Analysis of prognosis and influencing factors of No. 253 lymph node metastasis in descending colon, sigmoid colon, and rectal cancer: a multicenter study / 中华外科杂志

Objectives: To analyze the influencing factors of No. 253 lymph node metastasis in descending colon cancer, sigmoid colon cancer, and rectal cancer, and to investigate the prognosis of No. 253 lymph node-positive patients by propensity score matching analysis. Methods: A retrospective analysis was performed on clinical data from patients with descending colon cancer, sigmoid colon cancer, rectosigmoid junction cancer, and rectal cancer who underwent surgery between January 2015 and December 2019 from the Cancer Hospital of the Chinese Academy of Medical Sciences, China-Japan Friendship Hospital, Peking Union Medical College Hospital, General Hospital of the Chinese People's Liberation Army, and Peking University Cancer Hospital. A total of 3 016 patients were included according to inclusion and exclusion criteria, comprising 1 848 males and 1 168 females, with 1 675 patients aged≥60 years and 1 341 patients aged<60 years. Clinical and pathological factors from single center data were subjected to univariate analysis to determine influencing factors of No. 253 lymph node metastasis, using a binary Logistic regression model. Based on the results of the multivariate analysis, a nomogram was constructed. External validation was performed using data from other multicenter sources, evaluating the effectiveness through the area under the receiver operating characteristic curve and the calibration curve. Using data from a single center, the No. 253 lymph node-positive group was matched with the negative group in a 1∶2 ratio (caliper value=0.05). Survival analysis was performed using the Kaplan-Meier method and Log-rank test. The Cox proportional hazards model was used to determine independent prognostic factors. Results: (1) The tumor diameter≥5 cm (OR=4.496,95%CI:1.344 to 15.035, P=0.015) T stage (T4 vs. T1: OR=11.284, 95%CI:7.122 to 15.646, P<0.01), N stage (N2 vs. N0: OR=60.554, 95%CI:7.813 to 469.055, P=0.043), tumor differentiation (moderate vs. well differentiated: OR=1.044, 95%CI:1.009 to 1.203, P=0.044; poor vs. well differentiated: OR=1.013, 95%CI:1.002 to 1.081, P=0.013), tumor location (sigmoid colon vs. descending colon: OR=9.307, 95%CI:2.236 to 38.740, P=0.002), pathological type (mucinous adenocarcinoma vs. adenocarcinoma: OR=79.923, 95%CI:15.113 to 422.654, P<0.01; signet ring cell carcinoma vs. adenocarcinoma: OR=27.309, 95%CI:4.191 to 177.944, P<0.01), and positive vascular invasion (OR=3.490, 95%CI:1.033 to 11.793, P=0.044) were independent influencing factors of No. 253 lymph node metastasis. (2) The area under the curve of the nomogram prediction model was 0.912 (95%CI: 0.869 to 0.955) for the training set and 0.921 (95%CI: 0.903 to 0.937) for the external validation set. The calibration curve demonstrated good consistency between the predicted outcomes and the actual observations. (3) After propensity score matching, the No. 253 lymph node-negative group did not reach the median overall survival time, while the positive group had a median overall survival of 20 months. The 1-, 3- and 5-year overall survival rates were 83.9%, 61.3% and 51.6% in the negative group, and 63.2%, 36.8% and 15.8% in the positive group, respectively. Multivariate Cox analysis revealed that the T4 stage (HR=3.067, 95%CI: 2.357 to 3.990, P<0.01), the N2 stage (HR=1.221, 95%CI: 0.979 to 1.523, P=0.043), and No. 253 lymph node positivity (HR=2.902, 95%CI:1.987 to 4.237, P<0.01) were independent adverse prognostic factors. Conclusions: Tumor diameter ≥5 cm, T4 stage, N2 stage, tumor location in the sigmoid colon, adverse pathological type, poor differentiation, and vascular invasion are influencing factors of No. 253 lymph node metastasis. No. 253 lymph node positivity indicates a poorer prognosis. Therefore, strict dissection for No. 253 lymph node should be performed for colorectal cancer patients with these high-risk factors.

Development and validation of a prognostic prediction model for patients with stage Ⅰ to Ⅲ colon cancer incorporating high-risk pathological features / 中华外科杂志

Objective: To examine a predictive model that incorporating high risk pathological factors for the prognosis of stage Ⅰ to Ⅲ colon cancer. Methods: This study retrospectively collected clinicopathological information and survival outcomes of stage Ⅰ~Ⅲ colon cancer patients who underwent curative surgery in 7 tertiary hospitals in China from January 1, 2016 to December 31, 2017. A total of 1 650 patients were enrolled, aged (M(IQR)) 62 (18)years (range: 14 to 100). There were 963 males and 687 females. The median follow-up period was 51 months. The Cox proportional hazardous regression model was utilized to select high-risk pathological factors, establish the nomogram and scoring system. The Bootstrap resampling method was utilized for internal validation of the model, the concordance index (C-index) was used to assess discrimination and calibration curves were presented to assess model calibration. The Kaplan-Meier method was used to plot survival curves after risk grouping, and Cox regression was used to compare disease-free survival between subgroups. Results: Age (HR=1.020, 95%CI: 1.008 to 1.033,P=0.001), T stage (T3:HR=1.995,95%CI:1.062 to 3.750,P=0.032;T4:HR=4.196, 95%CI: 2.188 to 8.045, P<0.01), N stage (N1: HR=1.834, 95%CI: 1.307 to 2.574, P<0.01; N2: HR=3.970, 95%CI: 2.724 to 5.787, P<0.01) and number of lymph nodes examined (≥36: HR=0.438, 95%CI: 0.242 to 0.790, P=0.006) were independently associated with disease-free survival. The C-index of the scoring model (model 1) based on age, T stage, N stage, and dichotomous variables of the lymph nodes examined (<12 and ≥12) was 0.723, and the C-index of the scoring model (model 2) based on age, T stage, N stage, and multi-categorical variables of the lymph nodes examined (<12, 12 to <24, 24 to <36, and ≥36) was 0.726. A scoring system was established based on age, T stage, N stage, and multi-categorical variables of lymph nodes examined, the 3-year DFS of the low-risk (≤1), middle-risk (2 to 4) and high-risk (≥5) group were 96.3%(n=711), 89.0%(n=626) and 71.4%(n=313), respectively. Statistically significant difference was observed among groups (P<0.01). Conclusions: The number of lymph nodes examined was an independent prognostic factor for disease-free survival after curative surgery in patients with stage Ⅰ to Ⅲ colon cancer. Incorporating the number of lymph nodes examined as a multi-categorical variable into the T and N staging system could improve prognostic predictive validity.

Observation of acupoint application of gel plaster on insomnia / 中国针灸

OBJECTIVE@#To observe the effect of acupoint application of gel plaster on quality of sleep and life in patients with insomnia.@*METHODS@#A total of 63 patients with insomnia were randomized into a gel plaster group (32 cases, 1 case dropped off) and a placebo plaster group (31 cases). Acupoint application of gel plaster was applied at Yintang (GV 29) and Yongquan (KI 1) in the gel plaster group, placebo plaster was applied at the same acupoints in the placebo plaster group. The treatment was given from bedtime to early moming of the next day, 5 days were as one course, with 2-day interval, totally 4 courses were required in the both groups. Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS) and Flinders fatigue scale were used to evaluate the sleep quality and fatigue level of the patients in the both groups before and after treatment and at 2 weeks of follow-up. The variations of insomnia TCM syndrome score and the 36-item short-form health survey (SF-36) score before and after treatment were observed.@*RESULTS@#Compared before treatment, the scores of PSQI, ESS and FFS after treatment and at follow-up were decreased in the both groups (@*CONCLUSION@#Acupoint application of gel plaster can effectively improve the quality of sleep and life in patients with insomnia.

Inhibition of the Hedgehog Signaling Pathway Depresses the Cigarette Smoke-Induced Malignant Transformation of 16HBE Cells on a Microfluidic Chip / 中华医学杂志(英文版)

<p><b>Background</b>The hedgehog signaling system (HHS) plays an important role in the regulation of cell proliferation and differentiation during the embryonic phases. However, little is known about the involvement of HHS in the malignant transformation of cells. This study aimed to detect the role of HHS in the malignant transformation of human bronchial epithelial (16HBE) cells.</p><p><b>Methods</b>In this study, two microfluidic chips were designed to investigate cigarette smoke extract (CSE)-induced malignant transformation of cells. Chip A contained a concentration gradient generator, while chip B had four cell chambers with a central channel. The 16HBE cells cultured in chip A were used to determine the optimal concentration of CSE for inducing malignant transformation. The 16HBE cells in chip B were cultured with 12.25% CSE (Group A), 12.25% CSE + 5 μmol/L cyclopamine (Group B), or normal complete medium as control for 8 months (Group C), to establish the in vitro lung inflammatory-cancer transformation model. The transformed cells were inoculated into 20 nude mice as cells alone (Group 1) or cells with cyclopamine (Group 2) for tumorigenesis testing. Expression of HHS proteins was detected by Western blot. Data were expressed as mean ± standard deviation. The t-test was used for paired samples, and the difference among groups was analyzed using a one-way analysis of variance.</p><p><b>Results</b>The optimal concentration of CSE was 12.25%. Expression of HHS proteins increased during the process of malignant transformation (Group B vs. Group A, F = 7.65, P < 0.05). After CSE exposure for 8 months, there were significant changes in cellular morphology, which allowed the transformed cells to grow into tumors in 40 days after being inoculated into nude mice. Cyclopamine could effectively depress the expression of HHS proteins (Group C vs. Group B, F = 6.47, P < 0.05) and prevent tumor growth in nude mice (Group 2 vs. Group 1, t = 31.59, P < 0.01).</p><p><b>Conclusions</b>The activity of HHS is upregulated during the CSE-induced malignant transformation of 16HBE cells. Cyclopamine can effectively depress expression of HHS proteins in vitro and prevent tumor growth of the transformed cells in vivo.</p>

Application of laparoscopic technique in acute abdomen of gastrointestinal surgery / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the clinical application of laparoscopy in gastrointestinal abdominal emergency.</p><p><b>METHODS</b>Clinical data of 44 cases with undefined acute abdomen undergoing laparoscopic surgery from October 2008 to October 2011 were analyzed retrospectively. Sixty-five cases treated by regular surgery during the same period were enrolled as controls.</p><p><b>RESULTS</b>In laparoscopic surgery group, 42 cases were diagnosed under laparoscopy(95.5%, 42/44). Thirty-four (77.3%,34/44) patients received operation successfully after diagnosis, including 20 of total laparoscopy, 14 of assistant small incision. Compared with control group, laparoscopic group had shorter length of incision[(6.7±2.2) cm vs. (15.8±3.4) cm], less blood loss[(51.4±30.3) ml vs. (117.9±49.5) ml], faster recovery of postoperative gastrointestinal function[postoperative oral intake(15.0±6.1) d vs. (30.5±8.4) d], shorter hospital stay[(5.6±4.2) d vs. (8.4±4.8) d] (all P<0.05), lower complication rate, and less surgical cost(P>0.05).</p><p><b>CONCLUSION</b>Laparoscopy is safe and effective in treating gastrointestinal abdominal emergency and therapeutic operation can be performed after a definite diagnosis.</p>

Robotic anterior resection of rectal cancer: technique and early outcome / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The Da Vinci system is a newly developed device for colorectal surgery. With advanced stereoscopic vision, lack of tremor, and the ability to rotate the instruments surgeons find that robotic systems are ideal laparoscopic tools. Since conventional laparoscopic total mesorectal excision is a challenging procedure, we have sought to assess the utility of the Da Vinci robotic system in anterior resections for rectal cancer.</p><p><b>METHODS</b>Between November 2010 and December 2011, a total of 22 patients affected by rectal cancer were operated on with robotic technique, using the Da Vinci robot. Data regarding the outcome and pathology reports were prospectively collected in a dedicated database.</p><p><b>RESULTS</b>There were no conversions to open surgery and no postoperative mortality of any patient. Mean operative time was (220 ± 46) minutes (range, 152 - 286 minutes). The median number of lymph nodes harvested was (14.6 ± 6.5) (range, 8 - 32), and the circumferential margin was negative in all cases. The distal margin was (2.6 ± 1.2) cm (range, 1.0 - 5.5 cm). The mean length of hospital stay was (7.8 ± 2.6) days (range, 7.0 - 13.0 days). Macroscopic grading of the specimen was complete in 19 cases and nearly complete in three patients.</p><p><b>CONCLUSIONS</b>Robotic anterior resection for rectal surgery is safe and feasible in experienced hands. Outcome and pathology findings are comparable with those observed in open and laparoscopy procedures. This technique may facilitate minimally invasive radical rectal surgery.</p>

Treatment pattern of adoptive transfer of immune cells and its application in perioperative period for advanced gastric cancer / 中华胃肠外科杂志

Recently immunotherapy for gastrointestinal tumor has rapidly developed, and has improved the effect of cancer comprehensive treatment as an adjunctive therapy in combination with surgery, chemotherapy, and radiation therapy. Adoptive transfer of immune cells is an important treatment method for advanced gastric cancer. In this paper, we reviewed the application of adoptive transfer therapy for advanced gastric cancer in the perioperative period and propose a new model for immunotherapy of advanced gastric cancer based on our experience and the results of clinical experiment.

Analysis of treatment and prognosis in 34 patients with anorectal malignant melanoma / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To explore the prognostic factors of anorectal malignant melanoma (ARMM).</p><p><b>METHODS</b>Medical records and follow-up data of 34 patients with ARMM treated in the Chinese PLA General Hospital from March 1993 to November 2011 were analyzed retrospectively.</p><p><b>RESULTS</b>There were 26 abdominoperineal resections(APR) and 8 wide local excisions (WLE). Twenty patients underwent postoperative adjuvant therapy, including chemotherapy in 14 cases, radiotherapy in 2 cases, traditional Chinese medicine therapy in 4 cases and immunotherapy in 16 cases. Postoperative follow-up was carried out in all the patients and the mean follow-up period was 27 months. The 1-, 3- and 5-year overall survival rates were 76.3%, 39.6% and 20.6% respectively, while the 1-, 3- and 5-year disease-free survival rates were 60.6%, 30.8% and 12.8% respectively. APR and postoperative immunotherapy could significantly reduce the local recurrence rate. According to the Kaplan-Meier method, gross type of tumor, mural involvement, lymph metastasis, and clinical staging had significant effects on overall survival, while lymph metastasis and postoperative immunotherapy on disease-free survival. Cox proportional hazards model indicated that the clinical staging and postoperative immunotherapy were significant predictive factors.</p><p><b>CONCLUSIONS</b>Early diagnosis and correct choice of surgical method are the keys to the treatment. Postoperative immunotherapy can prolong disease-free survival.</p>

Assessment value of preoperative neutrophil-lymphocyte ratio for the prognosis of patients with colorectal cancer after radical operation / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To assess the value of preoperative neutrophil-lymphocyte ratio (NLR) for prognosis in patients with colorectal cancer after radical operation.</p><p><b>METHODS</b>Clinical data of 140 patients with colorectal cancer undergoing radical operation in the Department of General Surgery of General Hospital of PLA from July 2005 to July 2011 were analyzed retrospectively. According to preoperative NLR, patients were divided into the low NLR group (NLR<5, n=105) and the high NLR group (NLR≥5, n=35). The overall 5-year survival rates of two groups were compared and the independent risk factors were examined by univariate analysis and Cox model.</p><p><b>RESULTS</b>The overall 5-year survival rates of the low and high NLR groups were 74.8% and 54.7% respectively with significant difference (P=0.03). Univariate analysis revealed depth of tumor, lymph nodes metastasis, TMN stage and NLR were associated with survival (P<0.05, P<0.01). Cox model showed that NLR was independent risk factor of prognosis (RR=1.068, 95%CI:1.009-1.129, P=0.02).</p><p><b>CONCLUSION</b>Preoperative NLR≥5 predicts poorer prognosis of colorectal cancer patients.</p>

Clinical pathological analysis of rectal cancer lymph node skip metastasis / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze clinical and pathological of lymph node skip metastasis of rectal cancer and discuss the meaning of the high vascular ligation.</p><p><b>METHODS</b>A retrospective analysis of 207 cases for radical resection of rectal cancer was made, meanwhile the skip metastasis of the roots of the inferior mesenteric artery lymph nodes was studied. Combined with clinical data, the relevance of clinical and pathological factors with the skip metastasis was analyzed.</p><p><b>RESULTS</b>The 207 cases of rectal cancer patients surgical resection specimen detected 2305 pieces of lymph node, the transfer of 168 patients with. The statistical analysis found that skip metastasis related with tumor differentiation (χ(2) = 113.65, P = 0.037) and depth of tumor invasion (χ(2) = 108.22, P = 0.042), but gender, age, location, size, preoperative carcinoembryonic antigen level, gross type and tissue types factors were not significantly correlation.</p><p><b>CONCLUSIONS</b>Preoperative differentiation of cancer and tumor invasion depth assessment can help prompt the existence of lymph node skip metastasis. The assessment of the risk of skip metastasis for patients should be performed the high vascular ligation and lymph node dissection.</p>

Application and expectation of robot-assisted operation system in gastrointestinal surgery / 中华胃肠外科杂志

With the development of minimally invasive surgery in China, the da Vinci surgical system was used more and more widely in gastrointestinal surgery. This paper summarizes the development history of the artificial intelligence-assisted surgery system, the application and in the promotion of gastrointestinal surgery in China. Application of this new technology promotes further the innovation and development of minimally invasive surgery, and will drive leap in the field of gastrointestinal minimally invasive surgery.

Combination of single-port thoracoscopy and laparoscopy for the treatment of esophageal carcinoma: report of 6 cases / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To study the feasibility and early results of radical resection of esophageal carcinoma using single-port thoracoscopy combined with laparoscopy.</p><p><b>METHODS</b>From March 2010 to December 2010, 6 patients with esophageal carcinoma underwent radical resection by single-port thoracoscopy combined with laparoscopy in the General Hospital of People's Liberation Army. With the patients at a supine position, laparoscopy was performed to complete stomach mobilization and abdominal lymph node dissection. Thoracoscopy was then carried out with the patients lying on the left to mobilize the esophagus and dissect thoracic lymph nodes. Finally, the stomach was pulled into the thoracic cavity via the hiatus of the diaphragm to construct a tube-like stomach, which was then anastomosed to the esophagus using the OrVil system.</p><p><b>RESULTS</b>No patient was converted to open surgery during the operation. The total operative time ranged from 200 to 320 min. The mean laparoscopic time was 75(range, 45-90) min, and the mean thoracoscopic time 160(120-240) min. The mean intraoperative blood loss was 220(160-300) ml. The mean lymph node retrieval was 12(9-18). No anastomotic fistula, chylothorax, lung infection were found postoperatively.</p><p><b>CONCLUSION</b>After esophageal resection using single-port thoracoscopic and laparoscopy, reconstruction using OrVil system is safe and feasible.</p>

Laparoscopy-assisted D2 radical distal gastrectomy for advanced gastric cancer: initial experience / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Laparoscopy-assisted radical gastrectomy is gaining acceptance for treating early gastric cancer. However, few reports concerning the effectiveness of laparoscopy-assisted D2 radical distal gastrectomy (LADG) for advanced gastric cancer or data comparing the results obtained after open distal gastrectomy (ODG) are yet available. The aim of this study was to evaluate the method, feasibility and clinical result of LADG for advanced gastric cancer.</p><p><b>METHODS</b>A retrospective study was performed comparing LADG and ODG for advanced gastric cancer. Seventy-eight patients who underwent LADG were compared with 90 patients who underwent ODG in terms of pathologic findings, operative outcome, and complications.</p><p><b>RESULTS</b>There was no conversion to open surgery in the LADG group and no postoperative mortality of any patients. There were no significant differences between LADG and ODG in operative time ((245 +/- 35) vs (220 +/- 20) minutes), complication rate (7.7% vs 10.0%), and number of lymph nodes (23.5 +/- 6.0 vs 21.0 +/- 7.5), while the blood loss was less after LADG ((110 +/- 25) vs (196 +/- 30) ml, P < 0.05). The time to postoperative flatus and postoperative hospital stay were shorter after LADG ((73.0 +/- 8.5) vs (102.0 +/- 10.5) hours, and (8.6 +/- 1.2) vs (12.1 +/- 2.5) days, P < 0.05, respectively).</p><p><b>CONCLUSION</b>LADG for advanced gastric cancer is feasible, safe, and minimally invasive.</p>

Laparoscopic repair of incisional hernia with mesh in aged patients / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the methods, safety and efficacy of laparoscopic incisional hernia repair using mesh in aged patients.</p><p><b>METHODS</b>Seventeen aged patients with incisional hernia accepted the laparoscopic mesh herniorrhaphy from November 2004 to June 2006. The clinical data were collected to investigate the effects and feasibility of the procedure.</p><p><b>RESULTS</b>Sixteen patients completed the procedure successfully, 1 cases was converted to open operation because of extensive adhesion intraperitoneally. The operative time was 65 - 132 min (mean, 95 min). Flatus or feces passed at 31 hours and hospital stay was 5 to 7 days after the operation. Post-operative complications: 3 patients suffered pain for more than 3 months and 5 developed seroma. Trocar incision infection occurred in one case. All complications were cured conservatively. No operation death and intestinal fistula occurred. No recurrence occurred during the follow-up period (7 - 26 months, mean, 13 months).</p><p><b>CONCLUSIONS</b>The laparoscopic incisional hernia repair using mesh after complete dissection of adhesion and fixation with stapler and suture is a safe and effective procedure for aged patients.</p>