A comparative study of the effects of different treatment strategies on postoperative anal function and quality of life in patients with complete obstructive left hemicolon cancer / 中华胃肠外科杂志

Objective: To compare the effects of 3 treatment strategies (emergent surgery, self-expanding metallic stents, self-expanding metallic stents plus neoadjuvant chemotherapy) on postoperative anal function and quality of life in patients with complete obstructive left hemicolon cancer. Methods: A retrospective cohort study was conducted. Clinical data of patients with complete obstructive left hemicolon cancer admitted to General Surgery Department of Beijing Chaoyang Hospital between January 2017 and October 2019 were retrospectively collected. Patient inclusion criteria: (1) complete obstructive left hemicolon cancer was confirmed through clinical manifestation and abdominal computed tomography; (2) adenocarcinoma was confirmed by postoperative pathology; (3) emergent radical resection of primary tumor was performed with temporary stoma, or radical resection of primary tumor and primary anastomosis was performed without stoma, 7 to 14 days after completion of insertion of self-expanding metallic stents. Patients who did not receive stoma reversion after emergent operation were excluded. According to different therapies, patients were divided into three groups: emergent surgery (ES) group, self-expanding metallic stents (SEMS) group and self-expanding metallic stents plus neoadjuvant chemotherapy (SEMS+NAC) group. Wexner score for incotinence (higher score indicates the worse anal function), Vaizey score (>10 indicates fecal incontinence) and low anterior resection syndrome (LARS) scale (higher score indicates the worse anal function) were applied to evaluate anal function of patients among groups at postoperative 1-, 6- and 12-month. EORTC QLQ-C30 questionnaire was used to assess the quality of life. Risk factors of decreased anal function were identified by logistic regression analysis. Results: A total of 72 patients were enrolled, including 27 (37.5%) patients in ES group, 23 (31.9%) in SEMS group and 22 (30.6%) in SEME+NAC group. The baseline characteristics including age, gender, tumor location, comorbidities, total blood loss, operation time and postoperative complications, were comparable among groups, except that the proportion of laparoscopic surgery was significantly lower in ES group (4/27, 14.9%) than that in SEMS (15/23, 65.2%) and SEMS+NAC group (16/22, 72.7%) with significant difference (P<0.001). The follow-up ended up to October 2020, and the overall follow-up rate was 79.2% (57/72). No significant differences existed in the Wexner score of patients among groups at postoperative 1-, 6- and 12-month (all P>0.05). The Vaizey scores at postoperative 1-month in ES, SEMS and SEMS+NAC group were 7 (0-17), 3 (0-7) and 4 (0-8) respectively with significant difference (H=18.415, P=0.001), and the scores in SEMS and SEMS+NAC groups were significantly lower than that in ES group (both P<0.05), while no significant difference existed between SEMS and SEMS+NAC group (P>0.05). Vaizey scores at postoperative 6- and 12-month among 3 groups were not significantly different (both P>0.05). The LARS scores at postoperative 1-month in ES, SEMS and SEMS+NAC groups were 20 (0-37), 15 (0-24) and 16 (0-28) respectively with significant difference (H=3.660, P=0.036), and the scores in SEMS and SEMS+NAC groups were significantly lower than that in ES group (both P<0.05), while no significant difference existed between SEMS and SEMS+NAC groups (P>0.05). LARS scores at postoperative 6- and 12-month among 3 groups were not significantly different (both P>0.05). The QLQ-C30 score revealed that the social function of patients in SEMS group and SEMS+NAC group was significantly better than that in ES group (both P<0.05), while no significant difference existed between SEMS and SEMS+NAC group (P>0.05). The logistic regression analysis revealed that only ES was an independent risk factor of decreased anal function (OR=2.264, 95% CI: 1.098-4.667, P=0.027). Conclusion: Compared to ES, SEMS may improve quality of life and short-term anal function of patients with complete obstructive left hemicolon cancer.

Surgical management of postoperative stricture of anastomosis after operation of intersphincteric resection for lower rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To study surgical treatment of postoperative stricture of anastomosis for lower rectal cancer.</p><p><b>METHODS</b>The data of 9 cases who were diagnosed as postoperative stricture of anastomosis after operation of intersphincteric resection for lower rectal cancer during January 2008 to June 2011 were analyzed retrospectively. Transanal excision of stricture were used in 3 cases diagnosed as membranous stricture. Transanal radial incision of stricture were used in 5 cases diagnosed as tubulous stricture. Biologic patch was used to repair the defect of the posterior wall of rectum after excision of severe stricture in 1 case.</p><p><b>RESULTS</b>All 9 cases of postoperative stricture of anastomosis were cured by surgery. Anal dilation were performed every day by patients themselves after discharge. Digital examination showed that 1 to 2 fingers could pass through the anastomosis after operation. The patient whose rectal defect was repaired by biological patch underwent colonoscopy examination two weeks after operation. Colonoscopy showed that the biological patch had been filled with granulation and integrated into the surrounding intestinal tissue. All patients defecated without difficulty and the anal function of all patients was good after restoration of intestinal continuity.</p><p><b>CONCLUSION</b>Aggressive surgery, combining with the use of biological patch if necessary is an effective therapy of postoperative stricture of anastomosis for lower rectal cancer.</p>

Technical improvements and results of individual cylindrical abdominoperineal resection for locally advanced low rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of individual cylindrical abdominoperineal resection (CAPR) for locally advanced low rectal cancer.</p><p><b>METHODS</b>From June 2011 to February 2012, 11 patients with locally advanced low rectal cancer underwent individual CAPR. There were 7 male and 4 female patients, aged from 32 to 74 years with a median of 64 years. Forty-seven patients underwent classic CAPR from January 2008 to February 2012. Preoperative and postoperative parameters such as clinical information of patients, tissue morphometry and complications were compared.</p><p><b>RESULTS</b>In the individual surgical group, 6 patients were treated with one side levator ani muscle totally or partially reserved, 3 patients with sacrococcyx reserved, and 2 patients with dissection close to the anterior rectal wall. Compared with classical surgery, the individual surgical specimens of horizontal section area ((2197 ± 501) mm(2)) and intrinsic muscle layer outer area ((1722 ± 414) mm(2)) were small, but the difference was not statistically significant (P = 0.150 and 0.167). The operative time, intraoperative blood loss, circumferential resection margin, total cross sectional tissue area, cross sectional tissue area outside the muscularis propria and bowel perforation rate between the two groups were not significantly different. Individual CAPR showed less incidence of chronic perineal pain (2/11, χ(2) = 6.116, P = 0.013) and sexual dysfunction (2/9, χ(2) = 4.412, P = 0.036) compared with classic CAPR.</p><p><b>CONCLUSIONS</b>Individual CAPR has the potential to reduce the risk of chronic perineal pain and sexual dysfunction without influencing the radical effect when compare with classic CAPR for the treatment of low rectal cancer.</p>

Efficacy evaluation of anal intersphincteric resection with direct coloanal anastomosis for T1-2 ultra-low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the oncological and functional outcomes of intersphincteric resection (ISR) in T(1-2) ultra-low rectal cancer.</p><p><b>METHODS</b>From March 2000 to March 2007, ISR with total mesorectal excision (TME) was performed in 40 patients with very low rectal cancer,among whom total ISR in 5 patients, partial ISR in 23 patients, and partial ISR with partial dentate line preservation (modified partial ISR) in 12 patients. The preoperative tumor staging was T(1-2)N(0-1)M(0).</p><p><b>RESULTS</b>Morbidity was identified in 3 patients including anastomotic leakage in 1 patient and wound infection in 2 patients, and there was no postoperative mortality. The 5-year overall survival rate was 97%, and 5-year disease-free survival rate was 86%. Both patients with modified partial ISR (P=0.004) and patients with partial ISR (P=0.008) had significantly better continence than those with total ISR, and patients with a diverting stoma had significantly better continence (P=0.043) than those without a stoma at 12 months after surgery.</p><p><b>CONCLUSIONS</b>ISR is a safe procedure for sphincter-saving rectal surgery in selected patients with very low rectal tumors. A temporary diverting stoma may be beneficial to the improvement of anal function. Modified partial ISR under the precondition of radical resection shows better anal function and lower rate of incontinence.</p>

Application of pelvic floor dynamic MRI combining defecography with homemade high conformable sacculus in the management of obstructed defecation syndrome / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the sensitivity and feasibility of pelvic floor dynamic MRI combining defecography with homemade high conformable sacculus in the management of obstructed defecation syndrome.</p><p><b>METHODS</b>One hundred and nine female with pelvic floor disorders, such as difficult defecation, fecal incontinence or urinary incontinence, pelvic pain, were treated from July 2007 to March 2009. Pelvic floor dynamic MRI and defecography with homemade high conformable sacculus was performed in the patients to evaluate pelvic floor anatomy.</p><p><b>RESULTS</b>Fifty-four cases (49.6%) of cystocele and 11 cases (10.1%) of rectouterine pouch hernia, 29 cases (26.6%) of perineum prolapse and 71 cases (65.2%) of rectocele were found by dynamic MRI. The dynamic MRI also revealed 19 cases (18.2%) of external sphincter trophy and 32 cases (29.4%) of spastic pelvic floor syndrome. Compared with defecography, dynamic MRI was more positive in diagnosing enterocele. Defecography Of the patients, sacrum-rectal separate was found in 33 cases (30.3%) and rectal mucosal prolapse or internal rectal intussusceptions in 41 cases (37.7%) by defecography, while dynamic MRI found none.</p><p><b>CONCLUSIONS</b>As a new noninvasive imaging technique to evaluate the pelvic floor function, dynamic MRI is more sensitive, especially for patients with complicated multi-organs prolapse, and its deficiency could be remedied by defecography.</p>

Expression of hRad21 and clinicopathological analysis in gastrointestinal malignant tumors maintained their telomeres by a mechanism of alternative lengthening of telomeres / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the proportion between tumors which maintain their telomeres by a mechanism of alternative lengthening of telomeres(ALT) and telomerase-dependent tumors in gastrointestinal malignant tumors, the expression difference of hRad21 between the two groups and the clinicopathological characteristics of ALT tumors were also explored.</p><p><b>METHODS</b>One hundred and four cases of gastrointestinal malignant tumors were divided into 2 groups: ALT group and telomerase group by detecting telomerase activity using TRAP method. Expression difference of hRad21 was investigated between the two groups. All the patients were followed up and clinicopathological data of these patients were analyzed.</p><p><b>RESULTS</b>Of 104 cases, there were 12 cases in ALT group and 94 cases in telomerase group. Expression of hRad21 in ALT group was higher than that in telomerase group. Tumors in ALT group had a thinner invasion depth (lower T stage) as compared to telomerase group (P=0.021). Other indexes, such as age, gender, tumor size, tumor grade, location of tumor, CEA and CA199, were not significantly different between the two groups. Results of follow-up showed that the survival rate of ALT group was 100% while that of telomerase group was 56% at 30 months postoperatively.</p><p><b>CONCLUSIONS</b>There are tumors which maintain their telomeres by ALT in gastrointestinal malignant tumors, accounting for 10%-12% of the total tumors. As compared to telomerase group, ALT group presents higher expression of hRad21, thinner tumor invasion depth, and higher survival rate.</p>

Early results of per anus intersphincteric rectal dissection and direct coloanal anastomosis: sphincter-preserving surgery for patients with very low rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the safety and curative effect of per anus intersphincteric rectal dissection and direct coloanal anastomosis (PIDCA) for patients with very low rectal cancer.</p><p><b>METHODS</b>Nineteen patients were prospectively studied from June 2002 to October 2004. There were 11 males and 8 females, with a median age of 56 (range, 41 - 74) years. Nineteen patients had T(1) to T(4) tumors (T(1), n = 4; T(2), n = 10; T(3), n = 4; T(4), n = 1) located between 3.5 and 5.0 cm above the anal verge.The rectum, including the entire width of the internal analsphincter, was transected circumferentially via the anal route to secure the surgical margin of safety under direct vision and was mobilized proximally as far as possible through the intersphincteric plane. Per anus coloanal anastomosis was performed following transabdominal resection of the rectum.</p><p><b>RESULTS</b>There was no operative mortality. Of nineteen patients, two (10.5%) had anastomotic leakage. Median follow-up duration was 16 (range, 3 - 29) months. Up to now, one patient developed recurrence (5.3%). Acceptable anal function results were obtained in most patients.</p><p><b>CONCLUSIONS</b>Curability and anal function was obtained by PIDCA combined with preoperative or postoperative radiotherapy and postoperative chemotherapy. PIDCA is ideal and safe for selected patients with tumor located below 5 cm from the anal verge.</p>