切换至 "中华医学电子期刊资源库"

中华结直肠疾病电子杂志 ›› 2024, Vol. 13 ›› Issue (06) : 450 -458. doi: 10.3877/cma.j.issn.2095-3224.2024.06.002

梗阻性结直肠癌专栏

梗阻性左半结肠癌的治疗策略
韩加刚1,(), 王振军1   
  1. 1.100020 北京,首都医科大学附属北京朝阳医院普通外科
  • 收稿日期:2024-10-27 出版日期:2024-12-25
  • 通信作者: 韩加刚
  • 基金资助:
    国家自然科学基金面上项目(No.82070685)北京朝阳医院多学科临床创新团队项目(No.CYDXK202206)北京市卫生健康科技成果和适宜技术推广项目(No.BHTPP2024063)

The treatment strategies for obstructive left-sided colon cancer

Jiagang Han1,(), Zhenjun Wang1   

  1. 1.Department of General Surgery, Beijing Chaoyang Hosptial, Capital Medical University, Beijing 100020, China
  • Received:2024-10-27 Published:2024-12-25
  • Corresponding author: Jiagang Han
引用本文:

韩加刚, 王振军. 梗阻性左半结肠癌的治疗策略[J/OL]. 中华结直肠疾病电子杂志, 2024, 13(06): 450-458.

Jiagang Han, Zhenjun Wang. The treatment strategies for obstructive left-sided colon cancer[J/OL]. Chinese Journal of Colorectal Diseases(Electronic Edition), 2024, 13(06): 450-458.

梗阻性结直肠癌是常见的恶性肠梗阻,急诊手术可能会首选肠造口或切除肿瘤后肠造口,但急诊手术患者的肠道和全身条件往往较差,患者需要接受多次手术,增加手术风险和经济负担,降低了患者生活质量,术中视野较差也可能影响手术的根治性。肠梗阻导管可以快速减压、引流,有效解除梗阻症状,提高一期根治性切除手术成功率。肠梗阻导管对肿瘤的挤压较轻,较少引起肿瘤细胞播散,但价格较高,管腔较细,容易堵塞,需要繁琐的冲洗或定期更换,目前开展的研究较少。肠梗阻支架可以有效缓解肠梗阻,为择期手术提供了较为充分的准备时间,完善术前检查,充分评估肿瘤,改善患者全身状态,提高患者对根治性手术的耐受性,可以作为梗阻性结直肠癌的重要治疗策略选择。但肠梗阻支架可能对肿瘤产生挤压,导致穿孔或肿瘤细胞的播散,增加复发率和转移率,降低生存率。而且放入肠梗阻支架后手术时,肠壁水肿依然存在,吻合后的造口率高达34%。肠梗阻支架-新辅助化疗-手术的治疗策略,在缓解肠梗阻后,适当延长手术等待时间,有利于肠壁水肿消退,患者全身状态改善;同时新辅助化疗有助于局部肿瘤和潜在转移病灶的控制。研究证实,肠梗阻支架-新辅助化疗-手术策略提高了一期吻合和手术根治性,提高微创手术率,降低造口率,提高生存率,可能成为梗阻性左半结肠癌的治疗策略选择。

Obstructive colorectal cancer is a common malignant bowel obstruction.Loop colostomy or colostomy following tumor resection may be the first choice for emergency surgery.The intestinal and systemic conditions of patients undergoing emergency surgery are often poor, and patients need to undergo multiple operations, which increase the surgical risk and economic burden and reduce the quality of life of patients.Poor intraoperative visual field may also affect the radical operation of emergency surgery.Transanal decompression tube (TDT) can rapidly decompress and drain the obstructed bowel, effectively relieve obstruction symptoms, and improve the success rate of primary radical resection.The TDT squeeze the tumor lightly, causing no spread of tumor cells, and is cheap, but the cavity of transanal decompression tube is small and easily blocked, and requires tedious flushing or regular replacement.Self-expanding metallic stents (SEMS) can relieve intestinal obstruction effectively, provide sufficient preoperative preparation time,complete preoperative examination, evaluate the tumor thoroughly, improve the patient’s nutritional status,and improve the patient’s tolerance to radical surgery, which might be used as an important treatment strategy choice for obstructive colorectal cancer.However, SEMS may squeeze the tumor, leading to the spread of tumor cells, increase the recurrence rate and metastasis rate, and reduce the survival rate.Moreover, intestinal wall edema still existed during the operation following SEMS, and the rate of ostomy after anastomosis was as high as 34%.We hypothesized that prolonging the interval between stent insertion and surgery to 2 months, with neoadjuvant chemotherapy administered during this interval (SEMS-neoadjuvant chemotherapy strategy), would help improve outcomes.The SEMS-neoadjuvant chemotherapy strategy is a safe, effective,and well tolerated treatment approach with a high laparoscopic resection rate, low stoma formation rate and improvement in the overall survival for patients with left-sided colon cancer obstruction.The patient physical status is improved, the primary tumor is downstaged, and intestinal wall edema is relieved during the relatively longer interval between SEMS placement and surgery.The SEMS-neoadjuvant chemotherapy strategy may be one of the preferred therapeutic strategy for obstructive left colon cancer.

[1]
Baer C, Menon R, Bastawrous S, et al.Emergency presentations of colorectal cancer[J].Surg Clin North Am, 2017, 97(3): 529-545.
[2]
Arnaud JP, Bergamaschi R.Emergency subtotal/total colectomy with anastomosis for acutely obstructed carcinoma of the left colon[J].Dis Colon Rectum, 1994, 37(7): 685-688.
[3]
Single-stage treatment for malignant left-sided colonic obstruction: a prospective randomized clinical trial comparing subtotal colectomy with segmental resection following intraoperative irrigation.The SCOTIA Study Group.Subtotal colectomy versus on-table irrigation and anastomosis[J].Br J Surg, 1995, 82(12): 1622-1627.
[4]
Ghazal AH, El-Shazly WG, Bessa SS, et al.Colonic endolumenal stenting devices and elective surgery versus emergency subtotal/total colectomy in the management of malignant obstructed left colon carcinoma[J].J Gastrointest Surg, 2013, 17(6): 1123-1129.
[5]
Odermatt M, Miskovic D, Siddiqi N, et al.Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study[J].World J Surg, 2013, 37(10): 2458-2467.
[6]
Ouyang K, Yang Z, Yang Y, et al.Which treatment strategy is optimal for acute left-sided malignant colonic obastruction? A Bayesian metaanalysis[J].Int J Colorectal Dis, 2023, 38(1): 217.
[7]
Zwanenburg ES, Veld JV, Amelung FJ, et al.Short- and longterm outcomes after laparoscopic emergency resection of left-sided obstructive colon cancer: a nationwide propensity score-matched analysis[J].Dis Colon Rectum, 2023, 66(6): 774-784.
[8]
Buess G, Uekermann U, Grundmann R.Transanal application of a decompressive intestinal tube in the surgical treatment of a small intestine ileus.An alternative to enterostomy[J].Chirurg, 1982, 53(6):391-392.
[9]
Yamada T, Shimura T, Sakamoto E, et al.Preoperative drainage using a transanal tube enables elective laparoscopic colectomy for obstructive distal colorectal cancer[J].Endoscopy, 2013, 45(4): 265-271.
[10]
Okuda Y, Yamada T, Hirata Y, et al.Long-term outcomes of one stage surgery using transanal colorectal tube for acute colorectal obstruction of stage II/III distal colon cancer[J].Cancer Res Treat, 2019, 51(2):474-482.
[11]
Endo S, Kumamoto K, Enomoto T, et al.Comparison of survival and perioperative outcome of the colonic stent and the transanal decompression tube placement and emergency surgery for left-sided obstructive colorectal cancer: a retrospective multi-center observational study “The CODOMO study”[J].Int J Colorectal Dis, 2021, 36(5):987-998.
[12]
Okuda Y, Yamada T, Hirata Y, et al.Long-term outcomes of one stage surgery using transanal colorectal tube for acute colorectal obstruction of stage II/III distal colon cancer[J].Cancer Res Treat, 2019, 51(2):474-482.
[13]
Okuda Y, Shimura T, Kato H, et al.Pathological impact of transanal colorectal tube for obstructive colorectal cancer[J].Surg Endosc, 2020,34(9): 4011-4018.
[14]
Shimura T, Joh T.Evidence-based clinical management of acute malignant colorectal obstruction[J].J Clin Gastroenterol, 2016, 50(4):273-285.
[15]
Tejero E, Mainar A, Fernández L, et al.New procedure for the treatment of colorectal neoplastic obstructions[J].Dis Colon Rectum,1994, 37(11): 1158-1159.
[16]
Tomita M, Saito S, Makimoto S, et al.Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction:pooled analysis of 426 patients from two prospective multicenter series[J].Surg Endosc, 2019, 33(2): 499-509.
[17]
Amelung FJ, Borstlap W, Consten E, et al.Propensity score-matched analysis of oncological outcome between stent as bridge to surgery and emergency resection in patients with malignant left-sided colonic obstruction[J].Br J Surg, 2019, 106(8): 1075-1086.
[18]
Spannenburg L, Sanchez Gonzalez M, Brooks A, et al.Surgical outcomes of colonic stents as a bridge to surgery versus emergency surgery for malignant colorectal obstruction: a systematic review and meta-analysis of high quality prospective and randomised controlled trials[J].Eur J Surg Oncol, 2020, 46(8): 1404-1414.
[19]
Sabbagh C, Chatelain D, Trouillet N, et al.Does use of a metallic colon stent as a bridge to surgery modify the pathology data in patients with colonic obstruction? A case-matched study[J].Surg Endosc, 2013,27(10): 3622-3631.
[20]
Tung KL, Cheung HY, Ng LW, et al.Endo-laparoscopic approach versus conventional open surgery in the treatment of obstructing leftsided colon cancer: long-term follow-up of a randomized trial[J].Asian J Endosc Surg, 2013, 6(2): 78-81.
[21]
Vogel JD, Felder SI, Bhama AR, et al.The American society of colon and rectal surgeons clinical practice guidelines for the management of colon cancer[J].Dis Colon Rectum, 2022, 65(2): 148-177.
[22]
Benson AB, Venook AP, Al-Hawary MM, et al.Colon cancer, version 2.2021, NCCN clinical practice guidelines in oncology[J].J Natl Compr Canc Netw, 2021, 19(3): 329-359.
[23]
Tao Y, Li GB, Zhang HY, et al.Current practice for the treatment of obstructive left-sided colon cancer in China: a nationwide cross-sectional survey[J].Surg Today, 2023, 53(4): 459-469.
[24]
李干斌, 于剑锋, 翟志伟, 等.置入可扩张金属支架联合新辅助化疗治疗完全梗阻性左半结肠癌远期疗效分析[J].中国实用外科杂志, 2023, 43(4): 424-428.Li GB, Yu JF, Zhai ZW, et al.The long-term survival outcomes of self-expanding metallic stent followed by neoadjuvant chemotherapy for patients with acute obstructing left-sided colon cancer[J].Chinese Journal of Practical Surgery, 2023, 43(4): 424-428.
[25]
Takahashi H, Okabayashi K, Tsuruta M, et al.Self-expanding metallic stents versus surgical intervention as palliative therapy for obstructive colorectal cancer: a meta-analysis[J].World J Surg, 2015, 39(8): 2037-2044.
[26]
Gorissen KJ, Tuynman JB, Fryer E, et al.Local recurrence after stenting for obstructing left-sided colonic cancer[J].Br J Surg, 2013,100(13): 1805-1809.
[27]
Sabbagh C, Browet F, Diouf M, et al.Is stenting as “a bridge to surgery” an oncologically safe strategy for the management of acute,left-sided, malignant, colonic obstruction? A comparative study with a propensity score analysis[J].Ann Surg, 2013, 258(1): 107-115.
[28]
Avlund TH, Erichsen R, Ravn S, et al.The prognostic impact of bowel perforation following self-expanding metal stent as a bridge to surgery in colorectal cancer obstruction[J].Surg Endosc, 2018, 32(1): 328-336.
[29]
Suzuki Y, Moritani K, Seo Y, et al.Comparison of decompression tubes with metallic stents for the management of right-sided malignant colonic obstruction[J].World J Gastroenterol, 2019, 25(16): 1975-1985.
[30]
Foo CC, 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.
[31]
van Hooft JE, van Halsema EE, 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.
[32]
Pisano M, Zorcolo L, Merli C, et al.2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation[J].World J Emerg Surg, 2018, 13: 36.
[33]
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.
[34]
Malgras B, Brullé L, Lo Dico R, et al.Insertion of a stent in obstructive colon cancer can induce a metastatic process in an experimental murine model[J].Ann Surg Oncol, 2015, 22(Suppl.3): S1475-S1480.
[35]
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.
[36]
Takahashi G, Yamada T, Iwai T, et al.Oncological assessment of stent placement for obstructive colorectal cancer from circulating cell-free DNA and circulating tumor DNA dynamics[J].Ann Surg Oncol, 2018,25(3): 737-744.
[37]
Maruthachalam K, Lash GE, Shenton BK, et al.Tumour cell dissemination following endoscopic stent insertion[J].Br J Surg, 2007,94(9): 1151-1154.
[38]
Kim HJ, Choi GS, Park JS, 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.
[39]
Haraguchi N, Ikeda M, Miyake M, et al.Colonic stenting as a bridge to surgery for obstructive colorectal cancer: advantages and disadvantages[J].Surg Today, 2016, 46(11): 1310-1317.
[40]
曹可, 刁小丽, 于剑锋, 等.肠梗阻支架置入联合新辅助化疗对完全梗阻性结直肠癌患者手术标本病理特征的影响[J].中华胃肠外科杂志, 2022, 25(11): 1012-1019.Cao K, Diao XL, Yu JF, et al.Effect of intestinal obstruction stent combined with neoadjuvant chemotherapy on the pathological characteristics of surgical specimens in patients with complete obstructive colorectal cancer[J].Chin J Gastrointest Surg, 2022,25(11): 1012-1019.
[41]
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.
[42]
Ormando VM, 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.
[43]
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.Han JG, Wang ZJ, Dai Y, et al.Preliminary report on prospective,multicenter, open research of selective surgery after expandable stent combined with neoadjuvant chemotherapy in the treatment of obstructive left hemicolon cancer[J].Chin J Gastrointest Surg, 2018,21(11): 1233-1239.
[44]
Han JG, Wang ZJ, Zeng WG, et al.Efficacy and safety of selfexpanding metallic stent placement followed by neoadjuvant chemotherapy and scheduled surgery for treatment of obstructing leftsided colonic cancer[J].BMC Cancer, 2020, 20(1): 57.
[45]
Han JG, Wang ZJ, Dai Y, et al.Short-term outcomes of elective surgery following self-expandable metallic stent and neoadjuvant chemotherapy in patients with left-sided colon cancer obstruction[J].Dis Colon Rectum, 2023, 66(10): 1319-1328.
[46]
石阳, 翟志伟, 于剑锋, 等.置入可扩张金属支架联合新辅助化疗治疗完全梗阻性左半结肠癌5 年预后分析[J].中国实用外科杂志,2024, 7: 810-815.
[47]
李干斌, 韩加刚, 王振军, 等.不同治疗策略对完全梗阻性左半结肠癌患者术后肛门功能和生活质量影响的比较研究[J].中华胃肠外科杂志, 2021, 24(4): 335-343.Li GB, Han JG, Wang ZJ, et al.A comparative study of the effects of different treatment strategies on postoperative anal function and quality of life in patients with complete obstructive left hemicolon cancer[J].Chin J Gastrointest Surg, 2021, 24(4): 335-343.
[1] 洪玮, 叶细容, 刘枝红, 杨银凤, 吕志红. 超声影像组学联合临床病理特征预测乳腺癌新辅助化疗完全病理缓解的价值[J/OL]. 中华医学超声杂志(电子版), 2024, 21(06): 571-579.
[2] 张晓宇, 殷雨来, 张银旭. 阿帕替尼联合新辅助化疗对三阴性乳腺癌的疗效及预后分析[J/OL]. 中华乳腺病杂志(电子版), 2024, 18(06): 346-352.
[3] 许杰, 李亚俊, 韩军伟. 两种入路下腹腔镜根治性全胃切除术治疗超重胃癌的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 19-22.
[4] 高杰红, 黎平平, 齐婧, 代引海. ETFA和CD34在乳腺癌中的表达及与临床病理参数和预后的关系研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 64-67.
[5] 徐逸男. 不同术式治疗梗阻性左半结直肠癌的疗效观察[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 72-75.
[6] 李代勤, 刘佩杰. 动态增强磁共振评估中晚期低位直肠癌同步放化疗后疗效及预后的价值[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 100-103.
[7] 屈翔宇, 张懿刚, 李浩令, 邱天, 谈燚. USP24及其共表达肿瘤代谢基因在肝细胞癌中的诊断和预后预测作用[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 659-662.
[8] 顾雯, 凌守鑫, 唐海利, 甘雪梅. 两种不同手术入路在甲状腺乳头状癌患者开放性根治性术中的应用比较[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 687-690.
[9] 付成旺, 杨大刚, 王榕, 李福堂. 营养与炎症指标在可切除胰腺癌中的研究进展[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 704-708.
[10] 陈樽, 王平, 金华, 周美玲, 李青青, 黄永刚. 肌肉减少症预测结直肠癌术后切口疝发生的应用研究[J/OL]. 中华疝和腹壁外科杂志(电子版), 2024, 18(06): 639-644.
[11] 刘郁, 段绍斌, 丁志翔, 史志涛. miR-34a-5p 在结肠癌患者的表达及其与临床特征及预后的相关性研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 485-490.
[12] 陈倩倩, 袁晨, 刘基, 尹婷婷. 多层螺旋CT 参数、癌胚抗原、错配修复基因及病理指标对结直肠癌预后的影响[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 507-511.
[13] 曾明芬, 王艳. 急性胰腺炎合并脂肪肝患者CT 与彩色多普勒超声诊断参数与其病情和预后的关联性研究[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 531-535.
[14] 沈炎, 张俊峰, 唐春芳. 预后营养指数结合血清降钙素原、胱抑素C及视黄醇结合蛋白对急性胰腺炎并发急性肾损伤的预测价值[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 536-540.
[15] 王景明, 王磊, 许小多, 邢文强, 张兆岩, 黄伟敏. 腰椎椎旁肌的研究进展[J/OL]. 中华临床医师杂志(电子版), 2024, 18(09): 846-852.
阅读次数
全文


摘要