Anatomical classification of and laparoscopic surgery for left-sided colorectal cancer with persistent descending mesocolon / 中华胃肠外科杂志

Objective: To investigate anatomical morphology and classification of persistent descending mesocolon (PDM) in patients with left-sided colorectal cancer, as well as the safety of laparoscopic radical surgery for these patients. Methods: This is a descriptive study of case series. Relevant clinical data of 995 patients with left colon and rectal cancer who had undergone radical surgery in Fujian Medical University Union Hospital from July 2021 to September 2022 were extracted from the colorectal surgery database of our institution and retrospectively analyzed. Twenty-four (2.4%) were identified as PDM and their imaging data and intra-operative videos were reviewed. We determined the distribution and morphology of the descending colon and mesocolon, and evaluated the feasibility and complications of laparoscopic surgery. We classified PDM according to its anatomical characteristics as follows: Type 0: PDM combined with malrotation of the midgut or persistent ascending mesocolon; Type 1: unfixed mesocolon at the junction between transverse and descending colon; Type 2: PDM with descending colon shifted medially (Type 2A) or to the right side (Type 2B) of the abdominal aorta at the level of the origin of the inferior mesentery artery (IMA); and Type 3: the mesocolon of the descending-sigmoid junction unfixed and the descending colon shifted medially and caudally to the origin of IMA. Results: The diagnosis of PDM was determined based on preoperative imaging findings in 9 of the 24 patients (37.5%) with left-sided colorectal cancer, while the remaining diagnoses were made during intraoperative assessment. Among 24 patients, 22 were male and 2 were female. The mean age was (63±9) years. We classified PDM as follows: Type 0 accounted for 4.2% (1/24); Type 1 for 8.3% (2/24); Types 2A and 2B for 37.5% (9/24) and 25.0% (6/24), respectively; and Type 3 accounted for 25.0% (6/24). All patients with PDM had adhesions of the mesocolon that required adhesiolysis. Additionally, 20 (83.3%) of them had adhesions between the mesentery of the ileum and colon. Twelve patients (50.0%) required mobilization of the splenic flexure. The inferior mesenteric artery branches had a common trunk in 14 patients (58.3%). Twenty-four patients underwent D3 surgery without conversion to laparotomy; the origin of the IMA being preserved in 22 (91.7%) of them. Proximal colon ischemia occurred intraoperatively in two patients (8.3%) who had undergone high ligation at the origin of the IMA. One of these patients had a juxta-anal low rectal cancer and underwent intersphincteric abdominoperineal resection because of poor preoperative anal function. Laparoscopic subtotal colectomy was considered necessary for the other patient. The duration of surgery was (260±100) minutes and the median estimated blood loss was 50 (20-200) mL. The median number of No. 253 lymph nodes harvested was 3 (0-20), and one patient (4.2%) had No.253 nodal metastases. The median postoperative hospital stay was 8 (4-23) days, and the incidence of complications 16.7% (4/24). There were no instances of postoperative colon ischemia or necrosis observed. One patient (4.2%) with stage IIA rectal cancer developed Grade B (Clavien-Dindo III) anastomotic leak and underwent elective ileostomy. The other complications were Grade I-II. Conclusions: PDM is frequently associated with mesenteric adhesions. Our proposed classification can assist surgeons in identifying the descending colon and mesocolon during adhesion lysis in laparoscopic surgery. It is crucial to protect the colorectal blood supply at the resection margin to minimize the need for unplanned extended colectomy, the Hartmann procedure, or permanent stomas.

Efficacy and safety of sunitinib on patients with imatinib-resistant gastrointestinal stromal tumor / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the efficacy and safety of sunitinib on the management of gastrointestinal stromal tumors (GIST) patients with imatinib resistance.</p><p><b>METHODS</b>Clinical data of 48 patients with imatinib-resistant GIST received sunitinib therapy from May 2008 to April 2012 in the Union Hospital of Fujian Medical University were analyzed retrospectively. Eighteen patients received 50 mg/d of sunitinib in a protocol of 4/2 (4 weeks on and 2 weeks off) [50 mg/d (4/2)], and 30 patients received a protocol of 37.5 mg of sunitinib continuous daily dose (37.5 mg/d CDD).</p><p><b>RESULTS</b>The median duration of sunitinib administration of all the 48 patients was 56 weeks, and the short-term efficacy was evaluated at 24 weeks after the initial treatment according to the Choi criteria. The response rate was 27.1% (13/48), including 1 case with complete response (CR), 12 cases with partial response (PR), and 21 cases with stationary disease (SD). The disease control rate was 70.8% (34/48). The mean follow-up time of 48 patients was 89 weeks. The median progression-free survival (PFS) and overall survival (OS) were 48 weeks and 92 weeks respectively. Stratified analyses indicated that the median PFS of patients previously treated by imatinib 400 mg/d and >400 mg/d were 53 weeks and 35 weeks respectively (P=0.018), and the median OS of these two groups were 157 weeks and 71 weeks respectively (P=0.003). Patients with exon 11 mutations had a significantly shorter OS compared with those with exon 9 mutations (71 weeks vs 157 weeks, P=0.008). Hand-foot syndrome was the most common adverse effect (25/48, 52.1%), followed by nausea (24/48, 50.0%), fatigue (23/48, 47.9%), neutropenia(21/48, 41.7%). The sub-group analysis of two protocols of sunitinib administration showed that the incidence of diarrhea and hand-foot syndrome were higher in 50 mg/d (4/2) group than those in 37.5 mg/d CDD group (P=0.027, P=0.048).</p><p><b>CONCLUSIONS</b>Sunitinib is effective for the patients with imatinib-resistant GIST. After 400 mg/d imatinib treatment failure, sunitinib should be prescribed instead of increased dosage of imatinib. Patients with KIT exon 9 mutations present better prognosis than those with KIT exon 11 mutations. The protocol of sunitinib 37.5 mg/d CDD possesses better safety.</p>

Meta analysis of postoperative complications between laparoscopic resection and traditional open resection of mid-low rectal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To conduct a meta-analysis of postoperative complications between laparoscopic resection (Group LR) and traditional open resection (Group OR) of mid-low rectal carcinoma.</p><p><b>METHODS</b>Meta analysis was performed by two reviewers, who independently selected and extracted data retrieved from literatures and papers published in China Knowledge Resource Integrated Database (CNKI), Wangfang Data, Foreign Medical Journal Service (FMJS), PubMed, EMBASE and The Cochrane before August 2012 on comparison between two groups. The statistical analysis for research of complex standard was conducted through Revman 5.0.</p><p><b>RESULTS</b>Thirteen clinical case-control studies with a total of 2733 cases were enrolled for analysis, including 1368 cases in Group LR and 1365 in Group OR. The result showed that, compared with Group OR, Group LR had lower overall rate of postoperative complication (OR=0.76, 95%CI:0.62-0.92, P<0.01), lower rate of postoperative intestinal obstruction (OR=0.53, 95%CI:0.35-0.80, P<0.01), lower rate of incision complications (OR=0.43, 95%CI:0.28-0.67, P<0.01), similar incidence of anastomotic bleeding and fistula, and similar incidence of bleeding in abdominal cavity and pelvic cavity (all P>0.05).</p><p><b>CONCLUSIONS</b>The overall rate of postoperative complications of laparoscopic resection for mid-low rectal carcinoma is obviously lower than that of open resection. Laparoscope can be applied safely in the resection of mid-low rectal carcinoma.</p>

Short-term efficacy of laparoscopic-assisted right hemicolectomy with D3 lymph node dissection in colon cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the feasibility and short-term efficacy of laparoscopic-assisted D3 lymph node dissection for right colon cancer with a medial-to-lateral approach.</p><p><b>METHODS</b>Clinical data of 61 patients with right colon cancer undergoing D3 lymph node dissection from March 2006 to June 2010 were analyzed retrospectively. Among them,29 underwent laparoscopic-assisted right hemicolectomy (LARH group) and 32 underwent open right hemicolectomy (ORH group). The number of lymph node harvest, operative details, and complication rate were compared between the two groups.</p><p><b>RESULTS</b>The mean number of lymph node harvest did not differ significantly between the two groups (16.9±3.8 vs. 15.4±3.6). As compared to ORH group, although the operative time was significantly longer [(214.4±37.9) min vs. (193.3±28.8) min] in LARH group, the mean blood loss [(83.4±38.0) ml vs. (192.7±43.6) ml], time to first flatus [(44.6±20.8) h vs. (70.4±80.0) h], time to resumption of soft diet[(32.5±10.6) h vs. (59.7±10.4) h], and postoperative hospital stay [(11.2±2.2) d vs. (13.8±2.8) d] were more favorable(all P<0.05). Complication rate was lower in LARH group(10.4% vs. 9.4%), however the difference was not statistically significant.</p><p><b>CONCLUSIONS</b>LARH with D3 lymph node dissection is oncologically comparable with ORH for right colon cancer. It is a safe and feasible procedure associated with rapid postoperative recovery.</p>