Advances in preoperative treatment of colorectal cancer / 中华消化外科杂志

Preoperative treatment of colorectal cancer includes neoadjuvant therapy for initial resectable patients and conversion therapy for initial unresectable patients. In locally advanced rectal cancer, on the basis of neoadjuvant chemoradiotherapy or radiotherapy, increasing the intensity of concurrent chemotherapy, or raising postoperative adjuvant chemotherapy before surgery, or combining with immunotherapy can increase pathological downstaging, contribute to organ preservation, and improve survival of patients. In locally advanced colon cancer, neoadjuvant chemotherapy can improve surgical outcomes. In patients with resectable colorectal liver metastases, neoadjuvant chemotherapy is recommended in patients with unfavorable prognostic factors, but it remains controversial whether it should be combined with targeted therapy. However, in patients with initially unresectable colorectal liver metastases, under the guidance of molecular typing, chemotherapy, especially triple-drug chemotherapy, combined with targeted therapy, is expected to achieve higher objective response rate and convertible rate, thus accepting surgical resection, which improves long-term survival. In addition, for the patients with mismatch repair deficient/micro-satellite instability-high metastatic colorectal cancer, programmed death-1 monoclonal antibody (mAb) and/or cytotoxic T lymphocyte-associated antigen-4 mAb have become the standard first-line treatment option.

Risk factors for lymph node metastasis in T1 colorectal cancer and application value of its nomogram prediction model / 中华消化外科杂志

Objective:To investigate the risk factors for lymph node metastasis in T1 colorectal cancer and application value of its nomogram prediction model.Methods:The retrospective case-control study was conducted. The clinicopathological data of 914 patients with T1 colorectal cancer who underwent radical resection in the Zhongshan Hospital of Fudan University from June 2008 to December 2019 were collected. There were 528 males and 386 females, aged from 25 to 87 years, with a median age of 63 years. Observation indicators: (1) clinicopathological data of patients with T1 colorectal cancer; (2) follow-up; (3) analysis of influencing factors for lymph node metastasis; (4) development and internal validation of a nomogram predition model. Patients were regularlly followed up once three months within postoperative 2 years and once six months thereafter to detect tumor recurrence and survival. The endpoint of follow-up was at postoperative 5 years. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M (range). Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. The Kaplan-Meier method was used to calculate survival rates and draw survival curves. The Log-rank test was used for survival analysis. Univariate and multivariate analyses were performed using the Logistic regression analysis. Based on results of multivariate analysis, a Logistic regressional nomogram for prediction of lymph node metastasis probability was constructed using R language software. The calibration curve was used to evaluate the consistency between probability predicted by the nomogram model and actual observation probability, which was reprensented by a consistency index. The Bootstrap method was used for evaluation of the model performance to receive the calibration curve. The Hosmer-Lemeshow test was used to calculate the goodness of fit in model. Results:(1) Clinicopathological data of patients with T1 colorectal cancer: 687 of 914 patients underwent direct surgery and 227 underwent remedial operation after endoscopic resection. All the 914 patients were confirmed as pT1NxM0 colorectal cancer by pathological examination. The tumor diameter was (2.3±1.2)cm. The pathological catogaries of 914 patients included 865 cases of adenocarcinoma and 49 cases of mucinous adenocarcinoma. The tumor differentiation degree of 914 patients included 727 cases of high or middle differentiation and 187 cases of low differentiation or undifferentiation. Of the 914 patients, 633 cases had submucosal infiltration depth ≥1 000 μm and 281 cases had submucosal infiltration depth <1 000 μm. There were 110 cases with nerve vessel invasion and 804 without nerve vessel invasion. The number of intraoperative lymph node dissection was 13 (range, 1-48). There were 804 cases in stage N0 of N staging, 98 cases in stage N1 and 12 cases in stage N2. There was no perioperative death. (2) Follow-up: 886 of 914 patients were followed up for 25 months (range, 1-129 months). During the follow-up, 24 patients had tumor recurrence or metastasis. The 5-year cumulative tumor recurrence rate of 914 patients was 4.8% and the median recurrence time was 17.0 months. Liver was the main site of tumor recurrence, accounting for 58.3%(14/24). The 5-year recurrence-free survival rate of 914 patients was 95.2%. The 5-year recurrence-free survival rate was 96.3% of 804 patients without lymph node metastasis, versus 86.6% of 110 patients with lymph node metastasis, showing a significant difference between the two groups ( χ2=6.83, P<0.05). (3) Analysis of influencing factors for lymph node metastasis: results of univariate analysis showed that preoperative carcinoembryonic antigen (CEA), preoperative CA19-9, tumor differentiation degree, submucosal infiltration depth, nerve vessel invasion were related factors for lymph node metastasis in T1 colorectal cancer ( odds ratio=2.56, 3.25, 2.21, 2.68, 3.39, 95% confidence interval as 1.41-4.67, 1.22-8.66, 1.43-3.41, 1.56-4.88, 2.10-5.48, P<0.05). Results of multivariate analysis showed that preoperative CEA ≥5 μg/L, preoperative CA19-9 ≥37 U/mL, poor differentiation or undifferentiation, submucosal infiltration depth ≥1 000 μm and nerve vessel invasion were independent risk factors for lymph node metastasis in T1 colorectal cancer ( odds ratio=2.23, 3.47, 2.01, 2.31, 2.91, 95% confidence interval as 1.02-4.15, 1.08-10.87, 1.03-3.27, 1.40-4.47, 1.64-5.13, P<0.05). (4) Development and internal validation of a nomogram predition model: based on results of multivariate Logistic analysis, a nomogram prediction model for lymph node metastasis in T1 colorectal cancer was developed. The nomogram score was 59 for preoperative CEA >5 μg/L, 100 for preoperative CA19-9 ≥37 U/mL, 48 for poor differentiation or undifferentiation, 67 for submucosal infiltration depth ≥1 000 μm and 92 for nerve vessel invasion, respectively. The total of different scores for different clinicopathological factors corresponded to the probability of lymph node metastasis. The receiver operating characteristic curve was drawed to evaluate the predictive performance of nomogram for lymph node metastasis in T1 colorectal cancer, with the area under curve of 0.70(95% confidence interval as 0.64-0.75, P<0.05). The Bootstrap internal validation of predictive performance in the nomogram predition model showed a consistency index of 0.70 (95% confidence interval as 0.65-0.75). The calibration chart showed a good consistency between the probability predicted by the nomogram model and actual probability of lymph node metastasis. The Hosmer-Lemeshow test showed a good fitting effect in model ( χ2=1.61, P>0.05). Conclusions:Preoperative CEA ≥5 μg/L, preoperative CA19-9 ≥37 U/mL, poor differentiation or undifferentiation, submucosal infiltration depth ≥ 1 000 μm and nerve vessel invasion are independent risk factors for lymph node metastasis in T1 colorectal cancer. The constructed nomogram model can help predict the probability of lymph node metastasis in T1 colorectal cancer.

Moderating effect of sleep quality on the relationship between problematic mobile phone use and anxiety of college students / 中国学校卫生

Objective@#To describe the prevalence of problematic mobile phone use and anxiety in college students, and explore the mediating effect of sleep quality on the relationship between problematic mobile phone use and anxiety, and to provide reference for physical and mental health promotion of college students.@*Methods@#One medical college and a comprephensive college were selected in Hefei city of Anhui Province and Shangrao City of Jiangxi Province, respectively, and a cross-sectional survey was conducted. A total of 1 135 valid questionnaires were collected. The self-rating questionnaires regarding basic information of college students, use the Self-rating Questionnaire for Adolescent Problematic Mobile Phone Use(SQAPMPU) and the Self-Rating Questionnaire for Depression-Anxiety-Stress for Adolescent Problematic Mobile Phone Use(DASS-21) was used to evaluate problematic mobile phone use and anxiety, respectively. The Pittsburgh Sleep Quality Index(PSQI) was used to evaluate sleep quality.@*Conclusion@#The detection rates of college students with problematic mobile phone use and poor sleep quality were 24.6% and 13.3%, respectively. The detection rates of college students anxiety grouped by severity were 5.1%, 23.9%. Multiple Logistic regression analysis showed a positive linear correlation between problematic mobile phone use and anxiety[OR values(95%CI) were 1.86(1.01-3.44), 4.34(3.14-5.99), P<0.01]. The results of process showed that sleep quality played a moderating role between problematic mobile phone use and anxiety(R2=0.37, F=220.52, P<0.01). Interaction term s β=0.09(P<0.05).@*Conclusion@#The prevalence of problematic mobile phone use is high in college students, and problematic mobile phone use is positively related to anxiety. Good sleep quality can alleviate the relationship between mobile phone dependence and anxiety of college students.

Overall management strategies for colorectal cancer patients during the COVID-19 outbreak / 中华消化外科杂志

The Corona Virus Disease 2019 (COVID-19) since December, 2019 has a wide range of infection due to the strong infectious characteristics. Both medical staff and patients are at increased risk of infection. It is an urgent clinical problem for specialist doctors to work with diagnosis and treatment of cancer patients during the epidemic situation. Based on the colorectal cancer diagnosis and treatment guidelines (2019 CSCO guideline), combined with their own experience, the authors propose the overall management strategies for colorectal cancer patients. This strategies cover the key diagnosis and treatment of colorectal cancer, and provide targeted clinical practice. These work will be helpful for colorectal cancer specialists to carry out the diagnosis and treatment of colorectal cancer effectively under the epidemic of COVID-19.

Application and study on blended learning in practical training of acupuncture techniques / 中华医学教育探索杂志

Objective To explore the effect of blended learning in practical training of acupuncture techniques.Methods Sophomores of acupuncture and Tuinaspeciality were divided into two groups based on classes,with 38 students in experimental group and 34 in control group,adopting blended learning and traditional method in teaching acupuncture techniques respectively.Blended learning mainly adopts mixed methods of both online "punch-card" on WeChat community and offline class learning.Post-test score of two groups were compared by independent samples t-test with SPSS 19.0.The teaching effect of blended learning was evaluated in students in experimental group by questionnaire survey.Results The total score of acupuncture techniques (4.73 ± 0.15) in experimental group were significantly higher than that of control group (4.27 ± 0.46) (t=5.588,P＜0.01) and students' satisfaction concerning the blended learning in experimental group was up to 88％ (22/25).Conclusion Blended learning can promote students' acupuncture skills and cultivate good study habits,making practice in class more targeted.More friendly online learning tools needs to be further developed.

China Guideline for Diagnosis and Comprehensive Treatment of Colorectal Liver Metastases (Version 2018) / 中华胃肠外科杂志

The liver is the most common anatomical site for hematogenous metastases of colorectal cancer, and colorectal liver metastases is one of the most difficult and challenging points in the treatment of colorectal cancer. In order to improve the diagnosis and comprehensive treatment in China, the Guidelines have been edited and revised for several times since 2008, including the overall evaluation, personalized treatment goals and comprehensive treatments, to prevent the occurrence of liver metastases, improve the resection rate of liver metastases and survival. The revised Guideline includes the diagnosis and follow-up, prevention, MDT effect, surgery and local ablative treatment, neoadjuvant and adjuvant therapy, and comprehensive treatment, and with advanced experience, latest results, detailed content, and strong operability.

New progression and direction of translational medicine on colorectal cancer / 中华消化外科杂志

Translational medicine is characterized by its close association with precision medicine in the field of colorectal cancer.In particular,the studies of life histology promote the prevention and treatment of colorectal cancer entered the stage of precision medicine.Accurate molecular typing of colorectal cancer has been used to guide clinical practice is an important breakthrough in the field of colorectal cancer translational medicine in recent years,and its clinical value has been verified.As an important tool for the effective integration of clinical data and life histology data,the biomedical big data platform is expected to contribute to the continued breakthrough of translational medicine in precision molecular typing.New treatment methods,such as liquid biopsy technology with non-invasive,flexible features can be dynamically detected as soon as possible to find the state of somatic mutations.Among them,circulating tumor DNA has a good detection sensitivity and specificity,highlighting the value of early recurrence monitoring.In addition,new therapeutic strategies,such as immunological checkpoints and chimeric antigen receptor genetically modified T-cell therapy,are under intense study in the field of colorectal cancer.Based on the biomedical big data analysis in the context of the precise molecular typing,dynamic liquid biopsy monitoring technology,new immunotherapy and other fields will be the future of colorectal cancer translational medicine research hot and breakthrough direction.

The significance of combined detection of P-selectin, TM and vWF in early prediction of severe acute pancreatitis / 中华内分泌外科杂志

Objective To investigate the value of P-selectin,thrombomodulin (TM) and von Willebrand factor (vWF) in identifying severe acute pancreatitis (SAP) at an early stage of the disease.Methods 80 patients with acute pancreatitis (25 mild,30 moderate and 25 severe) were selected in this study when they were admitted within 24 hours of the onset of symptoms.20 healthy volunteers were collected as the healthy control.Enzyme-linked immunosorbent assay (ELISA) was used to determine the levels of vascular endothelial cell damage markers (P-selectin,TM and vWF) in SAP patients and the control group.Results The levels of 3 markers were significantly higher in SAP patients than in the mild and moderate acute pancreatitis patients and healthy volunteers (P＜0.05).P-selectin,TM and vWF were independent markers for the development of SAP and had higher discriminative powers than conventional marker tumor necrosis factor(TNF-α)(P＜0.05).They were similar to the APACHE-Ⅱ scoring system in distinguishing SAP at an early stage.Conclusions P-selectin,TM and vWF are independent markers to identify the development of SAP at an early stage.They are obviously superior to TNF-α and similar to the APACHE-Ⅱ scoring system.

Advances in colorectal cancer research from 2017 annual meeting of Chinese Society of Clinical Oncology / 中华消化外科杂志

There are several progresses in colorectal cancer research from 2017 annual meeting of Chinese Society of Clinical Oncology (CSCO).(1) Phase Ⅲ multi-center trial FRESCO and TERRA study have showed domestic new drug Fruquintinib and Japanese oral combination anti-cancer drug TAS-102 significantly improved overall survival (OS) comparing to placebo in third-line metastatic colorectal cancer (mCRC) patients.(2) Preoperative neoadjuvant chemotherapy with mFOLFOXIRI and selective radiotherapy or concomitant boost neoadjuvant chemoradiotherapy (nCRT) followed by one cycle of XELOX,can improve short-term outcome for locally advanced rectal cancer,and clinical and pathological features can be used to predict complete response following nCRT.(3) In asymptomatic elderly population,the specificity of septin9 methylation detection in plasma cfDNA as colorectal cancer screening is low,but the probability of negative predictions as non-colorectal cancer is high.And integrated signature of the gut microbiome and metabolome serves as diagnostic biomarkers in patients with colorectal cancer.(4) Immunoscore system predicts prognosis after liver metastasectomy in colorectal metastases,and the immune signature difference between right and left colon cancer could explain the difference of targeted therapy.

Study of variation and correlation of serum IL-6 level and intra-abdominal pressure before and after early continuous veno-venous hemofiltration in severe acute pancreatitis patients with abdominal compartment syndrome / 中华内分泌外科杂志

Objective To investigate the effect of early continuous veno-venous hemofiltration (CVVH) on intra-abdominal pressure (IAP) and serum interleukin-6 (IL-6) in severe acute pancreatitis (SAP) patients with abdominal compartment syndrome (ACS).Methods 41 SAP patients with ACS were selected as treatment group and treated with CVVH as well as conventional methods in ICU.The other 12 patients with the same disease were selected as the control group and were only treated with conventional methods because of economic reasons.IAP and blood level of IL-6 in the two groups were measured daily in order to investigate their changes and the correlation between the two parameters.Results The serum IL-6 level and IAP in the two groups were higher on admission day.IAP and serum IL-6 level in the treatment group were significantly decreased on the first day after treatment,and thereafter decreased rapidly.In the control group,IAP and serum IL-6 level were significantly decreased on the 3rd day after treatment.IAP and serum IL-6 level from the 1st day to the 6th day after treatment in the treatment group were significantly lower than those of the control group at the same time point (P＜0.05).There was a significant positive correlation between blood IL-6 level and IAP in SAP patients with ACS(r=0.48,P＜0.01).IL-6 difference before and after treatment was also positively correlated with the difference of IAP(R=0.39,P＜0.05).Conclusions VVH significantly decreased the IAP and the blood level of IL-6 in ACS patients of SAP.The blood level of IL-6 is significantly correlated with IAP,suggesting that IL-6 may play an important role in the pathogenesis of ACS.Therefore early CVVH may clear the cytokines such as IL-6 and lower IAP,thus to prevent multiple organ dysfunction syndrome (MODS),which should be applied in the early stage of ACS.

Clinical bottlenecks of individual diagnosis and treatment of colorectal cancer and breakthrough strategies / 中华消化外科杂志

The incidence and mortality of colorectal cancer (CRC) increased rapidly in recent decades and become enormous challenges in China.Lack of effective early warning of molecular markers and dynamic monitoring technology in term of early diagnosis,treatment evaluation,dynamic recurrence and metastasis monitoring are the clinical diagnosis and treatment bottlenecks of CRC.Traditional diagnosis and treatment of CRC rely on a single level of patient information with low accuracy.Based on the system of biology medical model,to carry out a joint diagnostic model,will overcome the traditional problems through a number of multi-level information integration of the joint diagnosis model,will significantly improve the sensitivity and specificity of diagnosis of CRC.The major challenge in patients with advanced and metastatic CRC is the instability of the tumor genome and the treatment-induced resistance during chemotherapy and targeted therapy.It is necessary to carry out continuous dynamic biopsy in order to accurately guide the development of treatment decisions.Compared with the pathological examination of traditional surgical specimen,liquid biopsy,such as circulating tumor cells,circulating tumor DNA detection technology,with noninvasive,real-time dynamic monitoring,could evaluate the efficacy of treatment,and guide the precise individual diagnosis and treatment.Today,the new strategy and new technology need to undergo clinical trials urgency,through technology optimization,reduction of costs and improvement of detection accuracy,would quickly extended to clinical applications in future.

Establishment of an Examination and Assessment System of Filiform Needle Manipulation / 上海针灸杂志

Filiform needle acupuncture technique is the core content of needling and moxibustion method. The examination and assessment of filiform needle manipulation are the most important measure for testing the effect of filiform needle acupuncture technique teaching. The establishment of a scientific examination and assessment system of filiform needle manipulation should involve comprehensive examination and assessment contents, definite and detailed evaluation rules and quantified scoring criteria to make the examination and assessment system be able to comprehensively and objectively assess the students' skills of filiform needle manipulation to achieve the purpose of improving the quality of filiform needle acupuncture technique teaching.

Surgical treatment of colorectal liver metastases / 中华外科杂志

Surgical resection of the metastases offers the only opportunity for long-term survival in colorectal liver metastases. However, only 10% to 20% of patients present with resectable disease, and so how to increase surgical patients has been a clinical hotspot. In addition to expanding surgical indications, two-stage hepatectomy and convertible therapy are optional. In convertible therapy, initial treatment regimen decides long-term benefit, and it is important to select appropriate patient population in addition to Ras status when anti-epithelial growth factor receptor monoclonal antibody is used. Minimally invasive surgery can also be used for liver resection and simultaneous resection, and it is safe and effective. For patients with colorectal cancer and unresectable asymptomatic liver metastases, the debate continues over the efficacy of primary resection compared to chemotherapy alone, limited by lack of prospective evidence. Therefore, multidisciplinary team assessment is essential to optimize outcomes in colorectal liver metastases.

Survival and late effects of comprehensive treatment on children with neuroblastoma / 中华实用儿科临床杂志

Objective To investigate the organ function survival and late effects and secondary malignancy of childhood neuroblastoma (NB) with high intensity comprehensive treatment.Methods A total of 23 children with NB who received comprehensive treatment in Shanghai Children's Medical Center from December 1998 to October 2010 were enrolled.All tests were formulated according to the Children's Oncology Group (COG)'s guidelines with the approval of parents.The late side effects were graded by CTCAE v3.0,and hearing loss related to platinum was graded by Brock and Chang.Results The median follow-up was 96 (65-170) months.All the patients had at least one late side effect.The occurrence rate of 1-2 adverse effects was 100％,and 17.4％ (4/23 cases) of patients had grade 3-4 adverse effects.90.5％ of children (19/21 cases)developed hearing loss on both sides.Eleven children (52.4％,11/21 cases) developed dental abnormities,comprising microdontia,missing teeth,root stunting and enamel hypoplasia.9.5％ of children (2/12 cases) had scoliosis.42.8％ of children (9/12 cases) developed hypogonadism with the approval of parents or delayed growth.47.4％ of children (9/19 cases) had abnormal respiratory function.36.8％ of children (7/19 cases)had abnormal cardiac function.33.4％ of children (7/21 cases)developed renal damage.23.8 ％ of children (5/21 cases) had abnormal liver function.66.7％ of children (14/21 cases) had low level of cortisol,but adrenocorticotrophic hormone was normal.All children had normal function of thyroid.Three children developed secondary malignancy:leukemia,malignant fibroma and liver tumor.Conclusions The incidence of long-term adverse reactions of patients with neuroblastoma treated with high intensity comprehensive treatment is very high and the patients may have adverse effects,like hearing loss,dental abnormality,cardiopulmonary function abnormality,musculoskeletal problems and secondary malignancy.The upmost importance is to establish long-term follow-up program to detect the life quality of children and amend current therapeutic schemes improve life quality.

Application of robotic surgical system in sphincter-preserving surgery for low rectal cancer / 中华胃肠外科杂志

Robotic surgical system has been widely applied in sphincter-preserving surgery for low rectal cancer with the advantages of clear 3D images and stably flexile manipulation. Its application principle includes radical resection of tumor and complete preservation of function. The main operation procedures of robotic surgical system in sphincter-preserving surgery for low rectal cancer are as follows: (1) Anterior resection of low rectal cancer: It is safe and feasible and has obvious advantages in observation of pelvic nerves, dissociation of presacral and sacral side, and high rate of sphincter-preserving, while the improvement of postoperative recovery and long-term survival needs to be verified by further large sample researches. (2) Per anus intersphincteric resection (ISR): It is mainly applied in T1 and T2 stage tumors with 2 cm distance from tumor low margin to anal edge after dissociation of mesorectum. The greater difficulty of manipulation is found in ISR, while robotic surgical system can complete the intersphincteric resection by transabdominal approach, but anal function may be affected with the possibility of feces spillage at night, so robotic ISR is now still in exploration stage. (3) Transanal everted pull-through resection (Welch resection): Associated application of this operation is rarely reported at home and abroad. Our department has completed 51 robotic procedures of Welch resection till March 2017. Welch resection is successfully performed in all the patients. The short-term clinical outcomes are quite satisfactory and long-term survival is followed up. We think that this procedure is safe and feasible under the strict mastering of indications. Owing to special manipulation advantages of quickly precise dissociation, cutting and anastomosis in small pelvic space, when compared to laparoscopic surgery, robotic surgical system has higher sphincter-preserving rate for low rectal cancer, however, no other advantages are found. We believe that with the development of surgical instruments and ongoing of large sample studies, robotic surgical system will play a more important role in the treatment of low rectal cancer.

Multidisciplinary team improves the comprehensive quality of colorectal surgeons / 中华胃肠外科杂志

Colorectal cancer is a systemic disease that requires multidisciplinary treatment. The comprehensive quality of colorectal surgeon directly impacts on the efficacy of diagnosis and treatment of colorectal cancer. Multidisciplinary teams help surgeons enhance their ability of evidence-based medicine, improve the quality of main specialty, expand the knowledge of other specialty, enhance the doctor-patient communication, and increase the research level. Thus, multidisciplinary teams can improve the comprehensive quality of colorectal surgeons.

Study on flipped classroom in teaching of “auricular needling method” / 中华医学教育探索杂志

Objective To explore the effect of flipped classroom in teaching auricular needling method. Methods Sophomores of acupuncture and Tuina speciality were divided into two groups based on classes, with 33 students in experimental group and 30 in control group. In teaching auricular needling method, experimental group adopted flipped classroom by online resources and classroom activities, while control group adopted traditional classroom such as teaching, watching video, demonstration. Post-test score of two groups were compared by independent samples t-test. The teaching effect of flipped classroom was evaluated by questionnaire survey of students in experimental group. Results The total score of auricular needling (88.4±13.91), score of location (55.40±7.34), and score of application (32.00±10.31) in experi-mental group were significantly higher than those in con-trol group (71.48±15.93, 47.55±12.23 and 23.94± 11.97) (P<0.05). Students' satisfaction concerning the flipped classroom in experimental group was up to 90%. Conclusion Flipped classroom can be used in teaching auricular needling method, which can improve teaching quality and promote improvement of students' self-study and communication skills.

Application of enhanced recovery after surgery in minimally invasive colorectal surgery / 中华胃肠外科杂志

ERAS combines modern anesthesia, pain control, and nutritional support technologies, and contains a series of evidence-based perioperative optimization measures, including preoperative preparation, intraoperative anesthesia and postoperative care, to reduce surgical stress and enhance recovery. Several clinical studies and meta-analysis have demonstrated that ERAS can accelerate postoperative rehabilitation in colorectal patients. In addition, minimally invasive colorectal surgery has the advantages of less trauma, less bleeding, and faster postoperative recovery, compared with open surgery. It has become the standard operation for colon resection. Recently 3D laparoscopic and robotic colorectal surgery, which overcomes limitations of conventional laparoscopic surgery, is increasingly used. Therefore, whether ERAS combined with minimally invasive colorectal surgery causes a cumulative advantage receives much concern. A number of studies and meta-analysis have demonstrated that ERAS combined with laparoscopic colorectal cancer surgery can shorten the length of hospital stay and reduce the incidence of complications, as the best perioperative plan for elective colorectal surgery.

Prevention and control of postoperative anastomotic leak after colorectal anastomosis / 中华胃肠外科杂志

Anastomotic leak is a major complication after colorectal resection. Risk factors for anastomotic leak include patient and disease related factors, preoperative factors(e.g. use of neoadjuvant chemoradiation and mechanical bowel preparation), intraoperative factors(e.g. anastomotic techniques, performing of water injection test, preventive colostomy, and surgical procedures, etc; postoperative factors, such as postoperative medication use, etc. Early diagnosis of anastomotic fistula is crucial, which can be made by combining laboratory examination with imaging examination or take the prediction and diagnosis model as reference. Once diagnosed, anastomotic leak should be managed immediately according to individual status and severity of disease. As for intraperitoneal anastomosis, no matter whether the bowel lack of blood supply or not, original anastomosis should be removed and terminal loop ileumstomy should be created. As for extraperitoneal anastomosis(mainly low rectal anastomosis), adequate drainage and terminal loop ileumstomy can be considered when anastomosis is slightly cracked or invisible due to adhesion. When anastomosis is severely cracked or blood supply is too limited, however, we must disconnect the original anastomotic and create a proximal colostomy.

Robotic surgery for colorectal cancer in elderly patients / 中华胃肠外科杂志

The outstanding advantages of robotic surgery include the stable and three-dimension image and the convenience of surgery manipulation. The disadvantages include the lack of factile feedback, high cost and prolonged surgery time. It was reported that robotic surgery was associated with less trauma stress and faster recovery in elderly patients(≥75 years old) when compared with open surgery. Elderly people have a higher incidence of carcinogenesis and also have more comorbidities and reduced functional reserve. Clinical data of patients over 75 years old treated by robotic surgery in Zhongshan Hospital affiliated to Fudan University from March 2011 to October 2014 were analyzed retrospectively. A total of 24 consecutive patients were included with a median age of 77.8 years old. There were 18 male and 6 female patients. Among them, 14 patients were diagnosed with descending and sigmoid colon cancers while 10 with rectal cancers; 19 had tumor size larger than 5 cm; 16 were diagnosed with ulcerative adenocarcinoma. Fourteen patients were complicated with hypertension, 6 with cardiopulmonary diseases, 4 with diabetes mellitus and 3 with cerebrovascular diseases. Twenty-two patients underwent low anterior resection and 2 abdominoperineal resection. The estimated blood loss was 85 ml; the median operation time was (123.1±45.2) min; the median number of retrieved lymph node was 12.4. Postoperative pathologic results showed that 3 patients were stage I, 10 stage II, and 11 stage III. Postoperative complication was observed in 3 patients: urinary infection in 1 case, intraperitoneal infection in 1 case and atria fibrillation in 1 case, respectively. Median time to first postoperative flatus was 2.8 days. Our results indicated that robotic surgery is safe and feasible in the elderly patients. The next generation of robotic system may make up for these deficiencies through new technologies. With the advantage of more advanced surgical simulator, robotic surgery will play a more important role in the treatment of colorectal cancer patients.