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Objective: To explore the efficacy of radiotherapy combined with surgery for locally advanced rectal mucinous adenocarcinoma., Methods: Clinical data of patients with locally advanced rectal mucinous adenocarcinoma (T3-4 and/or N+) diagnosed by postoperative pathology from 1992 to 2013 were retrieved from the US Surveillance, Epidemiology, and End Results (SEER) database. Patients with local excision only, tumor biopsy or combined organ excision and incomplete follow-up information were excluded. All the enrolled patients were divided into three groups according to different treatments, including surgery alone (SA) group, preoperative radiotherapy combined with surgery (RT+S) group and surgery combined with postoperative radiotherapy (S+RT) group. The extracted data included basic data of patients and tumor, treatment status, and follow-up results. The χ² test was used to compare the count data. Kaplan-Meier method was used to draw the survival curve and calculate the survival rate. The survival was analyzed and compared by Log-rank test. The R language 2.8.1 was used to match the patients as 1:1 pairing through the propensity score matching (PSM). The matching variables included gender, age at diagnosis, year at diagnosis, ethnicity, degree of tissue differentiation, TNM stage, depth of invasion, making the baseline data of subgroups comparable. The Cox proportional hazard model was used for multivariate analysis of prognostic factors., Results: A total of 2 149 patients with locally advanced rectal mucinous adenocarcinoma were enrolled in the study, including 1 255 males (58.4%) and 894 females (41.6%). There were 706 patients (32.9%) in the SA group, 772 patients (35.9%) in the RT+S group and 671 patients (31.2%) in the S+RT group. In SA, RT+S and S+RT groups, the median overall survival time was 39, 85, and 74 months respectively; the 5-year overall survival (OS) rate was 38.7%, 56.5%, and 55.2% respectively; the median cancer-specific survival (CSS) time was 86, 127, and 111 months respectively, and the 5-year CSS rate was 53.7%, 62.2% and 60.7% respectively. In comparison among the 3 groups, the 5-year OS rate and CSS rate in the SA group were significantly lower than those in the RT+S group and S+RT group (all P<0.001); the 5-year OS rate and CSS rate between RT+S group and S+RT group were not significantly different (P=0.166 and 0.392,respectively). After the baseline data of subgroups were corrected through PSM, the 5-year OS rate and CSS rate in the SA group (n=375) were significantly lower than those in the RT+S group (n=375)(OS:40.1% vs. 54.5%, P<0.001; CSS:54.3% vs. 63.3%, P=0.023). The 5-year OS rate and CSS rate in the SA group (n=403) were also lower than those in the S+RT group (n=403) (OS:37.4% vs. 54.7%,P<0.001;CSS:51.6% vs. 61.0%,P=0.031). The 5-year OS rate and CSS rate between RT+S group (n=363) and S+RT group (n=363) were not significantly different (OS:51.7% vs. 55.5%, P=0.789; CSS:57.7% vs. 60.5%, P=0.484). Cox multivariate analysis showed that radiotherapy (HR=0.845, 95%CI: 0.790 to 0.903, P=0.001) was an independent prognostic factor for OS of locally advanced rectal mucinous adenocarcinoma; radiotherapy (HR=0.907, 95% CI: 0.835 to 0.985, P=0.021) was also an independent prognostic factor affecting CSS in patients with locally advanced rectal mucinous adenocarcinoma., Conclusion: As compared with surgery alone, surgery combined with preoperative or postoperative radiotherapy is beneficial to the long-term survival of patients with locally advanced rectal mucinous adenocarcinoma.

Objective: To investigate the efficacy and safety of the bladder training in male patients before urinary catheter removal after mid-low rectal cancer surgery., Methods: This was a prospective, open, randomized controlled study., Inclusion Criteria: male patients; pathologically diagnosed as mid-low rectal adenocarcinoma; distance from tumor lower edge to anal margin ≤10 cm; standard radical surgery for rectal cancer, including intestinal resection and regional lymph node dissection., Exclusion Criteria: previous history of benign prostatic hyperplasia or history of prostate surgery; bladder dysfunction such as dysuria and urinary retention before surgery; local resection of rectal tumor or extended resection. According to the above criteria, 92 patients who underwent colorectal surgery at the Union Hospital of Fujian Medical University from June to December 2016 were prospectively included. The patients were randomly divided into bladder training group (n=43) and bladder non-training group (n=49) according to the random number table method. The study was approved by the Ethics Committee of the Union Hospital of Fujian Medical University (ethical approval number: 2016KY005) and registered with the China Clinical Trial Registration Center (ChiCTR) (registration No.ChiCTR-IOR-16007995). The implementation of patient's treatment measures, the data collection and analysis were based on the three-blind principle, using envelopes for distribution concealment. In the bladder training group, bladder training was routinely performed from the first day after operation to catheter removal, and in bladder non-training group the catheter was kept open till its removal. The catheter was removed in the early morning at the 5th day after surgery, and the spontaneous urine output was recorded and the residual urine volume of the bladder was measured after the first urination. The international prostate symptom score (IPSS) was applied to evaluate the patient's urinary function before and after surgery., Results: The age of whole group was (58.6±10.9) years old, the body mass index was (22.4±2.7) kg/m 2 , and the distance from tumor lower edge to anal margin was (6.5±1.9) cm. The baseline data, such as age, body mass index, distance from tumor lower edge to anal margin, preoperative IPSS score, preoperative bladder residual urine volume, neoadjuvant radiotherapy and chemotherapy, preventive ileostomy and surgical procedure were not significantly different between two groups (all P>0.05). There was no significant difference in IPSS scores evaluated at the second day (3.6±4.0 vs. 3.5±3.4, t=0.128, P=0.899) and one month (3.7±2.9 vs. 3.0±3.1, t=1.113, P=0.269) after catheter removal between the bladder training group and bladder non-training group. No significant difference in the postoperative residual urine volume of bladder (media 44 ml vs. 24 ml, Z=-1.466, P=0.143), the first spontaneous urination volume (median 200 ml vs. 150 ml, Z=-1.228, P=0.219) after catheter removal, and postoperative hospital stay [(8.2±4.5) days vs. (9.1±5.5) days, t=-0.805, P=0.423] was found. Urinary infection rate was 20.9%(9/43) in the training group, which was even higher than 8.2%(4/49) in the non-training group, but the difference was not significant(χ²=3.077, P=0.079). No patient needed re-catheterization in either group., Conclusions: The routine bladder training after mid-low rectal cancer surgery does not improve the urinary function, and can not reduce the residual urine volume of bladder after catheter removal. This routine clinical practice is not helpful for the bladder function recovery after rectal cancer surgery.

Many studies have focused on the identification of risk factors and prevention of anastomotic leakage following rectal cancer surgery. However, there is little knowledge regarding classification and management of anastomotic leakage in clinic. Herein, we reviewed and summarized the classification and management of anastomotic leakage after rectal cancer surgery. The relevant treatments of anastomotic leakage should be chosen based on patient's manifestation, including general and local reactions, anatomical location, and nature of the leakage (contained or free, controlled or uncontrolled leakage). 1) Surgery is imperative for anastomotic leakage with acute general peritonitis and sepsis. 2) Circumscribed peritonitis and the pelvic abscess can be managed conservatively with complete drainage. During the conservative management, diverting stoma, minimally invasive techniques of seal or repair should be implemented at an appropriate time, if necessary. 3) Subclinical leakage seldom requires surgical intervention promptly. 4) For persistent anastomotic leakage after diverting stoma, we should consider whether chronic presacral abscess, epithelialized sinus, fistula or local recurrence of cancer is present. With regard to definitive salvage surgery, reconstruction of the coloanal anastomosis or permanent stoma is usually required under these circumstances. 5)Complicated fistula often necessitates surgical repair with advancement tissue flap or tissue interposition under the condition of diversion. Reconstructing the coloanal anastomosis is the alternative management, whereas other treatments are invalid, including ultra-low anterior resection, intersphincteric resection, proctectomy with colon pull-through, and primary or staged coloanal anastomosis. 6) During the surgical repair of recto-vaginal fistula and recto-urinary fistula, colorectal surgeons may require the cooperation of gynecologists, urologists, and orthopedists. 7) For anastomotic leakage with local recurrence of cancer after conservative management, diverting stoma should be performed promptly to facilitate the subsequent chemoradiotherapy. Surgeons should pay more attention to systemic knowledge and understanding of the classification and management of anastomotic leakage following rectal cancer surgery. Accordingly, we can follow the principles of management, individualize the treatments, apply the concepts of damage control and minimally invasive surgery, and enhance the recovery of anastomotic leakage. Prevention remains more important than remedies. To prevent the occurrence of permanent injuries, not only early diagnoses and treatments should be performed, but also the timing of cancer treatments is warranted for anastomotic leakage.

Objective: To establish a nomogram model to predict the peritoneal metastasis in colon cancer patients without distant metastasis by preoperative imaging examination., Methods: Clinicopathological data of colon cancer patients without distant metastasis by preoperative imaging examination who underwent surgery in our department between January 2000 and December 2014 were retrospectively analyzed. Predictors of peritoneal carcinomatosis were analyzed by univariate and Logistic multivariate analyses. Base on the independent predictors by multivariable analysis results, a nomogram model was formulated with further use of R software. The total score was calculated by the addition of each predictor score, indicating the corresponding risk of peritoneal metastasis. The score was greater in the nomogram, and the risk was higher in peritoneal implantation metastasis. A receiver operating characteristic(ROC) curve was then constructed to evaluate the predictive abilities of the various preoperative factors and nomogram., Results: A total of 1 417 patients were defined as above and enrolled in the study. The median age was (60.5±13.3) years, 835 cases (58.9%) were male, and 132 cases (9.3%, 132/1417) were diagnosed with synchronous peritoneal carcinomatosis during operation. Univariate analysis showed that peritoneal metastasis was associated with age, incidence of abdominal pain, incidence of mucous bloody stool, CEA level, traversible rate, tumor diameter, ratio of infiltrating type cancer, differentiation, histological type, cT staging and cN staging (all P<0.05). Logistic multivariate analysis revealed that younger age (OR:0.974, 95%CI: 0.958 to 0.990, P=0.001), later clinical T stage (OR: 2.949, 95%CI: 1.588 to 5.476, P=0.001), lesion not traversible(OR: 0.519, 95%CI: 0.314 to 0.858, P=0.011), infiltrative gross type (OR: 1.812, 95%CI: 1.099 to 2.987, P=0.020), larger tumor (OR: 1.044, 95%CI: 0.998 to 1.093, P=0.061), higher preoperative serum CEA level(OR:1.004,95%CI: 1.001 to 1.007, P=0.007) and histopathologic type of mucinous or signet ring cell adenocarcinoma (OR:1.642, 95%CI: 1.009 to 2.673, P=0.046) were independent risk factors. The nomogram model was further established based on above 7 independent risk factors, whose total score was 350 and area under the ROC curve was 0.753(P=0.000)., Conclusion: The nomogram model can be helpful to screen the colon cancer patients with high risk of peritoneal metastasis and to avoid unnecessary laparotomy for colon cancer patients without distant metastasis by preoperative imaging examination.

Objective: To investigate the surgical endpoint of separation of mesorectum during total mesorectal excision (TME), suggesting the concept of "terminal line", in order to perform above separation better for middle-low rectal cancer., Methods: Gross anatomy of mesorectum endpoint from 81 surgical specimens of low anterior resection (LAR, 5 to 6 cm of distance from low margin of cancer to anal edge) and 71 surgical specimens of abdominal perineal resection(APR, <5 cm of distance from low margin of cancer to anal edge) was observed. Clinicopathological, magnetic resonance imaging(MRI) morphological and operative video data of 108 low rectal cancer patients undergoing TME at Department of Colorectal Surgery of Affiliated Union Hospital of Fujian Medical University between March 2016 and March 2017 were retrospectively analyzed. Rates of the "terminal line" exposure of TME between different surgical procedures(robot or laparoscope) and different anatomical instruments (ultrasonic knife or electric hook) were compared for evaluating the site of separation endpoint., Results: The gross anatomical findings of specimens from LAR showed that the rectal wall below the levator hiatus level had no mesorectum attachment, and gross anatomical finding of specimens from APR showed that the levator hiatus was the most terminal attachment margin of the mesorectum whose thickness was only 2 millimeters in levator hiatus level. MRI morphological findings of 108 low rectal cancer patients showed that high signal intensity of mesorectal tissue on T2 MRI gradually thinned to the level of levator hiatus. High quality laparoscopic and robotic operation revealed a white linear structure formed by pelvic fascia, which covered and surrounded levator hiatus, so the "terminal line" of TME was defined. The operation video of 108 revealed that the overall exposure rate of the "terminal line" was 45.4%, the exposure rate of "terminal line" in robotic surgery was similar to that in laparoscopic surgery [(60.0%(18/30) vs. 39.7%(31/78), P=0.058], while such rate in ultrasonic knife was superior to electric hook [55.4%(41/74) vs. 23.5%(8/34), P=0.002]. Laparoscopy combined with ultrasonic knife can also obtained a high exposure rate of 52.3%(23/44)., Conclusions: The white linear structure referring to pelvic fascia which covers and surrounds levator hiatus is the "terminal line" of TME. The use of an ultrasonic knife is easier to expose this structure and to guarantee the quality of TME.

Objective: To establish a nomogram to predict long-term survival in non-metastatic colorectal cancer patients., Methods: A retrospective analysis was conducted in patients with non-metastatic colorectal cancer who underwent radical surgery in the Department of Colorectal Surgery of Affiliated Union Hospital of Fujian Medical University between January 2000 and December 2014. Univariate and multivariate analyses on disease-free survival (DFS) were performed using the Cox proportional regression model. Based on the multivariate analysis results, a prognostic nomogram was formulated to predict the probability for DFS. Concordance index was applied in predictive evaluation of the nomogram and calibration curves were drawn to test the nomogram's prediction and actual observation of the 5-year DFS rate. The predictive ability of nomogram was compared with AJCC-7 staging system., Results: A total of 2 641 patients were identified. The median age was 59.3 years old, and 60.3% of cases were men. The number of patients with TNM stage 0, I(, II( and III( was 96, 505, 923 and 1043, respectively. The most common tumor site was the rectum, accounting for 43.2%. A total of 413 (15.6%) patients underwent neoadjuvant treatment. The most common gross type of tumor was ulcerative type, accounting for 79.5%. The 3- and 5-year DFS rate was 85.8% and 79.8%, respectively. Based on the Cox proportional regression model, the following six factors were independently associated with reduced DFS rate and were selected for the nomogram: older age, higher pathologic T stage, higher pathologic N stage, higher preoperative serum CEA level, infiltrative gross type and perineural invasion. The results of the nomogram showed that the score of T0, T1, T2, T3 and T4 stage was 0, 2.2, 3.9, 4.1 and 6, respectively, and the score of N0, N1 and N2 was 0, 3.8 and 9.3, respectively. For gross type, the score of expanding type, ulcerative type and infiltrative type was 6, 9 and 10, respectively. The score of perineural invasion was 5.2. Higher scores were added to older age and higher CEA level. The total scores were calculated by taking the sum of the points from all predictors. Higher total score was associated with poor DFS. The prognostic nomogram differentiated well and showed a concordance index of 0.718, which was better than AJCC-7 staging system (concordance index=0.683). Also, the calibration of nomogram predictions was good., Conclusions: A nomogram based on 6 independently prognostic factors to predict long-term survival in non-metastatic colorectal cancer patients is established successfully. The nomogram can be conveniently used to facilitate the accurate individualized prediction of DFS rates in patients with non-metastatic colorectal cancer.

Laparoscopic total mesorectal excision (TME) has been commonly applied in the operation of mid-low rectal cancer, but the conventional laparoscopic TME has the disadvantages of major operative difficulty and long learning-curve, due to its limitations of 2-dimension vision and common laparoscopic instruments. Robotic surgical system with high-qualified 3-dimenstion vision and flexible Endo Wrist instruments can overcome those limitations of conventional laparoscopy, and is useful for the TME that demands deep pelvic operation and flexible dissection in the space of distal rectum. Robotic TME has the advantages of shorter learning curve and lower conversion rate, and it can even be performed by the surgeon with little laparoscopic experience. But according to the current studies, the superiority of robotic TME over laparoscopic TME can not be confirmed. To confirm the efficacy of robotic surgery, more high-level evidences are needed. Currently, the biggest obstacle for the widespread use of robotic surgical system is its high expense. But there is an obvious advantage that is the more comfortable feeling of surgeon while performing robotic surgical system, compared with performing laparoscopic operation, and it is helpful for long-time complicated operation. It is confirmative that robotic operation is the results of science and technology development, and it is the direction of future development. With the expiration of patent right of Da Vinci robotic system, there will be more kinds of robotic surgical systems which will lead to the much lower operation expense and the widespread use. The young surgeons should master the laparoscopic TME, which will help them master robotic TME technique quickly.

Objective: To evaluate the efficacy of extralevator abdominoperineal excision (ELAPE) of rectal cancer., Methods: PubMed, Cochrane Library and Embase database were searched for clinical studies comparing the ELAPE and abdominoperineal excision (APE) for rectal cancer between 2007 and 2016. Two reviewers independently screened the articles and extracted the data. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the observational studies and the score more than 5 points was the inclusion criteria. Cochrane Handbook for Systematic Reviews of Interventions v5.1.0 was used to evaluate the quality of the randomized controlled trials (RCT). Intra-operative perforation rate, circumferential resection margin (CRM) involvement, local recurrence rate, perineal wound complications were brought into meta-analysis by Review Manager 5.3 software., Results: A total of 556 articles were retrieved and 12 articles were enrolled finally, including 11 observational studies and 1 RCT study. All the 12 articles were high quality (scores of all observational studies were more than 11 points, RCT study accorded with 6 criteria of the quality evaluation). A total of 3 788 patients were enrolled, including 2 141 cases of ELAPE and 1 647 cases of APE. Meta-analysis revealed that intra-operative perforation rate of ELAPE was lower than APE (RR=0.52, 95%CI:0.34-0.79, P=0.002). There were no significant differences between two groups in CRM involvement (RR=0.72, 95%CI:0.49-1.07, P=0.10), local recurrence rate (OR=0.55, 95%CI:0.24-1.29, P=0.17) and perineal wound complications (RR=0.94, 95%CI:0.58-1.53, P=0.800)., Conclusions: Compared with APE, ELAPE reduces the intra-operative perforation rate, and does not increase the perineal wound complications, but it has no advantages in decreasing the CRM involvement and local recurrence rate.

The efficacy of laparoscopic total mesorectum excision (TME) has been confirmed by many clinical trials and guidelines. But two issues on laparoscopic TME are still questioned, including the integrity of specimen membrane of TME and the incidence of postoperative sexual dysfunction. According to my experiences and the primary results of the multicenter clinical trial (LASRE, clinicaltrials.gov identifier: NCT01899547) conducted by me, the integrity of the specimen membrane of laparoscopic TME is not inferior to the open TME. With the further understanding of surgical membrane anatomy, the quality of surgical specimen after laparoscopic TME could be improved, and the incidence of postoperative sexual dysfunction could be lowered. With the combination of my laparoscopic experiences and the theory of surgical membrane anatomy, this article introduces the peri-rectal space dissection during TME and its relationship with the membrane anatomy for reference. It suggests that laparoscopic TME should be performed with the guidelines of surgical membrane anatomy: (1) To cut membrane bridge of left para-rectal furrow and enter left retroperitoneal space; (2) Along the autonomic nerve, to separate retrorectal space first, then rectal front space, and bilateral rectal space finally; (3) To cut anterior lobe of Denonvilliers fascia using U shape 0.5 to 1 cm away from the bottom of seminal vesicle, if existence of tumor invasion in fascia, to separate downward in front; (4) To separate mesorectum to the edge of hiatus of levator ani muscle and then bare.

Objective: To compare the short-term efficacy of laparoscopic and open transabdominal intersphincteric resection (ISR) for low rectal cancer., Methods: Clinicopathological data of 246 patients with low rectal cancer undergoing transabdominal ISR in our department from January 2005 to January 2015 were retrospectively analyzed. According to gender, age, ASA score, neoadjuvant chemoradiotherapy or not, pathological T stage, pathologic N stage, and tumor differentiation, propensity score matching was performed by R plug-in(version 2.8.1). Finally, 74 cases treated by laparoscopic transabdominal ISR(laparoscopic group) and 74 cases by open transabdominal ISR(open group) were enrolled. Short-term efficacy and anal function were compared between two groups., Results: No perioperative death was found in the two groups. Compared to open group, laparoscopic group had longer operation time [(236±45) minutes vs. (200±46) minutes, P=0.000], less median blood loss [50(10 to 200) ml vs. 100(20 to 400) ml, P=0.000] and shorter hospital stay [(7.8±2.4) days vs. (10.5±6.9) days, P=0.002]. Laparoscopic group and open group had similar morbidity of total complication [17.6%(13/74) vs. 28.4%(21/74), P=0.118]. Incidence of pneumonia was significantly lower in laparoscopic group [4.1%(3/74) vs. 13.5%(10/74), P=0.042), while incidence of anastomotic leakage and stenosis, and complication grading were not significantly different between the two groups (all P>0.05). During a mean follow-up of 52.0 months, anal function analysis was performed in 102 patients with stoma closure and the result showed that the ratio of patients with good continence was 87.1%(54/62) and 87.5%(35/40) in laparoscopic and open group respectively (P=0.066)., Conclusion: Laparoscopic transabdominal ISR is safe and feasible, which is minimally invasive with fast recovery, and is worth clinical application.

Objective: To explore the risk factors and clinical features of delayed anastomotic fistula (DAF) following sphincter-preserving operation for rectal cancer., Methods: Clinical data of 1 594 patients with rectal cancer undergoing sphincter-preserving operation in our department from January 2008 to May 2015 based on the prospective database of Dpartment of Colorectal Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. Sixty patients(3.8%) developed anastomotic fistula. Forty-one patients (2.6%) developed early anastomotic fistula (EAF) within 30 days after surgery while 19(1.2%) were DAF that occurred beyond 30 days. Univariate analyses were performed to compare the clinical features between EAF and DAF group., Results: DAF was diagnosed at a median time of 194(30-327) days after anastomosis. As compared to EAF group, DAF group had lower tumor site [(6.1±2.3) cm vs. (7.8±2.8) cm, P=0.023], lower anastomosis site [(3.6±1.8) cm vs. (4.8±1.6) cm, P=0.008], higher ratio of patients receiving neoadjuvant chemoradiotherapy (84.2% vs. 34.1%, P=0.000), and receiving preventive stoma (73.7% vs. 14.6%, P=0.000). According to ISREC grading system for anastomotic fistula, DAF patients were grade A and B, while EAF cases were grade B and C(P=0.000). During the first hospital stay for anastomosis, DAF group did not have abdominal pain, general malaise, drainage abnormalities, peritonitis but 8 cases(42.1%) had fever more than 38centi-degree. In EAF group, 29 patients(70.7%) had abdominal pain and general malaise, and 29(70.7%) had drainage abnormalities. General or circumscribed peritonitis were developed in 25(61.0%) EAF patients, and fever occurred in 39(95.1%) EAF cases. There were 13(68.4%) cases with sinus or fistula formation and 9(47.4%) with rectovaginal fistula in DAF group, in contrast to 5 (12.2%) and 5 (12.2%) in EAF group respectively. In DAF group, 5 (26.3%) patients received follow-up due to stoma (no closure), 5 (26.3%) received bedside surgical drainage, while 9(47.4%) patients underwent operation, including diverting stoma in 3 patients, Hartmann procedure in 1 case, intersphincteric resection, coloanal anastomosis plus ileostomy in 1case because of pelvic fibrosis and stenosis of neorectum after radiotherapy, mucosal advancement flap repair with a cellular matrix interposition in 3 rectovaginal fistula cases, incision of sinus via the anus in 1 case. During a median follow-up of 28 months, 14(73.7%) DAF patients were cured., Conclusions: It is advisable to be cautious that patients with lower site of tumor and anastomosis, neoadjuvant chemoradiotherapy and preventive stoma are at risk of DAF. DAF is clinically silent and most patients can be cured by effective surgical treatment.

Objective: To clarify the natural course and explore impact factors of distant metastasis in rectal cancer patients who received total mesorectal excision(TME) following neoadjuvant chemoradiotherapy (CRT)., Methods: Between Januray 2008 and December 2013, 317 patients with locally advanced rectal cancer who underwent radical surgical resection following neoadjuvant CRT (pre- and postoperative simple fluorouracil or fluorouracil combined with oxaliplatin plus preoperative three dimensional conformal radiotherapy) at Department of Colorectal Surgery in Fujian Medical University Union Hospital were included. Univariate analysis and Cox regression were performed to evaluate the clinicopathological parameters that may be associated with distant metastasis., Results: During a median follow-up of 39 months(range 15 - 89 months), 72 patients(22.7%) had disease recurrence, including local recurrence in 8 patients, and distant metastasis in 67 patients (among whom 3 patients had both). Distant metastasis occurred in 86.5%(58/67) patients during the first three years after surgery. The 3-year cumulative distant metastatic rate in all the patients was 22.4%. The 5-year overall survival rate in distant metastatic patient was significantly lower than that of non-distant metastatic patients following neoadjuvant CRT (36.2% vs. 81.2%, P=0.000). Univariate analysis showed that ypT stage (χ(2)=13.304, P=0.010), ypN stage(χ(2)=23.416, P=0.000), ypTNM stage (χ(2)=31.765, P=0.000) and RCRG(χ(2)=16.246, P=0.000) were associated with distant metastasis. Cox regression revealed that ypTNM stage(HR=1.959, 95% CI:1.171 ~ 3.277, P=0.010) was the only independent risk factor of distant metastasis., Conclusions: Distant metastasis is the early event during the progression in rectal cancer. ypTNM stage is the only independent risk factor of distant metastasis in locally advanced rectal cancer patients who undergo TME following neoadjuvant CRT.

Harmonic scalpel is an important instrument for laparoscopic surgery, and it can be used for dissection and hemostasis. During the procedure of laparoscopic surgery for colorectal tumor, surgeons can use Harmonic scalpel to identify the surgical plane around the mesorectum and mesocolon. We summarized technical points based on our own 15-year experiences of harmonic scalpel use in laparoscopic surgery for colorectal surgery, and extracts them into five words, which are 'shave, poke, cut, peel and push'. These skills are described in combination of the illustrations and videos in this article.

Objective: To introduce the diagnosis and the treatment of the long-segment bowel stenosis above the anastomosis and bowel obstruction caused by the radiation-induced pelvic wall and bowel fibrosis., Methods: Between January 2008 and June 2014, 468 patients with rectal carcinoma underwent sphincter-preserving operation after neoadjuvant chemoradiotherapy in Fujian Medical University Union Hospital. Among 241 patients without postoperative anastomotic leakage, anastomosis stenosis, local recurrence and small bowel obstruction, severe pelvic and bowel fibrosis with obstruction during follow-up was found in 14 patients(SFO group). Associated data of these 14 patients were retrospectively collected. Clinical and image characteristics, and treatment outcomes of these 14 patients were analyzed and compared to those of other 227 patients without fibrosis and obstruction (control group)., Results: Compared to control group, SFO group had lower BMI(19.7±2.3 vs. 22.5±3.2, P=0.000), higher ratio of male (92.9% vs. 63.9%, P=0.039) and smoking patients(78.6% vs. 32.2%, P=0.001), shorter preoperative distance from lower edge of tumor to anal verge [(4.9±0.7) cm vs. (5.7±1.4) cm, P=0.043), and longer time from the end of radiation to operation [(9.4±2.3) week vs. (8.1±1.7) week, P=0.024). The largest thickness of the bilateral obturator internus increased significantly after chemoradiotherapy (left side: P=0.030, right side: P=0.020) as compared to pre-chemoradiotherapy on MR image. Patients of SFO group received corresponding treatments according to the status of bowel stricture, and the outcomes were all satisfactory., Conclusions: Reconstructed rectum stricture can be caused by the radiation-induced fibrosis of pelvic wall soft tissue and proximal colon. Severe stricture can be treated with corresponding methods to relieve symptoms.

Objective: To investigate the influence of anastomotic leakage (AL) on long-term survival after resection for rectal cancer., Methods: Clinicopathological data of 653 rectal cancer cases confirmed by pathology and undergoing R0 resection for rectal cancer in our department from January 2007 to December 2011 were retrospectively analyzed. Anastomotic leakage was found in 40 cases (AL group) and not in the other 613 cases (non-AL group). After median 47 (1-91) months of follow-up, 5-year disease-free survival rate, distant metastasis rate and local recurrence rate were compared between the two groups. Risk factors affecting long-term prognosis were also analyzed., Results: The 5-year disease-free survival rate, 5-year distant metastasis rate, and 5-year local recurrence rate were 78.1%, 14.2% and 4.2% in the non-AL group, and 74.5%, 20.1% and 8.4% in the AL group respectively, and the differences were not statistically significant (P=0.808, P=0.965, P=0.309). Multivariate analysis showed that preoperative neoadjuvant radiochemotherapy, TNM staging, abnormal CA199, preoperative low level of albumin were independent prognostic factors of rectal cancer patients after R0 resection, while AL was not an independent factor of 5-year disease-free survival (P=0.910). Further multivariate analysis on 507 cases receiving postoperative adjuvant chemotherapy also revealed that AL was not an independent factor of 5-year disease-free survival (P>0.05). Percentage difference of patients finishing postoperative chemotherapy between the two groups was not statistically significant (79.4% vs. 76.3%, P=0.681)., Conclusion: AL is not an independent predictor of long-term survival for rectal cancer.

Currently, the safety and efficiency of laparoscopic surgery for rectal cancer have been confirmed by large amount of evidences. Laparoscopic surgery has been commonly applied in the treatment for low rectal cancer. Sphincter preservation is a highly concerning issue for patients and surgeons during rectal cancer surgery. Sphincter-preserving surgery should be based on the R0 resection. The article reviews the application of laparoscopic surgery for low rectal cancer and the choice of operations for sphincter-preserving surgery.

Objective: To evaluate the efficacy and safety of covered self-expanding metallic stents (CSEMS) implantation as a treatment option in patients with anastomotic leakages after colorectal cancer surgery., Methods: Short-term outcomes of 12 patients with anastomotic leakage after colorectal cancer surgery undergoing CSEMS implantation between May 2013 and November 2014 were analyzed retrospectively., Results: The mean time to diagnosis of anastomotic leakage was 6.3 days (range 2-13). The median time of CSEMS implantation after anastomotic leakage was 8 days (range 2-55). Clinical success without reoperation was achieved in 10 of 12 cases (83.3%) and there was no mortality. The median time to healing of the anastomotic leakage after CSEMS implantation was 13 days (range 10-33). The complications were stent migration (66.7%, 8/12), anorectal pain (58.3%, 7/12), fecal incontinence (25.0%, 3/12) and enterocolic fistula (8.3%, 1/12)., Conclusion: Stent implantation one week after relief of peritonitis of postoperative colorectal anastomotic leakages, combined with other conservative therapy (early indwelling of transanal double catheterization cannula and pelvic double catheterization cannula with persistent bathe and negative pressure aspiration) in the management of patients with early diagnosed anastomotic leakages is safe and effective.

Objective: To investigate the effect of intestinal resection on hydrogen sulfide (H2S) biosynthesis and interstitial cells of Cajal(ICC) in mice., Methods: After intestinal resection mouse model was established, the activity of MPO in the proximal anastomosis intestinal tissue were detected. Sensitive sulphur electrode assay was applied to measure the H2S level. RT-PCR technique was employed to investigate the mRNA expression of the endogenous H2S biosynthesis enzymes, cystathionine-b-synthase (CBS) and cystathionine-c-lyase (CSE). Immunofluorescence staining was used to detect the expression of c-kit in order to calculate the area of ICC., Results: The mRNA expression of CSE was detected in the small intestine tissue of mice, while no CBS mRNA was found. The mRNA expression of CSE in proximal anastomotic stoma increased in time-dependent manner in the model group. CSE mRNA expression began to increase 1 hour after operation, reached the peak at 6th hour, then decreased gradually, and was similar to the control group at postoperative 24th hour. Compared to the model group, in the intestinal tissues of proximal 3 cm to anastomotic stoma, the mRNA expression of CSE (1.16 ± 0.18 vs. 1.63 ± 0.13, P<0.05), the activity of MPO [(0.54 ± 0.07) U/g vs. (0.83 ± 0.09) U/g, P<0.05], the H2S level [(36.1 ± 6.1) nmol/mg vs. (5.3 ± 5.6) nmol/mg, P<0.05] were significantly reduced in the PPG group. Meanwhile, average percentage of positive ICC area in the PPG groups was significantly higher [(2.26 ± 0.19)% vs. (1.65 ± 0.24)%, P<0.05]., Conclusions: Inflammatory reaction in muscular layer induced by intestinal resection up-regulates the mRNA expression of CSE proximal to anastomotic stoma, generates excess H2S to damage ICC leading to intestinal motor dysfunction. Preoperative inhibition of endogenous H2S generation may protect the ICC.

Objective: To explore the risk factors of anal function after transabdominal intersphincteric resection(ISR) for low rectal cancer., Methods: Clinical and follow-up data of 96 patients with low rectal cancer who underwent transabdominal ISR in our department from January 2005 to December 2012 were analyzed retrospectively. The Wexner scoring scale was used to evaluate the anal function and the risk factors of anal function were analyzed by the Cox proportional hazard model., Results: Ninety-six patients completed Wexner scoring scale with mean follow-up of 32.7 months. Eighty-three cases(86.5%) presented good continence with a Wexner score less than 10. There was negative correlation between Wexner score and follow-up duration (Pearson coefficient, -0.078, P=0.003). Univariate analysis suggested the distance less than 5 cm from tumor to anal verge(P=0.043), height less than 2 cm from anastomosis to anal verge (P=0.001) and neoadjuvant chemoradiotherapy(P=0.001) were the risk factors. Multivariate analysis revealed that distance less than 2 cm from anastomosis to anal verge(P=0.020) and neoadjuvant chemoradiotherapy(P=0.001) were independent risk factors for fecal incontinence., Conclusions: Most patients have good continence after transabdominal ISR. A distance of less than 2 cm from anastomosis to anal verge and neoadjuvant chemoradiotherapy are independent risk factors for poor anal function after transabdominal ISR.

Objective: To investigate the impact of previous abdominal surgery on short-term outcomes in laparoscopy-assisted radical resection for rectal cancer., Methods: Clinical data of 731 consecutive patients with rectal cancer who underwent laparoscopy-assisted radical resection in Union Hospital from January 2000 to December 2012 were retrospectively analyzed. Patients were classified as having previous abdominal surgery(PAS group, n=121) or not having previous abdominal surgery (NPAS group, n=610). Short-term outcomes including intraoperative and postoperative parameters were compared. Data were analyzed by independent sample t-test, Chi-square test or Fisher's exact probability., Results: The mean number of lymph nodes dissected was 18.8 ± 7.9 in PAS group and 18.9 ± 8.2 in NPAS group, the length of proximal resection margin was (15.0 ± 1.2) cm and (15.1 ± 1.3) cm respectively, the length of distal resection margin was (3.9 ± 1.4) cm and (3.8 ± 1.5) cm respectively. The differences between the two groups were not statistically significant(all P>0.05). Moreover, there were no significant differences in operative time, intraoperative blood loss, intraoperative blood transfusion, sphincter preservation operation rate, conversion rate, time to first flatus, time to liquid intake, postoperative ambulation time, postoperative hospital stay, -and postoperative complication rate between the two groups(all P>0.05). However, postoperative ileus was more frequent in PAS group than that in NPAS group(5.0% vs. 1.5%, P<0.05)., Conclusions: Laparoscopy- assisted radical resection is safe and feasible for patients with rectal cancer who experienced abdominal operations. But the prevention and treatment of postoperative ileus should be handled with caution.

Objective: To explore predictive factors associated with pathologic complete response (pCR) after neoadjuvant chemoradiotherapy for rectal cancer., Methods: Clinicopathological data of 163 patients with locally advanced rectal cancer who were treated with neoadjuvant chemoradiotherapy followed by radical surgical resection from January 2007 to May 2013 were analyzed retrospectively. Univariate analysis and multivariate logistic regression analysis were performed to analyze associated factors of pCR, including age, gender, body mass index (BMI), diabetes, anemia, tumor diameter, distance of the tumor from the anal verge, circumferential extent of the tumor, tumor pathological types, tumor differentiation, pre-chemoradiotherapy T stage, pre-chemoradiotherapy N stage, pre-chemoradiotherapy CEA level, pre-chemoradiotherapy CA199 level, per-operation CEA level, pre-operation CA199 level, radiation dose, chemotherapy modality, time interval from completion of chemoradiotherapy to surgery, etc., Results: Twenty-nine patients(17.8%) achieved pCR after neoadjuvant chemoradiotherapy for rectal cancer. Univariate analysis showed circumferential extent of tumor(≥1/2 cycle)(P=0.018), tumor pathological types(adenocarcinoma)(P=0.036), tumor differentiation (moderate or high)(P=0.021) and pre-chemoradiotherapy CEA level(≤2.5 μg/L)(P=0.007) were significantly correlated with pCR after neoadjuvant chemoradiotherapy for rectal cancer. Logistic regression revealed that circumferential extent of tumor (≥1/2 cycle)(OR=2.901, P=0.020) and pre-chemoradiotherapy CEA level (≤2.5 μg/L)(OR=2.775, P=0.022) were independent predictive factors of pCR after neoadjuvant chemoradiotherapy for rectal cancer., Conclusion: Patients with circumferential extent of tumor ≤1/2 and pre-chemoradiotherapy CEA level ≤2.5 μg/L are more likely to achieve pCR after neoadjuvant chemoradiotherapy for rectal cancer, and these two indices can be used to predict pCR after neoadjuvant chemoradiotherapy for rectal cancer.

It has been reported that the conventional abdominoperineal excision has the disadvantages of higher rates of positive circumferential resection margin and intraoperative bowel perforation, which affect the prognosis. The technique of extralevator abdominoperineal excision proposed by Holm et al is used to overcome these disadvantages. But this new concept of abdominoperineal excision causes other new problems, such as increased complexity, major trauma and more complications. With further studies, the advanced knowledge about the indications, modifications and complications of this technique has been obtained by the domestic and overseas surgeons. This article reviews the characteristics of extralevator abdominoperineal excision and its indications, research progress and major associated complications.

The progress in the idea and technology of rectal cancer improve the rate of sphincter-preservation, while bowel dysfunction is the major problem puzzling patients after sphincter-preserving operation. Recent researches reveal bowel dysfunction is closely associated with the postoperative change of anatomy, nerve damage and sphincter functional injury based on the mechanism of defecation function change through the analysis of anatomy, physiology and dynamics. This paper summarizes the mechanism and epidemiology of bowel dysfunction after rectal cancer operation, and elucidate the role of such mechanism in treatment and prevention of above bowel dysfunction.

Objective: To investigate the associated factors for postoperative ileus following radical resection for colorectal cancer., Methods: Clinical data of 1366 colorectal cancer patients undergoing radical resection by the same surgical team in our hospital from January 2000 to September 2011 were analyzed retrospectively. Univariate analysis and multivariate logistic regression analysis were used to identify the associated factors of postoperative ileus., Results: A total of 70 patients(5.1%) developed postoperative ileus. Univariate and multivariate analyses showed that N2(OR=1.893, 95%CI:1.083-3.306), history of colorectal cancer resection(OR=4.899, 95%CI:1.490-16.110), preoperative obstruction (OR=2.616, 95%CI:1.297-5.280), right hemicolectomy(OR=2.024, 95%CI:1.052-3.894) and left hemicolectomy(OR=3.030, 95%CI:1.401-6.550) were risk factors for postoperative ileus following radical resection for colorectal cancer, while laparoscopic operation(OR=0.520, 95%CI:0.319-0.849) was protective., Conclusions: Postoperative ileus following radical resection for colorectal cancer is associated with surgical procedures. Laparoscopic colorectal resection can reduce the incidence of postoperative ileus.

Objective: To investigate the safety, feasibility, perioperational information and post-operational pathology of the modified abdominal operation of extralevator abdominoperineal excision (ELAPE), meaning transpelvic levator dissection under direct visualization., Methods: From January 2010 to March 2013, 36 patients with rectal tumors(≤5 cm distance to anal verge) underwent extralevator abdominoperineal excision with transpelvic levator dissection by laparoscopic or open surgery, without position change during the perineal operation. The preliminary result of this modified technique was summarized., Results: The levator ani muscles of all the patients were successfully dissected with transpelvic levator dissection and the extent of levator dissection was determined individually according to its involvement. No position was changed during the perineal operation. No conversion to open approach in laparoscopic surgery group was observed, and only 1 case of rectum perforation occurred in open surgery group. The mean operation time was (220.9±36.8) min, and mean intraoperative blood loss was(121.6±99.7) ml. All the specimens had levator ani muscles attached to the mesorectum and positive rate of circumferential resection margin was 5.6%(2/36)., Conclusions: Transpelvic levator dissection simplifies the procedure of ELAPE and achieves individualized dissection of levator. This technique is effective without position change during perineal operation, with shorter operation time and acceptable oncologic outcomes.

Objective: To examine the safety and efficacy of chewing gum in promoting intestinal function recovery after colorectal surgery., Methods: A thorough search of PubMed, Cochrane Library, CNKI, CBM and Wanfang data was performed. Randomized controlled trials(RCTs) about efficacy and safety of chewing gum in promoting intestinal function recovery after colorectal surgery were collected and meta-analysis was carried out with RevMan 5.0 software., Results: Thirteen RCTs including 993 patients were enrolled in this study with 499 patients in the chewing gum group and 494 patients in control group. Meta-analysis revealed that chewing gum could significantly reduce the time to first passage of flatus(MD=-11.66 h, 95%CI:-17.26--6.07, P<0.05), the time to the first defecation (MD=-32.31 h, 95%CI:-56.89--7.73, P<0.05), and postoperative hospital stay(MD=-1.10 d, 95%CI:-1.93--0.27, P<0.05) after colorectal surgery. Patients in chewing gum group also experienced less discomfort from bowel distension(OR=0.52, 95%CI:0.35-0.80, P<0.05) due to postoperative paralytic ileus. No significant difference in the incidence of nausea and vomiting was found., Conclusions: The addition of chewing gum, a well tolerated intervention, to standard treatment may facilitate intestinal recovery and contribute to a shorter hospital stay following colorectal surgery.

Objective: To investigate the efficacy and safety of sunitinib on the management of gastrointestinal stromal tumors (GIST) patients with imatinib resistance., Methods: Clinical data of 48 patients with imatinib-resistant GIST received sunitinib therapy from May 2008 to April 2012 in the Union Hospital of Fujian Medical University were analyzed retrospectively. Eighteen patients received 50 mg/d of sunitinib in a protocol of 4/2 (4 weeks on and 2 weeks off) [50 mg/d (4/2)], and 30 patients received a protocol of 37.5 mg of sunitinib continuous daily dose (37.5 mg/d CDD)., Results: The median duration of sunitinib administration of all the 48 patients was 56 weeks, and the short-term efficacy was evaluated at 24 weeks after the initial treatment according to the Choi criteria. The response rate was 27.1% (13/48), including 1 case with complete response (CR), 12 cases with partial response (PR), and 21 cases with stationary disease (SD). The disease control rate was 70.8% (34/48). The mean follow-up time of 48 patients was 89 weeks. The median progression-free survival (PFS) and overall survival (OS) were 48 weeks and 92 weeks respectively. Stratified analyses indicated that the median PFS of patients previously treated by imatinib 400 mg/d and >400 mg/d were 53 weeks and 35 weeks respectively (P=0.018), and the median OS of these two groups were 157 weeks and 71 weeks respectively (P=0.003). Patients with exon 11 mutations had a significantly shorter OS compared with those with exon 9 mutations (71 weeks vs 157 weeks, P=0.008). Hand-foot syndrome was the most common adverse effect (25/48, 52.1%), followed by nausea (24/48, 50.0%), fatigue (23/48, 47.9%), neutropenia(21/48, 41.7%). The sub-group analysis of two protocols of sunitinib administration showed that the incidence of diarrhea and hand-foot syndrome were higher in 50 mg/d (4/2) group than those in 37.5 mg/d CDD group (P=0.027, P=0.048)., Conclusions: Sunitinib is effective for the patients with imatinib-resistant GIST. After 400 mg/d imatinib treatment failure, sunitinib should be prescribed instead of increased dosage of imatinib. Patients with KIT exon 9 mutations present better prognosis than those with KIT exon 11 mutations. The protocol of sunitinib 37.5 mg/d CDD possesses better safety.

Objective: To compare the incidence of postoperative ileus following laparoscopic and open radical resection for colorectal cancer using meta-analysis., Methods: The Cochrane library, Pubmed, Ovid databases were searched as of October 2011. Two reviewers extracted the data and assessed the methodological quality independently. The homogeneity of studies was evaluated and the meta-analysis was conducted by the Cochrane Collaboration RevMan 5.0 software., Results: Seven studies including 3630 cases were analyzed. A total of 1814 patients received laparoscopic surgery, of whom 58 developed postoperative ileus. There were 1816 cases undergoing open surgery, of whom 105 developed early postoperative ileus. The pooled relative risk was 0.55 with a 95% confidence interval of 0.41-0.76. The difference was statistically significant(P<0.01)., Conclusion: Compared with open surgery, laparoscopic colorectal resection can reduce the incidence of postoperative ileus.

Objective: To compare the postoperative complications following laparoscopic and open colorectal cancer resection., Methods: From January 2000 to September 2011, 910 patients underwent laparoscopic surgery and 434 open surgery. The postoperative complications were compared between the two groups., Results: Forty-eight patients (5.3%, 48/910) in the laparoscopic group were converted to open operation, of whom 36 (75.0%, 36/48) were due to difficulty in procedure and exposure from obesity and narrow pelvis. The overall complication rate was 20.3% (185/910) in the laparoscopic group and 25.3%(110/434) in the open group (χ2=4.316, P<0.05). For patients with a diverting stoma, the anastomotic leak rate was 2.1% (3/145) and 2.2% (2/93) (χ2=0.002, P>0.05), anastomotic bleeding rate was 3.4% (5/145) and 4.3% (4/93) (χ2=0.113, P>0.05). For patients without a diverting stoma, the anastomotic leak rate was 3.1% (22/699) and 1.0% (3/301) (χ2=3.993, P<0.05), anastomotic bleeding rate was 1.6% (11/699) and 2.3% (7/301) (χ2=0.673, P>0.05), bowel obstruction rate was 3.4% (31/910) and 5.8% (25/434) (χ2=4.077, P<0.05), chyle leak rate was 5.8% (53/910) and 3.7% (16/434) (χ2=2.757, P>0.05), urinary retention rate was 1.5% (14/910) and 1.6% (7/434) (χ2=0.011, P>0.05), wound infection rate was 2.2% (20/910) and 4.6% (20/434) (χ2=5.913, P<0.05), pulmonary infection rate was 6.4% (58/910) and 10.6% (46/434) (χ2=7.349, P<0.05)., Conclusion: The overall postoperative complication rate in laparoscopic surgery is significantly lower than that in open surgery.

Objective: To evaluate the safety and feasibility of laparoscopic cylindrical abdominoperineal resection., Methods: Six patients with rectal adenocarcinoma within 3 cm above the anal verge underwent laparoscopic cylindrical abdominoperineal resection. Transabdominal levator transaction was performed laparoscopically, with no position change during the perineal operation. Pelvic reconstruction was achieved using human acellular dermal matrix mesh in 3 patients., Results: All the procedures were successfully performed without any intraoperative complications, laparoscopy-associated complications, or conversion to the open approach. The mean operation time was 186.7 minutes and intraoperative blood loss was 101.7 ml. All the specimens had a cylindrical shape with levator muscles attached to the mesorectum and circumferential margins were all negative. No adverse incidence followed the pelvic reconstruction using human acellular dermal matrix mesh., Conclusions: Laparoscopic transabdominal transection of the levator muscles without position change and pelvic floor reconstruction with human acellular dermal matrix mesh is feasible. This procedure simplifies cylindrical abdominoperineal resection which is aggressively invasive and technically complicated. The oncologic outcomes are acceptable and complications are less.

Chyle leak is a rare complication after abdominal surgery. According to the statistical results from our center, we summarized the experiences in the diagnosis, treatment and prevention of abdominal chyle leak after radical resection of colorectal cancer. Early prevention, early diagnosis, and early treatment may result in earlier recovery, shorter hospital stay, lower incidence, and better prognosis.

Objective: To investigate the incidence, risk factors and preventative methods associated with chyle leak following complete mesocolic excision(CME) for colon cancer., Methods: Clinical data of 592 patients with colon cancer undergoing CME in the department of Colorectal Surgery in the Fujian Medical University Union Hospital from September 2000 to September 2011 were analyzed retrospectively., Results: Chyle leak occurred in 46 patients(7.7%). The incidence of postoperative chyle leak following right CME hemicolectomy was 13.3%(30/226), significantly higher than that after left CME hemicolectomy (4.4%). On univariate analysis, chyle leak following CME was associated with tumor size(P<0.05), tumor location(P<0.01), and lymph nodes harvested(P<0.01). Multivariate logistic regression revealed that tumor location and lymph nodes harvested were independent risk factors associated with chyle leak following CME(P<0.05)., Conclusions: Tumor location and lymph nodes harvested are independent risk factors for chyle leak following complete mesocolic excision for colon cancer. When the drainage output suddenly increases after oral intake resumption, the chyle test of ascitic fluid should be performed for early diagnosis and prompt management.

Objective: To explore the differences in long-term outcomes between laparoscopic and open complete mesocolic excision(CME) for colon cancer., Methods: A total of 273 patients with colon cancer who underwent CME at the Fujian Medical University Union Hospital from September 2000 to December 2008 were divided into laparoscopic(LP, n=147) and open(OP, n=126) groups in a non-random manner. The oncologic and long-term outcomes were compared., Results: No significant differences were seen in the length of distal and proximal margin, and number of lymph nodes(all P>0.05). Median postoperative follow up was 50 months. Local regional recurrence rates (LP 6.1% vs. OP 7.9%) and distal metastasis rates(LP 23.8% vs. OP 16.7%) were similar between the two groups(all P>0.05). The 5-year overall survival rates (LP 69.4% vs. OP 74.0%, P=0.840) and 5-year disease-free survival rates(LP 68.5% vs. OP 70.9%, P=0.668) between the two groups were not statistically different., Conclusions: Laparoscopic CME has the same oncologic clearance effects compared with open CME for colon cancer. It might become a new standardized surgery for colon cancer.

Objective: To investigate the treatment of chyle leak following radical resection for colorectal cancer., Methods: The incidence of chyle leak was compared between the different surgical approaches (open vs. laparoscopic) as well as different tumor locations (right, left colon or rectum) in 1259 patients undergoing radical resection for colorectal cancer., Results: Overall incidence of chyle leak was 3.6% (46/1259) after surgery. Forty-five patients were successfully managed by conservative treatment and one patient required re-operation. No patients died. The incidence of chyle leak was not significantly different between the open (3.2%, 18/570) and laparoscopic (4.1%, 28/689) groups (P>0.05). However, right colectomy was associated with a significantly higher rate of chyle leak (9.6%, 16/167) as compared to left colectomy(2.6%, 7/268) and anterior resection (2.8%, 23/824) (P<0.05)., Conclusions: Conservative treatment is effective in early stage of chyle leak after radical resection for colorectal cancer. Right colectomy is associated with higher risk for chyle leak.

Objective: To compare the clinical efficacy of postoperative intraperitoneal chemotherapy combined with systemic chemotherapy to systemic chemotherapy alone for serosa-involved colorectal cancer., Methods: According to the criteria of serosa-involving in colorectal cancer, 332 cases were divided into 2 groups prospectively without randomization. Study group(n=166) was treated with intraperitoneal chemotherapy combined with systemic chemotherapy, and control group(n=166) with systemic chemotherapy alone. Incidence of local recurrence, peritoneal metastasis, hepatic metastasis, other distant metastasis and 3-year, 5-year overall survival(OS) rate of two groups were compared., Results: 3-year and 5-year OS rates of stage II(B in study group were similar to those in control group(chi(2)=0.612,P=0.434). The above rates of stage III( in study group were higher than those in control group(chi(2)=3.989,P=0.046). Either the study group or the control group, the 3-year and 5-year OS rates of patients undergone laparoscopic surgery or open surgery were similar(P=0.839, P=0.172). Incidences of local recurrence, peritoneal metastasis and hepatic metastasis in study group were 1.9%,3.8% and 3.8% respectively, lower than those in control group(8.2%,9.5% and 10.1%,P<0.05). Distant metastasis rate in study group was similar to that in control group. In study group, intraperitoneal chemotherapy regimen with Oxaliplatin had lower rates of peritoneal metastasis and hepatic metastasis as compared to that with Cisplatin(0.9% vs 8.8%,P=0.019), while the incidences of local recurrence and other distant metastasis were similar., Conclusions: Postoperative intraperitoneal chemotherapy combined with systemic chemotherapy improves 3-year and 5-year overall survival rates in patients with stage III( serosa-involved colorectal cancer, and decreases local recurrence, peritoneal metastasis and liver metastasis rate, especially when intraperitoneal chemotherapy regimen contains Oxaliplatin. Comparing with open surgery, laparoscopic surgery dose not improve 3-year and 5-year overall survival rates in patients receiving combined chemotherapy or systemic chemotherapy alone.

Objective: To observe the occurrence of anastomotic bleeding following laparoscopic and open radical resection for rectal carcinoma, and to explore its contributing factors., Methods: Two hundred and sixty-three cases of rectal carcinoma undergone radical resection were divided into 2 groups, laparoscopic surgery (LS) group (n=86) and open surgery (OS) group (n=177). According to the different locations of anastomotic stoma and with or without preventive colostomy, the two groups were divided into AR sub-group and LAR/UAR sub-group, colostomy sub-group and non-colostomy sub-group. After analyzing the incidence of anastomotic bleeding in each sub-group, a logistic regression model was established to determine the relationships between anastomotic bleeding and three contributing factors including surgical approaches (LS or OS), location of stoma (AR or LAR/UAR) and preventive colostomy., Results: Anastomotic bleeding occurred on 16 out of 263 patients with radical resection of rectal cancer (6.1%). The rates of anastomotic bleeding in LS group and OS group were 9.3% and 4.5%, in colostomy and non-colostomy were 8.1% and 5.5%, and in AR group and LAR/UAR group were 3.3% and 12.1% respectively, there were no significant differences between them (P>0.05). Comparing the two different surgical approaches (LS vs OS), the coefficient of regression, odd ratio and standard coefficient of regression for LS were 1.319, 3.741 and 0.342 respectively. In comparison of the locations of anastomosis (AR vs LAR/UAR), the three index for LAR/UAR were 2.460, 11.704, and 0.632 respectively. Comparing colostomy with non-colostomy, the three index for colostomy were -1.394, 0.248, and -0.327 respectively., Conclusions: Anastomotic bleeding after radical rectectomy is related to the choice of surgical approach, location of anastomosis and with or without preventive colostomy. Both LS and LAR/UAR are risk factors, and preventive colostomy is a protective factor. Regarding to the significance of three factors, location of anastomosis takes the first place, following by surgical method and with or without preventive colostomy.

Objective: To investigate and compare the incidence rates of postoperative anastomotic leak following laparoscopic (LP) versus open (OP) lower anterior resection for rectal cancer., Methods: Fifty-three cases of LP and 135 cases of OP lower anterior resection with rectal cancer site 5-8 cm away from anal edge were operated by the same surgeon team from Sep. 2000 to Dec. 2005. The differences of postoperative anastomotic leak of protective stomy and non-protective stomy between LP and OP groups were analysed., Results: In LP group, the incidence rates of the postoperative anastomotic leak of protective stomy and non-protective stomy were 4.6% (1/22) and 6.5% (2/31) respectively (P>0.05, chi(2)=0.088). In OP group, the incidence rates were 2.3% (1/43) and 8.7% (8/92) respectively (P>0.05, chi(2)=1.024). No significant difference existed between LP and OP groups with protective stomy (P=0.455), neither did LP and OP groups without protective stomy (P=0.288)., Conclusion: Laparoscopic low anterior resection of rectal cancer is a safe procedure. It doesn't increase the incidence rate of anastomotic leak as compared to traditional open surgery.

Objective: To compare the surgical complication rate between laparoscopic and open radical resection for colorectal cancer., Methods: From September 2000 to December 2005, 491 cases with colorectal cancer were divided into two groups prospectively and nonrandomly,and received radical laparoscopic operation (LP, n=214) and open operation (OP, n=277). The intra- and post-operative complication rate were compared between the two groups., Results: In laparoscopic groups, 14 cases (6.54%,14/214) were converted to open surgery,because of intra-operative complications in 7 cases,obesity or large tumors in 5 cases,narrow- pelvis in one case and retroperitoneal tumor in one case. The intra-operative complication rate was 4.8% (10/207) in LP group and 3.6% (10/277) in OP group (P > 0.05, chi2=0.446). There were no differences in post- operative intestinal obstruction, stoma leak, stoma bleeding, chyle leak, pulmonary infection except incision infection(5.5% vs 14.1%, P< 0.05) between LP and OP groups. The overall postoperative complication rate was 23.5% (47/200) in LP group and 36.8% (102/277) in OP group (P< 0.01, chi2=9.598)., Conclusions: There is no difference in intra-operative complication rate between LP and OP groups,but the post-operative complication rate is significantly lower in LP group than that in OP group.

Objective: To investigate the feasibility of lymphadenectomy with skeletonization in extended right hemicolectomy by hand-assisted laparoscopic surgery (HALS)., Methods: From November 2001 to September 2004, 30 cases with right hemicolonic cancer were divided into two groups, and received laparoscopic or open extended right hemicolectomy plus lymphadenectomy with skeletonization. Clinical data of two groups were compared., Results: The mean operative time were (214.0 +/- 16.5) min and (245.0 +/- 24.6) min (t=2.248, P< 0.05), the mean volumes of intraoperative bleeding (78.4 +/- 24.3) ml and (203.3 +/- 48.5) ml (t=4.927, P< 0.05), the mean time of anal aerofluxus (53.4 +/- 6.7) h and (67.3 +/- 9.7) h (t=2.530, P< 0.05), the mean postoperative hospital stay (11.5 +/- 1.11) d and (17.9 +/- 3.98) d (t=3.413, P< 0.05) respectively in laparoscopic and open operation groups. The mean numbers of N1, N2 and N3 lymph nodes cleared in laparoscopic group were (15.3 +/- 2.6), (5.6 +/- 1.6) and (4.3 +/- 2.2) respectively,while (16.2 +/- 3.3), (5.9 +/- 2.2) and (6.1 +/- 1.5) respectively in open operation group (all P > 0.05). The complication rates were 20.0% (3/15) and 33.3% (5/15) respectively in laparoscopic and open operation groups (chi(2)=0.0227, P > 0.05)., Conclusion: Extended right hemicolectomy plus lymphadenectomy with skeletonization can be perfectly performed by HALS.