Treatment of complications after laparoscopic intersphincteric resection for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management.</p><p><b>METHODS</b>An observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital. The clinicopathological parameters, perioperative and postoperative complications, and clinical outcomes were collected from a prospectively maintained database. Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation, respectively.</p><p><b>RESULTS</b>Forty-nine(67.1%) cases were male and 24(32.9%) were female with a median age of 61(25 to 79) years. The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm. The median operative time was 195 (120 to 360) min, median intra operative blood loss was 100 (20 to 300) ml, median number of harvested lymph nodes was 14(3 to 31) per case. All the patients underwent preventive terminal ileum loop stoma. No conversion or hospital mortality was presented. The R0 resection rate was 98.6% with totally negative distal resection margin. A total of 34 complication episodes were recorded in 21(28.8%) patients during perioperative period, and among which 20.6%(7/34) was grade III(-IIII( according to Dindo system. Anastomosis-associated morbidity (16.4%,12/73) was the most common after LapISR, including mucosa ischemia in 9 cases(12.3%), stricture in 7 cases (9.6%, 4 cases secondary to mucosa necrosis receiving anal dilation), grade A fistula in 3 cases (4.1%) receiving conservative treatment and necrosis in 1 case (1.4%) receiving permanent stoma. After a median follow up of 21(3 to 60) months, postoperative complications were recorded in 12 patients (16.4%) with 16 episodes, including anastomotic stenosis (8.2%), rectum segmental stricture (5.5%), ileus (2.7%), partial anastomotic dehiscence (1.4%), anastomotic fistula (1.4%), rectovaginal fistula (1.4%) and mucosal prolapse (1.4%). These patients received corresponding treatments, such as endoscopic transanal resection, anal dilation, enema, purgative, permanent stoma, etc. according to the lesions. Six patients (8.2%) required re-operation intervention due to postoperative complications.</p><p><b>CONCLUSION</b>Anastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods, which must be strictly managed with suitable methods.</p>

Comparison of oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection for low rectal cancers / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection(ISR) for low rectal cancers.</p><p><b>METHODS</b>From June 2011 to February 2016, a total of 79 consecutive patients with low rectal cancers underwent laparoscopic ISR with hand-sewn coloanal anastomosis at our department. According to the distal tumor margin, partial ISR (internal sphincter resection at the dentate line) was used to treat tumors with distance <1 cm from the anal sphincter (n=28), subtotal ISR was adopted for the tumors locating between the dentate line and intersphincteric groove (n=34), and total ISR (resection at the dentate line) was applied in the treatment of intra-anal tumors (n=17). Anal function was evaluated by a standardized gastrointestinal questionnaire, Wexner incontinence score and Kirwan's classification. Metaphase oncological results and postoperative anal function were compared among three groups, and.</p><p><b>RESULTS</b>Other than the distance of tumor low margin to dentate line (P=0.000) and serum CEA level (P=0.040), no significant differences were noted in baseline data among 3 groups (all P>0.05). The median follow up was 21(8-61) months. The 3-year disease-free survival rates in laparoscopic partial, subtotal and total ISR groups were 91.1%, 88.9%, 88.2% (P=0.901) and the 3-year local relapse-free survival rates were 91.1%, 72.9%, 80.2%(P=0.658), whose all differences were not significant. Thirty-eight patients who did not receive neoadjuvant chemoradiotherapy and underwent ileostomy closure for at least 24 months completed the evaluation of anal function, including 14 cases in partial group, 15 cases in subtotal group and 9 cases in total group. Of 38 patients, 73.7%(28/38) was classified as good function (Wexner incontinence score ≤10) and no patient adopted a colostomy because of severe fecal incontinence(Kirwan classification=grade 5). Furthermore, there were no significant differences in Wexner incontinence score and Kirwan classification among 3 groups (all P>0.05). However, patients with chronic anastomotic stoma stenosis showed worse anal function than those without stenosis [Wexner incontinence score: 18(9-20) vs 6(0-18), P=0.000; Kirwan grading: 3(2-4) vs. 2(1-4), P=0.002].</p><p><b>CONCLUSIONS</b>As the ultimate sphincter-saving technique, laparoscopic ISR can result in better oncologic outcomes and better anal function for patients with low rectal cancers. The different procedures of ISR may not affect the efficacy, but chronic anastomotic stoma stenosis deteriorates incontinence status.</p>

Effect of RASSF1A gene promoter methylation on its expression level in cervical cancer tissue and its clinical significance / 国际肿瘤学杂志

Objective To research the promoter methylation level of RAS association domain family 1A (RASSF1A) and RASSF1A gene mRNA expression level in cervical cancer tissue, and to analyze their relationships with clinicopathological parameters of cervical cancer and the clinical significance.Methods The RASSF1A gene promoter methylation and RASSF1A gene mRNA were detected respectively by methylation specific PCR and quantitative real-time PCR method in 40 cases of cervical cancer tissues and corresponding adjacent tissues.Results RASSF1A mRNA expression level in cervical cancer (0.26±0.05) was significantly lower than that in adjacent tissues (0.28±0.03), and the difference was statistically significant (t=2.27, P=0.026).The methylation rate of RASSF1A gene promoter region (0.71%±0.04%) was significantly higher than that in adjacent tissues (0.66%± 0.03%), and the difference was statistically significant (t=6.78, P=0.000).The expression of RASSF1A mRNA was significantly correlated with pathological differentiation (t=3.31, P=0.002), International Federation of Gynecology and Obstetrics (FIGO) stage (t=2.13, P=0.040), lymphatic metastasis (t=2.56, P=0.015).The promoter methylation level of RASSF1A gene was significantly correlated with pathological differentiation (t=2.08, P=0.045), FIGO stage (t=2.66, P=0.011), lymphatic metastasis (t=2.22, P=0.033), depth of invasion (t=2.12, P=0.041).Conclusion The RASSF1A gene promoter region methylation level and the RASSF1A gene mRNA expression level are associated with the malignant degree of cervical carcinoma.The RASSF1A gene promoter region methylation level may be used as a reference indicator for predicting the risk of metastasis of cervical cancer.

Research progress of rectoanal inhibitory reflex / 中华胃肠外科杂志

The understanding of rectoanal inhibitory reflex (RAIR) is progressing for the latest 100 years. From the discovery of its important role in diagnosis of Hirschsprung's disease to all aspects of its development, reflex pathways, neural regulation and physiological functions, there have been more in-depth explorations. It is now recognized that a number of other diseases also have a more specific performance of RAIR. It has become an important and indispensable part to anorectal manometry. Research progress of rectoanal inhibitory reflex is reviewed in this article.

Idiopathic chronic colonic pseudo-obstruction / 中国普通外科杂志

Objective To investigate the diagnosis and treatment of idiopathic chronic colonic pseudo-obstruction(ICCPO). MethodsIn this study 69 patients admitted for “constipation” were finally found falling into one of the 4 groups: 11 cases of outlet obstructive constipation, 16 cases of slow transit constipation, 26 cases of mixed type, and 16 of ICCPO. ResultsThe main symptoms of these 16 ICCPO cases were intractable constipation, compared with that in other entities ICCPO tends to affect patients at younger age, with shorter clinical course, and often needs surgical intervention due to intractable bowel obstruction, usually total colectomy. ConclusionsICCPO, STC and mixed constipation are different clinical entities. The differentiation of ICCPO from other entities is sometimes very difficult especially when patients are suffering from acute onset of bowel obstruction.