Stenting as bridge to surgery versus emergency surgery for acute left colonic malignant obstruction
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摘要:
目的：本研究旨在比较金属支架置入序贯限期手术（bridge to surgery，BTS）与急诊手术（emergency surgery，ES）对左半结肠癌伴急性肠梗阻的疗效。方法：本研究为回顾性研究。纳入2013年5月—2017年12月就诊于苏州大学附属第一医院或南京医科大学第一附属医院的左半结肠癌伴急性肠梗阻的患者资料，包括其定期随访结果。本研究中的临床成功定义为外科手术后肠功能恢复持续超过30 d，且无并发症或死亡。对一般资料、干预过程和随访结果等进行比较，分析疗效差异，并论证影响长期生存情况的危险因素。结果：BTS组短期疗效较好，包括：术中减压干预较少（85.1% vs. 69.6%，P=0.045），减压效果更好（64.2% vs. 27.5%，P＜0.001），一期吻合率较高（65.7% vs. 17.4%，P＜0.001），造瘘率较低（临时造瘘率：34.3% vs. 82.6%；永久造瘘率：13.4% vs. 58.7%；P均＜0.001），ICU入住率较低（10.4% vs. 27.5%，P=0.011），术中并发症较少（3.0% vs. 13.0%，P=0.031），以及术后30 d死亡率较低（0 vs. 8.7%，P=0.028）。两组在临床成功率（73.1% vs. 63.8%，P=0.240）、总死亡率（53.7% vs. 64.4%，P=0.247）和中位生存时间（52.0个月 vs. 35.0个月，P=0.121）方面差异无统计学意义。此外，TNM分期Ⅳ期、永久性造瘘和术后并发症是影响患者长期生存的独立危险因素。结论：对左半结肠癌伴急性肠梗阻，BTS是安全有效的治疗方法，且对长期生存时间无负面影响。BTS可通过减少围手术期并发症、术后30 d死亡率及永久性造瘘以改善短期疗效。
Abstract:
Objective：This retrospective study aims to compare the performance for managing acute left colonic malignant obstruction by emergency surgery（ES） or stenting as a bridge to surgery（BTS）. Methods：The medical records were collected from May 2013 to December 2017 in two tertiary hospitals in Eastern China. Clinical success was defined as resumption of intestinal function for 30 days without morbidity or mortality after surgical procedure. All demographics，intervention procedures and follow-up were analyzed for short-term and long-term outcomes. Risk factors for long-term survival were discussed as well. Results：BTS group showed better short-term performance，including less intraoperative decompressive intervention（85.1% vs. 69.6%，P=0.045），more complete decompression（64.2% vs. 27.5%，P＜0.001），more primary anastomosis（65.7% vs. 17.4%，P＜0.001），less temporary and permanent stoma（34.3% vs. 82.6%，13.4% vs. 58.7%，both P＜0.001），less intensive care unit requirement（10.4% vs. 27.5%，P=0.011），less intraoperative complications（3.0% vs. 13.0%，P=0.031）and reduced 30-day mortality（0 vs. 8.7%，P=0.028）. No significant difference was observed about clinical success（73.1% vs. 63.8%，P=0.240），overall mortality（53.7% vs. 64.4%，P=0.247）or long-term survival（52.0 months vs. 35.0 months，P=0.121）. TNM stage Ⅳ，permanent stoma and postoperative complication were the independent risk factors for long-term survival. Conclusion：BTS is a safe and effective therapeutic option for acute left colonic malignant obstruction，without adverse effect on long-term survival. It significantly improves short-term outcomes by reducing perioperative complications，30-day mortality and permanent stoma. More prospective studies are necessary to confirm the clinical findings.
