Transanal endoscopic microsurgery versus radical resection for early-stage rectal cancer: a systematic review and meta- analysis

PURPOSE

In the treatment of early-stage rectal cancer, a growing number of studies have shown that transanal endoscopic microsurgery is one of the alternatives to radical surgery adhering to total mesorectal excision that can reduce the incidence of adverse events without compromising treatment outcomes. The purpose of this meta-analysis is to compare the safety and treatment effect of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision to provide a basis for clinical treatment selections.

METHOD

We searched the literatures of four major databases, PubMed, Embase, Web of science, and Cochrane Library, without limitation of time. The literatures included randomized controlled studies and cohort studies comparing two surgical procedures of transanal endoscopic microsurgery and radical surgery adhering to total mesorectal excision. Treatment effectiveness and safety results of transanal endoscopic microsurgery and radical surgery were extracted from the included literatures and statistically analyzed using RevMan5.4 and stata17.

RESULT

Ultimately, 13 papers were included in the study including 5 randomized controlled studies and 8 cohort studies. The results of the meta-analysis showed that the treatment effect and safety of both transanal endoscopic microsurgery and radical surgery in distant metastasis (RR, 0.59 (0.34, 1.02), P > 0.05), overall recurrence (RR, 1.49 (0.96, 2.31), P > 0.05), disease-specific-survival (RR, 0.74 (0.09, 1.57), P > 0.05), dehiscence of the sutureline or anastomosis leakage (RR, 0.57 (0.30, 1.06), P > 0.05), postoperative bleeding (RR, 0.47 (0.22, 0.99), P > 0.05), and pneumonia (RR, 0.37, (0.10, 1.40), P > 0.05) were not significantly different. However, they differ significantly in perioperative mortality (RR, 0.26 (0.07, 0.93, P < 0.05)), local recurrence (RR, 2.51 (1.53, 4.21), P < 0.05),_overall survival_ (RR, 0.88 (0.74, 1.00), P < 0.05), disease-free-survival (RR, 1.08 (0.97, 1.19), P < 0.05), temporary stoma (RR, 0.05 (0.01, 0.20), P < 0.05), permanent stoma (RR, 0.16 (0.08, 0.33), P < 0.05), postoperative complications (RR, 0.35 (0.21, 0.59), P < 0.05), rectal pain (RR, 1.47 (1.11, 1.95), P < 0.05), operation time (RR, -97.14 (-115.81, -78.47), P < 0.05), blood loss (RR, -315.52 (-472.47, -158.57), P < 0.05), and time of hospitalization (RR, -8.82 (-10.38, -7.26), P < 0.05).

CONCLUSION

Transanal endoscopic microsurgery seems to be one of the alternatives to radical surgery for early-stage rectal cancer, but more high-quality clinical studies are needed to provide a reliable basis.

[Association between dietary vitamin A intake and gestational diabetes mellitus in the first trimester]

Objective: To investigate the relationship between dietary vitamin A intake and its sources in the first trimester and gestational diabetes mellitus (GDM). Methods: A prospective study was conducted to select women at 6-14 weeks of gestation in an obstetric clinic of a maternal and child health care medical institution in Chengdu in 2017. The types and quantities of food during the first trimester were collected by 3-day 24-hour dietary recalls. Dietary vitamin A intake was calculated based on the Chinese Food Composition Table (2018), and it was divided into animal and plant vitamin A intakes according to its food sources. An oral glucose tolerance test was performed at 24-28 weeks of gestation to diagnose GDM according to the Chinese guidelines for diagnosis and treatment of gestational diabetes mellitus (2014). According to the estimated average requirement (EAR) and recommended nutrient intake (RNI), dietary vitamin A intake was divided into low-level group (<EAR), medium-level group (EAR-RNI) and high-level group (>RNI). Animal and plant vitamin A intakes were divided into four groups (Q1-Q4) according to the quartile method, respectively. The association between dietary vitamin A intake, its different sources of vitamin A intake and GDM in the first trimester was analyzed by log-binomial regression models. Results: A total of 1 298 valid samples were finally included. The average dietary vitamin A intake, animal and plant vitamin A intakes in the first trimester were 341.1 (227.8-501.0) μgRAE/d, 139.3 (69.6-195.3) μgRAE/d and 184.2 (99.4-301.1) μgRAE/d, respectively. After adjusting for confounding factors, log-binomial regression analysis showed that the risk of GDM in high-level group of dietary vitamin A intake was lower than that in low-level group [RR (95%CI):0.53 (0.36-0.80)]. Pregnant women in the highest quartile of animal vitamin A intake had a lower risk of GDM than those in the lowest quartile [RR (95%CI):0.66 (0.47-0.95)]. No relationship between plant vitamin A intake and GDM was found. Conclusion: Dietary vitamin A intake in the first trimester is associated with the occurrence of GDM, and higher intake than RNI may reduce the risk of GDM. Higher vitamin A intake from animal-derived food is associated with decreased risk of GDM.

[Association between dietary glycemic load during first trimester and the risk of gestational diabetes mellitus: a prospective study]

Objective: To explore the effects of dietary glycemic load (GL) during first trimester on the risk of gestational diabetes mellitus (GDM). Methods: A prospective study was conducted among healthy women with singleton pregnancy at 8-14 weeks of gestation in a maternity out-patient clinic of maternal-and-child health care institution in Chengdu, Sichuan province. Information on dietary intake during the first trimester was collected through a 3-day 24-hour dietary recall. Glycemic index (GI) values were obtained from China Food Composition Tables (Standard Edition) and International Tables of Glycemic Index and Glycemic Load Values (2008). Dietary GL and GLs of staple foods were calculated based on GI values and the amount of carbohydrate consumed per day. Diagnostic criteria of GDM was followed the Guidelines for Diagnosis and Treatment of Pregnancy Diabetes in China (2014), and used on participants who underwent an oral glucose tolerant test during 24-28 weeks of gestation. Log-binomial regression models were used to explore the associations between both quartiles of dietary GL, GLs of staple foods and the risks of GDM,respectively. Results: The medians of dietary GL and GL of staple foods were 145.70 (113.23-180.85) and 121.05 (89.08-155.70), respectively. The median GL of both rice and tubers were 73.14 (43.89-107.50) and 3.43 (0.00-9.84), respectively. After adjusting for the age at pregnancy, pre-pregnancy body mass index and other confounding factors, results of log-binomial regressions analysis showed that when compared with the lowest quartile of dietary GL group, the third and highest quartiles of dietary GL groups increased the risk of GDM (RR=1.47, 95%CI: 1.20-1.80; RR=1.31, 95%CI: 1.04-1.64), respectively. Compared with the lowest quartile of GL of staple foods, the third and highest quartiles of GL of staple foods groups also increased the risk of GDM (RR=1.28, 95%CI: 1.04-1.58; RR=1.27, 95%CI: 1.02-1.60), respectively. The third and highest quartiles of GL of rice groups increased the risk of GDM (RR=1.30, 95%CI: 1.06-1.59; RR=1.28, 95%CI: 1.03-1.59), respectively, than the lowest quartile of GL of rice group. When compared with the lowest quartile of GL of tubers group, the highest quartile of GL of tubers group increased the risk of GDM (RR=1.30, 95%CI: 1.09-1.54). However, we did not notice the effects of wheat GL and coarse grain GL on the risk of GDM. Conclusions: A positive association was found between dietary glycemic load and the risk of GDM. Higher dietary glycemic load, especially in rice and tubers during first trimester, seemed to have increased the risk of GDM.

Dynamics of methanogenesis, ruminal fermentation, and alfalfa degradation during adaptation to monensin supplementation in goats

This study aimed to examine the temporal (hourly within a day and daily over the long term) effects of monensin on CH₄ emissions, ruminal fermentation, and in situ alfalfa degradation in dairy goats during dietary monensin supplementation by controlling the confounding effects of feed intake and ambient temperature. Six ruminally cannulated dairy goats were used, and they were housed in environmental chambers and fed a restricted amount of ration throughout the experiment. The experiment included a baseline period of 20 d followed by a treatment period of 55 d with 32 mg of monensin/d. During the whole experiment, CH₄ production was measured every 5 d, whereas fermentation characteristics and in situ alfalfa degradation were analyzed every 10 d. The CH₄-depressing effect of monensin was time dependent on the duration of treatment, highly effective at d 5 but thereafter decreased gradually until d 55 even though CH₄-suppressing effect still remained significant. The decreasing effects of monensin on ruminal acetate proportion and acetate to propionate ratio also faded over days of treatment, and the acetate proportion returned up to the pre-supplementation level on d 50. Monensin supplementation elevated ruminal propionate proportion and decreased the effective ruminal degradability of alfalfa NDF, but both measurements tended to recover over time. The postprandial increase rate of hourly CH₄ emissions was reduced, whereas that of propionate proportion was enhanced by monensin supplementation. However, the postprandial responses to monensin in CH₄ emission rates, ruminal VFA profiles, and in situ degradation kinetics declined with both hours after feeding and days of treatment. Our results suggest that the CH₄-suppressing effect of monensin supplementation in goats was attributed to reductions in both ruminal feed degradation and acetate to propionate ratio, but those reductions faded with time, hours after feeding, and days of treatment.

Dietary supplementation with Lactobacillus fermentum I5007 improves the anti-oxidative activity of weanling piglets challenged with diquat

AIMS

To determine the effects of Lactobacillus fermentum I5007 on the redox state of piglets oxidatively stressed with diquat.

METHODS AND RESULTS

Twenty-four, 28-day-old barrows were used in a 2 × 2 factorial design experiment with the main effects being Lact. fermentum supplementation and diquat challenge. Half of the pigs (n = 12) were orally administered with 20 ml of a solution containing 10(8 ) CFU ml(-1) of Lact. fermentum each morning of the 21-day trial, while the remainder received saline. On day 8, these two groups were further subdivided so that half of the pigs in each group (n = 6) were intraperitoneally injected with 10 mg kg(-1) BW diquat, while the remainder received saline. The diquat-injected pigs had significantly poorer performance and increased levels of plasma cortisol, adrenaline, carbonyl and malondialdehyde. Lactobacillus fermentum supplementation significantly increased superoxide dismutase and glutathione and increased the ability to inhibit superoxide anion production in liver and muscle.

CONCLUSIONS

Lactobacillus fermentum improved the anti-oxidative defence system and alleviated damage caused by diquat.

SIGNIFICANCE AND IMPACT OF THE STUDY

Lactobacillus fermentum has the potential to alleviate oxidative stress and improve weaning pig performance.

Alleviation of ischemia-reperfusion injury in rat liver transplantation by induction of small interference RNA targeting Fas

BACKGROUND

Cellular apoptosis plays an important role in ischemia-reperfusion (I/R) injury during organ transplantation. Synthetic small interference RNA (siRNA) targeting apoptotic receptor Fas has proven effective to protect mice against hepatitis and renal I/R injury. The objective of this study is to investigate the silencing impact of Fas siRNA to alleviate I/R injury in rat liver transplantation.

MATERIALS AND METHODS

Rat hepatocytes (BRL cells) were transfected with three pairs of synthesized Fas siRNA; cells untreated and treated with GFP siRNA were taken as blank and siRNA control. The most effective Fas siRNA was chosen for in vivo experiments. Syngeneic orthotopic liver transplantation was performed in Fas siRNA group, siRNA control group, and blank control group of Sprague-Dawley rats. There were 25 pairs of rats in each group. siRNA transfection of donor rats was done with hydrodynamic injection method 48 h before liver procurement. Blood and liver samples were collected for evaluation of serum ALT levels, Fas protein and mRNA expression, and apoptosis by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) staining, 1, 3, 6, 12, and 24 h after liver transplantation.

RESULTS

Fas siRNA2, which inhibited Fas gene expression much more than other siRNAs, was chosen for in vivo experiment. The serum ALT levels of Fas siRNA group were much less than those of blank and siRNA control groups 1, 3, 6, 12, and 24 h after blood reperfusion, indicating diminishing ischemia-reperfusion injury. Donor livers in Fas siRNA group had substantially less cell apoptosis. The expression of Fas mRNA and protein was reduced dramatically in the Fas siRNA group compared with the other two groups.

CONCLUSION

Fas-mediated apoptosis play an important role in I/R injury of rat liver transplantation. Silencing Fas by hydrodynamic injection of siRNA holds therapeutic promise to limit I/R injury.

[Clinical study of prophylactic use of gentamicin and metronidazole in the surgery of colorectal carcinoma]

From Oct. 1989 to Apr. 1990, 16 patients with colorectal carcinoma undergoing elective radical resection were randomly divided into two groups to receive oral and combined (oral + i.v.) antimicrobials respectively. Patients in the oral group received preoperative oral gentamicin and metronidazole for two days, in the combined group oral medication was followed by the same antimicrobials intravenously during perioperative period. Quantitative bacterial cultures were performed before and after the regimen. Results showed that the preoperative prophylaxis with oral antimicrobial resulted in a significant reduction in the bacterial counts of the rectum contents in all the patients (P < 0.001). The NICs of gentamicin and metronidazole for E. coli and B. fragilis were found to be 2.31 micrograms/ml and 0.66 micrograms/ml respectively. The perioperative blood samples and the intraoperative tissue specimens were taken for gentamicin and metronidazole determination. In the oral group, effective concentration of metronidazole were found in serum and tissues but gentamicin was undetected. In the combined group, effective concentrations of both gentamicin and metronidazole were detected. According to our results, the short-term preoperative oral medications combined with perioperative intravenous gentamicin and metronidazole prophylaxis appears to rational.

[The mechanical stapler in rectal carcinoma]

Forty rectal carcinoma subjected to anterior resection using GF stapler during November 1979-March 1983 were reviewed. 32 were radical resections with the remaining 8 for palliation. 36 (90%) could be traced. 23/32 (73%) of the radical resection group survived for more than 5 years. Long-term follow-up showed that neither local recurrence nor 5 year survival was stapler-related. A stapler may facilitate the performance of a low anterior resection, but it is merely a form of technical improvement. Therefore, the principles of radical resection should still be strictly observed and indications for anterior resection should not be unconditionally extended.

Use of staplers on oesophagogastric varices

Thirty-five gastrofundic devascularization procedures were performed with the side-to-side CF stapler of Chinese manufacture for obliteration of oesophagogastric varices. Four patients were operated on as emergencies, six patients 2-3 weeks after control of bleeding by tamponade and the remaining twenty-five electively (including four patients who had not bled). There were two operative deaths, an operative mortality of 6 per cent. In all, 30 patients have been followed, 20 for 1-3 years and 10 for less than 1 year. Twenty-five patients had postoperative barium meal examination. The varices were ameliorated in 19, not changed in 5 and exacerbated in 1. Nine patients rebled and of these, two died. The stapler is used in devascularization to interrupt intramural varices in the oesophagocardiac region. It must be emphasized that its use is only a part of the devascularization procedure. When used alone devascularization is not complete. The side-to-side stapler appears to be a convenient, safe and rational instrument for use in devascularization.