Effect of bladder training on bladder function recovery in the male patients after mid-low rectal cancer surgery: a prospective, open, randomized controlled study / 中华胃肠外科杂志

OBJECTIVE@#To investigate the efficacy and safety of the bladder training in male patients before urinary catheter removal after mid-low rectal cancer surgery.@*METHODS@#This was a prospective, open, randomized controlled study.@*INCLUSION CRITERIA@#male patients; pathologically diagnosed as mid-low rectal adenocarcinoma; distance from tumor lower edge to anal margin ≤10 cm; standard radical surgery for rectal cancer, including intestinal resection and regional lymph node dissection.@*EXCLUSION CRITERIA@#previous history of benign prostatic hyperplasia or history of prostate surgery; bladder dysfunction such as dysuria and urinary retention before surgery; local resection of rectal tumor or extended resection. According to the above criteria, 92 patients who underwent colorectal surgery at the Union Hospital of Fujian Medical University from June to December 2016 were prospectively included. The patients were randomly divided into bladder training group (n=43) and bladder non-training group (n=49) according to the random number table method. The study was approved by the Ethics Committee of the Union Hospital of Fujian Medical University (ethical approval number: 2016KY005) and registered with the China Clinical Trial Registration Center (ChiCTR) (registration No.ChiCTR-IOR-16007995). The implementation of patient's treatment measures, the data collection and analysis were based on the three-blind principle, using envelopes for distribution concealment. In the bladder training group, bladder training was routinely performed from the first day after operation to catheter removal, and in bladder non-training group the catheter was kept open till its removal. The catheter was removed in the early morning at the 5th day after surgery, and the spontaneous urine output was recorded and the residual urine volume of the bladder was measured after the first urination. The international prostate symptom score (IPSS) was applied to evaluate the patient's urinary function before and after surgery.@*RESULTS@#The age of whole group was (58.6±10.9) years old, the body mass index was (22.4±2.7) kg/m , and the distance from tumor lower edge to anal margin was (6.5±1.9) cm. The baseline data, such as age, body mass index, distance from tumor lower edge to anal margin, preoperative IPSS score, preoperative bladder residual urine volume, neoadjuvant radiotherapy and chemotherapy, preventive ileostomy and surgical procedure were not significantly different between two groups (all P>0.05). There was no significant difference in IPSS scores evaluated at the second day (3.6±4.0 vs. 3.5±3.4, t=0.128, P=0.899) and one month (3.7±2.9 vs. 3.0±3.1, t=1.113, P=0.269) after catheter removal between the bladder training group and bladder non-training group. No significant difference in the postoperative residual urine volume of bladder (media 44 ml vs. 24 ml, Z=-1.466, P=0.143), the first spontaneous urination volume (median 200 ml vs. 150 ml, Z=-1.228, P=0.219) after catheter removal, and postoperative hospital stay [(8.2±4.5) days vs. (9.1±5.5) days, t=-0.805, P=0.423] was found. Urinary infection rate was 20.9%(9/43) in the training group, which was even higher than 8.2%(4/49) in the non-training group, but the difference was not significant(χ²=3.077, P=0.079). No patient needed re-catheterization in either group.@*CONCLUSIONS@#The routine bladder training after mid-low rectal cancer surgery does not improve the urinary function, and can not reduce the residual urine volume of bladder after catheter removal. This routine clinical practice is not helpful for the bladder function recovery after rectal cancer surgery.

Discovery, anatomy and clinical significance of the mesorectal finish line of total mesorectal excision / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the surgical endpoint of separation of mesorectum during total mesorectal excision (TME), suggesting the concept of "terminal line", in order to perform above separation better for middle-low rectal cancer.</p><p><b>METHODS</b>Gross anatomy of mesorectum endpoint from 81 surgical specimens of low anterior resection (LAR, 5 to 6 cm of distance from low margin of cancer to anal edge) and 71 surgical specimens of abdominal perineal resection(APR, <5 cm of distance from low margin of cancer to anal edge) was observed. Clinicopathological, magnetic resonance imaging(MRI) morphological and operative video data of 108 low rectal cancer patients undergoing TME at Department of Colorectal Surgery of Affiliated Union Hospital of Fujian Medical University between March 2016 and March 2017 were retrospectively analyzed. Rates of the "terminal line" exposure of TME between different surgical procedures(robot or laparoscope) and different anatomical instruments (ultrasonic knife or electric hook) were compared for evaluating the site of separation endpoint.</p><p><b>RESULTS</b>The gross anatomical findings of specimens from LAR showed that the rectal wall below the levator hiatus level had no mesorectum attachment, and gross anatomical finding of specimens from APR showed that the levator hiatus was the most terminal attachment margin of the mesorectum whose thickness was only 2 millimeters in levator hiatus level. MRI morphological findings of 108 low rectal cancer patients showed that high signal intensity of mesorectal tissue on T2 MRI gradually thinned to the level of levator hiatus. High quality laparoscopic and robotic operation revealed a white linear structure formed by pelvic fascia, which covered and surrounded levator hiatus, so the "terminal line" of TME was defined. The operation video of 108 revealed that the overall exposure rate of the "terminal line" was 45.4%, the exposure rate of "terminal line" in robotic surgery was similar to that in laparoscopic surgery [(60.0%(18/30) vs. 39.7%(31/78), P=0.058], while such rate in ultrasonic knife was superior to electric hook [55.4%(41/74) vs. 23.5%(8/34), P=0.002]. Laparoscopy combined with ultrasonic knife can also obtained a high exposure rate of 52.3%(23/44).</p><p><b>CONCLUSIONS</b>The white linear structure referring to pelvic fascia which covers and surrounds levator hiatus is the "terminal line" of TME. The use of an ultrasonic knife is easier to expose this structure and to guarantee the quality of TME.</p>

Clinical analysis on lymph node metastasis pattern in left-sided colon cancers / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the pattern of lymph node metastasis in patients with left-sided colon cancer in order to provide evidences for the choice of operation mode and the range of lymph node clearance.</p><p><b>METHODS</b>Clinical data of 556 cases with left-sided colon carcinoma undergoing surgical treatment in Department of Colorectal Surgery, Fujian Medical University Union Hospital from January 2000 to October 2014 were retrospectively analyzed. Among these patients, cancer of splenic flexure and transverse colon close to splenic flexure (splenic flexure group) was found in 41 cases, descending colon cancer in 73 cases(descending colon goup) and sigmoid colon cancer in 442 cases (sigmoid colon group), respectively; T1 was found in 29 cases, T2 in 63 cases, T3 in 273 cases, T4 in 191 cases. All the patients underwent D3 radical operation or complete mesocolic excision(CME). Para-bowel lymph node was defined as the first station, mesenteric lymph node as the second station, and lymph node in root of mesentery and around upper and inferior mesenteric arteries as the third station. Metastasis was compared among these 3 stations with regard to different sites and tumor invasions.</p><p><b>RESULTS</b>The total lymph node metastasis rate was 49.6%(276/556). The lymph node metastasis rates of splenic flexure, descending colon and sigmoid colon groups were 53.7%(22/41), 52.1%(38/73) and 48.9%(216/442) respectively without significant difference (P>0.05). The lymph node metastasis rates of the first, second, and third stations were 47.3%(263/556), 16.9%(94/556) and 5.8%(32/556) respectively with significant difference (χ(2)=287.54, P=0.000). In the first, second and third station, the lymph node metastasis rate was 13.8%(4/29), 0 and 0 in T1; 25.4%(16/63), 4.8%(3/63) and 3.2%(2/63) in T2; 45.8%(125/273), 14.7%(40/273) and 4.8%(13/273) in T3; 61.8%(118/191), 26.7%(25/191) and 8.9%(17/191) in T4 respectively. In splenic flexure group, metastasis rates were similar between No.222 and No.232[14.6%(61/41) vs. 12.2%(5/41), χ(2)=0.11, P=1.000] and between No.223 and No.253 [7.3% (3/41) vs. 2.4% (1/41), χ(2)=1.05, P=0.616]. In descending colon group, metastasis rate of No.232 was higher as compared to No.222[15.1%(11/73) vs. 2.7% (2/73), χ(2)=6.84, P=0.017]; metastasis rate of No.253 was slightly higher as compared to No.223 without significant difference [4.1%(3/73) vs. 0, χ(2)=3.06, P=0.245]. Metastasis rates of No.222 and No.223 in splenic flexure group were significantly higher than those in descending colon and sigmoid colon groups (χ(2)=5.69, P=0.025; Fisher exact test, P=0.044); While such rates of No.232(No.242 for sigmoid colon group) and No.253 were not significantly different among 3 groups respectively (χ(2)=0.90, P=0.660; χ(2)=1.14, P=0.611).</p><p><b>CONCLUSIONS</b>Left-sided colon cancers in T1 should undergo D2 radical operation, while cancers in T2 to T4 should undergo D3 radical operation. The D3 radical operation for splenic flexure cancers and cancers of transverse colon close to splenic flexure should clear No.223 and No.253. The D3 radical operation for descending colon cancer should clear No.222 and No.253. The D3 radical operation for sigmoid colon should clear No.253.</p>

Long-term outcome of neoadjuvant chemoradiotherapy based on the depth of invasion in mrT3 low rectal cancer / 中国肿瘤临床

Objective:To investigate the prognosis of cT3 and the subgroups of low rectal cancer patients who underwent neoadju-vant chemoradiotherapy (CRT) and evaluate whether all patients with cT3 low rectal cancer should undergo CRT. Methods:A total of 223 patients with cT3 low rectal cancer treated in the Department of Colorectal Surgery of Fujian Medical University Union Hospital from January 2008 to December 2012 were divided into neoadjuvant chemoradiotherapy group (CRT group) (115 cases) and no neoad-juvant chemoradiotherapy group (nCRT group) (108 cases) according to whether the patients underwent CRT. Afterward, the patients were retrospectively divided into three subgroups (mrT3a, mrT3b, and mrT3c) according to the proposed criteria of the Radiologic Soci-ety of North America (RSNA) by measuring the depth of mesorectal invasion (DMI) (DMI10 mm). The prog-noses of the two groups and their subgroups were compared. Results:The CRT and nCRT groups revealed no significant differences in the 3-year disease-free survival rate and the local recurrence rate for all the mrT3 patients (78.2%vs. 71.9%, P=0.608;4.4%vs. 8.5%, P=0.120) and mrT3a patients (82.4%vs. 81.8%, P=0.837;5.8%vs. 5.9%, P=0.658). On the contrary, for the mrT3b patients, the CRT and nCRT groups revealed significant differences in the 3-year disease-free survival rate (84.4%vs. 42.4%, P=0.032) and local recurrence rate (0.0%vs. 18.2%, P=0.014). For the mrT3b,c patients, the CRT and nCRT groups revealed no significant difference in the 3-year dis-ease-free survival rate (72.8%vs. 42.4%, P=0.060) but revealed a significant difference in the local recurrence rate (2.4%vs. 18.2%, P=0.021). COX regression analysis was utilized for 3-year disease-free survival, DMI and circumferential resection margin (CRM) were significant in the univariate analysis. Additionally, the multivariate analysis indicated that CRM is an independent impact factor (OR=2.249, CI 1.067-4.742, P=0.033). Conclusion:CRT can improve the prognosis of patients with mrT3b,c low rectal cancer but may not significantly influence the prognosis of patients with mrT3a and CRM-negative low rectal cancer;surgical treatment can be performed in these patients without CRT.

Extralevator abdominoperineal excision with transpelvic levator dissection: a report of 36 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the safety, feasibility, perioperational information and post-operational pathology of the modified abdominal operation of extralevator abdominoperineal excision (ELAPE), meaning transpelvic levator dissection under direct visualization.</p><p><b>METHODS</b>From January 2010 to March 2013, 36 patients with rectal tumors(≤5 cm distance to anal verge) underwent extralevator abdominoperineal excision with transpelvic levator dissection by laparoscopic or open surgery, without position change during the perineal operation. The preliminary result of this modified technique was summarized.</p><p><b>RESULTS</b>The levator ani muscles of all the patients were successfully dissected with transpelvic levator dissection and the extent of levator dissection was determined individually according to its involvement. No position was changed during the perineal operation. No conversion to open approach in laparoscopic surgery group was observed, and only 1 case of rectum perforation occurred in open surgery group. The mean operation time was (220.9±36.8) min, and mean intraoperative blood loss was(121.6±99.7) ml. All the specimens had levator ani muscles attached to the mesorectum and positive rate of circumferential resection margin was 5.6%(2/36).</p><p><b>CONCLUSIONS</b>Transpelvic levator dissection simplifies the procedure of ELAPE and achieves individualized dissection of levator. This technique is effective without position change during perineal operation, with shorter operation time and acceptable oncologic outcomes.</p>

Effects of different surgical approaches on Siewert Ⅱ adenocarcinoma of esophagogastric junction / 中华普通外科杂志

ObjectiveTo compare the effects of different surgical approaches on SiewertⅡ (esophageal invasion ≤3 cm) adenocarcinoma of esophagogastric junction.MethodsThis retrospective study included 251 cases of Siewert Ⅱ adenocarcinoma of esophagogastric junction undergoing D2 or D2 + total gastrectomy by transabdominal approach ( TA group, 128 cases) or left thoracoabdominal approach ( LTA group, 123 cases).Operation time,blood loss, extent of esophageal resection, number of lymph nodes dissected,morbidity, mortality and the survival rate were a analyzed between the two groups.ResultsThe 3,5-year overall survival rates were 62. 5％, 39.0％ ( TA group) and 54. 9％, 31.9％ ( LTA group),respectively (P ＞ 0. 05). Length of esophageal resection in the LTA group were slightly longer than that in the TA group (5. 6 ± 1.1) cm vs. (5.4 ± 1.1 ) cm (P ＜0. 05), the positive surgical margin between two groups were not statistically different[1.6％ ( LTA group) vs. 3. 1％ ( TA group), ( P ＞ 0. 05 )]. The mean number of removed lymph node were not significantly different between two groups[23.4 ± 8.7 ( TA group) vs. 23.7 ± 8.4 ( LTA group)], ( P ＞ 0. 05 ). The operation time (227 ± 24) min, blood loss (270 ± 78)ml, and perioperative morbidity( 13.3％ ) and mortality( 1.6％ ) in TA group was significantly better than the LTA group[(261 ±32) min, (342 ±59)ml, 26.8％, 6.5％](P＜0.05).ConclusionsFor Siewert Ⅱ adenocarcinoma at esophagogastric junction (esophageal invasion ≤3 cm) ,total gastrectomy with D2 or D2 + lymph node dissection through the transabdominal approach could achieve curative purposes, with a low morbidity and mortality rate.

Predictive Value of Microvessel Density and Blood Vessel Invasion in Hepatic Metastasis from Early-stage Rectal Cancer / 中国医科大学学报

Objective To explore the predictive value of microvessel density(MVD)and blood vessel invasion(BVI)in hepatic metastasis from early-stage rectal cancer.Methods MVD and BVI in the tumor tissue from 380 patients with stage I and II rectal cancer was determined by immunohistochemical S-P method with anti-CDIOS antibody and anti-CD34 antibody,respectively.Multinomial logistic regression was performed to analyze the predictive value of MVD and BVI in hepatic metastasis from early-stage rectal cancer.Results CD105 was expressed in newborn blood vessels,not in normal blood veseels.in the rectal cancer tissue.MVD was correlated with histological type and infiltration depth(P＜0.05).Besides histological type and infiltration depth,BVI was also correlated with histological grade.Multivariate analysis revealed that histological type,tumor infiltration depth,BVI,adjuvant therapy,and MDV were independent predictors of hepatic metastasis from rectal cancer.The risk of hepatic metastasis in patients with postive expression of either MVD or BVI or both were significant higher than that in patients with low expression of MVD and those without BVI expression[hazard ratio(95%CI),4.210(2.182-11.214)].Conclusion BVI and MVD are independent predictors of hepatic metastasis from stage I and II rectal cancer.Combined detection of MVD and BVI may help to predict the clinical outcome of patients with early-stage rectal cancer.

Factors analysis on liver metastasis from rectal cancer / 中国医师进修杂志

Objective To detect the clinical factors related with liver metastasis in young patients with rectal cancer.Methods Three hundred and fifty young patients with rectal cancer were collected to set up the database.Single and multi-factor Logistic regression was applied to indicate the independent factors relating to liver metastasis.The regression equation to predict probability of liver metastasis from rectal cancer was established.Results Liver metastasis was 120 cases (34.3%).Single-factor analysis revealed that patho-organization type,pathologytype,infiltration extent,blood vessel invasion (BVI),TNM stage,operation character,the preoperative level of carcino-embryonic antigen,histology grading were related with liver metastasis.Multi-factor analysis revealed that only BVI (P=0.001),TNM stage (P=0.001),pathoorganization type (P=0.005),the preoperative level of CEA (P=0.008) and operation character (P=0.032) were independent factors to predict probability of liver metastasis.Conclusions Rectal cancer of young patients who being with BVI,advanced phase,high preoperative level of CEA,radical operation or poor differentiation degree,are apt to develop liver metastasis.They should be given further individualized intensive adjuvant treatment.

Surgical treatment of benign ulcer of the gastric cardia: an experience from 21 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To study the result of surgical treatment of benign ulcer of the gastric cardia.</p><p><b>METHODS</b>Clinical symptom, number, position and size of ulcer, preoperative X-ray gastroscopic examine, type and complication of operation were retrospective analyzed in 21 patients with benign ulcer of the gastric cardia.</p><p><b>RESULTS</b>Average age in 21 patients was 60. Ulcer complicated bleeding in 7 cases (33.3%) and perforation in 5 cases (23.8%). Diagnostic rate of preoperative X-ray and gastroscopic examine was 57.1% and 100%, respectively. Of 21 patients 18 (85.7%) were treated by upper partial gastrectomy, and 3 (14.3%) by total gastrectomy. All were not operative death and anastomotic leak.</p><p><b>CONCLUSIONS</b>upper partial gastrectomy can resect focus of ulcer and decrease secretion of stomach acid. It is a simple and ideal pattern of operation for patients with benign ulcer of the gastric cardia.</p>

The therapeutic effect of total gastrectomy D2~+ procedure for the treatment of advanced cardiac cancer / 中国普通外科杂志

Objective To evaluate total gastrectomy and regular lymph node dissection for the treatment of advanced cardiac cancer. Methods Three hundred and eighty-seven patients with advanced cardiac cancer underwent total gastrectomy D2+ procedure. The relationships between depth of invasion, lymph node metastasis,the number of metastastic lymph nodes dissected and postoperative survival rate were analyzed. Results The 3-year and 5-year survival rates were 47.3% and 34.2% , respectively. Metastatic rate of N3 lymph node was 4. 8% and 15. 2% in advanced cardiac patients of PT3 and PT4, respectively. Survival rates significantly decreased along with the increase of lymph node metastasis. The 3-year and 5-year survival of patients who had less than 15 lymph nodes dissected was significantly poorer than those who had more than 15 lymph nodes dissected, respectively. The postoperative complication rate and mortality rate of the two groups were 14. 2% and 2. 52% , respectively. Conclution To improve the quality of life and survival rate, D2 + radical total gastrectomy should be performed for advanced cardiac cancer, and when indicated resection of spleen and/or body and tail of the pancreas should be performed.