Matsuda Akihisa, Miyashita Masao, Matsumoto Satoshi, Sakurazawa Nobuyuki, Takahashi Goro, Matsutani Takeshi, Yamada Marina, Uchida Eiji
Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Chiba, Japan.
Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Chiba, Japan.
J Surg Res. 2016 Oct;205(2):474-481. doi: 10.1016/j.jss.2016.04.055. Epub 2016 Jul 6.
The short-term safety and efficacy of a self-expandable metallic colonic stent (SEMS) insertion followed by elective surgery, "bridge to surgery (BTS)", for malignant large-bowel obstruction (MLBO) have been well described comparing with emergency surgery. The aim of this study was to compare short-term outcomes of endoscopic decompression using a SEMS versus a transanal decompression tube (TDT).
From January 2005 to November 2014, a total of 101 patients with MLBO underwent surgery at our single institution were retrospectively identified. Among them, 73 patients who underwent preoperative complete insertion of a decompression device (TDT, n = 45; SEMS, n = 28) were finally included in this study. Six patients with incomplete insertion of a decompression device (TDT, n = 5; SEMS, n = 1) were also excluded. The primary endpoints of this study were the postoperative morbidity and mortality rates. The secondary endpoints were decompression-related outcomes. Additionally, propensity score matched (PSM) analysis was conducted in short-term outcomes between the groups.
The SEMS group had significantly higher proportion of right-sided tumor and bigger tumor size compared with those of the TDT group. The SEMS group had a significantly higher proportion of patients who underwent laparoscopic surgery, and consequently, a longer surgical duration than did the TDT group. Higher rates of insertion failure and perforation were recognized in the TDT group than in the SEMS group (10.0% versus 3.6% and 8.9% versus 0.0%, respectively), although these differences were not statistically significant (P = 0.406 and 0.291, respectively). The two groups showed similar occurrences of anastomotic leakage, bowel obstruction, overall complications, and mortality. Compared with the TDT group, the SEMS group had a significantly lower rate of surgical site infection (24.4% versus 3.6%, respectively; P = 0.023 and P = 0.025 after PSM) and a shorter length of hospital stay (median, 21 d [interquartile range, 18-29 d] versus 38 d [interquartile range, 28-45 d], respectively; P = 0.015 and P = 0.003 after PSM). Solid food intake after decompression and preoperative temporary discharge occurred only in the SEMS group.
Preoperative SEMS insertion for MLBO is effective with at least equivalent short-term outcomes and superior preoperative quality of life compared with decompression using TDT.
自膨式金属结肠支架（SEMS）置入后择期手术，即“手术桥接（BTS）”，用于治疗恶性大肠梗阻（MLBO）的短期安全性和有效性已与急诊手术进行了充分比较。本研究的目的是比较使用SEMS与经肛门减压管（TDT）进行内镜减压的短期效果。
回顾性纳入2005年1月至2014年11月在我们单中心接受手术的101例MLBO患者。其中，73例术前完全置入减压装置的患者（TDT组45例；SEMS组28例）最终纳入本研究。6例减压装置置入不完全的患者（TDT组5例；SEMS组1例）也被排除。本研究的主要终点是术后发病率和死亡率。次要终点是减压相关结果。此外，对两组的短期结局进行倾向评分匹配（PSM）分析。
与TDT组相比,SEMS组右侧肿瘤比例和肿瘤大小显著更高。SEMS组接受腹腔镜手术的患者比例显著更高，因此手术时间比TDT组长。TDT组的置入失败率和穿孔率高于SEMS组（分别为10.0%对3.6%和8.9%对0.0%），尽管这些差异无统计学意义（P分别为0.406和0.291）。两组吻合口漏、肠梗阻、总体并发症和死亡率的发生率相似。与TDT组相比，SEMS组手术部位感染率显著更低（分别为24.4%对3.6%；PSM后P = 0.023和P = 0.025），住院时间更短（中位数分别为21天[四分位间距，18 - 29天]对38天[四分位间距，28 - 45天]；PSM后P = 0.015和P = 0.003）。减压后固体食物摄入及术前临时出院仅发生在SEMS组。
与使用TDT减压相比，术前为MLBO患者置入SEMS有效，短期结局至少相当，且术前生活质量更高。
