Where is the optimal plane to mobilize the anterior rectal wall in female patients undergoing total mesorectal excision?

BACKGROUND: Since Heald proposed the total mesorectal excision (TME) procedure, the prognosis of patients with rectal cancer has been significantly improved. But Heald did not specifically describe the anterior surgical plane in female patients. And the surgical plane for mobilizing the anterior rectal wall during TME surgery in female patients remains controversial. AIM: To investigate the anatomy of the female pelvis and identify the optimal plane for mobilizing the anterior rectal wall. METHODS: We retrospectively collected surgical procedure videos and clinical data of female patients diagnosed with middle or low rectal cancer who underwent the TME procedure between January 2020 and October 2022 across six hospitals. The patients were divided into two groups based on the surgical approach used to mobilize the anterior rectal wall: The experimental group was to open the peritoneum at the lowest point of the peritonea reflection and enter the plane for mobilizing, while the control group was cut at 0.5-1 cm above the peritoneal reflection and enter another plan. Then, we compared the preoperative and postoperative information between the two groups. We also dissected and observed ten adult female pelvises to analyze the anatomic structure and compare the entry plane between the two approaches. Finally, we researched the pathological structure between the rectum and the vagina. RESULTS: Finally, 77 cases that met the criteria were included in our study. Our observations revealed that the experimental group underwent a smooth procedure, entering the plane amidst the mesorectal fascia and adventitia of the vagina, whereas the control group entered the plane between the vaginal adventitia and muscle layers. Compared to the control group, the experimental group showed a significant decrease in intraoperative bleeding [22.5 (19.5-50) mL vs 17 (5-20) mL, P = 0.01], as well as a shorter duration of hospitalization [9 (7-11.25) d vs 7 (6-10) d, P = 0.03]. Through the examination of surgical videos and cadaveric studies, we discovered that Denonvilliers' fascia is absent in females. Additionally, pathological sections further revealed the absence of Denonvilliers' fascia in females, with only loose connective tissue present between the mesorectal fascia and adventitia of the vagina. CONCLUSION: The plane amidst the mesorectal fascia and vaginal adventitia is the optimal surgical plane to mobilize the anterior rectal wall for female patients undergoing the TME procedure.

Down-regulation of fecal miR-143 and miR-145 as potential markers for colorectal cancer.

OBJECTIVE: To detect 4 MicroRNA (miRNA) in the stool samples of colorectal cancer (CRC) patients to determine whether these miRNAs could be biomarkers in CRC screening or treatment. METHODS: A retrospective comparison study was carried out in the Department of Colorectal Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China from September 2009 to March 2011. We detected 4 miRNAs (miR-143, miR-145, miR-21, and miR-106a) in the stool samples of 38 CRC patients and 13 healthy individuals. Total RNA from the stool samples was extracted using the EZNA TM stool RNA kit R6828-01. The miRNA quantification was carried out using TaqMan miRNA assays and the TaqMan Gene Expression Master Mix. RESULTS: The expression levels of miR-143 and miR-145 in the stool of the CRC patients were lower than in those of the healthy persons (p<0.005, median of 2-∆∆ct). No statistically significant difference was found in the expression levels of both miR-21 and miR-106a between the stool of CRC patients and those of the healthy persons (p>0.05). CONCLUSION: The detection of fecal miRNAs is a potential method for CRC diagnosis or screening. Particularly, the down-regulation of fecal miR-143 and miR-145 could be a potential marker for CRC.

Yiqi zhuyu decoction combined with FOLFOX-4 as first-line therapy in metastatic colorectal cancer.

OBJECTIVE: To evaluate the efficacy and safety of yiqi zhuyu decoction (YZD) combined with oxaliplatin plus 5-flurouracil/leucovorin (FOLFOX-4) in the patients with metastatic colorectal cancer (MCRC). METHODS: A total of 120 patients with MCRC were randomly divided into the experimental group (FOLFOX-4 plus YZD, 60 cases) and the control group (FOLFOX-4 plus placebo, 60 cases), according to the sequence of hospitalization from January 2005 to December 2007. The treatment was supposed to be continued until disease progression (PD) or for 48 weeks (i.e., up to 24 cycles of FOLFOX-4). Response rate (RR), progression-free survival (PFS), overall survival (OS) and adverse events (AEs) were observed. RESULTS: RR was 41.5% in the experimental group and 34.0% in the control group [odds ratio (OR): 1.18, 95% CI: 0.77 to 1.82, P=0.432]. Median PFS were 9.0 months and 8.0 months, respectively [hazard ratio (HR): 0.78, 95% CI: 0.53 to 1.15, P=0.215]. Median OS were 21.0 months and 18.0 months (HR: 0.65, 95% CI: 0.43 to 0.99, P=0.043) and grade 3/4 AEs were 56.6% and 76.7% (OR: 0.61, 95% CI: 0.18 to 0.87, P=0.020), respectively. CONCLUSIONS: YZD combined with FOLFOX-4 chemotherapy significantly improved OS in this first-line trial in the patients with MCRC and significantly decreased grade 3/4 AEs. However, RR was not improved, and PFS did not reach statistical significance by the addition of YZD. The treatment of YZD combined with FOLFOX-4 may be necessary in order to optimize efficacy and safety.

Evolution of the management of colorectal cancer using integrative medicine.

Colorectal cancer (CRC) remains one of the major causes of cancer death worldwide. In recent years, the development of new and effective management options, such as fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET), total mesorectal excision (TME) and monoclonal antibody novel "targeted" therapies has led to a considerable improvement in the outcome of this disease. In China, studies on CRC using integrative medicine (IM) have made remarkable progress. We therefore review the recent developments in CRC treatment through IM and Western medicine, including research studies such as the exploitation of Chinese herbs for the disruption of the tumor cell cycle or inhibition of tumor cell proliferation, induction of tumor cell apoptosis, improvement of the immune system, and the curative effect of chemotherapy. We also examine clinical studies such as those on special prescriptions and medicines and IM in anti-cancer therapy. Particularly, we analyze the advantages and disadvantages of management with IM, and propose a suggestion for the management of colorectal cancer with IM, such as screening for effective prescriptions. We also analyze Chinese medicine, studying the pharmacologic mechanism of its anti-cancer effect, further strengthening the study of IM on CRC.

Clinical study of external application of Qiyu oil gauze for promoting post-operational healing in patients with anal fistula.

OBJECTIVE: To observe the effects of the external application of Qiyu oil gauze (QYOG) for promoting post-operational healing in patients with anal fistula and to explore its mechanism of action so as to provide a beneficial scientific basis for its wide use. METHODS: Sixty patients with anal fistula scheduled to receive simple low anal fistulectomy were equally assigned, according to the sequence of hospitalization, to the tested group and the control group, and their wounds were classified according to longitudinal diameter into three grades (Grade I with a diameter below 2 cm; Grade II, 2-5 cm; and Grade III, over 5 cm). After the operation was completed and the operational wound was sterilized with benzalkonium bromide, the wound substratum was packed with QYOG in the test group and with vaseline gauze in the control group. The packing gauze was changed every day till the wound was healed. The healing time of the patients was observed, and the number of capillaries and positive cell percentages of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and epidermal growth factor (EGF) in wound granulation tissues were counted on the 5th day after the operation. RESULTS: The wound healing time was 17.80+/-5.46 days in the test group, which was significantly shorter than that in the control group (21.90+/-6.32 days, P<0.01). The number of capillaries and positive cell percentages of VEGF and bFGF in wound granulation tissues on the 5th day in the tested group were higher than those in the control group (P<0.01), though the difference in EGF between the two groups was insignificant (P>0.05). CONCLUSION: QYOG could shorten the wound healing time after anal fistulectomy, which suggests that it participates in the stimulation of wound granulation tissues to produce VEGF and bFGF, and thus promotes capillary genesis and improves blood circulation in wounds so as to promote wound healing.