Short-term outcomes of pure transvaginal laparoscopic right colectomy: A novel surgery approach based on an Idea, Development, Exploration, Assessment, Long-term framework stage IIa study.

BACKGROUND AND OBJECTIVES: The application of pure natural orifice translumenal endoscopic surgery (NOTES) to intra-abdominal visceral resections remains limited due to the complexity of the dissection. This study aimed to assess the safety and feasibility of laparoscopic right colectomy using a purely transvaginal approach. METHODS: The data of 12 continuous patients with colon neoplasia who underwent transvaginal right colectomy from November 2018 to July 2020 were prospectively collected, and their perioperative events were recorded. RESULTS: The patients' median age was 70.4 years. Four were diagnosed with colon adenoma and eight with adenocarcinoma. The median operative time was 185 min, with a median blood loss of 25 ml. The median time to gas passing was 32.5 h after surgery. The median postoperative hospital stay was 6 days. One operation was converted to hybrid NOTES due to difficulty with the anastomosis, and one was converted to laparoscopic surgery because of vascular injury. Three cases were grades I, II, and III according to the Clavien-Dindo classification. CONCLUSION: Pure NOTES right colectomy using the transvaginal approach is feasible and safe with good short-term outcomes. We recommend this novel technique for highly-selected patients with no more than a D2 dissection performed by experienced colorectal surgeons.

Robotic versus conventional laparoscopic surgery for rectal cancer: systematic review and meta-analysis.

BACKGROUND: The purpose of this meta-analysis is to evaluate the evidence available on the safety as well as effectiveness of robotic resection as compared to conventional laparoscopic surgery for rectal cancer. MATERIAL AND METHODS: A comparison of laparoscopic and robotic surgical treatments for rectal cancer was collected. Eligible trials that analyzed probabilistic hazard ratios (HR) for endpoints of interest (including perioperative morbidity) and postoperative complications were included in our review. RESULTS: A total of six studies were included based on the present inclusion criteria. The pooled data showed that R-TME appeared to have association with remarkable reduction in the postoperative morbidity rate as compared to L-TME. Moreover, R-TME was also linked to lower conversion, decreased lymph node number, and longer operation time compared with L-TME. However, there was no difference in hospital stay, positive range of circumferential resection and blood loss between the two study groups. CONCLUSIONS: Robotic rectal cancer surgery provides favorable outcomes and is considered as a safe surgical technique in terms of postoperative oncological safety. Like laparoscopic TME surgery, robotic surgery may be a valid alternative and complementary approach with beneficial effects on minimally-invasive surgery.

Can Endorectal Ultrasound, MRI, and Mucosa Integrity Accurately Predict the Complete Response for Mid-Low Rectal Cancer After Preoperative Chemoradiation? A Prospective Observational Study from a Single Medical Center.

BACKGROUND: Patients with locally advanced rectal cancer could be managed by a watch-and-wait approach if they achieve clinical complete response after preoperative chemoradiotherapy. Mucosal integrity, endorectal ultrasound, and rectal MRI are used to evaluate clinical complete response; however, the accuracy remains questionable. Clinical practice based on those assessment methods needs more data and discussion. OBJECTIVE: The aim of this prospective study was to evaluate the accuracy of mucosal integrity, endorectal ultrasound, and rectal MRI to predict clinical complete response after chemoradiotherapy. DESIGN: Endorectal ultrasound and rectal MRI were undertaken 6 to 7 weeks after preoperative chemoradiation therapy. Patients then received radical surgery based on the principles of total mesorectal excision. Preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity, specificity, and accuracy of each evaluation method were calculated. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients diagnosed with mid-low rectal cancer by biopsy between May 2014 and December 2016 were enrolled in this study. RESULTS: A total of 124 patients were enrolled in this study, and postoperative pathology revealed that 20 patients (16.13%) achieved complete response (ypT0N0). The sensitivity of mucosal integrity, endorectal ultrasound, and MRI to predict clinical complete response was 25%. The specificity of mucosal integrity, endorectal ultrasound, and MRI was 94.23%, 93.90%, and 93.27%. The combination of each 2 or all 3 methods did not improve accuracy. Regression analysis showed that none of these methods could predict postoperative ypT0. LIMITATIONS: The sample size is small, and we did not focus on the follow-up data and cannot compare prognosis data with previous research studies. CONCLUSIONS: Both single-method and combined mucosal integrity, endorectal ultrasound, and rectal MRI have poor correlation with postoperative pathologic examination. A watch-and-wait approach based on these methods might not be a proper strategy compared with radical surgery after neoadjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A693.

Resection of polyps involving the appendiceal orifice by combined endo-laparoscopic surgery: Two case reports.

BACKGROUND: The management of polyps involving the appendiceal orifice (AO) presents notable challenges. Endoscopic resection is frequently hindered by operational complexities, a heightened risk of incomplete removal, and an elevated risk of procedural complications, including appendicitis. Conversely, surgical resection may entail unnecessary excision of intestinal segments, leading to potential morbidity. CASE SUMMARY: Here, we reported two patients who presented with polyps deeply situated within the AO, with indistinct boundaries making it challenging to ensure completeness using traditional endoscopic resection. To overcome these challenges, we employed combined endo-laparoscopic surgery (CELS), achieving curative resection without postoperative complications. CONCLUSION: The application of CELS in managing polyps involving the AO is emerging as a safe and effective treatment modality.

Clinical characteristics and risk factors of post-operative intestinal flora disorder following laparoscopic colonic surgery: A propensity-score-matching analysis.

BACKGROUND: Intestinal flora disorder (IFD) poses a significant challenge after laparoscopic colonic surgery, and no standard criteria exists for its diagnosis and treatment. AIM: To analyze the clinical features and risk factors of IFD. METHODS: Patients with colon cancer receiving laparoscopic surgery were included using propensity-score-matching (PSM) methods. Based on the occurrence of IFD, patients were categorized into IFD and non-IFD groups. The clinical characteristics and treatment approaches for patients with IFD were analyzed. Multivariate regression analysis was performed to identify the risk factors of IFD. RESULTS: The IFD incidence after laparoscopic surgery was 9.0% (97 of 1073 patients). After PSM, 97 and 194 patients were identified in the IFD and non-IFD groups, respectively. The most common symptoms of IFD were diarrhea and abdominal, typically occurring on post-operative days 3 and 4. All patients were managed conservatively, including modulation of the intestinal flora (90.7%), oral/intravenous application of vancomycin (74.2%), and insertion of a gastric/ileus tube for decompression (23.7%). Multivariate regression analysis identified that pre-operative intestinal obstruction [odds ratio (OR) = 2.79, 95%CI: 1.04-7.47, P = 0.041] and post-operative antibiotics (OR = 8.57, 95%CI: 3.31-23.49, P < 0.001) were independent risk factors for IFD, whereas pre-operative parenteral nutrition (OR = 0.12, 95%CI: 0.06-0.26, P < 0.001) emerged as a protective factor. CONCLUSION: A stepwise approach of probiotics, vancomycin, and decompression could be an alternative treatment for IFD. Special attention is warranted post-operatively for patients with pre-operative obstruction or early use of antibiotics.

Clinical outcome of neoadjuvant chemoradiation therapy with oxaliplatin and capecitabine or 5-fluorouracil for locally advanced rectal cancer.

BACKGROUND AND OBJECTIVES: This study evaluated the safety and efficiency of preoperative chemoradiation therapy (CRT) with the XELOX or FOLFOX regimen in locally advanced rectal cancer patients. METHODS: One hundred forty-four patients (T3/T4 or N+) were enrolled between 2005 and 2011. The patients received preoperative concomitant CRT (XELOX or FOLFOX regimen). Patients were divided into four groups: pCR (pT0N0), downstaging, no-downstaging, and progression group. Clinical outcome with overall survival (OS) and disease-free survival (DFS) were compared for each group. RESULTS: One hundred thirty-eight patients received radical resection after preoperative CRT. Twenty-seven patients (20%) achieved pCR. The response rate (pCR + downstaging) was 67%. The most common side effects were nausea (64%), diarrhea (49%), and leucopenia (49%). The overall estimated 5-year OS was 86% for all patients. The estimated 5-year OS was significantly better in the responders (pCR + downstaging) than the non-responders (no-downstaging + progression, 94% vs. 68%, P = 0.001). There was also statistical difference in 3-year DFS between the two groups (93% vs. 68%, P = 0.000). CONCLUSIONS: pCR and downstaging after neoadjuvant CRT are associated with improved survival for locally advanced rectal cancer patients. Preoperative CRT with the XELOX or FOLFOX regimen is well tolerated and has mild adverse events.

Necrostatin-1, RIP1/RIP3 inhibitor, relieves transforming growth factor ß-induced wound-healing process in formation of hypertrophic scars.

BACKGROUND: Hypertrophic scars (HS) are common pathologic processes emerged during wound-healing process. The receptor-interacting protein kinase (RIP) might participate in keloid formation. AIMS: This study aimed to investigate Necrostatin-1 (Nec-1), a RIP1/RIP3 inhibitor, in the formation of hypertrophic scar. METHODS: Human hypertrophic scar fibroblasts (HSF) were extracted from patients with hypertrophic scar. Transforming growth factor-ß1 (TGF-ß1) was performed to induce wound-healing process including cell proliferation (CCK-8, Flow cytometry, and Western blot), migration (Transwell assay, Western blot), collagen production (Western blot), and extracellular matrix dysfunction (Western blotting and immunofluorescence). RESULTS: Our results reported that Nec-1 inhibited TGF-ß1-induced cell proliferation and promoted G0/G1 phase arrest in HSF. In addition, Nec-1 attenuated TGF-ß1-induced cell migration and inhibited the expression of MMP2 and MMP9 in TGF-ß1-induced HSF. Besides, Nec-1 also reduced TGF-ß1-induced collagen production and α-smooth muscle actin expression in HSF. CONCLUSIONS: The present data in this study showed the potential role of Nec-1 as a novel treatment for HS.

Neoadjuvant chemoradiotherapy might provide survival benefit in patients with stage IIIb/IIIc locally advanced rectal cancer: A retrospective single-institution study with propensity score-matched comparative analysis.

BACKGROUND: Neoadjuvant chemoradiotherapy (NACRT) and total mesorectal excision (TME) are standard treatments of stage II/III locally advanced rectal cancer (LARC), currently. Here, we evaluated the oncological outcomes in LARC patients treated with NACRT compared to TME alone, and determined whether tumor regression grade (TRG) and pathologic response after NACRT was related to prognosis. METHODS: This is a retrospective comparison of 358 LARC patients treated with either TME alone (non-NACRT group, n = 173) or NACRT plus TME (NACRT group, n = 185) during 2003-2013. Perioperative and oncologic outcomes, like overall survival (OS), disease-free survival (DFS) and recurrence were compared using 1:1 propensity score matching analysis. RESULTS: A total of 133 patients were matched for the analysis. After a median follow-up of 45 months (8-97 months), the 5-year OS (NACRT vs non-NACRT: 75.42% vs 72.76%; P = 0.594) and 5-year DFS (NACRT vs non-NACRT: 74.25% vs 70.13%; P = 0.224) were comparable between NACRT and non-NACRT, whereas the 5-year DFS rate was higher in the NACRT group when only stage IIIb/IIIc patients were considered (NACRT vs. non-NACRT: 74.79% vs. 62.29%; P = 0.056). In the NACRT group of 185 patients, those with pCR/stage I (vs stage II/stage III disease) or TRG3/TRG4 disease (vs TRG0/TRG1/TRG2) had significantly better prognosis. CONCLUSION: NACRT might provide survival benefit in patients with stage IIIb/IIIc locally advanced rectal cancer.

A single-center, prospective, randomized clinical trial to investigate the optimal removal time of the urinary catheter after laparoscopic anterior resection of the rectum: study protocol for a randomized controlled trial.

BACKGROUND: Urinary catheter placement is essential before laparoscopic anterior resection for rectal cancer. Whether early removal of the catheter increases the incidence of urinary retention and urinary tract infection (UTI) is not clear. This study aims to determine the optimal time for removal of the urinary catheter after laparoscopic anterior resection of the rectum. METHODS/DESIGN: A total of 220 participants meeting the inclusion criteria will be randomly assigned to an experimental group or a control group. The experimental group will have their urethral catheters removed on postoperative day 2 and the control group will have their urethral catheters removed on postoperative day 7. In both groups, catheter removal will be performed when the bladder is full. The incidence of urinary retention and UTI in the two groups will be compared to determine the optimal catheter removal time. DISCUSSION: This is a prospective, single-center, randomized controlled trial to determine whether early removal of the urinary catheter after laparoscopic anterior resection of the rectum will help to decrease the incidence of postoperative acute urinary retention and UTI. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03065855 . Registered on 23 February 2017.

A novel heterozygous germline deletion in MSH2 gene in a five generation Chinese family with Lynch syndrome.

Lynch syndrome (LS) is one of the most common familial forms of colorectal cancer predisposing syndrome with an autosomal dominant mode of inheritance. LS is caused by the germline mutations in DNA mismatch repair (MMR) genes including MSH2, MLH1, MSH6 and PMS2. Clinically, LS is characterized by high incidence of early-onset colorectal cancer as well as endometrial, small intestinal and urinary tract cancers, usually occur in the third to fourth decade of the life. Here we describe a five generation Chinese family with LS clinically diagnosed according to the Amsterdam II criteria. Immuno-histochemical staining of MSH2 and MSH6 shows only foci nuclear positive on the surface of the tumor with strong expression of MLH1 and PMS2 with diffuse immunoreactivity. In order to dig into the molecular basis of this LS pedigree, we collected the proband's blood sample, extracted the genomic DNA and applied the genetic screening. As a result, we identified a novel heterozygous deletion in MSH2 gene by targeted next generation sequencing, which is also proved to be co-segregated among other affected family members by following validation. To our knowledge, this novel heterozygous deletion (c.1676_1679 delTAAA) in MSH2 gene causes frameshift mutation (p.Asn560Lysfs*29) and leads to the formation of a truncated MSH2 protein which is confirmed to be a deleterious mutation according to the variant interpretation guidelines of American College of Medical Genetics and Genomics (ACMG). Identification of novel DNA mismatch repair (MMR) gene mutations can definitely benefit to the clinical diagnosis and management.

The Radical Extent of lymphadenectomy - D2 dissection versus complete mesocolic excision of LAparoscopic Right Colectomy for right-sided colon cancer (RELARC) trial: study protocol for a randomized controlled trial.

BACKGROUND: The extent of lymphadenectomy during laparoscopic right colectomy can affect the oncological outcome and the safety of surgery. The principle of complete mesocolic excision (CME) has been gradually accepted and increasingly applied by colorectal surgeons. The aim of this study is to investigate whether extended lymphadenectomy (CME) in laparoscopic colectomy could improve the oncological outcomes of patients with right-sided colon cancers, compared with D2 lymphadenectomy. METHODS/DESIGN: The Radical Extent of lympadenectomy: D2 dissection versus complete mesocolic excision of LAparoscopic Right Colectomy for right-sided colon cancer (RELARC) study is a prospective, multicenter, randomized controlled trial in which 1072 eligible patients with right-sided colon cancers will be randomly assigned to the CME group or the D2 dissection group during laparoscopic right colectomy. Inclusion criteria are locally advanced colon cancers situated from the cecum to the right third of the transverse colon and clinically staged as T2-4aN0M0 or TanyN + M0. The primary endpoint of this trial is 3-year disease-free survival. Secondary endpoints include 3-year overall survival, postoperative complication rates, perioperative mortality rates, and rates of positive central lymph nodes (the station 3 nodes). DISCUSSION: The RELARC trial is a prospective, multicenter, randomized controlled trial that will provide evidence on the optimal extent of lymphadenectomy during laparoscopic right colectomy in terms of better oncological outcome and operation safety. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02619942 . Registered on 29 November 2015.

Comparison of Transanal Endoscopic Microsurgery and Total Mesorectal Excision in the Treatment of T1 Rectal Cancer: A Meta-Analysis.

BACKGROUND: Transanal endoscopic microsurgery (TEM) for the treatment of early-stage rectal cancer has attracted attention due to its advantages of reduced surgical trauma, fewer complications, low operative mortality, rapid postoperative recovery and short hospital stay. However, there are still significant controversies regarding TEM for the treatment of rectal cancer, mainly related to the prognosis associated with this method. OBJECTIVE: This study sought to compare the efficacy of transanal endoscopic microsurgery (TEM) and total mesorectal excision (TME) for the treatment of T1 rectal cancer. METHODS: We searched the Cochrane Library, PubMed, Embase and CNKI databases. Based on the Cochrane Handbook for Systematic Reviews, we screened the trials, evaluated the quality and extracted the data. RESULTS: One randomized controlled trial (RCT) and six non-randomized controlled clinical trials (CCTs) were included in the meta-analysis (a total of 860 rectal cancer patients were included; 303 patients were treated with TEM, and 557 patients were treated with TME). Analysis revealed that all seven studies reported local recurrence rates, and there was a significant difference between the TEM and TME groups [odds ratio (OR) = 4.62, 95% confidence interval (CI) (2.03, 10.53), P = 0.0003]. A total of five studies reported distant metastasis rates, and there was no significant difference between the TEM and TME groups [OR = 0.74, 95%CI (0.32, 1.72), P = 0.49]. A total of six studies reported postoperative overall survival of the patients, and there was no significant difference between the TEM and TME groups [OR = 0.87, 95%CI(0.55, 1.38), P = 0.55]. In addition, two studies reported the postoperative disease-free survival rates of patients, and there was no significant difference between the TEM and TME groups [OR = 1.12, 95%CI (0.31, 4.12), P = 0.86]. CONCLUSIONS: For patients with T1 rectal cancer, the distant metastasis, overall survival and disease-free survival rates did not differ between the TEM and TME groups, although the local recurrence rate after TEM was higher than that after TME.

Ectopic variceal bleeding from colonic stoma: two case reports.

Parastomal variceal bleeding is a rare complication of portal hypertension, which often occurs in a recurrent manner and might be life-threatening in extreme situations. Treatment options vary, and no standard therapy has been established. Herein, we report 2 such cases. The first patient suffered from parastomal variceal bleeding after Hartmann procedure for rectal cancer. Stomal revision was performed, but bleeding recurred 1 month later. The second patient developed the disease after Miles procedure for rectal cancer. Embolization via the percutaneous transhepatic approach was performed using the Onyx liquid embolic system (LES) (Micro Therapeutics Inc, dba ev3 Neurovascular) in combination with coils, and satisfactory results were obtained after a 4-month follow-up. Our cases illustrate that surgical revision should be used with caution as a temporary solution due to the high risk of rebleeding, whereas transhepatic embolization via the Onyx LES and coils could be considered a safe and effective choice for skillful managers.