直肠癌围手术期辅助治疗的提出缘由是直肠癌发病率和死亡率仍不断上升。全球结、直肠癌发病率平均每年递增2%，在欧美国家其死亡率仍居癌症死亡第二位。我国情况亦相似，以上海为例，发病率每年递增4.2%，比全球平均递增速度还要高。1990～1992年我国十分之一人口的抽样调查显示，结、直肠癌平均调整死亡率为4.54/10万人口，居癌症死亡第五位。而直肠癌在美国占结、直肠癌的40%，在中国占50%以上。更甚的是，直肠癌治疗效果还不够理想，近30多年来提高并不显著。美国癌症协会Cutler统计分析25 000例结、直肠癌资料，其中外科治疗直肠癌5年生存率自1940～1960年由44%提高到50%。英国牛津大学临床试验研究中心收集1960～1987年世界各地所有结、直肠癌临床随机治疗资料共计97组154项研究，包含32 000余例，其中直肠癌3年和5年生存率分别为65.0%和45.1%。迄今，大宗直肠癌病例报告的术后5年生存率都徘徊在50%左右，扩大手术范围生存率提高不多，但随之而来的却是更大的手术损伤、合并症增加。术后远处转移，特别是局部复发是直肠癌治疗失败的原因，如何防止局部复发和肝转移，一直是困扰医学家们的临床课题。此外，随着社会进步和科学技术水平的提高，人们对生活质量要求也提高，更多直肠癌患者要求保留肛门。
ObjectiveTo analyze whether neoadjuvant chemoradiotherapy can impact patients’ anal function and quality of life after rectal cancer surgery.MethodThe domestic and international publications on the studies how the neoadjuvant chemoradiotherapy impacted patients’ anal function and quality of life were collected and reviewed.ResultsThe neoadjuvant chemoradiotherapy negatively impacted the patients’ anal function and quality of life, but which would be improved over time. The impact had no obvious difference between the long-course chemoradiotherapy and short-couse radiotherapy on the patients’ anal function and quality of life. Compared with the neoadjuvant chemoradiotherapy, the neoadjuvant chemotherapy might impact less on the anal function, but which still needed to evaluate the lower anterior resection syndrome (LARS) score. In present, it lacked evidence of a higher rate of anastomotic leakage caused by the neoadjuvant chemoradiotherapy, which might lead to the bowel dysfunction.ConclusionsNeoadjuvant chemoradiotherapy negatively impacts patients’ anal function and quality of life. Further studies are needed to figure out the best choice between long-course neoadjuvant chemoradiotherapy and short-couse radiotherapy. In long term, impact of neoadjuvant therapy can be improved over time and be accepted by patients. Some intervention treatments including medicine and operations are needed if major LARS occurs.
Objective To investigate the perioperative differences between video-assisted thoracoscopic surgery (VATS) and thoracotomy after neoadjuvant therapy in patients with non-small cell lung cancer (NSCLC). Methods Clinical data of NSCLC patients who underwent VATS or thoracotomy after neoadjuvant therapy at Shanghai Pulmonary Hospital from June 2020 to May 2022 were retrospectively collected. Perioperative outcomes were compared between the two groups. Results A total of 260 patients were enrolled, 184 (70.8%) patients underwent VATS and 76 (29.2%) patients underwent thoracotomy. After propensity matching, there were 113 (62.4%) patients in the VATS group and 68 (37.6%) patients in the thoracotomy group. VATS had similar lymph node dissection ability and postoperative complication rate with thoracotomy (P>0.05), with the advantage of having shorter operative time (146.00 min vs. 165.00 min, P=0.006), less intraoperative blood loss (50.00 mL vs. 100.00 mL, P<0.001), lower intraoperative blood transfusion rate (0.0% vs. 7.4%, P=0.003), less 3-day postoperative drainage (250.00 mL vs. 350.00 mL, P=0.011; 180.00 mL vs. 250.00 mL, P=0.002; 150.00 mL vs. 235.00 mL, P<0.001), and shorter postoperative drainage time (9.34 d vs. 13.84 d, P<0.001) and postoperative hospitalization time (6.19 d vs. 7.94 d, P=0.006). Conclusion VATS after neoadjuvant therapy for NSCLC is safer than thoracotomy and results in better postoperative recovery.
Neoadjuvant therapy has become the standard treatment for locally advanced resectable esophageal cancer, significantly improving long-term survival compared to surgery alone. Neoadjuvant therapy has evolved to include various strategies, such as concurrent chemoradiotherapy, chemotherapy, immunotherapy, or targeted combination therapy. This enriches clinical treatment options and provides a more personalized and scientific treatment approach for patients. This article aims to comprehensively summarize current academic research hot topics, review the rationale and evaluation measures of neoadjuvant therapy, discuss challenges in restaging methods after neoadjuvant therapy, and identify the advantages and disadvantages of various neoadjuvant therapeutic strategies.
ObjectiveTo understand the impact of preoperative nutritional status on the postoperative complications for patients with low/ultra-low rectal cancer undergoing extreme sphincter-preserving surgery following neoadjuvant therapy. MethodsThe patients with low/ultra-low rectal cancer who underwent extreme sphincter-preserving surgery following neoadjuvant therapy from January 2009 to December 2020 were retrospectively collected using the Database from Colorectal Cancer (DACCA), and then who were assigned into a nutritional risk group (the score was low than 3 by the Nutrition Risk Screening 2002) and non-nutritional risk group (the score was 3 or more by the Nutrition Risk Screening 2002). The postoperative complications and survival were analyzed for the patients with or without nutritional risk. The postoperative complications were defined as early-term (complications occurring within 30 d after surgery), middle-term (complications occurring during 30–180 d after surgery), and long-term (complications occurring at 180 d and more after surgery). The survival indicators included overall survival and disease-specific survival. ResultsA total of 680 patients who met the inclusion criteria for this study were retrieved from the DACCA database. Among them, there were 500 (73.5%) patients without nutritional risk and 180 (26.5%) patients with nutritional risk. The postoperative follow-up time was 0–152 months (with average 48.9 months). Five hundreds and forty-three survived, including 471 (86.7%) patients with free-tumors survival and 72 (13.3%) patients with tumors survival. There were 137 deaths, including 122 (89.1%) patients with cancer related deaths and 15 (10.9%) patients with non-cancer related deaths. There were 48 (7.1%) cases of early-term postoperative complications, 51 (7.5%) cases of middle-term complications, and 17 (2.5%) cases of long-term complications. There were no statistical differences in the incidence of overall complications between the patients with and without nutritional risk (χ2=3.749, P=0.053; χ2=2.205, P=0.138; χ2=310, P=0.578). The specific complications at different stages after surgery (excluding the anastomotic leakage complications in the patients with nutritional risk was higher in patients without nutritional risk, P=0.034) had no statistical differences between the two groups (P>0.05). The survival curves (overall survival and disease-specific survival) using the Kaplan-Meier method had no statistical differences between the patients with and without nutritional risk (χ2=3.316, P=0.069; χ2=3.712, P=0.054). ConclusionsFrom the analysis results of this study, for the rectal cancer patients who underwent extreme sphincter-preserving surgery following neoadjuvant therapy, the patients with preoperative nutritional risk are more prone to anastomotic leakage within 30 d after surgery. Although other postoperative complications and long-term survival outcomes have no statistical differences between patients with and without nutritional risk, preoperative nutritional management for them cannot be ignored.
Objective To compare the outcomes of ranibizumab and conbercept adjunct for pars plana vitrectomy (PPV) in the treatment of proliferative diabetic retinopathy (PDR). MethodsA prospective randomized case-control study. From June 2022 to December 2023, 90 cases (90 eyes) of PDR patients diagnosed through ophthalmic examination at Department of Ophthalmology of Gansu Provincial Hospital were included in the study. All patients underwent the best corrected visual acuity (BCVA), intraocular pressure, B-mode ultrasound, and optical coherence tomography (OCT) examinations. The central macular thickness (CMT) was measured using an OCT instrument. The patients were randomly divided into a intravitreal injection of ranibizumab group (monoclonal-antibody group) and a intravitreal injection of conbercept group (fusion-protein group) using a random number table method, with 45 cases (45 eyes) in each group. Two groups of patients were intravitreal injected with 10 mg/ml ranibizumab or conbercept 0.05 ml, respectively. A standard 23G PPV was performed through the flat part of the ciliary body 3-7 days after intravitreal injection. Relevant examinations were performed using the same equipments and methods as before surgery at postoperative 1 week, 1, 3, 6, and 12 months. The PPV time, intraoperative use of intraocular electrocoagulation, incidence of iatrogenic retinal breaks, and sterile air or silicone oil tamponade rate in the vitreous cavity, the postoperative changes of BCVA and CMT, and incidence of complications were compared between two groups. Independent sample t test was used for inter group comparison. ResultsThe intraoperative utilization rate of intraocular electrocoagulation in the monoclonal-antibody group was higher than that in the fusion-protein group, and the difference was statistically significant (χ2=3.876, P＜0.05). There were no statistically significant differences in the PPV time (t=0.152), intraoperative bleeding rate (χ2=0.800), incidence of iatrogenic retinal breaks (χ2=1.975), and sterile air and silicone oil tamponade rate in the vitreous cavity (χ2=1.607, 1.553) between the two groups (P＞0.05). There were no statistically significant differences in early and late postoperative vitreous hemorrhage (χ2=1.235, 2.355), and re-PPV (χ2=2.355) between two groups (P＞0.05). The BCVA of the fusion-protein group was significantly better than that of the monoclonal-antibody group at postoperative 3 months, and the difference was statistically significant (t=2.428, P＜0.05). The CMT of the fusion-protein group was lower than that in the monoclonal-antibody group at postoperative 1 week, and the difference was statistically significant (t=2.739, P＜0.05). None of the patients experienced endophthalmitis, retinal artery occlusion, or severe cardiovascular events after surgery. ConclusionCompared with intravitreal injection of ranibizumab before PPV, intravitreal injection of conbercept before PPV in PDR patients can shorten the surgical time, reduce intraoperative bleeding rate, lower the rate of electrocoagulation and intraocular tamponade, and incidence of iatrogenic retinal breaks, and improve the visual acuity.
ObjectiveTo analyze the factors influencing axillary pathological complete response (pCR) after neoadjuvant therapy (NAT) and to provide the possibility of exempting axillary surgery for patients with better pathological efficacy of primary breast lesions after NAT. MethodsAccording to the inclusion and exclusion criteria, the patients with breast cancer admitted to the Department of Breast Surgery, Affiliated Hospital of Southwest Medical University from January 1, 2020 to June 30, 2022 were retrospectively analyzed. All patients were diagnosed with ipsilateral axillary lymph node metastasis of breast cancer and the NAT cycle was completed according to standards. All patients underwent axillary lymph node dissection (ALND) after NAT. The therapeutic effect of primary breast lesions was evaluated by Miller-Payne (MP) grading system. The axillary pCR was judged according to whether there was residual positive axillary lymph nodes after ALND. The unvariate and multivariate logistic regressions were used to analyze the risk factors affecting the axillary pCR. At the same time, the possibility of exempting axillary surgery after NAT in the MP grade 5 or in whom without ductal carcinoma in situ (DCIS) was evaluated. The ALND was considered to exempt when the negative predictive value was 90% or more and false negative <10% or almost same. ResultsA total of 111 eligible patients with breast cancer were gathered in the study, 64 of whom with axillary pCR. There were 43 patients of MP grade 5 without DCIS after NAT, 41 of whom were axillary pCR. The univariate analysis results showed that the estrogen receptor and progesterone receptor statuses, molecular type, NAT regimen, and MP grade were associated with the axillary pCR after NAT, then the logistic regression multivariate analysis results showed that the MP grade ≤3 and MP grade 4 decreased the probability of axillary pCR as compared with the MP grade 5 [OR=0.105, 95%CI (0.028, 0.391), P=0.001; OR=0.045, 95%CI (0.012, 0.172), P<0.001]. There were 51 patients of MP grade 5 after NAT, 46 of whom were axillary pCR. The negative predictive value and the false negative rate of MP grade 5 on predicting the postoperative residual axillary lymph nodes were 90.2% [95%CI (81.7%, 98.6%)] and 10.6% [95%CI (1.5%, 19.8%)], respectively, which of MP grade 5 without DCIS were 95.3% [95%CI (88.8%, 101.9%)] and 4.3% [95%CI (–1.7%, 10.2%)] , respectively. ConclusionsThe probability of axillary pCR for the patient with higher MP grade of breast primary after NAT is higher. It is probable of exempting axillary surgery when MP grade is 5 after NAT.
Objective To summarize the research progression of video-assisted anal fistula treatment (VAAFT). Methods The related literatures in recent years were reviewed, and then the operation principle, operation process, advantages and disadvantages, matters needing attention, and clinical application of VAAFT were summarized. Results VAAFT is the treatment of fistulas by endoscopy. It don’t require the incision or resection of the fistula. It has the advantages of less surgical trauma, faster postoperative recovery, and less impact on the anal sphincter. The disadvantage of this method is relatively strict indications, fistula bending or horseshoe fistula is not suitable for this method. In addition, the endoscope using during the operation is a rigid mirror tube, and the operation is not convenient enough, so technical improvement is needed in the future. We should pay attention to distinguish true fistula and false fistula in clinical practice; the wall of the fistula should be adequately burned and the necrotic tissue should be cleaned; the treatment of the internal opening of anal fistula must be exact; the time of the first defecation should be appropriately delayed, and the incidence of infection should be reduced after operation. At present, the clinical reports of VAAFT are increasing gradually in foreign countries, and these reports have achieved good therapeutic effect. It is considered that this method maybe a safe and effective minimally invasive surgical treatment for anal fistula. However, there is few clinical reports on VAAFT in China, and it is still in the preliminary stage of exploration. Conclusion VAAFT is a new technology in the treatment of anal fistula, and it has advantages of minimally invasive, sphincter preservation, and so on, which is worthy of clinical application.