自膨式金属支架治疗梗阻性左半结肠癌的治疗现状

doi:10.3969/j.issn.1000-8535.2023.07.019

摘要/Abstract

摘要： 我国结直肠癌的发病率与死亡率逐年增加,约10%~30%新发结直肠癌患者可表现为急性肠梗阻,其中梗阻发生率较高的主要部位是左半结肠。急性梗阻性左半结肠癌患者的主要治疗方式仍是急诊手术（ES）,但术后并发症发生率及围手术期死亡率较高,自膨式金属支架（SEMS）被一些指南推荐为梗阻性结肠癌的初始治疗选择,SEMS可将部分ES转变为择期手术,支架置入后择期手术（SBTS）与ES相比不仅可改善患者的短期生存结局,且支架置入后新辅助化疗为梗阻性结肠癌的治疗提供了新的途径;就长期生存结果而言,选择SBTS还是ES存在一定的争议。对于支架置入后手术时机的选择尚未达成共识,有指南表明大约两周的短桥接间隔可使患者最大程度获益,因而可有效指导临床工作。肠道支架置入术目前看来是一种简单、有效的临时性或永久性的治疗手段。

关键词: 自膨式金属支架, 梗阻性左半结肠癌, 支架置入后择期手术, 临床效果, 桥接时间

Abstract: In recent years, the incidence and mortality of colorectal cancer in our country have been increasing year by year．Around 10% to 30% of newly diagnosed colorectal cancer patients showed acute intestinal obstruction, which the left colon cancer has higher incidence．Emergency surgery（ES）is still the main treatment for patients with acute obstructive left colon cancer, but the incidence of postoperative complications and perioperative mortality are high．Self-expanding metallic stents（SEMS）can convert some emergency procedures into stent as bridge to surgery（SBTS）, which is recommended by some guidelines as the initial treatment option for obstructive colon cancer．SBTS can not only improve the short-term survival outcome of patients compared with ES, but also provide a new approach for the treatment of obstructive colon cancer with neoadjuvant chemotherapy after intestinal obstruction stent placement．The choice of SBTS versus ES is somewhat controversial in terms of long-term survival outcomes．There is no consensus on the timing of surgery after stenting, and current guidelines suggest that bridging intervals of approximately two weeks strike a balance between potential adverse events and long-term outcomes．At present, intestinal stenting is still a simple, feasible and effective temporary or palliative permanent treatment with few complications．

Key words: self-expanding metallic stents, obstructive left colon cancer, elective surgery after stent placement, clinical effect, the time of bridge

刘冬琴, 赵书锋, 雷建祥, 周将来, 汪昌鑫, 黄玉祥, 曾祥福. 自膨式金属支架治疗梗阻性左半结肠癌的治疗现状[J]. 广州医药, 2023, 54(7): 103-109.

LIU Dongqin, ZHAO Shufeng, LEI Jianxiang, ZHOU Jianglai, WANG Changxin, HUANG Yuxiang, ZENG Xiangfu. Status of self-expanding metal stent in obstructive left colon cancer treatment[J]. Guangzhou Medical Journal, 2023, 54(7): 103-109.

参考文献

[1] NGUYEN D A,MAI-PHAN T,DO P T T,et al.Emergency surgery for obstructed colorectal cancer in Vietnam[J].Asian J Surg,2020,43(6):683-689.
[2] 丁毅. 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[J].中国实用医药,2020,15(18):54-56.
[3] VELD J V,AMELUNG F J,BORSTLAP W A A,et al.Comparison of decompressing stoma vs stent as a bridge to surgery for left-sided obstructive colon cancer[J].JAMA Surg,2020,155(3):206.
[4] SAITO S,YOSHIDA S,ISAYAMA H,et al.A prospective multicenter study on self-expandable metallic stents as a bridge to surgery for malignant colorectal obstruction in Japan:eEfficacy and safety in 312 patients[J].Surg Endosc,2016,30(9):3976-3986.
[5] ATUKORALE Y N,CHURCH J L,HOGGAN B L,et al.Self-expanding metallic stents for the management of emergency malignant large bowel obstruction:A systematic review[J].J Gastrointest Surg,2016,20(2):455-462.
[6] GUO M,FENG Y,LIU J,et al.Factors associated with mortality risk for malignant colonic obstruction in elderly patients[J].BMC Gastroenterol,2014,14(1):76.
[7] LEE H J,PARK S J,MIN B S,et al.The role of primary colectomy after successful endoscopic stenting in patients with obstructive metastatic colorectal cancer[J].Dis Colon Rectum,2014,57(6):694-699.
[8] VOGEL J D,ESKICIOGLU C,WEISER M R,et al.The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Colon Cancer[J].Dis Colon Rectum,2017,60(10):999-1017.
[9] FERRADA P,PATEL M B,POYLIN V,et al.Surgery or stenting for colonic obstruction:A practice management guideline from the Eastern Association for the Surgery of Trauma[J].J Trauma Acute Care Surg,2016,80(4):659-664.
[10] 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:rResults of a systematic review and meta-analysis of randomized controlled trials[J].Gastrointest Endosc,2017,86(3):416-426.
[11] GENZOR R S,GONZALEZ-NICOLAS T M,AGUIRRE P N,et al.Stent performance in obstructive left colon cancer.Unicentric and cross-sectional study[J].Cir Esp,2019,97(7):397-404.
[12] HO K,CHAN K,KWOK S,et al.Colonic self-expanding metal stent(SEMS)as a bridge to surgery in left-sided malignant colonic obstruction:aAn 8-year review[J].Surg Endoscy,2017,31(5):2255-2262.
[13] CAO Y,DENG S,WU K,et al.Oncological consequence of emergent resection of perforated colon cancer with complete obstruction after stent insertion as a bridge to surgery[J].Int J Colorectal Dis,2019,34(3):545-547.
[14] AVLUND T H,ERICHSEN R,IVERSEN L H.Sensitivity and positive predictive value of the registration of self-expanding metal stent treatment for obstructive colorectal cancer in two Danish nationwide registries[J].Clin Epidemiol,2018(10):1411-1415.
[15] FOO C C,POON S,CHIU R,et al.Is bridge to surgery stenting a safe alternative to emergency surgery in malignant colonic obstruction:A meta-analysis of randomized control trials[J].Surg Endosc,2019,33(1):293-302.
[16] KIM S J,KIM H W,PARK S B,et al.Colonic perforation either during or after stent insertion as a bridge to surgery for malignant colorectal obstruction increases the risk of peritoneal seeding[J].Surg Endosc,2015,29(12):3499-3506.
[17] WEBSTER P J,ALDOORI J,BURKE D A.Optimal management of malignant left-sided large bowel obstruction:dDo international guidelines agree?[J].World J Emerg Surg,2019(14):23.
[18] van HOOFT J E,van HALSEMA E E,VANBIERVLIET G,et al.Self-expandable metal stents for obstructing colonic and extracolonic cancer:European Society of Gastrointestinal Endoscopy(ESGE)Clinical Guideline[J].Endoscopy,2014,46(11):990-1053.
[19] CIROCCHI R,AREZZO A,SAPIENZA P,et al.Current status of the self-expandable metal stent as a bridge to surgery versus emergency surgery in colorectal cancer:results from an updated systematic review andMmeta-analysis of the literature[J].Medicina(Kaunas),2021,57(3):268.
[20] TEJERO E,MAINAR A,FERNANDEZ L,et al.New procedure for the treatment of colorectal neoplastic obstructions[J].Dis Colon Rectum,1994,37(11):1158-1159.
[21] KÖNEŞ O,KARTAL A,AKARSU M,et al.Colonic stent use in patients with malignant flexure tumors presenting with obstruction[J].JSLS,2019,23(1):e2018-e2088.
[22] KIM M H,KANG S I,LEE J,et al.Oncologic safety of laparoscopic surgery after metallic stent insertion for obstructive left-sided colorectal cancer:A multicenter comparative study[J].Surg Endosc,2022,36(1):385-395.
[23] 农文伟,张传珉,王征,等.内支架在左半结肠癌急性梗阻的应用价值[J].广东医学,2008,29(4):589-590.
[24] HAN J G,WANG Z J,ZENG W G,et al.Efficacy and safety of self-expanding metallic stent placement followed by neoadjuvant chemotherapy and scheduled surgery for treatment of obstructing left-sided colonic cancer[J].BMC Cancer,2020,20(1):57.
[25] 韩加刚,王振军,戴勇,等.可扩张支架联合新辅助化疗后择期手术治疗梗阻性左半结肠癌的前瞻性、多中心、开放研究初步报告[J].中华胃肠外科杂志,2018,21(11):1233-1239.
[26] 钱筱健,朱建华,周大勇.可扩张支架配合新辅助化疗后择期手术治疗梗阻性左半结肠癌106例分析[J].当代医学,2020,26(33):10-13.
[27] 马连港,赵宝成,马华崇,等.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[J].中国实用外科杂志,2020,40(7):837-841.
[28] TAMINI N,ANGRISANI M,ALDÈ S,et al.Does preoperative stent positioning in obstructive left sided colon cancer increase the risk of perineural invasion?[J].Updates Surg,2021,73(2):547-553.
[29] KATSUKI R,JO T,YASUNAGA H,et al.Outcomes of self-expandable metal stent as bridge to surgery versus emergency surgery for left-sided obstructing colon cancer:A retrospective cohort study[J].Am J Surg,2021,221(1):168-173.
[30] AREZZO A,FORCIGNANO E,BONINO M A,et al.Long-term oncologic results after stenting as a bridge to surgery versus emergency surgery for malignant left-sided colonic obstruction:A multicenter randomized controlled trial(ESCO trial)[J].Ann Surg,2020,272(5):703-708.
[31] KIM M K,KYE B H,LEE I K,et al.Outcome of bridge to surgery stenting for obstructive left colon cancer[J].ANZ J Surg,2017,87(12):E245-E250.
[32] KIM H J,CHOI G S,PARK J S,et al.Higher rate of perineural invasion in stent-laparoscopic approach in comparison to emergent open resection for obstructing left-sided colon cancer[J].Int J Colorectal Dis,2013,28(3):407-414.
[33] GIETELINK L,WOUTERS M W,BEMELMAN W A,et al.Reduced 30-day mortality after laparoscopic colorectal cancer surgery:A population based study from the dutch surgical colorectal audit(DSCA)[J].Ann Surg,2016,264(1):135-140.
[34] BOTTGER T.Endoscopic palliative treatment of tumors of the gastrointestinal tract[J].Zentralbl Chir,1998,123(6):687-696.
[35] TAL A O,FRIEDRICH-RUST M,BECHSTEIN W O,et al.Self-expandable metal stent for malignant colonic obstruction:oOutcome in proximal vs.left sided tumor localization[J].Z Gastroenterol,2013,51(6):551.
[36] NONAKA Y,KAWAI D,TAKEMOTO K.Results of palliative stent insertion for malignant colorectal obstruction[J].Gan To Kagaku Ryoho,2018,45(5):829-832.
[37] MAHFOUZ M F,SALAMA T M S,AFIFI A H,et al.Effectiveness and early postoperative outcomes of palliative endoluminal stenting versus Hartmann's procedure in acute malignant bowel obstruction in high-risk patients[J].Ann Coloproctol,2022,38(2):141-145.
[38] YOUNG C J,DE-LOYDE K J,YOUNG J M,et al.Improving quality of life for people with incurable large-bowel obstruction:rRandomized control trial of colonic stent insertion[J].Dis Colon Rectum,2015,58(9):838-849.
[39] 曾平. 直肠恶性狭窄梗阻的经肛门金属支架治疗[J].临床和实验医学杂志,2006(11):1780-1781.
[40] 姚礼庆,钟芸诗.急性结直肠梗阻内镜下金属支架引流术的操作要点和疗效评价[J].中华消化内镜杂志,2010(2):57-59.
[41] van HOOFT J E,BEMELMAN W A,OLDENBURG B,et al.Colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction:aA multicentre randomised trial[J].Lancet Oncol,2011,12(4):344-352.
[42] ALCÁNTARA M,SERRA-ARACIL X,FALCÓ J,et al.Prospective,controlled,randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer[J].World J Surg,2011,35(8):1904-1910.
[43] PIRLET I A,SLIM K,KWIATKOWSKI F,et al.Emergency preoperative stenting versus surgery for acute left-sided malignant colonic obstruction:aA multicenter randomized controlled trial[J].Surg Endosc,2011,25(6):1814-1821.
[44] ZHANG Y,SHI J,SHI B,et al.Self-expanding metallic stent as a bridge to surgery versus emergency surgery for obstructive colorectal cancer:aA meta-analysis[J].Surg Endosc,2012,26(1):110-119.
[45] LEE G J,KIM H J,BAEK J,et al.Comparison of short-term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer[J].Int J Surg,2013,11(6):442-446.
[46] CHEUNG H Y S,CHUNG C C,TSANG W W C,et al.Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer:A randomized controlled trial[J].Arch Surg,2009,144(12):1127-1132.
[47] MATSUDA A,MIYASHITA M,MATSUMOTO S,et al.Optimal interval from placement of a self-expandable metallic stent to surgery in patients with malignant large bowel obstruction:A preliminary study[J].Surg Laparosc Endosc Percutan Tech,2018,28(4):239-244.
[48] ORMANDO V M,PALMA R,FUGAZZA A,et al.Colonic stents for malignant bowel obstruction:Current status and future prospects[J].Expert Rev Med Devices,2019,16(12):1053-1061.
[49] BROHOLM M,KOBBORG M,FROSTBERG E,et al.Delay of surgery after stent placement for resectable malignant colorectal obstruction is associated with higher risk of recurrence[J].Int J Colorectal Dis,2017,32(4):513-516.
[50] YAMASHITA S,TANEMURA M,SAWADA G,et al.Impact of endoscopic stent insertion on detection of viable circulating tumor cells from obstructive colorectal cancer[J].Oncol Lett,2018,15(1):400-406.
[51] LIM T,THAM H Y,YAOW C Y L,et al.Early surgery after bridge-to-surgery stenting for malignant bowel obstruction is associated with better oncological outcomes[J].Surg Endosc,2021,35(12):7120-7130.
[52] KYE B,KIM J,KIM H,et al.The optimal time interval between the placement of self-expandable metallic stent and elective surgery in patients with obstructive colon cancer[J].Sci Rep,2020,10(1).
[53] van HOOFT J E,VELD J V,ARNOLD D,et al.Self-expandable metal stents for obstructing colonic and extracolonic cancer:European Society of Gastrointestinal Endoscopy(ESGE)Guideline - Update 2020[J].Endoscopy,2020,52(5):389.