Abstract:Using robotic system in colorectal cancer surgery facilitates precise dissection. However, there are some disadvantages such as high cost, extra time needed to dock the cart, and lack of haptic feedback. The development of techniques in robotic colorectal surgery will promote its application. Previous studies have demonstrated that robotic system can ensure the safety and feasibility of surgery and, at the same time, better protect the function of the pelvic autonomic nerves. The oncological outcomes of robotic surgery still need to be evaluated by multicenter, perspective, randomized clinical trials.

Abstract:After nearly 20 years of research, great achievements have been made in treatment of gastrointestinal stromal tumors (GISTs), which currently reached a relatively mature stage. However, there are still many problems that need to be solved. In recent years, a series of progresses have been made by the efforts of the researchers. Here, the authors briefly address the recent progress in the field of GISTs.

Abstract:Objective: To systematically evaluate the safety and efficacy of da Vinci robotic gastrectomy for gastric cancer. Methods: Literature on studies comparing da Vinci robotic gastrectomy and traditional laparoscopic gastrectomy was selected through searching several national and international databases. After data extraction, Meta-analysis was performed by using RevMan 5.2 software. Results: Seventeen studies were finally included in the analysis, involving 5 787 patients, of whom, 1 676 cases underwent da Vinci robotic gastrectomy and 4 111 cases underwent traditional laparoscopic gastrectomy. Results of Meta-analysis showed that da Vinci robotic gastrectomy compared with traditional laparoscopic gastrectomy, the operative time was prolonged (WMD=43.51, 95% CI=34.14–52.88, P<0.05), blood loss was reduced (WMD=–30.17, 95% CI=–42.83––17.51, P<0.05), number of harvested lymph nodes was increased (WMD=1.95, 95% CI=0.07-3.84, P<0.05) and time to first postoperative food intake shortened (WMD=–0.22, 95% CI=–0.32––0.12, P<0.05), while the other variables that included the proximal and distal margin, R0 resection rate, conversion rate, time to first postoperative gas passage, length of postoperative hospital stay, incidence of postoperative complications, mortality rate, and 3-year overall survival rate were all similar (all P>0.05). Conclusion: da Vinci robotic gastrectomy is safe and effective in treatment of gastric cancer, with better short- and long-term efficacy.

Abstract:Objective: To investigate the safety and feasibility as well as short-term efficacy of robotic total endoscopic single anastomosis in treatment of rectal cancer. Methods: The clinical data of 124 rectal cancer patients treated from January 2016 to February 2017 in First Affiliated Hospital of Chongqing Medical University were analyzed retrospectively. Of the patients, 26 cases underwent da Vinci robotic surgery (robotic group) and the other 98 cases underwent traditional laparoscopic surgery (laparoscopic group). The main clinical data between the two groups of patients were compared. Results: The general data of the two groups of patients showed no significant difference (all P>0.05), and were comparable. In robotic group compared with laparoscopic group, the operative time was significantly prolonged (273.5 min vs. 234.3 min) and total hospitalization cost was significantly increased (82 000 yuan vs. 72 000 yuan), but the intraoperative blood loss was significantly reduced (43.3 mL vs. 68.4 mL), and the time to first postoperative gas passage (3.3 d vs. 4.4 d), liquid food intake (3.9 d vs. 5.4 d), ambulation (4.5 d vs. 6.8 d), and urinary tube removal (5.0 d vs. 6.8 d), as well as the length of postoperative hospital stay (10.0 d vs. 12.3 d) were all significantly shortened (all P<0.05). No open conversion was required in either group, and no significant difference was noted in terms of the distance of the distal resection margin, number of resected lymph nodes and the incidence of positive circumferential resection margin and postoperative complications between the two groups (all P>0.05). Conclusion: Robotic total endoscopic single anastomosis in treatment of rectal cancer is a safe and feasible operative technique, with advantages of less trauma, fast postoperative recovery, and short length of hospital stay, but its long-term efficacy still needs follow-up assessment.

Abstract:

Objective: To assess the clinical application value of 3D laparoscopic surgery in treatment of gastrointestinal stromal tumor in the fundus of the stomach. Methods: The clinical data of 36 patients with gastrointestinal stromal tumor in gastric fundus treated between January 2014 and June 2015 in Renmin Hospital of Wuhan University were retrospectively analyzed. Of the patients, 18 cases underwent 3D laparoscopic resection (3D laparoscopic group) and 18 cases were subjected to open resection (open surgery group). The perioperative variables and postoperative pathological results as well as recurrence and metastasis were compared between the two groups of patients. Results: There were no differences between the two groups in terms of general data such as age, gender, tumor size and BMI (all P>0.05). No statistical difference in operative time was noted between the two groups, while the indices such as intraoperative blood loss, length of the incision, time to postoperative gas passage and length of hospital stay in 3D laparoscopic group were significantly better than those in open surgery group (all P<0.05). No tumor rupture or positive margin was found and no severe complications such as massive hemorrhage, anastomotic fistula and postoperative intestinal obstruction occurred in either group, and the postoperative pathological and immunohistochemical features of the two groups showed no significant difference (all P<0.05). All patients were followed up for 12 to 36 months, and no cases of tumor metastasis and recurrence or death occurred. Conclusion: Using 3D laparoscopic technique in treatment of gastrointestinal stromal tumor in the gastric fundus can significantly minimize the surgical trauma of the patients, and its long-term efficacy is similar to that of open resection.

Abstract:Objective: To assess the clinical efficacy and safety of imatinib treatment for advanced and high-risk gastrointestinal stromal tumor (GIST). Methods: The clinical data of 173 GIST patients treated between January 2011 and June 2016 were reviewed. Of the patients, 73 cases had advanced GIST, and 100 cases had high-risk GIST. The outcomes were compared between patients with and without imatinib treatment in these two categories of patients, respectively. Results: The 73 patients with advanced GIST were followed up for 31 (6–66) months, and of them, the Cox regression analysis showed that the overall survival (OS) in patients with imatinib treatment was significantly prolonged compared with those without imatinib treatment (1-year OS: 100.0% vs. 78.6%, 2-year OS: 93.1% vs. 26.1%; HR=0.040, 95% CI=0.011–0.152, P=0.000). Follow-up was conducted for 45 (6–73) months in the 100 patients with high-risk GIST, of whom, the subgroup analysis showed that the recurrence free survival (RFS) in patients receiving postoperative 1-year imatinib treatment was significantly longer than that in those without imatinib treatment (3-year RFS: 66.7% vs. 38.5%; HR=0.341, 95% CI=0.134–0.868, P=0.024) and moreover, the RFS in patients receiving postoperative 2-year imatinib treatment was significantly longer than those receiving 1-year imatinib treatment (1-year RFS: 100.0% vs. 100.0%, 2-year RFS: 100.0% vs. 88.9%, 3-year RFS: 91.7% vs. 66.7%; HR=0.108, 95% CI=0.015–0.778, P=0.027); the 3-year RFS was 100.0% in the 5 high-risk patients who received postoperative 3-year imatinib treatment. The common adverse effects from imatinib treatment were edema, leukopenia and gastrointestinal disorders, and most of them were grade 1 to 2 in severity. Conclusion: Imatinib has favourable safety in treatment of advanced and high-risk GIST, and it can effectively improve the survival of the patients. For those high-risk patients, at least 3 years’ postoperative imatinib administration is recommended, but whether to extend the 3-year time limit of drug administration needs to be determined by further clinical studies.

Abstract:Objective: To investigate the value of preoperative plasma levels of D-dimer (D-D) and fibrinogen (FIB) in predicting the postoperative prognosis of patients with gastrointestinal stromal tumor (GIST). Methods: The clinicopathologic and follow-up data of patients with GIST undergoing surgical treatment from January 2010 to December 2015 were collected. The relations of preoperative D-D and FIB levels with the prognosis of patients were analyzed. Results: Of the 170 GIST patients, 91 cases were male and 79 cases were female, ages mainly ranged from 50 to 70 years, and the primary tumors were mostly located in the stomach (122 cases, 71.8%) followed by the small intestine (34 cases, 20.0%). The 3- and 5-year recurrence free survival rate (RFS) of the entire group was 85% and 75%, respectively. The ROC curves with survival outcome (occurrence of metastasis or recurrence) as state variable demonstrated that the optimal cut-off point for D-D and FIB was 1.24 mg/L and 3.24 g/L, respectively. Univariate analysis showed that D-D≥1.24 mg/L, FIB≥3.24 g/L, moderate and high NIH risk categories, tumor diameter greater than 5 cm, and extra-gastric location were significantly associated with the reduced postoperative 3- and 5-year RFS of GIST patients (all P<0.05); multivariate analysis revealed that D-D (RR=0.382, 95% CI=0.151–0.967, P=0.042), FIB (RR=0.123, 95% CI=0.035–0.430, P=0.001) and tumor NIH risk category (RR=0.149, 95% CI=0.042–0.524, P=0.003) were independent risk factors for postoperative prognosis of GIST patients. There was significant correlation between tumor NIH risk category and either D-D or FIB in GIST patients (r=0.648; 0.868, both P<0.01). Conclusion: Preoperative plasma levels of D-D and FIB can potentially be used as predictors for postoperative outcome of GIST patients.

Abstract:Objective: To compare the clinical effects and influences on postoperative intestinal barrier function between laparoscopic-assisted and traditional open radical gastrectomy for gastric cancer. Methods: Forty-one eligible patients with gastric cancer from January 2016 to June 2016 were enrolled. Of the patients, 21 cases underwent laparoscopic-assisted D2 radical gastrectomy (laparoscopic group), and 20 cases underwent open D2 radical surgery (laparotomy group). The main clinical variables and changes in the plasma concentrations of diamine oxidase (DAO) and endotoxin (ETX) before and after operation between the two groups of patients were compared. Results: The general clinical data of the two groups of patients were comparable. Laparoscopic group was superior to laparotomy group in terms of incision length and intraoperative blood loss, but its operative time was longer than that in laparotomy group (all P<0.05), while, no significant difference was noted in other clinical variables that included intraoperative blood infusion requirements, number of lymph node resection, surgical margins and time to postoperative gas passage between the two groups of patients (all P>0.05). The plasma levels of DAO and ETX were significantly increased in both groups on postoperative day one compared with their preoperative levels (all P<0.05), but all returned to their preoperative levels later, and the DAO and ETX levels showed no significant difference between the two group before operation and at any observed time point after operation (all P>0.05). Further, there was a positive correlation betweern DAO and ETX levels in either group of patients (r=0.759; r=0.559, both P<0.05). The incidence of infectious complications showed no significant difference between the two groups (P>0.05). Conclusion: Laparoscopic-assisted radical gastrectomy is as safe and effective as traditional open radical gastrectomy, and it also does not increase the impact on intestinal barrier function.

Abstract:Objective: To investigate the safety and efficacy of using esophageal suspension method for manual esophagojejunostomy following totally laparoscopic total gastrectomy (TLTG). Methods: The clinical data of 34 patients undergoing TLTG and esophageal suspension manual esophagojejunostomy (suspension group) from January 2016 to January 2017 were retrospectively analyzed, and they were compared with the clinical data of 17 patients undergoing TLTG and traditional manual esophagojejunostomy (traditional group) during the same period. Results: The preoperative data of the two groups were comparable. Operations were successfully completed in all the 34 patients without any open conversion. In suspension group compared with traditional group, except for the length of incision that showed no significant difference (3.75 cm vs. 3.79 cm, P=0.142), the intraoperative variables that included the operative time (198.35 min vs. 211.65 min), anastomosis time (27.82 min vs. 48.74 min) and blood loss (49.68 mL vs. 50.85 mL) were all significantly improved (all P<0.05); the postoperative variables that included the time to gas passage (2.61 d vs. 2.78 d), pain score (3.21 vs. 3.89) and length of hospitalization (9.77 d vs. 10.32 d) were all significantly improved (all P<0.05). No relevant postoperative complications occurred in patients of both groups. Conclusion: Using esophageal suspension method for manual esophagojejunostomy during TLTG is safe and effective, with short-term efficacy superior to that of traditional esophagojejunostomy method.

Abstract:Objective: To investigate the safety and effectiveness of laparoscopic-assisted resection of colorectal cancer in elderly patients (≥70 years of age). Methods: According to the inclusion and exclusion criteria, 120 elderly patients with colorectal cancer admitted between January 2012 and January 2015 were prospectively enrolled, and randomly designated to laparoscopic group and laparotomy group with 60 cases in each group, undergoing laparoscopic-assisted or open resection of colorectal cancer, respectively. The main clinical variables between the two groups of patients were compared. Results: In laparoscopic group compared with laparotomy group, the operative time (118.23 min vs. 120.85 min, P=0.458) and number of resected lymph nodes (18.12 vs. 17.37, P=0.218) showed no significant difference, but the intraoperative blood loss (307.28 mL vs. 354.80 mL, P=0.000), time to first postoperative flatus (38.27 h vs. 47.02 h, P=0.000) and length of hospital stay (16.58 d vs. 20.07 d, P=0.000) were all significantly reduced. No statistical difference was noted in incidence of postoperative complications that included intestinal fistula, subcutaneous infection, anastomotic fistula, intestinal obstruction, urinary tract infection and lung infection (all P>0.05). The recurrence rate (35.0% vs. 41.7%, P=0.453) and mortality rate (13.3% vs. 18.3%, P=0.453) at postoperative 24 months had no statistical difference between the two groups. Conclusion: Performance of laparoscopic-assisted resection of colorectal cancer in elderly patients is safe and effective, and it is recommended to be used.

Abstract:Objective: To investigate the genes and signaling pathways associated with the sensitivity of advanced gastric cancer to S-1 plus oxaliplatin (SOX) neoadjuvant chemotherapy. Methods: The surgical specimens from 15 patients with stage III gastric cancer were collected, in which, 6 cases responded (responder group) and 6 cases did not respond (non-responder group) after SOX neoadjuvant chemotherapy, and 3 cases did not receive any neoadjuvant chemotherapy (non-chemotherapy group). After the gene expression profile in each group was detected by high-throughput gene microarray screening, choosing DNA damage repair and folate metabolism as two major analytical aspects, the differentially expressed genes were screened by systemic bioinformatics analysis, and then, pathways associated with the differentially expressed genes were identified through KEGG mapping. Results: There was an obvious different gene expression profiles among the three groups of specimens. The differentially expressed genes between responder group and non-responder group were highly enriched in pathways relevant for cytokine-cytokine interactions and cytotoxicity mediated by NK cells. Of the genes associated with DNA damage repair, three (HUS1, RECQL5 and XRCC4) were up-regulated and one (GADD45G) was down-regulated significantly in responder group compared with non-responder group; no differentially expressed gene related to folate metabolism was found among the three groups. Conclusion: The genes affecting the sensitivity of advanced gastric cancer to SOX neoadjuvant chemotherapy may be associated with immune signal transduction, and the detection of the relevant genes may have certain significance for estimating the efficacy of SOX neoadjuvant chemotherapy for gastric cancer.

Abstract:Objective: To investigate the EphA2 and VEGF-C expressions in gastric cancer and their clinical significance. Methods: The protein expressions of VEGF-C and EphA2 as well as the lymphatic vessel density (LVD) in 82 paired specimens of gastric cancer and adjacent gastric tissue were determined by immunohistochemical staining. The mRNA expressions of EphA2 and VEGF-C in 20 paired specimens of gastric cancer and adjacent gastric tissue were detected by real-time RT-PCR. The relations of EphA2 and VEGF-C expressions with the clinicopathologic characteristics of the patients and lymphangiogenesis were analyzed. Results: The positive expression rates of both EphA2 and VEGF-C in gastric cancer tissue were significantly higher than those in adjacent gastric tissue (65.8% vs. 42.6%; 71.9% vs. 39.0%, both P<0.05). The high expressions of EphA2 and VEGF-C were significantly associated with the depth of tumor invasion, lymph node metastasis and TNM stage (all P<0.001). The LVD count in gastric cancer tissue with high EphA2 or VEGF-C expression was significantly higher than that in gastric cancer tissue with low EphA2 or VEGF-C expression (15.25±5.41 vs. 10.95±5.41, P=0.001; 14.87±5.71 vs. 11.00±5.01, P=0.006). There was a significant correlation between EphA2 and VEGF-C in either protein or mRNA expression in gastric cancer tissue (r=0.375, P=0.001; r=0.559, P=0.01). Conclusion: Both EphA2 and VEGF-C expressions are increased in gastric cancer tissue, and they may jointly promote lymphangiogenesis and lymph node metastasis in gastric cancer.

Abstract:Objective: To investigate the effect of CDX2 gene expression on growth of colon cancer cells. Methods: Human colon cancer HT29 and SW480 cells transfected with lentiviral vectors expressing CDX2-shRNA, or empty lentiviral vectors or without any transfection were transplanted subcutaneously into nude mice to generate tumor xenografts, respectively. Then the growth of the xenografts in the three groups of mice was observed. At 28 d after transplantation, the mice were sacrificed and their xenografts were isolated and weighed, and the expressions of Ki-67 and CDX2 were determined by immunochemical staining and Western blot, respectively. Results: In either interference group (transplantation of HT29 or SW480 cells transfected with lentiviral vectors expressing CDX2-shRNA) compared with corresponding blank control (transplantation of HT29 or SW480 cells without any transfection), the tumor growth speed was significantly enhanced, the tumor weight was significantly elevated (SW480: 679.11 mg vs. 379.36 mg; HT29: 715.78 mg vs. 427.07 mg) and the Ki-67 protein expression was significantly increased, while the CDX2 protein expression was significantly upregulated in the tumor tissue (all P<0.05). No significant difference was found in any of above parameters between the two negative control groups (transplantation of HT29 or SW480 cells transfected with empty lentiviral vectors) and their blank control groups (all P>0.05). Conclusion: Inhibition of CDX2 gene expression can promote the growth of human colon cancer cells in nude mice, so CDX2 is probably an important cancer suppressor gene.

Abstract:Objective: To investigate the relationship between the expressions of long non-coding RNA (lncRNAs) and the inflammatory responses induced by lipopolysaccharide (LPS) in intestinal macrophages. Methods: Rat intestinal macrophages were isolated and cultured. The differentially expressed lncRNAs between LPS treated (experimental group) and untreated rat intestinal macrophages (control group) were determined by lncRNA expression microarray, and then the data from microarray were analyzed by hierarchical clustering method. The lncRNA-mRNA co-expression network was constructed, and then the biological function prediction was performed by GO analysis and pathway analysis. Finally, some differentially expressed lncRNAs detected by microarray were verified by RT-qPCR. Results: In experimental group compared with control group, a total of 357 differentially expressed lncRNAs (fold change >1.5) was identified, in which, 245 lncRNAs were up-regulated and 112 lncRNAs were down-regulated. GO analysis and pathway analysis indicated that these differentially expressed lncRNAs were involved in many biological processes that included in the inflammatory response, immune responses and apoptosis, and among them, the lncRNA NONMMUT024673 and NONMMUT047081 were probably most important in the network. The expressions of NONMMUT024673 and NONMMUT047081 examined by RT-qPCR were consistent with those obtained by microarray. Conclusion: LPS can elicit lncRNA differential expression in rat intestinal macrophages, and these differentially expressed lncRNAs may participate in the regulation of the inflammatory response intestinal macrophages induced by LPS.

Abstract:

Objective: To determine the value of using carbon nanoparticle tracer in radical laparoscopic colon cancer surgery. Methods: Thirty-five patients with colon cancer were randomly designated to study group (15 cases) and control group (20 cases). Patients in study group underwent submucosal or subserosal injection of carbon nanoparticles around the tumor prior to radical laparoscopic colon cancer surgery, while those in control group underwent laparoscopic surgery directly. The main clinical variables and lymph node detection were compared between the two groups. Results: There was no statistical difference in length of incision, time to gas passage, time to postoperative food intake and length of hospital stay between the two groups (all P>0.05), but the operative time and intraoperative blood loss were significantly reduced in study group compared with control group (both P<0.05). Except the number of dissected paracolic lymph nodes that showed no statistical difference between the two groups (P=0.078), the total number of dissected lymph nodes, the number of lymph nodes <5 mm and number of positive lymph nodes in study group were all superior to those in control group (all P<0.05). Conclusion: In radical laparoscopic colon cancer surgery, using carbon nanoparticle tracer technique can overcome the lack of tactile sense in the process of laparoscopic surgery, allow the combination of minimal invasiveness and precision, and significantly improve the lymph node detection rate.

Abstract:Objective: To investigate the value of preoperative peripheral blood neutrophil-lymphocyte ratio (NLR) in estimating the prognosis in elderly patients (75 years of age and older) after radical surgery for colon cancer. Methods: The clinical data of 67 colon cancer patients over 75 years of age undergoing radical surgery in Department of General Surgery of Liaohe Oil Field General Hospital from January 2008 to January 2013 were collected. The relations of preoperative NLR values of the patients with the clinicopathologic factors and postoperative survival rates were analyzed. Results: According to the cut-off point of NLR (2.98), the patients were divided into low NLR group (NLR<3) and high NLR group (NLR≥3), with 44 cases in the former and 23 cases in the latter. The degree of tumor differentiation was poorer (P=0.040), lymph node metastasis rate was higher (P=0.018), TNM stage was more advanced (P=0.008) and CEA level was higher (P=0.026) in high NLR group than those in low NLR group. The overall postoperative 3-year survival rate in the whole group of patients was 62.7%, which in low NLR group and high NLR group was 72.7% and 43.5% respectively, and the difference had statistical significance (P<0.05). Univariate analysis showed that the preoperative NLR value together with the degree of tumor differentiation, TMN stage, lymph nodes metastasis and CEA level were significantly associated with the postoperative survival of the patients (all P<0.05). Conclusion: Preoperative NLR has certain value in prognostic estimation for elderly colon cancer patients after radical surgery, and those with high NLR level may face an unfavorable prognosis.

Abstract:Objective: To evaluate the feasibility and effectiveness of using enhanced recovery after surgery (ERAS) protocols based on multidisciplinary team (MDT) cooperation in perioperative period of laparoscopic inguinal hernia repair. Methods: A total of 782 patients scheduled to undergo laparoscopic inguinal hernia repair were randomly assigned to ERAS group (392 cases) and control group (390 cases) according to hospital admission orders. Patients in control group underwent conventional treatment and nursing, while those in ERAS group received treatment and nursing under the concept of MDT-based ERAS, where the main interventions included the selection of hospitalization mode, health education based on integrative medicine and nursing, dietary requirements, bowel preparation, urinary retention prevention, early postoperative ambulation, wound pain treatment, preanesthetic medication, avoidance of perioperative hypothermia, perioperative fluid management, prophylaxis of postoperative nausea and vomiting, and patient comfort assessment at one month after surgery. The scenarios such as postoperative pain, patient recovery, incidence of complications and stress responses, and degree of comfort were compared between the two groups. Results: In the ERAS group compared with control group, the NRS pain score on the morning of postoperative day 1 was decreased, the time to normal diet and ambulation as well as length of hospital stay was shortened, the postoperative satisfaction rate was increased, the incidence of complications such as seroma, urinary retention and wound infection and incidence of discomfort and nausea reaction were reduced, and median score from inguinal pain questionnaire at one month after surgery was decreased (all P<0.05). Conclusion: In perioperative period of laparoscopic inguinal hernia repair, using MDT-based ERAS protocols can alleviate patient discomfort, accelerate rehabilitation, shorten hospital stay, and increase patient satisfaction and comfort.

Abstract:Undoubtedly, the treatment strategies for patients with rectal cancer especially for those with locally advanced rectal cancer (LARC) have changed dramatically. Neoadjuvant chemoradiotherapy (NCRT) combined with total mesorectal excision (TME) has been regarded as the gold standard treatment for LARC. NCRT can not only reduce tumor volume, downstage tumor grade and increase sphincter preservation rate, but also allow some patients to achieve a clinical even pathologic complete response. However, the radical surgery may cause great surgical trauma, multiple complications and lifelong suffering of permanent colostomy. So, whether radical surgery can be avoided by instead applying non-surgical “wait-and-see” approach in patients with complete response has become a top-level strategic issue for colorectal surgeons in recent years. Here, the authors address the definition, characteristics, evolution and research status of the “wait-and-see” strategy with some considerations for future prospects of this new strategy.

Abstract:Complete surgical resection has been considered to be the main treatment method for gastrointestinal stromal tumor (GIST) of the stomach. With the development of the surgical techniques and devices and the popularity of minimally invasive procedures, more and more cases of laparoscopic gastric GIST resection and relevant studies were reported. Meanwhile, the relative advantages and drawbacks of laparoscopic treatment of gastric GIST were also described in some respects. In this paper, the authors briefly address the issues concerning laparoscopic surgical treatment of gastric GIST based on recent literature review.