The impact of extended waiting time on tumor regression after neoadjuvant chemoradiotherapy for locally advanced rectal cancer / 中华外科杂志

Objective: To investigate the influence of extending the waiting time on tumor regression after neoadjuvant chemoradiology (nCRT) in patients with locally advanced rectal cancer (LARC). Methods: Clinicopathological data from 728 LARC patients who completed nCRT treatment at the First Affiliated Hospital, Naval Medical University from January 2012 to December 2021 were collected for retrospective analysis. The primary research endpoint was the sustained complete response (SCR). There were 498 males and 230 females, with an age (M(IQR)) of 58 (15) years (range: 22 to 89 years). Logistic regression models were used to explore whether waiting time was an independent factor affecting SCR. Curve fitting was used to represent the relationship between the cumulative occurrence rate of SCR and the waiting time. The patients were divided into a conventional waiting time group (4 to <12 weeks, n=581) and an extended waiting time group (12 to<20 weeks, n=147). Comparisons regarding tumor regression, organ preservation, and surgical conditions between the two groups were made using the t test, Wilcoxon rank sum test, or χ2 test as appropriate. The Log-rank test was used to elucidate the survival discrepancies between the two groups. Results: The SCR rate of all patients was 21.6% (157/728). The waiting time was an independent influencing factor for SCR, with each additional day corresponding to an OR value of 1.010 (95%CI: 1.001 to 1.020, P=0.031). The cumulative rate of SCR occurrence gradually increased with the extension of waiting time, with the fastest increase between the 9th to <10th week. The SCR rate in the extended waiting time group was higher (27.9%(41/147) vs. 20.0%(116/581), χ2=3.901, P=0.048), and the organ preservation rate during the follow-up period was higher (21.1%(31/147) vs. 10.7%(62/581), χ2=10.510, P=0.001). The 3-year local recurrence/regrowth-free survival rates were 94.0% and 91.1%, the 3-year disease-free survival rates were 76.6% and 75.4%, and the 3-year overall survival rates were 95.6% and 92.2% for the conventional and extended waiting time groups, respectively, with no statistical differences in local recurrence/regrowth-free survival, disease-free survival and overall survival between the two groups (χ2=1.878, P=0.171; χ2=0.078, P=0.780; χ2=1.265, P=0.261). Conclusions: An extended waiting time is conducive to tumor regression, and extending the waiting time to 12 to <20 weeks after nCRT can improve the SCR rate and organ preservation rate, without increasing the difficulty of surgery or altering the oncological outcomes of patients.

Application of colonoscopic tattooing with India ink for localization of colorectal lesions in laparoscopic surgery / 中国内镜杂志

Objective?To investigate the use of submucosal injection of India ink for localization of colorectal lesions in laparoscopic surgery, and to evaluate its efficiency and safety.?Methods?A retrospective study of 146 patients with colorectal lesions from January 2015 to November 2017, who underwent preoperative colonoscopic marking with India ink and subsequently received laparoscopic colectomy was conducted. 1.0 ml of physiologic saline solution was first injected into the submucosa to produce an artificial submucosal elevation, and then 0.2 ml of 1 : 10 diluted India ink followed with another 1ml of physiologic saline solution was injected. Operation time, success rate, complications, location efficiency, and postoperative pathology were evaluated.?Results?The India ink tattooing was easily applied for all patients without complication. At laparoscopic surgery, all lesions could be clearly visualized. No ink diffusion, leakage, and local inflammatory responses were observed. The surgical margins of all samples were tumor negative.?Conclusion?Preoperative submucosal tattooing with India ink is recommended as an easy, safe and economical procedure.

Emergence application of colonoscopic placement of self-expandable metal stent without fluoroscopic monitoring / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy and safety of colonoscopy-guided placement of self-expandable metallic stent without fluoroscopic monitoring in the emergence management for acute malignant colorectal obstruction.</p><p><b>METHODS</b>Clinical data of 42 patients (24 males and 18 females with a mean age of 64.3 years) undergoing colonoscopy-guided placement of self-expandable metallic stents without fluoroscopic monitoring for acute malignant colorectal obstruction between January 2010 and June 2012 were reviewed retrospectively.</p><p><b>RESULTS</b>The obstruction was located in the rectum (n=19), sigmoid (n=9), descending colon (n=8), splenic flexure (n=1), hepatic flexure (n=3), and ascending colon (n=2). Technical success was achieved in all the 42 patients (100%). The mean time of operation was (11.8±10.4) min (range 1.1-51.0 min). No serious procedure-related complication occurred. Minor bleeding occurred in 3 cases (7.1%). One patient died on the second day after surgery because of heart failure.</p><p><b>CONCLUSIONS</b>Colonoscopy-guided placement of self-expandable metallic stents without fluoroscopic monitoring in emergence management for acute malignant colorectal obstruction is effective and safe with shorter operative time.</p>

Primary coloduodenal fistula / 中华胃肠外科杂志

Coloduodenal fistula (CDF) is uncommon, and it is often secondary to other colon and duodenal diseases that are benign or malignant. The clinical manifestations of CDF are variable, and upper abdominal pain, feculent vomiting and diarrhea are the common symptoms. Digestive tract contrast radiography and enhanced CT imaging are very helpful for diagnosing CDF, and gastrointestinal endoscopy can give more information about the fistula. Procedure selection should depend on whether the primary disease is malignant and the extent of the lesion. Because the duodenum has complicated anatomic relationship with its adjacent organs including bile duct system and pancreas, procedure for this clinical entity is a challenging task. Decision-making and experienced surgical skills are critical.

Association of tumor budding with clinicopathological characteristics and prognosis in T2 rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To demonstrate the association of tumor budding with clinicopathological features and prognosis in T2 rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 123 patients who underwent potentially curative resection for T2 rectal carcinoma between 2001 and 2005 at the Changhai Hospital were collected. All pathology slides were stained with hematoxylin and eosin for microscopic examinations. The maximum value of tumor buds(MV) and average value of tumor buds(AV) were calculated, which were classified as low value (≤5), median value (5 < bud value < 10), and high value (≥10).</p><p><b>RESULTS</b>Univariate analysis and multivariate analysis revealed that MV(P=0.000), AV(P=0.001), and lymphatic invasion (P=0.006) were independent predictors for lymph node metastasis in T2 rectal cancer. Neural invasion and poorly differentiation were significantly associated with MV(P<0.05). Neural invasion, vascular invasion and poorly differentiation were were significantly associated to AV (P<0.01). Disease-free survival (DFS) of patients with low AV, median AV and high AV was 110.5 months, 95.8 months, and 60.0 months respectively. There were significance differences in DFS of low AV with median and high AV(P<0.05). DFS of patients with low MV, median MV and high MV was 115.1 months, 98.5 months, and 86.0 months respectively. There were significance differences in DFS between low and high AV, and median and high MV(P<0.01 and P<0.05), while no significant difference existed between low and median MV.</p><p><b>CONCLUSION</b>Tumor budding is a useful marker to indicate high invasiveness of rectal cancer and a valuable prognostic predictor.</p>

Colonoscopic restoration for sigmoid vovulus in the elderly / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the emergency therapeutic strategy for sigmoid vovulus in the elderly.</p><p><b>METHODS</b>Clinical data of 14 elderly patients with sigmoid vovulus were analyzed retrospectively.</p><p><b>RESULTS</b>The mean age was(79.1±7.2) years(range, 70-93), and 11 patients (78.6%) were male. Emergency decompression and restoration with colonoscopy was performed in all the patients with a success rate of 100%. No patient required emergent surgery. Four patients(28.6%) recurred and they were managed well by repeat colonoscopic restoration.</p><p><b>CONCLUSION</b>Emergency colonoscopic restoration is the first treatment of choice for sigmoid vovulus in the elderly because it is safe and effective, and can be performed repeatedly.</p>

Surgical treatment of recurrent colorectal carcinoma in the elderly / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of surgical treatment for recurrent colorectal carcinoma in the elderly.</p><p><b>METHODS</b>The clinical and follow up data of 24 elderly patients with recurrent colorectal carcinoma who were treated between January 2000 and June 2009 at the Changhai hospital of the Second Military Medical University were analyzed retrospectively.</p><p><b>RESULTS</b>Among the 24 patients there were 14 men and 10 women. The mean age of the patients was 76.9 ± 5.3 years. The local recurrence was found in 15 patients. In 9 patients, both distant metastases and local recurrence were found. A total of 24 patients received operation, including radical resection in 15 patients and palliative resection in 8 patients. One patient had laparotomy only because of diffuse metastases in the abdomen and involvement of the duodenum and common bile duct.The patient received stent placement in the common bile duct and chemotherapy after the surgery. Postoperative complication occurred in 7(29.2%) patients, which included ileus(n=1), pulmonary infection(n=1), urinary infection(n=1), wound infection(n=2), wound dehiscence(n=1), and wound fat liquefaction(n=1). There were no perioperative deaths. The median survival time was 6 months in the entire cohort. The median survival time was 33 months in patients undergoing radical resection, and the 1-, 3-, and 5-year survival rate was 71.4%, 28.6%, and 14.3%. The median survival time was 3 months in patients who underwent palliative resection, and the 1-year survival rate was 0. The difference between the two groups was statistically significant(P<0.01).</p><p><b>CONCLUSION</b>Outcomes are acceptable after radical resection for elderly patients with recurrent colorectal cancer if careful preoperative evaluation and perioperative management are performed.</p>

Effect of colonoscopy combined with placement of metallic clips on selecting colonic surgery incision / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the accuracy and value of the placement of metallic clips during colonoscopy in the localization of colorectal cancer and incision selection.</p><p><b>METHODS</b>A total of 30 patients received metallic clip placement by colonoscopy before operation. Abdominal plain film (supine and upright position) was taken and incision was determined by the projection of clips on the abdominal wall.</p><p><b>RESULTS</b>The inaccuracy rate of localization by colonoscopy was 30%(9/30). Colonoscopy combined with the placement of metallic clips achieved an accurate incision rate of 100% (30/30).</p><p><b>CONCLUSIONS</b>There is a considerable rate of inaccuracy for localization in colonic cancer by colonoscopy. Colonoscopy combined with placement of metallic clips should be considered in order to select a reasonable incision.</p>

Lymph node metastasis and its risk factors in T1-2 staging invasive rectal carcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the lymph node metastasis and its risk factors in T1-2 staging invasive rectal carcinoma.</p><p><b>METHODS</b>The data of 1116 patients with rectal cancer treated with total mesorectal excision (TME) technique from January 2000 to April 2009 was analyzed retrospectively. The clinicopathological factors analyzed included gender, age, primary symptom type, number of symptoms, duration of symptom, synchronous polyps, preoperative serum carcino-embryonic antigen level, preoperative serum CA19-9 level, the distance of tumor from the anal verge, tumor size, tumor morphological type, tumor circumferential extent, tumor differentiation and tumor T staging. Statistical analysis was performed by using Logistic regression analysis and Chi-square test.</p><p><b>RESULTS</b>A total of 1116 patients were enrolled, and 358 cases (32.1%) were classified as with T1-2 staging tumor. Two cases (5.6%, 2/36) in patients with a T1 staging tumor were found with lymph node metastasis, and 75 cases (23.3%, 75/322) in patients with a T2 staging tumor, respectively. Compared with patients with T3-4 staging tumor, lymph node metastasis rate of the patients with T1-2 staging tumor was significantly lower [21.5% (77/358) vs. 51.6% (391/758), P < 0.05]. Only the tumor T staging was found as the independent risk factor for the lymph node metastasis in patients with T1-2 staging tumor on multivariate Logistic regression analysis (odds ratio: 5.162; 95%CI: 1.212 to 21.991; P = 0.026).</p><p><b>CONCLUSIONS</b>A substantial proportion of T1-2 staging rectal cancers harbor metastatic lymph nodes and the clinicopathological features except for T staging fail to predict the lymph node metastasis. Further research is warranted to identify the risk factors and guide the clinical practice in patient with T1-2 staging tumor.</p>

Impact of meticulousness of pathologists on lymph node harvest after radical resection of invasive rectal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the impact of meticulousness of pathologists on the lymph node harvest after radical resection of invasive rectal carcinoma.</p><p><b>METHODS</b>From January 2008 to May 2009, the clinical data of rectal cancer patients undergone operation were reviewed retrospectively. After multidisciplinary cooperation on rectal cancer, a new rule was applied to request the pathologists to find no less than 15 nodes in single colorectal specimen from January 2009. Patients were divided into two groups (2008 group and 2009 group) and the node harvest numbers were compared. Excluded criteria were recurrent colorectal tumor, Tis tumor, R(1) or R(2) resection, tumor resection transanally or endoscopically, the cases enrolled in other prospective research, synchronous diseases affecting the surgical procedure for the rectal cancer (familial adenomatous polyposis, synchronous colorectal carcinoma) and rectal cancer receiving neoadjuvant chemoradiation. Statistical analysis was performed using One-Sample Kolmogorov- Smirnov test, Mann-Whitney test, Independent-Samples T test and Chi-Square test(SPSS 15.0).</p><p><b>RESULTS</b>A total of 232 patients were identified, including 76 cases in the 2009 group and 156 cases in 2008 group. The lymph node retrieval in the 2009 group was significantly more than that in 2008 group (16.0+/-0.3 vs 11.4+/-0.3, P<0.01). A significantly higher percentage of patients was found in 2009 group with a lymph node harvest equal to or more than 12 nodes (72/76 vs 71/156, P<0.01). There were no significant differences in gender (46/76 vs 86/156, P=0.436), age (58.1+/-1.3 vs 59.2+/-1.1, P=0.527), distance from tumor to anal verge (7.4+/-0.4 vs 7.1+/-0.3, P=0.761), proportion of sphincter-sparing surgery (67/76 vs 140/156, P=0.715), ratio of well and moderate differentiated tumors (68/76 vs 125/156, P=0.074) and overall TNM stage (P=0.167) between the two groups.</p><p><b>CONCLUSIONS</b>The lymph node harvest in 2009 group is significantly more than that in 2008 group. The good performance of pathologists could produce adequate number of lymph nodes for rectal cancer without neoadjuvant chemoradiation.</p>

Transsacral resection for presacral tumors / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the operation indication and safety of presacral tumor.</p><p><b>METHODS</b>Clinical data of 36 patients with presacral tumor from November 1990 to May 2006 treated in our hospital, in whom 23 patients underwent trans-sacral operation, were analyzed retrospectively.</p><p><b>RESULTS</b>The operation time was from 43 to 210 min (average 94 min). The volume of blood loss was from 30 to 2000 ml (average 350 ml). Hospital stay was from 8 to 16 days (average 10.7 days). There were 13 different pathology types of tumors in the 36 patients including 26.4% of malignancy. Complications of trans-sacral operation included 1 case of ureteral damage, 1 case of sacral wound hernia, 1 case of presacral abscess who was healed by sigmoid stoma and wound drainage.</p><p><b>CONCLUSION</b>Trans-sacral resection of low presacral tumor is safe and effective with less trauma, less bleeding and quick recovery.</p>

Factors associated with anastomotic leakage after anterior resection in rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the factors associated with anastomotic leakage after anterior resection in rectal cancer with the technique of total mesorectal excision (TME).</p><p><b>METHODS</b>From January 2005 and December 2007, 738 consecutive patients with rectal cancer underwent anterior resection. The data of those patients was collected and reviewed retrospectively. The associations between anastomotic leakage and 9 patient-related variables as well as 7 surgical-related variables were examined.</p><p><b>RESULTS</b>Low rectal cancer (located 7 cm or less above the anal edge), non-specialized surgeon and transanal tube use were the risk factors associated with anastomotic leakage on univariate analysis. The anastomotic leakage rate of low-rectal cancer was significantly higher than that of high-rectal cancer (5.9% vs. 0.9%, P = 0.003). The anastomotic leakage rate of the cases operated by colorectal surgeon was significantly lower than that of the cases operated by non-specialized surgeon (3.9% vs. 11.3%, P = 0.031). There was a tendency for colorectal surgeons to operate on a greater proportion of low rectal cancer than non-specialized surgeons (72.1% vs. 52.8%, P = 0.003). The leakage rate of transanal tube group was unexpectedly higher than that in patients without transanal tube (14.5% vs. 3.6%, P < 0.001). On multivariate logistic regression analysis, diabetes mellitus (P = 0.027), distance less than 1 cm from tumor to distal resection margin (P = 0.009) and defunctioning stoma (P = 0.031) were also associated with anastomotic leakage rate besides low rectal cancer, non-specialized surgeon and transanal tube use. In a further analysis of 522 patients with low rectal cancer, the leakage rate of defunctioning stoma group was significantly lower than that of non-stoma group (2.9% vs. 8.5%, P = 0.007). By contract, the leakage rate of transanal tube group was still higher than that in patients without transanal tube (15.1% vs. 4.9%, P = 0.008) because of its poor protective effect as well as the selection bias.</p><p><b>CONCLUSIONS</b>Low-rectal cancer, non-specialized surgeons and diabetes mellitus are risk factors of anastomotic leakage after rectal surgery. A defunctioning stoma was effective in preventing leakage after low-rectal cancer surgery.</p>

Familial adenomatous polyposis: Clinical characteristics and current progress / 第二军医大学学报

Familial adenomatous polyposis (FAP) is an autosomal dominantly inherited syndrome. It will inevitably progress to colorectal carcinoma if not handled properly. The extracolonic manifestations of FAP play important role in the clinical diagnosis and prognosis of FAP patients. This paper reviews the clinical characteristics of FAP and current progress in its research.

Diagnosis and treatment of familial adenomatous polyposis: An outcome analysis of 96 cases / 第二军医大学学报

Objective: To discuss the clinical manifestations of familial adenomatous polyposis (FAP) and summarize our experience in diagnosing and treating the FAP patients. Methods: Clinical data of 96 FAP patients (1985-2003) were reviewed and colonoscopic findings were analyzed retrospectively. Abdominal CT findings and endoscopic findings of the upper digestive tract in 22 FAP patients (2001-2003) were analyzed retrospectively in an attempt to seek extrarectal pathological manifestations in FAP patients. Results: Densely grown polyps were found in the colorectum in most patients (52/96, 54.2%), while moderate-to-high density of polyps were found in the left hemicolon and rectum. Frequency of cancerization was high for rectal adenoma (23/41, 56.1%). Of the 22 FAP patients, 19 (19/22, 86.3%) had proliferative polyps of the gastric antrum and 18 (18/22, 81.8%) had duodenal polyps, including 12 duodenal adenomatous polyps, without a single case of cancerization. In 3 of the 22 FAP patients, desmoid tumors were detected in the abdominal wall, abdominopelvic cavity or mesentery of small intestine 5 years after colectomy. Of the 3 patients, only one was cured by complete resection of the tumor. Conclusion: Dense growth of polyps in the colorectum is a typical clinical manifestation of FAP. Frequency of cancerization is high for rectal adenoma. Colonoscopy is safe and effective for early diagnosis of FAP. Presence of polyps in the upper digestive tract is a common extrarectal manifestation of FAP. Cancerization of duodenal adenoma is rare in Chinese FAP patients. Desmoid tumor significantly influences postoperative quality of life of FAP patients who received prophylactic colectomy.

Significance of colonoscopy in screening of family members from familial adenomatous polyposis families / 第二军医大学学报

Objective: To study the diagnostic value of colonoscopy in screening of family members of a familial adenomatous polyposis (FAP) family. Methods: The colonoscopic findings of 38 sibs from 23 FAP families (1985-2002) were retrospectively studied. The diagnostic value of colonoscopy for screening FAP in FAP families was analyzed through determining the amount, morphology, and pathology of polyps. Results: Sixteen of the 38 sibs were found to have polypous growths, the positive screening rate being 42.1%; of the 16 cases of polypous growths, one was found to be severe atypical proliferation. The left hemicolon and rectum had dense polyps. Conclusion: Colonoscopy is a safe and reliable screening examination in sibs of FAP families.

Outcomes of subtotal proctocolectomy for familial adenomatous polyposis: A follow-up study of 21 clinical cases / 第二军医大学学报

Objective: To evaluate the short- and long-term outcomes of subtotal proctocolectomy for familial adenomatous polyposis (FAP). Methods: Twenty-one FAP patients who had undergone subtotal proctocolectomy during 1985-2000 in our department were followed up colonoscopically to observe whether there was any recurrence of polyps in postoperatively residual colon or/and rectum. Results: Adenomatous recurrence with variant degrees was detected in the residual colon or/and rectum in all 21 patients, the recurrence rate being 100%. Polypous growth was denser in the residual rectum than in the proximal residual colon. The adenomatous polyp in one patient cancerized 4 years after the initial operation. The cumulative occurrence of colorectal cancer was 4.8%. Conclusion: Subtotal proctocolectomy is a simple procedure for FAP with fewer complications, but there is a risk of polyps cancerization in the residual colon or/and rectum.

Diagnosis and surgical management for adult Hirschsprung's disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the diagnosis and surgical management of adult Hirschsprung's disease.</p><p><b>METHODS</b>Clinical data of 15 patients with adult Hirschsprung's disease were reviewed retrospectively from June 1992 to June 2004.</p><p><b>RESULTS</b>Patients age ranged from 17 to 54 years old. The main manifestations included long-term (ranged from 9.5 month to 50 years) constipation and abdominal distention. Acute abdominal pain occurred in six patients, but no sign of de hydration and malnutrition occurred in all patients. Bowel stenosis and dilation could be examined by barium enema. Soave procedure was performed in 3 patients, subtotal colectomy with coloanal anastomosis was performed in twelve patients. The function of defecation was improved in all patients after operation.</p><p><b>CONCLUSIONS</b>The diagnosis of adult Hirschsprung's disease mainly depends on the history of constipation from infant and barium enema. Subtotal colectomy with coloanal anastomosis is an effective and safe operative procedure.</p>