[Comparative study of functional prognosis of transanal total mesorectal excision and conventional total mesorectal excision based on propensity score matching].

Objective: To compare the postoperative functional prognosis of transanal mesorectal excision (taTME) and conventional total mesorectal excision (TME) in rectal cancer. Methods: Totally 49 patients underwent taTME and 478 patients underwent conventional TME at Department of Gastroenterological Surgery, Peking University People's Hospital from January 2015 to December 2019 were retrospectively collected. Propensity score matching method was used to perform 1 versus 1 matching between the taTME and conventional TME groups, and 36 pairs of patients were successfully matched. After matching, the median age of patients in taTME group and conventional TME group was 60.5 (16.0) years and 60.5 (13.0) years (M(Q(R))), respectively, and the proportion of male patients was 66.7% (24/36) and 55.6% (20/36) , respectively. EORTC QLQ-C30 scale was used to assess quality of life, low anterior resection syndrome (LARS) scale and Wexner constipation score were used to evaluate anal function, international prostate symptom score (IPSS) was used to evaluate urinary function,international index of erectile function (IIEF) -5 and female sexual function index (FSFI) score were used to evaluate male and female sexual function, respectively, and generalized anxiety disorder (GAD-7) and patient health questionnaire (PHQ-9) scale were used to evaluate psych function. The t test, Mann-Whitney U test, χ(2) test, and Fisher exact test were used for comparison between groups, and Wilcoxon rank sum test or McNemar test was used for comparison between paired data. Results: There were no significant differences in surgery time, postoperative hospital stays, conversion rate, morbidity rate, surgery cost, and numbers of lymph node yield between the two groups (all P>0.05). Compared with the conventional TME group, the intraoperative blood loss in the taTME group was significantly higher (100 (100) ml vs. 80 (50) ml, U=424.5, P=0.010), the prophylactic stoma rate was significantly higher (96.9%(31/36) vs. 63.6%(21/36), χ(2)=11.218, P<0.01), the total hospitalization cost was significantly lower (74 297.7 (16 746.4) CNY vs. 91 781.3 (26 228.4) CNY, U=413.0, P=0.008). There were no significant differences in anal and urinary function between the two groups (LARS scalescore: Z=-0.513, P=0.608, Wexner constipation score: Z=-0.992, P=0.321, IPSS: Z=-1.807, P=0.071). In terms of psych function, significant difference in GAD-7 scale was seen between the two groups (Z=-2.311, P=0.021), patients with generalized anxiety disorder accounting for 26.7% (8/30) and 46.9% (15/32), respectively. Conclusions: Compared with conventional TME surgery, taTME has a significantly increased blood loss and prophylactic stoma rate. There are no significant difference in the incidence of postoperative anal, urinary, and sexual dysfunction between taTME and conventinal TME. taTME can alleviate the financial burden and general anxiety disorder to a certain extent.

[Whole-course management strategies for gastroesophageal reflux disease: an evidence mapping study based on clinical practice guidelines].

Gastroesophageal reflux disease (GERD) is one of the most common digestive diseases with high incidence, complicated clinical symptoms, difficulties in standard treatment, and heavy medical burden. At present, some GERD-relevant clinical practice guidelines (CPGs) have been issued by different countries and academic organizations, but some recommendations were inconsistent, which has caused some problems for the current clinical whole-course management of GERD. To summarize the relevant evidence among the CPGs on GERD and formulate the whole- course management strategies, we included GERD-relevant CPGs published or updated after 2010 by searching websites of guidelines, relevant professional societies, and electronic databases. We extracted the recommendations and summarized the evidence from the aspects of symptoms, epidemiology, diagnosis and treatment, which was presented in the form of evidence mapping. We included 24 CPGs, including three in Chinese and 21 in English. The clinical practice management strategies of GERD were formulated based on the evidence from the aspects of clinical symptoms, diagnostic methods, medical treatment, anti-reflux surgery and endoscopic treatment, psychological treatment, and traditional Chinese medicine treatment.

[Research progress of single-incision laparoscopic radical gastrectomy].

Gastric cancer is one of the most common malignant diseases in the world, which has a high incidence in our country and threatens people's health seriously. Laparoscopic radical gastrectomy is one of the main methods of surgical treatment for gastric cancer, whose clinical application has a history of near 30 years. With the in-depth understanding of minimally invasive surgery and the improvement of patients' cosmetic demand, single-incision laparoscopic surgery has emerged. Since the first report of single-incision laparoscopic radical gastrectomy in 2010, its safety has been preliminarily confirmed. While this result still needs to be further verified by more prospective randomized controlled studies. Compared with traditional laparoscopic radical gastrectomy, single-incision laparoscopic radical gastrectomy has the advantages of less trauma, less postoperative pain and faster postoperative recovery. So it has been favored by surgeons. However, the steeper learning curve and difficult operation of single-incision laparoscopic radical gastrectomy limit its promotion in clinical applications. At present, there are still controversies and confusions in the single-incision laparoscopic radical gastrectomy. This article elucidates the advances and existing problems of single-incision laparoscopic radical gastrectomy.

[Safety and efficacy of adjuvant chemotherapy with oxaliplatin and S-1 for patients with locally advanced gastric cancer after D2 lymph nodes dissection].

Objective: To investigate the safety and efficacy of oxaliplatin combined with S-1 (SOX) as adjuvant chemotherapy after D2 radical gastrectomy for locally advanced gastric cancer. Methods: A descriptive case series study was applied. Case inclusion criteria: (1) locally advanced gastric cancer confirmed by endoscopic biopsy or surgical specimen pathology as gastric adenocarcinoma; (2) receiving D2 radical gastric resection followed by SOX regimen adjuvant chemotherapy. Case exclusion criteria: (1) postoperative pathological TNM stage I or IV; (2) acute complications and emergency surgeries; (3) receiving neoadjuvant therapy; (4) concurrent malignancies and complications compromising patients' treatment or survival; (5) without receiving adjuvant SOX chemotherapy. A total of 94 patients with stage II-III gastric cancer who underwent D2 radical gastrectomy and postoperative adjuvant SOX chemotherapy at department of Gastrointestinal Surgery, Peking University People's Hospital from January 2014 to December 2019 were retrospectively enrolled. Chemotherapy-related adverse events, overall survival (OS) and progression-free survival (PFS) were analyzed. Kaplan-Meier survival analysis was performed and log rank test was used to analyze the difference between groups. P<0.2 or clinically significant indicators in univariate analysis were included in Cox regression model for multivariate survival analysis. Results: Among these 94 patients, there were 65 males and 29 females with an average age of (58.2±12.1) years; 33 patients with hypertension, diabetes mellitus, or cardiovascular and cerebrovascular diseases, 11 patients with family history of gastrointestinal tumors; 59 patients with tumors locating in the antrum or pylorus, 16 patients in the gastric body, 19 patients in the gastric fundus or cardia; 29 patients underwent total gastrectomy, 5 patients underwent proximal subtotal gastrectomy, and 60 patients underwent distal subtotal gastrectomy. In this study, 73 patients (77.7%) completed at least 5 cycles of adjuvant SOX regimen chemotherapy. Grade 3-4 adverse reactions included thrombocytopenia (23.4%, 22/94), nausea and vomiting (18.1%, 17/94) and peripheral neurotoxicity (6.4%, 6/94). Eighty-nine patients (94.7%) completed follow-up with a median follow-up time of 32 months. The 3-year and 5-year OS rates were 89.8% and 83.7%, respectively, and the 3-year and 5-year PFS rates were 81.4% and 78.1%, respectively. Taking 5 chemotherapy cycles as the cut-off point, the 3-year OS rate and 3-year PFS rate were 72.2% and 53.9% in the adjuvant chemotherapy < 5 cycles group, and 93.7% and 87.1% in the adjuvant chemotherapy ≥5 cycles group, respectively; the differences were statistically significant (P=0.029, P=0.006). Univariate analysis showed that the adjuvant chemotherapy < 5 cycles group was associated with worse 3-year OS (P=0.029). Multivariate analysis showed that insufficient chemotherapy cycle (HR=9.419, 95% CI: 2.330-38.007, P=0.002) was an independent risk factor for 3-year OS. Meanwhile, univariate analysis showed that the adjuvant chemotherapy <5 cycles (P=0.006), preoperative CEA > 4.70 µg/L (P=0.035) and adjacent organ resection (P=0.024) were associated with worse 3-year PFS. Multivariate analysis showed that adjuvant chemotherapy <5 cycles (HR=10.493, 95% CI: 2.466-44.655, P=0.001) and adjacent organ resection (HR=127.518, 95% CI: 8.885-1 830.136, P<0.001) were independent risk factors for 3-year PFS. Conclusions: Oxaliplatin combined with S-1 as an adjuvant chemotherapy regimen for locally advanced gastric cancer has high efficacy and low incidence of adverse reactions. At least 5 cycles of SOX regimen adjuvant chemotherapy can significantly improve prognosis of patients with stage II-III gastric cancer.

[Questionnaire investigation of radiation rectal injury with anxiety, depression and somatic disorder].

Objective: To observe the incidence and treatment of radiation rectal injury complicated with anxiety, depression and somatic symptom disorder. Methods: A cross-sectional survey research method was carried out. Patients with radiation rectal injury managed by members of the editorial board of Chinese Journal of Gastrointestinal Surgery were the subjects of investigation. The inclusion criteria of the survey subjects: (1) patients suffered from pelvic tumors and received pelvic radiotherapy; (2) colonoscopy showed inflammatory reaction or ulcer in the rectum. Exclusion criteria: (1) patient had a history of psycho-somatic disease before radiotherapy; (2) patient was unable to use a smart phone, unable to read and understand the questions in the questionnaire displayed on the phone; (3) patient refused to sign an informed consent form. According to the SOMA self-rating scale, PHQ-15 self-rating scale, GAD-7 and PHQ-9 self-rating scale, the electronic questionnaire of "Psychological Survey of Radiation Proctitis" was designed. The questionnaire was sent to patients with radiation rectal injury managed by the committee through the WeChat group. Observational indicators: (1) radiation rectal injury symptom assessment: using SOMA self-rating scale, radiation rectal injury symptom classification: mild group (≤3 points), moderate group (4-6 points) and severe group (> 6 points); (2) incidence of anxiety, depression and physical disorder: using GAD-7, PHQ-9 and PHQ-15 self-rating scales respectively for assessment; (3) correlation of radiation rectal injury symptom grading with anxiety, depression, and somatic symptom disorder. Results: Seventy-one qualified questionnaires were collected, of which 41 (56.9%) were from Guangzhou. Among the 71 patients, 6 were males and 65 were females; the mean age was (55.7±9.3) years old and 48 patients (67.6%) were less than 60 years old; the median confirmed duration of radiation rectal injury was 2.0 (1.0, 5.0) years. (1) Evaluation of symptoms of radiation rectal injury: 18 cases of mild (25.4%), 27 cases of moderate (38.0%), and 26 cases of severe (36.6%). (2) Incidence of anxiety, depression and somatic disorder: 12 patients (16.9%) without comorbidities; 59 patients (83.1%) with anxiety, depression, or somatic disorder, of whom 2 patients only had anxiety, 1 patient only had depression, 9 only had somatic disorder, 2 had anxiety plus depression, 4 had anxiety plus somatic disorder, 2 had depression plus somatic disorder, and 40 had all three symptoms. (3) correlation of radiation rectal injury grading with anxiety, depression, and somatic symptom disorder: as compared to patients in mild group and moderate group, those in severe group had higher severity of anxiety and somatic symptom disorder (Z=-2.143, P=0.032; Z=-2.045, P=0.041), while there was no statistically significant difference of depression between mild group and moderate group (Z=-1.176, P=0.240). Pearson correlation analysis revealed that radiation rectal injury symptom score was positively correlated with anxiety (r=0.300, P=0.013), depression (r=0.287, P=0.015) and somatic symptom disorder (r=0.344, P=0.003). Conclusions: The incidence of anxiety, depression, and somatic symptom disorder in patients with radiation rectal injury is extremely high. It is necessary to strengthen the diagnosis and treatment of somatic symptom disorder, so as to alleviate the symptoms of patients with pelvic perineum pain and improve the quality of life.

Carcinosarcoma of pancreas with liver metastasis combined with gastrointestinal stromal tumour of the stomach: is there a good prognosis with the complete resection?

We report a carcinosarcoma of the pancreas with liver metastasis combined with gastrointestinal stromal tumour (GIST) of the stomach in a 72-year-old woman who presented with right upper quadrant pain, nausea and vomiting. A radical resection including pancreaticoduodenectomy, left hepatic lobe resection and local resection of the gastric mass was performed. The tumour in the head of pancreas was found to be grossly yellow-white, and it infiltrated the common bile duct and duodenum; the mass of the liver metastasis is solitary. Pathologic examination showed two components separated from each other: one component was a conventional infiltrating pancreatic ductal adenocarcinoma, and the other component showed sarcomatous growth pattern composed of pleomorphic spindle cells. The neoplasm of the stomach was confirmed a low malignant potential GIST by histology and immunohistochemistry. The patient was obliged to be in hospital because of abnormal bowel function; moreover, surveillance CT scans performed at 1.5 months post-operatively showed multiple liver metastasis and recurrence in the tail of pancreas. Unfortunately, the patient died of multiple organ failure at 2 months post-operatively. To our knowledge, this is the first experience report about surgical treatment of carcinosarcoma of pancreas with liver metastasis combined with GIST of the stomach. The patient performed a radical surgery for the metastatic carcinosarcoma even if that could be resected completely did not have a good consequence.

[Role of gut microbiota in carcinogenesis and treatment for colorectal cancer].

Colorectal cancer is one of the most common malignant tumors of digestive tract. There are a large number of microorganisms in the digestive tract. Under normal physiological conditions, intestinal microorganisms can help with digestion and absorption, resist pathogen invasion and regulate the proliferation of intestinal mucosal cells. However, intestinal microflora imbalance will affect the intestinal microenvironment and intestinal cell function, and is closely related to the incidence and progression of colorectal cancer. Firstly, this paper introduces the changes of intestinal flora in patients with colorectal cancer, and then summarizes the mode of intestinal flora participating in the occurrence of colorectal cancer from the macro level. Then, we elaborate the involvement of intestinal flora in colorectal cancer from the aspects of cytokine-dependent chronic inflammation, DNA damage of intestinal epithelial cells, carcinogenic metabolites of intestinal flora and cellular enzymes, and changes of intestinal immune system. The pathogenesis of colorectal cancer provides a reference for further study of the pathogenesis of colorectal cancer. Finally, from the perspective of intestinal flora and colorectal cancer treatment, we analyze the significance of probiotics and bacterial flora transplantation for the treatment of colorectal cancer, and provide some new treatment ideas and methods that may be useful for the treatment of colorectal cancer.

[Clinicopathological features and prognosis in patients with presacral recurrent rectal cancer].

Objective: To investigate the clinicopathological features and prognostic factors in patients with presacral recurrent rectal cancer (PRRC). Methods: PRRC was defined as recurrence of rectal cancer after radical surgery involving posteriorly the presacral soft tissue, the sacrum/coccyx, and/or sacral nerve root. The diagnosis is confirmed with clinical symptoms (pain of pelvis/back/lower limb, bloody stools, increased frequency of defecation, and abnormal secretions), physical examination of perineal or pelvic masses, radiological findings, colonoscopy with histopathological biopsy, and the evaluation by multi-disciplinary team (MDT). Inclusion criteria: (1) primary rectal cancer undergoing radical surgery without distant metastasis; (2) PRRC was diagnosed; (3) complete inpatient, outpatient and follow-up data. According to the above criteria, clinical data of 72 patients with PRRC in Peking University People's Hospital from January 2008 to December 2017 were retrospectively analyzed. The clinicopathological features and follow-up data were summarized. Cox proportional hazard models was used to analyze the prognostic factors of PRRC. Results: Among 72 patients, 45 were male and 27 were female with a male-to-female ratio of 1.7:1.0. The median age at recurrence was 58 (34 to 83) years and the median interval from surgery to recurrence was 2.0 (0.2 to 17.0) years. The main symptom was pain in 48.6% (35/72) of patients. In addition, gastrointestinal symptoms were found in 25.0% (18/72) of patients. The presacral recurrent sites were presacral fascia in 36 (50.0%) patients, lower sacrum (S3~S5 or coccyx) in 25 (34.7%) patients, and higher sacrum (S1~S2) in 11 (15.3%) patients. Forty-seven (65.3%) patients underwent radical surgery (abdominal resection, abdominoperineal resection, sacrectomy, abdominosacral resection), 12 (16.7%) underwent non-radical surgery (colostomy, cytoreductive surgery), and 13 (18.1%) did not undergo any surgery but only receive palliative chemoradiotherapy and nutritional support treatment. Thirty-three (45.8%) patients received radiotherapy and/or chemotherapy (oxaliplatin, 5-fluorouracil, capecitabine, irinotecan, etc.). All the patients received follow-up, and the median follow-up time was 19 (2 to 72) months. The median overall survival time was 14 (1 to 65) months. The 1- and 3-year overall survival rates were 67.1% and 32.0%, respectively. Univariate analysis showed that age at recurrence (P=0.031) and radical resection (P<0.001) were associated with prognosis. Multivariate analysis demonstrated that radical resection was independent factor of good prognosis (RR=0.140, 95%CI: 0.061-0.322, P<0.001). Conclusions: Patients tend to develop presacral recurrent rectal cancer within 2 years after primary surgery. The main symptom is pain. Patients undergoing radical resection have a relatively good prognosis.

[Comparison of clinical efficacy among different surgical methods for presacral recurrent rectal cancer].

Objective: To investigate the efficacy and prognosis of three surgical methods for presacral recurrent rectal cancer (PRRC). Methods: A retrospective cohort study was carried out. Case inclusion criteria: (1) primary rectal cancer without distant metastasis and undergoing radical surgery; (2) patients undergoing radical surgery after the diagnosis of PRRC; (3) complete inpatient, outpatient and follow-up data. Clinical data of 47 patients meeting the above criteria who underwent operation at the Department of Gastrointestinal Surgery, The Peking University People's Hospital from January 2008 to December 2017 were reviewed and analyzed retrospectively. Of the 47 patients, 31 were male and 16 were female; the mean age was 57 years old; 9 (19.1%) were low differentiation or signet ring cell carcinoma, 38 (80.9%) were medium differentiation; 19 (40.4%) received neoadjuvant therapy. According to operative procedure, 22 patients were in the abdominal/abdominoperineal resection group, 15 in the sacrectomy group and 10 in the abdominosacral resection group. The operative data, postoperative data and prognosis were compared among the three groups. Survival curve was conducted using the Kaplan-Meier method, and log-rank test was used to compare survival difference among three groups. Results: There were no significant differences in baseline data among three groups (all P>0.05). All the 47 patients completed the radical resection successfully. The mean operation time was (4.7±2.1) hours, the median intraoperative blood loss was 600 ml, and the median postoperative hospitalization time was 17 days. Fifteen cases (31.9%) had perioperative complications, of which 3 cases were grade III-IV. There was no perioperative death. The mean operative time was (7.4±1.6) hours in the abdominosacral resection group, (4.9±1.6) hours in the abdominal/abdominoperineal resection group, and (3.0±1.1) hours in the sacroectomy group, with a significant difference (F=25.071, P<0.001). There were no significant differences in intraoperative blood loss, postoperative hospitalization days and perioperative complications among the three groups (all P>0.05). The median follow-up period of all the patients was 24 months, 12 cases (25.5%) developed postoperative dysfunction. The incidence of postoperative dysfunction in the abdominosacral resection group was 5/10, which was higher than 4/15 in the sacrectomy group and 3/22 (13.6%) in the abdominoperineal resection group with statistically significant difference (χ(2)=9.307, P=0.010). The 1-year and 3-year overall survival rates were 86.1% and 40.2% respectively. The 1-year overall survival rates were 86.0%, 86.7% and 83.3%, and the 3-year overall survival rates were 33.2%, 40.0% and 62.5% in the abdominal/abdominoperineal resection group, sacrectomy group and abdominosacral resection group, respectively, whose difference was not statistically significant (χ(2)=0.222, P=0.895). Conclusions: Abdominal/abdominoperineal resection, sacrectomy and abdominosacral resection are all effective for PRRC. Intraoperative function protection should be concerned for patients undergoing abdominosacral resection.

[Procedure for prolapse and hemorrhoids versus stapled transanal rectal resection in the treatment of grade IV hemorrhoids].

Objective: To compare the efficacy and safety of two procedures in the treatment of hemorrhoid: the procedure for prolapse and hemorrhoids (PPH) and stapled transanal rectal resection (STARR). Methods: A retrospective cohort research was conducted. Clinical data of 263 patients undergoing the first elective surgery for grade IV hemorrhoids by the same team of surgeons at our department from January 2015 to December 2016 were analyzed retrospectively, while those had other anorectal diseases, emergency surgery, inflammatory bowel disease, tumor and incomplete clinical data were excluded. PPH was performed in 129 patients and STARR was performed in 134 patients. PPH procedure: a circular purse 2-0 string suture was made at 4 cm above the dentate line; in accordance with the standard protocol, the PPH circular stapling devicewas introduced; the suture was closed, and a pull-through followed; the traction was continued; the stapler was fired; the prolapsed mucosa and submucosa were removed. STARR procedure: 3-5 needles were sutured in the anterior rectal mucosa, protecting the posterior wall mucosa; with the help of a finger the PPH stapler was inserted into the vaginal lumen; the sutures were hooked from both sides of the stapler to maintain traction; according to the disease condition, the suturewas tightened appropriately; stapler was screwed and activated; the anterior wall mucosa was removed; the joint of the both ends of anastomosis was cut; the posterior wall mucosa was removed as well. The short-term efficacy, surgical safety and prognosis of the two groups were compared. Results: There were 67 males (51.9%) in the PPH group and 57 (42.5%) males in the STARR group. The median age of the two groups was 51.0 (22.0, 80.0) years and 49.0 (24.0, 74.0) years, respectively. There were no significant differences in the baseline data between the two groups (all P>0.05). No significant differences in the intraoperative bleeding, length of hospital stay, postoperative analgesic drug use, postoperative bleeding, postoperative infection, etc. were found between two groups (all P>0.05). As compared to PPH group, STAAR group had longer operation time and higher hospitalization cost with significant differences [(44.0±19.3) minutes vs. (26.3±8.5) minutes, t=9.701, P=0.001; (11 047±473) yuan vs. (7674±309) yuan, t=32.826, P=0.001]. One case in STAAR group developed rectovaginal fistula. The median follow-up period of the whole group was 40 (33, 52) months. A total of 108 cases in STARR group and 114 cases in PPH group completed the follow-up. The 3-year disease-relapse rate was 0 in STARR group and 4.2% in PPH group (P=0.042). Conclusion: STARR procedure can improve the prognosis in the treatment of grade IV hemorrhoid, but attention should be paid to the development of complications.

Tonic GABA inhibition in hippocampal dentate granule cells: its regulation and function in temporal lobe epilepsies.

Both human and experimental evidence strongly supports the view of brain region- and cell-specific changes in tonic GABA inhibition in temporal lobe epilepsies (TLE). This 'tonic' form of signalling is not time-locked to presynaptic action potentials, which depends upon detection of ambient GABA by extrasynaptic GABAA receptors (GABAA Rs). Extrasynaptic GABAA Rs have distinct physiological and pharmacological features, including high GABA-binding affinity and low desensitization and a variety of the specific subunit combinations (α4δ-,α6δ-,α5γ-,ε-containing receptors). These features closely contribute to the function of tonic GABA current, which is preserved properly or increased in dentate gyrus in models of TLE, even in the face of a loss of synaptic inhibition and inhibitory interneurones. Markedly reduced tonic GABA inhibition may facilitate an episode of epilepsy, while persistent elevated tonic inhibition may contribute to the onset of spontaneous recurrent seizures. In dentate granule cells, tonic GABA inhibition is positively modulated by endogenous neurosteroids and other factors, which undergo changes related to hormonal status after TLE. Tonic inhibition regulates neuronal excitability through its effects on membrane potential by both offsetting the threshold and reducing the frequency of action potentials and input resistance. Therefore, extrasynaptic GABAA Rs are expected to be the most important pharmacological targets in TLE. It is likely that both elevate the ambient GABA concentration and potentiate the tonic currents, contributing to the antiepileptic effects.