Development and validation of a prognostic prediction model for patients with stage Ⅰ to Ⅲ colon cancer incorporating high-risk pathological features / 中华外科杂志

Objective: To examine a predictive model that incorporating high risk pathological factors for the prognosis of stage Ⅰ to Ⅲ colon cancer. Methods: This study retrospectively collected clinicopathological information and survival outcomes of stage Ⅰ~Ⅲ colon cancer patients who underwent curative surgery in 7 tertiary hospitals in China from January 1, 2016 to December 31, 2017. A total of 1 650 patients were enrolled, aged (M(IQR)) 62 (18)years (range: 14 to 100). There were 963 males and 687 females. The median follow-up period was 51 months. The Cox proportional hazardous regression model was utilized to select high-risk pathological factors, establish the nomogram and scoring system. The Bootstrap resampling method was utilized for internal validation of the model, the concordance index (C-index) was used to assess discrimination and calibration curves were presented to assess model calibration. The Kaplan-Meier method was used to plot survival curves after risk grouping, and Cox regression was used to compare disease-free survival between subgroups. Results: Age (HR=1.020, 95%CI: 1.008 to 1.033,P=0.001), T stage (T3:HR=1.995,95%CI:1.062 to 3.750,P=0.032;T4:HR=4.196, 95%CI: 2.188 to 8.045, P<0.01), N stage (N1: HR=1.834, 95%CI: 1.307 to 2.574, P<0.01; N2: HR=3.970, 95%CI: 2.724 to 5.787, P<0.01) and number of lymph nodes examined (≥36: HR=0.438, 95%CI: 0.242 to 0.790, P=0.006) were independently associated with disease-free survival. The C-index of the scoring model (model 1) based on age, T stage, N stage, and dichotomous variables of the lymph nodes examined (<12 and ≥12) was 0.723, and the C-index of the scoring model (model 2) based on age, T stage, N stage, and multi-categorical variables of the lymph nodes examined (<12, 12 to <24, 24 to <36, and ≥36) was 0.726. A scoring system was established based on age, T stage, N stage, and multi-categorical variables of lymph nodes examined, the 3-year DFS of the low-risk (≤1), middle-risk (2 to 4) and high-risk (≥5) group were 96.3%(n=711), 89.0%(n=626) and 71.4%(n=313), respectively. Statistically significant difference was observed among groups (P<0.01). Conclusions: The number of lymph nodes examined was an independent prognostic factor for disease-free survival after curative surgery in patients with stage Ⅰ to Ⅲ colon cancer. Incorporating the number of lymph nodes examined as a multi-categorical variable into the T and N staging system could improve prognostic predictive validity.

Splenic flexure cancer: surgical procedures and extent of lymphadenectomy / 中华胃肠外科杂志

Splenic flexure colon cancer occurs at a relatively lower rate than colon cancer of other sites. It is also associated with more advanced disease and higher rate of acute obstruction. The splenic flexure receives blood supply from both superior and inferior mesenteric arteries (SMA and IMA), and therefore has lymphatic drainage to both areas. The blood supply is also highly variable, causing difficulties in determining the main feeding vessels and the main direction of lymph drainage. Few studies with limited cases focused on this specific tumor site with respect to the patterns of lymph node spread, especially the main lymph node status and the value of its dissection. The lack of information limits the development of a consensus on the extent of surgical resection and lymphadenectomy. Adequate mobilization of the colon facilitates a sufficient length of bowel resection and the high ligation of feeding arteries from both SMA and IMA. Further evidence on the chnoice of procedures and the extent of lymph node dissection need multicenter collaboration, with the use of modern techniques, including CT 3D reconstruction of the colon and angiography, as well as intraoperative fluorescent real-time imaging of lymph nodes.

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.

Inter-fascial dissection in laparoscopic colorectal cancer surgery: principles of retraction and exposure and techniques in fascial separation / 中华胃肠外科杂志

Colorectal surgery for malignancies has evolved into an era of careful and precise dissection along mesorectal or mesocolic fascia to achieve the so-called total mesorectal excision or complete mesocolic excision. The wide use of laparoscopic technique prompted more anatomical, histological, and embryological studies. This leads to a deeper and more precise understanding of fascial anatomy concerning colorectal surgery, though controversies exist. The complicated anatomy of multilayer parietal fasciae and dense adhesion between fasciae at specific sites still represent a major hindrance to perform a precise inter-fascial dissection. Colorectal surgeons should be familiar with the onion-like arrangement of the visceral and parietal fasciae. The dedicated assistants should provide three-directional traction and adjust the direction of forces timely in a manner that the resultant forces are always in a direction perpendicular to the fasciae that are to be dissected. The fixation of the mesorectum and the mesocolon to the pelvic and abdominal wall can also be exploited as a natural counter-retraction. To separate loosely attached visceral and parietal fasciae, the application of splitting forces on opposite fasciae or sliding the forceps along the interface will provide quick separation and maintenance of the integrity of the fasciae. In summary, careful attention to the direction and strength of three directional retractions on parietal and visceral fasciae will help stretch and open up the areolar surgical tissue plane, skillful maneuver in separation and dividing of the attachment of two fasciae will ensure a precise inter-fascial dissection and help achieve total mesorectal excision or complete mesocolic excision, reducing the risk of the residual of the mesentery and inadvertent injuries to adjacent tissues and autonomic nerves.

Down-regulation of Notch1 by small interfering RNA enhances chemosensitivity to gemcitabine in pancreatic cancer cells through activating apoptosis activity / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To investigate the effect of down-regulation of Notch1 by Notch1 small interfering RNA (siRNA) on chemosensitivity to gemcitabine in pancreatic cancer cells and its mechanism.</p><p><b>METHODS</b>Notch1 siRNA was transfected to pancreatic cancer cell lines AsPC-1, BxPC-3, MIAPaCa-2 and Panc-1. The transfected pancreatic cancer cells were treated with 10 μmol/L gemcitabine in vitro. The relative quantity of Notch1 mRNA of pancreatic cancer cells was detected by real-time PCR. The inhibition rates of gemcitabine-treated cells were evaluated by CCK-8 method. The expression of Bax protein was examined by Western blot, and the caspase 3 activity was detected by CaspACETM assay system kit.</p><p><b>RESULTS</b>The relative quantity of Notch1 mRNA was the highest in BxPC-3 cell line and the lowest in Panc-1 cells. The inhibition rates of gemcitabine treated-cells were significantly higher in Notch1 siRNA transfection groups than in corresponding siRNA control groups (AsPC-1: 67.5±6.7 vs 47.5±6.8; BxPC-3: 90.5±4.4 vs 70.2±4.2; MIAPaCa-2: 80.9±5.7 vs 58.1±6.0; Ps<0.05), with the overexpression of protein Bax. The activity of caspase 3 was also significantly increased in Notch1 siRNA transfection groups compared with corresponding siRNA control groups (AsPC-1: 28.90±2.70 vs 12.82±3.44; BxPC-3: 59.87±6.77 vs 27.27±11.88; MIAPaCa-2: 29.34±4.06 vs 14.59±4.25; P<0.05).</p><p><b>CONCLUSION</b>Inhibition of Notch signaling pathway by Notch1 siRNA can enhance chemosensitivity to gemcitabine in pancreatic cancer cells through activating apoptosis activity．</p>

Transabdominal and transhiatal esophagogastrostomy or esophagojejunostomy using novel double stapling technique / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the techniques of esophagogastrostomy or esophagojejunostomy in the mediastinum through the abdomen and hiatus after extended proximal gastrectomy or total gastrectomy.</p><p><b>METHODS</b>From May 2010 to January 2012, 15 patients with esophagogastric junction carcinoma underwent open transhiatal extended gastrostomy or total gastrectomy. After full mobilization, the anvil was reversely introduced into the esophagus and the esophagus was transected with curved stapler. The rod of the anvil was then pulled out with a stitch to complete esophagogastrostomy after proximal gastrectomy(n=9) or esophagojejunostomy after total gastrectomy(n=6).</p><p><b>RESULTS</b>The anastomosis was successfully performed in all the patients. The mean operation time was(185.5±13.1) min. The mean operation time for anastomosis was(42.0±8.6) min. The mean estimated blood loss was (106.7±34.9) ml. The proximal resection margin was(4.4±1.2) cm. All the margins were negative for residual cancer. There was no postoperative death or fistula. During the follow up, there was one case of anastomotic stenosis which was successfully managed by endoscopic balloon dilatation.</p><p><b>CONCLUSIONS</b>Esophagogastrostomy or esophagojejunostomy can be safely performed with double stapling technique including reverse anvil introduction and curved stapling transection of the esophagus. It is an ideal technique for anastomosis after extended gastrectomy for esophagogastric junction carcinoma.</p>

Application and indication choice of hand-assisted laparoscopic operation in gastrointestinal surgery / 中华胃肠外科杂志

Despite gaining wider popularity in the management of both benign and malignant gastrointestinal diseases over the past decade, traditional laparoscopic surgery remains to be associated with several distinct disadvantages, including longer operative time, longer learning curve, technical difficulty in obese patients and complicated cases. As a hybrid technique between open surgery and traditional laparoscopic surgery, hand-assisted laparoscopic surgery (HALS) brings back tactile feeling and hand-to-eye coordination to surgeons. It allows surgeons to perform more complicated gastrointestinal surgery, while retaining the merits of traditional laparoscopic surgery. It also improves operative time and learning curve. The main disadvantages of HALS seem to be the hindering effect and fatigue of the inserted hand. The exact role of HALS in gastrointestinal surgery has not been well defined due to lack of substantial evidences from clinical trials.

Laparoscopic transhiatal extended gastrectomy for type II, III esophagogastric junction cancer: a preliminary report of 55 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the feasibility and safety of laparoscopic extended gastrectomy through the transhiatal approach in patients with esophagogastric junction cancer.</p><p><b>METHODS</b>From Feb 2008 to May 2010, 55 cases with Siewert type II or III esophagogastric junction cancer underwent laparoscopic transhiatal extended gastrectomy at the West China hospital. Clinical data were analyzed retrospectively.</p><p><b>RESULTS</b>Esophagogastric junction cancer was Siewert type II in 36 patients and Siewert type III in 19. Thirty-five cases underwent proximal gastrectomy, 20 total gastrectomy. There were 53 D2 lymph node excisions and 2 palliative resections. Fifty patients underwent laparoscopic extended gastrectomy successfully, with 5 converted to open operations. A safe anastomosis between inferior pulmonary vein and pulmonary hilum was achieved in the majority of patients. The mean operative time was(236.2±35.5) min and the mean estimated blood loss was(60.6±33.9) ml. There were no postoperative mortalities or anastomotic leakage/stenosis. No reoperations were required. Pleural laceration occurred in 11 cases during operation, of whom 10 were repaired intraoperatively and one was managed with drainage postoperatively. There were 3 patients developed pulmonary infection and one wound infection. Postoperative recovery was uneventful in other patients.</p><p><b>CONCLUSION</b>Laparoscopic transhiatal extended gastrectomy is feasible and safe for patients with esophagogastric junction cancer.</p>

Laparoscopic resection of gastric stromal tumors: report of 30 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the treatment efficacy of laparoscopic resection of gastric stromal tumors.</p><p><b>METHODS</b>The clinical data of 30 patients with laparoscopic resection of gastric stromal tumors from Apr. 2004 to Apr. 2006 were retrospectively analyzed.</p><p><b>RESULTS</b>The preoperative diagnosis of gastric stromal tumors mainly relied on gastroscope, ultrasound gastroscope, barium meal and abdominal CT scan. Tumor size ranged from 2 to 10 cm. Surgical procedures included laparoscopic wedge resection for 22 patients, laparoscopic distal gastrectomies for 6 patients, and laparoscopic proximal gastrectomies for 2 patients. All operations were successful, with an average operation time of 120+/-35 min and a blood loss of 5-200 ml. Postoperative length of stay was 4-10 days. No recurrence had occurred during 3-24 months follow-up.</p><p><b>CONCLUSION</b>Laparoscopic resection of gastric stromal tumors is a safe and reliable procedure, with quick postoperative recovery and minimal invasion.</p>

A modified method of laparoscopic side-to-side esophagojejunal anastomosis after laparoscopic total gastrectomy: a report of 12 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the method of alimentary reconstruction after laparoscopic total gastrectomy.</p><p><b>METHODS</b>The clinical data of 12 patients undergone laparoscopic total gastrectomy and side- to- side esophagojejunal anastomosis from Feb. 2006 to Oct. 2006 were analyzed retrospectively.</p><p><b>RESULTS</b>Laparoscopic side- to- side esophagojejunal anastomosis was successfully performed in 12 patients. The mean operation time was (247.0+/- 13.1) min and the anastomosis time was (43.5+/- 10.4) min. Bleeding volume during operation was (107.5+/- 44.9)ml. The distance between anastomosis and proximal margin of tumor was (3.4+/- 1.2)cm. There was no postoperative death, fistula or anastomotic stenosis occurred after short- term follow- up.</p><p><b>CONCLUSION</b>The modified laparoscopic side- to- side esophagojejunal anastomosis is a safe, less challenging and more economic method of alimentary reconstruction after laparoscopic total gastrectomy.</p>

Influence of CD4+ and CD25+ T regulatory cell on mouse bearing gastric tumor in vivo / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the influence of CD4+ CD25+ regulatory T cells(Treg cells) on mouse gastric cancer.</p><p><b>METHODS</b>Treg cell in mouse spleen bearing gastric tumor was tested in different time points. Magic cell sorting(MACS) method was used to purify mouse Treg cells and the Treg cells were injected into mouse bearing gastric tumor with different dosage. After 3 weeks, the tumor size and tumor cell apoptosis rate were measured.</p><p><b>RESULTS</b>Treg existed in normal mouse spleen with a rate of (3.86+/-0.07)%. In tumor model this percentage increased gradually and was (4.12+/-0.13)% after 3 weeks, which was significantly higher than that in control. When Treg cell applied in mouse reached 2.0 x 10(5), the tumor size enlarged significantly(P=0.013) and tumor cell apoptosis rate decreased significantly (P=0.012).</p><p><b>CONCLUSIONS</b>Treg cell is associated with gastric cancer progress in mouse tumor model. Treg cell can promote gastric cancer growth and decrease tumor apoptosis. The anti- Treg GITR can improve anti- tumor effects.</p>

Laparoscopic-assisted radical gastrectomy: a report of 105 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility and safety of laparoscopic-assisted radical gastrectomy for gastric cancer.</p><p><b>METHODS</b>One hundred and five patients with gastric cancer received laparoscopic-assisted radical gastrectomy, radical total gastrectomy were performed in 7 cases, proximal gastrectomy in 27 cases, proximal gastrectomy combined with splenectomy in 3 cases and distal gastrectomy in 68 cases.</p><p><b>RESULTS</b>One hundred and five cases had laparoscopic-assisted radical gastrectomy successfully. The mean operation time was 381 +/- 91 (300 - 435) min for total gastrectomy, 279 +/- 73 (212 - 390) min for proximal gastrectomy, 312 +/- 64 (265 - 405) min for proximal gastrectomy combined with splenectomy, 281 +/- 69 (230 - 360) min for distal gastrectomy, respectively. The mean blood loss was 260 +/- 202 (20 - 900) ml in total gastrectomy, 200 +/- 153 (20 - 400) ml in proximal gastrectomy, 333 +/- 116 (200 - 400) ml in proximal gastrectomy combined with splenectomy, 140 +/- 82 (20 - 450) ml in distal gastrectomy, respectively. The mean number of harvested lymph nodes was 34.2 +/- 20.5 (8 - 83). The mean time for gastrointestinal function recovery was 3.5 +/- 1.4 (2 - 5) days, 3.0 +/- 1.6 (2 - 6) days for patients' taking normal activity, 4.9 +/- 1.7 (3 - 7) days for taking liquid food. The short-term efficiency was obvious.</p><p><b>CONCLUSIONS</b>Laparoscopic-assisted radical gastrectomy is a feasible and safe surgical procedure combined with minimal trauma and fast recovery.</p>

Laparoscopy-assisted radical gastrectomy: a report of 71 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the feasibility and safety of laparoscopy-assisted radical gastrectomy for gastric cancer.</p><p><b>METHODS</b>Seventy-one patients with gastric cancer received laparoscopy-assisted radical gastrectomy for gastric cancer. Among them radical total gastrectomy was performed in 8 cases, proximal partial gastrectomy in 16 cases, proximal partial gastrectomy combined with splenectomy in 3 cases, and distal partial gastrectomy in 44 cases.</p><p><b>RESULTS</b>Sixty-nine cases had laparoscopic-assisted surgery performed successfully, but 2 cases were converted to open surgery. The mean operation time was (343 +/- 52) min for total gastrectomy, (268 +/- 62) min for proximal gastrectomy, (312 +/- 64) min for proximal gastrectomy combined with splenectomy, and (283 +/- 44) min for distal gastrectomy respectively. The mean volume of blood loss was (267 +/- 220) ml in total gastrectomy, (150 +/- 103) ml in proximal gastrectomy, (333 +/- 116) ml in proximal gastrectomy combined with splenectomy, (139+/- 84) ml in distal gastrectomy respectively. The mean numbers of harvested lymph nodes were (34.3 +/- 11.8). The mean time was (4.1 +/- 1.1) d for gastrointestinal function recovery, (3.5 +/- 1.0) d for patient's taking general activity, (5.0 +/- 1.2) d for taking liquid food. The short-term efficiency was obvious.</p><p><b>CONCLUSION</b>Laparoscopy-assisted radical gastrectomy is a feasible, safe and minimally invasive treatment and can achieve the same outcomes as the open operation.</p>

Expression of tumor suppressor gene-p33/ING1 in colorectal carcinoma / 第三军医大学学报

Objective　To explore the correlation between the expression of p33/ING1 and the clinicopathological features in patients with colorectal cancer, and to understand the possible mechanism of p33/ING1 in the oncogenesis of colorectal neoplasms. Methods　All samples of normal mucosa and cancer tissues from 52 patients with colorectal cancer were detected for their expression levels of p33/ING1 by RT-PCR. Results　A significant decrease in p33/ING1 mRNA expression was found in 30 out of 52(57.7%) colorectal cancer tissues. The results also showed that repression of p33/ING1 expression markedly related to both the Duke's stage and metastasis. Conclusion　Down-regulation of p33/ING1 may play an important role in the oncogenesis and development of colorectal carcinoma.

Expression of tumor suppressor gene-p33/ING1 in colorectal carcinoma / 第三军医大学学报

Objective　To explore the correlation between the expression of p33/ING1 and the clinicopathological features in patients with colorectal cancer, and to understand the possible mechanism of p33/ING1 in the oncogenesis of colorectal neoplasms. Methods　All samples of normal mucosa and cancer tissues from 52 patients with colorectal cancer were detected for their expression levels of p33/ING1 by RT-PCR. Results　A significant decrease in p33/ING1 mRNA expression was found in 30 out of 52(57.7%) colorectal cancer tissues. The results also showed that repression of p33/ING1 expression markedly related to both the Duke's stage and metastasis. Conclusion　Down-regulation of p33/ING1 may play an important role in the oncogenesis and development of colorectal carcinoma.