Interaction analysis of high-risk pathological features on adjuvant chemotherapy survival benefit in stage II colon cancer patients: a multi-center, retrospective study.

BACKGROUND: We aimed to analyze the benefit of adjuvant chemotherapy in high-risk stage II colon cancer patients and the impact of high-risk factors on the prognostic effect of adjuvant chemotherapy. METHODS: This study is a multi-center, retrospective study, A total of 931 patients with stage II colon cancer who underwent curative surgery in 8 tertiary hospitals in China between 2016 and 2017 were enrolled in the study. Cox proportional hazard model was used to assess the risk factors of disease-free survival (DFS) and overall survival (OS) and to test the multiplicative interaction of pathological factors and adjuvant chemotherapy (ACT). The additive interaction was presented using the relative excess risk due to interaction (RERI). The Subpopulation Treatment Effect Pattern Plot (STEPP) was utilized to assess the interaction of continuous variables on the ACT effect. RESULTS: A total of 931 stage II colon cancer patients were enrolled in this study, the median age was 63 years old (interquartile range: 54-72 years) and 565 (60.7%) patients were male. Younger patients (median age, 58 years vs 65 years; P < 0.001) and patients with the following high-risk features, such as T4 tumors (30.8% vs 7.8%; P < 0.001), grade 3 lesions (36.0% vs 22.7%; P < 0.001), lymphovascular invasion (22.1% vs 6.8%; P < 0.001) and perineural invasion (19.4% vs 13.6%; P = 0.031) were more likely to receive ACT. Patients with perineural invasion showed a worse OS and marginally worse DFS (hazardous ratio [HR] 2.166, 95% confidence interval [CI] 1.282-3.660, P = 0.004; HR 1.583, 95% CI 0.985-2.545, P = 0.058, respectively). Computing the interaction on a multiplicative and additive scale revealed that there was a significant interaction between PNI and ACT in terms of DFS (HR for multiplicative interaction 0.196, p = 0.038; RERI, -1.996; 95%CI, -3.600 to -0.392) and OS (HR for multiplicative interaction 0.112, p = 0.042; RERI, -2.842; 95%CI, -4.959 to -0.725). CONCLUSIONS: Perineural invasion had prognostic value, and it could also influence the effect of ACT after curative surgery. However, other high-risk features showed no implication of efficacy for ACT in our study. TRIAL REGISTRATION: This study is registered on ClinicalTrials.gov, NCT03794193 (04/01/2019).

Surgical site infection after intracorporeal and extracorporeal anastomosis in laparoscopic left colectomy for colon cancer: a multicenter propensity score-matched cohort study.

BACKGROUND: Intracorporeal anastomosis (IA) is associated with reduced surgical site infection (SSI) and other postoperative complications in laparoscopic right colectomy (LRC). However, evidence is inadequate for IA in laparoscopic left colectomy (LLC). This study aimed to determine the effect of IA and extracorporeal anastomosis (EA) on SSI and other short-term postoperative complications in LLC. METHODS: In this retrospective multicenter propensity score-matched (PSM) cohort study, we enrolled consecutive patients who underwent LLC with IA (TLLC/IA) and laparoscopic-assisted left colectomy with EA (LALC/EA) at two medical centers between January 2015 and September 2021. Propensity score matching with a 1:2 ratio was employed. The primary outcome was SSI occurrence. Secondary outcomes were operating time, intraoperative hemorrhage, other postoperative complications, and pathological outcomes. RESULTS: Overall, 574 and 99 patients received LALC/EA and TLLC/IA, respectively. After PSM, 84 patients with TLLC/IA were matched with 141 patients with LALC/EA. Thirty patients (13.3%) patients experienced SSI (17.0% in LALC/EA vs 7.1% in TLLC/IA). IA was associated with a reduced risk of overall SSI and superficial/deep SSI compared with EA after PSM, with OR of 0.375 (95% CI, 0.147-0.959, P = 0.041). and 0.148 (95% CI, 0.034-0.648, P = 0.011), respectively. Multivariate analysis of unmatched patients indicated similar results. In the analysis of secondary outcomes, LALC/EA may have a shorter operating time (absolute mean difference - 13.41 [95% CI, - 23.76 to - 3.06], P = 0.002) and a higher risk of intraoperative hemorrhage (absolute risk difference 4.96 [95% CI, - 0.09 to 9.89], P = 0.048). CONCLUSIONS: IA in LLC is associated with a reduced risk of overall SSI and superficial/deep SSI. However, it may require a longer operating time.

Laparoscopic resection of large retrorectal developmental cysts in adults: Single-centre experiences of 20 cases.

Context: Retrorectal tumours are rare with developmental cysts being the most common type. Conventionally, large retrorectal developmental cysts (RRDCs) require the combined transabdomino-sacrococcygeal approach. Aims: This study aims to investigate the surgical outcomes of the laparoscopic approach for large RRDCs. Settings and Design: A retrospective case series analysis. Subjects and Methods: Data of patients with RRDCs of 10 cm or larger in diameter who underwent the laparoscopic surgery between 2012 and 2017 at our tertiary centre were retrospectively analyzed. Statistical Analysis Used: Results are presented as median values or mean ± standard deviation for continuous variables and numbers (percentages) for categorical variables. Results: Twenty consecutive cases were identified (19 females; median age, 36 years). Average tumour size was 10.9 ± 1.1 cm. Cephalic ends of lesions ranged from S1/2 junction to S4 level. Caudally, 18 cysts extended to the sacrococcygeal hypodermis. Seventeen patients underwent the pure laparoscopy; three patients received a combined laparoscopic-posterior approach. The operating time was 167.1 ± 57.3 min for the pure laparoscopic group and 212.0 ± 24.5 min for the combined group. The intraoperative haemorrhage was 68.2 ± 49.7 and 66.7 ± 28.9 (mL), respectively. Post-operative complications included one trocar site hernia, one wound infection and one delayed rectal wall perforation. The median post-operative hospital stay was 7 days. With a median follow-up period of 36 months, 1 lesions recurred. Conclusions: The laparoscopic approach can provide a feasible and effective alternative for large RRDCs, with advantages of the minimally invasive surgery. For lesions with ultra-low caudal ends, especially those closely clinging to the rectum, a combined posterior approach is still necessary.

Can Endorectal Ultrasound, MRI, and Mucosa Integrity Accurately Predict the Complete Response for Mid-Low Rectal Cancer After Preoperative Chemoradiation? A Prospective Observational Study from a Single Medical Center.

BACKGROUND: Patients with locally advanced rectal cancer could be managed by a watch-and-wait approach if they achieve clinical complete response after preoperative chemoradiotherapy. Mucosal integrity, endorectal ultrasound, and rectal MRI are used to evaluate clinical complete response; however, the accuracy remains questionable. Clinical practice based on those assessment methods needs more data and discussion. OBJECTIVE: The aim of this prospective study was to evaluate the accuracy of mucosal integrity, endorectal ultrasound, and rectal MRI to predict clinical complete response after chemoradiotherapy. DESIGN: Endorectal ultrasound and rectal MRI were undertaken 6 to 7 weeks after preoperative chemoradiation therapy. Patients then received radical surgery based on the principles of total mesorectal excision. Preoperative tumor staging achieved by endorectal ultrasound and rectal MRI was compared with postoperative staging by pathologic examination. Sensitivity, specificity, and accuracy of each evaluation method were calculated. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients diagnosed with mid-low rectal cancer by biopsy between May 2014 and December 2016 were enrolled in this study. RESULTS: A total of 124 patients were enrolled in this study, and postoperative pathology revealed that 20 patients (16.13%) achieved complete response (ypT0N0). The sensitivity of mucosal integrity, endorectal ultrasound, and MRI to predict clinical complete response was 25%. The specificity of mucosal integrity, endorectal ultrasound, and MRI was 94.23%, 93.90%, and 93.27%. The combination of each 2 or all 3 methods did not improve accuracy. Regression analysis showed that none of these methods could predict postoperative ypT0. LIMITATIONS: The sample size is small, and we did not focus on the follow-up data and cannot compare prognosis data with previous research studies. CONCLUSIONS: Both single-method and combined mucosal integrity, endorectal ultrasound, and rectal MRI have poor correlation with postoperative pathologic examination. A watch-and-wait approach based on these methods might not be a proper strategy compared with radical surgery after neoadjuvant therapy. See Video Abstract at http://links.lww.com/DCR/A693.

Is adjuvant chemotherapy necessary for patients with pathological complete response after neoadjuvant chemoradiotherapy and radical surgery in locally advanced rectal cancer? Long-term analysis of 40 ypCR patients at a single center.

OBJECTIVES: According to practice guidelines, adjuvant chemotherapy (ACT) is required for all patients with locally advanced rectal cancer who have received neoadjuvant chemoradiotherapy (NCRT) and total mesorectal excision (TME). The objective of this study was to determine whether ACT is necessary for patients achieving pathological complete response (pCR) after NCRT followed by surgery. METHODS: By retrospectively reviewing a prospectively collected database in our single tertiary care center, 210 patients with locally advanced rectal cancer who underwent NCRT followed by TME were identified between February 2005 and August 2013. All patients achieving ypCR were enrolled in this study, in which who underwent ACT (chemo group) and who did not (non-chemo group) were compared in terms of local recurrence (LR) rate, 5-year disease-free survival (DFS) rate and overall survival (OS) rate. RESULTS: Forty consecutive patients with ypCR were enrolled, 19 (47.5 %) in chemo group and 21 (52.5 %) in non-chemo group. After a median follow-up of 57 months, five patients developed systemic recurrences, with the 5y-DFS rate of 83.5 %. No LR occurred in the two groups. The 5y-DFS rates for patients in chemo group and non-chemo group was 90.9 and 76.0 %, respectively, showing no statistically significant difference (p = 0.142). Multivariate analysis showed that tumor grade was the only independent prognostic factor for 5y-DFS and 5y-OS. CONCLUSIONS: Results of this study suggested that it may not be necessary for all rectal cancer patients with ypCR after NCRT and radical surgery to receive ACT. Prospective randomized trials are warranted to further determine the value of ACT for ypCR patients.

Prognostic Superiority of Log Odds of Positive Lymph Nodes in Stage 3 Colorectal Cancer.

Objective To evaluate the prognostic value of the log odds of positive lymph nodes (LODDS) in stage 3 colorectal cancer (CRC) patients who have undergone curative resection. Methods We performed a retrospective review of 175 stage 3 CRC patients who underwent curative resection in Peking Union Medical College Hospital from 2005 to 2012. Patients were categorized respectively according to the AJCC/UICC N grade,the metastatic lymph node ratio (LNR),and the ratio of their LODDS. The relationship between the N grade,LNR,LODDS,and overall survival (OS) rates were assessed.Results The five-year disease-free survival (DFS) was significantly different among stage 3 CRC patients in different N grade (Χ(2)=33.1,P=0.000),LNR (Χ(2)=14.3,P=0.001),and LODDS (Χ(2)=14.9,P=0.001). Univariate analysis showed that TNM stage (Χ(2)=27.0,P=0.000),cancerous node(Χ(2)=3.6,P=0.040),N grade (Χ(2)=33.1,P=0.000),LNR (Χ(2)=14.3,P=0.001),and LODDS (Χ(2)=30.4,P=0.000) were related to OS. Multivariate analysis indicated that TNM stage (HR:1.84,95%CI:1.59～6.29,P=0.001) and LODDS classification (HR:1.34,95%CI:1.01～1.80,P=0.047) were independent prognostic factors for OS in stage 3 CRC patients. Conclusion LODDS is a good prognostic indicator in stage 3 CRC patients who have undergone curative resection.

Ertapenem prophylaxis of surgical site infections in elective colorectal surgery in China: a multicentre, randomized, double-blind, active-controlled study.

OBJECTIVES: Our purpose was to evaluate ertapenem versus ceftriaxone/metronidazole for prophylaxis of surgical site infections (SSIs) following elective colorectal surgery in Chinese adult patients. METHODS: Eligible Chinese adults aged 18-80 years scheduled to undergo elective colorectal surgery by laparotomy were randomized to receive a 30 min infusion of 1 g of ertapenem/metronidazole placebo or 2 g of ceftriaxone/500 mg of metronidazole within 2 h before initial incision. The study endpoint was the proportion of patients with successful prophylaxis at 4 weeks after treatment. The primary analysis was based on the evaluable population (PP population) and the pre-specified non-inferiority margin was set at -15%. ClinicalTrials.gov: NCT01254344. RESULTS: Of 599 patients randomized, 499 (251 ertapenem and 248 ceftriaxone) were eligible for inclusion in the PP population. The proportions of patients with successful prophylaxis in the ertapenem and ceftriaxone groups were 90.4% (227/251) and 90.3% (224/248), respectively. The difference in the proportion of successful outcomes was 0.1% (95% CI -5.2%, 5.5%). Unexplained antibiotic use was the most frequent reason for prophylaxis failure in both groups [ertapenem 4.8% (12/251), ceftriaxone 4.4% (11/248); difference 0.3%; 95% CI -3.6, 4.3]. Pathogen species isolated from SSI sources were consistent with previously conducted studies and the product package insert. The incidence of adverse events (AEs) was similar between the groups, with the most common AE being pyrexia [ertapenem 7.6% (22/290), ceftriaxone 5.7% (17/297)]. CONCLUSIONS: Ertapenem is as effective as ceftriaxone/metronidazole for SSI prophylaxis in patients undergoing elective colorectal surgery, and is well tolerated.

Factors affecting operating time in laparoscopic anterior resection of rectal cancer.

BACKGROUND: The objective of this study is to clarify the relationship between demographic and surgical factors and operating time, and thus operative difficulty, in patients undergoing laparoscopic anterior resection for mid-low rectal cancer, since different studies have derived different results. METHODS: The records of patients with mid-low rectal cancer who underwent laparoscopic anterior resection were retrospectively studied. Demographic data, tumor characteristics, and pelvimetry measurements were collected and analyzed with respect to operating time, using correlation coefficient analysis, principle component analysis, and linear regression. RESULTS: A total of 14 patients (10 males, 4 females; 65.50 ± 7.12 years of age) were included. Demographic and tumor characteristics not correlated with operating time. Body mass index (BMI) (P = 0.001); interacetabular distance (IA) (P = 0.001); anatomical transverse distance (IP) (P = 0.008); interischial distance (IS) (P = 0.002); intertuberous distance (IT) (P = 0.005); distance between the coccyx and symphysis (CoSy) (P = 0.013); and the angle of the lower border of the symphysis pubis, upper border of symphysis pubis, and sacral promontory (angle 5) (P = 0.004) were significantly associated with operating time. The equation was:operatingtime=0.653 × BMI+0.818 × angle5-0.404 × IA-0.380 × IP-0.512 × IS-0.405×IT-0.570 × CoSy+330.8. CONCLUSIONS: Transverse diameters of the pelvis, BMI, angle 5, and CoSy played the most important role in affecting operating time. The equation can be a very useful tool for preoperative assessment.

[Effects of tumor distance from anal verge and types of operations on survival outcomes for low rectal cancer after neoadjuvant chemoradiotherapy].

OBJECTIVE: To assess the effects of neoadjuvant chemoradiotherapy on survival outcomes of low rectal cancer after sphincter-preserving or removing surgery. METHODS: A total of 135 patients with rectal cancer within 10 cm from anal verge after neoadjuvant chemoradiotherapy were enrolled into this retrospective study from 2005 to 2012 at a single institute. There were 79 males and 56 females with a mean age of (58 ± 12) years and an average distance of (5.2 ± 2.1) cm from anal verge. The effects of gender, age, distance of tumor from anal verge, surgical procedure, T-stage downstaging, lateral resection margin and post-treatment lymphatic node status on 3-year disease-free survival (DFS) were examined. RESULTS: The overall 3-year DFS was 85.2% (115/135). Among 95 sphincter-preserving operations, there were anterior resection (n = 79), anterior perineal plane for ultra low anterior resection (APPEAR) technique (n = 12), Hartmann procedure (n = 3) and Parks procedure (n = 1). Among 40 sphincter-removing operations, there were abdominoperineal resection (APR) procedure (n = 39) and intersphincteric resection(ISR) (n = 1). The survival of patients undergoing sphincter-preserving or removing procedures did not differ in 3-year DFS (85.3% (81/95) vs 85.0% (34/40) , χ(2) = 0.000, P = 0.985) . Lateral resection margin and post-treatment lymphatic node status significantly affected DFS. The differential level from anal verge showed a trend of close relationship to 3-year DFS (81.5% (22/27) for 2-3 cm, 82.5% (47/57) for 4-5 cm vs 95.1% (39/41) for 6-7 cm), but without statistic significance (χ(2) = 3.111, 3.522; P = 0.078, 0.061). The survival rate for patients with sphincter-preserving at 6-7 cm from anal verge was significantly higher than that at 4-5 cm (95.0% (38/40) vs 79.5% (31/39) ,χ(2) = 4.227, P = 0.039) , but showed no differences to that with sphincter-removing at 2-3 cm from anal verge (81.0% (17/21),χ(2) = 2.864, P = 0.091) . The multivariate analysis showed that post-treatment lymphatic node status was the only prognostic factor to 3-year DFS (Wald = 4.454, P = 0.035) . CONCLUSIONS: Lateral resection margin and post-treatment lymphatic node status play an important role on DFS for patients with low rectal cancer after neoadjuvant chemoradiotherapy. The distance from anal verge is correlated with 3-year disease-free survival. Patients with tumor at 4-5 cm from annal verge can not benefit for survival when they get sphincter-preserving operations.

[Effects of neoadjuvant chemoradiotherapy on anorectal function in patients with mid and low rectal cancer].

OBJECTIVE: To evaluate the effects of neoadjuvant chemoradiotherapy on anorectal function in patients with mid and low rectal cancer. METHODS: A total of 22 patients with mid and low rectal cancer were enrolled into this study from October 2012 to November 2013. There were 14 males and 8 females with a mean age of (59 ± 10) years. We collected the defecation-related symptoms with questionnaire interview and evaluated the anorectal function with three-dimensional high-resolution manometry before neoadjuvant chemoradiotherapy and at 6 weeks after radiotherapy. RESULTS: The defecation-related symptoms (including increase in stool frequency, change in stool form, hematochezia and urgency, etc.) improved significantly after neoadjuvant chemoradiotherapy (n = 21). Among those with lower rectal cancer (n = 8), the length of high-pressure zone in manometry increased significantly after neoadjuvant chemoradiotherapy ((3.84 ± 0.61) vs (2.96 ± 0.80) cm, P = 0.003). However, there was no significant change for other parameters in anorectal function (all P > 0.05). CONCLUSIONS: In patients with mid and low rectal cancer, neoadjuvant chemoradiotherapy may improve the defecation symptoms and enhance anal sphincter high-pressure zone for lower rectal cancer. And it is probably due to its tumor-downsizing effect.

[Feasibility and short-outcomes of laparoscopic extralevator abdominoperineal excision without changing position for distal rectal cancer].

OBJECTIVE: To evaluate the short-term outcomes of laparoscopic extralevator abdominoperineal excision (ELAPE) without changing position during operation. METHODS: Totally 51 patients with distal advanced rectal cancer received surgical operation in Peking Union Midical College Hospital from September 2011 to April 2014. There were 29 male and 22 female patients with a mean age of (61 ± 10) years. Twenty-six percent of the patients received preoperative concomitant chemotherapy and radiation. Twenty-seven patients underwent laparoscopic abdominoperineal excision (APE) procedure, while 24 patients underwent ELAPE procedure. In both groups, patients were kept Lithotomy-Trendelenburg position during operation. The fat tissue in ischialrectal fossa was not routinely removed, except the tumor invasion. All the patients' pelvic peritoneum was closed by continuous suturing, and subcutaneous tissue and skin by interrupted suturing. Retrospectively compare the pathoclinical features, operation time, bleeding, node retrieval, lateral margin and complications by t-text and χ(2) test respectively between ELAPE and APE procedures both by laparoscopic approach. RESULTS: No significant differences were found in term of age, gender, BMI, distance from anal verge, percentage of neoadjuvant chemoradiation, and TNM staging between these two groups (all P > 0.05). The operation time was significantly shorter in ELAPE group ((181 ± 41) minutes vs. (228 ± 58) minutes, t = -3.265, P = 0.002). The bleeding volume was less in ELAPEE group (50 (80) ml vs 80 (100) ml (M(QR)), Z = -2.259, P = 0.024). The lateral margin, urinal retention and perineal wound healing were comparable for these two groups. No pelvic hernia was found during the postoperative follow-up (2 to 34 months) in both groups (all P > 0.05). CONCLUSIONS: Laparoscopic extralevator abdominoperineal excision without changing position is feasible for distal rectal cancer. Some essential steps can be simultaneously accomplished during operation without changing position. Closing the pelvic peritoneum is important for preventing the intestine dropping from abdominal cavity to presacral cavity.

[Outcome of laparoscopic radical right hemicolectomy with complete mesocolic resection and D3 lymphadenectomy].

OBJECTIVE: To investigate the feasibility of laparoscopic approach for totally mesocolic resection and D3 lymphadenectomy in right colectomy. METHODS: A retrospective study was conducted to analyze the operating time, blood loss, lymph node retrieval, postoperative complications and converting rate. The relationships of 3-year disease-free survival (DFS), 3-year overall survival (OS) to gender, age, American Society of Anesthesiologists (ASA) score, body mass index (BMI), T-staging, N-staging and TNM classification were also analyzed by Kaplan-Meier surviving curve and Log-rank test. RESULTS: A total of 111 patients were enrolled in present study. There were 50 male and 61 female patients. The average operating time was (168 ± 42) minutes, blood loss was (81 ± 63) ml, lymph node retrieval was (30 ± 12). The converting rate to open surgery was 1.8%. There was no death within 30 days after operation. The 3-year DFS and 3-year OS was 86.5% and 93.7% respectively. The short-term complications occurred in 17.1% of the patients, including diarrhea (7 cases), ileus (3 cases), urinary infection (3 cases), wound dehiscence (2 cases) and so on. With the T staging progress, DFS and OS in patients showed a gradual decline, but the difference did not reach statistical significance (P > 0.05). TNM classification had relation to DFS (χ(2) = 6.985, P = 0.030), while N-staging showed significant relations both to DFS and OS (χ(2) = 14.397, P = 0.001; χ(2) = 16.699, P = 0.000). CONCLUSION: Laparascopic approach to right hemicolectomy with complete mesocolic resection and D3 lymphadenectomy is safe and has satisfied oncological outcome.

[Postoperative pathological staging correlates the prognosis of rectal cancer after neoadjuvant chemoradiotherapy].

OBJECTIVE: The present study assessed the pathological staging features of rectal cancer after neoadjuvant chemoradiotherapy, and its relation to prognosis. METHODS: Pathologic data related to TNM classification were analyzed on the surgical specimens of 135 patients with mid-low rectal cancer after neoadjuvant themoradiotherapy from 2005 to 2012. Tumor invasion, nodal status, local invasive factors (including cancer deposit, radial margin, perivascular or perineural invasion) were investigated with patients' 3-year disease-free survival (DFS). RESULTS: The overall 3-year DFS was 85.2%, with a pathological complete response (pCR) rate of 19.26%. Three out of 29 patients (10.4%) with ypT0 were found to have positive lymph nodes. There was a trend towards decreased survival as the ypT category and ypTNM staging increased (χ(2) = 14.296 and 52.643, P = 0.006 and 0.000). ypT0-T2 in T category and yp0-I in TNM staging showed a favorable survival above 92%, while the patients with ypT3, or ypIIIB had a comparable lower DFS of 70.2% and 46.7%. DFS in patients with negative lymph node were significantly improved than those with positive nodes (93.5% vs. 66.7%, χ(2) = 34.125, P = 0.000). Patients with or without local invasive factor significantly differed in DFS (42.9% vs. 90.1%, χ(2) = 32.666, P = 0.000) . Cox regression analyze showed that the nodal status (RR = 12.312, 95%CI: 2.828-39.258, P = 0.000) and local invasive factors (RR = 5.422, 95%CI: 1.202-8.493, P = 0.020) were independent risk factors to 3-year survival. As the concept of clinical complete response (cCR) is obscure, there were 27.6% of patients with ypT0 had normal mucosa or no evidence of tumor by EUS or MRI tests before surgery. CONCLUSION: Postoperative pathologic staging features were closely associated with patient's prognosis. The increasing of ypT or ypTNM staging was correlated to decreasing of DFS. Nodal status, positive radial margin, perivascular and perineural invasion were independent risk factors to DFS. Since cCR did not correlate and could not predict pCR, the ongoing radical surgery could not be avoided even there was no evidence of tumor existing before operation.

Clinical outcome of neoadjuvant chemoradiation therapy with oxaliplatin and capecitabine or 5-fluorouracil for locally advanced rectal cancer.

BACKGROUND AND OBJECTIVES: This study evaluated the safety and efficiency of preoperative chemoradiation therapy (CRT) with the XELOX or FOLFOX regimen in locally advanced rectal cancer patients. METHODS: One hundred forty-four patients (T3/T4 or N+) were enrolled between 2005 and 2011. The patients received preoperative concomitant CRT (XELOX or FOLFOX regimen). Patients were divided into four groups: pCR (pT0N0), downstaging, no-downstaging, and progression group. Clinical outcome with overall survival (OS) and disease-free survival (DFS) were compared for each group. RESULTS: One hundred thirty-eight patients received radical resection after preoperative CRT. Twenty-seven patients (20%) achieved pCR. The response rate (pCR + downstaging) was 67%. The most common side effects were nausea (64%), diarrhea (49%), and leucopenia (49%). The overall estimated 5-year OS was 86% for all patients. The estimated 5-year OS was significantly better in the responders (pCR + downstaging) than the non-responders (no-downstaging + progression, 94% vs. 68%, P = 0.001). There was also statistical difference in 3-year DFS between the two groups (93% vs. 68%, P = 0.000). CONCLUSIONS: pCR and downstaging after neoadjuvant CRT are associated with improved survival for locally advanced rectal cancer patients. Preoperative CRT with the XELOX or FOLFOX regimen is well tolerated and has mild adverse events.

Comparison of safety of loop ileostomy and loop transverse colostomy for low-lying rectal cancer patients undergoing anterior resection: A retrospective, single institution, propensity score-matched study.

INTRODUCTION: This study was to compare the prevalence of stoma-related complications and stoma reversal perioperative complications of patients with low-lying rectal cancer who received preventative loop ileostomy and those who underwent loop transverse colostomy. METHODS: This retrospective single-center study analyzed the clinicopathologic and surgical data of 288 patients with pathologically proven primary rectal cancer who underwent anterior resection with either preventative loop ileostomy (n = 82) or loop transverse colostomy. To achieve comparability of a propensity score matching method was used to match patients from each group in a 1:2 ratio. Determinants of stoma-related complications were analyzed by multivariate logistic regression analysis. RESULTS: Forty-nine (74.3%) patients in the loop ileostomy group experienced stoma-related complications versus 48.7% in the loop transverse colostomy group (P < 0.01). Irritant dermatitis was the most frequent complication in both groups. The loop ileostomy group had a significantly higher rate (24.24%) of stoma reversal perioperative complications than the loop transverse colostomy group. Multivariate logistic regression analysis showed that ileostomy versus loop transverse colostomy was a significant independent risk for stoma-related complications and stoma reversal perioperative complications. Furthermore, by Clavien-Dindo classification, patients receiving loop ileostomy had an overall higher rate of complications and stoma reversal perioperative complications versus those undergoing loop transverse colostomy (P < 0.01). The rate of grade II complications was significantly higher in the loop ileostomy group (43.9%) than that of loop transverse colostomy group (13.5%, P < 0.01), whereas the rate of grade I, and grade IIIa and IIIb complications and stoma reversal perioperative complications was comparable between the two groups. CONCLUSION: The study has demonstrated that loop transverse colostomy is associated with significantly lower rates of stoma-related complications and stoma reversal perioperative complications compared to loop transverse colostomy.

[A comparative study upon two surgical procedures of local resection of early rectal cancer].

OBJECTIVE: To compare the application of transanal endoscopic microsurgery (TEM) technique with Mason's operation in the treatment of early rectal cancer. METHODS: Patients with early rectal cancer were divided into two groups according to different surgical procedures they underwent during different period. Patients in Mason Group underwent Mason's operations during the period from January 2000 to March 2006; and in TEM Group were managed with TEM procedures from April 2006 to July 2011. There were 21 patients in TEM Group and 26 patients in Mason Group. No statistically significant difference was found between the two groups in terms of patient's age, gender, preoperative TNM staging, and tumor diameter. In comparison with Mason Group, TEM Group had a longer distance of the tumor from the anal verge. The safety, postoperative complications, patients' postoperative recovery, and the oncological outcomes of 2 groups were compared with each other. RESULTS: No perioperative death occurred in the two groups. The TEM Group had notably shorter operating time ((67 ± 24) minutes) and lesser intra-operative blood loss ((9 ± 6) ml) than Mason Group (t = 3.526 and 7.078, P < 0.05). The time of the postoperative bed rest, the urinary drainage, the recovery of oral intake, and the hospital stay in TEM Group were (1.3 ± 0.5) days, (1.2 ± 0.4) days, (1.5 ± 0.5) days, and (4.3 ± 1.6) days, respectively, and all were prominently shorter than those of Mason group (t = 4.925 - 14.640, P < 0.05). Patients in TEM group were followed up for an average of 36.5 months with one patient being lost, while patients in Mason group were followed up for an average of 81.6 months. The difference between the two groups in terms of short-term accumulated survival (94.8% vs. 96.3%) showed no statistical significance (P > 0.05). CONCLUSION: TEM technique is a favorable minimally invasive procedure associated with satisfactory oncological outcomes in the treatment of early rectal cancer.

[Acquiring laparoscopic skill for colorectal surgery: based on the experience of a colorectal surgeon].

OBJECTIVE: Laparoscopic colorectal surgery is a skill-dependent procedure. The present study aims to analyze the learning curve of a properly trained surgeon, with basic laparoscopic techniques, to become skillful in performing laparoscopic colorectal operations. METHODS: A series of non-selective, consecutive 189 cases of laparoscopic colorectal surgery were accomplished, from December 2009 to February 2012, by one surgeon with years of skilled technique in laparoscopic cholecystectomy, rich experience in assisting laparoscopic colorectal surgery, and experience of approximately 180 procedures of gastric and colorectal surgery annually. 170 out of 189 procedures were radical operations for colorectal neoplasma, including right colectomies in 28 cases, left colectomies in 5 cases, sigmoidectomies in 28 cases, high Dixon procedures in 45 cases, low Dixon (total mesorectal excision, TME) procedures in 41 cases and Miles procedure in 23 cases. 19 other patients underwent combined procedures for multi-primary tumors or inflammatory enteritis. All these procedures were analyzed according to time span (the earlier half and later half) in respect to length of surgery, intraoperative blood loss, number of lymph nodes retrieved, intraoperative events and postoperative complications. RESULTS: For radical right colectomy, the D2 dissection conducted in the earlier phase (n = 8) had the similar length of surgery, more blood loss and less LN retrieval, compared with the D3 dissection conducted in recent phase (n = 20). The earlier performed high Dixon procedures (n = 22) consumed longer time than the later procedures (n = 23) consumed, but with similar blood loss and LN retrieval. Low Dixon (TME) procedures showed significant differences in length of surgery and blood loss relative to time span. Recently performed simoidectomy and Miles procedures showed a trend of shorter time consumed compared with earlier performed procedures. Conversion ratio to open surgery was 1.05%. Adverse effects occurred in 8 cases of surgeries, including intestinal injury (3/189), insufficient distal margin (2/189), intraoperative bleeding (2/189) and vaginal injury (1/76). There was no operative death. Chief complications included urinary retention 5.82%, ileus 4.76%, anastomotic leak 4.24%, perineal infection 23.08% (6/26), wound dehiscence 2.65%, gastrointestinal bleeding 1.59%, peritoneal infection 1.06%. Surgery for distal rectum tended to have more complications, such as urinary retention, anastomotic leak and perineal infection. The later performed low Dixon procedures produced insignificantly fewer anastomotic leaks than those in the earlier phase. CONCLUSIONS: For a trained surgeon with basic laparoscopic techniques, there are at least 15 - 25 cases of different procedures needed for him/her to become skilled to perform laparoscopic surgery. The learning curve should also depend on the annual number of colorectal surgeries.

Comparing the techniques and outcomes of laparoscopic transverse colectomy to laparoscopic hemicolectomy in mid-transverse colon cancer resection.

Introduction: The mid-transverse colon cancer is relatively uncommon in all colon cancers and the optimal surgical approach of mid-transverse colon cancer remains debatable. Aim and Objectives: Our study aimed to depict the techniques and outcomes of laparoscopic transverse colectomy in one single clinical center and compare this surgical approach to traditional laparoscopic right hemicolectomy and laparoscopic left hemicolectomy. Method: This was a retrospective cohort study of patients with mid-transverse colon cancer in one single clinical center from February 2012 to October 2020. The enrolled patients were divided into two groups undergoing laparoscopic transverse colectomy and laparoscopic right/left hemicolectomy, respectively. The intraoperative, postoperative complications, oncological outcomes and functional outcomes were compared between the two groups. The primary endpoint was disease free survival (DFS). Results: The study enrolled 70 patients with 40 patients undergoing laparoscopic transverse colectomy and 30 patients undergoing laparoscopic hemicolectomy. The intraoperative accidental hemorrhage and multiple organ resection occurred similarly in the two groups. In transverse colectomy, caudal-to-cephalic approach was likely to harvest more lymph nodes although require more operation time than cephalic-to-caudal approach (23.1 ± 14.3 vs. 13.4 ± 5.4 lymph nodes, P = 0.004; 184.3 ± 37.1 min vs. 146.3 ± 44.4 min, P = 0.012). The laparoscopic transverse colectomy was marginally associated with lower incidence of overall postoperative complications and shorter postoperative hospital stay although without statistical significance (8(20.0%) vs. 12(40.0%), P = 0.067; 7(5-12) vs. 7(5-18), P = 0.060). The 3-year DFS showed no significant difference (3-year DFS 89.7% in transverse colectomy vs. 89.9% in hemicolectomy, P = 0.688) between the two groups. The alternating consistency of defecation occurred significantly less after laparoscopic transverse colectomy than laparoscopic hemicolectomy (15(51.7%) vs. 20(80.0%), P = 0.030). Conclusion: The laparoscopic transverse colectomy is technically feasible with satisfactory oncological and functional outcomes for mid-transverse colon cancer. Performing the caudal-to-cephalic approach might be more advantageous in lymphadenectomy.

Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry.

BACKGROUND: The quality of life in patients who develop low anterior resection syndrome (LARS) after surgery for mid-low rectal cancer is seriously impaired. The underlying pathophysiological mechanism of LARS has not been fully investigated. AIM: To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively. METHODS: Patients diagnosed with mid-low rectal cancer were included. The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure. Anorectal functions were assessed by three-dimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery. RESULTS: The study population consisted of 24 patients. The total LARS score was decreased at 6 mo compared with 3 mo after surgery (P < 0.05), but 58.3% (14/24) lasted as major LARS at 6 mo after surgery. The length of the high-pressure zone of the anal sphincter was significantly shorter, the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in all patients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focal pressure defects of the anal canal were detected in 70.8% of patients, and those patients had higher LARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spastic peristaltic contractions from the new rectum to anus were detected in 45.8% of patients, which were associated with a higher LARS score at 3 mo postoperatively (P < 0.05). CONCLUSION: The LARS score decreases over time after surgery in the majority of patients with mid-low rectal cancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spastic peristaltic contractions from the new rectum to anus postoperatively, might be the major pathophysiological mechanisms of LARS.

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.