Volume 31,Issue 10,2022 Table of Contents

1 Treatment strategies for Siewert type Ⅱ adenocarcinoma of esophagogastric junction

WANG Xin , ZHU Jiaming

2022, 31(10):1265-1271. DOI: 10.7659/j.issn.1005-6947.2022.10.001

[Abstract](747) [HTML](808) [PDF 803.27 K](1683)

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The incidence of esophagogastric junction (EGJ) cancer has been on the rise in recent years, and the treatment of Siewert type Ⅱ adenocarcinoma of EGJ (AEG) is still controversial. The core issues are mainly concentrated in the esophagus resection margin, the scope of gastrectomy, the extent of lymph node dissection, and the method of digestive tract reconstruction. With the continuous multidisciplinary discussion and verification for Siewert type Ⅱ AEG at home and abroad, the diagnosis and treatment of Siewert type Ⅱ AEG have become increasingly standardized. The standardization of Siewert type Ⅱ AEG treatment has also been explored through multi-center trials (e.g., CLASS-10) in our country. It is believed that the active advancement of more and more large-scale prospective clinical studies will bring more integration possibilities for communication and cooperation among various disciplines and innovation of new technologies, which will provide more survival benefits to patients.

2 Controversies and considerations regarding type choice of bariatric surgical procedures for extremely obese patients

WANG Geng , LI Gang , BAI Jie , LIU Yang , DENG Shichang , TAO Kaixiong , XIA Zefeng

2022, 31(10):1272-1284. DOI: 10.7659/j.issn.1005-6947.2022.10.002

[Abstract](789) [HTML](1032) [PDF 895.35 K](1863)

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Obese patients with a body mass index (BMI) ≥50 kg/m² are classified as extreme/super obese. These patients are not only seriously overweight but also complicated by serious obesity-related diseases such as hypertension, diabetes, cardiovascular and cerebrovascular disease, obstructive sleep apnea-hypopnea syndrome (OSAHS) and gastroesophageal reflux disease (GERD). The quality of life and health of extremly obese patients are greatly affected. However, drug therapies have very limited effects on the extremely obese. Bariatric surgeries are the main therapeutic options, but how to select an appropriate surgical procedure is still considerable controversy. First, the safety and smooth-going of the operation should be guaranteed, and the risk factors for perioperative complications should be minimized; secondly, the therapeutic efficacy should be confirmed to help patients to achieve the goals of satisfactory weight loss and improvements of metabolic syndrome; thirdly, existing clinical studies demonstrate that the treatment efficacy in super-obese population is inferior to that in other obese population, so revisional surgical options should be considered before performing the initial surgery. At present, the types of bariatric metabolic surgery are constantly developing and evolving. Each surgical type has its pros and cons because of its different design principles. Sleeve gastrectomy (SG) is the most popular bariatric surgery. It has the advantages of easy operation and relatively fewer postoperative complications but has the disadvantages of limited efficacy for weight loss and glucose-lowering and making no significant improvements in metabolic syndrome. Roux-en-Y gastric bypass (RYGB) is also currently a mainstream operation. It has strong efficacy for weight loss, glucose-lowering, and metabolic improvements, but it has shortcomings, such as complex operations and more postoperative complications. Biliopancreatic diversion duodenal switch (BPD-DS) has the highest efficacy for weight loss and glucose-lowering, but the procedure is most difficult with severe postoperative complications. In recent years, bariatric metabolic surgeons have created a series of modifications focused on the merits and demerits of the above procedures, resulting in many new surgical techniques. Here, the authors analyze and discuss the surgical methods currently recommended by the guidelines and the surgical methods with rapid development, analyze the current controversies and new insights according to the existing clinical evidence, and summarize the significant issues in clinical practice.

3 Perioperative management process of extremely obese patients with type 2 diabetes

ZHANG Tianyi , WANG Yong

2022, 31(10):1285-1292. DOI: 10.7659/j.issn.1005-6947.2022.10.003

[Abstract](499) [HTML](693) [PDF 714.70 K](1551)

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The diagnostic criteria for super obesity with type 2 diabetes mellitus include that body mass index (BMI) is above 50 kg/m², fasting plasma glucose (FPG) is greater than 7.0 mmol/L, and insulin and C-peptide secretion levels at each time point of oral glucose tolerance test (OGTT) are higher than those in fasting state. Metabolic surgery is almost the only effective treatment for patients with super obesity and type 2 diabetes. Therefore, the scientific perioperative management is the key to ensuring the safety of operation and improving the long-term results. Perioperative risks include the risk of the procedure itself, the risk of obesity-related diseases, and the risk of abnormal blood sugar. To reduce the perioperative risks, the following questions are required to be clarified: (1) whether there are effective interventions; (2) how long the intervention will last and what effect it will achieve; (3) whether there is an alternative solution if the expected effect cannot be achieved. Here, the authors put together the perioperative management process for patients with super obesity and type 2 diabetes by reviewing and extracting data from the domestic and foreign literature in recent years, so as to provide a reference for clinical treatment.

4 Perioperative management process for super obesity with hypertension

YAO Libin , ZHU Xiaocheng

2022, 31(10):1293-1298. DOI: 10.7659/j.issn.1005-6947.2022.10.004

[Abstract](789) [HTML](523) [PDF 640.52 K](1453)

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In recent years, due to the changes in lifestyle and diet structure, the number of overweight and obese people has increased obviously in China, and the degree of obesity is increasingly serious. The number of extremely obese patients with concomitant hypertension undergoing bariatric metabolic surgery is also on the rise. The control and standardized management of perioperative blood pressure in such patients have a significant impact on their prognosis. However, the current management process of perioperative blood pressure in patients with super obesity and hypertension still lacks the corresponding theory, experience, and evidence guidance. Herein, the authors discuss and summarize the pre-, intra-, and postoperative blood pressure management process of super obese patients with hypertension to improve the safety of bariatric surgery for such patients and reduce or even avoid the occurrence of intra- and postoperative complications.

5 Bariatric surgery and pregnancy: impact, advantages and disadvantages, as well as timing

YANG Juncheng , DU Xiao

2022, 31(10):1299-1306. DOI: 10.7659/j.issn.1005-6947.2022.10.005

[Abstract](1260) [HTML](772) [PDF 715.44 K](1473)

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Obesity affects the reproductive health of women of reproductive age and meanwhile, increases the possibility of maternal and fetal complications. Bariatric surgery improves obesity-related fertility impairment. Traditional treatment methods such as exercise, diet, and medications all have limitations. Bariatric surgery is currently the most effective and lasting treatment for obesity, which can significantly improve obesity-related complications while achieving weight loss. With more and more obese women of childbearing age undergoing bariatric surgery, post-bariatric pregnancy has attracted increasing attentions from the academic societies. However, only a few studies have evaluated the effect of bariatric surgery on pregnancy-related outcomes, and the relevant literature is even scarce in China. Here, the authors summarize the impact of bariatric surgery on pregnancy-related results and the appropriate timing of post-bariatric pregnancy, so as to help guide the management of pregnancy-related events before and after bariatric surgery and obtain the best pregnancy outcomes.

6 Weight loss efficacy and safety of laparoscopic sleeve gastrectomy in super obese patients

XING Ying , YAN Wenmao , BAI Rixing

2022, 31(10):1307-1315. DOI: 10.7659/j.issn.1005-6947.2022.10.006

[Abstract](817) [HTML](332) [PDF 757.56 K](1639)

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Background and Aims Laparoscopic sleeve gastrectomy (LSG) is presently one of the most common bariatric operations. Its weight-loss effect in simple obese patients has reached consensus among surgeons, but its effect in super obese (SO) patients has not been reported on a large scale. This was conducted to retrospectively investigate the weight-loss effect and perioperative safety of LSG for super-obese patients with a BMI greater than 50 kg/m².Methods Super obese patients who received LSG in the Department of General Surgery of Beijing Tiantan Hospital Affiliated to Capital Medical University from March 2017 to June 2022 were selected. The variables such as operative time, bleeding volume, and complication were recorded, the surgical safety of LSG in super obese patients was observed, and the improvements in body weight, BMI, excess weight loss (%EWL), fasting blood glucose, liver and kidney function, blood lipid, uric acid and comorbidities after LSG were analyzed.Results A total of 39 super obese patients were included, including 23 males and 16 females, with an average age of (31.15±8.37) years, an average preoperative weight of (159.97±19.97) kg, and an average BMI of (54.46±3.89) kg/m². In all patients, the routine preoperative examination, abdominal ultrasound, vascular ultrasound, gastroscopy, echocardiography, blood gas analysis, and other tests were completed, and preoperative evaluation through multidisciplinary consultation was made. All patients underwent a four-port laparoscopic operation without conversion to open surgery. The average operative time was (63.00±12.30) min, and the intraoperative blood loss was (23.00±4.30) mL. Cirrhosis was found in one patient during the operation, without hypersplenism and portal hypertension; there was no severe liver dysfunction, no abdominal bleeding, secondary operation, pulmonary infection, lower extremity venous thrombosis, and perioperative death after the procedure., From the first month after the operation, the weight and BMI of the patients began to decrease significantly. The %EWL at the 1st, 3rd, 6th, 12th, 24th, and 36th months after the operation was 17.69%, 38.84%, 54.21%, 62.09%, 61.12%, and 57.00%, respectively; from 3 months after the operation, alanine aminotransferase and aspartate aminotransferase decreased significantly compared with those before operation (all P<0.05); blood lipids were improved after operation, uric acid significantly reduced at 12 months after operation (P<0.05); there was no significant change of creatinine and urea nitrogen before and after the operation (both P>0.05); in 9 patients with type 2 diabetes, the glycosylated hemoglobin markedly decreased after the operation, and one patient still needed oral hypoglycemic drugs six months after operation; one year after the operation, the liver and kidney functions and blood lipids of all patients returned to normal, and only 3 of the 12 hypertensive patients still needed antihypertensive drugs.Conclusion LSG has a high safety in super obese patients and has a good effect on weight loss and comorbidity control. It can be the first weight loss surgery choice for such patients.

7 Procedure selection and efficacy comparison of bariatric and metabolic surgeries for super obesity

GUAN Wei , LIN Shibo , LI Cong , SHEN Jiajia , LIANG Hui

2022, 31(10):1316-1323. DOI: 10.7659/j.issn.1005-6947.2022.10.007

[Abstract](979) [HTML](663) [PDF 729.20 K](1833)

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Background and Aims Metabolic and bariatric surgery is the primary treatment for severe obesity. However, little is known about the effectiveness of different procedures in super-obesity Chinese patients (BMI≥50 kg/m²). This study was conducted to determine the short-term efficacy of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in treating super obesity patients to provide a reference for procedure selection.Methods The perioperative and postoperative follow-up data of 71 super obese patients who were treated by SG or RYGB in the First Affiliated Hospital of Nanjing Medical University from October 2011 to September 2020 were retrospectively analyzed.Results Of the 71 patients, 37 cases underwent SG (SG group), and 34 cases underwent RYGB (RYGB group). There were no significant differences in the baseline data (sex, age, weight, and BMI) and obesity-related metabolic complications between the two groups (all P>0.05). The average operative time in the RYGB group was longer than that in the SG group [（143.4±84.5）min vs.（ 93.2±31.2）min，P=0.001], and there was no significant difference in the overall incidence of postoperative complications between the two groups (P>0.05). The postoperative one-year follow-up results showed that there were no significant differences in weight, BMI, total weight loss rate, and excess weight loss rate between the two groups (all P>0.05); in terms of the improvements in metabolic complications, the remission rates of type 2 diabetes and hyperlipidemia in RYGB group were higher than those in SG group (88.9% vs. 25.0%, P=0.021; 100.0% vs. 22.2%, P<0.001), while the remission rate of liver malfunction in RYGB group was lower than that in SG group (61.5% vs. 87.5%, P=0.011); as for the postoperative nutritional assessment, the iron deficiency, and vitamin B₁₂ deficiency rates in RYGB group were significantly higher than those in SG group (55.9% vs. 13.5%, P<0.001; 29.4% vs. 5.4%, P=0.007), the hemoglobin level was significantly lower in RYGB group (121.5 g/L vs. 135.8 g/L, P=0.033), while the folate level was higher (25.3 nmol/L vs. 17.3 nmol/L, P=0.004) than those in SG group. In addition, the incidence of vitamin D deficiency was more than 60% in both groups.Conclusion SG and RYGB are safe and feasible for super obese patients, with similar weight loss effects. RYGB is more effective for those with glycolipid metabolism disorder, while its incidence of malnutrition is also higher. SG is more suitable for super-obese patients with severe complications owing to its shorter operative time, and SG is also more effective for improving liver malfunction. Postoperative education and follow-up should be strengthened for patients to avoid the occurrence of severe malnutrition. The specific procedure selection needs to follow the principle of individualization.

8 Meta-analysis of the effects of time-restricted eating on body weight and metabolism

QI Zitian , HAO Zhen , TAO Boyu , ZHANG Peng

2022, 31(10):1324-1338. DOI: 10.7659/j.issn.1005-6947.2022.10.008

[Abstract](1350) [HTML](630) [PDF 1.38 M](1353)

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Background and Aims Bariatric and metabolic surgery is the most effective treatment modality for moderate to severe obesity and pathological obesity, but there are strict surgical indications for bariatric surgery, and a feasible and effective approach for weight loss is also needed for some patients who do not meet the surgical criteria. The risk of bariatric surgery is significantly increased for super-obese patients. Such patients also need an acceptable and efficacious approach to lose weight before surgery to reduce the risk of surgery. Time-restricted eating (TRE) is a new strategy for weight loss and treatment of metabolic diseases based on circadian rhythm, which is expected to be a powerful supplement to bariatric surgery. However, there is no comprehensive assessment of the impact of TRE on weight, body composition, and metabolism. Therefore, this study was conducted to evaluate the effects of TRE on weight, body composition, and body metabolic parameters through systematic review and Meta-analysis to provide evidence-based medical information for clinical decision-making.Methods The randomized controlled studies regarding the effects of TRE on body weight, body composition, and body metabolism were searched in the PubMed, Web of Science, EMBASE, CNKI, and Wanfang databases. The retrieval time was from the inception of the database to April 1, 2022. After the literature screening, data extraction, and assessment of the bias risk of the included studies by two independent researchers, Meta-analysis was performed using Stata 17.0 software.Results A total of 14 studies with 587 subjects were included. The results of the Meta-analysis showed that in the individuals after TRE intervention versus those with a calorically unrestricted normal diet, the weight (WMD=-2.40, 95% CI=-3.52--1.29, P<0.001) and fat mass (WMD=-1.48, 95% CI=-2.26--0.69, P<0.001) were significantly reduced, and the concentration of triglyceride (WMD=-8.42 mg/dL, 95% CI=-13.69--3.15, P=0.002) was decreased; however, there were no significant differences in fat-free mass, fasting glucose, systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein, and low-density lipoprotein (all P>0.05).Conclusion TRE is an effective weight-loss treatment, which yields significant weight loss with a main effect on fat mass reduction and no significant influence on fat-free mass, and meanwhile is helpful for improving the triglyceride levels. It may be used as a powerful supplement to bariatric surgery. However, the above conclusion still needs to be verified by more high-quality studies due to the limitations in the number and quality of the included studies.

9 Efficacy of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in treatment of obese type 2 diabetes patients in China

WANG Zeyu , WANG Lun , ZHAO Yuhui , JIA Yongheng , MA Weiqi , JIANG Tao

2022, 31(10):1339-1346. DOI: 10.7659/j.issn.1005-6947.2022.10.009

[Abstract](1243) [HTML](524) [PDF 934.76 K](1476)

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Background and Aims Among many bariatric-metabolic procedures, the single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is one of the most effective treatments for obese type 2 diabetes. However, there are few reports on SADI-S in China. Therefore, this study was conducted to investigate the efficacy of SADI-S in obese type 2 diabetes patients in China to provide a reference for future treatment choices.Methods The clinical data of 50 patients with obese type 2 diabetes undergoing SADI-S at China-Japan Union Hospital of Jilin University between October 2018 and August 2021 were retrospectively analyzed. Patients were analyzed for intraoperative and postoperative conditions (operative time, postoperative hospital stay and surgical complications), weight, body mass index (BMI), extra weight loss (%EWL), total weight loss (%TWL), fasting glucose, glycosylated hemoglobin, and complete remission rate of diabetes after surgery. Follow-up was completed as of August 2022.Results Of the 50 patients, 24 cases were males and 26 cases were females, with a mean age of 34 (28-43) years. All patients completed SADI-S surgery by laparoscopic (11 cases) or robotic (39 cases) approach without conversion to laparotomy, and no death occurred. The operative time was (187.9±37.9) min and the length of postoperative hospital stay was 6 (6-7) d. Surgical complications occurred in 3 patients (6%), which included two Clavien-Dindo Grade Ⅱ complications (abdominal fluid collections and anastomotic leakage) and one Clavien-Dindo grade Ⅲ complication (gastric leakage). The patient with anastomotic leakage was discharged after a combination of conservative treatments, including water fasting, total intravenous nutrition, and intravenous antibiotic therapy. The patient with gastric leakage was discharged after treatment with gastric fistula repair. The patients' weight, BMI, fasting glucose and glycosylated hemoglobin decreased significantly at 3, 6, 12 and 24 months after surgery compared with their preoperative values (all P<0.05). The %EWL values were (57.8±17.5)%, (78.3±18.6)%, (97.3±22.1)%, and (92.5±9.9)%, the %TWL values were 23.2 (19.9-25.9)%, 31.9 (29.3-33.7)%, 39.3 (34.7-45.2)%, 43.0 (39.1-47.1)% and the complete remission rates of type 2 diabetes were 82.0% (41/50), 95.7% (45/47), 100% (36/36), and 100% (8/8) respectively at 3, 6, 12, and 24 months after surgery. SADI-S yielded better efficacy against diabetes in patients with high ABCD scores than those with low ABCD scores at 3 and 6 months after surgery, and yielded remarkable efficacy against diabetes in patients with ABCD scores of all levels.Conclusion SADI-S has an excellent effect in treating obese type 2 diabetes in the Chinese population, but its long-term impact needs to be further observed.

10 Robot-assisted synchronous sleeve gastrectomy and fundoplication surgery for obesity complicated with esophageal hiatal hernia: a single-center retrospective analysis

LI Xin , AIKEBAIER·Aili , ALIMUJIANG·Maisiyiti , WANG Zhi , JIANG Yuan , YIBITIHAER·Maimaitiaili , KELIMU·Abudureyimu

2022, 31(10):1347-1354. DOI: 10.7659/j.issn.1005-6947.2022.10.010

[Abstract](872) [HTML](545) [PDF 976.67 K](1757)

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Background and Aims Obesity patients are often complicated with hiatal hernia and gastroesophageal reflux symptoms, which may cause severe complications after sleeve gastrectomy. The robot-assisted system has the advantages of a short and gentle learning curve, a transparent and three-dimensional surgical field of vision, and accurate and stable surgical operation, which has been widely promoted in the surgical field. This study assessed the feasibility of robot-assisted sleeve gastrectomy plus Nissen fundoplication surgery to provide a better treatment scheme for obese patients with hiatal hernias.Methods The clinical data of 49 patients with obesity and concomitant hiatus hernia undergoing sleeve gastrectomy plus fundoplication surgery between March 2019 and December 2021 were retrospectively reviewed. Of the patients, 22 cases underwent robot-assisted sleeve gastrectomy combined with fundoplication (robotic group), and 27 cases underwent laparoscopic-assisted sleeve gastrectomy combined with fundoplication (laparoscopic group). The differences in perioperative clinical variables between the two groups were compared, and the treatment efficacy in the robotic group was analyzed.Results There were no significant differences in preoperative triglyceride level, preoperative fasting glucose level, length of postoperative hospital stay, and incidence of complications between the two groups (all P>0.05). In the robotic group compared to the laparoscopic group, the average total operation duration was prolonged (169.09 min vs. 143.33 min, P=0.023) and the average surgical cost was increased (63 600 yuan vs. 54 000 yuan, P<0.001), but the average operative time was shortened (115.09 min vs.134.19 min, P=0.047), and the average blood loss was reduced (25.45 mL vs. 40.00 mL, P=0.023). there were no statistical differences in BMI, percentage of excess weight loss (%EWL), triglyceride level, fasting blood glucose level, and GERD score between the two groups at one month after operation (all P>0.05). In robotic group at 1 month after the operation, the %EWL value (26.26%) reached the weight loss goal, and the weight, BMI, triglyceride level, fasting blood glucose level and GERD score were significantly decreased compared with the preoperative values (all P<0.05).Conclusion Robot-assisted sleeve gastrectomy combined with fundoplication surgery yields good weight loss results and significantly improves the metabolic and gastroesophageal reflux symptoms in obese patients with hiatal hernia, and is safe and reliable, with certain feasibility. However, there is still an urgent problem of high surgical cost, and the patient's family economic situation should be fully considered when choosing the surgical approach.

11 Mining of genes involved in microsatellite instability in colorectal cancer through machine learning and evaluation of their application values

LI Xiuqin , HAN Tenghui , WANG Shuai , SHEN Gang , ZHU Jun

2022, 31(10):1355-1362. DOI: 10.7659/j.issn.1005-6947.2022.10.011

[Abstract](1210) [HTML](774) [PDF 928.53 K](1428)

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Background and Aims Colorectal cancer (CRC) is the third most commonly diagnosed malignancy and the second leading cause of cancer death worldwide. The latest guidelines recommend that all CRC patients need to be tested for microsatellite instability (MSI). MSI patients often have deficient mismatch repair (dMMR). The MSI/dMMR has been used as a biomarker for predicting the favorable response to immunotherapy and prognosis of patients. However, MSI signature genes and their relationship to tumor-infiltrating immune cells have not been fully described. Therefore, this study was conducted to discover novel MSI signature genes in CRC through machine learning and verify their diagnostic values and relationships with immune cell infiltration.Methods According to the inclusion and exclusion criteria, the GSE39582 dataset in GEO database was used as the training set, and the COAD dataset in TCGA database was used as the external validation set. Using machine learning methods (LASSO regression and SVM-RFE algorithm), MSI signature genes were screened in the GSE39582 CRC data set and validated in the TCGA COAD dataset. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to evaluate the diagnostic performance of genes for MSI. The CIBERSORT algorithm evaluated each sample's immune infiltrating cell components, and Spearman correlation analysis was used to verify the relationship between MSI signature genes and immune cells.Results A total of 536 CRC patients were included in training set, of which 77 cases (for 14.37%) were high microsatellite instability (MSI-H). In validation set, there were a total of 389 CRC patients, of which 67 cases (17.22%) were MSI-H. The baseline data analysis showed that the TNM profiles and survival rates in MSI-H/dMMR CRC were superior to those in low microsatellite instability (MSI-L) or microsatellite stable (MSS)/proficient mismatch repair (pMMR) CRC (P<0.05). In GSE39582 dataset, 21 MSI signature genes were screened by LASSO regression, and 6 genes were screened by SVM-RFE algorithm. The MSI signature genes were identified as EIF5A, CXCL13, HNRNPL, HOXC6, RPL22L1, and Y16709 by combining the two algorithms. The diagnostic efficacy of MSI signature genes was further verified in TCGA database, and EIF5A was found to have the highest diagnostic efficacy. The AUC values for EIF5A in training and validation sets were 0.922 and 0.805, respectively. At the same time, Spearman correlation analysis found that EIF5A was mainly positively correlated with CD8⁺T cells, activated dendritic cells, helper T cells, M1 macrophages, γδ T cells, and neutrophils; it was negatively correlated with CD4⁺ memory T cells, M2 macrophages, quiescent dendritic cells, eosinophils, and regulatory T cells.Conclusion Analysis of novel MSI signature genes in CRC shows that EIF5A has a good diagnostic performance and clinical value for CRC MSI status. It is also associated with immune cells and immune microenvironment. Thus, EIF5A may become a new marker for immune checkpoint therapy.

12 Association of NF-κB activation with TRAF6, CCR5 and PTEN/PI3K pathway and its role in colorectal cancer cells

HE Yaqin , SU Jinda , ZHAO Shaohui , WANG Jian , XIE Xiaoliang

2022, 31(10):1363-1372. DOI: 10.7659/j.issn.1005-6947.2022.10.012

[Abstract](884) [HTML](641) [PDF 1.34 M](1398)

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Background and Aims The activation of NF-κB plays a crucial role in development and progression of various malignant tumors. Studies demonstrated abnormal expressions in tumor necrosis factor receptor-associated factor 6 (TRAF6) and proteins associated with PTEN/PI3K signaling pathway in malignant tumors. Therefore, this study investigated the expressions of molecules mentioned above and their relations in colorectal cancer cells.Methods In colorectal cancer HT29 and SW480 cells after treatment with Maraviroc (CCR5 inhibitor), MG132 (TRAF6 inhibitor), or NF-BAY (NF-κB inhibitor), the changes in the expressions of those proteins, as well as in proliferation, migration and invasion abilities were detected by Western blot, CCK-8 assay and Transwell assay, respectively.Results In the two types of colorectal cancer cells, the PI3K expression was decreased and the PTEN expression was increased (all P<0.05), while the expressions of TRAF6 and NF-κB showed no significant changes (all P>0.05) after inhibition of CCR5 protein; the expressions of PI3K and CCR5 were decreased and PTEN expression was increased (all P<0.05), while the NF-κB expression did not significantly change (both P>0.05) after inhibition of TRAF6 protein; the expressions of CCR5, TRAF6 and PI3K were decreased and PTEN expression was increased after inhibition of NF-κB expression (all P<0.05). The proliferation, migration and invasion abilities in the two types of colorectal cancer cells were significantly suppressed by the treatment of any of the three inhibitors (all P<0.05).Conclusion There is constitutive activation of the NF-κB in colorectal cancer cells, which may inhibit the activity of tumor suppressor molecule PTEN, and thereby lead to the increased activity of tumor-promoting molecule PI3K as well as its pathway through up-regulating the expressions of TRAF6 and CCR5.

13 Application of super-selective superior rectal artery embolization in rectal hemorrhage

WANG Xuemin , WU Jian , GAO Jianwei , HAN Xinqiang

2022, 31(10):1373-1380. DOI: 10.7659/j.issn.1005-6947.2022.10.013

[Abstract](1017) [HTML](928) [PDF 1.02 M](1297)

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Background and Aims Internal haemorrhoids are common causes of rectal bleeding. When haemorrhage severely impacts patients' quality of life or is even life-threatening, and surgery cannot be performed due to contraindications or the patients are unwilling to undergo the operation, superselective superior rectal artery (SRA) angiography and embolization are one of the best options for rapid haemostasis. Interventional endovascular haemostasis has the characteristics of minimally invasive, fast recovery, and fewer postoperative complications than traditional surgical procedures. However, there are few reports on the application of superselective SRA embolization in rectal bleeding caused by internal haemorrhoids in our country, and its haemostatic effect and safety are still controversial. This study was conducted to evaluate the safety and efficacy of transcatheter super-selective SRA embolization in the treatment of rectal haemorrhage and discuss the technical points and cautions that may influence clinical outcomes, and provide references for clinical practice.Methods The clinical data of all rectal bleeding patients who underwent super-selective SRA embolization at Binzhou Medical University Hospital between December 2016 and October 2021 were retrospectively analysed. The haemostatic effect and postoperative complications of 3-7 d (initial haemostatic rate) and 1-12 months (clinical success rate) after SRA embolization were observed and analysed.Results A total of 50 patients with rectal bleeding successfully underwent superselective SRA embolization, and only 29 patients were included in the final analysis according to the inclusion and exclusion criteria. Among them, 11 patients had grade Ⅱ internal haemorrhoids, and 18 had grade Ⅲ internal haemorrhoids; 17 patients were males, and 12 were females, with a mean age of (51.8±12.2) years. All patients underwent SRA embolization with metal coils (2-3 mm) combined with gelatine sponge particles (350-560 μm) or PVA particles (300-500 μm), and the technical success rate was 100%. Bleeding control or clinical success rate was achieved in 82.8% (24/29) of patients at day 3 to 7 and 86.2% (25/29) at one month postoperatively. Recurrent bleeding occurred in 3 patients (3/25) at 6 months follow-up, and the clinical success rate was 75.9% (22/29) at 6 months postoperatively; two of the three patients underwent internal iliac branches embolization and the symptoms dissipated, while one with conservative management. All patients were followed up for (10.7±2.5) months. In one patient who presented with obvious tenesmus, a colonoscopy revealed a small piece of superficial ulcer on the rectum in the first week after the operation, and conservative management was performed. Two patients had hematoma at the puncture site, which disappeared after conservative treatment. Other patients noted no severe complications, such as infection, intestinal perforation, or massive haemorrhage related to interventional embolization.Conclusion Super-selective SRA embolization is a relatively safe and low-risk surgical method in treating rectal bleeding caused by grade Ⅱ-Ⅲ internal haemorrhoids. It has positive short-term efficacy, especially in an emergency setting. This method has a satisfactory practical application and is worth being recommended.

14 Construction and validation of a nomogram for prognostic value of NLR and PLR in patients with gastric cancer

LI Wuhan , ZHANG Ying , PAN Jingjing , WANG Gaosheng

2022, 31(10):1381-1388. DOI: 10.7659/j.issn.1005-6947.2022.10.014

[Abstract](1100) [HTML](554) [PDF 942.77 K](1468)

Abstract:
Background and Aims The disease burden of gastric cancer in China is high and there are many prognostic factors. There are few studies on the quantitative and comprehensive assessment of prognostic risk. Therefore, this study explored the significance of inflammatory indicators neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) on the prognosis and survival of gastric cancer patients based on nomogram and included them in nomogram and traditional TNM staging to compare the prognostic evaluation efficacy.Methods A retrospective study was conducted in the Department of Gastrointestinal Surgery of the First Affiliated Hospital of University of Science and Technology of China from June 2013 to June 2018. Gastric cancer patients who underwent radical gastrectomy were included in the training group (n=300). Patients with the same diagnosis who experienced the same surgical treatment from another ward were included as the validation group (n=100). The patient's age, gender, tumor type, tumor site, invasion depth, and lymph node metastasis (LNM) were collected through the hospital's electronic medical record system. Peripheral venous blood data were collected 3 days before the operation, and NLR and PLR were calculated. The ROC curve determined the optimal critical points of NLR (1.98) and PLR (134.87). The patients were followed up every 3 months within 2 years and every 6 months after 2 years. Cox proportional hazards model was used to calculate the association between exposure and outcome indicators, and the independent risk factors affecting the prognosis of gastric cancer were identified according to the results of multivariate analysis. The stability of the nomogram was evaluated by C-index in the training group and the validation group after inclusion in the nomogram. Finally, the prediction performance of nomogram and traditional TNM staging was compared based on the area under the ROC curve (AUC).Results There were 220 male patients (73.3%) in the training group and 69 male patients (69.0%) in the validation group. The average age of the training and validation groups was (62.52±10.61) years and (63.67±10.21) years, respectively. There was no significant difference in other baseline characteristics between the two groups except tumor type, differentiation degree and invasion depth. The training group's median overall survival (OS) was 28 months, and the 1-year, 3-year and 5-year OS rates were 63.9%, 43.1% and 35.1%, respectively. The median OS in the validation group was 32 months, and the 1-year, 3-year and 5-year OS rates were 58.9%, 41.6% and 31.7%, respectively. Univariate Cox regression analysis showed that age, pathological type, degree of tumor differentiation, depth of invasion, LNM, NLR, PLR and CEA levels were all associated with OS (all P<0.05). After multivariate adjustment, patients with LNM, preoperative NLR>1.98, PLR >134.87 and carcinoembryonic antigen (CEA) ≥5 μg/L had significantly shorter OS (all P<0.01). The calibration curve results showed that the nomogram model fits well in the training group (C-index=0.81) and the validation group (C-index=0.75). In addition, the AUC values of the nomogram model in predicting the 1-year, 3-year, and 5-year OS rates of the training group (0.865, 0.855, 0.827) were higher than those of the TNM stage (0.677, 0.690, 0.683). The AUC values of 1-year, 3-year, and 5-year OS rates in the training group (0.856, 0.788, 0.725) were higher than those of the TNM stage (0.781, 0.691, 0.605).Conclusion NLR and PLR are independent risk factors for predicting the survival of patients with gastric cancer. The constructed nomogram could more accurately predict the 1-, 3-, and 5-year OS rates of gastric cancer patients undergoing gastrectomy and provide clinicians with more accurate treatment and nursing decision-making evidence.

15 Research progress of seroma after inguinal hernia repair

LI Shaochun , LI Shaojie , MA Hui , TANG Jianxiong

2022, 31(10):1389-1394. DOI: 10.7659/j.issn.1005-6947.2022.10.015

[Abstract](719) [HTML](945) [PDF 631.51 K](1549)

Abstract:
Seroma is a common complication after inguinal hernia repair. There are great differences in the reported incidence of seroma, possibly because different scholars have different understandings of this condition. The patient's own factors, the surgeon's experience, and the materials of the mesh as well as its fixation techniques are all important causes for the formation of postoperative seroma. With regard to the treatment, clinical interventions are not needed in most cases because the seroma can be spontaneously absorbed, and only should be performed in few cases such as patients who have severe symptoms or infection. Thus, prevention is still the main strategy to reduce the incidence of perioperative seroma. Here, the authors review the research literature concerning postoperative seroma following surgery for inguinal hernia, so as to provide reference for clinical use.

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