[Construction of a model based on multipoint full-layer puncture biopsy for predicting pathological complete response after neoadjuvant therapy for locally advanced rectal cancer].

Objective: To investigate the value of transanal multipoint full-layer puncture biopsy (TMFP) in predicting pathological complete response (pCR) after neoadjuvant radiotherapy and chemotherapy (nCRT) in patients with locally advanced rectal cancer (LARC) and to establish a predictive model for providing clinical guidance regarding the treatment of LARC. Methods: In this multicenter, prospective, cohort study, we collected data on 110 LARC patients from four hospitals between April 2020 and March 2023: Beijing Chaoyang Hospital of Capital Medical University (50 patients), Beijing Friendship Hospital of Capital Medical University (41 patients), Qilu Hospital of Shandong University (16 patients), and Zhongnan Hospital of Wuhan University (three patients). The patients had all received TMFP after completing standard nCRT. The variables studied included (1) clinicopathological characteristics; (2) clinical complete remission (cCR) and efficacy of TMFP in determining pCR after NCRT in LARC patients; and (3) hospital attended, sex, age, clinical T- and N-stages, distance between the lower margin of the tumor and the anal verge, baseline and post-radiotherapy serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA)19-9 concentrations, chemotherapy regimen, use of immunosuppressants with or without radiotherapy, radiation therapy dosage, interval between surgery and radiotherapy, surgical procedure, clinical T/N stage after radiotherapy, cCR, pathological results of TMFP, puncture method (endoscopic or percutaneous), and number and timing of punctures. Single-factor and multifactorial logistic regression analysis were used to determine the factors affecting pCR after NCRT in LARC patients. A prediction model was constructed based on the results of multivariat analysis and the performance of this model evaluated by analyzing subject work characteristics (ROC), calibration, and clinical decision-making (DCA) curves. pCR was defined as complete absence of tumor cells on microscopic examination of the surgical specimens of rectal cancer (including lymph node dissection) after NCRT, that is, ypT0+N0. cCR was defined according to the Chinese Neoadjuvant Rectal Cancer Waiting Watch Database Study Collaborative Group criteria after treatment, which specify an absence of ulceration and nodules on endoscopy; negative rectal palpation; no tumor signals on rectal MRI T2 and DWI sequences; normal serum CEA concentrations, and no evidence of recurrence on pelvic computed tomography/magnetic resonance imaging. Results: Of the 110 patients, 45 (40.9%) achieved pCR after nCRT, which was combined with immune checkpoint inhibitors in 34 (30.9%). cCR was diagnosed before puncture in 38 (34.5%) patients, 43 (39.1%) of the punctures being endoscopic. There were no complications of puncture such as enterocutaneous fistulae, vaginal injury, prostatic injury, or presacral bleeding . Only one (2.3%) patient had a small amount of blood in the stools, which was relieved by anal pressure. cCR had a sensitivity of 57.8% (26/45) for determining pCR, specificity of 81.5% (53/65), accuracy of 71.8% (79/110), positive predictive value 68.4% (26/38), and negative predictive value of 73.6% (53/72). In contrast, the sensitivity of TMFP pathology in determining pCR was 100% (45/45), specificity 66.2% (43/65), accuracy 80.0% (88/110), positive predictive value 67.2% (45/67), and negative predictive value 100.0% (43/43). In this study, the sensitivity of TMFP for pCR (100.0% vs. 57.8%, χ2=24.09, P<0.001) was significantly higher than that for cCR. However, the accuracy of pCR did not differ significantly (80.0% vs. 71.8%, χ2=2.01, P=0.156). Univariate and multivariate logistic regression analyses showed that a ≥4 cm distance between the lower edge of the tumor and the anal verge (OR=7.84, 95%CI: 1.48-41.45, P=0.015), non-cCR (OR=4.81, 95%CI: 1.39-16.69, P=0.013), and pathological diagnosis by TMFP (OR=114.29, the 95%CI: 11.07-1180.28, P<0.001) were risk factors for pCR after NCRT in LARC patients. Additionally, endoscopic puncture (OR=0.02, 95%CI: 0.05-0.77, P=0.020) was a protective factor for pCR after NCRT in LARC patients. The area under the ROC curve of the established prediction model was 0.934 (95%CI: 0.892-0.977), suggesting that the model has good discrimination. The calibration curve was relatively close to the ideal 45° reference line, indicating that the predicted values of the model were in good agreement with the actual values. A decision-making curve showed that the model had a good net clinical benefit. Conclusion: Our predictive model, which incorporates TMFP, has considerable accuracy in predicting pCR after nCRT in patients with locally advanced rectal cancer. This may provide a basis for more precisely selecting individualized therapy.

[Promote the high-quality development of gastrointestinal surgery with technological concept innovation].

In the past 30 years, gastrointestinal surgery in China has made significant progress, which is reflected in the gradual standardization of clinical diagnosis and treatment, significant improvement in surgical quality, improvement in short-term and long-term postoperative outcomes, and continuous development of high-quality clinical research. At present, the spectrum of disease in gastrointestinal surgery has changed from traditional benign diseases to malignant diseases represented by gastric cancer and colorectal cancer, metabolic diseases represented by obesity and diabetes, and immune diseases represented by inflammatory bowel disease. It is necessary to carry out full-cycle management for patients. In the new era full of opportunities and challenges, surgeons must be driven by innovation in surgical technology, guided by high-quality clinical research and guaranteed by standardized diagnosis and treatment of diseases, to continue to promote the high-quality development of gastrointestinal surgery in China.

[The value of transanal multipoint full-layer puncture biopsy in determining the response degree of rectal cancer following neoadjuvant therapy: a prospective multicenter study].

Objective: To verify the feasibility and accuracy of the transanal multipoint full-layer puncture biopsy (TMFP) technique in determining the residual status of cancer foci after neoadjuvant therapy (nCRT) in rectal cancer. Methods: Between April 2020 and November 2022, a total of 78 patients from the Beijing Chaoyang Hospital of Capital Medical University, the Beijing Friendship Hospital of Capital Medical University, the Qilu Hospital of Shandong University, the Zhongnan Hospital of Wuhan University with advanced rectal cancer received TMFP after nCRT participated in this prospective multicenter trial. There were 53 males and 25 females, aged (M(IQR)) 61 (13) years (range: 35 to 77 years). The tumor distance from the anal verge was 5 (3) cm (range: 2 to 10 cm). The waiting time between nCRT and TMFP was 73 (26) days (range: 33 to 330 days). 13-point transanal puncture was performed with a 16 G tissue biopsy needle with the residual lesion as the center. The specimens were submitted for independent examination and the complications of the puncture were recorded. The consistency of TMFP and radical operation specimen was compared. The consistency of TMPF with clinical remission rates for the diagnosis of complete pathological remission was compared by sensitivity, specificity, negative predictive value, positive predictive value and accuracy. Statistical analysis between groups was performed using the χ2 analysis, and a paired χ2 test was used to compare diagnostic validity. Results: Before TMFP, clinical complete response (cCR) was evaluated in 27 cases. Thirty-six cases received in vivo puncture, the number of punctures in each patient was 13 (8) (range: 4 to 20), 24 cases of tumor residue were found in the puncture specimens. The sensitivity to judgment (100% vs. 60%, χ2=17.500, P<0.01) and accuracy (88.5% vs. 74.4%, χ2=5.125, P=0.024) of TMFP for the pathologic complete response (pCR) were significantly higher than those of cCR. Implement TMFP based on cCR judgment, the accuracy increased from 74.4% to 92.6% (χ2=4.026, P=0.045). The accuracy of the in vivo puncture was 94.4%, which was 83.3% of the in vitro puncture (χ2=1.382, P=0.240). Overall, the accuracy of TMFP improved gradually with an increasing number of cases (χ2=7.112, P=0.029). Conclusion: TMFP is safe and feasible, which improves the sensitivity and accuracy of rectal cancer pCR determination after nCRT, provides a pathological basis for cCR determination, and contributes to the safe development of the watch and wait policy.

[Fortify clinical advantages and promote innovative development: comparison of the Chinese Colorectal Cancer Surgery Database with foreign databases].

With the continuous development of evidence-based medicine, increasing attention has been paid to the construction of a large medical database to ensure a source of high quality real-world data. The Chinese Medical Association Colorectal Surgery Group created the Chinese Colorectal Cancer Surgery Database (CCCD), whose objective is to promote the development of colorectal surgery and improve patient prognosis with evidence-based medicine theory. Compared to major databases around the world, CCCD contains more comprehensive information on colorectal cancer surgical cases, recording the main epidemiological characteristics and detailed surgical information, but perioperative treatment data still need to be strengthened. It is necessary to continuously expand the coverage, enrich perioperative data and strengthen data, quality control. In the future, CCCD is expected to play a role in promoting homogenization of medical services, promoting smooth and effective graded diagnosis and treatment, giving full role to the characteristics of each center to achieve integrated development, and connecting real-world data and artificial intelligence.

[Current status of research on short-term urogenital function after transanal total mesorectal excision and laparoscopic total mesorectal excision].

Thanks to the new surgical approach, transanal total mesorectal excision (taTME) has a better operative field exposure than laparoscopic-assisted total mesorectal excision (laTME), especially for male patients with obesity, pelvic stenosis or prostate hypertrophy. Nevertheless, whether the urogenital function and quality of life after taTME are better as compared to laTME requires further study. According to the existing studies, taTME and laTME are not significantly different in symptoms of the urology system for male patients, but some large sample clinical studies show that the incidence of urethral mechanical injury after taTME is higher. Unfortunately, there is no elaboration on that for females. The sexual function of male patients after taTME and laTME is both impaired. The sexual function of male patients will be relieved to different degrees over time, but there is no significant difference. Compared with laTME, taTME shows advantages in the sexual function for female patients. There is no significant difference in short-term urogenital system function between taTME and laTME at present. As a new surgical approach, the impact on urogenital system function after taTME is acceptable. However, whether there is a significant difference in urogenital function between taTME and laTME needs further research. In addition, functional results still need comprehensive evaluation, and preoperative baseline evaluation also needs to be enhanced. The functional evaluation for male and female should be carried out separately rather than confused. Questionnaire for evaluation of functional results also needs to be verified.

Experimental study on fire characteristics in cable compartment of utility tunnel with natural ventilation.

The fire characteristics under natural ventilation in the cable compartment of the utility tunnel are studied. A series of small-scale fire experimental tests are conducted to obtain the maximum temperature below the ceiling of different ignition vertical heights and cable types. In this paper, the ceiling temperature decay and heat release rate (HRR) are studied in the cable compartment of utility tunnel. Through experimental tests, the fire characteristics of placing the fire source on the near wall side 3.0 m away from the shaft of the utility tunnel cable compartment are studied. The results showed that under the action of natural ventilation, with the decrease of fuel quantity, the mass loss of cable decreases, and the maximum temperature below the ceiling of the cable compartment in the utility tunnel decreases. ZRYJV cables burn more sufficient combustion than RVVR cables. A new empirical association for total HRR is proposed. Those experimental test results are used as validation data for the newly proposed empirical correlation of total HRR. This paper hopes to provide some basic fire safety references for the utility tunnel planning of the urban underground cable compartment.

[Short-term complications after transanal total mesorectal excision for mid-low rectal cancer].

Objective: To summarize short-term postoperative complications of transanal total mesorectal excision (taTME) in the treatment of middle-low rectal cancer. Methods: A descriptive case series of cases was constructed. Clinical data of consecutive 83 patients with mid-low rectal cancer who received taTME treatment from November 2016 to April 2021 at Department of General Surgery of Beijing Friendship Hospital, Capital Medical University were collected. Among 83 patients, 58 (69.9%) were males, with a mean age of (61.4±11.8) years; 42 (50.6%) were low rectal cancer, 41 (49.4%) were middle rectal cancer. Short-term postoperative complication was defined as complication occurring within 30 days after operation. The complication was graded according to the Clavien-Dindo classification. At the same time, the morbidity of short-term postoperative complication in the first 40 patients and that in the last 43 patients were compared to understand the differences before and after passing the taTME learning curve. Results: Two patients (2.5%) were converted to laparotomy ; 78 (94.0%) completed anastomosis.While 5 (6.0%) underwent permanent stoma. The total operation time of transabdominal+ transanal procedure was (246.9±85.0) minutes, and the median intraoperative blood loss was 100 (IQR: 100) ml. Seventy-five cases (75 /78, 96.2%) underwent defunctioning stoma, including 74 cases of diverting ileostomy, 1 case of diverting transverse colostomy and 3 cases without stoma. The morbidity of complication within 30 days after operation was 38.6% (32/83), and the morbidity of complication after discharge was 8.4% (7/83). Minor complications accounted for 31.3% (26/83) and major complications accounted for 7.2% (6/83). No patient died within 30 days after operation. The incidence of anastomotic leakage was 15.4% (12/78). Eight patients (9.6%) were hospitalized again due to complications after discharge. The median postoperative hospital stay was 7 (IQR: 3) days. All the patients with minor (I-II) complications received conservative treatment. One patient with grade C anastomotic leakage was transferred to intensive care unit and received a second operation due to sepsis and multiple organ dysfunction. Two patients with paralytic ileus (Clavien-Dindo IIIa) underwent endoscopic ileus catheter placement. There were 3 patients with Clavien-Dindo III or above respiratory complications, including 1 patient with pleural effusion and ultrasound-guided puncture, 2 patients with respiratory failure who were improved and discharged after anti-infection and symptomatic treatment. One patient underwent emergency ureteral stent implantation due to urinary infection (Clavien-Dindo IIIb). The morbidity of postoperative complication in the first 40 cases was 50.0% (20/40), and that in the latter 43 cases decreased significantly (27.9%, 12/43), whose difference was statistically significant (χ(2)=4.270, P=0.039). Conclusions: The procedure of taTME has an acceptable morbidity of short-term postoperative complication in the treatment of mid-low rectal cancer. The accumulation of surgical experience plays an important role in reducing the morbidity of postoperative complication.

[Problems exposed in retrospective study of postoperative complications of rectal cancer and causal analysis].

Rectal cancer is a great threat to the health of the Chinese people. With the continuous improvement of surgical treatment level, complication as an important indicator to measure the safety of surgery has received increasing attention from clinicians both at home and abroad. Although there are many studies on postoperative complications of rectal cancer, the morbidity of complication reported by related studies varies greatly. An important reason occurs in the limitations of retrospective research, such as incomplete medical records, unclear diagnostic criteria for some complications, incomplete follow-up records after discharge, and poor communication mechanisms among MDT members. Starting from a retrospective study on postoperative complications of rectal cancer and finding out the defects and problems in the registration of complications in each center, then clarifying the definition of various postoperative complications, so as to establish a sound and standardized registration system, and carry out prospective research, this path could be a reliable method to obtain relatively accurate postoperative complications of rectal 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.

[Looking forward to the future direction of colorectal surgery in the perspective of clinical research and data collection].

Colorectal surgery has been developed rapidly in China because of the advance of minimally invasive surgical techniques, perioperative comprehensive treatment strategies and clinical research in recent years. Comparing the current diagnosis and treatment of colorectal cancer between China and western industrialized countries, it can be found that the specialized construction and standardized diagnosis and treatment of colorectal surgery in western industrialized countries are very mature, and the multidisciplinary diagnosis and treatment model of colorectal cancer has been standardized. Although there is almost no difference between high-level colorectal cancer centers in the eastern coastal areas of China and western countries, due to the vast size and uneven regional development of China, standardized surgery and standardized treatment concepts of colorectal surgery still need to be popularized. Combined with the current diagnosis and treatment of colorectal cancer in China, more high-quality clinical research should be carried out to seek new development and breakthroughs in the field of colorectal surgery. Combined with the experience of international and domestic clinical research that has been participated in or carried out, the author believes that quality control of clinical research should be carried out from the following two points: 1. structured training and quality control of research; 2. establishment and management of databases. In a word, we should not only focus on colon surgery itself, but also complete the transformation to research-oriented doctors and research-oriented disciplines, cultivate the concept of data collection and clinical research, enhance the scientific awareness of clinical research, and integrate high-quality data collection and clinical research into daily clinical practice. Only in this way can we fundamentally improve the comprehensive strength of China's colorectal surgery, effectively carry out surgical-related clinical research based on the current situation colorectal diseases in China, and obtain high-level evidence-based medical evidence based on the research results of the population of patients in China, and form a guide for the diagnosis and treatment of colorectal surgery in China, which will also guide the clinical practice of patients with colorectal diseases in China. This will certainly be a new direction for the development of Chinese colorectal surgery.

[Research progress on early diagnosis and prevention of anastomotic leak after rectal cancer surgery].

Anastomotic leak is a common and serious complication after anterior rectal resection. Despite the continuous advancement of anastomotic instruments and surgical techniques, the incidence of anastomotic leak has not decreased significantly compared with the past. As more studies on the early diagnosis of anastomotic leak are published, postoperative risk factors of anastomotic leak, such as fever, time to first bowel movement, CT, C-reactive protein (CRP) and procalcitonin (PCT), matrix metalloproteinase-9, and other cytokines and biomarkers (IL-6, TNF-α, lactate, pH, urinary neopterin/creatinine ratio), provide a reference for surgeons to assess the risk and increase the possibility of early diagnosis of anastomotic leak. Nevertheless, preventing the occurrence of anastomotic leak is still the ultimate goal. For the prevention of anastomotic leak, intraoperative ICG fluorescence imaging technology provides a simple and safe objective method for surgeons to evaluate anastomotic perfusion. The diversion stoma may reduce the incidence of anastomotic leak. More and more evidence shows that drainage through the anal canal can reduce the incidence of anastomotic leak after rectal cancer, but whether different types of drainage catheters can clearly reduce the incidence of anastomotic leak still needs more evidence. In addition, there has not yet been a unified opinion on the retention time and location of the drainage catheter. At present, the research of anastomotic leak has not adopted a unified definition and the heterogeneity among related studies is still great. We still look forward to more high-quality multi-center large prospective and randomized controlled studies.

[Incidence and risk factors of anastomotic leak after transanal total mesorectal excision in China: a retrospective analysis based on national database].

Objective: Transanal total mesorectal excision (taTME) was a very hot topic in the first few years since its appearance, but now more introspections and controversies on this procedure have emerged. One of the reasons why the Norwegian Ministry of Health stopped taTME was the high incidence of postoperative anastomotic leak. In current study, the incidence and risk factors of anastomotic leak after taTME were analyzed based on the data registered in the Chinese taTME Registry Collaborative (CTRC). Methods: A case-control study was carried out. Between November 15, 2017 and December 31, 2020, clinical data of 1668 patients undergoing taTME procedure registered in the CTRC database from 43 domestic centers were collected retrospectively. After excluding 98 cases without anastomosis and 109 cases without complete postoperative complication data, 1461 patients were finally enrolled for analysis. There were 1036 males (70.9%) and 425 females (29.1%) with mean age of (58.2±15.6) years and mean body mass index of (23.6±3.8) kg/m(2). Anastomotic leak was diagnosed and classified according to the International Study Group of Rectal Cancer (ISREC) criteria. The risk factors associated with postoperative anastomotic leak cases were analyzed. The impact of the cumulative number of taTME surgeries in a single center on the incidence of anastomotic leak was evaluated. As for those centers with the number of taTME surgery ≥ 40 cases, incidence of anastomic leak between 20 cases of taTME surgery in the early and later phases was compared. Results: Of 1461 patients undergoing taTME, 103(7.0%) developed anastomotic leak, including 71 (68.9%) males and 32 (31.1%) females with mean age of (59.0±13.9) years and mean body mass index of (24.5±5.7) kg/m(2). The mean distance between anastomosis site and anal verge was (2.6±1.4) cm. Thirty-nine cases (37.9%) were classified as ISREC grade A, 30 cases (29.1%) as grade B and 34 cases (33.0%) as grade C. Anastomotic leak occurred in 89 cases (7.0%,89/1263) in the laparoscopic taTME group and 14 cases (7.1%, 14/198) in the pure taTME group. Multivariate analysis showed that hand-sewn anastomosis (P=0.004) and the absence of defunctioning stoma (P=0.013) were independently associated with anastomotic leak after taTME. In the 16 centers (37.2%) which performed ≥ 30 taTME surgeries with cumulative number of 1317 taTME surgeries, 86 cases developed anastomotic leak (6.5%, 86/1317). And in the 27 centers which performed less than 30 taTME surgeries with cumulative number of 144 taTME surgeries, 17 cases developed anastomotic leak (11.8%, 17/144). There was significant difference between two kinds of center (χ(2)=5.513, P=0.019). Thirteen centers performed ≥ 40 taTME surgeries. In the early phase (the first 20 cases in each center), 29 cases (11.2%, 29/260) developed anastomotic leak, and in the later phase, 12 cases (4.6%, 12/260) developed anastomotic leak. The difference between the early phase and the later phase was statistically significant (χ(2)=7.652, P=0.006). Conclusion: The incidence of anastomotic leak after taTME may be reduced by using stapler and defunctioning stoma, or by accumulating experience.

[The development process and new requirements of structured training on transanal total mesorectal resection].

Due to the technical difficulty and long learning curve, the benefits of Transanal total mesorectal excision may be obscured by surgical complications that arise from rapid, large-scale development, therefore the surgeons need to receive sufficient training before performing this surgery. At present, a mature structured training system has been formed, but the development of structured training has not met the needs of existing surgical development. In order to standardize the development of transanal total mesorectal excision, the European Society of Colorectal Diseases and 14 international surgical societies recently launched the "International Expert Consensus Guidelines for the Indication, Implementation and Quality Evaluation of Transanal Total Mesorectum Resection". The consensus involves the requirements for trainees, the content and process of training, as well as the evaluation and registration of training results. Training in cadaver is the core of structured training. Beginners should receive repeated training and conduct the surgery under the guidance of instructors.

[Interpretation of international expert consensus guidance on indications, implementation and quality measures for transanal total mesorectal excision].

In recent years, transanal total mesorectal excision (taTME) has been a hot spot in the field of colorectal surgery. Compared with the traditional laparoscopic technique, taTME has potential advantages in the treatment of rectal diseases. However, the procedural safety and effectiveness of taTME need further verification. In order to ensure the safe and standardized implementation of this procedure, the European Society of Coloproctology, together with 14 international academic organizations related to colorectal surgery and minimally invasive surgery, has developed the international expert consensus guidance on indications, implementation and quality measures for taTME. This paper introduces the background of the international consensus guidance, and interprets its core contents, including the surgical indications (complex pelvic conditions, malignant and benign rectal diseases), surgical quality and outcome evaluation, structured training, and expert center. It is expected to provide reference and guidance for Chinese colorectal surgery colleagues performing taTME.

[Analysis of treatment and prognosis of 59 cases of vulvar melanoma].

Objective: To assess the treatment and prognosis of vulvar melanoma. Methods: A total of 59 cases of primary vulvar melanoma admitted to Cancer Hospital of Peking Union Medical College, Chinese Academy of Medical Sciences from January 1st, 1981 to November 30th, 2019 were collected. The clinical characteristics, treatment, survival and prognostic factors of vulvar melanoma were analyzed retrospectively. The end date of follow-up was January 15th, 2020.The median follow-up time was 26.0 months (range:2-198 months). Results: (1) Clinical characteristics: the median age of 59 patients with vulvar melanoma was 56 years old (range:18-83 years old). According to the American Joint Committee on Cancer stage manual, there were 18, 7, 26 and 8 cases of stage Ⅰ, Ⅱ, Ⅲ and Ⅳ respectively. The lesion of 38 cases was single and the other 21 cases were multiple. The largest diameter of the tumor ranged from 0.3 to 17.0 cm.The surface of the lesion was ulcerated in 17 cases. (2) Treatment: a total of 59 cases with vulvar melanoma, 56 patients received surgery, 36 cases of them received radical resection of vulva and 20 received local extended resection of vulvar tumor due to unilateral vulva lesion. Three patients did not receive surgery,one received chemotherapy combined with interferon, one received interferon, and one received radiotherapy. Lymph node management: among the 56 patients treated by surgery, 37 patients received inguinal lymphadenectomy, 24 (65%, 24/37) of whom were confirmed with inguinal lymph node metastasis by postoperative pathological examination. Inguinal lymph nodes enlargement were not found in 19 cases by preoperative imaging and clinical examination. In these 19 patients, three patients received inguinal lymph node biopsy, among them, one (1/3) patient was confirmed with inguinal lymph node metastasis by postoperative pathological examination, and the remaining 16 patients did not receive inguinal lymph node surgery. Postoperative adjuvant treatment: among the 56 patients who received surgery, 31 received adjuvant chemotherapy，one received adjuvant radiotherapy, four received interferon therapy, 17 received combination therapy including chemotherapy, and three did not receive postoperative adjuvant therapy. (3) Survival:during the follow-up period, the median survival time of 59 patients with vulvar melanoma was 30.0 months (range:2.0-198.0 months). The 3-year survival rate was 42.5%, and the 5-year survival rate was 23.8%. The median survival time of stage Ⅰ, Ⅱ, Ⅲ and Ⅳ were 72.0, 45.0, 24.0 and 23.0 months, respectively. The difference among stage Ⅰ, Ⅱ and stage Ⅲ, Ⅳ were statistically significant （P<0.01）. The median survival time of patients undergoing radical resection of the vulva (35.0 months) and local enlarged tumor resection (29.0 months) were significantly longer than that of patients without surgery (9.0 months, P<0.01). The median survival time of the patients who underwent inguinal lymphadenectomy, lymph node biopsy and those who did not undergo surgery were 35.0, 32.0 and 30.0 months, respectively. There were no significant differences among the 3 groups (P>0.05). The median survival time of postoperative adjuvant chemotherapy patients (49.0 months) were significantly longer than that of postoperative adjuvant radiotherapy, interferon,and combination therapy including chemotherapy (9.0, 14.0 and 26.0 months, respectively, all P<0.01). (4) Prognostic factors: the univariate analysis showed that stage, vulvar operation and postoperative adjuvant treatment were the risk factors affecting the prognosis of patients with vulvar melanoma (P<0.01). Multivariate analysis revealed that stage alone was an independent risk factor affecting the prognosis of patients with vulvar melanoma (P<0.01). Conclusions: The prognosis of patients with vulvar melanoma is poor, and stage is an independent prognostic factor.Surgery combined with postoperative adjuvant chemotherapy may achieve relatively good results.

[Gunsight closure versus purse-string closure techniques in loop stoma reversal: a multicenter prospective randomized controlled trial].

Objective: To compare the wound healing time, Surgical site infection (SSI) rate and other postoperative outcomes between the gunsight closure and purse-string closure technique in loop stoma closure. Methods: Between November 2013 and December 2017, a total of 143 patients who underwent gunsight stoma reversal were included in this multicenter prospective randomized controlled trial. The patients were randomized to undergo gunsight (gunsight group, n=72) or purse-string closure technique (purse-string group, n=71). The primary endpoint was wound healing time. The second endpoints were the incidence of SSI, morbidity, and patient satisfaction. Statistical analysis between groups was performed using the t-test, repeated measures analysis of variance, Mann-Whitney U test, χ(2) test or Fisher's exact test. Results: There were 45 males and 27 females with age of 67 (11) (M(Q(R))) years in gunsight group, 42 males and 29 females with age of 65 (20) years in purse-string group. The body mass index, American Society of Anesthesiologist classification, comorbidities, primary diagnosis, the type of ostomy, intraoperative blood loss, perioperative complications, postoperative hospital stay, hospitalization cost, SSI rate and incisional hernia (stoma site) between the 2 groups were not significantly different (P>0.05). Although had a statistically longer operating time (80(10) minutes vs. 70(10) minutes, Z=-2.381, P=0.017), patients who underwent gunsight procedure and a significantly shorter wound healing time (17(2) days vs. 25(4) days, Z=-10.199, P<0.01), higher patient satisfaction score with regards to wound healing time (3(1) vs. 3(1), Z=-4.526, P<0.01), and higher total patient satisfaction score (25(3) vs. 25(3), Z=-2.529, P=0.011) compared with those who underwent purse-string procedure. Conclusions: The gunsight and purse-string techniques are effective procedures for stoma reversal and both have low SSI rate. The gunsight technique is associated with shorter wound healing time, higher levels of patient satisfaction compared with purse-string technique, and is recommended as the closure technique of choice.

[Current status of research on short-term quality of life after sphincteric-saving surgery in rectal cancer patients].

Sphincteric-saving surgery (SSS) is currently a hot spot in the treatment of mid-low rectal cancer. Although it preserves the anatomical continuity of the colon and anus, the postoperative functional outcomes and quality of life (QOL) remains to be confirmed. Current studies have shown that quality of life worsens at the first month after surgery, improves within 3-6 months, and stabilizes at about 1 year. The QOL was associated with patient-related factors, tumor-related factors, treatment-related factors and postoperative complications. For patient-related factors, younger patients have worse role function and sexual function but better cognitive function and physical function. Male patients deteriorate significantly in sexual and social function. For tumor-related factors, patients with lower rectal cancer have poorer defecation function. Those with advanced rectal cancer are more likely to suffer from side-effects related to chemotherapy. For treatment-related factors, patients undergoing intersphincteric resection have worse role function, body image and sexual interest. Preventive ileostomy results in the deterioration of role function, body image and sexual interest. Chemotherapy causes taste changes and chest pain. For postoperative complication, patients with anastomotic leakage have worse bowel function and psychological state. Patients with major low anterior resection syndrome and genitourinary dysfunction have worse global health score, social function and role function. In conclusion, short-term quality of life after sphincteric-saving surgery is acceptable. To improve QOL, specific intervention and guidance should be given to patients in this stage. Meanwhile, since many factors influence the quality of life simultaneously, researchers are confused about the questionnaire outcomes. Therefore, more specific and comprehensive tools are needed to evaluate QQL after sphincteric-saving surgery.

[Looking back 2019: focusing on the development and research of colorectal surgery in China].

Although the surgical treatment of colorectal disease progresses slowly, with the advancement of minimally invasive surgical techniques, perioperative comprehensive treatment strategies and clinical research in recent years, Chinese colorectal surgery has developed rapidly. Transanal total mesorectal excision, lateral pelvic lymph node dissection,"watch and wait"strategy for clinical complete response of neoadjuvant radiotherapy for rectal cancer, and robotic colorectal surgery are still hot topics in colorectal surgery in recent years. The construction of clinical registry database and clinical research for colorectal cancer surgery are discussed, with a view to combing the development of colorectal surgery for colleagues in the surgical field, and to seek the development of colorectal surgery in China.

[The status analysis of diagnosis and treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China: a report of 1 003 cases in 16 domestic medical centers].

Objective: To analyze the status of domestic surgical treatment of synchronous peritoneal carcinomatosis from colorectal cancer in China. Methods: Clinicopathological data of patients who underwent surgery from October 2003 to October 2018 in 16 domestic medical centers was retrospectively analyzed. Excel database was created which covered 77 fields of 7 parts: baseline information of patients, laboratory tests, imaging tests, chemoradiotherapy information, intra-operative findings, postoperative pathology and follow-up data. The Wilcoxon rank-sum test was used for comparison of the measurement data between groups. The χ(2) test was used for comparison of the categorical data between groups. The survival curve was calculated by the Kaplan-Meier method. Results: Of the 1 003 patients, there were 575 male and 428 female patients with the age of (58.5±14.1) years (range: 18 to 92 years). In a total of 920 patients, the carcinoma of sigmoid colon was performed in 292 cases (31.8%) with the highest ratio. The proportion of patients with liver metastasis and lung metastasis were 27.9% (219/784) and 8.3% (64/769). Preoperative detection of carcino-embryonic antigen level was the most common method in China (87.74%, 880/1 003), and the positive rate was 64.5% (568/880). The correct rate of preoperative imaging tests was 40.7% (280/688). The ratio of peritoneal carcinomatosis index (PCI) scores between 0 and 10 was the highest (59.6%, 170/285). Two hundred and sixty-two (27.0%) patients were performed by totally laparoscopic operation in 971 patients. The resection of primary tumor was performed in 588 of the 817 patients (72.0%). In a total of 457 cases, 253 (55.4%) patients were performed cytoreduction which group scored completeness of cytoreduction (CCR) 0. The postoperative hyperthermic intraperitoneal chemotherapy was implemented in 70 of the 334 cases (21.0%). Among 1 003 cases, 562 cases (56.03%) had complete follow-up data and the median overall survival was 15 months. The primary tumor resection and the CCR scores were affected by the PCI scores. The patients underwent primary tumor resection (187/205 vs. 26/80, χ(2)=105.085, P=0.000) and the patients were performed cytoreduction which scored CCR 0 or CCR 1 (162/204 vs. 8/78, Z=-10.465, P=0.000) had significant difference between the groups of PCI<20 and ≥20. There was a close correlation between the surgical method and the CCR scores (Z=-3.246,P=0.001).When the maximum degree of tumor reduction was planned, most surgeons would choose laparotomy. The overall survival time was longer in patients with primary tumor resection (P=0.000). The median survival time was 18.6 months in the group of primary tumor resection. Conclusions: It is difficult to diagnose the synchronous peritoneal carcinomatosis from colorectal cancer before the operation. Primary tumor resection has an obvious effect to prolong the survival time. It is necessary to standardize the treatment of peritoneal metastasis.

Effects of compound porcine cerebroside and ganglioside on neurotoxicity caused by oxaliplatin chemotherapy: preliminary results.

OBJECTIVE: Oxaliplatin has shown good anti-tumour activity in the treatment of tumours involving the digestive system. However, its application is limited because of severe neurotoxicity in some patients. The purpose of this study was to evaluate whether compound porcine cerebroside and ganglioside (CPCG) can reduce or prevent oxaliplatin-induced neurotoxicity. PATIENTS AND METHODS: Patients with digestive system tumour who received oxaliplatin-based chemotherapy were retrospectively divided into experimental and control groups according to the receipt of CPCG during chemotherapy. Adverse events at the end of each chemotherapy cycle were recorded. We compared the incidence of neurotoxicity between the two groups and graded the neurotoxicity symptoms using the Common Terminology Criteria for Adverse Events v5.0. RESULTS: The study included 115 patients (experimental group, 57; control group, 58). The number of chemotherapy cycles (6.65 vs. 6.41, p=0.540) and oxaliplatin dose (775.92 mg/m2 vs. 724.20 mg/m2, p=0.250) were comparable between the two groups. All patients developed grade 1 to 3 neurotoxicity; grade 4-5 neurotoxicity was not observed. The incidence of neurotoxicity and the probability of advanced neurotoxicity were significantly lower in the experimental group than in the control group (p<0.05). After a 6 to 18 months follow-up, the two groups showed no significant differences in the chemotherapy response and recurrence rate (p=0.846). CONCLUSIONS: CPCG reduces oxaliplatin-induced neurotoxicity without reducing the efficacy of oxaliplatin-based regimens; thus, it can be used for preventing oxaliplatin-induced neurotoxicity in patients with cancer.