2.1 Results of meta-analysis
2.1.1 Anastomotic fistula
Data from eight publications were analyzed for this study criterion [18–25]. Since there was no significant heterogeneity (P=0.81, I2=0%) fixed effects model was used. The results of the meta-analysis [OR was 0.88 (95% CI: 0.46-1.67, P=0.69)]. showed that compared to emergency surgery, intestinal stent implantation followed by laparoscopic surgery did not increase the incidence of anastomotic leakage (Fig. 2.1.1).
2.1.2 Perioperative mortality
Data from eight publications were used for analyzing this study criterion [19–21, 23–27]. Since there was no significant heterogeneity (P=0.73, I2=0%), fixed effects model was adopted. The results of the meta-analysis [OR was 0.46 (95% CI: 0.22-0.95, P=0.04)] showed that compared to emergency surgery, intestinal stent placement followed by laparoscopic surgery reduced the incidence of perioperative mortality (Fig. 2.1.2).
2.1.3 Postoperative infection
Data from six publications were analyzed for this study criterion [19–24]. Since there was no significant heterogeneity (P=0.62, I2=0%), fixed effects model was adopted. The meta-analysis results [OR was 0.44 (95% CI: 0.24-0.82, P=0.009)] showed that compared to emergency surgery, colonic stent placement by laparoscopic surgery can reduce the incidence of postoperative wound infection (Fig. 2.1.3).
2.1.4 Operating time
Data from three publications were analyzed for this study criterion [19, 25, 28]. Since there was no significant heterogeneity (P=0.96, I2=19%), fixed effects model was used. The meta-analysis results [MD was 0.56 (95% CI: -21.79-22.91, P=0.96)]. showed that compared to emergency surgery, colorectal stent implantation followed by laparoscopic surgery did not increase the operating time (Fig. 2.1.4).
2.1.5 Length of postoperative hospital stay
Data from two publications were analyzed for this study criterion [19, 25]. Since there was no significant heterogeneity (P=0.22, I2=32%), fixed effects model was adopted. The meta-analysis results [MD is -2.07 (95% CI: -2.55- -1.59, P <0.00001)] showed that compared to emergency surgery, colorectal stent implantation followed by laparoscopic surgery can shorten the length of postoperative hospital stay (Fig. 2.1.5).
2.1.6 Results of subgroup analysis
We considered the possibility that difference in the surgical sites may lead to differences in the surgical outcomes due to anatomical factors. Therefore, procedures involving left colon and rectum were subjected to a subgroup analysis. The results of the anastomotic leakage study showed that in the case of left colon and high rectum, there was no significant difference between emergency surgery and intestinal stent implantation followed by laparoscopy (P=0.26 and P=0.77). However, there was a significant difference between the two methods as far as the incidence of postoperative incision infection was concerned in procedures involving left colon (P=0.01). There was no significant difference between the two surgical methods in procedures involving high rectum (Table 2.1).
Table 2.1 Subgroup analysis results of intestinal stent placement followed by laparoscopic surgery and emergency surgery group
Research criterion
|
SBTS(n)
|
E S(n)
|
OR (95%CI)
|
P
|
Subgroup
|
χ2 df I2(%) P
|
Anastomotic fistula (n)
|
|
|
|
|
|
Left colon
|
16
|
18
|
0.67(0.34,1.34)
|
0.26
|
0.62 1 0 0.43
|
High rectum
|
8
|
4
|
1.21(0.07,2.76)
|
0..77
|
Postoperative infection (n)
|
|
|
|
|
|
Left colon
|
17
|
25
|
0.44(0.23,0.85)
|
0.01
|
0.00 1 0 0.98
|
High rectum
|
2
|
4
|
0.45(0.07,2.76)
|
0.39
|
2.1.7 Results of the funnel chart analysis
Results of the funnel chart analysis of the five study criteria are shown below. The results suggest that they are not completely symmetrical, and there may be publication bias. Fig. 2.1.6 (a, b, c, d, e)
2.2 Retrospective analysis of the outcomes of intestinal stent placement followed by laparoscopic surgery and emergency surgery at our center
Surgical outcomes of 99 patients comprising 51 males and 48 females, who were admitted to our center were analyzed in the retrospective analysis part of the study. There were 23 patients in the endoscopic intestinal stent placement followed by laparoscopic surgery (SBTS) group and 76 patients in the emergency surgery (ES) group. The average age of the SBTS group was (58.17±16.03) years; the average age of the ES group was (63.87±13.84) years. There was no significant difference in age and gender between the two groups (P>0.05). Among the patients in SBTS group, 8 were in stage II and 15 in stage III; 16 cases involved left colon and 7 cases involved rectum. Among the patients in ES group, 25 were in stage II and 51 in stage III; 52 cases involved left colon and 24 cases involved rectum. The SBTS group and the ES group were not statistically different in gender, age, tumor location, and clinical staging indicators (P>0.05), (Table 2.2).
Table 2.2
Comparison of baseline data between the two groups (χ2/t)
Group
|
Anastomotic fistula
|
Incision infection
|
Perioperative mortality
|
Operating time (min)
|
Postoperative hospital stay(d)
|
Surgical bleeding(ml)
|
SBTS
|
2
|
2
|
0
|
204.13±37.35
|
12.91±5.47
|
155.65±94.90
|
ES
|
9
|
22
|
3
|
245.11±18.15
|
16.92±8.71
|
237.11±57.82
|
χ2/t
|
0.18
|
3.94
|
0.94
|
5.08
|
2.64
|
3.90
|
P
|
0.67
|
0.04
|
0.33
|
0.00
|
0.01
|
0.001
|
In the intestinal stent implantation followed by laparoscopic surgery group, 2 cases of intestinal perforation occurred after stent implantation and were switched to emergency surgery (not included in the study). The success rate of stent placement was 92%. After intestinal stent placement, the patient's clinical manifestations such as abdominal pain and bloating were significantly relieved, and laparoscopic surgery was performed 2 weeks later.
2.2.1 There were 2 instances (8.7%) of incision infection in the intestinal stent implantation followed by laparoscopic surgery group, while there were 22 instances (28.9%) in the emergency surgery group (χ2 = 3.94, P=0.04). The difference in the index of incision infection between the two groups was statistically significant (P<0.05).
2.2.2 Intestinal stent placement followed by laparoscopic surgery group had two instances of anastomotic leakage (8.7%), and the emergency surgery group had 9 instances (11.8%) (χ2 = 0.18, P=0.67). The difference between the two groups in the index of anastomotic leakage was not statistically significant (P>0.05).
2.2.3 No patient treated by the method of intestinal stent implantation followed by laparoscopic surgery group died during the perioperative period, (3.9%) cases died in the emergency surgery group (χ2 = 0.94, P=0.33). The difference between the two groups in the index of perioperative mortality was not statistically significant (P>0.05).
2.2.4 The operating time for intestinal stent implantation followed by laparoscopic surgery group was 204.13±37.35 min which was less than that for the emergency surgery group (245.11±18.15 min) (t=5.08, P=0.000). The difference between the two groups in the index of operating time was statistically significant (P<0.05).
2.2.5 Intestinal stent implantation followed by laparoscopic surgery group had intraoperative blood loss of 155.65±94.90 ml, which was less than that in the emergency surgery group (237.11±57.82 ml) (t=3.90, P=0.001). The difference between the two groups in the index of intraoperative blood loss was statistically significant (P<0.05).
2.2.6 The length of the postoperative hospital stay in the intestinal stent followed by laparoscopic surgery group was 12.91±5.47 days, which was shorter than that of the emergency surgery group (16.92±8.71 days) (t=2.64, P=0.01). The difference between the two groups in the index of postoperative hospital stay was statistically significant (P<0.05) (Table 2.3).
Table 2.3
Comparison of the surgical outcomes between the SBTS group (23 patients) and the ES group (76 Patients).
Group
|
Anastomotic fistula
|
Incision infection
|
Perioperative mortality
|
operating time (min)
|
Postoperative hospital stay (d)
|
Blood loss(ml)
|
SBTS
|
2
|
2
|
0
|
204.13±37.35
|
12.91±5.47
|
155.65±94.90
|
ES
|
9
|
22
|
3
|
245.11±18.15
|
16.92±8.71
|
237.11±57.82
|
χ2/t
|
0.18
|
3.94
|
0.94
|
5.08
|
2.64
|
3.90
|
P
|
0.67
|
0.04
|
0.33
|
0.00
|
0.01
|
0.001
|