Effects of the number of harvested lymph nodes in neoadjuvant chemoradiotherapy combined with surgery on prognosis of middle-low rectal cancer / 中华消化外科杂志

Objective To investigate the effects of the number of harvested lymph nodes in neoadjuvant chemoradiotherapy (nCRT) combined with surgery on prognosis of middle-low rectal cancer.Methods The retrospective case-control study was conducted.The clinicopathological data of 373 patients with middle-low rectal cancer who underwent nCRT combined with surgery in the Fujian Medical University Union Hospital from January 2009 to December 2013 were collected.There were 241 males and 132 females,aged from 26 to 81 years,with the age of (55 ± 11) years.Observation indicators:(1) treatment situations;(2) follow-up and survival;(3)influencing factors for the number of harvested lymph nodes;(4) prognostic analysis of the different number of harvested lymph nodes as cut-off for grouping;(5) stratified analysis.Follow-up using telephone interview and outpatient examination was performed to detect postoperative survival of patients once every three months within postoperative 2 years and once every 6 months during the postoperative third year up to March 2016.The endpoint of follow-up was tumor recurrence,retastasis or death.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was done using the independent sample t test.Measurement data with skewed distribution were represented as M (range),and comparison between groups was done using the Kruska1-Wallis H test.Count data was described as absolute numbers.Univariate and multivariate analyses were done by the multiple linear regression model.Survival rate was calculated by the Kaplan-Meier method,and Logrank test was used for survival analysis.Results (l) Treatment situations:373 patients underwent nCRT combined with surgery,including 329 combined with sphincter-sparing rectal resection and 44 combined with abdominoperineal rectal resection.The number of harvested lymph nodes was 12 ± 6 in 373 patients.There were 185 patients with the number of harvested lymph nodes ＜ 12 and 188 with the number of harvested lymph nodes ≥ 12.(2) Follow-up and survival:373 patients were followed up for 5-77 months,with a median follow-up time of 43 months.During the follow-up,the 1-,3-,5-year disease-free survival rates were respectively 90.4％,76.3％,and 67.5％ in the 373 patients.(3) Influencing factors for the number of harvested lymph nodes:univariate analysis showed that distance between the tumor and anal verge,tumor diameter,tumor pathological N staging,and regression grade of rectal cancer were associated factors for the number of harvested lymph nodes (t =3.156,2.992,x2=8.183,10.839,P＜0.05).Multivariate analysis showed that distance between the tumor and anal verge,regression grade of rectal cancer,and tumor pathological N staging were independent factors for the number of harvested lymph nodes (t=3.308,2.690,2.584,95％ confidence interval:0.808-3.180,0.446-2.873,0.332-2.448,P＜0.05).(4) Prognostic analysis of the different number of harvested lymph nodes as cut-off for grouping:with the number of harvested lymph nodes of 6,7,8,9,10,11,12,13,14,15,and 16 as cut-off for grouping,there was no significant difference in the 3-year disease-free survival rate,cumulative local recurrence rate,and cumulative distant metastasis rate between ＜6 group and ≥6 group,between ＜7 group and ≥7 group,between＜8 group and ≥8 group,between ＜9 group and ≥9 group,between ＜10 group and ≥ 10 group,between ＜11 group and ≥ll group,between ＜12 group and ≥12 group,between ＜13 group and ≥13 group,between ＜ 14 group and ≥ 14 group,between ＜ 15 group and ≥ 15 group,between ＜ 16 group and ≥ 16 group,respectively (P＞0.05).(5) Stratified analysis:with the number of harvested lymph nodes of 7,8,9,and 10 as cut-off for grouping in 45 of 373 patients with Ⅱ-Ⅲ regression grade of rectal cancer and negative lymph nodes (NO staging),there was no significant difference in the 3-year disease-free survival rate between ＜7 group and ≥ 7group,between ＜8 group and ≥8 group,between ＜9 group and ≥9 group,between＜10 group and ≥ 10 group,respetively (x2 =3.946,5.346,6.375,4.297,P＜0.05).Conclusions The number of lymph nodes as 12 is not the independent factor for prognosis of patients with middle-low rectal cancer after nCRT combined with surgery.The number of harvested lymph nodes as 7 to 10 is the important factor for evaluating the prognosis of middle-low rectal cancer patients with Ⅱ-Ⅲ regression grade of rectal cancer and negative lymph nodes after nCRT combined with surgery.

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

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

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

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

Risk factors and clinical features of delayed anastomotic fistula following sphincter-preserving surgery for rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the risk factors and clinical features of delayed anastomotic fistula (DAF) following sphincter-preserving operation for rectal cancer.</p><p><b>METHODS</b>Clinical data of 1 594 patients with rectal cancer undergoing sphincter-preserving operation in our department from January 2008 to May 2015 based on the prospective database of Dpartment of Colorectal Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. Sixty patients(3.8%) developed anastomotic fistula. Forty-one patients (2.6%) developed early anastomotic fistula (EAF) within 30 days after surgery while 19(1.2%) were DAF that occurred beyond 30 days. Univariate analyses were performed to compare the clinical features between EAF and DAF group.</p><p><b>RESULTS</b>DAF was diagnosed at a median time of 194(30-327) days after anastomosis. As compared to EAF group, DAF group had lower tumor site [(6.1±2.3) cm vs. (7.8±2.8) cm, P=0.023], lower anastomosis site [(3.6±1.8) cm vs. (4.8±1.6) cm, P=0.008], higher ratio of patients receiving neoadjuvant chemoradiotherapy (84.2% vs. 34.1%, P=0.000), and receiving preventive stoma (73.7% vs. 14.6%, P=0.000). According to ISREC grading system for anastomotic fistula, DAF patients were grade A and B, while EAF cases were grade B and C(P=0.000). During the first hospital stay for anastomosis, DAF group did not have abdominal pain, general malaise, drainage abnormalities, peritonitis but 8 cases(42.1%) had fever more than 38centi-degree. In EAF group, 29 patients(70.7%) had abdominal pain and general malaise, and 29(70.7%) had drainage abnormalities. General or circumscribed peritonitis were developed in 25(61.0%) EAF patients, and fever occurred in 39(95.1%) EAF cases. There were 13(68.4%) cases with sinus or fistula formation and 9(47.4%) with rectovaginal fistula in DAF group, in contrast to 5 (12.2%) and 5 (12.2%) in EAF group respectively. In DAF group, 5 (26.3%) patients received follow-up due to stoma (no closure), 5 (26.3%) received bedside surgical drainage, while 9(47.4%) patients underwent operation, including diverting stoma in 3 patients, Hartmann procedure in 1 case, intersphincteric resection, coloanal anastomosis plus ileostomy in 1case because of pelvic fibrosis and stenosis of neorectum after radiotherapy, mucosal advancement flap repair with a cellular matrix interposition in 3 rectovaginal fistula cases, incision of sinus via the anus in 1 case. During a median follow-up of 28 months, 14(73.7%) DAF patients were cured.</p><p><b>CONCLUSIONS</b>It is advisable to be cautious that patients with lower site of tumor and anastomosis, neoadjuvant chemoradiotherapy and preventive stoma are at risk of DAF. DAF is clinically silent and most patients can be cured by effective surgical treatment.</p>

Effect of different blood purification methods on serum cardiac troponin T/I,β2-microglobulin and interleukin-6 levels in patients with maintenance hemodialysis / 中国生化药物杂志

Objective To analyse the effect of different blood purification methods on serum cardiac troponinc T (cTnT), cardiac troponinⅠ(cTnI), β2-microglobulin (β2-MG) and interleukin-6 (IL-6) levels in patients with maintenance hemodialysis.Methods 60 uremic patients treated with maintenance hemodialysis were collected.All patients were randomly divided into conventional hemodialysis group (HD group) , hemodialysis and hemoperfusion group (HD+HP group) and hemodiafiltration group (HDF group) , 20 cases in each group.Corresponding dialysis treatment was given, then the serum levels of cTnT, cTnI,β2-MG and IL-6 were detected in all patients post-treatment.Results After treatment, the serum cTnT, cTnI,β2-MG and IL-6 levels in HD+HP group and HDF group were lower than those in HD group (P<0.05).Conclusions Different blood purification methods have different effects on serum cTnT, cTnI, β2-MG and IL-6 levels in patients with maintenance hemodialysis, HDF and HD +HP have better scavenging effect, which has the guiding significance to clinical application.

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

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

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

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

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

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

Clinical features of autoimmune pancreatitis: a case series of 16 patients / 中华胰腺病杂志

Objective To summarize the clinical features, diagnosis and treatment of autoimmune pancreatitis (AIP). Methods From March 2003 to January 2008, a total of 16 cases of AIP were reviewed retrospectively. Results The ratio of male: female was 15:1, with a mean age of 61 years old (range:47-79 years old). Jaundice was the main clinical presentation in 81.2% patients. 68.8% patients presented with high serum gammaglobulin, while 66.7% with high serum IgG, 56.2% with elevated ESR, 50.0% with positive rheumatoid factor(RF), 43.7% with eosinophilia, 26.7% with positive antinuclear antigen(ANA),31.2% with elevated lipase, 18.7% with elevated amylase, and 25.0% with elevated CA19-9. 93.7%patients showed diffuse swelling of the pancreas on CT and/or endoscopic ultrasound. Stricture of the main pancreatic duct was seen in 100% patients. Distal common bile duct stricture was seen in 87.5%, while thickened wall of bile duct was seen in 50%. Histological findings of the pancreas EUS-FNA showed nonspecific results in one patient, while no tumor cell was detected in other 5 patients; lymphocytes infiltration was noted in 3 patients; pancreatic fibrosis was seen in 2 patients. 75.0% patients was found to have diabetes or abnormal sugar tolerance, enlargement of the celiac lymph nodes in 43.7%, splenic vein or inferior cava vein involvement in 42.9%, swelling of the maxillary glands in 18.7%, the lacrimal glands in 12%. Prednisone was given to 11 patients, among them 5 patients underwent endoscopic stent placement, and 10 patients responded well while 1 patient discontinued therapy due to intolerance. 2 patients underwent endoscopic stent placement alone and jaundice disappeared. 3 patients received conventional medical treatment. Steroid therapy exerted different effects on levels of the blood glucose, the enlarged maxillary and lacrimal glands improved after steroid therapy. Conclusions AIP occurred in middle aged and senior male predominantly, painless obstructive jaundice was the main clinical presentation, and patients may be accompanied with elevated levels of IgG, hypergammaglobulin, positive RF and ANA, diffuse or focal pancreatic enlargement, pancreatic duct stricture and distal common bile duct stricture. Stent placement could improve the symptoms, and steroid therapy was effective.

Mineralization in dental germs observed with modified Mallory's trichrome staining / 实用口腔医学杂志

Objective:To observe the dynamic process of the development of dentin and enamel during their mineralization period. Methods: Dental germs in maxillae and mandibulae were obtained from spontaneously aborted 21 weeks and 32 weeks fetus. The samples were prepared and stained with modified Mallory's trichrome staining and observed under light microscope. Results: Different mineralized layers in different period of development appeared different color variation in the dental germs. Conciusion: Modified Mallory's trichrome staining method may be used to study the mineralization of dental germ.