Self-expanding metallic stent as a bridge to surgery versus emergency resection for obstructing left-sided colorectal cancer: A case-matched study

This study aimed to compare the outcomes of patients who suffered from obstructing left-sided colorectal cancer, treated with self-expanding metallic stent (SEMS) as a bridge to surgery, with those who underwent emergency operation. Twenty patients who had acute obstruction due to left-sided colorectal cancer underwent surgical resection after insertion of SEMS (group I) were matched to 40 patients with emergency colonic resection (group II). The two groups were compared for the incidence of primary anastomosis, stoma rate, hospital stay, duration of intensive care, postoperative morbidity, and mortality. Both groups had similar preoperative comorbidity and stage of disease, but the tumors in group I were more distally located (P<0.001). In group I, one patient developed colon perforation and required Hartmann’s operation. All the other patients underwent elective operation with primary anastomosis. In group II, primary anastomosis was performed in 29 patients (72.5%; P=0.047). The operative mortality of group I and group II was 5% and 12.5%, respectively (P=0.653). Significantly shorter median postoperative hospital stay and median stay in the intensive care unit (ICU) were observed in group I (9 days [range, 5–39 days] vs. 12 days [range, 8–49 days], P=0.015 and 0 day [range, 0–17 days] vs. 0.5 day [range, 0–18 days], P=0.022, respectively). There were no differences in hospital mortality (P=0.653) or 30-day mortality (P=0.653). Both groups had similar reoperation rates, surgical complications, and medical complications. When compared with emergency resection, insertion of SEMS as a bridge to surgery for obstructing left-sided colorectal cancer is associated with a higher rate of primary anastomosis as well as a better outcome in terms of hospital stay and stay in the ICU. The wider application of this treatment option for obstructing colorectal cancer warranted further studies. Presented at Digestive Disease Week, SSAT/ASCRS Joint Symposium, Forty-Sixth Annual Meeting of the Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–19, 2005.     

结肠内支架联合腹腔镜结肠癌根治术在结肠癌合并急性梗阻中的短期及中期疗效分析

目的:探讨结肠腔内支架置入联合腹腔镜下结肠癌根治术治疗结肠癌合并急性梗阻的短期及中期疗效。方法:选取2010年4月至2013年6月成功接受结肠腔内支架置入后行腹腔镜下结肠癌根治术的56例结肠癌合并急性梗阻患者(治疗组);另检索62例同期接受急诊开腹结肠癌根治术的结肠癌并急性梗阻患者作为对照(对照组)。对比两组患者的短期疗效指标及中期肿瘤学生存指标。结果:与对照组相比,治疗组术中出血量减少[(55.2±31.0)ml vs.(113.6±73.0)ml],淋巴结清扫数量增加[(20.0±5.1)vs.(15.4±5.2)],术后住院时间缩短[(7.3±2.1)d vs.(11.6±3.2)d],造口率(8.9%vs.67.7%)、术后吻合口漏发生率(2.0%vs.15.0%)、切口感染率(3.6%vs.16.1%)均降低,差异有统计学意义(P0.05)。两组患者3年局部复发率(17.9%vs.19.4%)、3年无病生存率(64.3%vs.62.9%)、3年总体生存率(78.6%vs.75.8%)差异均无统计学意义(P0.05)。结论:结肠内支架联合腹腔镜下结肠癌根治术治疗结肠癌合并急性梗阻具有良好的短期及中期疗效。     

A rare life-threatening complication of migrated nitinol self-expanding metallic stent (Ultraflex)

The use of self-expanding metallic stents (SEMS) as esophageal endoprosthesis represents an advancement in the palliation of dysphagia from unresectable esophageal carcinoma. However, the problem of stent migration persists. Although most migrated stents have a benign outcome, complications do occur. Rare reports of intestinal obstruction have been confined to the stiff plastic and stainless-steel stents. We report the first case of intestinal obstruction secondary to the pliable Nitinol SEMS (Ultraflex) migration.     

肠道支架减压在左侧大肠癌梗阻一期切除吻合中的应用

目的 探讨术前肠道支架减压在左侧大肠癌梗阻一期切除吻合中运用的安全性和有效性.方法 回顾性分析2005年5月至2008年9月浙江中医药大学附属第一医院收治的97例左侧大肠癌患者临床资料.支架联合手术组46例,为左侧大肠癌合并肠梗阻的患者,成功放置肠道支架减压后行手术一期切除吻合治疗.单纯手术组51例,为无梗阻的左侧大肠癌而限期手术治疗的患者.观察两组患者术后胃肠功能恢复、术后住院时间、并发症发生情况.采用t检验、χ~2检验对数据进行分析.结果 支架联合手术组46例中,1例乙状结肠癌患者于肠道支架植入术后第4天出现肠道穿孔致弥漫性腹膜炎,急诊行乙状结肠癌根治术.45例均顺利完成一期手术治疗,术后11～16 d痊愈出院,1例患者术后10 d死于呼吸道感染及心功能衰竭.术后随访4～48个月.两组患者在术后肛门排气时间、住院时间、围手术期并发症发生率、复发转移率、随访期内生存率方面比较差异无统计学意义(t=0.164,1.358,χ~2=0.252,1.200,0.580,P>0.05).结论 术前肠道支架减压是治疗左侧大肠癌梗阻患者安全、有效的方法.     

The clinical outcomes of the radiologic method for self-expandable metal-stent placement in patients with colorectal obstruction: A prospective study

ObjectivesTo assess the clinical outcomes of self-expandable metal stent (SEMS) placement for patients with colorectal obstruction.MethodsA total of 61 patients underwent SEMS placement using computerized tomography (CT) to confirm malignancy of intrinsic origin and evaluate the exact location, notch, and extent of the disruptive laceration.ResultsThe overall technical success rate and clinical success rate of SEMS placement using the radiological method were 59 (96.7%) and 57 (93.4%), respectively. The technical success rate and clinical success rate of SEMS placement in the palliative and bridge to elective surgery (BTS) groups were 35 (97.2%), 24 (96.0%), 33 (91.7%), and 24 (96.0%). The median cumulative primary stent patency duration and patients’ survival of SEMS placement was 123 days (95% CI, 65–123 days), and 133 days (95% CI, 72–133 days). The median cumulative primary stent patency duration and patient survival did not differ significantly between the palliative group 119 days; (95% CI, 59–119 days), 128 days; (95% CI, 71–128 days), and the BTS group 120 days; (95% CI, 68–120 days; p = 0.362), 130 days; (95% CI, 78–130 days); p = 0.412).ConclusionsThe colorectal obstruction had convoluted with curved angulation and located mainly at the rectum, sigmoid, descending colon, and the radiologic method of SEMS placement has more efficacious with a high technical and clinical success rate. However, SEMS placement was highly technical, and clinical success with median stent patency and patient survival did not differ significantly between the palliative group and the BTS group.     

老年患者应用自膨式金属支架作为结肠癌急性恶性肠梗阻择期手术的临时处理手段的短期评价

目的 评估自膨式金属支架（SEMS）在恶性肠梗阻患者应用价值和分析。方法 选择2014年至2017年作者收治的结肠癌伴急性肠梗阻患者的临床资料。包括接受SEMS处理23例（SEMS组）,未使用SEMS的急诊手术患者31例（no-SEMS组）,所有患者获得根治性切除。结果 所有患者均获得手术后30天的随访。SEMS组16例采用腔镜下结肠癌根治手术,7例实施开放手术;no-SEMS组均为开放手术。SEMS组术后恢复总体较no-SEMS组良好,如较短的肠功能恢复时间、较短的肠外营养时间、较短的住院时间和较少的术后并发症总数（均P<0.05）。但SEMS组术前发生1例肠穿孔、2例SEMS移位需要紧急处理。结论 针对结肠癌导致的恶性肠梗阻,SEMS内镜结肠支架置入术作为择期手术的桥梁,具有良好的短期效果,但是应该尽量避免SEMS操作并发症。     

125I内照射联合金属内支架治疗恶性食管狭窄的临床研究

目的探讨125I粒子与内支架结合治疗食管恶性狭窄的可行性及相关疗效。方法本组16例食管恶性狭窄的患者,临床分级为3~4期,在X线透视下经口腔将125I粒子联合内支架植入到患者食管内狭窄段进行治疗,术后随访并发症及疗效。结果16例患者125I粒子联合内支架植入均顺利释放,释放过程中未出现放射粒子脱落现象;所有患者术后吞咽困难症状消除或明显缓解,无明显并发症。结论125I内照射联合金属内支架治疗食管恶性狭窄,是一种安全、可行和有效的方法。     

A new technique for placement of a self-expanding metallic stent (SEMS) in patients with colon rectal obstruction: a prospective study of 43 patients

Background

Self-expanding metallic stent (SEMS) placement is a valid form of therapy for patients with obstructing colon rectal cancer. The procedure is not feasible for a minority of patients with a very low risk of bowel perforation. This report analyzes the results of a technical detail used for SEMS placement.

Methods

In 43 patients with colon rectal obstruction, the SEMS apparatus was introduced through a guidewire passed above the obstruction in the channel of a pediatric nasogastroscope (diameter, 4.9 mm). The pediatric nasogastroscope was passed into the obstruction and above, allowing the anatomy of the colorectal lesion and the passage of the guidewire to be visualized directly.

Results

The SEMS was inserted successfully in all cases without complications. In a previous series of 82 patients who had passage of the guidewire through the obstruction blindly, four technical failures occurred (nonsignificant difference).

Conclusions

A pediatric nasogastroscope can be useful for passing the colon rectal obstruction and guiding the passage of the guidewire under direct vision.     

Preoperative diagnosis of obstructive colitis in colorectal cancer patients who underwent self-expandable metallic stent insertion as a bridge to surgery

PurposeObstructive colitis (OC) is a risk factor of anastomotic leakage in colorectal cancer resection. We aimed to clarify the relationship between the severity of OC and clinicopathological findings and to detect predictive factors of OC.MethodsWe retrospectively reviewed 43 cases of colectomy after self-expandable metallic stent placement for left-sided colorectal cancer. Preoperative diagnosis of OC was made by multiple modalities (initial computed tomography (CT), presurgical CT, and colonoscopy). We classified OC macroscopically in resected specimens into five groups (Grade 0: none, 1: mild [mild edema], 2: moderate [severe edema, redness, erosion], 3: severe [ulceration, bleeding], 4: very severe [necrosis, perforation]), and investigated the relationship between the preoperative assessment, surgical findings and the severity of OC.ResultsOC of Grade 2 or more (53.5%) was significantly correlated with severe edema in initial CT. There was no significant correlation between OC and anastomosis rate. The creation of covering stoma was significantly higher in the Grade 2 or more OC group. No leakage was observed in either group.ConclusionsInitial CT may be most useful for prediction of OC. It is important to make a preoperative diagnosis of OC by combining multiple modalities, which enables to determine the appropriate location for resection, anastomosis, and construction of a covering stoma.     

金属支架和腹腔镜在结直肠癌伴梗阻治疗中的应用价值

目的研究联合金属支架与腹腔镜手术在治疗结直肠癌伴梗阻治疗中的疗效。方法将2012年3月至2015年3月期间收治的48例高龄结直肠癌伴梗阻病人分为两组,①观察组:24例结直肠癌伴梗阻病人,植入金属支架缓解梗阻作为过渡治疗,完善相关术前准备,之后在腹腔镜下行结直肠癌根治性切除术;②对照组:24例结直肠癌伴梗阻的同期病人直接采取腹腔镜下结直肠癌切除术。结果①采取过渡性植入金属支架后进行根治性手术的病人24例,其中21例施行根治性切除,2例因转移至肝脏和肺未能切除,另1例因房颤未行金属支架置入术和腹腔镜结直肠癌切除术。术后随访24例,随访时间12~29个月,平均21个月。其中施行根治性切21例均无复发和转移,3例未能切除者死于肿瘤远处转移。对照组:24例采取直接腹腔镜手术治疗,24例行根治性手术,2例因术后肠瘘、多器官功能衰竭死亡,1例因术后发生胃转移死亡。随访:24例,随访时间10~24个月,平均15个月,对比两组病人,发现病人在支架置入后行腹腔镜根治术,术后并发症及生活质量有显著改善,生存时间并无明显差异。结论相比直接采取腹腔镜手术切除的病人,联合金属支架植入与腹腔镜手术治疗方式具有安全、术后并发症少等优点,可提高病人生存质量,两组病人在生存时间上无明显差异。     

金属支架联合腹腔镜与急诊开腹手术治疗结直肠癌并急性肠梗阻近期疗效比较

目的比较金属支架联合腹腔镜与急诊开腹手术治疗结直肠癌并急性肠梗阻的近期疗效,寻求安全有效的治疗方法。 方法回顾性分析2017年1月至2019年3月120例结直肠癌并急性肠梗阻患者资料,根据手术方法分为两组,金属支架联合腹腔镜治疗的57例为联合组,63例行急诊开腹手术的患者为开腹组。应用SPSS19.0统计软件进行数据分析,围术期指标以( ±s)表示,独立t检验,并发症发生率、二期手术率等采用χ²检验,P<0.05为差异有统计学意义。 结果联合组手术时间为(179.8±17.3) min,术后排气时间为(2.3±0.5) d,术后住院时间为(7.3±1.9) d,均短于开腹组的(209.5±21.0) min、(4.6±0.8) d、(11.9±3.2) d;联合组淋巴结清扫数为(16.7±2.1)个,多于开腹组的(12.4±1.7)个,术中出血量为(27.9±4.1) ml,少于开腹组的(75.5±9.3) ml,差异均有统计学意义(P<0.05)。联合组造口4例,二期行造口关闭术4例,开腹组造口17例,二期行造口关闭术17例,联合组并发症发生率为12.3%,二期手术率为7.0%,均低于开腹组的44.4%、27.0%,差异均有统计学意义(P<0.05)。 结论金属支架联合腹腔镜治疗结直肠癌并急性肠梗阻安全、可行,且手术根治效果好,能有效降低二期手术率。     

术前腔内支架与急诊手术治疗左半结肠和直肠癌肠梗阻的安全性与有效性Meta分析

目的评价术前腔内支架治疗左半结肠和直肠癌肠梗阻的安全性与有效性。方法利用CENTRAL、PubMed、EMBASE、Medline、OvidLww等英文数据库和CMB、CNKI、万方等中文数据库．全面检索术前腔内支架与急诊手术治疗左半结肠和直肠癌肠梗阻的比较研究的中英文随机对照试验和回顾性分析文献．利用RevMan5．1软件对两种治疗方法的安全性和有效性指标进行Meta分析。结果最终纳入14篇文献共1083例患者,其中随机对照研究5篇,回顾性分析9篇。与急诊手术相比,术前腔内支架组围手术期死亡率（RR：O．52;95％CI：0．30-0．93。P〈0．05）和总并发症发生率降低（RR=0．46,95％U：0．31-0．70,P〈0．01）,手术切除率提高（RR：1．90,95％U：1．33-2．70,P〈0．01）,手术时间（MD=-59．77,95％CI：-87．51-32．04．P〈0．01）和术后排气时间缩短（MD=一10．78,95％CI：-16．67-4．90,P〈0．01）：两种方法的永久造瘘率和住院时间的差异则无统计学意义（均P〉0．05）。结论术前腔内支架治疗左半结肠和直肠癌肠梗阻的安全性和有效性均优于急诊手术。     

自膨胀型金属支架治疗晚期结直肠癌合并急性肠梗阻的临床初步研究

目的:探讨经结肠镜配合X线下置入钛镍记忆合金支架治疗晚期结直肠癌合并急性肠梗阻的安全性与临床疗效。方法:对35例晚期结直肠癌合并急性肠梗阻的患者行永久性支架置入术姑息治疗(支架组),以35例接受传统结肠造瘘手术的同类患者作为对照组,比较两组的手术成功率及临床疗效。结果:支架组放置成功率为100%,并发症发生率为8.57%(术后发生1例肠穿孔,2例支架再梗阻),患者术后即可下床活动,不需人工肛门,随访1年生存率为94.2%;对照组手术成功率100%,并发症发生率为31.42%(术后5例肺部感染,5例切口感染,1例腹腔感染),随访1年生存率为97.1%。两组患者术后肠梗阻均完全缓解,但支架组与对照比较,肠道梗阻缓解迅速,生活质量明显改善,费用更低,并发症发生率低,差异均有统计学意义(均P0.05)。结论:结肠镜配合X线下置入钛镍记忆合金支架治疗结直肠癌恶性梗阻是一种简单可行、安全有效、并发症少的姑息性治疗手段,能减轻患者痛苦、提高生活质量,并且患者可获得与外科手术相当的生存时间。     

Outcomes of self-expandable metal stent as bridge to surgery versus emergency surgery for left-sided obstructing colon cancer: A retrospective cohort study

BackgroundLong-term outcomes of self-expandable metal stents (SEMSs) as bridges to surgery versus emergency surgery in the treatment of left-sided obstructing colon cancer remain unclear.MethodsUsing a nationwide inpatient database in Japan, we performed one-to-one propensity score matching to compare overall survival, the stoma requirement, postoperative complications, and the length of stay between the SEMS and emergency surgery groups.ResultsCompared with the emergency surgery group, the SEMS group showed worse survival (hazard ratio, 1.80; 95% confidence interval, 1.07–3.01), a higher incidence of postoperative ileus (8% vs. 4%, P = 0.010), a longer postoperative length of stay (14 vs. 12 days, P < 0.001), and a lower stoma requirement (10% vs. 29%, P < 0.001).ConclusionsSEMSs as bridges to surgery are associated with significantly poorer overall survival, a higher incidence of postoperative ileus, a longer length of stay, and a lower stoma requirement than is emergency surgery.