Tumor recurrence after pathological complete response in locally advanced gastric cancer after neoadjuvant therapy: Two case reports.

BACKGROUND: The pathological complete response (ypCR) rate following neoadjuvant chemotherapy for advanced gastric cancer remains low and lacks a universally accepted treatment protocol. Immunotherapy has achieved breakthrough progress. CASE SUMMARY: We report two female patients with gastric cancer defined as clinical stage cT4N1-2M0. Detection of mismatch repair protein showed mismatch repair function defect, and perioperative treatment with programmed death protein 1 inhibitor combined with S-1+oxaliplatin achieved ypCR. Surprisingly, the patients underwent clinical observation after surgery but developed different degrees of metastasis at ~6 mo after surgery. CONCLUSION: PD-1 inhibitor combined with chemotherapy provides a more strategic choice for comprehensive perioperative treatment of gastric cancer.

Ligation of Intersphincteric Fistula Tract vs Ligation of the Intersphincteric Fistula Tract Plus a Bioprosthetic Anal Fistula Plug Procedure in Patients With Transsphincteric Anal Fistula: Early Results of a Multicenter Prospective Randomized Trial.

OBJECTIVE: The purpose of this study was to compare the ligation of intersphincteric fistula tract (LIFT) with an additional plug (LIFT-plug) in the treatment of transsphincteric anal fistula. SUMMARY BACKGROUND DATA: Both LIFT and LIFT-plug are recently reported effective alternatives of transsphincteric anal fistula. METHODS: This multicenter prospective randomized study (NCT01478139) was conducted at 5 university hospitals throughout China. A total of 235 patients were randomly assigned to undergo LIFT (118 patients) or LIFT-plug (117 patients) between March 2011 and April 2013. The primary outcome measured was primary healing rate at 6 months postoperatively and healing time. Secondary outcomes included recurrence rate, postoperative pain, and incontinence rate. RESULTS: The LIFT procedure showed shorter operative time than the LIFT-plug procedure (26.7 min vs 28.5 min, P = 0.03). Median healing time was 22 days in LIFT-plug group vs 30 days in LIFT group (P < 0.001). The difference in visual analog scale scores across all time points was not statistically significant between the groups (P = 0.13). The primary healing rate was higher in LIFT-plug group than in LIFT group [94.0% (95% confidence interval 89.7%-98.3%) vs 83.9% (95% confidence interval 77.2%-90.6%), P < 0.001]. There were no reported incontinence and recurrence within the follow-up period of 6 months. CONCLUSIONS: In patients with transsphincteric anal fistulas, both LIFT-plug and LIFT are simple, safe, and effective procedures. LIFT-plug has the advantage of a higher healing rate, less healing time, and a lower early postoperative pain score.

Histologic analysis of acellular dermal matrix in the treatment of anal fistula in an animal model.

BACKGROUND: Human acellular dermal matrix (ADM) has been used successfully for the treatment of severe burns, ureter support, and abdominal wall reconstruction. This study was designed to evaluate the mechanism of ADM in the closure of anal fistula in an experimental porcine model. STUDY DESIGN: The fistula-in-ano model was created in the porcine model and treated with ADM in 14 animals. Fistula specimens were obtained at hours 12 and 24 and on days 3, 7, 14, 28, 60. Hematoxylin and eosin staining, Masson trichrome staining, and immunohistochemical staining for alpha smooth muscle actin and matrix metalloproteinase 9 were performed. RESULTS: The cell density increased from hour 12 to day 7 and decreased from day 7 to day 28 (p < 0.001). Mature vessels stained with alpha smooth muscle actin were identified at day 7. Alpha smooth muscle actin-positive myofibroblasts were found in clusters at the edge of the ADM at day 7. The density of vessels (p < 0.001) and myofibroblasts (p < 0.001) increased from day 7 to day 14. The density of matrix metalloproteinase 9 increased from hour 12 to day 7 and decreased from day 14 to day 60 (p < 0.001). Partially organized bundles of muscle were found by day 60. CONCLUSIONS: We suggest that ADM is a reasonable new option for closure of anal fistulas. Anal fistulas begin to heal as early as 12 hours, and day 7 may be an important time point to judge whether the fistula healed preliminarily or not. The ability of ADM to become vascularized and remodeled by autologous cells may be advantageous for anal fistula healing.

Deep venous thrombosis after gastrectomy for gastric carcinoma: a case report.

The treatment of gastric carcinoma consists of neoadjuvant chemoradiation, partial gastrectomy, subtotal gastrectomy, total gastrectomy, extended resection, and postoperative chemotherapy. Currently, gastrectomy and extended lymphadenectomy is the optimal choice for late gastric carcinoma. Postoperative complications are common after total gastrectomy including hemorrhage, anastomotic leakage, fistula, and obstruction. However, deep venous thrombosis (DVT) is an uncommon complication after gastrectomy for gastric carcinoma. We describe a case of a 68-year-old female patient with DVT after gastrectomy for gastric carcinoma. The patient was treated with anticoagulants and thrombolytics and subjected to necessary laboratory monitoring. The patient recovered well after treatment and was symptom-free during a 3-mo follow-up. We conclude that correct diagnosis and treatment of DVT are crucial.

[Application of pelvic floor dynamic MRI combining defecography with homemade high conformable sacculus in the management of obstructed defecation syndrome].

OBJECTIVE: To evaluate the sensitivity and feasibility of pelvic floor dynamic MRI combining defecography with homemade high conformable sacculus in the management of obstructed defecation syndrome. METHODS: One hundred and nine female with pelvic floor disorders, such as difficult defecation, fecal incontinence or urinary incontinence, pelvic pain, were treated from July 2007 to March 2009. Pelvic floor dynamic MRI and defecography with homemade high conformable sacculus was performed in the patients to evaluate pelvic floor anatomy. RESULTS: Fifty-four cases (49.6%) of cystocele and 11 cases (10.1%) of rectouterine pouch hernia, 29 cases (26.6%) of perineum prolapse and 71 cases (65.2%) of rectocele were found by dynamic MRI. The dynamic MRI also revealed 19 cases (18.2%) of external sphincter trophy and 32 cases (29.4%) of spastic pelvic floor syndrome. Compared with defecography, dynamic MRI was more positive in diagnosing enterocele. Defecography Of the patients, sacrum-rectal separate was found in 33 cases (30.3%) and rectal mucosal prolapse or internal rectal intussusceptions in 41 cases (37.7%) by defecography, while dynamic MRI found none. CONCLUSIONS: As a new noninvasive imaging technique to evaluate the pelvic floor function, dynamic MRI is more sensitive, especially for patients with complicated multi-organs prolapse, and its deficiency could be remedied by defecography.

[Application of stapled transanal rectum resection in the treatment of obstructed defecation syndrome].

OBJECTIVE: To evaluate the effectiveness and safety of stapled transanal rectum resection (STARR) in the treatment of obstructed defecation syndrome (ODS). METHODS: Fifty-six patients with ODS who had rectocele and/or intussusception were treated with STARR from January 2007 to August 2008. The incidence of preoperative and postoperative symptoms of ODS was compared. Symptomatic relief was also observed by using scoring system. RESULTS: The average operation time was 28 min, and in the first 3 days after operation the average VAS pain score was 3.2 points. Two patients experienced mild anal incontinence when followed-up to 6 months; 2 patients suffered mild anal pain during defecation due to slight anastomotic inflammation 2 and 4 months after the operation, respectively. No other complications was found. The mean follow-up period was 8 months after surgery, and the rate of symptoms of ODS reduced significantly compared with that before surgery, in particular the incidence of the difficult and obstructive defecation feelings decreased for more than 50 percent (P<0.05). Compared with that before the operation, the sense of no emptying stool decreased for 65 percent and all the other symptoms reduced for more than 72 percent (all P<0.05). CONCLUSION: The stapled transanal rectum resection is simple, less invasive, less painful and with fewer complications and more satisfactory recent effect in treating obstructed defecation syndrome.

An anorectal fistula treatment with acellular extracellular matrix: a new technique.

AIM: To investigate a new technique of the anorectal fistula treatment with acellular extracellular matrix (AEM). METHODS: Thirty patients with anorectal fistula were treated with AEM. All fistula tracts and primary openings were identified using conventional fistula probe. All tracts were curetted with curet and irrigated with hydrogen peroxide and metronidazole. The AEM was pulled into the fistula tract from secondary to primary opening. The material was secured at the level of the primary opening. The excess AEM was trimmed at skin level at the secondary opening. RESULTS: All of the 30 patients had successful closure of their fistula after a 7-14 d follow-up. The healing rate of anal fistula in treatment group was 100%. The ache time, healing time and anal deformation of treatment group were obviously superior to traditional surgical methods. CONCLUSION: Using AEM anal fistula plug in treatment that causes the anorectal fistula is safe and successful in 100% of patients. It can reduce pain, shorten disease course and protect anal function.

Diagnosis and treatment of acute rejection in the first case of human living-related small bowel transplantation with a long-term survival in China.

AIM: To report the comprehensive diagnosis and treatment of acute rejection in the first case of living-related small bowel transplantation with a long-term survival in China. METHODS: A 18-year-old boy with short gut syndrome underwent living-related small bowel transplantation, with the graft taken from his father (44-year old). A segment of 150-cm distal small bowel was resected from the donor. The ileo-colic artery and vein from the donor were anastomosed to the infrarenal aorta and vena cava of the recipient respectively. The intestinal continuity was restored with an end-to-end anastomosis between the recipient jejunum and donor ileum, and the distal end was fistulized. FK506, MMF and prednisone were initially used for post-transplant immunosuppression. Endoscopic observation and mucosal biopsies of the graft were carried out through the terminal ileum enterostomy; serum was collected to detect the levels of IL-2R, IL-4, IL-6 and IL-8. The change of the graft secretion and absorption was observed. RESULTS: Acute rejection was diagnosed promptly and cured. The patient was in good health, 5 years after living-related small bowel transplantation. CONCLUSION: The correct diagnosis and treatment of acute rejection are the key to the long-term survival after living-related small bowel transplantation.