进展期低位直肠癌新辅助放化疗后侧方淋巴结清扫的选择和意义

侧方淋巴引流是低位直肠癌3个重要的淋巴引流方向之一。沿引流途径清扫淋巴结是直肠癌根治术基本要求,也决定淋巴结清扫范围。但侧方淋巴结是区域淋巴结还是远处淋巴结,一直存在争议。这带来新辅助放化疗和侧方淋巴结清扫、以及新辅助放化疗对侧方淋巴结转移疗效的争议。笔者综合分析国内外研究进展,对直肠癌侧方淋巴结转移规律、影响侧方淋巴结转移复发危险因素以及放化疗前后MRI检查对侧方淋巴结评估等进行深入阐述,并结合临床实践,探讨进展期低位直肠癌新辅助放化疗后侧方淋巴结清扫的选择和意义。     

海德堡三角清扫在胰腺癌根治术中的应用价值

目的探讨海德堡三角清扫在胰腺癌根治术中的应用价值。方法采用回顾性描述性研究方法。收集2020年3―7月南京医科大学第一附属医院收治的30例行海德堡三角清扫胰腺癌病人的临床病理资料;男12例,女18例;中位年龄为65岁,年龄范围为41~79岁。病人完成肿瘤可切除性评估和肝十二指肠韧带廓清后,显露肠系膜上动脉、腹腔干、肝总动脉、门静脉及肠系膜上静脉,根据肿瘤部位行胰十二指肠切除术、胰体尾切除术或者全胰腺切除术,并完成海德堡三角区域内神经纤维及淋巴结组织清扫。胰十二指肠切除术至少完成肠系膜上动脉和腹腔干右半周骨骼化,胰体尾切除术时至少完成肠系膜上动脉和腹腔干左半周骨骼化,全胰腺切除术时原则上需完成肠系膜上动脉和腹腔干全周骨骼化,手术均彻底清除肠系膜上动脉和腹腔干夹角处的神经纤维及淋巴结组织。观察指标:(1)手术情况与术后组织病理学检查。(2)术后恢复情况。(3)随访情况。采用电话或门诊方式进行定期随访,了解病人肿瘤复发转移情况,随访时间截至2021年1月。偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示,组间比较采用Fisher确切概率法。结果(1)手术情况与术后组织病理学检查:30例病人均行开腹手术,其中21例行胰十二指肠切除术,6例行胰体尾切除术,2例行全胰腺切除术,1例行保留中段的胰腺切除术;16例病人联合门静脉-肠系膜上静脉切除术;3例联合左侧肾上腺切除术。30例病人中,5例术中肠系膜上动脉-腹腔干周围组织清扫范围为1.00周,8例为1.25周,8例为1.50周,9例为1.75~2.00周。16例病人离断胃左静脉,14例保留胃左静脉。30例病人手术时间为287 min(165~495 min),术中出血量为275 mL(50~800 mL)。9例病人术中输注红细胞或冰冻血浆。术后组织病理学检查结果示肿瘤长径为3.4 cm(1.2~7.3 cm),淋巴结检出数目为20枚(9~35枚),阳性淋巴结数目为2枚(0~19枚)。30例病人中,20例肿瘤分化程度为中分化,10例为低分化。9例病人环周切缘为R0切除,17例为切缘1 mm R1切除,4例为R1切除。术后病理学T分期:30例病人中,3例为T1期,18例为T2期,5例为T3期,4例为T4期。术后病理学N分期:30例病人中,9例为N0期,13例为N1期,8例为N2期。术后病理学TNM分期:30例病人中,2例为Ⅰa期,2例为Ⅰb期,3例为Ⅱa期,11例为Ⅱb期,12例为Ⅲ期。(2)术后恢复情况:30例病人中,20例发生术后并发症,其中Clavien-DindoⅠ级并发症6例,Ⅱ级并发症9例,Ⅲa级并发症3例,Ⅴ级并发症2例。术中肠系膜上动脉-腹腔干周围组织清扫1.00周的病人术后腹泻发生情况为0,清扫1.25周的病人术后腹泻发生情况为1/8,清扫1.50周的病人术后腹泻发生情况为4/8,清扫1.75~2.00周的病人术后腹泻发生情况为9/9,4者比较,差异有统计学意义(P<0.05)。术中离断胃左静脉病人术后胃排空延迟发生情况为5/16,保留胃左静脉病人术后胃排空延迟发生情况为1/14,两者比较,差异无统计学意义(P>0.05)。30例病人中,19例行术后辅助化疗;28例顺利出院,术后住院时间为15 d(8~68 d);2例病人死亡。3例病人术后90 d内非计划性再入院。(3)随访情况:28例出院病人均获得随访,随访时间为1.0~9.0个月,中位随访时间为6.5个月。随访期间,1例局部进展期病人发生局部复发,9例病人发生肝转移(4例可切除胰腺癌、4例边界可切除胰腺癌、1例局部进展期胰腺癌),1例边界可切除胰腺癌病人发生腹膜转移。17例病人无瘤生存。结论海德堡三角清扫应用于胰腺癌根治术肿瘤根治程度较高,术后局部复发率较低,术后并发症发生率及病死率稍高,其远期疗效需进一步评估,建议对选择性病例行新辅助治疗后在高流量胰腺外科中心进行。     

食管癌早癌内镜黏膜下剥离术后发生食管狭窄的危险因素分析及预测模型建立

目的 分析食管癌早癌内镜黏膜下剥离术(ESD)后发生食管狭窄的危险因素并建立相应的预测模型。方法 回顾性分析六安市人民医院消化内科于2018年6月至2021年12月收治的52例符合标准的早期食管癌患者病理和临床资料,根据患者术后是否发生食管狭窄分为狭窄组(n=15例)与非狭窄组(n=37例)。比较两组患者基线资料,分析筛选获得与术后发生食管狭窄有关的指标,再将有关指标纳入多因素logistic回归分析中得出影响术后发生食管狭窄的独立因素,并基于上述因素对应系数构建线性回归模型,采取受试者工作特征(ROC)曲线评估模型的预测价值,选择拟合优度检验评判预测值与实际值的一致性情况。结果 两组患者固有肌层损伤、病变环周范围、肿瘤浸润深度、剥离的纵径长度比较,差异有统计学意义(均P<0.05)。多因素logistic回归分析结果提示有固有肌层损伤(OR=4.310,95%CI:2.307～8.055)、病变环周范围>3/4环周(OR=12.820,95%CI:3.781～43.470)、肿瘤浸润深度进展至M3～SM1期(OR=6.482,95%CI:2.747～15.294)、长剥离...     

Role of lateral neck dissection in cancers of the larynx and hypopharynx with No neck

Radical neck dissection is a standard procedure carried out for the teatment of palpable nodes in the neck but if carried out electively in cases where there are no palpable nodes in the neck it is considered to be an overtreatment with its associated morbity. Lateral neck dissection was carried out on twenty patients who had T31 T4 lesion of the larynx and hypophar-vnx with NO neck. The dissection entails removal of Level II. III and IV nodes. Occult metastasis 80% and 85% respectively. The mean follow up was 13 monts. It appears from our study that elective lateral neck dissection is a promising and safe procedure and may be useful as an important prognostic tool in sampling the lymph nodes and predicting recurrences in the neck.     

Right axillary arterial perfusion for a ruptured type B aortic dissection: Report of a case

The results of surgical treatment for a ruptured type B aortic dissection remain far from satisfactory. It is believed that additional perfusion from the right axillary artery might be more beneficial than perfusion from only the femoral artery during surgery for a ruptured thoracic aneurysm. The right axillary perfusion is more likely to perfuse the vital organs proximal to the ruptured area, and thus avoid retrograde emboli. In addition, if the open proximal method is performed, then the right axillary perfusion is able to facilitate the evacuation of air from the aortic lumen. We present herein the case of a patient in whom a ruptured type B acute aortic dissection was successfully treated by applying right axillary perfusion through a left thoracotomy.     

Quality control of surgical technique in a multicenter, prospective, randomized, controlled study on the surgical treatment of gastric cancer.

To evaluate the effect of lymph node dissection on gastric cancer patients operated upon with curative intent, we are carrying out a multicenter, prospective, randomized, controlled study in the Netherlands. The trial compares conventional gastrectomy to gastrectomy with extended lymph node dissection. In the first four months, a Japanese supervisor attended all the extended surgery and instructed many Dutch surgeons, including the eight consulting surgeons; since then, all extended gastrectomies have been attended by one of the consulting surgeons. The study coordinator attended all conventional cases. This assured that the quality of the extended surgery was as good as the Japanese standard, of which excellent results have been reported. To achieve this quality control, randomization before surgery was obligatory for practical reasons. Curability assessment at laparotomy, however, is done quite objectively with histological proof, except for the judgement of irresectability. Although this has resulted in many non-curative cases being randomized but subsequently not given the allocated surgery, the sample size should be sufficient to allow analysis according to randomization or the initial "intention to treat." This is the first protocol for a multicenter trial in surgical oncology to have such excellent surgical quality control and to assure a quality as high as that in the original report with uniformity in the level of technique. In studies comparing surgical techniques, it is vital that attention should be given to surgical quality control, otherwise survival rates may show little improvement and fail to make any impact on surgical practice.     

Technical aspects of hepatic portal dissection in biliary atresia.

During the past 8 yr, 37 patients with a noncorrectable type of biliary atresia have undergone hepatic portoenterostomy or portocholecystostomy at the Kobe Children's Hospital. The hepatic portal dissections employed in this series were classified as "supraportal" (9 procedures), "portal" (25 procedures), and "infra-portal" (3 procedures) based on the level at which the fibrous mass at the porta hepatis was transsected as determined by the operative record and the pathologic findings. Successful biliary drainage was achieved in 19 out of 25 patients (76%) with a "portal" type of dissection, while 1 out of 9 with "supra-portal" and none out of 3 with "infra-portal" type dissections were successful in this respect. Of the 19 patients who achieved significant biliary flow, 8 have lived for 2--7 yr without jaundice and 3 others are jaundice-free for shorter intervals.     

舌根癌的手术治疗

目的：探讨舌根癌的手术治疗方法。方法：舌根癌患者21例，经舌骨咽切开进路11例，下颌骨部分切除进路7例，下唇、下颌骨、舌正中切开进路3例。结果：3例下唇、下颌骨、舌正中切开者出现语言功能障碍，吞咽困难；余18例口腔功能均正常。随访2～5年，失访2例，2年生存18例，3年生存13例，5年生存5例。结论：经舌骨咽切开进路对吞咽功能及语言功能的影响较小，是一种值得推广的术式。     

颈分区性清扫术治疗头颈部鳞状细胞癌的远期疗效

目的　研究颈分区性清扫术在头颈部鳞状细胞癌 (简称鳞癌 )治疗中的效果。方法　回顾性分析 1997年 1月～ 2 0 0 1年 12月在中国医学科学院肿瘤医院接受分区性清扫术的头颈部鳞癌患者 12 3例 ,其中喉癌 77例、口腔癌 2 9例、口咽癌 2例、下咽癌 15例。分区性清扫术后发现淋巴结病理阴性 (pN0 ) 99例 ,淋巴结病理阳性 (pN + ) 2 4例。随访时间中位数为 2 5个月。结果　 10 1例cN0患者行分区性清扫术后发现pN + 14例 ( 13 9% ) ;2 2例cN +患者行分区性清扫术后发现pN + 10例( 4 5 5 % )。 15 7侧分区性清扫标本中共发现 5 2枚阳性淋巴结 ,其在颈部的分布如下 :Ⅰ区 2 5 % ,Ⅱ区4 8% ,Ⅲ区 2 5 % ,Ⅳ区 2 %。根据Kaplan Meier方法计算 5年颈部复发率 ,pN0患者为 5 87% ( 95 %可信区间 0 8% ,10 9% ) ,pN +患者为 9 2 % ( 95 %可信区间 0 0 % ,2 1 5 % )。结论　颈分区性清扫术从微创观念出发 ,只要选择恰当 ,对于头颈部鳞癌患者可以取得与传统颈清扫术相当的效果。更重要的是保留了患者的功能和外观 ,提高了生活质量