| Objectives1 To explore the clinical distribution characteristics of TCM syndromes and symptoms of colorectal cancer before and after surgery.2 To establish SEM confirmatory models based on TCM syndromes and symptoms of colorectal cancer.3 To explore the correlation between TCM syndromes and symptoms,the main and accompanied symptoms,and the correlation between symptoms of colorectal cancer.Methods1 To search and review the literatures in recent ten years related to the clinical study of TCM syndromes of colorectal cancer and SEM application based on Chinese medicine.2 In four hospitals from the Jiangsu area,there were 2042 cases of clinical inpatient of colorectal cancer collected.1252 of the cases compliant with specific criteria having 120 unique TCM symptoms were extracted and entered into a MS Access 2007 database.Statistical analysis was conducted based on the descriptive and frequency analysis method with the use of SPSS 22.0 software.The distribution characteristics of TCM syndromes and symptoms of colorectal cancer before and after surgery,the general information and the characteristics of pathogenesis of colorectal cancer were summarized and concluded.3 For the main TCM syndromes and symptoms of colorectal cancer before and after surgery,SEM confirmatory models were generated with symptoms classified as explicit variables and syndromes classified as implicit variables using SPSS 22.0 software and AMOS analysis method based on the principle of better fit index.An overall fit degree for the models were evaluated and discussed.4 With the use of Maximum Likelihood Estimation method,the standardized regression weights for all models were estimated.The structural regression equations in the form of the correlation between syndromes and symptoms of colorectal cancer were generated based on the theories of TCM.Furthermore,the main and accompanied symptoms for colorectal cancer were retrieved.5 With the use of Maximum Likelihood Estimation method,the correlation coefficients for all models were estimated in order to analyze the correlation between symptoms of colorectal cancer.A preliminary interpretation of the correlation between symptoms of colorectal cancer was derived based on the theories of TCM.Results1 Literature StudyWith the use of literatures review,76 modern papers related to the clinical study of colorectal cancer syndromes and 8 modern papers related to the clinical study of SEM application based on Chinese medicine were collected.The current situation of TCM clinical study on colorectal cancer and clinical study of SEM application based on Chinese medicine were concluded,laying down the evidence-based theory for this research.2 Clinical study of colorectal cancer in Chinese medicine(1)Among the 1252 clinical cases of colorectal cancer in Jiangsu Area,there were 493 clinical cases before surgery and 759 clinical cases after surgery.(2)Among the 1252 cases of colorectal cancer,male patients were the majority(58.3%),onset age between 50?79 years old was the majority(75.9%)and the average age was 62.84 years old,96.8%of patients married,99.7%was Genus Han,86.3%was born in Jiangsu area,retired patients were the majority(52.6%),hypertension was the majority(36.6%),patients with a history of smoking and drinking accounted for 15.6%and 11.4%respectively.(3)Among the 493 cases of colorectal cancer before surgery,male patients were the maj ority(5 9%),onset age between 50?79 years old was the majority(72%)and the average age was 63.78 years old,95.1%of patients married,99.8%was Genus Han,82.8%was born in Jiangsu area,retired patients were the majority(48.5%),hypertension was the majority(38.9%),patients with a history of smoking and drinking accounted for 17.2%and 13.4%respectively.(4)Among the 759 cases of colorectal cancer after surgery,male patients were the majority(57.8%),onset age between 50?79 years old was the majority(78.5%)and the average age was 62.23 years old,97.9%of patients married,99.6%was Genus Han,88.5%was born in Jiangsu area,retired patients were the majority(55.2%),hypertension was the majority(35%),patients with a history of smoking and drinking accounted for 14.5%and 10.1%respectively.(5)Among the 1252 cases of colorectal cancer,the ascending sequence of onset positions were sigmoid colon,hepatic flexure,ascending colon,transverse colon,rectum,ileocecum,descending colon and splenic flexure.The ascending sequence of histological classification of colorectal cancer were adenocarcinoma,mucinous adenocarcinoma,adenocarcinoma with partial mucinous adenocarcinoma,adenocarcinoma with signet-ring cell carcinoma,mucinous adenocarcinoma with signet-ring cell carcinoma,mucinous adenocarcinoma with partial mucinous adenocarcinoma and partial signet-ring cell carcinoma.(6)Among the 493 cases of colorectal cancer before surgery,the ascending sequence of onset positions were sigmoid colon,ascending colon,transverse colon,hepatic flexure,descending colon,ileocecum,rectum and splenic flexure.The ascending sequence of histological classification of colorectal cancer were adenocarcinoma,adenocarcinoma with partial mucinous adenocarcinoma,mucinous adenocarcinoma,adenocarcinoma with signet-ring cell carcinoma.(7)Among the 759 cases of colorectal cancer after surgery,the ascending sequence of onset positions were sigmoid colon,hepatic flexure,rectum,ascending colon,transverse colon,ileocecum,splenic flexure and descending colon.The ascending sequence of histological classification of colorectal cancer were adenocarcinoma,mucinous adenocarcinoma,adenocarcinoma with partial mucinous adenocarcinoma,mucinous adenocarcinoma with signet-ring cell carcinoma,adenocarcinoma with signet-ring cell carcinoma,mucinous adenocarcinoma with partial mucinous adenocarcinoma and partial signet-ring cell carcinoma.The ascending sequence of the clinical staging of colorectal cancer were phase ?(38.6%),phase?(35.4%),phase ?(20.6%),phase ?(5.1%)and phase 0(0.3%).(8)Among the 1252 cases of colorectal cancer,the ascending sequence of TCM syndromes with frequency>10%were Qi stagnation and blood stasis syndrome,Spleen and stomach deficiency syndrome,Spleen deficiency and qi stagnation syndrome,Qi and blood deficiency syndrome.The ascending sequence of symptoms with frequency>10%were Thin whitish coating of the tongue,stringy pulse,pale tongue,abdominal pain,small pulse,fatigue,whitish greasy coating of the tongue,diarrhea,anorexia,insomnia,red tongue,pale red tongue,hemafecia,constipation,abdominal distention,weight loss.(9)Among the 493 cases of colorectal cancer,Qi stagnation and blood stasis syndrome was the majority(71.8%),and the rest of the syndromes were less than 5%.The ascending sequence of symptoms with frequency>10%were abdominal pain,stringy pulse,thin whitish coating of the tongue,hemafecia,diarrhea,anorexia,insomnia,pale tongue,constipation,weight loss,red tongue,abdominal distention,small pulse,fatigue,whitish greasy coating of the tongue,dark red stool,bright red stool,pale red tongue,dark tongue.(10)Among the 759 cases of colorectal cancer,the ascending sequence of TCM syndromes with frequency>10%were Qi stagnation and blood stasis syndrome,Spleen and stomach deficiency syndrome,Spleen deficiency and qi stagnation syndrome,Qi and blood deficiency syndrome.The ascending sequence of symptoms with frequency>10%were thin whitish coating of the tongue,small pulse,fatigue,pale tongue,stringy pulse,whitish greasy coating of the tongue,anorexia,insomnia,pale red tongue,diarrhea,red tongue,abdominal pain.(11)For the main TCM syndromes,frequency statistical analysis for related symptoms was conducted.? Among the 354 cases of Qi stagnation and blood stasis syndrome of colorectal cancer before surgery,there were eighty-three related symptoms.Their sequence according to the frequency>10%were abdominal pain,stringy pulse,thin whitish coating of the tongue,hemafecia,diarrhea,insomnia,anorexia,pale tongue,constipation,weight loss,red tongue,abdominal distention,dark red stool,bright red stool,whitish greasy coating of the tongue,fatigue.?Among the 192 cases of Qi stagnation and blood stasis syndrome of colorectal cancer after surgery,there were fifty-three related symptoms.Their sequence according to the frequency>10%were stringy pulse,thin whitish coating of the tongue,anorexia,red tongue,insomnia,pale tongue,abdominal pain,whitish greasy coating of the tongue,small pulse,dark tongue.?Among the 136 cases of Spleen and stomach deficiency syndrome of colorectal cancer after surgery,there were seventy-two related symptoms.Their sequence according to the frequency>10%were thin whitish coating of the tongue,small pulse,fatigue,pale tongue,pale red tongue,stringy pulse,anorexia,diarrhea,abdominal pain,whitish greasy coating of the tongue,deep pulse,red tongue,insomnia,abdominal distention.?Among the 128 cases of Spleen deficiency and qi stagnation syndrome of colorectal cancer after surgery,there were sixty-two related symptoms.Their sequence according to the frequency>10%were fatigue,whitish greasy coating of the tongue,small pulse,pale tongue,insomnia,diarrhea,pale red tongue,anorexia,stringy pulse,abdominal distention,lusterless facial complexion.?Among the 121 cases of Qi and blood deficiency syndrome of colorectal cancer after surgery,there were sixty related symptoms.Their sequence according to the frequency>10%were thin whitish coating of tongue,stringy pulse,pale tongue,small pulse,anorexia,whitish greasy coating of tongue,red tongue,pale red tongue,insomnia.3 Study on correlation between TCM syndromes and symptoms of Colorectal Cancer based on SEM(1)For the main syndromes,including Qi stagnation and blood stasis syndrome before and after surgery,Spleen and stomach deficiency syndrome after surgery,Spleen deficiency and qi stagnation syndrome after surgery,Qi and blood deficiency syndrome after surgery,SEM confirmatory models were generated for each syndrome respectively based on the principle of better fit index.The proportion of each symptom to the formation of corresponding syndromes were shown as follows:? Qi stagnation and blood stasis syndrome before surgery<---0.768 whitish greasy coating of the tongue + 0.387 red tongue + 0.209 fatigue + 0.124 small pulse + 0.116 abdominal distention + 0.107 abdominal pain + 0.087 diarrhea + 0.072 anorexia + 0.018 dark tongue? Qi stagnation and blood stasis syndrome after surgery<---stringy pulse + 0.339 thin whitish coating of the tongue + 0.128 red tongue + 0.048 whitish greasy coating of the tongue +0.031 insomnia? Spleen and stomach deficiency syndrome after surgery<---0.504 anorexia + 0.449 pale tongue + 0.367 fatigue + 0.209 diarrhea + 0.201 thin whitish coating of the tongue + 0.129 abdominal pain?Spleen deficiency and qi stagnation syndrome after surgery<---0.827 small pulse +0.576 pale tongue + 0.393 whitish greasy coating of the tongue + 0.379 fatigue + 0.184 diarrhea+ 0.101 insomnia + 0.043 lusterless facial complexion? Qi and blood deficiency syndrome after surgery<---thin whitish coating of the tongue+ 0.310 pale tongue + 0.290 deep pulse + 0.177 pale red tongue + 0.083 stringy pulse + 0.060 slippery pulse(2)Each model was well adapted to the data.The value of the five most representative fit indexes for each model were as follows:? For the model of Qi stagnation and blood stasis syndrome before surgery,CMIN/DF =2.145,CFI = 0.965,NFI = 0.483,RMSEA= 0.057,AIC = 93.909.? For the model of Qi stagnation and blood stasis syndrome after surgery,CMIN/DF =8.352,CFI = 0.895,NFI = 0.351,RMSEA= 0.196,AIC = 68.113.? For the model of Spleen and stomach deficiency syndrome after surgery,CMIN/DF =1.046,CFI = 0.976,NFI = 0.681,RMSEA= 0.018,AIC = 33.412.? For the model of Spleen deficiency and qi stagnation syndrome after surgery,CMIN/DF = 6.078,CFI = 0.858,NFI = 0.439,RMSEA=0.200,AIC = 113.090.?For the model of Qi and blood deficiency syndrome after surgery,CMIN/DF = 7.197,CFI = 0.832,NFI = 0.279,RMSEA= 0.227,AIC = 93.971.(3)Among the SEM confirmatory models,Qi stagnation and blood stasis syndrome before surgery and Spleen and stomach deficiency syndrome after surgery were the best fitted models.(4)For the Qi stagnation and blood stasis syndrome of colorectal cancer before surgery,the main symptom was whitish greasy coating of the tongue.The accompanied symptoms were red tongue,fatigue,small pulse,abdominal distention,abdominal pain,diarrhea,anorexia and dark tongue.(5)For the Qi stagnation and blood stasis syndrome of colorectal cancer after surgery,the main symptom was stringy pulse.The accompanied symptoms were thin whitish coating of the tongue,red tongue,whitish greasy coating of the tongue and insomnia.(6)For the Spleen and stomach deficiency syndrome of colorectal cancer after surgery,the main symptom was anorexia.The accompanied symptoms were pale tongue,fatigue,diarrhea,thin whitish coating of the tongue and abdominal pain.(7)For the Spleen deficiency and qi stagnation syndrome of colorectal cancer after surgery,the main symptoms were small pulse and pale tongue.The accompanied symptoms were whitish greasy coating of the tongue,fatigue,diarrhea,insomnia and lusterless facial complexion.(8)For the Qi and blood deficiency syndrome of colorectal cancer after surgery,the main symptom was thin whitish coating of the tongue.The accompanied symptoms were pale tongue,deep pulse,pale red tongue,stringy pulse and slippery pulse.(9)For the Qi stagnation and blood stasis syndrome of colorectal cancer before surgery,red tongue and whitish greasy coating of the tongue were highly correlated.(10)For the Qi stagnation and blood stasis syndrome of colorectal cancer after surgery,stringy pulse and thin whitish coating of tongue were highly correlated.(11)For the Spleen and stomach deficiency syndrome of colorectal cancer after surgery,pale tongue and anorexia were highly correlated.(12)For the Spleen deficiency and qi stagnation syndrome of colorectal cancer after surgery,pale tongue and small pulse were highly correlated.(13)For the Qi and blood deficiency syndrome after surgery,pale tongue and thin whitish coating of tongue were highly correlated.Conclusions1 Base on the literatures reviewed,it shows that SEM can be used to analyze the correlation between syndromes and symptoms as well as the correlation between symptoms and symptoms of colorectal cancer.2 Base on the clinical study of colorectal cancer,it shows that male patients are more than females before surgery and after surgery.The ratio between males and females are approximately 1.4:1.Middle-aged and elderly patients are the majority.The average age is approximately 63 years old.The most common onset positions before surgery are the sigmoid colon,ascending colon and transverse colon while after surgery are the sigmoid colon,hepatic flexure and rectum.The histological type is mainly adenocarcinoma.In addition,the patients after surgery are more likely to be diagnosed as in the middle and later stages,with the majority in phase II and phase III,followed by phase IV.The results reveal the pathogenesis of colorectal cancer before surgery and after surgery.3 Base on the clinical study of colorectal cancer,it shows that among the cases of colorectal cancer after surgery,Qi stagnation and blood stasis syndrome is the majority,followed by Spleen and stomach deficiency syndrome,Spleen deficiency and qi stagnation syndrome,Qi and blood deficiency syndrome.And among the cases of colorectal cancer before surgery,Qi stagnation and blood stasis syndrome is the majority accounting for 71.8%.Thus,the Qi stagnation and blood stasis syndrome is the most common syndrome for colorectal cancer before surgery and after surgery,indicating that the excess syndrome is the majority before and after surgery.However,there are some changes in the distribution of syndromes before and after surgery.It shows that there are more syndromes after surgery including Spleen and stomach deficiency syndrome,Spleen deficiency and qi stagnation syndrome,Qi and blood deficiency syndrome.They are either deficiency syndromes or the syndrome of intermingled deficiency and excess which are not exactly the same as that specified in the literature studies.And also the distribution of syndromes appeared in the clinical practice before and after surgery are found to be more abundant.4 Base on the clinical study of colorectal cancer,the most common symptoms of colorectal cancer before surgery and after surgery are abdominal pain,stringy pulse,thin whitish coating of the tongue,diarrhea,anorexia,insomnia,pale tongue,red tongue,small pulse,fatigue,white greasy coating of the tongue,pale red tongue,etc.,but the proportion of each symptom is significantly different before surgery and after surgery.Firstly,the stringy pulse symptom is more common after surgery,but the small pulse symptom is more common before surgery.Secondly,abdominal pain and diarrhea are more common after surgery,but fatigue and anorexia are more common before surgery.This implies that the most common symptoms before surgery and after surgery are not exactly the same although they both have Qi stagnation and blood stasis syndrome as the majority.Thirdly,there are seven more symptoms before surgery,including hemafecia,constipation,weight loss,abdominal distention,dark red stool,bright red stool,dark tongue,etc.,which reveals the unique features of the clinical manifestations of colorectal cancer before surgery.5 Base on the construction of the SEM confirmatory models,all of the models indicate an acceptable fit level,which implies that the correlation between the TCM syndromes and symptoms of colorectal cancer are well established.The most ideal models are the model of Qi stagnation and blood stasis syndrome before surgery and the model of Spleen and stomach deficiency syndrome after surgery.It also shows that both of the ideal models are closely correlated with its corresponding symptoms respectively and the results are more in line with the actual clinical situation of Chinese medicine,than compare with the general TCM syndromes guidance.In addition,the transition of the syndromes from pre-surgery to post-surgery can provide reference for further studies on the clinical diagnosis and treatment in Chinese medicine.6 Base on the study of the SEM analysis,it shows that there are certain correlations between the symptoms and symptoms of colorectal cancer,which can be interpreted with the theories of TCM,and can also further reflect the hidden elements of syndromes in the clinical practice.And those hidden syndrome-elements are often ignored which can lead to certain quantitative relationships.7 Base on the extraction of the main symptoms and the correlation coefficients of the models,the structural regression equations have established.The equations show the degree of contributions of each symptom to the corresponding syndromes,that are also the proportion of each symptom to the formation of corresponding syndromes.Initially,all of the equations established are aligned with the theories of TCM,and they can be used to quantify the subject relationships.In addition,it shows that some symptoms are different from that specified in the standard of TCM syndrome,and those differences are found to be more in line with the actual clinical manifestations of colorectal cancer but they are often being ignored.Other symptoms that are not included in the structural regression equations require further investigation and study.8 In this research,valid SEM confirmatory models based on the correlation of syndromes and symptoms of colorectal cancer are generated.The models can be used to quantify the syndrome and sign correlation,and also to reflect the actual clinical manifestations of colorectal cancer.If we could further improve the methods of data collection and analysis,it would be possible to identify the clinical syndrome-elements for each syndrome of a disease,which could then give directions and contributions to further studies on the standardization of syndromes differentiation based on Chinese medicine. |
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