Primary Surgery Followed by Selective Chemoradiotherapy Versus Preoperative Chemoradiotherapy Followed by Surgery for Locally Advanced Rectal Cancer: A Randomized Clinical Trial.

PURPOSE: The aim of this work was to determine whether locally advanced rectal cancer (LARC) with negative mesorectal fascia (MRF) predicted by magnetic resonance imaging (MRI) can be excluded from preoperative radiation therapy treatment. METHODS AND MATERIALS: This multicenter, open-label, non-inferiority, randomized clinical trial enrolled patients with LARC within 6 to 12 cm from the anal verge and with negative MRI-predicted MRF. Participants were randomized to the intervention group (primary surgery, in which the patients with positive pathologic [CRM] circumferential margins were subjected to chemoradiotherapy [CRT] and those with negative CRM underwent adjuvant chemotherapy according to pathologic staging) or the control group (preoperative CRT, in which all patients underwent subsequent surgery and adjuvant chemotherapy). The primary endpoint was 3-year disease-free survival (DFS). RESULTS: A total of 275 patients were randomly assigned to the intervention (n = 140) and control (n = 135) groups, in which 33.57% and 28.15% patients were at clinical T4 stage and 85.92% and 80.45% patients were at "bad" or "ugly" risk in the intervention and control groups, respectively. There were 2 patients (1.52%) and 1 patient (0.77%) with positive CRM in the intervention and control groups, respectively (P > .05). The non-adherence rates for the intervention and control groups were 3.6% and 23.7%, respectively. After a median follow-up of 34.6 months (IQR, 18.2-45.7), 43 patients had positive events (28 patients and 15 patients in the intervention and control groups, respectively). There were 6 patients (4.4%) with local recurrence in the intervention group and none in the control group, which led to the termination of the trial. The 3-year DFS rate was 81.82% in the intervention group (95% CI, 78.18%-85.46%) and 85.37% in the control group (95% CI, 81.75%-88.99%), with a difference of -3.55% (95% CI, -3.71% to -3.39%; hazard ratio, 1.76; 95% CI, 0.94-3.30). In the per-protocol data set, the difference between 3-year DFS rates was -5.44% (95% CI, -5.63% to -5.25%; hazard ratio, 2.02; 95% CI, 1.01-4.06). CONCLUSIONS: Based on the outcomes of this trial, in patients with LARC and MRI-negative MRF, primary surgery could negatively influence their DFS rates. Therefore, primary surgery was an inferior strategy compared with preoperative CRT followed by surgery and cannot be recommended for patients with LARC.

[Clinical significance of hypersensitive C-reactive protein, fribrinogen and D-dimmer in connective tissue disease-related interstitial lung disease].

OBJECTIVE: To investigate the clinical significance of plasma levels of hypersensitive C-reactive protein (hs-CRP), fibriogen and D-dimmer (D-DI) in patients with connective tissue disease (CTD)-related interstitial lung disease (CTD-ILD). METHODS: Sixty-nine patients with interstitial lung disease admitted in Zhujiang Hospital between January, 2010 and April, 2016, including 29 with CTD-ILD and 40 with non-CTD-ILD were analyzed for plasma levels of hs-CRP, fibriogen and D-DI, with 25 healthy subjects as the control group. RESULTS: The plasma level of hs-CRP, fibriogen and D-DI in patients with CTD-ILD and non-CTD-ILD were all significantly higher than those in the control group. The patients with CTD-ILD had a significantly higher hs-CRP level than those with non-CTD-ILD, but the levels of fibriogen and D-DI were comparable between the two groups. Correlation analysis indicated that Hs-CRP level was positively correlated with the levels of D-DI (r=0.539, P<0.01) and fibrinogen (r=0.534, P<0.01). CONCLUSION: Hs-CRP, fibriogen and D-DI levels show an important value in clinical diagnosis of CTD, and an obvious elevation of hs-CRP is correlated with the CTD.

[Fluid resuscitation strategy in septic shock following urinary infection with severe pulmonary capillary leakage].

OBJECTIVE: To characterize septic shock following urinary infection with severe pulmonary capillary leakage, and to evaluate the fluid therapy on treatment of hypovolemic shock and the role of transpulmonary thermodilution technique with pulse induced continuous cardiac output (PiCCO) monitoring. METHODS: A retrospective study was conducted. Eight patients surviving septic shock following urinary infection with severe pulmonary capillary leakage were enrolled, and all of them underwent PiCCO monitoring in the intensive care unit (ICU) when the diagnosis was established. The monitoring started at admission, and ended when shock was corrected or transferred from ICU. The clinical data including general end diastolic volume index (GEDVI), extravascular lung water index (EVLWI), input and output volume of fluid, net fluid balance, oxygenation index (PaO2/FiO2), the level of arterial blood lactic acid, and chest X ray were collected and analyzed retrospectively the characteristics of septic shock following urinary infection, and the role of PiCCO monitoring in fluid resuscitation. RESULTS: Septic shock following urinary infection occurred in a median of 4.5 days in 8 patients after renal and ureteric calculi lithotripsy, accompanied with severe pulmonary vessel effusion and hypoxemia in different degrees. The mean value of EVLWI was (22±7) ml/kg, and the PaO2/FiO2 (164±82) mm Hg at the time of admission to ICU. Conservative fluid resuscitation strategy was adopted in management of septic shock with severe pulmonary capillary leakage, the mean fluid input in 8 patients was (2412±1121) ml/d, and the net fluid balance -553 ml/d, and the central venous pressure (CVP) and GEDVI were maintained at levels of (9±3) mm Hg and (749±236) ml/m(2) respectively. Diuretics were administered to 6 patients and the mean dosage of fursemide was (264±133) mg. Norepinephrine and dobutamine infusion were given to 7 patients to maintain blood pressure at normal range for (4±1) days. Seven patients were mechanically ventilated, and the mean length of ventilation was (8±6) days. All of the 8 patients survived from septic shock after fluid resuscitation therapy, with the mean level of EVLWI decreased gradually to (11±3) ml/kg, and the lung effusion was absorbed significantly as shown in chest X ray. The mean length of ICU stay was (17±11) days. Pearson correlate analysis showed EVLWI was significantly correlated with PaO(2)/FiO(2) and the levels of artery blood serum lactate, with r -0.91 and 0.70 respectively (both P<0.05). CONCLUSIONS: Successful management of septic shock following urinary infection with severe pulmonary vascular leakage is based on accurate assessment of blood volume status, especially the degree of EVLWI, emphasis on prevention of EVLWI increase, and adoption of conservative fluid resuscitation strategies according to hemodynamic monitoring parameters. PiCCO monitoring is a useful tool in assessment of the blood volume status and management of fluid resuscitation in patients with urinary lithotripsy-associated septic shock complicated with severe pulmonary edema.

[Multi-slice spiral computed tomography angiography for preoperative evaluation of laparoscopic right hemicolectomy].

OBJECTIVE: To explore the application value of multi-slice spiral CT angiography (MSCTA) for the preoperative evaluation of laparoscopic right hemicolectomy. METHODS: Abdominal CT slice images of 160 patients(group A) were collected for 3-dimensional reconstruction using volume rendering technique. Interpretation and anatomical classification of the major branches and course of the superior mesenteric artery(SMA) in the reconstructed images of the arterial phase were carried out. Forty-five patients(group B) undergoing laparoscopic right hemicolectomy were evaluated with MSCT combining images obtained from the arterial phase and portal venous phase. The relationship between ileocolic artery and ileocolic vein was analyzed. The preoperative imaging findings were compared to that revealed during the procedure. RESULTS: In group A, 70(43.8%) out of 160 patents showed anatomical variations of the superior mesenteric artery, of whom 51(31.9%) had two right colic arteries, and 14(8.8%) had two middle colic arteries. Preoperative MSCTA showed that in group B ileocolic artery was running ventrally to ileocolic vein in 13(28.9%) out of 45 patients, while running dorsally in 32(71.1%). Compared to the skeletonized vessels during the procedure, the consistency rate was 100%. CONCLUSION: Anatomical variations of superior mesenteric artery are common, therefore, multi-slice spiral CT scan is vital for preoperation evaluation.