| Part I Clinical Comparison of Total Laparoscopic Internal Anal Sphincter Resection for Rectal Cancer and Combined Abdominal Perineal ResectionObjective: To investigate the feasibility of total laparoscopic resection of the internal anal sphincter for radical resection of rectal cancer.Methods: Patients who underwent total laparoscopic anus sphincter resection of low rectal cancer in our hospital between december 2016 and december 2017 were included in this study using their medical records,while those who underwent joint laparoscopic abdominal perineal resection were selected as the control.The two groups were compared based on the basic surgical situation,a radical cure effect,life quality,survival situation and so on.The ISR group was divided into two subgroups-A(the complete ISR group,n=17),and B(the subtotal ISR group,n=21)-and the anorectal dynamic changes and subjective fecal incontinence scores of patients in the two groups were compared.Results: A total of 79 patients with ultra-low rectal cancer who underwent surgery were recruited for this study,including 38 patients with ISR and 41 patients with APR.There was no significant difference in the baseline between the two groups(P>0.05).Furthermore,there was no significant difference in the perioperative indexes,such as operative time and recovery of postoperative exhaust function(P>0.05),except for blood loss(P<0.05).There was no significant difference in the radical effect of the tumor between the two groups.The quality of life of the patients in the ISR group was significantly better than those in the APR group(P<0.05).Comparing groups A,B in the ISR group,there was a statistically significant difference in anal function(P<0.05),anal function in group B was significantly better than that in group A.The results of survival analysis showed that there were no significant differences between the ISR group and the APR group in 3-year cumulative tumor-free survival rate and overall survival rate(P>0.05).Conclusion: Total laparoscopic internal anal sphincterectomy for patients with ultra-low rectal cancer can significantly improve the postoperative quality of life and has the same radical cure effect as APR,it is a safe and feasible surgical method.ISR patient anal function is association with the length of the excision of the internal sphincter.Part II Analysis Structure of Anterior Sacral Tissue in Low Anterior Rectal Resection Syndrome Patients and Reconstruction of Anterior Mesosacral Rectum with Pedicled Greater Omentum Flap for Prevention of Low Anterior Resection SyndromeObjective: To analyze the anterior sacral structure of patients with low anterior rectal resection syndrome and to explore the causes of anterior resection syndrome;To evaluate the effects of low anterior resection syndrome(LARS)in patients with low rectal cancer by pedicled omentum flap transplantation in changing the postoperative presacral tissue structure.Methods: First,we retrospective analysis 47 patients with low rectal cancer who underwent conventional laparoscopic Dixon surgery(No-MRF reconstruction),and correlation analysis was used to investigate whether Mesorectal Fascia(MRF)and Rectal Compliance(RC)are associated with LARS severity;Secondly,17 Patients with low rectal cancer who underwent pedicled greater omentum skin flap transplantation to reconstruct the anterior mesosacral membrane of the rectum were selected as MRF reconstruction,the LARS score and RC at 12 weeks after stoma withdrawal were compared between the two groups.Results: Correlation analysis indicated,MRF thickness and RC were negatively correlated with LARS severity(P<0.05).The LARS score of MRF reconstruction at 12 weeks was significantly better than that of No-MRF reconstruction(32.97±2.65 vs 26.94±1.52,P<0.05),and the RC of MRF reconstruction was lower(2.72±0.57 vs 3.68±0.39,P<0.05).In addition,MRF reconstruction and No-MRF reconstruction have the same incidence of posto-perative complications(P>0.05).No hemorrhage or necrosis of the greater omentum flap was observed in any of the patients.Conclusion: The change in MRF thickness and the position of the tumor from the dentate line are related to postoperative LARS severity in patients with low rectal cancer.In this study,a pedicled omentum was used to fill the anterior sacral space to reconstruct the perirectal tissue structure,which effectively reduced the postoperative LARS score of the patients.Part III Study on the Lower Margin of Anus-Preserving Surgery for Ultra-low Rectal Cancer Based on Large Pathological SectionsObjective: To investigate the reasonable length of the lower margin of low rectal cancer by means of a large pathological section.Methods: Surgical specimens of patients with ultra-low rectal cancer who underwent total laparoscopic internal anal sphincter resection in our Hospital were collected,and large pathological sections were made.Using the EVOS FL Auto Imaging System(a fluorescence microscopic imaging system),according to the requirements of the project design,the ultra-low rectal cancer pathological lesion area,the adjacent lesion area,the normal tissue area distribution of different cells in the three parts,and various characteristics and the regularity of the cellular structure were analyzed by a professional.CEA expression in the lower margin was detected by an immunohistochemical method.Results: A total of 38 cases of large pathological sections were collected,and the preparation of large pathological sections was completed.The main lesion area showed the structural and morphological changes of typical colorectal adenocarcinoma.The basal cell layer structure was destroyed,and irregular glands of different sizes appeared in the tissue structure,arranged into nests,and presented as a sieve structure.The tumor cells gradually transformed into the peripheral lesion area along the basal cell layer,and the growth of the tumor cells in the peripheral area showed the staggered growth of crab foot without any trace of proliferative compression.The distribution and morphology of the peripheral cells still showed the characteristics of typical diffuse malignant cells.These can be seen in the lesion area(often atypical cells with tumor change markings),in addition to the severe structural damage.It is difficult to observe cancer cells in the peripheral lesion area around the normal tissue area.As the normal tissue structures of extrusion go into the basal cell layer and adjacent tissue,the adjacent lesion area is particularly visible to several abnormal cells and appears to have tumor change but retains the complete structure of gland cells—cells arranged in order and in basic form.Tumor cells are large and often have a squeezing and pushing effect on adjacent cell structures,while the increase in the number of gland cells is not significant.In the samples we collected,large pathological sections indicated that in 38 cases of ultra-low rectal cancer,the peripheral transitional zone was 0.02–1.5 cm.Only one case was 1.5 cm.The rest were less than 1 cm(97.36%,37/38),while33 cases(86.84%,33/38)were less than 0.5 cm,and no “jump metastasis” was found.Immunohistochemical results indicated that 7(46.67%,7/15)of the 15 patients with low rectal cancer were positive for CEA.Conclusion: We believe that for patients with ultra-low rectal cancer,a distal surgical margin greater than 1 cm can guarantee the safety of the operation.Part IV Multivariate Analysis of Pathological Regression after Neoadjuvant Chemoradiotherapy in Locally Advanced Low Rectal Cancer and The Application Value of the “Wait and See” StrategyObjective: Neoadjuvant chemoradiotherapy combined with TME surgery in the treatment of low rectal cancer significantly improved the anal preservation and survival rates of patients,but the efficacy of neoadjuvant chemoradiotherapy alone still exists-different patients have distinct efficacy of the same treatment strategy.This study aims to provide a reference for individualized treatment of patients by exploring factors related to the efficacy of neoadjuvant chemoradiotherapy and the application value of the “wait and watch” strategy in patients with clinical complete response(c CR).Methods: The data were collected from the medical records of our hospital between January 2014 and December 2018: 51 patients with ultra-low position rectal cancer after neoadjuvant chemoradiation(including the Part I of 38 cases)were included in the study.Radiation and chemotherapy after the histo Pathological change were evaluated by using single-factor analysis and logistic regression analysis-the influence factors of rectal cancer after neoadjuvant chemoradiation pathological fade.The c CR and pathological complete response(p CR)coincidence rates were compared to explore the application value of the“wait and see” strategy.Results: A total of 51 patients with low rectal cancer who completed neoadjuvant chemoradiotherapy and TME surgery were recruited for this study,of whom 31 patients(60.78%,31/51)achieved c CR after neoadjuvant therapy,while 16 patients(31.4%,16/51)achieved p CR.Univariate analysis showed that preoperative neoadjuvant concurrent Chemoradiotherapy in patients with locally advanced low rectal cancer was associated with Pathological regression by gender,body mass index,smoking history,drinking history,history of hypertension,diabetes,merge history of intestinal obstruction,pathological type,degree of tumor differentiation,the maximum diameter of the tumor,the tumor of intestinal weeks diameter,distance from the anus,c T staging before radiation and chemotherapy,chemoradiation c N before staging,neutrophils/lymphocytes,CEA,CA199 level before radiation and chemotherapy before chemoradiation,preoperative level of CEA,CA199 levels at the end of the radiation from the preoperative chemotherapy regimens,time interval,and the circumferential cutting edge,but no statistical significance(P>0.05).Age(P=0.025),nerve invasion(P=0.075),and lymphatic invasion(P=0.045)may be related to p CR after neoadjuvant chemotherapy.Logistic regression analysis showed that preoperative neoadjuvant concurrent chemoradiotherapy p PCR in patients with locally advanced low rectal cancer was not associated with age,nerve invasion,lymphatic invasion,CEA before chemoradiotherapy,the time between the last radiotherapy and the operation,the circumference of the tumor in the intestine,or the distance from the tumor to the anal area.Combined with univariate analysis results,age,nerve,and lymphatic invasion were not considered to be related to p CR after neoadjuvant chemoradiotherapy.Conclusions: Age,nerve invasion,and lymphatic invasion may be independent prognostic factors for obtaining p CR in low rectal cancer after neoadjuvant concurrent chemoradiotherapy.Nearly half of c CR patients still failed to reach PCR after neoadjuvant chemoradiotherapy for low rectal cancer,and such patients would not be able to preserve their anus in surgery once tumor recurrence.Therefore,more clinical studies are needed to further verify this conclusion. |
PDF Full Text Request