The effects of robotic-assisted versus laparoscopic-assisted radical right hemicolectomy on short-term outcome and long-term prognosis based on propensity score matching / 中华外科杂志

Objective: To compare the short-term and long-term outcomes between robotic-assisted and laparoscopic-assisted radical right hemicolectomy in patients with adenocarcinoma of the right colon. Methods: Retrospective review of a prospectively collected database identified 288 right colon cancer patients who underwent either robotic-assisted (n=57) or laparoscopic-assisted right hemicolectomy (n=231) between October 2014 and October 2020 at Department of Gastrointestinal Surgery, the Affiliated Hospital of Qingdao University. There were 161 males and 127 females, aging (60.3±12.8) years (range: 17 to 86 years). After propensity score matching as 1∶4 between robotic-assisted and laparoscopic-assisted right hemicolectomy, there were 56 cases in robotic group and 176 cases in laparoscipic group. Perioperative outcomes and overall survival were compared between the two groups using t test, Wilcoxon rank sum test, χ2 test, Fisher exact test, Kaplan-Meier method and Log-rank test, respectively. Results: The total operative time was similar between the robotic and laparoscopic group ((206.9±60.7) minutes vs. (219.9±56.3) minutes, t=-1.477, P=0.141). Intraoperative bleeding was less in the robotic group (50 (20) ml vs. 50 (50) ml, Z=-4.591, P<0.01), while the number of lymph nodes retrieved was significantly higher (36.0±10.0 vs. 29.0±10.1, t=4.491, P<0.01). Patients in robotic group experienced significantly shorter hospital stay, shorter time to first flatus, and defecation (t: -2.888, -2.946, -2.328, all P<0.05). Moreover, the overall peri-operative complication rate was similar between robotic and laparoscopic group (17.9% vs. 22.7%, χ²=0.596,P=0.465). The 3-year overall survival were 92.9% and 87.9% respectively and the 3-year disease-free survival rates were 83.1% and 82.6% with no statistical significance between the robotic and laparoscopic group (P>0.05). Conclusions: Compared to laparoscopic-assisted right hemicolectomy, robot-assisted right hemicolectomy could improve some short-term clinical outcomes. The two procedures are both achieving comparable survival.

Thinking and suggestions on pathway management of perioperative enhanced recovery after surgery in gastrointestinal tumors in China / 中华胃肠外科杂志

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care program to decrease the risk of delayed hospitalization, medical complications, readmission and to improve patient short- and long-term outcomes with minimized level of surgical stress responses through multidisciplinary cooperation. Despite its huge success, the program has challenges for further optimization with a primary focus on modification according to the specific pathophysiology and perioperative management characteristics of patients with gastrointestinal tumors to improve the compliance and implementation rate of items. Patient education, prehabilitation, multimodal analgesia, precision surgery, early mobilization, early oral feeding and oral nutrition supplement (ONS) should be regarded as core terms suitable for all the patients. During the application of ERAS pathway management, it is necessary to fully understand the perioperative changes of organ function and pathophysiology, and to strictly implement the ERAS program and items based on evidence-based medicine. Moreover, the close collaboration of multidisciplinary teams is needed to improve the compliance and increase the adherence rate of ERAS protocol for patients, which emphasizes the dynamic, gap-free and whole course management that covers pre-hospital, pre-operative, intra-operative, post-operative and post-hospital periods. Concurrently, we encourage our patients and their families to participate in the whole healthcare activities. Even more concerning, it is indispensable to adjust ERAS program for special time and special patients. At present, several consensus and guidelines on the ERAS management of gastrointestinal tumor surgery have come out for clinical practice in China, which, however, still lacks a high-level evidence from more high-quality clinical trials conducted by Chinese researchers. It is urgent to carry out a series of large-scale randomized controlled studies in accordance with international standards to obtain high-level evidence-based medical evidence for clinical practice, which is problem-oriented and integrated with features of metabolism and perioperative management of gastrointestinal tumor surgery.

Questionnaire investigation of radiation rectal injury with anxiety, depression and somatic disorder / 中华胃肠外科杂志

Objective: To observe the incidence and treatment of radiation rectal injury complicated with anxiety, depression and somatic symptom disorder. Methods: A cross-sectional survey research method was carried out. Patients with radiation rectal injury managed by members of the editorial board of Chinese Journal of Gastrointestinal Surgery were the subjects of investigation. The inclusion criteria of the survey subjects: (1) patients suffered from pelvic tumors and received pelvic radiotherapy; (2) colonoscopy showed inflammatory reaction or ulcer in the rectum. Exclusion criteria: (1) patient had a history of psycho-somatic disease before radiotherapy; (2) patient was unable to use a smart phone, unable to read and understand the questions in the questionnaire displayed on the phone; (3) patient refused to sign an informed consent form. According to the SOMA self-rating scale, PHQ-15 self-rating scale, GAD-7 and PHQ-9 self-rating scale, the electronic questionnaire of "Psychological Survey of Radiation Proctitis" was designed. The questionnaire was sent to patients with radiation rectal injury managed by the committee through the WeChat group. Observational indicators: (1) radiation rectal injury symptom assessment: using SOMA self-rating scale, radiation rectal injury symptom classification: mild group (≤3 points), moderate group (4-6 points) and severe group (> 6 points); (2) incidence of anxiety, depression and physical disorder: using GAD-7, PHQ-9 and PHQ-15 self-rating scales respectively for assessment; (3) correlation of radiation rectal injury symptom grading with anxiety, depression, and somatic symptom disorder. Results: Seventy-one qualified questionnaires were collected, of which 41 (56.9%) were from Guangzhou. Among the 71 patients, 6 were males and 65 were females; the mean age was (55.7±9.3) years old and 48 patients (67.6%) were less than 60 years old; the median confirmed duration of radiation rectal injury was 2.0 (1.0, 5.0) years. (1) Evaluation of symptoms of radiation rectal injury: 18 cases of mild (25.4%), 27 cases of moderate (38.0%), and 26 cases of severe (36.6%). (2) Incidence of anxiety, depression and somatic disorder: 12 patients (16.9%) without comorbidities; 59 patients (83.1%) with anxiety, depression, or somatic disorder, of whom 2 patients only had anxiety, 1 patient only had depression, 9 only had somatic disorder, 2 had anxiety plus depression, 4 had anxiety plus somatic disorder, 2 had depression plus somatic disorder, and 40 had all three symptoms. (3) correlation of radiation rectal injury grading with anxiety, depression, and somatic symptom disorder: as compared to patients in mild group and moderate group, those in severe group had higher severity of anxiety and somatic symptom disorder (Z=-2.143, P=0.032; Z=-2.045, P=0.041), while there was no statistically significant difference of depression between mild group and moderate group (Z=-1.176, P=0.240). Pearson correlation analysis revealed that radiation rectal injury symptom score was positively correlated with anxiety (r=0.300, P=0.013), depression (r=0.287, P=0.015) and somatic symptom disorder (r=0.344, P=0.003). Conclusions: The incidence of anxiety, depression, and somatic symptom disorder in patients with radiation rectal injury is extremely high. It is necessary to strengthen the diagnosis and treatment of somatic symptom disorder, so as to alleviate the symptoms of patients with pelvic perineum pain and improve the quality of life.

Adherence to adjuvant with therapy imatinib in patients with gastrointestinal stromal tumor: a national multi-center cross-sectional study / 中华胃肠外科杂志

Objective: To analyze the current adherence to imatinib in patients with gastrointestinal stromal tumors (GIST) in China and its influencing factors. Methods: A cross-sectional survey was conducted. Study period: from October 1, 2020 to November 31, 2020. Study subjects: GIST patients taking imatinib who were diagnosed and treated in public tertiary level A general hospitals or oncology hospitals; those who had not been pathologically diagnosed, those who never received imatinib, or those who had taken imatinib in the past but stopped afterwards were excluded. The Questionnaire Star online surgery platform was used to design a questionnaire about the adherence to adjuvant imatinib therapy of Chinese GIST patients. The link of questionnaire was sent through WeChat. The questionnaire contained basic information of patients, medication status and Morisky Medication Adherence Scale. Results: A total of 2162 questionnaires from 31 provinces, autonomous regions, and municipalities were collected, of which 2005 were valid questionnaires, with an effective rate of 92.7%. The survey subjects included 1104 males and 901 females, with a median age of 56 (22-91) years old. Working status: 609 cases (30.4%) in the work unit, 729 cases (36.4%) of retirement, 667 cases of flexible employment or unemployment (33.3%). Education level: 477 cases (23.8%) with bachelor degree or above, 658 cases (32.8%) of high school, 782 cases (39.0%) of elementary or junior high school, 88 cases (4.4%) without education. Marital status: 1789 cases (89.2%) were married, 179 cases (8.9%) divorced or widowed, 37 cases (1.8%) unmarried. Two hundred and ninety-four patients (14.7%) had metastasis when they were first diagnosed, including 203 liver metastases, 52 peritoneal metastases, and 39 other metastases. One thousand eight hundred and sixty-nine patients underwent surgical treatment, of whom 1642 (81.9%) achieved complete resection. The median time of taking imatinib was 25 (1-200) months. Common adverse reactions of imatinib included 1701 cases (84.8%) of periorbital edema, 1031 cases (51.4%) of leukopenia, 948 cases (47.3%) of fatigue, 781 cases (39.0%) of nausea and vomiting, 709 cases (35.4%) of rash, and 670 cases (33.4%) of lower extremity edema. The score of the Morisky Medication Adherence Scale showed that 392 cases (19.6%) had poor adherence, 1023 cases (51.0%) had moderate adherence, and 590 cases (29.4%) had good adherence. Univariate analysis showed that gender, age, work status, economic income, residence, education level, marriage, the duration of taking medication and adverse reactions were associated with adherence to adjuvant imatinib therapy (all P<0.05). Multivariate analysis showed that female (OR=1.264, P=0.009), non-retirement (OR=1.454, P=0.001), monthly income ≤4000 yuan (OR=1.280, P=0.036), township residents (OR=1.332, P=0.005), unmarried or divorced or widowed (OR=1.362, P=0.026), the duration of imatinib medication >36 months (OR=1.478, P<0.001) and adverse reactions (OR=1.719, P=0.048) were independent risk factors for poor adherence to adjuvant imatinib. Among patients undergoing complete resection, 324 (19.7%) had poor adherence, 836 (50.9%) had moderate adherence, and 482 (29.4%) had good adherence. Meanwhile, 55 patients with good adherence (11.4%) developed recurrence after surgery, 121 patients with moderate adherence (14.5%) developed recurrence, 61 patients with poor adherence (18.8%) developed recurrence, and the difference was statistically significant (P=0.017). Conclusions: The adherence to adjuvant therapy with imatinib in Chinese GIST patients is relatively poor. Females, non-retirement, monthly income ≤4000 yuan, township residents, unmarried or divorced or widowed, the duration of imatinib medication >36 months, and adverse reactions are independently associated with poor adherence of GIST patients. Those with poor adherence have a higher risk of recurrence after surgery. Positive interventions based on the above risk factors are advocated to improve the prognosis of patients with GIST.

Definition of tumor rupture in gastrointestinal stromal tumor / 中华胃肠外科杂志

Tumor rupture is a common clinical event in the process of tumorigenesis, progression, diagnosis and treatment of gastrointestinal stromal tumor, which is closely associated with tumor recurrence, metastasis and poor prognosis. Tumor rupture may be associated with some intrinsic biological aggressiveness qualities, such as large tumor size, high mitotic count, and KIT exon 11 deletion mutations involving codons 557 and 558, and may be relatively more frequent with small intestine GIST and excellent response to imatinib neoadjuvant therapy resulting in tumor tissue rapid liquefacient and necrosis. The triggering factors involve sudden increase in abdominal pressure, external pressure, collision and improper surgical operation, etc. Tumor rupture is considered as an important risk factor of recurrence after macroscopically complete resection of tumor, and an indication for determining interval or even lifelong adjuvant therapy with imatinib according to guidelines. However, there is no consensus or universally accepted definition of tumor rupture, and, consequently, its incidence varies greatly across reported series and lacks detailed epidemiological data. Without pre-defined criteria, it is difficult to assess the clinical significance of rupture. We reviewed the relevant literature and international guidelines, and generally divided tumor rupture into spontaneous rupture and iatrogenic rupture. Based on the Oslo criteria, we proposed the following six definitions for tumor rupture: (1) tumor fracture or spillage; (2) blood-stained ascites; (3) gastrointestinal perforation at the tumor site; (4) microscopic infiltration of an adjacent organ; (5) intralesional dissection or piecemeal resection; (6) incisional biopsy. The following types of minor defects of tumor integrity should not be defined as rupture: (1) mucosal defects or spillage contained within the gastrointestinal lumen; (2) microscopic tumor penetration of the peritoneum or iatrogenic damage only to the serosa; (3) uncomplicated transperitoneal needle biopsy; (4) R1 resection. In addition, we further emphasize the importance of identifying risk factors of tumor rupture, prevention and positive intervention.

A multi-center retrospective study of perioperative chemotherapy for gastric cancer based on real-world data / 中华胃肠外科杂志

Objective: To explore the effect of perioperative chemotherapy on the prognosis of gastric cancer patients under real-world condition. Methods: A retrospective cohort study was carried out. Real world data of gastric cancer patients receiving perioperative chemotherapy and surgery + adjuvant chemotherapy in 33 domestic hospitals from January 1, 2014 to January 31, 2016 were collected. Inclusion criteria: (1) gastric adenocarcinoma was confirmed by histopathology, and clinical stage was cT2-4aN0-3M0 (AJCC 8th edition); (2) D2 radical gastric cancer surgery was performed; (3) at least one cycle of neoadjuvant chemotherapy (NAC) was completed; (4) at least 4 cycles of adjuvant chemotherapy (AC) [SOX (S-1+oxaliplatin) or CapeOX (capecitabine + oxaliplatin)] were completed. Exclusion criteria: (1) complicated with other malignant tumors; (2) radiotherapy received; (3) patients with incomplete data. The enrolled patients who received neoadjuvant chemotherapy and adjuvant chemotherapy were included in the perioperative chemotherapy group, and those who received only postoperative adjuvant chemotherapy were included in the surgery + adjuvant chemotherapy group. Propensity score matching (PSM) method was used to control selection bias. The primary outcome were overall survival (OS) and progression-free survival (PFS) after PSM. OS was defined as the time from the first neoadjuvant chemotherapy (operation + adjuvant chemotherapy group: from the date of operation) to the last effective follow-up or death. PFS was defined as the time from the first neoadjuvant chemotherapy (operation + adjuvant chemotherapy group: from the date of operation) to the first imaging diagnosis of tumor progression or death. The Kaplan-Meier method was used to estimate the survival rate, and the Cox proportional hazards model was used to evaluate the independent effect of perioperative chemo therapy on OS and PFS. Results: 2 045 cases were included, including 1 293 cases in the surgery+adjuvant chemotherapy group and 752 cases in the perioperative chemotherapy group. After PSM, 492 pairs were included in the analysis. There were no statistically significant differences in gender, age, body mass index, tumor stage before treatment, and tumor location between the two groups (all P>0.05). Compared with the surgery + adjuvant chemotherapy group, patients in the perioperative chemotherapy group had higher proportion of total gastrectomy (χ(2)=40.526, P<0.001), smaller maximum tumor diameter (t=3.969, P<0.001), less number of metastatic lymph nodes (t=1.343, P<0.001), lower ratio of vessel invasion (χ(2)=11.897, P=0.001) and nerve invasion (χ(2)=12.338, P<0.001). In the perioperative chemotherapy group and surgery + adjuvant chemotherapy group, 24 cases (4.9%) and 17 cases (3.4%) developed postoperative complications, respectively, and no significant difference was found between two groups (χ(2)=0.815, P=0.367). The median OS of the perioperative chemotherapy group was longer than that of the surgery + adjuvant chemotherapy group (65 months vs. 45 months, HR: 0.74, 95% CI: 0.62-0.89, P=0.001); the median PFS of the perioperative chemotherapy group was also longer than that of the surgery+adjuvant chemotherapy group (56 months vs. 36 months, HR=0.72, 95% CI:0.61-0.85, P<0.001). The forest plot results of subgroup analysis showed that both men and women could benefit from perioperative chemotherapy (all P<0.05); patients over 45 years of age (P<0.05) and with normal body mass (P<0.01) could benefit significantly; patients with cTNM stage II and III presented a trend of benefit or could benefit significantly (P<0.05); patients with signet ring cell carcinoma benefited little (P>0.05); tumors in the gastric body and gastric antrum benefited more significantly (P<0.05). Conclusion: Perioperative chemotherapy can improve the prognosis of gastric cancer patients.

Prehabilitation for gastrointestinal cancer patients / 中华胃肠外科杂志

Gastrointestinal cancer and related treatments (surgery and chemoradiotherapy) are associated with declined functional status (FS) that has impact on quality of life, clinical outcome and continuum of care. Psychological distress drives an impressive burden of physiological and psychiatric conditions in oncologic care. Cancer patients often experience anxiety, depression, low self-esteem and fears of recurrence and death. Cancer prehabilitation is a process from cancer diagnosis to the beginning of treatment, which includes psychological, physical and nutritional assessments for a baseline functional level, identification of comorbidity, and targeted interventions that improve patient's health and functional capacity to reduce the incidence and the severity of current and future impairments with cancer, chemoradiotherapy and surgery. Multimodal prehabilitation program encompasses a series of planned, structured, repeatable and purposive interventions including comprehensive physical exercise, nutritional therapy, and relieving anxiety and depression, which integrates into best perioperative management ERAS pathway and aims at using the preoperative period to prevent or attenuate the surgery-related functional decline, to cope with surgical stress and to improve the consequences. However, a number of questions remain in regards to prehabilitation in gastrointestinal cancer surgery, which consists of the optimal makeup of training programs, the timing and approach of the intervention, how to improve compliance, how to measure functional capacity, and how to make cost-effective analysis. Therefore, more high-level evidence-based studies are expected to evaluate the value of implementation of prehabilitation into standard practice.

Meta-analysis of extralevator abdominoperineal excision and conventional abdominoperineal excision for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the perforation, circumferential resection margin (CRM) and postoperative perineal wound complications after extralevator abdominoperineal excision (ELAPE) and conventional abdominoperineal excision (APE) for low rectal cancer by using systematic review method.</p><p><b>METHODS</b>The Cochrane Library, PubMed, EMbase, CNKI and VIP database were searched for literatures in which ELAPE and APE were compared for the treatment of low rectal cancer. Meta-analysis was performed to deal with data extracted by Cochrane Systematic Reviews methods.</p><p><b>RESULTS</b>Six studies met the inclusion criteria including one randomized control study and five non-randomized control studies with a total of 656 cases including 346 cases of ELAPE and 310 cases of APE. Meta-analysis showed a lower positive CRM rate (RR=0.48, 95%CI:0.36-0.65) and a lower local recurrence rate (RR=0.43, 95%CI:0.19-0.99) in ELAPE compared with APE. There were no significant differences in operative perforation rate (RR=0.45, 95%CI:0.15-1.37) and post-operative perineal wound complications rate (RR=1.20, 95%CI:0.57-2.50) between the two surgical procedures.</p><p><b>CONCLUSION</b>ELAPE is associated with lower rates of positive CRM and local recurrence compared with APE.</p>

Effect of early oral enteral nutrition on clinical outcomes after colorectal cancer surgery / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of early oral feeding with enteral nutrition after surgery on clinical outcomes in patients with colorectal cancer.</p><p><b>METHODS</b>Forty-eight patients with colorectal cancer undergoing elective operation between January 2012 and May 2012 were randomly divided into study group (n=24) and control group (n=24). Patients in the group were given small amount of water several times and enteral nutrition early after surgery. Patients in the control group received conventional postoperative care protocol. Nutritional status, immune function, time of flatus, postoperative hospital stay, medical cost and incidence of complications between the two groups were compared.</p><p><b>RESULTS</b>As compared to the control group, nutritional status and immune function in the study group were significantly better (P<0.05). In the study group, time to flatus [(54.3±11.9) h vs. (65.7±10.0) h, P<0.05] and postoperative hospital stay [(5.4±1.1) d vs. (7.1±1.4) d, P<0.05] were significantly shorter, and medical cost [(36.3±6.4) thousand RMB vs. (42.8±4.3) thousand RMB, P<0.05] was significantly less as compared with the control group. No difference of the complication incidence was found [12.5% (3/24) vs. 16.7% (4/24), P>0.05].</p><p><b>CONCLUSION</b>Early oral feeding with enteral nutrition after surgery can improve the nutritional status and immune function, and accelerate the recovery of patients with colorectal cancer.</p>

Effects of preoperative oral carbohydrate on postoperative insulin resistance in radical gastrectomy patients / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the effects and mechanism of postoperative insulin resistance in gastrectomy patients with preoperative oral carbohydrate.</p><p><b>METHODS</b>From April to October 2011, 60 consecutive gastric cancer patients met inclusion criteria were divided into oral carbohydrate group and placebo group by randomized double-blind principles. Resting energy expenditure (REE), fasting blood glucose, insulin and triglyceride level were detected in 4 hours preoperatively. The 500 ml carbohydrate or placebo were administrated orally 2-3 hours before anaesthesia. Two group patients underwent radical distal subtotal gastrectomy under epidural compounded intravenous anesthesia. After laparotomy and before the abdomen was closed, a piece of rectus abdominis was taken and fixed in 3% glutaraldehyde. REE, fasting blood glucose, insulin and triglyceride level were detected immediately after surgery. The changes of insulin resistance index, blood triglycerides level, REE and respiratory quotient were compared pre- and post-operatively. The changes of rectus abdominis mitochondrial ultrastructure were observed by transmission electron microscopy respectively.</p><p><b>RESULTS</b>There were 48 patients (34 males and 14 females) completed the trial. The 24 and 24 patients in oral placebo and carbohydrate groups respectively. In oral placebo group, post-operative insulin resistance index, REE, respiratory quotient, serum triglyceride level and the rectus abdominis mitochondrial damage index were 12.68 ± 3.13, (1458 ± 169) kcal/d, 0.73 ± 0.42, (0.53 ± 0.24) g/L and 1.14 ± 0.33, respectively. And the above items were 5.67 ± 1.40, (1341 ± 110) kcal/d, 0.79 ± 0.22, (1.04 ± 0.97) g/L and 0.92 ± 0.19 in oral carbohydrate groups respectively. All difference was statistically significant (t = 6.646, 2.851, 6.546, 2.542 and 2.730, all P < 0.05). Oral placebo group showed a markedly swollen mitochondria, steep membrane was not clear, mitochondria appeared vacuolated changes.</p><p><b>CONCLUSIONS</b>Preoperative oral carbohydrate could reduce the insulin resistance and REE, improve the material metabolism status in radical gastrectomy patients. The possible mechanisms should be related to promotion of insulin release and protection of mitochondrial function.</p>

Prognosis analysis of 247 cases of gastrointestinal stromal tumor / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To study the clinicopathologic features and prognostic factors of gastrointestinal stromal tumor (GIST).</p><p><b>METHODS</b>Clinicopathologic data of 247 patients with GIST from January 2003 to November 2012 in the Affiliated Hospital of Qingdao University Medical College, and the prognostic factors were evaluated retrospectively by univariate and multivariate analysis with Log-rank test and Cox proportional hazard model.</p><p><b>RESULTS</b>Patients were followed up with a median time of 26 months (1 to 113 months). Twenty-six patients developed recurrence or metastasis, and 18 died of GIST. The 1-, 3-, 5-year survival rates were 94%, 91% and 83% respectively. Univariate analysis showed that age, tumor location, tumor size, mitotic count and tumor rupture were predictive factors of survival after resection of primary GIST (all P<0.01). For patients at intermediate and high risk to relapse, imatinib group had a higher 5-year overall survival rate than non-imatinib group (85.7% vs. 81.0%, P<0.05). Multivariate analysis revealed that tumor size (RR=2.248, 95%CI:1.081-4.677, P=0.030), mitotic count (RR=2.220, 95%CI:1.032-4.776, P=0.041) and tumor rupture (RR=5.183, 95%CI:1.677-16.017, P=0.004) were independent prognostic factors.</p><p><b>CONCLUSIONS</b>Tumor size, mitotic count and tumor rupture affect the prognosis after resection of primary GIST independently. Imatinib adjuvant therapy can improve overall survival of patients at intermediate and high risk to relapse after surgery.</p>

Progress of research in the relationship between microorganisms and colorectal cancer / 中华胃肠外科杂志

Colorectal cancer is a common carcinoma of gastrointestinal tract, and its incidence is associated with genetic mutations, environment as well as inflammation. Recent studies have shown that many microorganisms may have played an important role in pathogenesis of colorectal cancer. The common bacteria involved in colorectal cancer are Streptococcus bovis, Helicobacter pylori, Escherichia coli, Bacteroides, and Fusobacterium, etc. The common viruses are Polyomavirus, Epstein Barr virus, Cytomegalovirus and Human papillomavirus, etc. The detailed mechanism of these microorganisms in the pathogenesis of colorectal cancer is unclear, and there are no reports on specific pathogenic microorganisms which cause the disease directly. The direction of future researches will focus on metagenome, metatranscriptome, and metaproteome of microorganisms associated with the incidence of colorectal cancer.

Analysis of prognostic factors for gastric stump cancer / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To investigate the independent prognostic factors of long-term survival for gastric stump cancer after radical resection.</p><p><b>METHODS</b>The clinicopathological and follow-up data of 63 patients with gastric stump cancer undergoing surgical treatment from January 1996 to December 2006 in our hospital were analyzed retrospectively, including age, gender, types of reconstruction, tumor location, histological types, TNM stages, surgical treatment, prognosis and etc. The survival was estimated using Kaplan-Meier method and compared using log-rank test. The effect of independent factors on prognosis was determined by Cox regression multivariate analysis.</p><p><b>RESULTS</b>Radical resection was performed in 35 patients, including combined multiple organ resection (n=16). Surgery was palliative in 28 patients. All the 63 patients were followed up. The median survival time of these 63 patients was 21 months, and the overall 1-, 3-, 5-year survival rates were 76.2%, 31.7% and 18.8%, respectively. Univariate and multivariate analysis showed that surgical procedure, clinical stage and histological type were independent prognostic factors of gastric stump cancer, while age, gender, type of reconstruction and tumor location were not significantly correlated with prognosis.</p><p><b>CONCLUSIONS</b>Radical resection, clinical stage and histological type are main prognostic factors for gastric stump cancer. Radical resection is an effective way to prolong the postoperative survival time in patients with gastric stump cancer, especially in the early stage.</p>

Effect of early oral enteral nutrition on clinical outcomes after gastric cancer surgery / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of early oral feeding with enteral nutrition preparation after surgery on clinical outcomes in patients with gastric cancer.</p><p><b>METHODS</b>Sixty patients with gastric cancer undergoing radical operation between July 2010 and May 2011 were randomly divided into two groups using random digit table: experimental group(n=30, administration of water and enteral nutrition early after surgery) and control group(n=30, conventional postoperative care protocol). Clinical outcomes, immune function, and nutritional status between the two groups were compared.</p><p><b>RESULTS</b>As compared to the control group, duration of fever was significantly shorter in the experimental group [(81.1±6.4) h vs. (87.3±8.0) h, P<0.05], as were postoperative time of flatus [(79.9±9.5) h vs. (86.6±8.7) h, P<0.05] and postoperative hospital stay [(7.83±2.23) d vs. (9.57±1.96) d, P<0.01]. The medical cost [(30,220±3,220) RMB vs.(34,600±32,120) RMB, P<0.01] was lower than that in the control group. There was no significant difference in morbidity between the two groups[13.3%(4/30) vs. 16.7%(5/30), P>0.05]. The levels of CD3(+)T, CD4(+)T, NK cell, CD4(+)T/CD8(+)T, albumin, and prealbumin were higher in the experimental group as compared to the control group on postoperative day 3 and 7(P<0.05).</p><p><b>CONCLUSION</b>Early oral feeding with enteral nutrition preparation after surgery can improve the nutritional status and immune function, and accelerate the rehabilitation for patients with gastric cancer.</p>

Perioperative blood glucose control / 中华胃肠外科杂志

Hyperglycemia can result in severe adverse effects on the body. The mortality and morbidity of surgery are increased significantly in diabetic patients. The surgical stress-related hyperglycemia and insulin resistance can also produce the same adverse consequences. The metabolic state of the surgical patients, anesthesia method, glucose infusion, stress-induced neuroendocrine responses and insulin resistance can affect the perioperative blood glucose levels, resulting in poor clinical outcomes. The relationship between tight glycemic control and reducing post-operative mortality and morbidity is not clear. It's necessary to control blood sugar level during the perioperative period but the ideal state of glycemic control still needs a mult-center clinical trial evidence. It is generally believed that perioperative blood glucose level should be controlled below 10 mmol/L. The efficacy and safety of tight glycemic control needs further study.

Clinical study on risk factor associated with gut flora change in patients with rectal cancer during perioperative period / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effects of the different treatment on gut flora in patients with rectal cancer in the perioperative period.</p><p><b>METHODS</b>A total of 64 patients with rectal cancer were prospectively enrolled from July 2010 to June 2011 at the Qingdao University Medical College Affiliated Hospital, and randomized into 8 groups receiving different treatments in perioperative period. Factorial design was used to study three factors including preoperative bowel preparation, antibiotics use, and postoperative fasting. Patients were randomized into 8 groups with 8 patients in each group using the random digit table. Preoperative and postoperative stool specimens were collected and diluted, which were transferred to selective medium. Bacteria counts were calculated after 48 hours of culture under constant temperature. The changes in gut flora between the different groups were compared.</p><p><b>RESULTS</b>Compared to the preoperative parameters, total bacteria, Bifidobacterium, Peptostreptococcus, Lactobacillus, Bacteroides, Enterococcus decreased significantly(P<0.05), while the E.coli count increased significantly. The bacillus/coccus ratio was significantly imbalanced. Preoperative bowel preparation, oral antibiotics, and postoperative fasting were all predominant factors associated with gut flora(all P<0.05). Compared with the antibiotic restriction group, Bacteroides, Enterococcus, Lactobacillus, Peptostreptococcus, and total bacteria count were reduced significantly, and the bacillus/coccus ratio increased in the non-antibiotics restriction group(P<0.05). In the bowel preparation group, Bacteroides, Peptostreptococcus, total bacteria count, and the bacillus/coccus ratio decreased(P<0.05). In the postoperative fasting group, Bacteroides, Enterococcus, total bacteria, and bacillus/coccus ratio decreased(P<0.05).</p><p><b>CONCLUSIONS</b>Antibiotics, bowel preparation, and postoperative fasting can affect the number and ratio of gut flora in patients with rectal cancer in the perioperative period, leading to dysbacteriosis.</p>

Effect of different perioperative treatments on gut flora in SD rats / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To study the effects of different perioperative treatments on the number and proportion of gut flora in SD rats.</p><p><b>METHODS</b>Forty-eight SD rats were randomized into 8 groups including the control group, antibiotics group, bowel preparation group, fasting group, antibiotic-bowel preparation group, antibiotics-bowel preparation-fasting group, bowel preparation-surgery-antibiotics-early postoperative feeding group (early feeding group), and bowel preparation-surgery-antibiotics-postoperative fasting group. The rats were sacrificed and stool specimens were collected from the cecum. Stools were diluted and transferred to selective medium. Bacteria counts were calculated after 48 hours of culture under constant temperature. The changes in gut flora between the different groups were compared in terms of E.coli, Bacteroides, Bifidobacterium, and Enterococcus.</p><p><b>RESULTS</b>Compared with the control group, the total bacteria, Bacteroid, Enterococcus, Bifidobacterium were all significantly decreased(P<0.05), while the E.coli count and the bacillus/coccus ratio were significantly elevated(P<0.05). In the bowel preparation group, the total bacteria count, Bacteroid, Enterococcus, Bifidobacterium were all significantly decreased(P<0.05), while the E.coli count remained stable(P>0.05) and the bacillus/coccus ratio was significantly elevated(P<0.05). In the fasting group, the total bacteria count, Bacteroid, Enterococcus, Bifidobacterium were all significantly decreased(P<0.05), while the E.coli count remained stable(P>0.05) and the bacillus/coccus ratio was significantly elevated(P<0.05). Early postoperative feeding increased E.coli, Enterococcus, and total bacteria count(P<0.05), and lowered bacillus/coccus ratio(P<0.05) as compared to the fasting group.</p><p><b>CONCLUSIONS</b>Antibiotics, bowel preparation, and fasting have influence on the gut flora of SD rats in count and bacillus/coccus ratio, leading to dysbiosis. Early postoperative feeding may improve dysbiosis.</p>

Diagnostic value of combined modified Alvarado scores and computed tomography imaging in the pathological types of acute appendicitis in adults / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the diagnostic value of combined modified Alvarado scores (MAS) and computed tomography imaging in the pathological types of acute appendicitis in adults.</p><p><b>METHODS</b>Clinical data of a total of 396 adult patients with acute appendicitis confirmed by surgery and pathology were analyzed retrospectively from June 2007 to July 2010. Case-control study was used to investigate the MAS. CT signs were studied in 115 patients who underwent preoperative CT scan. Univariable analysis was performed using each indicator among different pathological types. Discriminant classification was formed by applying significant variables identified from univariable analysis and a Fisher discriminant function was created.</p><p><b>RESULTS</b>Twenty three variables were statistically significant among different pathological types after univariable analysis(P<0.05) and were selected for discriminant analysis. Six variables including temperature(X1), leucocyte count(X2), the proportion of neutrophil(X3), MAS points(X4), periappendiceal fat stranding(X5), and extraluminal air(X6) were enrolled. The discriminant function equation was Y1=0.012X1+0.041X2+0.069X3-0.039X4+2.653X5+1.418X6, Y2=0.327X1+0.041X2-0.034X3-0.140X4-1.114X5+2.982X6. The accuracy was 76.5%(88/115) in retrospective assessment and 77.8%(21/27) in prospective assessment.</p><p><b>CONCLUSION</b>The combined use of MAS and CT imaging signs is useful in identifying the pathological types of acute appendicitis in adults, so it is helpful in choosing reasonable therapeutic option for surgeons.</p>

Surgical treatment and prognostic factors for obstructing left colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the outcomes of surgical treatment and the prognostic factors of long-term survival for obstructing left colorectal cancer.</p><p><b>METHODS</b>Clinicopathological and follow-up data of 93 patients with obstructing left colorectal cancer undergoing surgical treatment from January 2001 to December 2006 in the Affiliated Hospital of Medical College of Qingdao University were analyzed retrospectively.</p><p><b>RESULTS</b>There were 53 males and 40 females. The median age was 61 years old. Fifty-one patients had concurrent medical condition. Radical resection was performed in 67 patients, including one-stage resection (n=21), Hartmann procedure (n=35), and Miles procedure (n=11). Surgery was palliative in 26 patients, including diverting stoma (n=14), bypass surgery (n=7), and palliative resection (n=5). All the 93 patients were followed up. The 1-, 3-, and 5-year survival rates were 94%, 59%, and 38%, respectively. Univariate and multivariate analyses showed that radical resection, TNM staging, and preoperative level of carcinoembryonic antigen were independent prognostic factors (all P<0.05).</p><p><b>CONCLUSIONS</b>Radical resection, TNM stage, and preoperative CEA level are prognostic factors of obstructing left colorectal cancer. Early diagnosis, radical resection, and selection of appropriate surgical procedure are helpful to prolong survival time of patients with obstructing left colorectal cancer.</p>

Effect of intensive insulin therapy on resting energy expenditure in postoperative patients underwent radical distal gastrectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of intensive insulin therapy on resting energy expenditure in postoperative patients underwent radical distal gastrectomy.</p><p><b>METHODS</b>Sixty-four patients with gastric neoplasms in the middle or lower part of stomach from January to October 2010 were enrolled and underwent radical distal gastrectomy, then were randomized to intensive insulin therapy (IIT) group to keep glucose levels from 4.4 to 6.1 mmol/L or conventional insulin therapy (CIT) group to keep levels from 4.4 to 10.0 mmol/L. Resting energy expenditure (REE), respiratory quotient (RQ), resting energy expenditure per kilogram (REE/kg) and lipid oxidation ratio (LOR) were monitored by indirect energy metabolic system on preoperative and postoperative 1(st), 3(rd) and 7(th) day. Fasting blood glucose and insulin concentration were measured for HOMA-IR assessment.</p><p><b>RESULTS</b>Compared with preoperative baseline, postoperative REE, REE/kg, LOR, Ln-HOMA-IR increased dramatically (P < 0.05, respectively). RQ decreased markedly (P < 0.05). Compared with group CIT, IIT reduced the REE/kg level [(27.2 ± 1.3) kcal/kg vs. (30.0 ± 1.5) kcal/kg, P = 0.008; (24.7 ± 1.4) vs. (25.7 ± 1.6) kcal/kg, P = 0.013]; and decreased the Ln-HOMA-IR score (P = 0.019 and 0.028) on postoperative 1(st) and 3(rd) day; IIT could decrease obviously the level of C-reaction protein level on postoperative 1(st) and 3(rd) day (P = 0.017, 0.006). The total protein and albumin concentration in IIT group were more than its levels in group CIT (P = 0.023, 0.009).</p><p><b>CONCLUSION</b>There are some benefits of IIT in reducing mean energy expenditure and the consumption of proteins, decreasing postoperative insulin resistance level in this small population underwent radical distal gastrectomy.</p>