[Transanal laparoscopic radical resection with telescopic anastomosis for low rectal cancer].

OBJECTIVE: To assess the safety, feasibility and clinical outcome of laparoscopic radical resection for low rectal cancer with telescopic anastomosis or with colostomy by stapler through transanal resection without abdominal incisions. METHODS: From January 2010 to September 2014, 37 patients underwent laparoscopic radical resection for low rectal cancer through transanal resection without abdominal incisions. The tumors were 4-7 cm above the anal verge. On preoperative assessment, 26 cases were T1N0M0 and 11 were T2N0M0. RESULTS: For all cases, successful surgery was performed. In telescopic anastomosis group, the mean operative time was (178±21) min, with average blood loss of (76±11) ml and (13±7) lymph nodes harvested. Return of bowel function was (3.0±1.2) d and the hospital stay was (12.0±4.2) d without postoperative complications. Patients were followed up for 3-45 months. Twelve months after surgery, 94.6%(35/37) patients achieved anal function Kirwan grade 1, indicating that their anal function returned to normal. CONCLUSIONS: Laparoscopic radical resection for low rectal cancer with telescopic anastomosis or colostomy by stapler through transanal resection without abdominal incisions is safe and feasible. Satisfactory clinical outcome can be achieved mini-invasively.

Laparoscopic resection of lower rectal cancer with telescopic anastomosis without abdominal incisions.

AIM: To assess laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions. METHODS: From March 2010 to June 2014, 30 patients (14 men and 16 women, aged 36-78 years, mean age 59.8 years) underwent laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through anus-preserving transanal resection. The tumors were 5-7 cm away from the anal margin in 24 cases, and 4 cm in six cases. In preoperative assessment, there were 21 cases of T1N0M0 and nine of T2N0M0. Through the middle approach, the sigmoid mesentery was freed at the root with an ultrasonic scalpel and the roots of the inferior mesenteric artery and vein were dissected, clamped and cut. Following the total mesorectal excision principle, the rectum was separated until the anorectal ring reached 3-5 cm from the distal end of the tumor. For perineal surgery, a ring incision was made 2 cm above the dentate line, and sharp dissection was performed submucosally towards the superior direction, until the plane of the levator ani muscle, to transect the rectum. The rectum and distal sigmoid colon were removed together from the anus, followed by a telescopic anastomosis between the full thickness of the proximal colon and the mucosa and submucosal tissue of the rectum. RESULTS: For the present cohort of 30 cases, the mean operative time was 178 min, with an average of 13 positive lymph nodes detected. One case of postoperative anastomotic leak was observed, requiring temporary colostomy, which was closed and recovered 3 mo later. The postoperative pathology showed T1-T2N0M0 in 19 cases and T2N1M0 in 11 cases. Twelve months after surgery, 94.4% patients achieved anal function Kirwan grade 1, indicating that their anal function returned to normal. The patients were followed up for 1-36 mo, with an average of 23 mo. There was no local recurrence, and 17 patients survived for > 3 years (with a survival rate of 100%). CONCLUSION: Laparoscopic radical resection of lower rectal cancer with telescopic anastomosis through transanal resection without abdominal incisions is safe and feasible.

Anus-preserving rectectomy via telescopic colorectal mucosal anastomosis for low rectal cancer: experience from a Chinese cohort.

AIM: To investigate the safety and efficacy of anus-preserving rectectomy via telescopic colorectal mucosal anastomosis (TCMA) for low rectal cancer. METHODS: From August 1993 to October 2012, 420 patients including 253 males and 167 females with low rectal cancer underwent transabdominal and transanal anterior resection, followed by TCMA. The distance between the anus and inferior margin of the tumor ranged from 5 to 7 cm, and was 5 cm in 6 patients, 6 cm in 127, and 7 cm in 287 patients. Tumor-node-metastasis staging showed that 136 patients had stage I, 252 had stage II and 32 had stage III. Fifty-six patients with T3 or over received preoperative neoadjuvant chemoradiotherapy. RESULTS: The postoperative follow-up rate was 91.9% (386/420) with a median time of 6.4 years. All 420 patients underwent radical resection. No postoperative death occurred. Postoperative complications included anastomotic leakage in 13 (3.1%) patients and anastomotic stenosis in 7 (1.6%). The local recurrence rate after surgery was 6.2%, the hepatic metastasis rate was 13.2% and the pulmonary metastasis rate was 2.3%. The 5-year survival rate was 74.0% and the disease-free survival rate was 71.0%. Kirwan classification showed that continence was good in 94.4% of patients with stage I when scored 12 mo after resection. CONCLUSION: TCMA for patients with low rectal cancer leads to better quality of life and satisfactory defecation function, and lowers anastomotic leakage occurrence, and might be one of the safe operative procedures in anus-preserving rectectomy.

Sphincter-preserving surgery after preoperative radiochemotherapy for T3 low rectal cancers.

The aim of this study was to evaluate the feasibility and the effectiveness of preoperative radiochemotherapy followed by total mesorectal excision (TME) and sphincter-preserving procedures for T3 low rectal cancer. Patients with rectal cancer and T3 tumors located within 1-6 cm of the dentate line received preoperative radiochemotherapy. Concurrent 5-fluorouracil-based radiochemotherapy was used. Radical resection with TME and sphincter-preserving procedures were performed during the six to eight weeks following radiotherapy. Survival was analyzed using the Kaplan-Meier method. The anal function was evaluated using the Wexner score. The clinical response rate was 83.5%, overall downstaging of T classification was 75.3% and pathological complete response was 15.3%. The anastomotic fistula rate was 4.7%. A median follow-up of 30 months showed the local recurrence rate to be 4.7% and the distant metastasis rate to be 5.9%. The three-year overall survival rate was 87%. The degree of anal incontinence as measured using the Wexner score decreased over time, and the anal sphincter function in the majority of patients gradually improved. Preoperative radiochemotherapy was found to improve tumor downstaging, reduces local recurrence, increase the sphincter preservation rate, and is therefore of benefit to patients with T3 low rectal cancer.

[Analysis of 61 cases undergoing sphincter-preserving procedure with intersphincteric resection by telescopic anastomosis for ultra-low rectal cancer].

OBJECTIVE: To investigate the efficacy and safety of sphincter-preserving procedure with transabdominal intersphincteric resection for ultra-low rectal cancer. METHODS: Clinical data of 61 cases with ultra-low rectal cancer (distance from anal verge ranged from 4-5 cm) were analyzed retrospectively. The patients underwent sphincter-preserving procedure with intersphincteric resection and telescopic anastomosis. RESULTS: There were 34 males and 27 females. The mean age was 56.7 years. The inferior border of the tumor was 4 cm above the anal verge in 21 cases, and 5 cm in 40 cases. There 55 patients with rectal adenocarcinoma in this cohort. The tumor was well-differentiated in 24 cases, moderately-differentiated in 29 cases, and poorly-differentiated in 2 cases. There were 6 cases with malignant adenoma. The TNM staging was T1N0M0 in 36 cases, T2N0M0 in 23, and T3N1M0 in 2. The ability to control defecation significantly improved in 1-3 months postoperatively, and returned to normal in 6-12 months. Two patients developed anastomotic leak (3.3%), and 3 anastomotic stenosis (4.9%) postoperatively. Fifty-four patients(88.5%) had follow-up. The median follow-up time was 6.2 years. The local recurrence rate was 5.6%, and the 5-year-survival rate was 73.5%. CONCLUSION: Sphincter-preserving procedure with intersphincteric resection and telescopic anastomosis is a safe and effective procedure for ultra-low rectal cancer.

[Clinical study of laparoscopic sphincter-preserving proctectomy for low rectal cancer using transanal telescopic anastomosis].

OBJECTIVE: To investigate the safety, feasibility and clinical outcomes of laparoscopic sphincter-preserving proctectomy for low rectal cancer using transanal telescopic anastomosis. METHODS: Five patients underwent laparoscopic sphincter-preserving proctectomy for low rectal cancer using transanal telescopic anastomosis between March 2011 and April 2011 at the General Hospital of Beijing Military Command. After lymph node dissection around the mesentery using harmonic scalpel, the root of the inferior mesenteric vessel was ligated and transected. Rectal dissection was further carried out until 5 cm distal to the lower margin of the tumor. A circumferential incision was made 1.0 cm above the dentate line using 5 support stitches for exposure. The submucous layer was striped upward to the level of the levator ani, and rectum was transected. Rectum and sigmoid colon were extracted transanally and removed. Finally, colonanal anastomosis was made using telescopic technique. RESULTS: Five patients underwent the procedure successfully. The mean operative time was 178 minutes. The mean intraoperative blood loss was 76 ml. The mean lymph nodes retrieval was 14. Bowel function recovered after a mean of 3 days. There were no postoperative complications. No obvious scars were seen in the abdomen or the anus. The mean hospital stay was 12 days. After one year of follow-up, all the patients survived cancer-free. CONCLUSIONS: Laparoscopic anterior resection with sphincter preservation by transanal telescopic anastomosis for low rectal cancer is feasible and safe. Abdominal incision is minimal. However, the long-term outcomes require further investigation.

Proteomic analysis of differentially expressed proteins involving in liver metastasis of human colorectal carcinoma.

BACKGROUND: Early diagnosis of liver metastasis of colorectal carcinoma is very important for the appropriate treatment of such patients. However, there has been no effective approach available for clinical application. The present study aimed to investigate the differential expression of proteins in patients with liver metastasis of colorectal carcinomas using proteomic analysis and evaluate its potentiality in clinical diagnosis. METHODS: Fluorescence two-dimensional differential in-gel electrophoresis (2-D DIGE) was used to analyze and compare the protein expression between normal mucosa, the primary focus, and liver metastases. Proteomic analysis was made to identify the differentially expressed proteins. Immunohistological staining was used to confirm the expression of differentially expressed proteins in colorectal carcinomas and areas of liver metastasis. RESULTS: A 1.5-fold difference was found with 46 differentially expressed proteins. In 20 differentially expressed proteins, 3 were down-regulated and 17 up-regulated in liver metastases. Proteomic analysis showed that the S-adenosylmethionine transgelin variant was down-regulated in liver metastasis tissues. Zinc finger protein 64 homolog (Zfp64), guanine nucleotide exchange factor 4 (GEF4), human arginase, glutathione S-transferases (GSTs) A3, and tumor necrosis factor alpha (TNF-alpha)-induced protein 9 were up-regulated in liver metastasis tissues. Immunohistochemical staining confirmed that human arginase expression was higher in liver metastases than in the primary focus. CONCLUSIONS: There was a significant difference in protein expression between the primary focus of colorectal carcinoma and liver metastases. The differentially regulated proteins were closely related to liver metastasis of colorectal carcinoma. Elevated human arginase may be an important molecular marker for liver metastasis from colorectal carcinoma.

[Clinical experience of 371 cases of sphincter-preservation with telescopic anastomosis after radical excision for low-middle rectal cancer].

OBJECTIVE: To evaluate the clinical efficacy, feasibility and safety of sphincter-preservation with telescopic anastomosis of colon and rectal mucosa in low-middle rectal cancer. METHODS: A retrospective analysis was carried out in 371 patients with low-middle rectal cancer in whom telescopic anastomosis was used. There were 224 males and 147 females, with a mean age of 57.9 (21-99) years. The lower margins of the tumors located between 5-8 cm from the anal verge. On histopathology, there were 361 adenocarcinomas, including 138 well-differentiated, 201 moderately differentiated, 11 poorly differentiated, 11 mucinous adenocarcinoma, and 10 adenomas with neoplastic changes. According to the Duke's stage classification, 120 were TNM stage I, 222 stage II, 26 stage III, and 3 stage IV. RESULTS: Three hundred and eighteen (318/371, 85.7%) cases were followed up, and the median follow up time was 5.8 years. Postoperative complications were observed, including 16(4.3%) cases with anastomotic leak, and 8 (2.1%) with anastomotic stenosis. All the patients resumed normal bowel function during 12-24 weeks after operation, with 1-3 times per day. The local recurrence rate was 6.3% (20/318). Hepatic and lung metastasis was 14.5% (46/318) and 2.5% (8/318), respectively. The 5-year survival rate was 69.7%. CONCLUSION: The sphincter-preservation with telescopic anastomosis procedure is safe and effective for low-middle rectal cancer, and the sphincter function can be well-preserved.

[Clinical study of 231 cases of radical excision with sphincter preservation by casing anastomosis in low rectal cancer].

OBJECTIVE: To investigate the clinical efficacy, feasibility and safety of sphincter-preserving procedure by casing anastomosis of colon and rectal mucosa in low rectal cancer. METHODS: A retrospective analysis was carried out in 231 cases of low rectal cancer performed casing anastomosis. RESULTS: One hundred and ninety-seven (197/231, 85.3%) cases were followed up, the median time of the follow up was 5.9 years (range, 2 months-14 years). Eight (3.4%) cases of stoma leak and 3 (1.2%) cases of stoma stenosis were found post operation. Defecating function recovered normally (1 - 3 times per day) in 12 - 24 weeks after operation in all patients. Local recurrence was found in 5.1% (10/197) of the cases. Hepatic and lung metastasis was found in 15.2% (30/197) and 2.5% (5/197) of the patients, respectively. The five-year survival rate was 71.6% totally. CONCLUSIONS: The casing anastomosis procedure with sphincter preservation is safe and efficacy for low rectal cancer. With the procedure, the anal function can be preserved well, stoma leak is decreased, and the five-year survival rate is the same as Miles operation.

[Clinical analysis of therapeutic effects of sphincter-preserving operation and Miles operation for rectal cancer].

OBJECTIVE: To investigate and compare therapeutic effects of sphincter-preserving operation and Miles operation for rectal cancer. METHODS: A retrospective analysis was carried out in 572 cases of rectal cancer operations performed from January 1980 to December 2006. RESULTS: Sphincter-preserving operation was carried out in 403 cases and Miles procedure in 169 cases. The follow-up rate was 76.2% (436/572) with a period of 0.5 - 25.0 years (median, 9.5 years). Local recurrence occurred in 6.3% (20/317) of sphincter-preserving operation and 7.6% (9/119) of Miles operation, the differences was not significant (chi2 = 1.3942, P > 0.05). Distal metastasis was found in 50 cases (15.7%) of sphincter-preserving operation and 19 cases (16.2%) of the Miles operation with no significant difference (chi2 = 0.6672, P > 0.05). There was no significant difference in five-year survival rate between the two groups, with 67.8% in sphincter-preserving operation and 67.2% in Miles operation. CONCLUSIONS: Sphincter-preserving operations can improve the quality of life in rectal cancer although with the same five-year survival rate and recurrence rate as Miles operation. The operation for rectal cancer should be performed individually according to the location, the bionomics and the clinical stage.

[Extended parietal cell vagotomy in the treatment of acute perforation of duodenal ulcer in 176 cases].

OBJECTIVE: To evaluate the long-term therapeutic efficacy of extended parietal cell vagotomy (EPCV) in the treatment of duodenal ulcer complicated with acute perforation. METHODS: Therapeutic efficacy of EPCV in 176 cases subjected to duodenal ulcer with acute perforation since 1979 was evaluated, including postoperative complication, ulcer recurrence rate, gastric empting function, endoscopic and radiographical examination, nutritional status and Visick classification. RESULTS: Among 176 patients, 153 (86.9%) cases were successfully followed-up for 5 years after operation. No operative death was found. Postprandial superior belly fullness occurred in 13 cases (8.5%) and heartburn in 12 cases (7.8%), which could be relieved by Domperidone. Adhesive ileus was noted in 4 cases (2.6%) which was cured by adhesiolysis. The total ulcer recurrence rate was 2.6% (4 cases) within 2 to 3 years after operation. Superficial gastritis occurred in 21 cases (13.7%) and duodenal bulb in 31 cases (20.3%). Sinus ventriculi vermicular motion was good and gastric emptying was normal. No anemia was found. Body weight gained in 116 cases (75.8%). One hundred and forty-six cases(95.4%) were reforming Visick grade I and II , 3 cases(2.0%) grade III , and 4 cases (2.6%) IV . CONCLUSIONS: EPCV is convenient for performance with low postoperative complication rate. Its long-term efficacies are quite good, which including normal nutritional status, high quality of life and low ulcer recurrence rate. EPCV is one of effective and safe treatments for duodenal ulcer complicated with acute perforation.

[Expression of cathepsin B and its clinical importance in colorectal cancer].

OBJECTIVE: To investigate the expression of cathepsin B (CatB) in colorectal cancer tissues and serum levels of CatB in patients with colorectal carcinoma and to study the association of CatB expression with lymph node and li ver metastasis. METHODS: Immunohistochemistry was used to detect CatB expression in tissues, and enzyme linked immunosorbent assay was applied to test CatB levels in peripheral vein blood in 83 patients with colorectal cancer. RESULTS: The expression rates of CatB in primary lesions, normal colon mucosa, lymph node metastases and hepatic metastases were 56.6%, 31.3%, 88.4%, 85.0% respectively. The positive rates of CatB in primary lesions, hepatic and lymph node metastases were higher than that in normal mucosa (chi (2)=45.6124, P< 0.01). The CatB expression rates in lymph node and hepatic metastases were higher than that in primary lesions chi (2)=11.5982, 4.3747, P< 0.05). The positive rate of CatB was higher in Dukes C and D tumors than that in Dukes A and B tumors (chi (2)=18.8871, 25.1650, P< 0.01), higher in poorly differentiated and mucous adenocarcinomas than that in well-moderately differentiated adenocarcinomas chi (2)=14.2338, P< 0.05). The mean serum level of CatB in 83 patients with colorectal cancer was (5.9+/- 2.9) ng/ml, higher than (2.3+/- 1.1) ng/ml in the controls of 30 healthy volunteers (t=6.6975, P< 0.01). The serum level of CatB in the patients with Dukes C, D stages were higher than that with Dukes A, B stages. CONCLUSIONS: Enhanced expression of CatB in colorectal cancer tissues is associated with tumor infiltration and metastasis. Monitoring serum CatB level in patients with colorectal cancer is important in the prediction and diagnosis of lymph node and hepatic metastasis,and valuable for evaluation of the therapeutic effect.

[Expression of metallothionein and FasL in colorectal cancer and its clinical significance].

OBJECTIVE: To study the expression of metallothionein (MT) and FasL in colorectal cancer and their relation to lymph node and liver metastasis. METHODS: Immunohistochemistry and quantitative RT-PCR were used to detect expression of MT and FasL in protein and mRNA levels in 93 cases of colorectal cancer. RESULTS: The rates of MT expression in primary foci, non-cancerous colon mucosa, lymph node metastasis and liver metastasis were 58.1%, 32.3%, 81.1%, 64.3% respectively. And the rates of FasL expression were 41.9%, 19.4%, 62.3%, and 92.9% respectively. The positive rates of MT and FasL in primary foci, liver and lymph node metastasis were higher than that in non-cancerous mucosa (chi(2) = 35.2421, 57.5152, P < 0.01). MT expression rate in lymph node metastasis was higher than that in primary foci (chi(2) = 8.0565, P < 0.01). In liver metastasis, FasL expression rate was higher than in lymph node metastasis and primary foci (chi(2) = 8.6674, 22.4455, P < 0.01). The positive rates of MT and FasL in Dukes stage C and D were higher than that in Dukes stage A and B (chi(2) = 18.8871, 25.1650, P < 0.01). And higher rates of MT and FasL expression were observed in low differentiation adenocarcinoma and mucus adenocarcinoma than in middle-high differentiation adenocarcinoma (chi(2) = 11.1546, 9.2239, P < 0.05). High MT mRNA level was found in lymph node metastasis and high FasL mRNA level in liver metastasis. CONCLUSIONS: Enhanced expression of MT and FasL was associated significantly with lymph node and liver metastasis of colorectal cancer. Assay of MT and FasL expression has prognostic values for colorectal cancer patients.

Combined liposome-mediated cytosine deaminase gene therapy with radiation in killing rectal cancer cells and xenografts in athymic mice.

PURPOSE: The aim of this study was to assess the antitumor efficacy of combination of cytosine deaminase (CD) suicide gene therapy with radiation and to grope for new therapeutic strategy for local recurrent rectal cancer. EXPERIMENTAL DESIGN: HR-8348 cell line of human rectal cancer was used to assess efficiency of transfection with plasmid pEGFP-N1 and PXJ41-CD. The cells were exposed to radiation followed by liposome-mediated transfection. Cell inhibition assay was done with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide method. Antitumor efficacy of combined liposome-mediated CD suicide gene therapy with radiation was determined by treatment of nude mice bearing HR-8348 cancer cell xenograft. RESULTS: The efficiency of liposome-mediated CD gene transfection can be improved by radiation. With radiation at 2, 4, 6, and 8 Gy, the efficiency of liposome-mediated transfection increased from 21.3% to 62.2%, 78.0%, 83.2%, and 87.8%, respectively. CD expression was enhanced as well. Cancer cell inhibition experiment showed that combined liposome-mediated CD gene therapy with radiation had much stronger antitumor effect. With HR-8348 tumor xenograft model, suppression of tumor xenograft was observed. Compared with control group, tumor volume was inhibited by 81.5%, 48.5%, and 37.4%, respectively, in the combined CD/5-fluorocytosine with radiation group, CD/5-fluorocytosine group, and radiation group and the wet weight of tumor was decreased by 80%, 41.7%, and 37.7%, respectively. CONCLUSION: These findings suggested that combination of liposome-mediated CD gene therapy with radiation is a safer and efficient anticancer method. Its therapeutic efficacy may meet clinical treatment on local recurrent rectal cancer.

[The construction of yeast two-hybrid method in the protein-interactions and its significance in hepatic metastasis of colorectal carcinoma].

OBJECTIVE: To construct the yeast two-hybrid system, and screen the proteins which interact with FasL, and investigate the relationship of FasL and hepatic metastasis of colorectal carcinoma. METHODS: We have cloned the FasL gene into the pGBKT7 vector as the bait, then screened the fetal liver cDNA library, and have got a series of specific proteins that interact with FasL protein. Using the bioinformatics, we analyzed the interacting proteins in the mechanism of hepatic metastasis of colorectal carcinoma. RESULTS: We have screened several proteins that interaction with FasL protein, including metallothionein 1K, 1G, 2A, cathepsin B, fatty acid synthase, interferon alpha-inducible protein 27, phospholipid scramblase, Ser/Thr-like kinase, anchor attachment protein, fibulin-5. CONCLUSIONS: We have successfully constructed the yeast two-hybrid system, and preliminary identified that the interaction between FasL, metallothionein, cathepsin and anchor attachment protein is radically related to the hepatic metastasis of colorectal carcinoma.

Influence of FasL gene expression on hepatic metastasis of colorectal carcinoma.

BACKGROUND: FasL expression was reported to be associated with hepatic metastasis of colorectal cancer. The aim of this study was to study FasL gene expression in colorectal carcinoma and its influences on biological behavior and hepatic metastasis of colorectal carcinoma. METHODS: FasL gene expressions were examined with reverse transcriptase-polymerase chain reaction (RT-PCR) in the primary focus of colorectal carcinoma, adjacent cancerous mucosae, and metastasized liver focus from colorectal cancer. HR-8348 cells of human rectal cancer cell line were transfected with FasL cDNA. Cell growth suppression rate and response to 5-FU and carboplatin were observed and analyzed with the MTT method. RESULTS: FasL gene expression was detected in the primary focus of colorectal cancer (n=58), adjacent cancerous mucosae (n=58), and metastasized hepatic tumor tissues (n=28). The positive rate of FasL expression was 24% (14/58), 8% (5/58), and 100% (58/58) in the primary focus, adjacent cancerous mucosae and metastasized hepatic tumor tissues respectively. FasL expression rate in the metastasized hepatic tumor tissues was higher than that in the primary focus (X(2)=43.49, P<0.01) and adjacent cancerous mucosae (X(2)=57.66, P<0.01). In a group of patients with hepatic metastasis, the FasL expression rate in primary focus was higher than that in patients without hepatic metastasis (X(2)=3.96, P<0.05). In vitro study positive expression of FasL was shown in transfected HR-8348 cells. When 5-FU or carboplatin was added, there was a significant difference in growth suppression rate between FasL positive and controlled cancer cells (t=9.02, t=11.93, P<0.01). Under the same concentration of chemotherapeutic agents, the survival rate of FasL positive HR-8348 cells was higher than that of controlled cells. CONCLUSIONS: FasL positive cancer cells are powerfully resistant to chemotherapeutic agents. The expression of the FasL gene in colorectal cancer cells is related to immune evasion to escape from being killed by immune cells, showing stronger drug-resistance, and it facilitates hepatic metastasis.