ObjectiveTo explore the causes of colon-anal anastomotic stenosis in patients with low rectal cancer after prophylactic ileostomy under complete laparoscopy. MethodsA total of 194 patients with low rectal cancer who received complete laparoscopic radical resection of rectal cancer combined with preventive ileostomy in our hospital from January 2020 to December 2020 were selected as the study objects, and were divided into non-stenosis group (n=136) and stenosis group (n=58) according to postoperative colon-anal anastomosis stenosis. The clinical data of the two groups were compared. Univariate and multivariate logistic regression were used to analyze the factors affecting postoperative colon-anal anastomotic stenosis, and stepwise regression was used to evaluate the importance of each factor. The risk prediction model of postoperative colon-anal anastomotic stenosis was constructed and evaluated. ResultsIn the stenosis group, the proportion of males, tumor diameter ＞3 cm, NRS2002 score >3 points, manual anastomosis, left colic artery not preserved, anastomotic leakage, pelvic infection and patients undergoing neoadjuvant radiotherapy and neoadjuvant chemotherapy were higher than those in the non-stenosis group (P<0.05). The results of univariate logistic analysis showed that female and preserving the left colonic artery were the protective factors for postoperative colon-anal anastomotic stenosis (P<0.05), and the tumor diameter >3 cm, NRS2002 score >3 points, manual anastomosis, anastomotic leakage, pelvic infection, neoadjuvant radiotherapy and neoadjuvant chemotherapy were the risk factors for postoperative colon-anal anastomotic stenosis (P<0.05). Multivariate logistic regression analysis showed that gender, tumor diameter, NRS 2002 score, anastomotic mode, anastomotic leakage, and pelvic infection were independent influencing factors for postoperative colon-anal anastomotic stenosis (P<0.05). Stepwise regression analysis showed that the top three factors affecting postoperative colon-anal anastomotic stenosis were NRS 2002 score, gender and anastomotic leakage. Multivariate Cox risk proportional model analysis showed that the multivariate model composed of NRS 2002 score, gender and anastomotic leakage had a good consistency in the risk assessment of postoperative colon-anal anastomotic stenosis. Based on this, a risk prediction model for postoperative colon-anal anastomotic stenosis was constructed. The results of strong influence point analysis show that there are no data points in the modeling data that have a strong influence on the model parameter estimation (Cook distance <1). Receiver operating characteristic curve results showed that the model had good differentiation ability, the area under curve was 0.917, 95%CI was (0.891, 0.942). The calibration curve was approximately a diagonal line, showing that the model has good predictive power (Brier value was 0.097). The results of the clinical decision curve showed that better clinical benefits can be obtained by using the predictive model to identify the corresponding risk population and implement clinical intervention. ConclusionThe prediction model based on NRS 2002 score, gender and anastomotic fistula can effectively evaluate the risk of colon-anal anastomotic stenosis after preventive ileostomy in patients with low rectal cancer under complete laparoscopy.
Objective To investigate the risk factors of liver metastasis in patients with middle and low rectal cancer of Ⅱ–Ⅲ stage after preoperative short course radiotherapy combined with chemotherapy. MethodsThe clinical data of 89 patients with middle and low rectal cancer of Ⅱ–Ⅲ stage admitted to the Dongnan Hospital of Xiamen University from January 2019 to June 2020 were retrospectively analyzed. All patients were treated with short-course radiotherapy combined with chemotherapy before operation. The risk factors of postoperative liver metastasis were analyzed by multivariate logistic regression. ResultsThe 89 patients were followed up for 7–53 months, with a median follow-up time of 33 months. During the follow-up period, 25 patients developed liver metastasis, the onset time was 7–35 months, and the median time of liver metastasis was 17 months. Among them, 5 patients (5.6%) developed liver metastasis in the first year after surgery, 15 patients (16.8%) developed liver metastasis at the second year after surgery, 5 patients (5.6%) developed liver metastasis at the 3rd year after surgery. Multivariate logistic regression results showed that lymph node metastasis [OR=3.550, 95%CI (1.425, 8.953), P=0.041], vascular invasion [OR=3.335, 95%CI (1.011, 11.001), P=0.048], maximum tumor diameter ≥5 cm [OR=4.477, 95%CI (1.273, 15.743), P=0.019], and peri-tumor diameter ≥1/2 [OR=4.633, 95%CI (1.387, 15.475), P=0.013] were risk factors for liver metastasis. ConclusionsLymph node metastasis, vascular invasion, maximum tumor diameter ≥5 cm, and circumferential tumor diameter ≥1/2 are risk factors for liver metastasis in patients with middle and low rectal cancer of Ⅱ–Ⅲ stage after preoperative short course radiotherapy combined with chemotherapy.
Objective To approach the curative effect of laparoscopic rectum resection combined with per anus intersphincteric rectal dissection and colo anal anastomosis for patients with ultra-low rectal cancer. Methods Thirteen patients were prospectively studied from June 2005 to December 2007. There were 8 male and 5 female patients, with a mean age of 53 (range, 41-69) years. All the tumors located less than 5 cm above the anal verge. All the patients were treated with general anaesthesia and then went through the following procedures: lied the reverse Trendelenburg reforming lithotomy position, the laparoscope went inside the abdomen through two apertures, the hylus aperture (observing aperture) and the McBurney point aperture (main performing aperture). After the resection through the laparoscope, the operation was translocated to the perineal region, the anus was enlarged to expose the operation area. Results The operation on all cases succeeded, there was no operative mortality, and no stomal leak in all patients. The follow-up duration ranged from 1 to 30 months (mean 17 months). Up to now, one patient developed recurrence in pelvic cavity, and one suffered hepatic metastasis, there was no port-site implantation metastasis， 9 patients had satisfactory functional recovery of anus in the sixth month after operation. Conclusion The therapy laparoscopic rectum resection combined with per anus intersphincteric rectal dissection and colo-anal anastomosis for patients with ultra-low rectal cancer is a safe, minimally invasive, anal-preserving technique with reliablity in curative effect and satisfaction in anal sphincter function.
ObjectiveTo investigate the effect of suprapubic catheterization(SPC) by using central venous catheter (CVC) on the perioperative complications in middle and low rectal cancer surgery. MethodsThe clinical data of 141 patients with middle and low rectal cancer underwent operation in Shengjing Hospital of China Medical University from April 2012 to January 2015 were collected. There were 65 patients performed SPC by using CVC, 76 patients performed routine transurethral catheterization(TUC). The incidences of bacteriuria and urinary retention, recatheterization rate, duration of catheterization, and catheter-related pain were analyzed and compared between these two groups. Results①Compared with the TUC, the SPC by using CVC could significantly reduce the incidence of bacteriuria(P=0.002), espe-cially in female(P=0.006), ≥60 years old(P=0.001), low rectal cancer(P=0.003), open surgery(P=0.018), Miles(P=0.016), and Dixon(P=0.032).②There was no significant difference in the incidence of urinary retention(P=0.464) between the SPC by using CVC and the TUC.③Compared with the TUC, the SPC by using CVC could significantly reduce the inci-dence of recatheterization rate(P=0.001), especially in the patients with male(P=0.016), ≥60 years old(P=0.008), low rectal cancer(P=0.019), laparoscopic surgery(P=0.013), and Miles(P=0.037).④Compared with the TUC, the point of catheter-related pain was significantly lower in the SPC by using CVC(P=0.001), no matter males(P=0.005) or females(P=0.010), aged 60 years and older(P=0.023) or younger(P=0.034), middle rectal cancer(P=0.017) or low rectal cancer(P=0.046), open surgery(P=0.033) or laparoscopic surgery(P=0.021), Dixon(P=0.019) or Miles(P=0.035).⑤The duration of catheterization was similar between the SPC by using CVC and the TUC(P=0.597). ConclusionSPC by using CVC is a safer, more effective and more acceptable method of bladder drainage in middle and low rectal cancer surgery as compared with routine TUC.
ObjectiveTo evaluate the efficacy of robotic intersphincteric resection (ISR) for rectal cancer.MethodsA literature search was performed using the China biomedical literature database, Chinese CNKI, Wanfang, PubMed, Embase, and the Cochrane library. The retrieval time was from the establishment of databases to April 1, 2019. Related interest indicators were brought into meta-analysis by Review Manager 5.2 software.ResultsA total of 510 patients were included in 5 studies, including 273 patients in the robot group and 237 patients in the laparoscopic group. As compared to the laparoscopic group, the robot group had significantly longer operative time [MD=43.27, 95%CI (16.48, 70.07), P=0.002], less blood loss [MD=–19.98.27, 95%CI (–33.14, –6.81), P=0.003], lower conversion rate [MD=0.20, 95%CI (0.04, –0.95), P=0.04], less lymph node harvest [MD=–1.71, 95%CI (–3.21, –0.21), P=0.03] and shorter hospital stay [MD=–1.61, 95%CI (–2.26, –0.97), P<0.000 01]. However, there were no statistically significant differences in the first flatus [MD=–0.01, 95%CI (–0.48, 0.46), P=0.96], time to diet [MD=–0.20, 95%CI (–0.67, 0.27), P=0.41], incidence of complications [OR=0.76, 95%CI (0.50, 1.14), P=0.18], distal resection margin [MD=0.00, 95%CI (–0.17, 0.17), P=0.98] and positive rate of circumferential resection margin [OR=0.61, 95%CI (0.27, 1.37), P=0.23].ConclusionsRobotic and laparoscopic ISR for rectal cancer shows comparable perioperative outcomes. Compared with laparoscopic ISR, robotic ISR has the advantages of less blood loss, lower conversion rate, and longer operation times. These findings suggest that robotic ISR is a safe and effective technique for treating low rectal cancer.
Objective To summarize the assessment methods of anal function after low/ultralow rectal anastomosis in patients with rectal cancer. Methods Domestic and international publications on the study of evaluation of anal function after low/ultralow rectal anastomosis in patients with rectal cancer were collected and reviewed. Results Anal function of patients with rectal cancer was usually evaluated by feeling of discharge, continence, perceptual function of rectum, defecate frequency, and defecation time, anal manometry and three-dimensional vector manometry were used as well. Recovery of anal function in patients with rectal cancer after low/ultralow rectal anastomosis depended on the integrity of anal canal, length of remaining rectum, level of anastomosis, and integrity of mucosa. Conclusions Subjective assessment methods and auxiliary measuring instruments are the common means to evaluate the rectal-anal function. Subjective assessment method is simple and direct, but its accuracy is low; Auxiliary measuring instruments have high accuracy, while their examination costs are high and that of costs are not popular, the new assessment methods are needed for further research.
ObjectiveTo investigate risk factors of anastomotic fistula after total mesorectum excision (TME) in middle and low rectal cancer. MethodsThe clinical data of 446 patients with middle and low rectal cancer received TME surgery from June 2004 to June 2014 were retrospectively analyzed.Single-factor analysis of risk factors was used by χ2 test,multiple-factor analysis was used by logistic regression analysis. ResultsThere were 36 patients with anastomotic fistula in these 446 patients,which of 22 patients were recovered after conservative treatment,of 14 patients were recovered after colostomy.The results of single-factor analysis showed that the age>60 years,preoperative hemoglobin<110 g/L,preoperative albumin<35 g/L,accompanied with diabetes mellitus,neoadjuvant chemoradiation,distance from anasto-mosis to anus<5 cm,non-strengthen suture by hand were the risk factors of anastomotic fistula after TME in the middle and low rectal cancer (P<0.05).The results of multiple-factor analysis showed that the preoperative hemoglobin<110 g/L,preoperative albumin<35 g/L,accompanied with diabetes mellitus,neoadjuvant chemoradiation,and distance from anastomosis to anus<5 cm were the independent risk factors of anastomotic fistula after TME in the middle and low rectal cancer (P<0.05). ConclusionsRisk of anastomotic fistula after TME in middle and low rectal cancer is higher.Basic complications of patient and local conditions of anastomosis,and intraoperative factors could affect incidence of anastomotic fistula,it should be paid enough attention.In general,most of anastomotic fistula could be cured with conservative treatment,in case of conservative treatment is invalid,colostomy is feasible.
ObjectiveTo evaluate the efficacy, safety, and feasibility of fecal drainage technique on rectal anastomosis for preventing anastomotic leakage after operation for middle-low rectal cancer.MethodsThe retrospective analysis was used to collect the middle-low rectal cancer which completed operation in this hospital from 2014 to 2019. According to the way of preventing annstomotic leakage, the patients were divided into two groups: fecal drainage on rectal anastomosis group (Abbreviation: fecal drainage group) and end ileum prophylactic stoma group (Abbreviation: ileostomy group). The incidence of anastomotic leakage after operation and the different treatment methods following leakage were compared between the two groups.ResultsA total of 231 cases were recorded, including 84 cases in the fecal drainage group, 147 cases in the ileostomy group. There were no significant differences in the baseline data such as the gender, age, preoperative complications, operation mode, etc. between the two groups (P>0.050). There were no significant differences in the operation time, intraoperative blood loss, incision infection, postoperative intestinal obstruction, total hospitalization cost, death, anastomotic leakage (overall, each grade, treatment, and outcome) between the two groups (P>0.050). Although the length of hospital stay except the patients with anastomotic leakage in the fecal drainage group was significantly longer than that in the ileostomy group (P<0.001), there was no significant difference in the total length of hospital stay between the two groups (P>0.050), and the incidence of anastomotic stenosis in the fecal drainage group was significantly lower than that in the ileostomy group (P=0.029).ConclusionAccording to the results of this study, fecal drainage technique on rectal anastomosis is effective, safe, and feasible in preventing anastomotic leakage after operation for middle-low rectal cancer.
Objective To evaluate the effects of neoadjuvant long-course chemoradiotherapy (CRT), neoadjuvant short-course radiotherapy (SCRT), and total neoadjuvant treatment (TNT) on chemoradiotherapy related complications and perioperative safety in mid-low rectal cancer patients. Methods The clinical data of 63 rectal cancer patients who received neoadjuvant (chemo) radiotherapies and surgery treatment in West China Hospital from Jul. 2014 to Feb. 2016 were retrospectively analyzed. According to the neoadjuvant regimen, the patients were divided into CRT group (n=15), SCRT group (n=30), and TNT group (n=18), and then the effects of these 3 kinds of neoadjuvant regimen on chemoradiotherapy related complications and perioperative safety were compared. Results ① Chemoradiotherapy related complications: among all the included 63 patients, 29 patients (46.0%) occurred chemoradiotherapy related complications, including radiation enteritis in 9 patients and bone marrow suppression in 25 patients. There were significant differences in the overall incidence of chemoradiotherapy related complications, incidence of radiation enteritis and bone marrow suppression (P≤0.001). The overall incidence of chemoradiotherapy related complications and incidence of bone marrow suppression of SCRT group were lower. ② Perioperative safety: no significant differences were found in the incidence of surgical complications, incidence of specific surgical complication, operation duration, intraoperative blood loss, and postoperative flatus time (P<0.05), but there was significant difference in the postoperative hospital stay among 3 groups (P=0.033), the postoperative hospital stay of SCRT group was shorter. Conclusion CRT, SCRT, and TNT have similar effect on the safety in the mid-low rectal cancer patients, which suggests that SCRT is worthy of further research and promotion.
ObjectiveTo investigate current status of anal sphincter preservation in low rectal cancer.MethodThe recent literatures on the progress of anal sphincter preservation in the low rectal cancer were reviewed.ResultsIn the past, the surgical treatment of the low rectal cancer was mainly based on the Miles. With the deepening of the anatomical understanding, the improvement of surgical concepts, and the development of minimally invasive techniques, the treatment concept of the low rectal cancer had gradually entered the era of retaining anal and anal function. At present, many surgical methods including the transanal local excision, intersphincteric resection, transanal total mesorectal excision, etc. could be applied to the anal sphincter preservation of the lower rectal cancer, but the advantages and disadvantages of each surgical procedure and the scope of application were slightly different.ConclusionsAlthough there are many surgical procedures that can be applied to patients with low rectal cancer, none of them can achieve perfection in terms of retaining anal and anal function, reducing complications and recurrence rates, and improving survival. It is believed that with continuous understanding of rectal anatomy by surgeons, emergence of various neoadjuvant chemoradiation and new devices, and more anal sphincter preservation procedures and even artificial anal surgery, treatment of low rectal cancer will also be more good care for anal and maintenance function, so that patients can obtain a higher quality and a long-term survival opportunity.