Preoperative combination score of neutrophils, monocytes, and lymphocytes as a predictor for locally advanced rectal cancer.

OBJECTIVE: The aim of this study was to investigate the prognostic value of baseline peripheral blood neutrophils, monocytes, and lymphocytes on locally advanced rectal cancer (LARC) patients. METHODS: Clinicopathologic data of 317 LARC patients during July 2010 and October 2016 were retrospectively gathered. X-tile software was used to acquire the optimal cutoff values of neutrophils, monocytes, and lymphocytes. Peripheral blood immune score (PBIS) system was proposed and built based on neutrophils, monocytes, and lymphocytes. The Cox model was used to analyze the associations between clinicopathological characteristics and potential outcomes. C-index was used to assess model performance. A nomogram was constructed to predict prognosis, and a calibration plot was used to verify the accuracy of the nomogram prediction model. RESULTS: Cutoff values of neutrophils, lymphocytes, and monocytes were 4.46 (× 109/L), 1.66 (× 109/L), and 0.39 (× 109/L), respectively. PBIS was related to sex (P < 0.001), tumor length (P = 0.003), and tumor thickness (P = 0.014). Multivariate Cox regression analysis revealed that PBIS (HR = 0.707, 95% CI: 0.549-0.912, P = 0.008) was an independent predictor of DFS. High PBIS (HR = 0.697, 95% CI: 0.492-0.988, P = 0.043) and high lymphocyte count (HR = 0.511, 95%CI: 0.273-0.958, P = 0.036) were favorable factors of OS. Both C-index (0.74, 95% CI: 0.549-0.912) and the calibration plot showed good prediction ability of the nomogram for DFS. CONCLUSION: PBIS, composed of baseline peripheral blood neutrophils, monocytes, and lymphocytes, is an independent predictor of the prognosis of LARC. Combination of PBIS and ypTNM stage may be a promising marker to guide adjuvant therapy after the operation.

Laparoscopic transabdominal approach partial intersphincteric resection for low rectal cancer: surgical feasibility and intermediate-term outcome.

BACKGROUND: Traditionally, conventional intersphincteric resection requires a combined abdominal and perineal approach and a handsewn coloanal anastomosis procedure, which is difficult to accomplish via the perineal approach. A completely abdominal approach partial intersphincteric resection (APISR) with laparoscopy can simplify the anastomosis procedure. This study evaluated the intermediate-term oncological and functional results of laparoscopic versus open APISR for low rectal cancer. METHODS: A total of 137 consecutive patients with low rectal cancer who underwent APISR from January 2006 to August 2013 were retrospectively evaluated. Patient groups were classified into as open surgery (OP, n = 48) group and laparoscopy (LAP, n = 89). The primary endpoint was 3-year disease-free survival and the Wexner score for anal function. RESULTS: The LAP group had longer operating time, less intraoperative blood loss, and shorter hospital stay after surgery compared with the OP group. Median follow-up was 32.3 months. The local recurrence rates were similar in the two groups (LAP 3.2% vs. OP 6.1%; P = 0.652). The combined 3-year disease-free survival rate was 83.2% in the LAP group and 83.8% in the OP group (P = 0.857). Wexner scores were similar in the two groups (LAP 2.9 ± 4.5 vs. OP 3.1 ± 5.0). In the LAP group, 89.7% of patients had good continence compared with 91.4% in the OP group (P = 0.311). CONCLUSIONS: Laparoscopic APISR can be performed safely and offers similar intermediate-term oncological and functional outcome compared with the open procedure. The oncological adequacy requires long-term follow-up data.

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.

Parametric analysis of a novel cryogenic CO2 capture system based on Stirling coolers.

CO(2) capture and storage (CCS) is an important alternative to control greenhouse gas (GHG) effects. In previous work, a novel desublimation CO(2) capture process has been exploited making use of three free piston Stirling coolers (namely, SC-1, SC-2, and SC-3, respectively). Based on the developed system, moisture and CO(2) in the flue gas can condense and desublimate in the prefreezing and main-freezing towers, respectively. Meanwhile, the storage column is chilled by SC-3 to preserve the frosted CO(2), and permanent gas (such as N(2)) passes through the system without phase change. The whole process can be implemented at atmospheric pressure and reduce the energy penalty (e.g., solvent regeneration and pressure drop) in other technologies. In this work, the influence of process parameters has been investigated in detail. The optimal conditions for the system are as follows: idle operating time is 240 min, flow rate is 5 L/min, vacuum degree of the interlayer is 2.2 × 10(3) Pa, and temperatures of SC-1, -2, and -3 are -30, -120, and -120 °C, respectively. Under these conditions, the energy consumption of the system is around 0.5 MJ(electrical)/kg CO(2) with above 90% CO(2) recovery.

[Clinical trial of sexual dysfunctions in male patients with pituitary adenomas].

OBJECTIVE: To explore the clinical features and related factors of sexual dysfunctions in male patients with pituitary adenomas. METHODS: The questionnaires of sexual functions were collected from 86 male patients with pituitary adenomas. We examined the clinical features of sexual dysfunctions and analyzed the correlations between sexual behaviors and age, tumor type, invasiveness, tumor size, serum levels of prolactin (PRL) and testosterone. RESULTS: The incidence of sexual dysfunctions was 80.2% (69/86). Sexual dysfunctions were found in 84.6% (66/78) of the patients with functioning pituitary adenomas and 37.5% (3/8) of those with non-functioning pituitary adenoma respectively. In the PRL group, the incidence of erectile dysfunctions was 92.1% (35/38) and it was higher than those in the FSH (follicle-stimulating hormone) and GH (growth hormone) groups (P < 0.05). In the FSH group, the incidence of reduced sexual desire was 78.3% (18/23). In the GH group, the incidence of erectile dysfunctions was 70.6% (12/17) and the incidence of reduced sexual desire or ejaculation dysfunction was lower than that of the PRL/FSH group (P < 0.05). CONCLUSION: The incidence of sexual dysfunctions is quite high in males with pituitary adenomas, especially for those with functioning pituitary adenomas. The clinical features of sexual dysfunctions vary in different types of functioning pituitary adenoma. The incidence of erectile dysfunctions is the highest in the PRL group. Pathological type of pituitary tumors is a major risk factor of sexual dysfunctions.

Short-term Outcomes of Laparoscopy-Assisted vs Open Surgery for Patients With Low Rectal Cancer: The LASRE Randomized Clinical Trial.

Importance: The efficacy of laparoscopic vs open surgery for patients with low rectal cancer has not been established. Objective: To compare the short-term efficacy of laparoscopic surgery vs open surgery for treatment of low rectal cancer. Design, Setting, and Participants: This multicenter, noninferiority randomized clinical trial was conducted in 22 tertiary hospitals across China. Patients scheduled for curative-intent resection of low rectal cancer were randomized at a 2:1 ratio to undergo laparoscopic or open surgery. Between November 2013 and June 2018, 1070 patients were randomized to laparoscopic (n = 712) or open (n = 358) surgery. The planned follow-up was 5 years. Data analysis was performed from April 2021 to March 2022. Interventions: Eligible patients were randomized to receive either laparoscopic or open surgery. Main Outcomes and Measures: The short-term outcomes included pathologic outcomes, surgical outcomes, postoperative recovery, and 30-day postoperative complications and mortality. Results: A total of 1039 patients (685 in laparoscopic and 354 in open surgery) were included in the modified intention-to-treat analysis (median [range] age, 57 [20-75] years; 620 men [59.7%]; clinical TNM stage II/III disease in 659 patients). The rate of complete mesorectal excision was 85.3% (521 of 685) in the laparoscopic group vs 85.8% (266 of 354) in the open group (difference, -0.5%; 95% CI, -5.1% to 4.5%; P = .78). The rate of negative circumferential and distal resection margins was 98.2% (673 of 685) vs 99.7% (353 of 354) (difference, -1.5%; 95% CI, -2.8% to 0.0%; P = .09) and 99.4% (681 of 685) vs 100% (354 of 354) (difference, -0.6%; 95% CI, -1.5% to 0.5%; P = .36), respectively. The median number of retrieved lymph nodes was 13.0 vs 12.0 (difference, 1.0; 95% CI, 0.1-1.9; P = .39). The laparoscopic group had a higher rate of sphincter preservation (491 of 685 [71.7%] vs 230 of 354 [65.0%]; difference, 6.7%; 95% CI, 0.8%-12.8%; P = .03) and shorter duration of hospitalization (8.0 vs 9.0 days; difference, -1.0; 95% CI, -1.7 to -0.3; P = .008). There was no significant difference in postoperative complications rate between the 2 groups (89 of 685 [13.0%] vs 61 of 354 [17.2%]; difference, -4.2%; 95% CI, -9.1% to -0.3%; P = .07). No patient died within 30 days. Conclusions and Relevance: In this randomized clinical trial of patients with low rectal cancer, laparoscopic surgery performed by experienced surgeons was shown to provide pathologic outcomes comparable to open surgery, with a higher sphincter preservation rate and favorable postoperative recovery. Trial Registration: ClinicalTrials.gov Identifier: NCT01899547.

Adjuvant imatinib treatment after R0 resection for patients with high-risk gastrointestinal stromal tumors: a median follow-up of 44 months.

BACKGROUND: The optimal duration of Imatinib adjuvant treatment for patients with high-risk gastrointestinal stromal tumors (GISTs) is uncertain. PATIENTS AND METHODS: A total of 90 patients with high-risk GISTs after curative resection were recruited into this non-randomized case-control study, including 35 having Imatinib adjuvant therapy and 55 having follow-up alone. The recurrence-free survival (RFS) was compared. RESULTS: After a median follow-up of 44.0 months, a significantly reduced recurrence rate was observed in the treatment group than the control group (17.1% vs. 78.2%, P = 0.000). One-year, 2-year, and 3-year RFS rates were 100% vs. 70.9%, 88.0% vs. 37.8%, and 88.0% vs. 27.5%, respectively; with a significant advantage for Imatinib adjuvant therapy versus the surgery only (P = 0.000, HR 0.122, 95% CI 0.041-0.363). Continuation Imatinib treatment further improved RFS by comparison with the interruption treatment (both 2-year and 3-year RFS were 95.8% vs. 63.6%, P = 0.011, HR 0.103, 95% CI 0.012-0.883). There were no serious adverse events in the adjuvant therapy group. CONCLUSIONS: Imatinib Adjuvant therapy could significantly prolong the RFS of patients with high-risk GISTs. Extended Imatinib adjuvant treatment strategy may further reduce the risk of relapse with a low drug resistance rate and toxicity profile.

Enhancement of hydrolysis and acidification of solid organic waste by a rotational drum fermentation system with methanogenic leachate recirculation.

A cascade process of a rotational drum fermentation system with leachate recirculation from a methanogenic to the acidogenic reactor was constructed to enhance the hydrolysis and acidification of solid organic waste. Using fresh soybean meal as substrates, two process configurations, Cascade process 1 and 2, without and with leachate recirculation, respectively were employed to perform the experimental estimation under mesophilic condition and a total HRT of 20 days. An apparent first-order hydrolysis rate constant of 9.0 x 10(-3)/d for Cascade process 1 at pH 4.5-4.6, and 15.8 x 10(-3)/d for Cascade process 2 at pH 4.6-5.2 were obtained. The apparent VS degradation ratios ranged from 16.5% to 21.1% and total VA (as acetic acid) from 14.5 to 16.7 g/L. Occupying ratios for ionized VA decreased from 40.5% to 35.3% for Cascade process 1 and increased to 68.5% for Cascade process 2. However, occupying ratios of acetic acid decreased from 96.1% to 94.3% for Cascade process 1 and to 72.6% for Cascade process 2, whereas propionic acid and butyric acid ratios increased in acidogenesis of Cascade process 2. The leachate recirculation promoted hydrolysis of substrate in Cascade process 2, where apparent hydrolysis rate constant and VS degradation ratio were higher than that of Cascade process 1.

Monitoring neoadjuvant therapy responses in rectal cancer using multimodal nonlinear optical microscopy.

Most patients with rectal cancer have a better prognosis after receiving neoadjuvant therapy because of its remarkable curative effect. However, no device delivers real-time histopathologic information on treatment response to help clinicians tailor individual therapeutic strategies. We assessed the potential of multimodal nonlinear optical microscopy to monitor therapeutic responses, including tumoral and stromal responses. We found that two-photon excited fluorescence imaging can, without labeling, identify colloid response, inflammatory cell infiltration, vascular proliferation, and tumor regression. It can also directly detect rare residual tumor cells, which may be helpful for distinguishing tumor shrinkage from tumor fragmentation. In addition, second harmonic generation imaging shows the ability to monitor three types of fibrotic responses: mature, intermediate, and immature. We also determined nonlinear spectra, collagen density, and collagen orientation indexes to quantitatively analyze the histopathologic changes induced by neoadjuvant therapy in rectal cancer. Our work demonstrates that nonlinear optical microscopy has the potential to become a label-free, real-time, in vivo medical imaging technique and provides the groundwork for further exploration into the application of nonlinear optical microscopy in a clinical setting.

Improving acidogenic performance in anaerobic degradation of solid organic waste using a rotational drum fermentation system.

The effects of leachate from a methanogenic process on acidogenic performance of a solid recycle (SR) process by a rotational drum fermentation (RDF) system were evaluated under mesophilic condition and a hydraulic retention time (HRT) of 20 days. Two SR process configurations, SR1 and SR2, were evaluated, using fresh soybean meal or Okara as substrates. An apparent first-order hydrolysis rate constant of 5.0 x 10(-3)/d for SR1 at pH values of 4.4 and 14.4 x 10(-3)/d for SR2 at pH of 5.0, were obtained. The apparent volatile solids (VS) degradation ratio ranged from 9.6% to 19.4% and total volatile acid (as acetic acid) from 10.8 to 14.9 g/L. Occupying ratios for ionized volatile acid (VA) increased from 30.6% to 63.4% after recycling the leachate to process. However, occupying ratios of acetic acid decreased from 93.3% to 42.0% whereas propionic acid and butyric acid ratios increased in SR2. Integrating the VA production with the hydrolysis rate constants, it is clear that the recirculation of leachate considerably enhanced acidogenic performance of solid recycle process.

Multiphoton microscopy for tumor regression grading after neoadjuvant treatment for colorectal carcinoma.

AIM: To evaluate the feasibility of using multiphoton microscopy (MPM) to assess a tumor regression grading (TRG) system. METHODS: Fresh specimens from seven patients with colorectal carcinoma undergoing neoadjuvant radiochemotherapy at the Fujian Medical University Union Hospital were obtained immediately after proctectomy. Specimens were serially sectioned (10 µm thickness) and used for MPM or stained with hematoxylin and eosin for comparison. Sections were imaged by MPM using 810 nm excitation, and images were collected in two wavelength channels corresponding to second-harmonic generation (SHG) and two-photon excited fluorescence (TPEF) signals. The ratio of these signal intensities was used to distinguish fibrosis from normal mucosal and serosal tissues. RESULTS: TRG of specimens assessed by MPM were in complete agreement with histologic grading performed by a consulting pathologist. SHG and TPEF images clearly revealed collagen fibers and fragmented elastic fibers in the muscularis propria specimens following neoadjuvant radiochemotherapy. Additionally, blood vessel hyperplasia was observed as thickening and fibrosis of the intima and media, which was accompanied by minimal inflammatory cell infiltration. Furthermore, the SHG/TPEF ratio in stromal fibrosis (4.15 ± 0.58) was significantly higher than those in the normal submucosal (2.31 ± 0.52) and serosal (1.47 ± 0.10) tissues (P < 0.001 for both). Analysis of emission spectra from cancerous tumor cells revealed two peaks corresponding to nicotinamide adenine dinucleotide hydrogen and flavin adenine dinucleotide signals; the ratio of these values was 1.19 ± 0.02, which is close to a normal metabolic state. CONCLUSION: MPM can be used to perform real-time diagnosis of tumor response after neoadjuvant treatment, and can be applied to evaluate TRG.

[Changes of dentin, dental pulp and periodontium tissue in tail-suspended rats].

OBJECTIVE: To investigate the metabolic changes of calcium and phosphorus in dentin, dental pulp and periodontium in tail-suspended rats, and the functions of TGF-beta 1, c-fos, collagen-I and collagen IV in dentin, dental pulp and periodontium. METHOD: Relative percentage contents of Ca, P in dentin, dental pulp and periodontium were measured with scanning electron microscope and energy spectrum analytical system in 3 groups of rats. The expression of TGF-beta 1, c-fos, collagen-I and collagen IV were also observed. RESULT: In the suspension group, the relative percentage content of Ca declined significantly, while P increased slightly. There were no significant differences of Ca, P in alveolar bone. The expressions of TGF-beta 1, c-fos and collagen-I declined, but the expression of collagen-IV in pulp vessel increased. There were no significant changes of expressions of TGF-beta 1, c-fos, collagen-I and collagen-IV in the vicinity of PDL. After adopting artificial countermeasures, the above expressions restored partly. CONCLUSION: Weightlessness might cause abnormal mineralization in dentin, and 1.5 G artificial countermeasures could eliminate the above changes of mineral metabolism. The poor mineralization of dentin might be associated with the reduced secretion of TGF-beta 1, c-fos and collagen-I in tail-suspended rats.

[Meta analysis of postoperative complications between laparoscopic resection and traditional open resection of mid-low rectal carcinoma].

OBJECTIVE: To conduct a meta-analysis of postoperative complications between laparoscopic resection (Group LR) and traditional open resection (Group OR) of mid-low rectal carcinoma. METHODS: Meta analysis was performed by two reviewers, who independently selected and extracted data retrieved from literatures and papers published in China Knowledge Resource Integrated Database (CNKI), Wangfang Data, Foreign Medical Journal Service (FMJS), PubMed, EMBASE and The Cochrane before August 2012 on comparison between two groups. The statistical analysis for research of complex standard was conducted through Revman 5.0. RESULTS: Thirteen clinical case-control studies with a total of 2733 cases were enrolled for analysis, including 1368 cases in Group LR and 1365 in Group OR. The result showed that, compared with Group OR, Group LR had lower overall rate of postoperative complication (OR=0.76, 95%CI:0.62-0.92, P<0.01), lower rate of postoperative intestinal obstruction (OR=0.53, 95%CI:0.35-0.80, P<0.01), lower rate of incision complications (OR=0.43, 95%CI:0.28-0.67, P<0.01), similar incidence of anastomotic bleeding and fistula, and similar incidence of bleeding in abdominal cavity and pelvic cavity (all P>0.05). CONCLUSIONS: The overall rate of postoperative complications of laparoscopic resection for mid-low rectal carcinoma is obviously lower than that of open resection. Laparoscope can be applied safely in the resection of mid-low rectal carcinoma.

[Efficacy and safety of sunitinib on patients with imatinib-resistant gastrointestinal stromal tumor].

OBJECTIVE: To investigate the efficacy and safety of sunitinib on the management of gastrointestinal stromal tumors (GIST) patients with imatinib resistance. METHODS: Clinical data of 48 patients with imatinib-resistant GIST received sunitinib therapy from May 2008 to April 2012 in the Union Hospital of Fujian Medical University were analyzed retrospectively. Eighteen patients received 50 mg/d of sunitinib in a protocol of 4/2 (4 weeks on and 2 weeks off) [50 mg/d (4/2)], and 30 patients received a protocol of 37.5 mg of sunitinib continuous daily dose (37.5 mg/d CDD). RESULTS: The median duration of sunitinib administration of all the 48 patients was 56 weeks, and the short-term efficacy was evaluated at 24 weeks after the initial treatment according to the Choi criteria. The response rate was 27.1% (13/48), including 1 case with complete response (CR), 12 cases with partial response (PR), and 21 cases with stationary disease (SD). The disease control rate was 70.8% (34/48). The mean follow-up time of 48 patients was 89 weeks. The median progression-free survival (PFS) and overall survival (OS) were 48 weeks and 92 weeks respectively. Stratified analyses indicated that the median PFS of patients previously treated by imatinib 400 mg/d and >400 mg/d were 53 weeks and 35 weeks respectively (P=0.018), and the median OS of these two groups were 157 weeks and 71 weeks respectively (P=0.003). Patients with exon 11 mutations had a significantly shorter OS compared with those with exon 9 mutations (71 weeks vs 157 weeks, P=0.008). Hand-foot syndrome was the most common adverse effect (25/48, 52.1%), followed by nausea (24/48, 50.0%), fatigue (23/48, 47.9%), neutropenia(21/48, 41.7%). The sub-group analysis of two protocols of sunitinib administration showed that the incidence of diarrhea and hand-foot syndrome were higher in 50 mg/d (4/2) group than those in 37.5 mg/d CDD group (P=0.027, P=0.048). CONCLUSIONS: Sunitinib is effective for the patients with imatinib-resistant GIST. After 400 mg/d imatinib treatment failure, sunitinib should be prescribed instead of increased dosage of imatinib. Patients with KIT exon 9 mutations present better prognosis than those with KIT exon 11 mutations. The protocol of sunitinib 37.5 mg/d CDD possesses better safety.

[Short-term efficacy of laparoscopic-assisted right hemicolectomy with D3 lymph node dissection in colon cancer].

OBJECTIVE: To explore the feasibility and short-term efficacy of laparoscopic-assisted D3 lymph node dissection for right colon cancer with a medial-to-lateral approach. METHODS: Clinical data of 61 patients with right colon cancer undergoing D3 lymph node dissection from March 2006 to June 2010 were analyzed retrospectively. Among them,29 underwent laparoscopic-assisted right hemicolectomy (LARH group) and 32 underwent open right hemicolectomy (ORH group). The number of lymph node harvest, operative details, and complication rate were compared between the two groups. RESULTS: The mean number of lymph node harvest did not differ significantly between the two groups (16.9±3.8 vs. 15.4±3.6). As compared to ORH group, although the operative time was significantly longer [(214.4±37.9) min vs. (193.3±28.8) min] in LARH group, the mean blood loss [(83.4±38.0) ml vs. (192.7±43.6) ml], time to first flatus [(44.6±20.8) h vs. (70.4±80.0) h], time to resumption of soft diet[(32.5±10.6) h vs. (59.7±10.4) h], and postoperative hospital stay [(11.2±2.2) d vs. (13.8±2.8) d] were more favorable(all P<0.05). Complication rate was lower in LARH group(10.4% vs. 9.4%), however the difference was not statistically significant. CONCLUSIONS: LARH with D3 lymph node dissection is oncologically comparable with ORH for right colon cancer. It is a safe and feasible procedure associated with rapid postoperative recovery.