Risk factors for anastomotic leakage after laparoscopic intersphincteric resection for low-lying rectal cancer / 中华普通外科杂志

Objective To investigate the risk factors for anastomotic leakage (AL) after laparoscopic intersphincteric resection (Lap-ISR) for patients with low-lying rectal cancer.Methods This retrospective study was conducted in the Characteristic Medical Center of PLA Rocket Force from Jun 2011 to Nov 2018.151 patients undergoing Lap-ISR were enrolled for this study.Results All patients in this series had a defunctioning ileostomy.The overall leakage rate was 17.2％ (26/151),including peri-operative AL (n =20) and delayed AL (n =6).In accordance with the grading system of the International Study Group of Rectal Cancer,there were 24 patients (15.9％) with AL Grade B (requiring active therapeutic intervention) and two patients (1.3％) with AL Grade C (requiring re-laparotomy).Univariate analysis showed that BMI (≥ 25 kg/m2),tumor annularity (≥ 3/4) and operation time (≥ 240 min) were associated with AL (P ＜ 0.05).Multivariate analysis showed that operation time (≥ 240 min,OR =7.390,95％ CI:2.483-21.988,P =0.000),tumor annularity (≥ 3/4,OR =6.233,95％ CI:1.932-20.107,P=0.002) and higher BMI (≥ 25 kg/m2,OR=3.523,95％ CI:1.275-9.738,P=0.015)were independently predictive of AL Conclusion Tumor annularity,operation time and higher BMI are independently associated with symptomatic AL after Lap-ISR.

Risk factors of coloanal anastomotic stricture after laparoscopic intersphincteric resection for low rectal cancer / 中华胃肠外科杂志

Objective@#To evaluate the risk factors of coloanal anastomotic stricture after laparoscopic intersphincteric resection (Lap-ISR) for patients with low rectal cancer.@*Methods@#A retrospective case-control study was performed to collect clinicopathological data from a prospective database (registration number: ChiCTR-ONC-15007506) at the Department of Colorectal Surgery, the Characteristic Medical center of PLA Rocket Force. From June 2011 to August 2018, a total of 144 consecutive patients with low rectal cancer who underwent Lap-ISR were enrolled in the study. Inclusion criteria: (1) reconstruction of digestive tract by end-to-end hand-made coloanal anastomosis (HCAA); (2) distance from lower tumor margin to anorected sphincter ring < 1 cm and distance from lower tumor margin to intersphincteric groove ≥ 1 cm; (3) T1-3 stage tumor with expected negative circumferential resection margin evaluated by preoperative MRI or 3D endoanal ultrasound; (4) rectal cancer confirmed as well- or moderately-differentiated adenocarcinoma; (5) preoperative Wexner incontinence score >10 points. Exclusion criteria: (1) follow-up period less than 3 months; (2) multiple primary cancers; (3) undergoing colonic J-pouch, coloplasty or reconstruction of end-to-side coloanal anastomosis; (4) death within perioperative period (within 3 months after surgery). Coloanal anastomotic stricture was diagnosed if the index finger or 12 mm electronic colonoscope had obvious resistance through the anastomosis or new rectum, or could not pass, accompanied by clinical symptoms such as difficult defecation and anal incontinence. Degree of anastomotic stricture was divided into 3 grades: grade A required anal enlargement, laxative or enema to assist defecation without active surgical treatment; grade B required surgery or endoscopic intervention; grade C required definitive ostomy, including unreducible preventive ileostomy or permanent colostomy. Univariate and multivariate analysis were used to evaluate the effects of 28 variables, including baseline data (age, gender, body mass index, neoadjuvant therapy, etc.), tumor-related factors (distance between tumor low margin and anal edge, maximum diameter of tumor, TNM staging, etc.), surgery-related factors (operation time, intraoperative blood loss, ISR procedure, anastomotic height, etc.) and anastomotic leakage, on the postoperative coloanal anastomotic stricture. Univariate analysis used χ2 test or Fisher′s exact test, then factors with P<0.05 were further included in multivariate analysis using logistic regression.@*Results@#A total of 144 patients were enrolled in the study, including 90 males and 54 females with a median age of 59 years and median BMI of 24.88 kg/m2. R0 resection rate was 96.5% (139/144). Median tumor distal resection margin was 1.5 (0.5 to 3.0) cm. Median follow-up was 31.5 (4 to 86) months. Coloanal anastomotic stricture was observed in 19 patients (13.2%), including 3 cases (2.1%) of grade A, 9 cases (6.2%) of grade B, and 7 cases (4.9%) of grade C. The median interval from the initial surgery to diagnosis of anastomotic stricture was 7 (1 to 31) months. Univariate analysis showed that male (χ2=6.795, P=0.009), radiotherapy (χ2=13.330, P=0.001), operation type of ISR (χ2=7.996, P=0.013), and anastomotic leakage (χ2=10.198, P=0.004) were associated with the postoperative coloanal anastomotic stricture. Multivariate analysis further indicated that male (OR=5.975, 95% CI: 1.209-29.534, P=0.028), postoperative radiotherapy (OR=8.748, 95% CI: 2.397-31.929, P=0.001), and anastomotic leakage (OR=6.313, 95% CI: 1.834-21.734, P=0.003) were independent risk factor of postoperative coloanal anastomotic stricture.@*Conclusion@#For male patients, or patients with postoperative radiotherapy or anastomotic leakage, close follow-up should be carried out to prevent postoperative coloanal anastomotic stricture following Lap-ISR.

Long-term efficacy of stapled transanal rectal resection for obstructed defecation syndrome / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the long-term efficacy of stapled transanal rectal resection (STARR) in treating obstructed defecation syndrome(ODS).</p><p><b>METHODS</b>Clinical data of 95 female patients with ODS undergoing STARR at Department of Colorectal Surgery, Rocket Army General Hospital from February 2010 to August 2012 were analyzed retrospectively. The Cleveland constipation scoring system (CSS), Longo ODS scoring system and severe symptoms score(SSS) were used to evaluate the degree and intensity of clinical symptoms. Patient satisfaction was assessed by visual analogue scale (VAS). Clinical symptoms at postoperative 12-month were defined as short-term efficacy, and at the end of follow up (≥48 months) were defined as long-term efficacy.</p><p><b>RESULTS</b>The mean age was 54.5 (29 to 79) years and the median follow-up was 65 (48 to 78) months. Eighty (84.2%) and 44 (46.3%) patients completed the short-term and long-term efficacy evaluation respectively. At the end of follow up, compared with the baseline levels before operation, the CSS score (14.69 vs. 6.02), ODS score (16.51 vs. 5.73) and SSS score (14.64 vs. 5.14) were significantly decreased (all P<0.01), but the VAS score (3.96 vs. 7.20, P<0.01) was significantly increased. A total of 10 patients (22.7%) developed symptomatic recurrence. The self-reported definitive satisfaction was excellent in 10 (22.7%) patients, fairly good in 17(38.6%), good in 9(20.5%), and poor in 8(18.2%). The total effective rate was 81.8%(36/44).</p><p><b>CONCLUSION</b>Long-term efficacy of STARR in the treatment of ODS is good, but the rate of symptomatic recurrence is relatively high.</p>

Treatment of complications after laparoscopic intersphincteric resection for low rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize the perioperative and postoperative complications follow laparoscopic intersphincteric resection (LapISR) in the treatment of low rectal cancer and their management.</p><p><b>METHODS</b>An observational study was conducted in 73 consecutive patients who underwent LapISR for low rectal cancer between June 2011 and February 2016 in our hospital. The clinicopathological parameters, perioperative and postoperative complications, and clinical outcomes were collected from a prospectively maintained database. Perioperative and postoperative complications were defined as any complication occurring within or more than 3 months after the primary operation, respectively.</p><p><b>RESULTS</b>Forty-nine(67.1%) cases were male and 24(32.9%) were female with a median age of 61(25 to 79) years. The median distance from distal tumor margin to anal verge was 4.0(1.0 to 5.5) cm. The median operative time was 195 (120 to 360) min, median intra operative blood loss was 100 (20 to 300) ml, median number of harvested lymph nodes was 14(3 to 31) per case. All the patients underwent preventive terminal ileum loop stoma. No conversion or hospital mortality was presented. The R0 resection rate was 98.6% with totally negative distal resection margin. A total of 34 complication episodes were recorded in 21(28.8%) patients during perioperative period, and among which 20.6%(7/34) was grade III(-IIII( according to Dindo system. Anastomosis-associated morbidity (16.4%,12/73) was the most common after LapISR, including mucosa ischemia in 9 cases(12.3%), stricture in 7 cases (9.6%, 4 cases secondary to mucosa necrosis receiving anal dilation), grade A fistula in 3 cases (4.1%) receiving conservative treatment and necrosis in 1 case (1.4%) receiving permanent stoma. After a median follow up of 21(3 to 60) months, postoperative complications were recorded in 12 patients (16.4%) with 16 episodes, including anastomotic stenosis (8.2%), rectum segmental stricture (5.5%), ileus (2.7%), partial anastomotic dehiscence (1.4%), anastomotic fistula (1.4%), rectovaginal fistula (1.4%) and mucosal prolapse (1.4%). These patients received corresponding treatments, such as endoscopic transanal resection, anal dilation, enema, purgative, permanent stoma, etc. according to the lesions. Six patients (8.2%) required re-operation intervention due to postoperative complications.</p><p><b>CONCLUSION</b>Anastomosis-associated morbidity is the most common after LapISR in the treatment of low rectal cancer in perioperative and postoperative periods, which must be strictly managed with suitable methods.</p>

Comparison of oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection for low rectal cancers / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the oncology outcomes and anal function among laparoscopic partial, subtotal and total intersphincteric resection(ISR) for low rectal cancers.</p><p><b>METHODS</b>From June 2011 to February 2016, a total of 79 consecutive patients with low rectal cancers underwent laparoscopic ISR with hand-sewn coloanal anastomosis at our department. According to the distal tumor margin, partial ISR (internal sphincter resection at the dentate line) was used to treat tumors with distance <1 cm from the anal sphincter (n=28), subtotal ISR was adopted for the tumors locating between the dentate line and intersphincteric groove (n=34), and total ISR (resection at the dentate line) was applied in the treatment of intra-anal tumors (n=17). Anal function was evaluated by a standardized gastrointestinal questionnaire, Wexner incontinence score and Kirwan's classification. Metaphase oncological results and postoperative anal function were compared among three groups, and.</p><p><b>RESULTS</b>Other than the distance of tumor low margin to dentate line (P=0.000) and serum CEA level (P=0.040), no significant differences were noted in baseline data among 3 groups (all P>0.05). The median follow up was 21(8-61) months. The 3-year disease-free survival rates in laparoscopic partial, subtotal and total ISR groups were 91.1%, 88.9%, 88.2% (P=0.901) and the 3-year local relapse-free survival rates were 91.1%, 72.9%, 80.2%(P=0.658), whose all differences were not significant. Thirty-eight patients who did not receive neoadjuvant chemoradiotherapy and underwent ileostomy closure for at least 24 months completed the evaluation of anal function, including 14 cases in partial group, 15 cases in subtotal group and 9 cases in total group. Of 38 patients, 73.7%(28/38) was classified as good function (Wexner incontinence score ≤10) and no patient adopted a colostomy because of severe fecal incontinence(Kirwan classification=grade 5). Furthermore, there were no significant differences in Wexner incontinence score and Kirwan classification among 3 groups (all P>0.05). However, patients with chronic anastomotic stoma stenosis showed worse anal function than those without stenosis [Wexner incontinence score: 18(9-20) vs 6(0-18), P=0.000; Kirwan grading: 3(2-4) vs. 2(1-4), P=0.002].</p><p><b>CONCLUSIONS</b>As the ultimate sphincter-saving technique, laparoscopic ISR can result in better oncologic outcomes and better anal function for patients with low rectal cancers. The different procedures of ISR may not affect the efficacy, but chronic anastomotic stoma stenosis deteriorates incontinence status.</p>

Comparison of the short-term efficacies of laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy in the treatment of obesity combined with type 2 diabetes mellitus / 中华消化外科杂志

Objective To compare the short-term efficacies of laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) in the treatment of obesity and type 2 diabetes mellitus,and to investigate the relationship between the body weight loss and the decrease of glucose of the 2 treatment methods.Methods The clinical data of 40 patients with obesity combined with type 2 diabetes mellitus who were admitted to the Changhai Hospital of the Second Military Medical University from January 2010 to December 2011 were retrospectively analyzed.There were 14 patients treated by LAGB (LAGB group) and 26 by LSG (LSG group).The body weight loss and the decrease of glucose at postoperative year 1 of the 2 groups were compared.The differences in the body weight and glucose before and after operation within groups were compared using the paired t test,and the differences in the body weight and glucose between the 2 groups were compared using the multiple analysis of variance.The correlation between the body weight loss and the decrease of glucose was analyzed using the linear regression analysis.Results Laparoscopic surgery was successfully done without conversion to open surgery or intraoperative complications.The operation time and volume of blood loss were (69 ± 16)minutes and (31 ± 14)mL in the LAGB group,(120 ± 15) minutes and (148 ± 48) mL in the LSG group.Complications including postoperative malnutrition,electrolyte disturbance,delayed gastric emptying,bleeding,anastomotic leakage did not occurr in the 2 groups.Two patients were complicated with abdominal incision fat liquefaction,and were cured by symptomatic treatment.(1) The body weight,body mass index (BMI) and waistline had a decrease trend.The body weight,BMI and waistline in the LAGB group were decreased from (117 ± 28)kg,(40 ± 8)kg/m2 and (118 ± 15) cm before operation to (94 ± 28) kg,(33 ± 8) kg/m2 and (92 ± 15) cm at postoperative week 48.The body weight,BMI and waistline in the LSG group were decreased from (119 ± 25)kg,(42 ± 6)kg/m2 and (123 ± 14)cm before operation to (74± 16)kg,(26± 4)kg/m2 and (86 ± 13)cm at postoperative week 48.The EWL had an increase trend in the 2 groups.The EWL in the LAGB group was increased from 7％ ± 2％ at postoperative week 1 to 53％± 24％ at postoperative week 48,and the EWL in the LSG group was increased from 11％ ± 4％ at postoperative week 1 to 90％ ± 20％ at postoperative week 48.There were significant differences in the changes of body weight,BMI,waistline and EWL between the 2 groups (F =60.660,74.490,57.650,90.020,P ＜ 0.05).(2) The levels of glycosylated hemoglobin,fasting glucose,fasting insulin,HOMA-IR,triglyceride,total cholesterol,low-density lipoprotein and high density lipoprotein in the LAGB group were decreased from 8.1％± 0.8％,(8.4±0.6)mmol/L,(21±8)μmol/L,7.9 ±2.9,(1.68±0.50)mmol/L,(6.0±1.1)mmol/L (4.1 ± 0.8) mmol/L,(1.09 ±0.15)mmol/L to 6.4％ ±0.8％,(6.3 ±0.3) mmol/L,(10 ± 3) μmol/L,2.7 ±0.9,(1.04 ± 0.09) mmol/L,(4.3 ± 0.8) mmol/L,(2.3 ± 0.4) mmol/L,(1.22 ± 0.09) mmol/L at postoperative week 48 ; the levels of glycosylated hemoglobin,fasting glucose,fasting insulin,HOMA-IR,triglyceride,total cholesterol,low-density lipoprotein and high density lipoprotein in the LSG group were changed from 7.9％ ± 1.0％,(9.0±1.0)mmol/L,(21 ±9) μ mol/L,8.5 ±3.5,(2.09 ± 0.70) mmol/L,(6.0 ± 1.2)mmol/L,(3.9 ± 1.1) mmol/L,(1.06 ± 0.21) mmol/L before operation to 5.1％ ± 0.8％,(5.2 ± 0.4) mmol/L,(4 ± 1)μmol/L,0.9±0.2,(1.22±0.17)mmol/L,(4.2±0.8)mmol/L,(2.3 ±0.6)mmol/L,(1.30±0.13)mmol/L at postoperative week 48.There was a decrease trend of the glycosylated hemoglobin,fasting glucose,fasting insulin,HOMA-IR,trigluceride,total cholesterol and low density lipoprotein and a increase trend of the high density lipoprotein in the 2 groups.There were significant differences in the levels of glycosylated hemoglobin,fasting glucose,fasting insulin,HOMA-IR,triglyceride,total cholesterol,low-density lipoprotein and high density lipoprotein between the 2 groups (F =57.650,74.270,36.750,42.960,10.870,30.650,32.560,11.490,P ＜0.05).The levels of glucose of the LAGB group at postoperative month 1 and 3 were influenced by BMI (b =0.543,0.753,P ＜ 0.05),while the levels of glucose of the LAGB group did not be influenced by BMI at postoperative month 6 and year 1 (b =0.130,0.222,P ＞0.05).The levels of glucose of the LSG group did not be influenced by BMI at postoperative month 1,3,6 and year 1 (b =0.185,0.035,0.212,0.126,P ＞0.05).Conclusions The efficacy of LSG is superior to LAGB for the treatment of obesity combined with type 2 diabetes mellitus.The efficacy of LAGB is correlated with the change of body weight,while the efficacy of LSG does not correlated with the change of body weight.

Efficacy analysis of laparoscopic sleeve gastrectomy in treatment of obesity with type 2 diabetes mellitus / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the efficacy and safety of laparoscopic sleeve gastrectomy(LSG) for the treatment of obesity with type 2 diabetes mellitus(T2DM).</p><p><b>METHODS</b>Clinical data of 32 obesity patients with T2DM patients undergoing LSG from May 2010 to February 2012 in our department were retrospectively analyzed. Their body weight indexes (body weight, waist circumference, BMI, EWL), blood glucose indexes [glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), insulin resistance index (HOMA-IR)], and blood lipid indexes [total cholesterol, triglyceride, low density lipoprotein cholesterol(LDL-C), high density lipoprotein cholesterol(HDL-C)] were measured 1, 3, 6, 12 months after operation and compared with preoperative levels. Improvement in complications was observed.</p><p><b>RESULTS</b>All the patients completed operation under laparoscopy except 1 case because of abdominal cavity adhesion. The average operative time was (115.0±19.6) min, and the average blood loss (69.0±29.7) ml. No operative death, anastomotic leakage, or surgical site infection were found. The body weight, waist circumference and BMI at 1, 3, 6, and 12 months after surgery were significantly lower(all P<0.05) showing a decreasing trend over time. EWL showed significant increasing trend (P<0.05). During 12 months of follow-up, no over-low weight was observed. From 1 month after surgery, HbA1c, FPG and HOMA-IR decreased significantly (P<0.05). HbA1c and FPG maintained stable level at 12 and 6 months after operation respectively. FPG of 28 patients returned to normal 3 months after operation. Clinical complete remission rate of T2DM was 87.5%(28/32), and clinical partial remission rate was 12.5%(4/32) at the 12-month follow-up. Serum total cholesterol, triglyceride and LDL-C decreased obviously after surgery(P<0.05).</p><p><b>CONCLUSION</b>LSG procedure is a safe and effective surgical method in treatment of obesity with T2DM.</p>