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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.
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Objective To investigate the clinicopathological characteristics,treatment,prognostic factors of primary small intestinal lymphoma (PSIL).Methods The clinical data of 68 patients with PSIL who were admitted to the Cancer Hospital of Tianjin Medical University from November 1999 to July 2009 were retrospectively analyzed.The diagnostic workup before operation included abdominal ultrasound,computed tomography (CT) scan of the abdomen,small intestinal barium radiography,endoscopy examination and laboratory examination.The patients with local PSIL underwent radical surgery,patients who were not eligible for radical surgery received palliative treatment,and then accurate staging was done according to Ann-Arbor system for gastrointestinal lymphoma,and chemotherapy was applied according to the condition of patients.The patients were followed up by letters,telephone and outpatient care till July 2012.Factors might have influence on the prognosis were analyzed by the Kaplan-Meier method and Log-rank test.COX regression model were used for univariate and multivariate analysis,respectively.Results The major symptoms of PSIL included abdominal pain (69.1％,47/68) and weight loss (29.4％,20/68).All of the 68 patients underwent small intestinal barium radiography and endoscopy examination,and 15 and 11 cases were definitely diagnosed as with PSIL.Abdominal mass were detected by abdominal ultrasound in 38 of 45 cases.Positive results were found in 30 cases by CT and 5 cases by positron emission tomography (PET)-CT.PSIL mainly involved ileum (73.5％,50/68),13 PSILs were located at the jejunum and 5 at the duodenum.Of all the 68 patients,64 were with B-cell subtype PSIL and 4 were with T-cell subtype PSIL.Most tumors belonged to stages Ⅰ and Ⅱ (66.2％,45/68).All of the 68 patients were treated with surgical procedure,including 51 patients received radical resection and 17 patients had palliative resection.After operation,4-8 cycles of chemotherapy were applied in 57 patients.Seven patients received COP regimen,50 received CHOP regimen (10 patients with positive expression of CD20 received R-CHOP regimen simutaneously),the remaining 11 patients did not receive chemotherapy.Sixty-four patients were followed up,and the follow-up rate was 94.1％ (64/68).The median follow-up time was 40 months (range,3-132 months).The median survival time was 40.5 months.The 1-,3-,and 5-year overall survival rates were 78.1％,62.2％ and 59.7％,respectively.The prognosis of patients with B-cell subtype PSIL,in stage Ⅰ-Ⅱ and received operation + chemotherapy was superior to those who were with T-cell subtype PSIL,in stage Ⅲ-Ⅳ and received operation (x2=22.459,45.535,15.782,P ＜ 0.05).The results of univariate analysis showed that level of LDH,pathological subtype,clinical stage,presence of systemic symptom,treatment modality,radical surgery and lymphatic metastasis were risk factors for prognosis (x2=7.245,22.459,45.535,5.796,15.782,45.926,9.214,P ＜ 0.05).The results of multivariate analysis revealed B cell phenotype,stage Ⅰ-Ⅱ and surgery + chemotherapy were independent prognostic factors for survival (RR =7.133,5.304,0.256,95％ CI:1.634-31.130,1.498-18.781,0.095-0.691,P ＜ 0.05).Conclusions The major symptoms of PISL include abdominal pain and weight loss.Definite diagnosis of PSIL depends on endoscopy and imaging examination.PSIL mainly involves ileum.Surgery based treatment is the preferred option,and the combined treatment of rituximab with chemotherapy may improve the survival.B-cell phenotype,early clinical stage (Ⅰ-Ⅱ) and surgical resection plus chemotherapy are independent prognostic factors for better survival.