹腔镜下治疗子宫内膜异位症的临床观察

目的评价腹腔镜手术治疗子宫内膜异位症的临床疗效. 方法回顾性分析1998年1月～2003年1月经腹腔镜治疗的102例子宫内膜异位症的临床资料. 结果所有病例无中转开腹和并发症发生.手术时间(80.5±28.3)min,术中出血量(25.2±23.2) ml,术后住院时间(3.0±1.2) d.83例术后随访6～66个月,21例复发;53例内异症合并不孕症中23例正常妊娠. 结论腹腔镜手术治疗子宫内膜异位症效果明显,但仍有术后复发.     

Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution

Background: Laparoscopic adjustable gastric banding (LAGB) has been adopted by many bariatric surgeons. It remains under scrutiny, although it represents a major innovation in the treatment of morbid obesity. We present the lessons from the first 500 patients treated in our institution. Methods: From April 1995 to November 1998, 500 patients (421 females, 79 males) underwent an LAGB in our institution: 432 were morbidly obese and 68 were superobese. Mean body mass index (BMI) was 43, and mean excess weight was 51 kg. Results: There have been no deaths. There was one case of gastric perforation reoperated on and three cases of pulmonary and/or abdominal collections treated by drains. Two rings were changed for leakage. One ring was removed for a postoperative sigmoiditis. Three late gastric erosions occurred, requiring re- moval of the ring. Five access- ports have been removed for infection. 25 cases (5%)of pouch dilatation have been observed of which 18 (3.6%) led to reoperation. Mean follow-up was 21 months. Mean excess weight loss was 56% at 1 year, 65% at 2 years, and 64% at 3 years. Conclusion: This favorable outcome led us to propose laparoscopic banding to all our patients instead of stapling gastroplasty. Short-term data should be confirmed by a longer follow-up, but indicate that LAGB should provide good results in terms of weight loss and that there are a limited number of failures. We believe that it should not be regarded just as a first-step procedure but as a final therapy, even for superobese patients.     

胰腺实性假乳头状瘤36例诊断与治疗

[摘 要] 目的 总结胰腺实性假乳头状瘤（solid pseudopapillary tumor of the pancreas,SPTP）的诊断与治疗经验。方法 回顾性分析湖南省人民医院胰脾外科2012年1月至2017年1月收治的36例经术后病理证实的SPTP临床病例资料,并对其进行随访。结果 本组患者中男10例,女26例,年龄12～57岁,平均32岁。36例患者中,SPTP发生于胰头14例（38.89%）,胰颈2例（5.56%）,胰体尾20例（55.56%）。术前诊断主要依赖于彩超、CT、MRI等影像学检查,特别是CT检查。肿瘤直径平均（6.3±2.6）cm。患者均行手术切除 治疗,其中行胰十二指肠切除术10例（其中腔镜下施行6例）,保留幽门胰十二指肠切除术1例,胰体尾切除+脾脏切除术8例（其中腔镜下施行4例）,保留脾脏的胰体尾切除术12例（其中腔镜下施行8例）,胰腺中段切除+胰肠内引流术2例,肿块局部切除+胰肠内引流术3例。随访时间3个月～5年,所有患者均获得随访,一般情况良好,均无糖尿病、腹泻、消化不良等胰腺功能减退情况发生,均未发现复发和转移,无死亡。结论 SPTP是一种少见的低度恶性胰腺肿瘤,CT上的典型表现对于该病的诊断有帮助,但确诊仍有赖于病理组织学检查。完整手术切除可获得较好的预后,微创化的手术和快速康复理念的实施能让患者获益。     

Laparoscopic Versus Open Ileo-Colonic Resection in Crohn’s Disease: Short- and Long-Term Results from a Prospective Longitudinal Study

Possible relations between surgical approaches, frequency, and severity of Crohn’s disease recurrence after ileo-colonic resection is unknown. We aimed to assess perioperative outcomes and postsurgical complications of laparoscopic versus standard open surgery and to detect differences between the two groups in endoscopical recurrence and patients’ satisfaction. Twenty-eight consecutive patients undergoing elective ileo-colonic resection by either laparoscopic approach (n = 15) or conventional open surgery (n = 13) were prospectively enrolled. No mortality or major intraoperative complications were observed in both groups. Significant differences between groups were the median operating time found shorter in the open group than in the laparoscopic group (p = 0.003), the higher dosage of pain killers needed in the open group (p = 0.05), the passage of flatus and\or stool after surgery found faster in group A (p = 0.004) and the shorter recovery period in the laparoscopic group (p = 0.007). Colonoscopy was performed in 27 patients. The frequency and pattern of recurrence did not differ between the two groups (p = 0.63). Patients’ satisfaction was significantly in favor of laparoscopy. Present findings support the feasibility and advantages in the short-term of laparoscopic ileo-colonic resection in patients with Crohn’s disease. No differences were observed in terms of frequency, time of onset, and severity of recurrence in a 1-year follow-up.     

AirSeal智能气腹系统在腹腔镜直肠癌根治手术中的应用价值:前瞻性随机对照研究

目的探讨AirSeal智能气腹系统在腹腔镜直肠癌根治手术中的应用价值。方法将2017年7月~2019年6月80例腹腔镜直肠癌根治手术,随机分为AirSeal组和对照组各40例,AirSeal组应用AirSeal智能气腹系统,对照组应用常规气腹机,比较2组术中擦镜次数、盆腔自主神经显示情况、手术时间、术中出血量、淋巴结清扫个数、术中动脉血气变化、肛门排气时间、腹腔引流量和并发症。结果均成功完成手术,无严重并发症和死亡。术中擦镜次数AirSeal组更少[(8.3±2.5)次vs.(12.8±3.7)次,t=-7.686,P=0.000],盆神经丛显示例数AirSeal组更多(25例vs.14例,χ^2=6.054,P=0.014),低位直肠癌手术时间AirSeal组更短[Dixon:(105.4±17.4)min vs.(136.8±25.6)min,t=-4.536,P=0.000;Miles:(145.2±17.6)min vs.(186.3±31.5)min,t=-2.829,P=0.016],术中动脉血气指标pH值、PaCO2、PaO2、BE和HCO-32组差异无显著性(P>0.05)。2组术中出血量、淋巴结清扫个数、肛门排气时间、术后腹腔引流量和术后并发症均无显著差异(P>0.05)。结论AirSeal智能气腹系统在腹腔镜直肠癌根治手术中能及时排出术中烟雾,减少术中擦镜次数,保持镜头清晰,缩短低位直肠癌腹腔镜手术时间,有一定的临床应用价值。