Advances in tumor regression patterns and safe distance of distal resection margin after neoadjuvant therapy for rectal cancer / 中华胃肠外科杂志

Neoadjuvant therapy has been widely applied in the treatment of rectal cancer, which can shrink tumor size, lower tumor staging and improve the prognosis. It has been the standard preoperative treatment for patients with locally advanced rectal cancer. The efficacy of neoadjuvant therapy for rectal cancer patients varies between individuals, and the results of tumor regression are obviously different. Some patients with good tumor regression even achieve pathological complete response (pCR). Tumor regression is of great significance for the selection of surgical regimes and the determination of distal resection margin. However, few studies focus on tumor regression patterns. Controversies on the safe distance of distal resection margin after neoadjuvant treatment still exist. Therefore, based on the current research progress, this review summarized the main tumor regression patterns after neoadjuvant therapy for rectal cancer, and classified them into three types: tumor shrinkage, tumor fragmentation, and mucin pool formation. And macroscopic regression and microscopic regression of tumors were compared to describe the phenomenon of non-synchronous regression. Then, the safety of non-surgical treatment for patients with clinical complete response (cCR) was analyzed to elaborate the necessity of surgical treatment. Finally, the review studied the safe surgical resection range to explore the safe distance of distal resection margin.

Emergence application of colonoscopic placement of self-expandable metal stent without fluoroscopic monitoring / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the efficacy and safety of colonoscopy-guided placement of self-expandable metallic stent without fluoroscopic monitoring in the emergence management for acute malignant colorectal obstruction.</p><p><b>METHODS</b>Clinical data of 42 patients (24 males and 18 females with a mean age of 64.3 years) undergoing colonoscopy-guided placement of self-expandable metallic stents without fluoroscopic monitoring for acute malignant colorectal obstruction between January 2010 and June 2012 were reviewed retrospectively.</p><p><b>RESULTS</b>The obstruction was located in the rectum (n=19), sigmoid (n=9), descending colon (n=8), splenic flexure (n=1), hepatic flexure (n=3), and ascending colon (n=2). Technical success was achieved in all the 42 patients (100%). The mean time of operation was (11.8±10.4) min (range 1.1-51.0 min). No serious procedure-related complication occurred. Minor bleeding occurred in 3 cases (7.1%). One patient died on the second day after surgery because of heart failure.</p><p><b>CONCLUSIONS</b>Colonoscopy-guided placement of self-expandable metallic stents without fluoroscopic monitoring in emergence management for acute malignant colorectal obstruction is effective and safe with shorter operative time.</p>

Colonoscopic restoration for sigmoid vovulus in the elderly / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the emergency therapeutic strategy for sigmoid vovulus in the elderly.</p><p><b>METHODS</b>Clinical data of 14 elderly patients with sigmoid vovulus were analyzed retrospectively.</p><p><b>RESULTS</b>The mean age was(79.1±7.2) years(range, 70-93), and 11 patients (78.6%) were male. Emergency decompression and restoration with colonoscopy was performed in all the patients with a success rate of 100%. No patient required emergent surgery. Four patients(28.6%) recurred and they were managed well by repeat colonoscopic restoration.</p><p><b>CONCLUSION</b>Emergency colonoscopic restoration is the first treatment of choice for sigmoid vovulus in the elderly because it is safe and effective, and can be performed repeatedly.</p>

Association of tumor budding with clinicopathological characteristics and prognosis in T2 rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To demonstrate the association of tumor budding with clinicopathological features and prognosis in T2 rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 123 patients who underwent potentially curative resection for T2 rectal carcinoma between 2001 and 2005 at the Changhai Hospital were collected. All pathology slides were stained with hematoxylin and eosin for microscopic examinations. The maximum value of tumor buds(MV) and average value of tumor buds(AV) were calculated, which were classified as low value (≤5), median value (5 < bud value < 10), and high value (≥10).</p><p><b>RESULTS</b>Univariate analysis and multivariate analysis revealed that MV(P=0.000), AV(P=0.001), and lymphatic invasion (P=0.006) were independent predictors for lymph node metastasis in T2 rectal cancer. Neural invasion and poorly differentiation were significantly associated with MV(P<0.05). Neural invasion, vascular invasion and poorly differentiation were were significantly associated to AV (P<0.01). Disease-free survival (DFS) of patients with low AV, median AV and high AV was 110.5 months, 95.8 months, and 60.0 months respectively. There were significance differences in DFS of low AV with median and high AV(P<0.05). DFS of patients with low MV, median MV and high MV was 115.1 months, 98.5 months, and 86.0 months respectively. There were significance differences in DFS between low and high AV, and median and high MV(P<0.01 and P<0.05), while no significant difference existed between low and median MV.</p><p><b>CONCLUSION</b>Tumor budding is a useful marker to indicate high invasiveness of rectal cancer and a valuable prognostic predictor.</p>

Surgical treatment of recurrent colorectal carcinoma in the elderly / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of surgical treatment for recurrent colorectal carcinoma in the elderly.</p><p><b>METHODS</b>The clinical and follow up data of 24 elderly patients with recurrent colorectal carcinoma who were treated between January 2000 and June 2009 at the Changhai hospital of the Second Military Medical University were analyzed retrospectively.</p><p><b>RESULTS</b>Among the 24 patients there were 14 men and 10 women. The mean age of the patients was 76.9 ± 5.3 years. The local recurrence was found in 15 patients. In 9 patients, both distant metastases and local recurrence were found. A total of 24 patients received operation, including radical resection in 15 patients and palliative resection in 8 patients. One patient had laparotomy only because of diffuse metastases in the abdomen and involvement of the duodenum and common bile duct.The patient received stent placement in the common bile duct and chemotherapy after the surgery. Postoperative complication occurred in 7(29.2%) patients, which included ileus(n=1), pulmonary infection(n=1), urinary infection(n=1), wound infection(n=2), wound dehiscence(n=1), and wound fat liquefaction(n=1). There were no perioperative deaths. The median survival time was 6 months in the entire cohort. The median survival time was 33 months in patients undergoing radical resection, and the 1-, 3-, and 5-year survival rate was 71.4%, 28.6%, and 14.3%. The median survival time was 3 months in patients who underwent palliative resection, and the 1-year survival rate was 0. The difference between the two groups was statistically significant(P<0.01).</p><p><b>CONCLUSION</b>Outcomes are acceptable after radical resection for elderly patients with recurrent colorectal cancer if careful preoperative evaluation and perioperative management are performed.</p>

Preliminary study on relationship between multi-drug resistance-associated protein 4 and radiosensitivity of rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the correlation between multi-drug resistance-associated protein 4(MRP4) and the sensitivity of rectal cancer to radiation.</p><p><b>METHODS</b>A total of 95 patients with advanced rectal cancer and received radiation therapy between January 2000 and January 2009. MRP4 and P53 protein expression in the paraffin-embedded specimen were detected by immunohistochemistry. Logistic regression analysis was used to evaluate factors associated with the sensitivity of rectal cancer to radiation.</p><p><b>RESULTS</b>Forty patients(42%) were sensitive to radiation therapy, of whom 10(11%) achieved pathological complete remission. Fifty-five patients were (58%) not responsive to radiation. Patients with low expression of MRP4 had a 66.7%(24/36) response rate, significantly higher than that of patients with high MRP4 expression (29.1%,16/59)(P<0.05). Patients with low expression of P53 had a 63.9%(23/36) response rate, significantly higher than that of patients with high P53 expression(28.8%,17/59)(P<0.01). The response rate after long course radiation therapy was 83.3%(20/24), significantly higher than that of patients who underwent short and medium course radiation[(31.3%, 5/16) and(27.3%,15/55)](P<0.01). Multivariate Logistic regression analysis showed radiation regimen, the expression of P53 and MRP4 protein were independently associated with the sensitivity of rectal cancer to radiation(P<0.05).</p><p><b>CONCLUSION</b>MRP4 may serve as a predictive marker for the sensitivity of rectal cancer to preoperative radiation.</p>

Analysis of risk factors associated with lymph node metastasis and prognosis of T1-2 colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate factors associated with lymph node metastasis and prognosis in patients with T1-2 colorectal cancer.</p><p><b>METHODS</b>Patients with pT1-2 colorectal cancer between January 1999 to January 2005 were included. Chi-square test and multivariable logistic analysis were performed to evaluate risk factors associated with lymph node metastasis. Survival outcomes were analyzed using Kaplan-Meier and Cox regression model.</p><p><b>RESULTS</b>Tumor location and depth of invasion were independent risk factors for lymph node metastasis(P<0.01 and P<0.05). Gender, age, tumor gross pattern, tumor differentiation, carcinoembryonic antigen level, and tumor diameter were not associated with lymph node metastasis. Lymph node metastasis and distant metastasis on postoperative follow-up were independent risk factors for survival(P<0.05 and P<0.01).</p><p><b>CONCLUSION</b>Factors associated with lymph node metastasis in pT1-2 colorectal cancer do not affect the survival. However, lymph node metastasis and distant metastasis are predictive for survival.</p>

Lymph node metastasis and its risk factors in T1-2 staging invasive rectal carcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the lymph node metastasis and its risk factors in T1-2 staging invasive rectal carcinoma.</p><p><b>METHODS</b>The data of 1116 patients with rectal cancer treated with total mesorectal excision (TME) technique from January 2000 to April 2009 was analyzed retrospectively. The clinicopathological factors analyzed included gender, age, primary symptom type, number of symptoms, duration of symptom, synchronous polyps, preoperative serum carcino-embryonic antigen level, preoperative serum CA19-9 level, the distance of tumor from the anal verge, tumor size, tumor morphological type, tumor circumferential extent, tumor differentiation and tumor T staging. Statistical analysis was performed by using Logistic regression analysis and Chi-square test.</p><p><b>RESULTS</b>A total of 1116 patients were enrolled, and 358 cases (32.1%) were classified as with T1-2 staging tumor. Two cases (5.6%, 2/36) in patients with a T1 staging tumor were found with lymph node metastasis, and 75 cases (23.3%, 75/322) in patients with a T2 staging tumor, respectively. Compared with patients with T3-4 staging tumor, lymph node metastasis rate of the patients with T1-2 staging tumor was significantly lower [21.5% (77/358) vs. 51.6% (391/758), P < 0.05]. Only the tumor T staging was found as the independent risk factor for the lymph node metastasis in patients with T1-2 staging tumor on multivariate Logistic regression analysis (odds ratio: 5.162; 95%CI: 1.212 to 21.991; P = 0.026).</p><p><b>CONCLUSIONS</b>A substantial proportion of T1-2 staging rectal cancers harbor metastatic lymph nodes and the clinicopathological features except for T staging fail to predict the lymph node metastasis. Further research is warranted to identify the risk factors and guide the clinical practice in patient with T1-2 staging tumor.</p>

Effect of colonoscopy combined with placement of metallic clips on selecting colonic surgery incision / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the accuracy and value of the placement of metallic clips during colonoscopy in the localization of colorectal cancer and incision selection.</p><p><b>METHODS</b>A total of 30 patients received metallic clip placement by colonoscopy before operation. Abdominal plain film (supine and upright position) was taken and incision was determined by the projection of clips on the abdominal wall.</p><p><b>RESULTS</b>The inaccuracy rate of localization by colonoscopy was 30%(9/30). Colonoscopy combined with the placement of metallic clips achieved an accurate incision rate of 100% (30/30).</p><p><b>CONCLUSIONS</b>There is a considerable rate of inaccuracy for localization in colonic cancer by colonoscopy. Colonoscopy combined with placement of metallic clips should be considered in order to select a reasonable incision.</p>

Impact of meticulousness of pathologists on lymph node harvest after radical resection of invasive rectal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To analyze the impact of meticulousness of pathologists on the lymph node harvest after radical resection of invasive rectal carcinoma.</p><p><b>METHODS</b>From January 2008 to May 2009, the clinical data of rectal cancer patients undergone operation were reviewed retrospectively. After multidisciplinary cooperation on rectal cancer, a new rule was applied to request the pathologists to find no less than 15 nodes in single colorectal specimen from January 2009. Patients were divided into two groups (2008 group and 2009 group) and the node harvest numbers were compared. Excluded criteria were recurrent colorectal tumor, Tis tumor, R(1) or R(2) resection, tumor resection transanally or endoscopically, the cases enrolled in other prospective research, synchronous diseases affecting the surgical procedure for the rectal cancer (familial adenomatous polyposis, synchronous colorectal carcinoma) and rectal cancer receiving neoadjuvant chemoradiation. Statistical analysis was performed using One-Sample Kolmogorov- Smirnov test, Mann-Whitney test, Independent-Samples T test and Chi-Square test(SPSS 15.0).</p><p><b>RESULTS</b>A total of 232 patients were identified, including 76 cases in the 2009 group and 156 cases in 2008 group. The lymph node retrieval in the 2009 group was significantly more than that in 2008 group (16.0+/-0.3 vs 11.4+/-0.3, P<0.01). A significantly higher percentage of patients was found in 2009 group with a lymph node harvest equal to or more than 12 nodes (72/76 vs 71/156, P<0.01). There were no significant differences in gender (46/76 vs 86/156, P=0.436), age (58.1+/-1.3 vs 59.2+/-1.1, P=0.527), distance from tumor to anal verge (7.4+/-0.4 vs 7.1+/-0.3, P=0.761), proportion of sphincter-sparing surgery (67/76 vs 140/156, P=0.715), ratio of well and moderate differentiated tumors (68/76 vs 125/156, P=0.074) and overall TNM stage (P=0.167) between the two groups.</p><p><b>CONCLUSIONS</b>The lymph node harvest in 2009 group is significantly more than that in 2008 group. The good performance of pathologists could produce adequate number of lymph nodes for rectal cancer without neoadjuvant chemoradiation.</p>

Factors associated with anastomotic leakage after anterior resection in rectal cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the factors associated with anastomotic leakage after anterior resection in rectal cancer with the technique of total mesorectal excision (TME).</p><p><b>METHODS</b>From January 2005 and December 2007, 738 consecutive patients with rectal cancer underwent anterior resection. The data of those patients was collected and reviewed retrospectively. The associations between anastomotic leakage and 9 patient-related variables as well as 7 surgical-related variables were examined.</p><p><b>RESULTS</b>Low rectal cancer (located 7 cm or less above the anal edge), non-specialized surgeon and transanal tube use were the risk factors associated with anastomotic leakage on univariate analysis. The anastomotic leakage rate of low-rectal cancer was significantly higher than that of high-rectal cancer (5.9% vs. 0.9%, P = 0.003). The anastomotic leakage rate of the cases operated by colorectal surgeon was significantly lower than that of the cases operated by non-specialized surgeon (3.9% vs. 11.3%, P = 0.031). There was a tendency for colorectal surgeons to operate on a greater proportion of low rectal cancer than non-specialized surgeons (72.1% vs. 52.8%, P = 0.003). The leakage rate of transanal tube group was unexpectedly higher than that in patients without transanal tube (14.5% vs. 3.6%, P < 0.001). On multivariate logistic regression analysis, diabetes mellitus (P = 0.027), distance less than 1 cm from tumor to distal resection margin (P = 0.009) and defunctioning stoma (P = 0.031) were also associated with anastomotic leakage rate besides low rectal cancer, non-specialized surgeon and transanal tube use. In a further analysis of 522 patients with low rectal cancer, the leakage rate of defunctioning stoma group was significantly lower than that of non-stoma group (2.9% vs. 8.5%, P = 0.007). By contract, the leakage rate of transanal tube group was still higher than that in patients without transanal tube (15.1% vs. 4.9%, P = 0.008) because of its poor protective effect as well as the selection bias.</p><p><b>CONCLUSIONS</b>Low-rectal cancer, non-specialized surgeons and diabetes mellitus are risk factors of anastomotic leakage after rectal surgery. A defunctioning stoma was effective in preventing leakage after low-rectal cancer surgery.</p>

Diagnosis and surgical management for adult Hirschsprung's disease / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the diagnosis and surgical management of adult Hirschsprung's disease.</p><p><b>METHODS</b>Clinical data of 15 patients with adult Hirschsprung's disease were reviewed retrospectively from June 1992 to June 2004.</p><p><b>RESULTS</b>Patients age ranged from 17 to 54 years old. The main manifestations included long-term (ranged from 9.5 month to 50 years) constipation and abdominal distention. Acute abdominal pain occurred in six patients, but no sign of de hydration and malnutrition occurred in all patients. Bowel stenosis and dilation could be examined by barium enema. Soave procedure was performed in 3 patients, subtotal colectomy with coloanal anastomosis was performed in twelve patients. The function of defecation was improved in all patients after operation.</p><p><b>CONCLUSIONS</b>The diagnosis of adult Hirschsprung's disease mainly depends on the history of constipation from infant and barium enema. Subtotal colectomy with coloanal anastomosis is an effective and safe operative procedure.</p>

Bowel control of anus-preserving operation for low rectal cancer in elderly patients over 75 years / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the bowel control of the anus-preserving operation for elderly patients over 75 years with low rectal cancer.</p><p><b>METHODS</b>Thirty-nine elderly patients over 75 years with low rectal carcinoma (4-7 cm from anal verge) were treated during the study period. The patients were divided into different groups according to the surgical procedures and anastomotic locations. The bowel control and patients satisfaction were compared.</p><p><b>RESULTS</b>The time of recovering normal defecation frequency was (9.8+/- 2.9) months. There were no differences in bowel control and anorectal manometric findings between the lower anastomosis group and super-lower anastomosis group, the lower anastomosis group and anorectal anastomosis group. The patients in anorectal anastomosis group displayed significantly better bowel control and anorectal manometric findings than those in the super-lower anastomosis group (P< 0.05). The time of recovering normal defecation frequency in colonic J-pouch-anal anastomosis group was (7.7+/- 1.7) months, shorter than (10.6+/- 2.8) months in direct anastomosis group (P< 0.01). The complication rate of I degree incontinence was 36.1%, but there was no difference between the two groups. The anorectal manometric findings were better in J-pouch-anal anastomosis group than those in direct anastomosis group (P< 0.05).</p><p><b>CONCLUSION</b>Colonic J-pouch-anal anastomosis for lower rectal carcinoma can significantly improve the bowel control in a short term without increasing the complication rate.</p>