Sagar Jayesh
1Department of Surgery, Royal Free Hampstead NHS Foundation Trust, London, UK.
Cochrane Database Syst Rev. 2011 Nov 9;2011(11):CD007378. doi: 10.1002/14651858.CD007378.pub2.
Colorectal cancer is one of the most common cancer in the western world. Acute colonic obstruction is one of the common presentations of colon cancer. Emergency surgical decompression is the traditional treatment of choice but is associated with high morbidity and mortality. In recent years colonic stents have been used to relieve the obstruction.
The aim was to compare the colonic stenting versus emergency surgical decompression with regards to benefits and risks.
Searches were carried out May 2010 in the Cochrane Colorectal Cancer Specialised Register, the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid EMBASE and Ovid CINAHL.
Randomised clinical trials comparing colonic stenting versus surgical decompression for obstructing colorectal cancers were considered for inclusion.
Data on the characteristics of the trial, methodological quality of the trials, mortality, morbidity, technical and clinical success rate, operating time, hospital stay and other measured secondary outcomes from each trial were collected. And the data were analysed with both the fixed-effect and the random-effects models using RevMan Analysis. For each outcome, odds ratio (OR) with 95% confidence intervals (CI) based on available data analysis was calculated.
Five randomised trials were identified with a total of 207 participants, 102 to colorectal stenting and 105 to emergency surgery. There was statistically significant higher clinical success rate in the emergency surgery group. The average time of clinical relief of obstruction was 0.66 day in the colonic stent group and was 3.55 days in the emergency surgery group. The stent insertion was successful in 86.02% of attempted stent placements. There was no statistically significant difference in the 30-day mortality between two groups. The 30 day mortality rate was similar, 2.3% in both groups. The stent related perforation rate was 5.88%. The stent migration rate was 2.13%. The stent obstruction rate was 2.13%. There was no statistically significant difference in overall complication rate in both groups. The complication rate was 39.22% in the colonic stent group and was 45.71% in the emergency surgery group. The mean hospital stay was 11.53 days in the colonic stent group and was 17.15 days in the emergency surgery group. The mean procedure/operating time was 113.93 minutes in the colonic stent group compared to 143.85 minutes in the emergency surgery group. The median blood loss was 50 ml in the colonic stent group and 350 ml in the emergency surgery group.
AUTHORS' CONCLUSIONS: The use of colonic stent in malignant colorectal obstruction seems to have no advantage over emergency surgery. The clinical success rate was statistically higher in emergency surgery group. However, use of colorectal stents seems to be as safe in the malignant colorectal obstruction as the emergency surgery with no statistically significant difference in the mortality and morbidity. Colorectal stents are associated with acceptable stent perforation, migration and obstruction rates. The advantages of colorectal stent includes shorter hospital stay and procedure time and less blood loss. However, due to the variability in the sample size and trial designs in the included studies, further randomised trials with bigger sample size and well defined trial design are needed to achieve the robust evidence.
结直肠癌是西方世界最常见的癌症之一。急性结肠梗阻是结肠癌常见的临床表现之一。急诊手术减压是传统的治疗选择，但与高发病率和死亡率相关。近年来，结肠支架已被用于缓解梗阻。
目的是比较结肠支架置入术与急诊手术减压的益处和风险。
于2010年5月在Cochrane结直肠癌专科注册库、Cochrane对照试验中央注册库、Ovid MEDLINE、Ovid EMBASE和Ovid CINAHL中进行检索。
纳入比较结肠支架置入术与手术减压治疗结直肠癌梗阻的随机临床试验。
收集每个试验的试验特征、试验方法学质量、死亡率、发病率、技术和临床成功率、手术时间、住院时间及其他测量的次要结局的数据。并使用RevMan分析软件，采用固定效应模型和随机效应模型对数据进行分析。对于每个结局，根据可用数据分析计算比值比（OR）及95%置信区间（CI）。
共纳入5项随机试验，总计207名参与者，其中102名接受结肠支架置入术，105名接受急诊手术。急诊手术组的临床成功率在统计学上显著更高。结肠支架组梗阻临床缓解的平均时间为0.66天，急诊手术组为3.55天。86.02%的支架置入尝试成功。两组30天死亡率无统计学显著差异。30天死亡率相似，两组均为2.3%。支架相关穿孔率为5.88%。支架迁移率为2.13%。支架梗阻率为2.13%。两组总体并发症发生率无统计学显著差异。结肠支架组并发症发生率为39.22%，急诊手术组为45.71%。结肠支架组平均住院时间为11.53天，急诊手术组为17.1天。结肠支架组平均手术/操作时间为113.93分钟，急诊手术组为143.85分钟。结肠支架组中位失血量为50ml，急诊手术组为350ml。
在恶性结直肠梗阻中使用结肠支架似乎并不比急诊手术更具优势。急诊手术组的临床成功率在统计学上更高。然而，在恶性结直肠梗阻中使用结肠支架似乎与急诊手术一样安全，死亡率和发病率无统计学显著差异。结肠支架的穿孔、迁移和梗阻率是可接受的。结肠支架的优点包括住院时间和手术时间更短，失血量更少。然而，由于纳入研究的样本量和试验设计存在差异，需要进一步开展样本量更大、试验设计明确的随机试验以获得有力证据。
