Comparative study of emergency surgery <i>versus</i> self-expanding metal stent in treatment of malignant left-sided colonic obstruction_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

WANG Reng , CHEN Zhimin , JI Zhenxin , WANG Lei , JU Xiang , LI Qiang , LU Qicheng ,  ZHANG Feng

Department of Gastrointestinal Surgery, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P. R. China;

Corresponding author：

ZHANG Feng, Email: zf3027@163.com

Keywords：

colon cancer; obstruction; self-expanding metal stent; emergency surgery; long-term effect

DOI：

10.7507/1007-9424.202103132

Video：

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Objective To compare the short- and long-term effects of emergency surgery (ES) and self-expanding metal stent (SEMS) in treatment of malignant left-sided colonic obstruction.Methods The patients with malignant left-sided colonic obstruction who met the inclusion and exclusion criteria in the Third Affiliated Hospital of Soochow University from October 2010 to October 2020 were retrospectively collected and divided into ES group (n=43) and SEMS group (n=22). The baseline data, surgical data, postoperative data, and prognosis (overall survival and relapse free survival) were compared, and the risk factors of tumor recurrence after surgery were further analyzed by Cox proportional hazards regression model. Results In this study, 65 cases of malignant left-sided colonic obstruction were included, including 43 cases in the ES group and 22 cases in the SEMS group. There were no statistical differences in the baseline data of the two groups (P>0.05). There were no significant differences in the incidence of postoperative complications [13.6% (3/22) vs. 23.3% (10/43), P=0.555], recurrence rate [40.9% (9/22) vs. 37.2% (16/43), P=0.772], and rate of receiving postoperative chemotherapy [68.2% (15/22) vs. 48.8% (21/43), P=0.138] between the SEMS group and ES group. Compared with the ES group, although the median hospitalization time was longer (20 d vs. 12 d, P=0.001), and the median hospitalization cost was higher (65 033 yuan vs. 40 045 yuan, P=0.001), the stoma rate of the SEMS group was lower [36.4% (8/22) vs. 88.4% (38/43), P=0.001], and the minimally invasive (laparoscopic) rate was higher [36.4% (8/22) vs. 7.0% (3/43), P=0.008]. There were no significant differences in the 4-year cumulative overall survival (46.9% vs. 48.4%, P=0.333) and 4-year cumulative relapse free survival (36.2% vs. 44.8%, P=0.724) between the SEMS group and ES group, but the overall survival of the SEMS group was better than that of the ES group for the patients with stage Ⅲ–Ⅳ (χ²=4.644, P=0.047). Multivariate analysis of Cox proportional hazards regression model showed that increased TNM stage increased the risk of postoperative tumor recurrence of patients with malignant left-sided colonic obstruction [HR=2.092, 95%CI (1.261, 3.469), P=0.004]. Conclusions Short- and long-term effects of ES and SEMS in treatment of malignant left-sided colonic obstruction are equivalent. Although SEMS mode has a longer hospital stay and higher hospitalization costs, stoma rate is lower and laparoscopic surgery rate is higher. Overall survival of SEMS mode in treatment malignant left-sided colonic obstruction patients with stage Ⅲ–Ⅳ is better.

Citation： WANG Reng, CHEN Zhimin, JI Zhenxin, WANG Lei, JU Xiang, LI Qiang, LU Qicheng, ZHANG Feng. Comparative study of emergency surgery versus self-expanding metal stent in treatment of malignant left-sided colonic obstruction. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2021, 28(11): 1450-1456. doi: 10.7507/1007-9424.202103132 Copy

1.	Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2018, 68(6): 394-424.
2.	Lee HJ, Hong SP, Cheon JH, et al. Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc, 2011, 73(3): 535-542.
3.	Ahn HJ, Kim SW, Lee SW, et al. Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery. Surg Endosc, 2016, 30(11): 4765-4775.
4.	Tanis PJ, Paulino Pereira NR, van Hooft JE, et al. Resection of obstructive left-sided colon cancer at a national level: a prospective analysis of short-term outcomes in 1 816 patients. Dig Surg, 2015, 32(5): 317-324.
5.	Young CJ, De-Loyde KJ, Young JM, et al. Improving quality of life for people with incurable large-bowel obstruction: Randomized control trial of colonic stent insertion. Dis Colon Rectum, 2015, 58(9): 838-849.
6.	Dohmoto M. New method: endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endosc Dig, 1991, 3: 1507-1512.
7.	Tejero E, Mainar A, Fernández L, et al. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum, 1994, 37(11): 1158-1159.
8.	Arezzo A, Passera R, Lo Secco G, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc, 2017, 86(3): 416-426.
9.	Atukorale YN, Church JL, Hoggan BL, et al. Self-expanding metallic stents for the management of emergency malignant large bowel obstruction: a systematic review. J Gastrointest Surg, 2016, 20(2): 455-462.
10.	Zhang Y, Shi J, Shi B, et al. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc, 2012, 26(1): 110-119.
11.	Almadi MA, Azzam N, Alharbi O, et al. Complications and survival in patients undergoing colonic stenting for malignant obstruction. World J Gastroenterol, 2013, 19(41): 7138-7145.
12.	Maruthachalam K, Lash GE, Shenton BK, et al. Tumour cell dissemination following endoscopic stent insertion. Br J Surg, 2007, 94(9): 1151-1154.
13.	van Hooft JE, van Halsema EE, Vanbiervliet G, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Gastrointest Endosc, 2014, 80(5): 747-761.
14.	Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc, 2010, 71(3): 560-572.
15.	Pirlet IA, Slim K, Kwiatkowski F, et al. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc, 2011, 25(6): 1814-1821.
16.	王世垚, 胡欢, 张向向, 等. 腔内支架置入术与急诊手术治疗近端结肠癌梗阻的安全性和有效性的meta分析. 中国普外基础与临床杂志, 2019, 26(7): 834-840.
17.	Lara-Romero C, Vilches Á, Caunedo-Álvarez Á, et al. Better recurrence-free survival after stent bridge to surgery compared to emergency surgery for obstructive left-sided colonic cancer in patients with stage Ⅲ status of the American Joint Committee on Cancer (AJCC): a bicentric retrospective study. Int J Colorectal Dis, 2019, 34(7): 1241-1250.
18.	Yan FH, Lou Z, Liu XS, et al. Long-term oncological outcomes of endoscopic stenting as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: a comparative study. J Laparoendosc Adv Surg Tech A, 2017, 27(6): 611-617.
19.	Tan CJ, Dasari BV, Gardiner K. Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg, 2012, 99(4): 469-476.
20.	Ghazal AH, El-Shazly WG, Bessa SS, et al. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg, 2013, 17(6): 1123-1129.
21.	刘刚, 张浩, 高威, 等. 可切除结直肠癌肠梗阻SEMS术后手术时机临床研究. 中国实用外科杂志, 2019, 39(12): 1306-1309.
22.	van Hooft JE, Bemelman WA, Oldenburg B, et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol, 2011, 12(4): 344-352.
23.	Kim HJ, Huh JW, Kang WS, et al. Oncologic safety of stent as bridge to surgery compared to emergency radical surgery for left-sided colorectal cancer obstruction. Surg Endosc, 2013, 27(9): 3121-3128.
24.	Vonk-Klaassen SM, de Vocht HM, den Ouden ME, et al. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res, 2016, 25(1): 125-133.
25.	卢清平, 兰启龙, 陈龙, 等. 内镜下金属支架联合择期腹腔镜手术在梗阻性结直肠癌中的应用. 中华胃肠外科杂志, 2017, 20(6): 684-688.
26.	蔡圣彬, 马仙华. 肠道支架置入术后择期手术和急诊手术治疗结直肠癌急性肠梗阻疗效的meta分析. 中国普外基础与临床杂志, 2019, 26(11): 1320-1329.
27.	Yamashita S, Tanemura M, Sawada G, et al. Impact of endoscopic stent insertion on detection of viable circulating tumor cells from obstructive colorectal cancer. Oncol Lett, 2018, 15(1): 400-406.
28.	Gorissen KJ, Tuynman JB, Fryer E, et al. Local recurrence after stenting for obstructing left-sided colonic cancer. Br J Surg, 2013, 100(13): 1805-1809.
29.	Ceresoli M, Allievi N, Coccolini F, et al. Long-term oncologic outcomes of stent as a bridge to surgery versus emergency surgery in malignant left side colonic obstructions: a meta-analysis. J Gastrointest Oncol, 2017, 8(5): 867-876.
30.	Amelung FJ, Burghgraef TA, Tanis PJ, et al. Critical appraisal of oncological safety of stent as bridge to surgery in left-sided obstructing colon cancer; a systematic review and meta-analysis. Crit Rev Oncol Hematol, 2018, 131: 66-75.
31.	Amelung FJ, Borstlap WAA, Consten ECJ, et al. Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction. Br J Surg, 2019, 106(8): 1075-1086.
32.	Sloothaak DA, van den Berg MW, Dijkgraaf MG, et al. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg, 2014, 101(13): 1751-1757.
33.	Kim HJ, Choi GS, Park JS, et al. Higher rate of perineural invasion in stent-laparoscopic approach in comparison to emergent open resection for obstructing left-sided colon cancer. Int J Colorectal Dis, 2013, 28(3): 407-414.
34.	Gianotti L, Tamini N, Nespoli L, et al. A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction. Surg Endosc, 2013, 27(3): 832-842.
35.	Choi JM, Lee C, Han YM, et al. Long-term oncologic outcomes of endoscopic stenting as a bridge to surgery for malignant colonic obstruction: comparison with emergency surgery. Surg Endosc, 2014, 28(9): 2649-2655.

1. Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2018, 68(6): 394-424.
2. Lee HJ, Hong SP, Cheon JH, et al. Long-term outcome of palliative therapy for malignant colorectal obstruction in patients with unresectable metastatic colorectal cancers: endoscopic stenting versus surgery. Gastrointest Endosc, 2011, 73(3): 535-542.
3. Ahn HJ, Kim SW, Lee SW, et al. Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery. Surg Endosc, 2016, 30(11): 4765-4775.
4. Tanis PJ, Paulino Pereira NR, van Hooft JE, et al. Resection of obstructive left-sided colon cancer at a national level: a prospective analysis of short-term outcomes in 1 816 patients. Dig Surg, 2015, 32(5): 317-324.
5. Young CJ, De-Loyde KJ, Young JM, et al. Improving quality of life for people with incurable large-bowel obstruction: Randomized control trial of colonic stent insertion. Dis Colon Rectum, 2015, 58(9): 838-849.
6. Dohmoto M. New method: endoscopic implantation of rectal stent in palliative treatment of malignant stenosis. Endosc Dig, 1991, 3: 1507-1512.
7. Tejero E, Mainar A, Fernández L, et al. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum, 1994, 37(11): 1158-1159.
8. Arezzo A, Passera R, Lo Secco G, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc, 2017, 86(3): 416-426.
9. Atukorale YN, Church JL, Hoggan BL, et al. Self-expanding metallic stents for the management of emergency malignant large bowel obstruction: a systematic review. J Gastrointest Surg, 2016, 20(2): 455-462.
10. Zhang Y, Shi J, Shi B, et al. Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer: a meta-analysis. Surg Endosc, 2012, 26(1): 110-119.
11. Almadi MA, Azzam N, Alharbi O, et al. Complications and survival in patients undergoing colonic stenting for malignant obstruction. World J Gastroenterol, 2013, 19(41): 7138-7145.
12. Maruthachalam K, Lash GE, Shenton BK, et al. Tumour cell dissemination following endoscopic stent insertion. Br J Surg, 2007, 94(9): 1151-1154.
13. van Hooft JE, van Halsema EE, Vanbiervliet G, et al. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Gastrointest Endosc, 2014, 80(5): 747-761.
14. Small AJ, Coelho-Prabhu N, Baron TH. Endoscopic placement of self-expandable metal stents for malignant colonic obstruction: long-term outcomes and complication factors. Gastrointest Endosc, 2010, 71(3): 560-572.
15. Pirlet IA, Slim K, Kwiatkowski F, et al. Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction: a multicenter randomized controlled trial. Surg Endosc, 2011, 25(6): 1814-1821.
16. 王世垚, 胡欢, 张向向, 等. 腔内支架置入术与急诊手术治疗近端结肠癌梗阻的安全性和有效性的meta分析. 中国普外基础与临床杂志, 2019, 26(7): 834-840.
17. Lara-Romero C, Vilches Á, Caunedo-Álvarez Á, et al. Better recurrence-free survival after stent bridge to surgery compared to emergency surgery for obstructive left-sided colonic cancer in patients with stage Ⅲ status of the American Joint Committee on Cancer (AJCC): a bicentric retrospective study. Int J Colorectal Dis, 2019, 34(7): 1241-1250.
18. Yan FH, Lou Z, Liu XS, et al. Long-term oncological outcomes of endoscopic stenting as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: a comparative study. J Laparoendosc Adv Surg Tech A, 2017, 27(6): 611-617.
19. Tan CJ, Dasari BV, Gardiner K. Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction. Br J Surg, 2012, 99(4): 469-476.
20. Ghazal AH, El-Shazly WG, Bessa SS, et al. Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma. J Gastrointest Surg, 2013, 17(6): 1123-1129.
21. 刘刚, 张浩, 高威, 等. 可切除结直肠癌肠梗阻SEMS术后手术时机临床研究. 中国实用外科杂志, 2019, 39(12): 1306-1309.
22. van Hooft JE, Bemelman WA, Oldenburg B, et al. Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction: a multicentre randomised trial. Lancet Oncol, 2011, 12(4): 344-352.
23. Kim HJ, Huh JW, Kang WS, et al. Oncologic safety of stent as bridge to surgery compared to emergency radical surgery for left-sided colorectal cancer obstruction. Surg Endosc, 2013, 27(9): 3121-3128.
24. Vonk-Klaassen SM, de Vocht HM, den Ouden ME, et al. Ostomy-related problems and their impact on quality of life of colorectal cancer ostomates: a systematic review. Qual Life Res, 2016, 25(1): 125-133.
25. 卢清平, 兰启龙, 陈龙, 等. 内镜下金属支架联合择期腹腔镜手术在梗阻性结直肠癌中的应用. 中华胃肠外科杂志, 2017, 20(6): 684-688.
26. 蔡圣彬, 马仙华. 肠道支架置入术后择期手术和急诊手术治疗结直肠癌急性肠梗阻疗效的meta分析. 中国普外基础与临床杂志, 2019, 26(11): 1320-1329.
27. Yamashita S, Tanemura M, Sawada G, et al. Impact of endoscopic stent insertion on detection of viable circulating tumor cells from obstructive colorectal cancer. Oncol Lett, 2018, 15(1): 400-406.
28. Gorissen KJ, Tuynman JB, Fryer E, et al. Local recurrence after stenting for obstructing left-sided colonic cancer. Br J Surg, 2013, 100(13): 1805-1809.
29. Ceresoli M, Allievi N, Coccolini F, et al. Long-term oncologic outcomes of stent as a bridge to surgery versus emergency surgery in malignant left side colonic obstructions: a meta-analysis. J Gastrointest Oncol, 2017, 8(5): 867-876.
30. Amelung FJ, Burghgraef TA, Tanis PJ, et al. Critical appraisal of oncological safety of stent as bridge to surgery in left-sided obstructing colon cancer; a systematic review and meta-analysis. Crit Rev Oncol Hematol, 2018, 131: 66-75.
31. Amelung FJ, Borstlap WAA, Consten ECJ, et al. Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction. Br J Surg, 2019, 106(8): 1075-1086.
32. Sloothaak DA, van den Berg MW, Dijkgraaf MG, et al. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. Br J Surg, 2014, 101(13): 1751-1757.
33. Kim HJ, Choi GS, Park JS, et al. Higher rate of perineural invasion in stent-laparoscopic approach in comparison to emergent open resection for obstructing left-sided colon cancer. Int J Colorectal Dis, 2013, 28(3): 407-414.
34. Gianotti L, Tamini N, Nespoli L, et al. A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction. Surg Endosc, 2013, 27(3): 832-842.
35. Choi JM, Lee C, Han YM, et al. Long-term oncologic outcomes of endoscopic stenting as a bridge to surgery for malignant colonic obstruction: comparison with emergency surgery. Surg Endosc, 2014, 28(9): 2649-2655.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Comparative study of emergency surgery versus self-expanding metal stent in treatment of malignant left-sided colonic obstruction

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