Patients with complete obstructing left-sided colon cancer admitted into the General Surgery Department of Beijing Chaoyang Hospital from January 2017 to January 2019 were included. The inclusion criteria were as follows: (1) complete left-sided colonic obstruction, confirmed by clinical manifestations and abdominal computed tomography (CT); (2) tumors located at the distal splenic flexure and 15 cm above the anal verge; (3) adenocarcinoma confirmed by pathologic results; (4) patients who underwent ES with resection of the primary tumor and one-stage stoma, and reversal of stoma 6 ~ 18 months after surgery; (5) patients who underwent surgery after deployment of a SEMS without a stoma; and (6) patients who received a SEMS followed by NAC, then scheduled for surgery without a stoma. The exclusion criteria were as follows: (1) patients who underwent decompressing surgery only without radical resection of the primary tumor; (2) obstruction due to tumor recurrence or distant metastasis; and (3) incomplete clinical data. According to different treatment strategies, patients were divided into the ES, SEMSs, and SEMSs + NAC groups. This study was approved by the Institutional Research Ethics Committee of Beijing Chaoyang Hospital (Capital Medical University). Informed consent was obtained from all patients.
Patients who sought evaluation in the Emergency Department with symptoms of acute obstruction immediately received an abdominal CT scan and pre-operative examination, then the patient was prepared for surgery as long as malignant left-sided colonic obstruction was accurately made. The standard protocol for ES was a radical resection of the primary tumor with primary anastomosis and ileostomy or Hartmann surgery with a colostomy, and reversal of the stoma 9 ~ 18 months after surgery.
Based on an “intention-to-treat” strategy, patients diagnosed with complete obstructing left-sided colon cancer underwent deployment of SEMSs (WallFlex; Boston Scientific Corporation, Natick, MA, USA) under fluoroscopy guidance. Clinical success was defined as passage of feces through the anus and complete alleviation of acute obstruction. ES was indicated for SEMS failure. Radical resection of the primary tumor with primary anastomosis was then performed for patients 1 ~ 2 weeks after deployment of a SEMS.
SEMS + NAC group
Patients with complete obstructing left-sided colon cancer first received three cycles of fluorouracil, leucovorin and oxaliplatin (mFOLFOX6) or two cycles of capecitabine and oxaliplatin (CAPEOX) chemotherapy after successful deployment of a SEMS. Radical resection of the tumor with primary anastomosis was then performed 2 weeks after chemotherapy. Adjuvant chemotherapy was given based on the pathologic results and at the patient’s discretion.
The Wexner 14, Vaizey 15, and LARS 16 scales were used to assess anal function of patients at the 1-, 6- and 12-month follow-up evaluations, respectively. The Wexner scale has five items with a total score of 20, including solid, gas, liquid incontinence, use of a pad, and alteration of lifestyle. The Vaizey scale adds another two items (the need for drugs to facilitate defecation and control of feces within 30 min) on the basis of the Wexner scale. Reduced anal function was considered if the total Wexner or Vaizey score was > 10. The LARS scale also has five items, including general control of feces and gas, defecation time, and frequency and urgency. A total score of 0 ~ 20 represents no LARS, while 21 ~ 29 and 30 ~ 42 represent mild and severe LARS, respectively.
The EORTC QLQ C30 (version 3) questionnaire was used to assess the quality of life 17. This scale has a total of 30 items, including 5 functional domains (physical, role, emotional, cognitive, and social functions), 3 symptom domains (fatigue, nausea and vomiting, and pain), and 1 overall healthy domain. In the functional and overall healthy domains, the higher the score, the better the quality of life; however, a relatively higher score indicated a poor quality of life in the symptom domains.
SPSS (version 25; IBM, Armonk, NY, USA) was used for statistical analysis. Consecutive variables are described as the mean ± standard deviation (x̄± s) or median (range). Differences among groups was analyzed by one-way ANOVA or the Kruskal-Wallis H test. Categorical data are described as a number (percentage) and the chi-square or Fisher exact test was chosen for statistical analysis. Logistic regression analysis was applied to identify risk factors affecting anal function; the results are described as the odds ratio (OR) and 95% confidence interval (CI).