Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China: a national questionnaire survey

Background Pancreaticoduodenectomy(PD)has been widely applied in general hospitals in China;however,there is still a lack of unified standards for each surgical technique and procedure.This survey is intended to investigate the current status of digestive tract reconstruction after PD in university hospitals in China.Method A cross-sectional survey was conducted among the members of the Young Elite Pancreatic Surgery Club of China by using the Questionnaire for Digestive Tract Reconstruction after Pancreaticoduodenectomy.The questionnaire was disseminated and collected by point-to-point communication via WeChat public platforms.Results A total of 73 valid questionnaires were returned from 65 university hospitals in 28 provincial divisions of China's Mainland.The respondents who performed PD surgery with an annual volume of over 100 cases accounted for 63%.Generally,laparoscopic PD was performed less often than open PD.Child and Whipple reconstructions accounted for 70%and 26%,respectively.The sequence of pancreatoenteric,biliary-enteric,and gastrointestinal reconstruction accounted for 84%of cases.In pancreatoenteric anastomosis,double-layer anastomosis is the most commonly employed type,accounting for approximately 67%,while single-layer anastomosis accounts for 30%.Of the double-layer anastomoses,duct-to-mucosa/dunking(94%/4%)PJ was performed with duct-mucosa using the Blumgart method(39%)and Cattel-Warren(29%),with continuous/interrupted sutures in the inner layer(69%/31%)and continuous/interrupted sutures in the outer layer(53%/23%).In single-layer anastomosis,continuous/interrupted sutures accounted for 41%/45%.In hepatojejunostomy,single-layer/double-layer suture accounted for 79%/4%,and continuous/interrupted suture accounted for 75%/9%.Forty-six percent of the responding units had not applied double-layer biliary-intestinal anastomosis in the last 3 years,75%of the responding surgeons chose the anastomosis method according to bile duct diameter,with absorbable/non-absorbable suture accounting for 86%/12%.PD/pylorus-preserving PD accounted for 79%/11%of GJ cases,the distance between GJ and HJ<30 cm,30-50 cm and>50 cm were 11%,75%,and 14%,respectively.Antecolic/retrocolic GJ accounted for 71%/23%of cases.Twenty-two percent of GJ cases employed Braun anastomosis,while 55%and 19%of GJ cases used linear cutting staplers/tube-type staplers,respectively;60%/14%were reinforced/not reinforced via manual suturing after stapler anastomosis.Manual anastomosis in GJ surgery employed absorbable/non-absorbable sutures(91%/9%).Significant differences in reconstruction techniques were detected between different volumes of PD procedures(<100/year and>100/year),regions with different economic development levels,and between north and south China.Conclusion Digestive tract reconstruction following PD exists heterogeneity in Chinese university hospitals.Corresponding prospective clinical studies are needed to determine the consensus on pancreatic surgery that meets the clinical reality in China.

Colostomy is a simple and effective procedure for severe chronic radiation proctitis

AIM: To assess the efficacy and safety of diverting colostomy in treating severe hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with severe hemorrhagic CRP who were admitted from 2008 to 2014 were enrolled into this study. All CRP patients were diagnosed by a combination of pelvic radiation history, clinical rectal bleeding, and endoscopic findings. Inclusion criteria were CRP patients with refractory bleeding with moderate to severe anemia with a hemoglobin level < 90 g/L. The study group included patients who were treated by diverting colostomy, while the control group included patients who received conservative treatment. The remission of bleeding was defined as complete cessation or only occasional bleeding that needed no further treatment. The primary outcome was bleeding remission at 6 mo after treatment. Quality of life beforetreatment and at follow-up was evaluated according to EORTC QLQ C30. Severe CRP complications were recorded during follow-up.RESULTS: Forty-seven consecutive patients were enrolled, including 22 in the colostomy group and 27 in the conservative treatment group. When compared to conservative treatment, colostomy obtained a higher rate of bleeding remission(94% vs 12%), especially in control of transfusion-dependent bleeding(100% vs 0%), and offered a better control of refractory perianal pain(100% vs 0%), and a lower score of bleeding(P < 0.001) at 6 mo after treatment. At 1 year after treatment, colostomy achieved better remission of both moderate bleeding(100% vs 21.5%, P = 0.002) and severe bleeding(100% vs 0%, P < 0.001), obtained a lower score of bleeding(0.8 vs 2.0, P < 0.001), and achieved obvious elevated hemoglobin levels(P = 0.003), when compared to the conservative treatment group. The quality of life dramatically improved after colostomy, which included global health, function, and symptoms, but it was not improved in the control group. Pathological evaluation after colostomy found diffused chronic inflammation cells, and massive fibrosis collagen depositions under the rectal wall, which revealed potential fibrosis formation. CONCLUSION: Diverting colostomy is a simple, effective and safe procedure for severe hemorrhagic CRP. Colostomy can improve quality of life and reduce serious complications secondary to radiotherapy.

Comparison of efficacy and safety of transpancreatic septotomy, needle-knife fistulotomy or both based on biliary cannulation unintentional pancreatic access and papillary morphology

Background: Precut sphincterotomy has been widely performed to facilitate selective biliary access when standard cannulation attempts failed during endoscopic retrograde cholangiopancreatography(ERCP). However, scarce data are available on different precut techniques for difficult biliary cannulation. This study aimed to evaluate the efficacy and safety of transpancreatic septotomy(TPS), needle-knife fistulotomy(NKF) or both based on the presence of unintentional pancreatic access and papillary morphology. Methods: Between March 2008 and December 2016, 157 consecutive patients undergoing precutting for an inaccessible bile duct during ERCP were identified. Precut techniques were chosen depending on repetitive inadvertent pancreatic cannulation and the papillary morphology. We retrospectively assessed the rates of cannulation success and procedure-related complications among three groups, namely TPS, NKF, and TPS followed by NKF. Results: The baseline characteristics of the three groups were comparable. The overall success rate of biliary cannulation reached 98.1%, including 111 of 113(98.2%) with TPS, 35 of 36(97.2%) with NKF and 8 of 8(100%) with NKF following TPS, without significant difference among groups. The incidences of total complications and post-ERCP pancreatitis were 9.6% and 7.6%, respectively. There was a trend towards less frequent post-ERCP pancreatitis after NKF(0%) compared with 11 cases(9.7%) after TPS and one case(12.5%) after NKF following TPS, but not significantly different( P = 0.07). No severe adverse event occurred during this study period. Conclusions: The choice of precut techniques by the presence of unintended pancreatic access and the papillary morphology brought about a high success rate without increasing risk in difficult biliary cannulation.

Formalin irrigation for hemorrhagic chronic radiation proctitis

AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with CRP who did not respond to previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.RESULTS: Twenty-four patients(19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo(range: 2-24 mo). Six patients(25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score(VRS) was 3 points. Nineteen patients(79.2%) received only one course of topical formalin irrigation, and five(20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in14; the effectiveness rate was 79.1%(19/24). For longterm efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula. CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.

Long-term outcomes of a phase Ⅱ randomized controlled trial comparing intensity-modulated radiotherapy with or without weekly cisplatin for the treatment of locally recurrent nasopharyngeal carcinoma

Background:Salvage treatment for locally recurrent nasopharyngeal carcinoma(NPC) is complicated and relatively limited.Radiotherapy,combined with effective concomitant chemotherapy,may improve clinical treatment outcomes.We conducted a phase Ⅱ randomized controlled trial to evaluate the efficacy of intensity-modulated radiotherapy with concomitant weekly cisplatin on locally recurrent NPC.Methods:Between April 2002 and January 2008,69 patients diagnosed with non-metastatic locally recurrent NPC were randomly assigned to either concomitant chemoradiotherapy group(n = 34) or radiotherapy alone group(n = 35).All patients received intensity-modulated radiotherapy.The radiotherapy dose for both groups was 60 Gy in 27 fractions for 37 days(range 23-53 days).The concomitant chemotherapy schedule was cisplatin 30 mg/m^2 by intravenous infusion weekly during radiotherapy.Results:The median follow-up period of all patients was 35 months(range 2-112 months).Between concomitant chemoradiotherapy and radiotherapy groups,there was only significant difference in the 3-year and 5-year overall survival(OS) rates(68.7%vs.42.2%,P = 0.016 and 41.8%vs.27.5%,P = 0.049,respectively).Subgroup analysis showed that concomitant chemoradiotherapy significantly improved the 5-year OS rate especially for patients in stage rT3-4(33.0%vs.13.2%,P = 0.009),stages Ⅲ-Ⅳ(34.3%vs.13.2%,P = 0.006),recurrence interval >30 months(49.0%vs.20.6%,P = 0.017),and tumor volume >26 cm^3(37.6%vs.0%,P = 0.006).Conclusion:Compared with radiotherapy alone,concomitant chemoradiotherapy can improve OS of the patients with locally recurrent NPC,especially those with advanced T category(rT3-4) and stage(lll-IV) diseases,recurrence intervals >30 months,and tumor volume >26 cm^3.

Risk factors for sporadic colorectal cancer in southern Chinese

AIM:To investigate the role of smoking, alcohol drinking, family history of cancer, and body mass index(BMI) in sporadic colorectal cancer in southern Chinese.METHODS:A hospital-based case-control study was conducted from July 2002 to December 2008.There were 706 cases and 723 controls with their sex and age(within 5 years) matched.An unconditional logistic regression model was used to analyze the association between smoking, alcohol drinking, family history of cancer, BMI and sporadic colorectal cancer.RESULTS:No positive association was observed between smoking status and sporadic colorectal cancer risk.Compared with the non alcohol drinkers, the current and former alcohol drinkers had an increased risk of developing sporadic colorectal cancer(CRC)(adjusted OR = 8.61 and 95% CI = 6.15-12.05;adjusted OR = 2.30, 95% CI = 1.27-4.17).Moreover, the increased risk of developing sporadic CRC was significant in those with a positive family history of cancer(adjusted OR = 1.62, 95% CI = 1.12-3.34) and in those with their BMI ≥ 24.0 kg/m2(adjusted OR = 1.39, 95% CI = 1.10-1.75).Stratification analysis showed that the risk of developing both colon and rectal cancers was increased in current alcohol drinkers(adjusted OR = 7.60 and 95% CI = 5.13-11.25;adjusted OR = 7.52 and 95% CI = 5.13-11.01) and in those with their BMI ≥ 24.0 kg/m2(adjusted OR = 1.38 and 95% CI = 1.04-1.83;adjusted OR = 1.35 and 95% CI = 1.02-1.79).The risk of developing colon cancer, but not rectal cancer, was found in former alcohol drinkers and in those with a positive family history of cancer(adjusted OR = 2.51 and 95% CI = 1.24-5.07;adjusted OR = 1.82 and 95% CI = 1.17-2.82).CONCLUSION:Alcohol drinking, high BMI(≥ 24.0 kg/m2) and positive family history of cancer are the independent risk factors for colorectal cancer in southern Chinese.

A simple taurocholate-induced model of severe acute pancreatitis in rats

AIM: To investigate gut barrier damage and intestinal bacteria translocation in severe acute pancreatitis (SAP), a simple rat model of SAP was induced and studied.METHODS: Pancreatitis was induced by uniformly distributed injection of 3.8% Na taurocholate (1 mL/kg) beneath the pancreatic capsule. Rats in the control group were injected with normal saline in the identical location. RESULTS: Serum amylase, plasma endotoxin, intestinal permeability, and pancreatitis pathology scores were all markedly higher in the pancreatitis group than in the control group (P < 0.01). The bacterial infection rate was signif icantly higher in the SAP group than in the control group (P < 0.01), observed in parallel by both bacterial culture and real-time polymerase chain reaction. Acute damage of the pancreas was observed histologically in SAP rats, showing interstitial edema, leukocyte infiltration, acinar cell necrosis and hemorrhage. The microstructure of the intestinal mucosa of SAP ratsappeared to be destroyed with loose, shortened microvilli and rupture of the intercellular junction, as shown by electron microscopy. CONCLUSION: Significant gut barrier damage and intestinal bacterial translocation were def initely observed with few potential study confounders in this SAP rat model, suggesting that it may be an appropriate animal model for study of gut barrier damage and bacterial translocation in SAP.

Alpha-2-macroglobulin as a radioprotective agent: a review

Radiation is an important modality in cancer treatment, and eighty percent of cancer patients need radiotherapy at some point during their clinical management. However, radiation-induced damage to normal tissues restricts the therapeutic doses of radiation that can be delivered to tumours and thereby limits the effectiveness of the treatment. The use of radioprotectors represents an obvious strategy to obtain better tumour control using a higher dose in radiotherapy. However, most of the synthetic radioprotective compounds studied have shown inadequate clinical efficacy owing to their inherent toxicity and high cost. Hence, the development of radioprotective agents with lower toxicity and an extended window of protection has attracted a great deal of attention, and the identification of alternative agents that are less toxic and highly effective is an absolute necessity. Recent studies have shown that alpha-2-macroglobulin（α2M） possesses radioprotective effects. α2M is a tetrameric, disulfide-rich plasma glycoprotein that functions as a nonselective inhibitor of different types of non-specific proteases and as a carrier of cytokines, growth factors, and hormones. α2M induces protein factors whose interplay underlies radioprotection, which supports the idea that α2M is the central effector of natural radioprotection in the rat. Pretreatment with α2M has also induced a significant reduction of irradiation-induced DNA damage and the complete restoration of liver and body weight. Mihailovi？ et al. concluded that the radioprotection provided by α2M was in part mediated through cytoprotection of new blood cells produced in the bone marrow; these authors also indicated that an important aspect of the radioprotective effect of amifostine was the result of the induction of the endogenous cytoprotective capability of α2M. The radioprotective effects of α2M are possibly due to antioxidant, antifibrosis, and anti-inflammatory functions, as well as the maintenance of homeostasis, and enhancement of the DNA repair and cell recovery processes. This review is the first to summarise the observations and elucidate the possible mechanisms responsible for the beneficial effects of α2M. The lacunae in the existing knowledge and directions for future research are also addressed.

Efficacy of noninvasive evaluations in monitoring inflammatory bowel disease activity: a prospective study in China

AIM To optimize the efficacy of noninvasive evaluations in monitoring the endoscopic activity of inflammatory bowel disease(IBD).METHODS Fecal calprotectin(FC), clinical activity index(CDAI or CAI), C-reactive protein(CRP), erythrocyte sedimentation rate(ESR), and procalcitonin(PCT) were measured for 136 IBD patients. Also, FC was measured in 25 irritable bowel syndrome(IBS) patients that served as controls. Then, endoscopic activity was determined by other two endoscopists for colonic or ileo-colonic Crohn's disease(CICD) with the "simple endoscopic score for Crohn's disease"(SES-CD), CDrelated surgery patients with the Rutgeerts score, and ulcerative colitis(UC) with the Mayo score. The efficacies of these evaluations to predict the endoscopic disease activity were assessed by Mann-Whitney test, χ~2 test, Spearman's correlation, and multiple linear regression analysis.RESULTS The median FC levels in CD, UC, and IBS patients were 449.6(IQR, 137.9-1344.8), 497.9(IQR, 131.7-118.0), and 9.9(IQR, 0-49.7) μg/g, respectively(P < 0.001). For FC, CDAI or CAI, CRP, and ESR differed significantly between endoscopic active and remission in CICD and UC patients, but not in CD-related surgery patients. The SES-CD correlated closely with levels of FC(r = 0.802), followed by CDAI(r = 0.734), CRP(r = 0.658), and ESR(r = 0.557). The Mayo score also correlated significantly with FC(r = 0.837), CAI(r = 0.776), ESR(r = 0.644), and CRP(r = 0.634). For FC, a cut-off value of 250 μg/g indicated endoscopic active inflammation with accuracies of 87.5%, 60%, and 91.1%, respectively, for CICD, CD-related surgery, and UC patients. Moreover, clinical FC activity(CFA) calculated as 0.8 × FC + 4.6 × CDAI showed higher area under the curve(AUC) of 0.962 for CICD and CFA calculated as 0.2 × FC + 50 × CAI showed higher AUC(0.980) for UC patients than the FC. Also, the diagnostic accuracy of FC in identifying patients with mucosal inflammation in clinical remission was reflected by an AUC of 0.91 for CICD and 0.96 for UC patients. CONCLUSION FC is the most promising noninvasive evaluation for monitoring the endoscopic activity of CICD and UC. CFA might be more accurate for IBD activity evaluation.

Enhancement of vitamin A combined vitamin D supplementation on immune response to Bacille Calmette-Guerin vaccine revaccinated in Chinese infants

Objective:To investigate whether there is an association between diameter of bacille CalmetteGuerin(BCG)sears and effect of purified protein derivative(PPD)reaction anil to determine whether vitamin A(VA)combined vitamin I)(VD)supplementation influences the immune response to BCG revueeinated in Chinese infants.Methods:A cross-section and 3-month community-randomised trial was conducted.A total of 5 629 infants at 3,6 and 12 months of age in Junan County of China were examined for BCG scar fonnation.Then,597 revuccinated infants were randomly assigned to supplementation(n=307)and control(n=290)groups.The supplementation group were daily assigned to 1 500 IU VA and 500 IU VD for 3 months.Then all infants were subjected to skin test with PPD.Results:The diameter of BCG sears was positively con-elated with diameter of skin indurations of PPD(r=0.17,P<0.05)in the 5 629 infants.The rate of positive response to PP1)was higher in the supplementation group than in the control group(96.1%versus 89.7%,P<0.05,prevalence ratio 1.07.95%CI 1.02-1.12).The prevalence ralio of PPD response for the supplementation group compared with that for the control group was 1.07(95%CI 1.01-1.13)for the males and 1.08(95%CI 1.00-1.17)for the females.For the supplementation group,the males got larger tuberculin induration than the females[(0.73±0.2l)cm versus(0.67±0.20)cm.P<0.05)after intervention.Conclusions:The diameter of BCG scars was effectively correlated with PPD response,which indicates BCG scar formation may be an useful tool Io evaluate the effect of tuberculosis prevention.VA combined VD supplementation may play an immunoregulatory rale in BCG revuecination.This may contribute to the prevention of childhood tuberculosis.

In vitro and In vivo Evaluation of the Developed PLGA/HAp/Zein Scaffolds for Bone-Cartilage Interface Regeneration

Objective To investigate the effect of electronspun PLGA/HAp/Zein scaffolds on the repair of cartilage defects. Methods The PLGA/HAp/Zein composite scaffolds were fabricated by electrospinning method. The physiochemical properties and biocompatibility of the scaffolds were separately characterized by scanning electron microscope （SEM）, transmission electron microscope （TEM）, and fourier transform infrared spectroscopy （FTIR）, human umbilical cord mesenchymal stem cells （hUC-MSCs） culture and animal experiments. Results The prepared PLGA/HAp/Zein scaffolds showed fibrous structure with homogenous distribution, hUC-MSCs could attach to and grow well on PLGA/HAp/Zein scaffolds, and there was no significant difference between cell proliferation on scaffolds and that without scaffolds （P〉0.05）. The PLGA/HAp/Zein scaffolds possessed excellent ability to promote in vivo cartilage formation. Moreover, there was a large amount of immature chondrocytes and matrix with cartilage lacuna on PLGA/HAp/Zein scaffolds. Conclusion The data suggest that the PLGA/HAp/Zein scaffolds possess good biocompatibility, which are anticipated to be potentially applied in cartilage tissue engineering and reconstruction.

A nomogram to predict prognosis for gastric cancer with peritoneal dissemination

Objective： To identify independent prognostic factors to be included in a nomogram to predict the prognosis ofgastric cancer patients with peritoneal dissemination.Methods： This is a retrospective study on 684 patients with a histological diagnosis of gastric cancer withperitoneal dissemination from the Sun Yat-sen University Cancer Center as the development set, and 62 gastriccancer patients from the Sixth Affiliated Hospital of Sun Yat-sen University as the validation group. Chi-square testand Cox regression analysis were used to compare the clinicopathological variables and the prognosis of gastriccancer patients with peritoneal dissemination. The Harrell＇s concordance index （C-index） and calibration curvewere determined for comparisons of predictive ability of the nomogram.Results： Univariate and multivariate analyses showed that serum carcinoembryonic antigen （CEA） level（P=0.032）, ascites grading （P=0.008）, presence of extraperitoneal metastasis （P〈0.001）, seeding status （P=0.016） andperformance status （P=0.009） were independent prognostic factors for gastric cancer patients with peritonealdissemination in the development set. The nomogram model was constructed using these five factors. Internalvalidation showed that the C-index of the model was 0.641. For the external validation, the C-index of this modelwas 0.709.Conclusions： We developed and validated a nomogram to predict the prognosis for gastric cancer patients withperitoneal dissemination. This nomogram may play an important clinical role in guiding palliative therapy for thesetypes of patients, although it may need more data for optimization.

Stapled transperineal repair for low-and mid-level rectovaginal fistulas:A 5-year experience and comparison with sutured repair

BACKGROUND Currently,rectovaginal fistula(RVF)continues to be a surgical challenge worldwide,with a relatively low healing rate.Unclosed intermittent suture and poor suture materials may be the main reasons for this.AIM To evaluate the efficacy and safety of stapled transperineal repair in treating RVF.METHODS This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University(Guangzhou,China).Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included.Among the 82 total patients,37 underwent repair with direct suturing and 45 underwent repair with stapling.Patient demographic data,Wexner faecal incontinence score,and operative data were analyzed.Recurrence rate and associated risk factors were assessed.RESULTS The direct suture and stapled repair groups showed similar clinical characteristics for aetiology,surgical history,fistula features,and perioperative Wexner score.The stapled repair group did not show superior results over the suture repair group in regard to operative time,blood loss,and hospital stay.However,the stapled repair group showed better postoperative Wexner score(1.04±1.89 vs 2.73±3.75,P=0.021),less intercourse pain(1/45 vs 17/37,P=0.045),and lower recurrence rate(6/45 vs 17/37,P=0.001).There was no protective effect from previous repair history,smaller diameter of fistula(<0.5 cm),better control of defecation(Wexner<10),or stapled repair.Direct suture repair and preoperative high Wexner score(>10)were risk factors for fistula recurrence.Furthermore,stapled repair gave better efficacy in treating complex RVFs(i.e.,multiple transperineal repair history,mid-level fistula position,and poor control of defecation).CONCLUSION Stapled transperineal repair is advantageous for management of RVF,providing a high primary healing rate and low recurrence rate.

Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth Ⅱ gastrectomy patients

Background： Endoscopic papillary balloon dilation （EPBD） for common bile duct （CBD） stones removal in Billroth II gastrectomy patients is feasible. However, the long-term outcomes of this technique are notclear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth II gastrectomy patients.

PhaseⅡstudy of oxaliplatin combined with S-1 and leucovorin(SOL)for Chinese patients with metastatic colorectal cancer

Background:Fluoropyrimidine and oxaliplatin are widely used for patients with colorectal cancer.This phase II study was conducted to evaluate the efficacy and safety of the combination of S-1,oxaliplatin,and leucovorin(SOL) in the treatment of Chinese patients with metastatic colorectal cancer(mCRC).Methods:Eligible patients with untreated mCRC from four hospitals in China received intravenous oxaliplatin(85 mg/m2) on day 1,oral S-1 twice daily(80-120 mg per day) on day 1-7,and leucovorin twice daily(50 mg per day)simultaneously with S-1,every 2 weeks.Results and discussion:Forty patients were enrolled in our study.In total,296 cycles of SOL were administered.The overall response rate was 50.0%.At a median follow-up of 27 months,progression-free survival and overall surviva were 7.0 months(95%confidence interval[CI]6.0-10.6 months) and 22.2 months(95%CI 15.1-29.3 months),respectively.The most common grade 3/4 non-hematological adverse events were diarrhea(n = 8,20.0%),nausea(n = 3,7.5%),and vomiting(n = 3,7.5%).The most common grade 3/4 hematological toxicities were thrombocytopenia(n = 3,7.5%),neutropenia(n = 1,2.5%),and abnormal alanine transaminase/aspartate transaminase levels(n = 1,2.5%).There was one treatment-related death.Conclusions:The data indicate that the SOL regimen is effective and moderately tolerated in Chinese patients with mCRC.Trial registration:Clinical trial

Expert consensus on maintenance treatment for metastatic colorectal cancer in China

The impact of maintenance therapy on progression-free survival and overall survival as well as quality of life of Chinese patients with metastatic colorectal cancer has long been under discussion.Recently,some phase III clinical trials have revealed that maintenance therapy can significantly prolong the progression-free survival while maintain an acceptable safety profile.Based on this evidence and common treatment practice in China,we now generated one Expert Consensus on Maintenance Treatment for Metastatic Colorectal Cancer in China to further specify the necessity of maintenance therapy,suitable candidates for such treatment,and appropriate regimens.

Diverting colostomy is an effective and reversible option for severe hemorrhagic radiation proctopathy

BACKGROUND Severe chronic radiation proctopathy(CRP) is difficult to treat.AIM To evaluate the efficacy of colostomy and stoma reversal for CRP.METHODS To assess the efficacy of colostomy in CRP,patients with severe hemorrhagic CRP who underwent colostomy or conservative treatment were enrolled.Patients with tumor recurrence,rectal-vaginal fistula or other types of rectal fistulas,or who were lost to follow-up were excluded.Rectal bleeding,hemoglobin(Hb),endoscopic features,endo-ultrasound,rectal manometry,and magnetic resonance imaging findings were recorded.Quality of life before stoma and after closure reversal was scored with questionnaires.Anorectal functions were assessed using the CRP symptom scale,which contains the following items:Watery stool,urgency,perianal pain,tenesmus,rectal bleeding,and fecal/gas incontinence.RESULTS A total of 738 continual CRP patients were screened.After exclusion,14 patients in the colostomy group and 25 in the conservative group were included in the final analysis.Preoperative Hb was only 63 g/L ± 17.8 g/L in the colostomy group compared to 88.2 g/L ± 19.3 g/L(P < 0.001) in the conservative group.All14 patients in the former group achieved complete remission of bleeding,and the colostomy was successfully reversed in 13 of 14(93%),excepting one very old patient.The median duration of stoma was 16(range:9-53) mo.The Hb level increased gradually from 75 g/L at 3 mo,99 g/L at 6 mo,and 107 g/L at 9 mo to111 g/L at 1 year and 117 g/L at 2 years after the stoma,but no bleeding cessation or significant increase in Hb levels was observed in the conservative group.Endoscopic telangiectasia and bleeding were greatly improved.Endoultrasound showed decreased vascularity,and magnetic resonance imaging revealed an increasing presarcal space and thickened rectal wall.Anorectal functions and quality of life were significantly improved after stoma reversal,when compared to those before stoma creation.CONCLUSION Diverting colostomy is a very effective method in the remission of refractory hemorrhagic CRP.Stoma can be reversed,and anorectal functions can be recovered after reversal.

Chidamide based combination regimen for treatment of monomorphic epitheliotropic intestinal T cell lymphoma following radical operation:Two case reports

BACKGROUND Monomorphic epitheliotropic intestinal T cell lymphoma(MEITL)is a rare extranodal T-cell lymphoma that has uniformly aggressive features with a poor prognosis.No standardized treatment protocols have been established.Previous experience has demonstrated favorable outcomes with combination chemotherapy followed by autologous hematopoietic stem cell transplant.However,many patients are unable to tolerate the toxicities.Chidamide is a new histone deacetylase inhibitor that has shown preferential efficacy in mature T-cell lymphoma.CASE SUMMARY We herein present two cases of MEITL who were both intermediate risk according to enteropathy-associated T cell lymphoma prognostic index.Case one was a 61-year-old man.He complained of upper abdominal pain and intermittent black stool for 2 mo.Imaging examination revealed that the intestinal wall was thickened.He received a partial excision of the small intestine.A chidamidebased combination regimen was given postoperatively.Eleven months later,he presented with recurrence in the bilateral lungs.He passed away 15 mo after his diagnosis.Case two was a 35-year-old woman who complained of abdominal distention for 1 mo.Positron emission tomography/computed tomography demonstrated wall thickening of the small intestine and upper sigmoid colon.Colon perforation and septic shock occurred on the fourth day of her admission.She was treated by sigmoid colostomy.Chidamide-based combination therapy was then provided.She was recurrence-free for 6 mo until lesions were found in the bilateral brain and lived for 17 mo since her diagnosis.Compared to historical data,chidamide seems to improve the prognosis of MEITL slightly.CONCLUSION MEITL is a type of aggressive lymphoma.Chidamide is a new promising approach for the treatment of MEITL.

Pilot study on efficacy of reduced cathartic bowel preparation with polyethylene glycol and bisacodyl

AIM:To evaluate the efficacy of reduced cathartic bowel preparation with 2 L polyethylene glycol(PEG)-4000 electrolyte solution and 10 mg bisacodyl enteric-coated tablets for computed tomographic colonography(CTC).METHODS:Sixty subjects who gave informed consent were randomly assigned to study group A,study group B or the control group.On the day prior to CTC,subjects in study group A were given 20 mL 40% wt/vol barium sulfate suspension before 3 mealtimes,60 mL 60% diatrizoate meglumine diluted in 250 mL water after supper,and 10 mg bisacodyl enteric-coated tablets 1 h before oral administration of 2 L PEG-4000 electrolyte solution.Subjects in study group B were treated identically to those in study group A,with the exception of bisacodyl which was given 1 h after oral PEG-4000.Subjects in the control group were managed using the same strategy as the subjects in study group A,but without administration of bisacodyl.Residual stool and fluid scores,the attenuation value of residual fluid,and discomfort during bowel preparation in the three groups were analyzed statistically.RESULTS:The mean scores for residual stool and fluid in study group A were lower than those in study group B,but the differences were not statistically significant.Subjects in study group A showed greater stool and fluid cleansing ability than the subjects in study group B.The mean scores for residual stool and fluid in study groups A and B were lower than those in the control group,and were significantly different.There was no significant difference in the mean attenuation value of residual fluid between study group A,study group B and the control group.The total discomfort index during bowel preparation was 46,45 and 45 in the three groups,respectively,with no significant difference.CONCLUSION:Administration of 10 mg bisacodyl enteric-coated tablets prior to or after oral administration of 2 L PEG-4000 electrolyte solution enhances stool and fluid cleansing ability,and has no impact on the attenuation value of residual fluid or the discomfort index.The former is an excellent alternative for CTC colorectum

Modified frontolateral partial laryngectomy operation: combined muscle-pedicle hyoid bone and thyrohyoid membrane flap in laryngeal reconstruction

Objective: Laryngeal reconstruction is needed to preserve laryngeal function in patients who have undergone extensive vertical or frontal partial laryngectomy. However, the procedure remains a difficult challenge. Several reconstruction techniques have been described, but these techniques pose risks of complications such as laryngeal stenosis. This study aimed to evaluate the postoperative course and functional outcomes of a new technique that combined a muscle-pedicle hyoid bone and a thyrohyoid flap during laryngeal reconstruction after tumor resection. Methods: Four patients underwent extensive vertical partial or frontal partial laryngectomy for cancer. After tumor resection, laryngeal reconstruction was performed using the proposed technique. Postoperative recovery time, complications, and oncologic results were evaluated. Results: The four patients were successfully treated with the proposed technique. No dyspnea, dysphagia, or death occurred during the postoperative course. Decannulation was performed after a median of 3 days. The average postoperative hospital stay was 7 days. Short-term postoperative functional recovery was normal. No laryngeal stenosis or tumor recurrence was observed in any of the four patients after a follow-up period of more than 24 months. Conclusion: The combination of the muscle-pedicle hyoid bone and the thyrohyoid flap is a reliable procedure for laryngeal reconstruction after extensive vertical partial or frontal partial laryngectomy.