Incidence and influencing factors of anastomotic leakage after laparoscopic anterior resection for rectal cancer / 中华消化外科杂志

Objective:To investigate the incidence and influencing factors of anastomotic leakage after laparoscopic anterior resection for rectal cancer.Methods:The retrospective case-control study was conducted. The clinicopathological data of 804 patients with rectal cancer who were admitted to Peking Union Medical College Hospital of Chinese Academy of Medical Sciences from January 2017 to December 2019 were collected. There were 521 male and 283 female, aged 63(range, 27-94)years. All 804 patients underwent laparoscopic anterior resection for rectal cancer. Observation indicators: (1) surgical situations; (2) incidence of postoperative anastomotic leakage; (3) follow-up; (4) influencing factors of postoperative anastomotic leakage; (5) subgroup analysis. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the independent sample t test. Measurement data with skewed distribu-tion were represented as M(range), and comparison between groups was conducted using the Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was conducted using the chi-square test or Fisher exact probability. Univariate analysis was conducted using the chi-square test or independent sample t test. Factors with P≤0.2 in univariate analysis were included in multivariate Logistic regression analysis. Results:(1) Surgical situations. All 804 patients underwent laparoscopic radical resection of upper and middle rectal cancer successfully, with the operation time and volume of intraoperative blood loss as 135(range, 118-256)minutes and 30(range, 5-350)mL. All 804 patients completed end-to-end colon rectal anastomosis, including 287 patients with reinforced sutures at the anastomotic site, and 517 patients with routine anastomosis. (2) Incidence of postoperative anastomotic leakage. Of the 804 patients, 40 patients had postoperative anastomotic leakage, with the incidence rate as 4.98%(40/804). (3) Follow-up. All 804 patients were followed up for 32(range, 6-49)months. None of patient died during the perioperative period. (4) Influencing factors of postoperative anastomotic leakage. Results of multivariate analysis showed that unreinforced suture at the anastomotic site was an independent risk factor for postoperative anastomotic leakage ( odds ratio=2.78, 95% confidence interval as 1.21-6.37, P<0.05). (5) Subgroup analysis. Of the 804 patients, 202 patients received neoadjuvant therapy and 602 patients did not receive neoadjuvant therapy. Of the 602 patients who did not receive neo-adjuvant therapy, cases with postoperative anastomotic leakage was 6 in the 253 patients with reinforced sutures, versus 21 in the 349 patients with routine sutures, showing a significant difference between them ( χ2=4.56, P<0.05). Conclusion:Unreinforced anastomosis at the anasto-motic site is an independent risk factor for anastomotic leakage after laparoscopic anterior rectal resection, especially for rectal cancer patients without neoadjuvant radiochemotherapy.

Safety and feasibility of right colectomy via a transvaginal approach: early experience from a single center / 中华胃肠外科杂志

Objective: To investigate the safety and feasibility of performing right colectomy via a transvaginal approach. Methods: This was a retrospeltive cohort study. Data of 30 patients who had undergone transvaginal laparoscopic right colectomy (transvaginal group) and 23 women who had undergone laparoscopic right colectomy (laparoscopic group) from January 2019 to March 2022 in the Division of Colorectal Surgery, Department of General Surgery, Peking Union Medical College Hospital were collected retrospectively. The inclusion criteria for the transvaginal group were as follows: (1) post-menopausal woman; (2) transverse diameter of the tumor < 6 cm; and (3) diagnosis of benign polyps that were unresectable by endoscopy, mucinous tumors of the appendix, or confirmed right colon cancer not requiring D3 lymphadenectomy. The inclusion criteria for the laparoscopic group were as follows: (1) pathologically confirmed adenocarcinoma or high-grade intraepithelial neoplasia; (2) lesion located from the cecum to the right third of the transverse colon; and (3) clinically stage T1-4NanyM0. The exclusion criteria for the laparoscopic group were as follows: (1) distant metastasis discovered during surgical exploration; (2) multiple organ resection required or R0 resection not possible; or (3) conversion to open surgery required. Safety was evaluated on the basis of intra- and post-operative complications. Feasibility was assessed by postoperative recovery and quality of operative specimen. The body mass index was lower in the transvaginal than the laparoscopic group (22.0±3.1 kg/m2 vs. 24.1±2.6 kg/m2, t=2.617, P=0.012). Results: Among the 30 transvaginal laparoscopic right colectomies, 26 were pure transvaginal surgeries, three required laparoscopic assistance because of difficulties with anastomosis (n=2) or abdominal adhesions (n=1), and one required conversion to laparoscopic surgery because of vascular injury. Compared with the laparoscopic group, the transvaginal group had a longer surgery time (175.0 [147.5, 216.3] minutes vs. 120.0 [100.0, 120.0] minutes, U=63.000, P<0.001) and more blood loss (30.0 [10.0, 50.0] ml vs. 23.0 [10.0, 20.0] ml, U=208.000, P=0.011). The incidence of intraoperative complications (16.7% [5/30) vs. 0, P=0.061] was comparable between the two groups. In the transvaginal group, the sites of intraoperative injuries were bladder (n=3), ileocecal artery (n=1), and right uterine artery (n=1). The incidence of postoperative complications (20.0% [6/30] vs. 17.4% [4/23], χ2<0.001,P>0.999) was also comparable between the two groups. Clavien-Dindo grade III postoperative complications occurred in two patients in the transvaginal group (one patient had a pelvic hematoma that required embolization; the other had a vesico-vaginal fistula that required surgery). Postoperative visual analogue scale scores were significantly lower (P<0.001) in the transvaginal group. Times to first flatus, ambulation, and first intake and duration of postoperative hospital stay were comparable between the two groups (P>0.05). The proportion of specimens of moderate quality was 83.3% (25/30) in the transvaginal group and 100% (23/23) in the laparoscopic group; this difference is not significant (P=0.061). Among patients who underwent D2 lymph node dissection, the number of lymph nodes examined was comparable between the transvaginal (n=23) and laparoscopic groups (n=7) (18 [15, 27] vs. 20 [16, 29], U=69.500, P=0.589). Conclusion: Transvaginal right colon surgery is associated with less postoperative pain than laparoscopic surgery, but is not yet the preferred alternative because of the incidence of surgical complications.

Analysis of influencing factors and clinical value of anterior peritoneal reflection for patients with rectal cancer / 中华外科杂志

Objectives: To investigate the factors influencing the height of anterior peritoneal reflection (APR) for patients with rectal cancer, and to analyze the relationship between the APR and the lateral lymph node metastasis. Methods: Clinical data of 432 patients with tumor located within and below APR were retrospectively collected from the rectal cancer database at the Department of General Surgery, Peking Union Medical College Hospital from August 2020 to September 2022. Ninty-eight non-rectal cancer patients were also enrolled as a control group. There were 308 males and 124 females in the tumor group, aged (M(IQR)) 62 (16) years (range: 24 to 85 years) and 53 males and 45 females in the control group, aged 60 (22) years (range: 27 to 87 years). The APR height, pelvis, and tumor-related parameters were measured by MRI. A multifactor linear regression model was established to analyze the dependent correlation factors of APR height. These factors of the two groups were matched by propensity score matching and their APR heights were compared after matching. An ordinal Logistic regression model was established to explore the relationship between APR-related parameters and radiographic lateral lymph node metastasis. Results: The APR height of the tumor group was (98.7±14.4) mm (range: 43.3 to 154.0 mm) and the control group was (95.1±12.7) mm (range: 68.0 to 137.9 mm). Multivariable linear regression revealed that the greater the weight (B=0.519, 95%CI: 0.399 to 0.640, P<0.01), the anterior pelvic depth (B=0.109, 95%CI: 0.005 to 0.213, P=0.039) and the smaller the bi-ischial diameter (B=-0.172, 95%CI:-0.294 to -0.049, P=0.006), the higher the APR height. The tumor group had a higher APR height than the control group after propensity score matching ((98.3±14.2) mm vs. (95.1±12.7) mm, t=-1.992, P=0.047). Ordinal Logistic regression indicated that the longer segment of the tumor invade the nonperitoneal rectum was an independent influencing factor of radiographic lateral lymph node metastasis (OR=1.016, 95%CI: 1.002 to 1.030, P=0.021), while the distance between the anal verge and the tumor was not (OR=0.986, 95%CI: 0.972 to 1.000, P=0.058). Conclusions: The higher the weight, the deeper and narrower the pelvis, the higher the APR height. There is a certain relationship between APR and lateral lymph node metastasis on imaging.

Analysis of prognosis and influencing factors of No. 253 lymph node metastasis in descending colon, sigmoid colon, and rectal cancer: a multicenter study / 中华外科杂志

Objectives: To analyze the influencing factors of No. 253 lymph node metastasis in descending colon cancer, sigmoid colon cancer, and rectal cancer, and to investigate the prognosis of No. 253 lymph node-positive patients by propensity score matching analysis. Methods: A retrospective analysis was performed on clinical data from patients with descending colon cancer, sigmoid colon cancer, rectosigmoid junction cancer, and rectal cancer who underwent surgery between January 2015 and December 2019 from the Cancer Hospital of the Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Peking Union Medical College Hospital, General Hospital of the Chinese People's Liberation Army, and Peking University Cancer Hospital. A total of 3 016 patients were included according to inclusion and exclusion criteria, comprising 1 848 males and 1 168 females, with 1 675 patients aged≥60 years and 1 341 patients aged<60 years. Clinical and pathological factors from single center data were subjected to univariate analysis to determine influencing factors of No. 253 lymph node metastasis, using a binary Logistic regression model. Based on the results of the multivariate analysis, a nomogram was constructed. External validation was performed using data from other multicenter sources, evaluating the effectiveness through the area under the receiver operating characteristic curve and the calibration curve. Using data from a single center, the No. 253 lymph node-positive group was matched with the negative group in a 1∶2 ratio (caliper value=0.05). Survival analysis was performed using the Kaplan-Meier method and Log-rank test. The Cox proportional hazards model was used to determine independent prognostic factors. Results: (1) The tumor diameter≥5 cm (OR=4.496,95%CI:1.344 to 15.035, P=0.015) T stage (T4 vs. T1: OR=11.284, 95%CI:7.122 to 15.646, P<0.01), N stage (N2 vs. N0: OR=60.554, 95%CI:7.813 to 469.055, P=0.043), tumor differentiation (moderate vs. well differentiated: OR=1.044, 95%CI:1.009 to 1.203, P=0.044; poor vs. well differentiated: OR=1.013, 95%CI:1.002 to 1.081, P=0.013), tumor location (sigmoid colon vs. descending colon: OR=9.307, 95%CI:2.236 to 38.740, P=0.002), pathological type (mucinous adenocarcinoma vs. adenocarcinoma: OR=79.923, 95%CI:15.113 to 422.654, P<0.01; signet ring cell carcinoma vs. adenocarcinoma: OR=27.309, 95%CI:4.191 to 177.944, P<0.01), and positive vascular invasion (OR=3.490, 95%CI:1.033 to 11.793, P=0.044) were independent influencing factors of No. 253 lymph node metastasis. (2) The area under the curve of the nomogram prediction model was 0.912 (95%CI: 0.869 to 0.955) for the training set and 0.921 (95%CI: 0.903 to 0.937) for the external validation set. The calibration curve demonstrated good consistency between the predicted outcomes and the actual observations. (3) After propensity score matching, the No. 253 lymph node-negative group did not reach the median overall survival time, while the positive group had a median overall survival of 20 months. The 1-, 3- and 5-year overall survival rates were 83.9%, 61.3% and 51.6% in the negative group, and 63.2%, 36.8% and 15.8% in the positive group, respectively. Multivariate Cox analysis revealed that the T4 stage (HR=3.067, 95%CI: 2.357 to 3.990, P<0.01), the N2 stage (HR=1.221, 95%CI: 0.979 to 1.523, P=0.043), and No. 253 lymph node positivity (HR=2.902, 95%CI:1.987 to 4.237, P<0.01) were independent adverse prognostic factors. Conclusions: Tumor diameter ≥5 cm, T4 stage, N2 stage, tumor location in the sigmoid colon, adverse pathological type, poor differentiation, and vascular invasion are influencing factors of No. 253 lymph node metastasis. No. 253 lymph node positivity indicates a poorer prognosis. Therefore, strict dissection for No. 253 lymph node should be performed for colorectal cancer patients with these high-risk factors.

Development and validation of a prognostic prediction model for patients with stage Ⅰ to Ⅲ colon cancer incorporating high-risk pathological features / 中华外科杂志

Objective: To examine a predictive model that incorporating high risk pathological factors for the prognosis of stage Ⅰ to Ⅲ colon cancer. Methods: This study retrospectively collected clinicopathological information and survival outcomes of stage Ⅰ~Ⅲ colon cancer patients who underwent curative surgery in 7 tertiary hospitals in China from January 1, 2016 to December 31, 2017. A total of 1 650 patients were enrolled, aged (M(IQR)) 62 (18)years (range: 14 to 100). There were 963 males and 687 females. The median follow-up period was 51 months. The Cox proportional hazardous regression model was utilized to select high-risk pathological factors, establish the nomogram and scoring system. The Bootstrap resampling method was utilized for internal validation of the model, the concordance index (C-index) was used to assess discrimination and calibration curves were presented to assess model calibration. The Kaplan-Meier method was used to plot survival curves after risk grouping, and Cox regression was used to compare disease-free survival between subgroups. Results: Age (HR=1.020, 95%CI: 1.008 to 1.033,P=0.001), T stage (T3:HR=1.995,95%CI:1.062 to 3.750,P=0.032;T4:HR=4.196, 95%CI: 2.188 to 8.045, P<0.01), N stage (N1: HR=1.834, 95%CI: 1.307 to 2.574, P<0.01; N2: HR=3.970, 95%CI: 2.724 to 5.787, P<0.01) and number of lymph nodes examined (≥36: HR=0.438, 95%CI: 0.242 to 0.790, P=0.006) were independently associated with disease-free survival. The C-index of the scoring model (model 1) based on age, T stage, N stage, and dichotomous variables of the lymph nodes examined (<12 and ≥12) was 0.723, and the C-index of the scoring model (model 2) based on age, T stage, N stage, and multi-categorical variables of the lymph nodes examined (<12, 12 to <24, 24 to <36, and ≥36) was 0.726. A scoring system was established based on age, T stage, N stage, and multi-categorical variables of lymph nodes examined, the 3-year DFS of the low-risk (≤1), middle-risk (2 to 4) and high-risk (≥5) group were 96.3%(n=711), 89.0%(n=626) and 71.4%(n=313), respectively. Statistically significant difference was observed among groups (P<0.01). Conclusions: The number of lymph nodes examined was an independent prognostic factor for disease-free survival after curative surgery in patients with stage Ⅰ to Ⅲ colon cancer. Incorporating the number of lymph nodes examined as a multi-categorical variable into the T and N staging system could improve prognostic predictive validity.

Correlation between self-efficacy and discharge readiness in patients with enterostomy / 中华健康管理学杂志

Objective:To explore the correlation between self-efficacy and discharge readiness in patients with enterostomy.Methods:It was a cross-sectional study. Using the self-efficacy Scale and the Readiness for Discharge Scale as research tools, the patients who underwent enterostomy in the Department of General Surgery of Peking Union Medical College Hospital from December 2018 to December 2019 were conveniently selected for questionnaire survey. Statistical descriptive variables such as mean values, median values and frequency were used to investigate the current situation of self-efficacy and discharge readiness of patients with enterostomy. Pearson correlation analysis (or Spearman correlation analysis) was used to explore the correlation between self-efficacy and discharge readiness in these patients.Results:The total self-efficacy score of the 121 patients with enterostomy was (75.81±21.16) points, and the total discharge readiness score was (138.11±34.60) points. The total score of self-efficacy in the patients with enterostomy was positively correlated with the total score of readiness for hospital discharge ( r=0.379, P<0.01). No correlation was found between the self-condition dimension and the confidence and efficacy of sexual life ( r=0.125, P>0.05) and the confidence and efficacy of sexual life satisfaction ( r=0.062, P>0.05). The disease knowledge dimension was positively correlated with the following variables, self-efficacy score ( r=0.311, P<0.01), stoma care efficacy ( r=0.358, P<0.01), self-social efficacy ( r=0.227, P<0.05), diet choice efficacy ( r=0.221, P<0.05) and stoma self-care confidence efficacy ( r=0.249, P<0.01). The post-discharge coping ability dimension was positively correlated with the total score of self-efficacy ( r=0.428, P<0.01). Anticipatory social support dimension was positively correlated with self-efficacy ( r=0.218, P<0.05), self-social efficacy ( r=0.226, P<0.01), vitality confidence ( r=0.202, P<0.05) and stoma self-care confidence ( r=0.198, P<0.05). Conclusion:The self-efficacy level of patients with enterostomy can positively predict the level of readiness for discharge.

Spatiotemporal Dynamics of the Molecular Expression Pattern and Intercellular Interactions in the Glial Scar Response to Spinal Cord Injury / 神经科学通报·英文版

Nerve regeneration in adult mammalian spinal cord is poor because of the lack of intrinsic regeneration of neurons and extrinsic factors - the glial scar is triggered by injury and inhibits or promotes regeneration. Recent technological advances in spatial transcriptomics (ST) provide a unique opportunity to decipher most genes systematically throughout scar formation, which remains poorly understood. Here, we first constructed the tissue-wide gene expression patterns of mouse spinal cords over the course of scar formation using ST after spinal cord injury from 32 samples. Locally, we profiled gene expression gradients from the leading edge to the core of the scar areas to further understand the scar microenvironment, such as neurotransmitter disorders, activation of the pro-inflammatory response, neurotoxic saturated lipids, angiogenesis, obstructed axon extension, and extracellular structure re-organization. In addition, we described 21 cell transcriptional states during scar formation and delineated the origins, functional diversity, and possible trajectories of subpopulations of fibroblasts, glia, and immune cells. Specifically, we found some regulators in special cell types, such as Thbs1 and Col1a2 in macrophages, CD36 and Postn in fibroblasts, Plxnb2 and Nxpe3 in microglia, Clu in astrocytes, and CD74 in oligodendrocytes. Furthermore, salvianolic acid B, a blood-brain barrier permeation and CD36 inhibitor, was administered after surgery and found to remedy fibrosis. Subsequently, we described the extent of the scar boundary and profiled the bidirectional ligand-receptor interactions at the neighboring cluster boundary, contributing to maintain scar architecture during gliosis and fibrosis, and found that GPR37L1_PSAP, and GPR37_PSAP were the most significant gene-pairs among microglia, fibroblasts, and astrocytes. Last, we quantified the fraction of scar-resident cells and proposed four possible phases of scar formation: macrophage infiltration, proliferation and differentiation of scar-resident cells, scar emergence, and scar stationary. Together, these profiles delineated the spatial heterogeneity of the scar, confirmed the previous concepts about scar architecture, provided some new clues for scar formation, and served as a valuable resource for the treatment of central nervous system injury.

Safety and prognosis analysis of transanal total mesorectal excision versus laparoscopic mesorectal excision for mid-low rectal cancer / 中华胃肠外科杂志

Objective: To compare the short-term and long-term outcomes between transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laTME) for mid-to-low rectal cancer and to evaluate the learning curve of taTME. Methods: This study was a retrospective cohort study. Firstly, consecutive patients undergoing total mesorectal excision who were registered in the prospective established database of Division of Colorectal Diseases, Department of General Surgery, Peking Union Medical College Hospital during July 2014 to June 2020 were recruited. The enrolled patients were divided into taTME and laTME group. The demographic data, clinical characteristics, neoadjuvant treatment, intraoperative and postoperative complications, pathological results and follow-up data were extracted from the database. The primary endpoint was the incidence of anastomotic leakage and the secondary endpoints included the 3-year disease-free survival (DFS) and the 3-year local recurrence rate. Independent t-test for comparison between groups of normally distributed measures; skewed measures were expressed as M (range). Categorical variables were expressed as examples (%) and the χ(2) or Fisher exact probability was used for comparison between groups. When comparing the incidence of anastomotic leakage, 5 variables including sex, BMI, clinical stage evaluated by MRI, distance from tumor to anal margin evaluated by MRI, and whether receiving neoadjuvant treatment were balanced by propensity score matching (PSM) to adjust confounders. Kaplan-Meier curve and Log-rank test were used to compare the DFS of two groups. Cox proportional hazard model was used to analyze and determine the independent risk factors affecting the DFS of patients with mid-low rectal cancer. Secondly, the data of consecutive patients undergoing taTME performed by the same surgical team (the trananal procedures were performed by the same main surgeon) from February 2017 to March 2021 were separately extracted and analyzed. The multidimensional cumulative sum (CUSUM) control chart was used to draw the learning curve of taTME. The outcomes of 'mature' taTME cases through learning curve were compared with laTME cases and the independent risk factors of DFS of 'mature' cases were also analyzed. Results: Two hundred and forty-three patients were eventually enrolled, including 182 undergoing laTME and 61 undergoing taTME. After PSM, both fifty-two patients were in laTME group and taTME group respectively, and patients of these two groups had comparable characteristics in sex, age, BMI, clinical tumor stage, distance from tumor to anal margin by MRI, mesorectal fasciae (MRF) and extramural vascular invasion (EMVI) by MRI and proportion of receiving neoadjuvant treatment. After PSM, as compared to laTME group, taTME group showed significantly longer operation time [(198.4±58.3) min vs. (147.9±47.3) min, t=-4.321, P<0.001], higher ratio of blood loss >100 ml during surgery [17.3% (9/52) vs. 0, P=0.003], higher incidence of anastomotic leakage [26.9% (14/52) vs. 3.8% (2/52), χ(2)=10.636, P=0.001] and higher morbidity of overall postoperative complications [55.8%(29/52) vs. 19.2% (10/52), χ(2)=14.810, P<0.001]. Total harvested lymph nodes and circumferential resection margin involvement were comparable between two groups (both P>0.05). The median follow-up for the whole group was 24 (1 to 72) months, with 4 cases lost, giving a follow-up rate of 98.4% (239/243). The laTME group had significantly better 3-year DFS than taTME group (83.9% vs. 73.0%, P=0.019), while the 3-year local recurrence rate was similar in two groups (1.7% vs. 3.6%, P=0.420). Multivariate analysis showed that and taTME surgery (HR=3.202, 95%CI: 1.592-6.441, P=0.001) the postoperative pathological staging of UICC stage II (HR=13.862, 95%CI:1.810-106.150, P=0.011), stage III (HR=8.705, 95%CI: 1.104-68.670, P=0.040) were independent risk factors for 3-year DFS. Analysis of taTME learning curve revealed that surgeons would cross over the learning stage after performing 28 cases. To compare the two groups excluding the cases within the learning stage, there was no significant difference between two groups after PSM no matter in the incidence of anastomotic leakage [taTME: 6.7%(1/15); laTME: 5.3% (2/38), P=1.000] or overall complications [taTME: 33.3%(5/15), laTME: 26.3%(10/38), P=0.737]. The taTME was still an independent risk factor of 3-year DFS only analyzing patients crossing over the learning stage (HR=5.351, 95%CI:1.666-17.192, P=0.005), and whether crossing over the learning stage was not the independent risk factor of 3-year DFS for mid-low rectal cancer patients undergoing taTME (HR=0.954, 95%CI:0.227-4.017, P=0.949). Conclusions: Compared with conventional laTME, taTME may increase the risk of anastomotic leakage and compromise the oncological outcomes. Performing taTME within the learning stage may significantly increase the risk of postoperative anastomotic leakage.

Risk factors of postoperative surgical site infection in colon cancer based on a single center database / 中华胃肠外科杂志

Objective: To explore the incidence and risk factors of postoperative surgical site infection (SSI) after colon cancer surgery. Methods: A retrospective case-control study was performed. Patients diagnosed with colon cancer who underwent radical surgery between January 2016 and May 2021 were included, and demographic characteristics, comorbidities, laboratory tests, surgical data and postoperative complications were extracted from the specialized prospective database at Department of General Surgery, Peking Union Medical College Hospital. Case exclusion criteria: (1) simultaneously multiple primary colon cancer; (2) segmental resection, subtotal colectomy, or total colectomy; (3) patients undergoing colostomy/ileostomy during the operation or in the state of colostomy/ileostomy before the operation; (4) patients receiving natural orifice specimen extraction surgery or transvaginal colon surgery; (5) patients with the history of colectomy; (6) emergency operation due to intestinal obstruction, perforation and acute bleeding; (7) intestinal diversion operation; (8) benign lesions confirmed by postoperative pathology; (9) patients not following the colorectal clinical pathway of our department for intestinal preparation and antibiotic application. Univariate analysis and multivariate analysis were used to determine the risk factors of SSI after colon cancer surgery. Results: A total of 1291 patients were enrolled in the study. 94.3% (1217/1291) of cases received laparoscopic surgery. The incidence of overall SSI was 5.3% (69/1291). According to tumor location, the incidence of SSI in the right colon, transverse colon, left colon and sigmoid colon was 8.6% (40/465), 5.2% (11/213), 7.1% (7/98) and 2.1% (11/515) respectively. According to resection range, the incidence of SSI after right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoid colectomy was 8.2% (48/588), 4.5% (2/44), 4.8% (8 /167) and 2.2% (11/492) respectively. Univariate analysis showed that preoperative BUN≥7.14 mmol/L, tumor site, resection range, intestinal anastomotic approach, postoperative diarrhea, anastomotic leakage, postoperative pneumonia, and anastomotic technique were related to SSI (all P<0.05). Multivariate analysis revealed that anastomotic leakage (OR=22.074, 95%CI: 6.172-78.953, P<0.001), pneumonia (OR=4.100, 95%CI: 1.546-10.869, P=0.005), intracorporeal anastomosis (OR=5.288, 95%CI: 2.919-9.577,P<0.001) were independent risk factors of SSI. Subgroup analysis showed that in right hemicolectomy, the incidence of SSI in intracorporeal anastomosis was 19.8% (32/162), which was significantly higher than that in extracorporeal anastomosis (3.8%, 16/426, χ(2)=40.064, P<0.001). In transverse colectomy [5.0% (2/40) vs. 0, χ(2)=0.210, P=1.000], left hemicolectomy [5.4% (8/148) vs. 0, χ(2)=1.079, P=0.599] and sigmoid colectomy [2.1% (10/482) vs. 10.0% (1/10), χ(2)=2.815, P=0.204], no significant differences of SSI incidence were found between intracorporeal anastomosis and extracorporeal anastomosis (all P>0.05). Conclusions: The incidence of SSI increases with the resection range from sigmoid colectomy to right hemicolectomy. Intracorporeal anastomosis and postoperative anastomotic leakage are independent risk factors of SSI. Attentions should be paid to the possibility of postoperative pneumonia and actively effective treatment measures should be carried out.

Clinical efficacy of laparoscopic resection of retrorectal cystic lesions / 中华消化外科杂志

Objective:To investigate the clinical efficacy of laparoscopic resection of retrorectal cystic lesions.Methods:The retrospective and descriptive study was conducted. The clinicopathological data of 58 patients undergoing laparoscopic resection of retrorectal cystic lesions in the Peking Union Medical College Hospital, Chinese Academy of Medical Sciences from August 2012 to August 2019 were collected. There were 5 males and 53 females, aged from 15 to 70 years, with a median age of 38 years. All the 58 patients underwent laparoscopic resection of retrorectal cystic lesions and the combined operation through the transsacral approach was chosen according to the patient condition. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) postoperative histopathological examination; (4) follow-up. Patients were followed up regularly using outpatient examination once every 6 months during the first postoperative year and once every 12 months after the first postoperative year. The recurrence of cysts was evaluated by computed tomography or magnetic resonance imaging examinations during the follow-up up to August 2020. Measurement data with normal distribution were represented as Mean± SD and measurement data with skewed distribution were described as M(range). Count data were described as absolute numbers. Results:(1) Surgical situations: of the 58 patients, 54 cases underwent laparoscopic resection of retrorectal cystic lesions and 4 cases underwent laparoscopic resection of retrorectal cystic lesions combined with the transsacral approach operation. One of the 58 patients who had a huge cyst surrounding the rectum underwent transverse colostomy after repairing the damage of separated posterior wall of rectum. Two cases underwent preventive transverse colostomy because the external rectal wall heat injury could not be excluded after separation of the tight adhesion between cyst and rectum. The operation time and volume of intraoperative blood loss were (123±56)minutes, 20 mL(range, 5?500 mL) of 54 cases who underwent laparoscopic resection of retrorectal cystic lesions and (232±38)minutes, 90 mL(range, 30?800 mL) of 4 cases who underwent laparoscopic resection of retrorectal cystic lesions combined with the transsacral approach operation, respectively. (2) Postoperative situations: 7 of the 58 patients had complica-tions. Of the 7 patients, 2 cases had postoperative rectal fistula and were cured after the treatment of transverse colostomy combined with pelvic drainage, 2 cases had postoperative urinary tract infection and were relieved after anti-infection treatment, 2 cases had urinary retention after removal of catheter and were recovered after 3 weeks of re-indwelling catheter, and 1 case had poor incision healing of transsacral and was healed after wound dressing change. The duration of postoperative hospital stay of the 58 patients was (7±4)days. (3) Postoperative histopathological examination: results of the postoperative histopathological examination showed that there were 26 of 58 patients with epidermoid cyst, 20 patients with teratoma (2 cases with mature teratoma accompanied by mucinous adenocarcinoma and 1 case with mature teratoma accompanied by neuroendocrine carcinoma), 10 patients with dermoid cyst, and 2 patients with tailgut cyst. (4) Follow-up: 57 of the 58 patients were followed up for 2-85 months, with a median follow-up time of 51 months. Of the 57 patients who were followed up, 1 patient was diagnosed with buttock subcutaneous cyst at postoperative 8 months and treated with local excision, 1 patient was diagnosed with a small presacral cyst recurrence by pelvic magnetic resonance imaging at postoperative 6 months and continued follow-up as the cyst without obvious enlargement, and the other 55 patients had no cyst recurrence.Conclusion:The laparoscopic resection of retrorectal cystic lesions is safe and feasible.

Current situation and problems of national standards for Chinese medicinal materials / 中国中药杂志

To learn the current situation and strengthen the management of national standards for Chinese medicinal materials, we sorted out the relevant national standards. According to incomplete statistics, there are 1 185 kinds of Chinese medicinal materials, including 1 024 kinds of plant medicines, 106 kinds of animal medicines, and 54 kinds of mineral medicines, in addition to ethnic medicinal materials with different functions. The relevant standards include 819 Pharmacopoeia standards, 342 standards issued by the Ministry of Health or National Medicinal Products Administration, 7 standards for new medicinal materials, and 17 standards for imported medicinal materials. In this paper, the sources of standards as well as the distribution of families and genera and the distribution of medicinal parts of medicinal materials are analyzed. The suggestions are as follows:(1)to improve the coordination among different national standards of Chinese medicinal materials;(2)to improve the standardization and controllability of relevant standards;(3)to revise the issued standards for Chinese medicinal materials(including Tibetan, Uygur, and Mongolian medicinal materials).

Overlap gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer / 中华胃肠外科杂志

Objective@#The aim of the current study is to compare the short-term clinical outcomes between Billroth-I reconstruction using an overlap method and delta-shaped anastomosis in totally laparoscopic distal gastrectomy (TLDG).@*Method@#A retrospective cohort study was performed. The following inclusion criteria were applied: (1) Preoperative gastroscopy and CT confirmed that the tumor is located in the antrum of the stomach, and the biopsy suggested adenocarcinoma; (2) Chest, abdomen and pelvis enhanced CT showed no evidence of distant metastasis; (3) Preoperative gastric reconstruction CT or endoscopic ultrasonography suggested that the clinical stage of the tumor is stage I-III. (4) During the operation, the tumor position was confirmed to be located in the antrum of the stomach by nanocarbon injection or gastroscope; (5) Complete laparoscopic radical gastrectomy for distal gastrectomy, and the gastrointestinal reconstruction was performed by delta-shaped anastomosis or overlap anastomosis. And the following exclusion criteria were applied: (1) History of gastric surgery; (2) Patients who cannot tolerate laparoscopic surgery because of comorbidities. Finally, data on 43 consecutive patients who underwent TLDG with Billroth-I reconstruction between January 2016 and November 2018 in Peking Union Medical College Hospital were retrospectively reviewed. Patients were divided into those who underwent Billroth-I reconstruction using an overlap method (n=20) or using delta-shaped anastomosis (n=23). The demographic and clinical characteristics and perioperative data of the two groups were analyzed. Measurement data that conformed to the normal distribution were expressed as the mean ± s, and differences between groups were compared using Student′s t-test; comparisons between the counting data groups were performed using the χ2 test or the continuously corrected χ2 test.@*Results@#The demographic and clinical characteristics were similar between the delta-shaped group and the overlap group (P>0.05). There was no significant difference between groups regarding operation time [(185.9±22.8) minutes vs. (184.0±25.8) minutes, t=0.260, P=0.796], blood loss [(50.9±36.0) ml vs. (47.0±30.8) ml, t=0.375, P=0.709], number of stapler reloads used for anastomosis (5.1±0.3 vs. 5.2±0.6, t=-0.465, P=0.651), time to flatus [(3.3±0.9) days vs. (3.6±0.9) days, t=-1.067, P=0.292) and postoperative hospitalization [(8.8±3.1) days vs. (10.4±3.8) days,t=-1.494, P=0.143]. As for the delta-shaped group and the overlap group, the anastomotic leakage rate was 4.3% (1/23) and 0 (χ2=0.000, P=1.000), respectively. The incidence of anastomotic bleeding was 4.3% (1/23) and 5.0% (1/20) (χ2=0.000, P=1.000), while the incidence of intra-abdominal hemorrhage was 4.3% (1/23) and 0 (χ2=0.000, P=1.000). The incidence of gastric emptying disorders was 4.3% (1/23) and 30.0% (6/20), respectively (χ2=3.454, P=0.063). All complications were cured after conservative treatment or symptomatic treatment.@*Conclusion@#The overlap method for Billroth-I reconstruction is safe and feasible.

Clinical anatomy study of superior mesenteric vessels and its branches / 中华外科杂志

Objective@#To examine the anatomical relationships of tributaries to superior mesenteric artery and vein in surgical procedures.@*Methods@#A prospectively designed observational trial, registried to Chinese Clinical Trial Registry, ChiCTR 1800014610, was conducted in Department of General Surgery, Peking Union Medical College Hospital from July 2016 to Decmeber 2018 to record the relationships of ileocolic artery and vein, right colic artery and vein, middle colic artery and vein, and combinations to assemble Henle′s trunk, during the laparoscopic operation of radical right colectomy for right colon malignancies. The length of middle colic artery, length of Henle′s trunk, and distance from Henle′s trunk to the inferior margin of pancreatic head to duodenum were measured during operation. A total of 100 patients, 52 male and 48 female, with right colon cancer, who underwent radical right colectomy, were enrolled in present study from July 2016 to December 2018, with age of (61.0±12.3) years (range: 31 to 82 years), and body mass index of (23.3±3.5) kg/m2 (range: 16.0 to 34.2 kg/m2).@*Results@#The ileocolic artery and vein presented as rates of 97.0% (97/100, 95%CI: 91.5% to 99.4%, the same below) and 98.0% (98/100, 93.0% to 99.8%), respectively. The ileocolic vein ran ventrally in 51 of 97 patients (52.6%, 42.7% to 62.5%). The right colic artery, which raised from superior mesenteric artery directly, was found in 42 of 100 patients (42.0%, 32.3% to 51.7%); and the right colic vein drained directly into superior mesenteric vein in 19 of 100 patients (19.0%, 11.3% to 26.7%). The presence of middle colic artery and vein were 95.0% (95/100, 90.7% to 99.3%) and 90.0% (90/100, 84.1% to 95.9%) respectively. The average length of middle colic artery, from its origin to bifurcation into right and left branches, was (2.6±1.6) cm (range: 0.1 to 7.2 cm). All the dissected middle colic vein drained into superior mesenteric vein (87.8% (79/90), 81.0% to 94.6%) and Henle′s trunk (12.2% (11/90), 5.4% to 19.0%). Henle′s trunk was found in 93 of 100 patients (93.0%, 88.0% to 98.0%), with average length of (1.0±0.6) cm (range: 0.1 to 2.4 cm). The distance between Henle′s trunk to the inferior margin of pancreatic head was (2.7±0.7) cm (range: 1.3 to 4.5 cm). More than half of the Henle′s trunk were composed of 3 tributaries (54.8% (53/93), 40.8% to 61.2%). The most frequently discovered tributaries to form Henle′s trunk were right gastroepiploic vein (98.0% (98/100), 93.0% to 99.8%), superior right colic vein (82.0% (82/100), 74.5% to 89.5%), and superior anterior pancreaticoduodenal vein (78.0% (78/100), 69.9% to 86.1%). In present study, the right branch of middle colic vessels was often found to run closely with Henle′s trunk, veins drained from small intestine could be found to run over superior mesenteric artery to converge into superior mesenteric vein. There were 2 incidences, injuries to Henle′s trunk and middle colic vein, happened during the operation, which were overcomed by bipolar coagulation and dividing the vessels.@*Conclusions@#Ileocolic vessels and middle colic vessels could be used as landmarks for laparoscopic surgery based on their constant anatomical existence. In contrast, the chances are rare for the presence of right colic artery or right colic vein. Nearly half of the Henle′s trunk was consisted of right gastroepiploic vein, superior right colic vein and superior anterior pancreaticoduodenal vein. Exceptional cautions should be made for the variations of the Henle′s trunk during the operation.

The clinical evaluation of clinical complete response to neoadjuvant chemoradiotherapy for rectal cancer / 中华消化外科杂志

Neochemoradiotherapy has been implemented in the multidisciplinary therapy for advanced rectal cancer.The patients with complete response after neothemoradiation could avoid surgical resection and thereafter might be free of surgical complications,as well as functional impairment.However,the preoperative evaluated clinical complete response is not equally to the pathologic complete response after surgery.The accurate methods to evaluate the status of complete response remained controversy.Based on the digital rectal examination and endoscopic observation,rectal MRI and endorectal ultrasound could verify the integrity of mucosa and the structural changes in rectal wall.These preoperative staging methods,as well as PET-CT and needle biopsy,had been widely used,but with a low sensitivity.

Graded motor imagery for rehabilitating upper extremity motor function after stroke / 中华物理医学与康复杂志

Objective To investigate the effect of graded motor imagery ( GMI) therapy combined with rou-tine occupational therapy on the recovery of upper extremity function after stroke. Methods Thirty stroke survivors who met inclusion criteria were randomly assigned to a control group ( n=15) or a GMI group ( n=15) . The control group received routine medication, conventional physical therapy and routine occupational therapy ( one hour a day) , while the GMI group received 30 minutes of routine occupational therapy and 30 minutes of graded motor imagery therapy every day in addition to conventional medication and physical therapy. Before and after four weeks of treat-ment, the patients in both groups were evaluated using the Fugl-Meyer Assessment for the Upper Extremities ( FMA-UE) , the Box and Block Test ( BBT) and Brunnstrom arm and hand staging. Surface electromyography of the biceps brachii and triceps brachii was performed as the affected elbow flexed and stretched in maximum isometric contrac-tions, and the co-contraction ratios ( CRs) were calculated. Results After the treatment, the average FMA-UE score, Brunnstrom arm and hand stage, BBT and CR scores in both groups had improved significantly. The average improvement in the GMI group was significantly greater than in the control group. Conclusions Graded motor im-agery therapy can significantly promote motor recovery of the upper extremities of hemiplegic patients after a stroke.

Reference and Innovation: Research on the Construction of Medical Device Registrar System / 中国医疗器械杂志

In order to strengthen the integration of reform system and build a comprehensive integration of openness and innovation, the medical device registrar system has become the institutional choice to promote the reform of the medical approval system and the innovation and development of the industry. The system allows scientific researchers, R&D institutions and enterprises to become applicants for medical device registration and to consign the production of samples and products, thus realizing the separation of market license and production license, and breaking the binding relationship between registration and production in current regulations. The medical device registrar system has laid a theoretical foundation for remolding the management system of medical devices, and has also made practical exploration for improving the reform of the medical devices supervision system, so it has important theoretical and practical significance.

Oncological outcomes analysis of colorectal cancer with unfavorable histological features / 中华外科杂志

Objective@#To explore the effect of unfavorable histological features on the clinical outcomes of patients receiving radical resection of colorectal cancer.@*Methods@#A retrospective analysis of patients with colorectal cancer who received radical surgery between January 2013 and December 2015 at Department of General Surgery, Peking Union Medical College Hospital was performed. The impact of unfavorable histological features on the oncological outcomes of patients with lymph node-negative colorectal cancer were analyzed.A total of 167 patients were enrolled, including 98 males and 69 females with age of (63.6±11.6) years. Observation indicators included age, T stage, lymphovascular invasion, perineural invasion, tumor deposits, number of lymph node dissection, degree of differentiation, tissue type, and circumferential margin. Univariate analysis was performed with χ2 test and multivariate analysis was performed with Cox regression model.@*Results@#Univariate analysis showed that positive circumferential margins (CRM), tumor deposits and age were associated with disease free survival (DFS) rate; positive CRM, age, tumor deposits, and lymph nodes dissection less than 12 were significantly associated with overall survival (OS) rate (all P<0.05). Multivariate analysis showed that over 70 years of age (HR=1.053, 95% CI: 1.013 to 1.095, P=0.009), poorly differentiated adenocarcinoma (HR=7.572, 95%CI: 1.815 to 31.587, P=0.005), tumor deposits (HR=4.711, 95% CI: 1.809 to 12.264, P=0.002), mucinous adenocarcinoma (HR=3.063, 95% CI: 1.003 to 9.354, P=0.049), lymphovascular invasion (HR=2.885, 95% CI: 1.062 to 7.832, P=0.038), and nerve infiltration (HR=6.610, 95% CI: 1.037 to 42.122, P=0.046) were adverse prognostic factors of DFS rate; poorly differentiated adenocarcinoma (HR=12.200, 95% CI: 1.985 to 74.972, P=0.007), tumor nodules (HR=5.379, 95% CI: 1.636 to 17.685, P=0.006), over 70 years of age (HR=1.062, 95% CI: 1.013 to 1.114, P=0.013), and perineural invasion (HR=8.043, 95% CI: 1.026 to 63.055, P=0.047) were adverse prognostic factors of OS rate. There was no significant difference in the 3-year DFS rate and 3-year OS rate between T1-2 group and T3-4 group (P>0.05).@*Conclusion@#Over 70 years of age, poorly differentiated adenocarcinoma, mucinous adenocarcinoma, tumor nodules, lymphovascular invasion, and perineural invasion are independent adverse prognostic factors of lymph node-negative colorectal cancer.

Analysis of Clavien-Dindo classification and its prognosis factors of complications after laparoscopic right hemicolectomy / 中华外科杂志

Objective@#To analyze the Clavien-Dindo classification of complications after right hemicolectomy and to explore the prognosis factors for postoperative complications.@*Methods@#The retrospective case-control study was adopted. The clinical data of 176 patients who underwent right hemicolectomy at Department of General Surgery, Peking Union Medical College Hospital from October 2016 to February 2018 were collected. There were 95 male and 81 female patients with age of (62.4±12.7) years. The Clavien-Dindo classification was used for postoperative complications. Univariate and multivariate analysis were used to analyze the independent prognosis factors of complications after right colon resection.@*Results@#Of the 176 patients, 2 patients had intraoperative complications (1.1%) and 39 patients had postoperative complications (22.2%), of which 10 cases had more than two complications, with a total of 53 complications. The proportions of Clavien-Dindo grade Ⅰ, Ⅱ, Ⅲ and Ⅳ complications were 41.5% (22/53), 49.1% (26/53), 7.5% (4/53), and 1.9%(1/53). Postoperative complications were associated with age, smoking history of the last 1 year, combined organ resection, lymph node dissection, intracorporeal anastomosis, and preoperative blood AST and Ca levels (all P<0.05). The results of multivariate analysis showed that intracorporeal anastomosis (OR=5.62, 95% CI: 2.46 to 12.85, P=0.00), preoperative blood AST (OR=-0.009, 95% CI: -0.018 to 0.000, P=0.04) and Ca (OR=0.51, 95% CI: 0.08 to 0.95, P=0.02) levels were independent prognosis factors affecting complications after right hemicolectomy.@*Conclusions@#Complications of right hemicolectomy were mainly Clavien-Dindo grade Ⅰ and Ⅱ. Laparoscopic intracorporeal anastomosis should be carefully chosen, which may increase postoperative complications.

SIRT6 regulating IGF2 though recruiting mRNA binding protein IMP1 in 293T cells / 基础医学与临床

Objective To investigate the post-transcriptional regulation mechanism of insulin-like growth factor 2 (IGF2),which is an important tumor regulator,by SIRT6. Methods SIRT6 was overexpressed in 293T cells and IP was used to enrich SIRT6 and mass spectrometry(MS)was used to detect the protein that interacted with SIRT6. Western blot was used to validate the interacted protein and its acetylation/phosphorylation modification status. Results SIRT6 did not change the acetylation modification status of IMP1,but the phosphorylation status of IMP1 was elevated in the presence of SIRT6. Conclusions SIRT6 may regulate IGF2 though promoting the phosphoryla-tion of IMP1 in 293T cells.

Experience of transanal total mesorectal excision with laparoscopic assisted for min-low rectal cancer / 国际外科学杂志

Objective To investigate the advantages and disadvantages of transanal total mesorectal excision with laparoscopic assisted for min-low rectal cancer.Methods Retrospectively analyzed the clinical data of 38 patients with min-low rectal cancer who undement laparoscopically assisted transanal total anorectal rectal cancer from November 2014 to May 2018 in the Department of General Surgery,Peking Union Medical College Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College.The main outcome measures included gender,BMI,the operating time,intra-operative blood loss,the intraand post-operative complication rate,the distal resection margin length and the circumferential resection margin status of the pathological specimen,the number of lymph nodes acquisitions,as well as the postoperative average hospitalization time.Results The surgery was completed smoothly for all patients in this studying,with no conversion to open surgery.Among all the 38 patients,there were 26 (68.4％) male cases and 12(31.6％) female cases,and 25 cases were with a body mass index (BMI) over 24 kg/m2.The average operating time was (175.2 ± 37.6) minutes.The average intra-operative blood loss was (63.9 ± 42.7) ml.The complications included 1 case of intra-operative presacral venous hemorrhage,and 6 cases of post-operative anastomotic leak (15.8％).There were 18 cases happened perioperative complications,and the rate was 47.4％.The average distance from the distal resection margin to the lower end of the tumor was (2.1 ± 0.4) cm.There were 34 cases of complete mesorectal excision.The average number of lymph nodes retrieved was 14.2 ± 4.5.The average postoperative hospital stay was (9.8 ±5.9) days.Conclusion Transanal total mesorectal excisionwithlaparoscopic-assisted formid-lowrectal cancer can more accurately ensure adequate distal margin and mesorectal integrity.