Objectives: To investigate the factors influencing the height of anterior peritoneal reflection (APR) for patients with rectal cancer, and to analyze the relationship between the APR and the lateral lymph node metastasis. Methods: Clinical data of 432 patients with tumor located within and below APR were retrospectively collected from the rectal cancer database at the Department of General Surgery, Peking Union Medical College Hospital from August 2020 to September 2022. Ninty-eight non-rectal cancer patients were also enrolled as a control group. There were 308 males and 124 females in the tumor group, aged (M(IQR)) 62 (16) years (range: 24 to 85 years) and 53 males and 45 females in the control group, aged 60 (22) years (range: 27 to 87 years). The APR height, pelvis, and tumor-related parameters were measured by MRI. A multifactor linear regression model was established to analyze the dependent correlation factors of APR height. These factors of the two groups were matched by propensity score matching and their APR heights were compared after matching. An ordinal Logistic regression model was established to explore the relationship between APR-related parameters and radiographic lateral lymph node metastasis. Results: The APR height of the tumor group was (98.7±14.4) mm (range: 43.3 to 154.0 mm) and the control group was (95.1±12.7) mm (range: 68.0 to 137.9 mm). Multivariable linear regression revealed that the greater the weight (B=0.519, 95%CI: 0.399 to 0.640, P<0.01), the anterior pelvic depth (B=0.109, 95%CI: 0.005 to 0.213, P=0.039) and the smaller the bi-ischial diameter (B=-0.172, 95%CI:-0.294 to -0.049, P=0.006), the higher the APR height. The tumor group had a higher APR height than the control group after propensity score matching ((98.3±14.2) mm vs. (95.1±12.7) mm, t=-1.992, P=0.047). Ordinal Logistic regression indicated that the longer segment of the tumor invade the nonperitoneal rectum was an independent influencing factor of radiographic lateral lymph node metastasis (OR=1.016, 95%CI: 1.002 to 1.030, P=0.021), while the distance between the anal verge and the tumor was not (OR=0.986, 95%CI: 0.972 to 1.000, P=0.058). Conclusions: The higher the weight, the deeper and narrower the pelvis, the higher the APR height. There is a certain relationship between APR and lateral lymph node metastasis on imaging.

Objective: To compare the short-term and long-term outcomes between transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laTME) for mid-to-low rectal cancer and to evaluate the learning curve of taTME. Methods: This study was a retrospective cohort study. Firstly, consecutive patients undergoing total mesorectal excision who were registered in the prospective established database of Division of Colorectal Diseases, Department of General Surgery, Peking Union Medical College Hospital during July 2014 to June 2020 were recruited. The enrolled patients were divided into taTME and laTME group. The demographic data, clinical characteristics, neoadjuvant treatment, intraoperative and postoperative complications, pathological results and follow-up data were extracted from the database. The primary endpoint was the incidence of anastomotic leakage and the secondary endpoints included the 3-year disease-free survival (DFS) and the 3-year local recurrence rate. Independent t-test for comparison between groups of normally distributed measures; skewed measures were expressed as M (range). Categorical variables were expressed as examples (%) and the χ(2) or Fisher exact probability was used for comparison between groups. When comparing the incidence of anastomotic leakage, 5 variables including sex, BMI, clinical stage evaluated by MRI, distance from tumor to anal margin evaluated by MRI, and whether receiving neoadjuvant treatment were balanced by propensity score matching (PSM) to adjust confounders. Kaplan-Meier curve and Log-rank test were used to compare the DFS of two groups. Cox proportional hazard model was used to analyze and determine the independent risk factors affecting the DFS of patients with mid-low rectal cancer. Secondly, the data of consecutive patients undergoing taTME performed by the same surgical team (the trananal procedures were performed by the same main surgeon) from February 2017 to March 2021 were separately extracted and analyzed. The multidimensional cumulative sum (CUSUM) control chart was used to draw the learning curve of taTME. The outcomes of 'mature' taTME cases through learning curve were compared with laTME cases and the independent risk factors of DFS of 'mature' cases were also analyzed. Results: Two hundred and forty-three patients were eventually enrolled, including 182 undergoing laTME and 61 undergoing taTME. After PSM, both fifty-two patients were in laTME group and taTME group respectively, and patients of these two groups had comparable characteristics in sex, age, BMI, clinical tumor stage, distance from tumor to anal margin by MRI, mesorectal fasciae (MRF) and extramural vascular invasion (EMVI) by MRI and proportion of receiving neoadjuvant treatment. After PSM, as compared to laTME group, taTME group showed significantly longer operation time [(198.4±58.3) min vs. (147.9±47.3) min, t=-4.321, P<0.001], higher ratio of blood loss >100 ml during surgery [17.3% (9/52) vs. 0, P=0.003], higher incidence of anastomotic leakage [26.9% (14/52) vs. 3.8% (2/52), χ(2)=10.636, P=0.001] and higher morbidity of overall postoperative complications [55.8%(29/52) vs. 19.2% (10/52), χ(2)=14.810, P<0.001]. Total harvested lymph nodes and circumferential resection margin involvement were comparable between two groups (both P>0.05). The median follow-up for the whole group was 24 (1 to 72) months, with 4 cases lost, giving a follow-up rate of 98.4% (239/243). The laTME group had significantly better 3-year DFS than taTME group (83.9% vs. 73.0%, P=0.019), while the 3-year local recurrence rate was similar in two groups (1.7% vs. 3.6%, P=0.420). Multivariate analysis showed that and taTME surgery (HR=3.202, 95%CI: 1.592-6.441, P=0.001) the postoperative pathological staging of UICC stage II (HR=13.862, 95%CI:1.810-106.150, P=0.011), stage III (HR=8.705, 95%CI: 1.104-68.670, P=0.040) were independent risk factors for 3-year DFS. Analysis of taTME learning curve revealed that surgeons would cross over the learning stage after performing 28 cases. To compare the two groups excluding the cases within the learning stage, there was no significant difference between two groups after PSM no matter in the incidence of anastomotic leakage [taTME: 6.7%(1/15); laTME: 5.3% (2/38), P=1.000] or overall complications [taTME: 33.3%(5/15), laTME: 26.3%(10/38), P=0.737]. The taTME was still an independent risk factor of 3-year DFS only analyzing patients crossing over the learning stage (HR=5.351, 95%CI:1.666-17.192, P=0.005), and whether crossing over the learning stage was not the independent risk factor of 3-year DFS for mid-low rectal cancer patients undergoing taTME (HR=0.954, 95%CI:0.227-4.017, P=0.949). Conclusions: Compared with conventional laTME, taTME may increase the risk of anastomotic leakage and compromise the oncological outcomes. Performing taTME within the learning stage may significantly increase the risk of postoperative anastomotic leakage.
Anastomotic Leak/etiology* ; Humans ; Laparoscopy/methods* ; Postoperative Complications/epidemiology* ; Prognosis ; Prospective Studies ; Rectal Neoplasms/pathology* ; Rectum/surgery* ; Retrospective Studies ; Transanal Endoscopic Surgery/methods* ; Treatment Outcome

Objective: To explore the incidence and risk factors of postoperative surgical site infection (SSI) after colon cancer surgery. Methods: A retrospective case-control study was performed. Patients diagnosed with colon cancer who underwent radical surgery between January 2016 and May 2021 were included, and demographic characteristics, comorbidities, laboratory tests, surgical data and postoperative complications were extracted from the specialized prospective database at Department of General Surgery, Peking Union Medical College Hospital. Case exclusion criteria: (1) simultaneously multiple primary colon cancer; (2) segmental resection, subtotal colectomy, or total colectomy; (3) patients undergoing colostomy/ileostomy during the operation or in the state of colostomy/ileostomy before the operation; (4) patients receiving natural orifice specimen extraction surgery or transvaginal colon surgery; (5) patients with the history of colectomy; (6) emergency operation due to intestinal obstruction, perforation and acute bleeding; (7) intestinal diversion operation; (8) benign lesions confirmed by postoperative pathology; (9) patients not following the colorectal clinical pathway of our department for intestinal preparation and antibiotic application. Univariate analysis and multivariate analysis were used to determine the risk factors of SSI after colon cancer surgery. Results: A total of 1291 patients were enrolled in the study. 94.3% (1217/1291) of cases received laparoscopic surgery. The incidence of overall SSI was 5.3% (69/1291). According to tumor location, the incidence of SSI in the right colon, transverse colon, left colon and sigmoid colon was 8.6% (40/465), 5.2% (11/213), 7.1% (7/98) and 2.1% (11/515) respectively. According to resection range, the incidence of SSI after right hemicolectomy, transverse colectomy, left hemicolectomy and sigmoid colectomy was 8.2% (48/588), 4.5% (2/44), 4.8% (8 /167) and 2.2% (11/492) respectively. Univariate analysis showed that preoperative BUN≥7.14 mmol/L, tumor site, resection range, intestinal anastomotic approach, postoperative diarrhea, anastomotic leakage, postoperative pneumonia, and anastomotic technique were related to SSI (all P<0.05). Multivariate analysis revealed that anastomotic leakage (OR=22.074, 95%CI: 6.172-78.953, P<0.001), pneumonia (OR=4.100, 95%CI: 1.546-10.869, P=0.005), intracorporeal anastomosis (OR=5.288, 95%CI: 2.919-9.577,P<0.001) were independent risk factors of SSI. Subgroup analysis showed that in right hemicolectomy, the incidence of SSI in intracorporeal anastomosis was 19.8% (32/162), which was significantly higher than that in extracorporeal anastomosis (3.8%, 16/426, χ(2)=40.064, P<0.001). In transverse colectomy [5.0% (2/40) vs. 0, χ(2)=0.210, P=1.000], left hemicolectomy [5.4% (8/148) vs. 0, χ(2)=1.079, P=0.599] and sigmoid colectomy [2.1% (10/482) vs. 10.0% (1/10), χ(2)=2.815, P=0.204], no significant differences of SSI incidence were found between intracorporeal anastomosis and extracorporeal anastomosis (all P>0.05). Conclusions: The incidence of SSI increases with the resection range from sigmoid colectomy to right hemicolectomy. Intracorporeal anastomosis and postoperative anastomotic leakage are independent risk factors of SSI. Attentions should be paid to the possibility of postoperative pneumonia and actively effective treatment measures should be carried out.
Case-Control Studies ; Colonic Neoplasms/surgery* ; Humans ; Retrospective Studies ; Risk Factors ; Surgical Wound Infection/etiology*

OBJECTIVE: To explore the effect of modified Bacon coloanal anastomosis in transanal total mesorectal excision(TaTME).METHODS: The clinical data of 8 patients with low rectal cancer treated with TaTME from January 2016 to January 2019 in the division of colorectal surgery of department of general surgery of Peking Union Medical College Hospital were retrospectively analyzed. Laparoscopic assisted modified Bacon coloanal anastomosis was used during operation. The incidence of postoperative complications including anastomotic leakage was observed and the anal function was evaluated.RESULTS: All 8 patients underwent operation successfully. The distance from the inferior margin of the tumor to the anal verge was(4.8 ±0.4) cm. The number of retrieved lymph nodes in postoperative pathological examination was(12.9±2.5). The mean time of first operation was(140.8±8.6) min, and the Second stage operation time was(39.1±9.6) min. The median time between the two operations was 19(13, 20) days, and the median hospital stay was22(17, 24) days. The median follow-up time was 16(4, 36) months. No anastomotic leakage occurred and the anal function was good after operation. Six patients had uncontrollable anal exhaust after operation, and two patients had occasional mucous or watery fecal incontinence after operation, but they were less than once a month. They could be improved by dietary structure adjustment and external sanitary pads.CONCLUSION: Laparoscopic-assisted modified Bacon operation in TaTME avoids anastomotic leakage, and reduces the incidence of anal incontinence after operation.However, the hospital stay is prolonged.

Objective To evaluate the prognostic value of the log odds of positive lymph nodes (LODDS) in stage 3 colorectal cancer (CRC) patients who have undergone curative resection. Methods We performed a retrospective review of 175 stage 3 CRC patients who underwent curative resection in Peking Union Medical College Hospital from 2005 to 2012. Patients were categorized respectively according to the AJCC/UICC N grade,the metastatic lymph node ratio (LNR),and the ratio of their LODDS. The relationship between the N grade,LNR,LODDS,and overall survival (OS) rates were assessed.Results The five-year disease-free survival (DFS) was significantly different among stage 3 CRC patients in different N grade (Χ(2)=33.1,P=0.000),LNR (Χ(2)=14.3,P=0.001),and LODDS (Χ(2)=14.9,P=0.001). Univariate analysis showed that TNM stage (Χ(2)=27.0,P=0.000),cancerous node(Χ(2)=3.6,P=0.040),N grade (Χ(2)=33.1,P=0.000),LNR (Χ(2)=14.3,P=0.001),and LODDS (Χ(2)=30.4,P=0.000) were related to OS. Multivariate analysis indicated that TNM stage (HR:1.84,95%CI:1.59～6.29,P=0.001) and LODDS classification (HR:1.34,95%CI:1.01～1.80,P=0.047) were independent prognostic factors for OS in stage 3 CRC patients. Conclusion LODDS is a good prognostic indicator in stage 3 CRC patients who have undergone curative resection.
Colorectal Neoplasms ; diagnosis ; pathology ; Disease-Free Survival ; Humans ; Lymph Nodes ; pathology ; Lymphatic Metastasis ; diagnosis ; Multivariate Analysis ; Neoplasm Staging ; Prognosis ; Retrospective Studies ; Survival Rate

Objective To investigate the clinical efficacy and long-term outcomes of laparoscopic radical re-section for stageⅢcolon cancer.Methods A total of 169 stageⅢcolon cancer patients treated with laparoscopic surgery (n=75) or open surgery (n=94) between January 2007 and December 2012 in Department of General Sur-gery, Peking Union Medical College Hospital were included.The clinicopathologic features, as well as long-term outcomes including 5-year local recurrence rate, overall survival, and disease-free survival, were compared between the two groups.Results Compared with the open surgery group, the laparoscopic surgery group had significantly longer operation time [ (171.3 ±43.2) minutes vs.(132.7 ±60.4) minutes, P<0.001], significantly less blood loss [ (86.3 ±61.7) ml vs.(109.8 ±74.6) ml, P=0.030], and significantly more invaded lymph nodes detec-ted (23.3 ±12.2 vs.19.3 ±9.6, P=0.022).No significant difference was found between the laparoscopic surgery group and open surgery group in cumulative local recurrence rate (6.7%vs.8.5%, P=0.876), 5-year overall survival (73.6% vs.58.8%, P=0.317), and 5-year disease-free survival (61.6% vs.56.3%, P=0.544). Conclusion Laparoscopic colectomy is safe and effective for stageⅢcolon cancer, comparable with the conven-tional open colectomy in terms of long-term oncological outcomes.

Objective To investigate the feasibility of extralevator abdominoperineal excision ( ELAPE) under laparoscope .Methods We retrospectively analyzed 12 patients with distal rectal cancer who underwent ELAPE in our center from June 2012 to August 2013 .During the procedures , the levator ani muscles were cut off laparoscopically at its origin at both sides on the pelvic wall , and its attachment on coccyx was removed posterior-ly.The dissection plane was taken along the Denonvillier fascia anteriorly as far as possible to the perineal body . The adjacent organs were removed if invaded by the tumors .The anus and its surrounding tissue were removed by perineal approach without changing patients'positions .The pelvic perinium was closed laparoscopically to prevent the intestine dropping .The operation time , blood loss , retrieval of lymph nodes , radial margin , and postoperative complications were recorded .Results The patients aged ( 65.2 ±12.5 ) years and their body mass index was 21.6 ±3.1.The distance from lower edge of tumor to anal verge was (3.3 ±0.7) cm.The procedure lasted (176.1 ±27.5) minutes, with a blood loss of (49.6 ±38.2) ml.The average number of node retrieval was 18.3 ±7.8 , and no positive radial margin was identified .The postoperative complications included urinary reten-tion in 2 patients.The perineal incision appeared to be class A healing in 9 patients.Conclusion By extensive-ly removing the levator ani muscles laterally and posteriorly , ELAPE procedure can be accomplished under lapa-roscope without changing operative position or flap repair of the pelvic floor .

Objective To investigate the clinical features of and surgical choices for rectal carcinoids of 1-2 cm in diameter .Methods The clinical data of 31 rectal carcinoid patients with tumors of 1-2 cm in diame-ter who were treated in Peking Union Medical College Hospital between January 2000 and December 2012 were col-lected and analyzed retrospectively .The selected patients included 17 males and 14 females, aged 24-77 years (median age 46 years).Results Abdominal discomfort and diarrhea (18/31, 58.1%) were the most common symptoms.Two (2/31, 6.5%) patients had hematochezia.The other 11 were asymptomatic.Twenty-six patients underwent local excision: transanal endoscopic microsurgery ( TEM) in 19 (61.3%), transsphincteric resection ( York-Mason approach ) in 4 (12.9%) , and transanal excision in 3 (9.7%) .Five (16.1%) patients received radical surgery .Postoperative pathological results showed rectal carcinoid in all the 31 patients, including limited submucosal lesions in 25 cases and muscular invasion in 6.Lymph node metastasis occurred in 1 case.Among the 29 patients who were followed up , the 23 patients with limited submucosal lesions had a 5-year survival rate of 95.7%, significantly higher than that of the 6 patients with muscular invasion (50%, P<0.001).Conclusion For the rectal carcinoid tumors of 1-2 cm in diameter without muscular invasion , local excision is an appropriate surgical choice; while for those with muscular invasion , radical resection is necessary .

OBJECTIVETo summarize clinical experience in the treatment of low rectal cancer with anterior perineal plane for ultra-low anterior resection of the rectum(APPEAR).

METHODSClinical and follow-up data of 26 patients with low rectal cancer undergoing the APPEAR operation in Department of General Surgery at Peking Union Medical College from September 2009 to August 2011 were retrospectively analyzed.

RESULTSThe 26 cases consisted of 19 male and 7 female patients with an average age of (63.4 ± 9.5) years. The average tumor distance from the anal verge was (4.6 ± 0.7) cm according to preoperative examinations. Fourteen patients received neoadjuvant radiochemotherapy before the operation. All the 26 patients had successful sphincter-preserving operations. The average operative time was (170 ± 21) min and the average intra-operative blood loss (140 ± 69) ml. Complications included one case of intraoperative injury to the rectal wall and 4 cases of postoperative perineal wound infection. Postoperative pathological examination showed well to moderately differentiated adenocarcinomas(n=10), moderately differentiated adenocarcinomas with partial mucinous adenocarcinomas (n=7), poorly differentiated adenocarcinoma(n=1), villous adenoma with high-grade intraepithelial neoplasia (n=1), and rectal villous adenoma(n=1). In 6 cases no residual tumor cells were detected in the surgical specimens. All the patients were followed-up for an average period of(11.4 ± 5.6) months. No impaired urinary function or tumor recurrence was observed during the follow-up. Eighteen patients had the transverse colon stoma closure six months after the operation. The average Wexner continence score was 5.5 after colostomy reversal surgery. The anorectal manometry tests showed that maximum squeeze pressure of the anal sphincter was(224.0 ± 59.3) mm Hg. The maximum resting pressure was (42.5 ± 11.8) mm Hg, and the maximum tolerable volume of the rectum was (120.0 ± 27.4) ml. Anorectal reflexes were present in all these patients.

CONCLUSIONThe APPEAR technique can be applied in the sphincter-preserving operations for low rectal cancer patients with satisfactory anal function.

Aged ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Perineum ; surgery ; Rectal Neoplasms ; surgery ; Rectum ; surgery ; Retrospective Studies ; Treatment Outcome

OBJECTIVETo investigate the safety and efficacy of prophylactic single antibiotic administration in selective open colorectal surgery.

METHODSTwo hundred and seventy-five patients undergoing selective open colorectal surgery in the Peking Union Medical College Hospital from October 2009 to October 2011 were retrospectively reviewed. Prophylatic single antibiotic administration was used by intravenous infusion 30-60 min before incision. No antibiotics would be given after operation if there was no surgical site infection(SSI). According to the incidence of postoperative SSI, unexplained use of antibiotics, anastomotic leakage and distant-site infection, the clinical outcome was assessed to be prophylactic success, prophylactic failure or distant-site infection, respectively.

RESULTSThere was no intraoperative or postoperative antibiotics related drug anaphylaxis in all the 275 patients. By prophylactic single antibiotic administration, there were prophylactic success in 243 patients(88.4%,243/275), prophylactic failure in 23(8.4%,23/275), distant-site infection in 9(3.3%,9/275). In the 23 patients with failed prophylaxis, there were SSI in 13(4.7%,13/275) patients, postoperative use of broad-spectrum antibiotics for unexplained fever in 2(0.7%,2/275), postoperative anastomotic leakage in 8(3.6%,8/222).

CONCLUSIONProphylactic single antibiotic administration in selective open colorectal surgery is safe and effective.

Anti-Bacterial Agents ; therapeutic use ; Antibiotic Prophylaxis ; Colorectal Surgery ; Humans ; Incidence ; Retrospective Studies ; Surgical Wound Infection ; epidemiology ; prevention & control