Development and validation of a prognostic prediction model for patients with stage Ⅰ to Ⅲ colon cancer incorporating high-risk pathological features / 中华外科杂志

Objective: To examine a predictive model that incorporating high risk pathological factors for the prognosis of stage Ⅰ to Ⅲ colon cancer. Methods: This study retrospectively collected clinicopathological information and survival outcomes of stage Ⅰ~Ⅲ colon cancer patients who underwent curative surgery in 7 tertiary hospitals in China from January 1, 2016 to December 31, 2017. A total of 1 650 patients were enrolled, aged (M(IQR)) 62 (18) years (range: 14 to 100). There were 963 males and 687 females. The median follow-up period was 51 months. The Cox proportional hazardous regression model was utilized to select high-risk pathological factors, establish the nomogram and scoring system. The Bootstrap resampling method was utilized for internal validation of the model, the concordance index (C-index) was used to assess discrimination and calibration curves were presented to assess model calibration. The Kaplan-Meier method was used to plot survival curves after risk grouping, and Cox regression was used to compare disease-free survival between subgroups. Results: Age (HR=1.020, 95%CI: 1.008 to 1.033, P=0.001), T stage (T3:HR=1.995,95%CI:1.062 to 3.750,P=0.032;T4:HR=4.196, 95%CI: 2.188 to 8.045, P<0.01), N stage (N1: HR=1.834, 95%CI: 1.307 to 2.574, P<0.01; N2: HR=3.970, 95%CI: 2.724 to 5.787, P<0.01) and number of lymph nodes examined (≥36: HR=0.438, 95%CI: 0.242 to 0.790, P=0.006) were independently associated with disease-free survival. The C-index of the scoring model (model 1) based on age, T stage, N stage, and dichotomous variables of the lymph nodes examined (<12 and ≥12) was 0.723, and the C-index of the scoring model (model 2) based on age, T stage, N stage, and multi-categorical variables of the lymph nodes examined (<12, 12 to <24, 24 to <36, and ≥36) was 0.726. A scoring system was established based on age, T stage, N stage, and multi-categorical variables of lymph nodes examined, the 3-year DFS of the low-risk (≤1), middle-risk (2 to 4) and high-risk (≥5) group were 96.3% (n=711), 89.0% (n=626) and 71.4% (n=313), respectively. Statistically significant difference was observed among groups (P<0.01). Conclusions: The number of lymph nodes examined was an independent prognostic factor for disease-free survival after curative surgery in patients with stage Ⅰ to Ⅲ colon cancer. Incorporating the number of lymph nodes examined as a multi-categorical variable into the T and N staging system could improve prognostic predictive validity.

Risk factors of postoperative surgical site infection in colon cancer based on a single center database / 中华胃肠外科杂志

Objective: To explore the incidence and risk factors of postoperative surgical site infection (SSI) after colon cancer surgery. Methods: A retrospective case-control study was performed. Patients diagnosed with colon cancer who underwent radical surgery between January 2016 and May 2021 were included, and demographic characteristics, comorbidities, laboratory tests, surgical data and postoperative complications were extracted from the specialized prospective database at Department of General Surgery, Peking Union Medical College Hospital. Case exclusion criteria: (1) simultaneously multiple primary colon cancer; (2) segmental resection, subtotal colectomy, or total colectomy; (3) patients undergoing colostomy/ileostomy during the operation or in the state of colostomy/ileostomy before the operation; (4) patients receiving natural orifice specimen extraction surgery or transvaginal colon surgery; (5) patients with the history of colectomy; (6) emergency operation due to intestinal obstruction, perforation and acute bleeding; (7) intestinal diversion operation; (8) benign lesions confirmed by postoperative pathology; (9) patients not following the colorectal clinical pathway of our department for intestinal preparation and antibiotic application. Univariate analysis and multivariate analysis were used to determine the risk factors of SSI after colon cancer surgery. Results: A total of 1291 patients were enrolled in the study. 94.3% (1217/1291) of cases received laparoscopic surgery. The incidence of overall SSI was 5.3% (69/1291). According to tumor location, the incidence of SSI in the right colon, transverse colon, left colon and sigmoid colon was 8.6% (40/465), 5.2% (11/213), 7.1% (7/98) and 2.1% (11/515) respectively. According to resection range, the incidence of SSI after right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoid colectomy was 8.2% (48/588), 4.5% (2/44), 4.8% (8 /167) and 2.2% (11/492) respectively. Univariate analysis showed that preoperative BUN≥7.14 mmol/L, tumor site, resection range, intestinal anastomotic approach, postoperative diarrhea, anastomotic leakage, postoperative pneumonia, and anastomotic technique were related to SSI (all P<0.05). Multivariate analysis revealed that anastomotic leakage (OR=22.074, 95%CI: 6.172-78.953, P<0.001), pneumonia (OR=4.100, 95%CI: 1.546-10.869, P=0.005), intracorporeal anastomosis (OR=5.288, 95%CI: 2.919-9.577,P<0.001) were independent risk factors of SSI. Subgroup analysis showed that in right hemicolectomy, the incidence of SSI in intracorporeal anastomosis was 19.8% (32/162), which was significantly higher than that in extracorporeal anastomosis (3.8%, 16/426, χ(2)=40.064, P<0.001). In transverse colectomy [5.0% (2/40) vs. 0, χ(2)=0.210, P=1.000], left hemicolectomy [5.4% (8/148) vs. 0, χ(2)=1.079, P=0.599] and sigmoid colectomy [2.1% (10/482) vs. 10.0% (1/10), χ(2)=2.815, P=0.204], no significant differences of SSI incidence were found between intracorporeal anastomosis and extracorporeal anastomosis (all P>0.05). Conclusions: The incidence of SSI increases with the resection range from sigmoid colectomy to right hemicolectomy. Intracorporeal anastomosis and postoperative anastomotic leakage are independent risk factors of SSI. Attentions should be paid to the possibility of postoperative pneumonia and actively effective treatment measures should be carried out.

Safety and prognosis analysis of transanal total mesorectal excision versus laparoscopic mesorectal excision for mid-low rectal cancer / 中华胃肠外科杂志

Objective: To compare the short-term and long-term outcomes between transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laTME) for mid-to-low rectal cancer and to evaluate the learning curve of taTME. Methods: This study was a retrospective cohort study. Firstly, consecutive patients undergoing total mesorectal excision who were registered in the prospective established database of Division of Colorectal Diseases, Department of General Surgery, Peking Union Medical College Hospital during July 2014 to June 2020 were recruited. The enrolled patients were divided into taTME and laTME group. The demographic data, clinical characteristics, neoadjuvant treatment, intraoperative and postoperative complications, pathological results and follow-up data were extracted from the database. The primary endpoint was the incidence of anastomotic leakage and the secondary endpoints included the 3-year disease-free survival (DFS) and the 3-year local recurrence rate. Independent t-test for comparison between groups of normally distributed measures; skewed measures were expressed as M (range). Categorical variables were expressed as examples (%) and the χ(2) or Fisher exact probability was used for comparison between groups. When comparing the incidence of anastomotic leakage, 5 variables including sex, BMI, clinical stage evaluated by MRI, distance from tumor to anal margin evaluated by MRI, and whether receiving neoadjuvant treatment were balanced by propensity score matching (PSM) to adjust confounders. Kaplan-Meier curve and Log-rank test were used to compare the DFS of two groups. Cox proportional hazard model was used to analyze and determine the independent risk factors affecting the DFS of patients with mid-low rectal cancer. Secondly, the data of consecutive patients undergoing taTME performed by the same surgical team (the trananal procedures were performed by the same main surgeon) from February 2017 to March 2021 were separately extracted and analyzed. The multidimensional cumulative sum (CUSUM) control chart was used to draw the learning curve of taTME. The outcomes of 'mature' taTME cases through learning curve were compared with laTME cases and the independent risk factors of DFS of 'mature' cases were also analyzed. Results: Two hundred and forty-three patients were eventually enrolled, including 182 undergoing laTME and 61 undergoing taTME. After PSM, both fifty-two patients were in laTME group and taTME group respectively, and patients of these two groups had comparable characteristics in sex, age, BMI, clinical tumor stage, distance from tumor to anal margin by MRI, mesorectal fasciae (MRF) and extramural vascular invasion (EMVI) by MRI and proportion of receiving neoadjuvant treatment. After PSM, as compared to laTME group, taTME group showed significantly longer operation time [(198.4±58.3) min vs. (147.9±47.3) min, t=-4.321, P<0.001], higher ratio of blood loss >100 ml during surgery [17.3% (9/52) vs. 0, P=0.003], higher incidence of anastomotic leakage [26.9% (14/52) vs. 3.8% (2/52), χ(2)=10.636, P=0.001] and higher morbidity of overall postoperative complications [55.8%(29/52) vs. 19.2% (10/52), χ(2)=14.810, P<0.001]. Total harvested lymph nodes and circumferential resection margin involvement were comparable between two groups (both P>0.05). The median follow-up for the whole group was 24 (1 to 72) months, with 4 cases lost, giving a follow-up rate of 98.4% (239/243). The laTME group had significantly better 3-year DFS than taTME group (83.9% vs. 73.0%, P=0.019), while the 3-year local recurrence rate was similar in two groups (1.7% vs. 3.6%, P=0.420). Multivariate analysis showed that and taTME surgery (HR=3.202, 95%CI: 1.592-6.441, P=0.001) the postoperative pathological staging of UICC stage II (HR=13.862, 95%CI:1.810-106.150, P=0.011), stage III (HR=8.705, 95%CI: 1.104-68.670, P=0.040) were independent risk factors for 3-year DFS. Analysis of taTME learning curve revealed that surgeons would cross over the learning stage after performing 28 cases. To compare the two groups excluding the cases within the learning stage, there was no significant difference between two groups after PSM no matter in the incidence of anastomotic leakage [taTME: 6.7%(1/15); laTME: 5.3% (2/38), P=1.000] or overall complications [taTME: 33.3%(5/15), laTME: 26.3%(10/38), P=0.737]. The taTME was still an independent risk factor of 3-year DFS only analyzing patients crossing over the learning stage (HR=5.351, 95%CI:1.666-17.192, P=0.005), and whether crossing over the learning stage was not the independent risk factor of 3-year DFS for mid-low rectal cancer patients undergoing taTME (HR=0.954, 95%CI:0.227-4.017, P=0.949). Conclusions: Compared with conventional laTME, taTME may increase the risk of anastomotic leakage and compromise the oncological outcomes. Performing taTME within the learning stage may significantly increase the risk of postoperative anastomotic leakage.

Prognosis and complications of local excision for rectal cancer after neoadjuvant chemoradiotherapy / 中华胃肠外科杂志

Objective: To investigate the prognosis and postoperative complications of local excision for rectal cancer after neoadjuvant chemoradiotherapy (nCRT). Methods: A descriptive case series study was carried out. Patient inclusion criteria: (1) patients who underwent local excision by transanal endoscopic microsurgery (TEM) after nCRT; (2) magnetic resonance evaluated tumor regression grade (mrTRG) as 1, 2 after nCRT;(3) American Society of Anesthesiologists class I to III. Patient exclusion criteria: (1) with multiple primary colorectal cancers; (2) with other malignant tumors within five years; (3) with emergency surgicery indications like digestive tract obstruction, perforation or bleeding. Clinicopathological and follow-up data of rectal cancer patients with obvious tumor regression after nCRT who underwent local excision in Peking Union Medical College Hospital from January 2010 to August 2019 were retrospectively collected. Outcome measures included disease-free survival (DFS), short-term postoperative complications, and at postoperative 1-year during follow up, gas continence, fecal continence, and quality of life (using the EORTC QLQ-CR29 scale, higher score indicated worse quality of life) at postoperative 1-year. Results: A total of 40 patients were included in this study. There were 27 males and 13 females with an average age of (66.7±12.3) years. Preoperative rectal ultrasound and other imaging examinations indicated that the tumor was located in the anterior wall in 16 cases, the lateral wall in 12 cases, and the posterior wall in 12 cases. The distance between the lower margin of the tumor and the anal verge was (4.3±1.2) cm before nCRT and (5.1±0.9) cm after nCRT. According to mrTRG, 31 cases were assessed as mrTRG 1 and 9 cases as mrTRG 2. All the patients received local extended excision of rectal cancer using TEM platform. A total of 19 cases(47.5%) suffered from complications within one month postoperatively. Clavien-Dindo grade I complications happened in 14 cases, grade II in 3 patients, and grade III in 2 cases, who all were healed by conservative treatment. Except that 2 patient presented severe low anterior resection syndrome (LARS) at 1 year postoperatively, no severe anal dysfunction was found in this cohort patients. EORTC QLQ CR29 scale results for quality of life showed that at 1 year after TEM excision, except taste (Z=-1.968, P=0.049), anxiety (Z=-3.624, P<0.001) and skin irritation (Z=-2.420, P=0.023) were worse than the situation before neoadjuvant therapy, there were no statistically significant differences in other assessment results between pre-operation and post-operation (all P>0.05). Postoperative pathological results indicated complete tumor regression (pTRG0) in 17 cases, moderate remission (pTRG1) in 13, and mild remission (pTRG2) in 10. During the follow-up of (49.1±29.6) months, 3 patients had local recurrence and 4 had distant metastasis (3 patients with liver metastasis and 1 patient with lung metastasis followed by liver metastasis). No death was found and the 5-year disease-free survival (DFS) was 84.3%. Conclusions: Local excision through TEM following nCRT not only can be adopted as an important means to accurately determine complete clinical remission (cCR), but also has high therapeutic value for rectal cancer patients presenting cCR or near cCR, with little impact on defecatory function and quality of life. However, the morbidity of complication of TEM excision after nCRT is relatively high and there is a risk of recurrence and metastasis. Therefore, it is still necessary to strictly select the indications of local excision.

Protective colostomy and protective ileostomy for the prevention of anastomotic leak in patients with rectal cancer after neoadjuvant chemoradiotherapy and radical surgery / 中华胃肠外科杂志

Objective: To investigate whether protective colostomy and protective ileostomy have different impact on anastomotic leak for rectal cancer patients after neoadjuvant chemoradiotherapy (nCRT) and radical surgery. Methods: A retrospectively cohort study was conducted. Inclusion criteria: (1) Standard neoadjuvant therapy before operation; (2) Laparoscopic rectal cancer radical resection was performed; (3) During the operation, the protective enterostomy was performed including transverse colostomy and ileostomy; (4) The patients were followed up regularly; (5) Clinical data was complete. Exclusion criteria: (1) Colostomy and radical resection of rectal cancer were not performed at the same time; (2) Intestinal anastomosis is not included in the operation, such as abdominoperineal resection; (3) Rectal cancer had distant metastasis or multiple primary colorectal cancer. Finally 208 patients were included in this study. They suffered from rectal cancer and underwent protective stoma in radical surgery after nCRT at our hospital from January 2014 to December 2018. There were 148 males and 60 females with age of (60.5±11.1) years. They were divided into protective transverse colostomy group (n=148) and protective ileostomy group (n=60). The main follow up information included whether the patient has anastomotic leak and the type of leak according to ISREC Grading standard. Besides, stoma opening time, stoma flow, postoperative hospital stay, stoma related complications and postoperative intestinal flora were also collected. Results: A total of 28 cases(13.5%) suffered from anastomotic leak and 26 (92.9%) of them happened in the early stage after surgery (less than 30 days) . As for these early-stage leak, ISREC Grade A happened in 11 cases(42.3%), grade B in 15 cases(57.7%) and no grade C occurred. There was no significant difference in the incidence [12.8% (19/148) vs. 15.0% (9/60) , χ(2)=0.171, P=0.679] or type [Grade A: 5.4%(8/147) vs. 5.1%(3/59); Grade B: 6.8%(10/147) vs. 8.5%(5/59), Z=0.019, P=1.000] of anastomotic leak between the transverse colostomy group and ileostomy group (P>0.05), as well as operation time, postoperative hospital stay, drainage tube removal time or stoma reduction time (P>0.05). There were 10 cases (6.8%) and 24 cases (40.0%) suffering from intestinal flora imbalance in protective transverse colostomy and protective ileostomy group, respectively (χ(2)=34.503, P<0.001). Five cases (8.3%) suffered from renal function injury in the protective ileostomy group, while protective colostomy had no such concern (P=0.002). The incidence of peristomal dermatitis in the protective colostomy group was significantly lower than that in the protective ileostomy group [12.8% (9/148) vs. 33.3%(20/60), χ(2)=11.722, P=0.001]. Conclusions: It is equally feasible and effective for rectal cancer patients after nCRT to carry out protective transverse colostomy or ileostomy in radical surgery. However, we should pay more attention to protective ileostomy patients, as they are at high risk of intestinal flora imbalance, renal function injury and peristomal dermatitis.

Effect of modified laparoscopic Bacon coloanal anastomosis in transanal totalmesorectal excision:A 8 cases report / 中国实用外科杂志

OBJECTIVE: To explore the effect of modified Bacon coloanal anastomosis in transanal total mesorectal excision(TaTME).METHODS: The clinical data of 8 patients with low rectal cancer treated with TaTME from January 2016 to January 2019 in the division of colorectal surgery of department of general surgery of Peking Union Medical College Hospital were retrospectively analyzed. Laparoscopic assisted modified Bacon coloanal anastomosis was used during operation. The incidence of postoperative complications including anastomotic leakage was observed and the anal function was evaluated.RESULTS: All 8 patients underwent operation successfully. The distance from the inferior margin of the tumor to the anal verge was(4.8 ±0.4) cm. The number of retrieved lymph nodes in postoperative pathological examination was(12.9±2.5). The mean time of first operation was(140.8±8.6) min, and the Second stage operation time was(39.1±9.6) min. The median time between the two operations was 19(13, 20) days, and the median hospital stay was22(17, 24) days. The median follow-up time was 16(4, 36) months. No anastomotic leakage occurred and the anal function was good after operation. Six patients had uncontrollable anal exhaust after operation, and two patients had occasional mucous or watery fecal incontinence after operation, but they were less than once a month. They could be improved by dietary structure adjustment and external sanitary pads.CONCLUSION: Laparoscopic-assisted modified Bacon operation in TaTME avoids anastomotic leakage, and reduces the incidence of anal incontinence after operation.However, the hospital stay is prolonged.

Prognostic Superiority of Log Odds of Positive Lymph Nodes in Stage 3 Colorectal Cancer / 中国医学科学院学报

Objective To evaluate the prognostic value of the log odds of positive lymph nodes (LODDS) in stage 3 colorectal cancer (CRC) patients who have undergone curative resection. Methods We performed a retrospective review of 175 stage 3 CRC patients who underwent curative resection in Peking Union Medical College Hospital from 2005 to 2012. Patients were categorized respectively according to the AJCC/UICC N grade,the metastatic lymph node ratio (LNR),and the ratio of their LODDS. The relationship between the N grade,LNR,LODDS,and overall survival (OS) rates were assessed.Results The five-year disease-free survival (DFS) was significantly different among stage 3 CRC patients in different N grade (Χ(2)=33.1,P=0.000),LNR (Χ(2)=14.3,P=0.001),and LODDS (Χ(2)=14.9,P=0.001). Univariate analysis showed that TNM stage (Χ(2)=27.0,P=0.000),cancerous node(Χ(2)=3.6,P=0.040),N grade (Χ(2)=33.1,P=0.000),LNR (Χ(2)=14.3,P=0.001),and LODDS (Χ(2)=30.4,P=0.000) were related to OS. Multivariate analysis indicated that TNM stage (HR:1.84,95%CI:1.59～6.29,P=0.001) and LODDS classification (HR:1.34,95%CI:1.01～1.80,P=0.047) were independent prognostic factors for OS in stage 3 CRC patients. Conclusion LODDS is a good prognostic indicator in stage 3 CRC patients who have undergone curative resection.

Three major problems and solutions in laparoscopic abdominoperineal resection for rectal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the three major problems and solutions in laparoscopic abdominoperineal resection(APR) for rectal carcinoma.</p><p><b>METHODS</b>A retrospective study of 60 low rectal carcinoma cases undergoing selective laparoscopic APR from September 2010 to May 2013 in our hospital was undertaken. A laparoscopic sigmoid stoma was performed through the extraperitoneal route at the left lower abdomen puncture point after lymphadenectomy and tumor excision during operation. Using the unique intracorporeal suture technique of transanal endoscopic microsurgery(TEM), the pelvic peritoneum was closed by continuous suture with TEM needle-forceps and absorbable suture. Those patients with the successful pelvic peritoneum closure received continuous irrigation of presacral space from the third postoperative day to prevent perineal incision infection.</p><p><b>RESULTS</b>Only one patient (1.7%) was converted to laparotomy. Fifty-nine patients underwent laparoscopic APR and laparoscopic sigmoid stoma was successfully performed through the extraperitoneal route without abdominal incision, and the incidence of stoma complication was only 3.4%. Out of 59 patients undergoing laparoscopic APR, the pelvic peritoneum of 56 patients(94.9%) was closed successfully. The median time of closing the pelvic peritoneum was 15 min. Fifty-seven patients with pelvic peritoneum successfully closed by laparotomy or laparoscopic approach received continuous irrigation of presacral space and the median time of presacral drainage tube placement was 7.8 days. No patient developed postoperative intestinal obstruction. The rate of perineal wound healing in grade A, B and C was 87.7%, 8.8% and 3.5%, respectively. In the 3 patients whose pelvic peritoneum failed to be closed with simple drainage of presacral space, one developed postoperative intestinal obstruction and one had a grade C perineal wound healing.</p><p><b>CONCLUSIONS</b>Laparoscopic sigmoid stoma through the extraperitoneal route during laparoscopic APR for rectal carcinoma is feasible and safe. It is convenient and effective to close pelvic peritoneum by using TEM intracorporeal suture technique. It is worth discussing the role of continuous irrigation of presacral space postoperatively to prevent perineal incision infection.</p>

Clinical application of anterior perineal plane for ultra-low anterior resection of the rectum / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize clinical experience in the treatment of low rectal cancer with anterior perineal plane for ultra-low anterior resection of the rectum(APPEAR).</p><p><b>METHODS</b>Clinical and follow-up data of 26 patients with low rectal cancer undergoing the APPEAR operation in Department of General Surgery at Peking Union Medical College from September 2009 to August 2011 were retrospectively analyzed.</p><p><b>RESULTS</b>The 26 cases consisted of 19 male and 7 female patients with an average age of (63.4 ± 9.5) years. The average tumor distance from the anal verge was (4.6 ± 0.7) cm according to preoperative examinations. Fourteen patients received neoadjuvant radiochemotherapy before the operation. All the 26 patients had successful sphincter-preserving operations. The average operative time was (170 ± 21) min and the average intra-operative blood loss (140 ± 69) ml. Complications included one case of intraoperative injury to the rectal wall and 4 cases of postoperative perineal wound infection. Postoperative pathological examination showed well to moderately differentiated adenocarcinomas(n=10), moderately differentiated adenocarcinomas with partial mucinous adenocarcinomas (n=7), poorly differentiated adenocarcinoma(n=1), villous adenoma with high-grade intraepithelial neoplasia (n=1), and rectal villous adenoma(n=1). In 6 cases no residual tumor cells were detected in the surgical specimens. All the patients were followed-up for an average period of(11.4 ± 5.6) months. No impaired urinary function or tumor recurrence was observed during the follow-up. Eighteen patients had the transverse colon stoma closure six months after the operation. The average Wexner continence score was 5.5 after colostomy reversal surgery. The anorectal manometry tests showed that maximum squeeze pressure of the anal sphincter was(224.0 ± 59.3) mm Hg. The maximum resting pressure was (42.5 ± 11.8) mm Hg, and the maximum tolerable volume of the rectum was (120.0 ± 27.4) ml. Anorectal reflexes were present in all these patients.</p><p><b>CONCLUSION</b>The APPEAR technique can be applied in the sphincter-preserving operations for low rectal cancer patients with satisfactory anal function.</p>

A comparative study upon two surgical procedures of local resection of early rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the application of transanal endoscopic microsurgery (TEM) technique with Mason's operation in the treatment of early rectal cancer.</p><p><b>METHODS</b>Patients with early rectal cancer were divided into two groups according to different surgical procedures they underwent during different period. Patients in Mason Group underwent Mason's operations during the period from January 2000 to March 2006; and in TEM Group were managed with TEM procedures from April 2006 to July 2011. There were 21 patients in TEM Group and 26 patients in Mason Group. No statistically significant difference was found between the two groups in terms of patient's age, gender, preoperative TNM staging, and tumor diameter. In comparison with Mason Group, TEM Group had a longer distance of the tumor from the anal verge. The safety, postoperative complications, patients' postoperative recovery, and the oncological outcomes of 2 groups were compared with each other.</p><p><b>RESULTS</b>No perioperative death occurred in the two groups. The TEM Group had notably shorter operating time ((67 ± 24) minutes) and lesser intra-operative blood loss ((9 ± 6) ml) than Mason Group (t = 3.526 and 7.078, P < 0.05). The time of the postoperative bed rest, the urinary drainage, the recovery of oral intake, and the hospital stay in TEM Group were (1.3 ± 0.5) days, (1.2 ± 0.4) days, (1.5 ± 0.5) days, and (4.3 ± 1.6) days, respectively, and all were prominently shorter than those of Mason group (t = 4.925 - 14.640, P < 0.05). Patients in TEM group were followed up for an average of 36.5 months with one patient being lost, while patients in Mason group were followed up for an average of 81.6 months. The difference between the two groups in terms of short-term accumulated survival (94.8% vs. 96.3%) showed no statistical significance (P > 0.05).</p><p><b>CONCLUSION</b>TEM technique is a favorable minimally invasive procedure associated with satisfactory oncological outcomes in the treatment of early rectal cancer.</p>

Expression of hMLH1 in rectal intraepithelial neoplasm and early rectal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore whether the abnormality of hMLH1 gene may be an early event of carcinogenesis in rectal carcinoma, and to evaluate the diagnostic value in differentiation between intraepithelial neoplasm and early stage of colorectal carcinoma.</p><p><b>METHODS</b>The expression of hMLH1 protein in 28 cases with early invasive rectal carcinoma(EIRC), 36 cases with rectal intraepithelial neoplasm(RIEN), and 30 cases with normal rectal mucosa(NRM) which were collected through surgical operations were detected by PV-9000 immunohistochemical method.</p><p><b>RESULTS</b>The positive expression rates of hMLH1 protein were 100%(30/30), 77.8%(28/36), and 39.3%(11/28) in NRM, RIEN, and EIRC respectively. The difference was statistically significant between RIEN and EIRC(P=0.002), and the difference was also statistically significant between RIEN and NRM(P=0.006). The positive expression of hMLH1 was not related to age, gender, tumor maximum diameter, dysplasia, tumor types, and distance from the anal verge in RIEV group(P>0.05). In EIRC group, hMLH1 was associated with tumor differentiation(P<0.05).</p><p><b>CONCLUSION</b>hMLH1 gene deletion may be an early event during carcinogenesis of rectal carcinoma, which may be useful in differentiation of intraepithelial neoplasm from early rectal carcinoma.</p>

Safety and efficacy of prophylactic single antibiotics administration in selective open colorectal surgery / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the safety and efficacy of prophylactic single antibiotic administration in selective open colorectal surgery.</p><p><b>METHODS</b>Two hundred and seventy-five patients undergoing selective open colorectal surgery in the Peking Union Medical College Hospital from October 2009 to October 2011 were retrospectively reviewed. Prophylatic single antibiotic administration was used by intravenous infusion 30-60 min before incision. No antibiotics would be given after operation if there was no surgical site infection(SSI). According to the incidence of postoperative SSI, unexplained use of antibiotics, anastomotic leakage and distant-site infection, the clinical outcome was assessed to be prophylactic success, prophylactic failure or distant-site infection, respectively.</p><p><b>RESULTS</b>There was no intraoperative or postoperative antibiotics related drug anaphylaxis in all the 275 patients. By prophylactic single antibiotic administration, there were prophylactic success in 243 patients(88.4%,243/275), prophylactic failure in 23(8.4%,23/275), distant-site infection in 9(3.3%,9/275). In the 23 patients with failed prophylaxis, there were SSI in 13(4.7%,13/275) patients, postoperative use of broad-spectrum antibiotics for unexplained fever in 2(0.7%,2/275), postoperative anastomotic leakage in 8(3.6%,8/222).</p><p><b>CONCLUSION</b>Prophylactic single antibiotic administration in selective open colorectal surgery is safe and effective.</p>

Transanal endoscopic microsurgery for rectal cancer / 中华胃肠外科杂志

In comparison with the radical resection for rectal cancer, the local excision of rectal cancer is associated with advantages of less trauma, lower risks, anal sphincter preservation, and sexual and urinary function preservation. Being one of the local excision techniques for rectal cancers, transanal endoscopic microsurgery(TEM) becomes increasingly prevailing worldwide in recent years. As compared to traditional local excision procedures, TEM has been proven to improve the operative exposure and provide more adequate operating space. In addition, the TEM is equipped with multiple well-crafted surgical instruments that offer superior performances, which allows delicate surgical dissection and precise tumor excision. TEM provides surgeons with perfect technical support to decrease the chance of or to prevent insufficient removal of the lesion, which leaves an unsafe or positive surgical margin. Good therapeutic results are based on the accurate preoperative evaluation and careful selection of the patient, as well as strict adherence to the indications of this procedure. The best indications for TEM procedure include rectal adenomas with high-grade dysplasia (Tis stage), medium- or low-risk T1 rectal cancers, and cancers that only infiltrate into the Sm1 and Sm2 layers of the submucosa. Patients of T2 and T3 rectal cancers acquiring marked tumor downstaging (or tumor size decreases by more than 50%) after the neoadjuvant therapy may also be candidates for TEM local excision in clinical research studies. TEM technique enables a locally radical excision of the lesion, which is the key to prevent the postoperative recurrence.

Acquiring laparoscopic skill for colorectal surgery: based on the experience of a colorectal surgeon / 中华外科杂志

<p><b>OBJECTIVE</b>Laparoscopic colorectal surgery is a skill-dependent procedure. The present study aims to analyze the learning curve of a properly trained surgeon, with basic laparoscopic techniques, to become skillful in performing laparoscopic colorectal operations.</p><p><b>METHODS</b>A series of non-selective, consecutive 189 cases of laparoscopic colorectal surgery were accomplished, from December 2009 to February 2012, by one surgeon with years of skilled technique in laparoscopic cholecystectomy, rich experience in assisting laparoscopic colorectal surgery, and experience of approximately 180 procedures of gastric and colorectal surgery annually. 170 out of 189 procedures were radical operations for colorectal neoplasma, including right colectomies in 28 cases, left colectomies in 5 cases, sigmoidectomies in 28 cases, high Dixon procedures in 45 cases, low Dixon (total mesorectal excision, TME) procedures in 41 cases and Miles procedure in 23 cases. 19 other patients underwent combined procedures for multi-primary tumors or inflammatory enteritis. All these procedures were analyzed according to time span (the earlier half and later half) in respect to length of surgery, intraoperative blood loss, number of lymph nodes retrieved, intraoperative events and postoperative complications.</p><p><b>RESULTS</b>For radical right colectomy, the D2 dissection conducted in the earlier phase (n = 8) had the similar length of surgery, more blood loss and less LN retrieval, compared with the D3 dissection conducted in recent phase (n = 20). The earlier performed high Dixon procedures (n = 22) consumed longer time than the later procedures (n = 23) consumed, but with similar blood loss and LN retrieval. Low Dixon (TME) procedures showed significant differences in length of surgery and blood loss relative to time span. Recently performed simoidectomy and Miles procedures showed a trend of shorter time consumed compared with earlier performed procedures. Conversion ratio to open surgery was 1.05%. Adverse effects occurred in 8 cases of surgeries, including intestinal injury (3/189), insufficient distal margin (2/189), intraoperative bleeding (2/189) and vaginal injury (1/76). There was no operative death. Chief complications included urinary retention 5.82%, ileus 4.76%, anastomotic leak 4.24%, perineal infection 23.08% (6/26), wound dehiscence 2.65%, gastrointestinal bleeding 1.59%, peritoneal infection 1.06%. Surgery for distal rectum tended to have more complications, such as urinary retention, anastomotic leak and perineal infection. The later performed low Dixon procedures produced insignificantly fewer anastomotic leaks than those in the earlier phase.</p><p><b>CONCLUSIONS</b>For a trained surgeon with basic laparoscopic techniques, there are at least 15 - 25 cases of different procedures needed for him/her to become skilled to perform laparoscopic surgery. The learning curve should also depend on the annual number of colorectal surgeries.</p>

Laparoscopic-assisted anterior perineal plane for ultra-low anterior resection of the rectal cancer(APPEAR) / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To report a case of APPEAR performed using a laparoscopic-assisted approach.</p><p><b>METHODS</b>A laparoscopic-assisted APPEAR was performed with end-to-end anastomosis on October 12, 2010 for a patient with low rectal cancer who received neoadjuvant chemoradiation. After total mesorectal excision was completed laparoscopically, a crescent-shape incision was then made in the middle perineum. The distal part of the rectum was dissected with electrocautery. An double-stapling end-to-end anastomosis was performed after transaction of the rectum.</p><p><b>RESULTS</b>Total operative time was 195 minutes. The perineal approach cost 30 minutes. The estimated blood loss was 50 ml. First stoma output with flatus was on postoperative day 3, and the patient resumed liquid diet. The patient was discharged on postoperative day 7. There were no complications including pelvic sepsis, perineal infection, or anastomotic leak.</p><p><b>CONCLUSION</b>The APPEAR procedure can be performed safely with the abdominal approach completed laparoscopically.</p>

Impact of neoadjuvant chemoradiation on perineal wound healing after abdominoperineal resection for lower rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the impact of neoadjuvant chemoradiation on perineal wound healing following abdominoperineal resection(APR) for lower rectal cancer.</p><p><b>METHODS</b>Data of 93 patients who underwent APR for low rectal cancer between January 2005 and January 2009 in Peking Union Medical College Hospital were reviewed, including patients who received neoadjuvant chemoradiation (n=29) and those undergoing surgery alone(n=64). Perineal wound healing was the primary outcome measurement. Condition of wound healing was classified as good, moderate, and poor and was compared between the two groups.</p><p><b>RESULTS</b>Twenty nine patients in the neoadjuvant group received preoperative regional radiation(50 Gy, 25 fractions/5 weeks) with synchronous FOLFOX4 chemotherapy(fluorouracil and oxaliplatin). In the neoadjuvant group, wound healing after APR was good in 18 patients(62.1%), moderate in 6(20.7%), and poor in 5(17.2%). In patients who had surgery alone, wound healing after APR was good in 41 patients(64.1%), moderate in 15(23.4%), and poor in 8(12.5%). There was no significant difference in the incidence of wound infection(poor wound healing)between the two groups(P=0.773).</p><p><b>CONCLUSION</b>Neoadjuvant chemoradiation therapy is not associated with increased perineal wound infection following abdominoperineal resection for low rectal cancer.</p>

Hand-assisted laparoscopic versus laparoscopic-assisted right hemicolectomy: a clinical controlled study / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the outcomes of right hemicolectomy performed either by the hand-assisted laparoscopic(HALS) or conventional laparoscopic surgery(LAS).</p><p><b>METHODS</b>Ninety-five patients undergoing HALS(n=47) from March 2002 to November 2006 or by LAS (n=48) from January 2007 to December 2009 were retrospectively studied. All the operations were performed by the same surgical team. Patient safety, postoperative recovery, complications, oncologic outcomes, medical expenses, and the follow-up results were compared between the two groups.</p><p><b>RESULTS</b>No severe complications or perioperative deaths were oberved. There were significant differences between the two groups in terms of intraoperative bleeding, operative time, and length of incision(all P<0.05). However, the conversion rate, intraoperative injuries, time to first bowel movement, postoperative bed-rest time, hospital stay, time to first oral intake, and the number of patients requiring postoperative analgesia were comparable between the two groups(P>0.05). Length of surgical specimen was (25.6±9.9) cm in the HALS group and was (26.8±7.9) cm in the LAS group, the diffenence was not statistically significant(P<0.05). The mean number of lymph nodes retrieved in HALS group was 18.2±12.1, which was significantly lower than that in LAS group(24.1±9.3, P<0.05). The medical expense of the LAS group was (28 049.8±7576.1) RMB, which was significantly higher than that of the HALS group(21 132.7±5323.4) RMB(P<0.05). A follow-up rate of 93.7% was achieved in the HALS group with 3 patients lost to follow-up. The follow-up duration ranged from 45.4 to 101.9 months with a median of 66.7 months. In LAS group, the follow-up rate was 96% with 2 patients lost to follow-up and the follow-up duration ranged from 12.4 to 45.7 months with a median of 21.6 months. There was no significant difference in 3-year disease-free survival(91.3% vs. 87.9%, P>0.05) between the two groups.</p><p><b>CONCLUSION</b>HALS and LAS can achieve similar minimal invasiveness efficacy and oncologic outcomes for right hemicolectomy.</p>

The diagnosis and treatment of colorectal Non-Hodgkin's lymphoma 32 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the clinical features, diagnostic and therapeutic experiences of colorectal Non-Hodgkin's lymphoma (NHL).</p><p><b>METHODS</b>Clinical data of 32 patients with colorectal NHL admitted to our hospital from January 1988 to December 2006 was retrospectively analyzed.</p><p><b>RESULTS</b>This study included 22 B-cell NHL and 10 T-cell NHL cases. In the B-cell NHL group, the male: female ratio was 14:8 and the median age was 60.5 years. In the T-cell NHL group, the male: female ratio was 5:5 and the median age was 31.0 years. The ileocecal region was most frequently involved in both groups, which accounted for 77.3% and 60.0% of the B and T group respectively. The common clinical manifestations included abdominal pain, weight loss, and abdominal mass. Of the 14 cases of B-cell NHL with definite subtype classifications, 64.3% were of the Diffuse Large B-cell Lymphoma (DLBCL) type. Among the 22 B-cell NHL, 40.9% were with localized diseases (stage I-II1), while all 10 patients in T-cell NHL group were in stage IV with 3 patients complicated with massive GI bleeding and 4 with perforation. All patients of B-cell type received chemotherapy utilizing mainly CHOP after surgical resection. After a median follow-up of 55 months, the disease-free survival was rate 88.2%. Among the T-cell NHL group, 8 out of 10 patients underwent surgery and chemotherapy was given to all those who could tolerate it. Five patients died within 2 months after surgery. It's known that 3 patients were still alive after 23 months.</p><p><b>CONCLUSIONS</b>The ileocecal region is the most frequently involved site of the colorectal NHL. The histology is usually B-cell type with a majority being DLBCL. Currently R-CHOP chemotherapy after the surgical resection is the principal treatment modality. Patients of B-cell type have a better prognosis while the prognosis of T-cell NHL is poor. Therefore more aggressive diagnostic and therapeutic approaches are recommended for T-cell NHL patients. The prospective of organ preservation treatment for colorectal NHL is still in need of further investigations.</p>

Clinical pathologic factors predicting tumor response after preoperative neoadjuvant therapy for rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To identify the clinical pathologic factors predicting tumor response of preoperative neoadjuvant therapy in patients with rectal cancer.</p><p><b>METHODS</b>Seventy-nine patients with rectal cancer underwent neoadjuvant therapy before surgery from July 2000 to July 2009 were included in this study. Clinical pathologic factors were retrospectively analyzed to check the predicting effect of tumor response to the neoadjuvant therapy.Pathologic complete response (pCR) and T down-staging were the study endpoints.</p><p><b>RESULTS</b>Of the 79 patients, 10 cases (12.7%) got pCR after the neoadjuvant treatment. T down-staging was achieved in 41 patients (51.9%). The colonoscopy showed that the tumor occupied < or = 1/3 proportion of the bowel lumen in 22 patients, and 7 of them got pCR after the neoadjuvant therapy. Chi-square analysis showed that the proportion of tumor occupied in the bowel lumen was relevant to pCR rate (P < 0.05). Serum carcino-embryonic antigen (CEA) level was examined in 74 patients. Twenty-seven cases of the 46 patients with a serum CEA level < 5 microg/L got a T down-staging. Twenty-three cases of the 38 patients with a normal range of both serum CEA/CA19-9 levels got a T down-staging. Chi-square analysis showed normal range of both serum CEA/CA19-9 levels indicated better T down-staging.</p><p><b>CONCLUSIONS</b>It's defined some possible predictive factors for effects of neoadjuvant therapy in patients with rectal cancer. Particularly, patients with less tumor occupation of the bowel lumen and a serum CEA level < 5 microg/L seem to be more likely to get better clinical results.</p>

Management of presacral developmental cysts:experience of 22 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the clinical features, diagnostic and therapeutic experiences of presacral developmental cysts.</p><p><b>METHODS</b>Clinical data of 22 patients with presacral developmental cysts underwent tumor excision surgery from January 1989 to December 2008 was retrospectively analyzed.</p><p><b>RESULTS</b>In this group, 8 male and 14 female patients were included with a median age of 29.5 yrs (18 - 72 yrs) at diagnosis. The mean diameter of the cysts was (8.3 + or - 2.7) cm. Of the cases, 6 patients presented with epidermoid cysts, 4 cases with dermoid cysts and 12 cases with teratomas (2 with malignant change). Surgical approaches included the trans sacrococcygeal approach (18 cases), the transabdominal approach (3 cases), and the combined transabdominal-sacrococcygeal approach (1 case). The operative duration and blood loss of each operative approach was as follows: modified Kraske's procedure (142 + or - 43) min/(192 + or - 149) ml, Mason's procedure (102 + or - 27) min/(54 + or - 37) ml, transabdominal procedure (147 + or - 25) min/(117 + or - 76) ml, combined approach 360 min/1000 ml. In the trans sacrococcygeal group, 1 case (6.3%) of intra-operative presacral vein bleeding and 1 case (6.3%) of the surgical incision infection occurred. One case in the combined approach group suffered from incision infection. No significant complication was found in the transabdominal group. The patients were followed up for 9-92 months (mean, 40 months) and meanwhile the tumor relapsed in 2 cases in 20 patients with benign lesions: one patient underwent trans sacrococcygeal surgery and the other received transabdominal surgery.</p><p><b>CONCLUSIONS</b>The presacral developmental cysts develop slowly with a tendency toward malignancy. And delayed treatment brings much more difficulties to the surgical excision, so it should be radically excised once diagnosed. The trans sacrococcygeal approach is a preferable surgical procedure with direct access, minimal operative injuries and complications; and the combined transabdominal-sacrococcygeal approach could be employed when needed.</p>