Volume 32,Issue 10,2023 Table of Contents

1 Future development of hernia and abdominal wall surgery in China: a historical perspective

TANG Jianxiong , LI Shaochun

2023, 32(10):1445-1452. DOI: 10.7659/j.issn.1005-6947.2023.10.001

[Abstract](641) [HTML](917) [PDF 738.35 K](1651)

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The knowledge of hernias in our country can be traced back to several hundred years ago. Through the continuous efforts of generations of surgeons, China has made significant progress in various aspects of hernia diagnosis and treatment. This includes the development of guidelines and consensus, establishment of standardized training systems, implementation of hernia follow-up systems, and quality control measures. Currently, China is at the forefront of the world in hernia diagnosis and treatment. However, it is also important to recognize that innovative breakthroughs are still needed, particularly in complex hernia cases, such as advancements in abdominal wall reconstruction techniques and the development of repair materials. Material science should be a key focus in achieving the unity of the integrity of abdominal wall structure and function. Of course, we should also be aware of our own shortcomings, such as the need for specialization in hernia care and addressing the varying skill levels of surgeons at the grassroots level. Additionally, efforts should be directed towards effectively integrating technologies such as robotic surgery, artificial intelligence, and 4G networks, in order to further benefit hernia patients in our country.

2 Incision hernia, abdominal wall mechanics and surgical techniques

CHEN Shuang , JIANG Zhipeng

2023, 32(10):1453-1459. DOI: 10.7659/j.issn.1005-6947.2023.10.002

[Abstract](495) [HTML](476) [PDF 991.21 K](1586)

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The treatment of incisional hernia has always been a difficult problem in abdominal wall surgery because there are still many issues that have not been clarified and resolved. To deepen the understanding of incisional hernia, we need to start with its essence, occurrence, and the principle of its occurrence and development, which cannot be separated from the exploration of the structure and mechanical characteristics of the abdominal wall. In addition, the abdominal wall is a complex organ with multiple functions, and surgical techniques need to focus on its functions in order to achieve to unity of "from structure to function". Here, the authors discuss relevant issues from multiple perspectives such as "functional unit of abdominal wall", the development of incisional hernia under mechanical action, the mechanical characteristics of the abdominal wall, and the functional characteristics of the abdominal wall, address some issues in current incisional hernia surgical techniques, and propose the directions and strategies for improvement, with the aim of enhancing surgeons' understanding of incisional hernia for better use and innovation of abdominal wall surgery techniques.

3 Advances in minimally invasive procedures based on the concept and characteristics of primary ventral hernias

LI Jianwen , YUE Fei , XUE Pei

2023, 32(10):1460-1468. DOI: 10.7659/j.issn.1005-6947.2023.10.003

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Ventral hernia and primary ventral hernia have different meanings. In this article, primary ventral hernia refers to non-surgically induced hernias located on the anterolateral and posterior abdominal walls (excluding inguinal and femoral hernias). Patients with primary ventral hernias do not have surgical incisions and are more willing to undergo minimally invasive treatment. Meanwhile, their intact abdominal wall tissue is suitable for applying novel minimally invasive techniques. The therapeutic efficacy of primary ventral hernias is significantly better than that of incisional hernias. Currently, there are numerous minimally invasive procedures, each reflecting its own advantages in the treatment of primary ventral hernias. The laparoscopic intraperitoneal onlay mesh repair (IPOM) and the minimally invasive non-intraperitoneal mesh repair (MINIM) have different concepts but complement each other technologically, with the common goal of pursuing minimally invasive procedures and abdominal wall functional reconstruction. MINIM dominantly consists of various endoscopic extraperitoneal repair procedures (EER), most of which start from primary ventral hernias and gradually expand their indications. Another type of procedure is laparoscopic-assisted onlay repair, which plays a unique role in primary midline ventral hernias. Umbilical hernias, diastasis recti, primary supra-pubic hernias, Spigelian hernias, and primary lumbar hernias are commonly encountered types of primary ventral hernias. This article discusses each of them individually, elucidating their definitions, characteristics, and the progress of minimally invasive procedures.

4 A multicenter retrospective study comparing laparoscopic extraperitoneal sublay mesh repair and intraperitoneal onlay mesh repair for ventral hernias

CHEN Lu , ZHANG Zhuo , LI Pengzhou , LIU Hai , YAO Dunwu , XU Jiapu , XU Dayong , YIN Huiming , WEI Yuanshui , LIU Xiqin , LIU Jiefeng , CHEN Guangpu , ZHOU Xin , ZHU Liyong , HUANG Gengwen

2023, 32(10):1469-1475. DOI: 10.7659/j.issn.1005-6947.2023.10.004

[Abstract](699) [HTML](274) [PDF 702.23 K](1056)

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Background and Aims The ventral hernia repair surgery is one of the most common surgical procedures, with approximately two million cases of ventral hernia patients undergoing surgical treatment worldwide each year. Compared to open surgery, laparoscopic ventral hernia repair offers significant advantages. However, there is currently no large-scale clinical research confirming the advantages, disadvantages, and therapeutic effects of two laparoscopic techniques: intraperitoneal onlay mesh (IPOM) and extraperitoneal sublay repair (ESR) for repairing ventral hernias. Therefore, this study was conducted to compare the short- and long-term efficacy of ESR and IPOM in the treatment of ventral hernias, so as to provide evidence-based references for clinical practice.Methods The clinical data of 157 patients who underwent laparoscopic ventral hernia repair in 11 medical institutions in Hunan Province from January 1, 2017 to December 31, 2022 were retrospectively analyzed. Among them, 124 cases underwent ESR (ESR group) and 33 cases underwent IPOM (IPOM group). A comparative analysis was performed on the clinical characteristics, surgical methods, and short- and long-term postoperative outcomes of the two groups of patients.Results There were no cases of conversion to open surgery or perioperative deaths in the entire cohort. There were no statistically significant differences in age, gender, BMI, or hernia type between the two groups (all P>0.05). There were no statistically significant differences in hernia defect diameter, operative time, intraoperative blood loss, or hernia ring closure rate between the two groups (all P>0.05). In terms of mesh fixation methods, self-fixation and suture fixation were mainly used in the ESR group (91.1%), while helical tack fixation was mainly used in the IPOM group (69.7%), and the difference was statistically significant (P<0.05). The postoperative pain score in the ESR group was significantly lower than that in the IPOM group (2.37±0.82 vs. 2.76±1.00, P<0.05), and the hospitalization cost was significantly lower in the ESR group compared to the IPOM group (21 001 yuan vs. 38 437 yuan, P<0.05). There were no statistically significant differences in postoperative hospital stay and short-term complication rates between the two groups (all P>0.05). With a median follow-up of 10.3 months, there were no cases of recurrence in the ESR group, while the IPOM group had 2 cases of recurrence (6.1%), and the difference was statistically significant (P<0.05).Conclusion ESR is one of the main techniques for laparoscopic abdominal ventral repair in the Hunan region. Due to differences in fixation methods and mesh selection, ESR has advantages over IPOM, including milder postoperative pain, lower costs, and lower recurrence rates. Furthermore, it does not significantly increase operative time or the incidence of short-term postoperative complications.

5 Surgical approach selection and safety analysis for elderly patients with inguinal hernia

LI Renjie , REN Xiaomei , SHAO Xiangyu , CHENG Tao , LI Junsheng

2023, 32(10):1476-1482. DOI: 10.7659/j.issn.1005-6947.2023.10.005

[Abstract](572) [HTML](318) [PDF 684.47 K](1253)

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Background and Aims Inguinal hernia is a common surgical condition, with elderly individuals being the primary population undergoing inguinal hernia repair. However, there is currently no consensus on the choice of surgical approach for elderly inguinal hernia patients. Local anesthesia Lichtenstein repair is characterized by low difficulty, good outcomes, and faster postoperative recovery and is widely used in clinical practice. Laparoscopic tension-free inguinal hernia repair is increasingly accepted and recommended by surgeons due to its advantages such as a wide field of vision, and the ability to detect contralateral occult hernia and to simultaneously repair a bilateral hernia. This study was performed to analyze the clinical data of elderly patients undergoing local anesthesia open hernia repair or general anesthesia laparoscopic hernia repair, so as to provide guidance for clinical practice.Methods The clinical data of 130 elderly patients (>60 years old) who underwent inguinal hernia repair in Zhongda Hospital Affiliated with Southeast University from January 2019 to December 2021 were collected through telephone follow-up and medical record system and retrospectively analyzed. Among them, 67 cases underwent open Lichtenstein surgery (open surgery group), and 63 cases underwent laparoscopic hernia repair surgery (laparoscopic group). Baseline data and surgery-related variables were compared between the two groups.Results The analysis of baseline data showed that the average age of patients in the open surgery group was higher than that in the laparoscopic group (78.94 years vs. 71.83 years), and the proportion of cases with high anesthesia risk, the proportion of cases with different comorbidities, and the rate of bilateral hernia were all higher in the open group than those in the laparoscopic group (all P<0.05); the remaining baseline variables showed no statistically significant differences between the two groups (all P>0.05). Analysis of surgery-related variables showed that the length of postoperative hospital stay was shorter (1.51 d vs. 2.16 d), and the pain score on postoperative day 1 was lower in the laparoscopic group (2.70 vs. 3.58) than those in the open surgery group (both P<0.05); there were no statistically significant differences between the two groups in terms of postoperative complications (incision infection, hematoma, seroma, nerve sensory abnormalities, urinary retention), one-year recurrence rate, and long-term pain (>3 months) (all P>0.05).Conclusion In elderly patients, the hernia side, anesthesia risk classification, and preoperative comorbidities are factors that clinical physicians need to assess when choosing a surgical approach. After comprehensive preoperative assessment, laparoscopic surgery is a safe option.

6 Application of the "contraposition and alignment" mesh placement technique in laparoscopic hiatal hernia repair: a single-center analysis of 120 cases

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

2023, 32(10):1483-1490. DOI: 10.7659/j.issn.1005-6947.2023.10.006

[Abstract](676) [HTML](488) [PDF 1.54 M](1074)

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Background and Aims Laparoscopic hiatal hernia (HH) repair with mesh placement has become the primary surgical method for the treatment of HH due to its advantages of minimal trauma, rapid recovery, and fewer complications. However, the technique for mesh placement and fixation remains a challenge. This study was to introduce a novel method for HH mesh placement and explore its clinical application efficacy.Methods The clinical data of 120 patients who underwent laparoscopic HH repair at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to December 2020 were retrospectively analyzed. All patients included underwent mesh placement using the "contraposition and alignment" technique.Results The average operative time for the whole group of patients was (112±27) min, and the average length of postoperative hospital stay was (4.5±2.2) d. There were no deaths during the perioperative period. Early postoperative complications included dysphagia in 7 cases, with 5 cases achieving relief after 2 weeks and 2 cases still complaining swallowing difficulties at 4 weeks after operation, which were alleviated with gastroscopic balloon dilatation; postoperative urinary retention in 2 cases, which were relieved after symptomatic treatment with indwelling catheter; postoperative intra-abdominal bleeding in one case, which was managed with emergency laparoscopic exploration and hemostasis; postoperative bowel obstruction in 2 cases, which were cured with conservative treatment. The median follow-up time was 26 months, with 14 cases (11.7%) lost to follow-up. Among the followed-up patients, 5 cases complained clinical symptoms that did not significantly improve compared to preoperative conditions, while the rest of the patients reported complete or partial improvement in clinical symptoms. No cases of anatomical recurrence were observed in the followed-up patients. Furthermore, none of the followed-up cases experienced mesh-related complications such as mesh displacement, infection, and mesh erosion into the esophagus or major blood vessels.Conclusion The use of the "contraposition and alignment" technique for mesh placement in laparoscopic HH repair is safe and effective. This method is straightforward, easy to implement, and suitable for clinical promotion.

7 Application of "multidimensional suture" technique in laparoscopic Sugarbaker repair of parastomal hernia

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

2023, 32(10):1491-1498. DOI: 10.7659/j.issn.1005-6947.2023.10.007

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Background and Aims Parastomal hernia is a common complication following intestinal stoma creation. The laparoscopic Sugarbaker procedure is currently the mainstream surgical approach, and the biggest challenge lies in how to suture and close the fascial defect. Conventional suture closure techniques have limitations such as difficulty in closing or reducing the defect, high incidence of postoperative seroma formation, and poor abdominoplasty outcome. In our center, we have successfully addressed these issues by utilizing the " multidimensional suturing" technique to close the defect. This study was performed to compare the clinical efficacy of the "multidimensional suture" technique with conventional suture technique in the laparoscopic Sugarbaker repair of parastomal hernia, to assess the clinical value of the "multidimensional suture" technique in parastomal hernia repair.Methods The data of patients with parastomal hernia who underwent laparoscopic Sugarbaker repair in the Department of Hernia and Abdominal Wall Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 2018 to December 2021 were retrospectively analyzed. Of the patients, 44 cases received a "multidimensional suture" for the treatment of hernia sac and defect (study group), and 29 cases underwent the conventional suture method for the defect closure (control group). The main clinical variables were compared between the two groups of patients.Results The fascia defects were completely closed in all patients in the study group, while 9 patients (31.0%) failed to achieve complete defect closure in the control group. The average time for fascial defect closure was (47.45±10.44) min in the study group and (33.72±8.64) min in the control group. The average operative time was (132.14±13.72) min in the study group and (113.97±18.30) min in the control group. The differences in these variables between the two groups were statistically significant (all P<0.001). The postoperative seroma formation rate in the study group was significantly lower than that in the control group (6.8% vs. 27.6%, P=0.036). The incidence of mesh infection after surgery showed no statistically significant difference between the two groups (2.3% vs. 3.4%, P=0.640). The study group had a significantly lower postoperative recurrence rate compared to the control group (2.3% vs. 20.7%, P=0.027). The postoperative hospital stay was 6 (5-7) d in both the study and control groups, and the hospital costs were (72 998.79±15 352.46) yuan and (72 998.79±11 542.77) yuan in the study group and the control group, respectively. There were no statistically significant differences in these two variables between the two groups (P=0.447, P=0.708).Conclusion Applying the "multidimensional suture" technique in laparoscopic Sugarbaker repair of parastomal hernia can effectively close the fascia defect and reduce the risk of postoperative seroma and recurrence.

8 Laparoscopic transabdominal preperitoneal hernioplasty for the treatment of recurrent inguinal hernia: a single-center experience

LI Feng , MA Tiexiang , ZENG Jian , LI Huanyu , LIU Xiang , ZHOU Xin

2023, 32(10):1499-1507. DOI: 10.7659/j.issn.1005-6947.2023.10.008

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Background and Aims Inguinal hernia is the most common disease in the field of abdominal wall surgery, and the main treatment approach is surgical intervention. With the advancement of surgical techniques and material sciences, the effectiveness of inguinal hernia surgery has gradually improved, and there are various surgical methods available. However, none of these surgical approaches can completely eliminate the possibility of postoperative recurrence, and managing recurrent hernias is more complex than dealing with primary hernias. Currently, there is no consensus on the treatment of recurrent inguinal hernias. The development of modern laparoscopic surgical techniques has made transperitoneal preperitoneal hernia repair (TAPP) a minimally invasive surgical option for inguinal hernia treatment, which is less traumatic and offers quicker recovery. This study was conducted to explore the efficacy of TAPP in the treatment of various types of recurrent inguinal hernias and provide guidance for the surgical management of recurrent inguinal hernias.Methods The clinical data of 90 cases of recurrent inguinal hernia treated from July 2012 to July 2022 were retrospectively analyzed. Of these patients, 46 cases undergoing TAPP treatment were assigned to the observation group, while 44 patients receiving other surgical procedures were served as the control group. The relevant clinical variables of the two groups of patients were compared.Results Surgical procedures in both groups were successfully performed. There were no cases of conversion to open surgery in the observation group. During surgery, 26 cases (56.5%) were confirmed as true recurrent hernias, and 20 cases (45.4%) were diagnosed as false recurrent hernias in the observation group. There was no statistically significant difference in the operative time between the two groups (P>0.05). However, the observation group exhibited superior results in terms of intraoperative blood loss, time to first ambulation, and length of hospital stay (all P<0.05). The observation group had a significantly lower overall incidence of postoperative complications compared to the control group (19.6% vs. 43.1%, P<0.05). There were no cases of re-recurrence in the observation group, while the control group had 2 cases of re-recurrence, but the difference in recurrence rates between the two groups was not statistically significant (P>0.05).Conclusion In the surgical treatment of various types of recurrent inguinal hernias, the use of TAPP can reduce intraoperative blood loss, facilitate early ambulation, shorten hospital stays, and result in a lower rate of postoperative complications. It is a safe, effective, and feasible surgical approach for treating various types of recurrent inguinal hernias.

9 Analysis of clinical characteristics and management of obturator hernia: a report of 10 cases

XING Jingxiao , GAO Lei , GU Yan , LI Shaochun , TANG Jianxiong

2023, 32(10):1508-1515. DOI: 10.7659/j.issn.1005-6947.2023.10.009

[Abstract](299) [HTML](592) [PDF 1.23 M](1136)

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Background and Aims Obturator hernia is a relatively rare type of external abdominal hernia, and elderly women are more susceptible to this condition due to characteristics such as pelvic floor laxity. The narrow and non-elastic nature of the obturator ring often leads to patients seeking medical treatment due to acute abdomen caused by bowel incarceration, typically discovered during surgery for intestinal obstruction. Completely suturing the semi-rigid hernia ring can be challenging, which leads to a higher risk of hernia recurrence and a high reoperation rate, but the use of repair materials can effectively reduce this risk. In this article, the authors analyze the disease characteristics and share clinical experiences in the diagnosis and treatment of obturator hernia through review treated cases of obturator hernia, in the hope of providing reference for the clinical diagnosis and treatment of this condition.Methods The clinical data of 10 patients with obturator hernia treated in the Department of Hernia and Abdominal Wall Surgery, Huadong Hospital Affiliated to Fudan University and Zhengzhou Central Hospital Affiliated to Zhengzhou University from June 2019 to June 2021 were retrospectively summarized.Results All ten patients were females, aged between 48 and 86 years, with a median age of (70.7±11.8) years. Prior to surgery, all patients underwent abdominal and pelvic CT scans, which identified left-sided obturator hernia in 2 cases and right-sided obturator hernia in 8 cases. The contents of incarcerated hernia identified by intraoperative findings were intestinal canal in 8 cases, greater omentum in 1 case, and extraperitoneal fat in 1 case. There were no absolute contraindications to tension-free repair in the entire group. Based on the degree of abdominal contamination, 2 patients received biological mesh, while the remaining 8 patients received polypropylene mesh. Six cases were completely repaired laparoscopically, one case required conversion to an open surgery after laparoscopic repair due to poor recovery of intestinal vitality, and one case underwent laparotomy for intestinal resection and hernia repair after initial laparoscopic exploration. Two patients directly underwent open laparotomy for repair due to poor tolerance of laparoscopic operation. The surgery duration ranged from 50 to 120 min, with an average of 75.5 min. One patient died from concomitant medical condition during perioperative period, while the rest were discharged uneventfully with hospital stay lasting 3 to 28 d. Follow-up at 6, 12, and 18 months after operation showed no recurrences or mesh-related infections.Conclusion Obturator hernia has a low incidence and often presents with concealed symptoms, making incarceration common. Abdominal and pelvic CT scans are valuable for diagnosis. Using mesh repair with appropriate fixation can help reduce the recurrence rate. In cases of abdominal contamination, one-stage synthetic mesh repair is feasible, with biological mesh having an advantage in cases of severe contamination. If the repair site is severely infected, mesh repair should be avoided.

10 Single-incision laparoscopic totally extraperitoneal sublay for adult umbilical hernia: a report of 13 cases

HU Weize , ZHENG Huiming , DAI Yujian

2023, 32(10):1516-1521. DOI: 10.7659/j.issn.1005-6947.2023.10.010

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Background and Aims Single-incision laparoscopic surgery (SILS) has been widely utilized in abdominal surgeries, but its application in umbilical hernia repair has been limited. Building on the department's prior experience with single-incision laparoscopic inguinal hernia repair (TEP), the authors attempted to treat adult umbilical hernias using single-incision laparoscopic totally extraperitoneal sublay (SIL-TES) and gained certain experience. This study was to explore the feasibility and efficacy of SIL-TES for the treatment of adult umbilical hernia.Methods The data from 13 adult umbilical hernia patients who underwent SIL-TES in Quanzhou First Hospital Affiliated to Fujian Medical University from January 2021 to August 2022 were retrospectively analyzed. Among these patients, there were 9 males and 4 females, with an average age of (38.9±6.1) years and an average hernia ring diameter of (2.4±0.6) cm. The requirements of SIL-TES included: building upon the three-port laparoscopic totally extraperitoneal sublay as the foundation, incorporating the techniques of single-incision laparoscopy, achieving seamless coordination between the camera-holding assistant and the primary surgeon, placing the laparoscope and instruments logically to minimize the "chopstick effect" during the procedure; proficiency in mastering the multi-layer anatomy of the abdominal wall for avoiding intraoperative anatomical errors and peritoneal damage, ensuring the mesh placed in the correct layer.Results All 13 cases were successfully completed without any conversions to open surgery. The average operative time was (138.5±20.9) min, with an average postoperative pain score of 2.5±0.9 at postoperative day 3. The mean duration of postoperative drainage tube placement was (4.1±1.1) d. The average length of postoperative hospital stay was 3 to 6 d, with a median length of 4.1 d. No complications such as seroma, bleeding, wound dehiscence, wound infection, umbilical skin necrosis, bowel obstruction, or bowel fistula occurred. The average follow-up duration was (14.7±6.3) months, and no cases of hernia recurrence or chronic pain occurred.Conclusion The use of SIL-TES for the treatment of adult umbilical hernia is feasible and can serve as a supplementary surgical option. However, due to the limited number of cases and short follow-up duration, the long-term effectiveness of this approach requires further clarification.

11 Relationship between the glucose metabolism reprogramming regulation by the circRAD18/miR-516b/PDK1 axis and proliferation in colorectal cancer cells

LI Wei , TANG Yunyun , PENG Juan , JIANG Xungui

2023, 32(10):1522-1530. DOI: 10.7659/j.issn.1005-6947.2023.10.011

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Background and Aims Circular RNA circRAD18 has been found to play a promoting role in the progression of breast cancer and thyroid cancer, but its expression and function in other malignant tumors have not been fully elucidated. In our previous study, we used bioinformatics software to predict that circRAD18 can interact with miR-516b through complementary binding, and pyruvate dehydrogenase kinase 1 (PDK1), a key regulator of glucose metabolism, may a target gene of miR-516b. Therefore, this study was conducted to preliminarily investigate the expression and function of circRAD18 in colorectal cancer cells and its regulatory relationship with the target miRNA and downstream target genes.Methods The expression of circRAD18 in different colorectal cancer cell lines (SW480, SW620, HT-29) and normal colorectal epithelial cells (NCM460) was detected using qRT-PCR. After silencing circRAD18 with si-circRAD18 in colorectal cancer cells, cell proliferation, glucose uptake, and lactate production were assessed using CCK-8 assay and corresponding kits. The binding relationship between circRAD18, miR-516b, and PDK1 was analyzed through dual-luciferase reporter gene assay and RNA immunoprecipitation (RIP) experiment. Finally, overexpression and knockdown experiments were conducted to further validate the relationships among them.Results Compared to normal colorectal epithelial cells, circRAD18 was significantly upregulated in all colorectal cancer cell lines (all P<0.05). Transfection with si-circRAD18 resulted in a significant decrease in colorectal cancer cell proliferation, glucose uptake, and lactate production (all P<0.05). Dual-luciferase reporter gene assay and RIP experiments confirmed the binding of circRAD18 to miR-516b, and PDK1 was identified as a downstream target gene of miR-516b. Transfection with miR-516b mimic or si-circRAD18 significantly inhibited cellular glucose uptake, lactate production, and PDK1 protein expression in colorectal cancer cells, and the supplementation of PDK1 could reverse this inhibitory effect (all P<0.05).Conclusions CircRAD18 is upregulated in colorectal cancer cells and is closely associated with enhanced cell proliferation. The underlying mechanism may involve circRAD18 adsorbing miR-516b through sponge uptake, leading to upregulation of PDK1 expression, and subsequently, reprogramming of glucose metabolism in colorectal cancer cells.

12 Expression of mir-520c-3p and its regulatory mechanism on pyruvate metabolism in colorectal cancer stem cells

ZHAO Yingxuan , BAI Yuqin , OUYANG Weidong

2023, 32(10):1531-1538. DOI: 10.7659/j.issn.1005-6947.2023.10.012

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Background and Aims Studies have shown that changes in the metabolism of pyruvate play an important role in the occurrence and development of colorectal cancer, and abnormal expression of microRNAs (miRNAs) in colorectal cancer stem cells may be closely related to pyruvate metabolism. The author's previous analysis of the TCGA database found that miR-520c-3p was upregulated in colorectal cancer and correlated with prognosis. However, it is not clear whether miR-520c-3p is involved in pyruvate metabolism. Therefore, this study explores the relationship between the expression of miR-520c-3p in colorectal cancer stem cells and pyruvate metabolism.Methods Human colon cancer cell lines were selected, and colorectal cancer stem cells were isolated and purified from them. Changes in the proliferation ability, pyruvate oxidation levels, and lactate production in colorectal cancer stem cells and colorectal cancer cells were detected after overexpression or knockdown of miR-520c-3p. Cells were incubated with _D-(U-¹³C) glucose, and mass isotopomer analysis was used to trace the fate of glucose-derived carbons. MiR-520c-3p functional substrates were analyzed and identified through miRNA sequence analysis and genetic approaches.Results After overexpression of miR-520c-3p, the proliferation ability of colorectal cancer stem cells significantly increased, while the levels of pyruvate oxidation significantly decreased and lactate production significantly increased (all P<0.05). When cultured with _D-(U-¹³C) glucose, the unlabeled citrate (m+0) in colorectal cancer stem cells significantly increased, while the higher-order citrate isotopomers (m+1, m+4, and m+5) significantly decreased (all P<0.05). Conversely, after knockdown of miR-520c-3p, the above-mentioned changes in colorectal cancer stem cells were reversed (all P<0.05). Overexpression or knockdown of miR-520c-3p had no significant effect on the above-mentioned indicators in colorectal cancer cells (all P>0.05). MiR-520c-3p could target the 3'UTR of mitochondrial pyruvate carrier 1 (MPC1) mRNA (P<0.05). After overexpression of miR-520c-3p, both mRNA and protein levels of MPC1 in colorectal cancer stem cells significantly decreased, while the opposite was observed after knockdown of miR-520c-3p (all P<0.05). Analysis of TCGA database showed that colorectal cancer patients with low MPC1 expression had poorer prognosis (P<0.05). Knockdown of MPC1 led to a significant decrease in pyruvate oxidation levels, significant increase in lactate production, and significant enhancement of proliferation ability in colorectal cancer stem cells (all P<0.05). When cultured with _D-(U-¹³C) glucose, the unlabeled citrate (m+0) significantly increased, while the higher-order citrate isotopomers (m+1, m+4, and m+5) significantly decreased in colorectal cancer stem cells with MPC1 knockdown (all P<0.05). Meanwhile, after knockdown of both miR-520c-3p and MPC1, there were no significant changes in pyruvate oxidation levels, lactate production, and proliferation ability in colorectal cancer stem cells (all P>0.05).Conclusions The high expression of miR-520c-3p in colorectal cancer is associated with poor prognosis, and its mechanism may be related to its regulation of pyruvate metabolism in colorectal cancer stem cells through targeting MPC1, promoting the proliferation of colorectal cancer stem cells.

13 A randomized controlled clinical study comparing different concentrations of alanyl-glutamine for parenteral nutrition in postoperative gastrointestinal tumor patients

LIANG Hongyan , GE Jie , LIU Ting , ZHAO Tingyu , XIE Kaiqiang , LIU Heli , TANG Mimi

2023, 32(10):1539-1551. DOI: 10.7659/j.issn.1005-6947.2023.10.013

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Background and Aims Proper nutritional support can provide essential nutrients and promote the recovery of patients after gastrointestinal tumor surgery. Adding alanyl-glutamine (Ala-Gln) to parenteral nutrition has been shown to improve clinical outcomes in patients. However, there are significant differences in the recommended concentration of Ala-Gln in parenteral nutrition in domestic and international drug manuals and clinical practice. Therefore, this study aims to investigate the effects of different ratios of Ala-Gln in parenteral nutrition on postoperative nutrition, liver and kidney function, and inflammation/immune status in gastrointestinal tumor patients to guide the standardized use of Ala-Gln.Methods This study was a randomized controlled clinical trial conducted on gastrointestinal tumor patients receiving postoperative parenteral nutrition support from June 2021 to April 2022 in the Department of Gastrointestinal Surgery, Xiangya Hospital, Central South University. Patients were randomly assigned to either the low ratio group (Ala-Gln dosage in enteral nutrition accounts for 20% of total amino acids) or the high ratio group (Ala-Gln dosage in enteral nutrition accounts for 30% of total amino acids). Both groups received parenteral nutrition support through central venous infusion starting the first day after surgery (once daily, lasting 8-12 h). Nutritional indicators, liver and kidney function parameters, and inflammation/immunity variables were monitored before surgery and on the first day after parenteral nutrition. Patient data on postoperative infections/complications, length of hospital stay, and in-hospital costs were collected from the hospital information system.Results A total of 77 patients were enrolled in this study, with 39 in the low ratio group and 38 in the high ratio group. The two groups had no statistically significant differences in baseline characteristics, preoperative nutritional indicators, liver and kidney function parameters, and inflammation/immunity variables (all P>0.05). Analysis of variance with repeated measurement tests showed that on the first day after enteral nutrition, all patients had a significant decrease in prealbumin, total protein, serum albumin, hemoglobin, total bile acid levels, as well as T lymphocytes (CD3⁺, CD4⁺, CD8⁺), immunoglobulins (IgG, IgA, IgM) levels compared to preoperative values; total bilirubin, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, and urea levels, as well as inflammatory markers, the Th/Ts ratio, and complement C4 levels, were significantly higher after surgery compared to preoperative values (all P<0.05); only the Th/Ts ratio in the high ratio group was significantly higher than that in the low ratio group (P=0.026), while the differences in other indexes between the two groups were not statistically significant (all P>0.05). Total protein (P=0.032) and serum albumin (P=0.008) showed a significant interaction between the group and time. Multivariate linear regression analysis further indicated that the grouping had no significant impact on total protein and serum albumin levels (both P>0.05). There were no statistically significant differences in the incidence of postoperative infections/complications, length of hospital stays, and in-hospital costs between the two groups (all P>0.05).Conclusion The addition of different ratios of Ala-Gln in parenteral nutrition (20% of total amino acids vs. 30% of total amino acids) had no significant impact on the nutrition, liver and kidney function parameters, and postoperative recovery of gastrointestinal tumor patients. However, higher proportions of Ala-Gln had a better immunomodulatory effect on T lymphocytes. Clinical decisions should be based on individual patient needs to choose the appropriate ratio of Ala-Gln concentration.

14 Clinical value of preoperative endoscopic ultrasound-guided titanium clip marking for predicting surgical approach in Siewert type Ⅱ adenocarcinoma of the esophagogastric junction

FANG Yongchao , ZHU Xingshu , HUANG Yanyun , WU Weihang , LIN Nan , YANG Jin , LIU Wangwu , WANG Yu

2023, 32(10):1552-1559. DOI: 10.7659/j.issn.1005-6947.2023.10.014

[Abstract](743) [HTML](365) [PDF 965.80 K](1006)

Abstract:
Background and Aims Siewert Type Ⅱ adenocarcinoma of the esophagogastric junction (AEG), located at the gastroesophageal junction, has been a subject of controversy regarding the optimal surgical approach due to its unique anatomical location. This study was performed to investigate the value of preoperative endoscopic ultrasound (EUS)-guided titanium clip marking in predicting the surgical approach for Siewert type Ⅱ AEG, so as to provide assistance in developing safe and precise surgical strategies in clinical practice.Methods Using a prospective controlled study design, 60 patients with Siewert type Ⅱ AEG who underwent surgery in the 900th Hospital of the Chinese People's Liberation Army Joint Logistic Support Force from February 2020 to December 2021 were enrolled. The patients were randomly assigned to a study group and a control group, with 30 patients in each group. After standard admission examinations, the patients in the study group underwent determination of the longest infiltrating position of the tumor along its longitudinal axis under EUS-assisted direct visualization, which was positioned by placing two titanium clips at the same height plane 1 cm beyond on the oral side The clip position was immediately confirmed by abdominal X-ray. The patients in the control group did not undergo any marking. The surgical approach for the study group was determined based on the relationship between the titanium clips and the 10th thoracic vertebra, while the surgical approach for the control group was determined based on preoperative routine examinations, such as CT and gastroscopy. Relevant clinical data were compared between the two groups.Results There were no statistically significant differences between the two groups in baseline characteristics, including gender, age, body mass index, smoking history, alcohol history (all P>0.05); there were also no statistically significant differences between the two groups in terms of surgical duration, intraoperative bleeding, tumor diameter, esophageal margin, length of hospital stay, postoperative pathological stage, tumor T stage, and N stage (all P>0.05). The analysis of the concordance between predicted and actual surgical approaches showed a significantly higher rate of concordance in the study group compared to the control group (96.67% vs. 86.21%, P<0.001). The incidence of postoperative complications in the study group and the control group was 26.67% and 30.00%, respectively, with no statistically significant difference (P=0.783).Conclusion Preoperative EUS-guided titanium clip marking is a simple, safe, and highly reliable procedure with practical clinical application value for determining the surgical approach in Siewert type Ⅱ AEG.

15 Analysis of clinicopathologic characteristics and diagnosis/treatment of colorectal mixed adeno-neuroendocrine carcinoma

DU Li , CHEN Zihua

2023, 32(10):1560-1567. DOI: 10.7659/j.issn.1005-6947.2023.10.015

[Abstract](616) [HTML](351) [PDF 1.44 M](1055)

Abstract:
Background and Aims Mixed adeno-neuroendocrine carcinoma (MANEC) is a rare and highly malignant tumor. In recent years, the incidence of colorectal MANEC has shown a certain growth trend. This study summarizes the clinicopathologic data as well as the diagnosis and treatment process of colorectal MANEC cases treated over the past decade, with the aim of increasing awareness of this disease and thereby standardizing its treatment and management.Methods The clinical data of 13 patients diagnosed with colorectal MANEC through pathological and immunohistochemical examination of surgical specimens from January 2010 to March 2023 were retrospectively analyzed.Results Among the 13 patients with colorectal MANEC, 10 were male (76.9%), with an average age of 65.1 years. The most common complaints were bloody stools and changes in stool characteristics, with 61% of patients showing positive physical signs. All patients were found to have thickening of the bowel wall through CT or MRI, and a mass was detected through endoscopy, which led to preoperative histopathological reports. However, only 2 cases had a preoperative pathological report indicating the presence of neuroendocrine components, and additional whole-body PET/CT imaging using ¹⁸F-octreotide (¹⁸F-OC) as the imaging agent indicated increased somatostatin receptor expression in the thickened bowel wall and surrounding lymph nodes. All 13 patients underwent surgical treatment, with 3 cases receiving preoperative neoadjuvant therapy. The majority of patients were classified as stage Ⅲ or Ⅳ after surgery (84.6%). Common sites of metastasis included per-intestinal lymph nodes and the liver. The average tumor size was 4 cm × 3.4 cm × 2.6 cm, and 84.6% (11/13) of tumors were ulcerative. In 92.2% of cases, the tumors were moderately to poorly differentiated adenocarcinomas. Seven patients received postoperative drug therapy. The survival periods for 8 patients were obtained, and the average survival was 20.6 months with a median survival of 13.5 months. Two patients had a postoperative survival exceeding 3 years.Conclusion Colorectal MANEC has a generally unfavorable prognosis, and survival may be primarily associated with clinical pathological stage and the presence of distant metastasis. The preoperative pathological diagnosis rate is relatively low, and the use of octreotide-based PET/CT imaging can increase the detection rate of this disease. The main treatment approach is surgery, with chemotherapy as an adjuvant therapy. Further clinical studies are needed to determine whether a combination chemotherapy regimen targeting both the neuroendocrine and adenocarcinoma components, as well as immunotherapy, can provide advantages in the treatment of advanced colorectal MANEC.

16 Radical resection combined with artificial material bridging for the treatment of abdominal wall type aggressive fibromatosis: a report of 16 cases

LIU Yaling , ZHOU Ting , ZHOU Jingyu , WANG Shalong , ZHOU Jianping , REN Feng

2023, 32(10):1568-1576. DOI: 10.7659/j.issn.1005-6947.2023.10.016

[Abstract](585) [HTML](564) [PDF 1.48 M](1007)

Abstract:
Background and purpose Aggressive fibromatosis (AF) is a relatively rare borderline tumor with a tendency for local invasion but generally lacking distant metastasis. It is associated with a high recurrence rate. For patients with abdominal wall AF, achieving radical resection often requires disrupting the integrity of the abdominal wall, making abdominal wall reconstruction after tumor resection a challenging task. This study was performed to investigate the safety and efficacy of radical resection combined with artificial material bridging for the treatment of abdominal wall AFMethods The clinical and follow-up data of 16 patients with abdominal wall AF treated in the Department of Geriatric Surgery, the Second Xiangya Hospital of Central South University, from January 2013 to October 2021 were retrospectively analyzed. All patients underwent one-stage radical resection of the abdominal wall lesion and simultaneous repair of the abdominal wall defect with artificial material bridging.Results The average operative time for the 16 patients was 98 (70-235) min, and the average tumor size was 8.6 (4-14) cm. After tumor resection, abdominal wall defects ranged from 6 cm × 8 cm to 14 cm × 19 cm. Abdominal wall defects were repaired and reconstructed using artificial materials, with 6 cases using sublay bridging, 9 cases using IPOM bridging, and 1 case using three-dimensional bridging. All surgeries were completed successfully. Postoperative pathology reports confirmed AF in all cases, with one male patient showing a CMNNB1 exon 3 (T41A) mutation. One patient developed postoperative seroma, which was successfully treated with vacuum-assisted closure (VAC) after open wound management, and healed after secondary closure. The remaining 15 patients experienced no serious postoperative complications, such as wound infections, mesh infections, or intestinal obstruction, and were discharged after achieving grade I wound healing. The median follow-up period was 46 (12-110) months, with a 100% follow-up rate. No tumor recurrence, chronic pain, mesh-related infections, mesh protrusion, or incisional hernia occurred during the follow-up period.Conclusion Abdominal wall AF can occur in different parts within the muscle layer of the abdominal wall and typically presents as a local mass. Surgical treatment is the primary therapeutic approach. Complete tumor resection with negative margins effectively prevents tumor recurrence. Therefore, preoperative assessment of tumor size, depth of invasion, defect location, and extent is crucial for designing individualized surgical approaches to achieve effective abdominal wall reconstruction in terms of both form and function. Radical resection combined with artificial material bridging repair for post-resection abdominal wall defects is a safe and effective treatment for abdominal wall AF.

17 Visualization and hotspots analysis of research for gastric stump cancer based on Web of Science

HUANG Chuyin , LIU Lin , WANG Zhongyi , HU Yanfeng , YU Jiang , LI Guoxin , CHEN Hao

2023, 32(10):1577-1587. DOI: 10.7659/j.issn.1005-6947.2023.10.017

[Abstract](442) [HTML](451) [PDF 1.45 M](944)

Abstract:
Background and Aims Gastric stump cancer is a subtype of malignant gastric tumors characterized by distinct pathogenic factors, clinical features, and prognosis. Its incidence has been on the rise in recent years, yet there remain several controversies regarding its development mechanism and surgical treatment. Furthermore, there has been no comprehensive or visualized analysis of the existing literature in the international field of gastric stump cancer. Therefore, this study was conducted to make a visualized analysis of English literature in the field of gastric stump cancer through bibliometric methods, aiming to summarize its current research status and hotspots, discuss research trends, and provide a reference for future studies in this field.Methods The literature in the field of gastric stump cancer was searched in the Web of Science Core Collection from the inception of the database to December 31, 2022. The analyses of overall publication patterns, social network, temporal features, co-citation of authors, keyword co-occurrence network and keyword burst were performed using Excel, VOSviewer, and CiteSpace.Results A total of 400 English literature publications were included, with the earliest publication dating back to 1964. Within the analyzed timeframe, English literature on gastric stump cancer was predominantly published in specialized journals related to gastroenterology, oncology, and surgery. The annual publication rate showed slow fluctuations, with a recent stabilization over the past three years. The most frequently cited literature was authored by O hashi M (2007), followed by S asako M (1991). The top three countries in terms of publication output were Japan (n=127), China (n=42), and Republic of Korea (n=32). The University of Amsterdam in the Netherlands was the leading institution in terms of publications (n=10), with Offerhaus GJA being the most prolific author in the field of gastric stump cancer from this institution (n=10). The top three co-cited authors were Ohashi M (87 citations), Sasako M (77 citations), and Balfour DC (72 citations). Collaboration among authors within the same institution was a prevalent trend in gastric stump cancer research, with relatively limited inter-country and inter-institutional collaborations, except the National Cancer Center in Japan which demonstrated close collaborations with domestic and foreign institutions. The co-occurrence network of keywords highlighted terms such as Surgery (137 occurrences) and Distal Gastrectomy (126 occurrences) as high-frequency keywords in the field. Keyword burst analysis revealed that earlier research focused on gastric stump cancer following Billroth Ⅱ gastrectomy for benign ulcerative diseases. In the intermediate phase, attention shifted to the role of Helicobacter pylori infection in gastric carcinogenesis, endoscopic resection of early gastric stump cancer, and surgical lymph node dissection. Recent research hotspots included minimally invasive treatments, surgical complications, clinicopathologic characteristics, and survival and prognosis of gastric stump cancer, which were likely to become future research trends.Conclusion The overall quantity of English literature on gastric stump cancer is relatively limited. VOSviewer and CiteSpace enable a systematic and visually informative analysis of the current research landscape in gastric stump cancer. China should enhance collaboration with countries such as Japan and the Netherlands and align its research with the current hotspots in gastric stump cancer, thereby increasing its academic influence in this field.

18 Advances in application of immune checkpoint inhibitors in neoadjuvant therapy for gastrointestinal malignancies

DU Xiaoyu , FAN Ruifang , XU Shumei , SONG Lei , XU Wei , YANG Jiaxing , CHENG Yunhua , LI Luyao , MA Shang , YAN Long

2023, 32(10):1588-1598. DOI: 10.7659/j.issn.1005-6947.2023.10.018

[Abstract](519) [HTML](419) [PDF 866.19 K](1462)

Abstract:
The main treatment approach for gastrointestinal malignancies still involves surgical procedures complemented by radiotherapy and chemotherapy. However, the high recurrence and low 5-year survival rates after surgery have become significant issues affecting the life and health of patients. In contrast to traditional conventional treatments involving surgery followed by radiotherapy and chemotherapy, neoadjuvant therapy is a treatment method that moves radiotherapy, chemotherapy, interventional therapy, targeted therapy, and immunotherapy to preoperative period. It offers advantages such as improving radical resection rate, prolonging survival, and enhancing the quality of life. Because it is difficult to significantly extend the survival of patients with gastrointestinal malignancies through traditional conventional treatments, the advantages of neoadjuvant therapy have become increasingly apparent in the treatment of various malignant tumors. It is gradually being included in the recommended treatment standards of the latest authoritative clinical guidelines. Immune checkpoint inhibitors (ICIs) are a new class of anti-tumor immunotherapy drugs that activate the immune system to attack tumor cells by blocking immune checkpoints. This category includes programmed cell death protein 1 (PD-1) and its ligand (PD-L1) inhibitors, as well as cytotoxic T-lymphocyte-associated protein 4 (CTAL-4) inhibitors. The development and application of ICIs have brought new hope to countless cancer patients and are considered groundbreaking in the field of medical oncology. ICIs have been widely used in the comprehensive treatment of gastrointestinal malignancies. The combination of chemotherapy and immunotherapy, as well as immunotherapy alone, has shown significant effects in patients with advanced, unresectable, or metastatic gastrointestinal malignancies. It has become one of the treatment choices for these patients. This provides a promising opportunity for the use of ICIs in the neoadjuvant treatment of locally resectable or potentially resectable gastrointestinal malignancies. Recent results from phase I/Ⅱ clinical trials indicate that neoadjuvant immunotherapy based on ICIs holds great potential in the treatment of gastrointestinal malignancies. It significantly reduces tumor stage, and increases the pathological remission and complete resection rates, with controllable safety. However, the long-term survival outcomes still require further observation, and more phase Ⅲ studies are needed to elucidate the effectiveness of ICIs in neoadjuvant treatment of gastrointestinal malignancies. Here, the authors analyze and discuss the current clinical applications of ICIs in the neoadjuvant treatment of gastrointestinal malignancies, recent clinical research findings, and potential mechanisms of action.

19 Research progress on neutrophil extracellular traps in colorectal cancer

JIA Dong , CHEN Shun , XIE Youcheng , KANG Yinnan , ZHAO Baoyin , WU Zhaohui , WANG Junke , YU Xiaohui

2023, 32(10):1599-1607. DOI: 10.7659/j.issn.1005-6947.2023.10.019

[Abstract](609) [HTML](543) [PDF 998.88 K](1195)

Abstract:
Neutrophil extracellular traps (NETs) are special networks composed of DNA chromatin and various granular proteins that neutrophils release extracellularly in response to stimuli such as viruses, bacteria, immune complexes, and cytokines. As an important component of the innate immune extracellular defense system, NETs play a crucial role. Under normal circumstances, NETs mediate antimicrobial activity and pathogen clearance, thereby maintaining the body's protection against external threats. However, excessive or dysfunctional NETs can further amplify inflammatory responses and contribute to the occurrence and development of various diseases. The formation of NETs is closely associated with autoimmune diseases, diabetes, cardiovascular diseases, cancer, and more. In this review, the authors provide an overview of the role of NETs formation in regulating the occurrence and development of colorectal cancer (CRC). The review discusses the mechanisms by which NETs formation promotes malignant biological behaviors in CRC, including proliferation, epithelial-mesenchymal transition, angiogenesis, immune evasion, and tumor-related thrombosis. Furthermore, the review discusses the clinical prospects of NETs formation as a biomarker and potential therapeutic target for CRC.

20 Research progress of hyperglycemia after enteral nutrition

ZHENG Yu , ZHOU Bingqian , GONG Ni

2023, 32(10):1608-1616. DOI: 10.7659/j.issn.1005-6947.2023.10.020

[Abstract](310) [HTML](384) [PDF 842.92 K](1144)

Abstract:
In hospitalized patients receiving enteral nutrition, the incidence of hyperglycemia is as high as 34.5%, causing significant harm to the patients. In response to the increasing nutritional needs of hospitalized patients each year, understanding the mechanism of hyperglycemia in patients receiving enteral nutrition is crucial for improving the prognosis of these patients. Strengthening the management of hyperglycemia in patients after enteral nutrition by healthcare professionals is of utmost importance. In this article, the authors provide an overview of the current status of blood sugar management after enteral nutrition, the mechanisms of high blood sugar occurrence, and adverse outcomes. Additionally, relevant treatment recommendations are proposed, intending to provide clinical reference and assistance.

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Volume 32,Issue 10,2023 Table of Contents

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