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Shrimanker N, Heller NP, Souza F, Kim DE. Late anastomotic perforation of the ileum 3 years after intestinal resection. BMJ Case Rep 2024; 17:e260668. [PMID: 39142848 DOI: 10.1136/bcr-2024-260668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024] Open
Abstract
Late perforation of the ileum is a rare and potentially life-threatening complication following intestinal resection. We present a unique case of a woman in her 60s with a history of appendiceal carcinoid tumour, who underwent a right hemicolectomy. Positron emission tomography and surveillance CTs showed normal surgical changes and no recurrent malignancy. Three years postoperatively, she presented with severe abdominal pain. CT revealed a perforation along the ileal wall of the ileocolonic anastomosis. She underwent emergent resection and repeat ileocolonic anastomosis. We conclude that the patient had subclinical ischaemia of the anastomosis, which eventually progressed to perforation 3 years later. We discuss a literature review on late small intestinal anastomotic perforations and their associated risk factors. Our case and literature review emphasise the importance of considering delayed anastomotic leak in postoperative patients with a history of intestinal cancer, inflammatory bowel disease, Roux-en-Y enteroenterostomy or side-to-side anastomosis.
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Affiliation(s)
| | - Nathan P Heller
- Department of Medicine, Greenwich Hospital, Greenwich, Connecticut, USA
| | - Fabiola Souza
- Department of Pathology, Greenwich Hospital, Greenwich, Connecticut, USA
| | - Daniel E Kim
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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Liu J, Wang X, Chen H, Mei S, Qiu W, Tang J. Risk factors, quality of life, and oncological effects of refractory anastomotic leakage for laparoscopic intersphincteric resection. J Gastroenterol Hepatol 2023; 38:1934-1941. [PMID: 37394244 DOI: 10.1111/jgh.16270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 05/28/2023] [Accepted: 06/12/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND AND AIM Refractory anastomotic leakage (RAL) after intersphincteric resection (ISR) usually leads to failure of protective stoma reversal in ultralow rectal cancers. The aim of this study is to assess the risk factors and oncological outcomes of both anastomotic leakage (AL) and RAL, and quality of life (QoL) of RAL after laparoscopic ISR (LsISR). METHODS A total of 371 ultralow rectal cancer patients with LsISR were enrolled from a tertiary colorectal surgery referral center. Risk factors for AL and RAL were identified by logistic regression. Three-year disease-free survival (DFS) of AL and RAL was analyzed by the Cox regression. QoL of RAL group (compared with non-RAL group) was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires. RESULTS The rates of AL and RAL after LsISR accounted for 8.4% (31/371) and 4.6% (17/371) in this cohort, respectively. Non-left colic artery preservation (odds ratio [OR] = 3.491, P = 0.009), neoadjuvant chemoradiotherapy (nCRT) (OR = 6.038, P < 0.001), and lower anastomosis height (OR = 5.271, P = 0.010) were independent risk factors for AL, while nCRT (OR = 11.602, P < 0.001) was the only independent risk factor for RAL. Male (hazard ratio [HR] = 1.989, P = 0.014), age > 60 years (HR = 1.877, P = 0.018), and lymph node metastasis (HR = 2.125, P = 0.005) were independent risk factors of poor 3-year DFS, but not RAL (P = 0.646). RAL patients have significantly worse global health status, worse emotional and social function scores at the late postoperative stage, and worse urinary and sexual function at the early postoperative stage (all P < 0.05). CONCLUSIONS Neoadjuvant chemoradiotherapy was an independent risk factor for RAL after LsISR. RAL shows similar oncological outcomes, but with poor QoL.
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Affiliation(s)
- Junguang Liu
- Department of General Surgery, Peking University First Hospital, Beijing, China
| | - Xiaolin Wang
- Department of General Surgery, The Second Hospital of Yulin, Yulin, China
| | - Hekai Chen
- Department of General Surgery, Tianjin Fifth Central Hospital, Tianjin, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenlong Qiu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Kitaguchi D, Hasegawa H, Ando K, Ikeda K, Tsukada Y, Nishizawa Y, Ito M. Can the Single-stapling Technique Following Intersphincteric Resection with Transanal Total Mesorectal Excision Become the New Standard Anastomosis? J Anus Rectum Colon 2023; 7:232-240. [PMID: 37900691 PMCID: PMC10600260 DOI: 10.23922/jarc.2023-026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/19/2023] [Indexed: 10/31/2023] Open
Abstract
For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.
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Affiliation(s)
- Daichi Kitaguchi
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Koji Ando
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Liu F, Zhang B, Xiang J, Zhuo G, Zhao Y, Zhou Y, Ding J. Does anastomotic leakage after intersphincteric resection for ultralow rectal cancer influence long-term outcomes? A retrospective observational study. Langenbecks Arch Surg 2023; 408:394. [PMID: 37816844 DOI: 10.1007/s00423-023-03131-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/02/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To determine whether anastomotic leakage (AL) following intersphincteric resection (ISR) for ultralow rectal cancer (uLRC) is associated with long-term negative outcomes. METHODS Between June 2011 and January 2022, 236 consecutive patients who underwent ISR with diverting ileostomy for uLRC were included. The primary outcome was long-term clinical consequences of AL, including chronic stricture, stoma reversal, and oncological and functional results. RESULTS Forty-one (17.4%) patients developed symptomatic AL, whereas only two (0.8%) required re-laparotomy due to severe leakage. Patients with leaks had a significantly increased incidence of chronic stricture (29.3% vs. 8.7%, P = 0.001) and stoma non-reversal (34.1% vs. 4.6%, P < 0.0001) than controls. The severe consequences were particularly common in patients with anastomotic separation, resulting in 60% of those presenting with chronic stricture and 50% ending up with stoma non-reversal. After a median follow-up of 59 (range, 7-139) months, AL did not compromise long-term oncological outcomes, including tumor recurrence (9.8% vs. 5.6%, P = 0.3), 5-year disease-free, and overall survival (73.4% vs. 74.8% and 85.1% vs. 85.4%, P = 0.56 and P = 0.55). A total of 149 patients with bowel continuity who completed self-assessment questionnaires were enrolled for functional evaluation. The median follow-up was 24 (range, 12-94) months after ileostomy reversal, and functional results were comparable between patients with and without leaks. CONCLUSION AL is an unfortunate reality for patients who underwent ISR for uLRC, but the rate of severe leakage is limited. Leaks contribute to possible adverse impacts on chronic stricture and stoma non-reversal, especially for patients with anastomotic separation. However, long-term oncological and functional results may not be compromised. TRIAL REGISTRATION Chictr.org.cn identifier: ChiCTR-ONC-15007506 and ChiCTR2100051614.
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Affiliation(s)
- Feifan Liu
- Postgraduate Training Base of Jinzhou Medical University, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Bin Zhang
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Jianbin Xiang
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Guangzuan Zhuo
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Yujuan Zhao
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China
| | - Yiming Zhou
- Department of General Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianhua Ding
- Department of Colorectal Surgery, the Characteristic Medical Center of PLA Rocket Force, Beijing, 100088, China.
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Ou W, Wu X, Zhuang J, Yang Y, Zhang Y, Liu X, Guan G. Clinical efficacy of different approaches for laparoscopic intersphincteric resection of low rectal cancer: a comparison study. World J Surg Oncol 2022; 20:43. [PMID: 35193605 PMCID: PMC8862381 DOI: 10.1186/s12957-022-02521-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background The operative results of different approaches for the laparoscopic intersphincteric resection (LAISR) of low rectal cancer vary, and the patient characteristics associated with the best outcomes for each procedure have not been reported. We compared the efficacy of different approaches for LAISR of low rectal cancer and discussed the surgical indications for each approach. Methods We retrospectively reviewed data from 235 patients with low rectal cancer treated via LAISR from October 2010 to September 2016. Patients underwent either the transabdominal approach for ISR (TAISR, n = 142), the transabdominal perineal approach for ISR (TPAISR, n = 57), or the transanal pull-through approach for ISR (PAISR, n = 36). Results The PAISR and TAISR groups exhibited shorter operation times and less intraoperative blood loss than the TPAISR group. The anastomotic distance was shorter in the PAISR and TPAISR groups than in the TAISR group. No differences in the ability to perform radical resection, overall complications, postoperative recovery, Wexner score recorded 12 months after ostomy closure, 3-year disease-free survival, local recurrence-free survival, distant metastasis-free survival, or overall survival (OS) were observed among the three groups. Conclusions TAISR, TPAISR, and PAISR have unique advantages and do not differ in terms of operation safety, patient outcomes, or anal function. TPAISR requires a longer time to complete and is associated with more bleeding and a slower recovery of anal function. PAISR should be considered when TAISR cannot ensure a negative distal margin and the tumor and BMI are relatively small; otherwise, TPAISR is required.
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Affiliation(s)
- Wenquan Ou
- Department of General Surgery, Affiliated Nanping First Hospital, Fujian Medical University, 317 Zhongshan Road, Nanping, 353000, Fujian, China
| | - Xiaohua Wu
- Department of General Surgery, Affiliated Nanping First Hospital, Fujian Medical University, 317 Zhongshan Road, Nanping, 353000, Fujian, China
| | - Jinfu Zhuang
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Yuanfeng Yang
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Yiyi Zhang
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China
| | - Xing Liu
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China. .,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fujian Medical University, 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
| | - Guoxian Guan
- Department of Colorectal Surgery, Affiliated First Hospital, Fujian Medical University, 20 Chazhong Road, Fuzhou, 350005, Fujian, China. .,Department of Colorectal Surgery, Fujian Medical University Union Hospital, Fujian Medical University, 29 Xinquan Road, Fuzhou, 350001, Fujian, China.
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Latest Advances in Intersphincteric Resection for Low Rectal Cancer. Gastroenterol Res Pract 2020; 2020:8928109. [PMID: 32765603 PMCID: PMC7387965 DOI: 10.1155/2020/8928109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR. Methods A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR. Results Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter. Conclusions The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.
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Influence of concurrent capecitabine based chemoradiotherapy with bevacizumab on the survival rate, late toxicity and health-related quality of life in locally advanced rectal cancer: a prospective phase II CRAB trial. Radiol Oncol 2020; 54:461-469. [PMID: 32738130 PMCID: PMC7585344 DOI: 10.2478/raon-2020-0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 06/13/2020] [Indexed: 01/02/2023] Open
Abstract
Background Few studies reported early results on efficacy, toxicity of combined modality treatment for locally advanced rectal cancer (LARC) by adding bevacizumab to preoperative chemoradiotherapy, but long-term data on survival, and late complications are lacking. Further, none of the studies reported on the assessment of quality of life (QOL). Patients and methods After more than 5 years of follow-up, we updated the results of our previous phase II trial in 61 patients with LARC treated with neoadjuvant capecitabine, radiotherapy and bevacizumab (CRAB study) before surgery and adjuvant chemotherapy. Secondary endpoints of updated analysis were local control (LC), disease free (DFS) and overall survival (OS), late toxicity and longitudinal health related QOL (before starting the treatment and one year after the treatment) with questionnaire EORTC QLQ-C30 and EORTC QLQ-CR38. Results Median follow-up was 67 months. During the follow-up period, 16 patients (26.7%) died. The 5-year OS, DFS and LC rate were 72.2%, 70% and 92.4%. Patients with pathological positive nodes or pathological T3–4 tumors had significantly worse survival than patients with pathological negative nodes or T0–2 tumors. Nine patients (14.8%) developed grade 33 late complications of combined modality treatment, first event 12 months and last 87 months after operation (median time 48 months). Based on EORTC QLQ-C30 scores one year after treatment there were no significant changes in global QOL and three symptoms (pain, insomnia and diarrhea), but physical and social functioning significantly decreased. Based on QLQ-CR38 scores body image scores significantly increase, problems with weight loss significantly decrease, but sexual dysfunction in men and chemotherapy side effects significantly increase. Conclusions Patients with LARC and high risk factors, such as positive pathological lymph nodes and high pathological T stage, deserve more aggressive treatment in the light of improving long-term survival results. Patients after multimodality treatment should be given greater attention to the regulation of individual aspects of quality of life and the occurrence of late side effects.
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Du P, Wang SY, Zheng PF, Mao J, Hu H, Cheng ZB. Comparison of overall survival and quality of life between patients undergoing anal reconstruction and patients undergoing traditional lower abdominal stoma after radical resection. Clin Transl Oncol 2019; 21:1390-1397. [PMID: 31006088 DOI: 10.1007/s12094-019-02106-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 03/18/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Miles procedure is often necessary for patients with low rectal carcinoma. However, this operation often affects the quality of life of patients, to evaluate the advantages of improved operation (anal reconstruction), the quality of life and survival between patients undergoing anal reconstruction and patients undergoing traditional lower abdominal stoma after radical resection were analyzed. METHODS The clinical data of 43 patients with low situated rectal carcinoma were retrospectively analyzed. 23 patients with left lower abdominal stoma after radical resection (Miles procedure) were divided into group A, and 20 patients with reconstruction of the anus in situ after radical resection were in group B. All patients were investigated by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-CR38 questionnaire, the clinical data are recorded. Independent sample T test was used to analyze the difference in quality of life between group A and group B at 3, 6, and 12 months after surgery, and Kaplan-Meier was used to compare the difference in overall survival between group A and group B. RESULTS The results of T test showed that there were statistical significance in global health status and physical functioning between group A and group B at 3 and 6 months, but no statistical significance at 12 months (P = 0.024, P = 0.019, P = 0.115 for global health status; P = 0.004, P = 0.006, P = 0.065 for physical functioning, respectively). Emotional functioning and social functioning were also statistically significant between group A and group B at 3, 6, and 12 months (P = 0.041, P = 0.040, P = 0.034 for Emotional functioning; P = 0.020, P = 0.009, P = 0.032 for social functioning, respectively). This study also found that there was no statistical significance in body image and sexual functioning between group A and group B at 3 months, but there was statistical significance at 6 and 12 months(P = 0.098, P = 0.035, P = 0.045 for body image; P = 0.110, P = 0.048, P = 0.047 for sexual functioning, respectively). There were statistically significant about sexual enjoyment and defecation problems at 3, 6, and 12 months (P = 0.023, P = 0.028, P = 0.050 for sexual enjoyment; P = 0.013, P = 0.011, P = 0.050 for defecation problems, respectively).The results of Kaplan-Meier showed that the overall survival (OS) between group A and group B was not statistically significant (χ2 = 0.600, P = 0.439). CONCLUSIONS There was no difference in survival time between group A and group B, but compared with the patients with left lower abdominal stoma(group A), the quality of life was better in patients with reconstruction of the anus in situ (group B). It is significant to improve the traditional lower abdominal stoma operation.
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Affiliation(s)
- P Du
- The Department of General Surgery, Second Hospital of Lanzhou University, No. 82, Cuiying Gate, Chengguan District, Lanzhou, 730030, Gansu, China
| | - S-Y Wang
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, China
| | - P-F Zheng
- The Department of General Surgery, Second Hospital of Lanzhou University, No. 82, Cuiying Gate, Chengguan District, Lanzhou, 730030, Gansu, China
| | - J Mao
- The Department of General Surgery, Second Hospital of Lanzhou University, No. 82, Cuiying Gate, Chengguan District, Lanzhou, 730030, Gansu, China
| | - H Hu
- Second Clinical Medical College, Lanzhou University, Lanzhou, 730030, Gansu, China
| | - Z-B Cheng
- The Department of General Surgery, Second Hospital of Lanzhou University, No. 82, Cuiying Gate, Chengguan District, Lanzhou, 730030, Gansu, China.
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