Effect of bladder training on bladder function recovery in the male patients after mid-low rectal cancer surgery: a prospective, open, randomized controlled study / 中华胃肠外科杂志

OBJECTIVE@#To investigate the efficacy and safety of the bladder training in male patients before urinary catheter removal after mid-low rectal cancer surgery.@*METHODS@#This was a prospective, open, randomized controlled study.@*INCLUSION CRITERIA@#male patients; pathologically diagnosed as mid-low rectal adenocarcinoma; distance from tumor lower edge to anal margin ≤10 cm; standard radical surgery for rectal cancer, including intestinal resection and regional lymph node dissection.@*EXCLUSION CRITERIA@#previous history of benign prostatic hyperplasia or history of prostate surgery; bladder dysfunction such as dysuria and urinary retention before surgery; local resection of rectal tumor or extended resection. According to the above criteria, 92 patients who underwent colorectal surgery at the Union Hospital of Fujian Medical University from June to December 2016 were prospectively included. The patients were randomly divided into bladder training group (n=43) and bladder non-training group (n=49) according to the random number table method. The study was approved by the Ethics Committee of the Union Hospital of Fujian Medical University (ethical approval number: 2016KY005) and registered with the China Clinical Trial Registration Center (ChiCTR) (registration No.ChiCTR-IOR-16007995). The implementation of patient's treatment measures, the data collection and analysis were based on the three-blind principle, using envelopes for distribution concealment. In the bladder training group, bladder training was routinely performed from the first day after operation to catheter removal, and in bladder non-training group the catheter was kept open till its removal. The catheter was removed in the early morning at the 5th day after surgery, and the spontaneous urine output was recorded and the residual urine volume of the bladder was measured after the first urination. The international prostate symptom score (IPSS) was applied to evaluate the patient's urinary function before and after surgery.@*RESULTS@#The age of whole group was (58.6±10.9) years old, the body mass index was (22.4±2.7) kg/m , and the distance from tumor lower edge to anal margin was (6.5±1.9) cm. The baseline data, such as age, body mass index, distance from tumor lower edge to anal margin, preoperative IPSS score, preoperative bladder residual urine volume, neoadjuvant radiotherapy and chemotherapy, preventive ileostomy and surgical procedure were not significantly different between two groups (all P>0.05). There was no significant difference in IPSS scores evaluated at the second day (3.6±4.0 vs. 3.5±3.4, t=0.128, P=0.899) and one month (3.7±2.9 vs. 3.0±3.1, t=1.113, P=0.269) after catheter removal between the bladder training group and bladder non-training group. No significant difference in the postoperative residual urine volume of bladder (media 44 ml vs. 24 ml, Z=-1.466, P=0.143), the first spontaneous urination volume (median 200 ml vs. 150 ml, Z=-1.228, P=0.219) after catheter removal, and postoperative hospital stay [(8.2±4.5) days vs. (9.1±5.5) days, t=-0.805, P=0.423] was found. Urinary infection rate was 20.9%(9/43) in the training group, which was even higher than 8.2%(4/49) in the non-training group, but the difference was not significant(χ²=3.077, P=0.079). No patient needed re-catheterization in either group.@*CONCLUSIONS@#The routine bladder training after mid-low rectal cancer surgery does not improve the urinary function, and can not reduce the residual urine volume of bladder after catheter removal. This routine clinical practice is not helpful for the bladder function recovery after rectal cancer surgery.

Comparison of robotic and laparoscopic total mesorectal excision / 中华胃肠外科杂志

Laparoscopic total mesorectal excision (TME) has been commonly applied in the operation of mid-low rectal cancer, but the conventional laparoscopic TME has the disadvantages of major operative difficulty and long learning-curve, due to its limitations of 2-dimension vision and common laparoscopic instruments. Robotic surgical system with high-qualified 3-dimenstion vision and flexible Endo Wrist instruments can overcome those limitations of conventional laparoscopy, and is useful for the TME that demands deep pelvic operation and flexible dissection in the space of distal rectum. Robotic TME has the advantages of shorter learning curve and lower conversion rate, and it can even be performed by the surgeon with little laparoscopic experience. But according to the current studies, the superiority of robotic TME over laparoscopic TME can not be confirmed. To confirm the efficacy of robotic surgery, more high-level evidences are needed. Currently, the biggest obstacle for the widespread use of robotic surgical system is its high expense. But there is an obvious advantage that is the more comfortable feeling of surgeon while performing robotic surgical system, compared with performing laparoscopic operation, and it is helpful for long-time complicated operation. It is confirmative that robotic operation is the results of science and technology development, and it is the direction of future development. With the expiration of patent right of Da Vinci robotic system, there will be more kinds of robotic surgical systems which will lead to the much lower operation expense and the widespread use. The young surgeons should master the laparoscopic TME, which will help them master robotic TME technique quickly.

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>

Skills of using harmonic scalpel in laparoscopic surgery for colorectal cancer / 中华胃肠外科杂志

Harmonic scalpel is an important instrument for laparoscopic surgery, and it can be used for dissection and hemostasis. During the procedure of laparoscopic surgery for colorectal tumor, surgeons can use Harmonic scalpel to identify the surgical plane around the mesorectum and mesocolon. We summarized technical points based on our own 15-year experiences of harmonic scalpel use in laparoscopic surgery for colorectal surgery, and extracts them into five words, which are 'shave, poke, cut, peel and push'. These skills are described in combination of the illustrations and videos in this article.

Laparoscopic surgery for low rectal cancer, intersphincteric resection, Miles or extralevator abdominoperineal excision / 中华胃肠外科杂志

Currently, the safety and efficiency of laparoscopic surgery for rectal cancer have been confirmed by large amount of evidences. Laparoscopic surgery has been commonly applied in the treatment for low rectal cancer. Sphincter preservation is a highly concerning issue for patients and surgeons during rectal cancer surgery. Sphincter-preserving surgery should be based on the R0 resection. The article reviews the application of laparoscopic surgery for low rectal cancer and the choice of operations for sphincter-preserving surgery.

Influence of anastomotic leakage on long-term survival after resection for rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the influence of anastomotic leakage (AL) on long-term survival after resection for rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 653 rectal cancer cases confirmed by pathology and undergoing R0 resection for rectal cancer in our department from January 2007 to December 2011 were retrospectively analyzed. Anastomotic leakage was found in 40 cases (AL group) and not in the other 613 cases (non-AL group). After median 47 (1-91) months of follow-up, 5-year disease-free survival rate, distant metastasis rate and local recurrence rate were compared between the two groups. Risk factors affecting long-term prognosis were also analyzed.</p><p><b>RESULTS</b>The 5-year disease-free survival rate, 5-year distant metastasis rate, and 5-year local recurrence rate were 78.1%, 14.2% and 4.2% in the non-AL group, and 74.5%, 20.1% and 8.4% in the AL group respectively, and the differences were not statistically significant (P=0.808, P=0.965, P=0.309). Multivariate analysis showed that preoperative neoadjuvant radiochemotherapy, TNM staging, abnormal CA199, preoperative low level of albumin were independent prognostic factors of rectal cancer patients after R0 resection, while AL was not an independent factor of 5-year disease-free survival (P=0.910). Further multivariate analysis on 507 cases receiving postoperative adjuvant chemotherapy also revealed that AL was not an independent factor of 5-year disease-free survival (P>0.05). Percentage difference of patients finishing postoperative chemotherapy between the two groups was not statistically significant (79.4% vs. 76.3%, P=0.681).</p><p><b>CONCLUSION</b>AL is not an independent predictor of long-term survival for rectal cancer.</p>

Diagnosis and treatment of pelvic wall and bowel fibrosis with bowel obstruction induced by neoadjuvant chemoradiotherapy for rectal carcinoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To introduce the diagnosis and the treatment of the long-segment bowel stenosis above the anastomosis and bowel obstruction caused by the radiation-induced pelvic wall and bowel fibrosis.</p><p><b>METHODS</b>Between January 2008 and June 2014, 468 patients with rectal carcinoma underwent sphincter-preserving operation after neoadjuvant chemoradiotherapy in Fujian Medical University Union Hospital. Among 241 patients without postoperative anastomotic leakage, anastomosis stenosis, local recurrence and small bowel obstruction, severe pelvic and bowel fibrosis with obstruction during follow-up was found in 14 patients(SFO group). Associated data of these 14 patients were retrospectively collected. Clinical and image characteristics, and treatment outcomes of these 14 patients were analyzed and compared to those of other 227 patients without fibrosis and obstruction (control group).</p><p><b>RESULTS</b>Compared to control group, SFO group had lower BMI(19.7±2.3 vs. 22.5±3.2, P=0.000), higher ratio of male (92.9% vs. 63.9%, P=0.039) and smoking patients(78.6% vs. 32.2%, P=0.001), shorter preoperative distance from lower edge of tumor to anal verge [(4.9±0.7) cm vs. (5.7±1.4) cm, P=0.043), and longer time from the end of radiation to operation [(9.4±2.3) week vs. (8.1±1.7) week, P=0.024). The largest thickness of the bilateral obturator internus increased significantly after chemoradiotherapy (left side: P=0.030, right side: P=0.020) as compared to pre-chemoradiotherapy on MR image. Patients of SFO group received corresponding treatments according to the status of bowel stricture, and the outcomes were all satisfactory.</p><p><b>CONCLUSIONS</b>Reconstructed rectum stricture can be caused by the radiation-induced fibrosis of pelvic wall soft tissue and proximal colon. Severe stricture can be treated with corresponding methods to relieve symptoms.</p>

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.

Application of extralevator abdominoperineal excision for low rectal carcinoma / 中华胃肠外科杂志

It has been reported that the conventional abdominoperineal excision has the disadvantages of higher rates of positive circumferential resection margin and intraoperative bowel perforation, which affect the prognosis. The technique of extralevator abdominoperineal excision proposed by Holm et al is used to overcome these disadvantages. But this new concept of abdominoperineal excision causes other new problems, such as increased complexity, major trauma and more complications. With further studies, the advanced knowledge about the indications, modifications and complications of this technique has been obtained by the domestic and overseas surgeons. This article reviews the characteristics of extralevator abdominoperineal excision and its indications, research progress and major associated complications.

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>

Updates in the diagnosis and treatment of anastomotic leakage after surgery for rectal cancer / 中华消化外科杂志

With the common application of total mesorectal excision (TME) technique,the proportion of sphincterpreserving surgery for the mid-low rectal carcinoma is significantly increased.Anastomotic leakage after sphincter-preserving surgery is the most severe complication of rectal surgery,and it is the main reason which will lead to other complications and death.Many researches on the early diagnosis,prevention and treatment of anastomotic leakage are conducted by surgeons at home and abroad,and a further understanding of this complication is deeply realized.

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.