Application and challenge of microsatellite instability detection in colorectal cancer / 中华消化外科杂志

Colorectal cancer (CRC) is one of the most common gastrointestinal cancers. The incidence and mortality of CRC are still rising in China. It is of great importance to explore the molecular mechanisms of the development and progression of CRC. Microsatellites are short tandem repeats that are distributed throughout the genome. Detection of microsatellite instability (MSI) is of great value in the diagnosis and treatment of CRC. MSI detection is an important method for Lynch syndrome screening. For patients with stage Ⅱ CRC, MSI status is an influencing factor for post-operative recurrence and an important reference for adjuvant therapy. For patients with stage Ⅳ CRC, MSI status is an important indicator for screening potential patients suitable for treatment of immune checkpoint inhibitors. However, there are still problems concerning the application of MSI. The detection methods of MSI have not been fully unified. The requirement of MSI detection in CRC patients are universal but not precise. MSI is not a valid predictor for the prognosis of CRC patients, and it could not effectively predict the efficacy of chemotherapy and immunotherapy. Moreover, with the application of other molecular markers, such as programmed death-1, programmed death-ligand 1, tumor mutation burden and immunoscore, the value of MSI in CRC is being challenged and remains to be unveiled with more studies. The authors investigate the problems in MSI detection and application, in order to provide reference for clinical practice.

Characteristics of No.253 lymph node metastasis in middle and low rectal cancer and its influencing factors: a report of 2 316 cases / 中华消化外科杂志

Objective:To investigate the characteristics of No.253 lymph node metastasis in middle and low rectal cancer and its influencing factors.Methods:The retrospective case-control study was conducted. The clinicopathological data of 2 316 patients with middle and low rectal cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2013 to October 2021 were collected. There were 1 339 males and 977 females, aged (61±12)years. All patients underwent D 3 radical surgery for rectal cancer. Observation indicators: (1) No.253 lymph node metastasis in patients with middle and low rectal cancer; (2) analysis of influencing factors for No.253 lymph node metastasis in patients with middle and low rectal cancer. Measurement data with normal distribution were represented as Mean± SD. Count data were expressed as absolute numbers and percentages, and comparison between groups was performed by the chi-square test. Logistic regression model was used for multivariate analysis. Results:(1) No.253 lymph node metastasis in patients with middle and low rectal cancer. There were 128 of 2 316 patients with positive No.253 lymph node and 2 188 cases with negative No.253 lymph node. The No.253 lymph node metastasis rate was 5.527%(128/2 316). There were 568 of 2 316 patients with the distance from distal margin of tumor to anal margin as 8?10 cm, 766 cases as ≥6 cm and<8 cm, 982 cases as <6 cm. Of the 568 patients with the distance from distal margin of tumor to anal margin as 8?10 cm, 57 cases had positive No.253 lymph node, including 3 cases(5.263%) of high differentiated tumor, 9 cases(15.789%) of moderate differentiated tumor, 45 cases(78.948%) of low differentiated tumor, respectively. There was 0 case of the above 57 patients with positive No.253 lymph node in TNM stage Ⅰ, 0 case in TNM stage Ⅱ, 20 cases(35.088%) in TNM stage Ⅲ, 37 cases(64.912%) in TNM stage Ⅳ, respectively. Of the 766 patients with the distance from distal margin of tumor to anal margin as ≥6 cm and <8 cm, 42 cases had positive No.253 lymph node, including 4 cases(9.524%) of high differentiated tumor, 11 cases(26.190%) of moderate differentiated tumor, 27 cases(64.286%) of low differentiated tumor, respectively. There was 0 case of the above 42 patients with positive No.253 lymph node in TNM stage Ⅰ, 0 case in TNM stage Ⅱ, 19 cases(45.238%) in TNM stage Ⅲ, 23 cases(54.762%) in TNM stage Ⅳ, respectively. Of the 982 patients with the distance from distal margin of tumor to anal margin as <6 cm, 29 cases had positive No.253 lymph node, including 1 case (3.448%) of high differentiated tumor, 3 cases (10.345%) of moderate differentiated tumor, 25 cases (86.207%) of low differentiated tumor, respectively. There was 0 case of the above 29 patients with positive No.253 lymph node in TNM stage Ⅰ, 0 case in TNM stage Ⅱ, 12 cases(41.379%) in TNM stage Ⅲ, 17 cases(58.621%) in TNM stage Ⅳ, respectively. (2) Analysis of influencing factors for No.253 lymph node metastasis in patients with middle and low rectal cancer. Results of univariate analysis showed that tumor T staging, tumor N staging, tumor TNM staging, tumor differentiation degree, the distance from distal margin of tumor to anal margin were related factors for No.253 lymph node metastasis in patients with middle and low rectal cancer ( χ2=28.48, 44.58, 172.62, 227.67, 34.57, P<0.05). Results of multivariate analysis showed that tumor T staging as stage T4, tumor N staging as stage N2, tumor TNM staging as stage Ⅳ, low differentiated tumor, the distance from distal margin of tumor to anal margin as ≥6 cm and <8 cm, 8?10 cm were independent risk factors for No.253 lymph node metastasis in patients with middle and low rectal cancer ( odds ratio=2.74, 3.48, 10.72, 21.47, 1.92, 3.67, 95% confidence intervals as 1.91?3.92, 2.42?4.98, 7.36?15.62, 10.33?44.60, 1.27?2.91, 2.31?5.81, P<0.05). Conclusions:The risk of No.253 lymph node metastasis is relatively high in middle and low rectal cancer patients with long distance from distal margin of tumor to anal margin, low differentiated tumor, and in high TNM stages. Tumor T staging as stage T4, tumor N staging as stage N2, tumor TNM staging as stage Ⅳ, low differentiated tumor, the distance from distal margin of tumor to anal margin as ≥6 cm and <8 cm, 8?10 cm are independent risk factors for No.253 lymph node metastasis in patients with middle and low rectal cancer.

Controversy and discussion on primary lymph node metastasis and dissection of middle and low rectal cancer / 中华消化外科杂志

Middle and low rectal cancer is one of the most common colorectal cancers. The lymph node metastasis, especially primary lymph node metastasis, is an important factor affecting prognosis of middle and low rectal cancer. Inferior mesenteric artery root lymph nodes and lateral lymph nodes are the primary lymph nodes of middle and low rectal cancer in different drainage direction. Based on literatures and clinical experiences, the author discusses the characteristics, main areas, clinical significance of metastasis, range of dissection and operation methods of the above two lymphatic drainage way, to find out the focus of controversy. The author advocates to focus on the clinical and basic researches of related problems and make more appropriate clinical decisions to improve the curative effect of middle and low rectal cancer.

Clinical value of stylized laparoscopic hemicolectomy for left colon cancer / 中华消化外科杂志

Objective:To investigate the clinical value of stylized laparoscopic hemicolec-tomy for left colon cancer.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 174 patients who underwent laparoscopic hemicolectomy for left colon cancer in the First Affiliated Hospital of Nanjing Medical University from January 2016 to December 2020 were collected. There were 106 males and 68 females, aged 59(range, 17?86)years. All patients underwent stylized laparoscopic hemicolectomy for left colon cancer. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) postoperative histopathological examinations; (4) follow-up. Follow-up was conducted using outpatient examination or telephone interview to detect tumor recurrence and metastasis and survival of patients up to October 2021. Follow-up was performed once every 3 months within postoperative 2 years, once every 6 months within postoperative 2 to 5 years and once a year after postoperative 5 years, with the end point as tumor recurrence and metastasis or death of patients. Measurement data with normal distribution were represented as Mean±SD and measurement data with skewed distribution were represented as M(range) or M( Q1, Q3). Count data were described as absolute numbers or percentages. Kaplan-Meier method was used to draw survival curve and calculate survival rate. Results:(1) Surgical situations. All the 174 patients underwent stylized laparoscopic hemicolectomy for left colon cancer successfully, including 6 cases receiving preoperative enteral stent placement due to bowel obstruc-tion, 3 cases receiving defunctioning ileostomy and 1 case receiving Hartmann procedure. The operation time, volume of intraoperative blood loss, time to postoperative initial defecation and duration of postoperative hospital stay of the 174 patients were 97(80,106)minutes, 45(25,60)mL, 5(3,6)days and 7(6,8)days, respectively. (2) Postoperative complications. Twelve of the 174 patients had complications, including 4 cases with incision infection or fat liquefaction, 3 cases with anastomotic leakage, 2 cases with incomplete bowel obstruction, 1 case with abdominal hemo-rrhage, 1 case with chylous leakage and 1 case with pulmonary infection. The 2 cases with anastomotic leakage underwent ileostomy. The patient with abdominal hemorrhage underwent laparotomy to stop bleeding. One elder patient died of postoperative pulmonary infection. The other patients with complications recovered with conservative treatment. (3) Postoperative histopatho-logical examinations. Of the 174 patients, there were 27 cases in stage Ⅰ of TNM staging, 68 cases in stage Ⅱ, 77 cases in stage Ⅲ and 2 cases in stage Ⅳ. There were 9 cases with well differentiated tumor, 107 cases with moderately differentiated tumor and 58 cases with poorly differentiated tumor. The number of lymph node detected, the number of positive lymph node and tumor diameter of the 174 patients were 19(15,23), 0(0,2) and 4(3,5)cm, respectively. Of the 174 patients, there were 79 cases with lymph node metastases, 21 cases with cancerous nodules, 35 cases with vascular invasion and 29 cases with nerve invasion. (4) Follow-up. Of the 174 patients, 157 cases were followed up for 27(range, 1?70)months. Of the 157 patients who conducted follow-up, 20 cases had tumor metastasis, including 9 cases with multiple metastasis, 5 cases with liver metastasis, 4 cases with lung metastasis, 1 case with bone metastasis and 1 case with spleen metastasis. The 5-year overall survival rate and tumor free survival rate of the 157 patients were 90.9% and 80.8%, respectively.Conclusion:The stylized laparoscopic hemicolectomy for left colon cancer is safe and feasible.

Surgery for iatrogenic perforation of colorectum following colonoscopy / 国际外科学杂志

Objective:To investigate the strategy and feasibility of surgery for iatrogenic perforation of colorectum following colonoscopic examination or treatment.Methods:A retrospectively descriptive study was conducted. Twenty-one patients aged from 35 to 84 years old from the Department of General Surgery of the First Affiliated Hospital of Nanjing Medical University between Jan. 2015 and Dec. 2020 were enrolled in this study. There were 15 male and 6 female patients with a median age of 64 years.Observation indicators included patient demographics, including sex, age, comorbidity, abdominal surgical history; findings and outcomes of colonoscopy, including purpose of colonoscopy, time to the diagnosis of perforation; findings and outcomes of surgical treatment, including perforation site, perforation size, surgical methods, postoperative complications.Results:Eight patients were found with diagnostic colonoscopic perforation, 13 patients with therapeutic perforation (2 patients with endoscopic mucosal resection, 7 patients with endoscopic submucosal dissection and 4 patients with stent placement). Thirteen perforation occurred during the procedure of colonoscopy. Eleven patients with perforation occurred in the sigmoid colon, 3 in the ascending colon, 3 in the rectum, 2 in the descending colon, 1 in the cecum and 1 in the hepatic flexure. The perforation size ranged from 0.3 cm to 10.0 cm with a high likelihood of a bigger perforation occurred in diagnostic colonoscopy than therapeutic colonoscopy. Seven patients received primary surgical repair with 3 patients receiving diversion. Four patients received direct colostomy in the perforation site. Six patients received segmental colectomy or radical resection with primary anastomosis, among them 2 patients received defunctioning ileostomy. Four patients received resection with the Hartmann procedure. Nine patients were performed with laparoscopic surgery with 3 patients converted to open surgery. Six patients developed postoperative complications, including 1 bowel leakage, 2 wound infection, 1 wound infection accompanied with abdominal infection, 1 kidney infection. One patient with hepatic flexure perforation after stent placement died from septic shock after the Hartmann procedure.Conclusion:With proper indication, the performance of optimal surgical treatment will save lives of patients with colonoscopic perforation.

Selection and significance of lateral lymph node dissection in advanced low rectal cancer after neoadjuvant chemoradiotherapy / 中华消化外科杂志

Lateral lymphatic drainage is one of the three important directions for low rectal cancer. Radical surgery of rectal cancer requires the dissection of lymph nodes along the drainage route which determines the extent of lymph node dissection. However, controversial arguments exist whether lateral lymph node belonging to the regional lymph node or the distant lymph node. This arguments has also brought the controversy about neoadjuvant chemoradiotherapy and lateral lymph node dissection, as well as the controversy about efficacy of neoadjuvant chemoradiotherapy on lateral metastatic lymph nodes. Combined with the preliminary clinical practices, the authors comprehensively analyze research advances at home and abroad, further elaborate the lateral lymph node metastasis of rectal cancer, the risk factors affecting lateral lymph node metastasis and tumor recurrence, and the evaluation of lateral lymph node by magnetic resonance imaging before and after chemoradiotherapy, et al, in order to investigate the selection and significance of lateral lymph node dissection in advanced low rectal cancer after neoadjuvant chemoradiotherapy.

Clinical characteristics and prognosis of multiple primary colorectal carcinoma / 肿瘤研究与临床

Objective:To explore the clinical characteristics and prognosis of multiple primary colorectal carcinoma.Methods:The clinical data of 42 cases of colorectal cancer admitted to the First Affiliated Hospital of Nanjing Medical University between January 2013 and December 2018 were retrospectively analyzed. The clinicopathological features, diagnosis, treatment and prognosis were summarized.Results:There were 42 patients with multiple primary colorectal carcinoma, accounting for 1.20% (42/3 499) of all colorectal carcinoma patients in the same period. The main pathological type was adenocarcinoma. Among them, 32 cases were synchronous multiple primary carcinoma. And the age ranged 38-86 years old, and the median age was 66 years old. A total of 73 colorectal cancer lesions were detected, mostly located in the proximal colon, sigmoid colon and rectum. A total of 527 lymph nodes were detected, and the positive rate was 1.9% (10). Patients with positive lymph nodes accounted for 37.5% (12/32), including 27 cases of multiple primary carcinoma, 3 cases of triple primary carcinoma, 2 cases of five primary carcinoma. The 1-year and 3-year overall survival rates were 83.75% and 74.38%, respectively. There were 10 cases of metachronous multiple primary carcinoma. Patients were aged 33-86 years old. The first cancer was mostly located in the rectum and sigmoid colon, and the second cancer was mostly located in the ascending colon area. A total of 276 lymph nodes were detected, and the positive rate was 12.3% (34). The 1-year and 3-year overall survival rates were 100.00% and 66.67%, respectively.Conclusions:Multiple primary colorectal cancer is not rare clinically and its distribution shows a certain regularity. More attention should be paid to improve the early diagnosis rate. Early operation is needed to improve the survival rate of patients.

Application of convalescent plasma for the treatment of adult patients with coronavirus disease 2019 / 中华危重病急救医学

The high incidence of coronavirus disease 2019 (COVID-19) and high mortality of critical patients have posed a great challenge to global public health resources. Currently there are no specific antiviral drugs and vaccines available for COVID-19, which has drawn the attention to the usefulness of convalescent plasma (CP) again, so the application of CP in the adult patients with COVID-19 is reviewed. The main contents include the possible mechanism of CP, the evidence of CP in the treatment of COVID-19 patients, the safety of clinical application of CP and the main factors affecting the clinical effect of CP, which may provide some basis for clinicians to choose CP for the treatment of adult patients with COVID-19.

Risk factors analysis of anastomotic leakage after low anterior resection of rectal cancer / 国际外科学杂志

Objective To analyze the risk factors for anastomotic leakage after low anterior resection(LAR) for rectal cancer.Methods The retrospective study of 1 336 patients with rectal cancer who underwent LAR from Jan.2013 to Dec.2017 in the Department of Colorectal Surgery,First Affiliated Hospital of Nanjing Medical University was conducted.There were 838 male and 498 female patients.The median age was 62 (53,70) years.Observation indicators:①intraoperative conditions,including the performance of preventive enterostomy,the preservation of left colic artery,the placement of transanal decompression tube;②postoperative conditions,for example,postoperative clinical symptoms and physical examination,postoperative hospital stay.Anastomotic leakage patients were graded according to the grading system of anastomotic leakage following anterior resection of the rectum proposed by the International Study Group of Rectal Cancer in 2010.Measurement data with non-normal distribution were described as median,and comparison between groups was done using Mann-Whitney U test.Ranked data were compared with rank sum test.Comparison of count data between groups were analyzed using the Chi-square test or Fisher exact test.Potential risk factors for anastomotic leakage were further analyzed with multiple logistic regression.Results Anastomotic leakage was noted in 138 (10.4％) of 1 336 patients with 93 patients (7.0％) of Grade B and 46 patients (3.4％) of Grade C respectively.The occurrence of Grade C anastomotic leakage was on the 3th day postoperatively,which was earlier than Grade B anastomotic leakage [5 (3,7) d,Z =2.746,P =0.006].There were significant differences in sex,BMI,placement of transanal decompression tube and tumor location between anastomotic leakage cases and non-anastomotic leakage cases by Chi-squared test (x2 =10.897,9.033,6.343,6.34,Z =-2.380,P ＜0.05).On multiple logistic regression analysis,male sex (OR =1.840,95 ％ CI:1.210-2.799,P =0.004),BMI ≥ 24 kg/m2 (OR =1.573,95 ％ CI:1.088-2.274,P =0.016),placement of transanal decompression tube(OR =2.418,95％ CI:1.196-4.888,P =0.014),middle rectal cancer (OR =1.536,95％ CI:O.836-2.822,P =0.167),low rectal cancer(OR =1.989,95％ CI:1.068-2.822,P =0.03),ultralow rectal cancer (OR =2.908,95％ CI:1.289-6.560,P =0.01) were independent risk factors of anastomotic leakage.Conclusion Male sex,high BMI,placement of transanal decompression tube and low rectal tumor were independent risk factors of anastomotic leakage for patients receiving LAR.

Application value of superior mesenteric artery-oriented complete mesocolic excision in the treatment of right colon cancer / 中华消化外科杂志

Objective To investigate the application value of superior mesenteric artery (SMA)-oriented complete mesocolic excision (CME) in the treatment of right colon cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 955 patients with right colon cancer who were admitted to the First Affiliated Hospital of Nanjing Medical University from January 2013 to June 2018 were collected.There were 514 males and 441 females,aged from 18 to 96 years,with a median age of 65 years.Of the 955 patients,377 undergoing SMA-oriented CME of right colon with the lymph node dissection along the left boundary of SMA were allocated into SMA-oriented group,and 578 undergoing superior mesenteric vein (SMV)-oriented CME of right colon with the lymph node dissection along the left boundary of SMV were allocated into SMV-oriented group.Observation indicators:(1) intraoperative and postoperative conditions;(2) postoperative complications;(3) postoperative pathological examinations;(4) follow-up and survival situations.Follow-up was performed by telephone interview and outpatient examination once every 3-6 months within 2 years after surgery and once a year after 2 years up to January 2019,using tumor recurrence and metastasis or death as the end point.Follow-up included physical examination and tumor marker test,including carcino embryonic antigen,CA19-9,chest and abdomen CT examination and enteroscopy.Measurement data with skewed distribution were described as M (P25,P75),and comparison between groups was done using the Mann-Whitney U test.Count data were described as absolute numbers or percentages,and comparison between groups was analyzed using the chi square test.Ordinal data were analyzed using the rank sum test.Kaplan-Meier method was used to calculate survival time and rate,and draw survival curve.Log-rank test was used for survival analysis.Patients with loss to follow-up were involved in survival analysis as censored data.Results (1) Intraoperative and postoperative conditions:the operation time,volume of intraoperative blood loss,duration of postoperative hospital stay were 100 minutes (90 minutes,110 minutes),50.0 mL (50.0 mL,70.0 mL),8 days (8 days,10 days) in the SMA-oriented group,and 110 minutes (90 minutes,135 minutes),50.0 mL (50.0 mL,122.5 mL),10 days (8 days,12 days) in the SMV-oriented group,showing significant differences between the two groups (Z=-5.400,-5.799,-7.461,P＜0.05).After the exclusion of 47 patients unsuitable for defecation analysis because of postoperative complications,365 in the SMA-oriented group and 543 in the SMV-oriented group were analyzed.The time to first defecation,the maximum number and the median number of daily defecation postoperatively were 5 days (3 days,5 days),2.0 (1.0,2.5),1.0 (1.0,1.0) in the SMA-oriented group,which showed no significant difference from 4 days (3 days,5 days),2.0 (1.0,3.0),1.0 (1.0,1.0) in the SMV-oriented group (Z=-1.622,-1.541,-1.024,P＞ 0.05).(2) Postoperative complications:cases with postoperative complications,cases with incisional liquefaction or infection,cases with anastomostic leakage,cases with delayed gastric emptying,cases with intra-abdominal bleeding,cases with complete or incomplete ileus,cases with anastomostic bleeding,cases with intra-abdominal infection,cases with disruption of wound,the number of death were 55,10,3,3,2,2,1,1,1,1 in the SMA-oriented group,which showed no significant difference from 83,30,13,4,3,8,3,6,2,3 in the SMV-oriented group,respectively (x2 =0.045,3.662,2.926,0.034,0.001,1.604,0.352,1.873,0.048,0.352,P＞0.05).There were 32 of 377 patients in the SMA-oriented group and 14 of 578 in the SMV-oriented group with chylous leakage,showing a significant difference between the two groups (x2 =18.312,P＜ 0.05).Patients with chylous leakage were improved after conservative treatment,without reoperation.Patients with other complications were improved after anti-infection,fluid infusion,and reoperation.Four of 955 patients died after surgery.(3) Postoperative pathological examinations:patients with stage Ⅰ,stage Ⅱ,and stage Ⅲ (pathological TNM staging),patients with high-differentiation,mid-differentiation,and low-differentiation (tumor differentiation degree),length of intestine specimen,number of positive lymph nodes,maximum tumor diameter,patients with cancer nodules,patients with vascular invasion,patients with perineural invasion were 57,174,146,30,174,173,23 cm (21 cm,26 cm),0 (0,2),5.0 cm (3.0 cm,6.0 cm),37,81,53 in the SMA-oriented group,which showed no difference from 66,280,232,33,303,242,23 cm (21 cm,25 cm),0 (0,2),5.0 cm (3.5 cm,6.0 cm),80,108,82 in the SMV-oriented group (Z=-1.020,-0.216,-0.243,-0.220,-0.814,x2=3.441,1.127,0.003,P＞0.05).The number of harvested lymph nodes was 22.0 (17.0,27.0) and 18.0 (15.0,22.0) in the SMA-oriented group and SMV-oriented group,respectively,with a significant difference between the two groups (Z=-7.800,P＜0.05).There were 202 patients extracted for further analysis.The number of harvested lymph nodes and harvested central lymph nodes was 25.0 (20.0,31.3),5.0 (3.0,8.0) of 166 patients in the SMA-oriented group,and 21.5 (18.0,28.8),1.5 (0,4.5) of 36 patients in the SMV-oriented group,respectively,showing significant differences between the two groups (Z =-1.995,-4.309,P＜0.05).(4) Follow-up and survival situations:840 of 955 patients including 346 in the SMA-oriented group and 494 in the SMV-oriented group were followed up for 1.0-73.2 months,with a median time of 31.5 months.SMA-oriented group had a higher 5-year overall survival rate than SMV-oriented group (91.8％ vs.84.9％,x2 =4.384,P＜0.05),but had no significant difference in the 5-year tumor-free survival rate compared with the SMV-oriented group (84.4％ vs.78.2％,x2=2.158,P＞0.05).Conclusion Compared with SMV-oriented CME of right colon,SMA-oriented CME of right colon is safe and feasible,with larger number of harvested lymph nodes,which can achieve complete lymph node dissection.

Clinical effects of laparoscopic left colic artery-preserving total mesorectal excison for middle-low rectal cancer / 中华消化外科杂志

Objective To investigate the clinical effects of laparoscopic left colic artery (LCA) preserving total mesorectal excision (TME) for middle-low rectal cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 339 patients with middle-low rectal cancer who underwent laparoscopic TME in the First Affiliated Hospital of Nanjing Medical University from July 2016 to July 2017 were collected.There were 216 males and 123 females,aged from 35 to 89 years,with an average age of 62 years.No lymph node enlargement was detected at the root of inferior mesenteric artery as evaluated by preoperative examination.Of the 339 patients,173 undergoing laparoscopic TME with preservation of LCA and 166 without preservation of LCA were allocated into observation group and control group,respectively.Observation indicators:(1) surgical situations;(2) postoperative situations;(3) follow-up.Follow-up using outpatient examination and telephone interview was performed to detect complications and survival of patients after hospital discharge up to August 2018.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was analyzed using the t test.Measurement data with skewed distribution were described as M (range),and comparison between groups was analyzed using the Mann-Whitney U test.Count data were represented as absolute number or percentage,and comparison between groups was analyzed using the chi-square test or Fisher exact propability.Comparisons of ordinal data were analyzed by Mann-Whitney U test.Results (1) Surgical situations:339 patients underwent laparoscopic TME successfully,without conversion to open surgery or death.The operation time,volume of intraoperative blood loss and number of lymph nodes dissected at the root of inferior mesenteric artery were (77± 15)minutes,(32±22)mL and 3.5± 1.3 in the observation group,(74± 16)minutes,(30±21) mL and 3.6± 1.3 in the control group,respectively,showing no statistically significant difference between the two groups (t =1.730,0.790,-0.378,P＞0.05).There were 21 and 37 patients receiving preventive stoma in the observation group and control group,with a statistically significant difference between the two groups (x2 =6.154,P＜0.05).(2) Postoperative situations:no lymphatic metastasis at the root of inferior mesenteric artery was detected in the observation group or control group.The incidence of anastomotic leakage was 8.55％ (13/152) and 16.28％(21/129) of patients without preventive stoma in the observation group and control group,with a statistically significant difference between the two groups (x2=3.917,P＜0.05).The overall incidence of anastomotic leakage was 7.51％ (13/173) and 12.65％ (21/166),with no statistically significant difference between the two groups (x2 =2.477,P＞0.05).Cases with anastomotic hemorrhage and time to first anal sufflation were 18 and (2.2±0.9) days in the observation group,10 and (2.4±1.0) days in the control group,respectively,showing no statistically significant difference between the two groups (x2 =2.145,t =-1.370,P＞0.05).(3) Follow-up:339 patients were followed up for 13-22 months,with a median time of 14 months.During the follow-up,2 patients had postoperative intestinal obstruction,19 had tumor recurrence or metastasis,and 4 died in the observation group.In the control group,1 patient had postoperative intestinal obstruction,17 had tumor recurrence or metastasis,and 3 died.The other patients in the two groups survived well.Conclusion Laparoscopic TME with preservation of LCA can reduce incidence of anastomotic leakage in patients with middle-low rectal cancer who don't undergo preventive stoma.

Controversies and surgical techniques in the laparoscopic radical resection for right colon cancer / 中华消化外科杂志

Right colon cancer is a kind of clinically common colorectal cancer.Surgical resection is the main treatment and the only curative method for patients.Improvement of surgical methods in recent years is one of the hotspots in the surgical treatment of colorectal cancer.There are controversies in laparoscopic surgery or traditional open surgery,intestine resection extent,D3 radical surgery or complete mesocolic excision,selective arterial guidance or venous guidance,pyloric lymph nodes (No.6 group lymph nodes) dissection,and most of the issues are currently lacking of prospectively randomized controlled trials.Therefore,this article discusses the above problems.At the same time,in view of the complicated operation of right hemicolectomy,and the greater risk of surgery,the author consulted the relevant literature and combined his clinical experience to introduce the key techniques of the operation.

Hsa_circ_0071589 promotes carcinogenesis via the miR-600/EZH2 axis in colorectal cancer.

Previous studies have revealed that miRNAs and lncRNAs participate in the pathogenesis of colorectal cancer (CRC); however, whether circular RNAs (circRNAs) are also involved remains unclear. In the present study, qRT-PCR was used to examine the expression of hsa_circ_0071589, miR-600, and enhancer of zeste homolog 2 (EZH2) in CRC. MTT assay, colony formation assay, transwell assay, and wound-healing assay were performed to assess the effects of hsa_circ_0071589, miR-600, and EZH2 on CRC cell viability, proliferation, invasion, and migration. Bioinformatics analysis, luciferase reporter assay, and RIP assay were used to explore the correlations among hsa_circ_0071589, miR-600, and EZH2 expression in CRC cells. The results showed that hsa_circ_0071589 expression was significantly higher in CRC tissues than in normal tissues. Blockage of hsa_circ_0071589 in CRC cells inhibited tumor growth, invasion and migration. Hsa_circ_0071589 was able to promote the expression of EZH2 by acting as a sponge of miR-600. In addition, miR-600 expression was negatively correlated to hsa_circ_0071589 expression in CRC tissues. These results demonstrated that the hsa_circ_0071589/miR-600/EZH2 axis may play critical regulatory roles in the pathogenesis of CRC and may serve as a novel therapy target in CRC.

Clinical efficacy of superior mesenteric artery-oriented laparoscopic complete mesocolic excision in the treatment of right colonic cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the clinical efficacy of superior mesenteric artery (SMA)-oriented laparoscopic complete mesocolic excision (CME) with a medial-to-lateral approach in the treatment of right colonic cancer.</p><p><b>METHODS</b>A total of 166 patients with right colonic cancer who were admitted to The First Affiliated Hospital of Nanjing Medical University from January 2015 to December 2016 underwent SMA-oriented laparoscopic CME by the same surgical team. Clinical data of these patients were retrospectively analyzed.</p><p><b>RESULTS</b>All the 166 cases were enrolled in this study, including 96 male and 70 female patients. Right colon adenocarcinoma was diagnosed by preoperative colonoscopy, enhanced computerized tomography(CT) and pathological examination, and the tumor was resectable. There were no emergency surgery patients for bowel obstruction or perforation, no patients with multiple primary cancers, and no stage IIII( patients with liver or lung metastasis. All the patients underwent SMA-oriented laparoscopic CME successfully, without conversion to laparotomy. No ureteral injury, duodenal injury, and superior mesenteric vein injury occurred during the operation. R0 resections were performed in all the cases. The average operation time was (102.4±28.3) min, blood loss was (67.2±26.3) ml, number of lymph nodes retrieved was 20.5±7.6, postoperative anal exhaust time was (2.1±1.1) d, postoperative hospital stay was (7.9±1.4) d. There was no perioperative death or anastomotic leakage. Two patients with small bowel obstruction were readmitted within 30 days after operation. The postoperative complications occurred in 15.1%(25/166) of the patients, including wound infection (2 cases), chylous fistula (20 cases), anastomotic bleeding (1 case), small bowel obstruction (2 cases). A total of 161 patients (97.0%) were followed up for 1 to 24 months, and 10 patients had distant metastasis during the follow-up period. The 2-year overall survival (OS) rate was 96.4%.</p><p><b>CONCLUSION</b>Superior mesenteric artery-oriented laparoscopic complete mesocolic excision with a medial-to-lateral approach for right colonic cancer has good short-term efficacy.</p>

Mechanism of IL-1β enhance Blood-Brain Tumor Barrier permeability / 中国药理学通报

Aim To study the effect of IL-1β on pro-tein expression of vascular endothelial growth factor in glioma cells and plasma membrane microcapsule struc-ture protein caveolin-1 and plasma membrane vesicles in brain microvascular endothelial cells, and prelimi-narity discuss the possible mechanism of IL-1β opening blood tumor barrier. Methods The tumor barrier mod-el was established by transwell in vitro. The effect of IL-1β on the expression of VEGF in glioma cells and caveolin-1 in brain microvascular endothelial cells was dynamically monitored by Western blot. TEM was used to observe the number of plasma membrane vesicles of brain microvascular endothelial cells. Sodium fluores-cein leakage test was used to assess the permeability of blood tumor barrier after IL-1β. Results The tumor barrier model was successfully established by transwell in vitro. When IL-1β treated the model of blood tumor barrier,the expression of VEGF increased,and reached the peak at 60min,and recovered to the initial state at 120min. The permeability of the blood tumor barrier model was the highest at 60min. In addition,our re-sults also found that,the protein expression of plasma membrane microcapsule structure protein caveolin-1 and number of plasma membrane vesicles in brain mi-crocapsule endothelial cells reached peak at 60 min, subsequently reduced and returned to non drug state at 120min. Conclusion IL-1β increases blood tumor barrier permeability,which may be related to IL-1β in-creasing the number of plasma membrane vesicles through VEGF/ caveolin-1 pathway.

Expression and function of BRAF-activated long non-coding RNA in colorectal cancer / 中华消化外科杂志

Objective To investigate the expression of BRAF-activated long non-coding RNA (BANCR) in colorectal cancer,and the influence of BANCR on the biological function of HCT116 cells.Methods Fifty-six samples of colorectal cancer specimen (including the cancer tissues and precancerous tissues) were obtained at the First Affiliated Hospital of Nanjing Medical University from March 2012 to June 2013.The expressions of BANCR in all the specimens were detected by qRT-PCR (28 cases in the BANCR-high expression group and 28 cases in the BANCR-low expression group).The relationship between the expressions of BANCR and the clinicopathological factors of colorectal cancer was analyzed.The HCT116 cells were divided into 4 groups after interfering BANCR with lentiviral-mediated shRNA-1 and shRNA-2:interference group 1 (HCT116 cells transfected with LV-shRNA-1),interference group 2 (HCT116 cells transfected with LV-shRNA-2),negative control group (HCT116 cells transfected with lentivirus vector with nonsense sequence) and blank control group (HCT116 cells cultured in RPMI 1640 medium).The proliferation,apoptosis and migration of HCT116 cells in the 4 groups were detected by CCK-8 assay,flow cytometry and Transwell assay,respectively.The comparison between the 2 groups was analyzed by u test,and multiple groups were compared by one-way analysis of variance,repeated measurement analysis of variance and LSD-t test.Multivariate analysis was done by Logistic regression model.The difference between categorical data was compared by chi-square test.Results The relative expression of BANCR in the cancer tissues was 1.6 ± 0.4,which was significantly higher than 0.9 ± 0.7 of the precancerous tissues (u =1 020.000,P ＜ 0.05).The result of univariate analysis showed that the high expression of BANCR was correlated with the lymph node metastasis and tumor stage (x2 =4.595,7.487,P ＜ 0.05).The result of multivariate analysis showed that lymph node metastasis and tumor stage (stage Ⅲ-Ⅳ) were the independent risk factors influencing the high expression of BANCR(OR =4.000,5.914,95％ CI:1.230-12.900,1.685-20.760,P ＜ 0.05).The relative expressions of BANCR of the interference group 1,interference group 2,negative control group and the blank control group were 0.25 ±0.04,0.20±0.06,0.96 ±0.04,0.98 ±0.03,with significant difference among the 4 groups (F =271.610,P ＜ 0.05).The cell proliferation rates at day 6 of the interference group 1,interference group 2 and the negative control group were 80.6％ ± 7.6％,81.2％ ± 5.1％ and 87.9％ ± 13.6％,with no significant difference among the 3 groups (F =0.559,P ＞ 0.05).The apoptotic rates of the interference group 1,interference group 2,negative control group and the blank control group were 4.7％ ± 1.7％,5.1％ ± 1.1％,3.1％ ± 0.6％ and 2.8％ ± 0.9％,with no significant difference among the 4 groups (F =2.881,P ＞ 0.05).The numbers of transmembrane cells of the interference group 1,interference group 2,negative control group and the blank control group were 135 ± 29,107 ± 18,240 ± 24 and 245 ± 22,with significant difference among the 4 groups (F =45.194,P ＜ 0.05).Conclusions BANCR was overexpressed in the HCT116 cells,and the BANCR overexpression was correlated with lymph node metastasis and tumor stage.BANCR can promote the migration of HCT116 cells.BANCR could be an important biomarker for the diagnosis and prognosis of colorectal cancer.

Expression of pSTAT5 in pancreatic carcinoma cells and effect of growth hormone on pSTAT5 / 中华胰腺病杂志

Objective To investigate the expression of pSTAT5 in 7 pancreatic carcinoma cell lines,and the change of expression of pSTAT5 in pancreatic carcinoma cells SW1990 after growth hormone (GH) treatment, and explore its molecular mechanism. Methods Human pancreatic carcinoma cell lines (SW1990, Cap-1, Colo, Mia, AsPc, P3, PANC1) were cultured in vitro, and Western blotting was used to detect the expression of pSTAT5 in these cell lines. SW1990 in exponential growth phase was collected and nude Balb/c mice were inoculated with SW1990 cells. When tumors became palpable after inoculation, mice (normal saline group). 1 h, 2 h and 24 h after the last dose of GH treatment, the mice were sacrificed.Western blotting was used to detect the expression of pSTAT5 in SW1990 and inoculation tumor cells after GH injection. Results Positive expression of pSTAT5 was observed in all human pancreatic carcinoma cell lines (SW1990, Cap-1, Colo, Mia, Aspc, P3, PANC1). 5 minutes after GH (50 ng/ml) stimulation, the expression of pSTAT5 in SW1990 was 0.57 ±0.05, which was significantly increased; and it reached 0.64 ±0.04 at 10 minutes, then decreased to 0.39 ±0.03 at 15 minutes, however, it remained higher than that in the control group at 1 h (0.33 ± 0.02 vs 0.25 ± 0.06), and its expression at 2 h was 0.26 ± 0.03 and returned to the normal level. The expression of pSTAT5 in xenograft was not significantly changed. Conclusions GH could rapidly up-regulate the expression of pSTAT5 in SW1990 but the effect lasted for a relatively short period. GH had no significant effect on the expression of pSTAT5 in xenograft.

Laparoscopy Roux-en-Y pseudocystojejunostomy in the treatment of pancreatic pseudocyst / 中华肝胆外科杂志

ObjectiveTo explore the feasibility, safety and clinical value of laparoscopic Rouxen-Y cystojejunostomy in the treatment of pancreatic pseudocyst. Method Four patients with pancreatic pseudocyst received totally laparoscopic pancreatic pseudocystojejunostomy. The data on intraoperative bleeding, operative time, postoperative time to get out of bed, time of first flatus/bowel motion, complication and duration of hospital stay were collected and analyzed retrospectively. ResultsAll operations were carried out successfully with laparoscopic surgery. The mean operative time was 90 min. The average intraoperative blood loss was 40 ml. The mean postoperative time to get out of bed was 1.5 d, and the mean time of first flatus/bowel motion was 2. 3 d. All patients recovered smoothly without any pancreatic fistula. The average hospital stay was 7 days. Fever, pancreatitis,adhesive intestinal obstruction and other complications did not occur. ConclusionsTotally laparoscopic Roux-en-Y pancreatic pseudocystojejunostomy was an efficacious, safe, and minimally invasive procedure.

Clinical analysis of laparoscopic assisted distal radical gastrectomy for 23 cases / 中国医师进修杂志

Objective To investigate the safety, feasibility and results of laparoscopic assisted distal radical gastrectomy for gastric cancer. Methods Twenty-three cases of gastric cancer were subjected to laparoscopic assisted distal radical gastrectomy, D_(1+α)/D_(1+β) lymphadenectomy on 3 cases and D_2 lymphadenectomy on 20 cases. All cases received Billroth I reconstruction. Results Laparoscopic assisted distal radical gastrectomy was carried out in all cases successfully. The mean operative time was (205 ±38 )min, mean blood loss was (105 ± 66) ml and mean number of lymph nodes dissected was 19.7 ± 6.2 each case. The mean postoperative time of recovery of bowel function was (3.5 ±1.2) d,mean postoperative time of liquid intake was (4.9 ±0.9) d and mean hospitalization was (10.2 ± 2.7) d. No postoperative death or anastomotic fistula was found. Postoperative upper gastrointestinal bleeding occurred in 1 case and was cured by conservative treatment. Follow-up for 1-12 months revealed no recurrence or metastasis. Conclusions Laparoscopic assisted distal radical gastrectomy is a safe and feasible procedure with satisfactory short-term outcomes.Moreover,the short-term outcomes may be improved if the patients are treated under the notion of fast track surgery.