The closure of abdominal wounds in cancer patients.

A total of 102 abdominal surgical wounds in cancer patients were closed with absorbable suture material. The object of the study was to evaluate whether patients with cancer having possible wound healing impairments could be closed with absorbable sutures, thereby omitting the difficulties involved with retention sutures or nonabsorbable material. Polyglycolic acid sutures were used in the fascia in all of these patients, and they were studied regarding the incidence of wound infection, wound dehiscence, and incisional hernias. There were no instances of wound dehiscence in the entire series. A wound infection rate of 14.8% was encountered. The incidence of incisional hernia following either infection or primary healing was noted to be markedly decreased. The rate of wound dehiscence and wound hernia was sufficiently low to lead us to recommend this type of abdominal wound closure in all cancer patients.     

改良全层切口缝合在腹盆部手术中的应用

 目的　探讨和评价腹、盆部手术切口全层丝线间断缝合的关腹方法在临床中的应用。方法　2002年5月至2007年8月对3200例腹、盆部手术采用丝线间断全层关腹技术，对其临床资料、随访结果进行回顾性分析。结果　上腹部手术1780例（55.6 %），Ⅰ期愈合率98.5 %；下腹部（包括盆腔）1420例（44.3 %），Ⅰ期愈合率98.2 %。老年组Ⅰ期愈合率97.9 %，非老年组98.8 %（P＞0.05）；糖尿病组Ⅰ期愈合率为97.4 %，非糖尿病组98.2 %（P＞0.05）；关腹时间（11±4）min，主要并发症为切口裂开（0.5 %），感染（1.4 %）。随访率66 %，随访时间分别为30 d、3个月、6个月、1年和3年，切口疝的发生率为0.2 %。结论　全层丝线缝合切口愈合良好，便于操作，经济实用，适用于各种腹、盆手术。     

The abdominoinguinal incision: The equivalent of thoracoabdominal incision for the lower quadrants of the abdomen

In the past, tumors of the iliac fossa, those of the area of the external iliac vessels, and those fixed to the wall of the lesser pelvis with extension into and involvement of the pubic bone were often considered unresectable through the conventional surgical incisions or were treated with hemipelvectomy. For such tumors, although there was exposure of the cephalad aspect through routine incisions, there was lack of exposure on the caudal or lateral aspects, which often extended anteriorly to involve the lower abdominal wall or continued behind the inguinal ligament or through the obturator foramen into the thigh. The abdominoinguinal incision provides exposure for resection of the majority of these tumors with preservation of the extremity. It involves a lower midline incision, which is extended from the pubic symphysis transversely to the midinguinal point on the affected side and then vertically for a few centimeters in the femoral triangle. The femoral vessels are exposed, the ipsilateral rectus abdominis and anterior sheath are divided off the pubic crest, the inguinal ligament is divided off the pubic tubercle, the inferior epigastric vessels are ligated and divided near their origin from the vessels, and the lateral third of the inguinal ligament is detached from the iliac fascia. This incision provides full exposure of the lower abdominal aorta, inferior vena cava, and iliac vessels on the side of involvement in their continuity with the femoral vessels. With improved exposure and vascular control, the majority of tumors with lateral pelvic fixation become resectable. J. Surg. Oncol. 1998;69:249–257. © 1998 Wiley-Liss, Inc.     

Laparoscopy technique in the setting of peritoneal metastases to avoid port site relapse

BackgroundLaparoscopy is indicated in many patients with abdominal and pelvic malignancy. If cancer cells are present within the peritoneal space, there is a possibility for port site metastases to develop.MethodsThe pathophysiology for occurrence of port site metastases was reviewed. Technical modifications to reduce the incidence of these abdominal wall sites for disease progression were suggested.ResultsEvacuation of all gases and all fluid from the peritoneal space through the trocars prior to their removal will reduce the contamination of the tissue surrounding the port site by intraperitoneal cancer cells. If port sites are confined to the midline, they can be removed as part of a midline abdominal incision if metastases occur. If port site metastases occur through lateral port sites, the rectus abdominus muscle may need to be widely excised to achieve negative margins.ConclusionTechnical modifications of laparoscopy in patients with peritoneal metastases may reduce incidence of this iatrogenic dissemination of cancer.     

医源性肿瘤种植

医源性肿瘤种植是指在诊治过程中因各种诊疗方法造成或促进了恶性或有种植潜能的细胞脱落或播散，形成转移灶，使肿瘤局部复发或远处转移，其主要临床特征是在操作孔道或切口部位有肿物结节形成．结合病史易诊断，病理检查可确诊。肿瘤种植可发生在各种穿刺术孔道，腹腔镜手术穿刺点，腹壁切口和会阴切口等除恶性肿瘤外，交界瘤，子宫内膜异位症等有种植能力的疾病也可发生种植。一旦诊断或怀疑肿瘤种植，一般采用手术切除在诊治过程中避免及减少医源性种植和播散被视为肿瘤外科治疗中一个重要原则，临床操作中．活检术时尽可能采取切除活栓术，穿刺术时避免反复穿刺，腹腔镜手术时将组织装入标本袋中再由穿刺点取出．腹腔镜手术后应仔细关闭腹膜，腹肌筋膜，皮肤，或切除穿刺孔道。另外，关腹前应以蒸馏水浸泡，使脱落的肿瘤细胞在低渗透压溶液中易膨胀破裂及更换手套及器械后再关腹，子宫肌瘤剔除术时也应尽量避免进入宫腔。本文的目的在于通过回顾文献．使临床医师加深对肿瘤种植的重视．并注意避免或减少医源性种植和播散.     

超声引导下腹直肌鞘阻滞复合静脉自控镇痛对胃癌术后镇痛的疗效分析

目的 超声引导下腹直肌鞘阻滞复合静脉自控镇痛用于胃癌术后镇痛的疗效.方法 将行胃癌切除术的患者40例,分为采用超声引导下腹直肌鞘阻滞复合静脉镇痛组(复合镇痛组)、静脉镇痛组,观察比较两组患者术后2 h、6 h、12 h、24 h静息痛、运动痛的VAS评分,两组患者术后的躁动及镇静情况,两组患者的并发症发生率.结果 复合镇痛组患者在2 h、6 h、12 h、24 h静息痛、运动痛的VAS评分均较静脉镇痛组降低,差异有统计学意义;复合镇痛组在术后2 h、6 h、12 h、24 h的躁动发生率明显低于静脉镇痛组,Ramsay评分较静脉镇痛组升高,差异有统计学意义;复合镇痛组并发症发生率较静脉镇痛组明显降低,差异有统计学意义.结论 超声引导下腹直肌鞘组织复合静脉自控镇痛,能够明显缓解胃癌患者术后的静息痛、运动痛,降低术后躁动的发生,不良反应发生率低,安全有效.     

皮肤胶水粘合与皮内缝合在甲状腺良性结节手术中应用的随机对照 研究

目的:探讨皮肤胶水粘合和皮内缝合闭合甲状腺手术切口的优缺点。方法:将甲状腺结节患者随机分为皮内缝合组（A组）30例、皮肤胶水粘合组（B组）30例。观察两组患者关闭皮肤切口时间、住院天数、并发症、切口疼痛、切口愈合情况。远期疗效随访观察患者切口瘢痕程度及切口美观程度、异物感。结果:A组与B组术后均无并发症。A组住院天数5天,B组3天。两组切口甲级愈合率均为100%,在切口疼痛率（A组3.4%、B组3.2%）、美观度（好的比率A组95%、B组97%）、异物感（A组1.7%、B组1.3%）方面,差异无统计学意义（P＞0.05）。A组关闭皮肤平均时间为13min,B组为7min,A组关闭皮肤时间明显长于B组（P＜0.05）。结论:皮肤胶水粘合切口可缩短患者住院时间与皮肤切口闭合时间,简单省时、安全可行,患者乐于接受。     

Cosmetic reconstruction after resection of breast cancer: use of the ELD-MC flap and EVRAM flap

Breast reconstruction following the resection of breast cancer with inadequate residual chest-wall tissue may be performed with an implant or a myocutaneous flap, such as the latissimus dorsi or a rectus abdominis. Among a variety of operative procedures, each method has advantages and disadvantages. The insertion of a silicone-bag prosthesis is the easiest method, but the prosthetic implant sometimes has complications, such as unfavorable capsular contracture formation around the implant, rupture, infection, or exposure. We therefore use an extended latissimus dorsi myocutaneous (ELD-MC) flap with some amount of surrounding subcutaneous fat from the lumbar area, and avoid the use of any implant with an MC flap. Also, for the reconstruction and correction of infraclavicular and axillary depression, we use the extended vertical rectus abdominis myocutaneous (EVRAM) flap. This method uses the skin and fat on both sides of the umbilicus as a lenticular flap vascularized by only one of the rectus abdominis muscles. The patients are satisfied with the outcome because symmetry and good breast volume can be obtained. There have been no functional or anatomical defects of the donor area. No abdominal hernia after an EVRAM flap has resulted to date. Both the ELD-MC and EVRAM flaps can be successfully used for cosmetic breast reconstruction after the resection of breast cancer.     

Prospective randomized study of two laparotomy incisions for gastrectomy: midline incision versus transverse incision

Background We performed a randomized study to evaluate the differences between upper midline incision and transverse incision for gastrectomy.Methods Patients undergoing distal gastrectomy or total gastrectomy for gastric cancer were randomly allocated to have either an upper midline incision or a transverse incision. The times taken to open and close the abdominal cavity, the number of doses of postoperative analgesics, and the incidence of postoperative pneumonia, wound infection, and intestinal obstruction were compared between the patients having the two incisions.Results Times for both opening and closing the abdominal cavity were longer with a transverse incision, in both the distal gastrectomy group and total gastrectomy group. In the patients in whom continuous epidural analgesia was used postoperatively, the number of additional doses of analgesics was smaller in the transverse-incision group after distal gastrectomy. The incidence of postoperative pneumonia was lower in the transverse-incision group after distal gastrectomy. The number of patients with postoperative intestinal obstruction was smaller in the transverse-incision group than in the midline-incision group after distal gastrectomy. In contrast to distal gastrectomy, there was no significant difference in the number of doses of postoperative analgesics, incidence of postoperative pneumonia, or incidence of postoperative intestinal obstruction between the two study groups after total gastrectomy.Conclusion A transverse incision for distal gastrectomy may be more beneficial than an upper midline incision in attenuating postoperative wound pain, decreasing the incidence of postoperative pneumonia, and preventing postoperative intestinal obstruction.     

Intragastric single-port surgery (IGS) for gastric endophytic gastrointestinal stromal tumor (GIST): A novel surgical treatment

BackgroundIntragastric surgery with a single incision has been performed for several diseases, such as gastric tumors[1] and pancreatic pseudocyst[2], safety, feasibility and potential benefits of which have been reported in previous relevant studies[3].MethodsThe video shows a 65-year-old man with upper gastrointestinal hemorrhage, preoperative abdominal CT scan and endoscopy suggested an endophytic tumor located in gastric corpus, suggesting gastrointestinal stromal tumor (GIST). Intragastric single-port surgery (IGS) was indicated.ResultsUnder general anesthesia, patient was placed in supine position. Surgeons stood on the right side of the patient. After a 2.5cm transverse incision was made on left upper abdominal wall, gastric anterior wall was exteriorized and fixed to the skin incision. Single-port device was inserted inside the stomach after anterior gastric wall was opened. Next, laparoscope was introduced into gastric cavity and identified the location of tumor. Full thickness resection of the tumor was performed by using linear stapler, then stapler line was embedded with continuous sutures. Finally, after specimen and single-port device removal, the stomach incision was closed extracorporeally. The operation time was 112 minutes. Final pathology confirmed GIST (4.5cm) with negative margins and patient discharged after 4 days, without postoperative complications. In 1-year follow-up time, without recurrence or death.ConclusionIGS is safe and effective for gastric endophytic GIST resection, which not only preserves all advantages of conventional laparoscopic operation, but also includes other benefits like obviating the need of abdominal cavity exploration, potential reduction of risk of neoplasm seeding, and offering good postoperative cosmetic result.     

Foreign body granulomas mimic peritoneal dissemination caused by incarcerated femoral hernia perforation: A case report

BACKGROUNDForeign body granuloma (FBG) is a well-known type of granulomatous formation, and intraabdominal FBG (IFBG) is primarily caused by surgical residues. Multifocal IFBGs caused by gastrointestinal perforation is an extremely rare and interesting clinicopathological condition that resembles peritoneal dissemination. Here, we present a case of IFBGs mimicking peritoneal dissemination caused by bowel perforation and describe the value of intraoperative pathological examinations for rapid IFBG diagnosis.CASE SUMMARYAn 86-year-old woman with an incarcerated femoral hernia was admitted to the hospital and underwent operation. During the operation, the incarcerated ileum was perforated during repair due to hemorrhage necrosis, and a small volume of enteric fluid leaked from the perforation. The incarcerated ileum was resected, and the femoral hernia was repaired without mesh. Four months later, a second operation was performed for an umbilical incisional hernia. During the second operation, multiple small, white nodules were observed throughout the abdominal cavity, resembling peritoneal dissemination. The results of peritoneal washing cytology in Douglas’ pouch and the examination of frozen nodule sections were compatible with IFBG diagnosis, and incisional hernia repair was performed.CONCLUSIONIFBGs can mimic malignancy. Intraoperative pathological examinations and operation history are valuable for the rapid diagnosis to avoid excessive treatments.     

早期乳腺癌保留乳头乳晕复合体的改良根治术--Ⅰ期腹直肌肌皮瓣重建乳房

背景与目的：改良根治术目前已成为早期乳腺癌主要外科治疗方法之一,但术后如何重建乳房及保留乳头乳晕复合体一直是争论的焦点。本研究探讨早期乳腺癌保留乳头乳晕复合体的改良根治术——Ⅰ期腹直肌肌皮瓣重建乳房的方法及临床应用。方法：对早期乳腺癌患者行皮下乳腺切除,腋窝淋巴结清除,腹直肌肌皮瓣Ⅰ期乳房再造,最大限度地保留乳房皮肤以及乳头乳晕复合体。结果：应用该方法治疗10例早期乳腺癌,术后随访24～48个月,所有病例均无肿瘤局部复发及远处转移,重建乳房外形良好,乳头乳晕区皮肤无坏死,皮肤无明显萎缩、变硬,半年后乳头感觉恢复,供区无腹壁疝形成。结论：保留乳头乳晕复合体的乳腺癌改良根治术——Ⅰ期腹直肌肌皮瓣重建乳房,外形效果良好,对早期乳腺癌要求保持乳房外形的患者可能是一种较好的治疗方法;因本研究例数较少,该技术的疗效有必要行更大样本的研究来证实。     

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument “Endo-PSI (II)” and circular stapler

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the “Endo-PSI (II)”, and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.     

自体全厚皮片修补肿瘤切除后腹壁缺损25例体会

[目的]探讨腹部肿瘤切除术后腹壁缺损的修复方法以及自体全厚皮片修补术的意义。[方法]对25例腹部肿瘤切除术后腹壁缺损患者采用自体全厚皮片修复缺损,观察腹壁缺损范围、排斥反应、术后并发症、愈合时间。[结果]一期愈合率96%,皮下积液1例(4%);无切口感染、裂开和切口疝发生、无肠管粘连和腹壁癌复发;修复成功率100%。[结论]自体全厚皮片具有张力强度大、良好的生物兼容性、修补术后并发症少特点,能够保证无瘤皮缘,是一种良好的肿瘤切除腹壁缺损修复材料。     

Long-term results of breast volume replacement using an inframammary adipofascial flap after breast-conserving surgery

We have used an inframammary adipofascial flap for breast-conserving reconstruction in the inferior portion of the breast since 2005. The aim herein is to report this oncoplastic procedure in detail, including the long-term results. The surgical procedure was as follows: A skin incision is made at the inframammary line. After partial resection of the breast, a tongue-shaped flap of the fat and the anterior sheath of the rectus abdominis muscle are pulled up in the inframammary area. The flap is then inserted into the breast area where the tumor was removed, and it is secured with absorbable sutures to the surrounding breast tissue. When making the flap, it is very important to preserve several intercostal perforators around the inframammary line. Cosmetic results at more than 5 years after the operation in the 5 patients were assessed using photographs. The results were found to be good in 4 cases (80%) and poor in 1 case. The poor outcome was a case with 100% fat necrosis of the flap. This surgical procedure is easy to perform, and the long-term cosmetic outcomes were good, without complications. We consider this procedure to be useful for breast-conserving reconstruction after breast cancer occurring in the inferior portion of the breast.     

Prognoses of superficial soft tissue sarcoma: The importance of fascia-tumor relationship on MRI

BackgroundSuperficial soft tissue sarcoma (S-STS) has been reported to have more favorable prognoses than deep-seated STS. However, for some patients, poor prognoses have been observed and there is a need for better prognostication. The deep peripheral fascia lies in the border of the S-STS and can be consistently detected using magnetic resonance imaging (MRI). The relationship of the subcutaneous tumor with the fascia on MRI scan was reported to be useful in classifying the tumor as benign or malignant; this in turn, may reflect the biological aggressiveness of STS. This study was performed to evaluate the oncologic outcomes and to identify the prognostic factors of S-STS by focusing on the relationship of S-STS with the underlying fascia on MRI.Material and methodsWe retrospectively reviewed data on 253 patients who underwent resection of localized S-STS. Potential factors that might influence the oncologic outcomes were identified. The fascia-tumor relationship on MRI was classified into three groups: no fascial contact group (n = 46), fascial contact group (n = 77), and fascial invasion group (n = 84).ResultsOverall, 39 patients (16.5%) died due to S-STS; the 5- and 10-year survival rates were 82.6 ± 2.9% and 73.2 ± 4.5%, respectively. Fascial invasion detected on MRI scans (OR = 2.190, p = 0.034) and advanced age (OR = 2.408, p = 0.034) were found to be independent factors for worse disease specific survival. The fascia-tumor relationship on MRI scan was not associated with local recurrence of S-STS.ConclusionThe fascia-tumor relationship on MRI scan reflects the biological aggressiveness of S-STS and can serve as a prognostic factor.     

CT-guided Radioactive 125I Seed Implantation for Abdominal Incision Metastases of Colorectal Cancer: Safety and Efficacy in 17 Patients

IntroductionTo retrospectively evaluate the safety and efficacy of computed tomography (CT)-guided iodine-125 (¹²⁵I) seed implantation for patients with abdominal incision metastases from colorectal cancer.Materials and MethodsData of patients with abdominal incision metastases of colorectal cancer from November 2010 to October 2020 were retrospectively reviewed. Each incisional metastasis was percutaneously treated with ¹²⁵I seed implantation under CT guidance. Follow-up contrast-enhanced CT was reviewed, and the outcomes were evaluated in terms of objective response rate, complications, and overall survival.ResultsA total of 17 patients were enrolled in this study. The median follow-up was 18 months (range, 2.7-22.1 months). At 3, 6, 12, and 18 months after the treatment, objective response rate was 52.9%, 63.6%, 33.3%, and 0%, respectively. A small amount of local hematoma occurred in two patients and resolved spontaneously without any treatment. Two patients experienced a minor displacement of radioactive seeds with no related symptoms. Severe complications, such as massive bleeding and radiation injury, were not observed. No ≥ grade 3 adverse events were identified. By the end of follow-up, 14 patients died of multiple hematogenous metastases. The one-year overall survival rate was 41.6%, and the median overall survival was 8.6 months.ConclusionCT-guided ¹²⁵I seed implantation brachytherapy is safe and feasible for patients with abdominal incision metastases from colorectal cancer.     

Primary pedunculated fibrosarcoma of the peritoneum: A case report

Fibrosarcoma is a primitive, mesenchymal tumor frequently arising from superficially located soft tissues. A case of a primary intraperitoneal, pedunculated fibrosarcoma is reported, initially presenting as an abdominal mass protruding into a large incisional hernia of the anterior abdominal wall. Despite total tumor resection, multiple intraperitoneal tumor nodules of varying sizes were found and resected six months and one year later. The patient died 18 months after the first surgical intervention. This case illustrates the highly malignant behavior and poor prognosis of fibrosarcomas of the peritoneum.     

Use of an instrument-holding clip for deeply recessed anastomoses of the rectum and esophagus.

Posterior layer closure of deeply located anastomoses including those performed in the course of low anterior rectal resection, total gastrectomy, and esophagogastrectomy, are often difficult. Usually five to six seromuscular or through-and-through posterior wall sutures are inserted sequentially and the loop or cut end of bowel is advanced over these parallel sutures. The sutures are then tied down. Entanglement of these sutures in a deep surgical field with limited access can lead to tears in the bowel wall. In addition, uneven and nonsequential tying of these sutures may compromise the anastomosis itself. We have described here how manual anastomosis in deep, hard to reach surgical fields can be better accomplished with the use of an instrument-holding clip. Use of the described instrument-holding clip, to clearly delineate and anchor each suture in sequence, eliminates these problems. An easily available device, it can save operative time, facilitate a more even anastomosis, and decrease the chance of bowel wall tearing, thus enhancing the security of the anastomosis.     

Intraperitoneal vascular endothelial growth factor burden in peritoneal surface malignancies treated with curative intent: The first step before intraperitoneal anti-vascular endothelial growth factor treatment?

IntroductionVascular endothelial growth factor (VEGF) is one of the most important angiogenic factors in solid tumours and plays an important role in ascites development in peritoneal surface malignancies (PSM). The main goal of this study was to determine the evolution and factors influencing intraperitoneal (IP) VEGF burden during cytoreductive surgery (CRS) with curative intent.Patients and methodsNinety-seven consecutive patients with PSM were treated with CRS at a single centre with curative intent. Patient data were collected prospectively between February 2012 and October 2012. An enzyme-linked immunosorbent assay technique was used to assess VEGF levels in intravenous (IV) systemic blood samples before incision and after abdominal closure, and in IP samples during abdominal cavity exploration, after completion of CRS, after hyperthermic IP chemotherapy, and at 1 and 24 h after abdominal closure.ResultsThe IP VEGF burden increased significantly after CRS, and then decreased progressively (p < 0.005). In multivariate analysis, neoadjuvant IV bevacizumab significantly decreased the preoperative IP VEGF burden, tumour load according to Peritoneal Cancer Index value increased significantly the preoperative IP VEGF burden and a low preoperative IP VEGF burden was associated with significantly increased postoperative complications. Neoadjuvant IV bevacizumab is the only factor that influences the preoperative IV VEGF concentration.ConclusionFor patients with PSM who were treated with curative intent, the IP VEGF burden increased after CRS, and was reduced prior to surgery by the administration of neoadjuvant IV bevacizumab.