Postoperative short-term complications of laparoscope-assisted transanal total mesorectal excision for rectal cancer after neoadjuvant therapy and their management: a single center report / 中华胃肠外科杂志

OBJECTIVE@#To summarize and analyze the postoperative short-term complications of laparoscope-assisted transanal total mesorectal excision (taTME) for rectal cancer patients after neoadjuvant therapy.@*METHODS@#A prospectively established database on taTME patients at Peking University Cancer Hospital was screened with the following conditions: data retrieval from June 2016 to August 2018, pathologically confirmed adenocarcinoma, receiving preoperative neoadjuvant chemoradiotherapy or chemotherapy. The transabdominal procedure and the transanal procedure were performed simultaneously in the taTME operation. Occurrence of complications during perioperative period (within postoperative 3 months) in these patients, especially anastomosis-related complications and their management were analyzed. The relevant complications were recorded according to the Clavien-Dindo (CD) grading criteria. The severity of anastomotic leakage and anastomotic stenosis was evaluated according to criteria developed by the International Rectal Cancer Research Group.@*RESULTS@#A total of 29 patients were enrolled in this study. In the 29 patients, 25 (86.2%) were male and 4 (13.8%) were female, the median age was 60 (range, 30 to 72) years, the median body mass index was 25.8 (range, 19.8 to 36.4) kg/m, the median distance from the tumor to anal verge was 4 (range, 2 to 8) cm. All the patients completed laparoscope-assisted taTME operations successfully without conversion to laparotomy, intra-operative severe complication or death. The median operation time was 300 (range, 198 to 405) minutes, and the median intra-operative blood loss was 100 (range, 50 to 200) ml. All the TME specimens were complete according to the Nagtegaal standard. All the patients underwent prophylactic ileostomy. Hartmann procedure was performed in one case due to poor blood supply in the proximal bowel without the possibility of anastomosis. Anal sphincter preservation rate was 96.6% (28/29). The median postoperative exhaust time was 2 (range, 1 to 10) days, and the median postoperative hospital stay was 9 (range, 7 to 24) days. Fifteen patients (51.7%) had postoperative complications, among which serious complication (CD grade IIIb and above) accounted for 6.9% (2/29). No perioperative death was observed. Five patients (17.2%) presented anastomosis-related complications, including 2 cases of grade C anastomotic leakage due to anastomotic rupture, who underwent abdominal perineal resection 1 month after operation; 2 cases of grade B anastomotic leakage, who improved after conservative treatment; 1 case of grade A anastomotic stenosis, who improved with anal expansion 1 month after operation. The incidence of postoperative infection was 24.1% (7/29), including 6 cases of pelvic infection and 1 case of trocar site infection, all of which were CD grade II. One case had incomplete intestinal obstruction (CD grade II); 1 case had gastroplegia; 1 case had abdominal trocar hernia. All the patients were followed up for a median of 12.0 (range, 3.9 to 29.9) months. Seven cases did not undergo ileal stoma closure. The anal sphincter preservation rate was 75.9% (22/29).@*CONCLUSION@#Pelvic infection and anastomosis-related complications are common after laparoscope-assisted taTME surgery for rectal cancer patients following neoadjuvant chemoradiotherapy, which require active management and appropriate treatment.

"Watch and wait" strategy after neoadjuvant therapy for rectal cancer: status survey of perceptions, attitudes and treatment selection in Chinese surgeons / 中华胃肠外科杂志

Objective@#To understand the perceptions, attitudes and treatment selection of Chinese surgeons on the "watch and wait" strategy for rectal cancer patients after achieving a clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT).@*Methods@#A cross-sectional survey was used in this study. Selection of subjects: (1) Domestic public grade III A (provincial and prefecture-level) oncology hospitals or general hospitals possessing the radiotherapy department and the diagnosis and treatment qualifications for colorectal cancer. (2) Surgeons of deputy chief physician or above. Using the "Questionnaire Star" online survey platform to create a questionnaire about cognition, attitude and treatment choice of the "watch and wait" strategy after cCR following nCRT for rectal cancer. The questionnaire contained 32 questions, such as the basic information of doctor, the current status of rectal cancer surgery, the management of pathological complete remission (ypCR) after nCRT for rectal cancer, the selection of examination items for diagnosis of cCR, the selection of suitable people undergoing "watch and wait" approach, the nCRT mode for promotion of cCR, the choice of evaluation time point, the willingness to perform "watch and wait" approach and the treatment choice, and the risk and monitoring of "watch and wait" approach. A total of 116 questionnaires were sent to the respondents via WeChat between January 31 and February 19, 2019. Statistical analysis was performed using Fisher′s exact test for categorical variables.@*Results@#Forty-eight hospitals including 116 surgeons meeting criteria were enrolled, of whom 77 surgeons filled the questionnaire with a response rate of 66.4%. "Watch and wait" strategy was carried out in 76.6% (59/77) of surgeons. Seventy surgeons (90.9%) were aware of the ypCR rate of rectal cancer after preoperative nCRT and 49 surgeons (63.6%) knew the 3-year disease-free survival of patients with ypCR in their own hospitals. Fifty-five surgeons (71.4%) believed that patients with ypCR undergoing radical surgery met the treatment criteria and were not over-treated. Three most necessary examinations in diagnosing cCR were colonoscopy (96.1%, 74/77), digital rectal examination (DRE) (90.9%,70/77) and DWI-MRI (83.1%, 64/77). Responders preferred to consider a "watch and wait" strategy for patients with baseline characteristics as mrN0 (77.9%, 60/77), mrT2 (68.8%, 53/77) and well-differentiated adenocarcinoma (68.8%, 53/77). Sixty-six surgeons (85.7%) believed that long-term chemoradiotherapy (LCRT) with combination or without combination of induction and/or consolidation of the CapeOX regimen (capecitabine + oxaliplatin) should be the first choice as a neoadjuvant therapy to achieve cCR. Forty-one surgeons (53.2%) believed that a reasonable interval of judging cCR after nCRT should be ≥ 8 weeks. Forty-four surgeons (57.1%) routinely, or in most cases, informed patient the possibility of cCR and proposed to "watch and wait" strategy in the initial diagnosis of patients with non-metastatic rectal cancer. Thirteen surgeons (16.9%) would take the "watch and wait" strategy as the first choice after the patient having cCR. Fifty-two surgeons (67.5%) would be affected by the surgical method, that was to say, "watch and wait" approach would only be recommended to those patients who would achieve cCR and could not preserve the anus or underwent difficult anus-preservation surgery. Sixteen surgeons (20.8%) demonstrated that "watch and wait" strategy would not be recommended to patients with cCR regardless of whether the surgical procedure involved anal sphincter. Eleven surgeons (14.3%) believed that the main risk of "watch and wait" approach came from distant metastasis rather than local recurrence or regrowth. Twenty-nine of surgeons (37.7%) did not understand the difference between "local recurrence" and "local regrowth" during the period of "watch and wait". Twenty-six surgeons (33.8%) thought that the monitoring interval for the first 3 years of "watch and wait" strategy was 3 months, and the follow-up monitoring interval could be 6 months to 5 years. Surgeons from cancer specialist hospitals had higher approval rate, notification rate, and referral rate of "watch and wait" strategy than those from general hospitals. Thirty-one surgeons (42.5%) considered that the difficulty and concern of carrying out "watch and wait" approach in the future was the disease progress leading to medical disputes. Twenty-six surgeons (35.6%) demonstrated that their concern was lack of uniform evaluation standard for cCR.@*Conclusions@#Chinese surgeons seem to have inadequate knowledge of non-operative management for rectal cancer patients achieving cCR after nCRT and show relatively conservative attitudes toward the strategy. Chinese consensus needs to be formed to guide the non-operative management in selected patients. Chinese Watch & Wait Database (CWWD) is also needed to establish and provide more evidence for the use of alternative procedure after a cCR following nCRT.

Short-term outcome of transanal total mesorectal excision for male low rectal cancer patients with "difficult pelvis" : a single center report from Peking University Cancer Hospital / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the applicable value of transanal total mesorectal excision (taTME) in male low rectal cancer patients with narrow pelvis-"difficult pelvis", which remains difficult for both open and laparoscopic sphincter-saving operations.</p><p><b>METHODS</b>Clinical data of male low rectal cancer patients diagnosed by pathology undergoing taTME between June 2016 and January 2018 at Peking University Cancer Hospital were collected. A retrospective cohort study was performed. Patients were selected according to the following criteria: (1) low rectal cancer, the distance between inferior margin of tumor and anal verge ≤5 cm; (2) the distance between two sciatic tubercles <5 cm; (3) body mass index (BMI) >25 kg/m; (4) tumor horizontal diameter ≤4 cm. Operation time, intraoperative blood loss, postoperative hospital stay, postoperative complications and anal function were analyzed.</p><p><b>RESULTS</b>A total of 20 patients were included in this study. All the patients received preoperative neoadjuvant chemoradiation and hybrid transabdominal and transanal surgery. The median BMI was 27.7(26.2-36.4) kg/m; the median distance between two sciatic tubercles was 92.5 (78-100) mm; the median distance between the inferior margin of tumor to the anal verge was 4 (2-5) cm; the median operation time was 302 (215-402) min; the median intraoperative blood loss was 100 (50-200) ml; the median postoperative hospital stay was 9 (5-15) d. Postoperative complications occurred in 5 patients (25%), including 3 pelvic infection, 1 intestinal obstruction, 1 anastomotic leakage receiving sigmoid colostomy. There was no perioperative death. Sphincter-preservation rate was 100%. Nineteen patients received anal manometry 1 month after operation with normal resting pressure (41.5±8.6) mmHg and squeeze pressure (121.0±11.6) mmHg. All the patients were followed up to March 2018, and the median follow-up time was 4.5 months. Only 1 patient had supraclavicular lymph node metastasis and no local recurrence was found.</p><p><b>CONCLUSIONS</b>The safety of transanal total mesorectal excision for male patients with low rectal cancer and difficult pelvis is acceptable. TaTME is helpful to preserve the anal sphincter.</p>

Effect of adjuvant chemotherapy on the prognosis of stage II( colon cancer patients with high risk factors / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of adjuvant chemotherapy on the prognosis of stage II( colon cancer patients with high risk factors.</p><p><b>METHODS</b>Clinicopathological and follow-up data of stage II( colon cancer patients undergoing radical surgery from January 2001 to March 2012 at Gastrointestinal Cancer Center of Peking University Cancer Hospital were retrospectively analyzed. The effect of adjuvant chemotherapy (within postoperative 2 month, fluorine uracil as main drugs) on the prognosis of high-risk patients was analyzed. High risk factors were defined as having at least one of the following factors: (1) tumor stage T4; (2) poor differentiation; (3) with vascular cancer embolus; (4) number of harvested lymph node less than 12; (5) complicated with obstruction or perforation.</p><p><b>RESULTS</b>A total of 497 patients with stage II( colon cancer were included in this study, of whom 258 cases(51.9%) had high risk factors, including stage T4 tumor in 80 cases(16.1%), poor differentiation in 80 cases (16.1%), cancer embolus in 37 cases (7.4%), lymph node harvested number less than 12 in 88 cases (17.7%), and obstruction or perforation in 85 cases (17.1%). Among 497 patients, number of cases with 1 to 4 high risk factors was 170 (34.2%), 68 (13.7%), 16 (3.2%) and 4 (0.8%), respectively. The last follow-up time was December 2016. The 5-year overall survival rate of all the 497 patients was 81.7%. The 5-year overall survival rate of 239 patients without high risk factors was 87.0%. The 5-year survival rate in patients with 1 to 4 risk factors was 81.9%, 73.7%, 66.7% and 25.0%, respectively (P=0.001). There was no significant difference in 5-year survival rate between 103 patients with adjuvant chemotherapy and 394 patients without adjuvant chemotherapy (79.6% vs. 82.8%, P=0.814). In patients with high risk factors, 80(31.0%) received adjuvant chemotherapy. There was no significant difference of 5-year survival rate between 80 patients with adjuvant chemotherapy and 178 patients without adjuvant chemotherapy (81.4% vs. 74.7%, P=0.147). Multivariate analysis showed that preoperative CEA level, T4 stage, lymph node harvested number, and tumor differentiation were the independent prognostic factors of patients with stage II( colon cancer (all P<0.05).</p><p><b>CONCLUSIONS</b>The proportion of patients with at least one risk factor is quite high in stage II( colon cancer cases. Adjuvant chemotherapy can not prolong the overall survival time of high risk patients.</p>

The effects of limited fluid resuscitation on hemodynamics and myocardial injury in patients with septic shock caused by myocardial injury / 重庆医学

Objective To evaluate the effects of limited fluid resuscitation on septic shock caused by myocardial injury . Methods 60 severe traumatic sepsis and septic shock patients were randomly divided into study group and control group ,with 30 cases in each group ,the control group was given active fluid resuscitation ,maintain the mean arterial pressure (MAP) in 70 mm Hg ;the study group were treated with limited fluid resuscitation ,namely when MAP rose to a slow infusion rate 50-60 mm Hg ,we restrict the amount of fluid ,maintain MAP at about 50 mm Hg ,observe and record the two groups of patients hemodynam-ics index ,APACHE Ⅱ score and heart function index ,and compared serum cTnI ,NT proBNP and CRP in the two groups .Results (1)In study group the infusion volume before admission was (258 ± 105)mL ,preoperative was (558 ± 226)mL ;in the control group that of before admission was (816 ± 422)mL ,preoperative was (1 668 ± 780) mL (P0 .05) .(3)After the treatment APACHEⅡscore of the two groups was significantly decreased ,car-diac output ,stroke volume and left ventricular ejection fraction significantly increased in control group ,the study group were better than control group (P<0 .05) .(4) The plasma cTnI ,NT proBNP ,CRP levels of the two groups significantly decreased after treat-ment (P<0 .05) ,plasma cTnI ,NT proBNP and CRP levels of research group were significantly lower than that of control group (P<0 .05) .Conclusion Limited fluid resuscitation can maintain hemodynamic ,reduce the interference on the internal environment ,re-duce myocardial injury ,and improve the success rate of treatment .

Clinical observation of Entecavir combined Liuweiwuling Pian in the treatment of chronic hepatitis B patients with HBeAg+ / 中国基层医药

Objective To explore the curative effect and safety of of Entecavir ( ETV) combined Liuweiwul-ing Pian in the treatment of chronic hepatitis B patients with HBeAg +.Methods 124 patients according to the ran-dom number table were divided into the two groups ,which respectively used ETV combined Liuweiwuling Pian treat-ment and ETV.The liver function and index of viral replication of the two groups were compared .Results The effec-tiveness of the observation group was 91.94%,which of the control group was 82.26%,the difference between the two groups had statistical significance(Ridit=32.251,P=0.000);Since 24 week treatment,HBV DNA of the observa-tion group was lower than the control group,the difference was statistically significant (t =2.365,4.595,all P<0.05);After treatment,ALT,AST of the observation group decreasing degree was higher than the control group ,the difference was statistically significant (t=78.512,62.145,all P<0.05);after treatment,the ALT rate,effective rate and bounce rate in the two groups was statistically significant differences (χ2 =25.621,46.241,11.512, all P<0.05);After treatment,the HBV DNA and HBeAg positive in two groups was below cut-off test cases,differences was statistically significant(χ2 =17.265,21.264,all P<0.05).Conclusion Entecavir combined Liuweiwuling Pian in the treatment of chronic hepatitis B patients with HBeAg +can reduce liver fibrosis , and has obvious detoxification and anti-viral.

Study on subtype of human papillomavirus infection among aged 25 - 54 reproductive women in Beijing from 2006 to 2008 / 中华妇产科杂志

Objective To investigate subtype of HPV infection among women at age of 25 to 54 years in Beijing. Methods From Sept. 2006 to Dec. 2008, 5552 reproductive women at age of 25 to 54 years classified into each 5-year as group were screened. Each participant completed a questionnaire and a sample of exfoliated cervical cells for liquid-based cytology and HPV subtype gene testing was performed.Results The overall prevalence of HPV was 6.68% (371/5552). High-risk HPV and Low-risk HPV prevalence were 5.76% (320/5552) and 2.00% (111/5552), respectively. The most common HPV types were HPV16 (2.61%, 145/5552), HPV58 (0. 97%, 54/5552), HPV33 (0.85%, 47/5552), HPV43 (0.74% ,41/5552) and HPV56(0.70% ,39/5552). There were two peaks of HPV prevalence: groups of 30 -34 years and 40 -44 years. Conclusion The most common HPV subtypes in Beijing were HPV 16,58, 33 and 43 and HPV prevalence showed a bi-medal age-specific curve.

Epidemiological study of high risk human papillomavirus infection in 25 to 54 years old married women in Beijing / 中华妇产科杂志

Objective To investigate high risk human papillomavirus(HR-HPV)prevalence among married women in Beijing and to study the high risk flactors.nethods During March 2007 to September 2008.a total of 6185 married women sampled from 137 communities in 12 districts were screened bv HR-HPV DNA test and cytogical test.The interview was carried out with unified questionnaires.The databage was set up and twice entered in EpiDam 3.0.After checked up,the data were analyzed in SPSS 15.0.Results (1) The HR-HPV infection rate was 9.89%.The HR-HPV infection rate of the city zone,the suburb and the exurb were 9.34%,10.51% and 9.51% (P>0.05).The HR-HPV infection rate of the native and the oudander were 9.53%,11.30% (P<0.05).(2) The age distribution of HR-HPV infection was that the rate was around 10% among 25 to 44 age groups,which was the highest(11.21%) in 30 to 34 age group;then the rate was descended as the age raising,the rate of 50 to 54 age group was the lowest(7.78%).(3) Multiple logistic regression showed that the related risk factors of HR-HPV infection mainly included 1000 RMB and above of family income per person per month.possessing more than 1 sexual partner of her husband,outlander and hish levels of education.(4) The prevalence of cervical intraepithelial neoplasia(CIN)in HR-HPV positive group wag significantly higher than that in HR-HPV negative group(29.76% vs 3.32%,P<0.01).Conclusions(1)The HR-HPV infection rate among aged 25 to 54 years was 9.9% and there was no significant difference in area distribution.(2)The hish risk population which should strengthen screening was the married bearing-age women with high level of family income,outlander,high levels of education and her husband possessing more than 1 sexual partner.(3)HR-HPV infection is the main risk factor for CIN and cervical cancer.while does not provide a causal relationship with them.The high risk population should be checked regularly to understand the development of HR-HPV infection and CIN incidence.

Emergent percutaneous transhepatic embolization of gastroesophageal varices for the treatment of acute upper gastrointestinal bleeding / 中国普通外科杂志

Objective To evaluate the effect of percutaneous transhepatic embolization of gastroesophageal varices on acute upper gastrointestinal bleeding in cirrhotic portal hypertensive patients. Methods Percutaneous transhepatic embolization was performed in 37 cases of acute upper gastrointestinal bleeding until varix thrombosed. Results Bleeding stopped in all patients. No technical complications occurred. During 1～38 months follow-up, variceal bleeding recurred in two cases in 3 months. One died of heart failure, five died of hepatic carcinoma in 6 months . Conclusion Percutaneous transhepatic embolization of gastroesophageal varices is a safe and effective treatment for acute upper gastrointestinal bleeding in portal hypertensive patients.