Patients
This is a single-institution retrospective study of consecutive SEMS placement or decompression ostomy and neoadjuvant prior to elective surgery in the Sixth Affiliated Hospital of Sun Yat-sen University between January 2012 and December 2020 Data in patients with acute left-sided malignant colorectal obstruction treated with chemotherapy. We retrospectively collected clinicopathological characteristics, including gender, age, location of obstructive lesions, clinical cancer stage, comorbidities, American Society of Anesthesiologists (ASA) classification, neoadjuvant chemotherapy regimen, preoperative carcinoembryonic antigen (CEA), surgical Data on post carcinoembryonic antigen (CEA), Preoperative albumin and hemoglobin. Perioperative details include operation type, operation time, intraoperative blood loss, recovery time of hindgut function, postoperative hospital stay, total hospital stay, intensive care hospital stay, postoperative adjuvant chemotherapy, stent complications, perioperative complications Symptoms and histopathological findings, as well as the presence of stoma, recurrence and death one year after surgery were collected. The study was approved by institutional ethics board of the Sixth Affiliated Hospital, Sun Yat-sen University (NO. 2022ZSLYEC-121). We confirm that we have obtained ethical approval to conduct the study as well as permission from the dataset, and that the study was conducted in accordance with the provisions of the Declaration of Helsinki (as revised in Fortaleza, Brazil, October 2013). The obtained data was only collected and analyzed; however, detailed patient information was not released publically, and patient information confidentiality regulations were strictly adhered to.
Definitions
The diagnosis of acute left colonic obstruction is made by clinical symptoms (bloating, pain, and inability to pass stool and gas), clinical examination, endoscopy, abdominal plain radiography, and abdominal computed tomography (CT). Left-sided colon cancer was defined as carcinoma of the splenic flexure and distal to the splenic flexure, including the rectosigmoid colon. Bridging time was defined as the date of stenting or post-decompression stomy to the date of surgery. Technical success of self-expanding metal stent placement was defined as successful deployment of the SEMS through the obstructing lesion, radiographically confirmed stent expansion, and clear visualization of the fecal passage. Clinical success was defined as significant colonic decompression on abdominal radiograph or CT, resolution of obstructive symptoms, and absence of SEMS-related complications.The recovery time of bowel function is the time from postoperative to the first gas or defecation.The postoperative hospital stay is the time from resection of colorectal malignant tumor to discharge from hospital.The death of the colorectal cancer one year after the operation is the death of colorectal cancer within one year after the radical resection of the colorectal cancer. Local recurrence was defined as colorectal, anastomotic, regional lymph node, mesenteric, and peritoneal recurrence.Whether the patients died and whether they relapsed one year after the operation was tracked according to the medical record system, and some patients were vacant due to loss of follow-up in the database.
Treatment
The surgical group consisted of emergency surgery and stenting followed by surgery, with a median interval between stenting and surgery of 13.00 days.The neoadjuvant chemotherapy group consisted of stent placement followed by neoadjuvant chemotherapy followed by surgery, and stoma decompression followed by neoadjuvant chemotherapy followed by surgery.Written informed consent was obtained from all patients before surgery. Self-expanding metal stent placement was performed under fluoroscopic guidance by an experienced endoscopist. The placement of self-expanding metal stents includes interventional placement and endoscopic placement. The patient was placed on the DSA operating bed supine, the perineum was routinely sterilized and draped, a 5F-DAV catheter was placed through the anus, and the catheter-guided angiography showed the site of lesion obstruction, and a guide wire was inserted through the catheter. After reaching the distal end, transcatheter angiography showed obvious expansion and gas accumulation in the obstructed part of the lesion. A rigid guide wire was placed through the catheter to the lesion obstruction site, and the obstruction site and length were determined again. A self-expanding metal stent system was inserted through the guide wire, and a 25mm*8cm (model: M00565060, batch number: 20619027) stent was released. Endoscopic self-expanding metal stent implantation: intravenous injection of midazolam, phloroglucinol and dezocine, observation of the guide wire placed in the stenotic site under DSA, and the smooth passage of the guide wire. In the stenotic part, a self-expanding metal stent was introduced under direct vision. Monitor patients' vital signs and clinical condition before, during, and after surgery. Record and address any adverse events. Stoma decompression procedures include ileostomy and transverse colostomy. Neoadjuvant chemotherapy was administered after stenting and after successful stoma decompression. Patients received FOLFOX, FOLFOXIRI, or XELOX, and specific neoadjuvant chemotherapy regimens were made by gastroenterologists or medical oncologists on a case-by-case basis. Elective surgery was performed after chemotherapy. Patients underwent laparoscopic or open surgery depending on the surgeon's decision and the patient's condition. Radical surgery was defined as complete resection of any measurable disease, without involving resection of the margins. Left hemicolectomy, anterior resection, low anterior resection, subtotal colonectomy, and non-sphincter-sparing procedures (including abdominoperineectomy and Hartmann procedure) were performed according to the site of the obstructive lesion and the presence or absence of edematous intestinal edema. A wealth of colorectal surgeons perform the surgery.
Inclusion and exclusion criteria
Inclusion criteria included colorectal obstruction due to malignant colorectal cancer or colon cancer, patients with obstructive symptoms or imaging signs of obstruction, located in the left colon and rectum, and with intent to curative treatment. Exclusion criteria were bowel ischemia, suspected or imminent perforation, any contraindication to endoscopic therapy, obstruction caused by non-colonic malignancy or benign disease, no chance of surgery after evaluation, contraindication to chemotherapy, and refusal by the patient and family members Surgery, and history of colectomy,and self-expanding metal stent implantation in other hospitals.
Study Outcomes
The primary outcome of this study was short-term clinical outcomes and whether there is a stoma one year after the operation, short-term clinical outcomes including postoperative complications, postoperative hospital stay,whether to undergo intensive care unit treatment,and time to recovery of bowel function, to evaluate the safety and feasibility of this treatment decision for acute left-sided malignant colorectal obstruction. Secondary outcomes included operative time, intraoperative blood loss, total hospital stay,and postoperative carcinoembryonic antigen, one-year postoperative mortality,and one-year locoregional recurrence rate.
Statistical analysis
One-to-two propensity score matching was performed without replacement. Propensity scores were estimated using a generalized linear model based on sex, age,Whether the tumor has distant metastasis, body mass index.Categorical data were evaluated using either the Chi square or Fisher exact tests, whereas numerical data were evaluated using the Student’s t test or Mann–Whitney U test. Numerical variables were dichotomized according to clinical importance or the median value of each variable for cut-off.All p values were two-sided, and p<0.05 was considered statistically significant.