A modified method for precise anastomosis during laparoscopic low anterior resection for rectal cancer: the first clinical experience and application.

BACKGROUND: There is no criterion to guide and evaluate the anastomosis of laparoscopic low anterior resection (LAR). We developed a new technique for precise anastomosis. This study endeavored to evaluate the effectiveness and safety of this new technology. METHODS: Patients with mid-low rectal cancer who underwent laparoscopic LAR in our department were enrolled retrospectively between January 1, 2021 and July 1, 2023. During the LAR, the distance between the sacral promontory and the rectal stump was measured and used to determine the length of the sigmoid colon, which was preserved for anastomose. The demographic characteristics and short-term outcomes were analyzed. RESULTS: Forty-nine patients (26 men, 23 women) with low and middle rectal cancer were retrospectively enrolled in the study. The distance of the tumor from the anal verge was 6.4 ± 2.7 cm. The operative time was 193 ± 42 min. All patients underwent precise anastomosis, among which 12 patients underwent freeing of the splenic flexure of the colon. According to our criteria, there was no redundant or tense state of the colon anterior to the sacrum after the anastomosis. Only one patient had a postoperative anastomotic leak (Grade B). All 15 patients receiving neoadjuvant chemoradiotherapy underwent terminal ileostomy. No postoperative death occurred within 30 days of the surgery. The median follow-up time in our study was 12 months. One patient developed a single metastasis in the right lobe of the liver in the eighth month after surgery and underwent microwave radiofrequency ablation, which did not recur in the four months of postoperative follow-up, and the rest of the patients survived disease-free without recurrence of metastasis. CONCLUSIONS: Precise measurement of the proximal colon of the anastomosis can ensure accurate and convenient colorectal anastomosis and this may be a technique worthy of clinical application. However, its effectiveness needs to be further verified in a multicenter clinical trial.

Mechanical bowel preparation combined with oral antibiotics reduces infectious complications and anastomotic leak in elective colorectal surgery: a pooled-analysis with trial sequential analysis.

OBJECTIVE: A pooled analysis combined with trial sequential analysis (TSA) was conducted in order to explore the effect of mechanical bowel preparation (MBP) combined with oral antibiotic bowel decontamination (OAB) versus MBP alone on patients who have undergone colorectal resection. METHODS: Comprehensive and systematic searches of PubMed, Embase, Cochrane Library, Web of Knowledge, and Clinical Trials.gov databases were conducted. The quality of literature was evaluated using Cochrane risk bias assessment tool as well as Newcastle-Ottawa Scale (NOS) score. A pooled analysis of randomized controlled trials (RCTs) and prospective studies was performed comparing patients who underwent colorectal resection and received MBP plus OAB or MBP alone. The outcome endpoints were the incidence of anastomotic leak (AL) and surgical site infection (SSI). TSA is a tool used to assess the reliability of currently available evidence to determine further clinical trial validation. RESULTS: The analysis included a total of 22 studies involving 8852 patients, including 3016 patients in the MBP + OAB group and 4415 patients exposed to MBP alone. The pooled analysis showed that the incidence of postoperative anastomotic leak was significantly lower in the group treated with MBP plus OAB compared with MBP alone (OR = 0.43, 95% CI: 0.23-0.81, P = 0.009, I2 = 73%). The incidence of postoperative surgical site infections was significantly lower in the group exposed to the combination of MBP and OAB compared with MBP alone (OR = 0.38, 95% CI: 0.32-0.46, P < 0.0001, I2 = 24%). The TSA demonstrated significant benefits of MBP plus OAB intervention in terms of AL and SSI. CONCLUSION: MBP combined with OAB significantly reduces the incidence of AL and SSI in patients after colorectal resection compared with MBP alone.

A technique for laparoscopic extraperitoneal colostomy with an intact posterior sheath of rectus.

Regardless of the advances in surgical techniques, parastomal hernia is still an inevitable complication for many patients with low rectal cancer undergoing abdominal perineal resection (APR). Extraperitoneal colostomy (EPC) seems to be a effective method to reduce the risk of parastomal hernia. We propose a new approach to simplify and standardize laparoscopic EPC to make this operation easy to perform. We used the technique of laparoscopic TEP groin hernia repair to produce an extraperitoneal tunnel, which can not only facilitate precise visualization of the extraperitoneal tunnel but also utilize the intact posterior rectus abdominis sheath as biologic materials to maintain soft-tissue augmentation, with a satisfactory result. With laparoscopy, we can create adequate space without insufficient dissection of the extraperitoneal tunnel while avoiding damage to the retrorectus sheath. At the time of writing, we had performed this method in four patients, without any complications. This technique is effective at preventing parastomal hernia without extra costs.

First-line cetuximab versus bevacizumab for RAS and BRAF wild-type metastatic colorectal cancer: a systematic review and meta-analysis.

BACKGROUND: A first-line biologic treatment for metastatic colorectal cancer (mCRC) is still controversial. We, therefore, performed a meta-analysis to determine the efficacy of first-line cetuximab versus bevacizumab for RAS and BRAF wild-type mCRC. METHODS: In March 2018, an electronic search of the following biomedical databases was performed: PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov and Web of Knowledge. Randomized controlled trials (RCTs) and prospective or observational cohort studies (OCSs) were included. Subgroup analyses of all RCTs were performed in all outcomes. All statistical analyses were performed using RevMan software 5.3. RESULTS: Two RCTs and three OCSs, involving a total 2576 patients, were included. The meta-analysis reported that cetuximab was associated with a longer overall survival (OS) [HR 0.89, 95% CI (0.81-0.98); p = 0.02], a higher ORR [RR 1.11, 95% CI (1.03-1.19); p = 0.006], higher complete response [RR 3.21, 95% CI (1.27-8.12); p = 0.01] and a greater median depth of response than bevacizumab. However, no significant difference was observed between cetuximab and bevacizumab groups for PFS, DCR, partial response, progressive disease, curative intent metastasectomy, EORR and incidence of grade 3 or higher adverse events. In the subgroup meta-analyses of the RCTs, inconsistent results compared to the main analysis, however, were found, in the ORR, DCR and curative intent metastasectomy. CONCLUSIONS: The current evidence indicates that compared to bevacizumab treatment, cetuximab provides a clinically relevant effect in first-line treatment against mCRC, at the cost of having lower stable disease.

Methane-Rich Saline Suppresses ER-Mitochondria Contact and Activation of the NLRP3 Inflammasome by Regulating the PERK Signaling Pathway to Ameliorate Intestinal Ischemia‒Reperfusion Injury.

Intestinal ischemia‒reperfusion (I/R) injury is a common pathological process in patients undergoing gastrointestinal surgery, leading to local intestinal damage and increased microvascular permeability, eventually causing extraintestinal multiple organ dysfunction or sepsis. The NLRP3-mediated inflammatory response is associated with I/R injury. Methane saline (MS) has anti-pyroptosis properties. This study aims to explore the protective effect of MS on intestinal I/R injury and its potential mechanisms. After MS pretreatment, the in vivo model was established by temporarily clipping the mouse superior mesentery artery with a noninvasive vascular clamp, and the in vitro model was established by OGD/R on Caco-2 cells. The results of HE and TUNEL staining showed intestinal barrier damage after I/R injury, which was consistent with the IHC staining results of tight junction proteins. Moreover, the expression of the NLRP3 signaling pathway was increased after I/R injury, and inhibition of NLRP3 activation reduced Caco-2 cell injury, indicating that NLRP3-mediated pyroptosis was one of the main forms of cell death after I/R injury. Subsequently, we found that MS treatment ameliorated intestinal barrier function after I/R injury by suppressing NLRP3-mediated pyroptosis. MS treatment also reduced mitochondria-associated membrane (MAM) formation, which was considered to be a platform for activation of the NLRP3 inflammasome. Importantly, MS reduced ER stress, which was related to the PERK signaling pathway. Knocking down PERK, a key protein involved in ER stress and MAM formation, reversed the protective effect of MS, indicating that MS suppressed NLRP3 by reducing ER stress and MAM formation. In conclusion, we believe that MS suppresses MAMs and activation of the NLRP3 inflammasome by regulating the PERK signaling pathway to ameliorate intestinal I/R injury.

Effectiveness of anastomotic reinforcement sutures in reducing anastomotic leakage risk after laparoscopic rectal cancer surgery: a pooled and integration analysis.

Background and objectives: Anastomotic leakage (AL) is one of the most serious complications after laparoscopic anus-preserving surgery for rectal cancer, which significantly prolongs the patient's hospital stay, leads to dysfunction, and even increases the patient's perioperative morbidity and mortality, and little is known about the effectiveness of anastomotic reinforcement sutures to prevent AL. Thus, this study was conducted to evaluate the efficacy of anastomotic reinforcement sutures as a means to prevent AL during laparoscopic surgery for rectal cancer. Methods: A comprehensive and systematic search was performed in the literature database by combining subject and free terms up to 10 October 2023. The overall literature included was integrated and analyzed using Stata 12.0 software and Review Manager version 5.4 software to assess the effect of anastomotic reinforcement sutures on the incidence of AL. Results: A total of 2,452 patients from 14 studies were included, and an integrated analysis showed that the use of anastomotic reinforcement sutures significantly reduced the incidence of AL [odds ratio (OR) = 0.26; 95% confidence interval (CI), 0.18-0.37; P < 0.00001; I2 = 0%]. However, the findings confirmed whether or not the anastomosis reinforced with sutures did not affect the incidence of anastomotic stenosis (OR = 0.69; 95% CI, 0.37-1.32; P = 0.27; I2 = 0%). We performed subgroup analyses of the results of the study, the randomized controlled studies (OR = 0.31; 95% CI, 0.15-0.65; P < 0.001) as well as retrospective studies (OR = 0.28; 95% CI, 0.19-0.41; P < 0.001), 3-0 sutures (OR = 0.28; 95% CI, 0.17-0.45; P < 0.001) versus 4-0 sutures (OR = 0.26; 95% CI, 0.13-0.53; P < 0.001), barbed wire sutures (OR = 0.26; 95% CI, 0.14-0.48; P < 0.001) versus non-barbed wire sutures (OR = 0.30; 95% CI, 0.20-0.46; P < 0.001), interrupted (OR = 0.30, 95% CI, 0.20-0.46; P < 0.001) versus continuous sutures (OR = 0.29, 95% CI, 0.16-0.51; P < 0.001) to the anastomosis, full-thickness suture (OR = 0.29; 95% CI, 0.16-0.51; P < 0.001) versus sutured with the seromuscular layer (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001), anastomotic sutured in one (OR = 0.27; 95% CI, 0.14-0.53; P < 0.001) versus non-one circle (OR = 0.30; 95% CI, 0.20-0.44; P < 0.001), and reinforcing sutures to the dog-ear area (OR = 0.26; 95% CI, 0.14-0.50; P < 0.001) versus the non-dog-ear area (OR = 0.30; 95% CI, 0.20-0.45; P < 0.001), which have suggested that there is no significant difference between each other and that all of them reduce the incidence of AL. Conclusions: This study provides evidence that performing reinforcement suturing of the anastomosis during laparoscopic rectal surgery significantly lowers the incidence of postoperative AL but has no significant effect on anastomotic stenosis. It is important to note that further randomized controlled studies are required to confirm this conclusion. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022368631.

Noteworthy impacts of COVID-19 pandemic on cancer screening: A systematic review.

The sudden onset of the coronavirus disease 2019 (COVID-19) in January 2020 has affected essential global health services. Cancer-screening services that can reduce cancer mortality are strongly affected. However, the specific role of COVID-19 in cancer screening is not fully understood. This study aimed to assess the efficiency of global cancer screening programs before and during the COVID-19 pandemic and to promote potential cancer-screening strategies for the next pandemic. Electronic searches in PubMed, Embase, and Web of Science, and manual searches were performed between January 1, 2020 and March 1, 2023. Cohort studies that reported the number of participants who underwent cancer screening before and during the COVID-19 pandemic were included. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale. Differences in cancer-screening rates were estimated using the incidence rate ratio (IRR). Fifty-five cohort studies were included in this meta-analysis. The screening rates of colorectal cancer using invasive screening methods (Pooled IRR = 0.52, 95% CI: 0.42 to 0.65, p < 0.01), cervical cancer (Pooled IRR = 0.56, 95% CI: 0.47 to 0.67, p < 0.01), breast cancer (Pooled IRR = 0.57, 95% CI: 0.49 to 0.66, p < 0.01) and prostate cancer (Pooled IRR = 0.71, 95% CI: 0.56 to 0.90, p < 0.01) during the COVID-19 pandemic were significantly lower than those before the COVID-19 pandemic. The screening rates of lung cancer (Pooled IRR = 0.77, 95% CI: 0.58 to 1.03, p = 0.08) and colorectal cancer using noninvasive screening methods (Pooled IRR = 0.74, 95% CI: 0.50 to 1.09, p = 0.13) were reduced with no statistical differences. The subgroup analyses revealed that the reduction in cancer-screening rates varied across economies. Our results suggest that the COVID-19 pandemic has had a noteworthy impact on colorectal, cervical, breast, and prostate cancer screening. Developing innovative cancer-screening technologies is important to promote the efficiency of cancer-screening services in the post-COVID-19 era and prepare for the next pandemic.

Which site is better for prophylactic ileostomy after laparoscopic rectal cancer surgery? By the specimen extraction site or new site: A systematic review and meta-analysis.

Background: There is controversy about the outcomes of prophylactic ileostomy via the specimen extraction site (SES) after laparoscopic rectal cancer surgery (LRCS). We, therefore, performed a meta-analysis to determine the efficacy and safety of stoma through the SES versus new site (NS). Methods: All relevant studies from 1997 to 2022 were searched in the PubMed, EMBASE, Cochrane Library, CNKI, VIP databases. This meta-analysis was performed using RevMan software 5.3 for statistical analysis. Results: 7 studies with 1736 patients were included. The present meta-analysis noted that prophylactic ileostomy via SES was associated with a higher risk of overall stoma-related complications, especially parastomal hernia (OR, 2.39, 95% CI 1.43-4.00; p=0.0008). No statistical difference was found in terms of wound infection, ileus, stoma edema, stoma prolapse, stoma necrosis, stoma infection, stoma bleeding, stoma stenosis, skin inflammation around the stoma, stoma retraction and postoperative pain score on postoperative day 1 and 3 between SES group and NS group. However, prophylactic ileostomy via SES was associated with lesser blood loss (MD = -0.38, 95% CI: -0.62 - -0.13; p=0.003), shorter operation time(MD = -0.43, 95% CI: -0.54 - -0.32 min; p<0.00001), shorter post-operative hospital stay (MD = -0.26, 95% CI: -0.43 - -0.08; p=0.004), shorter time to first flatus(MD = -0.23, 95% CI: -0.39 - -0.08; p=0.003) and lower postoperative pain score on postoperative day 2. Conclusion: Prophylactic ileostomy via SES after LRCS reduces new incision, decreases operative time, promotes postoperative recovery, and improves cosmetic outcomes, but may increase the incidence of parastomal hernias. The vast majority of parastomal hernias can be repaired by closing the ileostomy, therefore SES remain an option for temporary ileostomy after LRCS.

Can neoadjuvant chemoradiotherapy combined with immunotherapy benefit patients with microsatellite stable locally advanced rectal cancer? a pooled and integration analysis.

Objective: To assess the clinical efficacy of neoadjuvant chemoradiotherapy combined with immunotherapy for patients with microsatellite stable (MSS) locally advanced rectal cancer and provide evidence to support clinical decision-making. Methods: A systematic search was conducted on the PubMed, Embase, Cochrane Collaboration databases, conference summaries, and Chinese databases for clinical studies that investigated neoadjuvant chemoradiotherapy combined with immunotherapy for the treatment of locally advanced rectal cancer with MSS status. The search spanned from the inception of each database through July 2023. Data from the identified studies were extracted using a pre-designed table, and efficacy outcomes were analyzed. An integrated analysis was conducted using Stata 12.0 software. Results: Eight studies were included, comprising 204 patients with locally advanced MSS rectal cancer who received chemoradiotherapy combined with immunotherapy. The integrated analysis revealed a pathologic complete remission rate of 0.33, a sphincter preservation rate of 0.86, an R0 resection rate of 0.83, a major pathologic remission rate of 0.33, and a clinical complete remission rate of 0.30. Conclusion: Neoadjuvant chemoradiotherapy combined with immunotherapy demonstrates significant short-term efficacy in MSS-type locally advanced rectal cancer, notably enhancing the pathologic complete remission and sphincter preservation rates. This combination is a recommended treatment for patients with MSS-type rectal cancer.

Effectiveness of intraoperative peritoneal lavage with saline in patient with intra-abdominal infections: a systematic review and meta-analysis.

BACKGROUND: Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs. METHODS: The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence. RESULTS: Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02-6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70-1.48]; I2 = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18-2.86]; I2 = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39-1.41]; I2 = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74-3.93]; I2 = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48-1.87]; I2 = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45-2.09], I2 = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16-6.98], I2 = 0%) in patients with peritonitis when compared to non-IOPL. CONCLUSION: IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated.

Endoscopic stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction.

The aim of the present study was to analyze endoscopic stenting versus gastrojejunostomy of malignant gastric outlet obstruction (GOO). A systematic review of the literature was undertaken to analyze clinical trials on GOO. Six studies were eligible for analysis (three randomized control trials and three controlled clinical trials). Technical success (OR [95% CI]: 0.10 [0.02, 0.47]; I(2) = 0%; P = 0.003) and minor complications (OR [95% CI]: 0.28 [0.10, 0.83]; I(2) = 49%; P = 0.02). Time to oral intake and length of survival were also shorter in the endoscopic stenting (ES) group. There was no statistically significant difference in clinical success, length of survival, mortality and major complications. The present review demonstrated potentially improved quality of life in the ES group. ES is a safe and effective, minimally invasive and cost-effective option for palliation of malignant gastric outlet obstruction. The present review provides supportive evidence that ES should be considered as the gold standard treatment for malignant GOO.

Network Pharmacology and Molecular Docking Validation to Reveal the Pharmacological Mechanisms of Kangai Injection against Colorectal Cancer.

Background: Kangai injection is a traditional Chinese medicine (TCM) mixed by extracts from astragalus, ginseng, and kurorinone with modern technology. It is a commonly used antitumor injection in China, but the mechanism of Kangai injection in the treatment of colorectal cancer (CRC) is still unclear. The purpose of this study is to explore the mechanism of Kangai injection against CRC using network pharmacology and molecular docking technology. Methods: Targets of Kangai injection in CRC were predicted by SwissTargetPrediction and DisGeNET databases. Gene Ontology (GO) analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) were performed by using the DAVID database. A component-disease-target gene-pathway network was constructed by Cytoscape 3.8.0 software. Results: 114 overlapping targets of Kangai injection and CRC were used to construct a PPI network, and the top 10 hub targets of Kangai injection were rated from high to low as TP53, VEGFA, EGFR, TNF, ESR1, STAT3, HSP90AA1, HDAC1, AR, and MMP9. The ingredient-target-disease interactive network was constructed, which included 22 compounds and 114 overlapping targets with 161 nodes and 707 edges. Entries of enrichment analysis were obtained based on P value (<0.05), which included 19 of GO-MF, 217 of GO-BP, 8 of GO-CC, and 13 KEGG. Molecular docking analysis showed that Kangai injection strongly interacted with top 10 hub target proteins. Conclusion: Network pharmacology intuitively showed the multicomponent, multiple targets, and multiple pathways of Kangai injection in the treatment of CRC. The molecular docking experiment verified that compounds of Kangai injection had good binding ability with top 10 hub target proteins as well.

Effectiveness of intraoperative peritoneal lavage (IOPL) with saline in patient with intra-abdominal infections: a systematic review and meta-analysis protocol.

INTRODUCTION: Intra-abdominal infections (IAIs) are common surgical emergencies and cause a significant worldwide burden per year. Since the concept of intraoperative peritoneal lavage (IOPL) was proposed in 1905, it has been widely used in the surgery practice. However, the effectiveness of IOPL in patients with IAIs has always been controversial. Our objective is to identify whether it is beneficial to flush the abdominal cavity with saline in IAIs surgery through a comprehensive systematic review and meta-analysis. METHODS AND ANALYSIS: This protocol is reported in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Electronic databases (including the Cochrane library, MEDLINE, EMBASE, Web of Science, etc) and clinical trial registry platforms will be searched from inception to 8 September 2019. Randomised controlled trials, quasi-randomised clinical trials and cohort studies comparing IOPL and suction alone in IAIs will be included. The primary outcomes are mortality and abscess rate. Two independent reviewers will screen literature, collect data and assess risk of bias of included studies. Discussion or a third reviewer will be referred for any disagreements. The Grading of Recommendations Assessment, Development and Evaluation approach will be used to assess the quality of the evidence. We will perform meta-analysis using random-effects model. Subgroup analysis, sensitivity analysis and publication bias will be conducted if data are enough. ETHICS AND DISSEMINATION: Ethical approval is not required for this systematic review and meta-analysis protocol. Results of this study will be published in a peer-reviewed journal, presented at relevant conferences and disseminated to local and international policy makers. PROSPERO REGISTRATION NUMBER: CRD42019145109.

b-Shaped Laparoscopic Dual Anastomosis for Mid-Low Rectal Cancer: A Safe and Feasible Technique.

Aims: To assess the feasibility, safety, 1-year postoperative quality of life, and 2-year postoperative local recurrence of b-shaped laparoscopic dual anastomosis (bSLDA) technique in laparoscopic anterior resection (LAR) for mid-low rectal cancer. Methods: In this case-matched study, we retrospectively reviewed the database of 120 patients with mid-low rectal cancer who underwent LAR in Tangdu hospital between June 2014 and January 2017. The database included baseline characteristics, operative data and short-term outcomes, specimen, and pathological results. Among all the participants, 60 patients underwent bSLDA and 60 patients underwent conventional laparoscopic dual anastomosis (CLDA). After lymph node dissection and rectal dissociation, patients in the bSLDA group received the operation as follows: (1) the rectum distal end was closed vertically instead of horizontally; (2) the anastomosis was conducted in an end-lower corner of rectal stump. We also performed at least 2 years of follow-up (the median follow-up was 36 months, ranging from 24 to 54 months), including 2-year recurrence scores, 1-year low anterior resection syndrome (LARS) scores, and QLQ-C30 scores. Results: In this case-matched study, there were no differences between bSLDA group and CLDA group in operative data and short-term outcomes, which suggested that bSLDA and CLDA were equally safe. Furthermore, compared with CLDA group, bSLDA group had no statistical difference in the rate of anastomotic leakage (AL), but there was a trend that the rate in bSLDA was lower. In postoperative specimen data, the maximum and minimum edge distances of the ring from the rectal stump are longer in the bSLDA group. What is more, in the EORTC QLQ-C30 (version 3.0), the diarrhea score in bSLDA group was statistically lower (better) than in CLDA group (P = .043). Although bSLDA group had no significant differences in the LARS scores with CLDA group, there was a trend that the LARS scores were lower in bSLDA. At last, the 2-year local recurrence rate in both groups was not significantly different. Conclusions: The bSLDA technique is safe and accessible, which may reduce the incidence of AL to some extent. Therefore, it could be an alternative to laparoscopic proctectomy for mid-low rectal cancer and may also improve postoperative quality of life for many patients.

[Application of Overlap method to digestive tract reconstruction of totally laparoscopic left colectomy].

OBJECTIVE: To investigate the application value of the Overlap method in digestive tract reconstruction of totally laparoscopic left colectomy(TLLC) and its potential advantage. METHODS: The retrospective cohort study was adopted. Clinicopathological data of 16 patients with left colon cancer who underwent TLLC and Overlap anastomosis between August 2016 and August 2017 at Tangdu Hospital were retrospectively collected as Overlap group. Twenty-one patients who underwent laparoscopic assisted left colectomy (LALC) between January 2015 and July 2016 at Tangdu Hospital were used as control (traditional group). The intraoperative and postoperative data were compared between the two groups. During digestive tract reconstruction in the Overlap group, the proximal colon and distal colon were lined up side by side; a side-to-side anastomosis was conducted on colic band with a 60 mm linear stapler; and the common entry hole was closed using running suture. While in traditional group, the bowel was pulled out of abdominal wall through the assisted incision; the sample was resected and a proximal and distal end-to-end anastomosis was performed. RESULTS: In Overlap group, 10 cases were male and 6 cases were female, with a mean age of (66.4±4.8) years and a BMI of (23.6±2.3) kg/m2; the tumor located in distal transverse colon in 1 case, in splenic flexure in 2 cases, in descending colon in 4 cases, in upper sigmoid colon in 9 cases. TLLC was successfully completed in all the cases without conversion to laparotomy. In traditional group, 12 cases were male and 9 cases were female, with mean age of (65.9±5.8) years and BMI of (22.7±2.8) kg/m2; the tumor located in the distal transverse colon in 1 case, in the splenic flexure in 3 cases, in the descending colon in 6 cases, in the upper sigmoid colon in 11 cases. No statistically significant differences in baseline data were found between the two groups (all P>0.05). Compared to the traditional group, the total operation time was shorter [(143.4±11.1) minutes vs. (166.4±16.5) minutes, t=4.792, P=0.000], the anastomosis time was prolonged [(44.3±3.3) minutes vs. (22.4±3.0) minutes, t=-20.948, P=0.000], the amount of bleeding was reduced [(46.6±13.6) ml vs. (70.5±20.0) ml, t=4.106, P=0.000], and the incision length was shorter [(3.9±0.9) cm vs. (6.7±1.3) cm, t=7.056, P=0.000] in the Overlap group. There were no significant differences in lymph nodes harvested (17.3±2.9 vs. 15.5±3.0), time to flatus [(2.8±1.3) days vs. (2.6±1.0)days], postoperative complications [6.2%(1/16) vs. 9.5%(2/21)] and postoperative hospitalization [(4.6±1.4) days vs.(4.7±1.2) days] between the two groups (all P>0.05). CONCLUSION: The Overlap reconstruction method in totally laparoscopic left colectomy is a safe and feasible procedure, and provides less injury and better cosmetic outcome of abdominal wall.

Preoperative short-course radiotherapy and long-course radiochemotherapy for locally advanced rectal cancer: Meta-analysis with trial sequential analysis of long-term survival data.

BACKGROUND AND PURPOSE: The role of preoperative short-course radiotherapy (SCRT) in rectal cancer treatment, when compared to long-course radiochemotherapy (LCRT), is still controversial. Thus the meta-analysis with trial sequential analysis (TSA) was performed to evaluate the long-term survival of SCRT and LCRT as therapeutic regimens for locally advanced rectal cancer. MATERIAL AND METHODS: PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched up to August 2017 for eligible studies. Hazard ratios (HRs) or odds ratios (ORs) of overall survival (OS), disease free survival (DFS) and local recurrence (LR) with the corresponding 95% confidence intervals (CIs) were calculated and TSA was applied. RESULTS: 11 studies with 1984 patients were included. There was no significant difference in OS (HR = 0.92, 95% CI: 0.75-1.13, p = 0.44), DFS (HR = 0.94, 95% CI: 0.79-1.12, p = 0.50) and LR (OR = 0.73, 95% CI: 0.49-1.08, p = 0.11) between SCRT and LCRT groups. TSA suggested firm evidence for lacking on average a -10% relative risk reduction (RRR) in 4-year OS but no statistical significance in 4-year DFS. CONCLUSIONS: Preoperative SCRT is as effective as LCRT for locally advanced colorectal cancer in long-term survival. SCRT could be preferential while facing long waiting lists or lacking medical resource.

[Application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery in laparoscopic radical proctectomy].

OBJECTIVE: To investigate the application value of the clearance of No.253 lymph nodes with priority to fascial space and preserving left colic artery (LCA) in patients undergoing laparoscopic radical proctectomy. METHODS: From August 2015 to August 2016, 97 consecutive middle-low rectal cancer patients underwent laparoscopic radical proctectomy using the clearance of No.253 lymph nodes with priority to fascial space and preserving LCA at Department of General Surgery, Tangdu Hospital. Among 97 patients, 45 were females , 52 were males, mean age was (64.3±5.5) years and mean BMI was (22.4±1.8) kg/m2. Brief steps of this clearance: traditional medial approach was the commencement of the dissection at the membrane bridge line in front of iliac vascular bifurcation, then entering into the Toldt's space; superior rectal artery served as the top of the tent and the Toldt's space was extended as far as possible; blunt separation was developed caudally (reaching 2 cm below the sacral promontory), cephalad (reaching the lower part of the pancreas), left laterally (reaching Toldt's line), dextrally (reaching abdominal aorta); after giving priority to fascias space, from the root of inferior mesenteric artery, LCA was exposed and No.253 lymph nodes were dissected. This regimen was suitable for the rectal adenocarcinoma patients without distant metastasis. RESULTS: There was no tension in the intestine and mesenteria after anastomosis in all the 97 patients. One patient received LCA ligation during the clearance, because of thinner LCA resulting in bleeding. The other 96 cases completed the clearance and operation successfully. The mean No.253 lymphadenectomy time was 11-27(17.1±5.3) minutes. The mean number of harvested No.253 lymph node was 0-6(4±2). The No.253 lymph nodes of 6 patients were positive. No.253 regional mesentery was complete in 95 patients. The total harvested number of lymph node was 11-26(17.3±5.3). Six patients with positive lymph nodes aged from 68 to 72 years old and all of them underwent TME operation 6-8 weeks after neoadjuvant chemoradiotherapy. The mean operative time was 89-189(125±35) minutes. The mean estimated blood loss was 10.5-38.6(22.4±10.5) ml. The first exhaust time was 3.0-6.0(5.6±2.1) days. The mean time to extracting the drainage tube was 3.0-5.0(4.5±2.5) days. Anastomotic fistula appeared in 1 case and hemorrhage appeared in 1 case, and these 2 cases were cured by conservative treatment. No perioperative death occurred. The mean postoperative hospital stay was 3.0-10.0(3.6±2.6) days. CONCLUSION: The clearance of No.253 lymph nodes with priority to fascial space and preserving LCA in laparoscopic radical proctectomy is safe and feasible.

[Application of ß-shaped intracorporeal Roux-en-y reconstruction in totally laparoscopic distal gastrectomy].

OBJECTIVE: To explore the technical feasibility, safety, and clinical efficacy of ß-shaped Roux-en-Y reconstruction(ß reconstruction) in totally laparoscopic distal gastrectomy (TLDG). METHODS: Clinical data of 21 patients with gastric cancer undergoing TLDG with ß reconstruction from January 2014 to May 2014 were retrospectively analyzed. RESULTS: TLDG with ß reconstruction was successfully performed in all the patients. The mean time of operation and ß reconstruction was (229.0±18.7) min and (27.5±4.2) min. The blood loss was (91.0±38.3) ml and number of dissected lymph node was 33.2±4.6 per patient. The length of upper and lower segment of resection from lesion was (5.9±0.4) cm and (3.2±0.8) cm. The average time to resume fluid diet, time to restore flatus and hospital stay were (2.1±0.8) d, (3.1±0.9) d and (5.9±2.4) d, respectively. CONCLUSION: The ß reconstruction is a safe and feasible procedure for TLDG and provides satisfactory short-term efficacy.

[Comparison of cranial-to-caudal medial versus traditional medial approach in laparoscopic right hemicolectomy: a case-control study].

OBJECTIVE: To compare the short-term efficacy of modified medial (M-M) with traditional medial(T-M) approach in laparoscopic right hemicolectomy(LRHC)/or extended laparoscopic right hemicolectomy(ELRHC) for right or hepatic flexure colon cancer. METHODS: A comparative, retrospective study was performed that included all the patients scheduled for LRHC or ELRHC for right or hepatic flexure colon cancer between June 2013 and August 2014. The following factors of two groups were assessed: patient characteristics, operative details, pathology, and surgical outcomes. RESULTS: A total of 99 patients were evaluated, including 52 patients in the M-M group and 47 patients in the T-M group. Age, gender, body mass index, American Society of Anesthesiology(ASA) class, tumor location, diameter of tumor were not significantly different between the two groups. As compared to the T-M group, M-M group was associated with a significantly shorter operative time [(105.6±38.8) min vs. (138.2±39.5) min, P<0.05], less estimated mean blood loss[(38.4±12.4) ml vs. (87.2±24.6) ml, P<0.05] and lower intraoperative vascular damage rate [5.8%(3/52) vs. 25.5%(12/47), P<0.05]. There were no significant differences between these two groups in terms of intraoperative complications, CME, conversion rate, number of harvested lymph node, postoperative ileus, hospital stay, wound, lung and urinary system infections. CONCLUSION: The use of M-M approach in laparoscopic right hemicolectomy provides short-term benefits in operative time and estimated blood loss compared with traditional medial approach.

[Application study of totally laparoscopic distal gastrectomy with delta-shaped anastomosis].

OBJECTIVE: To compare the short-term efficacy between totally laparoscopic distal gastrectomy(TLDG) with delta-shaped anastomosis (DS) and laparoscopic-assisted distal gastrectomy (LADG) with BrillrothI ( anastomosis (BI(), and to evaluate the application of DS. METHODS: Between March 2013 and February 2014, 50 patients underwent TLDG with DS using linear staplers, and 43 patients underwent LADG with BI( using circular staplers. Clinical features and short-term efficacy of the two groups were analyzed retrospectively. RESULTS: There were no significant differences between the two groups in terms of demographic indicators, operation time, intraoperative blood loss, number of removal lymph node, time to first flatus, incidence of complication and postoperative discharge day(all P>0.05). First-day postoperative pain was milder (3.1 ± 1.0 vs. 4.6 ± 1.4), and operative incision was shorter [(3.4 ± 0.4) cm vs. (6.9 ± 0.8) cm] significantly in TLDG with DS group(P<0.05). CONCLUSION: TLDG with DS is safe and feasible for patients with gastric cancer, and has more advantages in cosmetic and comfort level than LADG with BI.