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Objective:To investigate the incidence and influencing factors of anastomotic leakage after laparoscopic anterior resection for rectal cancer.Methods:The retrospective case-control study was conducted. The clinicopathological data of 804 patients with rectal cancer who were admitted to Peking Union Medical College Hospital of Chinese Academy of Medical Sciences from January 2017 to December 2019 were collected. There were 521 male and 283 female, aged 63(range, 27-94)years. All 804 patients underwent laparoscopic anterior resection for rectal cancer. Observation indicators: (1) surgical situations; (2) incidence of postoperative anastomotic leakage; (3) follow-up; (4) influencing factors of postoperative anastomotic leakage; (5) subgroup analysis. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribu-tion were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Univariate analysis was conducted using the chi-square test or independent sample t test. Factors with P≤0.2 in univariate analysis were included in multivariate Logistic regression analysis. Results:(1) Surgical situations. All 804 patients underwent laparoscopic radical resection of upper and middle rectal cancer successfully, with the operation time and volume of intraoperative blood loss as 135(range, 118-256)minutes and 30(range, 5-350)mL. All 804 patients completed end-to-end colon rectal anastomosis, including 287 patients with reinforced sutures at the anastomotic site, and 517 patients with routine anastomosis. (2) Incidence of postoperative anastomotic leakage. Of the 804 patients, 40 patients had postoperative anastomotic leakage, with the incidence rate as 4.98%(40/804). (3) Follow-up. All 804 patients were followed up for 32(range, 6-49)months. None of patient died during the perioperative period. (4) Influencing factors of postoperative anastomotic leakage. Results of multivariate analysis showed that unreinforced suture at the anastomotic site was an independent risk factor for postoperative anastomotic leakage ( odds ratio=2.78, 95% confidence interval as 1.21-6.37, P<0.05). (5) Subgroup analysis. Of the 804 patients, 202 patients received neoadjuvant therapy and 602 patients did not receive neoadjuvant therapy. Of the 602 patients who did not receive neo-adjuvant therapy, cases with postoperative anastomotic leakage was 6 in the 253 patients with reinforced sutures, versus 21 in the 349 patients with routine sutures, showing a significant difference between them ( χ2=4.56, P<0.05). Conclusion:Unreinforced anastomosis at the anasto-motic site is an independent risk factor for anastomotic leakage after laparoscopic anterior rectal resection, especially for rectal cancer patients without neoadjuvant radiochemotherapy.
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Objective:To investigate the status of We-Media platforms opened and opera-ted by surgeons in tertiary first-class hospitals nationwide and analyze its influence on patients and surgeons.Methods:The retrospective cross-sectional investigation study was conducted. The investigation was conducted on the surgeons who had opened We-Media platforms in their units or associations through the contact of all members of the second Elite Committee of Chinese Digestive Surgery of the Chinese Journal of Digestive Surgery from November 5 to 30, 2021. Questionnaires were distributed through wechat, and the software platform was Questionnaire Star. Observation indicators: (1) results of questionnaire survey; (2) basic information of surgeons running We-Media platforms; (3) daily workload and research background of surgeons running We-Media platforms; (4) information related to We-Media platforms; (5) influence of running We-Media platforms on patients; (6) influence of running We-Media platforms on surgeons; (7) feelings and suggestion of surgeons after running We-Media platforms. Measurement data with normal distribution were expressed as Mean± SD, and count data were expressed as absolute numbers and percentages. Results:(1) Results of questionnaire survey: a total of 229 complete and valid questionnaires were collected in this survey. (2) Basic information of surgeons running We-Media platforms: of 229 surgeons, there were 195 males and 34 females, aged (40±8)years. There were 120 surgeons aged from 36-45 years, 80 surgeons aged <35 years and 29 surgeons aged >45 years. There were 86.46% (198/229) of surgeons from teaching hospitals and 74.67%(171/229) of surgeons from provincial cities. Of 229 surgeons, junior, intermediate, deputy senior and senior titles accounted for 17.90%(41/229), 27.51%(63/229), 37.12%(85/229) and 17.47%(40/229), respectively. Surgeons with working years ≤5 years, 6-10 years, 11-15 years and ≥16 years accounted for 19.21%(44/229), 22.27%(51/229), 26.64%(61/229) and 31.88%(73/229), respectively. Hepatobiliary and pancreatic surgeons, esophageal and gastrointestinal surgeons were the main specialties, accounting for 48.03%(110/229) and 14.41%(33/229), respectively. The original intentions of opening We-Media platforms (multiple choice) included increasing patient population and improving the income, accumulating cases to facilitate clinical research projects, increasing the popularity of the industry and gain peer recognition, increasing social awareness and improving spiritual satisfaction, passive assignments form units or hospitals, which accounted for 52.84% (121/229), 54.15%(124/229), 64.19%(147/229), 58.08%(133/229), 17.90%(41/229), respectively. (3) Daily workload and research background of surgeons running We-Media platforms: 60.26%(138/229) of surgeons participated in offline social welfare activities 1-3 times per year and 26.64%(61/229) of surgeons participated >3 times per year. There were 47.60% (109/229) of surgeons performing 5-10 operations per week and 33.19%(76/229) of surgeons performing >10 operations per week. In terms of scientific researches, 38.43%(88/229) of surgeons had not published high-quality English articles as the first author or co-first author, 24.89%(57/229) of surgeons had published 1-3 articles and 36.68%(84/229) of surgeons had published >3 articles. There were 51.09%(117/229) of surgeons without any longitu-dinal projects, 13.54%(31/229) of surgeons with national projects, 35.37%(81/229) of surgeons with provincial and ministerial projects. (4) Information related to We-Media platforms: there were 65.50%(150/229) of surgeons running wechat public account, 55.02%(126/229) of surgeons running consultation platform, 31.44%(72/229) of surgeons running TikTok, 21.40%(49/229) of surgeons running wechat video account (some surgeons operated multiple We-Media platforms). The time of operating the platform was <1 year in 35.81%(82/229) of surgeons, 1-3 years in 42.79%(98/229) of surgeons, >3 years in 21.40%(49/229) of surgeons, respectively. The contents of We-Media platforms were updated >2 weeks in 45.85%(105/229) of surgeons. There were 63.32%(145/229) of surgeons with We-Media platforms win-ning emotional support from their department or hospital, 12.66%(29/229) of surgeons with We-Media platforms winning financial support. There were 82.53%(189/229) of surgeons operating We-Media platforms by theirselves. The We-Media plat-form operation was smooth in 47.16%(108/229) of surgeons, unsustainable in 50.22%(115/229) of surgeons and suspended in 2.62%(6/229) of surgeons. On average, it took less than 30 minutes for 60.70%(139/229) of surgeons and 30-60 minutes for 27.07%(62/229) of surgeons to operate the We-Media platforms of surgeons every times, respec-tively. The background message or consulta-tion was allowed in 89.08%(204/229) of surgeons. The number of leaving messages was <5 times in 52.84%(121/229) of surgeons and >50 times in 6.99%(16/229) of surgeons. On average, each content in 59.39%(136/229) of surgeons were "liked" or "viewed" <100 times, and each content in 29.26%(67/229) of surgeons were "liked" or "viewed" 100-300 times. There were 60.26%(138/229) of surgeons having content with the highest "liked" or "viewed" clicks <1 000 times and 6.99%(16/229) of surgeons having content with the highest "liked" or "viewed" clicks >10 million times. On average, each content in 74.67%(171/229) of surgeons were "forwarded" <100 times, and each content in 6.55%(15/229) of surgeons were "forwarded" >300 times, respectively. The number of followers was <1 million in 87.34%(200/229) of surgeons. The We-Media audiences (multiple choices) included related professional peers, related health care professionals, patients of surgeons, general public, accounting for 42.36%(97/229), 31.00%(71/229), 52.40%(120/229), 53.71%(123/229), respectively. (5) Influence of running We-Media platforms on patients: 34.93%(80/229) of surgeons believed that the operation of We-Media platform significantly increased the number of outpatient and inpatient patients of themselves, 29.69%(68/229) of surgeons believed that the operation of We-Media platform significantly increased the number of outpatient and inpatient patients in their departments, respectively. In the view of 75.98%(174/229) of surgeons, the percent of outpatient and inpatient patients by We-Media platforms was <10%. After 6 months of We-Media operation, 39.74%(91/229) and 25.33%(58/229) of surgeons believed that inpatient and outpatient compliance was significantly improved, respectively, and 46.29% (106/229) of surgeons believed that preopera-tive and pre-chemotherapy or pre-radiotherapy conversations saved more time. (6) Influence of running We-Media platforms on surgeons: 20.09%(46/229) and 6.55%(15/229) of surgeons attributed the success to "long-term, sustainable, absorbed operation" and "important contents of We-Media platforms and wide audiences". There were 72.49%(166/229) of surgeons yet to be successful. There were 26.64% (61/229) and 22.27%(51/229) of surgeons believing that opening We-Media platforms was conducive to the association's employment and multicenter clinical research. Operating We-Media platforms was conducive to professional knowledge improvement, clinical research ability enhancement and teaching level of students, which was believed by 54.59%(125/229), 40.17%(92/229) and 48.91%(112/229) of surgeons, respectively. Although the total income in 88.65%(203/229) of surgeons increased less than 20% after 6 months of operation, 47.60%(109/229) of surgeons believed that "the sense of achievement or pleasure in work has been significantly improved", and 48.91%(112/229) of surgeons did not have the idea of quitting. There were 7.42%(17/229) of surgeons with the idea of quitting the operation of We-Media platforms. (7) Feelings and suggestions of surgeons after running We-Media platforms: the proportion of surgeons who hoped to get help from departments, hospitals, associations and the society were 61.57%(141/229), 72.05%(165/229), 47.16%(108/229) and 53.28%(122/229), respectively. Only 9.61%(22/229) of surgeons did not require help. Commercial advertisement was allowed by 40.17%(92/229) of surgeons and forbidden by 59.83%(137/229) of surgeons. In terms of alternative suggestion, 70.74%(162/229) of surgeons believed that it was necessary for the We-Media platforms to involve more doctors of different specialties, but 40.61%(93/229) of surgeons believed that relevant departments or associations should strengthen supervision under the current situation. In addition, 32.75%(75/229) of surgeons believed that the operation of We-Media platform requires more investment. The were 27.95%(64/229) of surgeons giving specific suggestions on running We-Media platforms, 7.81%(5/64) of which did not suggest a blind try.Conclusions:Most surgeons who open and operate We-Media platforms in China are faced with problems such as busy work, limited time and energy, low-income increase, and lack of professional promotion and maintenance teams and external support. Even so, there are still many surgeons who have achieved success through long-term persistence and high-quality content output, thus increasing the number of patient visits, improving their own ability and industry influence, and bringing a greater sense of professional achievement.
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Since the establishment of the Chinese Journal of Digestive Surgery, progress has been made by generations of experts together with the journal. In November 2017, Chinese Journal of Digestive Surgery established the first session 'Elite Group of Chinese Digestive Surgery', and the author was fortunate to become one member of the Colorectal Surgery Group. Under the leadership of the group leader, Professor Yao Hongwei, heated academic discussions was carried out on the topics of colorectal surgery. Time flies, in the last few years, the author took part in the review work of the Chinese Journal of Digestive Surgery. In the process of reviewing articles, the author saw splendid researches and new outlook in the digestive surgery field with a lot of harvest, and was awarded twice with the title of excellent reviewing experts. With the rapid development of the Chinese Journal of Digestive Surgery, the author have gradually opened up new orientation in media and education. The author not only opened accounts on we-media platforms, but also actively participated in TV programs, striving to popularize health science knowledge to the general public. In July 2021, the second inaugural conference and the first plenary meeting of the 'Elite Group of Chinese Digestive Surgery' was successfully held in Chongqing. The author was honored to be the leader of the Media and Education Group. Together with all the other members, the author summari-zed experience in science popularization and media and share it with the fellow gastroenterology colleagues. At the first working meeting of the Media and Education Group of the 'Elite Groups of Chinese Digestive Surgery', members shared their practical experience and future work plans, and gained a lot of new inspiration. Now, The Chinese Journal of Digestive Surgery has celebrated its 20 th anniversary. The author sincerely wishes the Chinese Journal of Digestive Surgery with a marvelous future and popularization of health science promoting the development of colorectal surgery.
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Objective:To evaluate the clinical efficacy of transanal total mesorectal excision (taTME) on transanal endoscopic microsurgery (TEM) platform in the treatment of middle and low rectal cancer.Methods:The retrospective and descriptive study was conducted. The clinico-pathological data of 28 patients with middle and low rectal cancer who underwent taTME on TEM platform in the Peking Union Medical College Hospital of Chinese Academy of Medical Science from October 2014 to October 2017 were collected. There were 21 males and 7 females, aged 59 years (51 years, 68 years). Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up was conducted using outpatient examination or telephone interview to detect post-operative defecation function and survival of patients up to October 2020. Patients underwent physical examination, examination of tumor markers including carcinoembryonic antigen and CA19-9, colonoscopy, rectal magnetic resonance imaging, thoracoabdominal and pelvic enhanced computed tomography (CT) and (or) PET-CT examination during the follow-up. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M( P25,P75) or M (range), and comparison between groups was analyzed using the non parameter Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Surgical and postoperative situations: 28 patients underwent successful surgery, without intra-operative conversion to laparotomy. Of 28 patients, 24 cases underwent colorectal anastomosis and 4 cases underwent colon-anal anastomosis. Twenty-six cases underwent primary protective enterostomy and 2 cases didn't undergo primary protective enterostomy. The operation time of 28 patients was (182±37)minutes and the volume of intraoperative blood loss was 40mL(30 mL, 55 mL). One patient with intraoperative presacral hemorrhage received compression hemostasis. Eleven patients had postoperative complications, including 4 cases with anastomotic leakage, 2 cases with alteration of intestinal flora, 2 cases with paralytic ileus, 2 cases with urinary retention, 2 cases with urinary infection, 1 case with prolapse necrosis of small intestinal stoma, 1 case with anal hemorrhage, 1 case with rectovaginal fistula, 1 case with pelvic infection; some patients had multiple complications. Three patients had non-planned reoperation. One case without primary protective enterostomy had anastomotic leakage at postoperative 3 days, and was improved after emergency transversostomy. One case had prolapse necrosis of small intestinal stoma at postoperative 3 days and was improved after emergency enterostomy and reconstruction. One case with anal hemorrhage was stopped hemorrhage under anoscopy. Patients with other complications were cured after conservative treatments. The duration of postoperative hospital stay of 28 patients was 8 days(7 days, 9 days). Results of pathological examination in 28 patients showed 16 cases of moderately differentiated adenocarcinoma, 3 cases of moderately to highly differentiated adenocarcinoma, 5 cases of highly differentiated adenocarcinoma, 1 case of mucinous adenocarcinoma, 3 cases of pathological complete response. TNM staging of 28 patients showed 3 cases in stage T0N0, 4 cases in stage T1N0, 6 cases in stage T2N0, 4 cases in stage T2N1, 7 cases in stage T3N0, 3 cases in stage T3N1, 1 case in stage T4N1. The distance from tumor to distal margin was (2.2±1.7)cm. The surgical specimens of 28 patients showed negative for proximal, distal and circumferential margins. The number of lymph node dissection was 15±7. The complete rate of total mesorectal excision was 100%(28/28). Eleven of 28 patients underwent neoadjuvant therapy and 17 patients didn't receive neoadjuvant therapy. The tumor diameter, distance from tumor to anal margin, operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 2 cm(1 cm, 4 cm), 5 cm(4 cm, 6 cm), (187±25)minutes, 45 mL(38 mL, 53 mL), 8 days(7 days, 12 days) for patients with neoadjuvant therapy, respectively, versus 3 cm(2 cm, 4 cm), 5 cm(4 cm, 6 cm), (177±35)minutes, 40 mL(30 mL, 60 mL), 8 days(7 days, 8 days) for patients without neoadjuvant therapy, showing no significant difference between the two groups ( Z=-1.127, -0.293, t=0.590, Z=-0.790, -0.876, P>0.05). (2) Follow-up: 23 of 28 patients were followed up for (44±14)months. Of the 23 patients,11 cases were classified as grade A of Williams score for defecation function at postoperative 6 months, 8 cases were classified as grade B and 4 cases were classified as grade C. Eighteen of 23 patients with follow-up had disease-free survival, 1 of whom didn't undergo stoma closure due to anastomotic stenosis at postoperative 6 months. Three patients had distant metastasis, including 1 case with parastomal implantation metastasis, 1 case with sacral metastasis, 1 case with pulmonary metastasis. Two patients died, 1 case of whom died of urinary obstruction and 1 case with mucinous adenocarcinoma died at postoperative 24 months. Conclusion:TaTME based on TEM platform is feasible for middle and low rectal cancer, which has the advantages of preserving anus and negative circumferential margin.
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A 78-year-old man was admitted to Peking Union Medical College Hospital with fever, weakness of lower extremities, less speech, loss of memory. Fever was relieved after antibiotic treatment, while cognitive impairment and disorder of consciousness progressed rapidly, followed by critical pulmonary infections, respiratory failure, and septic shock. Lab tests showed negative occult blood, normal serum CEA level and positive Anti-nuclear-antibody. PET-CT suggested that strong FDG uptake signals were seen at sigmoid, while bilateral frontal lobe, temporal lobe, parietal lobe, posterior cingulate gyrus showed lower metabolic activity. Colonoscopy biopsy revealed differentiated adenocarcinoma of sigmoid colon. Therefore, paraneoplastic syndrome of nervous system secondary to colon cancer was considered. Rapid and proper diagnosis and treatment were completed by multidisciplinary team including departments of neurology, gastroenterology, general surgery, ICU, rheumatology, clinical nutrition. The laparoscopic sigmoid colectomy was performed under general anesthesia. The patient finally presented with significant improvement of cognition and consciousness. Respiratory function was totally recovered.
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Objective@#To introduce a new technique of protective ostomy using the specimen extraction auxiliary incision following laparoscopic low anterior resection for rectal cancer, and to compare the pros and cons of loop ileostomy (LI) and loop transverse colostomy (LTC).@*Methods@#A retrospective cohort study was performed. The data of patients who underwent laparoscopic low anterior resection for rectal cancer and ostomy using the auxiliary incision in Peking Union Medical College Hospital from January 2010 to December 2017 were retrospectively analyzed. Inclusion criteria: (1) patient underwent neoadjuvant chemoradiotherapy before operation; (2) patient was classified as tumor stage II or III; (3) patient was followed up and underwent stoma closure at our center; (4) ostomy was performed through specimen extraction incision. Patients with multiple gastrointestinal carcinomas or inflammatory bowel disease were excluded. Two hundred and eight patients were included in the study and divided into the LI group (n=86) and LTC group (n=122). The operation parameters and postoperative complications were compared between the two groups.@*Results@#There were 135 males and 73 females (1.85∶1.00). Mean age of the 208 patients was (59.6±11.6) years (range 29-85 years). There were no significant differences between LI and LTC groups in baseline data (all P>0.05). All of the patients completed surgery successfully. The severe complication rate after ostomy was 2.9% (6/208). In the fecal diversion period, LI group showed significantly faster defecation [(1.6±1.0) days vs. (2.2±1.9) days, t=-2.918, P=0.004] and lower incidence of parastomal hernia [8.1% (7/86) vs. 19.7% (24/122), χ2=5.290, P=0.021], but higher incidence of peristomal dermatitis [18.6% (16/86) vs. 4.9% (6/122), χ2=9.990, P=0.002] as compared to LTC group. The incidence of renal insufficiency was lower in LTC group, though the difference was not significant [4.9% (6/122) vs. 10.5% (9/86), χ2=2.320, P=0.128]. The severe complication rate after stoma closure was 1.9% (4/208). In the stoma closure period, a significantly higher incidence of wound infection was noted in LTC group [18.0% (22/122) vs. 4.7% (4/86), χ2=8.258, P=0.004]. There were no significant differences between the two groups in the incidence of anastomotic leakage, stenosis, and incisional hernia (all P>0.05). All complications were improved after treatment.@*Conclusions@#Both LI and LTC through auxiliary incision following laparoscopic low anterior resection for rectal cancer are safe and feasible. LTC is an optional method for those patients with sensitive skin.
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Objective@#To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT).@*Methods@#Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients.@*Results@#There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead.@*Conclusion@#For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.
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OBJECTIVE@#To investigate the efficacy of transanal endoscopic microsurgery (TEM) combined with imatinib for rectal gastrointestinal stromal tumors(GIST).@*METHODS@#Clinical data of 35 patients with rectal GIST undergoing TEM at Peking Union Medical College Hospital from February 2008 to May 2017 were analyzed retrospectively. Operation details, postoperative recovery condition, and follow-up information were reviewed. The differences in clinicopathological features and perioperative parameters were compared between patients who received neoadjuvant therapy (12 patients, imatinib mesylate, oral, 400 mg daily for 6 months before surgery) and those without neoadjuvant therapy (23 patients).@*RESULTS@#Of 35 patients, 18 were males and 17 were females with the mean age of (49.3±13.3) years. Mean tumor diameter was (1.8±1.1) cm and mean distance from lower tumor margin to anal verge was (4.0±1.8) cm. Mean operative time was (82.4±21.1) minutes and mean blood loss was (11.7±7.5) ml. No conversion to laparotomy occurred. Complete resection with negative margins was achieved in all cases. Complications were classified according to Clavien-Dindo system: 4 cases of grade I, 3 of grade II and 1 of grade IIIb. The tumor size in patients who received neoadjuvant therapy reduced from (3.1±1.2) cm to (2.6±1.2) cm, though it was still larger than the tumor size in patients without neoadjuvant therapy[(1.5±0.8) cm, P0.05]. Thirty patients (85.7%) were followed up for (50.3±36.6) months, and no local recurrence or metastasis was observed.@*CONCLUSIONS@#TEM is safe and effective in the treatment of rectal GIST. Preoperative neoadjuvant therapy is beneficial to TEM in treating larger tumors without increasing operating time. Satisfactory follow-up result is observed.
Subject(s)
Adult , Female , Humans , Male , Middle Aged , Gastrointestinal Stromal Tumors , Drug Therapy , General Surgery , Imatinib Mesylate , Therapeutic Uses , Rectal Neoplasms , Drug Therapy , General Surgery , Retrospective Studies , Transanal Endoscopic Microsurgery , Reference Standards , Treatment OutcomeABSTRACT
Objective@#To analyze the Clavien-Dindo classification of complications after right hemicolectomy and to explore the prognosis factors for postoperative complications.@*Methods@#The retrospective case-control study was adopted. The clinical data of 176 patients who underwent right hemicolectomy at Department of General Surgery, Peking Union Medical College Hospital from October 2016 to February 2018 were collected. There were 95 male and 81 female patients with age of (62.4±12.7) years. The Clavien-Dindo classification was used for postoperative complications. Univariate and multivariate analysis were used to analyze the independent prognosis factors of complications after right colon resection.@*Results@#Of the 176 patients, 2 patients had intraoperative complications (1.1%) and 39 patients had postoperative complications (22.2%), of which 10 cases had more than two complications, with a total of 53 complications. The proportions of Clavien-Dindo grade Ⅰ, Ⅱ, Ⅲ and Ⅳ complications were 41.5% (22/53), 49.1% (26/53), 7.5% (4/53), and 1.9%(1/53). Postoperative complications were associated with age, smoking history of the last 1 year, combined organ resection, lymph node dissection, intracorporeal anastomosis, and preoperative blood AST and Ca levels (all P<0.05). The results of multivariate analysis showed that intracorporeal anastomosis (OR=5.62, 95% CI: 2.46 to 12.85, P=0.00), preoperative blood AST (OR=-0.009, 95% CI: -0.018 to 0.000, P=0.04) and Ca (OR=0.51, 95% CI: 0.08 to 0.95, P=0.02) levels were independent prognosis factors affecting complications after right hemicolectomy.@*Conclusions@#Complications of right hemicolectomy were mainly Clavien-Dindo grade Ⅰ and Ⅱ. Laparoscopic intracorporeal anastomosis should be carefully chosen, which may increase postoperative complications.
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Objective@#To explore the effect of unfavorable histological features on the clinical outcomes of patients receiving radical resection of colorectal cancer.@*Methods@#A retrospective analysis of patients with colorectal cancer who received radical surgery between January 2013 and December 2015 at Department of General Surgery, Peking Union Medical College Hospital was performed. The impact of unfavorable histological features on the oncological outcomes of patients with lymph node-negative colorectal cancer were analyzed.A total of 167 patients were enrolled, including 98 males and 69 females with age of (63.6±11.6) years. Observation indicators included age, T stage, lymphovascular invasion, perineural invasion, tumor deposits, number of lymph node dissection, degree of differentiation, tissue type, and circumferential margin. Univariate analysis was performed with χ2 test and multivariate analysis was performed with Cox regression model.@*Results@#Univariate analysis showed that positive circumferential margins (CRM), tumor deposits and age were associated with disease free survival (DFS) rate; positive CRM, age, tumor deposits, and lymph nodes dissection less than 12 were significantly associated with overall survival (OS) rate (all P<0.05). Multivariate analysis showed that over 70 years of age (HR=1.053, 95% CI: 1.013 to 1.095, P=0.009), poorly differentiated adenocarcinoma (HR=7.572, 95%CI: 1.815 to 31.587, P=0.005), tumor deposits (HR=4.711, 95% CI: 1.809 to 12.264, P=0.002), mucinous adenocarcinoma (HR=3.063, 95% CI: 1.003 to 9.354, P=0.049), lymphovascular invasion (HR=2.885, 95% CI: 1.062 to 7.832, P=0.038), and nerve infiltration (HR=6.610, 95% CI: 1.037 to 42.122, P=0.046) were adverse prognostic factors of DFS rate; poorly differentiated adenocarcinoma (HR=12.200, 95% CI: 1.985 to 74.972, P=0.007), tumor nodules (HR=5.379, 95% CI: 1.636 to 17.685, P=0.006), over 70 years of age (HR=1.062, 95% CI: 1.013 to 1.114, P=0.013), and perineural invasion (HR=8.043, 95% CI: 1.026 to 63.055, P=0.047) were adverse prognostic factors of OS rate. There was no significant difference in the 3-year DFS rate and 3-year OS rate between T1-2 group and T3-4 group (P>0.05).@*Conclusion@#Over 70 years of age, poorly differentiated adenocarcinoma, mucinous adenocarcinoma, tumor nodules, lymphovascular invasion, and perineural invasion are independent adverse prognostic factors of lymph node-negative colorectal cancer.
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For colorectal surgeons, how to reduce anastomotic leakage after laparoscopic rectal cancer surgery remains to be challenging. We provide a brief discussion regarding the surgical skills required to prevent anastomotic leakage after rectal cancer surgery, such as the following: 1) Low ligation of inferior mesenteric vessel during laparoscopic total mesorectal excision can improve anastomotic tension and blood supply, thus reducing the risk of anastomotic leakage.While high ligation of inferior mesenteric artery resultsin poor blood supply and high tension in atastomotic site, thus increasing the risk of anastomotic leakage. 2) Protective enterostomy is recommended for patients with high risk of developing anastomotic leakage. 3) Use of abdominal/pelvic drains after colorectal anastomosis is recommended to decrease the incidence of anastomotic leakage, early detect anastomotic leakage, and conservativdy manage anastomotic leackage through drainage of pelvic effusion. 4) Laparoscopic reinforcing sutures should be used if anastomotic tension and blood supply are unsatisfactory, including continuous suture with 3-0 or 4-0 absorbable suture and 2-needle interrupted suture in the weak anastomosis. However, these sutures should be performed by experienced surgeons. For male patients with narrow pelvis and those with low rectal cancer, laparoscopic reinforcing sutures should be performed carefully due to the limited operative space. 5) Intraoperative air leak test is recommended to identify the anastomotic integrity for those with suspicious mechanically insufficient rectal anastomosis. 6) Experienced surgeon can reduce the incidence of anastomotic leakage after rectal cancer operation.
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Objective To investigate the advantages and disadvantages of transanal total mesorectal excision with laparoscopic assisted for min-low rectal cancer.Methods Retrospectively analyzed the clinical data of 38 patients with min-low rectal cancer who undement laparoscopically assisted transanal total anorectal rectal cancer from November 2014 to May 2018 in the Department of General Surgery,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College.The main outcome measures included gender,BMI,the operating time,intra-operative blood loss,the intraand post-operative complication rate,the distal resection margin length and the circumferential resection margin status of the pathological specimen,the number of lymph nodes acquisitions,as well as the postoperative average hospitalization time.Results The surgery was completed smoothly for all patients in this studying,with no conversion to open surgery.Among all the 38 patients,there were 26 (68.4％) male cases and 12(31.6％) female cases,and 25 cases were with a body mass index (BMI) over 24 kg/m2.The average operating time was (175.2 ± 37.6) minutes.The average intra-operative blood loss was (63.9 ± 42.7) ml.The complications included 1 case of intra-operative presacral venous hemorrhage,and 6 cases of post-operative anastomotic leak (15.8％).There were 18 cases happened perioperative complications,and the rate was 47.4％.The average distance from the distal resection margin to the lower end of the tumor was (2.1 ± 0.4) cm.There were 34 cases of complete mesorectal excision.The average number of lymph nodes retrieved was 14.2 ± 4.5.The average postoperative hospital stay was (9.8 ±5.9) days.Conclusion Transanal total mesorectal excisionwithlaparoscopic-assisted formid-lowrectal cancer can more accurately ensure adequate distal margin and mesorectal integrity.
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<p><b>OBJECTIVE</b>To investigate the treatment of colorectal anastomotic tubular stricture after anterior resection of rectal cancer.</p><p><b>METHODS</b>A retrospective study on 23 cases of anastomotic tubular stricture after anterior resection of rectal cancer from 2008 to 2017 at the Division of Colorectal Surgery, Department of General Surgery of Peking Union Medical College Hospital was performed. The general conditions of the patients, surgical procedures of rectal cancer, perioperative treatment, specific conditions of anastomotic stricture, treatment methods and outcomes were summarized and analyzed. Anastomotic tubular stricture was defined as follows: (1) The length of scar stenosis was >1 cm with thickening anastomotic intestinal wall and a 12 mm diameter colonoscopy could not pass through the anastomosis; (2) Patients were often accompanied by left abdominal pain when exhaust and defecation, increased frequency of defecation, fecal thinning and difficulty in defecation; (3) Anastomotic stricture was indicated by anal examination, colonoscopy, transanal proctography, and rectal MRI.</p><p><b>RESULTS</b>Among 2035 patients undergoing anterior resection of rectal cancer from 2008 to 2017, 23 patients (1.1%) had anastomotic tubular stricture after operation, including 20 males and 3 females with age of 36 to 78 (58.3±10.2) years old. The anastomotic distance from the anal verge was less than 6 cm in 7 cases, 6 to 10 cm in 12 cases, and more than 10 cm in 4 cases. Twelve patients received radiotherapy, among whom 6 patients received neoadjuvant chemoradiation before surgery, and 6 patients received postoperative radiotherapy and chemotherapy. The initial treatment after anastomotic stricture: 9 cases (39.1%) underwent balloon dilation; 1 case(4.3%) underwent stenting; 1 case (4.3%) underwent transanal endoscopic microsurgery (TEM); 7 cases (30.5%) underwent permanent stoma and 5 patients (21.7%) underwent digestive tract reconstruction. Of the 12 patients receiving radiotherapy, 4 cases initially failed to undergo balloon dilatation; 1 case initially received a bare stent to relieve obstruction due to intestinal obstruction, but had re-stricture 1 month after stent removal, then was followed by permanent stoma surgery; 7 cases underwent resection of stenosis and permanent stoma, because the remaining intestine was too short for anastomosis. Of the 11 patients without radiotherapy, 5 patients were treated with balloon dilatation to relieve stenosis; 1 patient was initially treated with TEM, while posterior urethra was injured intraoperatively, and the urinary fistula finally healed with indwelling catheter; 5 patients underwent resection of the anastomotic stenosis, and no stenosis occurred after reconstruction of digestive tract, but 1 patient suffered from intraoperative presacral bleeding.</p><p><b>CONCLUSIONS</b>Balloon dilatation is considered an effective treatment of anastomotic tubular stricture following anterior resection of rectal cancer, but with the risk of re-stenosis. Stricture resection and digestive tract reconstruction can be a radical way to improve stricture but with high risk of complications.</p>
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Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Anastomosis, Surgical , Constriction, Pathologic , General Surgery , Postoperative Complications , Rectal Neoplasms , General Surgery , Rectum , General Surgery , Retrospective StudiesABSTRACT
<p><b>OBJECTIVE</b>To analyze the clinical features, possible reasons and management of anastomotic leakage after laparoscopic-assisted radical right hemicolectomy.</p><p><b>METHODS</b>Clinical data of 546 patients undergoing laparoscopic-assisted radical right hemicolectomy in Peking Union Medical College Hospital from October 2010 to September 2016 were retrospectively analyzed. The occurrence of anastomotic leakage and its countermeasures were evaluated.</p><p><b>RESULTS</b>Among 546 patients, 8(1.5%) cases developed anastomotic leakage, including 7 males and 1 female with mean age of (54.3±10.3) years. Six cases of ascending colon cancer, 1 case of phlegmon and 1 case of arterior-venous malformation were confirmed after operation. The incidence of anastomotic leakage after D3 and D2 lymphadenectomy was 2.1%(6/290) and 0.8%(2/256). The time from operation to the diagnosis of anastomotic leakage was (6.6±3.6) days. The clinical manifestation of anastomotic leakage were stool-like drainage in 7 patients, fever in 4 and abdominal pain in 3. Amylase and bilirubin in drainage of 4 patients increased obviously. All the 8 patients underwent secondary ileostomy, including 4 with laparoscopy and 4 with laparotomy. One patient suffered from respiratory failure after re-operation because of severe abdominal infection and was cured by ventilator support treatment. Another one had pelvic encapsulated effusion and was treated by puncture drainage. All the patients discharged from hospital smoothly.</p><p><b>CONCLUSIONS</b>Anastomotic leakage after laparoscopic-assisted right hemicolectomy is a quite rare but serious complication, which may be associated with over-cleaning of lymph fatty tissues. Ileostomy should be the first choice of anastomotic leakage after laparoscopy-assisted right hemicolectomy and its efficacy is satisfactory.</p>
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Transanal endoscopic microsurgery (TEM) is currently the only one-port system in endoscopic surgery, which a direct endoluminal approach can lead to the target organ through a natural opening of human body. TEM has been applied in colorectal surgery for over 3 decades. Compared with radical surgery, TEM has the advantages, such as quicker recovery, shorter hospital stay and fewer complications. One perfect TEM surgical system, which mainly consists of three parts, namely peculiar rectoscope for surgery, special surgical instruments and imaging system, is the foundation of standardized development of TEM. Accurate preoperative evaluation and staging is the key for good outcomes in TEM technology. In addition to digital examination of rectum, rigid sigmoidoscopy(or rectoscopy) should be routinely performed to confirm the location of the lesion and record it in a "time-in-clock" form. For lesions with undetermined nature, biopsy should be performed. For patients with rectal tumor, pelvic MRI examination can be used on the basis of routine endorectal ultrasonography (ERUS). Endoluminal suture is the challenge for standardized development of TEM, especially for those with large intestinal wall defects. Professional training is required to master suture technique. In 2016, the consensus of experts on TEM technology was formulated by TEM Study Group of Colorectal Cancer Specialty Committee of Chinese Anticancer Association. The recommended surgical indications for TEM include (1)rectal adenoma; (2)early rectal cancer with good histopathological features; (3)extended resection of locally malignant polyps by colonoscopy; (4)other rectal tumors suitable for local resection; (5)benign stricture or anastomotic stricture of the rectum; (6)repair of anastomotic leakage after low anterior resection of rectum; (7)diagnosis of rectal hemorrhage; (8)biopsy of rectum and surrounding lesions; (9)repair of rectovaginal fistula or mucosal flap transposition of the internal mouth of anal fistula; (10)treatment of rectal foreign body. With the maturity of TEM technology, the indication of TEM continues to expand. Nowadays, TEM is applicable to rectal neuroendocrine tumor or gastrointestinal stromal tumor resection, as well as rectovaginal fistula repair. It can even serve as a "bottom-up" operation platform for transanal total mesorectal excision (taTME). This article introduces the standardization of TEM, its current indications, novel implications, and future perspectives, expecting that TEM will be further popularized and healthily developed in China.
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<p><b>OBJECTIVE</b>To assess the efficacy of full-thickness excision using transanal endoscopic microsurgery (TEM) in the treatment of rectal neuroendocrine tumors (NET).</p><p><b>METHODS</b>Clinicopathological and follow-up data of 90 rectal NET patients who underwent TEM between December 2006 and December 2016 at our department were retrospectively analyzed. TEM was performed as primary excision in 66 patients and as the second complete surgery because of suspected positive margin of samples after colonoscopic polypectomy in 24 patients.</p><p><b>RESULTS</b>TEM was successfully performed in all the rectal NET patients, and in 10 patients(41.7%,10/24) among those undergoing the second excision, postoperative pathologic results showed remnant tumor. The mean diameter of all the tumors was (1.03±0.46) cm, and the mean tumor diameter of primary excision and secondary excision was (1.10±0.50) and (0.84±0.23) cm respectively (t=2.454, P=0.016). The mean distance from tumor low margin to anal verge was (7.7±1.8) cm for all the patients, and such distance for those undergoing primary excision and secondary excision was (7.4±1.7) cm and (8.4±1.8) cm respectively (t=2.233, P=0.028). Of all the patients, the mean intra-operative blood loss was (13.7±5.1) ml, and the mean operation time was (56.6±12.1) min. The intra-operative blood loss and operative time were similar in primary excision and secondary excision (both P>0.05). Histopathologically, both fundus and lateral margins of all the samples were negative. Of the 76 samples, cancer tissue developed outside the mucosal layer in 37 samples, infiltrated into the submucosal layer (pT1 stage) in 33 samples, and infiltrated into the muscular layer (pT2 stage) in 6 samples; 57 samples were classified as grade G1 and 19 samples were classified as grade G2, respectively. The operative complication rate was 6.7%(6/90). The mean postoperative hospital stay was (3.0±1.5) d. No recurrence was noted during the follow-up (median 3.9, 0.4 to 10.0 years).</p><p><b>CONCLUSIONS</b>TEM can be the preferred option for complete removal of middle-upper small (<2 cm) rectal NET(G1-2). For rectal NET with incomplete resection by colonoscopic polypectomy, the secondary TEM can still obtain ideal efficacy even though operative difficulty increases.</p>
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Precision medicine is to customize the treatment options for individual patient based on the personal genome information. Colorectal cancer (CRC) is one of the most common cancer worldwide. Molecular heterogeneity of CRC, which includes the MSI phenotype, hypermutation phenotype, and their relationship with clinical preferences, is believed to be one of the main factors responsible for the considerable variability in treatment response. The development of powerful next-generation sequencing (NGS) technologies allows us to further understand the biological behavior of colorectal cancer, and to analyze the prognosis and chemotherapeutic drug reactions by molecular diagnostic techniques, which can guide the clinical treatment. This paper will introduce the new findings in this field. Meanwhile we integrate the new progress of key pathways including EGFR, RAS, PI3K/AKT and VEGF, and the experience in selective patients through associated molecular diagnostic screening who gain better efficacy after target therapy. The technique for detecting circulating tumor DNA (ctDNA) is introduced here as well, which can identify patients with high risk for recurrence, and demonstrate the risk of chemotherapy resistance. Mechanism of tumor drug resistance may be revealed by dynamic observation of gene alteration during treatment.
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Humans , Colorectal Neoplasms , Drug Resistance, Neoplasm , Molecular Diagnostic Techniques , Mutation , Patient Selection , Phenotype , Phosphatidylinositol 3-Kinases , Precision Medicine , Prognosis , RecurrenceABSTRACT
In recent years, the laparoscopic anterior rectal cancer resection is increasingly applied in clinical practice, however, laparoscopic operations and stapling techniques can bring a series of related complications. The anastomotic bleeding is one of the early complications in laparoscopic anterior rectal cancer resections. If the continuous anastomotic bleeding is not diagnosed or managed in time, it could lead to serious consequences, such as secondary surgery and shock. Therefore, the diagnosis and treatment of anastomotic bleeding is meaningful. This paper investigates the reasons of anastomotic bleeding after laparoscopic anterior resection of rectal cancer, and introduces related preventions and treatments. Conservative treatment can be used first for small or delayed bleeding. As for acute bleeding from low anastomosis, transanal suture hemostasis can be considered. When the bleeding comes from high anastomosis and is massive and active, laparoscopic or open surgery must be performed immediately.
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Humans , Anastomotic Leak , General Surgery , Digestive System Surgical Procedures , Hemorrhage , Laparoscopy , Rectal Neoplasms , General SurgeryABSTRACT
Gastrointestinal neuroendocrine tumors are a group of highly heterogeneous tumors. Their incidences have increased in the Western countries as well as in Asia for years. In recent years, predominant progression has been made in the basic and translational studies on gastrointestinal neuroendocrine tumors. Gastric neuroendocrine neoplasmas are classified as four types: type I( occurs on the basis of autoimmune atrophic gastritis, type II( clinically manifests as multiple endocrine tumor type I( and Zollinger-Ellison syndrome, type III( is sporadic neuroendocrine neoplasmas, and type IIII( is neuroendocrine carcinoma. According to the location of primary tumor, intestinal neuroendocrine neoplasmas are classified as small intestine neuroendocrine neoplasmas and colorectal neuroendocrine neoplasmas. The latest finding shows that familial type I( gastric neuroendocrine neoplasmas exists homozygous missense mutation (c.2107C>T) of ATP4A gene. A number of researches focus on small intestine neuroendocrine neoplasmas recently. The chromosome instability, whole genome low methylation and abnormal expression of microRNA can be found in small intestine neuroendocrine neoplasmas. Part of them presents heterozygous mutations and loss of heterozygosity of CDKN1B gene. A recent study showed the heterozygous mutations of IPMK gene (c.990-993del) in familial small intestinal neuroendocrine neoplasmas. PROX1 and Annexin A1 may be involved in the malignant progression of rectal neuroendocrine neoplasmas via the Wnt pathway. The molecular mechanism of gastrointestinal neuroendocrine carcinoma is significantly different from gastrointestinal neuroendocrine tumors. The expression of mTOR, thymidylate synthase and PD-L1 protein, and gene mutation of BRAF V600E and KRAS have been exclusively found in gastrointestinal neuroendocrine carcinoma. The expression of thymidylate synthase, p27, p16, Gα15, PROX1 and Annexin A1 in gastrointestinal neuroendocrine neoplasmas is associated with the prognosis of these patients. Neurokinin A is a specific peripheral blood tumor biomarker for the prognosis and response to the treatment of patients with small intestinal neuroendocrine neoplasmas. INSL5 can be used as a unique biomarker for rectal neuroendocrine neoplasmas.
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Humans , Biomarkers, Tumor , Carcinoma, Neuroendocrine , Gastrointestinal Neoplasms , Intestine, Small , Mutation , Neuroendocrine Tumors , Prognosis , Translational Research, BiomedicalABSTRACT
<p><b>OBJECTIVE</b>To investigate the expression of metastasis-associated colon cancer 1 (MACC1) protein in colorectal cancer and its clinical significance.</p><p><b>METHODS</b>Immunohistochemistry method was used to determine the expression of MACC1 protein in colorectal cancer and normal colorectal mucosal tissues (>5 cm distance to cancer tissue). Statistic analysis was performed to investigate the association between clinicopathologic features and MACC1 expression.</p><p><b>RESULTS</b>The positive rate of MACC1 protein in colorectal cancer tissues was significantly higher than that in normal tissues [75%(72/96) vs. 14.6%(14/96), P<0.01, χ(2)=68.43]. Expression of MACC1 protein was associated with TNM staging (P<0.01, χ(2)=16.82) and distant metastasis (P<0.01, χ(2)=10.53), but not with age, gender, tumor size, differentiation degree, invasion depth, and lymph node metastasis(all P>0.05). Positive rate of MACC1 expression increased with the advanced TNM staging. When distant metastasis occurred, high expression of MACC1 protein in cancer tissues was found. During median 13(4 to 21) months of follow-up, 7 patients died, including 6(8.3%, 6/72) with high expression and 1(4.2%, 1/24) with low expression. Distant metastasis occurred in 9 patients, including 7 with high expression and 2 with low expression. Two patients had local relapse, whose MACC1 expressions were both high.</p><p><b>CONCLUSION</b>MACC1 protein is highly expressed in colorectal cancer tissues, which may be associated with the invasion and metastasis of colorectal cancer.</p>