Efficacy analysis of Da Vinci robotic assisted and laparoscopic assisted complete mesocolic excision for right hemicolon cancer / 中华消化外科杂志

Objective:To investigate the clinical efficacy of Da Vinci robotic assisted and laparos-copic assisted complete mesocolic excision (CME) for right hemicolon cancer.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopatho-logical data of 119 patients with right hemicolon cancer who were admitted to Daping Hospital, Army Medical University from July 2016 to July 2019 were collected. There were 63 males and 56 females, aged (61±11)years. All the 119 patients underwent CME of right hemicolon. Of 119 patients, 37 cases undergoing Da Vinci robotic assisted CME of right hemicolon were divided into robotic group and 82 cases undergoing laparoscopic assisted CME of right hemicolon were divided into laparoscopic group. Observation indicators: (1) the propensity score matching conditions and comparison of general data between the two groups after propensity score matching; (2)intraoperative and postoperative situations; (3) postoperative pathological examination; (4)follow-up. Follow-up was conducted by outpatient examination or telephone interview to detect tumor metastasis and survival of patients after surgery up to August 2019. The propensity score matching was conducted by 1∶1 matching using the nearest neighbor method. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Count data were represented as absolute numbers, and comparison between groups was conducted using the chi-square test or Fisher exact probability. The Kaplan-Meier method was used to calculate survival rate and the GraphPad Prism 5 software was used to draw survival curve. The Log-rank test was used for survival analysis. Results:(1) The propensity score matching conditions and comparison of general data between the two groups after propensity score matching: 68 of 119 patients had successful matching, including 34 cases in each group. Before propensity score matching, cases undergoing surgery by surgeon A or surgeon B were 32, 5 of the robotic group, versus 49, 33 of the laparoscopic group, showing a significant difference between the two groups ( χ2=8.381, P<0.05). After propensity score matching, the gender (males or females), age, body mass index (BMI), cases with tumor classified as stageⅠ, stage Ⅱ or stage Ⅲ of TNM staging, cases with tumor located at ileocecal region, ascending colon, hepatic flexor of colon or transverse colon, cases undergoing surgery by surgeon A or surgeon B were 17, 17, (62±10)years, (22.4±2.7)kg/m 2, 4, 14, 16, 3, 15, 10, 6, 29, 5 of the robotic group, versus 15, 19, (62±11)years, (22.4±2.8)kg/m 2, 4, 18, 12, 2, 19, 7, 6, 30, 4 of the laparoscopic group, showing no significant difference between the two groups ( χ2=0.236, t=0.127, 0.044, χ2=1.071, 1.200, 0.000, P>0.05). (2) Intraoperative and postoperative situations: after propensity score matching, the operation time, volume of intraoperative blood loss, cases undergoing conversion to open surgery, time to postoperative initial out-of-bed activities, time to postoperative first flatus, time to postoperative initial liquid food intake, duration of postoperative hospital stay and treatment expenses were (235±50)minutes, (73±45)mL, 0, (1.9±0.7)days, (2.9±1.2)days, (3.1±2.4)days, (9.1±4.9)days, (9.6±1.8)×10 4 yuan of the robotic group, versus (183±35)minutes, (74±74)mL, 1, (2.1±0.6)days, (3.3±1.4)days, (3.5±4.2)days, (9.1±3.9)days, (6.3±1.6)×10 4 yuan of the laparoscopic group, respectively. There were significant differences in the operation time and treatment expenses between the two groups ( t=5.050, 8.165, P<0.05) while there was no significant difference in the volume of intraoperative blood loss, time to postoperative initial out-of-bed activities, time to postoperative first flatus, time to postoperative initial liquid food intake or duration of postoperative hospital stay between the two groups ( t=0.118, ?0.462, ?1.129, ?1.291, 0.027, P>0.05). There was no significant difference in the conversion to open surgery between the two groups ( P>0.05). Five patients of the robotic group and 7 patients of the laparoscopic group had postoperative complications. There was no significant difference in the postoperative complications between the two groups ( χ2=0.405, P>0.05). (3) Postoperative pathological examination: after propensity score matching, cases with R 0 resection, the number of lymph node dissected, cases with lymph node metastasis and cases with tumor differentiation as well differentiated adenocarcinoma, moderately differentiated adeno-carcinoma, poorly differentiated adenocarcinoma or mucinous adenocarcinoma were 34, 17±5, 14, 1, 22, 6, 5 of the robotic group, versus 34, 17±5, 12, 2,20, 2, 10 of the laparoscopic group, respectively. There was no significant difference in the R 0 resection between the two groups ( P>0.05) and there was no significant difference in the number of lymph node dissected, lymph node metastasis and tumor differentiation between the two groups ( t=0.488, χ2=0.249, 4.095, P>0.05). (4) Follow-up: after propensity score matching, 68 patients were followed up for 1?36 months, with a median follow-up time of 24 months. The follow-up time was (20±13)months of the robotic group, versus (21±13)months of the laparoscopic group, showing no significant difference between the two groups ( t=0.409, P>0.05). During the follow-up, 3 cases of the robotic group and 4 cases of the laparoscopic group had tumor distant metastasis. The disease-free survival rate and overall survival rate at postoperative 3 years were 83.9% and 86.8% of the robotic group, versus 82.0% and 86.6% of the laparoscopic group, showing no significant difference between the two groups ( χ2=0.188, 0.193, P>0.05). Conclusion:Da Vinci robotic assisted CME for right hemicolon cancer is safe and feasible.

Analysis of factors related to anastomotic leakage after transanal total mesorectal excision / 国际外科学杂志

Objective To investigate the risk factors of anastomotic leakage after transanal total mesorectal excision.Methods Retrospective analysis of clinical data of 46 patients with rectal cancer who underwent TaTME surgery from May 2015 to May 2018 in Daping Hospital,Army Medical University.There were 22 males and 24 females,the median age was 61.2 (range from 40 to 79)years.To observe the correlation between perioperative factors and anastomotic leakage,including preoperative staging,operation time,bleeding volume,anastomotic approach,anastomotic height,intraoperative adverse events,and concurrent diseases.The software of SPSS 20.0 was adopted to analyze the above indicators.Results Among 46 patients with rectal cancer,38 were treated with TaTME combined with laparoscopic surgery,5 with robotic transanal combined with transabdominal surgery,and 3 with pure transanal total mesorectal excision.There were no deaths in the whole group.The incidence of postoperative anastomotic leakage was 13.0％,1 case of grade B and 1 cases of grade A anastomotic leakage,both accounting for 2.2％ and 4 cases of grade C anastomotic leakage,accounting for 8.7％.Anastomotic leak discovery time average (9.8 ± 4.8) d.No anastomotic leakage occurred in 17 cases of ileostomy.Among them,diabetes mellitus,protective ostomy,blood loss ≥ 100 ml,BMI,height of anastomosis and total operation time were significantly correlated with anastomotic leakage.Conclusions In addition to the influence of the learning curve during TaTME surgery,obesity,diabetes,anastomotic height,intraoperative blood loss ≥ 100 ml,and prolonged total operation time are risk factors for anastomotic leakage.Ileal protective ostomy is valuable for reducing anastomotic leakage.

Short-term outcomes of robot-assisted transanal total mesorectal excision / 中华胃肠外科杂志

OBJECTIVE@#To explore the feasibility and safety of Da Vinci robot-assisted transanal total mesorectal excision (taTME).@*METHODS@#From May 2017 to July 2018, six rectal cancer patients underwent Da Vinci robot-assisted taTME at our hospital. The clinical data and short-term follow-up results were retrospectively analyzed.@*SURGICAL PROCEDURE@#The patient was placed in a Trendelenburg lithotomy position and sutured with purse string 1-2 cm from the anus to the distal end of the tumor. A self-made platform for transanal surgery was installed and the robot was connected. The rectum was transected circumferentially 0.5 cm from the distal end of the purse. The robot entered the " holy plane" and separated upward between the visceral parietal fasciae to the level of the third sacrum posteriorly and the peritoneal refcection anteriorly. The abdominal trocar was repositioned and connected to the robot. Through the abdominal cavity, the Toldt space of the posterior sigmoid mesentery was entered, and the D3 lymph nodes were dissected proximally. Separation was performed distally to join the perineal approach. Specimen was pulled out from the anus and excised. The cut end of sigmoid colon was anastomosed with the distal rectum or anal canal. Operative status, postoperative pathology and short-term efficacy were analyzed. Mesorectum of specimen was evaluated as complete, near complete and incomplete according to the Nagtegaal criteria. Anastomotic leakage was evaluated according to the criteria developed by the International Rectal Cancer Research Group.@*RESULTS@#All the 6 patients received Da Vinci robot-assisted taTME and sigmoid-anal anastomosis. In the 6 patients, 3 were male and 3 female; mean age was (62.6±2.6) years old; body mass index was (20.5±3.0) kg/m; distance from tumor to anal edge was (39.4±12.0) mm; length of tumor was (33.6±9.2) mm. Four patients received neoadjuvant therapy before surgery. All the patients completed operations successfully without conversion to laparotomy perioperative, severe complications or death. The mean total operative time was (245.8±24.2) minutes; transition interval of two procedures was (21.2±2.6) minutes; time of transanal robotic dissection of mesorectum was (72.3±15.2) minutes; intra-operative blood loss was (86.7±59.9) ml; the height of anastomosis was (16.0±6.1) mm. There were no intra-operative complications including accidental hemorrhage or urethral injury in any patients. The length of the specimens was (177.0±33.3) mm, and the mesorectum was complete in 5 cases, and near complete in 1 case. The mean distal margin was (20.2±3.2) mm, and the proximal, distal and circumferential margins were all negative. Postoperative pathological staging: T0N0 in 1 case, T0N1 in 1 case , T2N0 in 2 cases , T4N1 in 1 case, T3N0 in 1 case. The former 5 cases received clear fluit diet on the first day, and received fluid diet on the second day after operation. The drainage tube was removed 3 to 6 days after operation. The postoperative hospital stay was 5 to 7 days. The sixth case developed grade B anastomotic leakage on the third day after operation and healed by conservative treatment. No postoperative death, and no serious complications such as intra-abdominal hemorrhage, intestinal obstruction were found. All the patients were followed up for 5 to 19 months, and no local recurrence and death were observed.@*CONCLUSION@#The robotic system is safe and feasible for taTME procedure in rectal cancer with good short-term efficacy. However, the long-term outcomes require further observation.

Robotic-assisted transanal total mesorectal excision for lower rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the availability of Da Vinci robotic-assisted transanal total mesorectal excision(taTME) for lower rectal cancer, which have been regarded as challenging situations in rectal cancer surgery.</p><p><b>METHODS</b>The medical records of a patient who underwent robotic-assisted transanal total mesorectal excision, coloanal anastomosis and ileostomy for lower rectal cancer on May 31st 2017 were reported.</p><p><b>RESULTS</b>The case was a sixty-three year-old male patient with a body mass index of 19.1 kg/m. Preoperative examinations showed the tumor size was 4 cm×4 cm×3 cm. With a distance from the anal verge of 4 cm.The tumor was moderately differentiated and staged as cT3N2M0.taTME was performed successfully and the patient recovered quickly without any complications. The histological report showed a complete mesorectal excision with freee distal and circumferential margins.</p><p><b>CONCLUSION</b>Robotic-assisted taTME is available. Robotics may help to overcome technical difficulties.</p>

Enhanced recovery after surgery in the west China: problems, strategy and future / 中华胃肠外科杂志

Enhanced recovery after surgery (ERAS) has been widely used in the world for near 20 years, which should be considered as the milestone of modern medicine advancement, changing the routine perioperative principle, accelerating the recovery speed following operation, minimizing the postoperative pain, and saving the medical resources. Despite the remarkable advance, the quality and application of ERAS in the west China needs further improvement if compared with international level or even some domestic hospitals. The postoperative hospital stay in west China is much longer than the reported 3 to 5 days according to published references. Several suggestions can be help: (1) Based on the published consensus and the successful experiences of ERAS in colorectal surgery, the medical institution should make great effort to extend this technique to change the profound traditional idea in medical staffs and patients. (2) The medical administrations should take the application of ERAS as a key performance index and annual work plan in hospital. (3) Multiple disciplinary team including anesthetist, surgeon, dietitian, and nurses is essential for hospital to promote the quality of ERAS. Undoubtedly, ERAS is going to be the conventional medical care in the western area of China. We may look forward to seeing more researches from western China to update the ERAS consensus.

Clinical analysis of 11 cases undergoing transanal minimal invasive or combined laparoscopy total mesorectal excision for rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the feasibility and safety of transanal minimal invasive or combined laparoscopy total mesorectal excision.</p><p><b>METHODS</b>Clinical data of 11 cases with rectal cancer undergoing transanal total mesorectal excision(taTME) in our hospital between September 2014 and May 2015 were analyzed retrospectively.</p><p><b>RESULTS</b>Among 11 patients, 3 underwent pure-taTME successfully without abdominal incision and ileostomy, whose operation time was 210, 230, 215 min respectively, while other 8 patients underwent laparoscopy-assisted taTME(hybrid-taTME) with operation time ranging from 150 to 290 (median 205) min. No patient was transferred to open operation, while larger tumors of two patients were removed from hypogastric 5 cm incision. Postoperative first day VAS score was 1 to 3(2.0±0.6), the first flatus was 6 to 70(30.2±17.3) h, hospital stay was 4 to 12(7.5±2.5) d, the blood loss was (104±127) ml and the liquid food intake was (28.3±6.3) h. Postoperative complications included 1 case of subcutaneous emphysema, 1 case of anastomotic stoma bleeding, 2 cases of dysuria, which were cured by conservative therapy. One patient developed rectovaginal fistula 20 days after operation and then underwent ileostomy. No relapse of tumor or death during follow-up.</p><p><b>CONCLUSIONS</b>For suitable rectal cancer patients, taTME or hybrid-taTME is feasible.</p>

Current situation of and thoughts on surgery for diabetes mellitus patients with low body mass index / 中华消化外科杂志

The value of surgery in the diabetes mellitus treatment receives much attention in the medical field,however,Chinese metabolic surgeons adopt the surgical experience from surgeries for morbid obesity in western countries.There are many controversies on the operative indication,operation method and postoperative follow-up of surgery for diabetes mellitus with low body mass index (BMI).Our nation has a large number of patients with diabetes mellitus and low BMI,in which uncheckedoperative indication,unstandard operation method and non-systematic follow-up are common problems.It has profound significance to investigate operative indication,operation method and efficacy evaluation for patients with diabetes mellitus and low BMI.

Progress in the surgical management of advanced colorectal cancer / 中华消化外科杂志

Despite the progress in the comprehensive management of colorectal cancer,locally advanced (T3 and T4 stages) and metastatic colorectal cancer is still a challenging problem.Although researches on neoadjuvant therapy and targeted therapy have obtained many encouraging results,many unanswered questions still remain.These include the indication of multivisceral resection for locally advanced colorectal cancer,the optimal management of patients with hepatic and (or) pulmonary metastasis.R0 resection was the first choice for the treatment of metastatic colorectal cancer,but it is only suitable for selected patients.Chemotherapy and targeted therapy are effective in converting some unresectable liver metastasis into resectable disease.This review focuses on recent improvements in the management of locally advanced colorectal cancer,as well as the management of hepatic and (or) pulmonary metastasis.