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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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Locally advanced rectal cancer has historically been considered as a challenge in colorectal surgery. Preoperative neoadjuvant chemoradiotherapy combined with total mesorectal excision is the current standard mode. However, there are differences between domestic and foreign guidelines for patients with different stages. Neoadjuvant treatment of locally advanced rectal cancer has improved local control and enhanced sphincter preservation but has not improved overall survival. In addition, neoadjuvant therapy also brings related complications and affects the quality of life of patients. Stratified treatment according to accurate staging of rectal MRI is the focus of current clinical research. For low-intermediate risk patients, surgery alone or neoadjuvant chemotherapy combined with selective radiotherapy will hopefully lead to a more personalized treatment of rectal cancer. For high risk patients, total neoadjuvant therapy mode enhances the intensity of neoadjuvant chemotherapy, which may prevent distant failure and benefit overall survival. The role of immunotherapy in neoadjuvant treatment of rectal cancer has achieved exciting short-term results, while the long-term efficacy needs to be further confirmed. This article will describe the revelant strategies for optimizing the neoadjuvant treatment mode of rectal cancer based on the existing evidence.
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Some patients with rectal cancer can achieve clinical complete response (cCR) after neoadjuvant chemoradiotherapy. The watch and wait strategy for cCR patients can achieve similar curative effects as radical surgery, avoid surgical complications, and significantly improve the quality of life of patients, which is attracting increasing attention. Although the existing research results support that the watch and wait strategy is safe and feasible, there is still a lack of high-level evidence-based medicine evidence. There are still many issues in the implementation of the watch and wait strategy that need to be further clarified, including long-term oncology efficacy, cCR diagnosis and evaluation criteria, appropriate patient selection, follow-up strategies during the observation period, and treatment methods for local tumor regeneration. This article will explain the above problems based on the results of the existing literature and the clinical experience of our center.
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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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Objective@#The aim of the current study is to compare the short-term clinical outcomes between Billroth-I reconstruction using an overlap method and delta-shaped anastomosis in totally laparoscopic distal gastrectomy (TLDG).@*Method@#A retrospective cohort study was performed. The following inclusion criteria were applied: (1) Preoperative gastroscopy and CT confirmed that the tumor is located in the antrum of the stomach, and the biopsy suggested adenocarcinoma; (2) Chest, abdomen and pelvis enhanced CT showed no evidence of distant metastasis; (3) Preoperative gastric reconstruction CT or endoscopic ultrasonography suggested that the clinical stage of the tumor is stage I-III. (4) During the operation, the tumor position was confirmed to be located in the antrum of the stomach by nanocarbon injection or gastroscope; (5) Complete laparoscopic radical gastrectomy for distal gastrectomy, and the gastrointestinal reconstruction was performed by delta-shaped anastomosis or overlap anastomosis. And the following exclusion criteria were applied: (1) History of gastric surgery; (2) Patients who cannot tolerate laparoscopic surgery because of comorbidities. Finally, data on 43 consecutive patients who underwent TLDG with Billroth-I reconstruction between January 2016 and November 2018 in Peking Union Medical College Hospital were retrospectively reviewed. Patients were divided into those who underwent Billroth-I reconstruction using an overlap method (n=20) or using delta-shaped anastomosis (n=23). The demographic and clinical characteristics and perioperative data of the two groups were analyzed. Measurement data that conformed to the normal distribution were expressed as the mean ± s, and differences between groups were compared using Student′s t-test; comparisons between the counting data groups were performed using the χ2 test or the continuously corrected χ2 test.@*Results@#The demographic and clinical characteristics were similar between the delta-shaped group and the overlap group (P>0.05). There was no significant difference between groups regarding operation time [(185.9±22.8) minutes vs. (184.0±25.8) minutes, t=0.260, P=0.796], blood loss [(50.9±36.0) ml vs. (47.0±30.8) ml, t=0.375, P=0.709], number of stapler reloads used for anastomosis (5.1±0.3 vs. 5.2±0.6, t=-0.465, P=0.651), time to flatus [(3.3±0.9) days vs. (3.6±0.9) days, t=-1.067, P=0.292) and postoperative hospitalization [(8.8±3.1) days vs. (10.4±3.8) days,t=-1.494, P=0.143]. As for the delta-shaped group and the overlap group, the anastomotic leakage rate was 4.3% (1/23) and 0 (χ2=0.000, P=1.000), respectively. The incidence of anastomotic bleeding was 4.3% (1/23) and 5.0% (1/20) (χ2=0.000, P=1.000), while the incidence of intra-abdominal hemorrhage was 4.3% (1/23) and 0 (χ2=0.000, P=1.000). The incidence of gastric emptying disorders was 4.3% (1/23) and 30.0% (6/20), respectively (χ2=3.454, P=0.063). All complications were cured after conservative treatment or symptomatic treatment.@*Conclusion@#The overlap method for Billroth-I reconstruction is safe and feasible.
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Objective@#To examine the anatomical relationships of tributaries to superior mesenteric artery and vein in surgical procedures.@*Methods@#A prospectively designed observational trial, registried to Chinese Clinical Trial Registry, ChiCTR 1800014610, was conducted in Department of General Surgery, Peking Union Medical College Hospital from July 2016 to Decmeber 2018 to record the relationships of ileocolic artery and vein, right colic artery and vein, middle colic artery and vein, and combinations to assemble Henle′s trunk, during the laparoscopic operation of radical right colectomy for right colon malignancies. The length of middle colic artery, length of Henle′s trunk, and distance from Henle′s trunk to the inferior margin of pancreatic head to duodenum were measured during operation. A total of 100 patients, 52 male and 48 female, with right colon cancer, who underwent radical right colectomy, were enrolled in present study from July 2016 to December 2018, with age of (61.0±12.3) years (range: 31 to 82 years), and body mass index of (23.3±3.5) kg/m2 (range: 16.0 to 34.2 kg/m2).@*Results@#The ileocolic artery and vein presented as rates of 97.0% (97/100, 95%CI: 91.5% to 99.4%, the same below) and 98.0% (98/100, 93.0% to 99.8%), respectively. The ileocolic vein ran ventrally in 51 of 97 patients (52.6%, 42.7% to 62.5%). The right colic artery, which raised from superior mesenteric artery directly, was found in 42 of 100 patients (42.0%, 32.3% to 51.7%); and the right colic vein drained directly into superior mesenteric vein in 19 of 100 patients (19.0%, 11.3% to 26.7%). The presence of middle colic artery and vein were 95.0% (95/100, 90.7% to 99.3%) and 90.0% (90/100, 84.1% to 95.9%) respectively. The average length of middle colic artery, from its origin to bifurcation into right and left branches, was (2.6±1.6) cm (range: 0.1 to 7.2 cm). All the dissected middle colic vein drained into superior mesenteric vein (87.8% (79/90), 81.0% to 94.6%) and Henle′s trunk (12.2% (11/90), 5.4% to 19.0%). Henle′s trunk was found in 93 of 100 patients (93.0%, 88.0% to 98.0%), with average length of (1.0±0.6) cm (range: 0.1 to 2.4 cm). The distance between Henle′s trunk to the inferior margin of pancreatic head was (2.7±0.7) cm (range: 1.3 to 4.5 cm). More than half of the Henle′s trunk were composed of 3 tributaries (54.8% (53/93), 40.8% to 61.2%). The most frequently discovered tributaries to form Henle′s trunk were right gastroepiploic vein (98.0% (98/100), 93.0% to 99.8%), superior right colic vein (82.0% (82/100), 74.5% to 89.5%), and superior anterior pancreaticoduodenal vein (78.0% (78/100), 69.9% to 86.1%). In present study, the right branch of middle colic vessels was often found to run closely with Henle′s trunk, veins drained from small intestine could be found to run over superior mesenteric artery to converge into superior mesenteric vein. There were 2 incidences, injuries to Henle′s trunk and middle colic vein, happened during the operation, which were overcomed by bipolar coagulation and dividing the vessels.@*Conclusions@#Ileocolic vessels and middle colic vessels could be used as landmarks for laparoscopic surgery based on their constant anatomical existence. In contrast, the chances are rare for the presence of right colic artery or right colic vein. Nearly half of the Henle′s trunk was consisted of right gastroepiploic vein, superior right colic vein and superior anterior pancreaticoduodenal vein. Exceptional cautions should be made for the variations of the Henle′s trunk during the operation.
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Total mesorectal excision (TME) has become the gold standard for mid-low rectal cancer surgery. However, for some patients with obesity and narrow pelvis, there are great challenges in both open and laparoscopic surgery. Transanal total mesorectal excision (taTME) uses a transanal approach, in " bottom-up" direction, which reduces the difficulty of distal mesorectal excision and may improve the quality of the TME specimen. The taTME provides a direct sight of the tumor and the distal resection margin is more precise. However, whether taTME can achieve complete total mesorectal excision, especially for mid-rectal cancer, is still controversial. This study compares the quality and integrity of mesorectum among open surgery, laparoscopic surgery, and taTME surgery according to TME principles and quality evaluation criteria of TME specimen. In conclusion, the integrity of mesorectum of taTME specimens for low-rectal cancer is good. But for the mid-rectal cancer, the integrity of mesorectum of taTME specimens and long-term efficacy are still controversial and need high-level evidence support.
Subject(s)
Humans , Laparoscopy , Mesocolon , Obesity , Rectal Neoplasms , Rectum , General SurgeryABSTRACT
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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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 compare the difference of intra-abdominal infection between intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) in patients undergoing laparoscopic right hemicolectomy within postoperative 30 days.</p><p><b>METHODS</b>Clinical date of right colon cancer patients undergoing laparoscopic right hemicolectomy at the Department of Colorectal Surgery, PUMCH from January 1st, 2013 to October 31st, 2016 were retrospectively analyzed. Patients with stage IV cancers which could not be radically resected, emergency operation and conversion to open surgery were excluded. The intracorporeal anastomosis and extracorporeal anastomosis were compared in the items of operation time, postoperative infection and postoperative hospital stay.</p><p><b>RESULTS</b>A total of 194 patients were enrolled in the study, including 73 patients with IA and 121 patients with EA. No significant differences were found in gender, age, previous operation history, tumor site and T stage of the tumor between two groups (all P>0.05). There were also no significant differences in mean operative time (162.4 minutes vs. 167.7 minutes, P=0.257), time to first flatus (3.3 days vs. 3.4 days, P=0.744), number of harvested lymph nodes (30.3 nodes vs. 33.8 nodes, P=0.071) and postoperative hospital stay (7 days vs. 7 days, P=0.067) between two groups. The incidence of intra-abdominal infection in patients with IA was significantly higher than that in those with EA [13.7%(10/73) vs. 1.7%(2/121), P=0.001], while the differences of the incidence of wound infection [1.4%(1/73) vs. 3.3%(4/121), P=0.652], respiratory infection [1.4%(1/73) vs. 3.3%(4/121), P=0.652] and urinary tract infection [2.7%(2/73) vs. 0.8%(1/121), P=0.558] were not significant.</p><p><b>CONCLUSION</b>Compared with EA, IA may increase the risk of intra-abdominal infection in patients undergoing laparoscopic right hemicolectomy.</p>
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<p><b>OBJECTIVE</b>To investigate the safety and feasibility of the posterior transsphincteric approach for rectovaginal fistulas repair.</p><p><b>METHOD</b>Data of 23 cases of rectovaginal fistulas treated by the transsphincteric approach in the Peking Union Medical College Hospital, from April 1994 to May 2014 were reviewed. The success rate of this surgical procedure and the postoperative complications were analyzed.</p><p><b>RESULTS</b>The procedure of the transsphincteric approach for the repair of rectovaginal fistulas was performed successfully in all 23 cases. Three patients(13%) suffered surgical wound infection, which healed after regular dressing changes. In 19 cases, the fistulas were successfully repaired with an initial healing rate of 82.6%. The surgical repair failed to accomplish initial healing in 3 cases(13%). No complications including rectocutaneous fistula or anal sphincter malfunction occurred in these patients.</p><p><b>CONCLUSION</b>The transsphincteric approach for the repair of rectovaginal fistulas is a safe and feasible procedure with a good success rate.</p>
Subject(s)
Female , Humans , Anal Canal , Rectovaginal Fistula , Wound HealingABSTRACT
<p><b>OBJECTIVES</b>To evaluate the safety and effectiveness of open preperitoneal herniorraphy comparing with traditional Lichtenstein tension-free herniorraphy on the surgical treatment of inguinal hernia.</p><p><b>METHODS</b>The clinical data of 249 patients with inguinal hernia admitted from October 2008 to December 2013 were reviewed retrospectively.Eighty-three patients received preperitoneal herniorraphy (preperitoneal group), there were 76 male and 7 female patients with a mean age of (70 ± 10) years.One hundred and seventy-three patients underwent Lichtenstein procedure (Lichtenstein group), there were 162 male and 11 femal patients with a mean age of (60 ± 16) years. The peri-operative performance, recurrence rate and postoperative morbidities of the patients underwent preperitoneal herniorraphy and traditional Lichtenstein herniorraphy were analyzed.</p><p><b>RESULTS</b>The operation time of the preperitoneal group (60 ± 11) minutes was significantly shorter than the Lichtenstein group (63 ± 8) minutes (t = -2.16, P = 0.032). The preperitoneal group showed significantly earlier out-of-bed activity ((6.2 ± 1.8) hours) than the Lichtenstein group ((15.0 ± 2.8) hours) (t = -13.2, P = 0.000). The visual analogue scale score on 24 hours postoperative was also lower in the preperitoneal group (4.0 ± 0.9) than in the Lichtenstein group (4.6 ± 1.4) (t = -4.11, P = 0.000). The two groups had no significant difference on the cost. There was one incision infection in preperitoneal group (1.20%).Four fat liquefaction (2.31%) and one patch rejection (0.58%) were found in Lichtenstein group. The incidence of complication of the two groups had no significant difference (P > 0.05). All the patients were followed up for 6 to 36 months, and there was no recurrence among all these patients.</p><p><b>CONCLUSIONS</b>There is no significant difference on the safety and effectiveness between preperitoneal herniorraphy and traditional Lichtenstein procedure on inguinal hernia.Open preperitoneal herniorraphy and can be applied for surgical treatment of recurrent or femoral hernia.</p>
Subject(s)
Aged , Female , Humans , Male , Middle Aged , Hernia, Inguinal , General Surgery , Operative Time , Recurrence , Retrospective Studies , Surgical MeshABSTRACT
<p><b>OBJECTIVE</b>The present study assessed the pathological staging features of rectal cancer after neoadjuvant chemoradiotherapy, and its relation to prognosis.</p><p><b>METHODS</b>Pathologic data related to TNM classification were analyzed on the surgical specimens of 135 patients with mid-low rectal cancer after neoadjuvant themoradiotherapy from 2005 to 2012. Tumor invasion, nodal status, local invasive factors (including cancer deposit, radial margin, perivascular or perineural invasion) were investigated with patients' 3-year disease-free survival (DFS).</p><p><b>RESULTS</b>The overall 3-year DFS was 85.2%, with a pathological complete response (pCR) rate of 19.26%. Three out of 29 patients (10.4%) with ypT0 were found to have positive lymph nodes. There was a trend towards decreased survival as the ypT category and ypTNM staging increased (χ(2) = 14.296 and 52.643, P = 0.006 and 0.000). ypT0-T2 in T category and yp0-I in TNM staging showed a favorable survival above 92%, while the patients with ypT3, or ypIIIB had a comparable lower DFS of 70.2% and 46.7%. DFS in patients with negative lymph node were significantly improved than those with positive nodes (93.5% vs. 66.7%, χ(2) = 34.125, P = 0.000). Patients with or without local invasive factor significantly differed in DFS (42.9% vs. 90.1%, χ(2) = 32.666, P = 0.000) . Cox regression analyze showed that the nodal status (RR = 12.312, 95%CI: 2.828-39.258, P = 0.000) and local invasive factors (RR = 5.422, 95%CI: 1.202-8.493, P = 0.020) were independent risk factors to 3-year survival. As the concept of clinical complete response (cCR) is obscure, there were 27.6% of patients with ypT0 had normal mucosa or no evidence of tumor by EUS or MRI tests before surgery.</p><p><b>CONCLUSION</b>Postoperative pathologic staging features were closely associated with patient's prognosis. The increasing of ypT or ypTNM staging was correlated to decreasing of DFS. Nodal status, positive radial margin, perivascular and perineural invasion were independent risk factors to DFS. Since cCR did not correlate and could not predict pCR, the ongoing radical surgery could not be avoided even there was no evidence of tumor existing before operation.</p>
Subject(s)
Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Young Adult , Chemoradiotherapy, Adjuvant , Neoadjuvant Therapy , Neoplasm Staging , Postoperative Period , Prognosis , Rectal Neoplasms , Diagnosis , Mortality , PathologyABSTRACT
<p><b>OBJECTIVE</b>To evaluate the impact of downstaging factors on oncologic outcomes in a cohort of patients with rectal cancer after intensified neoadjuvant chemoradiotherapy.</p><p><b>METHODS</b>Clinical and follow-up data of 135 patients with mid-low rectal cancer receiving intensified neoadjuvant chemoradiotherapy in our hospital from 2005 to 2012 were analyzed retrospectively. Tumor stages before chemoradiotherapy (uTNM) and after surgery (ypTNM) were compared. The therapeutic regimen consisted of 25 fractions of totaled 50 Gy radiation and 2-3 cycles of combination chemotherapy with 5-Fu/capecitabine plus oxaliplatin. Association of 3-year disease-free survival (DFS) with T-stage, N-stage and TNM-stage was examined through the comparison of uTNM and ypTNM.</p><p><b>RESULTS</b>The mean follow-up of 135 patients was 37.1 (12 to 87) months. The 3-year DFS was 85.2%. The 3-year DFS of patients with downstaging of T-stage (n=76) was 90.8%, which was significantly better compared to those without downstaging (n=48, 75.0%, P=0.040). The 3-year DFS of patients with downstaging of N-stage (n=54) was 98.1%, which was n=53, better compared to those without downstaging (significantly 77.4%) and those with progressive disease (n=16, 75.0%) (P=0.009). Multivariate analysis showed downstaging in N-stage was a prognostic factor for DFS (HR=0.793, 95%CI:0.626-1.004, P=0.054).</p><p><b>CONCLUSIONS</b>Patients with pathologic downstaging in T-stage, N-stage and TNM classification after intensified neoadjuvant chemoradiotherapy may improve patient survival. Downstaging in N-stage may be an independent predictor of survival.</p>
Subject(s)
Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Young Adult , Chemoradiotherapy , Follow-Up Studies , Neoadjuvant Therapy , Neoplasm Staging , Prognosis , Rectal Neoplasms , Therapeutics , Retrospective Studies , Treatment OutcomeABSTRACT
Objective To summarize the experience in diagnosis and treatment of intraductal papillary mucinous neoplasm(IPMN) of the pancreas and identify potential preoperative factors predicting invasiveness of intraductal papillary mucinous neoplasm of the pancreas. Methods From September 2003 to July 2010,27 patients underwent pancreatic resection for IPMN. All cases were divided into invasive and noninvasive groups. Preoperative medical records were reviewed retrospectively between the two groups. Results Pathological results revealed 15 cases of invasive IPMN and 12 noninvasive cases. The incidence of obstructive jaundice, tumor size and serum total bilirubin values were significantly different between the two groups. The other factors including sex ratio, age, incidence of abdominal pain or back pain, diarrhea, weight loss, new onset diabetes, serum CEA, CA19-9 values showed no statistical difference. Conclusion Serum total bilirubin≥22.2μmol/L and tumor size≥3 cm could be predicting factors of invasive IPMN.