Anatomical relationship between fascia propria of the rectum and visceral pelvic fascia in the view of continuity of fasciae / 中华胃肠外科杂志

Objective@#To perform an anatomical observation on the extension of the mesocolon to the mesorectum and the continuity of the fasciae lining the abdomen and pelvis, in order to clarify the appropriate surgical plane of total mesorectal excision.@*Methods@#This is an descriptive study. The operation videos of 61 cases (28 males, 33 females, median age of 61) were collected. All the patients underwent laparoscopic colorectal surgery from January 2018 to December 2018 in Yangpu Hospital, including low anterior resection for rectal cancer in 25 cases, left hemicolectomy for descending colon cancer in 15 cases, and subtotal resection of the colon for intractable constipation in 21 cases. Among these 21 constipation patients, 8 received additional modified Duhamel surgeries. Gross anatomy was performed on 24 adult cadavers provided by Department of Anatomy, Shanghai Jiaotong University School of Medicine, including 23 formalin-fixed and 1 fresh cadaver (12 males, 12 females). Sixty-one patients and 24 cadavers had no previous abdominal or pelvic surgical history. The anatomy and extension of fasciae related to descending colon, sigmoid colon and rectum, especially the morphology of Toldt fascia, and the continuities of mesocolon and mesorectum were observed carefully. The distribution characteristics of the fasciae and anatomical landmarks during laparoscopic surgery were recorded and described.@*Results@#The anatomical study on 24 cadavers showed that visceral fascia was the densest connective tissue in the pelvic, posterolateral to the rectum, and stretched as a hammock to lift all pelvic organs. Among 61 patients undergoing laparoscopic surgery, 36 (59.0%) needed to free the left colon during operation, and Toldt fascia in the descending colon segment presented as potential, avascular and extensible loose connective tissue plane between the mesocolon and posterior Gerota fascia; 33 (54.1%) needed to free the rectum during operation, and Toldt fascia extended downward to pelvis as loose connective tissue between the fascia propria of the rectum and visceral fascia; the fascia propria of the rectum exposed completely in 32 (32/33, 97.0%) cases, which ran downward and fused with visceral fascia at the level of the fourth sacral vertebra. The anatomy of 24 cadavers also showed that fascia propria of the rectum fused with visceral fascia at the level of Waldeyer fascia. The fusion line of these two fasciae was supposed to be the extension of Waldeyer fascia. There were two avascular planes behind the rectum: one between the fascia propria of the rectum and visceral fascia, and the other between the visceral fascia and parietal fascia. In 8 constipation cases undergoing laparoscopic subtotal colon resection plus modified Duhamel operation, both mesocolon and mesorectum needed to be mobilized. It was obvious that the mesocolon of descending colon extended and became the mesocolon of sigmoid colon, and ran further into the pelvic and became the mesorectum. The colon fascia of descending colon served as the natural boundary of mesocolon extended downward as the fascia of sigmoid colon and the fascia propria of the rectum, respectively. Toldt fascia locating between mesocolon of descending colon and Gerota fascia extended to pelvis as the 'presacral space’ between the fascia propria of the rectum and visceral fascia. Gerota fascia in descending colon segment extended as urogenital fascia in sigmoid colon segment and visceral fascia in the pelvis, respectively. In the cadaver anatomy study, the visceral fascia served as a corridor carrying the hypogastric nerve, and ureter was observed in 23 (23/24, 95.8%) cases. The visceral fascia passed from posterior to anterior lateral of rectum, fusing with Denonvilliers fascia in a fan shape. The pelvic plexus located exactly external to the junction of visceral fascia and Denonvilliers fascia. Pelvic splanchnic nerves went through the parietal fascia toward to the inferolateral of the pelvic plexus.@*Conclusion@#Fascia propria of the rectum and the visceral pelvic fascia are two independent layers of fascia, and the TME surgical plane is between the fascia propria of the rectum and visceral pelvic fascia instead of between the visceral and the parietal pelvic fascia.

Association between KRAS gene mutations and clinicopathological characteristics and prognosis of colorectal cancer patients / 中华消化外科杂志

Objective To investigate the association between KRAS gene mutations and clinicopathological characteristics and prognosis of colorectal cancer (CRC) patients.Methods The retrospective casecontrol study was conducted.The clinicophathological data of 315 patients who underwent radical resection of CRC in the Yangpu Hospital Affiliated to Tongji University between January 2007 and July 2011 were collected.Nextgeneration sequencing was performed to identify KRAS gene mutations from surgical specimens.Observation indicators:(1) detection of KRAS gene;(2) association between KRAS gene mutations and clinicopathological characteristics of CRC patients;(3) follow-up and survival situations;(4) multivariate analysis of KRAS gene mutations in the prognosis of CRC patients.Follow-up using outpatient examination and telephone interview was performed to detect postoperative overall survival up to August 2016.Comparisons of count data were analyzed using the chi-square test.Measurement data with skewed distribution were described as M (interquartile range),and comparison between groups was analyzed using the nonparametric test.The survival rate was calculated using the Kaplan-Meier method,and survival was compared using the Log-rank test.The multivariate analysis was done using the COX regression model.Results (1) Detection of KRAS gene:all the 315 patients finished gene detection of surgical specimens,including 172 in wide-type mutations and 143 in mutant-type mutations (mutations at codon 12 and 13 of KRAS exon 2 and other mutant points were respectively detected in 80,24 and 40 patients,and 1 patient had simultaneous mutations at codon 12 and 13 of KRAS exon 2;missense and nonsense mutations were respectively detected in 141 and 2 patients).The major point mutations were at p.G12D and p.G13D.(2) Association between KRAS gene mutations and clinicophathological characteristics of CRC patients:tumors located in the proximal colon,distal colon and rectum were respectively detected in 34,48,90 patients with wild-type mutation and in 44,27,72 patients with mutant-type mutation,with a statistically significant difference (x2 =0.038,P＜0.05).(3) Follow-up and survival situation:315 patients were followed up for 3-115 months,with a median time of 78 months.The postoperative overall survival rate was 41.0％ in 172 patients with wild-type KRAS mutations,27.4％ in 80 patients with KRAS codon 12 mutations,26.3％ in 24 patients with KRAS codon 13 mutations and 48.2％ in 40 patients with other KRAS mutations,showing a statistically significant difference (x2=0.040,P＜0.05).(4) Multivariate analysis of KRAS gene mutations in the prognosis of CRC patients:the results of multivariate analysis showed that mutations at codon 12 of KRAS exon 2 was an independent factor affecting poor prognosis of CRC patients (Hazard ratio=1.543,95％ confidence interval:1.050-2.265,P＜0.05).Conclusions Most KRAS mutations of CRC patients are at codon 12 and 13 of KRAS exon 2,and the major point mutations are at p.G12D and p.G13D.KRAS gene mutations may be associated with tumor location.Mutations at codon 12 of KRAS exon 2 is an independent factor affecting poor prognosis of CRC patients.

Impact of neutrophil-to-lymphocyte ratio on the prognosis of patients with locally advanced colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the impact of neutrophil-to-lymphocyte ratio(NLR) on the prognosis of patients with locally advanced colorectal cancer (LACRC).</p><p><b>METHODS</b>Clinicopathological data of 684 patients with stage II(-III( CRC undergoing radical resection at Shanghai Ruijin Hospital from January 2008 to December 2010 were analyzed retrospectively. NLR was calculated from neutrophil and lymphocyte counts on routine blood tests prior to surgery. The optimal cutoff value of NLR for predicting 5-year overall survival (OS) was determined through receiver operating characteristic (ROC) curve analysis. According to the cut-off value, patients were divided into high NLR and low NLR groups. Clinicopathological characteristics and prognosis were compared between two groups. Univariate and multivariate analyses were performed with Cox proportional hazards model to evaluate the impact of clinical factors on prognosis.</p><p><b>RESULTS</b>A total of 396 male and 288 female patients were included in the study, with a median age of 62 years(range 21-92).Among these patients, 335 had rectal cancers and 349 had colonic cancers; 328 were TNM stage II( and 356 were stage III(. The end of follow-up was January 2016. ROC curve showed that the optimal cut-off value of NLR was 3.0, then patients were divided into low NLR group (NLR≤3.0, n=481) and high NLR group (NLR>3.0, n=203). Compared with low NLR group, the high NLR group was more likely to be older (median 64 vs. 61, t=-2.412, P=0.016), presented higher ratio of colonic cancer [66.0%(134/203) vs. 44.7%(215/481), χ=25.945, P=0.000] and stage III( tumor [60.1%(122/203) vs. 48.6%(234/481), χ=7.499, P=0.007], but lower ratio of first-degree relative cancer history [8.9%(18/203) vs. 15.6%(75/481); χ=5.496, P=0.020]. However, no significant differences were observed between two groups in gender, smoking and drinking history, tumor differentiation grade, vessel invasion and nerve invasion (all P>0.05). The median follow-up time was 67 months (range 3-92), and the 5-year OS rates of high NLR and low NLR group were 59.6% and 73.2% respectively, with significant difference (P=0.001). Cox multivariate analysis revealed that age >65 years (HR=2.07, 95%CI=1.59-2.70, P=0.000), no first-degree relative cancer history (HR=2.01, 95%CI=1.23-3.28, P=0.005), poor differentiation grade (HR=1.65, 95%CI=1.26-2.15, P=0.000), positive vessel or nerve invasion (HR=1.92, 95%CI=1.35-2.71, P=0.000), high TNM stage(HR=2.10, 95%CI=1.59-2.77, P=0.000) and preoperative NLR>3.0(HR=1.51, 95%CI=1.14-2.00, P=0.004) were independent risk factors of prognosis for patients with LACRC.</p><p><b>CONCLUSIONS</b>Preoperative NLR can influence the prognosis of patients with LACRC receiving radical surgery. High NLR is associated with poor prognosis.</p>

Preliminary efficacy of video-assisted anal fistula treatment for complex anal fistula / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the preliminary efficacy of video-assisted anal fistula treatment (VAAFT) for complex anal fistula.</p><p><b>METHODS</b>Clinical data of 11 consecutive patients with complex anal fistula undergoing VAAFT in our department from May to July 2015 were reviewed. VAAFT was performed to manage the fistula under endoscope without cutting or resection.</p><p><b>RESULTS</b>VAAFT was successfully performed in all the 11 patients. The internal ostium was closed using mattress suture in 10 cases, and Endo-GIA stapler in 1 case. The mean operative time was (42.0±12.4) min, mean hospital stay was (4.1±1.5) d. Complication included bleeding and perianal infection in 1 case respectively. After 1 to 3.2 months follow-up, success rate was 72.7%(8/11), and no fecal incontinence was observed.</p><p><b>CONCLUSION</b>Video-assisted anal fistula treatment is an effective, safe and minimally invasive surgical procedure for complex anal fistula with preservation of anal sphincter function.</p>

Laparoscopy assisted with transanal endoscopic microsurgery in the treatment of severe functional constipation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility and efficacy of laparoscopic subtotal colectomy and modified Duhamel procedure combined with transanal endoscopic microsurgery (TEM) in the treatment of severe functional constipation(SFC).</p><p><b>METHODS</b>The clinical data of 10 patients with SFC treated by laparoscopic surgery combined with TEM between May 2010 and October 2012 in Ruijin Hospital of Shanghai Jiaotong University School of Medicine were retrospectively analyzed. The gastrointestinal quality of life index(GIQLI), Wexner constipation scale and daily frequency of defecation postoperatively during follow-up were collected.</p><p><b>RESULTS</b>All the 10 operations were successfully accomplished laparoscopic subtotal colectomy combined with TEM without abdominal incision. There was no conversion to open procedure. One case had preventive terminal ileum stoma. The mean operative time was (256 ± 58) min. The mean blood loss was (178 ± 67) ml. The mean time to first flatus was (40 ± 11) h. There were no ureteric injury, anastomotic leak, pelvic sepsis and other complications postoperatively. There was one case of insufficient small bowel obstruction which was released by conservative treatments. The patients were discharged from the hospital in (9.0 ± 1.5) d postoperatively. The GIQLI in one year postoperatively was (112 ± 10) points, which indicated good results compared to (75 ± 12) points preoperatively (P=0.000). The Wexner constipation scale was 20.8 ± 2.2 preoperatively and decreased to 5.2 ± 1.8 at one year follow-up(P=0.000).</p><p><b>CONCLUSION</b>Laparoscopic subtotal colectomy and modified Duhamel procedure combined with TEM provides SFC patients a safe and feasible minimally invasive surgery.</p>