-
摘要: 结直肠癌是常见的消化系统恶性肿瘤。结直肠癌合并梗阻的概率达20%,其中有70%发生在左半结肠。针对梗阻性左半结肠癌的治疗目前未达成共识。面对恶性梗阻患者,临床通常选择紧急手术或者自体膨胀性金属支架植入后择期手术。紧急手术可及时切除肿瘤,但是却带来高死亡率和并发症率;金属支架植入极大降低了危险并发症的概率,但是对远期预后的改善并没有明显提高。而选择手术时又面临分期手术还是一期肠切除吻合术的抉择,分期手术患者花费高,一期肠切除吻合术吻合口瘘风险高。如何选择最有利于患者的治疗方式取决于外科医生的临床决策能力,同时也需要开展更多的多中心临床研究。本文就梗阻性左半结肠癌的治疗现状与争议进行综述。Abstract: Colorectal cancer is a common malignant tumor of the digestive system. The incidence of colorectal cancer with obstruction is up to 20%, and 70% of such cases occur in the left colon. There is still no consensus on the treatment of obstructive left colon cancer. In patients with malignant obstruction, emergency or elective surgery is usually performed after implantation of autologous expandable metal stents. Tumor removal as an emergency procedure has high mortality and complication rates. Metal stent implantation greatly reduces the incidence of dangerous complications, but the long-term prognosis is not significantly improved. The surgical options available are staged surgery and one-stage intestinal resection and anastomosis. Staged surgery is expensive, while one-stage intestinal resection and anastomosis has a high risk of leakage. Choosing the most beneficial treatment for patients tests the clinical ability of surgeons, and more multi-center clinical research is needed. This article will review the current status and controversies in the treatment of obstructive left colon cancer.
-
[1] Tolba MF. Revolutionizing the landscape of colorectal cancer treatment: The potential role of immune checkpoint inhibitors[J]. Int J Cancer, 2020, 147(11):2996-3006. doi: 10.1002/ijc.33056 [2] Webster PJ, Aldoori J, Burke DA. Optimal management of malignant left-sided large bowel obstruction: do international guidelines agree [J]? World J Emerg Surg, 2019, 14:23. [3] Nguyen DA, Mai-Phan TA, Do P, et al. Emergency surgery for obstructed colorectal cancer in Vietnam[J]. Asian J Surg, 2020, 43(6):683-689. [4] van Hooft JE, Veld JV, 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):389-407. doi: 10.1055/a-1140-3017 [5] Krouse RS. Malignant bowel obstruction[J]. J Surg Oncol, 2019, 120(1):74-77. doi: 10.1002/jso.25451 [6] Hsu J, Sevak S. Management of malignant large-bowel obstruction[J]. Dis Colon Rectum, 2019, 62(9):1028-1030. doi: 10.1097/DCR.0000000000001441 [7] Dudley HA, Racliffe AG, McGeehan D. Intraoperative irrigation of the colon to permit primary anastomosis[J]. Br J Surg, 1980, 67(2):80-81. [8] Lim TZ, Tan KK. Endoscopic stenting in colorectal cancer[J]. J Gastrointest Oncol, 2019, 10(6):1171-1182. doi: 10.21037/jgo.2019.02.15 [9] Zattoni D, Christoforidis D. How best to palliate and treat emergency conditions in geriatric patients with colorectal cancer[J]. Eur J Surg Oncol, 2020, 46(3):369-378. doi: 10.1016/j.ejso.2019.12.020 [10] Di Saverio S, Birindelli A, Segalini E, et al. "To stent or not to stent"?: immediate emergency surgery with laparoscopic radical colectomy with CME and primary anastomosis is feasible for obstructing left colon carcinoma[J]. Surg Endosc, 2018, 32(4):2151-2155. doi: 10.1007/s00464-017-5763-y [11] Rosander E, Holm T, Sjovall A, et al. Emergency resection or diverting stoma followed by elective resection in patients with colonic obstruction due to locally advanced cancer: a national cohort study[J]. Colorectal Dis, 2021, 23(9):2387-2398. [12] Yang HY, Wu CC, Jao SW, et al. Two-stage resection for malignant colonic obstructions: the timing of early resection and possible predictive factors[J]. World J Gastroenterol, 2012, 18(25):3267-3271. [13] Flor-Lorente B, Baguena G, Frasson M, et al. Self-expanding metallic stent as a bridge to surgery in the treatment of left colon cancer obstruction: Cost-benefit analysis and oncologic results[J]. Cir Esp, 2017, 95(3):143-151. doi: 10.1016/j.ciresp.2016.12.014 [14] 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. doi: 10.1007/BF02049822 [15] OrmandoVM, 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. doi: 10.1080/17434440.2019.1697229 [16] Lauro A, Binetti M, Vaccari S, et al. Obstructing left-sided colonic cancer: is endoscopic stenting a bridge to surgery or a bridge to nowhere [J] ? Dig Dis Sci, 2020, 65(10): 2789-2799. [17] Biondo S, Pares D, Frago R, et al. Large bowel obstruction: predictive factors for postoperative mortality[J]. Dis Colon Rectum, 2004, 47(11):1889-1897. doi: 10.1007/s10350-004-0688-7 [18] 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. doi: 10.1016/j.amjsurg.2020.06.012 [19] Arezzo A, Passera R, Lo SG, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials[J]. Gastrointest Endosc, 2017, 86(3):416-426. doi: 10.1016/j.gie.2017.03.1542 [20] Alcantara M, Serra-Aracil X, Falco J, et al. Prospective, controlled, randomized study of intra operative colonic lavage versus stent placement in obstructive left-sided colonic cancer[J]. World J Surg, 2011, 35(8):1904-1910. doi: 10.1007/s00268-011-1139-y [21] 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. doi: 10.1007/s00384-018-3137-0 [22] Lee GJ, Kim HJ, Baek JH, 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. doi: 10.1016/j.ijsu.2013.04.010 [23] 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: efficacy and safety in 312 patients[J]. Surg Endosc, 2016, 30(9):3976-3986. doi: 10.1007/s00464-015-4709-5 [24] Cheung HY, Chung CC, Tsang WW, 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. doi: 10.1001/archsurg.2009.216 [25] Mege D, Manceau G, Bridoux V, et al. Surgical management of obstructive left colon cancer at a national level: results of a multicentre study of the french surgical association in 1500 patients[J]. J Visc Surg, 2019, 156(3):197-208. doi: 10.1016/j.jviscsurg.2018.11.008 [26] Hennekine-Mucci S, Tuech JJ, Brehant O, et al. Management of obstructed left colon carcinoma[J]. Hepatogastroenterology, 2007, 54(76):1098-1101. [27] Lee YM, Law WL, Chu KW, et al. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions[J]. J Am Coll Surg, 2001, 192(6):719-725. doi: 10.1016/S1072-7515(01)00833-X [28] 李树贵.急诊Ⅰ期切除吻合术治疗梗阻性左半结肠癌的效果及防范再次手术的价值分析[J].中国基层医药,2019,29(16):1956-1959. doi: 10.3760/cma.j.issn.1008-6706.2019.16.010 [29] Lim JF, Tang CL, Seow-Choen F, et al. Prospective, randomized trial comparing intraoperative colonic irrigation with manual decompression only for obstructed left-sided colorectal cancer[J]. Dis Colon Rectum, 2005, 48(2):205-209. doi: 10.1007/s10350-004-0803-9 [30] 叶颖江,高志冬,祝丽宇.结直肠癌急性肠梗阻一期切除吻合的共识与争议[J].中国实用外科杂志,2019,39(12):1283-1287. [31] Arslan K, Eryilmaz MA, Okus A, et al. Is total-subtotal colectomy and primary anastomosis a good treatment alternative in malignant obstructive lesions of the left colon[J]? Ulus Travma Acil Cerrahi Derg, 2012, 18(4): 311-316. [32] Carraro PG, Segala M, Cesana BM, et al. Obstructing colonic cancer: failure and survival patterns over a ten-year follow-up after one-stage curative surgery[J]. Dis Colon Rectum, 2001, 44(2):243-250. doi: 10.1007/BF02234300 [33] Harris GJ, Senagore AJ, Lavery IC, et al. Factors affecting survival after palliative resection of colorectal carcinoma[J]. Colorectal Dis, 2002, 4(1):31-35. doi: 10.1046/j.1463-1318.2002.00304.x [34] Xinopoulos D, Dimitroulopoulos D, Theodosopoulos T, et al. Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis[J]. Surg Endosc, 2004, 18(3):421-426. doi: 10.1007/s00464-003-8109-x [35] Scomparin RC, Martins BC, Lenz L, et al. Long-term survival analysis after endoscopic stenting as a bridge to surgery for malignant colorectal obstruction: comparison with emergency diverting colostomy[J]. Clinics (Sao Paulo), 2020, 75:e2046. doi: 10.6061/clinics/2020/e2046 [36] Xu J, Fan J, Qin X, et al. Chinese guidelines for the diagnosis and comprehensive treatment of colorectal liver metastases (version 2018)[J]. J Cancer Res Clin Oncol, 2019, 145(3):725-736. doi: 10.1007/s00432-018-2795-1
点击查看大图
计量
- 文章访问数: 188
- HTML全文浏览量: 83
- PDF下载量: 40
- 被引次数: 0