Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent. Received: 7 May 1996/Accepted: 12 December 1996     

162例气管插管患者的气道管理

笔者通过报道162例气管插管患者的气道管理，阐述痰痂形成的原因：(1)气道干燥，湿化不够。(2)吸痰管插入深度不够，吸痰不彻底。管理措施：(1)用金霉素眼膏润滑吸痰管，使之易于插入，保证吸痰管插入深度超过插管远端3-5cm。(2)预防气道干燥，注重湿化效果，重视吸痰环节。认为气囊不需定时放气，只需不定时调整气囊压力。     

阻塞性睡眠呼吸暂停综合征患者手术治疗的麻醉研究

目的：探讨阻塞性睡眠呼吸暂停综合征(obstructive sleep apnea syndrome，OSAS)患者手术治疗的麻醉处理。方法：72例OSAS患者手术前先正压通气治疗(continue positive airway pressure，CPAP)和评价上气道，55例患者经鼻或经口气管插管全身麻醉；在手术完毕患者完全清醒后拔除插管。结果：72例患者中，轻度16例、中度24例、重度32例。合并晨起高血压28例，心电图均有不同程度心肌缺血的表现；红细胞增多症12例；腭咽平面Ⅰ级9例、Ⅱ级24例、Ⅲ级的27例、Ⅳ级12例。术前3．5d行自动调压正压通气治疗(Auto—CPAP)，经口气管内插管48例，经鼻气管内插管6例，均无术中插管困难和术后高血压危象，呼吸道梗阻发生。结论：充分认识OSAHS患者全身麻醉的手术风险，术前CPAP治疗和上气道评估，术中正确处理、严格掌握气管内插管、术后拔管的时机，是保证OSAHS患者手术成功、麻醉安全的关键。     

急性左半结肠癌梗阻一期切除吻合治疗39例

目的：探讨左半结肠癌致急性肠梗阻的手术处理方法。方法：回顾分析1995－2001年间39例左半结肠癌致肠梗阻一期切除吻合术的外科临床效果。结果：全组39例病人均采用梗阻近端肠管减压灌洗，并留置盲肠造瘘管术后接负压吸引，术后均一期愈合，未出现吻合口漏。随访2例中，1例存活率58％，3年存活率16％，5年存活率8％。结论：严格掌握手术适应症和基本操作，在病情允许时，对左半结肠癌急性肠梗阻行一期切除吻合手术是可行的。     

Cast syndrome

The term cast syndrome is used to denote duodenal obstruction occurring after application of a corrective plaster cast to patients with scoliosis. We report a classical case in a 14-year-old female who required surgical intervention after conservative treatment failed. Six months later the patient had no further gastrointestinal symptoms. Clinical, radiological, and pathological details as well as the surgical treatment are described and discussed. Offprint requests to: M. E. Martín Hortigüela     

Respiratory obstruction following vocal cord injection

Two patients who each had a paralysed left vocal cord are discussed. Both had poor coughing ability preoperatively. The affected cords had been injected with tetrafluoroethylene (Teflon) paste 3 days before operation and this had given immediate improvement in coughing and speech. During induction of anaesthesia, respiratory obstruction occurred that was related to the injected cord. This cause of obstruction has not been reported previously. The potential benefits of cord injection for voice, cough and laryngeal competence are reviewed.     

Surgical Management of Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus

Background. The optimal management of patients with renal cell carcinoma with inferior vena cava tumor thrombus remains unresolved. Traditional approaches have included resection with or without the use of cardiopulmonary bypass. Chemotherapy has played a minor role except for biotherapeutic agents used for metastatic disease.

Methods. From January 1989 to January 1996, 37 patients with renal cell carcinoma and inferior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thirty-six patients presented with symptoms; 21 had hematuria. Distant metastases were present in 12 patients. Tumor thrombi extended to the infrahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus.

Results. Complications occurred in 11 patients, and 1 patient died 2 days postoperatively of a myocardial infarction (mortality, 2.7%). Twenty patients are alive; overall 2- and 5-year survival rates were 61.7% and 33.6%, respectively. For patients without lymph node or distant metastases (stage IIIa), 2- and 5-year survival rates were 74% and 45%, respectively. The presence of distant metastatic disease (stage IV) at the time of operation did not have a significant adverse effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adversely affected survival as there were no long-term survivors.

Conclusions. Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged survival even in the presence of metastatic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart.     

Treatment of resistant distal intestinal obstruction syndrome with a modified antegrade continence enema procedure

We report a case of a patient with CF who had a long history of recurrent distal intestinal obstruction syndrome. She had been treated with conventional treatment including gastrografin, n-acetyl cysteine, Klean prep and Picolax. She underwent a modified antegrade continence enema procedure. She currently irrigates her conduit every 2-3 days. She has had no further symptoms of distal intestinal obstruction syndrome.     

Modified Damus–Kaye–Stansel procedure using aortic flap technique for systemic ventricular outflow tract obstruction in functionally univentricular heart

Damus–Kaye–Stansel procedure is a useful method to relieve the systemic ventricular outflow tract obstruction in functionally univentricular heart. Regurgitation of pulmonary valve and recurrence of systemic ventricular outflow obstruction are the major concerns at the late phase of this procedure. Modification of original Damus–Kaye–Stansel procedure that can prevent the use of prosthetic materials is evaluated. The modified Damus–Kaye–Stansel procedure using aortic flap technique was performed in eight patients with functionally univentricular heart. Patients’ ages ranged from 3 to 28 months (mean 14 months). Follow-up period was 37 months as a mean (9–71 months), and the follow-up was complete. There was no operative mortality and no late death. In addition, there was no recurrence of systemic ventricular outflow tract obstruction throughout the follow-up period. Regurgitation of the pulmonary valve estimated by echocardiography at the latest follow-up was none to trivial in seven patients and mild in one. The modified Damus–Kaye–Stansel procedure using aortic flap technique is a safe, useful and reproducible technique to solve systemic ventricular outflow tract obstruction in functionally univentricular heart, and it can be an alternative for original technique or the so-called double-barrel modification.     

MRI relaxation fluctuations in acute reperfused hemorrhagic infarction.

MRI evaluations of intramyocardial hemorrhage in acute infarction have relied on T(2) and T(2)(*) shortening only. We propose a more comprehensive evaluation of hemorrhagic infarction based on the concept that fluctuations in T(2) and T(1) relaxation in acute reperfused infarction will reflect transient edema and hemoglobin oxidative denaturation to uncompartmentalized methemoglobin. Anteroapical infarction was created via percutaneous balloon in young swine (22-25 kg, N = 12). T(2), T(1), diastolic wall thickness (DWT), and the Gd-DTPA partition coefficient (lambda) were measured on days 0, 2, and 7. DWT was elevated at 1 hr postreperfusion (128% +/- 53%, P = 0.0001), and alleviated on days 2 and 7 (48% +/- 10%, P = 0.008; 53% +/- 24%, P = 0.003). T(2) and T(1) elevations were coincident with early edema (DeltaT(2) = 55% +/- 24%, P < 0.0001; DeltaT(1) = 27% +/- 18%, P < 0.04). T(2) and T(1) were nearly normal on day 2 (DeltaT(2) = 8% +/- 8%, P = 0.27; DeltaT(1) = 0% +/- 1%, P = 0.65). On day 7, T(2) increased while T(1) decreased (DeltaT(2) = 27% +/- 16%, P = 0.005; DeltaT(1) = -14% +/- 10%, P = 0.02). Lambda was elevated by >150% at all time points (P < or = 0.002). Histology verified hemorrhagic injury. T(1) and T(2) fluctuations are consistent with transient edema, as well as hemoglobin oxidative denaturation to decompartmentalized methemoglobin. This methodological development may broaden our understanding of hemorrhagic microvascular injury and improve its detection in clinical populations.