Chylous ascites has a higher incidence after robotic surgery and is associated with poor recurrence-free survival after rectal cancer surgery / 中华医学杂志(英文版)

BACKGROUND@#Postoperative chylous ascites is an infrequent condition after colorectal surgery and is easily treatable. However, its effect on the long-term oncological prognosis is not well established. This study aimed to investigate the short-term and long-term impact of chylous ascites treated with neoadjuvant therapy followed by rectal cancer surgery and to evaluate the incidence of chylous ascites after different surgical approaches.@*METHODS@#A total of 898 locally advanced rectal cancer patients treated with neoadjuvant chemoradiotherapy followed by surgery between January 2010 and December 2018 were included. The clinicopathological data and outcomes of the patients with chylous ascites were compared with those of the patients without chylous ascites. The primary endpoint was recurrence-free survival (RFS). To balance baseline confounders between groups, propensity score matching (PSM) was performed for each patient with a logistic regression model.@*RESULTS@#Chylous ascites was detected in 3.8% (34/898) of the patients. The incidence of chylous ascites was highest after robotic surgery (6.9%, 6/86), followed by laparoscopic surgery (4.2%, 26/618) and open surgery (1.0%, 2/192, P = 0.021). The patients with chylous ascites had a significantly higher number of lymph nodes harvested (15.6 vs. 12.8, P = 0.009) and a 3-day longer postoperative hospital stay (P = 0.017). The 5-year RFS rate was 64.5% in the chylous ascites group, which was significantly lower than the rate in the no chylous ascites group (79.9%; P = 0.007). The results remained unchanged after PSM was performed. The chylous ascites group showed a nonsignificant trend towards a higher peritoneal metastasis risk (5.9% vs. 1.6%, P = 0.120). Univariate analysis and multivariate analysis confirmed chylous ascites (hazard ratio= 3.038, P < 0.001) as an independent negative prognostic factor for RFS.@*CONCLUSIONS@#Considering the higher incidence of chylous ascites after laparoscopic and robotic surgery and its adverse prognosis, we recommend sufficient coagulation of the lymphatic tissue near the vessel origins, especially during minimally invasive surgery.

Prognostic value of gastroepiploic lymph node metastasis in transverse colon cancer / 中华消化外科杂志

Objective:To investigate the prognostic value of gastroepiploic lymph node (GLN) metastasis in transverse colon cancer.Methods:The propensity score matching and retrospective cohort study was conducted. The clinicopathological data of 371 patients with transverse colon cancer who were admitted to Fujian Medical University Union Hospital from November 2010 to November 2017 were collected. There were 202 males and 169 females, aged from 21 to 92 years, with a median age of 58 years. Patients were performed complete mesocolic excision combined with GLN dissection by one group of surgeons. Of the 371 patients with transverse colon cancer, 15 cases had positive GLN metastasis (GLN+), and 356 cases had negative GLN metastasis (GLN-). Observation indicators: (1) the propensity score matching conditions and comparison of baseline data between GLN- patients and GLN+patients with transverse colon cancer after propensity score matching; (2) follow-up and survival of GLN- patients and GLN+patients with transverse colon cancer; (3) influencing factors for prognosis of patients with transverse colon cancer. Patients were followed up by outpatient examination or telephone interview to detect tumor metastasis and survival. Follow-up was conducted once every 3 months within postoperative 2 years, once every 6 months within postoperative 2-5 years and once a year thereafter up to January 2020. The propensity score matching was conducted by 1∶4 matching using the nearest neighbor method. Measurement data with skewed distribution were described as M (range), and comparison between groups was analyzed using the rank sum test. Count data were represented as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. The Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-rank test was used for survival analysis. Univariate and multivariate analyses were performed using the COX proportional hazard regression model. The variables with P<0.10 in the univariate analysis were included for multivariate analysis. Results:(1) The propensity score matching conditions and comparison of baseline data between GLN- patients and GLN+ patients with transverse colon cancer after propensity score matching: 55 of 371 patients had successful matching, including 44 GLN- patients and 11 GLN+ patients. Before propensity score matching, the age, cases in stage 0 or stage 1 of M staging, preoperative carcinoembryonic antigen were 60 years(range, 24-92 years), 328, 22, 4.1 μg/L(range, 0.2-343.7 μg/L) for GLN- patients, respectively, versus 67 years(range, 21-79 years), 11, 4, 5.0 μg/L(range, 0.7-952.4 μg/L) for GLN+ patients, showing significant differences in the above indicators between the two groups ( Z=-1.440, χ2=9.031, Z=-2.086, P<0.05). After propensity score matching, the above indicators were 58 years(range, 45-67 years), 40, 4, 4.0 μg/L(range, 2.0-10.0 μg/L) for GLN- patients, respectively, versus 67 years(range, 59-71 years), 9, 2, 5.0 μg/L(range, 8.0-19.0 μg/L) for GLN+ patients, showing no significant difference between the two groups ( Z=-1.580, χ2=0.105, Z=-0.821, P>0.05). (2) Follow-up and survival of GLN- patients and GLN+ patients with transverse colon cancer: GLN- patients and GLN+ patients with transverse colon cancer were followed-up for 12-92 months and 1-70 months, with a median time of 53 months and 30 months respectively. Three cases of GLN- patients and 2 cases of GLN+patients had postoperative liver metastasis, respectively, showing no significant difference between the two groups ( χ2 =0.344, P>0.05). One case of GLN- patients and 3 cases of GLN+ patients had heterochronous lung metastasis, respectively, showing a significant difference between the two groups ( χ2 =4.870, P<0.05). The 5-year disease progression-free survival rates were 82.3% and 33.9% for GLN- patients and GLN+ patients, respectively, showing a significant difference between the two groups ( χ2 =13.366, P<0.05). (3) Influencing factors for prognosis of patients with transverse colon cancer: results of univariate analysis showed that pT staging, pN staging, M staging and GLN metastasis were related factors for prognosis of patients with transverse colon cancer ( hazard ratio=1.599, 5.107, 4.511, 6.273, 95% confidence interval as 0.467-5.471, 1.867-13.971, 1.385-14.694, 2.052-19.176, P<0.05). Results of multivariate analysis showed that pN staging, M staging and GLN metastasis were independent influencing factors for prognosis of patients with transverse colon cancer ( hazard ratio=6.399, 6.163, 4.024, 95% confidence interval as 2.028-20.189, 1.666-22.800, 1.177-13.752, P<0.05). Conclusion:For the patients with transverse colon cancer, GLN metastasis is associated with high postoperative heterochronous lung metastasis rate and poor prognosis. GLN metastasis is an independent prognostic factor for patients with transverse colon cancer.

Controversies and prospects of rectum preserving surgery after neoadjuvant therapy for rectal cancer / 中华消化外科杂志

There are three goals of the treatments for rectal cancer, including risk reduction of local recurrence in the pelvic cavity through treatment to the most extent (better down to less than 5%), reduction of acute or chronic complications as soon as possible, and preservation of good sphincter function as well as life quality. As a new concept, rectum preserving surgery following neoadjuvant therapy, remains controversial in its implementation process. There are controversies in the selection criteria, regimens of neoadjuvant therapy, therapy procedures, complications, and evaluation of oncological prognosis and life quality. The authors discuss the above issues in this article based on literatures and our own practical experience, in order to provide references for the promotion of rectum preserving surgery.

Efficacy analysis of radiotherapy combined with surgery for locally advanced rectal mucinous adenocarcinoma: a retrospective study based on data of Surveillance, Epidemiology, and End results population / 中华胃肠外科杂志

OBJECTIVE@#To explore the efficacy of radiotherapy combined with surgery for locally advanced rectal mucinous adenocarcinoma.@*METHODS@#Clinical data of patients with locally advanced rectal mucinous adenocarcinoma (T3-4 and/or N+) diagnosed by postoperative pathology from 1992 to 2013 were retrieved from the US Surveillance, Epidemiology, and End Results (SEER) database. Patients with local excision only, tumor biopsy or combined organ excision and incomplete follow-up information were excluded. All the enrolled patients were divided into three groups according to different treatments, including surgery alone (SA) group, preoperative radiotherapy combined with surgery (RT+S) group and surgery combined with postoperative radiotherapy (S+RT) group. The extracted data included basic data of patients and tumor, treatment status, and follow-up results. The χ² test was used to compare the count data. Kaplan-Meier method was used to draw the survival curve and calculate the survival rate. The survival was analyzed and compared by Log-rank test. The R language 2.8.1 was used to match the patients as 1:1 pairing through the propensity score matching (PSM). The matching variables included gender, age at diagnosis, year at diagnosis, ethnicity, degree of tissue differentiation, TNM stage, depth of invasion, making the baseline data of subgroups comparable. The Cox proportional hazard model was used for multivariate analysis of prognostic factors.@*RESULTS@#A total of 2 149 patients with locally advanced rectal mucinous adenocarcinoma were enrolled in the study, including 1 255 males (58.4%) and 894 females (41.6%). There were 706 patients (32.9%) in the SA group, 772 patients (35.9%) in the RT+S group and 671 patients (31.2%) in the S+RT group. In SA, RT+S and S+RT groups, the median overall survival time was 39, 85, and 74 months respectively; the 5-year overall survival (OS) rate was 38.7%, 56.5%, and 55.2% respectively; the median cancer-specific survival (CSS) time was 86, 127, and 111 months respectively, and the 5-year CSS rate was 53.7%, 62.2% and 60.7% respectively. In comparison among the 3 groups, the 5-year OS rate and CSS rate in the SA group were significantly lower than those in the RT+S group and S+RT group (all P<0.001); the 5-year OS rate and CSS rate between RT+S group and S+RT group were not significantly different (P=0.166 and 0.392,respectively). After the baseline data of subgroups were corrected through PSM, the 5-year OS rate and CSS rate in the SA group (n=375) were significantly lower than those in the RT+S group (n=375)(OS:40.1% vs. 54.5%, P<0.001; CSS:54.3% vs. 63.3%, P=0.023). The 5-year OS rate and CSS rate in the SA group (n=403) were also lower than those in the S+RT group (n=403) (OS:37.4% vs. 54.7%,P<0.001;CSS:51.6% vs. 61.0%,P=0.031). The 5-year OS rate and CSS rate between RT+S group (n=363) and S+RT group (n=363) were not significantly different (OS:51.7% vs. 55.5%, P=0.789; CSS:57.7% vs. 60.5%, P=0.484). Cox multivariate analysis showed that radiotherapy (HR=0.845, 95%CI: 0.790 to 0.903, P=0.001) was an independent prognostic factor for OS of locally advanced rectal mucinous adenocarcinoma; radiotherapy (HR=0.907, 95% CI: 0.835 to 0.985, P=0.021) was also an independent prognostic factor affecting CSS in patients with locally advanced rectal mucinous adenocarcinoma.@*CONCLUSION@#As compared with surgery alone, surgery combined with preoperative or postoperative radiotherapy is beneficial to the long-term survival of patients with locally advanced rectal mucinous adenocarcinoma.

Identification of gene biomarkers to predict responses to neoadjuvant chemoradiotherapy in patients with rectal cancer and pathways enrichment analysis / 中华胃肠外科杂志

Objective@#To screen out the potential gene biomarkers to predict responses to neoadjuvant chemoradiotherapy (CRT) in patients with rectal cancer and to explore the main downstream pathways of resistance.@*Methods@#The gene expression profiles (GSE35452) of locally advanced rectal cancer undergoing neoadjuvant chemoradiotherapy from 46 specimens (24 responders, TRG 0/1, and 22 non-responders, TRG 2/3) were downloaded from the GEO database. The differentially expressed genes were identified to screen out the potential biomarkers by use of the GCBI platform. GO and KEGG pathways enrichment analysis were performed to integrate enrichment results of differentially expressed genes. Signal-signal interaction network was constructed and analyzed to screen out potential main downstream pathways.@*Results@#A total of 1079 differentially expressed genes were screened, including 657 up-regulated and 422 down-regulated ones. Among these genes, REG4 had the maximum fold change value of -6.029 491. In GO term, these differentially expressed genes were mainly enriched in molecule metabolic process, cell cycle, DNA-dependent transcription, signal transduction and apoptotic process. The KEGG pathways enrichment analysis showed that the differentially expressed genes were enriched in 65 KEGG pathways, including metabolic pathways, cell cycle and metabolism pathways. Signal-signal interaction network analysis showed that MAPK signaling pathway and cell cycle pathway might play a determinant role in the development of neoadjuvant chemoradiotherapy resistance. Further analysis showed that CDKN1B, CDKN2A, RBL1, TFDP1, CCND2, CCNE2, CDC6 and CDK6 in cell cycle might induce chemoradiotherapy resistance by blocking G1/S phase cell cycle arrest, decreasing the apoptosis of tumor cells and increasing S phase ratio of chemoradiotherapy resistance.@*Conclusion@#G1/S phase cell cycle arrest blocking plays an important role in the development of chemoradiotherapy resistance in patients with rectal cancer. Moreover, the key genes, such as REG4, may be useful in predicting responses to neoadjuvant chemoradiotherapy.

Anastomotic leakage after rectal cancer surgery: classification and management / 中华胃肠外科杂志

Many studies have focused on the identification of risk factors and prevention of anastomotic leakage following rectal cancer surgery. However, there is little knowledge regarding classification and management of anastomotic leakage in clinic. Herein, we reviewed and summarized the classification and management of anastomotic leakage after rectal cancer surgery. The relevant treatments of anastomotic leakage should be chosen based on patient's manifestation, including general and local reactions, anatomical location, and nature of the leakage (contained or free, controlled or uncontrolled leakage) . 1) Surgery is imperative for anastomotic leakage with acute general peritonitis and sepsis. 2) Circumscribed peritonitis and the pelvic abscess can be managed conservatively with complete drainage. During the conservative management, diverting stoma, minimally invasive techniques of seal or repair should be implemented at an appropriate time, if necessary. 3) Subclinical leakage seldom requires surgical intervention promptly. 4) For persistent anastomotic leakage after diverting stoma, we should consider whether chronic presacral abscess, epithelialized sinus, fistula or local recurrence of cancer is present. With regard to definitive salvage surgery, reconstruction of the coloanal anastomosis or permanent stoma is usually required under these circumstances. 5) Complicated fistula often necessitates surgical repair with advancement tissue flap or tissue interposition under the condition of diversion. Reconstructing the coloanal anastomosis is the alternative management, whereas other treatments are invalid, including ultra-low anterior resection, intersphincteric resection, proctectomy with colon pull-through, and primary or staged coloanal anastomosis. 6) During the surgical repair of recto-vaginal fistula and recto-urinary fistula, colorectal surgeons may require the cooperation of gynecologists, urologists, and orthopedists. 7) For anastomotic leakage with local recurrence of cancer after conservative management, diverting stoma should be performed promptly to facilitate the subsequent chemoradiotherapy. Surgeons should pay more attention to systemic knowledge and understanding of the classification and management of anastomotic leakage following rectal cancer surgery. Accordingly, we can follow the principles of management, individualize the treatments, apply the concepts of damage control and minimally invasive surgery, and enhance the recovery of anastomotic leakage. Prevention remains more important than remedies. To prevent the occurrence of permanent injuries, not only early diagnoses and treatments should be performed, but also the timing of cancer treatments is warranted for anastomotic leakage.

A six-gene model using an artificial neural network to predict regional lymph node metastasis after neo-adjuvant chemoradiotherapy for locally advanced rectal cancer / 中华消化外科杂志

Objective To screen out the potential gene to predict regional lymph node metastasis after neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer (LARC) and develop a 6-gene model using an artificial neural network (ANN).Methods The gene expression profiles (GSE46862) of locally advanced rectal cancer undergoing preoperative chemoradiotherapy from 64 specimens (21 with ypN-and 43 with ypN+) were downloaded from the gene expression omnibus (GEO) database.The differentially expressed genes were identified to screen out the potential biomarkers through the Gene-Cloud of Biotechnology Information (GCBI) platform.The top 6 genes were screened out for building model.An ANN model was trained and validated using the SPSS Modeler software.The study samples were allocated randomly into the training sample group and testing sample group with a 7∶3 ratio.The training samples and testing samples were respectively used for building an ANN model and independent back-substitution test.Observation indicators:(1) screening results of differentially expressed genes;(2) analysis results of ANN model.The receiver operating characteristic (ROC) curve was drawn and the area under the curve (AUC) was calculated to evaluate the predictive abilities of ANN and each biomarker.Results (1) Screening results of differentially expressed genes:A total of 50 genes were screened.Six top genes included IL6,AKR1B1,AREG,SELE,ROBO1 and CD274.(2) Analysis results of ANN model:Six top genes were selected to construct a three-layer ANN model with a 7-5-2 structure.The IL6 made the greatest effect on the ANN model,followed by ROBO1,AKR1B1,AREG,CD274 and SELE.The AUC was 0.929.The sensitivity and specificity of ANN model were 96.7％ and 85.7％,and accuracy of training samples was 93.2％.In the independent back-substitution test,sensitivity and specificity were 92.3％ and 85.7％,and accuracy of testing samples was 90.0％.Conclusion The prediction ANN model based on multiple molecular markers (IL6,ROBO1,AKR1B1,AREG,CD274 and SELE) for regional lymph node metastases in LARC patients after CRT would be beneficial in selecting potential candidates for rectum-preserving surgery following CRT for LARC.

Role of GABAA receptors in sevoflurane-induced inhibition of discharge activities of inspiratory neurons in medullary respiratory center of neonatal rats / 中华麻醉学杂志

Objective To evaluate the role of GABAA receptors in sevoflurane-induced inhibition of the discharge activities of inspiratory neurons in the medullary respiratory center of neonatal rats.Methods The medulla oblongnta slices of neonatal rats (aged 0-4 days) including the medial region of the nucleus retrofacialis with the hypoglossal nerve rootlets retained were prepared.The slices were perfused with artificial cerebrospinal fluid (ACSF),and the activity of the inspiratory neurons in the medial region of the nucleus retrofacialis and the respiratory rhythmical discharge activity of the hypoglossal nerve rootlets were simultaneously recorded using microelectrodes and suction electrodes,respectively.The ACSF,5％ sevoflurane,GABAA receptor blocker bicuculline 10 μmol/L and combination of 5％ sevoflurane and 10 μmol/L bicuculline were added to the perfusion liquid after the discharge activity was stable.The respiratory cycle (RC),inspiratory time (TI),integral amplitude (IA) and changes in peak frequency (PFn) of the inspiratory neurons were recorded.Results Compared with that after giving ACSF,RC was significantly prolonged,TI was shortened,and IA and PFn were decreased after giving sevoflurane,and RC was significantly shortened,IA and PFn were increased (P＜0.05),and no significant change was found in TI after giving bicuculline (P＞ 0.05).Compared with that after giving sevoflurane,RC was significantly shortened,TI was prolonged,and IA and PFn were increased after giving sevoflurane and bicuculline (P＜ 0.05).Conclusion Sevoflurane inhibits the discharge activities of inspiratory neurons through GABAA receptors in the medullary respiratory center of neonatal rats.

Establishment of a prognostic nomogram to predict long-term survival in non-metastatic colorectal cancer patients / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To establish a nomogram to predict long-term survival in non-metastatic colorectal cancer patients.</p><p><b>METHODS</b>A retrospective analysis was conducted in patients with non-metastatic colorectal cancer who underwent radical surgery in the Department of Colorectal Surgery of Affiliated Union Hospital of Fujian Medical University between January 2000 and December 2014. Univariate and multivariate analyses on disease-free survival (DFS) were performed using the Cox proportional regression model. Based on the multivariate analysis results, a prognostic nomogram was formulated to predict the probability for DFS. Concordance index was applied in predictive evaluation of the nomogram and calibration curves were drawn to test the nomogram's prediction and actual observation of the 5-year DFS rate. The predictive ability of nomogram was compared with AJCC-7 staging system.</p><p><b>RESULTS</b>A total of 2 641 patients were identified. The median age was 59.3 years old, and 60.3% of cases were men. The number of patients with TNM stage 0, I(, II( and III( was 96, 505, 923 and 1043, respectively. The most common tumor site was the rectum, accounting for 43.2%. A total of 413 (15.6%) patients underwent neoadjuvant treatment. The most common gross type of tumor was ulcerative type, accounting for 79.5%. The 3- and 5-year DFS rate was 85.8% and 79.8%, respectively. Based on the Cox proportional regression model, the following six factors were independently associated with reduced DFS rate and were selected for the nomogram: older age, higher pathologic T stage, higher pathologic N stage, higher preoperative serum CEA level, infiltrative gross type and perineural invasion. The results of the nomogram showed that the score of T0, T1, T2, T3 and T4 stage was 0, 2.2, 3.9, 4.1 and 6, respectively, and the score of N0, N1 and N2 was 0, 3.8 and 9.3, respectively. For gross type, the score of expanding type, ulcerative type and infiltrative type was 6, 9 and 10, respectively. The score of perineural invasion was 5.2. Higher scores were added to older age and higher CEA level. The total scores were calculated by taking the sum of the points from all predictors. Higher total score was associated with poor DFS. The prognostic nomogram differentiated well and showed a concordance index of 0.718, which was better than AJCC-7 staging system (concordance index=0.683). Also, the calibration of nomogram predictions was good.</p><p><b>CONCLUSIONS</b>A nomogram based on 6 independently prognostic factors to predict long-term survival in non-metastatic colorectal cancer patients is established successfully. The nomogram can be conveniently used to facilitate the accurate individualized prediction of DFS rates in patients with non-metastatic colorectal cancer.</p>

Establishment of nomogram model to predict peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To establish a nomogram model to predict the peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination.</p><p><b>METHODS</b>Clinicopathological data of colon cancer patients without distant metastasis by preoperative imaging examination who underwent surgery in our department between January 2000 and December 2014 were retrospectively analyzed. Predictors of peritoneal carcinomatosis were analyzed by univariate and Logistic multivariate analyses. Base on the independent predictors by multivariable analysis results, a nomogram model was formulated with further use of R software. The total score was calculated by the addition of each predictor score, indicating the corresponding risk of peritoneal metastasis. The score was greater in the nomogram, and the risk was higher in peritoneal implantation metastasis. A receiver operating characteristic(ROC) curve was then constructed to evaluate the predictive abilities of the various preoperative factors and nomogram.</p><p><b>RESULTS</b>A total of 1 417 patients were defined as above and enrolled in the study. The median age was (60.5±13.3) years, 835 cases (58.9%) were male, and 132 cases (9.3%, 132/1417) were diagnosed with synchronous peritoneal carcinomatosis during operation. Univariate analysis showed that peritoneal metastasis was associated with age, incidence of abdominal pain, incidence of mucous bloody stool, CEA level, traversible rate, tumor diameter, ratio of infiltrating type cancer, differentiation, histological type, cT staging and cN staging (all P<0.05). Logistic multivariate analysis revealed that younger age (OR:0.974, 95%CI: 0.958 to 0.990, P=0.001), later clinical T stage (OR: 2.949, 95%CI: 1.588 to 5.476, P=0.001), lesion not traversible(OR: 0.519, 95%CI: 0.314 to 0.858, P=0.011), infiltrative gross type (OR: 1.812, 95%CI: 1.099 to 2.987, P=0.020), larger tumor (OR: 1.044, 95%CI: 0.998 to 1.093, P=0.061), higher preoperative serum CEA level(OR:1.004,95%CI: 1.001 to 1.007, P=0.007) and histopathologic type of mucinous or signet ring cell adenocarcinoma (OR:1.642, 95%CI: 1.009 to 2.673, P=0.046) were independent risk factors. The nomogram model was further established based on above 7 independent risk factors, whose total score was 350 and area under the ROC curve was 0.753(P=0.000).</p><p><b>CONCLUSION</b>The nomogram model can be helpful to screen the colon cancer patients with high risk of peritoneal metastasis and to avoid unnecessary laparotomy for colon cancer patients without distant metastasis by preoperative imaging examination.</p>

Efficacy of ultrasound-guided continuous transverses abdominis plane block when used for postoperative analgesia in patients undergoing total hysterectomy / 中华麻醉学杂志

Objective To evaluate the efficacy of ultrasound-guided continuous transverses abdominis plane (TAP) block when used for postoperative analgesia in the patients undergoing total hysterectomy.Methods Forty American Society of Anesthesiologists physical status Ⅰ or Ⅱ patients,aged 38-64 yr,weighing 50-80 kg,undergoing elective total hysterectomy with general anesthesia,were divided into 2 groups using a random number table:continuous TAP block group (CTAP group,n =21) and patient-controlled intravenous analgesia (PCIA) group (n=19).In group CTAP,bilateral TAP block was performed with 0.2％ ropivacaine 20 ml under ultrasound guidance before operation,and 0.2％ ropivacaine 5 ml/h was infused into bilateral TAPs after extubation.In group PCIA,the patients received PCIA with sufentanil 1 μg/ml after extubation,and the PCIA pump was set up to deliver a 2 ml bolus dose,a 15 min lockout interval and background infusion at a rate of 2 ml/h.Analgesia lasted until 72 h after operation in both groups.When visual analog scale＞4,morphine 5 mg was intramuscularly injected as rescue analgesic.The recovery time of postoperative intestinal function,length of hospital stay,patient's satisfaction with analgesia,requirement for rescue analgesia,TAP block-related adverse reactions and development of postoperative nausea and vomiting were recorded.In group CTAP,blood samples were collected from the peripheral vein immediately after the end of operation and at 2,6,12,24,48 and 72 h after operation for determination of concentrations of ropivacaine in plasma and free ropivacaine in plasma using high-performance liquid chromatography.Results Compared with group PCIA,the requirement for rescue analgesia and incidence of nausea and vomiting were significantly decreased,the recovery time of postoperative intestinal function was shortened,the score for patient's satisfaction with analgesia was increased (P＜0.05),and no significant change was found in the length of hospital stay in group CTAP (P＞0.05).No TAP block-related adverse reactions were found in group CTAP.In group CTAP,the concentration of ropivacaine in plasma began to increase at 2 h after operation and peaked at 48 h after operation,the concentration of free ropivacaine in plasma began to increase at 2 h after operation and peaked at 24 h after operation (P＜0.05).Conclusion Ultrasound-guided continuous TAP block produces good analgesic efficacy when used for the patients undergoing total hysterectomy.

Short-term efficacy comparison of laparoscopic versus open transabdominal intersphincteric resection for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the short-term efficacy of laparoscopic and open transabdominal intersphincteric resection (ISR) for low rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 246 patients with low rectal cancer undergoing transabdominal ISR in our department from January 2005 to January 2015 were retrospectively analyzed. According to gender, age, ASA score, neoadjuvant chemoradiotherapy or not, pathological T stage, pathologic N stage, and tumor differentiation, propensity score matching was performed by R plug-in(version 2.8.1). Finally, 74 cases treated by laparoscopic transabdominal ISR(laparoscopic group) and 74 cases by open transabdominal ISR(open group) were enrolled. Short-term efficacy and anal function were compared between two groups.</p><p><b>RESULTS</b>No perioperative death was found in the two groups. Compared to open group, laparoscopic group had longer operation time [(236±45) minutes vs. (200±46) minutes, P=0.000], less median blood loss [50(10 to 200) ml vs. 100(20 to 400) ml, P=0.000] and shorter hospital stay [(7.8±2.4) days vs. (10.5±6.9) days, P=0.002]. Laparoscopic group and open group had similar morbidity of total complication [17.6%(13/74) vs. 28.4%(21/74), P=0.118]. Incidence of pneumonia was significantly lower in laparoscopic group [4.1%(3/74) vs. 13.5%(10/74), P=0.042), while incidence of anastomotic leakage and stenosis, and complication grading were not significantly different between the two groups (all P>0.05). During a mean follow-up of 52.0 months, anal function analysis was performed in 102 patients with stoma closure and the result showed that the ratio of patients with good continence was 87.1%(54/62) and 87.5%(35/40) in laparoscopic and open group respectively (P=0.066).</p><p><b>CONCLUSION</b>Laparoscopic transabdominal ISR is safe and feasible, which is minimally invasive with fast recovery, and is worth clinical application.</p>

Risk factors and clinical features of delayed anastomotic fistula following sphincter-preserving surgery for rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the risk factors and clinical features of delayed anastomotic fistula (DAF) following sphincter-preserving operation for rectal cancer.</p><p><b>METHODS</b>Clinical data of 1 594 patients with rectal cancer undergoing sphincter-preserving operation in our department from January 2008 to May 2015 based on the prospective database of Dpartment of Colorectal Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. Sixty patients(3.8%) developed anastomotic fistula. Forty-one patients (2.6%) developed early anastomotic fistula (EAF) within 30 days after surgery while 19(1.2%) were DAF that occurred beyond 30 days. Univariate analyses were performed to compare the clinical features between EAF and DAF group.</p><p><b>RESULTS</b>DAF was diagnosed at a median time of 194(30-327) days after anastomosis. As compared to EAF group, DAF group had lower tumor site [(6.1±2.3) cm vs. (7.8±2.8) cm, P=0.023], lower anastomosis site [(3.6±1.8) cm vs. (4.8±1.6) cm, P=0.008], higher ratio of patients receiving neoadjuvant chemoradiotherapy (84.2% vs. 34.1%, P=0.000), and receiving preventive stoma (73.7% vs. 14.6%, P=0.000). According to ISREC grading system for anastomotic fistula, DAF patients were grade A and B, while EAF cases were grade B and C(P=0.000). During the first hospital stay for anastomosis, DAF group did not have abdominal pain, general malaise, drainage abnormalities, peritonitis but 8 cases(42.1%) had fever more than 38centi-degree. In EAF group, 29 patients(70.7%) had abdominal pain and general malaise, and 29(70.7%) had drainage abnormalities. General or circumscribed peritonitis were developed in 25(61.0%) EAF patients, and fever occurred in 39(95.1%) EAF cases. There were 13(68.4%) cases with sinus or fistula formation and 9(47.4%) with rectovaginal fistula in DAF group, in contrast to 5 (12.2%) and 5 (12.2%) in EAF group respectively. In DAF group, 5 (26.3%) patients received follow-up due to stoma (no closure), 5 (26.3%) received bedside surgical drainage, while 9(47.4%) patients underwent operation, including diverting stoma in 3 patients, Hartmann procedure in 1 case, intersphincteric resection, coloanal anastomosis plus ileostomy in 1case because of pelvic fibrosis and stenosis of neorectum after radiotherapy, mucosal advancement flap repair with a cellular matrix interposition in 3 rectovaginal fistula cases, incision of sinus via the anus in 1 case. During a median follow-up of 28 months, 14(73.7%) DAF patients were cured.</p><p><b>CONCLUSIONS</b>It is advisable to be cautious that patients with lower site of tumor and anastomosis, neoadjuvant chemoradiotherapy and preventive stoma are at risk of DAF. DAF is clinically silent and most patients can be cured by effective surgical treatment.</p>

Analysis of risk factors of distant metastasis in rectal cancer patients who received total mesorectal excision following neoadjuvant chemoradiotherapy / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To clarify the natural course and explore impact factors of distant metastasis in rectal cancer patients who received total mesorectal excision(TME) following neoadjuvant chemoradiotherapy (CRT).</p><p><b>METHODS</b>Between Januray 2008 and December 2013, 317 patients with locally advanced rectal cancer who underwent radical surgical resection following neoadjuvant CRT (pre- and postoperative simple fluorouracil or fluorouracil combined with oxaliplatin plus preoperative three dimensional conformal radiotherapy) at Department of Colorectal Surgery in Fujian Medical University Union Hospital were included. Univariate analysis and Cox regression were performed to evaluate the clinicopathological parameters that may be associated with distant metastasis.</p><p><b>RESULTS</b>During a median follow-up of 39 months(range 15 - 89 months), 72 patients(22.7%) had disease recurrence, including local recurrence in 8 patients, and distant metastasis in 67 patients (among whom 3 patients had both). Distant metastasis occurred in 86.5%(58/67) patients during the first three years after surgery. The 3-year cumulative distant metastatic rate in all the patients was 22.4%. The 5-year overall survival rate in distant metastatic patient was significantly lower than that of non-distant metastatic patients following neoadjuvant CRT (36.2% vs. 81.2%, P=0.000). Univariate analysis showed that ypT stage (χ(2)=13.304, P=0.010), ypN stage(χ(2)=23.416, P=0.000), ypTNM stage (χ(2)=31.765, P=0.000) and RCRG(χ(2)=16.246, P=0.000) were associated with distant metastasis. Cox regression revealed that ypTNM stage(HR=1.959, 95% CI:1.171 ~ 3.277, P=0.010) was the only independent risk factor of distant metastasis.</p><p><b>CONCLUSIONS</b>Distant metastasis is the early event during the progression in rectal cancer. ypTNM stage is the only independent risk factor of distant metastasis in locally advanced rectal cancer patients who undergo TME following neoadjuvant CRT.</p>

Influence of anastomotic leakage on long-term survival after resection for rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the influence of anastomotic leakage (AL) on long-term survival after resection for rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 653 rectal cancer cases confirmed by pathology and undergoing R0 resection for rectal cancer in our department from January 2007 to December 2011 were retrospectively analyzed. Anastomotic leakage was found in 40 cases (AL group) and not in the other 613 cases (non-AL group). After median 47 (1-91) months of follow-up, 5-year disease-free survival rate, distant metastasis rate and local recurrence rate were compared between the two groups. Risk factors affecting long-term prognosis were also analyzed.</p><p><b>RESULTS</b>The 5-year disease-free survival rate, 5-year distant metastasis rate, and 5-year local recurrence rate were 78.1%, 14.2% and 4.2% in the non-AL group, and 74.5%, 20.1% and 8.4% in the AL group respectively, and the differences were not statistically significant (P=0.808, P=0.965, P=0.309). Multivariate analysis showed that preoperative neoadjuvant radiochemotherapy, TNM staging, abnormal CA199, preoperative low level of albumin were independent prognostic factors of rectal cancer patients after R0 resection, while AL was not an independent factor of 5-year disease-free survival (P=0.910). Further multivariate analysis on 507 cases receiving postoperative adjuvant chemotherapy also revealed that AL was not an independent factor of 5-year disease-free survival (P>0.05). Percentage difference of patients finishing postoperative chemotherapy between the two groups was not statistically significant (79.4% vs. 76.3%, P=0.681).</p><p><b>CONCLUSION</b>AL is not an independent predictor of long-term survival for rectal cancer.</p>

Effect of intestinal resection on hydrogen sulfide biosynthesis and the damage of Cajal interstitial cells / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of intestinal resection on hydrogen sulfide (H2S) biosynthesis and interstitial cells of Cajal(ICC) in mice.</p><p><b>METHODS</b>After intestinal resection mouse model was established, the activity of MPO in the proximal anastomosis intestinal tissue were detected. Sensitive sulphur electrode assay was applied to measure the H2S level. RT-PCR technique was employed to investigate the mRNA expression of the endogenous H2S biosynthesis enzymes, cystathionine-b-synthase (CBS) and cystathionine-c-lyase (CSE). Immunofluorescence staining was used to detect the expression of c-kit in order to calculate the area of ICC.</p><p><b>RESULTS</b>The mRNA expression of CSE was detected in the small intestine tissue of mice, while no CBS mRNA was found. The mRNA expression of CSE in proximal anastomotic stoma increased in time-dependent manner in the model group. CSE mRNA expression began to increase 1 hour after operation, reached the peak at 6th hour, then decreased gradually, and was similar to the control group at postoperative 24th hour. Compared to the model group, in the intestinal tissues of proximal 3 cm to anastomotic stoma, the mRNA expression of CSE (1.16 ± 0.18 vs. 1.63 ± 0.13, P<0.05), the activity of MPO [(0.54 ± 0.07) U/g vs. (0.83 ± 0.09) U/g, P<0.05], the H2S level [(36.1 ± 6.1) nmol/mg vs. (5.3 ± 5.6) nmol/mg, P<0.05] were significantly reduced in the PPG group. Meanwhile, average percentage of positive ICC area in the PPG groups was significantly higher [(2.26 ± 0.19)% vs. (1.65 ± 0.24)%, P<0.05].</p><p><b>CONCLUSIONS</b>Inflammatory reaction in muscular layer induced by intestinal resection up-regulates the mRNA expression of CSE proximal to anastomotic stoma, generates excess H2S to damage ICC leading to intestinal motor dysfunction. Preoperative inhibition of endogenous H2S generation may protect the ICC.</p>

Triggering receptor expressed on myeloid cells 2 in synovial tissue of rheumatoid arthritis rats / 中国组织工程研究

BACKGROUND:Triggering receptor expressed on myeloid cel s 2 (TREM-2) is highly expressed throughout the synovial tissue in active rheumatoid arthritis patients, but the role of TREM-2 in the pathogenesis of rheumatoid arthritis stil remains unclear. OBJECTIVE:To explore the TREM-2 expression in the synovial tissue of col agen type II-induced arthritis rats. METHODS:The col agen-induced arthritis models were established in rats. The activity indicators and pathological changes of arthritis synovial were dynamical y observed. The mRNA levels of TREM-2, tumor necrosis factor-α, interleukin-1β, and interleukin-10 were detected in synovial tissue of rats by RT-PCR. The protein expression and location of TREM-2 were measured with western blot assay and immunohistochemistry, respectively. RESULTS AND CONCLUSION:At day 13 after immunization, the paws of model rats appeared red and swel ing, the arthritis index scores were increased (P<0.01). At day 19-25 after immunization, the inflammation reached the peak. Hematoxylin-eosin staining showed that, the synovium of col agen-induced arthritis rats were proliferated and were infiltrated by inflammatory cel s, cartilage was destroyed. Compared with the control group, the expression of TREM-2 mRNA and protein, the mRNA levels of tumor necrosis factor-αand interleukin-1βin synovial tissue of the model rats were significantly increased (P<0.05 or P<0.01), while interleukin-10 mRNA expression was significantly decreased (P<0.05). Experimental findings indicate that, TREM-2 is a crucial inflammatory regulator and the increasing expression of TREM-2 plays an important role in the pathogenesis of col agen-induced arthritis.

Predictive factors associated with pathologic complete response after neoadjuvant chemoradiotherapy in rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore predictive factors associated with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy for rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 163 patients with locally advanced rectal cancer who were treated with neoadjuvant chemoradiotherapy followed by radical surgical resection from January 2007 to May 2013 were analyzed retrospectively. Univariate analysis and multivariate logistic regression analysis were performed to analyze associated factors of pCR, including age, gender, body mass index (BMI), diabetes, anemia, tumor diameter, distance of the tumor from the anal verge, circumferential extent of the tumor, tumor pathological types, tumor differentiation, pre-chemoradiotherapy T stage, pre-chemoradiotherapy N stage, pre-chemoradiotherapy CEA level, pre-chemoradiotherapy CA199 level, per-operation CEA level, pre-operation CA199 level, radiation dose, chemotherapy modality, time interval from completion of chemoradiotherapy to surgery, etc.</p><p><b>RESULTS</b>Twenty-nine patients(17.8%) achieved pCR after neoadjuvant chemoradiotherapy for rectal cancer. Univariate analysis showed circumferential extent of tumor(≥1/2 cycle)(P=0.018), tumor pathological types(adenocarcinoma)(P=0.036), tumor differentiation (moderate or high)(P=0.021) and pre-chemoradiotherapy CEA level(≤2.5 μg/L)(P=0.007) were significantly correlated with pCR after neoadjuvant chemoradiotherapy for rectal cancer. Logistic regression revealed that circumferential extent of tumor (≥1/2 cycle)(OR=2.901, P=0.020) and pre-chemoradiotherapy CEA level (≤2.5 μg/L)(OR=2.775, P=0.022) were independent predictive factors of pCR after neoadjuvant chemoradiotherapy for rectal cancer.</p><p><b>CONCLUSION</b>Patients with circumferential extent of tumor ≤1/2 and pre-chemoradiotherapy CEA level ≤2.5 μg/L are more likely to achieve pCR after neoadjuvant chemoradiotherapy for rectal cancer, and these two indices can be used to predict pCR after neoadjuvant chemoradiotherapy for rectal cancer.</p>

Risk factors of anal function after transabdominal intersphincteric resection for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the risk factors of anal function after transabdominal intersphincteric resection(ISR) for low rectal cancer.</p><p><b>METHODS</b>Clinical and follow-up data of 96 patients with low rectal cancer who underwent transabdominal ISR in our department from January 2005 to December 2012 were analyzed retrospectively. The Wexner scoring scale was used to evaluate the anal function and the risk factors of anal function were analyzed by the Cox proportional hazard model.</p><p><b>RESULTS</b>Ninety-six patients completed Wexner scoring scale with mean follow-up of 32.7 months. Eighty-three cases(86.5%) presented good continence with a Wexner score less than 10. There was negative correlation between Wexner score and follow-up duration (Pearson coefficient, -0.078, P=0.003). Univariate analysis suggested the distance less than 5 cm from tumor to anal verge(P=0.043), height less than 2 cm from anastomosis to anal verge (P=0.001) and neoadjuvant chemoradiotherapy(P=0.001) were the risk factors. Multivariate analysis revealed that distance less than 2 cm from anastomosis to anal verge(P=0.020) and neoadjuvant chemoradiotherapy(P=0.001) were independent risk factors for fecal incontinence.</p><p><b>CONCLUSIONS</b>Most patients have good continence after transabdominal ISR. A distance of less than 2 cm from anastomosis to anal verge and neoadjuvant chemoradiotherapy are independent risk factors for poor anal function after transabdominal ISR.</p>

Comparison of the effects of preload with hydroxyethyl starch combined with phenylephrine/dopamine to prevent hypotension after combined epidural-spinal anesthesia in parturient undergoing caesarean section / 中国医师杂志

Objective To compare the effects of preload with intravenous infusion of 6％ hydroxyethyl starch combined with phenylephrine or dopamine to prevent the hypotension after combined epiduralspinal anesthesia in parturient undergoing caesarean section.Methods Eighty patients with ASA class Ⅰ or Ⅱ[,were randomly divided into Dopamine group and Phenylephrine group,40 cases in each group.The 6％hydroxyethyl starch 500 ml was infused at the tate of 20 ml/(kg · h) after the intravenous catheterization was established and after the finishing of the infusion of 250 ml,the dopamine 5 mg (Dopamine group) or 200 ug phenylephrine (Phenylephrine group) were added respectively in residual liquid.After the bupivacaine was injected into the subarachnoid space,the intravenous infusion was continued at the same rate until the fetus was taken out and the blood pressure and heart rate were measured at intervals of 1 min.The blood sample of fetal cord was taken to measure ther troponin Ⅰ concentration.Results The incidence of hypotension after combined epidural-spinal anesthesia anesthesia in dopamine group (2/40) and in phenylephrine group (3/40) was with no statistical difference (P ＞ 0.05) ;The incidence of bradycardia in dopamine group (0/40) was significantly lower than that in phenylephrine group (6/40)) (P ＜0.05) ; The incidence of tachycardia in dopamine group (8/40) was significantly higher than that in phenylephrine group (1/40) (P ＜0.05) ; The troponin Ⅰ concentration of fetal cord blood in dopamine group [(0.21 ±0.07) ng/ml] and in phenylephrine group [(0.18 ±0.09)ng/ml]was with no statistical difference (P ＞0.05).Conclusion Preload with intravenous infusion of 6％ hydroxyethyl starch combined with phenylephrine or dopamine can effectively prevent the hypotension after combined epidural-spinal anesthesia in parturient undergoing caesarean section with no significant effect on the fetus and both can be chosen in terms of the heart rate of parturient before anesthesia.