This study aimed to compare perioperative results, postoperative anal function, quality of life (QoL), and long-term outcomes between conformal sphincter preservation operation (CSPO) and modified Bacon operation for ultralow rectal cancer. Patients with ultralow rectal cancer undergoing CSPO (n = 123) and modified Bacon (n = 109) were included from Changhai and Xiangya Hospital, respectively, between 2011 and 2020. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were used to balanced baseline characteristics. Anal function was evaluated with Wexner scores and low anterior resection syndrome (LARS) score, and visual analog scale (VAS) for satisfaction. QoL was evaluated via EORTC QLQ-C30 and QLQ-CR38 questionnaires. After exclusions, 122 patients in the CSPO group and 108 in the modified Bacon group were analyzed. Following adjustment via PSM and IPTW, the CSPO group demonstrated a shorter operative time, postoperative hospital stay, flatus and defecation time, postoperative anal function recovery time, and better satisfaction with anal function compared to the modified Bacon group. Multivariable analysis showed that neoadjuvant radiotherapy (β=-1.184, 95

Abstract Background: T cells, the key mediators of tumor destruction, have a considerable impact on tumor prognosis. However, the clinical significance of T cell-associated biomarkers in colorectal cancer (CRC) haven’t been well understood. The aim of this study was to investigate the expression profile of T cell marker genes in CRC and develop a prognostic signature based on these genes. Methods: Single-cell RNA-sequencing (scRNA-seq) data were retrieved from the Gene Expression Omnibus (GEO) database. Bulk RNA-sequencing data and clinical information were downloaded from The Cancer Genome Atlas (TCGA) and GEO databases. We firstly conducted a comprehensive analysis of scRNA-seq data to investigate the heterogeneity of various cells in the CRC tumor microenvironment (TME). Then, we performed cell-cell communication analysis and cell trajectory analysis to explore the intercellular interactions and functional changes of T cells. By combing the bulk RNA-seq data, a T-cell related gene signature was eventually constructed and its predictive ability was determined by the Kaplan–Meier (K-M), and receiver operating characteristic (ROC) curves in three independent cohorts. Results: ScRNA-seq data obtained from the GEO database were re-integrated and analyzed, resulting in 23 cell clusters. Distinct cell clusters were annotated using extensively reported cell markers. The CellChat algorithm revealed that tumor cells suppress the cellular function of tumor-infiltrating T cells through the MIF/CD74 pathway. The evolutionary trajectory of tumor-infiltrating T cells was elucidated by the CytoTRACE and monocle2 algorithms. Eventually, a prognostic prediction model based on 5 T cell-related genes was constructed using single-cell and bulk RNA sequencing data. The validation results from several independent CRC cohorts indicated that the 5 T cell-related genes prognostic model could accurately predict the survival outcomes of CRC patients, providing new evidence for precision treatment in CRC. Conclusions: Our study not only offers prospects for a better understanding of the cellular heterogeneity of TME, but also provides a useful tool for stratifying patients with different prognoses and facilitating personalized treatment.

目的 探讨中低位直肠癌新辅助放化疗(neoadjuvant chemoradiotherapy,nCRT)后达到ypT0病人的临床病理特征和影响预后的因素.方法 回顾性分析2011年1月至2021年12月海军军医大学第一附属医院接受长程新辅助治疗、术后病理证实ypT0的中低位直肠癌病人的临床病理资料,采用Cox比例风险模型检验分析无病生存率(disease-free survival,DFS)和总生存率(overall survival,OS)的影响因素.结果 共入组132例病人,接受局部切除术病人26例(19.7％),术后病理提示ypN0和ypN+的病人分别为98例(74.2％)和8例(6.1％),接受辅助治疗的病人79例(59.8％).中位随访时间为43.5个月,全组5年DFS和OS分别为84.4％ 和90.4％.多因素Cox回归分析显示,新辅助治疗前癌胚抗原(CEA)水平升高(H R=3.540,P=0.029)和糖类抗原(CA)19-9水平升高(HR=4.982,P=0.020),以及ypN+/ypNx(HR=8.821/7.379,P=0.002/0.008)是DFS的独立危险因素;未发现OS的独立影响因素.结论 中低位直肠癌nCRT后达到ypT0的病人肿瘤学结局良好,nCRT前CEA、CA19-9水平升高及术后病理淋巴结状态为ypN+/ypNx的病人应加强术后治疗和随访.

［Abstract］ Radiation-induced rectal injury, a form of radiation-induced intestine injury occurring after post-pelvic malignancies radiotherapy, primarily presents as inflammation of the rectal mucosa, accompanied by symptoms such as abdominal pain, diarrhea, tenesmus, rectal bleeding, rectal stricture, and enterocutaneous fistula. Diagnosis, often hindered by the lack of specific clinical manifestations, relies on auxiliary examinations such as imaging and electronic colonoscopy. As neoadjuvant radiotherapy and chemotherapy become increasingly prevalent in rectal cancer treatment, radiation-induced rectal injury emerges as a common issue significantly impacting patients’quality of life. Beyond the direct impact on the rectal mucosa, radiation can also damage the anal sphincter, affecting anal function. Anastomotic leakage stands out as the primary postoperative complication for rectal cancer patients undergoing neoadjuvant radiotherapy and chemotherapy. Reasonable selection of surgical timing and methods can reduce postoperative complications to a certain extent. This article provides a comprehensive review of radiation-induced rectal and anal injury associated with neoadjuvant chemoradiotherapy for rectal cancer, aiming to offer new ideas for the diagnosis and treatment for such patients.

Lateral lymph node metastasis is one of the main causes of local recurrence after low rectal cancer surgery. The diagnosis of lateral lymph node metastasis in low rectal cancer provides strong evidence for surgeons to perform lateral lymph node dissection. Currently, it mainly relies on preoperative MRI, CT and other imaging methods. In recent years, the intraoperative diagnosis technology for lateral lymph node metastasis in low rectal cancer has been continuously developed. Nano carbon tracer technology, indocyanine green fluorescence imaging, lymphoscintigraphy, and laparoscopic ultrasound have emerged, which are expected to improve the efficiency of diagnosis and guide the operation more effectively. This review provides an overview of the research progress in the diagnostic methods for lateral lymph node metastasis in low rectal cancer.

The mesentery has been defined as a double fold of the peritoneum connecting some regions of the intestine to the posterior abdominal wall. It emerges from the superior mesenteric root region and fans out to span the intestine from the duodenum to the rectum. The mesorectal is a continuation of the intraperitoneal mesentery in the pelvic cavity. The lateral structure of the rectum is complex and the traditional view calls it the lateral ligament of the rectal. However, this structure could be called the lateral mesorectum from the perspective of embryonic development and membrane anatomy. The lateral mesorectum is the bridge of the vessels, lymphatic, and nerves between the rectum and the pelvic wall. It anchors the rectum to the lateral pelvic wall and is the anatomical basis of lateral lymph node metastasis in low rectal cancer. Meanwhile, it is important to identify the lateral mesorectum and its surrounding structure to radically resect the tumor and protect the pelvic autonomic nerve during the total mesorectal excision procedure.

Objective:To investigate the influence of extending the waiting time on tumor regression after neoadjuvant chemoradiology (nCRT) in patients with locally advanced rectal cancer (LARC).Methods:Clinicopathological data from 728 LARC patients who completed nCRT treatment at the First Affiliated Hospital, Naval Medical University from January 2012 to December 2021 were collected for retrospective analysis. The primary research endpoint was the sustained complete response (SCR). There were 498 males and 230 females, with an age ( M(IQR)) of 58 (15) years (range: 22 to 89 years). Logistic regression models were used to explore whether waiting time was an independent factor affecting SCR. Curve fitting was used to represent the relationship between the cumulative occurrence rate of SCR and the waiting time. The patients were divided into a conventional waiting time group (4 to <12 weeks, n=581) and an extended waiting time group (12 to<20 weeks, n=147). Comparisons regarding tumor regression, organ preservation, and surgical conditions between the two groups were made using the t test, Wilcoxon rank sum test, or χ2 test as appropriate. The Log-rank test was used to elucidate the survival discrepancies between the two groups. Results:The SCR rate of all patients was 21.6% (157/728). The waiting time was an independent influencing factor for SCR, with each additional day corresponding to an OR value of 1.010 (95% CI: 1.001 to 1.020, P=0.031). The cumulative rate of SCR occurrence gradually increased with the extension of waiting time, with the fastest increase between the 9 th to <10 th week. The SCR rate in the extended waiting time group was higher (27.9%(41/147) vs. 20.0%(116/581), χ2=3.901, P=0.048), and the organ preservation rate during the follow-up period was higher (21.1%(31/147) vs. 10.7%(62/581), χ2=10.510, P=0.001). The 3-year local recurrence/regrowth-free survival rates were 94.0% and 91.1%, the 3-year disease-free survival rates were 76.6% and 75.4%, and the 3-year overall survival rates were 95.6% and 92.2% for the conventional and extended waiting time groups, respectively, with no statistical differences in local recurrence/regrowth-free survival, disease-free survival and overall survival between the two groups ( χ2=1.878, P=0.171; χ2=0.078, P=0.780; χ2=1.265, P=0.261). Conclusions:An extended waiting time is conducive to tumor regression, and extending the waiting time to 12 to <20 weeks after nCRT can improve the SCR rate and organ preservation rate, without increasing the difficulty of surgery or altering the oncological outcomes of patients.

Abstract Background To investigate the learning curve of conformal sphincter preservation operation (CSPO) in the treatment of ultralow rectal cancer and to further explore the influencing factors of operation time. Methods From August 2011 to April 2020, 108 consecutive patients with ultralow rectal cancer underwent CSPO by the same surgeon in the Department of Colorectal Surgery of Changhai Hospital. The moving average and cumulative sum control chart (CUSUM) curve were used to analyze the learning curve. The preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data were compared before and after the completion of learning curve. The influencing factors of CSPO operation time were analyzed by univariate and multivariate analysis. Results According to the results of moving average and CUSUM method, CSPO learning curve was divided into learning period (1–45 cases) and learning completion period (46–108 cases). There was no significant difference in preoperative clinical baseline data, postoperative pathological data, postoperative complications, and survival data between the two stages. Compared with the learning period, the operation time (P < 0.05), blood loss (P < 0.05), postoperative flatus and defecation time (P < 0.05), liquid diet time (P < 0.05), and postoperative hospital stay (P < 0.05) in the learning completion period were significantly reduced, and the difference was statistically significant. Univariate and multivariate analysis showed that distance of tumor from anal verge (≥ 4cm vs. < 4cm, P = 0.039) and T stage (T3 vs. T1-2, P = 0.022) was independent risk factors for prolonging the operation time of CSPO. Conclusions For surgeons with laparoscopic surgery experience, about 45 cases of CSPO are needed to cross the learning curve. At the initial stage of CSPO, beginners are recommended to select patients with ultralow rectal cancer whose distance of tumor from anal verge is less than 4 cm and tumor stage is less than T3 for practice, which can enable beginners to reduce the operation time, accumulate experience, build self-confidence, and shorten the learning curve on the premise of safety.

Objective:To investigate the safety and efficacy of pelvic peritoneal reconstruction and its effect on anal function in laparoscopy-assisted anterior resection of low and middle rectal cancer.Methods:A prospective cohort study was conducted. Consecutive patients with low and middle rectal cancer who underwent laparoscopy-assisted transabdominal anterior resection at Naval Military Medical University Changhai Hospital from February 2020 to February 2021 were enrolled. Inclusion criteria: (1) the distance from tumor to the anal verge ≤10 cm; (2) laparoscopy-assisted transabdominal anterior resection of rectal cancer; (3) complete clinical data; (4) rectal adenocarcinoma diagnosed by postoperative pathology. Exclusion criteria: (1) emergency surgery; (2) patients with a history of anal dysfunction or anal surgery; (3) preoperative diagnosis of distant (liver, lung) metastasis; (4) intestinal obstruction; (5) conversion to open surgery for various reasons. The pelvic floor was reconstructed using SXMD1B405 (Stratafix helical PGA-PCL, Ethicon). The first needle was sutured from the left anterior wall of the neorectum to the right. Insertion of the needle was continued to suture the root of the sigmoid mesentery while the Hemo-lok was used to fix the suture. The second needle was started from the beginning of the first needle, after 3-4 needles, a drainage tube was inserted through the left lower abdominal trocar to the presacral space. Then, the left peritoneal incision of the descending colon was sutured, after which Hemo-lok fixation was performed. The operative time, perioperative complications, postoperative Wexner anal function score and low anterior resection syndrome (LARS) score were compared between the study group and the control group. Three to six months after the operation, pelvic MRI was performed to observe and compare the pelvic floor anatomical structure of the two groups.Results:A total of 230 patients were enrolled, including 58 who underwent pelvic floor peritoneum reconstruction as the study group and 172 who did not undergo pelvic floor peritoneum reconstruction as the control group. There were no significant differences in general data between the two groups (all P>0.05). The operation time of the study group was longer than that of control group [(177.5±33.0) minutes vs. (148.7±45.5) minutes, P<0.001]. There was no significant difference in the incidence of perioperative complications (including anastomotic leakage, anastomotic bleeding, postoperative pneumonia, urinary tract infection, deep vein thrombosis, and intestinal obstruction) between the two groups (all P>0.05). Eight cases had anastomotic leakage, of whom 2 cases (3.4%) in the study group were discharged after conservative treatment, 5 cases (2.9%) of other 6 cases (3.5%) in the control group were discharged after the secondary surgical treatment. The Wexner score and LARS score were 3.1±2.8 and 23.0 (16.0-28.0) in the study group, which were lower than those in the control group [4.7±3.4 and 27.0 (18.0-32.0)], and the differences were statistically significant ( t=-3.018, P=0.003 and Z=-2.257, P=0.024). Severe LARS was 16.5% (7/45) in study group and 35.5% (50/141) in control group, and the difference was no significant differences ( Z=4.373, P=0.373). Pelvic MRI examination 3 to 6 months after surgery showed that the incidence of intestinal accumulation in the pelvic floor was 9.1% (3/33) in study group and 46.4% (64/138) in control group (χ 2=15.537, P<0.001). Conclusion:Pelvic peritoneal reconstruction using stratafix in laparoscopic anterior resection of middle and low rectal cancer is safe and feasible, which may reduce the probability of the secondary operation in patients with anastomotic leakage and significantly improve postoperative anal function.

Objective:To investigate the clinical efficacy and prognosis of simultaneous resection of synchronous colorectal liver metastasis in patients admitted in different phases.Methods:The retrospective cohort study was conducted. The clinicopathological data of 346 patients who underwent simultaneous resection of synchronous colorectal liver metastasis in the First Affiliated Hospital of Naval Medical University (Changhai Hospital of Shanghai) from January 2000 to April 2021 were collected. There were 217 males and 129 females, aged (58±12)years. Patients under-went simultaneous resection of synchronous colorectal liver metastasis. Observation indicators: (1) clinicopathological features of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021; (2) surgical and postoperative situations of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021; (3) analysis of prognosis of patients with synchro-nous colorectal liver metastasis in 2000?2010 and 2011?2021. Follow-up was conducted using telephone interview or outpatient examination to detect survival of patients. The follow-up was performed once every 3 months, including blood routine test, liver and kidney function test, car-cinoembryonic antigen (CEA) test, CA19-9 test, abdominal B-ultrasound examination, and once every 6 months, including chest computed tomography (CT) plain scan, liver magnetic resonance imaging (MRI) and/or CT enhanced scan, abdominal or pelvic MRI and/or CT enhanced scan, within postoperative 2 year. The follow-up was performed once every 6?12 months within postoperative 2?5 years including above reexaminations. Electronic colonoscopy was performed once a year after operation. The follow-up was up to November 12, 2021. Measurement data with normal distribution were represented as Mean± SD, and comparison between groups was conducted using the t test. Measurement data with skewed distuibution were represented as M(range). Count data were described as absolute numbers, and comparison between groups was conducted using the chi-square test. Comparison of ordinal data was conducted using the rank sum test. Kaplan-Meier method was used to calculate survival rates and draw survival curves, and Log-Rank test was used to conduct survival analysis. Results:(1) Clinicopathological features of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021. Of the 346 patients, 59 cases underwent simultaneous resection within 2000?2010 and 287 cases underwent simultaneous resection within 2011?2021. The gender (males and females), cases with or without fundamental diseases, cases with the number of lymph nodes harvested in primary lesion as <12 or ≥12, the tumor diameter of primary lesion, the tumor diameter of liver metastasis lesion, the number of liver metastasis lesions, cases with or without preoperative treatment, cases with or without postoperative treatment, cases with adjuvant therapy as perioperative treatment, surgery or other treatment were 47, 12, 36, 23, 19, 40, (5.5±2.4)cm, (2.1±0.7)cm, 1.6±0.5, 59, 0, 16, 16, 0, 16, 43 in patients admitted in 2000?2010, respectively. The above indicators in patients admitted in 2011?2021 were 170, 117, 121, 166, 58, 229, (4.2±2.0)cm, (3.0±2.0)cm, 1.9±1.4, 208, 79, 34, 235, 74, 29, 184, respectively. There were significant differences in the above indicators between patients admitted in 2000?2010 and 2011?2021 ( χ2=8.73, 7.02, 4.07, t= 4.40, ?6.04, ?3.10, χ2=21.05, 28.82, 26.68, P<0.05). (2) Surgical and postoperative situations of patients with synchronous colorectal liver metastasis in 2000?2010 and 2011?2021. Cases with surgical methods as complete open surgery or laparoscopy combined with open surgery, the operation time, time to postoperative initial liquid food intake, cases with or without postoperative complications, cases with postoperative duration of hospital stay as ≤10 days or >10 days were 58, 1, (281±57)minutes, (5±1)days, 33, 26, 14, 45 in patients admitted in 2000?2010, respec-tively. The above indicators in patients admitted in 2011?2021 were 140, 147, (261±82)minutes, (3±1)days, 233, 54, 198, 89, respectively. There were significant differences in the above indicators between patients admitted in 2000?2010 and 2011?2021 ( χ2=49.04, t=2.24, 7.53, χ2=17.56, 26.02, P<0.05). There was no death in the 346 patients. (3) Analysis of prognosis of patients with synchro-nous colorectal liver metastasis in 2000?2010 and 2011?2021. Of the 346 patients, 295 cases were followed up for 47(range, 1?108)months. Of the 29 patients admitted in 2000?2010 who were followed up, there were 27 cases died. The median survival time, 1-, 3-, 5-year overall survival rates, 1-, 3-, 5-year disease free survival rates of patients admitted in 2000?2010 were 18.0 months (95% confidence interval as 12.7?23.3 months), 82.8%, 11.5%, 3.8%, 53.6%, 8.3%, 4.2%, respec-tively. Of the 266 patients admitted in 2011?2021 who were followed up, there were 109 cases died. The median survival time, 1-, 3-, 5-year overall survival rates, 1-, 3-, 5-year disease free survival rates of patients admitted in 2011?2021 were 54.0 months (95% confidence interval as 38.1?70.4 months), 93.3%, 61.8%, 47.0%, 68.2%, 33.7%, 28.3%, respectively. There were significant differences in overall survival rate and disease free survival rate between patients admitted in 2000?2010 and 2011?2021 ( χ2=47.57, 9.17, P<0.05). Conclusions:With the increase of the operation volume of simultaneous resection of synchronous colorectal liver metastasis, the operation time, time to postoperative initial liquid food intake, postoperative duration of hospital stay and postoperative complications have significantly decreased, while the overall survival rate and disease free survival rate have significantly increased.

本文介绍1例乙状结肠癌伴肝巨大转移灶的多学科专家组(multi-disciplinary team,MDT)诊疗过程.该病例初诊时乙状结肠癌即伴肝右叶巨大多发转移灶,病理证实为腺癌,鼠类肉瘤病毒癌基因(Kirsten rat sarcoma viral oncogene,KRAS)基因突变型,肝转移瘤因切除后剩余肝脏体积不足,考虑为潜在可切除,经MDT讨论后行4个周期mFOLFOXIRI三药化疗方案(氟尿嘧啶+奥沙利铂+伊立替康)联合贝伐珠单抗靶向治疗先行缩瘤转化治疗,化疗后评估肝转移灶较前缩小,乙状结肠病灶退缩良好,第2次MDT讨论考虑具备手术条件,进行门静脉栓塞(portal vein embolization,PVE)代偿性增大左肝体积后,行腹腔镜辅助乙状结肠切除术+开腹肝转移瘤切除术.术后mFOLFOXIRI联合贝伐珠单抗治疗6个周期,后因化疗耐受不佳改卡培他滨联合贝伐珠单抗维持治疗,术后近1年发现肝脏转移复发,再次引入mFOLFOXIRI联合贝伐珠单抗治疗无效,行肝脏转移瘤切除术,后因新发肝脏转移和盆腔淋巴结转移予以口服呋喹替尼治疗维持,近期肝脏新发转移灶,行根治性切除术,术后恢复佳.该病例考虑了患者意愿、个人身体状况并结合MDT团队的意见,通过转化治疗+PVE术后腹腔镜结合开腹同期切除乙状结肠癌伴肝巨大转移灶,有效控制疾病进展,患者获得较好的生活质量.

骶前肿瘤是临床上少见的一类异质性较大的肿瘤.它具有发病率低、发生发展缓慢、临床症状不明显等特点,患者多数因体检偶然发现或肿瘤较大引起压迫症状而就诊.虽然大部分骶前肿瘤为良性肿瘤,但其本身组织学差异较大,部分肿瘤为恶性或具有潜在恶性可能,因而骶前肿瘤一经发现原则上均应行手术切除.传统开放手术为其主要手术方式,手术入路主要包括经腹入路、经骶入路、经腹+经骶联合入路和经腹会阴联合入路.近年来,腹腔镜技术已发展成熟,其凭借微创、术野清晰等优势,现已常规应用于外科手术治疗.腹腔镜技术也为骶前肿瘤的手术治疗带来变革,尽管开展的病例数相对较少,但自1995年Sharpe和Van Oppen[1]首次报道使用腹腔镜技术切除骶前肿瘤以来,陆续有外科医师应用这一手术方式.本文将结合既往文献及本研究团队的一些经验和体会,对腹腔镜手术在骶前肿瘤治疗中的应用做一简要概述.

Colorectal surgeons have focused on the lateral structure of rectum for a long time and lateral ligament is the common term to depict this structure. A better understanding of lateral rectal structure could be beneficial to performing the total mesorectum excision (TME) procedure and protecting patients' urinary, sexual and defecation function. The main controversies focus on two aspects: (1) Does the lateral ligament exist? (2) What dose it contain? Does the middle rectal artery exist? Up to now, anatomic studies have failed to reach consensus on the lateral rectal structure. However, surgeons do find the lateral rectal ligament during surgery and it may be the pathway for lateral lymph node metastasis in rectal cancer. The lateral rectal structure contains the middle rectal artery, nerve branches, lymphatics and adipose fibrous tissue around them. We summarize our clinical experience and conclude that the middle rectal artery appears in lateral ligament constantly but some of them are too small to be easily observed. Therefore, regarding the perspective of membrane anatomy, embryology and surgery, this structure may be more appropriate to be called the "lateral mesorectum". We propose this new term based on the previous literature and our own experience for the readers' reference.

Objective:This study aims to analyze the prognosis of patients who underwent a simultaneous operations for colorectal cancer and liver metastases, and to establish a prognostic scoring system for these patients.Methods:From January 2010 to March 2019, the clinicopathological data of patients with colorectal cancer and liver metastases simultaneously operated at Shanghai Changhai Hospital were collected. The clinicopathological prognostic factors on tumor recurrence and survival outcomes on follow-up were analyzed. Single and multiple factors Cox regression analyses were used to determine the risk factors which affected the prognosis of patients. Using the risk factors of poor prognosis on Cox analysis, 1 point was given to each risk factor. Patients were then divided into different groups according to the different total scores. The median overall survival and disease-free survival of each group were analyzed.Results:Of 234 patients included in this study, there were 126 males and 108 females. The average age was (57.4±10.8) years. The median survival was 44.85 months. The 1-, 3-, and 5-year survival rates of the whole group were 87.3%, 55.2%, and 22.9%, respectively. Primary tumor in right colon, preoperative carcinoembryonic antigen ≥200 ng/ml, multiple liver metastases, and poorly differentiated adenocarcinoma/mucinous adenocarcinoma were independent risk factors of poor prognosis. After 1 point was given to each of the above 4 items, patients were then divided into the low-risk (0-1) and high-risk (2-4) groups. The median survivals of patients in the low-risk group ( n=174) and high-risk group ( n=60) were 53 months and 29 months, respectively. The corresponding median disease-free survivals were 21.34 months and 8.48 months, respectively. The differences between the 2 groups were significant ( P<0.05). Conclusion:The results of this study preliminary established a predictive scoring system for patients with simultaneous colorectal cancer and liver which can play a role in selecting treatment options for these patients.

Total mesorectal excision (TME) is the basic principle of surgery in rectal cancer which requires en bloc removal of the tumor and its regional lymph nodes. This conincides with the theory of membrane anatomy that emphasizes en bloc resection and avoids cancer leakage. The basis of membrane anatomy is the fusion of peritoneum and three key pointsare needed to understand the fusion and fusion fascia:(1) the fusion only occursin peritoneum; (2) the inside of fusion fascia cannot be separated; (3) the fusion can be diversiform. Only mastering these key points can we comprehend and apply this theory dialectically. The membrane anatomy in rectum is different from stomach or colon because of its specific location. The posterior space of rectum is filled with the loose connective tissue which is the degeneration of peritoneum fusion. In this space, the anterior lay of presacral fascia fuses with the proper fascia of rectum at the S4 level and separates the space into the retrorectal space and the supralevator space. Denonvilliers fascia is the fusion fascia in front of rectum, which forms the prerectal space and retroprostatic space, and extends to lateral pelvic wall with fusion of the parietal fascia of pelvis, covering the neurovascular bundle (NVB) together. The proper fascia of rectum surrounds the middle rectal artery, the pelvic plexus rectal branch and the adipose tissue to form the lateral rectal pedicle at 10 o'clock and 2 o'clock near the pelvic floor. At the level of levator ani hiatus, the fusion of levator ani muscle fascia and the proper fascia of rectum forms the Hiatal ligament, which fixs the anal canal and closes the levator ani hiatus.This article intends to discuss the above points from the perspective of membrane anatomy, in order to better guide surgeons to complete laparoscopic total mesorectal excision for rectal cancer.

随着对盆腔解剖和直肠癌生物学特性认识的加深,越来越多的低位直肠癌患者能够保留肛门,保肛手术已成为目前临床上治疗直肠癌最常用的术式.高质量的手术需要同时在肿瘤学和功能学方面使患者受益,因而低位直肠癌保肛手术需兼顾肿瘤根治和肛门功能.全直肠系膜切除(total me-sorectal excision,TME)原则、安全的远切缘和环周切缘是保证肿瘤学效果的关键,能够有效降低直肠癌局部复发率和远处转移率.而保留更多的肛门括约肌以及术中对盆腔植物神经的保护则是改善术后肛门功能,提高患者生活质量的重要因素.

Rectal cancer is a common intestinal malignant tumor in China and most of them are low rectal cancer which located under the peritoneal reflection. For the past few years, the rate of sphincter-saving is increased significantly due to the development of theory and surgical skill. At present, the low anterior resection and the intersphincter resection are widely used as the sphincter-preserving surgery. However, a variety of problems in anal function perplex patients and surgeons. In this article, we will investigate the factors on anal function and its countermeasure after sphincter-preserving surgery based on literature review and our experience. Key words: Rectal neoplasms; Low rectal cancer; Anal function; Low anterior resection; Intersphincter resection; Abdominoperineal resection

目前,新辅助治疗联合根治性手术已成为中低位局部进展期直肠癌的标准治疗方式.新辅助治疗能够降低肿瘤分期和环周切缘阳性率,进而提高R0切除率,显著改善患者预后并能够提高保肛率.NCCN指南就明确推荐对直肠癌侵犯肠壁全层或肠壁周围有淋巴结转移的患者均应实施新辅助治疗.但是不同患者对新辅助治疗的反应有所不同,有超过30％的患者不能从新辅助治疗中获益甚至出现进展,其后续需接受12～ 16周的化疗后再进行评估[1].而对新辅助治疗有良好反应的患者中有16％～30％能够达到病理完全缓解(pCR)[24],这部分患者的后续治疗及手术方式有了更多的选择,同时也存在较多争议,是结直肠外科有待研究的热点问题.现就目前常用的几种术式选择进行简单分析.