Specimen extraction through natural orifices with Cai tubes in gastrointestinal surgery: a single-institute series of 234 cases / 中华胃肠外科杂志

Objective: To investigate the feasibility of Cai tube-assisted natural orifice specimen extraction surgery (NOSES) in gastrointestinal surgery. Methods: This was a descriptive case-series study. Inclusion criteria: (1) colorectal or gastric cancer diagnosed by preoperative pathological examination or redundant sigmoid or transverse colon detected by barium enema; (2) indications for laparoscopic surgery; (3) body mass index <30 kg/m2 (transanal surgery) and 35 kg/m2 (transvaginal surgery); (4) no vaginal stenosis or adhesions in female patients undergoing transvaginal specimen extraction; and (5) patients with redundant colon aged 18-70 years and a history of intractable constipation for more than 10 years. Exclusion criteria: (1) colorectal cancer with intestinal perforation or obstruction, or gastric cancer with gastric perforation, gastric hemorrhage, or pyloric obstruction; (2) simultaneous resection of lung, bone, or liver metastases ; (3) history of major abdominal surgery or intestinal adhesions; and (4) incomplete clinical data. From January 2014 to October 2022, 209 patients with gastrointestinal tumors and 25 with redundant colons who met the above criteria were treated by NOSES utilizing a Cai tube (China invention patent number:ZL201410168748.2) in the Department of Gastrointestinal Surgery, Zhongshan Hospital, Xiamen University. The procedures included eversion and pull-out NOSES radical resection in 14 patients with middle and low rectal cancer, NOSES radical left hemicolectomy in 171 patients with left-sided colorectal cancer, NOSES radical right hemicolectomy in 12 patients with right-sided colon cancer, NOSES systematic mesogastric resection in 12 patients with gastric cancer, and NOSES subtotal colectomy in 25 patients with redundant colons. All specimens were collected by using an in-house-made anal cannula (Cai tube) with no auxiliary incisions. The primary outcomes included 1-year recurrence-free survival (RFS) and postoperative complications. Results: Among 234 patients, 116 were male and 118 were female. The mean age was (56.6±10.9) years. NOSES was successfully completed in all patients without conversion to open surgery or procedure-related death. The negative rate of circumferential resection margin was 98.8% (169/171) with both two positive cases having left-sided colorectal cancer. Postoperative complications occurred in 37 patients (15.8%), including 11 cases (4.7%) of anastomotic leakage, 3 cases(1.3%) of anastomotic bleeding, 2 cases (0.9%) of intraperitoneal bleeding, 4 cases (1.7%) of abdominal infection, and 8 cases (3.4%) of pulmonary infection. Reoperations were required in 7 patients (3.0%), all of whom consented to creation of an ileostomy after anastomotic leakage. The total readmission rate within 30 days after surgery was 0.9% (2/234). After a follow-up of (18.3±3.6) months, the 1-year RFS was 94.7%. Five of 209 patients (2.4%) with gastrointestinal tumors had local recurrence, all of which was anastomotic recurrence. Sixteen patients (7.7%) developed distant metastases, including liver metastases(n=8), lung metastases(n=6), and bone metastases (n=2). Conclusion: NOSES assisted by Cai tube is feasible and safe in radical resection of gastrointestinal tumors and subtotal colectomy for redundant colon.

Comparison between laparoscopic-assisted natural orifice specimen extraction surgery and conventional laparoscopic surgery for left colorectal cancer: a randomized controlled study with 3-year follow-up results / 中华胃肠外科杂志

Objective: To evaluate the mid-term efficacy of laparoscopic-assisted natural orifice specimen extraction surgery (NOSES) colectomy using the Cai tube in the treatment of left colorectal cancer. Methods: A prospective randomized control trial (China Clinical Trials Registration Number: ChiCTR-OOR-15007060) was performed. Sixty patients with left colorectal cancer at Department of Gastrointestinal Surgery of Zhongshan Hospital from September 2015 to August 2017 were prospectively enrolled. Case inclusion criteria: (1) left colorectal adenocarcinoma (rectal cancer with distance ≥ 8 cm from tumor low margin to anal edge, sigmoid colon cancer, descending colon cancer and left transverse colon cancer) confirmed by preoperative pathology; (2) satisfactory conditions of conventional laparoscopic surgery; (3) maximum diameter of the tumor < 4.5 cm confirmed by preoperative abdominal and pelvic CT or MRI; (4) BMI < 30 kg/m2. Case exclusion criteria: (1) benign lesions, mucinous adenocarcinoma, signet-ring cell carcinoma and other special pathological types of tumors confirmed by preoperative pathological examination; (2) multiple or recurrent cancers; (3) with a history of neoadjuvant chemoradiotherapy; (4) obvious regional infiltration or distant metastasis indicated by preoperative imaging examination; (5) intestinal obstruction, intestinal perforation, etc. Participants were randomly assigned to NOSES group (using the Cai tube) and conventional laparoscopy (CL) group by random number table method. Clinical data between two groups were compared and analyzed, including perioperative conditions, tumor exfoliation cell detection and bacterial culture results of intraperitoneal lavage fluid, postoperative complications (Clavien-Dindo grading), postoperative pain [visual simulation scoring (VAS) assessment], anal function (Kirwan anal function grading assessment), and postoperative 3-year disease-free survival (DFS), overall survival (OS), overall recurrence rate, and local recurrence rate. Results: A total of 60 patients were enrolled, with 30 in the NOSES group and 30 in the CL group. All the patients in the NOSES group successfully completed operation with Cai tube. Baseline data between the two groups were not significantly different (all P>0.05). There were no statistically significant differences between two groups in conversion rate to open surgery, number of lymph node harivested, proximal and distal resection margin of tumor, negative rate of circumferential margin, operation time, blood loss, inflammatory indexes, postoperative anal function, postoperative hospital stay, hospitalization cost, morbidity of postoperative complications (Clavien-Dindo grade II or above) (all P>0.05). Compared to the CL group, the NOSES group had lower maximum postoperative VAS score (2.5±0.3 vs. 5.1±0.4, t=3.187, P<0.01), and fewer use of additional postoperative analgesia [6.7% (2/30) vs. 33.3% (10/30),χ2=6.670, P=0.02]. The postoperative time to gas passage was shorter in the NOSES group [(2.2±1.4) days vs. (3.1±1.2) days,P=0.026]. No tumor cells and bacterial contamination were found in abdominal lavage fluid before and after operation in either group. The anal function at postoperative 3-month of all the patients in the NOSES group was Kirwan grade I to II, while in the CL group, anal function of 2 cases (6.7%) was Kirwan grade III, and of 28 cases was also Kirwan grade I to II, whose difference was not statistically significant (P>0.05). In the NOSES group and the CL group, 3-year DFS was 96.7% and 83.3% (P=0.090), OS was 100% and 90% (P=0.096), overall recurrence rate was 3.3% and 10.0% (P=0.166), and local recurrence rate was 3.3% and 3.3% (P=0.999), respectively, whose differences were not statistically significant (all P>0.05). Conclusions: In the treatment of left colorectal cancer, compared with conventional laparoscopic colectomy, NOSES colectomy using Cai tube exhibits less scar, less postoperative pain, shorter recovery of gastrointestinal function, and similar mid-term outcomes. Given proper surgical indications, the surgical procedure is safe and feasible.

Protective effects of allicin on islet tissue in diabetic rats induced by streptozotocin / 国际药学研究杂志

Objective To investigate the protective effects of allicin (diallyl thiosulfinate) on islet tissue in diabetic rats induced by streptozotocin (STZ). Methods A hundred diabetic rat models induced by intraperitoneal injecting STZ were randomly devided into five groups: diabetic model control group, allicin (5,10 and 20 mg/kg) treated groups and metformin hydrochloride 200 mg/kg treated group. Another 20 same-aged rats were used as normal group. Each week before and after the drug was given, the levels of blood sugar and insulin were determined. Four weeks later, the histopathological changes in pancreatic tissue and islet cells apoptosis were observed, and the apoptosis index (AI) was analyzed; the level of T-AOC and the content of MDA in serum were determined; the activities of SOD, GSH-Px, CAT in pancreatic tissue were also determined. Results Compared with the diabetic model control group, the levels of insulin in allicin 10, 20 mg/kg treated groups were significantly increased and the blood sugar level was significantly decreased (P<0.05, P<0.01) the pancreatic tissue histopathological changes and islet cells apoptosis were obviously improved, the AI was significantly decreased (P<0.01) the content of MDA in serum was significantly decreased; the activities of SOD and CAT in pancreatic tissue were significantly increased(P<0.05, P<0.01). The level of T-AOC in allicin 20 mg/kg treated group was significantly increased (P<0.05), and the activity of GSH-PX in pancreatic tissue was significantly increased (P< 0.05). Compared with Metformin hydrochloride 200 mg/kg treated group, the level of insulin in allicin 20 mg/kg treated groups was significantly increased (P<0.05), the level of T-AOC in serum was significantly increased (P<0.05), the activity of SOD, GSH-Px, CAT in pancreatic tissue were also significantly increased (P<0.05, P<0.01). Conclusion Allicin could effectively improve insulin secretion, lower blood sugar, depress the pancreatic tissue histopathological changes and islet cells apoptosis, suggesting that allicin has dose-dependent protective effects on islet tissue in diabetic rats induced by STZ, which is perhaps related to its effects of improving antioxidant ability and inhibiting the oxidative stress.

Transumbilical single-port access laparoscopic surgery for colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the surgical outcomes after transumbilical single-port access laparoscopic surgery for colorectal cancer.</p><p><b>METHODS</b>Patients undergoing transumbilical single-port access laparoscopic radical resection for colorectal cancer at the Zhongshan Hospital of Xiamen University were included.</p><p><b>RESULTS</b>Three patients underwent transumbilical single-port access laparoscopic radical resection for sigmoid colon cancer and 1 for rectal cancer between August 2010 and September 2010. There were no intraoperative or postoperative complications. No conversion was required. The mean operative time was 206 min and the mean estimated blood loss was 75 ml. The mean number of harvested lymph nodes was 21. Patients were ambulatory in the same day of surgery or postoperative day 1. Length of hospital stay ranged from 7 to 10 days.</p><p><b>CONCLUSIONS</b>Transumbilical single-port access laparoscopic surgery is safe for colorectal cancer. Long-term outcomes warrant further investigation.</p>