Cross-sectional study of low anterior resection syndrome in patients who have survived more than 5 years after sphincter-preserving surgery for rectal cancer / 中华胃肠外科杂志

Objective: In this study, we aimed to investigate the prevalence of low anterior resection syndrome (LARS) in patients who had survived for more than 5 years after sphincter-preserving surgery for rectal cancer and to analyze its relationship with postoperative time. Methods: This was a single-center, retrospective, cross-sectional study. The study cohort comprised patients who had survived for at least 5 years (60 months) after undergoing sphincter- preserving radical resection of pathologically diagnosed rectal adenocarcinoma within 15 cm of the anal verge in the Department of Gastrointestinal Surgery, Peking University People's Hospital from January 2005 to May 2016. Patients who had undergone local resection, had permanent stomas, recurrent intestinal infection, local recurrence, history of previous anorectal surgery, or long- term preoperative defecation disorders were excluded. A LARS questionnaire was administered by telephone interview, points being allocated for incontinence for flatus (0-7 points), incontinence for liquid stools (0-3 points), frequency of bowel movements (0-5 points), clustering of stools (0-11 points), and urgency (0-16 points). The patients were allocated to three groups based on these scores: no LARS (0-20 points), minor LARS (21-29 points), and major LARS (30-42 points). The prevalence of LARS and major LARS in patients who had survived more than 5 years after surgery, correlation between postoperative time and LARS score, and whether postoperative time was a risk factor for major LARS and LARS symptoms were analyzed. Results: The median follow-up time of the 160 patients who completed the telephone interview was 97 (60-193) months; 81 (50.6%) of them had LARS, comprising 34 (21.3%) with minor LARS and 47 (29.4%) with major LARS. Spearman correlation analysis showed no significant correlation between LARS score and postoperative time (correlation coefficient α=-0.016, P=0.832). Multivariate analysis identified anastomotic height (RR=0.850, P=0.022) and radiotherapy (RR=5.760, P<0.001) as independent risk factors for major LARS; whereas the postoperative time was not a significant risk factor (RR=1.003, P=0.598). The postoperative time was also not associated with LARS score rank and frequency of bowel movements, clustering, or urgency (P>0.05). However, the rates of incontinence for flatus (3/31, P=0.003) and incontinence for liquid stools (8/31, P=0.005) were lower in patients who had survived more than 10 years after surgery. Conclusions: Patients with rectal cancer who have survived more than 5 years after sphincter-preserving surgery still have a high prevalence of LARS. We found no evidence of major LARS symptoms resolving over time.

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.

Identifying a Safe Range of Stimulation Current for Intraoperative Neuromonitoring of the Recurrent Laryngeal Nerve: Results from a Canine Model / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Intraoperative neuromonitoring (IONM) of the recurrent laryngeal nerve (RLN) has been widely applied during thyroid surgery. However, the safe range of stimulation intensity for IONM remains undetermined.</p><p><b>METHODS</b>Total thyroidectomies were performed on twenty dogs, and their RLNs were stimulated with a current of 5-20 mA (step-wise in 5 mA increments) for 1 min. The evoked electromyography (EMG) of vocal muscles before and after supramaximal stimulation were recorded and compared. Acute microstructural morphological changes in the RLNs were observed immediately postoperatively under an electron microscope.</p><p><b>RESULTS</b>The average stimulating threshold for RLNs stimulated with 15 mA and 20 mA showed no significant changes compared to the unstimulated RLNs (15 mA group: 0.320 ± 0.123 mA vs. 0.315 ± 0.097 mA, P = 0.847; 20 mA group: 0.305 ± 0.101 mA vs. 0.300 ± 0.103 mA, P = 0.758). Similar outcomes were shown in average evoked EMG amplitude (15 mA group: 1,026 ± 268 μV vs. 1,021 ± 273 μV, P = 0.834; 20 mA group: 1,162 ± 275 μV vs. 1,200 ± 258 μV, P = 0.148). However, obvious acute microstructural morphological changes were observed in the nerves that were stimulated with 20 mA.</p><p><b>CONCLUSIONS</b>A stimulation intensity less than 15 mA might be safe for IONM of the RLN.</p>

Surveillance of bacterial distribution and drug resistance in inpatients with surgical infections: a single center study / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the bacterial distribution and drug resistance in patients with surgical infections, and provide the basis for the standardization treatment of the surgical infection.</p><p><b>METHODS</b>Retrospectively analyzed from January 2008 to December 2011 surgical infection in our samples bacteria identification and drug sensitivity test results.</p><p><b>RESULTS</b>A total of 3829 nonduplicate isolates from 3257 samples, Gram-negative bacteria accounted for 62.4% (the main microbes were P.aeruginosa, K. pneumonia and E.coli etc) and Gram-positive bacteria accounted for 37.6% (the main microbes were Enterococcus, Staphylococcus and coagulase negative Staphylococcus). Incidence of Staphylococcus aureus and Enterococcus faecalis were on an obvious increase. For the performance of the high level of sensitive to Imipenem, Amikacin, Piperacillin and Tazobactam by E. coli and K. pneumonia. The Pseudomonas aeruginosa and Acinetobacter baumannii to cephalosporins, Carbapenems and Fluoroqinolones were higher resistant with Multidrug resistance. No vancomycin and teicoplanin resistant Enterococcus faecium were found. The prevalence of ESBL E.coli was 45.6%-61.5% and ESBL K.pneumoniae isolates were fluctuated. The methicillin-resistant S.aureus (MRSA) isolates were relatively high (21.1%-55.8%), and methicillin-resistant Staphylococcus epidermidis was higher than the other Gram-positive cocci. Vancomycin for Staphylococcus performance was highly sensitive.</p><p><b>CONCLUSIONS</b>The main composition of surgical clinical infection pathogens are Gram-negative bacillus, and the emergency of resistance of bacteria to antibacterial drugs is a common phenomenon. The resistant rate shows ascendant trend; Drug resistance is significantly higher in Pseudomonas aeruginosa and Acinetobacter baumannii. Antimicrobial resistance is a serious and challenging issue.</p>

Short-term efficacy comparison of complete mesocolic excision and traditional colon cancer resection / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the short-term efficacy of complete mesocolic excision (CME).</p><p><b>METHODS</b>Clinical data of 62 cases of colon cancer (I-III phase) with radical resection including CME surgery group of 31 cases and traditional surgery group of 31 cases from January 2011 to October 2011 in Peking University People's Hospital were retrospective analyzed.</p><p><b>RESULTS</b>The number of removed lymph node in CME and traditional resection group was 22.5±1.8 and 17.6±1.3 respectively (P<0.05) and the positive rate of lymph node in mesentery root was 9.7% (3/31) in CME surgery group. Operative blood loss was (123.5±17.6) ml and (143.5±15.3) ml in CME and traditional resection group without significant difference (P>0.05). Except for more abdominal drainage volume of 3 days post-operation in CME group (P<0.05), the postoperative recovery indicators of postoperative drainage tube removed time, exhaust time, eating time, and the socioeconomic effects indicators of postoperative hospitalization, hospitalization costs were not significantly different between two groups (all P>0.05). Postoperative intestinal obstruction occurred in 3 cases and 4 cases, lymph fistula in 2 cases and 0 case, wound dehiscence in 1 case and 1 case in CME group and traditional resection group respectively. Postoperative complication rate was not significantly different (19.4% vs. 16.1%, P>0.05).</p><p><b>CONCLUSION</b>Compared with traditional radical surgery, CME sweeps lymph nodes more thoroughly, including lymph nodes of mesocolic roots, and does not affect postoperative recovery and increase the risk of postoperative complications.</p>

Clinical and microbiological features of community-acquired and nosocomial bloodstream infections in the surgical department of a tertiary-care hospital in Beijing / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Bloodstream infections (BSIs) remain a major cause of morbidity and mortality in patients undergoing surgery. This study aimed at elucidating the clinical characteristics of community-acquired BSIs (CABs) and nosocomial BSIs (nBSIs) in patients admitted to the surgical wards of a teaching hospital in Beijing, China.</p><p><b>METHODS</b>This cross-sectional study compared 191 episodes of BSIs in 4074 patients admitted to the surgical wards between January 2008 and December 2011. Cases of BSIs were classified as CABs or nBSIs, and the characteristics, relevant treatments, and outcomes of CABs and nBSIs were compared.</p><p><b>RESULTS</b>Of the 191 BSIs, 52 (27.2%) and 139 (72.8%) were CABs and nBSIs, respectively. Escherichia coli, coagulasenegative staphylococci, and Klebsiella spp, were the most frequently isolated microorganisms. There were significant differences between CABs and nBSIs with respect to the use of hormonal drugs, ventilation, acute physiology and chronic health evaluation (APACHE) II and American Society of Anesthesiologists scores, and prevalence of cancer (P < 0.05). Empirical antibacterial therapy did not decrease the crude mortality, but multivariate analysis showed that high APACHE II was independently associated with a risk of mortality (odds ratio = 0.97, 95% confidence interval: 0.93-1.02 for APACHE II).</p><p><b>CONCLUSIONS</b>We found significant differences in the clinical characteristics of surgical patients with CABs and nBSIs. The outcome of patients seems to be related to high APACHE II scores.</p>

Complete mesocolic excision versus traditional radical resection in colon cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the short-term efficacy and safety between complete mesocolic excision (CME) and traditional radical resection in colon cancer.</p><p><b>METHODS</b>Between January 2008 and August 2011, 92 patients undergoing elective open surgery for colon were included in the study. CME was performed in 54 patients in the period from November 2009 to August 2011. The other 38 patients underwent traditional radical resection from January 2008 to October 2009. Short-term outcomes were compared between the patients of two different time periods.</p><p><b>RESULTS</b>Lymph nodes retrieved in the CME group (22.2 ± 8.0) were significant more than that in the control group (18.6 ± 4.7)(P<0.05). In patients with stage III cancer, CME group was associated with higher lymph node counts (23.8 ± 7.6 vs. 16.7 ± 3.6, P<0.01), however, there were no significant differences for those with stage I and stage II cancer (P>0.05). The number of positive lymph nodes and metastatic lymph node ratio (LNR) for stage III patients in two groups were not significantly different (P>0.05). There were no differences in operation time, time to first bowel movement, hospital stay, and postoperative complications between the two groups (P>0.05). However, intraoperative blood loss in the CME group was significantly reduced (median, 100 vs. 115 ml, P<0.05).</p><p><b>CONCLUSIONS</b>CME can achieve en-bloc resection of the tumor and mesocolon, and have optimal lymph nodes harvest. Despite wider resection extent with CME technique, the surgical risk and postoperative complications are not increased and the short-term efficacy is good.</p>

Learning curve of complete mesocolic excision for colon cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the learning curve of complete mesocolic excision(CME) for colon cancer.</p><p><b>METHODS</b>Clinical data of 75 cases in whom CME was performed by a group of surgeons in the Department of Gastrointestinal Surgery, Peking University People's Hospital from November 2009 to June 2011 were reviewed. The patients were divided into three groups(groups A, B, C, 25 cases in each group) by operative chronologic sequence.</p><p><b>RESULTS</b>There were no significant differences in age, sex, preoperative staging, cancer location, operation history of abdomen, ASA among the three groups(P>0.05). The operative time in group A was (205.4 ± 53.2) min and decreased to (180.4 ± 29.7) min in group B and (169.8 ± 41.3) min in group C (P<0.05). The postoperative hospital stay decreased from (17.8 ± 10.9) d in group A to(12.9 ± 4.1) d in group B and(11.0 ± 3.5) d in group C(P<0.05). The postoperative complication rate decreased from 32%(8/25) in group A and 36%(9/25) to 8%(2/25) in group C. The specimen quality was superior in group C compared to group A (WEST grade C above were 20 and 11 respectively, P<0.05). There were no significant differences in intraoperative bleeding, time to first flatus, postoperative fasting time, number of retrieved lymph nodes among the three groups(P>0.05).</p><p><b>CONCLUSION</b>From the learning curve of CME, surgeons can learn CME skill after performing 25 cases.</p>

Strategies in diagnosis and management for advanced or metastatic gastrointestinal stromal tumor / 中华胃肠外科杂志

With deeper understanding of gastrointestinal stromal tumor(GIST), more and more patients are diagnosed as GIST. Although the prognosis of early GIST is satisfactory after complete surgical resection, there are still many problems in the treatment of advanced GIST. Variety of treatment options has been used in the treatment of GIST, such as surgery, targeted drug therapy, and surgery plus imatinib therapy. However, post-operative recurrence, imatinib-resistance, multi-targeted drug resistance are still challenges. Many clinical evidences show that a reasonable management strategy can improve the prognosis of patients with advanced GIST. All the doctors should have a clear mind to carry out appropriate interventions. Advanced GIST should not be simply considered to be either medical or surgical disease, but rather must be systematically managed by multidisciplinary team approach combining surgical oncology, medical oncology, pathology, and interventional medicine. This review will advocate suitable treatment strategies based on the most recent progresses in systemic treatment for advanced GIST and our clinical experience to achieve early detection, early prevention, proper management, and therefore improve the survival of these patients.

Prevention strategy of post-operative complications in elderly patients with colorectal cancer based on scoring systems / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the risk factors and prevention strategies of post-operative complications in elderly patients with colorectal cancer.</p><p><b>METHODS</b>Data of 107 elderly patients (≥75 years) undergoing surgery for colorectal cancer were collected from January 2006 to December 2009 in the Department of Gastrointestinal Surgery, Peking University People's Hospital. POSSUM and E-POSSUM scoring systems were used to predict post-operative complications. ROC curve and observe/expect(O/E) were used to assess the validity of scoring systems. Logistic regression was used to evaluate the independent risk factors associated with post-operative complications of elderly patients with colorectal cancer.</p><p><b>RESULTS</b>The predictive complication rates of E-POSSUM and POSSUM in elderly patients with colorectal cancer were 13.9%-86.6%(average, 32.7%) and 19.1%-99.1% (average, 55.5%). The predictive validity of E-POSSUM was better than POSSUM(AUC of ROC: 0.862 vs. 0.576, O/E: 0.771 vs. 0.454), the former was closer to the actual complication rate(25.2%, 27/107). Concurrent diabetes mellitus(P=0.019) and rectal lesion(P=0.005) were independent risk factors associated with surgery-related post-operative complications. Anastomotic leakage was the most common surgery-related post-operative complications. Chronic obstructive pulmonary disease(P=0.026), ASA score(P=0.025), intestinal obstruction(P=0.037) and perforation(P=0.001) were independent risk factors associated with non-surgery-related post-operative complications. Pulmonary infection was the most common non-surgery-related post-operative complication.</p><p><b>CONCLUSIONS</b>The application of E-POSSUM scoring system can provide more accurate prediction of post-operative complications in elderly patients undergoing surgery for colorectal cancer. Positive interventions should be taken for high-risk patients to prevent post-operative complications.</p>

Feasibility of complete mesocolic excision in elderly patients with colon cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the short-term outcomes and safety of complete mesocolic excision (CME) in elderly patients with colon cancer.</p><p><b>METHODS</b>The clinical pathological factors of 71 patients with colon cancer undergoing CME procedure by the same group of surgeons were analyzed retrospectively from November 2009 to February 2012. The elderly group(≥70 years) and the non-elderly group(<70 years) were compared regarding short-term outcomes and safety.</p><p><b>RESULTS</b>Similar extent of resection could be achieved in the elderly and non-elderly groups in terms of area of mesentery[(13 049±4332) vs. (13 163±4725) mm2, P=0.916], distance between the tumor and the high ligation site[(95±22) vs. (98±20) mm, P=0.516], distance between normal bowel and high ligation site [(130±25) vs. (128±25) mm, P=0.731], the length of colon [(262±60) vs. (245±49) mm, P=0.212], and lymph nodes retrieved(22.0±6.4 vs. 24.8±9.9, P=0.168). The mean operative time, intraoperative blood loss, postoperative complications, time to first flatus, time to first bowel movement, drainage removal time, diet resumption, drainage volume in three days after surgery, and hospital deaths showed no statistical significances(all P>0.05), while hospital stay and expenses of the elderly group were significantly increased(both P<0.01).</p><p><b>CONCLUSION</b>Elderly patients undergoing elective CME operation can achieve similar operative extent and lymph nodes harvest, and the surgical risk is not increased.</p>