Volume 31,Issue 4,2022 Table of Contents

1 Guidelines for performing laparoscopic IPOM repair of incision hernia by seven-step method (2022 edition)

2022, 31(4):421-432. DOI: 10.7659/j.issn.1005-6947.2022.04.001

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Incisional hernia repair has been steadily promoted in recent years. Years of experience and clinical studies have shown that laparoscopic intraperitoneal onlay mesh (IPOM) can effectively close the defect and reduce recurrence, so it is an ideal method for the treatment of incisional hernia. Standardization of operation procedure for laparoscopic IPOM repair of incisional hernia is urgently needed. After years of training practice and clinical comparative analyses, our team found that the "seven-step method" follows the learning pattern, is suitable for the operator to master, meanwhile, it can reduce postoperative complications. Therefore, the Hernia and Abdominal Wall Surgeons Branch of Guangdong Medical Doctor Association organized the compilation of the first edition of the "Guidelines for performing laparoscopic IPOM repair of incision hernia by seven-step method", which aims to regularize and standardize the operation of laparoscopic IPOM repair in the field of hernia and abdominal wall surgery, and to provide help for standardizing the repair operation and shortening the learning curve of the hernia and abdominal wall surgeons as well as reducing postoperative complications.

2 Application value of preoperative progressive pneumoperitoneum plus botulinum toxin A injection in large incisional hernia repair

TANG Fuxin , MA Ning , LIU Chuangxiong , HUANG Enmin , MA Tao , CHEN Shuang , WANG Hui , ZHOU Taicheng

2022, 31(4):441-448. DOI: 10.7659/j.issn.1005-6947.2022.04.005

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background and Aims Large incisional hernia repair is always a matter of challenge, because the closure of large defects may likely lead to serious pathophysiological consequences or even life-threatening complications such as abdominal compartment syndrome （ACS）. The preoperative progressive pneumoperitoneum (PPP) can widen the abdominal cavity of the patients, and facilitate reduction of the hernia contents, and the botulinum toxin A (BTA) can cause revisable relaxation the abdominal wall muscles, so their combined use in preoperative preparation of large incisional hernia repair surgery is considered to produce a complementary effect. Therefore, this study was performed to evaluate the application value of PPP combined with BTA injections in large incisional hernia repair.Methods The clinical data of 7 patients with large incisional hernia undergoing laparoscopic intraperitoneal onlay mesh repair (IPOM) using the combination of PPP and BTA injections for preoperative preparation in the Sixth Affiliated Hospital of Sun Yat-sen University from June 2018 to December 2021 were retrospectively analyzed. Before operation, the patients underwent BTA injections into the lateral abdominal wall muscles and abdominal catheter insertion for the PPP under ultrasound guidance. The changes in the volumes of the incisional hernia (VIH), the volumes of abdominal cavity (VAC) and the length and thickness of the lateral abdominal wall muscle before and after PPP plus BTA treatment were measured by CT software. The adverse reactions after PPP plus BTA treatment, the intra- and postoperative complications and follow-up results were recorded.Results Among the 7 patients, 4 cases were males and 3 cases were females, with a median age of 59 (44-71) years and a median body mass index of 25.6 (21.3-31.2) kg/m²; 6 cases had primary hernia and one case had recurrent hernia; 2 cases complicated with underlying diseases. After PPP plus BTA treatment, the average increase in length of the lateral abdominal muscle on each side was 3.5 cm, the average decrease in thickness of the abdominal wall muscle on each side was 0.3 cm, the average increaseing value of VIH was 829 mL, the average increaseing value of VAC was 2 982 mL, and the average decreasing value of VIH/VAC ratio was 1.7%, respectively; varying degrees of spontaneous reduction of the hernia contents into the abdominal cavity occurred in all patients. During PPP plus BTA preparation, abdominal distention and abdominal pain occurred in 2 patients, shoulder and back pain occurred in one patient, and subcutaneous emphysema occurred in one patient, but all resolved spontaneously without special treatment. The IPOM operation was uneventfully completed in all patients, the average operative time was (186±114) min and the length of postoperative hospital stay was (6.4±1.1) d. The postoperative VAS scores for all patients were lower than 3, and no analgesic supplement was needed. After surgery, low intestinal obstruction occurred in one patient, which was relieved after symptomatic treatment, and no serious complications such as ACS occurred. The average follow-up time was (10.4±8.8) months, and no chronic pain, recurrence and mesh infection complications were observed.Conclusion PPP plus BTA treatment for preoperative preparation can significantly increase the abdominal volume of large incisional hernia and prolong the length of the lateral abdominal muscles of the patients, which is helpful for defect closure and reducing the occurrence of serous postoperative complications. So, it is recommended to be use in clinical paractice.

3 Application of modelized port arrangement based on data analysis and calculation in laparoscopic repair of abdominal wall incisional hernia

ZHOU Junjie , MA Ning , TANG Fuxin , HUANG Enmin , MA Tao , YANG Weisheng , LIU Chuangxiong , CHEN Shuang , ZHOU Taicheng

2022, 31(4):449-456. DOI: 10.7659/j.issn.1005-6947.2022.04.006

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Background and Aims With the development of minimally invasive concepts and techniques, laparoscopic incisional hernia surgery has become a major trend. However, due to the varied size and location of the abdominal incisional hernia, there are no established trocar arrangement criteria to apply for surgeons, which makes the learning process of this procedure more difficult, and the inappropriate trocar arrangement will also likely lead to increased surgical difficulty. Here, the authors introduce a modelized trocar arrangement method based on data analysis and calculation, and show its advantages and clinical efficacy by comparison with the conventional trocar arrangement method based on experience.Methods A total of 44 eligible patients with abdominal wall incisional hernia scheduled to undergo laparoscopic intraperitoneal onlay mesh repair (IPOM) in the Sixth Affiliated Hospital of Sun Yat-sen University from January 2017 to May 2018 were enrolled, and randomly designated to control group (21 cases) and study group (23 cases) by computer generated randomization. During operation, the arrangement of the operating trocars after the observation trocar placement was performed according to the surgical experience in control group, while the layout of the trocar ports was directed by calculation of the reasonable distance according to the operation instruments size after preoperative abdominal contour analysis and stepwise determination of the restrictive parameters. The main intra- and postoperative clinical variables between the two groups were compared.Results There were no significant differences in the general characteristics between the two groups of patients (all P>0.05). In study group compared with control group, the average trocar placement time (7.28 min vs. 9.93 min), the average operative time (67.62 min vs. 79.10 min), and the intraoperative trocar addition rate (17% vs. 48%) were all significantly reduced (all P<0.05). There were no significant differences between study group and control group in terms of the incidence of postoperative complications (4.3% vs. 19.0%), the length of postoperative hospital stay (5.13 d vs. 5.76 d) and postoperative recurrence rate (4.3% vs. 4.8%) between the two groups (all P>0.05).Conclusion In laparoscopic IPOM repair of abdominal wall incisional hernia, using the modelized trocar arrangement method can shorten the trocar placement time after operation initiation, and its rational placement of the operating trocars can reduce the difficulty of adhesion separation, defect suturing and mesh fixation, reduce the total operative time and the probability of additional operating trocar requirement during the operation, and meanwhile, it will not increase the incidence of postoperative complications, hospitalization time and the probability of hernia recurrence. The modelized trocar arrangement method that uses the objective data plus quantitative assessment to replace the experience-oriented decision-making of the conventional port arrangement, is more explicit in the using process, and also can be continuously updated and improved in practice. So, it is helpful for the standardization and promotion of laparoscopic abdominal wall incisional hernia surgery.

4 Diagnosis, classification and dissection skills of abdominal adhesions in laparoscopic incisional hernia repair

ZENG Bing , LI Yingru , GAN Wenchang , HOU Zehui , MA Ning , JIANG Zhipeng , ZHOU Taicheng , CHEN Shuang

2022, 31(4):457-464. DOI: 10.7659/j.issn.1005-6947.2022.04.007

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Background and Aims Incisional hernia is one of the common postoperative complications of abdominal surgery. Patients undergoing abdominal surgery will usually develop intra-abdominal adhesions of varying degrees, and adhesion separation is an unavoidable and relatively difficult task during incisional hernia repair. Preoperative progressive pneumoperitoneum (PPP) is an important component of laparoscopic incisional hernia repair, and the authors previously found that comparison of the imaging data before and after PPP can assess the intra-abdominal status of patients with incisional hernia, thereby is helpful for surgical predetermination, improving surgical precision and reducing surgical risk. Therefore, this study was conducted to further evaluate the application value of PPP combined with abdominal wall CT imaging in laparoscopic repair for patients with incisional hernia and concomitant intra-abdominal adhesions, and summarize the types of intra-abdominal adhesions and surgical skills of adhesion separation.Methods The clinical data and surgical videos of patients meeting the inclusion criteria and undergoing laparoscopic incisional hernia repair in the Department of Gastrointestinal, Hernia and Abdominal Wall Surgery of the Sixth Affiliated Hospital of Sun Yat-sen University from April 2019 to May 2020 were retrospectively collected. The presence or absence of intra-abdominal adhesions was determined by comparison of the abdominal CT before and after PPP. Through the operation video review, the classification of intra-abdominal adhesions was observed, the techniques of adhesion separation were summarized, and the time and complications of intraoperative adhesion separation were recorded. The associated injuries during puncture, and postoperative complications and recovery were also documented.Results A total of 72 cases of laparoscopic incisional hernia repair were collected, of whom, 15 cases with no preoperative artificial pneumoperitoneum, 7 cases with no preoperative abdominal CT review after the establishment of artificial pneumoperitoneum, and 15 cases with no three-dimensional CT reconstruction of the hernia sac before or after pneumoperitoneum were excluded. A total of 35 patients were included finally. All of them were type II abdominal wall defect including recurrent hernia in 5 cases. Of the patients, 16 were males and 19 were females, with an age of (63.26±11.11) years; body mass index was 25.04 (23.03-27.34) kg/m²; 4 cases had intra-abdominal infection with incision infection and 7 cases had incision infection after previous operation; the maximum number of operations that a single patient experienced was 5. By comparing the abdominal CT before and after PPP, 33 patients (94.29%) were diagnosed with adhesions between the abdominal contents and the abdominal wall, and 2 patients (5.71%) had no adhesions. Among them, the dominant findings were intestinal adhesions in 20 cases (60.61%), and omental adhesions in 13 cases (39.39%). According to the morphological characteristics, the adhesions were classified as point-like adhesions, linear adhesions, sheet-like adhesions, and mixed adhesions. According to the texture of adhesions, the adhesions were categorized into membranous adhesions, cicatricial adhesions, and complex adhesions. The adhesion separation was performed by a procedural approach of changing the plane to the peak plane, transforming the plane to the line and point, blunt-sharp separation of the membranous adhesions, and sharp separation of the cicatricial adhesions. Adhesion separation was successfully completed in the whole group. The separation time was 32 (4.50-46.50) min. Small intestinal wall seromuscular injury occurred in 5 patients, which was repaired with a 3-0 absorbable suture. No intra-abdominal organ injury occurred during observation port puncture. One patient developed pulmonary infection after operation, and the time to anal gas passage was 3 (2-4) d.Conclusion PPP combined with abdominal CT imaging is helpful for determining the presence or absence of intra-abdominal adhesions as well as the location of the adhesions, and also helpful for the selection of the layout of the observation port. A procedural approach based on the morphology and nature of adhesion is beneficial for simplifying the dissection of intraperitoneal adhesions.

5 Application efficacy of "multidimensional suture" technique in laparoscopic repair of giant incisional hernia

HOU Zehui , YU Zhuomin , LIANG Zhiqiang , ZHOU Taicheng , LI Yingru , ZENG Bin , CHEN Shuang , JIANG Zhipeng

2022, 31(4):465-473. DOI: 10.7659/j.issn.1005-6947.2022.04.008

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Background and Aims The repair of giant incisional hernia is a difficult surgical procedure in the practice of hernia and abdominal wall surgery, especially for the problem of suture and closure of the fascia defect. At present, the suture method commonly used in clinical practice is often faced with many problems in repairing giant incisional hernia, such as excessive tension and unobliterated dead space. Based on the development of suture materials, the authors' team has previously developed a new suture technique- "multidimensional suture", and use of this technique in incisional hernia repair can effectively solve the above problems. This study was performed to demonstrate the clinical value of "multidimensional suture" technique in giant incision hernia repair by comparing its clinical efficacy with that of conventional suture technique in laparoscopic repair of large incisional hernia.Methods The data of patients with giant incisional hernia who underwent laparoscopic intraperitoneal onlay mesh repair for giant incision hernia in the Department of Gastrointestinal and Hernia Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to June 2020 were retrospectively analyzed. Of the patients, 43 cases received “multidimensional suture” for the treatment of hernia sac and defect (study group), and 36 cases underwent the conventional suture method for the closure of defect (control group). The main clinical variables were compared between the two groups of patients.Results No open conversion was needed and the fascia defects were completely closed in all patients in study group, while, 7 patients (19.44%) were converted to open surgery and complete defect closure failed in 5 patients (13.89%) in control group. The open conversion rate and incidence of failed complete defect closure were significantly different between the two groups (P=0.003, P=0.017). The average time of fascia defect closure, the average operative time and the average intraoperative blood loss were (89.84±15.29) min, (181.51±18.23) min, and (26.84±12.67) mL for study group, and were (61.28±14.09) min, (157.72±19.17) min, and (27.25±11.83) mL for control group, respectively. The difference between the two groups had statistical significance in time of fascia defect closure and operative time (both P<0.001), and had no statistical significance in intraoperative blood loss (P=0.871). The incidence of postoperative surgical site occurrences (SSO) in study group was significantly lower than that in control group (2.33% vs. 16.77%, P=0.043), while there was no statistical difference in postoperative recurrence rates between two groups (0 vs. 2.78%, P=0.456). The postoperative time to ambulation, the length of postoperative hospital stay and hospitalization cost were (22.36±4.45) h, (5.23±1.26) d, and (75 924.21±6 065.61) yuan for study group, and (22.92±5.15) h, (5.46±1.93) d, and (74 185.99±5 476.48) yuan for control group, respectively. No significant differences in these 3 variables were noted between the two groups (P=0.192, P=0.440, P=0.283).Conclusion The application of "multidimensional suture" technique in giant incision hernia repair can decrease the conversion rate to open surgery, effectively close the fascia defect, and reduce the risk of postoperative surgical site occurrence.

6 Application of "contraposition and alignment" mesh fixation in laparoscopic incisional hernia repair

MA Ning , TANG Fuxin , HUANG Enmin , MA Tao , YANG Weisheng , LIU Chuangxiong , ZHOU Taicheng , CHEN Shuang

2022, 31(4):474-480. DOI: 10.7659/j.issn.1005-6947.2022.04.009

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Background and Aims The concept of minimally invasive repair of incisional hernia has reached a certain consensus in the field of hernia surgery. Laparoscopic incisional hernia repair is becoming more popular in clinical practice, but endoscopic mesh fixation technique is still a difficult issue. This study was to introduce a new method of incisional hernia mesh fixation and evaluate its clinical application effect.Methods The clinical data of 120 patients undergoing laparoscopic incisional hernia repair (IPOM) in the Department of Gastroenterology, Hernia and Abdominal Wall Surgery of the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to December 2019 were retrospectively analyzed. Of the patients, the "contraposition and alignment" mesh fixation was used as the mesh fixation method in 60 cases (observation group), and the traditional mesh fixation method of double-crown tacker fixation was used in the other 60 cases (control group). The relevant clinical variables and economic indexes of the two groups were compared.Results There were no significant differences in gender, age, BMI, course of disease and the maximum diameter of the defect of the hernia between the two groups (all P>0.05). Compared with control group, the mean mesh fixation time was shortened (35.5 min vs. 47.7 min, P<0.05), the mean number of hernia tackers used for fixation was decreased (36.6 vs. 44.2, P<0.05), the mean VSA score of postoperative pain was lowered (3.2 vs. 4.6, P<0.05), and the hospitalization cost was reduced (39 000 yuan vs. 48 000 yuan, P<0.05) in observation group. There were no significant differences in incidence rates of seroma formation and mesh infection as well as the length of postoperative hospital stay between the two groups (all P>0.05). The average follow-up time for observation group and control group were 26.3 and 25.8 months, respectively. No significant differences were noted between observation group and control group in recurrence rate of incisional hernia (1.7% vs. 5%, P=0.61) and the incidence of postoperative chronic pain (6.7% vs. 8.3%, P=1.00).Conclusion The "contraposition and alignment" mesh fixation could shorten the mesh fixation time, reduce the number of hernia, save hospitalization costs, and reduce the occurrence of early postoperative pain after incisional hernia. The application of this method in laparoscopic incisional hernia repair is safe and effective, and can be widely used in clinical practice.

7 Expression of Bcl-2 transcription inhibitor 1 in gastric cancer and its biological function

ZHAO Xinxu , HUANG Linsheng , LIU Jialing , HAN Junxiang , YU Huifan , LI Fei

2022, 31(4):481-489. DOI: 10.7659/j.issn.1005-6947.2022.04.010

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Background and Aims Anoikis effector Bcl-2 transcription inhibitor 1 (Bit1) is abnormally expressed in gastric cancer tissue, the function and mechanism of Bit1 in gastric cancer is worth studying. This study was conducted to further examine the expression of Bit1 in gastric cancer tissue, and present a preliminary analysis of the effects of Bit1 on the biological behavior of gastric cancer cells.Methods The expressions of Bit1 in the surgical specimens of gastric cancer and corresponding adjacent tissue from 20 patients with primary gastric cancer were determined by Western blot analysis. In gastric cancer BGC-803 cells after transfection with Bit1 shRNA lentivirus or empty lentivirus vector, with the untreated wild type BGC-803 cells as blank control, the transfection efficiency and Bit1 silencing effect were validated by immunofluorescence assay, and then, the invasion, migration, proliferation and apoptosis were Transwell invasion assay, scratch wound assay, CCK-8 assay and TUNEL staining assay, respectively.Results The results of Western blot showed that the expression level of Bit1 protein in gastric cancer tissue was significantly up-regulated compared with corresponding adjacent tissues (P<0.01). The results of immunofluorescence assay demonstrated the successful transfection and effective Bit1 silencing. The results of series of cellular behavior experiments revealed that the wound-healing rate, number of invaded cells, and proliferation ability were all significantly decreased, while the number of late apoptotic cells was significantly increased in BGC-803 cells with Bit1 shRNA transfection compared with blank control cells (all P<0.05); there were no statistical differences in these cellular behavior parameters between BGC-803 cells transfected with empty vector and blank control cells (all P>0.05).Conclusion The expression level of Bit1 is up-regulated in gastric cancer, and it is closely related to the malignant biological behavior of gastric cancer cells, suggesting that Bit1 may be a biomarker associated with the initiation, progression and prognosis as well as a candidate therapeutic target for gastric cancer.

8 Safety analysis of continuation of antithrombotic agents in patients with moderate or high thromboembolic risk undergoing Lichtenstein surgery during perioperative period

WEI Qin , CHEN Lu , ZHU Shuai , ZHANG Tao , SUN Zefang , NING Caihong , LIN Jiayan , LI Jiarong , ZHONG Qiaoqing , TANG Zhaohui , HUANG Gengwen

2022, 31(4):490-496. DOI: 10.7659/j.issn.1005-6947.2022.04.011

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Background and Aims In patients receiving long-term antithrombotic prophylaxis who require surgery, the continuation of therapy during perioperative period will raise the risk of surgical bleeding, while the incidence of thromboembolic events will increase after drug discontinuation. For inguinal hernia procedures, there is, at present, no consensus or high-quality evidence regarding the perioperative management of antithrombotic medication. Therefore, this study was designed to observe the safety of performing Lichtenstein hernioplasty in inguinal hernia patients on long-term anticoagulation without antithrombotic treatment withdrawal during the perioperative period, so as to help investigate the strategies for perioperative management of anticoagulation in these patients.Methods Using a prospective cohort design, 18 inguinal hernia patients with moderate or high risk of thromboembolism on long-term anticoagulation admitted to the Department of Hernia and Abdominal Wall Surgery, Xiangya Hospital, Central South University were consecutively enrolled from November 2018 to February 2022. All patients underwent Lichtenstein hernioplasty under nerve block anesthesia combined with laryngeal mask general anesthesia, without interruption of anticoagulation during the perioperative period. The intra- and postoperative bleeding, visual analog pain score (VAS) on postoperative day (POD) 1, postoperative major cardiac adverse events (MACEs), cerebrovascular complications, incision-related adverse events, hernia recurrence and mortality of the patients were observed and followed up.Results The 18 inguinal hernia patients included 4 cases who had previously undergone heart valve replacement surgery, one case with concomitant atrial fibrillation, 9 cases who had previously undergone coronary stenting, one case who had previously undergone coronary artery bypass grafting, and 3 cases with previous myocardial infarction. Among them, 5 patients received long-term oral warfarin therapy, and 13 patients treated with long-term oral antiplatelet-agent therapy that included aspirin administration in 8 cases, clopidogrel administration in 3 cases, and aspirin plus clopidogrel or indobufen administration in 2 cases. Of the 18 patients, the mean length of hospital stay was (9.61±2.59) d, the mean intraoperative blood loss was (3.77±2.53) mL, and the mean operative duration was (70.13±13.44) min. After surgery, one patient had obvious wound bruising, one patient had mild wound bruising, and 16 patients had no obvious wound bleeding. Blood transfusion or reoperation was required in none of them. The median VAS was 1.72 on POD 1. There was no MACEs and cerebrovascular complications occurred during perioperative period. All patients were discharged from the hospital 15 d after surgery. The median follow-up time after discharge was 19.34 months, and the follow-up rate was 100%. No wound-related adverse events, hernia recurrence, MACEs, cerebrovascular complications, and death occurred during follow-up.Conclusion For inguinal hernia patients with moderate or high thromboembolic risk, the strategy of continuous use of antithrombotic drugs during the perioperative period of Lichtenstein hernia repair is safe and feasible on the premise of a comprehensive perioperative management. So, it is recommended as an appropriate choice for application.

9 Analysis of risk factors and prognosis of intra-abdominal infection after robotic-assisted radical gastric cancer resection

MA Diaolong , HU Ming , SU Ade , XU Yongcheng , HE Xinglong , YANG Jing , FANG Wei , SU He , MA Yuntao

2022, 31(4):497-506. DOI: 10.7659/j.issn.1005-6947.2022.04.012

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Background and Aims Intra-abdominal infection is a common complication after radical gastrectomy for gastric cancer. However, there are few studies concerning the influencing factors for intra-abdominal infection after robotic-assisted radical gastrectomy and the associated prognosis. Therefore, this study was conducted to analyze the risk factors for intra-abdominal infection after robotic-assisted radical gastrectomy and the associated prognosis, so as to provide a reference for clinical practice.Methods The clinical data of 262 gastric cancer patients undergoing robotic-assisted radical gastrectomy from January 2017 to March 2021 in the First Department of General Surgery, Gansu Provincial Hospital were reviewed. The incidence of postoperative intra-abdominal infection and its influencing factors as well as the influence of postoperative intra-abdominal infection on the treatment outcomes and prognosis of the patients were analyzed.Results Among the 262 patients, postoperative intra-abdominal infection occurred in 14 cases (5.34%). The causes for infection were intraperitoneal abscess in 12 cases (4.58%), transverse colon fistula in one case (0.38%) and pancreatic fistula in one case (0.38%), respectively; the Clavien-Dindo classification included grade II in 9 cases (3.44%), grade IIIa in 4 cases (1.53%), and grade IIIb in one case (0.38%). The results of univariate analysis showed that body mass index (BMI), preoperative albumin, preoperative anemia, tumor diameter, synchronous other organ resection, intraoperative blood loss, pTNM stage, N stage, lymphovascular invasion, nerve invasion and the percentage of neutrophils (NEUT%) on postoperative day (POD) 3 were significantly associated with the occurrence of intra-abdominal infection after robotic-assisted radical gastrectomy (all P<0.05). the results of multiple logistic regression analysis revealed that BMI <18.5 kg/m² (OR=11.160, 95% CI=2.289-54.410, P=0.003), preoperative albumin <30 g/L (OR=6.612, 95% CI=1.630-26.820, P=0.008), synchronous other organ resection (OR=5.236, 95% CI=1.068-25.661, P=0.041), tumor lymphovascular invasion (OR=8.151, 95% CI=1.771-37.52, P=0.007) and NEUT% on POD 3 (OR=1.208, 95% CI=1.069-1.366, P=0.003) were independent risk factors for intro-abdominal infection in patients after robotic-assisted radical gastrectomy. The results ROC curve analysis of the NEUT% on POD 1, 3 and 7 demonstrated that the NEUT% on POD 3 had the largest AUC (0.805) for diagnosis of intra-abdominal infection, with the cut-off value of 82.65%, sensitivity of 71.4% and specificity of 84.7%. In patients with postoperative intro-abdominal infection compared with those without intro-abdominal infection, the time to first gas passage, time to first food intake, volumes of abdominal drainage on POD 1 to 7, time to drainage tube removal, length of postoperative hospital stay and total medical cost were all significantly increased (all P<0.05). The results of survival analysis indicated that the overall survival rate of patients with intro-abdominal infection was lower than that of patients without intro-abdominal infection (45.4% vs. 67.8%, P=0.046).Conclusion For patients with above risk factors, aggressive preventive measures against intro-abdominal infection should be implemented after robotic-assisted radical gastrectomy, and thereby promotes the postoperative recovery and improves the postoperative prognosis of them. The NEUT% on POD 3 has certain application value for predicting intro-abdominal infection after robotic-assisted radical gastrectomy.

10 Meta-analysis of efficacy and safety of laparoscopic total mesorectal excision and transanal total mesorectal resection in treatment of middle and low rectal cancer

YU Nan , ZHEN Yunhuan

2022, 31(4):507-520. DOI: 10.7659/j.issn.1005-6947.2022.04.013

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Background and Aims Although the laparoscopic total mesorectal excision (LaTME) has been widely used in the treatment of rectal cancer, it still has technical obstacles. Transanal total mesorectal excision (TaTME) can overcome the limitations of LaTME and has certain advantages in the treatment of middle and low rectal cancer. However, there is still controversy over the efficacy and safety of TaTME. Therefore, this study was conducted to compare the short-term efficacy and safety of TaTME and LaTME through Meta, so as to provide evidence-based information for clinical decision-making.Methods The studies comparing TaTME and LaTME in the treatment middle and low rectal cancer were collected by searching several national and international online databases. After data extraction and quality evaluation of the included studies, Meta-analysis was performed using RevMan5.3 software.Results A total of 18 controlled studies were included, involving 2 334 patients with 1 133 cases in TaTME group and 1 201 cases in LaTME group. The results of Meta-analysis showed that the rate positive circumferential resection margin (CRM) (OR=0.58, 95% CI=0.40-0.83, P=0.003), open conversion rate (OR=0.18, 95% CI=0.11-0.31, P<0.000 01), length of hospital stay after surgery (WMD=-1.51, 95% CI =-2.70--0.33, P=0.01), and R₁ resection rate (OR=0.30, 95% CI=0.15-0.60, P=0.000 7) were reduced in TaTME group compared with LaTME group; there were no significant differences in terms of the number of harvested lymph nodes, operative time, blood loss, completeness of mesorectal excision, CRM distance, rate of positive distal resection margin (DRM), DRM distance, and incidence rates of anastomotic leakage and intestinal obstruction (all P>0.05).Conclusion Under strict surgical indications, the safety of TaTME is not inferior to that of LaTME in the treatment of middle and low rectal cancer, and it also can achieve better oncological outcomes. However, the above conclusion still needs to be further verified by including more high-quality studies.

11 Research progress of early recognition and treatment of ileostomy diarrhea

WANG Kai , DENG Yunxuan , YANG Chao , DING Weiwei , LI Jieshou

2022, 31(4):521-526. DOI: 10.7659/j.issn.1005-6947.2022.04.014

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Ileostomy is a common procedure in surgical practice. After this procedure, the patients may be in a state of relative fluid depletion due to the increased fluid and electrolyte losses resulting from the loss of colonic absorption. Within weeks after ileostomy creation, there is a body adaptation process of increased fluid absorption. However, some patients will fail to adapt adequately and have a large volume of ileostomy output, or will develop ileostomy diarrhea due to other causes. Many patients with ileostomy diarrhea are at risk of dehydration and electrolyte loss, and often require hospital readmission, which consumes a lot of medical resources. Except for the mastery of surgical skills of ileostomy, surgeons should fully understand its pathophysiological processes, so as to allow the implementation of targeted treatment. Here, the authors address the pathogenesis and treatment of ileostomy diarrhea, hoping to provide a reference for the treatment of patients with this condition.

12 Research progress on role of intestinal flora in occurrence and development as well as diagnosis and treatment of colorectal cancer

SONG Dexin , WANG Weidong , GAO Ruiqi , WEI Jiangpeng , LI Xiaohua , WANG Shiqi , YU Pengfei

2022, 31(4):527-536. DOI: 10.7659/j.issn.1005-6947.2022.04.015

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In recent years, the intestinal flora has become a research hotspot, and a large amount of evidence indicates that the intestinal flora imbalance is closely related to the occurrence and development of various diseases, especially the colorectal cancer (CRC). Intestinal flora disturbance exerts carcinogenesis by inducing chronic inflammation, DNA damage in epithelial cells, immune abnormalities, and production of intestinal flora metabolites and bacterial enzymes. With the development of high-throughput sequencing technology and metagenomic sequencing technology, our understanding of the relationship between gut microbiota and CRC has reached a remarkable level by constant breakthroughs. Intestinal flora can be used as biomarkers for the early diagnosis and prognosis of CRC, and affects the efficacy of immunotherapy and radiotherapy or chemotherapy, and provides a large number of potential targets for targeted therapy of CRC. Here, the authors review the research progress on the role of intestinal flora in the aspects of occurrence, development, diagnosis and treatment of CRC, aiming to provide reference for clinical praxis and basic research.

13 Clinical research progress in Lynch syndrome associated colorectal cancer

CHEN Jia , SHI Yanlong , WEI Qian , ZHANG Cong , LI Li , CAO Liyu , YU Hongzhu

2022, 31(4):537-543. DOI: 10.7659/j.issn.1005-6947.2022.04.016

[Abstract](845) [HTML](1057) [PDF 642.37 K](1292)

Abstract:
Lynch syndrome (LS) is an autosomal dominant disease caused by pathogenic mutation of mismatch repair (MMR) genes that confers a predisposition to cancer development, and microsatellite instability (MSI) is its main feature in clinical assay. LS is responsible for most hereditary colorectal cancer. With the continuous improvement of molecular diagnostic technology, the accurate diagnosis and treatment of LS-related colorectal cancer through LS molecular detection has gradually become the focus of clinical attention. Despite the favorable prognosis of LS-related colorectal cancer, it is still an important task to further improve the screening and follow-up strategies for patients with family history of LS in our country. In addition, using the immunological characteristics of LS to guide its treatment and prevention is a new challenge for many scholars. Herein, the authors review the recent advances concerning LS-related colorectal cancer in the aspects such as the epidemiology, clinicopathologic features, screening diagnosis and treatment as well as prevention.

14 Application of immune checkpoint inhibitors in colorectal cancer: current and future strategies

XIE Guisheng , WU Yuantao

2022, 31(4):544-553. DOI: 10.7659/j.issn.1005-6947.2022.04.017

[Abstract](772) [HTML](1629) [PDF 781.85 K](1476)

Abstract:
Immune checkpoint inhibitors (ICIs) mainly include pembrolizumab, nivolumab and ipilimumab, which have changed the standard treatment for many types of cancer. In colorectal cancer (CRC), the status of microsatellite instability (MSI) or mismatch repair (MMR) is the most important factor affecting the efficacy of ICIs. Metastatic CRC (mCRC) with microsatellite instability-high (MSI-H) or MMR deficiency (dMMR) usually has a tumor microenvironment T-cell infiltration and is associated with a good response to ICIs, but the proportion of mSI-H/dMMR accounts for less than 5% of the mCRC. Paprizumab and navumab with or without combination of ipilimumab have been included in the standard treatment regimen for MSI-H/dMMR mCRC. In contrast, low T-cell infiltration in tumor microenvironments of mCRCs with microsatellite stable (MSS) or mismatch repair stable (pMMR) is considered to be the main mechanism of ICIs resistance. Here, the authors review the existing clinical data and some ongoing clinical trials of ICIs for CRC treatment, and discuss the possible limitations.

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Volume 31,Issue 4,2022 Table of Contents

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