Simple instruments facilitating achievement of transanal total mesorectal excision in male patients.

AIM: To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer. METHODS: A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated. RESULTS: All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130). CONCLUSION: Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors.

Prognostic Value of Lymph Node Ratio in Locally Advanced Rectal Cancer Patients After Preoperative Chemoradiotherapy Followed by Total Mesorectal Excision.

Although the absolute number of positive lymph nodes (LNs) has been established as 1 of the most important prognostic factors in rectal cancers, many researchers have proposed that the lymph node ratio (LNR) may have better predicted outcomes. We conducted a retrospective study to compare the predictive ability of LNR and ypN category in rectal cancer. A total of 264 locally advanced rectal cancer (LARC) patients who underwent preoperative chemoradiotherapy (CRT) followed by total mesorectal excision (TME) between 2005 and 2012 were reviewed. All patients were categorized into 3 groups or patients with metastatic LNs were categorized into 2 groups according to the LNR. The prognostic effect on overall survival (OS) and disease-free survival (DFS) was evaluated. With a median follow-up of 45 months, the OS and DFS were 68.4% and 59.3% for the entire cohort, respectively. The respective 5-year OS and DFS rates for the 3 groups (LNR = 0, 0 < LNR ≤ 0.20, and 0.20 < LNR ≤ 1.0) were as follows: 83.2%, 72.6%, and 49.4% (P < 0.001) and 79.5%, 57.3%, and 33.5% (P < 0.001), respectively. Multivariate analysis revealed that LNR and differentiation, but not the number of positive LNs, had independent prognostic value for OS (hazard ratio [HR] = 2.328, 95% confidence interval [CI]: 1.850-4.526, P < 0.001) and DFS (HR = 3.004, 95% CI: 1.616-5.980, P < 0.001). As for patients with positive LNs, the respective 5-year OS and DFS rates for the 2 groups (0 < LNR ≤ 0.20, and 0.20 < LNR ≤ 1.0) were 72.6% and 49.4% (P < 0.001) and 57.3% and 33.5% (P < 0.001), respectively. Multivariate analysis revealed that only LNR was an independent factor for OS (HR = 3.214, 95% CI: 1.726-5.986, P < 0.001) and DFS (HR = 4.230, 95% CI: 1.825-6.458, P < 0.001). Subgroups analysis demonstrated that the ypN category had no impact on survival whereas increased LNR was a significantly prognostic indicator for worse survival in the LNs < 12 subgroup. LNR is an independent prognostic factor in LARC patients treated with preoperative CRT followed by TME. It may be a better independent staging method than the number of metastatic LNs when <12 LNs are harvested after preoperative CRT.

[A procedure to assist achievement of total mesorectal excision through the extending intersphincteric plane].

OBJECTIVE: To investigate the value of assisted achievement total mesorectal excision (TME) through the extending intersphincteric plane. METHODS: From February 2006 to April 2010, 65 patients with low rectal cancer underwent assisted implementing TME through the extending intersphincteric plane under direct vision and achieved sphincter preservation. The clinical data was summarized and analyzed retrospectively. Follow-up visits were conducted on complications and oncological outcomes. RESULTS: The mean operation time was (245 ± 42) minutes, and the mean intraoperative blood loss was (114 ± 76) ml. There was no postoperative mortality. Postoperative complications included 2 cases of anastomotic leak, 13 cases of anastomotic stenosis, 2 cases of early postoperative inflammatory ileus, 1 case of urinary tract infection, and 1 case of incision infection. Distal margins and circumferential resection margin of all specimens were negative. For pathological stage, there were 26 cases at stage pTNMI, 17 cases at stage pTNMII and 22 cases at stage pTNMIII. The mean follow-up time was (47.9 ± 18.9) months. 10 patients were lost to follow up, 15 cases had distant metastasis or local recurrence in, and 8 cases died of tumor metastasis at the latest follow up. Local recurrence occurred in 3 cases, including recurrence in presacral region, metastasis of lymph node at the left side in pelvis cavity, and metastasis at the sacrum at 35, 36, and 52 months postoperatively. There was no anastomotic recurrence. Log-rank survival analysis showed 5-year cumulative survival rate was 100%, 93.3%, and 63.1% in TNM stage I, II, and III, respectively. The cumulative disease-free survival rate was 96.2%, 83.3%, 44.8% in TNM stage I, II, and III, respectively. CONCLUSION: It has a good oncological effect and was an advantageous procedure to assist achievement total mesorectal excision (TME) through the extending intersphincteric plane as surgeons encountered with difficulties from transabdominal TME.

[Laparoscopic total mesorectal excision combined with intersphincteric resection for ultra-low rectal cancer].

OBJECTIVE: To evaluate clinical outcomes after laparoscopic total mesorectal excision (TME) combined with intersphincteric resection (ISR) for ultra-low rectal tumors. METHODS: Clinical data of 36 patients with ultra-low rectal tumor undergoing laparoscopic TME combined with ISR were analyzed retrospectively. RESULTS: The median distance from the inferior margin of the tumor to the anal verge was 3.4 (2.0-5.0) cm. There were 33 cases of well/moderately differentiated adenocarcinoma and 3 rectal malignant villous adenoma. There were 16 patients with stage I disease, 15 with stage II A, 3 with stage III A, and 1 with III B. Postoperatively, one patient developed stenosis at the end ileostomy and 3 anastomotic leakage. After a median follow-up of 16(4-49) months, one patient developed local recurrence at the anastomosis and one case died of liver metastasis. In the 19 patients who had a minimum follow-up of one year, the bowel movements frequency ranged from 1-4 times per day, and these patients were able to withhold defecation for more than 5 minutes. CONCLUSIONS: Laparoscopic TME combined with ISR can achieve oncologic clearance, sphincter preservation, and minimal invasiveness for ultra-lower rectal cancer. However, patients selection should be cautious.

[Value of protective stoma in intersphincteric resection for ultra-low rectal cancer].

OBJECTIVE: To investigate the value of protective stoma in intersphincteric resection (ISR) for ultra-low rectal cancer. METHODS: Clinical data of 56 ultra-low rectal cancer patients without involvement of external anal sphincter treated during January 1999 to July 2009 with trans-anal ISR plus trans-abdominal total mesorectum excision and coloanal anastomosis were retrospectively analyzed. The patients were divided into two groups based on whether they received protective ostomy: ostomy group (16 cases) and ostomy-free group (40 cases). The postoperative complications as well as anal functional restoration were compared between the two groups. RESULTS: Sixteen cases (32.1%) of the 56 patients received protective stoma. The complication rate of anastomosis and anus complication rate in the ostomy-free group were significantly higher than those in ostomy group [35.0% (14/40) and 40.0% (16/40) vs. 1/16 and 1/16; P < 0.05]. In the ostomy-free group, one patient developed anastomotic dehiscence and tumor recurrence, the patients was given permanent colostomy, and the other three patients with lesions in the anastomosis and anus received ostomy and secondary surgical treatment, with a reoperation rate of 10.0% (4/40). The anal function of patients in the two groups were both decreased after the operation. The rate of patients got Kirwan grade I anal sphincter function in the 3rd, 6th and 12th month after protective stoma operation was 11/16, 13/15 and 11/13 in the ostomy group, respectively; and those were 30.0%, 37.5% and 45.0% in the ostomy-free group, respectively. Anal function was significantly better in the ostomy group than that in the ostomy-free group during the same postoperative period (P < 0.05). CONCLUSION: Protective stoma can avoid anastomotic leakage following ISR for ultra-low rectal cancer, and alleviate the suffering of anal incontinence in the early postoperative period, and is conducive to the restoration of anal function.

[Application of Altemeier procedure in the emergent management of acute incarcerated rectal prolapse].

OBJECTIVE: To evaluate the perineal rectosigmoidectomy(Altemeier procedure) in the emergent management of acute incarcerated rectal prolapse. METHODS: Clinical and follow-up data of 9 patients with acute incarcerated rectal prolapse undergone Altemeier procedure were retrospectively analyzed. RESULTS: The mean operation time was 1.7 (range 1.0-1.5) hours. The mean total blood loss during surgery was 109 (50-200) ml. The mean time to the first bowel movements was 2.8(1-6) days after surgery. The hospital stay was 5.3(3-10) days. There were no postoperative complications such as anastomotic leakage, intra-abdominal infection, or urogenital dysfunction. One patient developed thrombosis in the mesorectum and one patient had symptoms of anal discomfort. After a mean follow-up of 3.5(5 months-6.5 years) years, no patient had recurrent prolapse. Six months after operation, anal function was Kirwan grade I( in 8 cases and grade II( in 1 case. All the patients were satisfied with the result. CONCLUSION: Altemeier procedure can result in good postoperative anal function when treating incarcerated rectal prolapse, which should be the first choice in emergency treatment.

[Combination of trans-anal intersphincteric resection and trans-abdominal total mesorectal excision for anus-retained ultra-low rectal tumors].

OBJECTIVE: To study the combination of trans-anal intersphincteric resection and transabdominal total mesorectal excision for anus-retained ultra-low rectal tumors. METHODS: Clinical data of 34 ultra-low rectal tumor patients without external anal sphincter involved, who underwent the combination surgery, were retrospectively analyzed. RESULTS: The distance from the distal incisal margin of the rectum to the inferior margin of the tumor ranged from 1.8 cm to 3.0 cm on an average of 2.1 cm. For pathological types, there were 23 cases of adenocarcinoma (9 well differentiated and 14 moderately differentiated), 1 papillary carcinoma, 2 rectal stromal tumor, 5 rectal villous adenoma with neoplasia and 3 giant villous adenoma. For pathological stages, there were 18 cases at stage pTNM I, 5 at IIA, 1 at IIB, 4 at IIIA, 1 at III and for T grading, there were 15 cases at stage T1, 5 at T2, 8 at T3, 1 at T4. In these 34 patients, there were 3 cases with postoperative anastomotic stenosis, 2 with postoperative anastomotic rupture, 2 with rectovaginal fistula and no operative death. Because of the dysfunction of bowel control, bowel frequency varied from 3 to 12 in the early stage after operation, but with the recovery of anus function, bowel frequency decreased and ranged form 1 to 5 times a day and the time of formed bowel control could be more than 5 min in 6-12 months after operation. However, patients underwent total resection of internal anal sphincter still suffered from incontinence of loose stool after 1 year. After operation, anastomotic recurrence was found in 1 case in 5 months, liver metastasis in 1 case in 10 months and 28 months respectively, cardiac sudden death in 1 case in 26 months. CONCLUSION: The combination of trans-anal ISR and trans-abdominal TME for anus-retained ultra low rectal tumor is not only coincident with radical tumor principle but also retains the function of anus, on the premise of the strict indication.

[Clinical application of intersphincteric resection in the anal-preserving operation for ultra-low rectal carcinoma].

OBJECTIVE: To investigate the clinical application of intersphincter resection (ISR) combined with total mesorectal excision (TME) and colon-anal anastomosis in the treatment for ultra-low rectal carcinoma. METHODS: To review and analyze retrospectively the data of 34 patients with ultra-low rectal carcinoma (without external anal sphincter involvement) who received treatment of ISR, TME and colon-anal anastomosis. RESULTS: Partial resection of internal sphincter was performed in the patients with a distal edge of the tumor greater than or equal to 2 cm from the dentate line. Subtotal removal of the rectum was performed between 1 cm and 2 cm. Total resection was performed in less than 1 cm or involvement of dentate line. Reconstruction of digestive tract was done by manual colon-anal anastomosis. The average distance from distal excised margin to the tumor was 2.3 (1.8 - 3.2) cm among 34 patients. The pathological types were as follows: 28 cases of adenocarcinoma (11 were well differentiated, 17 moderately differentiated), 1 case of papillary carcinoma and 5 cases of villous adenoma with malignant change. The postoperative pathological stages were: Dukes stage A in 28 cases, stage B in 1 and stage C in 5 cases. The pTNM staging was 28 cases in phase I, 1 in phase IIa, 4 in phase IIIa and 1 in phase IIIb. The T stages of the patients were as following: 16 Tl, 17 T2 and 1 T3. Postoperative anastomotic stenosis occurred in 3 cases, anastomotic dehiscence in 2 cases and rectovaginal fistula in 2 cases. The ability of controlling feces of patients decreased significantly in the early postoperative period, and restored gradually at 6 to 12 months after operation. Anastomotic recurrence occurred in 1 case at 5 months after operation and liver metastasis in 1 case at 40 months. CONCLUSION: With strictly grasping indications, radical resection can be attained and anal sphincter preserved by ISR combined with TME and colon-anal anastomosis. It is an effective sphincter-preserving operation.

Multi-central randomized controlled trials of electroacupunture at Zhigou (TE 6) for treatment of constipation induced by stagnation or deficiency of qi / 中国针灸

<p><b>OBJECTIVE</b>To assess the therapeutic effect and safety of electroacupuncture (EA) at Zhigou (TE 6) on constipation induced by stagnation or deficiency of qi.</p><p><b>METHODS</b>Multi-central randomized controlled trials were adopted and the patients conforming to the criteria for diagnosis, enrolling and excluding were divided into an observation group and a control group according to random number table. The observation group were treated with EA at Zhigou (TE 6) and the control group with EA at non-acupoint for 4 weeks. The cumulative score of clinical symptoms, colon transmission test and various safety indexes were assessed. The following-up was carried out 1 and 3 months after the end of treatment.</p><p><b>RESULTS</b>EA at Zhigou (TE 6) could obviously improve clinical symptoms and colon transmission time, decrease using rate of Kaisailu and cathartics, with an effective rate of 94.4%, which was better than 61.3% in the control group (P < 0.0001).</p><p><b>CONCLUSION</b>EA at Zhigou (TE 6) has a function of regulating qi and relaxing the bowels and it is an effective method for treatment of constipation with safety and no adverse effect.</p>

Controlled study on the needling method for regulating the spleen and stomach for treatment of diabetic retinopathy / 中国针灸

<p><b>OBJECTIVE</b>To probe clinical therapeutic effect of acupuncture on diabetic retinopathy and the mechanism.</p><p><b>METHODS</b>One hundred and twenty cases of diabetic retinopathy were randomly divided into an observed group and a control group, 60 cases in each group. On the basis of routine diabetic treatment, the observation group were treated with the acupoints for regulating the spleen and stomach, and the control group with the acupoints around eye mainly. Clinical therapeutic effect was evaluated by eye fundus condition, blood glucose, blood lipids, nitric oxide (NO) and endothelin (ET) levels.</p><p><b>RESULTS</b>The needling method for regulating the spleen and stomach not only can improve the eye fundus condition, but also has benign regulative action on metabolism of blood glucose and blood lipids, and NO and ET levels, with significant differences as compared with those in the control group (P < 0.05, P < 0.01).</p><p><b>CONCLUSION</b>The needling method for regulating the spleen and stomach is an effective therapy for diabetic retinopathy, and the mechanism is possibly related with the regulation of levels of vascular active substances, NO and ET.</p>

Clinical observation on acupuncture for treatment of bronchial asthma at acute stage / 中国针灸

<p><b>OBJECTIVE</b>To observe effect of acupuncture on asthma at acute stage.</p><p><b>METHODS</b>Ninety cases of asthma at acute stage were randomly divided into an observation group of 60 cases and a control group of 30 cases. Clinical therapeutic effect and the mechanisms were studied from symptoms and signs, pulmonary function and serum interleukin -4 (IL-4), gamma-interferon (INF-gamma).</p><p><b>RESULTS</b>The pulmonary function was improved, the vital capacity was increased and attack of asthma was reduced in both the observation group and the control group, but the observation group was better than the control group in the pulmonary function improving degree (P < 0.05).</p><p><b>CONCLUSION</b>Acupuncture can strengthen the relieving action of medicine on asthma and it is one of effective methods for bronchial asthma.</p>