结肠镜非透视下金属支架置入序贯手术治疗梗阻性结直肠癌的临床研究

目的比较肠镜下金属支架(self-expanding metallic stents,SEMS)置入序贯手术与急诊手术(emergency surgery,ES)治疗梗阻性结直肠癌的远期肿瘤学效果。方法接受手术治疗的梗阻性结直肠癌病人60例。将60例病人分成两组,ES组33例,接受急诊手术治疗;SEMS组27例,接受非透视下SEMS置入序贯手术。比较两组病人临床病理特征及总体生存率。所有病人术前均由多学科团队讨论、制定治疗方案。结果两组病人一般资料、肿瘤分期、肿瘤部位等比较差异无统计学意义。SEMS组病人中位总体生存时间为37个月,ES组病人为23个月。SEMS组和ES组病人接受术后辅助化疗分别为70.4%和45.5%,术后3年总体生存率分别为55.6%和39.4%,5年总体生存率分别为48.1%和36.4%,两组比较差异均无统计学意义(P0.05)。结论SEMS置入序贯手术治疗梗阻性结直肠癌安全、可行,远期肿瘤学结果有效。     

梗阻性结直肠癌Ⅰ期回肠造口加新辅助治疗，Ⅱ期根治性切除临床应用价值

目的 探讨Ⅰ期急诊回肠造口解除梗阻加新辅助放化疗,Ⅱ期根治性手术切除治疗梗阻性结直肠癌的临床应用价值。方法 回顾总结我院2004年1月～2008年12月间64例梗阻性结直肠癌患者行Ⅰ期回肠造口加新辅助治疗（A组）,Ⅱ期根治性切除的临床和随访资料,并与同期（B组）75例梗阻性结直肠癌患者行Ⅰ期根治性切除的相应资料进行对比分析。结果 A组病例在急性生理改变及慢性健康状况评分（APACHEⅡ[1]）于急诊手术前高于B组（P<0.01）。两组肿瘤的临床分期（cTNM）无显著差别。新辅助放化疗对梗阻性结直肠癌的治疗有效率为82.8%（53/64）。其中临床完全缓解率7.8%（5/64）。行根治手术后A组的切口感染、盆腹腔感染、吻合口漏发生率分别为7.8%（5/64）、6.25%（4/64）和4.7%（3/64）,明显低于B组的21.3%（16/75）、18.7%（14/75）和14.7%（11/75）。P<0.01差异有显著意义。而A组的三年无病生存率为59.4%（38/64）高于B组的49.3%（37/75）,差异有显著意义（P<0.05）。 结论 新辅助放化疗对梗阻性结直肠癌有治疗价值,配合Ⅰ期回肠造口解除梗阻,Ⅱ期根治性手术切除治疗梗阻性结直肠癌的效果要好于Ⅰ期根治性手术。     

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。     

腹腔镜下结直肠癌肝转移同时根治切除的临床研究

目的研究腹腔镜结直肠癌根治性切除联合腹腔镜切除治疗结直肠癌肝转移的临床疗效。 方法回顾性分析2014年1月至2015年12月确诊为同时性结直肠癌肝转移患者90例资料。分为腹腔镜组(n＝45)和开腹组(n＝45),采用SPSS21.0统计软进行数据分析,术中术后指标采用( ±s)表示,独立t检验;术后并发症采用χ²检验;偏态分布的资料采用M(Qn)和M(范围)表示,应用Mann－Whitney U检验。P<0.05为差异有统计学意义。 结果两组患者手术时间、术中出血量、术中输血量、神经浸润及脉管侵犯等差异无统计学意义(P>0.05)。术后情况：两组患者在进食时间、术后TBIL、术后ALT、并发症及住院时间差异无统计学意义(P>0.05);而腹腔镜组入住ICU的患者时间为(2.1±1.6) d,明显短于开腹组(1.0±06) d (t＝1.804, P<0.05)。随访结果：两组术后1、2年累积无瘤生存率和生存时间差异无统计学意义(P>0.05)。 结论腹腔镜结直肠癌根治性切除术联合腹腔镜肝切除术在安全性优于腹腔镜结直肠癌根治性切除治疗联合开腹肝切除术,但两种治疗方法在术后并发症发生率及临床预后等方面效果相当。     

梗阻性左半结肠癌治疗新策略-支架扩张联合新辅助化疗

正目前15%～29%的结直肠癌在就诊时合并肠梗阻,其中70%的肠梗阻发生在左半结肠,给临床治疗带来挑战~([1])。1994年Tejero等~([2])报道使用自膨胀的金属支架(self-expanding metallic stents,SEMS)治疗左半结肠肿瘤梗阻,将急诊手术转变为择期或限期手术,改善了病人营养和肠道梗阻状况。后续研究发现SEMS有可能降低手术并发症、提高根治性、降低造口率。包括2017美国结直肠外科医师协会治疗指南、NCCN指南和美国东部创伤外科协会指南等均推荐,SEMS可以作为梗阻性结肠癌的初始治疗选择。     

左半结肠切除一期吻合加回肠末端造瘘治疗老年梗阻性左半结肠癌的临床效果

目的分析左半结肠切除一期吻合加回肠末端造瘘治疗老年梗阻性左半结肠癌的临床效果。 方法回顾性分析2014年1月至2017年6月80例行左半结肠切除一期吻合术患者的临床资料，根据左半结肠切除一期吻合术后是否加行回肠末端造瘘手术分为研究组(加行回肠末端造瘘手术，39例)和对照组(未加行回肠末端造瘘手术，41例)。数据采用SPSS 20.0统计软件进行分析，患者术中术后各项指标以( ±s)表示，组间比较采用独立t检验。术后并发症的发生情况采用χ²检验。以P<0.05表示差异具有统计学意义。 结果两组患者术中出血量相比，差异无统计学意义(P>0.05)；研究组患者手术时间较对照组显著延长(P<0.05)；研究组患者术后首次排气时间、首次进食时间、引流管拔出时间以及住院时间分别为(2.5±0.9) d、 (2.5±0.7) d、 (5.7±1.5) d、 (14.3±1.8) d，较对照组均显著缩短，差异具有统计学意义(P<0.05)。研究组吻合口漏及总并发症发生率分别为2.6%、17.9%，显著低于对照组(17.1%、41.5%)，差异具有统计学意义(P<0.05)。两组患者术后存活率分别为92.3%、 90.2%，差异无统计学意义(P>0.05)。 结论左半结肠切除一期吻合联合回肠末端造瘘，可促进梗阻性左半结肠癌患者进术后恢复，缩短住院时间，减少术后并发症，值得在临床推广使用。     

结直肠癌患者腹腔镜根治术前后肠道菌群的变化研究

目的研究结直肠癌患者腹腔镜根治术前后肠道菌群的变化。 方法选择2016年6月到2017年12月收治的结直肠癌患者46例作为结直肠癌组,选择同期健康体检者46例为健康体检组。纳入患者均行腹腔镜根治术,在术前、术后分别采集一次新鲜粪便,测定采集粪便中肠道菌群DNA情况,采用聚合酶链式反应－变性梯度凝胶电泳测定患者手术前、后肠道菌群情况,根据测定结果绘制相应的图谱,分析手术前、后肠道菌群的变化情况。采用SPSS18.0软件处理,肠道菌群的多样性及丰富度采用( ±s)表示,采用配对t检验或F检验,P<0.05差异有统计学意义。 结果对粪便进行PCR扩增,获得的肠道菌群各带均处于200 bP左右,与预期的DNA片段长度相吻合;健康体检者粪便标本多样性指数(H)为(5.6±0.2),丰富度(E)为(77.1±0.4)条;结直肠癌患者术前粪便标本多样性指数(H)为(3.8±0.1)、术后为(4.1±0.1),术前丰富度(E)为(45.3±0.9)条、术后为(50.6±0.6)条,术后肠道菌群多样性及丰富度比术前增加(P<0.05),但仍低于健康体检组(P<0.05)。肠道菌群的多样性及丰富度与患者的年龄、临床分期有关(P<0.05),与性别、病程、肿瘤类型无关(P>0.05)。 结论正常人肠道菌群的多样性及丰富度较结直肠癌患者高,其与患者的年龄、临床分期有关。临床通过肠道菌群变化分析有助于指导临床治疗。     

X线辅助内镜置入支架联合腹腔镜手术治疗结直肠癌并梗阻的疗效分析

目的:探讨X线辅助内镜置入支架联合腹腔镜治疗结直肠癌并梗阻的临床价值。方法:选择2007年1月—2013年12月75例符合条件的降结肠及直肠癌并梗阻患者,其中37例行X线辅助腹腔镜联合肠镜治疗(联合组),38例行开腹手术加术中结肠灌洗治疗(传统组),比较两组患者的相关临床资料。结果:两组术前资料有可比性。联合组经肠镜置支架成功率89.19%(33/37),腹腔镜手术成功率93.94%(31/33),手术失败的6例患者排除出组。与传统组比较,联合组除治疗费用增加外(3.06万元vs.2.55万元),术中诊断息肉阳性率(35.48%vs.7.89%)、根治性切除率(83.9%vs.71.1%)、术中预防性回肠末端造口(6.45%vs.23.68%)、手术时间(175.45 min vs.202.24 min)、切口长度(4.88 cm vs.16.84 cm)、清扫淋巴结数(16.80枚vs.11.92枚)、围手术期总并发症及感染相关并发症发生率(16.13%vs.39.47%;6.45%vs.26.32%)、术后住院时间(7.36 d vs.11.05 d)、二期手术率(6.5%vs.28.9%)、术后3个月肠镜检查发现结直肠息肉阳性率(3.23%vs.23.68%)方面均有明显优势(均P0.05)。术后1、3、5年生存率两组差异无统计学意义(均P0.05)。结论:X线辅助腹腔镜联合肠镜治疗结直肠癌并梗阻安全、可行,且手术根治效果好,能有效降低二期手术率。     

减孔腹腔镜手术治疗结直肠癌对胃肠功能恢复时长及生存质量的影响

目的探讨减孔腹腔镜手术治疗结直肠癌的临床疗效。 方法回顾性分析2015年1月至2017年12月120例接受腹腔镜手术治疗的结直肠癌患者资料,分为减孔组和传统组,各60例。采用SPSS23.0统计学软件,两组间疗效评定、并发症发生率采用卡方检验;术中术后指标、血清胃泌素、胃动素水平及SF－36评分以( ±s)表示,采用独立t检验,P<0.05差异有统计学意义。 结果减孔组有效率、血清胃泌素、胃动素水平及SF－36生活质量评分均高于传统组(P<0.05),而并发症发生率,术后肠鸣音恢复时间,排气、排便和进食时间均少于传统组(P<0.05)。 结论减孔腹腔镜手术治疗结直肠癌可有效缩短胃肠功能恢复时长,改善患者生存质量。     

三种手术方式用于结直肠癌肝转移病灶切除的疗效及安全性比较

目的比较三种手术方式用于结直肠癌肝转移病灶切除的疗效及安全性。 方法回顾性分析2014年1月至2017年1月接受手术治疗的108例结直肠癌肝转移患者病例资料,根据术式不同分为三组,将接受3D腹腔镜辅助肝转移病灶切除术的35例患者纳入3D组,将受2D腹腔镜辅助肝转移病灶切除术的33例患者纳入2D组,将接受传统开腹肝转移病灶切除术的40例患者纳入开腹组。采用SPSS 23.0统计分析软件,符合正态分布的手术相关指标以( ±s)表示,多组间均值比较采用单因素方差分析,多组间两两比较采用LSD检验;并发症、生存率以率表示,采用χ²检验,P<0.05为差异有统计学意义。 结果手术时间、术中出血量、肛门排气时间、住院时间比较,开腹组>2D组>3D组,差异均有统计学意义(P<0.05);三组术后1年、2年、3年生存率比较,差异均无统计学意义(P>0.05)。3D组并发症总发生率(11.4%)与2D组(9.1%)比较,差异无统计学意义(P>0.05);开腹组并发症发生率(30.0%)比3D组、2D组高,差异均有统计学意义(P<0.05)。 结论3D腹腔镜用于结直肠癌肝转移病灶切除可减少手术时间,降低术后并发症风险,且术后恢复较快,但在提高中远期生存率方面无明显优势。     

结肠支架联合术前化疗治疗急性左半结肠癌梗阻对照研究

目的 对比分析自膨胀支架置入（SEMS）联合术前化疗治疗急性左半结肠癌恶性梗阻的近期疗效,探讨手术方式和手术时机选择。方法 回顾性分析2016年1月至2019年6月首都医科大学附属北京朝阳医院收治的109例急性左半结肠癌梗阻病例的临床资料,比较SEMS联合术前化疗+择期手术（支架化疗组,27例）、SEMS联合择期手术（支架手术组,33例）以及急诊手术（急诊手术组,49例）3种治疗方案的临床疗效。结果 支架化疗组、支架手术组与急诊手术组的腹腔镜手术比例（74.1%、 42.4% vs. 20.4%,P<0.001）、肿瘤近端肠管切除长度［（10.5±4.7）cm、（10.3±4.6）cm vs. （5.0±2.2）cm,P=0.033］以及淋巴结检出数目［（23.7±6.0）枚、（26.0±9.3）枚 vs. （17.3±5.9）枚,P=0.037］差异有统计学意义。支架化疗组与支架手术组的消化道造口率（18.5%、21.2% vs. 79.6%,P <0.001）和术后感染发生率（14.8%、27.3% vs. 46.9%,P=0.012）明显低于急诊手术组。支架化疗组的肿瘤近端10 cm左右结肠管壁厚度小于支架手术组（4 mm vs. 9 mm,P<0.001）。支架化疗组的术前等待时间>4周者的肿瘤退缩分级显著优于等待时间≤3周者（P=0.029）。结论 与急诊手术比较,SEMS联合术前化疗+择期手术治疗急性左半结肠癌恶性梗阻,实施腹腔镜手术比例更高,消化道造口率和术后并发症发生率明显降低,术前化疗后等待时间>4周可以提高肿瘤退缩程度,但暂无肿瘤降期的证据。     

肠道支架置入联合择期手术与急诊手术在梗阻性结直肠癌治疗中的对比分析

目的:对比肠道支架置入联合择期手术与急诊手术治疗梗阻性结直肠癌的安全性、可行性及近期疗效。方法:回顾分析2013年1月至2019年6月收治的148例梗阻性结直肠癌患者的临床资料,其中42例行肠道支架置入联合择期手术(CSCES),106例行急诊手术(ES)。对比两组患者基本信息、病理资料、术中情况、术后恢复情况及并发症情况。结果:CSCES组中肠道支架置入与手术的间隔时间为(8.3±2.0)d。与ES组相比,CSCES组术中出血量[(88.3±54.9)min vs.(108.7±53.2)min,P=0.041]更少,淋巴结清扫数量[(20.4±6.2)vs.(17.4±4.4),P=0.001]更多,Ⅰ期吻合率(83.3%vs.53.8%,P=0.001)、腔镜手术率(45.2%vs.5.7%,P=0.001)更高,造口率(23.8%vs.55.7%,P=0.001)、永久造口率(16.7%vs.48.1%,P=0.001)更低,术后住院时间[(10.79±5.05)d vs.(12.73±5.00)d,P=0.036]更短,术后通气[(2.12±0.73)d vs.(2.44±0.83)d,P=0.029]更早,差异有统计学意义。结论:肠道支架置入联合择期手术治疗梗阻性结直肠癌安全、可靠,并且在提高Ⅰ期吻合率、降低造口率、促进患者术后恢复方面具有显著优势。     

Feasibility of Single-Stage Laparoscopic Resection After Placement of a Self-Expandable Metallic Stent for Obstructive Left Colorectal Cancer

BACKGROUND: The present study investigated the feasibility of a single-stage operation consisting of self-expandable metallic stent (SEMS) placement followed by laparoscopic surgery for obstructive left colorectal cancer. METHODS: From July 2002 to March 2007, 17 consecutive patients with primary obstructive left colorectal cancer underwent SEMS placement followed by laparoscopic surgery. Data were collected retrospectively regarding clinicopathological findings, SEMS placement, operative procedures, and perioperative outcomes. Technical success was defined as successful stent deployment across the obstructive lesion, and clinical success as the possibility of performing a single-stage operation without creating a stoma. RESULTS: In the laparoscopic group, the technical success rate was 100% (17/17) and there was no morbidity associated with SEMS placement. The median interval to laparoscopic surgery was 7 (range, 2-11) days, and the procedures included 11 anterior resections, 3 left hemicolectomies, 2 Hartmann's procedures, and 1 subtotal colectomy. All procedures were completed laparoscopically without conversion to open surgery. The median operating time was 178 (range, 93-377) minutes, and the median estimated blood loss was 100 (range, 50-400) ml with no cases requiring intraoperative transfusions. The clinical success rate was 82.4% (14/17), and there was no surgical morbidity other than two patients in whom chyloperitoneum and ileus were controlled by using conservative management. The median postoperative hospital stay was 9 (range, 7-49) days. CONCLUSIONS: A single-stage operation consisting of SEMS placement followed by laparoscopic surgery seems to be a feasible and safe treatment option for obstructive left colorectal cancer.     

Elective (planned) colectomy in patients with colorectal obstruction after placement of a self-expanding metallic stent as a bridge to surgery: the results of a prospective study

Introduction  Acute malignant colorectal obstruction (CRO) can be satisfactorily dealt by the placement of a self-expanding metallic stent (SEMS). The aim of this prospective study was to evaluate the rate of elective (planned) colectomy (EPC) in patients with CRO after SEMS placement as a bridge to surgery on an intention-to-treat (ITT) basis.
Method  From 2002 to 2007, 30 SEMS were placed as a bridge to surgery in 30 CRO patients (median age 73 ± 12 years). The obstructing lesions were located in the right ( n  = 1), transverse ( n  = 1) or left colon ( n  = 24) or the upper third of the rectum ( n  = 4).
Results  The SEMS was placed successfully in 25 (83%) patients. Five patients underwent Hartmann's procedure ( n  = 2) or a diverting colostomy ( n  = 3). The SEMS was functionally operational in 23 (92%) of the 25 patients. A diverting colostomy was avoided in 23 (77%) of the 30 patients (placement failure n  = 5, clinical failure n  = 2). There were no complications in 17 (80%) patients. On an ITT basis, 70% of the patients (21 out of 30) underwent an EPC.
Conclusion  On an ITT basis, SEMS placement in CRO patients enabled EPC in 70% of patients.     

Adoption of self-expanding metallic stents in the palliative treatment of obstructive colorectal cancer-look out for perforations!

Self-expanding metallic stents (SEMSs) are increasingly used for the palliative treatment of inoperable colorectal cancer. The aim of the current study was to analyze the safety and efficacy of SEMS in the palliative treatment of obstructive colorectal cancer. Between 2003 and 2006, SEMS placement was attempted in 26 patients suffering from inoperable obstructive colorectal cancer. The recovery of the patients and the outcome of this treatment modality were analyzed prospectively. SEMS was successfully inserted in 19 (73%) of 26 patients. In 16 (84%) of these 19 cases, the placement of SEMS was the definitive treatment of colorectal obstruction and no additional surgical palliation was needed. There were 3 (16%) colonic perforations related to stent application. SEMS insertion seems to be an effective alternative in the palliative treatment of patients with malignant colorectal obstruction. However, perforation is a dangerous complication of the procedure.     

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??Comparison of self-expandable metallic stent placement for acute colorectal obstruction caused by extracolonic malignancy and colorectal cancer ZHOU Jia-min, ZHONG Yun-shi, XU Mei-dong, et al. Endoscopy Center, Zhongshan Hospital, Fudan University; Endoscopy Clinics Institute of Fudan University; Technology Engineering Research Center of Shanghai Endoscopy Clinics, Shanghai200032, China
Corresponding author??YAO Li-qing, ZHONG Yun-shi, E-mail??13564623481@126.com
Abstract Objective To evaluate the safety??efficacy and prognosis of self-expendable metallic stent (SEMS??placement in patients with acute colorectal obstruction (ACO) caused by extracolonic malignancies (ECM). Methods One hundred and nine cases of ACO admitted between November 2006 and April 2012 in Zhongshan Hospital of Fudan University were analyzed. The cases caused by metastatic or recurrent colorectal cancer (CRC) (n = 96) were compared with the cases caused by ECM (n = 13) in success rate??complications and survival time. Results ECM group included 8 cases of gastric cancer??61.5%????3 cases of gynecologic cancer??23.1%????1 case of bladder cancer ??7.7%??and 1 case of pelvic inflammatory fibroblastic tumor ??7.7%??. The technical success rate was 100% in both ECM group and CRC group. The clinical remission rate was not significantly different between the two groups (77.0% vs. 83.3%??P = 0.696). The stent patency time was also similar between the two groups (117.0 ± 148.8 vs. 188.2 ± 203.6??P =0.230). Stent related complications in ECM group included 2 cases of reobstruction and 1 case of migration. Symptom was not relieved in 1 case performed SEMS placement. There were not significantly difference in 30-day mortality??1-year survival rate and overall survival rate between two groups (P= 1.000??P= 0.140??P= 0.282). Conclusion The safety and effectiveness of SEMS placement in patients with ACO caused by ECM are comparable to that in patients with ACO caused by metastatic or recurrent CRC. It may be an appropriate option for treating malignant ACO.     

Minimally invasive treatment for obstructive tumors of the left colon: endoluminal self-expanding metal stent and laparoscopic colectomy. Preliminary results

BACKGROUND: Obstruction of the left colon may be the first manifestation of colorectal cancer. Resection of the colonic segment involved and the construction of an end colostomy (Hartman's procedure) is the most frequent treatment. Alternatives to the placement of a stoma are subtotal colectomy or intraoperative lavage of the colon and primary anastomosis, but their application depends on intraoperative findings and the availability of a skilled surgeon. The use of an expandable stent (SEMS) can enhance the feasibility of laparoscopic colectomy, avoiding the need for a colostomy and offering the advantages of a combination of two minimally invasive procedures. STUDY DESIGN: Between 1997 and 2004, an SEMS was placed in 11 cases of left colonic obstruction due to cancer, the obstruction being successfully resolved in each case. Seven patients were approached by laparoscopy to attempt the definitive colectomy. We evaluated the location and pathological characteristics of the tumor, effectiveness and complications of SEMS insertion, time interval between the insertion of SEMS and laparoscopic surgery, and postoperative data. RESULTS: The tumors were situated in the recto-sigma (1 case), sigma (3 cases) and descending colon (3 cases). Immediate relief of the obstruction was achieved in all cases after SEMS insertion of the stent, and oral diet was started at 24 h. The 7 patients were operated on an average of 8 days (range 6-14) after insertion of the stent. Conversion to open surgery was necessary in one case for reasons not related to the stent. CONCLUSIONS: Preliminary results of the combination of SEMS and elective laparoscopic surgery demonstrate that the procedure is feasible and that it presents all the clinical advantages of a minimally invasive approach. The procedure is a valid alternative to traditional major urgent surgery.     

Long-term oncologic outcomes of endoscopic stenting as a bridge to surgery for malignant colonic obstruction: comparison with emergency surgery

Background

Self-expandable metallic stents (SEMS) are now regarded as an effective and safe intervention for malignant colorectal obstruction (MCO). However, manipulation of the tumor might lead to the spillage of tumor cells and result in distant metastases. We aimed to compare the long-term oncologic outcomes of SEMS as a bridge to surgery with those of emergency surgery for MCO.

Methods

Between June 2005 and December 2011, 60 patients who underwent elective curative resection after endoscopic SEMS insertion were included in the “SEMS group”. The SEMS group was matched to 180 patients who underwent emergency curative surgery for MCO during the same period [“Emergency surgery (ES) group”]. The clinicopathologic characteristics, recurrence-free survival (RFS), and overall survival (OS) were compared between the two groups.

Results

There were no significant differences in demographics, tumor stage, location, and histology between the SEMS group and the ES group. The median follow-up times were 41.4 months (IQR, 22.2–60.0 months) for the SEMS group and 45.0 months (IQR, 20.9–68.1 months) for the ES group. The proportions of patients who received postoperative adjuvant chemotherapy were comparable (SEMS group vs. ES group, 68.3 % vs. 77.8 %; P = 0.210). The long-term prognosis did not significantly differ between two groups in either the 5-year RFS rate (79.6 % vs. 70.2 %; P = 0.218) or the 5-year OS rate (97.8 % vs. 94.3 %; P = 0.469).

Conclusions

Long-term oncologic outcomes of SEMS insertion as a bridge to surgery were comparable to those of primary curative surgery.     

Extraordinary role of self-expanding metal stent (SEMS) in the malignant colorectal obstruction: different care in two cases

The colorectal cancer presents with bowel obstruction in 10%-30% of patients. Established treatment of this evolutive condition, until 15 years ago, was emergency surgery. Primary resection with or without ileostomy, staged resection, Hartmann's procedure, or definitive colostomy are the therapeutical options. There is ongoing controversy on the best procedure to apply, because the choice depends on the patient's condition, age, electrolyte imbalances, nutritional status, obstructional grade, comorbidity and surgeon's attitude. However, the obstruction and the emergency operation add risk of complications and mortality instead of elective surgery. The efficacy of self-expanding metal stent to solve the obstruction had recently changed the management of malignant luminal obstruction: it is safe, effective, with very low mortality, low morbidity and also cheap. In the inoperable cases it represents the first line therapy avoiding the colostomy. In the operable patients, instead of two-step surgery, the SEMS had to be preferred because is a one-time and election surgery and avoid colostomy too, even if temporary. SEMS versus emergency primary surgery, without randomized and controlled study, allows a safer single-staged surgery. Finally it improves the quality of life avoiding colostomy, and reducing operative risk. We present two different use of SEMS: the palliation in inoperable patient and the "bridge to surgery" in critical obstructed patient.