Patient experience in the implementation of enhanced recovery after surgery strategy after radical gastric cancer surgery / 中华胃肠外科杂志

Objective: To investigate the experience of patients in the implementation of enhanced recovery after surgery (ERAS) strategy after radical gastrectomy and the factors affecting the treatment experience. Methods: A prospective cohort study was carried out. Patients who were diagnosed with gastric cancer by pathology and underwent radical gastrectomy at the Xijing Digestive Disease Hospital from December 2019 to December 2020 were consecutively enrolled. Those who received emergency surgery, residual gastric cancer surgery, preoperative neoadjuvant chemotherapy, non-curative tumor resection, intraperitoneal metastasis, or other malignant tumors were excluded. Patients' expectation and experience during implementation were investigated by questionnaires. The questionnaire included three main parts: patients' expectation for ERAS, patients' experience during the ERAS implementation, and patients' outcomes within 30 days after discharge. The items on the expectation and experience were ranked from 0 to 10 by patients, which indicated to be unsatisfied/unimportant and satisfied/important respectively. According to their attitudes towards the ERAS strategy, patients were divided into the support group and the reject group. Patients' expectation and experience of hospital stay, and the clinical outcomes within 30 days after discharge were compared between the two groups. Categorical data were reported as number with percentage and the quantitative data were reported as mean with standard deviation, or where appropriate, as the median with interquartile range (Q1, Q3). Categorical data were compared using the Chi-squared test or Fisher's exact test, where appropriate. For continuous data, Student's t test or Mann-Whitney U test were used. Complication was classified according to Clavien-Dindo classification. Results: Of the included 112 patients (88 males and 24 females), aged (57.8±10.0) years, 35 patients (31.3%) were in the support group and 77 (68.7%) in the reject group. Anxiety was detected in 56.2% (63/112) of the patients with score >8. The admission education during the ERAS implementation improved the patients' cognitions of the ERAS strategy [M(Q1, Q3) score: 8 (4, 10) vs. 2 (0, 5), Z=-7.130, P<0.001]. The expected hospital stay of patients was longer than the actual stay [7 (7, 10) days vs. 6 (6, 7) days, Z=-4.800, P<0.001]. During the ERAS implementation, patients had low score in early mobilization [3 (1, 6)] and early oral intake [5 (2.25, 8)]. Fifty-eight (51.8%) patients planned the ERAS implementation at home after discharge, while 32.1% (36/112) preferred to stay in hospital until they felt totally recovered. Compared with the reject group, the support group had shorter expected hospital stay [7 (6, 10) days vs. 10 (7, 15) days, Z=-2.607, P=0.009], and higher expected recovery-efficiency score [9 (8, 10) vs. 7(5, 9), Z=-3.078, P=0.002], lower expected less-pain score [8 (6, 10) vs. 6 (5, 9) days, Z=-1.996, P=0.046], expected faster recovery of physical strength score [8 (6, 10) vs. 6 (4, 9), Z=-2.200, P=0.028] and expected less drainage tube score [8 (8, 10) vs. 8 (5, 10), Z=-2.075, P=0.038]. Worrying about complications (49.1%) and self-recognition of not recovery (46.4%) were the major concerns when assessing the experience toward ERAS. During the follow-up, 105 patients received follow-up calls. There were 57.1% (60/105) of patients who experienced a variety of discomforts after discharge, including pain (28.6%), bloating (20.0%), nausea (12.4%), fatigue (7.6%), and fever (2.9%). Within 30 days after discharge, 6.7% (7/105) of patients developed Clavien-Dindo level I and II operation-associated complications, including poor wound healing, intestinal obstruction, intraperitoneal bleeding, and wound infection, all of which were cured by conservative treatment. There were no complications of level III or above in the whole group after surgery. Compared with the support group, more patients in the reject group reported that they had not yet achieved self-expected recovery when discharged [57.1% (44/77) vs. 22.9% (8/35), χ2=11.372, P<0.001], and expected to return to their daily lives [39.0% (30/77) vs. 8.6% (3/35), χ2=10.693, P<0.001], with statistically significant differences (all P<0.05). Only 52.4% (55/105) of patients returned home to continue rehabilitation, and the remaining patients chose to go to other hospitals to continue their hospitalization after discharge, with a median length of stay of 7 (7, 9) days. Compared with the reject group, the support group had a higher proportion of home rehabilitation [59.7% (12/33) vs. 36.4% (43/72), χ2=4.950, P=0.026], and shorter time of self-perceived postoperative full recovery [14 (10, 20) days vs. 15 (14, 20) days, Z=2.100, P=0.036], with statistically significant differences (all P<0.05). Conclusions: Although ERAS has promoted postoperative rehabilitation while ensuring surgical safety, it has not been unanimously recognized by patients. Adequate rehabilitation education, good analgesia, good physical recovery, and early removal of drainage tubes may improve the patient's experience of ERAS.

Questionnaire investigation of radiation rectal injury with anxiety, depression and somatic disorder / 中华胃肠外科杂志

Objective: To observe the incidence and treatment of radiation rectal injury complicated with anxiety, depression and somatic symptom disorder. Methods: A cross-sectional survey research method was carried out. Patients with radiation rectal injury managed by members of the editorial board of Chinese Journal of Gastrointestinal Surgery were the subjects of investigation. The inclusion criteria of the survey subjects: (1) patients suffered from pelvic tumors and received pelvic radiotherapy; (2) colonoscopy showed inflammatory reaction or ulcer in the rectum. Exclusion criteria: (1) patient had a history of psycho-somatic disease before radiotherapy; (2) patient was unable to use a smart phone, unable to read and understand the questions in the questionnaire displayed on the phone; (3) patient refused to sign an informed consent form. According to the SOMA self-rating scale, PHQ-15 self-rating scale, GAD-7 and PHQ-9 self-rating scale, the electronic questionnaire of "Psychological Survey of Radiation Proctitis" was designed. The questionnaire was sent to patients with radiation rectal injury managed by the committee through the WeChat group. Observational indicators: (1) radiation rectal injury symptom assessment: using SOMA self-rating scale, radiation rectal injury symptom classification: mild group (≤3 points), moderate group (4-6 points) and severe group (> 6 points); (2) incidence of anxiety, depression and physical disorder: using GAD-7, PHQ-9 and PHQ-15 self-rating scales respectively for assessment; (3) correlation of radiation rectal injury symptom grading with anxiety, depression, and somatic symptom disorder. Results: Seventy-one qualified questionnaires were collected, of which 41 (56.9%) were from Guangzhou. Among the 71 patients, 6 were males and 65 were females; the mean age was (55.7±9.3) years old and 48 patients (67.6%) were less than 60 years old; the median confirmed duration of radiation rectal injury was 2.0 (1.0, 5.0) years. (1) Evaluation of symptoms of radiation rectal injury: 18 cases of mild (25.4%), 27 cases of moderate (38.0%), and 26 cases of severe (36.6%). (2) Incidence of anxiety, depression and somatic disorder: 12 patients (16.9%) without comorbidities; 59 patients (83.1%) with anxiety, depression, or somatic disorder, of whom 2 patients only had anxiety, 1 patient only had depression, 9 only had somatic disorder, 2 had anxiety plus depression, 4 had anxiety plus somatic disorder, 2 had depression plus somatic disorder, and 40 had all three symptoms. (3) correlation of radiation rectal injury grading with anxiety, depression, and somatic symptom disorder: as compared to patients in mild group and moderate group, those in severe group had higher severity of anxiety and somatic symptom disorder (Z=-2.143, P=0.032; Z=-2.045, P=0.041), while there was no statistically significant difference of depression between mild group and moderate group (Z=-1.176, P=0.240). Pearson correlation analysis revealed that radiation rectal injury symptom score was positively correlated with anxiety (r=0.300, P=0.013), depression (r=0.287, P=0.015) and somatic symptom disorder (r=0.344, P=0.003). Conclusions: The incidence of anxiety, depression, and somatic symptom disorder in patients with radiation rectal injury is extremely high. It is necessary to strengthen the diagnosis and treatment of somatic symptom disorder, so as to alleviate the symptoms of patients with pelvic perineum pain and improve the quality of life.

Totally laparoscopic Billroth II( gastrectomy without intracorporeal hand-sewn sutures / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and feasibility of a novel totally laparoscopic Billroth II gastrectomy.</p><p><b>METHODS</b>Twelve gastric cancer patients underwent totally laparoscopic D2 dissection without intracorporeal hand-sewn sutures in the Xijing Hospital of Fourth Military Medical University between May 2011 and July 2011. In this technique, circular stapling device was used for gastrojejunostomy, and an Endo GIA was used to close the incision at the greater curvature of the stomach. After the completion of the anastomosis, a side-to-side anastomosis (jejunum-afferent loop or jejunum-efferent loop) was performed using an Endo-GIA.</p><p><b>RESULTS</b>No patients required conversion to laparoscopy-assisted or open surgery. The operative time was 196.0±19.3 min, and the blood loss was 169.5±28.8 ml. The number of lymph node harvested was 25.1±3.3. The proximal resection margin and distal resection margin were 8.8±2.4 cm and 6.9±5.5 cm, respectively. The mean time to the first postoperative flatus was 3.1±1.3 days. The length of hospital stay was 4.5±1.9 days.</p><p><b>CONCLUSION</b>This technique is simple and quick. There is no need for laparoscopic hand-sewn suturing. It is safe to perform for totally laparoscopic gastrectomy and reconstruction.</p>

Intracorporeal hand-sewn technique used in totally laparoscopic colectomy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and feasibility of hand-sewn anastomosis in totally laparoscopic colectomy.</p><p><b>METHODS</b>Clinical data of 19 consecutive patients with benign(n=5) or malignant colonic diseases(n=14, 4 ascending colon cancers, 2 transverse colon cancers, and 8 sigmoid colon cancers) treated with totally laparoscopic colectomy with a hand-sewn anastomosis were reviewed. All the procedures were performed by the same surgeon team including totally laparoscopic resection and hand-sewn anastomosis, ileocolic anastomosis after right hemicolectomy, and hand-sewn purse-string sutures in the colon.</p><p><b>RESULTS</b>Hand-sewn anastomosis was performed for 11 patients and circular-stapled anastomosis with hand-sewn purse-string sutures was performed for other 8 patients. The mean hand-sewn anastomosis time was (49.5 ± 29.4) min, and the mean hand-sewn purse-string sutures time was (13.3 ± 5.5) min. No patients required conversion to laparoscopy-assisted or open surgery, and there were no postoperative complications related to anastomosis. One patient with transverse colon lipoma developed mild intra-abdominal infection after surgery and recovered after conservative treatment.</p><p><b>CONCLUSION</b>Totally laparoscopic intracorporeal hand-sewn anastomosis or hand-sewn purse-string sutures for colectomy is feasible and safe when performed by experienced laparoscopic surgeons.</p>

Risk factors for oncologic outcome after surgical treatment in patients with gastric cancer: a multivariable analysis of 1031 patients / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the risk factors for the prognosis in patients with gastric cancer undergoing surgery.</p><p><b>METHODS</b>Clinical data of 1031 cases who underwent gastric cancer resection from January 2003 to December 2007 were studied using univariable analysis and multivariable regression analysis.</p><p><b>RESULTS</b>In 1031 cases,95 (9.2%) cases were early-stage gastric cancer. The other 936 (90.8%) cases were advanced gastric cancer. The tumor was resectable in 980 (95.1%) cases, of which 874 (84.8%) were curative resection,106 (10.3%) were palliative, and 51 (4.9%) were bypass procedures or laparotomy alone. The stage-specific 5-year survival rates were 93.2% (stage IA), 65.1%(stage IB), 52.3% (stage II), 41.4% (stage IIIA), 16.6% (stage IIIB) and 10.6% (stage IV), respectively. The 1-, 3- and 5-year survival rates were 80.2%, 58.0% and 48.2%, respectively. The independent risk factors associated with the prognosis of these patients were tumor size, serum albumin, curative resection, TNM staging and multidisciplinary treatment in both univariable and multivariable analyses.</p><p><b>CONCLUSIONS</b>Early curative resection is the most important treatment for the patients with gastric cancer. Individualized surgical procedure combined with multidisciplinary treatment can improve the outcome. Tumor size, serum albumin level and TNM staging are important predictors of survival in patients with gastric cancer.</p>

Histochemical and ultrastructure study of bile cast in liver transplantation patients / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the histological components and solubility of the bile-cast, and to study the pathological course of bile cast formation.</p><p><b>METHODS</b>HE staining, bilirubin staining (Gmelin reaction), Masson's staining, alcian blue staining and fibrin staining (weigert's) were performed on the formalin-fixed paraffin-embedded section of the bile cast. Ultrastructure was examined under the scanning electron microscope. Solubility test was also conducted using chymotrypsin, heparin, trypsin solution, HCl and NaOH solution to dissolve the bile-cast.</p><p><b>RESULTS</b>The major components of the bile-cast were bilirubin crystals and collagen fibers. Between the mass of collagen fibers there was certain blood vessel structure. Necrosis bile duct structure was not found in the cast. Under the scanning electron microscope, four kinds of crystal morphologies were viewed. There were some mucoid mass and necrosis defluvium epithelial cells in the bile cast. Solubility test showed that the bile cast could be partial dissolved in NaOH solution (pH = 12.5). No dissolution was found in HCl solution (pH = 5.0), chymotrypsin solution, heparin and trypsin solution.</p><p><b>CONCLUSIONS</b>Collagen fibers work as framework in the bile cast with bilirubin crystal filling between the framework. The emergence of fibroblast and blood vessels indicated the formation of bile cast might be the course of exudation and organization due to bile duct epithelium damage. Bile cast could be partially dissolved in alkaline solution, but could not be dissolved in acid solution, or in chymotrypsin, heparin and trypsin solutions.</p>

Significance of glypican-3 mRNA expression in hepatocellular carcinoma tissues and peripheral blood cells / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the expressions of glypican-3 (GPC3) mRNA in hepatocellular carcinoma (HCC) tissues and peripheral blood cells (PBCs), and to determine the values of GPC3 mRNA in the diagnosis of HCC and HCC micrometastasis.</p><p><b>METHODS</b>Using semi-quantitative and nested reverse transcription polymerase chain reactions (RT-PCR), we detected the expressions of AFP and GPC3 genes in the tissues of 41 HCC, 41 paracancer and 52 non-HCC liver samples (41 far from HCC tissues and 11 normal liver tissues), and in the PBCs of 67 specimens from subjects.</p><p><b>RESULTS</b>The semi-quantitative RT-PCR displayed GPC3 mRNA was expressed in all samples of tissues and PBCs, and the relative intensities of its expressions in HCC, paracancer, non-HCC liver tissues were 78.9 +/- 35.5, 30.6 +/- 21.6, 23.8 +/- 15.5 respectively. The AFP mRNA expression values were 61.2 +/- 32.6, 31.5 +/- 23.6, and 21.2 +/- 15.9 respectively. The expression of each gene in HCC differed significantly from those in other two kinds of tissue samples (P < 0.01). The expressions of GPC3 mRNA and AFP mRNA, accounting for 80.5% and 63.4% in all the HCC tissues, were higher than their respective peak values in the tissues of non-HCC liver (+1.96s), but the expressions of at least one of the two genes was elevated in 92.7% of all the HCC tissues. There was a significant difference between combined detection of two genes and single AFP mRNA detection in HCC tissues (P < 0.01). Clinicopathologically, AFP mRNA was related with the grade of HCC and serum AFP, while GPC3 mRNA was related with not only the grade of HCC but also the invasion of HCC. The relative intensities of GPC3 mRNA expressions in PBCs of 67 specimens was 15.9 +/- 9.0, and GPC3 mRNA expressed in three kinds of tissue samples were all stronger than its counterparts in PBCs (P < 0.01). The GPC3 mRNA expression values in PBCs of the HCC group and the non-HCC group were respectively 16.1 +/- 8.3, 15.6 +/- 10.2, there was no significant difference between the two groups. Of the HCC metastasis group and the HCC non-metastasis group, the respective GPC3 mRNA expression values in PBCs were 16.0 +/- 9.0 and 16.3 +/- 7.7, there was also no significant difference between the two groups. The nested RT-PCR showed that the positive rates of AFP mRNA expressions in PBCs from the HCC group and the non-HCC group were 56.1% and 23.1%, and the difference between the two groups was significant (P = 0.011). The positive rates of AFP mRNA expressions in PBCs from the HCC metastasis group and the HCC non-metastasis group were 80.9% and 30.0%, and there was also a significant difference between the two groups (P = 0.002).</p><p><b>CONCLUSIONS</b>Although GPC3 mRNA is expressed broadly, it still may serve as a potential tissue biomarker in the diagnosis of HCC. Detecting the expression of the two genes in the tissues will improve the screening and diagnosis of HCC. GPC3 is prevalently transcribed in the PBCs, but we have not found any relationship between the GPC3 expression in PBCs and the metastasis or recurrence of hepatocellular carcinoma, thus we can not identify HCC micrometastasis with GPC3 mRNA.</p>