1998年 · 第111卷第10期

OBJECTIVE To investigate the safety and efficacy of mechanical anastomosis with Chinese staplers in the surgical treatment of esophageal carcinoma and carcinoma of gastric cardia in order to find out an alternative effective anastomotic technique to hand-sewn method. METHODS From August 1980 to April 1996, there were totally 1264 cases of esophageal carcinoma and 701 cases of carcinoma of gastric cardia receiving esophagogastric anastomosis with Chinese staplers combined with telescope suturing of seromuscular layers after resection of tumors, with age ranging from 28 years to 81 years and a man to woman ratio of 4:1 (1572/393). The anastomosis was performed at the cervical region in 44 patients, and intrathoracically in 1921. Our technical essential points also included fixation of the gastric substitute to the thoracic apex or mediastinum with 3-4 stitches to relieve the anastomotic tension. RESULTS Compared with the reported postoperative leakage rate from 2%-4% in China and 4.2%-12.3% abroad, our techniques reduced the total leakage rate to 0.8%, that is, cervical leakage rate was 11.4% (5/44), and intrathoracic leakage rate 0.57% (11/1921). The intrathoracic leakage rate was 0.99% (8/808) for the first 8 years, and 0.27% for the following 8 years. There was no leakage (0/350) in the last 3 years. There anastomotic stricture occurred in 98 patients (4.99%) which could be relieved by Bougie or balloon dilatation. The total operative mortality was reduced to 0.76%. CONCLUSIONS Mechanical anastomosis with Chinese staplers combined with telescope suturing should be an effective method to prevent the occurrence of anastomotic leakage after esophageal resections.

OBJECTIVE To prove the protective effect of lung ischemic preconditioning on enhancing the canine lung preservation and reducing allograft lung dysfunction after transplantation. METHODS Ten pairs of adult canines underwent left lung allotransplantation. Five donors were treated with ischemic preconditioning [their left hilus was clamped for 10 minutes and released for 15 minutes (Group IP)], and five donors were not treated with ischemic preconditioning (Group C). The donor lungs were flushed with 4 ℃ Euro-Collin's solution (ECS) and stored in the same solution for two and a half hour, then transplanted to the recipient canines, who were observed for one to two hours after transplantation. The lung venous blood of the recipient and the donor lung tissue were collected just after thoracotomy and one hour after reperfusion of the transplanted lung in both groups. RESULTS The number of polymorphonuclear (PMN) was significantly higher in Group IP than in Group C (P<0.05). However, the number of PMN in lung interstitium under microscope was less in Group IP than in Group C. The thromboxane (TXB2), malondialdehyde (MDA) and mean pulmonary artery pressure (MPAP) contents were significantly lower in Group IP than in Group C (P<0.05). The superoxide dismutase (SOD) and the lung venous blood oxygen tension (PvO2) contents were significantly higher in Group IP than in Group C (P<0.05). Histological findings showed less damages in Group IP than in Group C. CONCLUSIONS The protective effect of ischemic preconditioning together with ECS flush and storage is superior to using ECS alone. The possible mechanisms may be that ischemic preconditioning inhibits the accumulation and activation of PMN in lung tissue and reduces the production of oxygen free radicals.

OBJECTIVE To investigate the effect of C8 nerve root division on the treatment of spastic cerebral palsy in the upper limbs. METHODS Two patients were treated with division of the C8 never root. Supraclavicular incision was made to expose the C5-T1 nerve roots. The intraoperative electromyographic recording technique was used to monitor the responses from the flexor digitorum and flexor carpi ulnaris muscle groups simultaneously. The C5-T1 nerve roots were stimulated and the evoked muscle amplitude potentials (EMAP) were recorded from the muscle groups. The EMAP of the muscle groups obtained during electrical stimulation of the C8 nerve root was the largest, which was used as the basis for C8 nerve root division. RESULTS Division of the C8 nerve root slightly affected the function of the upper limb, and reduced the muscle tone of the flexor wrist and digitorum. CONCLUSIONS Division of the C8 nerve root can reduce the muscle tone of the flexor wrist and digitorum in a short time. The long-term effects need to be followed up further.

OBJECTIVE To investigate the feasibility of adrenal sparing surgery for selected renal cell carcinoma (RCC), since the necessity of routine adrenalectomy during radical nephrectomy for RCC has been challenged in recent years. METHODS 178 patients underwent perifascial nephrectomy in a 16-year period. Of these patients, 96 had ipsilateral adrenal gland preserved during nephrectomy and 82 underwent concomitant adrenalectomy. 75 excised adrenal specimens were examined pathologically. Disease specific survival rates were assessed according to the pathological stage of the tumors. RESULTS Of the 75 patients, 53 presented a macroscopically normal adrenal gland without pathohistological changes. The other 22 patients were suspected to have adrenal metastasis intraoperatively, while only 5 of them were confirmed to have adrenal involvement by histopathology. Two patients in the adrenal gland preservation group developed ipsilateral adrenal recurrence and synchronous or metachronous contralateral adrenal metastasis during follow-up, although both were documented to have a normal-appearing adrenal gland intraoperatively. Five patients with adrenal metastasis and 2 patients with adrenal recurrence had large renal tumors. The survival difference among subgroups of patients undergoing adrenalectomy or with adrenal gland left in situ was not statistically significant. CONCLUSIONS Adrenal sparing surgery could be done for patients with small renal tumors along with macroscopically normal ipsilateral adrenal glands.

OBJECTIVE To study the pathophysiologic significance of gastroesophageal and duodenogastric-esophageal refluxes in pediatric patients. METHODS Gastroesophageal double pH monitoring was performed on 68 children with gastroesophageal reflux (GER) diseases and 39 normal children. The pH shifts in the intra-gastric and esophageal lumina were recorded for a total of 24 hour period (P1) and for the period of gastric empty (P2) in supine and upright body postures. RESULTS The following reflux types were identified: acid GER in 40 cases (58.8%), alkaline GER (AGER) in 8 cases (11.8%), mixed GER (MGER) in 14 cases (20.6%) and silent GER (SGER, i.e., reflux with normal pH values in P1) in 6 cases (8.8%) as well as duodenogastric reflux (DGR). The RESULTS showed a number of transient GER and DGR (19 of 39 children) in the control group, recorded mainly in the upright position at meal times and 2 hours postprandially. All pH variables for acid reflux were higher in the acid GER and MGER groups than those in the control group (P<0.01). The alkaline episode was significantly noted in cases with AGER and MGER in the supine position during P2. There was no significant difference in terms of incidence of esophagitis between GER groups. The gastroesophageal double pH monitoring produces the higher positive diagnostic rate of 91.2% than single esophageal pH testing (79.4%). CONCLUSIONS Transitory GER and DGR at meal times and 2 hours later might be a physiologic phenomenon. Acid and alkaline reflux occurring in the supine position during P2 should be considered of pathologic significance. This combined gastroesophageal pH monitoring is used not only to improve the diagnostic rate but also to guide clinicians to choose efficient anti-reflux therapy based on the type of reflux as well as to provide refined information for the further study of the pathophysiology of duodenogastroesophageal reflux.

OBJECTIVE To determine whether lidocaine can improve the cerebral protection provided by retrograde cerebral perfusion. METHODS Sixteen mongrel dogs were placed on cardiopulmonary bypass and cooled to 20 degrees C. Retrograde cerebral perfusion was then carried out for 120 minutes, with the external jugular venous pressure kept at 3.33 kPa. Cardiopulmonary bypass was resumed, and the animals were rewarmed to 36 degrees C. The animals were divided into two groups. In the lidocaine group (n = 8), lidocaine was administrated continuously throughout the experiment. In the control group (n = 8), normal saline was given at the same rate. RESULTS In both groups, cerebral tissue creatine phosphate and adenosine triphosphate concentrations and energy charge increased by the end of hypothermic cardiopulmonary bypass, decreased continuously during retrograde cerebral perfusion, and recovered gradually after resuming cardiopulmonary bypass. Nevertheless, they recovered to significantly higher levels in the lidocaine group than in the control group (creatine phosphate: 2.44±0.53 versus 1.61±0.49 μmol/g wet weight, P = 0.006; adenosine triphosphate: 0.71±0.18 versus 0.50±0.17 μmol/g wet weight, P = 0.029; energy charge: 0.59±0.10 versus 0.48±0.09, P = 0.044) by the end of the experiment. There was no significant difference between the two groups in the cerebral tissue water content (control group: 77.6%±1.9%; lidocaine group: 77.6%±1.3%). CONCLUSIONS Continuous lidocaine infusion accelerates the recovery of cerebral tissue high energy phosphate contents after resuming cardiopulmonary bypass, but it has no effect on the formation of cerebral edema after retrograde cerebral perfusion.

OBJECTIVE To investigate the incidence and clinical characteristics of gsp oncogene positive growth hormone-secreting adenomas of Chinese acromegalic patients. METHODS Continuously 40 patients were studied. Serum hormone levels of pituitary and target glands were measured and growth hormone (GH)-TRH stimulating tests were done before transsphenoidal or transfrontal hypophysectomy. Deoxyribonucleic acid (DNA) was extracted from the frozen tumor tissue, and the DNA fragment encompassing codon 201 and 227 of the Gsα gene was amplified by polymerase chain reaction (PCR). Point mutations at codon 201 and 227 were detected using PCR direct sequencing method in order to get the incidence of gsp oncogene in GH secreting adenomas. RESULTS Of 40 tumors studied, 22 (55%) were gsp positive. The point mutation from CGT (Arg) to TGT (Cys) at codon 201 was detected in 21 pituitary tumors, but the point mutation from CAG (Gln) to CTG (Leu) at codon 227 of the Gsα gene was found in only 1 tumor. All of the point mutations are heterozygous. The number of gsp positive patients which have 30% or more decrease of serum GH concentration after glucose inhibition is less than that of gsp negative patients (P = 0.042). Compared to gsp negative patients, most of gsp positive patients showed paradoxical response to TRH stimulation (P = 0.002). There were more gsp positive patients with the tumor diameter less than 25 mm (P = 0.029) and with normal GH levels in OGTT after surgery (P = 0.007). CONCLUSIONS Gsp mutation is one of the major intrinsic defects in the pathogenesis of growth hormone-secreting pituitary tumors and the identification of gsp mutation can be a reference for classification and prognosis of GH tumors.

OBJECTIVE To explore the relationship between the genetic markers of the candidate genes (insulin receptor, glucose transporter 2 and glucokinase) and non-insulin dependent diabetes mellitus (NIDDM) in Chinese pedigrees. METHODS Genomic DNA of 87 members in 12 Chinese NIDDM pedigrees was amplified using PCR technique. Denaturing polyacrylamide gel electrophoresis was applied to detect short tandem repeat polymorphisms. The linkage program was used under the models of autosomal dominant and recessive. The individuals with impaired glucose tolerance (IGT) of age<or = 45 and age>45 were counted as affected and unknown status respectively. RESULTS Linkage of insulin receptor gene and NIDDM was strongly and significantly rejected with total LOD score of-infinity (theta = 0.000). Linkage analysis of glucose transporter 2 gave the result with total LOD score of 2.646 (theta = 0.000) in 4 pedigrees. Linkage of glucokinase and NIDDM was of significance with total LOD score reaching 3.150 in the integration of 6 pedigrees. CONCLUSIONS Mutations in or near the insulin receptor gene are unlikely to be the major cause of inherited predisposition to NIDDM in Chinese pedigrees that are related in this study, not excluding the principal role in the other Chinese or populations, while the mutations/variations near or at the glucose transporter 2 gene locus might be something of the cause, which needs more data to be ascertained, of familial NIDDM in Chinese pedigrees. However, the variations in or near the glucokinase gene might play a dominant role in the development of NIDDM in some Chinese and represent a subgroup of common NIDDM.

OBJECTIVE To study the effect of human insulin gene modified fibroblasts on blood glucose in diabetic rats. METHODS An expression vector containing human insulin gene was constructed by recombinant DNA technique and introduced into fibroblast Ltk- cells by lipofectin-mediated DNA transfection. Following G418 screening, the survived cells were selected and enriched. Finally a cell line, PRI-12 was generated for the highest insulin production. Then, these cells were injected into streptozocin (STZ)-induced diabetic rats. RESULTS Insulin DNA transfected Ltk- cells were able to express insulin at a high level in a long-term culture. Furthermore, these Ltk- transfectants could decrease blood glucose significantly (P<0.01) and obviously increase the body weight (P<0.01) when they were injected into STZ-induced diabetic rats. CONCLUSIONS These results suggest that the cell lines transfected insulin gene could secrete insulin and execute effect on diabetic rats. The study provides support for the view that somatic cell gene therapy offers a potential approach to delivery insulin into diabetes mellitus.

OBJECTIVE To investigate the possible association between the Xbal polymorphism of the glycogen synthase gene and non-insulin-dependent diabetes mellitus (NIDDM) in Chinese population. METHODS 216 NIDDM patients and 106 healthy controls were studied. DNA fragment containing Xbal restriction site was amplified by the polymerase chain reaction, digested by the Xbal enzyme and compared by gel electrophoresis with a positive control from Finland. RESULTS The Xbal polymorphism was found in 18 of 216 Chinese patients (8.3%) and was also found in 10 of 106 controls (9.4%) (P &gt; 0.05). CONCLUSIONS The results suggest that the Xbal polymorphism of the glycogen synthase gene could not be used as a genetic marker for NIDDM in Chinese population of Henan Han nationality.

Madelung reported 33 patients with cervical lipomatosis and Launois and Bensaude as the presence of multiple symmetrical unencapsulated fat accumulations diffusely involving the cervical and upper dorsal regions, abdomen and groin. We present the ultrasound (US) and computed tomographic (CT) finding in two Chinese patients.