Clinical efficacy and prognosis of simultaneous resection of synchronous colorectal liver metastasis in patients admitted in different phases / 中华消化外科杂志

Objective:To investigate the clinical efficacy and prognosis of simultaneous resection of synchronous colorectal liver metastasis in patients admitted in different phases.Methods:The retrospective cohort study was conducted. The clinicopathological data of 346 patients who underwent simultaneous resection of synchronous colorectal liver metastasis in the First Affiliated Hospital of Naval Medical University (Changhai Hospital of Shanghai) from January 2000 to April 2021 were collected. There were 217 males and 129 females, aged (58±12)years. Patients under-went simultaneous resection of synchronous colorectal liver metastasis. Observation indicators: (1) clinicopathological features of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021; (2) surgical and postoperative situations of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021; (3) analysis of prognosis of patients with synchro-nous colorectal liver metastasis in 2000?2010 and 2011?2021. Follow-up was conducted using telephone interview or outpatient examination to detect survival of patients. The follow-up was performed once every 3 months, including blood routine test, liver and kidney function test, car-cinoembryonic antigen (CEA) test, CA19-9 test, abdominal B-ultrasound examination, and once every 6 months, including chest computed tomography (CT) plain scan, liver magnetic resonance imaging (MRI) and/or CT enhanced scan, abdominal or pelvic MRI and/or CT enhanced scan, within postoperative 2 year. The follow-up was performed once every 6?12 months within postoperative 2?5 years including above reexaminations. Electronic colonoscopy was performed once a year after operation. The follow-up was up to November 12, 2021. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distuibution were represented as M(range). Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was conducted using the rank sum test. Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-Rank test was used to conduct survival analysis. Results:(1) Clinicopathological features of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021. Of the 346 patients, 59 cases underwent simultaneous resection within 2000?2010 and 287 cases underwent simultaneous resection within 2011?2021. The gender (males and females), cases with or without fundamental diseases, cases with the number of lymph nodes harvested in primary lesion as <12 or ≥12, the tumor diameter of primary lesion, the tumor diameter of liver metastasis lesion, the number of liver metastasis lesions, cases with or without preoperative treatment, cases with or without postoperative treatment, cases with adjuvant therapy as perioperative treatment, surgery or other treatment were 47, 12, 36, 23, 19, 40, (5.5±2.4)cm, (2.1±0.7)cm, 1.6±0.5, 59, 0, 16, 16, 0, 16, 43 in patients admitted in 2000?2010, respectively. The above indicators in patients admitted in 2011?2021 were 170, 117, 121, 166, 58, 229, (4.2±2.0)cm, (3.0±2.0)cm, 1.9±1.4, 208, 79, 34, 235, 74, 29, 184, respectively. There were significant differences in the above indicators between patients admitted in 2000?2010 and 2011?2021 ( χ2=8.73, 7.02, 4.07, t= 4.40, ?6.04, ?3.10, χ2=21.05, 28.82, 26.68, P<0.05). (2) Surgical and postoperative situations of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021. Cases with surgical methods as complete open surgery or laparoscopy combined with open surgery, the operation time, time to postoperative initial liquid food intake, cases with or without postoperative complications, cases with postoperative duration of hospital stay as ≤10 days or >10 days were 58, 1, (281±57)minutes, (5±1)days, 33, 26, 14, 45 in patients admitted in 2000?2010, respec-tively. The above indicators in patients admitted in 2011?2021 were 140, 147, (261±82)minutes, (3±1)days, 233, 54, 198, 89, respectively. There were significant differences in the above indicators between patients admitted in 2000?2010 and 2011?2021 ( χ2=49.04, t=2.24, 7.53, χ2=17.56, 26.02, P<0.05). There was no death in the 346 patients. (3) Analysis of prognosis of patients with synchro-nous colorectal liver metastasis in 2000?2010 and 2011?2021. Of the 346 patients, 295 cases were followed up for 47(range, 1?108)months. Of the 29 patients admitted in 2000?2010 who were followed up, there were 27 cases died. The median survival time, 1-, 3-, 5-year overall survival rates, 1-, 3-, 5-year disease free survival rates of patients admitted in 2000?2010 were 18.0 months (95% confidence interval as 12.7?23.3 months), 82.8%, 11.5%, 3.8%, 53.6%, 8.3%, 4.2%, respec-tively. Of the 266 patients admitted in 2011?2021 who were followed up, there were 109 cases died. The median survival time, 1-, 3-, 5-year overall survival rates, 1-, 3-, 5-year disease free survival rates of patients admitted in 2011?2021 were 54.0 months (95% confidence interval as 38.1?70.4 months), 93.3%, 61.8%, 47.0%, 68.2%, 33.7%, 28.3%, respectively. There were significant differences in overall survival rate and disease free survival rate between patients admitted in 2000?2010 and 2011?2021 ( χ2=47.57, 9.17, P<0.05). Conclusions:With the increase of the operation volume of simultaneous resection of synchronous colorectal liver metastasis, the operation time, time to postoperative initial liquid food intake, postoperative duration of hospital stay and postoperative complications have significantly decreased, while the overall survival rate and disease free survival rate have significantly increased.

The research progress on the efficacy enhancement of paclitaxel in chemotherapy for colorectal cancer / 药学实践杂志

Colorectal cancer is a malignant tumor with increasing incidence in China. Chemotherapy or neoadjuvant therapy are needed when the patients have deep tumor invasion of distant metastasis due to the hidden clinical manifestations and limited screening methods for the colorectal cancer. With many side effects of the current chemo-medications and the drug resistance, researchers are actively exploring new chemotherapy drugs for colorectal cancer. Paclitaxel is a first-line chemotherapy drug for the treatment of breast cancer, ovarian cancer, pancreatic cancer and other malignant tumors. Colorectal cancer cells are prone to become resistant to paclitaxel and the treatment efficiency was limited. However, new drug delivery systems and the combination drug therapy can enhance the treatment efficiency. This article reviews the effective treatment strategies of paclitaxel for colorectal cancer with the hope for new ideas and more effective chemotherapy.

A single center retrospective study on surgical efficacy of T3NxM0 middle-low rectal cancer without neoadjuvant therapy / 中华胃肠外科杂志

OBJECTIVE@#To investigate the surgical efficacy and prognostic factors of T3NxM0 middle-low rectal cancer without neoadjuvant therapy.@*METHODS@#Clinical data of patients with middle-low rectal cancer undergoing TME surgery with T3NxM0 confirmed by postoperative pathology at Colorectal Surgery Department of Changhai Hospital from January 2008 to December 2010 were analyzed retrospectively.@*INCLUSION CRITERIA@#(1)no preoperative neoadjuvant chemoradiotherapy (nCRT); (2) complete preoperative evaluation, including medical history, preoperative colonoscopy or digital examination, blood tumor marker examination, and imaging examination; (3) distance between tumor lower margin and anal verge was ≤ 10 cm; (4) negative circumferential resection margin (CRM-). Finally, a total of 331 patients were included in this study. According to the number of metastatic lymph node confirmed by postoperative pathology, the patients were divided into N0 group without regional lymph node metastasis (190 cases) and N+ group with regional lymph node metastasis (141 cases). The perioperative conditions, local recurrence, distant metastasis and prognostic factors were analyzed.@*RESULTS@#Compared to N0 group in the perioperative data, N+ group had higher ratio of tumor deposit [29.8%(42/141) vs. 0, χ²=64.821, P0.05). The median follow-up period was 73.4 months. The merged 5-year local recurrence rate was 2.7%(9/331), 5-year distant metastasis rate was 23.3% (77/331), 5-year disease-free survival (DFS) rate was 73.4%, and 5-year overall survival (OS) rate was 77.2%. Multivariate analysis showed that lymph node metastasis (HR=3.120, 95%CI: 1.918 to 5.075, P<0.001), nerve invasion (HR=0.345, 95%CI: 0.156 to 0.760, P=0.008) and vascular invasion (HR=0.428, 95%CI: 0.189 to 0.972, P=0.043) were independent risk factors for DFS in patients with T3NxM0 rectal cancer after operation. Preoperative carcinoembryonic antigen level (HR=1.858, 95%CI:1.121 to 3.079, P=0.016), lymph node metastasis (HR=3.320, 95%CI: 1.985 to 5.553, P<0.001) and nerve invasion (HR=0.339, 95%CI: 0.156 to 0.738, P=0.006) were independent risk factors for OS in patients with T3NxM0 rectal cancer after operation.@*CONCLUSIONS@#Optimal local control rate of middle-low rectal cancer patients with T3NxM0 and CRM- can be achieved by standard TME surgery alone. For patients with preoperative elevated blood carcinoembryonic antigen level, regional lymph node metastasis, or neurovascular invasion confirmed by pathology after surgery, adjuvant chemoradiotherapy should be actively applied after surgery to improve prognosis.

Correlation between neutrophils changes and prognosis of colorectal cancer / 中华普通外科杂志

Objective To investigate the prognostic value of neutrophil changes in patients with colorectal cancer.Methods The neutrophils in patients with colorectal cancer were classified into twotypes:peripheral blood neutrophils and tumor-associated neutrophils (TANs).Peripheral blood neutrophils are expressed as neutrophil/lymphocyte ratio (neutrophil to lymphocyte ratio,NLR).Results The 5 year's survival rates of patients with high and low NLR were 75.2％ and 88.2％,respectively.The 5 year's survival rates of patients with high and low TANs were 97.6％ and 64.2％,respectively.The survival rates of patients with low NLR and high TANs;high NLR and high infiltrating TANs;low NLR and low infiltrating TANs;and high NLR and low infiltrating TANs were respectively 100％,95.7％,76.4％ and 53.5％.With the two joining together the ability to distinguish long-term prognosis of patients was significantly better than any one alone.Multivariate regression analysis showed that,high peripheral blood NLR,low TANs infiltration,tumor located in the rectum,TNM staging are independent risk factors for colorectal cancer prognosis.Conclusions NLR in preoperative peripheral blood combined with infiltrating TANs in colorectal cancer tissues can be used as a prognostic indicator for patients with colorectal cancer.High NLR in preoperative peripheral blood combined with low infiltrating TANs in colorectal cancer tissue predicts poor prognosis.

Curative resection with minilaparotomy approach in the treatment of rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the surgical safety and short-term efficacy of minilaparotomy and laparoscopic approach for curative resection of rectal cancer.</p><p><b>METHODS</b>The retrospective cohort study was adopted. A review of patients scheduled to undergo a curative resection of rectal cancer via minilaparotomy or laparoscopic approach at Department of Colorectal Surgery of Changhai Hospital from June 2016 to May 2017 was carried out. All the patients were confirmed as rectal cancer by postoperative pathology. The following patients were excluded from the study: patients who had acute complete obstruction or perforation; patients underwent Miles or Hartmann procedure; patients who required an elongation of the skin incision in minilaparotomy or a conversion from laparoscopic to open surgery. Finally, 216 patients were enrolled in this study, of whom 143 were performed with minilaparotomy approach (minilaparotomy group) and 73 with laparoscopic approach (laparoscopic group) for curative resection of rectal cancer. For the minilaparotomy technique, a 7 cm longitudinal midline incision was made between the pubic symphysis and umbilicus; a wound retractor was applied to the edge of the wound; lymph node dissection around the inferior mesenteric and artery high ligation of inferior mesenteric artery were performed; by moving the minilaparotomy wound laterally and caudad or cephalad with the S-shaped hook, cautious mobilization of the relevant segment of the bowel loop was performed; bowel anastomosis was achieved by using the double-stapled technique; the gap of the pelvic floor peritoneum and mesentery were routinely closed by the absorbable surgical suture in cases with middle and low position rectal cancer. The surgical safety, the condition of resuming and the morbidity of postoperative complication were compared between the two groups.</p><p><b>RESULTS</b>There were 145 men and 71 women. Age ranged from 26 to 87 years, with of mean age of 61 years. According to the TNM stage grouping, there were 61 patients with stage I(, 62 with stage II(, 85 with stage III(, and 8 with stage IIII( disease, respectively. These two groups did not differ significantly in terms of age, sex, body mass index, site of tumor, TNM stage(all P>0.05). All the patients completed the operation successfully. The median operation time of minilaparotomy group was significantly shorter than that of laparoscopic group [164(80-296) minutes vs. 230(90-665) minutes, Z=4.410, P=0.000]. The intraoperative medical consumable expense [11000(7000-22000) yuan vs. 23000(12000-47000) yuan, Z=11.759, P=0.000] and the total hospitalization expense [44000(22000-146000) yuan vs. 57000(45000-126000) yuan, Z=9.637, P=0.000] were significantly lower in the minilaparotomy group. There were no significant differences between the two groups in terms of operative blood loss, number of harvested lymph nodes, distance of distal resection margin, positive rate of circumferential resection margin (all P>0.05). The rate of postoperative complication in minilaparotomy group was 7.0%(10/143) and in laparoscopic group was 9.6%(7/73) without significant difference (χ=0.449, P=0.503). There were 2 patients in each group who required readmission to the hospital within postoperative 30 days. The cause of readmission was ileus or acute hyponatremia in minilaparotomy group, and ileus or pevic infection in laparoscopic group. One patient died of brain death caused by acute pulmonary embolism during the perioperative period in minilaparotomy group.</p><p><b>CONCLUSIONS</b>The minilaparotomy approach for curative resection of rectal cancer is safe and feasible. As compared with laparoscopic approach, it is advantageous to achieve minimal invasiveness and early recovery, but much cheaper and less time consuming.</p>

Diagnosis and treatment of iatrogenic colonoscopic perforation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To summarize the diagnosis and treatment of iatrogenic colonoscopic perforation (ICP).</p><p><b>METHODS</b>Clinical data, treatment course and outcome of 17 patients who developed ICP following colonoscopic examination or operation at Department of Colorectal Surgery, Changhai Hospital from January 2000 to December 2013 were retrospectively analyzed.</p><p><b>RESULTS</b>During above 13 years, a total of 127 106 patients underwent colonoscopic examination or operation, of whom 17 cases (0.013%) had ICP. There were 8 males and 9 females with an average age of 65.2 (32-85) years. The interval between the onset of ICP and clinically diagnosed ICP was 0 to 6 days after performance. ICP occurred in 8 patients following colonoscopy operations, including simple colonic polyp excision, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), while in 9 patients following simple colonoscopy examination. Except for one patient who was immediately diagnosed with ICP through the finding of "yellow adipose tissue visible in the vision field" during operation,7 early cases (41.2%) were diagnosed by abdominal X-ray examination, and 9 later cases were confirmed by abdominal CT examination. The perforation sites included sigmoid colon in 5 cases, caecum in 3 cases, descending colon in 3 cases, descending and sigmoid junction in 2 cases, ileum in 1 case, splenic flexure in 1 case, sigmoid and rectum junction in 1 case, retum in 1 case. One case with ICP following ESD after resection of polyp in caecum was cured successfully with conservative treatment, including fasting, gastrointestinal decompression, fluid infusion, anti-infection and nutritional support. One case with ICP, which was found during colonoscopic operation and the perforation was immediately closed with titanium clip, received conservative treatment, including anti-infection and then was cured. Fifteen patients underwent surgery, including 8 patients with primary intention intestinal perforation repair, 4 patients with primary intention resection of associated intestine and anastomosis, 2 patients with primary intention resection of associated intestine and ostomy, 1 patient with primary intention intestinal perforation repair and ostomy. Postoperative abdominal incision infection occurred in 4 cases, pulmonary infection in 1 case, incision infection with cardiovascular event or urinary tract infection in 1 case each. All the patients were cured and discharged. Average hospital stay was 18.6(3-45) days.</p><p><b>CONCLUSIONS</b>ICP should be diagnosed by physical examination and imaging examination as soon as possible. For perforation during colonoscopic performance, colonoscopic titanium clip can be used for closure. Perforation repair is still the main procedure for ICP. If necessary, partial intestinal resection and anastomosis or ostomy can be selected.</p>

Risk factor analysis for brain metastasis after radical resection of colorectal cancer within 5 years / 第二军医大学学报

Objective To explore the risk factors of brain metastasis after radical resection of colorectal cancer within 5 years.Methods We retrospectively analyzed the clinical data of 1 104 patients with colorectal cancer in the Department of Colorectal Surgery of Changhai Hospital of Second Military Medical University from Jan.2003 to Dec.2011.Thirty of 1 104 cases (2.7％) had brain metastasis.All patients received radical resection of colorectal cancer,and the rectal cancer patients followed the total mesorectal excision (TME) principle.According to the TME stage,the patients of stage Ⅱ or later were treated with capecitabine combined with oxaliplatin (XELOX) or fluorouracil plus oxaliplatin (FOLFOX) chemotherapy.The clinicopathological features that might affect post-operative brain metastasis,including gender,age,tumor location,pre-operative serum carcino-embryonic antigen (CEA) level,tumor histological type,depth of tumor invasion,lymph node metastasis,pulmonary metastases and liver metastases,were analyzed by univariate analysis using Chi square test.Multivariate analysis was performed to search for the independent risk factors of brain metastasis from colorectal cancer using logistic regression.Results Univariate Chi square test indicated that the relative factors associated with the brain metastasis of colorectal cancer within 5 years were tumor location (x2=5.844,P=0.016),pre-operative CEA level (x2 =5.395,P =0.020),tumor histological type (x2 =4.950,P =0.026) and with pulmonary metastasis (x2=52.569,P=0.000).Multivariate analysis showed that the tumor location (OR=0.278,95％CI:0.095-0.817,P=0.020),pre-operative CEA level (OR=0.423,95％CI:0.192-0.933,P=0.033) and with pulmonary metastasis (OR=-10.814,95％CI:4.705-24.856,P=0.000) were the independent risk factors of brain metastasis of colorectal cancer within 5 years.Conclusion Patients with rectal cancer,higher pre-operative CEA level and pulmonary metastasis have a high risk of brain metastasis of colorectal cancer within 5 years.

Study on the relationship between tumor regression grade and lymph node regression grade / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the relationship between tumor regression grade (TRG) and lymph node regression grade (LRG) after neoadjuvant chemoradiotherapy (CRT) for rectal cancer and its clinical implication.</p><p><b>METHODS</b>Clinicopathological data of 176 rectal cancer patients undergoing radical excision after neoadjuvant CRT from January 2005 to December 2013 in our department were retrospectively analyzed.</p><p><b>INCLUSION CRITERIA</b>(1) Radiology indicated locally advanced low rectal cancer and patients had strong desire to preserve the sphincter before neoadjuvant CRT; (2) there was no definite metastatic lesion before neoadjuvant CRT; (3) patients received whole course of neoadjuvant CRT (regular radiotherapy plus synchronous fluorouracil-like drugs chemotherapy); (4) patients underwent radical operation after neoadjuvant CRT. Patients with short-course CRT and emergency surgery were excluded. TRG and LRG of postoperative specimens (including tumor and lymph nodes) were carried out based on the percentage of the fibrosis and the cancer residue. No cancer residue was defined as TRG1 and LRG1; rare cancer cell residue as TRG2 and LRG2; fibrosis growth over residual cancer as TRG3 and LRG3; residual cancer growth over fibrosis as TRG4 and LRG4; absence of regressive changes as TRG5 and LRG5; and normal lymph nodes as LRG0. Spearman correlation test was used to assess the correlation between TRG and LRG.</p><p><b>RESULTS</b>Of 176 patients, 111 were men and 65 were women. The mean age was (53.9±13.0) years. The number of patients with stage I(, II(, and III( before operation was 10, 49 and 62 while other 55 patients were unknown. Transabdominal low anterior resection (LAR) was performed in 118 cases and abdominal-perineal resection(APR) in 47 cases following the principle of total mesorectal excision (TME). Postoperative pathology of specimens revealed that the number of patients from TRG1 to TRG5 was 19 (10.8%), 25 (14.2%), 66 (37.5%), 47 (26.7%), 19 (10.8%), and from LRG0 to LRG5 was 35 (19.9%), 68 (38.6%), 10 (5.7%), 14 (8.0%), 15(8.5%), 34 (19.3%), respectively. TRG was correlated to LRG (P=0.005) while the Spearman correlation coefficient was only 0.24. The analysis of subgroup without LRG1 also showed that TRG was correlated to LRG(P=0.0005) and the Spearman correlation coefficient was 0.40.</p><p><b>CONCLUSIONS</b>TRG can not represent LRG. Therefore, both TRG and LRG should be assessed when evaluating the response of rectal cancer to neoadjuvant CRT.</p>

Comparison of short-term outcomes of transrectal specimen extraction during laparoscopic sigmoid radical resection versus conventional laparoscopically assisted procedure / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the short-term outcomes between transrectal specimen extraction during laparoscopic sigmoid radical resection and conventional laparoscopy-assisted sigmoid radical resection.</p><p><b>METHODS</b>Sixteen patients(transrectal specimen extraction group,4 females and 12 males), who were planned to undergo laparoscopically assisted sigmoid radical resection with BMI<28 kg/mand were evaluated as T1-T3 tumor by iconography without distant metastasis, were selected to undergo transrectal specimen extraction during laparoscopic sigmoid radical resection from December 2015 to April 2016 in the Department of Anorectal Surgery of Changhai Hospital. The procedure of specimen extraction was as follows: Perineal anal expansion was performed. The rectum was cut in rectal distal ligature within the abdominal cavity. Telescope cover was placed through Trocar hole in right low abdomen and rectal stump was pulled out of the body through the anus to form an access tunnel. Planned resected bowel was placed in the tunnel and the specimen was dissociated and removed completely from anus. Each patient in transrectal specimen extraction group was individually matched with two patients who underwent laparoscopically assisted sigmoid radical resection by gender, age, BMI and date of surgery. The perioperative outcomes and pathological evaluation of surgical specimen of two groups were retrospectively collected and compared.</p><p><b>RESULTS</b>The differences of baseline data (gender, age, BMI, distance from tumor to anal verge measured by colonoscopy and clinical tumor category) between two groups were not significant (all P>0.05). Compared to laparoscopy-assisted group, transrectal specimen extraction group presented longer operation time [(140.6±8.3) minutes vs. (122.2±26.2) minutes, t=-3.629, P=0.001], and more blood loss[(43.8±9.2) ml vs. (35.3±10.2) ml, t=-2.795, P=0.008], but shorter time to first flatus [(43.1±8.3) hours vs. (52.0±11.4) hours, t=2.756, P=0.008] and lower pain score at operative day and the first postoperative day (3.8±0.8 vs. 4.8±1.1, t=3.558, P=0.001; 2.6±0.6 vs. 3.8±0.8, t=5.165, P=0.000). The case ratio of additional analgesia [6.3%(1/16) ns. 18.8%(6/32)], postoperative hospital stay [(6.8±3.4) days vs. (5.6±0.8) days] and postoperative morbidity of complication [12.5%(2/16) vs. 9.4%(3/32)] were not significantly different between the two groups (all P>0.05). Within postoperative 30-day follow-up, transrectal specimen extraction group had ileus in one patient and anastomotic leakage in one patient, and laparoscopy-assisted group had fat necrosis of assisted incision in two patients and gastric retention in one patient. There were also no significant differences in specimen length[(18.2±4.8) cm vs. (19.8±5.7) cm, P>0.05], tumor size [(4.0±1.2) cm vs. (4.4±1.5) cm, P>0.05] and number of harvested lymph node (14.6±2.6 vs. 16.0±3.0, P>0.05] between two groups. During follow-up of 7-10(mean 9) months of transrectal specimen extraction group and 2-16 (mean 7) months of laparoscopically assisted group, no tumor local relapse and distant metastasis were found in the both groups.</p><p><b>CONCLUSION</b>As compared to laparoscopy-assisted sigmoid radical resection, transrectal specimen extraction laparoscopic sigmoid radical resection has better short-term efficacy, meanwhile they have comparable oncologic clearance.</p>

Clinical and pathologic prognostic factors affecting local recurrence and overall survival in 1 166 rectal cancer resection patients / 中华普通外科杂志

Objective To explore the clinicopathologic factors impacting recurrence and survival in rectal cancer patients after radical resection.Methods Clinicopathologic data of 1 166 patients with rectal cancer in Changhai Hospital,were recruited between 2005 and 2010.Kaplan-Meier analysis and the logrank test were used to evaluate the effects of the pathology on patients' survival.Cox regression model was used to assess independent factors associated with clinical prognosis.Results The 1,3,5-year overall survival rates were 94.3％,81.2％ and 76.5％,median survival time was 53 months.328 patients had recurrence and metastases,with a median recurrence time of 18 months.The independent prognostic factors for overall survival time were CEA,CA19-9,tumor distance to dentate line,surgical modality,radical operation,tumor invasion,tumor differentiation,lymph node metastasis and postoperative treatment.Surgical treatment,radical operation or not,tumor invasion and lymph node metastasis were statistically significant associated with tumor recurrence and metastases.Conclusions The important factors inffuencing the prognosis of rectal cancer patients were CEA,CA19-9,tumor distance to dentate line,surgical modality,radial operation,tumor in vasion,tumor differentiation,lymph node metastasis,and post operative treatment.

Assessment of the risk factors relating to lymph node metastasis in rectal cancer after neoadjuvant chemoradiotherapy and the clinical significance / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To identify the risk factors associated with lymph node metastasis in rectal cancer after neoadjuvant chemoradiotherapy (CRT).</p><p><b>METHODS</b>From January 2005 to December 2013, the clinical data of 178 patients with advanced rectal cancer undergoing radical excision after neoadjuvant CRT in our department were reviewed retrospectively. A total of 11 clinicopathologic factors relating to lymph node metastasis were studied using univariate and multivariate Logistic regression analyses.</p><p><b>RESULTS</b>There were 74(41.6%) cases with lymph node metastasis, while 104 cases without lymph node metastasis. Univariate analysis showed that age(P=0.000 2), post-CRT CEA level(P=0.011 2), ypT stage(P=0.000 0), pathologic type(P=0.004 0), and tumor regression grade(TRG)(P=0.033 8) were significantly associated with lymph node metastasis. Multivariate analysis showed that age(OR=2.385, 95% CI:1.372 ~ 4.147, P=0.002 1), post-CRT CEA level(OR=2.310, 95% CI:1.005 ~ 5.307, P=0.048 6) and ypT stage(OR=2.592, 95% CI:1.236 ~ 5.432, P=0.011 7) were independent risk factors. However, 15.8% of the patients who achieved TRG1 had lymph node metastasis and TRG failed to independently correlate with lymph node metastasis in rectal cancer after neoadjuvant CRT.</p><p><b>CONCLUSIONS</b>There was a higher ratio of lymph node metastasis in rectal cancer patients who were young, CEA≥5 μg/L or deep invasion after neoadjuvant CRT. Therefore, neoadjuvant CRT should be carefully considered in these patients.</p>

Adenoma detection rate of fecal occult blood test-positive population in colorectal cancer screening and potential influence of“resection and discard”strategy / 中华消化内镜杂志

Objective To evaluate the adenoma detection rate( ADR)of fecal occult blood test (FOBT)-positive population in colorectal cancer screening programme and to analyse potential influence of“resection and discard”strategy on ADR. Methods Data of patients who paticipated in the Shanghai color-ectal cancer screening programme with FOBT-positive and received colonoscopy in the Digestive Endoscopic Center of Changhai Hospital from July 2013 to July 2014 were retrospectively analysed. ADR was calculated and compared by different genders. Multivariate logistic regression model was used to analyse the risk factors of polyp resection without retrieval. Results A total of 222 FOBT-positive patients were involved with 36. 5% male proportion. The total ADR was 19. 8%,higher in male(28. 4%)than in female(14. 9%)(P=0. 015). The independent risk factors of polyp resection without retrieval were diminutive polyp( OR =15. 256,95% CI:4. 159-55. 957),located in rectum( OR = 3. 663,95% CI:1. 427-9. 398) and polyp number >2(OR= 3. 988,95%CI:1. 562-10. 187).Conclusion ADR of FOBT-positive population is approx-imately 20%in our center. Low male proportion and“resection and discard”strategy may lead to lower ADR. ADR should be calculated by different genders and advanced endoscopic technology should be employed rou-tinely to predict the pathological diagonosis of the lesions.

Analysis of risk factors associate with lymph node metastasis of T1 and T2 rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To investigate the risk factors associated with lymph node metastasis of T1 and T2 rectal cancer.</p><p><b>METHODS</b>Clinicopathological data of 576 patients with stage T1 to T2 rectal cancer without serosal invasion confirmed by pathology undergoing curative resection in Changhai Hospital from January 1999 to December 2013 were analyzed retrospectively. The relationship of clinicopathological factors of overall patients and stage T1 patients with lymph node metastasis was analyzed by univariate or multivariate analysis.</p><p><b>RESULTS</b>The lymph node metastasis rate of stage T2 rectal cancer was significantly higher than that of stage T1[22.9% (108/463) vs. 9.7%(11/113), P=0.002], and the difference of stage T2a and T2b was not significant[22.0%(38/173) vs. 23.4% (68/290), P=0.733]. Multivariate analysis showed that poor differentiation(HR=1.54, 95% CI:1.12 to 2.13), abnormal carbohydrate antigen (CA) 199 level (HR=2.05, 95% CI:1.16 to 3.62), ulcerative mass (HR=1.58, 95% CI:1.05 to 2.39) and invasion of muscle (of inner ring muscle HR=3.55, 95% CI:1.79 to 7.02; of outer longitudinal muscle, HR=2.35, 95% CI:1.21 to 4.60) were independent risk factors of lymph node metastasis in patients with stage T1-T2 rectal cancer(all P<0.05). Meanwhile poor differentiation(HR=4.43, 95% CI:1.51 to 13.03), abnormal carcinoembryonic antigen(CEA) level (HR=4.66, 95% CI:1.18 to 20.11) and ulcerative mass (HR=6.23, 95% CI:1.51 to 25.66) were risk factors of lymph node metastasis in patients with stage T1 rectal cancer.</p><p><b>CONCLUSION</b>Poor differentiation, preoperative high CA199, ulcerated tumor, invasion of inner ring muscle or outer longitudinal muscle are risk factors of lymph node metastasis in patients with stage T1-T2 rectal cancer, while the invasion depth of muscularis propria is not risk factor. Besides, poor differentiation, abnormal CEA level, ulcerated tumor are risk factors of lymph node metastasis in stage T1 rectal cancer patients, which can be used as reference for local excision in patients with stage T1 rectal cancer.</p>

Practice and investigation of clinical teaching mode of standardized treatment in colorectal cancer for fellows in training / 中华胃肠外科杂志

A new clinical teaching mode of standardized treatment in colorectal cancer for fellows in training is reported here with good results. This one-year program included medical ethics education, humanistic management, pre job training, clinical thinking mode, surgery teaching, and computerized teaching. This new clinical teaching mode with distinct features is effective and introduced in this article.

Comparison of oncologic clearance and long-term outcomes of laparoscopic surgery versus open surgery in radical resection of rectal cancer / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To compare the oncologic clearance and long-term outcomes between laparoscopic surgery and open surgery in radical resection of rectal cancer.</p><p><b>METHODS</b>Clinicopathological and follow-up data of 1184 cases with rectal cancer undergoing radical resection from July 2005 to December 2011 were analyzed retrospectively. According to the surgical method, cases were divided into laparoscopy group (104 cases) and open group(1080 cases). Demographics, number of harvested lymph nodes, distance between distal margin and tumor, incidence of anastomotic complications, disease-free survival (DFS) and overall survival(OS) were compared between the two groups.</p><p><b>RESULTS</b>There were no significant differences in the number of harvested lymph nodes (15.5 vs. 14.4, P>0.05), length of distal margin (2.5 cm vs. 2.1 cm, P>0.05) and incidence of anastomotic complications (1.9% vs. 1.9%, P>0.05) between the two groups. And there were no significant differences in DFS and OS between the two groups (both P>0.05). The 3-year and 5-year DFS in laparoscopy group were 79.0% and 69.3%, and were 78.0% and 72.5% in open group. The 3-year and 5-year OS in laparoscopy group were 93.5% and 81.2%, which were 87.6% and 80.7% in open group. There were no significant differences in DFS and OS after stratification by TNM stage.</p><p><b>CONCLUSION</b>The oncologic clearance and long-term outcomes after laparoscopic surgery are comparable with open surgery in radical resection of rectal cancer.</p>

Upper-gastrointestinal polyps found in cases of familial adenomatous polyposis / 中华普通外科杂志

ObjectiveTo discuss the incidence,endoscopic manifestion and pathological features of the upper-gastrointestinal polyps ( stomach and deodenum) in FAP patients. MethodsDuring 2004 -2010 a total 57 FAP patients at Changhai Hospital underwent screening for polyps in upper-gastrointestinal tract by gastroscopy and sideward-viewing duodenoscopy. Biopsies were taken on the polypoid lesions.ResultsGastric polyps were found in 38 patients (67％).Most polyps were located at gastric body and antrum,the pathologic diagnosis was hyperplastic. Duodenal polyps were found in 12 patients (21％) including 7 cases of adenomatous polys. ConclusionsUpper- gastrointestinal polyps are the most common extra-colonic manifestion in FAP. Most stomach polyps are located at gastric body and antrum and are hyperplastic.Polyps at duodenum may be adenomatous,which is a precusor of carcinoma.

A study on the number of lymph node harvested after radical resection of invasive rectal carcinoma / 中华普通外科杂志

Objective To evaluate the number of lymph node harvested during radical resection of invasive rectal carcinoma(stage Ⅰ toⅢ).Methods From January 2000 to June 2008,the pathological data of colorectal carcinoma patients who were operated on were retrospectively reviewed.Exclusion criteria included recurrent colorectal tumor,Tis tumor,R1 or R2 resection,tumor resection transanally or endoscopically,synchronous diseases affecting the surgical procedure for the reetal cancer(familial adenomatous polyposis.synchronous coloreetal carcinoma)and rectal cancer receiving perioperative neoadiuvant chemoradiation.Statistical analysis was performed using Mann-Whitney Test and Chi-Square Test (SPSS 15.0).Results were expressed as mean±SEM.Results A total of 2282 patients were identified.including 1216 cases in the rectal carcinoma group and 1066 cases in the colon carcinoma group.There were no significant difference in gender(719/1216 vs.593/1066,P=0.092)and overall TNM stage (P=0.067)between the two groups.But patients of rectal cancer were younger(58.6±0.4 vs.62.0±0.4.P=0.000).The lymph node retrieval in the rectal carcinoma group was significantly less than that of colon carcinoma group(9.4±0.1 vs.10.5±0.1,P=0.000).There were significantly less rectal cancer patients with a 1ymph node harvest equal to or more than 12 nodes(P=0.000).Patients in the low rectal cancer group(≤7 cm from the anal verge.n=834)had less lymph nodes harvested than the mid-high rectal cancer group(＞7 am and≤15 cm from the anal verge.n=382)(9.2±0.1 vs.9.9±0.2,P=0.009).Conclusion The lymph node harvest in the rectal carcinoma group was significantly less than that in the colon carcinoma group.A new standard may be necessary to define the adequate number of lymph nodes for rectal cancer.

Natural orifice transluminal endoscopic surgery on animal models / 中华消化内镜杂志

Objective To evaluate the safety and feasibility of natural orifice transluminal endoscopic surgery(NOTES)with current available techniques and endoscopic accessories.Methods Transgastric and transvaginal endoscopic abdominal cavity exploration were performed in 6 female pigs.A needle-knife and a ERCP scalpel were used to make an anterior gastric wall incision,and a dilating balloon to expand the passage,through which a therapeutic gastroscope was sent into the abdominal cavity to seek the target organ.Partial liver resection was performed in 2 cases.For incision closure,a clip was applied to the incision orifice or it was just given putting-aside therapy.One week later,the abdominal cavity was examined via vagina.Another week later,it was observed via other incision of the stomach.Four weeks after the operation,the pigs were sacrificed.Adhesion,injury to the organs and closure of the incision were evaluated.Results Transgastric procedures were performed 12 times and transvaginal procedures 6 times.Mean operation time via stomach was 33.4±10.9 min.and that via vagina WaS 10.1±2.5 min.All animals recovered and gained weight after the operation.The incision healed up with no obvious complications.Re-exploration showed adhesion of various degrees,no effusion,or injury to the organs were observed.Ketamine plus propofol achieved satisfactory anesthetic effect with no complications.One of the two animals which underwent liver partial resection died of disphragmatic muscle perforation.Hemarrhage occurred twice,both in the procedures via satisfied.One case developed abdominal abscess.Conclusion It Was feasible and safe to perform NOTES via transgastric and transvaginal approach to the abdominal cavity and liver resection.But development of NOTES specific instruments is essential to the procedure.

Laparoscopy-assisted trans-gastric endoscopic biopsy of retroperitoneal lymph node:a report of 1 case in human being / 中华消化内镜杂志

Objective To evaluate the feasibility of getting retroperitoneal lymph node biopsy via technique of natural orifice transluminal endoscopic surgery(NOTES)in human being with current available devices.Methods We performed trans-gastric endoscopic biopsy of retroperitoneal lymph node with the aid of laparoscopy in a 50-year-old man,who presented with abdominal pain and enlarged retroperitoneal lymph nodes and signed a written informed consent before the procedure.After routine anesthesia and abdominal skin sterilization,a pneumoperitoneum was induced with a Veress needle placed in the umbilical area,followed by the introduction of a 5-mm trocar.Gastral cavity Was sterilized with antibiotics and povidone iodine.Under laparoscopie optical control,we made a styliform incision in the anterior wall of gastric corpus with a needle knife,and enlarged the incision by a dilatation balloon and then entered the peritoneal cavity with a sterile endoscope.We got two biopsies from the enlarged lymph node with a heat forceps assisted by laparoscopy.The specimen was taken out by retrieval basket through the stomach.The gastric incision Was closed with metal clips.Results The biopsy by means of NOTES was successfully performed without intra-or postoperative complications.The diagnosis was confirmed as lymphoma pathologically.The patient received chemotherapy and was discharged on the sixth postoperative day.There was no short or long-term complication.Conclusion Transgastric access for laparoscopy-assisted biopsy of retroperitoneal lymph node is feasible and safe in human being.