Analysis of Ethical Review of Clinical Study on Defecation Function of Patients with Rectal Cancer after sphincter-preserving Surgery / 中国医学伦理学

In order to understand the status quo of ethical review of clinical research on the defecation function of patients with rectal cancer after sphincter-preserving surgery, analyze its causes and put forward corresponding suggestions, to arouse researchers’ attention to ethical review in subsequent relevant clinical studies. The ethical review of literatures related to the defecation function of patients with rectal cancer after sphincter-preserving surgery published on CNKI in recent 10 years was sorted out and summarized. The results showed that the ethical review of clinical research papers on defecation function of patients with rectal cancer after sphincter-preserving surgery was not optimistic. We should strengthen the ethical training of researchers, improve the ethical awareness of researchers, strictly implement the ethical norms of paper publication, strengthen the ethical requirements of manuscript contracts, perfect the ethical review system, and pay attention to the examination and supervision of informed consent, so as to promote the construction of ethical examination and approval norms of clinical research documents.

Clinical efficacy of redo rectal resection and coloanal anastomosis / 中华消化外科杂志

Objective:To investigate the clinical efficacy of redo rectal resection and coloanal anastomosis.Methods:The retrospective and descriptive study was conducted. The clinicopatholo-gical data of 49 patients who underwent redo rectal resection and coloanal anastomosis for the treatment of local recurrence of tumors and failure of colorectal or coloanal anastomosis after rectal resection in the Sixth Affiliated Hospital of Sun Yat-sen University from November 2012 to December 2021 were collected. There were 32 males and 17 females, aged 57(range,31-87)years. Redo rectal resection and coloanal anastomosis was performed according to the patient′s situations. Observa-tion indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distri-bution were represented as M( Q1, Q3) or M(range). Count data were described as absolute numbers or percentages. Results:(1) Surgical situations. All 49 patients underwent redo rectal resection and coloanal anastomosis successfully, with the interval between the initial surgery and the reopera-tion as 14.2(7.1,24.3)months. The operation time and volume of intraoperative bold loss of 49 patients in the redo rectal resection and coloanal anastomosis was 313(251,398)minutes and 125(50,400)mL, respectively. Of the 49 patients, there were 38 cases receiving laparoscopic surgery including 12 cases with transanoscopic laparoscopic assisted surgery, 11 cases receiving open surgery including 2 cases as conversion to open surgery, there were 20 cases undergoing Bacon surgery, 14 cases undergoing Dixon surgery, 12 cases undergoing Parks surgery, 2 cases undergoing intersphincter resection and 1 case undergoing Kraske surgery, there were 20 cases undergoing rectum dragging out excision and secondary colonic anastomosis, 13 cases undergoing dragging out excision single anastomosis, 12 cases undergoing rectum dragging out excision double anastomosis, 4 cases undergoing first-stage manual anastomosis, there were 21 cases with enterostomy before surgery, 16 cases with prophylactic enterostomy after surgery, 12 cases without prophylactic enterostomy after surgery. The duration of postoperative hospital stay of 49 patients was (14±7)days. (2) Postoperative situations. Fifteen of 49 patients underwent postoperative complications, including 8 cases with grade Ⅱ Clevien-Dindo complications and 7 cases with ≥grade Ⅲ Clevien-Dindo complications. None of 49 patient underwent postoperative transferring to intensive care unit and no patient died during hospitalization. Results of postoperative histopathological examination in 23 patients with tumor local recurrence showed negative incision margin of the surgical specimen. (3) Follow-up. All 49 patients underwent post-operative follow-up of 90 days. There were 42 cases undergoing redo rectal resection and coloanal anastomosis successfully and 7 cases failed. Of the 37 patients with enterostomy, 20 cases failed in closing fistula, and 17 cases succeed. There were 46 patients receiving follow-up with the median time as 16.1(7.5,34.6)months. The questionnaire response rate for low anterior resection syndrome (LARS) score was 48.3%(14/29). Of the patients who underwent redo coloanal anastomosis and closure of stoma successfully, there were 9 cases with mild-to-moderate LARS.Conclusion:Redo rectal resection and coloanal anastomosis is safe and feasible for patients undergoing local recurr-ence of tumors and failure of colorectal or coloanal anastomosis after rectal resection, which can successfully restore intestinal continuity in patients and avoid permanent enterostomy.

Influence of different sphincter-preserving surgeries on postoperative defecation function / 中华胃肠外科杂志

Advances in surgical techniques and treatment concept have allowed more patients with low rectal cancer to preserve sphincter without sacrificing survival benefit. However, postoperative dysfunctions such as fecal incontinence, frequency, urgency, and clustering often occur in patients with low rectal cancer. The main surgical procedures for low rectal cancer include low anterior rectum resection (LAR), intersphincteric resection (ISR), coloanal anastomosis (Parks) and so on. The incidence of major LARS after LAR is up to 84.6%. The postoperative function of ISR is even worse than LAR. Moreover, the greater the extent of resection ISR surgery, the worse the postoperative function. There are few studies on the function of Parks procedure. Current evidence suggests that the short-term function of Parks procedure is inferior to LAR, but function can gradually recovered over time. Colorectal surgeons have attempted to improve postoperative defecation by modifying bowel reconstructions. Current evidence suggests that J pouch or end-to-side anastomosis during LAR does not reduce the incidence of defecation disorders. Pouch reconstruction during ISR cannot reduce the incidence of severe LARS either. In general, the protection of postoperative defecation function in patients with low rectal cancer still has a long way to go.

Chinese expert consensus on protective ostomy for mid-low rectal cancer (version 2022) / 中华胃肠外科杂志

The rate of sphincter-preserving surgery for mid-low rectal cancer is increasing, but anastomotic leakage remains to be one of the common serious complications after operation. How to reduce the morbility and mortality of anastomotic leakage is always a hot and difficult point in colorectal surgery. Protective ostomy is a common method to deal with the above problems in clinical practice. However, some problems such as inappropriate stoma and stoma-related complications etc. become the current clinical challenges. The purpose of this consensus focusing on indication of ostomy, clinical value, ostomy skills, prevention of stoma complications, reversion of stoma and stoma nursing aims to provide guidance for the clinical practice of protective ostomy in the operation of mid-low rectal cancer in China.

Current status and influencing factors of bowel function in patients with rectal cancer after sphincter-preserving surgery / 中国实用护理杂志

Objective:To understand the status and influencing factors of the bowel function in patients with rectal cancer after sphincter-preserving surgery, and then to improve the patients′ quality of life.Methods:From January 2017 to April 2020, a total of 179 patients with rectal cancer after sphincter-preserving surgery in Sun Yat-sen University Cancer Center were selected as study subjects. General questionnaire and the scale about bowel function of patients with rectal cancer after sphincter-preserving surgery were used to investigate.Results:The total score of bowel function in patients with rectal cancer after sphincter-preserving surgery was (71.82±7.67), and the average score of all the items was (3.99 ± 0.43). In all dimensions of intestinal function, the average score of "defecation affected by diet" was the highest (4.39 ± 0.80), followed by "frequent and urgent defecation" (4.22 ± 0.49), and the average score of "defecation paresthesia" was the lowest (3.03 ± 0.67). Tumor distance from the anal border was the influencing factor of bowel function in patients with rectal cancer after sphincter-preserving surgery ( P<0.05). Conclusions:The bowel function of patients with rectal cancer after sphincter-preserving surgery was well, while the bowel function of patients with rectal cancer after sphincter-preserving surgery with the distance between the tumor and the lower edge of the anus <5.0 cm was relatively poor.

Emphasize on the postoperative anal function of middle and low rectal cancer patients / 中国实用外科杂志

Organ function preservation emphasizes the application of various therapeutic techniques to avoid or reduce the influence of tumor treatment process on the normal function of cancer organs and adjacent organs under thepremise of ensuring the best prognosis of oncology. Modern surgical treatment of middle and low rectal cancer does requireanal organ function preservation, but the current rectal cancer guidelines lack guidance on how to protect organ function. Inthe author's opinion,modern colorectal surgeons should recognize that anal function is an important factor affecting the quality of life after rectal cancer surgery. Functional considerations should be raised to the same level as techniqueas to whether the patient should preserve the anus. Correct evaluation of postoperative defecation function of patients isthe basis of selecting anal preservation indications.Preoperative evaluation of risk factors for anal dysfunction are helpful to predict postoperative functional status. The rational use of multidisciplinary strategies is recommended to reduce surgical trauma and improve anastomosis techniques to achieve functional preservation in middle and low rectal cancer.

Current state and progress of preserving anal function in treatment of low or ultral-low rectal cancer / 中国内镜杂志

As the development of society, people pay more attention to life quality. Nowadays, the therapeutic strategy to low or ultra-low rectal cancer has turned to anussaving as important as radical resection. Following the deep research in biology rule-rs of rectal cancer and a series of important theories, such as the 2 cm distal resection margin, total mesorectal excision technique, pelvic autonomic nerve preservation, variet-y of surgical methods can be chose in dealing with low or ultra-low rectal cancer a-nd achieving the goal of anus preservation. But, because of so many organs around the low or ultra-low rectal cancer and complicated anatomy, we should select patients strictly in order to avoid preserve one's anus blindly. if not, patients will face the condition of residual neoplasms or severe incontinence.

Clinical efficacy of preoperative SIB-IMRT for 26 cases of locally-advanced low rectal cancer / 中华放射肿瘤学杂志

Objective To evaluate the feasibility and clinical efficacy of preoperative simultaneous integrated boost intensity-modulated radiotherapy (SIB-IMRT) combined with neoadjuvant chemotherapy of capecitabine in patients with locally-advanced low rectal cancer.Methods Between 2015 and 2016,26 patients admitted to 301 Hospital who were diagnosed with locally-advanced low rectal cancer,which was located within 5 cm from the anal verge,were enrolled in this investigation.Dose fractionation pattern was delivered:58.75 Gy in 25 fractions (2.35 Gy/fraction) for rectal cancer and lymph node metastasis and 50 Gy in 25 fractions for the pelvic lymphatic drainage area and simultaneously combined with capecitabine chemotherapy (825 mg/m2,bid d 1-5 weekly).One cycle of capecitabine (1 250 mg/m2,twice daily,d 1-14)was given at one week after the completion of chemoradiotherapy (CRT).Total mesorectal excision (TME)was performed at 6 to 8 weeks after the completion of CRT.The primary endpoints included pathological complete response rate (ypCR) and sphincter-preserving rate.The secondary endpoints included acute toxicity,tumor downstaging rate and postoperative complications.Results Twenty-six patients successfully completed neoadjuvant CRT,25 of them underwent surgical resection and one patient failed to receive surgery due to pxrianal edema.Postoperative ypCR rate was 32％ (8/25),the sphincter-preserving rate was 60％ (15/25),the tumor downstaging rate was 92％ (23/25) and the R0 resection rate was 100％.During the period of CRT,grade 1 and 2 adverse events occurred in 24 patients,grade 3 radiation dermatitis was noted in 2 cases.No ≥ grade 4 acute adverse event was observed.Postoperative complications included ureteral injury in one case and intestinal obstruction in one patient.Conclusions Preoperative SIB-IMRT combined with neoadjuvant chemotherapy of capecitabine is a feasible and safe treatment for patients with locallyadvanced low rectal cancer,which yields expected ypCR rate,R0 resection rate and sphincter-preserving rate.Nevertheless,the long-term clinical benefits remain to be elucidated.Clinical Trial Registry Chinese Clinical Trial Registry,registration number:ChiCTR-ONC-12002387.

Application of terminal ileum suspension in laparoscopic operation for low rectal cancer / 实用医学杂志

Objective To explore the value of terminal ileum suspension in the treatment of low rectal cancer.Methods 80 patients with low rectal cancer who underwent laparoscopic operation in our hospital from June 2015 to February 2017,were randomly divided into two groups:the control group (group C) and the test group (group T),40 cases in each group.In group C,laparoscopic radical resection of rectal cancer (Dixon) was performed and in group T Dixon was combined with terminal ileum suspension.Peripheral blood nutritional indicators (total plasma protein,albumin,pre-albumin,transferrin) and major electrolytes of two groups were observed 1 day before operation and 1,3 and 7 days after operation.The two groups were compared in terms of first exhaust time,postoperative hospital stay,total costs for hospitalization,postoperative discomforts and complications.Results There were no statistical differences in the levels of nutrition indicators and electrolytes between them (P ＞ 0.05) and neither it was with first exhaust time,hospital stay,total costs of hospitalization,incidence of postoperative discomforts and complications (P ＞ 0.05).The re-operation rate of group T with anastomotic leak was significantly lower than group C (P ＜ 0.05).Conclusion Terminal ileal suspension does not affect patients' postoperative recovery without increasing the patient's suffering and economic burden,and can effectively reduce the reoperation rate caused by anastomotic leak.It is easy to operate.

Multivariate Analysis of Risk Factors Associated With the Nonreversal Ileostomy Following Sphincter-Preserving Surgery for Rectal Cancer

PURPOSE: A loop ileostomy is used to protect an anastomosis after anal sphincter-preserving surgery, especially in patients with low rectal cancer, but little information is available concerning risk factors associated with a nonreversal ileostomy. The purpose of this study was to identify risk factors of ileostomy nonreversibility after a sphincter-saving resection for rectal cancer. METHODS: Six hundred seventy-nine (679) patients with rectal cancer who underwent sphincter-preserving surgery between January 2004 and December 2011 were evaluated retrospectively. Of the 679, 135 (19.9%) underwent a defunctioning loop ileostomy of temporary intent, and these patients were divided into two groups, that is, a reversal group (RG, 112 patients) and a nonreversal group (NRG, 23 patients) according to the reversibility of the ileostomy. RESULTS: In 23 of the 135 rectal cancer patients (17.0%) that underwent a diverting ileostomy, stoma reversal was not possible for the following reasons; stage IV rectal cancer (11, 47.8%), poor tone of the anal sphincter (4, 17.4%), local recurrence (2, 8.7%), anastomotic leakage (1, 4.3%), radiation proctitis (1, 4.3%), and patient refusal (4, 17.4%). The independent risk factors of the nonreversal group were anastomotic leakage or fistula, stage IV cancer, local recurrence, and comorbidity. CONCLUSION: Postoperative complications such as anastomotic leakage or fistula, advanced primary disease (stage IV), local recurrence and comorbidity were identified as risk factors of a nonreversal ileostomy. These factors should be considered when drafting prudential guidelines for ileostomy closure.

New progress in the surgical treatment of low rectal cancer / 国际外科学杂志

Rectal cancer is one of the common malignant tumors in China,and the incidence rate is rising year by year.Comprehensive treatment based on surgical operation is the major treatment of low rectal cancer.The treatment concept requires not only radical resection of tumor,but also preservation of the anal and urogenital function,to improve the quality of patients' life.By improving the accuracy of preoperative staging of rectal cancer,neoadjuvant therapy,and following the principle of total mesorectal excision,patients can benefit in terms of increased resection rate,decreased operation complication incidence,increased sphincter preservation,decreased local recurrence and increased overall survival rate.With the development of medical technology,minimally invasive surgery of low rectal cancer has been developed rapidly.In this paper,new progress in the surgical treatment of low rectal cancer will be reviewed.

Strategies of local recurrence after sphincter preserving surgery for low rectal cancer / 中国医师进修杂志

Objective To investigate the treatment of local recurrence after sphincter preserving surgery for low rectal cancer. Methods Fifty-six patients with local recurrence after sphincter preserving surgery for low rectal cancer were divided into three groups, 20 cases underwent radical resection (group A), 21 cases underwent palliative resection combined with 3 dimensional conformal radiation therapy (group B), and 15 cases only received 3 dimensional conformal radiation therapy (group C). Results All the patients were followed up from 6 months to 3 years. The 1-year,2-year and 3-year survival rates were 100.0%(20/20),80.0% (16/20),65.0% (13/20) in group A,90.5% (19/21),52.4% (11/21),33.3% (7/21) in group B and 80.0%(12/15),40.0%(6/15),20.0%(3/15) in group C respectively. Both 2-year and 3-year survival rates in group A were significantly higher than those in group B and group C (P <0.05). Conclusions The first choice of patients with local recurrence after sphincter preserving surgery for low rectal cancer is radical resection. Palliative resection combined with 3 dimensional conformal radiation therapy is the second choice.

Function of Contour in the sphincter-preserving surgery in low rectal cancer / 中国综合临床

Objective To study the function of Contour stapler in the sphincter-preserving surgery in 121 cases with low rectal cancer. Methods One hundred and twenty-one cases enrolled were divided into 2 groups randomly and accepted Contour or other kinds of staplers after operation respectively. Further comparison were performed on the rate of sphincter-preserving,anastomosis stricture and leakage,infection of incision and stool frequency between two groups. Results We found no significant differences in the comparison of rate of anastomosis stricture or leakage,stool frequency,but the Contour group had significant higher rate of sphincter-preserving (98. 3%)than other stapler group(68. 9%),and lower rate of infection of incision(3.94%)than control(11.9%)(P ＜0. 05 respectively). Conclusions It is secure,reliable and practical to use Contour stapler in operation on low rectal cancer,which can increase the opportunity of sphincter-preserving,decrease the the rate of infection of incision.

Clinical analysis of laparoscopy-assisted sphincter-preserving surgery for low rectal cancer with 18 cases attached / 重庆医科大学学报

Objective:To explore the application and clinical effects of laparoscopy-assisted sphincter-preserving surgery for low rectal cancer. Methods:Following total mesorectum excision,ultra-low colon-anus anastomosis was performedin 18 cases with low rectal cancer by using laparoscopy and disposable circular stapler,then from 6-month to 12-month follow-up was did.The clinical data on intaoperative blood loss,residual tumour at the resection margin,postoperation defecation function,operative complications and local recurrence rate were analyzed retrospectively. Results:The mean blood loss was 86 ml in all cases,none of these cases suffered from residual tumour at the resection margin,fecal incontinence,anastomotic leakage,operative death and local recurrence. Conclusion:Based on the principle of radical resection, laparoscopy-assisted sphincter-preserving surgery for low rectal cancer is charactered with less bleeding,can preserve anus defecate function and improve quality of life in cases with low rectal cancer.

Sphincter-preserving Surgery for Rectal Cancer / 대한소화기학회지

Although optimal treatment of tumors at mid and distal rectum continues to be a matter of great debate to oncologic surgeons, a surgical goal of sphincter preservation should be considered in all patients with an intact sphincter. There are growing evidences and indications that sphincter-preserving procedure might be a valid alternative to conventional modality in tumors of the mid or lower rectum. Traditionally, an abdominoperineal resection with permanent colostomy would be the sole surgical option. Recently, a variety of sphincter-preserving procedures are performed in majority of distal rectal cancers with acceptable oncologic and optimal functional results. Several recent advances may further influence future treatment strategies and many issues are, at present, under evaluation. Here, some of the most relevant topics regarding current methods of sphincter-preserving procedures with their oncologic and functional results are discussed to establish the guideline of surgical treatment in rectal cancer.

Management of anastomotic leakage after sphincter preserving surgery for rectal cancer / 中国现代普通外科进展

Objective:To explore the risk factors,diagnosis,treatment and management of anastomotic leakage after radical resection for rectal cancer and preservation of anal sphincter.Methods:The clinical data of 220 rectal cancer patients,undergone sphincter preserving surgery from 2003 to 2008,was analyzed retrospectively.Results:The incidence of anastomotic leakage among the 220 rectal cancer patients was 7.3%(16 patients).14 cases of anastomotic leakage were healed by conservative therapy.The treatment included nutritional support,catheter drainage of abscesses and the use of antibiotics.The other 2 patients were healed by secondary operation.Conclusions:Age,general condition,anastomotic location,operative technique and bowel preparation are the risk factors for the development of anastomotic leakage.Early diagnosis and effective treatment are the crucial to heal anastomotic leakage.

Clinical analysis of ano-saving surgery in low rectal carcinoma / 中国普通外科杂志

ObjectiveTo evaluate the indication, the operation pattern and therapeutic effect of the ano-saving surgery in low rectal carcinoma. MethodsAccording to anorectal finger-examination, IRUS,and CT, 94 out the 161 rectal cancer patients were selected to have ano-saving surgery from August 1993 to December 1994.Excreting function, 5-year survival rate and local recurrence rate of the various operation were compared. ResultsThe perfomed rate of ano-saving operation in low rectal cancer was 58.4%. Among them, low anastomosis was done in 6 cases, ultra-low anastomosis in 48 cases,Park′s operation in 25 cases,and Bacon operation in15 . The death rate was 2.1%(2 cases).Incidence of anastomotic leakage after the surgery was 3.2%(3 cases), and only 13 cases had anastomotic narrowing(13.8%) within 1 year. The successful rates of excreting function after the surgery were respectively as follows: low anastomosis 100%, ultra-low anastomosis 97.9%,Park′s surgery 88.0%,and Bacon surgery 53.3%. The 5 year survival rates and the local recurrence rates were respectively,as follows: low anastomosis 83.3% and 0; ultra-low anastomosis 79.2% and 4.2%; Park′s 64.0% and 12.0%; and Bacon 66.7% and 13.3%,respectively. ConclusionsUltra-low colo rectum anastomosis becomes the main operative pattern to preserve anal sphincter in low rectal cancer.There is no difference in the 5-year survival rate and the excreting function among low, ultra-low anastomosis and Park′s operation, but the low and ultra-low colo-rectum anastomosis were obviously better than that of Bacon and Miles operation.The local recurrence rates of low and ultra-low colon-rectum anastomosis are lower than that of Miles′.There is no difference in the 5-year survival rate and local recurrence rate between Park′s, Bacon and Miles operation.