Objective:To investigate the influencing factors of anastomotic leakage after laparoscopic intersphincter resection (ISR) for extremely low rectal cancer and construction of nomogram prediction model.Methods:The retrospective case-control study was conducted. The clinicopathological data of 812 patients who underwent laparoscopic ISR for extremely low rectal cancer in the Second Affiliated Hospital of Naval Medical University (Shanghai Changzheng Hospital) from February 2012 to February 2022 were collected. There were 459 males and 353 females, aged (51±11)years. Observation indicators: (1) surgical situations; (2) follow-up; (3) influencing factors of postoperative anastomotic leakage; (4) construction and evaluation of nomogram prediction model for postoperative anastomotic leakage. Measurement data with normal distribution were represented as Mean± SD, and measurement data with skewed distribution were represented as M(range). Count data were described as absolute numbers. The COX proportional hazard model was used for univariate and multivariate analyses. The R software(3.5.1 version) was used to construct nomogram prediction model. The receiver operating characteristic (ROC) curve was drawn and the area under curve (AUC) was used to evaluate the efficacy of the nomogram prediction model. The Bootstrap method was used for internal verification and to calculate the average consistency index (C-index). Results:(1) Surgical situations. All 812 patients underwent laparoscopic ISR for extremely low rectal cancer, including 388 cases undergoing partial ISR, 218 cases undergoing subtotal ISR and 206 cases undergoing complete ISR. All 812 patients underwent ileal protective ostomy, and there were 306 cases with double anastomosis and 203 cases with left colic artery preserved, respectively. The operation time and volume of intraoperative blood loss of 812 patients was (179±33)minutes and (33±13)mL, respectively. (2) Follow-up. All 812 patients were followed up for (13.5±0.9)months. Of the 812 patients, there were 62 cases with postoperative anastomotic leakage and the healing time of these cases was (33±6)days. (3) Influencing factors of postoperative anastomotic leakage. Results of multivariate analysis showed that male, neoadjuvant chemoradiotherapy, failure of reser-ving left colic artery were independent risk factors of anastomotic leakage after laparoscopic ISR for extremely low rectal cancer ( hazard ratio=5.98, 4.00, 16.26, 95% confidence interval as 1.66-24.12, 1.30-12.42, 3.00-90.89, P<0.05). (4) Construction and evaluation of nomogram prediction model for postoperative anastomotic leakage. According to the results of multivariate analysis, male, neoadju-vant chemoradiotherapy and failure of reserving left colic artery were used to construct the nomogram prediction model for anastomotic leakage after laparoscopic ISR for extremely low rectal cancer, and the score of these indexes in the nomogram prediction model was 50, 49, 93, respectively. The total score of these index corresponded to the incidence rate of anastomotic leakage. Results of ROC curve showed that the AUC of nomogram prediction model of anastomotic leakage after laparoscopic ISR for extremely low rectal cancer was 0.87 (95% confidence interval as 0.80-0.93, P<0.05), with sensi-tivity and specificity 0.96 and 0.60, respectively. Results of internal verification showed that the C-index of nomogram prediction model was 0.87. Conclusion:Male, neoadjuvant chemoradiotherapy, failure of reserving left colic artery are independent risk factors of anastomotic leakage after laparo-scopic ISR for extremely low rectal cancer, and the nomogram prediction model based on these indexes can predict the incidence rate of postoperative anastomotic leakage.

BACKGROUND:Chemotherapy resistance is an important bottleneck affecting the efficacy of chemotherapy in colon cancer. Therefore, improving the chemotherapy sensitivity of colorectal cancer cells is of great significance for improving the prognosis of patients with colon cancer.METHODS:CCK-8 assay was employed to examine the cell viability of colorectal cancer cell lines. Realtime-PCR and western blot were used to explore toll-like receptor 4 (TLR4) expression in colorectal cancer cell lines. The functions of TLR4 in the stemness of the colorectal cancer cell lines were analyzed by infecting cells with lentivirus containing TLR4 siRNA.RESULTS:We found that aspirin could effectively enhance the chemosensitivity of CT26 and HCT116 colorectal cancer cell lines. Aspirin can also inhibit the stemness of colorectal cancer cell including inhibiting the number of clone formation and reducing the volume and number of cell spheres and inducing the down-regulation of stemness-related genes. Besides that, aspirin also lead to down-regulation of TLR4 expression in colorectal cancer cells. The TLR4 positive colorectal cancer cells demonstrated a higher chemotherapy resistance potential than TLR4 negative colorectal cancer cells. In addition, the stemness of TLR4 positive colorectal cancer cells is stronger than TLR4 negative colorectal cancer cells.CONCLUSION:The results of our study indicate that aspirin increases chemosensitivity of colorectal cancer cells and inhibits the expression of toll-like receptor 4.

目的 探讨进展期胃癌SOX方案新辅助化疗(NAT)的疗效及影响疗效的因素.方法 回顾性分析我院2010年2月至2016年4月收治的128例接受SOX方案NAT的进展期胃癌患者(NAT组)及128例行手术治疗未接受NAT的进展期胃癌患者(对照组)的临床资料.采用多因素Cox比例风险回归模型分析影响总生存期的因素,并基于相关变量建立预测NAT疗效的列线图预测模型.结果 NAT组患者中位生存时间为31个月,对照组为21个月,两组比较差异有统计学意义(P<0.05).多因素Cox比例风险回归模型分析显示,年龄、肿瘤位置、肿瘤大小、癌胚抗原、CA 19-9、临床T分期、临床N分期、淋巴结转移及未接受SOX方案NAT是胃癌患者预后的独立危险因素(P均<0.05).成功构建列线图预测模型,经内部验证该模型符合率良好,有较好的区分度和准确度,该预测模型与TNM分期相比具有较高的灵敏度和特异度.结论 SOX方案NAT能够改善进展期胃癌患者的状况,根据年龄、肿瘤大小、肿瘤部位、癌胚抗原、CA 19-9、临床T分期、临床N分期、是否有淋巴结转移和是否接受SOX方案NAT建立的列线图预测模型能够较好地预测进展期胃癌患者的预后.

新型冠状病毒肺炎疫情下急诊外科存在较大的职业暴露风险,如何在疫情时期实施急诊外科临床培训是当前形势下医学教育面临的一个重大问题.我们根据疫情下急诊外科病例特点和新冠防控要求,制定严格的人员管控方案与周密的教学培训方案,按照教学要求实施急诊外科临床培训,确保了人员安全,完成相应的教学任务,在实际教学活动中取得了良好的效果.

目的 比较右侧和中央两种不同观察孔位置在腹腔镜直肠癌根治术中对肠系膜下动脉根部淋巴结清扫显露的临床效果.方法 回顾性分析2017年1月至2017年5月于上海中医药大学附属曙光医院胃肠外科行腹腔镜直肠癌根治术的25例患者的临床资料,清扫肠系膜下动脉淋巴结时分别采用右侧观察孔(右上Trocar)和中央观察孔(脐上Trocar)显露,其中右侧观察孔组13例,中央观察孔组12例.对比两组手术视野、总手术时间、实际淋巴结清扫时间(即自系膜切开至D3淋巴结清扫完成的时间)、术中出血量、淋巴结清扫数目、中转开腹率及术后早期并发症发生率,两组手术均由同组医师完成.结果 右侧观察孔较中央观察孔更易于显露肠系膜下动脉及神经走行,手术均无中转,右侧观察孔和中央观察孔两组患者实际淋巴结清扫时间分别为(28.0±5.9)min和(33.1±6.1)min,差异有统计学意义(P=0.045);总手术时间分别为(140.3±16.7) min和(146.4±16.9)min,术中出血量分别为(59.6±17.6)ml和(63.3±14.4)ml,淋巴结清扫数目分别为(18.4±3.8)枚和(16.2±3.1)枚,术后住院时间分别为(8.2±2.2)天和(8.3±2.1)天,术后早期并发症发生率分别为7.7％(1/13)和16.7％(2/12),以上差异均无统计学意义(P＞0.05).结论 在腹腔镜直肠癌根治术中,右侧观察孔较中央观察孔更有利于手术野的显露,在肠系膜下动脉根部淋巴结清扫、分支血管保留及神经保护中具有优势.

目的 探讨同一术者腹腔镜下结直肠癌肝转移同期切除的临床疗效.方法 回顾性分析长征医院结直肠外科2014年2月至2017年4月实施的20例腹腔镜下结直肠癌肝转移同期切除的临床资料.结果 所有手术均顺利完成,无一例中转开腹.手术时间为175～280 min,平均216 min;出血量50～350 mL,平均140 mL;住院时间8～11 d,平均9.5 d;无一例出现术后严重并发症.随访4～39个月,1例死于腹腔转移,3例肝转移灶切除术后复发并再次给予切除.结论 腹腔镜下结直肠癌肝转移同期切除是安全和可行的.

Objective:To investigate the safety and feasibility of laparoscopic assisted left hemicolectomy with D3 lymph node dissection for descending colon and proximal sigmoid cancer with preservation of superior rectal artery.Methods:The clinical data of 13 patients underwent laparoscopic D3 lymph node dissection with preservation of superior rectal artery between Dec.2013 and Dec.2015 were retrospectively analyzed.There were 8 cases of proximal sigmoid colon cancer and 5 cases of descending colon cancer,of which,two cases with complete intestinal obstruction were treated by endoscopic stent placement,and underwent operation one week later after adequate preparation of gastrointestinal tract.The root of inferior mesentery artery was dissected by harmonic scalpel,then the artery wall was exposed to the root of left colic artery and several branches of sigmoid artery,which were cut with preservation of superior rectal artery.The inferior mesentery vein was cut at the point of joining to the splenic vein.Results:One case was lack of left colic artery,the left colic artery originating from sigmoid artery was found in one case,and two cases were lack of Riolan arcade.There was no conversion.The mean operation time was (148.1±15.5) min,the mean time from the first incision on the mesentery to accomplishing the D3 lymph node dissection was (44.9±11.8) min,the mean blood loss was (40.0±17.3) ml,the mean number of dissected lymph nodes was (21.9±4.5).The anastomosis was located at the middle or distal end of sigmoid.No anastomotic fistula occurred.There were no cases of side injury,accident bleeding and patient death originating from the lymph node dissection.One patient developed proximal intestinal obstruction 7 days after the operation,another developed chylous leakage,and all improved after conservative therapy.Conclusions:The laparoscopic D3 lymph node dissection with preservation of superior rectal artery for treatment of descending colon and proximal sigmoid cancer is safe and feasible,and it avoids excess resection of distal sigmoid.

腹腔镜胃癌手术开展至今已有20余年历史,随着医学理念及医疗器械领域的不断进步,腹腔镜胃癌手术近年发展迅速.目前,根据手术方式,腹腔镜胃癌手术主要包括小切口辅助、全腹腔镜及手助腹腔镜手术,而每一种术式又有多种消化道重建方式.越来越多的研究结果表明腹腔镜胃癌手术安全、可行.相较开放手术,腹腔镜胃癌手术具有操作精细、创伤小、康复快的优势,且已被证实手术疗效相当,目前已被越来越多的胃肠外科医生所认可.本文现就腹腔镜在胃癌手术中的应用历史及现状作一简要综述.

近年,随着微创理念的深入及医疗器械领域的快速发展,腹腔镜技术在胃肠手术中已得到广泛应用.尤其直肠癌手术中,由于盆腔操作空间狭窄,开腹手术操作困难且解剖不清晰,因此腔镜的优势更为凸显,目前已成为各大医院的主流术式[1].相较开放手术而言,腔镜手术尤其重视整个团队的默契及和谐配合,一台完美的腔镜手术必然是包括主刀、第一助手、持镜手等人,通过"眼和手"心领神会的协调配合而实现的.其中持镜手担当整个手术团队的"眼睛",他的表现直接关系到整台手术的顺利完成,以及手术的安全性、观赏性,甚至可决定手术的成功[2].近年有关腹腔镜手术持镜技巧的报道较多,最具代表性的即为李国新等提出的八字诀:"泡、擦、平、中、进、退、旋、跟",具有重要的临床指导意义[3].根据多年的临床实践,我们也总结了腹腔镜直肠癌手术中的一些持镜技巧及相关经验,具体如下.

Colorectal cancer (CRC) has a rising morbidity worldwide and its resistance to chemotherapy has been observed in clinical treatment. Tumor suppressor p53 is well-studied in CRC, but little is known about its effects during DNA damage of CRC cells. This study was aimed at uncovering potential mechanisms of p53 regarding microRNA-374b and v-akt murine thymoma viral oncogene homolog 1 (AKT1) during DNA damage of CRC cells. CRC cells HCT116 and HT29 were transfected with p53-specific small interfering RNA (siRNA), p53 overexpression vector or miR-374b inhibitor, and then treated with 10 µM bleomycin (BLM) for 24 h to induce DNA damage. Primary (pri), precursor (pre) and mature miR-374b levels were quantified by qRT-PCR. AKT1 and p53 protein levels were detected by western blotting. Cell apoptosis changes were assessed by flow cytometry. AKT1 mRNA was detected to be induced by BLM treatment (P<0.05), but its protein level was strongly inhibited. Knockdown of p53 reversed the inhibition of AKT1 protein by BLM. Overexpression of p53 in p53-knockout HCT116 and HT29 cells upregulated the AKT1 regulator miR-374b (P<0.05), and knockdown of p53 reversed the induction of miR-374b by BLM. qRT-PCR suggested that besides mature miR-374b, p53 could also promote pre-miR-374b level (P<0.05), rather than pri-miR-374b. Moreover, inhibition on miR-374b relieved the suppressed AKT1 protein, and reduced cell apoptosis induced by BLM. These data depict the p53/miR-374b/AKT1 signaling that may regulate BLM-induced apoptosis in CRC cells, thus facilitating to improve the outcome of chemotherapy in CRC.

Objective:To investigate the influence of different specimen extraction methods on the prognosis of patients who underwent laparoscopic anterior resection of rectal cancer (L-Dixon).Method: A retrospective analysis was made on the clinical data of 80 cases, who were diagnosed as rectal cancer and treated by laparoscopic anterior resection (L-Dixon) from August 2012 to May 2013 in our hospital. The patients were averagely divided into group A and B. The operation specimens of the group A were extracted from the incision in lower left abdomen and resected outside of the abdomen. While the specimens of the group B were resected in the abdomen and removed through a similar incision by a laparoscopic specimen bag.Result:All the patients got successful operation without a protectivestoma and conversion to laparotomy or Miles operation. There were no significant differences about operation time, amount of blood loss, intestinal function recovery and postoperative hospital stay between two groups(P>0.05). For patients in the group B, the recurrence and metastasis rate within 2 years after surgery was significantly lower than that in the group A(P<0.05).Conclusion: Specimen extraction is very important in laparoscopic anterior resection of rectal cancer (L-Dixon). We must strictly follow the principle of “no-touch”. Resecting the specimen in the abdomen and removed by a laparoscopic specimen bag is very reasonable and safe. It can effectively reduce the risk of tumor metastasis.

目的：探讨腹腔镜辅助下超低位直肠癌ISR手术的疗效及相关的治疗体会。方法选择2011年7月至2013年5月，在本院实施腹腔镜辅助下内括约肌切除术的20例超低位直肠癌患者进行回顾性分析。结果所有患者手术顺利，无中转开腹及改行Miles术者，患者的手术时间为（152.5±12.5）分钟，术中出血量为（60±15）毫升；术后肠道功能恢复时间为（2.5±1.5）天；术后住院时间为（12.5±4.5）天；术后共出现1例（5%）吻合口瘘、1例（5%）血栓性外痔、2例（10%）吻合口狭窄；所有病人的末端回肠造口均在（8±2）月内还纳；造口还纳术后1、3、6、12月分别对患者的肛门功能进行评估，发现随着时间推移，肛门功能总体恢复良好。结论腹腔镜辅助下内括约肌切除术是一种安全、可行的手术方式，只要病人条件符合，均可尝试行该手术。

目的：探讨乙状结肠憩室穿孔的诊断与治疗。方法选择上海长征医院自2013年1月至2014年6月共收治的2例乙状结肠憩室穿孔患者进行回顾性分析。结果2例患者术前均未明确诊断，术中经探查证实，根据病情采取不同手术方式均获得成功。结论乙状结肠憩室在国内是一种罕见的疾病，易误诊，在临床工作中需充分重视，综合多种检查以明确，并根据患者的实际情况制定合适的治疗方案。

目的 探讨腹腔镜器下完成经肛微创手术治疗直肠肿瘤的可行性及疗效.方法 我院2012年6月至12月14例适合于局部切除的直肠良性肿瘤、类癌病例选择腹腔镜下经肛微创治疗.手术方法以肛管扩张器、手套联合切口保护套建立腹腔镜操作通路,使用腹腔镜/结肠镜作为照明和充气设备,超声刀完成直肠黏膜下切除或全层切除,全层切除创面采用可吸收线缝合.结果 14例患者手术过程顺利,无围手术期并发症.手术时间30 ～ 70 min,其中建立操作入路平均花费15 min.切除的肿瘤直径1.5 ～3.8cm,大体观和病理检查证实均为R0切除.随访6～12个月无复发及远期并发症.结论 使用腹腔镜器械设备完成经肛微创手术治疗直肠肿瘤安全有效,但该术式部分操作细节仍需改进.