Influencing factors of refractory anastomotic stenosis after laparoscopic intersphincteric resec-tion for rectal cancer and construction of nomogram prediction model / 中华消化外科杂志

Objective:To investigate the influencing factors of refractory anastomotic stenosis after laparoscopic intersphincteric resection (Ls-ISR) for rectal cancer and construction of nomogram prediction model.Methods:The retrospective case-control study was conducted. The clinicopatho-logical data of 495 patients who underwent Ls-ISR for rectal cancer in two medical centers, including 448 patients in Peking University First Hospital and 47 patients in Cancer Hospital Chinese Academy of Medical Sciences, from June 2012 to December 2021 were collected. There were 311 males and 184 females, aged 61 (range, 20-84)years. Observation indicators: (1) incidence of anastomotic stenosis; (2) influencing factors of refractory anastomotic stenosis after Ls-ISR; (3) construction and evaluation of nomogram prediction model for refractory anastomotic stenosis after Ls-ISR. Follow-up was conducted using outpatient examination and telephone interview to detect the incidence of postoperative anastomotic leakage and anastomotic stenosis up to August 2022. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Univariate and multivariate analyses were conducted using the Logistic regression model. Factors with P<0.10 in univariate analysis were included in multivariate analysis. The R software (3.6.3 version) was used to construct nomogram prediction model. The receiver operating characteristic (ROC) curve was drawn and the area under curve (AUC) was used to evaluate the efficacy of nomogram prediction model. Results:(1) Incidence of anastomotic stenosis. All 495 patients underwent Ls-ISR successfully, without conversion to laparotomy, and all patients were followed up for 47(range, 8-116)months. During the follow-up period, there were 458 patients without anas-tomotic stenosis, and 37 patients with anastomotic stenosis. Of the 37 patients, there were 15 cases with grade A anastomotic stenosis, 3 cases with grade B anastomotic stenosis and 19 cases with grade C anastomotic stenosis, including 22 cases being identified as the refractory anastomotic stenosis. Fifteen patients with grade A anastomotic stenosis were relieved after anal dilation treat-ment. Three patients with grade B anastomotic stenosis were improved after balloon dilation and endoscopic treatment. Nineteen patients with grade C anastomotic stenosis underwent permanent stoma. During the follow-up period, there were 42 cases with anastomotic leakage including 17 cases combined with refractory anastomotic stenosis, and 453 cases without anastomotic leakage including 5 cases with refractory anastomotic stenosis. There was a significant difference in the refractory anastomotic stenosis between patients with and without anastomotic leakage ( χ2=131.181, P<0.05). (2) Influencing factors of refractory anastomotic stenosis after Ls-ISR. Results of multivariate analysis showed that neoadjuvant therapy, distance from tumor to anal margin ≤4 cm, clinic N+ stage were independent risk factors of refractory anastomotic stenosis after Ls-ISR ( hazard ratio=7.297, 3.898, 2.672, 95% confidence interval as 2.870-18.550, 1.050-14.465, 1.064-6.712, P<0.05). (3) Construction and evaluation of nomogram prediction model for refractory anastomotic stenosis after Ls-ISR. Based on the results of multivariate analysis, neoadjuvant therapy, distance from tumor to anal margin and clinic N staging were included to constructed the nomogram prediction model for refractory anastomotic stenosis after Ls-ISR. Results of ROC curve showed the AUC of nomogram prediction model for refractory anastomotic stenosis after Ls-ISR was 0.739 (95% confidence interval as 0.646-0.833). Conclusions:Neoadjuvant therapy, distance from tumor to anal margin ≤4 cm, clinic N+ stage are independent risk factors of refractory anastomotic stenosis after Ls-ISR. Nomogram prediction model based on these factors can predict the incidence of refractory anastomotic stenosis after Ls-ISR.

Clinical efficacy of radical resection of rectal cancer with different surgical approaches and analysis of influencing factors of postoperative complications: a report of 3 418 cases / 中华消化外科杂志

Objective:To investigate the clinical efficacy of radical resection of rectal cancer with different surgical approaches and influencing factors of postoperative complications.Methods:The retrospective study was conducted. The clinicopathological data of 3 418 patients who underwent radical resection of rectal cancer in the Second Affiliated Hospital of Harbin Medical University from July 2011 to September 2020 were collected. There were 2 060 males and 1 358 females, aged (61±11)years. Patients meeting the requirements of radical resection and surgical indications underwent surgeries choosing from open radical colorectal cancer surgery, laparoscopic radical colorectal cancer surgery, and natural orifice specimen extraction surgery (NOSES). Observation indicators: (1) intraoperative and postoperative conditions of patients undergoing different surgical approaches; (2) comparison of preoperative clinical characteristics in patients undergoing different surgical approaches; (3) comparison of postoperative histopathological characteristics in patients undergoing different surgical approaches; (4) postoperative complications of patients undergoing different surgical approaches; (5) analysis of influencing factors of postoperative complications. Measurement data with normal distribution were represented as Mean± SD. Measurement data with skewed distribution were represented as M(range), and comparisons between groups was analyzed using the Kruskal-Wallis rank test. Comparison of ordinal data was analyzed using the non-parameter rank sum test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Multivariate analysis was conducted using the Logistic regression model. Results:(1) Intraoperative and postoperative conditions of patients undergoing different surgical approaches. Of the 3 418 patients, 1 978 cases underwent open radical colorectal cancer sur-gery, 1 028 cases underwent laparoscopic radical colorectal cancer surgery and 412 cases underwent NOSES, respectively. The operation time, volume of intraoperative blood loss, cases with permanent stoma, preventive stoma or without fistula, time to postoperative first flatus, time to postoperative liquid food intake, cases transferred to intensive care unit after surgery, duration of postoperative hospital stay were 145(range, 55?460)minutes, 100(range, 30?1 000)mL, 435, 88, 1 455, 72(range, 10?220)hours, 96(range, 16?296)hours, 158, 10(range, 6?60)days, respectively, in patients undergoing open radical colorectal cancer surgery. The above indicators were 175(range, 80?450)minutes, 50(range, 10?800)mL, 172, 112, 744, 48(range, 14?120)hours, 72(range, 38?140)hours, 17, 9(range, 4?40)days, respectively, in patients undergoing laparoscopic radical colorectal cancer surgery and 180(range, 80?400)minutes, 30(range, 5?500)mL, 0, 45, 367, 48 (range, 14?144)hours, 72(range, 15?148)hours, 1, 6(range, 3?30)days, respectively, in patients undergoing NOSES. There were significant differences in the above indicators among the patients undergoing different surgical approaches ( H=291.38, 518.56, χ2=153.82, H=408.86, 282.97, χ2=78.66, H=332.30, P<0.05). (2) Com-parison of preoperative clinical characteristics in patients undergoing different surgical approaches. The gender, age, body mass index, cases with diabetes, cases with hypertension, cases with coronary heart disease, cases with anemia, cases with hypoproteinemia, cases with intestinal obstruction, tumor location, preoperative carcinoembryonic antigen, preoperative CA19-9 showed significant differences among patients undergoing open radical colorectal cancer surgery, laparoscopic radical colorectal cancer surgery and NOSES ( P<0.05). (3) Comparison of postoperative histopathological characteris-tics in patients undergoing different surgical approaches. Tumor histological type, tumor differentiation degree, tumor diameter, number of lymph node detected, nerve invasion, vascular invasion, lymph node invasion, tumor T staging, tumor N staging, tumor M staging, tumor TNM staging showed significant differences among patients undergoing open radical colorectal cancer surgery, laparos-copic radical colorectal cancer surgery and NOSES ( P<0.05). (4) Postoperative complications of patients undergoing different surgical approaches. Cases with postoperative complications as anastomotic leakage, abdominal infection, intestinal obstruction, anastomotic bleeding, incision complications, pulmonary infection, other complications were 52, 21, 309, 8, 130, 51, 59, respectively, in patients undergoing open radical colorectal cancer surgery. The above indicators were 33, 17, 75, 3, 45, 58, 9, respectively, in patients undergoing laparoscopic radical colorectal cancer surgery and 13, 4, 8, 0, 11, 10, 15, respectively, in patients undergoing NOSES. There were significant differences in the intes-tinal obstruction, incision complications, pulmonary infection, other complications among patients undergoing different surgical approaches ( χ2=122.56, 13.33, 20.44, 15.59, P<0.05) and there was no significant difference in the anastomotic leakage, abdominal infection, anastomotic bleeding among patients undergoing different surgical approaches ( χ2=0.96, 2.21, 3.08, P>0.05). (5) Analysis of influencing factors of postoperative complications. ① Analysis of influencing factors of intestinal obstruction in patients with radical resection of rectal cancer. Age as 20?39 years and 40?59 years, surgical approach as laparoscopic radical colorectal cancer surgery and NOSES were independent protective factors of intestinal obstruction in patients with radical resection of rectal cancer ( odds ratio=0.46, 0.59, 0.43, 0.13, 95% confidence interval as 0.21?1.00, 0.36?0.96, 0.33?0.56, 0.06?0.27, P<0.05). ② Analysis of influencing factors of incision complications in patients with radical resection of rectal cancer. Body mass index as 24.0?26.9 kg/m 2, surgical approach as laparoscopic radical colorectal cancer surgery and NOSES were independent protective factors of incision complications in patients with radical resection of rectal cancer ( odds ratio=0.24, 0.63, 0.46, 95% confidence interval as 0.11?0.51, 0.44?0.89, 0.24?0.87, P<0.05). ③ Analysis of influencing factors of pulmonary infection in patients with radical resection of rectal cancer. The surgical approach as laparoscopic radical colorectal cancer surgery was an independent risk factor of pulmonary infection in patients with radical resection of rectal cancer ( odds ratio=2.15, 95% confidence interval as 1.46?3.18, P<0.05), and tumor TNM staging as 0?Ⅰ stage was an independent protective factor ( odds ratio=0.10, 95% confidence interval as 0.01?0.88, P<0.05). ④ Analysis of influencing factors of other complica-tions in patients with radical resection of rectal cancer. Age as 20?39 years, 40?59 years, 60?79 years, body mass index as <18.5 kg/m 2, 18.5?23.9 kg/m 2, 24.0?26.9 kg/m 2, 27.0?29.9 kg/m 2, surgical approach as laparoscopic radical colorectal cancer surgery were independent protective factors of other complications in patients with radical resection of rectal cancer ( odds ratio=0.10, 0.29, 0.37, 0.08, 0.22, 0.35, 0.32, 0.29, 95% confidence interval as 0.01?0.81, 0.13?0.64, 0.17?0.78, 0.02?0.40, 0.09?0.52, 0.15?0.83, 0.12?0.89, 0.14?0.59, P<0.05). Conclusions:Compared to laparoscopic radical colorectal cancer surgery and NOSES, open radical colorectal cancer surgery has wide indication and short operation time, but less perioperative treatment effect. Laparoscopic radical colorectal cancer surgery and NOSES can achieve better surgical result and less postoperative complication when patients meeting surgical indications.

Evolution of Colorectal Surgery: from Classic to Innovation / 肿瘤防治研究

Colorectal surgery originated in early civilizations, since then, its evolution follows a certain pattern. Most surgical techniques have their historical basis and have never been separated from social, technological, and conceptual progress. Given that the development of colorectal surgery and the development of surgical platforms and surgical concepts have mutually reinforced each other, this article collects historical information related to colorectal surgery and provides its historical review from the ancient Egyptian culture to modern civilization, taking into account the development of surgical platforms and concepts. The evolution of colorectal surgery is described as "for an understanding of the future, look to the past". For colorectal surgeons, in particular, a proper understanding of the evolution of colorectal surgery is the best way to understand its direction.

Progress of clinicopathological features, diagnosis and treatment and screening of early-onset colorectal cancer / 肿瘤研究与临床

The incidence of early-onset colorectal cancer is increasing year by year, and it occupies an important position in colorectal cancer. Most of the characteristics of patients with early-onset colorectal cancer are different from those with late-onset colorectal cancer, the patients are diagnosed in a late stage, and their pathological manifestations show a type of poor prognosis. At present, there is a lack of consensus and guideline for the diagnosis, treatment and screening of early-onset colorectal cancer. A full understanding of the characteristics of early-onset colorectal cancer helps to understand its pathogenesis and guide screening and treatment to reduce the incidence and mortality of colorectal cancer. This article reviews the clinicopathological characteristics, molecular pathological mechanisms, diagnosis and treatment, and prognosis of early-onset colorectal cancer, in order to provide references for elucidating its etiology and formulating scientific and standardized screening strategies.

Expression of glutathione peroxidases 4 in colon adenocarcinoma tissues and its relationship with clinicopathological features and prognosis of patients / 肿瘤研究与临床

Objective:To investigate the expression of glutathione peroxidases 4 (GPX4) in colon adenocarcinoma and its relationship with clinicopathological features and prognosis of patients.Methods:The data set of colon adenocarcinoma was obtained from The Cancer Genome Atlas (TCGA) database to analyze the expression of GPX4 in colon adenocarcinoma tissues and its predictive value for overall survival (OS). A total of 93 colon adenocarcinoma tissues and 87 adjacent mucosa tissues after operation from November 2009 to May 2010 provided by the National Human Genetic Resources Sharing Service Platform were selected. The expression of GPX4 protein was detected by using tissue chip immunohistochemistry. The relations between the expression of GPX4 protein and the clinicopathological features and OS of colon adenocarcinoma patients were analyzed. Cox proportional hazards regression model was used to analyze the factors affecting the prognosis. The nomogram for predicting OS rate was established and drawn.Results:The analysis of data from TCGA database showed that in 380 cases of colon adenocarcinoma, the expression of GPX4 in colon adenocarcinoma tissues were higher than that in the normal colonic mucosa tissues [the value of fragments per kilobase of exon per million fragments mapped (FPKM): 85.654 (20.351-356.237) vs. 56.230 (48.783-63.931)], and the difference was statistically significant ( Z = -6.150, P<0.05). The OS in GPX4 high-expression group (FPKM ≥83.614) were poorer than that in GPX4 low-expression group (FPKM < 83.614) (median OS time: 84.40 months vs. 94.03 months, 5-year OS rate: 58.6% vs. 72.7%), and the difference was statistically significant ( P<0.05). Tissue chip immunohistochemical staining results show that the high-expression rate of GPX4 protein in colon adenocarcinoma tissues was higher than that in adjacent normal tissues [38.0% (35/92) vs. 7.3% (6/82)], and the difference was statistically significant ( χ2 = 22.727, P<0.01); the high-expression rate of GPX4 protein in left colon adenocarcinoma tissues was higher than that in right colon adenocarcinoma tissues [47.2% (25/53) vs. 25.6% (10/39), and the difference was statistically significant ( χ2 = 4.42, P = 0.036); the 5-year OS rate of patients in GPX4 high-expression group was lower than that in GPX4 low-expression group (25.7% vs. 57.9%), and the difference was statistically significant ( χ2 = 9.051, P<0.05). Multivariate Cox proportional hazards regression model analysis showed that lymph node metastasis (stage N 1-N 3) ( HR = 2.241, 95% CI 1.242-4.046, P = 0.007) and high expression of GPX4 ( HR = 2.783, 95% CI 1.598-4.848, P<0.01) were independent factors affecting the poor prognosis of colon adenocarcinoma patients. The above factors were used to establish a nomogram for predicting the prognosis of patients with colon adenocarcinoma, the C index was 0.739, indicating that the nomogram had good predictive performance. Conclusion:The expression of GPX4 is up-regulated in colon adenocarcinoma tissues, and its high expression is related to the malignant biological behavior of the tumor and poor prognosis.

Risk factor analysis for perineal incision complications after abdominoperineal resection in elderly patients with rectal cancer / 中华肿瘤杂志

Objective@#To evaluate the risk factors of perineal incision complications after abdominal abdominoperineal resection (APR) in elderly patients with rectal cancer.@*Methods@#From January 2007 to September 2018, the clinical data of 72 elderly rectal cancer patients (age≥80 years) underwent abdominoperineal resection at Department of Colorectal Surgery, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were collected and retrospectively analyzed. Univariate and multivariate analyses were performed to determine the risk factors of perineal incision complications in elderly patients with rectal cancer after APR.@*Results@#Of the 76 patients, 47 were male and 25 were female, with an average age of (81.8±1.8) years. The incidence of postoperative perineal incision complications was 23.6% (17/72), including 5 cases of wound infection, 4 cases of incision fat liquefaction, and 8 cases of delayed wound healing. All of the patients were well recovered and discharged without death. The result of univariate analysis showed that, the occurrence of perineal incision complications was associated with serum albumin level < 35g/L (χ2=4.860, P=0.027), intraperitoneal chemotherapy with fluorouracil sustained release/lobaplatin rinse (χ2=8.827, P=0.003), pelvic restoration (χ2=9.062, P=0.003), diabetes (χ2=6.387, P=0.011) and coronary heart disease (χ2=7.688, P=0.006). Multivariable logistic regression analysis showed that the intraoperative pelvic restoration (OR=0.17, 95% CI: 0.04~0.82, P=0.027) and diabetes (OR=4.32, 95% CI: 1.05~17.81, P=0.043) were independent risk factors for perineal incision complications.@*Conclusions@#Elderly patients with rectal cancer who undergo APR should preserve and restore the pelvic peritoneum as much as possible. Moreover, perioperative blood glucose monitoring is a powerful guarantee for preventing complications of perineal incision.

Molecular mechanisms of cetuximab resistance in metastatic colorectal cancer / 国际肿瘤学杂志

Cetuximab has become an important molecular targeted drug for the treatment of metastatic colorectal cancer (mCRC), which increases the curative effect of chemotherapy and prolongs the survival time. However, some patients develop insensitiveness or resistance to cetuximab, while the complicated molecular mechanisms are not quite clear. With the deep research in epidermal growth factor receptor (EGFR) signaling pathway, the genetic alteration of KRAS, BRAF, PTEN and PIK3CA and polymorphism of microRNA (miRNA) have been proved to associated with cetuximab resistance. Wnt signaling pathway with its negative regulator RNF43 is also considered to be related with cetuximab resistance in recent studies. The review of the progress on molecular mechanisms of cetuximab resistance in mCRC can establish theoretical basis for finding out reasonable drugs to overcome the resistance.

Current Status of “Watch-and-Wait” Rectal Cancer Treatment in Asia-Pacific Countries

Purpose@#Current acceptance of the watch-and-wait (W&W) approach by surgeons in Asia-Pacific countries is unknown. An international survey was performed to determine status of the W&W approach on behalf of the Asia-Pacific Federation of Coloproctology (APFCP). @*Methods@#Surgeons in the APFCP completed an Institutional Review Board-approved anonymous e-survey and/or printed letters (for China) containing 19 questions regarding nonsurgical close observation in patients who achieved clinical complete response (cCR) to neoadjuvant chemoradiotherapy (nCRT). @*Results@#Of the 417 responses, 80.8% (n = 337) supported the W&W approach and 65.5% (n = 273) treated patients who achieved cCR after nCRT. Importantly, 78% of participants (n = 326) preferred a selective W&W approach in patients with old age and medical comorbidities who achieved cCR. In regard to restaging methods after nCRT, the majority of respondents based their decision to use W&W on a combination of magnetic resonance imaging results (94.5%, n = 394) with other test results. For interval between nCRT completion and tumor response assessment, most participants used 8 weeks (n = 154, 36.9%), followed by 6 weeks (n = 127, 30.5%) and 4 weeks (n = 102, 24.5%). In response to the question of how often responders followed-up after W&W, the predominant period was every 3 months (209 participants, 50.1%) followed by every 2 months (75 participants, 18.0%). If local regrowth was found during follow-up, most participants (79.9%, n = 333) recommended radical surgery as an initial management. @*Conclusion@#The W&W approach is supported by 80% of Asia-Pacific surgeons and is practiced at 65%, although heterogeneous hospital or society protocols are also observed. These results inform oncologists of future clinical study participation.

Effect of cardiovascular comorbidities on the perioperative period of patients with colorectal cancer aged over 80 years / 中国肿瘤临床

Objective: To investigate the effect of comorbid cardiovascular diseases on the perioperative period of colorectal cancer pa-tients aged over 80 years. Methods: Clinicopathological data of 313 elderly patients aged over 80 years who underwent radical surgery for colorectal cancer at Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, from January 2007 to December 2018 were retrospectively collected and analyzed. Propensity score matching was used for 1 : 1 matching of 10 covari-ates. Finally, 128 patients with comorbid cardiovascular diseases were matched with 128 patients without comorbid cardiovascular dis-eases. Perioperative indicators and postoperative complications were compared between the two groups. Result: Both groups were balanced in terms of baseline variables (all P>0.05). In terms of postoperative complications, there was no statistical difference be-tween the two groups [37.5% (48/128) vs . 30.5% (39/128), P=0.235]. According to the Clavien-Dindo classification of postoperative complications, the incidence of postoperative Clavien-DindoⅣcomplications in the comorbid cardiovascular disease group was signifi-cantly higher than that in the non-cardiovascular disease group [7.0% (9/128) vs . 1.6% (2/128), P=0.031]. In terms of local surgical complications, the incidence of postoperative anastomotic leakage in patients with cardiovascular diseases was significantly higher than that in patients without cardiovascular diseases [7.8% (10/128) vs . 2.3% (3/128), P=0.046]. In terms of other local surgical compli-cations, there was no statistical difference between the two groups (all P>0.05). In terms of non-surgical local complications, the inci-dence of postoperative blood circulatory system complications in patients with cardiovascular diseases was significantly higher than that in patients without cardiovascular diseases [10.2% (13/128) vs . 3.1% (4/128), P=0.024]. There was no significant difference in the incidence of other non-surgical local complications between the two groups (all P>0.05). Conclusions: Comorbid cardiovascular diseas-es did not increase the risk of colorectal cancer surgery in patients aged over 80 years. However, it should be noted that the incidence of postoperative blood circulatory system complications and anastomotic leakage is significantly increased in elderly patients with car-diovascular diseases. For such patients, adequate preoperative evaluation, close postoperative monitoring, and the application of pro-tective stoma are key to ensure that elderly patients with colorectal cancer can successfully survive the perioperative period.

Treatment progress of colorectal cancer with lateral lymph node metastasis / 肿瘤研究与临床

About 15％-25％ of patients with locally advanced rectal cancer have lateral lymph node metastasis, lymph node metastasis is an important cause of postoperative recurrence and death. Currently, scholars hold different attitudes towards lateral pelvic lymph node dissection (LPLND), because LPLND has many problems such as difficult operation, long operation time and large amount of bleeding. Therefore, there is no optimal treatment strategy for colorectal cancer with enlarged lateral lymph nodes. This article reviews the treatment strategy of lateral lymph node metastasis, the selection factors of LPLND and the safety and feasibility of laparoscopic LPLND.

Short-term outcomes of patients treated with enhanced recovery after surgery combined with laparoscopic colorectal cancer surgery / 中华普通外科杂志

Objective To investigate the safety and efficacy of enhanced recovery after surgery (ERAS) used in laparoscopic colorectal cancer surgery.Methods We conducted a retrospective analysis of the medical records of 99 cases treated with ERAS programed laparoscopic colorectal cancer surgery (ERAS group) and 103 cases treated with traditional perioperative care and laparoscopic colorectal cancer surgery (controlled group) from Mar 2017 to Sep 2017 in our center.Results There was no significant difference in age,gender,BMI,ASA classification,tumor location,operation time,pathological stage and the incidence of postoperative complications between ERAS group and controlled group (all P ＞ 0.05).Compared to control group,ERAS had less blood loss,shorter time to pass first flatus,stool and start diet and shorter hospitalization day,with all the difference statistically significant [(60 ± 63)ml vs.(112 ± 245)ml,(3.0±0.8)dvs.(4.3 ±1.2)d,(3.5 ±1.0)dvs.(4.6±1.3)d,(4.1 ±1.2)dvs.(5.4± 2.0)d,(5.8±2.1)dvs.(7.8±2.5)d,t=-2.021、-9.216、-6.887、-5.252、-6.163,allP＜ 0.05].No patients in both groups suffered from readmission or death within 30 days after surgery.Conclusion Patients treated with ERAS programed laparoscopic colorectal cancer surgery is safe and effective,with rapid recovery and reduced hospital stay.

Application and prospect of fecal DNA test in colorectal cancer screening / 中华胃肠外科杂志

Effective early screening and primary prevention is one of the major initiatives to decrease the morbidity and mortality of colorectal cancer in China. As a new non-invasive screening method for colorectal cancer in recent years, fecal DNA test detects colorectal cancer by analyzing gene mutations from intestinal tumor cells in the feces. The most widely used method among fecal DNA test is multi-target stoolDNA test (MT-sDNA). Many studies abroad on this emerging technique have been carried out to verify its high sensitivity, and it is gradually used in the clinic with continuous improvement and development of technology. Meanwhile, domestic MT-sDNA is still in the prototype stage, and more researches from Chinese population are needed. Compared with traditional screening methods, MT-sDNA technology has the advantages of non-invasiveness, painlessness and convenience. But its defects exist, such as high cost and low specificity. MT-sDNAis in accordance with precision medicine, and can largely make up for the shortcomings of traditional screening methods for colorectal cancer. It also holds a great promise for promoting the screening for colorectal cancer. This paper is aimed to discuss the application value of fecal DNA test by introducing its related researches at home and abroad,and summarizing its merits and demerits.

Application value of fascia orientation in lateral lymph node dissection of low rectal cancer / 中华胃肠外科杂志

Lateral lymph node metastasis is an important pathway for metastasis of low rectal cancer, which is also one of the most important risk factors for bad prognosis. Numerous evidences from evidence-based medicine demonstrate that both preoperative and postoperative chemoradiotherapy cannot eradicate lateral lymph node metastasis. Since selective resection of lateral lymph nodes with tumor residue after chemoradiotherapy can significantly decrease local recurrence rate and improve cancer prognosis, it is the only treatment modality for these patients to achieve disease-free survival. However, because of the narrow space, complicated anatomy and dense vessels and nerves of lateral area around rectum, lateral lymph node dissection (LLND) has many problems, such as long operation time, excessive intraoperative bleeding, piecemeal resection of lymphoid issue and high morbidity of postoperative complications, which restrict the clinical promotion of LLND. With the development in the study of fascia anatomy, surgeons are gradually familiarized with the perirectal fascia. Partitioning rectal lateral space and performing LLND based on fascia orientation can provide clear surgical plane and dissection boundary. Furthermore, it can avoid insufficient and excessive resection. Moreover, resecting tissue along fascia structure can avoid entering lymph tissue and prevent dissemination of malignant cells. Meanwhile, it can reduce exudation and bleeding, and present better pelvic autonomic nerve preservation. LLND based on fascia orientation is more in line with the concept of modern anatomy, more efficient both in tumor radical resection and function protection, and contributes to the promotion and quality control of LLND.

The Short-term Analysis of Overlapped Delta-shaped Anastomosis in Total Laparoscopic Transverse Colectomy / 中华肿瘤杂志

Objective@#The aim of this study was to explore the clinical safety, feasibility and short-term effect of overlapped delta-shaped anastomosis in total laparoscopic transverse colectomy.@*Methods@#The records, which were based on China National Cancer Center, of 20 and 31 patients who underwent total laparoscopic transverse colectomy with overlapped delta-shaped anastomosis and laparoscopic-assisted transverse colectomy with conventional extracorporeal anastomosis, from March 2017 to May 2018 were reviewed retrospectively. Data regarding surgical outcomes, postoperative recovery, pathological outcomes and perioperative complications were collected and compared.@*Results@#There was no difference between the two groups in overall operation time, anastomosis time and intraoperative blood loss (P>0.05), however, the length of incision was significantly shorter in overlapped delta-shaped group [(4.7±0.6) cm vs. (5.5±1.0) cm, P=0.002]. The time to ground activities, first flatus and postoperative hospitalization did not differ between the two groups (P>0.05). The postoperative visual analogue scale was lower in the overlapped delta-shaped group than the control group on postoperative day 1 (3.7±0.7 vs. 4.2±0.9, P=0.015) and postoperative day 3 (2.7±0.5 vs. 3.2±0.9, P=0.040). The perioperative complication rates were 10.0% and 12.9% in the overlapped delta-shaped group and the control group, respectively, and the difference was not significant (P=0.753).@*Conclusion@#Compared to conventional extracorporeal anastomosis, total laparoscopic transverse colectomy with overlapped delta-shaped anastomosis was a safe and feasible procedure with satisfactory short-term effect, shorter incision and less postoperative pain.

The Short-term Analysis of Overlapped Delta-shaped Anastomosis in Total Laparoscopic Transverse Colectomy / 中华肿瘤杂志

Objective@#The aim of this study was to explore the clinical safety, feasibility and short-term effect of overlapped delta-shaped anastomosis in total laparoscopic transverse colectomy.@*Methods@#The records, which were based on China National Cancer Center, of 20 and 31 patients who underwent total laparoscopic transverse colectomy with overlapped delta-shaped anastomosis and laparoscopic-assisted transverse colectomy with conventional extracorporeal anastomosis, from March 2017 to May 2018 were reviewed retrospectively. Data regarding surgical outcomes, postoperative recovery, pathological outcomes and perioperative complications were collected and compared.@*Results@#There was no difference between the two groups in overall operation time, anastomosis time and intraoperative blood loss (P>0.05), however, the length of incision was significantly shorter in overlapped delta-shaped group [(4.7±0.6) cm vs. (5.5±1.0) cm, P=0.002]. The time to ground activities, first flatus and postoperative hospitalization did not differ between the two groups (P>0.05). The postoperative visual analogue scale was lower in the overlapped delta-shaped group than the control group on postoperative day 1 (3.7±0.7 vs. 4.2±0.9, P=0.015) and postoperative day 3 (2.7±0.5 vs. 3.2±0.9, P=0.040). The perioperative complication rates were 10.0% and 12.9% in the overlapped delta-shaped group and the control group, respectively, and the difference was not significant (P=0.753).@*Conclusion@#Compared to conventional extracorporeal anastomosis, total laparoscopic transverse colectomy with overlapped delta-shaped anastomosis was a safe and feasible procedure with satisfactory short-term effect, shorter incision and less postoperative pain.

Clinical analysis of laparoscopic remedial surgery for endoscopic lesions in early colorectal cancer / 中华肿瘤杂志

Objective@#To investigate the safety and feasibility of laparoscopic remedial surgery in patients who didn′t reach the cure criterion of early colorectal cancer after endoscopic resection.@*Methods@#The clinical and follow-up data of 12 patients who didn′t reach the cure criterion of early colorectal cancer and then underwent endoscopic resection was collected. The clinicalpathological features and remedial indications were analyzed to evaluate the effects of laparoscopic remedial surgery.@*Results@#The average number of lymph nodes in the lymph node dissection was 15 during remedial surgery, and 3 of them had lymph node metastasis. Among the 3 patients with residual cancer, two cases were poorly differentiated, 1 case was moderately differentiated, 1 case was positive for basal margin, and 1 case had vascular invasion. No lymph node metastasis occurred in the 9 patients who had no residual cancer. Among these, 8 cases were moderately differentiated, 1 case was poorly differentiated and 2 cases had positive basal margin. The average follow-up duration was 40 months and all 12 patients were in a state of survival at the last follow-up. During the follow-up of the 3 patients with residual cancer, 1 patient received adjuvant chemotherapy with unknown prognosis; 1 patient received postoperative adjuvant radiochemotherapy, and lung metastasis occurred; 1 patient did not receive any treatment after surgery and survived for 33 months.@*Conclusions@#Laparoscopic remedial surgery is a safe and feasible remedy for patients who didn′t reach the cure criterion of early colorectal cancer after endoscopic resection. However, the choice of remedial strategy for colorectal carcinoma needs further investigation for patients with no vascular invasion, high degree of differentiation, and negative basal margin.

Clinical application of fusion indocyanine green fluorescence imaging in total laparoscopic radical resection for right colon cancer / 中华肿瘤杂志

Objective@#This study aims to explore the clinical value of fusion indocyanine green fluorescence imaging (FIGFI) in total laparoscopic radical resection for right colon cancer.@*Methods@#From October, 2018 to December, 2018, 15 patients who underwent total laparoscopic radical resection for right colon cancer using FIGFI in Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were retrospectively enrolled in this study. Data regarding surgical outcomes, postoperative recovery, pathological outcomes and complications were collected and analyzed.@*Results@#All patients successfully underwent total laparoscopic radical resection for right colon cancer using FIGFI. 1 patients (6.7%) received extended resection of bowel due to poor blood supply after mesentery excision. The average operation time was 133.7 minutes and intraoperative blood loss was 26.7 ml. The average time to ground activities, fluid diet intake, first flatus and postoperative hospitalization were 19.1 h, 11.7 h, 32.5 h and 5.0 d, respectively. The average length of tumor was 4.5 cm. The average proximal and distal resection margins were 14.9 cm and 12.1 cm, respectively. The average number of lymph nodes retrieved was 29.3 per patient. Only one patient suffered from incisional fat liquefaction after surgery and was managed effectively by regular dressing change. No severe complications such as indocyanine green allergy, anastomotic stenosis, anastomotic leakage, abdominal bleeding, bowel obstruction, pulmonary infection, and abdominal infection occurred in any patients.@*Conclusions@#FIGFI is helpful to judge the blood supply of intestinal segments and anastomotic stoma in total laparoscopic radical resection for right colon cancer quickly. It is a safe and feasible technique with satisfactory short-term effect.

Clinical application of enterostomy using running suture of dermis and seromuscular layer in laparoscopic-assisted radical resection for rectal carcinoma / 中华肿瘤杂志

Objective@#To explore the clinical safety and feasibility of enterostomy using running suture of dermis and seromuscular layer in laparoscopic-assisted radical resection for rectal carcinoma.@*Methods@#From May 1, 2017 to May 1, 2018, 46 patients who underwent laparoscopic-assisted radical resection for rectal carcinoma with enterostomy using running suture of dermis and seromuscular layer in Cancer Hospital, Chinese Academy of Medical Sciences were retrospectively enrolled in this study. Data regarding clinicopathologic characteristics, operation and postoperative outcomes, stoma-related complications and functions of stoma were collected and analyzed.@*Results@#All of the 46 patients successfully underwent this operation. Among them, 30 patients underwent laparoscopic-assisted abdominoperineal resection for rectal cancer with sigmoidostomy and 16 patients underwent laparoscopic-assisted low anterior resection for rectal cancer with loop ileostomy. The mean operation time was 115.3 minutes and intraoperative blood loss was 86.1 ml. The mean time for enterostomy was 14.1 minutes. The average time to flatus, time to fluid diet intake and length of hospital stay were 1.8 days, 2.9 days and 6.5 days, respectively. During the follow-up period, three patients suffered from stomal edema, two patients suffered from parastomal hernia, and two patients suffered from skin inflammation surrounding stoma. None of re-operation related stoma and severe mobility such as stomal stenosis, stomal necrosis, stomal prolapse, stomal retraction and stomal mucocutaneous separation occurred. Thirty-five patients recovered with satisfactory stomal function, two with middle function and one with poor function.@*Conclusion@#Enterostomy using running suture of dermis and seromuscular layer in laparoscopic-assisted radical resection for rectal carcinoma is a safe and feasible procedure with a satisfactory short-term effect.

Prospects and challenges of natural orifice specimen extraction surgery, natural orifice transluminal endoscopic surgery and transanal total mesorectal excision / 中华胃肠外科杂志

In recent years, our country has gained unprecedented achievements in minimally invasive surgery. Natural orifice specimen extraction surgery (NOSES), natural orifice transluminal endoscopic surgery (NOTES) and transanal total mesorectal excision (TaTME) are the three most representative techniques for minimally invasive surgery. They are hot in Chinese surgical field due to their superior minimally invasive advantages. It is true that these three technologies are still in their early stages of development. Each of them also faces many problems and challenges that need to be resolved and overcome. Therefore, it is necessary for us to understand these technologies thoroughly on the premise of accurate definitions, clear concepts, and standardized operating procedures. We should not blindly follow, nor should we confuse concepts and surgical names. This is an important prerequisite for the orderly development of minimally invasive surgery. NOSES emphasizes the removal of specimens through natural orifice, while NOTES mainly emphasizes the use of natural orifice as a surgical approach into the body cavity. TaTME emphasizes the trans-anal approach. NOSES and NOTES are two wide surgical concepts that apply to a variety of tissues and organs, while TaTME is a narrow surgical concept that is confined to the rectum. The main purpose of the three is to demonstrate a good minimally invasive effect on the basis of ensuring effective treatment of the disease. From the current technical conditions, no surgical technique is perfect. Only by selecting the best surgical method according to the patient's condition, can the advantages of minimally invasive technology be maximized, and patients can benefit the most.

Impact of previous abdominal surgery on the outcomes of laparoscopic resection for colorectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the effect of previous abdominal surgery(PAS) on laparoscopic resection of colorectal cancer.</p><p><b>METHODS</b>The retrospective cohort study was adopted.Clinical data of consecutive colorectal cancer patients with PAS history (past history of at least one abdominal surgery, exclusion of previous inguinal hernia repair, simple laparoscopic approach, appendectomy of the right lower quadrant and endoscopic therapy) undergoing laparoscopic surgery at the Cancer Hospital of Chinese Academy of Medical Sciences between 2010 and 2015 were collected, meanwhile other colorectal cancer patients without PAS history were selected according to 1 to 1 match in age, sex, body mass index, American Society of Anesthesiologists score, tumor location, type of surgery, and staging of tumor. A total of 464 pairs were successfully matched. Intraoperative and postoperative conditions, perioperative complications and prognosis were compared between the two groups.</p><p><b>RESULTS</b>In PAS group, there were 341 males (73.5%) and 123 females (26.5%) with a median age of 62 (24-85) years; 317(68.3%) cases with only one previous abdominal surgery and 147(31.7%) with more than one; 389(83.8%) cases with abdominal midline incisions, 37(8.0%) with transverse incisions, 34(7.3%) with right subcostal incision and 4(0.9%) with left subcostal incision; 146(31.5%) cases undergoing gynecologic surgery, 84(18.1%) cholecystectomy, 52(11.2%) gastroduodenal surgery, 89(19.2%) colorectal surgery, 11(2.4%) small intestine surgery, 23(5.0%) hapatectomy, 16(3.4%) pancreatic surgery, 8(1.7%) urological surgery, 18(3.9%) retroperitoneal tumor resection and 1(0.2%) other surgery. In no PAS group, there were 328 males (70.7%) and 136 females (29.3%) with a median age of 62(24-86) years. No significant differences in baseline data were found between the two groups (all P>0.05). As compared to no PAS group, PAS group had longer mean operative time [(208.0±27.0) minutes vs. (179.0±15.3) minutes, t=4.695, P=0.003] and higher rate of conversion to laparotomy [18.1%(84/464) vs. 11.6%(54/464), χ=7.217, P=0.003]. In the PAS group, conversion to laparotomy was more common due to adhesion reaction [8.8%(41/464) vs. 4.5%(21/464), χ=4.886, P=0.007]. There were no significant differences between the two groups in intraoperative bleeding and transfusion, lymph node dissection, circumferential margin and surgical margin, time to the first diet and postoperative hospital stay(all P>0.05). No significant differences in intraoperative and postoperative morbidity of complication were found between PAS group and no PAS group [3.7%(17/464) vs. 2.8%(13/464), P=0.346; 20.3%(94/464) vs. 18.5%(86/464), P=0.739]. Median follow-up of the whole patients was 32.0(0.5-79.0) months, and there was no significant difference between the two groups [PAS group 31.0(0.5-79.0) months vs. no PAS group 33.0(1.0-75.0) months, P=0.391]. In PAS and no PAS group, the 3-year disease-free survival rate was 68.1%(95%CI: 62.0%-74.2%) and 68.5%(95%CI: 63.0%-74.0%)(P=0.764), and 3-year overall survival rate was 78.5%(95%CI: 72.8%-81.4%) and 80.2%(95%CI:74.3%-86.1%)(P=0.528) respectively, whose differences were not significant.</p><p><b>CONCLUSION</b>Except higher risk of conversion to laparotomy due to adhesion reaction, laparoscopic resection of colorectal cancer is safe and feasible in patients with PAS, and the prognosis is not affected by PAS.</p>