BACKGROUND:Primary tumor resection with simultaneous para-aortic lymph node dissection has curative potential in selected patients with isolated infrarenal para-aortic lymph node metastasis secondary to colorectal cancer. However, para-aortic lymph node dissection is technically challenging, and en bloc resection is difficult. Traditional piecemeal removal may increase the risk of missing lymphatic tissue and contribute to local recurrence. IMPACT OF INNOVATION:A modified "lawn-mowing" technique is introduced for en bloc para-aortic lymph node dissection that simplifies this complex procedure. By initially identifying anatomical boundaries and then systematically removing lymph nodes in a sequential "lawn-mowing" manner, this approach maximizes lymphatic clearance and facilitates appropriate vessel ligation, potentially reducing recurrence and complications. TECHNOLOGY, MATERIALS, AND METHODS:There are 2 steps in the technique: 1) identification of boundaries: establishing the left (left ureter, gonadal vessels, and psoas), distal (left common iliac vein level), right (right ureter, gonadal vessels, and psoas), and proximal (left renal vein) boundaries; and 2) en bloc resection: sequential dissection from distal to proximal and right to left in a "lawn-mowing" pattern, collecting all para-aortic lymph nodes up to the left renal vein and ligating the main lymphatic vessels, superior and inferior to the left renal artery. Key considerations include preserving the sympathetic ganglia and avoiding injury to hemorrhage-prone veins. PRELIMINARY RESULTS:Successful en bloc para-aortic lymph node resection was achieved in a 26-year-old woman with sigmoid colon cancer and para-aortic metastasis. Surgery last 380 minutes and resulted in approximately 100 mL of blood loss. The patient was discharged without complications. Histopathological examination revealed 2 of 23 positive para-aortic lymph nodes. At the 9-month follow-up, there was no recurrence or formation of lymphocysts. CONCLUSIONS AND FUTURE DIRECTIONS:En bloc para-aortic lymph node resection using the "lawn-mowing" technique, after identification of boundaries, is feasible and reproducible. This simplified approach reduces the risk of lymphatic residue. Further evaluation in a larger series is required to assess oncological and functional outcomes. See New Technology Report Video.

BackgroundThe preoperative diagnosis of lateral lymph node metastasis presents a significant challenge. In this study, we aimed to predict the pathological characteristics of lateral lymph nodes in patients with rectal cancer using preoperative clinical information and to develop a logistic prediction model for lateral lymph node metastasis.MethodsA retrospective analysis of 143 patients who underwent total mesorectal excision (TME) and lateral lymph node dissection (LLND) at Tianjin Union Medical Center, from January 2017 to June 2024 was conducted. Patients were categorized into lateral lymph node metastasis and non-metastasis groups based on postoperative pathological findings. Basic information, tumor markers, and MRI reports were compared. Patients were segmented into training and validation sets at an 8:2 ratio. The R software was used to create a logistic prediction model and a nomogram.ResultsThis study included 66 pathologically positive and 77 pathologically negative lateral lymph node cases. Extramural vascular invasion (EMVI), MRI clinical N stage (MRI cN stage), and the number of enlarged lateral lymph nodes (NoELLN) were used to construct the logistic prediction model. The model achieved an accuracy of 0.62, sensitivity of 0.80, specificity of 0.43, and area under the curve (AUC) of 0.80 in predicting the pathological characteristics of lateral lymph nodes using the test dataset.ConclusionEMVI, MRI cN stage, and NoELLN are significant predictive factors for predicting lateral lymph node pathology in patients with rectal cancer. These findings offer guidance for determining patient eligibility for LLND surgery.

ObjectiveThis study aimed to investigate the role of TMEM59L in colorectal cancer (CRC) and its interaction with the TGF-β/Smad signaling pathway.MethodsWe analyzed the correlation between TMEM59L expression levels and patient survival, as well as its impact on the TGF-β/Smad signaling pathway, using data from The Cancer Genome Atlas (TCGA). Additionally, transwell, CCK-8, EdU, and colony formation assays were conducted to assess the effects of TMEM59L on CRC cell migration, invasion, and proliferation. Gene silencing and overexpression, along with specific inhibitors/agonists, were used to validate the involvement of TMEM59L in the regulation of the TGF-β/Smad signaling pathway.ResultsWe found that high TMEM59L expression was associated with poor patient survival and TGF-β pathway activation. After si-TMEM59L treatment, the migration and invasion abilities of CRC cells were reduced, while cell proliferation remained affected to a lesser extent. Additionally, the levels of TGF-β protein were decreased, and the phosphorylation of Smad2/3 was reduced. In vivo, TMEM59L knockdown reduced metastatic potential as demonstrated by decreased fluorescence intensity, while overexpression of TMEM59L increased metastatic potential, which was reversed by TGF-β inhibition.ConclusionTMEM59L may promote CRC metastasis by enhancing cell migration and invasion, with minimal impact on cell proliferation, potentially through the TGF-β/Smad signaling pathway.

BACKGROUND:The ligation of the inferior mesenteric artery (IMA) is the primary procedure during surgeries of the left colon, sigmoid colon, and rectal cancer. Despite the ongoing debate on high or low ligation of the IMA, high ligation (HL) is now preferred by most of the surgeons. However, there is still a lack of consistency in the exact position of HL among surgical videos or introductions presented by different teams, causing confusion to new learners. The fascia-oriented dissection could help to clarify this issue. RESULTS:This video shows two definite levels of HL, the supra-nerve HL and the infra-nerve HL based on three biological fasciae around the root of the IMA, with priority given to fascia-oriented dissection, HL of the IMA could be performed safely and efficiently, even in cases with enlarged para-IMA nodes. CONCLUSIONS:It is feasible to adopt the fascial space priority approach for HL of the IMA, and this approach is suitable for patients with enlarged para-IMA lymph nodes.

Introduction: Lateral lymph node dissection (LLND) has now been widely accepted as the optimal procedure to minimize lateral local recurrence (LLR) for selected cases with advanced lower rectal cancer in Asian countries. However, there is still controversy over the preservation or resection of the inferior vesical vessels (IVVs) during LLND due to concerns of impaired post-operative urinary function. Moreover, the standardized procedure for autonomic nerve preservation has not yet been established. Aim: To evaluate the early-stage postoperative voiding function in patients who underwent LLND with uni- versus bilateral resection of the IVVs and to introduce an autonomic nerve sparing technique with a fascial space priority Material and methods: LLND was performed in 106 consecutive patients with advanced low rectal cancer at Tianjin Union Medical Center from May 2017 to October 2022. Prospectively collected clinical data were retrospectively compared between patients who received uni-lateral and bilateral LLND. A video with narration was provided to introduce the stepwise procedure of autonomic nerve preservation during IVV resection. Results: The unilateral lymph node dissection (LND) group and the bilateral LND group included 75 and 31 cases, respectively. All LLNDs were performed with FSPA with IVV resection as a standard procedure. No significant differences were observed in overall catheterization days (p = 0.336) and re-catheterization rate (p = 0.575) between groups. No patients in either group suffered from long-term (>= 30 days) voiding dysfunction. Conclusions: Autonomic nerve sparing is achievable with resection of IVVs during LLND. Satisfactory early-stage voiding function could be obtained with IVV resection on both sides.

The urinary tract is one of the most frequently involved organs in advanced non-urologic pelvic malignances. Extensive resection of ureteric organs is mandatory during a curative surgery. Urinary reconstruction after partial ureterectomy, the most challenging situation, is associated with a higher incidence of complication than cystectomy, especially when performed with laparoscopy. Furthermore, to date, no generally accepted strategy for urinary reconstruction after extensive tumor resection with partial ureterectomy has been established. The study identified and scrutinized intraoperative videos and clinical records of patients with locally advanced or recurrent pelvic malignancies who underwent segmental ureterectomy during en bloc resection of advanced tumors between February 2020 and February 2024. The study enrolled nine patients, including four cases managed by ureteroureteral anastomosis, two cases managed by ureteroneocystomy, two cases managed by Boari flap reconstruction, and one case managed by ileal interposition. In all nine cases, R0 margins were obtained, and no case needed conversion to laparotomy. No clinical evidence of postoperative urinary leakage was identified. The median follow-up period was 14 months (range, 5–19 months). In three of the nine cases, recurrence was identified, at the 3rd, 18th, and 19th month follow-up evaluations, respectively. One patient died of systemic metastasis. Laparoscopic ureteric reconstruction is feasible for patients who undergo segmental ureterectomy during extensive surgery for locally advanced or recurrent pelvic malignancies. A low anastomotic leakage rate and favorable postoperative renal function could be achieved in this study when anastomosis was performed laparoscopically.

Etoposide is a second-line chemotherapy agent widely used for metastatic colorectal cancer. However, we discovered that etoposide treatment induced greater motility potential in four colorectal cancer cell lines. Therefore, we used microarrays to test the mRNA of these cancer cell lines to investigate the mechanisms of etoposide promoting colorectal cancer metastasis. Differentially expressed genes (DEGs) were identified by comparing the gene expression profiles in samples from etoposide-treated cells and untreated cells in all four colorectal cancer cell lines. Next, these genes went through the Gene Set Enrichment Analysis (GSEA), Gene Ontology (GO) and the Kyoto Encyclopedia of Genes and Genomes (KEGG) Pathway analysis. Among the top 10 genes including the upregulated and downregulated, eight genes had close interaction according to the STRING database: FAS, HMMR, JUN, LMNB1, MLL3, PLK2, STAG1 and TBL1X. After etoposide treatment, the cell cycle, metabolism-related and senescence signaling pathways in the colorectal cancer cell lines were significantly downregulated, whereas necroptosis and oncogene pathways were significantly upregulated. We suggest that the differentially expressed genes LMNB1 and JUN are potential targets for predicting colorectal cancer metastasis. These results provide clinical guidance in chemotherapy, and offer direction for further research in the mechanism of colorectal cancer metastasis.

BackgroundIt remains unclear whether combining neoadjuvant chemoradiotherapy (nCRT) with lateral lymph node dissection (LLND) improves survival in patients with rectal cancer suspected of lateral lymph node metastasis (LLNM) compared with LLND alone.MethodsA retrospective analysis of clinical data from rectal cancer patients from January 2017 to November 2022 was conducted. Univariate and multivariate Cox regression analyses were performed on patient clinical data, with a focus on identifying potential risk factors that affect disease-free survival (DFS) and overall survival (OS). Patients were divided into nCRT+LLND and LLND groups. K‒M survival curves and log-rank tests were used to analyze the survival outcomes of the different groups.ResultsThe study included 92 patients. Univariate Cox regression analysis revealed that intraoperative bleeding, pathological LLNM and histological type were associated with DFS. When these factors were included in multivariate Cox regression, pathological LLNM was identified as an independent risk factor for reduced DFS. There were no statistically significant differences between the nCRT+LLND and LLND groups when comparing survival curves for both DFS and OS.ConclusionIn rectal cancer patients with suspected LLNM, TME+LLND without nCRT may be a viable, yet to be validated, therapeutic strategy.

IntroductionLateral lymph node (LLN) metastasis in rectal cancer significantly affects patient treatment and prognosis. This study aimed to comprehensively compare the performance of various predictive models in predicting LLN metastasis.MethodsIn this retrospective study, data from 152 rectal cancer patients who underwent lateral lymph node (LLN) dissection were collected. The cohort was divided into a training set (n=86) from Tianjin Union Medical Center (TUMC), and two testing cohorts: testing cohort (TUMC) (n=37) and testing cohort from Gansu Provincial Hospital (GSPH) (n=29). A clinical model was established using clinical data; deep transfer learning models and radiomics models were developed using MRI images of the primary tumor (PT) and largest short-axis LLN (LLLN), visible LLN (VLLN) areas, along with a fusion model that integrates features from both deep transfer learning and radiomics. The diagnostic value of these models for LLN metastasis was analyzed based on postoperative LLN pathology.ResultsModels based on LLLN image information generally outperformed those based on PT image information. Rradiomics models based on LLLN demonstrated improved robustness on external testing cohorts compared to those based on VLLN. Specifically, the radiomics model based on LLLN imaging achieved an AUC of 0.741 in the testing cohort (TUMC) and 0.713 in the testing cohort (GSPH) with the extra trees algorithm.ConclusionData from LLLN is a more reliable basis for predicting LLN metastasis in rectal cancer patients with suspicious LLN metastasis than data from PT. Among models performing adequately on the internal test set, all showed declines on the external test set, with LLLN_Rad_Models being less affected by scanning parameters and data sources.

Objective: The aim of this study was to explore the clinical value of a radiomics prediction model based on T2 -weighted imaging (T2WI) and clinical indexes in predicting lateral lymph node (LLN) metastasis in rectal cancer patients. Methods: This was a retrospective analysis of 106 rectal cancer patients who had undergone LLN dissection. The clinical risk factors for LLN metastasis were selected by multivariable logistic regression analysis of the clinical indicators of the patients. The LLN radiomics features were extracted from the pelvic T2WI of the patients. The least absolute shrinkage and selection operator algorithm and backward stepwise regression method were adopted for feature selection. Three LLN metastasis prediction models were established through logistic regression analysis based on the clinical risk factors and radiomics features. Model performance was assessed in terms of discriminability and decision curve analysis in the training, verification and test sets. Results: The model based on the combined T2WI radiomics features and clinical risk factors demonstrated the highest accuracy, surpassing the models based solely on either T2WI radiomics features or clinical risk factors. Specifically, the model achieved an AUC value of 0.836 in the test set. Decision curve analysis revealed that this model had the greatest clinical utility for the vast majority of the threshold probability range from 0.4 to 1.0. Conclusion: Combining T2WI radiomics features with clinical risk factors holds promise for the noninvasive assessment of the biological characteristics of the LLNs in rectal cancer, potentially aiding in therapeutic decision -making and optimizing patient outcomes. (c) 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY -NC -ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Objective. This study aimed to explore the genes regulating lymph node metastasis in colorectal cancer (CRC) and to clarify their relationship with tumor immune cell infiltration and patient prognoses. Methods. The data sets of CRC patients were collected through the Cancer Gene Atlas database; the differentially expressed genes (DEGs) associated with CRC lymph node metastasis were screened; a protein–protein interaction (PPI) network was constructed; the top 20 hub genes were selected; the Gene Ontology functions and the Kyoto Encyclopedia of Genes and Genomes pathways were enriched and analyzed. The Least Absolute Shrinkage and Selection Operator (LASSO) regression method was employed to further screen the characteristic genes associated with CRC lymph node metastasis in 20 hub genes, exploring the correlation between the characteristic genes and immune cell infiltration, conducting a univariate COX analysis on the characteristic genes, obtaining survival-related genes, constructing a risk score formula, conducting a Kaplan–Meier analysis based on the risk score formula, and performing a multivariate COX regression analysis on the clinical factors and risk scores. Results. A total of 62 DEGs associated with CRC lymph node metastasis were obtained. Among the 20 hub genes identified via PPI, only calcium-activated chloride channel regulator 1 (CLCA1) expression was down-regulated in lymph node metastasis, and the rest were up-regulated. A total of nine characteristic genes associated with CRC lymph node metastasis (KIF1A, TMEM59L, CLCA1, COL9A3, GDF5, TUBB2B, STMN2, FOXN1, and SCN5A) were screened using the LASSO regression method. The nine characteristic genes were significantly related to different kinds of immune cell infiltration, from which three survival-related genes (TMEM59L, CLCA1, and TUBB2B) were screened. A multi-factor COX regression showed that the risk scores obtained from TMEM59L, CLCA1, and TUBB2B were independent prognostic factors. Immunohistochemical validation was performed in tissue samples from patients with rectal and colon cancer. Conclusion. TMEM59L, CLCA1, and TUBB2B were independent prognostic factors associated with lymphatic metastasis of CRC.

This study aimed to develop a radiomics model for predicting lateral lymph node (LLN) metastasis in rectal cancer patients using MR-T2WI and CT images, and assess its clinical value. This prospective study included rectal cancer patients with complete MR-T2WI and portal enhanced CT images who underwent LLN dissection at Tianjin Union Medical Center between June 2017 and November 2022. Primary lesions and LLN were segmented using 3D slicer. Radiomics features were extracted from the region of interest using pyradiomics in Python. Least absolute shrinkage and selection operator algorithm and backward stepwise regression were employed for feature selection. Three LLN metastasis radiomics prediction models were established via multivariable logistic regression analysis. The performance of the model was evaluated using receiver operating characteristic curve analysis, and the area under the curve (AUC), sensitivity, specificity were calculated for the training, validation, and test sets. A nomogram was constructed for visualization, and decision curve analysis (DCA) was performed to evaluate clinical value. We included 94 eligible patients in the analysis. For each patient, we extracted a total of 1344 radiomics features. The CT combined with MR-T2WI model had the highest AUC for all sets compared to CT and MR-T2WI models. AUC values for the CT combined with MR-T2WI model in the training, validation, and test sets were 0.957, 0.901, and 0.936, respectively. DCA revealed high prediction value for the combined MR-T2WI and CT model. A radiomics model based on CT and MR-T2WI data effectively predicted LLN metastasis in rectal cancer patients preoperatively.

目的 生物信息学分析寻找大肠癌(CRC)生物标志及治疗CRC的潜在中药.方法 检索并分析GEO数据库CRC相关的3个基因芯片(GPL27956、GSE128435和GSE156355),对差异表达基因(DEG)行GO与KEGG通路富集分析,从DEG中筛选关键基因,根据受试者工作特征曲线(ROC)下面积(AUC)值评估关键基因的诊断效能,绘制生存曲线,通过Coremine Medical对关键基因进行中药预测.结果 共得到41个DEG,4个关键基因(CD27、NEIL1、NLRP3、PRKACB),其中CD27、PRKACB、NEIL1表达预测CRC组织类型的AUC分别为0.889、0.889和0.833,CD27表达水平与CRC患者总生存期呈正相关.筛选出虎掌南星、秦皮、人参花等可能为CRC治疗潜在的分子药物来源.结论 筛选出了CRC候选关键基因及其潜在疗效相关中药,为CRC临床治疗的新靶点及新药研发提供了方向.

Objective:To analyze the learning curve of fascia space priority approach laparoscopic lateral lymph node dissection in rectal cancer by a retrospective study.Methods:The clinical data of 108 patients who had fascia space priority approach laparoscopic lateral lymph node dissection in the initial stage in Tianjin Union Medical Center from June 2017 to April 2022 were collected. CUSUM curve analysis was performed on the operative time and intraoperative blood loss, so as to obtain the learning curve of the technique. The cut-off value was determined by the learning curve and then group analysis was taken.Results:A total of 108 patients were included. The cut-off value of operation time and intraoperative blood loss was 30 cases analyzed by CUSUM curve, including 12 cases with bilateral dissection, so a total of 42 unilateral lateral node dissection were performed. The 108 patients were divided into 3 groups, including 30 cases in the learning improvement stage, thirty cases and 48 cases in the proficiency stage. There were no statistically significant differences in baseline level and pathological condition among the three groups, while there were statistically significant differences in operative time and intraoperative bleeding. Learning time in the learning improvement stage was significantly higher than that in the proficiency stage (442.7 min vs. 356.5 min, 428.4 min, F=10.768, P＜0.01). Intraoperative blood loss in the learning improvement stage was significantly higher than that in the proficiency stage (200 mL vs. 150 mL, 150 mL, H=8.839,P=0.012).Conclusion:In order to enter proficiency stage, thirty cases (42 unilateral) of fascia space priority approach laparoscopic lateral lymph node dissection are necessary, that means it can be considered to have passed the learning curve and mastered the technique after 30 cases (42 unilateral) of this procedure conducted.

Locally advanced tumor with involvement of surrounding tissues and organs is a common situation in pelvic malignancies. Up to 10% of newly diagnosed rectal cancer cases infiltrate to adjacent tissues and organs. Satisfactory resection margins obtained by pelvic exenteration can achieve a 5-year survival rate similar to cases that without adjacent tissue invasion. The 5-year survival rate of patients with locally recurrent pelvic malignancies is almost zero if they are treated only with radiotherapy and chemotherapy. To obtain negative margins through pelvic exenteration is the only chance for a long-term survival of these patients. However, pelvic exenteration is a complicated procedure with higher morbidity and mortality. The development of fascia anatomy enables surgeons to have a deeper understanding and comprehensive application of pelvic fasciae. Meanwhile, the improvement of laparoscopic technology provides a clearer view for surgeons and enables the application of minimally invasive techniques in complex pelvic exenteration. The fascial space priority approach is based on the fascia anatomy of pelvis and giving priority to the separation of the pelvic avascular fascial spaces, which provides a reproducible surgical approach for complex pelvic exenteration.

Locally advanced and locally recurrent rectal cancer pose significant challenges in their treatment. Although the comprehensive treatment approaches based on neoadjuvant chemoradiotherapy and targeted therapy are constantly innovated, surgery remains the only way for these patients to achieve promising oncological outcomes. Negative resection margin is an independent predictor of long-term survival. Total pelvic exenteration is commonly used for patients with locally advanced and locally recurrent rectal cancer involving the genitourinary system. It is expected that patients with locally advanced rectal cancer can achieve similar oncological prognosis as those without extramural invasion, and about 40%-50% of patients with locally recurrent rectal cancer can achieve satisfactory 5-year survival. However, due to its complexity and difficulty, total pelvic exenteration carries a higher morbidity rate and most surgeons are hesitant to perform it. With the development of fascial anatomy, the avascular spaces between pelvic fasciae have been gradually recognized and applied, which provides an anatomical basis for simplifying the surgery. We have summarized the approach of“fascia space priority approach”for total pelvic exenteration. During the total pelvic exenteration, the whole pelvic organs are considered as a whole. By separating the avascular spaces around the organ and preferentially controlling supply vessels and nerve branches, the surgical procedure is procedural, anatomically clear, safe, and reproducible.

Introduction: In this prospective observational study, we aimed to evaluate the consequences of laparoscopic fascia space priority lymph node dissection on urination and sexual function. Aim: To assess the consequences of laparoscopic lateral lymph node dissection (LLND) using the fascial space priority approach on urinary and sexual function in patients with advanced middle and low rectal cancer. Material and methods: Consecutive patients undergoing laparoscopic LLND using the fascial space priority approach from December 2020 to November 2022 were identified from Tianjin Union Medical Center. Clinical data including patient characteristics, surgical details, and pathology were analysed. The urinary function was assessed by international prostate symptom score (IPSS) questionnaire and residual urine volume. The sexual function was investigated using the international index of erectile function (IIEF) questionnaire. Results: A total of 51 patients, mean age 60.5 +/- 10.9 years, were identified. The lymph nodes were positive in 70.6% (36/51) of the patients. There was no significant difference between the preoperative IPSS score and that at 6 months (5.2 +/- 2.1 vs. 5.6 +/- 1.5; p = 0.16). And there was no significant difference between the residual urine volume and that at 6 months (9.5 +/- 10.6 vs. 8.6 +/- 6.3; p = 0.61). The IIEF score before the surgery showed no significant difference from that at 6 months after the surgery (21.1 +/- 2.2 vs. 20.6 +/- 2.3; p = 0.26). Conclusions: Laparoscopic LLND using a fascial space priority approach can effectively protect the autonomic nerves. The procedure reduces short-term urination and sexual function, but it has little effect on long-term function.