BACKGROUND Laparoscopic low anterior resection(LLAR)has become a mainstream surgical method for the treatment of colorectal cancer,which has shown many advantages in the aspects of surgical trauma and postoperative re...BACKGROUND Laparoscopic low anterior resection(LLAR)has become a mainstream surgical method for the treatment of colorectal cancer,which has shown many advantages in the aspects of surgical trauma and postoperative rehabilitation.However,the effect of surgery on patients'left coronary artery and its vascular reconstruction have not been deeply discussed.With the development of medical imaging technology,3D vascular reconstruction has become an effective means to evaluate the curative effect of surgery.AIM To investigate the clinical value of preoperative 3D vascular reconstruction in LLAR of rectal cancer with the left colic artery(LCA)preserved.METHODS A retrospective cohort study was performed to analyze the clinical data of 146 patients who underwent LLAR for rectal cancer with LCA preservation from January to December 2023 in our hospital.All patients underwent LLAR of rectal cancer with the LCA preserved,and the intraoperative and postoperative data were complete.The patients were divided into a reconstruction group(72 patients)and a nonreconstruction group(74 patients)according to whether 3D vascular reconstruction was performed before surgery.The clinical features,operation conditions,complications,pathological results and postoperative recovery of the two groups were collected and compared.RESULTS A total of 146 patients with rectal cancer were included in the study,including 72 patients in the reconstruction group and 74 patients in the nonreconstruction group.There were 47 males and 25 females in the reconstruction group,aged(59.75±6.2)years,with a body mass index(BMI)(24.1±2.2)kg/m^(2),and 51 males and 23 females in the nonreconstruction group,aged(58.77±6.1)years,with a BMI(23.6±2.7)kg/m^(2).There was no significant difference in the baseline data between the two groups(P>0.05).In the submesenteric artery reconstruction group,35 patients were type Ⅰ,25 patients were type Ⅱ,11 patients were type Ⅲ,and 1 patient was type Ⅳ.There were 37 type Ⅰ patients,24 type Ⅱ patients,12 type Ⅲ patients,and 1 type Ⅳ patient in the nonreconstruction group.There was no significant difference in arterial typing between the two groups(P>0.05).The operation time of the reconstruction group was 162.2±10.8 min,and that of the nonreconstruction group was 197.9±19.1 min.Compared with that of the reconstruction group,the operation time of the two groups was shorter,and the difference was statistically significant(t=13.840,P<0.05).The amount of intraoperative blood loss was 30.4±20.0 mL in the reconstruction group and 61.2±26.4 mL in the nonreconstruction group.The amount of blood loss in the reconstruction group was less than that in the control group,and the difference was statistically significant(t=-7.930,P<0.05).The rates of anastomotic leakage(1.4%vs 1.4%,P=0.984),anastomotic hemorrhage(2.8%vs 4.1%,P=0.672),and postoperative hospital stay(6.8±0.7 d vs 7.0±0.7 d,P=0.141)were not significantly different between the two groups.CONCLUSION Preoperative 3D vascular reconstruction technology can shorten the operation time and reduce the amount of intraoperative blood loss.Preoperative 3D vascular reconstruction is recommended to provide an intraoperative reference for laparoscopic low anterior resection with LCA preservation.展开更多
Anastomotic leakage(AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low an...Anastomotic leakage(AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection(LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.展开更多
AIM: To investigate whether transanal natural orifice specimen extraction (NOSE) is a better technique for rectal cancer resection.METHODS: A prospectively designed database of a consecutive series of patients undergo...AIM: To investigate whether transanal natural orifice specimen extraction (NOSE) is a better technique for rectal cancer resection.METHODS: A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classi?cations from March 2011 to February 2012 at the First Affiliated Hospital of Sun Yat-Sen University was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed.RESULTS: None of the patients was converted to laparotomy. Respectively, there were 16 cases in the low anastomosis and five in the ultralow anastomosis groups. Mean age of the patients was 45.4 years, and mean body mass index was 23.1 kg/m2. Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm. Mean operating time was 132 min, and mean intraoperative blood loss was 84 mL. According to the principle of rectal cancer surgery, we performed D2 lymph node dissection in 13 cases and D3 in eight. Mean lymph nodes harvest was 17.8, and the number of positive lymph nodes was 3.4. Median hospital stay was 6.7 d. No serious postoperative complication occurred except for one anastomotic leakage. All patients remained disease free. Mean Wexner score was 3.7 at 11 mo after the operation.CONCLUSION: Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible, safe and oncologically sound. Further studies with long-term outcomes are needed to explore its potential advantages.展开更多
Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity...Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal Plan E for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic Micro Surgery(TEM) and Trans Anal Minimally Invasive Surgery(TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.展开更多
BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to...BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.展开更多
文摘BACKGROUND Laparoscopic low anterior resection(LLAR)has become a mainstream surgical method for the treatment of colorectal cancer,which has shown many advantages in the aspects of surgical trauma and postoperative rehabilitation.However,the effect of surgery on patients'left coronary artery and its vascular reconstruction have not been deeply discussed.With the development of medical imaging technology,3D vascular reconstruction has become an effective means to evaluate the curative effect of surgery.AIM To investigate the clinical value of preoperative 3D vascular reconstruction in LLAR of rectal cancer with the left colic artery(LCA)preserved.METHODS A retrospective cohort study was performed to analyze the clinical data of 146 patients who underwent LLAR for rectal cancer with LCA preservation from January to December 2023 in our hospital.All patients underwent LLAR of rectal cancer with the LCA preserved,and the intraoperative and postoperative data were complete.The patients were divided into a reconstruction group(72 patients)and a nonreconstruction group(74 patients)according to whether 3D vascular reconstruction was performed before surgery.The clinical features,operation conditions,complications,pathological results and postoperative recovery of the two groups were collected and compared.RESULTS A total of 146 patients with rectal cancer were included in the study,including 72 patients in the reconstruction group and 74 patients in the nonreconstruction group.There were 47 males and 25 females in the reconstruction group,aged(59.75±6.2)years,with a body mass index(BMI)(24.1±2.2)kg/m^(2),and 51 males and 23 females in the nonreconstruction group,aged(58.77±6.1)years,with a BMI(23.6±2.7)kg/m^(2).There was no significant difference in the baseline data between the two groups(P>0.05).In the submesenteric artery reconstruction group,35 patients were type Ⅰ,25 patients were type Ⅱ,11 patients were type Ⅲ,and 1 patient was type Ⅳ.There were 37 type Ⅰ patients,24 type Ⅱ patients,12 type Ⅲ patients,and 1 type Ⅳ patient in the nonreconstruction group.There was no significant difference in arterial typing between the two groups(P>0.05).The operation time of the reconstruction group was 162.2±10.8 min,and that of the nonreconstruction group was 197.9±19.1 min.Compared with that of the reconstruction group,the operation time of the two groups was shorter,and the difference was statistically significant(t=13.840,P<0.05).The amount of intraoperative blood loss was 30.4±20.0 mL in the reconstruction group and 61.2±26.4 mL in the nonreconstruction group.The amount of blood loss in the reconstruction group was less than that in the control group,and the difference was statistically significant(t=-7.930,P<0.05).The rates of anastomotic leakage(1.4%vs 1.4%,P=0.984),anastomotic hemorrhage(2.8%vs 4.1%,P=0.672),and postoperative hospital stay(6.8±0.7 d vs 7.0±0.7 d,P=0.141)were not significantly different between the two groups.CONCLUSION Preoperative 3D vascular reconstruction technology can shorten the operation time and reduce the amount of intraoperative blood loss.Preoperative 3D vascular reconstruction is recommended to provide an intraoperative reference for laparoscopic low anterior resection with LCA preservation.
文摘Anastomotic leakage(AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection(LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.
文摘AIM: To investigate whether transanal natural orifice specimen extraction (NOSE) is a better technique for rectal cancer resection.METHODS: A prospectively designed database of a consecutive series of patients undergoing laparoscopic low anterior resection for rectal cancer with various tumor-node-metastasis classi?cations from March 2011 to February 2012 at the First Affiliated Hospital of Sun Yat-Sen University was analyzed. Patient selection for transanal specimen extraction and intracorporeal anastomosis was made on the basis of tumor size and distance of rectal lesions from the anal verge. Demographic data, operative parameters, and postoperative outcomes were assessed.RESULTS: None of the patients was converted to laparotomy. Respectively, there were 16 cases in the low anastomosis and five in the ultralow anastomosis groups. Mean age of the patients was 45.4 years, and mean body mass index was 23.1 kg/m2. Mean distance of the lower edge of the lesion from the anal verge was 8.3 cm. Mean operating time was 132 min, and mean intraoperative blood loss was 84 mL. According to the principle of rectal cancer surgery, we performed D2 lymph node dissection in 13 cases and D3 in eight. Mean lymph nodes harvest was 17.8, and the number of positive lymph nodes was 3.4. Median hospital stay was 6.7 d. No serious postoperative complication occurred except for one anastomotic leakage. All patients remained disease free. Mean Wexner score was 3.7 at 11 mo after the operation.CONCLUSION: Transanal NOSE for total laparoscopic low/ultralow anterior resection is feasible, safe and oncologically sound. Further studies with long-term outcomes are needed to explore its potential advantages.
文摘Low rectal cancer is traditionally treated by abdominoperineal resection. In recent years, several new techniques for the treatment of very low rectal cancer patients aiming to preserve the gastrointestinal continuity and to improve both the oncological as well as the functional outcomes, have been emerged. Literature suggest that when the intersphincteric resection is applied in T1-3 tumors located within 30-35 mm from the anal verge, is technically feasible, safe, with equal oncological outcomes compared to conventional surgery and acceptable quality of life. The Anterior Perineal Plan E for Ultra-low Anterior Resection technique, is not disrupting the sphincters, but carries a high complication rate, while the reports on the oncological and functional outcomes are limited. Transanal Endoscopic Micro Surgery(TEM) and Trans Anal Minimally Invasive Surgery(TAMIS) should represent the treatment of choice for T1 rectal tumors, with specific criteria according to the NCCN guidelines and favorable pathologic features. Alternatively to the standard conventional surgery, neoadjuvant chemo-radiotherapy followed by TEM or TAMIS seems promising for tumors of a local stage T1sm2-3 or T2. Transanal Total Mesorectal Excision should be performed only when a board approved protocol is available by colorectal surgeons with extensive experience in minimally invasive and transanal endoscopic surgery.
基金Shanghai Jiaotong University,No.YG2019QNB24This study was reviewed and approved by Ruijin Hospital Ethics Committee(Approval No.2019-82).
文摘BACKGROUND Multiple linear stapler firings during double stapling technique(DST)after laparoscopic low anterior resection(LAR)are associated with an increased risk of anastomotic leakage(AL).However,it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.AIM To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging(MRI).METHODS We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis,which were randomly divided into a training set(n=260)and testing set(n=68).Binary logistic regression was adopted to create a clinical model using six factors.The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed.Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks.Sensitivity,specificity,accuracy,positive predictive value(PPV),and area under the receiver operating characteristic curve(AUC)was calculated for each model.RESULTS The prevalence of≥3 linear stapler cartridges was 17.7%(58/328).The prevalence of AL was statistically significantly higher in patients with≥3 cartridges compared to those with≤2 cartridges(25.0%vs 11.8%,P=0.018).Preoperative carcinoembryonic antigen level>5 ng/mL(OR=2.11,95%CI 1.08-4.12,P=0.028)and tumor size≥5 cm(OR=3.57,95%CI 1.61-7.89,P=0.002)were recognized as independent risk factors for use of≥3 linear stapler cartridges.Diagnostic performance was better with the integrated model(accuracy=94.1%,PPV=87.5%,and AUC=0.88)compared with the clinical model(accuracy=86.7%,PPV=38.9%,and AUC=0.72)and the image model(accuracy=91.2%,PPV=83.3%,and AUC=0.81).CONCLUSION MRI-based deep learning model can predict the use of≥3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery.This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for≥3 linear stapler cartridges.
