Clinicopathological features and prognostic analysis of primary duodenal adenocarcinoma / 中华普通外科杂志

Objective:By analyzing the clinical data of patients with primary duodenal adenocarcinoma (PDA), the risk factors affecting the postoperative prognosis of PDA patients were discussed.Methods:The clinical data of 191 patients diagnosed with PDA in Peking University First Hospital from Jan 2009 to Dec 2022 were collected. The survival rate was calculated and the survival curve was plotted by Kaplan-Meier method. Univariate analysis was performed by Log-Rank test, and multivariate analysis was performed by COX proportional hazards regression model to obtain independent risk factors.Results:The median age of onset in patients with PDA is 65 years old, and the most common symptoms are abdominal pain and abdominal distension. Prognostic analysis showed that the survival rates at 1, 3 and 5 years were 73.8%, 44.6%, and 23.0%. The analysis of Cox risk proportional regression model showed that preoperative CA19-9 level, depth of tumor invasion, degree of differentiation, TNM stage, and surgical mode were independent risk factors for the prognosis of PDA (all P<0.01). Conclusion:The overall incidence of PDA is low, but the prognosis is rather poor. Multvariable factors are associated with its prognosis and surgery is still the mainstay for hope of cure.

Diagnosis and surgical treatment of autoimmune pancreatitis / 中华普通外科杂志

Objective:To explore the indications and effect of surgical treatment of autoimmune pancreatitis.Methods:Clinical data of these 15 patients with autoimmune pancreatitis diagnosed and treated at the Department of General Surgery, the First Hospital of Peking University from 2010 to 2021 were retrospectively analyzed.Results:The main clinical symptoms were obstructive jaundice, abdominal pain, distension and weight loss. The diagnosis of AIP was confirmed by EUS-FNA in 6 patients,among them, 4 did not relapse after oral hormone treatment, 2 did not receive relevant treatment, and 1 developed gastric cancer one year later. Under a suspicion of malignancy, 9 patients underwent surgical laparotomy ,and the diagnosis was established by pathology. There was no recurrence after oral hormone therapy in 1 patient who underwent laparotomy and pancreatic biopsy. One out of the 3 patients with choledochojejunostomy relapsed after 3 years. Of the 5 patients who underwent pancreatectomy, 4 had no obvious recurrence, and 1 had recurrence after 3 years.Conclusions:Untypical autoimmune pancreatitis is likely to be misdiagnosed as pancreatic cancer. For patients with suspicious malignancy, operational management and biopsy may benefit.

Clinicopathological characteristics and treatment strategies of undifferentiated carcinoma with osteoclast-like giant cells of pancreas / 中华消化外科杂志

Objective:To investigate the clinicopathological characteristics and treatment strategies of undifferentiated carcinoma with osteoclast-like giant cells of pancreas (UCOGCP).Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 5 patients with UCOGCP who were admitted to Peking University First Hospital from January 2004 to January 2019 were collected. There were 1 male and 4 females, aged from 33 to 71 years, with a median age of 56 years. Patients underwent preoperative laboratory test, imaging and histopatho-logical examinations. Patients with pancreatic head tumors underwent pancreaticoduodenectomy, and those with tumors in the body or tail of pancreas underwent distal pancreatectomy combined with splenectomy. All patients underwent standard lymph node dissection. Postoperative adjuvant therapy was individually decided by a multidisciplinary team. Observation indicators: (1) preopera-tive examination and treatment; (2) postoperative histopathological situations; (3) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect tumor recurrence of patients up to January 2020. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were described as M (range). Count data were described as absolute numbers. Results:(1) Preoperative examination and treatment: of the 5 UCOGCP patients, CA19-9 was elevated as 65.43 U/mL in only 1 patient preoperatively, while the CA19-9 was normal in other 4 patients. Four patients showed a solid cystic mass on preoperative contrast-enhanced computed tomography (CT) scan, and 1 patient showed a delayed peripheral enhancement of the solid tumor with central necrosis. The magnetic resonance imaging (MRI) scan showed hypointense signals on T1, T2 and weighted diffusion sequences in all 5 patients. Three of the 5 patients were resectable according to imaging data, 1 patient had locally advanced tumor, infiltrating the transverse colon, stomach, and partial small intestine, with the portal vein thrombus, and 1 patient had pancreatic head tumor with a liver metastatic lesion of 0.4 cm diameter which was detected on position emission tomography CT and was diagnosed as UCOGCP by endoscopic ultrasound-guided fine-needle aspiration biopsy. All patients underwent radical resection. Of the 3 patients with resectable tumors, 2 patients underwent pancreaticoduo-denectomy and 1 patient underwent distal pancreatectomy combined with splenectomy. One patient with locally advanced tumor in the body and tail of pancreas underwent distal pancreatectomy + transverse colostomy + partial gastrectomy + portal vein thrombectomy, and 1 patient with pancreatic head tumor and liver metastasis underwent pancreatoduodenectomy combined with left lateral hepatectomy. Of the 5 patients, 2 received postoperative adjuvant chemotherapy with single-agent gemcitabine, 1 received albumin-paclitaxel+gemcitabine combination chemotherapy, 1 received S1 as single agent chemotherapy, and 1 did not receive adjuvant chemotherapy. (2) Postoperative histopathological situations: of the 5 patients, 4 cases showed a cystic solid appearance of gross specimens, and 1 case had a solid appearance with central hemorrhagic necrosis. The tumor diameter was 5.2 cm(range, 2.0?14.0 cm). All the 5 patients achieved negative margins. Of the 5 patients, there was 1 case with portal vein invasion, 2 cases with vascular invasion, 3 cases with perineural invasion, and 2 cases with regional lymph node metastasis. One patient may had multiple tumor invasion and metastasis. Four of 5 patients had paraffin specimens available for immuno-histochemical staining. Four patients were positive for both CD68 and vimentin stains, while 3 patients were positive for programmed death ligand-1 (PD-L1), including 2 samples with 5% positive cells and 1 sample with 25% positive cells. Postoperative pathological examination showed a large number of spindle histiocytoid sarcoma cells scattered with osteoclast like giant cells and pleomorphic carcinoma giant cells. The tumor mutation burden in the 4 patients was 3.23 Muts/Mb(range, 2.61?21.77 Muts/Mb). Microsatellite status was stable in 4 patients. The next generation sequencing of 4 patients showed that all patients had KRAS mutation which was the most frequently mutation in pancreatic ductal adenocarcinoma. Of the 4 patients, 1 case had germline pathogenic mutation in TP53, 1case had somatic mutation in TP53, 1 case had somatic mutation in TP53, BLM, CDKN2A, and 1 case had somatic mutation in ARID1A. (3) Follow-up: 5 patients were followed up for 14?173 months, with a median follow-up time of 46 months. During the follow-up, 4 patients achieved disease-free survival and 1 patient had local recurrence at postoperative 11 months.Conclusions:UCOGCP is a rare variant of pancreatic tumor that exhibits a cystic solid mass in imaging examinations. High expression of PD-L1 is common in UCOGCP. The prognosis for UCOGCP is favorable following radical surgery. Patients may benefit from extended radical surgery even if the tumor has locally progression or distant metastasis.

Assessment of rapid on-line evaluation of endoscopic ultrasound-guided fine needle aspiration for pancreatic masses (with video) / 中华消化内镜杂志

Objective:To assess rapid on-line evaluation (ROLE) of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for pancreatic masses.Methods:Data of patients with solid pancreatic masses who underwent EUS-FNA in Peking University First Hospital from October 2017 to October 2019 were retrospectively analyzed. Patients were divided into the ROLE group and the control group. The number of FNA passes in ROLE group was decided by the cytopathologist based on the number of pancreatic tissue cells or heteromorphic cells obtained, while that in the control group was decided by the endoscopy physician according to the visual observation of tissue strips. The cytological and histological diagnosis of EUS-FNA specimen were made by another cytopathologist. The gold standard for final diagnosis was based on the histological diagnosis of surgically resected specimens. For patients who did not undergo surgical treatment, the final diagnosis was made based on the clinical course, imaging, tumor markers and feedback on treatment. The diagnostic yield, the accuracy, the sensitivity, the specificity, FNA passes, puncture time and adverse events were compared between the two groups.Results:A total of 87 patients were enrolled, 51 in the ROLE group and 36 in the control group. The diagnostic yield of the ROLE group was higher than that of the control group without significant difference [98.0% (50/51) VS 86.1%(31/36), P=0.078]. The number of FNA passes in the ROLE group was significantly less than that in the control group (median 2 VS 3, P<0.001). No significant difference in mean FNA puncture time was found between the ROLE group and the control group (19.4 min VS 18.5 min, P=0.089). There were no significant differences between the two groups with regard to the diagnostic yield, the sensitivity, the specificity, the positive predictive value, the negative predictive value or the incidence of adverse events. Conclusion:ROLE of EUS-FNA for pancreatic solid tumor may improve tissue acquisition for puncture, reduce the number of FNA passes, and may not significantly increase the procedure time and risk of puncture.

Effectiveness and safety of endoscopic submucosal dissection for Siewert type Ⅱ early esophagogastric junction cancer and precancerous lesion / 中华消化内镜杂志

Objective:To assess the effectiveness and safety of endoscopic submucosal dissection (ESD) in the treatment of early esophagogastric junction (EGJ) cancer and precancerous lesion.Methods:Clinical data of 67 patients with Siewert type Ⅱ early EGJ cancer or precancerous lesion who underwent ESD at Endoscopy Center of Peking University First Hospital from July 2012 to June 2019 were retrospectively analyzed. Clinical and pathological features, technical data and complication rate were reviewed. The factors that may affect the curative resection were analyzed.Results:Among the 67 cases, 5 were protruding type, 59 flat type, and 3 depressed type. The median lesion diameter was 1.6 ( QR: 1.8) cm, the median operation time was 60.0 ( QR: 56.0) min. The en bloc resection rate was 97.0% (65/67), the complete resection rate was 91.0% (61/67), and the curative resection rate was 82.1% (55/67). Factors related to non-curative resection were tumor size ( OR=8.457, 95% CI: 1.227-58.302, P=0.030) and pathological type ( OR=15.133, 95% CI: 1.518-150.870, P=0.021). ESD-related complications occurred in 3 cases (4.5%), including 1 case of delayed hemorrhage who received endoscopic hemostasis therapy, and 2 cases of post-operative cicatricial stricture who then received endoscopic dilation. Fifty-eight patients were followed up, and recurrence was found in 1 patient during follow-up with positive vertical margin who refused subsequent therapy.Metachronous early gastric cancer was found in another patient during follow-up, who was treated with a second ESD. Conclusion:ESD is a safe, effective and less invasive technique for early EGJ cancer and precancerous lesion. Tumor size, boundary and infiltration depth of the lesion should be accurately evaluated before operation to formulate appropriate treatment strategies.

Application of rubber band and clip facilitated endoscopic submucosal dissection for colorectal neoplasms (with video) / 中华消化内镜杂志

Objective:To evaluate the safety and efficacy of rubber band and clip facilitated endoscopic submucosal dissection (RAC-ESD) for colorectal neoplasms.Methods:A retrospective cohort study was performed. Clinical data of 115 patients with colorectal neoplasm receiving ESD from September 2018 to August 2019 were retrospectively analyzed. Thirty-four patients received RAC-ESD treatment (RAC-ESD group) and 81 received conventional ESD treatment (conventional ESD group). The procedure time, the dissected area per minute during ESD, en bloc resection rate, complete resection rate, curative resection rate, complication occurence and recurrence rate were compared between the two groups.Results:The median specimen area of RAC-ESD group was 6.32 (7.53) cm 2, and the median procedure time was 40.0 (55.0) min. The mean dissected area per minute was 0.14 (0.20) cm 2/min. While in conventional ESD group, the median specimen area was 4.71 (5.02) cm 2, the median procedure time was 50.0 (50.0) min and the mean dissected area per minute was 0.09 (0.07) cm 2/min. The median specimen area of RAC-ESD group was slightly larger and the median procedure time was slightly shorter than those of conventional ESD group, but neither was significantly different(both P>0.05). The median dissected area per minute of RAC-ESD group was significantly larger than that of the conventional ESD group ( P=0.008). The en bloc resection rate, complete resection rate and curative resection rate of RAC-ESD group were 100.0% (34/34), 100.0% (34/34) and 97.1% (33/34), while those of the conventional ESD group were 100.0%(81/81), 96.3%(78/81) and 91.4%(74/81), respectively. There was no ESD-related complication in either group. After 10.0±5.5 months of follow-up, there was no local recurrence in both groups. Conclusion:RAC-ESD may increase resection efficacy with safety.

Clinical short-term and long-term efficacy of endoscopic submucosal dissection in the treatment of early low rectal cancer and precancerous lesions / 中华胃肠外科杂志

Objective@#To evaluate the short-term and long-term efficacy of endoscopic submucosal dissection (ESD) in the treatment of early low rectal cancer and precancerous lesions.@*Methods@#Inclusion criteria: (1) Distance from the lower margin of tumor to the anal was ≤ 5 cm. (2) Early low rectal cancers were any size rectal epithelial tumors with infiltration depth limited to the mucosa and submucosa, which were diagnosed by postoperative pathology as high-grade intraepithelial neoplasia or adenocarcinoma of the rectum with infiltration depth of intramucosal or submucosal cancer (M or SM stage). (3) Precancerous lesions included adenoma and low-grade intraepithelial neoplasia of the rectum. (4) Patients received ESD treatment. Patients with tumor invasion depth over submucosa by pathology were excluded. From January 2008 to January 2018, 63 patients meeting the above criteria in Peking University First Hospital were enrolled in this descriptive cohort study. The disease characteristics, clinical manifestations, pathological types, treatment time, hospitalization time, en bloc resection rate (resection of the whole lesion), complete resection rate (both the horizontal and vertical incision margins were negative), postoperative complications and follow-up results were analyzed. Cummulative survival rate was calculated by Kaplan-Meier.@*Results@#The diameter of the lesion was (29.0±23.4) mm and the distance from the lesion to the anus was (2.7±1.8) cm. The median operation time was 45.0 (range, 10.0 to 360.0) minutes, the median hospitalization time was 3.0 (range, 2.0 to 12.0) days, en bloc resection rate was 100%, complete resection rate was 96.8% (61/63), and 1 case (1.6%) had postoperative bleeding. The follow-up rate was 87.3% (55/63) and the median follow-up time was 57.9 (range, 15.6 to 121.1) months. No local recurrence was found during the follow-up period and the 5-year survival rate was 100%.@*Conclusion@#Short- and long-term efficacy of ESD are quite good in the treatment of patients with early low rectal cancer and precancerous lesions.

Clinical pathologic characteristics of extranodal follicular dendritic cell sarcoma / 中华肿瘤杂志

Objective@#To investigate the clinical pathologic characteristics of extranodal follicular dendritic cell sarcoma (FDCS).@*Methods@#We collected 7 cases of extranodal FDCS, HE staining, immunohistochemical study were performed. The V600E mutation of BRAF in 7 cases were detected by real-time PCR and EBER in situ hybridization was performed on 4 cases.@*Results@#Among the 7 cases of FDCS, 5 cases were male and 2 cases were female, the median age was 55 years old, including 4 cases of low-grade FDCS and 3 cases of high-grade FDCS. The tumor location of 2 cases was in mediastinum, the tumor locations of others were in nasopharynx, kidney, lung, rectum and liver, respectively. The results of immunohistochemistry showed that, the tumor cells were diffusely or focally positive for CD21, CD23, CD35, D2-40, EGFR and CXCL13, but negative for S-100, CD68, HMB45, SMA, Desmin, CD117, Dog-1, CD34, CD30, EMA and CK.Five cases were positive for PD-L1 and the its expression in high-grade FDCS were higher than that in low-grade FDCS.Two cases of low-grade FDCS were positive for BRAF V600E, but the BRAF V600E mutation weren′t detected in all of 7 cases. The result of EBER in-situ hybridization showed that only the nasopharynx FDCS was positive.The follow-up information of 5 patients were available (7~43 months), 4 patients died and 1 still alive with rectum metastasis.@*Conclusions@#FDCS is a rare malignant disease with relapse and metastatic tendency. The combined applications of the first-line antibodies including CD21, CD23, CD35 and second-line antibodies including D2-40, CXCL13, EGFR are helpful for its diagnosis and differential diagnosis. The high expression of PD-L1 implicates the potential benefit of FDCS patients acquired from immunotherapy.

Preoperative evaluation using multi-slice spiral CT angiography of right-side colon vascular in laparoscopic radical operation for right colon cancer / 中华外科杂志

Objectives@#To examine the value of multi-slice spiral CT angiography (MSCTA) in the analysis of anatomical variation and structural classification of right colon vessels.@*Methods@#From August 2015 to August 2017, 198 patients (96 of whom underwent laparoscopic radical resection of right colon cancer) at Department of General surgery of Peking University First Hospital were retrospectively collected, and the results of abdominal enhanced CT scan were collected and three-dimensional reconstruction of blood vessels was performed. There were 104 males and 94 females. The age was 64(27) years (M(QR), range: 19 to 87 years). Right gastroepiploic vein, anterior superior pancreaticoduodenal vein, right colonic vein (RCV), superior right colonic vein, ileocolon artery or vein (ICA or ICV), middle colon artery or vein (MCA or MCV) and Henle trunk were observed and recorded respectively. The anatomical relationship between the positions of blood vessels, the length of Henle trunk and surgical trunk were measured.@*Results@#ICV and ICA were the most constant anatomic structures. The ICV/ICA of all patients came directly from SMV/SMA, 36.9% (73/198) ICV going in front of SMV and 63.1% (125/198) behind SMV. 72.2% (143/198) of the patients had RCV imported into Henle trunk and the rest into SMV. Middle colonic vein (MCV) could be observed in 81.3% (161/198) of the cases. 81.4% (131/161) of MCV were imported into SMV, 16.8% (27/161) into Henle trunk, 1.2% (2/161) into the first jejunal vein and 0.6% (1/161) into the splenic vein. Henle trunk was divided into 4 types, among which the occurrence probability of gastric node and pancreatic trunk was the highest. The dry length of Henle trunk was (0.82±0.39) cm (range: 0.37 to 1.68 cm). The length of surgical trunk was (2.54±0.83) cm (range: 1.57 to 3.95 cm). Accuracy of MSCTA results was 96.9%(93/96).@*Conclusions@#Anatomical variation of blood vessels in the right colon is common. Abdominal CT angiography can accurately determine the anatomical structure of the blood vessels in the right colon.

Efficacy analysis of neoadjuvant chemoradiotherapy combined with total pelvic exenteration in the treatment of primary T4b rectal cancer / 中华胃肠外科杂志

OBJECTIVE@#To investigate the value of neoadjuvant chemoradiotherapy (nCRT) combined with total pelvic exenteration (TPE) in the treatment of primary T4b rectal cancer.@*METHODS@#A retrospective cohort study was conducted to analyze the clinicopathological data of 31 patients with primary T4b rectal cancer who underwent TPE from January 2008 to December 2015 at Peking University First Hospital.@*INCLUSION CRITERIA@#preoperative clinical stage (cTNM) was defined as cT4b primary rectal cancer with only front wall Invasion; the lower edge of tumor was within 10 cm from the anal margin; TPE was performed; R0 resection was confirmed by pathology. Patients with recurrent rectal cancer, distant metastasis, and undergoing TPE for non-rectal tumors were excluded. Patients were divided into nCRT group and non-nCRT group according to whether receiving nCRT before surgery. The nCRT group received long course radiotherapy (total dose 50 Gy in 25 daily fractions) with concomitant chemotherapy (Capecitabine), and the surgery was performed 6-8 weeks after the neoadjuvant chemoradiation, while the non-nCRT group received surgery directly. The intraoperative, postoperative and pathological conditions and local recurrence were compared between the two groups. The survival curves were drawn by Kaplan-Meier method and the survival of two groups were compared.@*RESULTS@#A total of 31 patients were enrolled, including 13 patients in the nCRT group and 18 patients in the non-nCRT group. The baseline data, such as age, duration of disease, preoperative basic disease, body mass index, smoking rate, and tumor distance from the anal margin, were not significantly different between the two groups (all P>0.05). In the nCRT group and non-nCRT group respectively, the ratio of anal preservation was 30.8%(4/13) and 38.9%(7/18) (P=0.468), the median intraoperative blood loss was 1 000 ml and 800 ml (P=0.644), the operation time was (531.7±137.2) minutes and (498.0±90.1) minutes (P=0.703), the median hospital stay was 18 days and 14 days (P=0.400), the morbidity of complications within 30 days after surgery was 23.1%(3/13) and 38.9%(7/18)(P=0.452), the incidence of postoperative abdominal abscess was 15.4%(2/13) and 0 (P=0.168), the proportion of secondary surgery was 7.7%(1/13) and 11.1%(2/18)(P=1.000), whose differences were not significantly different. The proportion of postoperative pathological pT4b in whole group was 58.1%(18/31), including 53.8%(7/13) in nCRT group and 61.1%(11/18) in non-nCRT group, which was not significantly different between the two groups (P=0.691). The number of harvested lymph node in nCRT group was 13.5±5.9, which was significantly less than 23.0±11.8 in non-nCRT group (P=0.013). There was no pathological complete remission (ypCR) case in nCRT group, and among 13 patients, tumor regression grade (TRG) of 2, 3, 4, and 5 was in 1 case (7.7%), 6 cases (46.2%), 5 cases(38.5%), and 1 case (7.7%), respectively. The median follow-up time was 33 (2 to 115) months, and the follow-up rate was 93.5%(29/31). One case was lost in both the nCRT group and non-nCRT group. The 3-year disease-free survival rate was 43.5% in pooled data, and was 43.6% and 43.3% in nCRT group and non-CRT group respectively without significant difference (P=0.833). The 3-year overall survival rate was 51.1% in pooled data, and was 45.7% and 54.7% in nCRT group and non-nCRT group respectively without significant difference (P=0.653).The local recurrence rate of nCRT and non-nCRT groups was 8.3%(1/12) and 5.9%(1/17) respectively, and the distant metastasis rate was 50.0%(6/12) and 41.2%(7/17) respectively, whose differences were not statistically significant as well (P=1.000 and P=0.865, respectively).@*CONCLUSION@#For primary T4b rectal cancer which can achieve R0 resection through total pelvic exenteration, neoadjuvant chemoradiotherapy has not been demonstrated any advantage in tumor regression, reducing local recurrence, or improving survival, and may increase postoperative complications.

Specimen processing and pathological evaluation of 113 samples of early colorectal cancer and precancerous lesion after endoscopic submucosal dissection / 中华消化内镜杂志

Objective@#To study the pathology and its significance of early colorectal cancer and precancerous lesions treated by endoscopic submucosal dissection (ESD).@*Methods@#A total of consecutive 113 cases were collected at the endoscopy center from August 2012 to June 2016, which were diagnosed as early colorectal cancer and precancerous lesions and undergone ESD. According to Japanese colorectal cancer treatment guidelines, specimens were processed and pathologically evaluated for histological type, tumor diameter, depth of invasion, budding grading, vessel invasion, and horizontal and vertical margin, as well as curative resection.@*Results@#There were 63 cases of adenoma (55.75%), including 29(25.66%) tubular adenoma, 2(1.77%) villous adenoma, and 32(28.32%) villioustublar adenoma. Thirty-four cases of serrated lesion were found, which included 19(16.81%) traditional serrated adenoma, 11(9.73%) sessile serrated adenoma, and 4(3.54%) hyperplasic polyp. There were also 16(14.16%) cases of early colorectal cancer with 7 cases of well-differentiated adenocarcinoma, 7 cases of moderately-differentiated adenocarcinoma, 1 case of poorly-differentiated adenocarcinoma, and 1 case of mucinous adenocarcinoma. Vessel invasion were observed in 2 of 16 cases of early colorectal cancer which were both moderately-differentiated adenocarcinoma in sigmoid colon. The vertical margins were negative in 108(95.58%) of 113 cases. Positive vertical margin were found in only 1 case (moderately-differentiated adenocarcinoma, pT1b2) and another case was suspected as positive. The rest 3 cases could not be precisely diagnosed. The horizontal margins were negative in 80(70.80%) of 113 cases and positive horizontal margin were found in 20(17.7%) cases (19 adenoma and 1 moderately-differentiated adenocarcinoma). Thirteen cases cannot be precisely diagnosed. Histologically, complete resection rate was 82.30%. The complete resection rate of invasive adenocarcinoma was 93.75%. Among 16 cases of invasive adenocarcinoma, 5 cases (curative rate: 31.25%) were judged as curative resection whereas 11 cases were considered as non-curative resection. Seven non-curative resection cases were treated with further surgery and did not relapse after the follow-up.@*Conclusion@#The standardized processing and precise histopathological evaluation are key factors for colorectal ESD technique, which play an important role in the success of endoscopic therapy.

Risk factors of anastomotic leakage after anterior resection for rectal cancer and the diagnostic value of computed tomography signs in anastomotic leakage / 中华胃肠外科杂志

Objective@#To investigate the risk factors and computed tomography (CT) diagnostic accuracy of anastomotic leakage after resection of rectal cancer (Dixon) .@*Methods@#This retrospective study was conducted in Peking University First Hospital from January 2013 to June 2015. A cohort of 452 patients with rectal cancer was enrolled in the study. All the patients underwent anterior resection. The relationship between clinical-pathological data (including sex, age, body mass index (BMI) , presence of diabetes, hypohemoglobin (Hb < 90 g/L) , hypoalbuminemia (Alb < 35 g/L) , the distance from the lower edge of the tumors to the anus, tumor diameter, tumor differentiation, tumor TNM stage, neoadjuvant therapy status, ligation of the left colonic artery (LCA) , preventive colostomy, and anastomotic leakage was analyzed retrospectively. Univariate analysis using χ2 test and multivariate analysis by using the Ordered Classification Arguments Logistic regression model.@*Results@#Of all the cases, 281 and 171 patients were men and women, respectively. The median age was 64 years (range, 18-88 years) . Forty-seven patients (10.4%) were diagnosed with anastomotic leakage, and the median diagnostic time of anastomotic leakage was 6.5 days (range, 3-31 days) . One patient with anastomotic leakage died because of respiratory failure within 1 month postoperatively; 11 patients underwent salvage colostomy performed 2-34 days (median, 7 days) after the first surgery. All the 11 patients underwent colostomy closure within 2 years. The other 35 patients recovered by antibiotic and peritoneal lavage treatment. The mean length of postoperative hospital stay in patients without anastomotic leakage was 8.4±2.4 days, which was significantly shorter than that in patients with anastomotic leakage (34.6±15.7 days) , and the difference was statistically significant (t = 24.127, P = 0.008) . The results of the univariate analysis showed that BMI≥28 kg/m2 (χ2 = 7.550, P = 0.000) , diabetes mellitus (χ2 = 5.055, P = 0.025) , Hb < 90 g/L preoperatively (χ2 = 5.718, P = 0.017) , Alb < 35 g/L preoperatively (χ2 = 8.096, P = 0.004) , distance of < 6 cm from the lower edge of the tumors to the anus (χ2 = 8.205, P = 0.004) and LCA ligation (χ2 = 16.540, P = 0.000) were risk factors for the occurrence of anastomotic leakage. Multivariate analysis showed that BMI≥28 kg/m2 (OR = 1.758, 95%CI: 1.265-2.454, P = 0.021) , distance of < 6 cm from the lower edge of the tumors to the anus (OR=1.530, 95%CI: 1.035-2.117, P = 0.037) , LCA ligation (OR = 1.551, 95%CI: 1.035-2.131, P = 0.042) were independent risk factors for anastomotic leakage. The CT diagnostic sensitivity of anastomotic leakage was 91.2% (31/34) . The false positive rate of CT for diagnosing anastomotic leakage was zero 7 days after the Dixon procedure.@*Conclusion@#Important factors, including BMI of patients, LCA ligation, and the distance from the lower edge of the tumors to the anus are related with anastomotic leakage. The individual treatments should be considered based on the patient′s clinical condition. CT was recommended 7 days postoperatively when anastomotic leakage was highly suspected.

Efficacy comparison between surgical resection and endoscopic submucosal dissection of early gastric cancer in a domestic single center / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the clinical efficacy of endoscopic submucosal dissection (ESD) and surgical resection for early gastric cancer (EGC). Method The retrospective case-control study was conducted. Clinical and pathological data of 246 patients who were diagnosed as early gastric cancer and received ESD or surgery for EGC at Peking University First Hospital from 2010 to 2015 were collected, including 171 males and 75 females with average age of (63.6±10.8) years. Eighty-one patients received ESD according to the following indications: no peritoneal lymph node metastasis in preoperative CT; differentiated mucosal cancer without ulcer findings, irrespective of tumor size; differentiated mucosal cancer with diameter ≤30 mm and ulcer; differentiated minimal submucosal invasive cancer (≤500 μm from the muscularis mucosa) with diameter ≤30 mm and without ulcer; undifferentiated mucosal cancer with diameter ≤20 mm and without ulcer; high grade intraepithelial neoplasia with diameter >20 mm; mucous lesion recurrence after EMR without chance of EMR again. One-hundred and sixty-five cases received surgery according to the findings of peritoneal lymph node metastasis in preoperative CT or the growth of carcinoma beyond the expanding criteria of ESD (surgery group). En block resection rate (removing all the lesion at once) and curative resection rate [standard: negative horizontal and vertical surgical margins; negative vessel carcinoma embolus; pT1a and pT1b (SM1); lesion diameter <3 cm with differentiated type, pT1a with ulcer or pT1b(SM1); lesion diameter <2 cm with undifferentiated type, pT1a without ulcer] were compared between two groups. According to pathological results, including tumor location, macrographic type, size, pathological type, differentiated type, invasive depth, surgical margin, vessel carcinoma embolus and lymph node metastasis, all the patients meeting the ESD curative resection criteria in both groups were subgrouped in order to compare the baseline information, surgical conditions, postoperative complications, recovery, follow-up and survival. The end of follow up was December 2016.</p><p><b>RESULTS</b>The en block resection rate was 93.8%(76/81), while curative resection rate was 91.4% (74/81) in ESD group. The en block resection rate and curative resection rate was both 100% in surgery group. According to the pathological results, 170 cases were confirmed to be in accordance with the curative resection standard, including 74 cases in ESD group and 96 cases in surgery group. Subgroup analysis showed that ESD group had older cases (t=2.939, P=0.004) and more cases with lesion in upper 1/3 of stomach (χ=8.992, P=0.011), while no significant differences in tumor size, invasion depth, degree of differentiation (t=1.875, 2.393, 3.074, all P>0.05) were observed. Compared to surgery group, ESD group had significantly shorter operative time [(76.4±46.3) minutes vs. (271.9±92.6) minutes, t=17.950, P=0.000], shorter fasting period [(3.2±1.4) days vs. (8.8±5.4) days, t=9.801, P=0.000], shorter hospital stay [(9.0±5.8) days vs. (22.1±9.1) days, t=11.471, P=0.000], less costs [(2.6±2.2) ten thousand yuan vs (7.4±3.0) ten thousand yuan, t=12.235, P=0.000] and lower morbidity of early-stage postoperative complication [1.4%(1/74) vs. 20.8%(20/96), χ=14.502, P=0.013]. One-hundred and sixty-two of 170 patients (95.3%) were followed up for median time of 28 months (range, 11 to 84 months). The recurrence rate was 2.7% (2/74) in ESD group and 4.2% (4/96) in surgery group respectively without significant difference(χ=1.787, P=0.409). Five-year overall survival rate was 97.5% and 96.5% respectively without significant difference as well (χ=0.115, P=0.735).</p><p><b>CONCLUSIONS</b>ESD is an effective and safe treatment of early gastric cancer. It can be used as the first protocol for well-differentiated mucosal or SM1 EGC without ulcer as well as undifferentiated mucosal EGC with diameter less than 2 cm.</p>

Comparison and analysis of the efficacy and safety of minimally invasive surgery and craniotomy in the treatment of hypertensive intracerebral hemorrhage

Objective: This study was aimed to compare and analyze the effects and safety of minimally invasive and craniotomy in the treatment of hypertensive intracerebral hemorrhage

Methods: A total of 130 patients with hypertensive intracerebral hemorrhage were recruited. The patients were randomly divided into two groups [research and control group]. Research group was treated with endoscopic minimally invasive surgery, while control group was treated with craniotomy and hematoma clearance. The basic situation, clinical effects, prognosis, nerve function and inflammatory factors of the two groups were compared while the condition of postoperative complications was also observed

Results: The operative time of patients in research group showed statistically significant [P<0.05] difference when compared with control group. Hematoma clearance rate and intraoperative blood loss of research group was significantly better than control group. There was no significant difference [P>0.05] between the two groups in preoperative hemorrhage and edema around the hematoma, however hemorrhage and edema around the hematoma after four weeks of surgery in the research group was significantly [P<0.05] lower than control group. After four weeks of treatment, the BI and SSS score, SP and IL-2 level of the research group were significantly higher than control group [P<0.05], while MRS score, IL-6, hs-CRP, TNF-? and SF was significantly lower than control group [P<0.05]

Conclusion: Compared with craniotomy, minimally invasive surgery is more effective in the treatment of hypertensive intracerebral hemorrhage, as well as it is more conducive to restore neurological function, improve prognosis and reduce serum inflammatory factor levels

Efficacy analysis of endoscopic therapy for early colorectal carcinoma: a retrospective study of 113 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the clinical efficacy of endoscopic therapy for early colorectal cancer.</p><p><b>METHODS</b>Clinical data of 113 early colorectal mucosal carcinoma or submucosal carcinoma receiving endoscopic therapy were retrospectively analyzed and compared with 39 early colorectal cancer cases receiving surgery during the same time.</p><p><b>RESULTS</b>All the cases were well-moderately differentiated adenocarcinoma. Size of tumors in endoscopic group was (26.2±21.5) mm, and that was (30.9±24.3) mm in surgery group (P=0.257). Baseline data between the two groups were not significantly different (all P>0.05). Significantly shorter median operating time [15.0 minutes vs. 203.0 minutes, χ=69.322, P=0.000] and median hospital stay [3.0 days vs. 17.0 days, χ=76.180, P=0.000] were observed in endoscopic group compared with surgery group. The en bloc resection rate, curative resection rate, lymph node metastatic rate and complication rate were not significantly different between two groups (all P>0.05). Ten patients in endoscopic group were referred to additional surgery for deep invasion and/or incomplete resection, of whom 7 received radical surgery, and the other 3 cases without radical surgery did not develop recurrence during follow-up of (20.5±0.9) months. After follow-up for (17.5±15.8) months, the local recurrence rate was 5.3% (6/113) in endoscopic group and 0 (0/39) in surgery group without significant difference (χ=0.983, P=0.321). There was no significant difference in 5-year tumor-free survival rate between two groups (91.8% vs. 97.0%, χ=1.533, P=0.216).</p><p><b>CONCLUSION</b>Endoscopic therapy possesses shorter operating time, shorter hospital stay and similar efficacy as compared to surgery in the treatment of early colorectal cancer.</p>

Clinical analysis of endoscopic submucosal dissection on treatment of colorectal lesions / 中华消化内镜杂志

Objective To assess the efficiency and safety of endoscopic submucosal dissection (ESD)on treatment of colorectal lesions. Methods Clinical data of 163 patients with colorectal lesions, who underwent ESD at Endoscopy Center of Peking University First Hospital from June 2012 to June 2016, were retrospectively analyzed. The clinicopathologic features, the rate of en bloc resection, complete resection,complication and recurrence were reviewed. Results Among the 163 colorectal lesions,118 were mucosal lesions and 45 were submucosal ones. The mucosal lesions included 31 cases of protruding type,22 of flat type and 65 of laterally spreading tumor(LST). The submucosal lesions were all protruding type. The median lesion diameter was 2.2(2.0)cm, median operation time was 42(53)min. En bloc resection rate was 92.6%(151/163),and complete resection rate was 86.5%(141/163). The risk factor related to en bloc resection rate and complete resection rate was tumor size(P<0.05).Complications occurred in 4 cases, including 2 cases of intraoperative bleeding and 1 case of delayed bleeding who received endoscopic hemostasis therapy,and 1 patient with delayed perforation,which was managed by emergency surgery. Four recurrences were observed in 135 cases during follow-up, of which 3 were cured by additional endoscopic treatment,and 1 by surgery. Conclusion ESD is a safe and effective, but less invasive technique for colorectal lesions. Favorable long-term clinical outcomes can be achieved when en bloc curative resection is performed.

Clinicopathological features of small gastrointestinal stromal tumors / 临床与实验病理学杂志

Purpose To assess the clinical and pathological features of small gastrointestinal stromal tumours (sGIST).Methods To reevaluated the clinical,histological and immunohistochemical parameters of 21 sGISTs.The standard immunohistochemical panel antibodies were studied on the tumor sections.All data were compared with clinical sGIST.Results There were a total of 7 females and 14 males of sGISTs.The median age was 63 years old.The tumors were predominantly located in the stomach showing a spindle cell morphology and the tumor sizes ranged from 0.5 cm to 1.5 cm.9 sGISTs combined with malignant tumors,which were gastric cancer have been incidentally detected during surgery.As the lesions were small in size,with infrequent bleeding,necrosis,mucosal invasion,ulceration and less mitotic index,sGISTs reoccurred less compared with clinical sGIST.p53,Ki-67 labeling index and microvascular density (MVD) in sGIST were significantly lower than clinical sGIST (P ＜ 0.05).Conclusion sGIST may occure with digestive tract cancer synchronously.p53,Ki-67 labeling index and MVD were lower than clinical GIST,which means better prognosis.

Clinicopathological screening of Lynch syndrome：a report of 2 cases and literature review / 北京大学学报(医学版)

Lynch syndrome is an autosomal dominant genetic disease characterized by the early onset of colon cancer, endometrial cancer and other tumors caused by a genetic mutation within DNA mismatch repair (MMR) genes.A small subgroup (approximately 3% -5%) of endometrial cancer and colorectal cancer is related to Lynch syndrome .Identification of these patients in clinical practice will be of great benefit to the relatives and patients themselves .We reported two cases, and reviewed the literature and clinical diagnostic guideline.MMR protein was lost in the tumors.Meanwhile the two cases had different clinicopathological characteristics.Together with the literature, our findings may suggest that the MMR protein expression, associated molecular alterations and clinicopathological features and biological behavior of endometrial cancer and colorectal cancer related to Lynch syndrome are different .Thus the algorithm for detection the patients at highest risk is different .To detect the MMR loss by immunohisto-chemistry is a practicalscreening method.

Effects of intermittent hypoxic exposure on the parameter of erythrocyte and serum hypoxia inducible factor-1 alpha and erythropoietin levels / 细胞与分子免疫学杂志

AIM: To investigate the effects of intermittent hypoxic exposure and normoxic convalescence on the parameter of erythrocyte and serum hypoxia inducible factor1 alpha (HIF-1α) and erythropoietin (EPO)levels. METHODS: Rat models of intermittent hypoxic exposure were established, combined with the clinical research on volunteers experiencing the intermittent plateau work. Blood samples for red blood cell (RBC) counts, hemoglobin (Hb) and hematocrit (HCT) were collected, serum HIF-1α and EPO levels were measured using enzymelinked immunosorbentassy. RESULTS: RBC counts, Hb concentration and HCT were significantly higher than the normoxic group (P < 0.05), after exposure of rats to hypoxia from 7 to 28 days. Compared with the normoxic group, serum HIF-1α levels were higher in the group of IH3, 7, 14 days, and EPO had a corresponding increase in the group of IH3, 7 days. Then, a decrease was observed in parameter of erythrocyte and serum HIF-1α and EPO levels after 14 days normoxic convalescence treat. In volunteers studies, RBC counts in 8 monthes group and Hb concentration in 2 years group were significantly higher than the plain group (P < 0.05). The change of HCT was nearly the same as RBC, and HCT in 2 years group was higher than the plain group (P < 0.05). Compared with the plain group, EPO had no significant differences in any of plateau group. CONCLUSION: Intermittent hypoxic exposure can enhance serum hypoxia inducible factor-1 alpha and erythropoietin levels and the generation of red blood cells, which leads to an increase in hemoglobincon concentration and hematocrit. The results have changed with the hypoxic exposure period prolonged. Normoxic convalescence after intermittent hypoxic exposure can make the related indexes reduced, and contribute to the organism recovery.