Efficacy and safety of self-expanding metallic stent placement followed by neoadjuvant chemotherapy and scheduled surgery for treatment of obstructing left-sided colonic cancer.

BACKGROUND: This study aimed to evaluate the safety and feasibility of self-expanding metallic stent (SEMS) followed by neoadjuvant chemotherapy prior to elective surgery for obstructing left-sided colon cancer. METHODS: Eleven consecutive patients with obstructing left-sided colon cancer between May 2014 and November 2015 were included retrospectively. All patients received SEMS followed by neoadjuvant chemotherapy. The primary outcome measure was stoma and laparoscopic surgery. RESULTS: Chemotherapy was with two cycles of CAPOX (54.5%) or three cycles mFOLFOX6 (45.5%). Median serum albumin and hemoglobin levels before surgery were significantly higher than before neoadjuvant chemotherapy (p = 0.01 and p = 0.008 respectively) and before SEMS (p = 0.01 and p = 0.003 respectively). Median bowel wall thickness proximal to the upper edge of tumor was significantly more before neoadjuvant chemotherapy than before stent (p = 0.003), and significantly less before surgery than before neoadjuvant chemotherapy (p = 0.003). No patient underwent stoma creation. Laparoscopic surgery was performed in nine (81.8%) patients. No local recurrence or metastases developed over median cancer-specific follow-up of 44 months (range, 37-55 months). CONCLUSION: SEMS followed by neoadjuvant chemotherapy prior to elective surgery appears to be safe and well tolerated in patients with obstructing left-sided colon cancer.

Perineal Wound Complications After Extralevator Abdominoperineal Excision for Low Rectal Cancer.

BACKGROUND: Reconstruction of the pelvic floor defect caused by extralevator abdominoperineal excision poses a challenge for the surgeon. OBJECTIVE: The aim of this study was to analyze the long-term perineal wound complications in patients undergoing conventional primary closure versus biological mesh-assisted repair after extralevator abdominoperineal excision. DESIGN: This was a single-institution retrospective observational study. SETTINGS: The study was conducted at a tertiary academic medical center. PATIENTS: Patients with low advanced rectal cancer undergoing extralevator abdominoperineal excision from August 2008 to December 2016 (N = 228) were included. INTERVENTIONS: All of the patients received extralevator abdominoperineal excision operation. MAIN OUTCOME MEASURES: The primary outcome measure was perineal wound complications after the operation. RESULTS: Of the 228 patients who underwent extralevator abdominoperineal excision, 174 received biological mesh repair and 54 received primary closure. Preoperative radiotherapy was administered to 89 patients (51.1%) in the biological mesh group and 20 patients (37.0%) in the primary closure group. The biological mesh group had significantly lower rates of perineal wound infection (11.5% vs 22.2%; p = 0.047), perineal hernia (3.4% vs 13.0%; p = 0.022), wound dehiscence (0.6% vs 5.6%; p = 0.042), and total perineal wound complications (14.9% vs 35.2%; p = 0.001) compared with the primary closure group. Multivariable logistic regression analysis showed preoperative radiotherapy (p < 0.001), conventional primary closure (p < 0.001), and intraoperative bowel perforation (p= 0.001) to be significantly associated with perineal procedure-related complications. LIMITATIONS: This was a single-center retrospective study. CONCLUSIONS: Although perineal wound repair with biological mesh prolongs the operative time of perineal portion, the perineal drainage retention time, and the length of hospital stay, it may reduce perineal procedure-related complications and improve wound healing. Preoperative radiotherapy and intraoperative bowel perforation appear to be independent predictors of perineal complications. See Video Abstract at http://links.lww.com/DCR/B42. COMPLICACIONES DE LA HERIDA PERINEAL DESPUÉS DE LA EXCISIÓN ABDOMINOPERINEAL EXTRA-ELEVADORA EN CASO DE CÁNCER DE RECTO BAJO: La reconstrucción del defecto en el suelo pélvico, resultado de una resección abdominoperineal extra-elevadora plantea un desafío para el cirujano.El analisis de las complicaciones de la herida perineal a largo plazo en pacientes sometidos a un cierre primario convencional versus una reparación asistida por malla biológica después de una resección abdominoperineal extra-elevadora.Estudio retrospectivo observacional en una sola institución.Investigación realizada en un centro médico académico terciario.Se incluyeron los pacientes con cáncer rectal bajo avanzado que se sometieron a una resección abdominoperineal extra-elevadora desde agosto de 2008 hasta diciembre de 2016 (n= 228).Todos aquellos pacientes que fueron sometidos a una resección abdominoperineal extra-elevadora.Todas las complicaciones de la herida perineal en el postoperatorio.De los 228 pacientes que se sometieron a una resección abdominoperineal extra-elevadora, 174 fueron reparados con una malla biológica y 54 se beneficiaron de un cierre primario. La radioterapia preoperatoria se administró a 89 (51,1%) pacientes en el grupo de malla biológica y 20 (37,0%) pacientes en el grupo de cierre primario. El grupo de malla biológica tuvo tasas significativamente más bajas de infección de la herida perineal (11.5% vs. 22.2%; p = 0.047), hernia perineal (3.4% vs. 13.0%; p = 0.022), dehiscencia de la herida (0.6% vs. 5.6%; p = 0,042) y complicaciones perineales de la herida (14,9% frente a 35,2%; p = 0,001) en comparación con el grupo de cierre primario. El análisis de regresión logística multivariable mostró que la radioterapia preoperatoria (p <0.001), el cierre primario convencional (p <0.001) y la perforación intestinal intra-operatoria (p = 0.001) se asociaron significativamente como complicaciones relacionadas con el procedimiento perineal.Estudio retrospectivo de centro único.Aunque la reparación de la herida perineal con malla biológica prolonga el tiempo perineal de la operación, la presencia y duración del drenaje perineal y la hospitalización pueden reducir las complicaciones relacionadas con el procedimiento perineal y mejorar la cicatrización de la herida. La radioterapia preoperatoria y la perforación intestinal intra-operatorias parecen ser predictores independientes de complicaciones perineales. Vea el Resumen del Video en http://links.lww.com/DCR/B42.

[Surgical management of postoperative stricture of anastomosis after operation of intersphincteric resection for lower rectal cancer].

OBJECTIVE: To study surgical treatment of postoperative stricture of anastomosis for lower rectal cancer. METHODS: The data of 9 cases who were diagnosed as postoperative stricture of anastomosis after operation of intersphincteric resection for lower rectal cancer during January 2008 to June 2011 were analyzed retrospectively. Transanal excision of stricture were used in 3 cases diagnosed as membranous stricture. Transanal radial incision of stricture were used in 5 cases diagnosed as tubulous stricture. Biologic patch was used to repair the defect of the posterior wall of rectum after excision of severe stricture in 1 case. RESULTS: All 9 cases of postoperative stricture of anastomosis were cured by surgery. Anal dilation were performed every day by patients themselves after discharge. Digital examination showed that 1 to 2 fingers could pass through the anastomosis after operation. The patient whose rectal defect was repaired by biological patch underwent colonoscopy examination two weeks after operation. Colonoscopy showed that the biological patch had been filled with granulation and integrated into the surrounding intestinal tissue. All patients defecated without difficulty and the anal function of all patients was good after restoration of intestinal continuity. CONCLUSION: Aggressive surgery, combining with the use of biological patch if necessary is an effective therapy of postoperative stricture of anastomosis for lower rectal cancer.

[Technical improvements and results of individual cylindrical abdominoperineal resection for locally advanced low rectal cancer].

OBJECTIVE: To evaluate the safety and efficacy of individual cylindrical abdominoperineal resection (CAPR) for locally advanced low rectal cancer. METHODS: From June 2011 to February 2012, 11 patients with locally advanced low rectal cancer underwent individual CAPR. There were 7 male and 4 female patients, aged from 32 to 74 years with a median of 64 years. Forty-seven patients underwent classic CAPR from January 2008 to February 2012. Preoperative and postoperative parameters such as clinical information of patients, tissue morphometry and complications were compared. RESULTS: In the individual surgical group, 6 patients were treated with one side levator ani muscle totally or partially reserved, 3 patients with sacrococcyx reserved, and 2 patients with dissection close to the anterior rectal wall. Compared with classical surgery, the individual surgical specimens of horizontal section area ((2197 ± 501) mm(2)) and intrinsic muscle layer outer area ((1722 ± 414) mm(2)) were small, but the difference was not statistically significant (P = 0.150 and 0.167). The operative time, intraoperative blood loss, circumferential resection margin, total cross sectional tissue area, cross sectional tissue area outside the muscularis propria and bowel perforation rate between the two groups were not significantly different. Individual CAPR showed less incidence of chronic perineal pain (2/11, χ(2) = 6.116, P = 0.013) and sexual dysfunction (2/9, χ(2) = 4.412, P = 0.036) compared with classic CAPR. CONCLUSIONS: Individual CAPR has the potential to reduce the risk of chronic perineal pain and sexual dysfunction without influencing the radical effect when compare with classic CAPR for the treatment of low rectal cancer.

Long-term outcomes of human acellular dermal matrix plug in closure of complex anal fistulas with a single tract.

BACKGROUND: Bioprosthetic plugs represent a promising technique for the treatment of anal fistula simple because they allow simple and repeatable application, preservation of sphincter integrity, minimal patient discomfort, and subsequent surgical options if needed. However, success rates vary widely. OBJECTIVE: The aim of this study was to assess long-term outcome in patients treated with an acellular dermal matrix plug for closure of complex single-tract anal fistulas. DESIGN: This was a retrospective analysis of a prospective database. SETTING: The study was conducted at a university hospital in Beijing, People's Republic of China. PATIENTS: The study population comprised 114 patients treated between January 2007 and May 2010 for complex high transsphincteric anal fistula with a single tract. INTERVENTION: Fistulas were treated with an acellular dermal matrix plug derived from donated human skin. MAIN OUTCOME MEASURES: The main outcome measures were fistula closure rate and postoperative incontinence (Wexner scores). RESULTS: No mortality or major complications were observed. The overall success rate was 54.4% (62/114), with a median follow-up of 19.5 (range, 11-46) months. Of the 52 patients with plug failure, 11 (21%) had plug extrusion and 9 (17%) had sepsis. Most plug failures occurred within 30 days, with only 1 plug failure occurring 6 months after surgery. On multiple logistic regression analysis, smoking (P < .001), long distance between external opening (P < .001), and performance of the operation by a nonexpert surgeon (P = .018) were significantly associated with plug failure. Of 40 patients who underwent cutting seton placement after plug failure, 33 (82.5%) reported a successful outcome. However, the rate of incontinence 6 months after seton placement was 75% (30/40), whereas the rate in the overall study population 6 months after insertion of the ADM plug was 1.75% (2/114; P < .001). LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: Given the low morbidity and relative simplicity of the procedure, we suggest that an acellular dermal matrix plug is a reasonable option for closure of complex anal fistulas with a single tract.

Comparison of clinicopathological features and hRad21 expression between telomerase-dependent and telomerase-independent colorectal cancer.

BACKGROUND/AIMS: To investigate the difference of clinicopathological features and expression of hRad21 between telomerase-dependent and telomerase-independent colorectal cancer (CRC). METHODOLOGY: By detecting telomerase activity of surgical specimens using the TRAP method, 251 cases diagnosed as CRC were allocated to the telomerase-dependent and telomerase-independent groups, as appropriate. Expression difference of hRad21 between the two groups was investigated by immunohistochemistry. All patients were followed-up and clinicopathological features were compared. RESULTS: There were 38 and 213 cases in the telomerase-independent and telomerase-dependent groups, respectively. Expression of hRad21 in the telomerase-independent group is higher than that in the telomerase-dependent group. Clinicopathological analysis indicated that invasion of the rectal wall (T stage) in the telomerase-independent group was more superficial than that in the telomerase group (p=0.022). Age, gender, location of tumor, serum CEA, CA19-9, lymph node metastasis, distant metastasis, TNM stage and tumor differentiation showed no difference between groups. Follow-up indicated a significantly shortened survival time in the telomerase-dependent group (p=0.006). CONCLUSIONS: Most CRC (84.9%) maintain their telomeres by telomerase, while a minority (15.1%) do so by telomerase-independent pathway. Depth of invasion in the telomerase-independent group was lower than that the telomerase group. Follow-up indicated that patients of telomerase-independent group had a higher survival rate than that of telomerase-dependent group. Expression of hRad21 in telomerase-independent CRC is higher than that of telomerase-dependent group, which suggested that hRad21 may be an important protein involved in telomerase-independent telomere maintenance mechanisms.

Human acellular dermal matrix in the surgical management of rectal anastomotic stricture.

Anastomotic stricture after rectal resection is an intractable complication of rectal sugery. We present a case to introduce a new method to deal with rectal defect after dissecting anastomotic stricture by using biomaterial. The patient was diagnosed with rectal anastomotic stricture after radical resection for rectal carcinoma and was treated by reoperation. There was a defect in the posterior wall of the rectum after the anastomotic stenosis was dissected. We rapaired the defect successfully by using human acellular dermal matrix (HADM). The repair of rectal defect using HADM was easily and safely performed and provided long-term clinical success. It might be considered an innovative method for rectal defect repair.

[Efficacy evaluation of anal intersphincteric resection with direct coloanal anastomosis for T1-2 ultra-low rectal cancer].

OBJECTIVE: To evaluate the oncological and functional outcomes of intersphincteric resection (ISR) in T(1-2) ultra-low rectal cancer. METHODS: From March 2000 to March 2007, ISR with total mesorectal excision (TME) was performed in 40 patients with very low rectal cancer,among whom total ISR in 5 patients, partial ISR in 23 patients, and partial ISR with partial dentate line preservation (modified partial ISR) in 12 patients. The preoperative tumor staging was T(1-2)N(0-1)M(0). RESULTS: Morbidity was identified in 3 patients including anastomotic leakage in 1 patient and wound infection in 2 patients, and there was no postoperative mortality. The 5-year overall survival rate was 97%, and 5-year disease-free survival rate was 86%. Both patients with modified partial ISR (P=0.004) and patients with partial ISR (P=0.008) had significantly better continence than those with total ISR, and patients with a diverting stoma had significantly better continence (P=0.043) than those without a stoma at 12 months after surgery. CONCLUSIONS: ISR is a safe procedure for sphincter-saving rectal surgery in selected patients with very low rectal tumors. A temporary diverting stoma may be beneficial to the improvement of anal function. Modified partial ISR under the precondition of radical resection shows better anal function and lower rate of incontinence.

hRad21 overexpresses and localizes to the ALT-associated promyelocytic leukemia body in ALT cells.

Telomerase-negative immortalized cells maintain their telomeres through a telomerase-independent pathway termed alternative lengthening of telomeres (ALT). The mechanism of ALT is based on homologous recombination (HR). A hallmark of ALT cells is presence of a nuclear structure termed ALT-associated promyelocytic leukemia body (APB). Here, we demonstrated that hRAD21, an important subunit of cohesin complex, was overexpressed in ALT cells. We additionally showed that hRAD21 protein localized to APB in ALT cells. Thus, one role of hRAD21 appeared to involve telomere maintenance in ALT cells. We suggested that hRAD21 facilitated telomere HR in ALT cells by participating in APB formation.

Deep venous thrombosis after gastrectomy for gastric carcinoma: a case report.

The treatment of gastric carcinoma consists of neoadjuvant chemoradiation, partial gastrectomy, subtotal gastrectomy, total gastrectomy, extended resection, and postoperative chemotherapy. Currently, gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma. Postoperative complications are common after total gastrectomy including hemorrhage, anastomotic leakage, fistula, and obstruction. However, deep venous thrombosis (DVT) is an uncommon complication after gastrectomy for gastric carcinoma. We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma. The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring. The patient recovered well after treatment and was symptom-free during a 3-mo follow-up. We conclude that correct diagnosis and treatment of DVT are crucial.

[Application of pelvic floor dynamic MRI combining defecography with homemade high conformable sacculus in the management of obstructed defecation syndrome].

OBJECTIVE: To evaluate the sensitivity and feasibility of pelvic floor dynamic MRI combining defecography with homemade high conformable sacculus in the management of obstructed defecation syndrome. METHODS: One hundred and nine female with pelvic floor disorders, such as difficult defecation, fecal incontinence or urinary incontinence, pelvic pain, were treated from July 2007 to March 2009. Pelvic floor dynamic MRI and defecography with homemade high conformable sacculus was performed in the patients to evaluate pelvic floor anatomy. RESULTS: Fifty-four cases (49.6%) of cystocele and 11 cases (10.1%) of rectouterine pouch hernia, 29 cases (26.6%) of perineum prolapse and 71 cases (65.2%) of rectocele were found by dynamic MRI. The dynamic MRI also revealed 19 cases (18.2%) of external sphincter trophy and 32 cases (29.4%) of spastic pelvic floor syndrome. Compared with defecography, dynamic MRI was more positive in diagnosing enterocele. Defecography Of the patients, sacrum-rectal separate was found in 33 cases (30.3%) and rectal mucosal prolapse or internal rectal intussusceptions in 41 cases (37.7%) by defecography, while dynamic MRI found none. CONCLUSIONS: As a new noninvasive imaging technique to evaluate the pelvic floor function, dynamic MRI is more sensitive, especially for patients with complicated multi-organs prolapse, and its deficiency could be remedied by defecography.

[Expression of hRad21 and clinicopathological analysis in gastrointestinal malignant tumors maintained their telomeres by a mechanism of alternative lengthening of telomeres].

OBJECTIVE: To investigate the proportion between tumors which maintain their telomeres by a mechanism of alternative lengthening of telomeres(ALT) and telomerase-dependent tumors in gastrointestinal malignant tumors, the expression difference of hRad21 between the two groups and the clinicopathological characteristics of ALT tumors were also explored. METHODS: One hundred and four cases of gastrointestinal malignant tumors were divided into 2 groups: ALT group and telomerase group by detecting telomerase activity using TRAP method. Expression difference of hRad21 was investigated between the two groups. All the patients were followed up and clinicopathological data of these patients were analyzed. RESULTS: Of 104 cases, there were 12 cases in ALT group and 94 cases in telomerase group. Expression of hRad21 in ALT group was higher than that in telomerase group. Tumors in ALT group had a thinner invasion depth (lower T stage) as compared to telomerase group (P=0.021). Other indexes, such as age, gender, tumor size, tumor grade, location of tumor, CEA and CA199, were not significantly different between the two groups. Results of follow-up showed that the survival rate of ALT group was 100% while that of telomerase group was 56% at 30 months postoperatively. CONCLUSIONS: There are tumors which maintain their telomeres by ALT in gastrointestinal malignant tumors, accounting for 10%-12% of the total tumors. As compared to telomerase group, ALT group presents higher expression of hRad21, thinner tumor invasion depth, and higher survival rate.

[Early results of per anus intersphincteric rectal dissection and direct coloanal anastomosis: sphincter-preserving surgery for patients with very low rectal cancer].

OBJECTIVE: To explore the safety and curative effect of per anus intersphincteric rectal dissection and direct coloanal anastomosis (PIDCA) for patients with very low rectal cancer. METHODS: Nineteen patients were prospectively studied from June 2002 to October 2004. There were 11 males and 8 females, with a median age of 56 (range, 41 - 74) years. Nineteen patients had T(1) to T(4) tumors (T(1), n = 4; T(2), n = 10; T(3), n = 4; T(4), n = 1) located between 3.5 and 5.0 cm above the anal verge.The rectum, including the entire width of the internal analsphincter, was transected circumferentially via the anal route to secure the surgical margin of safety under direct vision and was mobilized proximally as far as possible through the intersphincteric plane. Per anus coloanal anastomosis was performed following transabdominal resection of the rectum. RESULTS: There was no operative mortality. Of nineteen patients, two (10.5%) had anastomotic leakage. Median follow-up duration was 16 (range, 3 - 29) months. Up to now, one patient developed recurrence (5.3%). Acceptable anal function results were obtained in most patients. CONCLUSIONS: Curability and anal function was obtained by PIDCA combined with preoperative or postoperative radiotherapy and postoperative chemotherapy. PIDCA is ideal and safe for selected patients with tumor located below 5 cm from the anal verge.