In the past several years of 21 century, there are many updates of concepts on the diagnosis and treatment of colorectal cancer, which indicates the era of experience-based medicine has been gradually replaced by that of evidence-based medicine. Despite emerging evidence from randomized controlled trials(RCT) and meta-analyses questioning its use, concurrent suggestion on the indication of preoperative bowel preparation has not been reached. The authors agree with the opinion of The Huang Jia-si Textbook of Surgery(7th Edition). Preoperative bowel preparation should be emphasized before the consensus is confirmed, though there are so many trials showing that bowel preparation before elective colorectal surgery was unnecessary. In the authors' consideration, compared with the Westerner, the Chinese prefer to the food style of low fat and high cellulose, which would make more food residue. So whether the oversea finding of the preoperative bowel preparation is fit for the colorectal patients in China is questioned. Therefore large-sample, multi-centre, prospective RCT is expected to be carried out by the national academic organization, by which high-ranking evidence suitable for the Chinese could be obtained.
Colorectal Surgery ; Elective Surgical Procedures ; Enema ; adverse effects ; methods ; Humans ; Preoperative Care

The routine bowel preparation before colorectal surgery usually includes mechanical and medicine preparations, with the original purpose of reducing complications such as anastomosis leakage, wound, and abdominal infections. Many domestic hospitals are still employing the methods of three-day bowel preparation, while in the West, the way of this preparation has dramatically changed. In last decade, one-day preparation has been widely accepted internationally, with two major medications of sodium phosphate and polyethylene glycol frequently used in the clinic. It has also been indicated that excessive mechanical and medicinal bowel preparations exert harmful effects on the combined intestinal barrier, and may result in various complications. A few reports have suggested to omit the mechanical bowel preparation before surgery, which is still under controversy, however, well-designed clinical trials are needed to readjust and regulate the duration and intensity of bowel preparation before colorectal surgery in China.
Colorectal Surgery ; Humans ; Intestinal Mucosa ; physiology ; Phosphates ; adverse effects ; therapeutic use ; Polyethylene Glycols ; adverse effects ; therapeutic use ; Preoperative Care ; adverse effects ; methods

OBJECTIVETo explore the feasibility and safety of enteral nutrition in preoperative bowel preparation for rectal cancer patients undergoing radical operation.

METHODSSixty rectal cancer patients undergoing selective low anterior resection were randomized into the trial group(n=30) and the control group(n=30). Patients in the trial group received clean liquid integral protein diet for 3 days before operation without mechanical bowel preparation. Patients in the control group received traditional diet and mechanical bowel preparation. The intraoperative and postoperative clinical data, the quality of bowel preparation, postoperative complications, and nutritional parameters were compared between the two groups.

RESULTSThere were no significant differences in clinicopathological characteristics between the two groups before operation. The operative time, blood loss, quality of bowel preparation as well as postoperative hospital stay were not significantly different(all P>0.05). While the time to first flatus [(2.53±0.91) d vs. (3.03±0.68) d] and semi-liquid diet intake[(3.95±0.83) d vs. (4.52±1.14) d] were significantly shorter in the trial group as compared with the control group(all P<0.05). There were no death and no significant difference in postoperative complications [16.7%(5/30) vs. 20.0%(6/30), P>0.05]. The levels of postoperative total protein, albumin, and prealbumin decreased significantly. Meanwhile, the levels of postoperative albumin[(36.2±2.5) g/L vs. (33.5±2.6) g/L, P<0.01] and prealbumin [(325.4±28.2) mg/L vs. (302.5±34.2) mg/L, P<0.01] in the trial group were significantly higher than those in the control group.

CONCLUSIONSPreoperative enteral nutrition can replace the mechanical bowel preparation with better efficacy, and improve the postoperative nutritional status without increasing surgical risk in rectal cancer patients undergoing radical operation.

Digestive System Surgical Procedures ; adverse effects ; Enteral Nutrition ; Humans ; Postoperative Complications ; Preoperative Care ; methods ; Rectal Neoplasms ; surgery

OBJECTIVETo explore efficacy of neoadjuvant radiochemotherapy in locally advanced low rectal cancer.

METHODSFrom May 2001 to August 2005, 105 patients with locally advanced low rectal cancer (T3, T4) were treated by preoperative radiotherapy to pelvis, 2.0 Gy daily up to 40-46 Gy in 4-5 weeks concomitantly with oral capecitabine at 1250 mg x m(-2) x d(-1) for 10 weeks up to surgery. In all patients surgery was carried out under the rule of total mesorectal excision technique.

RESULTSAll patients finished the course of neoadjuvant radiochemotherapy. Among them, 36 patients experienced adverse effects. Thirteen patients resulted in complete tumor response and spared the operation. Ninety-two patients were operated on with radical resection, among them 71 patients with low anterior resection, 17 with Parks' colo-anal anastomosis and 4 with abdomino-perineal resection, so sphincter preservation was achieved in 96.2%. In postoperative pathological studies, 11 cases showed complete tumor regression. According to the TNM staging system, 24 cases were ranged T0N0, and 23 cases T2N0, 43 cases T3N0, 2 cases T4N0, 5 cases T2N1, 8 cases T3N1; and according to Dworak's tumor regression grading, 5 cases were ranked TGR0, and 18 cases TGR1, 11 cases TGR2, 47 cases TGR3, 24 cases TGR4. Pathologic downstaging was achieved in 78.1%, including complete response (TGR4) and intermediate response (TGR2 + 3). No operative death occurred. Anastomotic leakage was found in 5 cases, including 3 rectovaginal fistula. All patients have been followed up for 16-67 months, and lung metastasis occurred in 4 cases, liver metastasis in 2 patients and local recurrence in 4 patients. Three patients died of distant metastasis. The 3-year disease-free survival was 82.8% and overall survival was 96.5%.

CONCLUSIONSNeoadjuvant radiochemotherapy brings tumor down-staging and increases resectability and sphincter preservation, decreases recurrence and improves survival in locally advanced low rectal cancer.

Chemotherapy, Adjuvant ; adverse effects ; methods ; Disease-Free Survival ; Follow-Up Studies ; Humans ; Neoadjuvant Therapy ; adverse effects ; methods ; Preoperative Care ; methods ; Radiotherapy, Adjuvant ; adverse effects ; methods ; Rectal Neoplasms ; mortality ; surgery ; therapy ; Survival Rate ; Treatment Outcome

PURPOSE: To evaluate the influence of preoperative mechanical bowel preparation (MBP) based on the occurrence of anastomosis leakage, surgical site infection (SSI), and severity of surgical complication when performing elective colorectal surgery. MATERIALS AND METHODS: MBP and non-MBP patients were matched using propensity score. The outcomes were evaluated according to tumor location such as right- (n=84) and left-sided colon (n=50) and rectum (n=100). In the non-MBP group, patients with right-sided colon cancer did not receive any preparation, and patients with both left-sided colon and rectal cancers were given one rectal enema before surgery. RESULTS: In the right-sided colon surgery, there was no anastomosis leakage. SSI occurred in 2 (4.8%) and 4 patients (9.5%) in the non-MBP and MBP groups, respectively. In the left-sided colon cancer surgery, there was one anastomosis leakage (4.0%) in each group. SSI occurred in none in the rectal enema group and in 2 patients (8.0%) in the MBP group. In the rectal cancer surgery, there were 5 anastomosis leakages (10.0%) in the rectal enema group and 2 (4.0%) in the MBP group. SSI occurred in 3 patients (6.0%) in each groups. Severe surgical complications (Grade III, IV, or V) based on Dindo-Clavien classification, occurred in 7 patients (14.0%) in the rectal enema group and 1 patient (2.0%) in the MBP group (p=0.03). CONCLUSION: Right- and left-sided colon cancer surgery can be performed safely without MBP. In rectal cancer surgery, rectal enema only before surgery seems to be dangerous because of the higher rate of severe postoperative complications.
Aged ; Anastomosis, Surgical ; Colorectal Surgery/adverse effects/*methods ; Elective Surgical Procedures/*adverse effects/methods ; Female ; Humans ; Male ; Middle Aged ; Preoperative Care/*adverse effects/methods ; *Propensity Score ; Retrospective Studies ; Surgical Wound Infection/epidemiology ; Treatment Outcome

OBJECTIVETo evaluate safety and efficacy of preoperative administration of enteral nutrition support in gastric cancer patients at risk of malnutrition.

METHODSA single center randomized controlled clinical trial was performed in 60 gastric cancer patients in West China Hospital from May to October 2012. Thirty patients were given enteral nutrition support(Ensure(R)) manufactured by Abbott Laboratories for ten consecutive days before surgical operation in the treatment group, and 30 patients were given an isocaloric and isonitrogenous homogenized diet in the control group for 10 days as well. The laboratory parameters of nutritional status and hepatorenal function were observed and compared between the two groups on admission, preoperative day 1 and postoperative day 3, respectively. Clinical observations, such as nausea and vomiting, were carried out until patients were discharged.

RESULTSBefore the intervention, there were no significant differences in the baseline characteristics between the two groups. The levels of serum albumin [(33.9±5.6) g/L vs. (31.0±5.3) g/L, P<0.05], and hemoglobin[(103.4±7.7) g/L vs.(96.6±10.5) g/L, P<0.01] were significantly improved in the treatment group on postoperative day 3. However, the levels of body mass index, lymphocyte count, liver and renal function, serum glucose, sodium, and potassium were not significantly different between the two groups(all P>0.05). Moreover, two patients with nausea and one with vomiting in each group were found. In clinical observation period, no severe treatment-related adverse event were observed.

CONCLUSIONThe enteral supplement with Ensure(R) in gastric cancer patients at risk of malnutrition during preoperative period is effective and safe, which is superior to homogenized diet and an appropriate choice for gastric cancer patients with nutritional risk.

Enteral Nutrition ; Gastrectomy ; adverse effects ; Humans ; Malnutrition ; etiology ; prevention & control ; Nutritional Status ; Postoperative Period ; Preoperative Care ; methods ; Risk Factors ; Stomach Neoplasms ; surgery

For elective surgery of colorectal cancer, current evidence supports preoperative mechanical bowel preparation combined with oral antibiotics. Meanwhile, for patients with varied degrees of intestinal stenosis, individualized protocol is required to avoid adverse events. We hereby summarize recent high-quality evidences and updates of guidelines and consensus, and recommend stratified bowel preparation based on the clinical practice of our institute as follows. (1) For patients with unimpaired oral intake, whose tumor can be passed by colonoscopy, mechanical bowel preparation and oral antibiotics are given. (2) For patients without symptoms of bowel obstruction but with impaired oral intake or incomplete colonoscopy due to tumor-related stenosis, small-dosage laxative is given for several days before surgery, and oral antibiotics the day before surgery. (3) For patients with bowel obstruction, mechanical bowel preparation or enema is not indicated. We proposed this evidence-based, individualized protocol for preoperative bowel preparation for the reference of our colleagues, in the hope of improving perioperative outcomes and reducing adverse events.
Anti-Bacterial Agents/therapeutic use* ; Colorectal Neoplasms/drug therapy* ; Constriction, Pathologic/etiology* ; Elective Surgical Procedures/adverse effects* ; Humans ; Preoperative Care/methods* ; Surgical Wound Infection/etiology*

BACKGROUND/AIMS: The aims of this study were to compare the bowel-cleansing efficacy, patient affinity for the preparation solution, and mucosal injury between a split dose of poly-ethylene glycol (SD-PEG) and low-volume PEG plus ascorbic acid (LV-PEG+Asc) in outpatient scheduled colonoscopies. METHODS: Of the 319 patients, 160 were enrolled for SD-PEG, and 159 for LV-PEG+Asc. The bowel-cleansing efficacy was rated according to the Ottawa bowel preparation scale. Patient affinity for the preparation solution was assessed using a questionnaire. All mucosal injuries observed during colonoscopy were biopsied and histopathologically reviewed. RESULTS: There was no significant difference in bowel cleansing between the groups. The LV-PEG+Asc group reported better patient acceptance and preference. There were no significant differences in the incidence or characteristics of the mucosal injuries between the two groups. CONCLUSIONS: Compared with SD-PEG, LV-PEG+Asc exhibited equivalent bowel-cleansing efficacy and resulted in improved patient acceptance and preference. There was no significant difference in mucosal injury between SD-PEG and LV-PEG+Asc. Thus, the LV-PEG+Asc preparation could be used more effectively and easily for routine colonoscopies without risking significant mucosal injury.
Adult ; Ascorbic Acid/administration & dosage/*adverse effects ; Cathartics/administration & dosage/*adverse effects ; Colonoscopy/methods ; Drug Therapy, Combination ; Female ; Humans ; Intestinal Mucosa/drug effects/*injuries ; Male ; Middle Aged ; Patient Compliance ; Patient Satisfaction ; Polyethylene Glycols/administration & dosage/*adverse effects ; Preoperative Care/*adverse effects/methods ; Surveys and Questionnaires ; Vitamins/administration & dosage/adverse effects

BACKGROUND/AIMS: Controversy remains over the optimal approach to preoperative biliary drainage in patients with resectable perihilar cholangiocarcinoma. We compared the clinical outcomes of endoscopic biliary drainage (EBD) with those of percutaneous transhepatic biliary drainage (PTBD) in patients undergoing preoperative biliary drainage for perihilar cholangiocarcinoma. METHODS: A total of 106 consecutive patients who underwent biliary drainage before surgical treatment were divided into two groups: the PTBD group (n=62) and the EBD group (n=44). RESULTS: Successful drainage on the first attempt was achieved in 36 of 62 patients (58.1%) with PTBD, and in 25 of 44 patients (56.8%) with EBD. There were no significant differences in predrainage patient demographics and decompression periods between the two groups. Procedure-related complications, especially cholangitis and pancreatitis, were significantly more frequent in the EBD group than the PTBD group (PTBD vs EBD: 22.6% vs 54.5%, p<0.001). Two patients (3.8%) in the PTBD group experienced catheter tract implantation metastasis after curative resection during the follow-up period. CONCLUSIONS: EBD was associated with a higher risk of procedure-related complications than PTBD. These complications were managed properly without severe morbidity; however, in the PTBD group, there were two cases of cancer dissemination along the catheter tract.
Aged ; Aged, 80 and over ; Bile Duct Neoplasms/*surgery ; Bile Ducts/surgery ; Cholangitis/etiology ; Drainage/adverse effects/*methods ; Endoscopy, Gastrointestinal/adverse effects/*methods ; Female ; Humans ; Klatskin Tumor/*surgery ; Liver/surgery ; Male ; Middle Aged ; Pancreatitis/etiology ; Postoperative Complications/etiology ; Preoperative Care/adverse effects/*methods ; Treatment Outcome

The anastomotic complications following radical gastrectomy mainly include anastomotic leakage, anastomotic hemorrhage, and anastomotic stricture. Theanastomotic complications are not rare and remain the most common complications resulting in the perioperativedeath of patients with gastric cancer. Standardized training could let surgeons fully realize that strict selection of operative indications, thorough preoperative assessment and preparation, and refined operation in surgery are the essential measures to prevent the anastomotic complications following radical gastrectomy. In addition, identifying these complications timely and taking effective measures promptly according to the clinical context are the keys to treating these complications, reducing the treatment cycle, and decreasing the mortality.
Anastomosis, Surgical ; adverse effects ; Anastomotic Leak ; prevention & control ; therapy ; Constriction, Pathologic ; prevention & control ; therapy ; Gastrectomy ; adverse effects ; methods ; Gastrointestinal Hemorrhage ; prevention & control ; therapy ; Humans ; Postoperative Complications ; diagnosis ; therapy ; Preoperative Care ; methods ; standards ; Risk Assessment ; methods ; standards ; Risk Factors ; Stomach Neoplasms ; complications ; mortality ; surgery