Clinical study of enhanced recovery after surgery in laparoscopic appendectomy for acute appendicitis.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocol is a comprehensive management modality that promotes patient recovery, especially in the patients undergoing digestive tumor surgeries. However, it is less commonly used in the appendectomy. AIM: To study the application value of ERAS in laparoscopic surgery for acute appendicitis. METHODS: A total of 120 patients who underwent laparoscopic appendectomy due to acute appendicitis were divided into experimental group and control group by random number table method, including 63 patients in the experimental group and 57 patients in the control group. Patients in the experimental group were managed with the ERAS protocol, and those in the control group were received the traditional treatment. The exhaust time, the hospitalization duration, the hospitalization expense and the pain score between the two groups were compared. RESULTS: There was no significant difference in age, gender, body mass index and Sunshine Appendicitis Grading System score between the experimental group and the control group (P > 0.05). Compared to the control group, the patients in the experimental group had earlier exhaust time, shorter hospitalization time, less hospitalization cost and lower degree of pain sensation. The differences were statistically significant (P < 0.01). CONCLUSION: ERAS could significantly accelerate the recovery of patients who underwent laparoscopic appendectomy for acute appendicitis, shorten the hospitalization time and reduce hospitalization costs. It is a safe and effective approach.

[Surgical management of postoperative stricture of anastomosis after operation of intersphincteric resection for lower rectal cancer].

OBJECTIVE: To study surgical treatment of postoperative stricture of anastomosis for lower rectal cancer. METHODS: The data of 9 cases who were diagnosed as postoperative stricture of anastomosis after operation of intersphincteric resection for lower rectal cancer during January 2008 to June 2011 were analyzed retrospectively. Transanal excision of stricture were used in 3 cases diagnosed as membranous stricture. Transanal radial incision of stricture were used in 5 cases diagnosed as tubulous stricture. Biologic patch was used to repair the defect of the posterior wall of rectum after excision of severe stricture in 1 case. RESULTS: All 9 cases of postoperative stricture of anastomosis were cured by surgery. Anal dilation were performed every day by patients themselves after discharge. Digital examination showed that 1 to 2 fingers could pass through the anastomosis after operation. The patient whose rectal defect was repaired by biological patch underwent colonoscopy examination two weeks after operation. Colonoscopy showed that the biological patch had been filled with granulation and integrated into the surrounding intestinal tissue. All patients defecated without difficulty and the anal function of all patients was good after restoration of intestinal continuity. CONCLUSION: Aggressive surgery, combining with the use of biological patch if necessary is an effective therapy of postoperative stricture of anastomosis for lower rectal cancer.

[Technical improvements and results of individual cylindrical abdominoperineal resection for locally advanced low rectal cancer].

OBJECTIVE: To evaluate the safety and efficacy of individual cylindrical abdominoperineal resection (CAPR) for locally advanced low rectal cancer. METHODS: From June 2011 to February 2012, 11 patients with locally advanced low rectal cancer underwent individual CAPR. There were 7 male and 4 female patients, aged from 32 to 74 years with a median of 64 years. Forty-seven patients underwent classic CAPR from January 2008 to February 2012. Preoperative and postoperative parameters such as clinical information of patients, tissue morphometry and complications were compared. RESULTS: In the individual surgical group, 6 patients were treated with one side levator ani muscle totally or partially reserved, 3 patients with sacrococcyx reserved, and 2 patients with dissection close to the anterior rectal wall. Compared with classical surgery, the individual surgical specimens of horizontal section area ((2197 ± 501) mm(2)) and intrinsic muscle layer outer area ((1722 ± 414) mm(2)) were small, but the difference was not statistically significant (P = 0.150 and 0.167). The operative time, intraoperative blood loss, circumferential resection margin, total cross sectional tissue area, cross sectional tissue area outside the muscularis propria and bowel perforation rate between the two groups were not significantly different. Individual CAPR showed less incidence of chronic perineal pain (2/11, χ(2) = 6.116, P = 0.013) and sexual dysfunction (2/9, χ(2) = 4.412, P = 0.036) compared with classic CAPR. CONCLUSIONS: Individual CAPR has the potential to reduce the risk of chronic perineal pain and sexual dysfunction without influencing the radical effect when compare with classic CAPR for the treatment of low rectal cancer.

[Value of self-expanding metallic stent for obstructing left-sided colon cancer or rectal cancer].

OBJECTIVE: To investigate the therapeutic value of self-expanding metallic stent (SEMS) for resectable obstructing left-sided colon cancer or rectal cancer. METHODS: Clinical data of 73 patients who had acute obstruction due to left-sided colon cancer or rectal cancer during May 2007 to January 2012 were retrospectively analyzed. The patients were divided into 2 groups: SEMS group (34 cases) underwent surgical resection after insertion of SEMS; emergency surgery group (39 cases) underwent emergency operation. The 2 group patients were compared for the incidence of primary anastomosis, stoma rate, laparoscopic surgery rate, mortality, postoperative morbidity, ICU admission rate, length of ICU stay, hospital stay, and hospitalization costs. RESULTS: The incidence of primary anastomosis in SEMS group was significantly higher than that in emergency surgery group (97.1% vs. 56.4%, χ(2) = 16.256, P < 0.001), and the protective stoma rate and permanent stoma rate in SEMS group were both lower than those in emergency surgery group (33.3% vs. 86.3%, 2.9% vs. 43.6%, χ(2) value were 14.972 and 16.156, both P < 0.001). Patients in SEMS group underwent significantly more laparoscopic surgery than in emergency surgery group (47.1% vs. 0, χ(2) = 23.505, P < 0.001). There were no significant difference in postoperative mortality (2.9% vs. 10.3%, P = 0.364). The postoperative morbidity in SEMS group was significantly lower than that in emergency surgery group (35.3% vs. 66.7%, P = 0.007). Incisional infection was the most common complication in both groups, and the incidence of which seemed to be more higher in emergency surgery group (17.6% vs. 38.5%, χ(2) = 3.840, P = 0.050). There was a lower ICU admission rate in SEMS group (24.2% vs. 53.9%, χ(2) = 6.972, P = 0.008), and the mean length of ICU stay and hospital stay were both shorter in SEMS group ((69.5 ± 7.4) hours vs. (114.3 ± 10.9) hours, t = -20.23, P < 0.001; (19.6 ± 4.8) days vs. (23.4 ± 6.2) days, t = -2.90, P = 0.005). The cost of hospitalization was less in SEMS group (45 383 ± 15 648 vs. 61 485 ± 20 380, t = -3.74, P < 0.001). CONCLUSIONS: SEMS can effectively relieve the large intestinal obstruction caused by left-sided colon cancer or rectal cancer, and change the traditional emergency surgery into a selective surgery with better outcomes. SEMS appears to be a valuable technique for resectable obstructing left-sided colorectal cancer.

Human acellular dermal matrix in the surgical management of rectal anastomotic stricture.

Anastomotic stricture after rectal resection is an intractable complication of rectal sugery. We present a case to introduce a new method to deal with rectal defect after dissecting anastomotic stricture by using biomaterial. The patient was diagnosed with rectal anastomotic stricture after radical resection for rectal carcinoma and was treated by reoperation. There was a defect in the posterior wall of the rectum after the anastomotic stenosis was dissected. We rapaired the defect successfully by using human acellular dermal matrix (HADM). The repair of rectal defect using HADM was easily and safely performed and provided long-term clinical success. It might be considered an innovative method for rectal defect repair.

Successful diagnosis and treatment of jejunal diverticular haemorrhage by full-thickness enterotomy: A case report.

BACKGROUND: Jejunal diverticula are the rarest of all small bowel diverticula and usually have no classic clinical symptoms. Jejunal diverticular haemorrhage (JDH) is a rare complication and can be difficult to identify and manage, hence it always resulting in a diagnostic delay and unsatisfactory clinical outcomes. Although with the advances in endoscopic technology, no consensus have been reached on the diagnosis and management of JDH, the conventional surgical intervention still remains the mainstream for the management of JDH. We report an unique case of a 63-year-old male who presented with massive haemorrhage from jejunal diverticula, which was successfully managed by initial resuscitation and definitive surgery. CASE SUMMARY: A 63-year-old male was admitted as an emergency with 6 h history of haematemesis and melena. The haematemesis appeared to be bright red, with volume exceeding 100 mL. The amount of melena was estimated to be 200 mL. Initially, the patient received fluid resuscitation and three unit blood transfusion. Then, in order to localize the bleeding sites, colonoscopy, upper gastrointestinal endoscopy, and mesenteric angiography were utilized but failed to identify the source of haemorrhage. Informed consent form was obtained for further treatment, and he was treated with an exploratory laparotomy and the bleeding site was successfully located during the procedure. He was diagnosed with JDH. The postoperative period was uneventful, and he was discharged on day 18 after surgery. No rebleeding occurred at the 1-year follow-up. CONCLUSION: In patients with gastrointestinal bleeding, if various techniques fail to identify the cause of haemorrhage in small bowel and haemodynamic instability is sustained with continuous resuscitation, we recommend surgical intervention should be the ultimate treatment of choice.

Adipose-derived stem cells promote gastric cancer cell growth, migration and invasion through SDF-1/CXCR4 axis.

BACKGROUND/AIMS: The CXCR4/SDF-1 axis regulates the trafficking of various cell types. In the study we investigated whether adipose-derived stem cells can promote gastric cancer cell growth and migration through SDF-1/CXCR4 axis. METHODOLOGY: The expression of CXCR4 in gastric cancer cell line MGC-803 and SDF-1 in Adipose-derived stem cells was detected by using PCR method. Furthermore, cell proliferation, migration and invasion assays were examined and inhibitors of CXCR4 were used to determine the effect on cell migration. RESULTS: The cells isolated from subcutaneous adipose tissue show characteristics of stem cells. Gastric cancer cells express CXCR4 and Adipose-derived stem cells express SDF-1. Additionally, the tumor cells showed vigorous proliferative and migratory responses to ADSCs. AMD3100 can effectively reduce the migration of gastric cancer cells. CONCLUSIONS: Adipose-derived stem cells can promote gastric cancer cell growth, migration and invasion through SDF-1/CXCR4 axis. CXCR4 can be used in the treatment of gastric cancer as a potential therapeutic target.

Preliminary study on proteomics of gastric carcinoma and its clinical significance.

AIM: To explore the preliminary identification of serum protein pattern models that may be novel potential biomarkers in the detection of gastric cancer. METHODS: A total of 130 serum samples, including 70 from patients with gastric cancer and 60 from healthy adults, were detected by surface-enhanced laser desorption and ionization time-of-flight mass spectrometry (SELDI-TOF-MS). The data of spectra were analyzed by Biomarker Patterns Software (BPS). Thirty serum samples of gastric cancer patients and 30 serum samples of healthy adults were grouped into the training group to build models, and the other 70 samples were used to test and evaluate the models. The samples of the test group were judged only with their peaks' height and were separated into cancer group or healthy control group by BPS automatically and the judgments were checked with the histopathologic diagnosis of the samples. RESULTS: Sixteen mass peaks were found to be potential biomarkers with a significant level of P< 0.01. Among them, nine mass peaks showed increased expression in patients with gastric cancer. Analyzed by BPS, two peaks were chosen to build the model for gastric cancer detection. The sensitivity, specificity, and accuracy of the model were 90%, 36/40, 86.7%, 26/30, and 88.6%, 62/70, respectively, which were greatly higher than those of clinically used serum biomarkers CEA (carcinoembryonic antigen), CA19-9 and CA72-4. Stage I/II gastric cancer samples of the test group were all judged correctly. CONCLUSION: The novel biomarkers in serum and the established model could be potentially used in the detection of gastric cancer. However, large-scale studies should be carried on to further explore the clinical impact on the model.

Extensively infiltrating colon adenocarcinoma similar to Crohn's disease: a case report.

A 38-year-old Chinese man presenting with chronic diarrhea and secondary incomplete intestinal obstruction was hospitalized in April 2010. Electronic colonoscopy and barium enema examination initially showed longitudinal scar-like strictures and cobblestone appearance in the colon that was similar to those in Crohn's disease. After subtotal colectomy and partial intestinal resection, the pathological examination indicated colon adenocarcinoma that diffusely infiltrated along the colon longitudinal axis rather than the initial diagnosis of Crohn's disease. Pathological examination revealed colon adenocarcinoma with excessive desmoplastic reaction and infiltrating cancer cells along the colon longitudinal axis that may have accounted for the morphological similarities to Crohn's disease in this case. The findings in the present case suggest that colon carcinoma should be considered when Crohn's disease-like findings are encountered, not only in individuals with concurrent cancer in other sites, but also in patients with a long history of gastrointestinal symptoms such as chronic diarrhea or abdominal pain.

Colonic transit time in patient with slow-transit constipation: comparison of radiopaque markers and barium suspension method.

BACKGROUND: Colonic transit study provides valuable information before surgical treatment is considered for patient with constipation. The radiopaque markers method is the most common way for evaluating colon transit time. The aim of this study is to compare the barium suspension with the radiopaque makers to assess the colonic mobility in patient with constipation. METHODS: Colonic transit time was measured in 11 female patients with slow-transit constipation using both radiopaque markers and barium suspension method. In radiopaque markers method, the patient ingested 20 markers on the first day, and an abdominal radiograph was performed every 24h until 80% markers were excreted. In barium suspension method, the patient swallowed up to 50 ml of 200% (w/v) barium meal. The abdominal radiographs were taken at the same time point as the former. RESULTS: The total or segmental colonic transit time were obviously prolonged in all patients. Segmental transits time spent in the right colon, left colon and rectosigmoid for radiopaque markers and barium suspension method was, respectively, 30 ± 6 h and 34 ± 7 h; 38 ± 9h and 32 ± 6 h; 40 ± 8 h and 38 ± 10 h. In the radiopaque markers method, total colonic transit time was 108 ± 14 h and it was 103 ± 13 h in the barium suspension method (P>0.05). CONCLUSION: The barium suspension and radiopaque markers gave the similar results for colonic transit time. The barium suspension was a simple and cheap method for evaluating the colonic mobility.

CXCR4/SDF-1 axis is involved in lymph node metastasis of gastric carcinoma.

AIM: To investigate the role of CXC chemokine receptor-4 (CXCR4) and stromal cell-derived factor-1 (SDF-1) in lymph node metastasis of gastric carcinoma. METHODS: In 40 cases of gastric cancer, expression of CXCR4 mRNA in cancer and normal mucous membrane and SDF-1 mRNA in lymph nodes around the stomach was detected using quantitative polymerase chain reaction (PCR) (TaqMan) and immunohistochemistry assay. SGC-7901 and MGC80-3 cancer cells were used to investigate the effect of SDF-1 on cell proliferation and migration. RESULTS: Quantitative reverse transcription PCR and immunohistochemistry revealed that the expression level of CXCR4 in gastric cancer was significantly higher than that in normal mucous membrane (1.6244 ± 1.3801 vs 1.0715 ± 0.5243, P < 0.05). The expression level of CXCR4 mRNA in gastric cancer with lymph node metastasis was also significantly higher than that without lymph node metastasis (0.823 ± 0.551 vs 0.392 ± 0.338, P < 0.05). CXCR4 expression was significantly related to poorly differentiated, high tumor stage and lymph node metastasis. Significant differences in the expression level of SDF-1 mRNA were found between lymph nodes in metastatic gastric cancer and normal nodes (0.5432 ± 0.4907 vs 0.2640 ± 0.2601, P < 0.05). The positive expression of SDF-1 mRNA in lymph nodes of metastatic gastric cancer was consistent with the positive expression of CXCR4 mRNA in gastric cancer (r = 0.776, P < 0.01). Additionally, human gastric cancer cell lines expressed CXCR4 and showed vigorous proliferation and migratory responses to SDF-1. AMD3100 (a specific CXCR4 antagonist) was also found to effectively reduce the migration of gastric cancer cells. CONCLUSION: The CXCR4/SDF-1 axis is involved in the lymph node metastasis of gastric cancer. CXCR4 is considered as a potential therapeutic target in the treatment of gastric cancer.

Application of acellular dermal matrix for intestinal elongation in animal models.

AIM: To investigate the efficacy of acellular dermal matrix (ADM) for intestinal elongation in animal models. METHODS: Japanese white big-ear rabbits (n = 9) and Wuzhishan miniature pigs (n = 5) were used in the study. Home-made and commercial ADM materials were used as grafts, respectively. A 3-cm long graft was interposed in continuity with the small bowel and a side-to-side anastomosis, distal to the graft about 3-4 cm, was performed. The animals were sacrificed at 2 wk, 4 wk, 8 wk and 3 mo after surgery and the histological changes were evaluated under light microscope and electron microscope. RESULTS: The animals survived after the operation with no evidence of peritonitis and sepsis. Severe adhesions were found between the graft and surrounding intestine. The grafts were completely absorbed within postoperative two or three months except one. Histological observation showed inflammation in the grafts with fibrinoid necroses, infiltration of a large amount of neutrophils and leukomonocytes, and the degree varied in different stages. The neointestine with well-formed structures was not observed in the study. CONCLUSION: It is not suitable to use acellular dermal matrix alone as a scaffold for the intestinal elongation in animal models.

[Efficacy evaluation of anal intersphincteric resection with direct coloanal anastomosis for T1-2 ultra-low rectal cancer].

OBJECTIVE: To evaluate the oncological and functional outcomes of intersphincteric resection (ISR) in T(1-2) ultra-low rectal cancer. METHODS: From March 2000 to March 2007, ISR with total mesorectal excision (TME) was performed in 40 patients with very low rectal cancer,among whom total ISR in 5 patients, partial ISR in 23 patients, and partial ISR with partial dentate line preservation (modified partial ISR) in 12 patients. The preoperative tumor staging was T(1-2)N(0-1)M(0). RESULTS: Morbidity was identified in 3 patients including anastomotic leakage in 1 patient and wound infection in 2 patients, and there was no postoperative mortality. The 5-year overall survival rate was 97%, and 5-year disease-free survival rate was 86%. Both patients with modified partial ISR (P=0.004) and patients with partial ISR (P=0.008) had significantly better continence than those with total ISR, and patients with a diverting stoma had significantly better continence (P=0.043) than those without a stoma at 12 months after surgery. CONCLUSIONS: ISR is a safe procedure for sphincter-saving rectal surgery in selected patients with very low rectal tumors. A temporary diverting stoma may be beneficial to the improvement of anal function. Modified partial ISR under the precondition of radical resection shows better anal function and lower rate of incontinence.

hRad21 overexpresses and localizes to the ALT-associated promyelocytic leukemia body in ALT cells.

Telomerase-negative immortalized cells maintain their telomeres through a telomerase-independent pathway termed alternative lengthening of telomeres (ALT). The mechanism of ALT is based on homologous recombination (HR). A hallmark of ALT cells is presence of a nuclear structure termed ALT-associated promyelocytic leukemia body (APB). Here, we demonstrated that hRAD21, an important subunit of cohesin complex, was overexpressed in ALT cells. We additionally showed that hRAD21 protein localized to APB in ALT cells. Thus, one role of hRAD21 appeared to involve telomere maintenance in ALT cells. We suggested that hRAD21 facilitated telomere HR in ALT cells by participating in APB formation.