Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Japan.
Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
Dig Endosc. 2019 Jan;31(1):51-58. doi: 10.1111/den.13260. Epub 2018 Sep 3.
Colorectal cancer patients often present with large bowel obstruction. Elective placement of a self-expandable metallic stent (SEMS) can relieve obstruction, but can be challenging. Previous studies have compared cases by outcomes only, but the present study investigated successful cases only to identify factors related to prolonged and difficult SEMS placement in patients with malignant colonic obstruction.
A post-hoc analysis of a multicenter clinical trial conducted between March 2012 and October 2013 at 46 facilities across Japan (UMIN000007953) was carried out; 511 patients who required SEMS placement for acute colorectal obstruction or symptomatic stricture secondary to malignant neoplasm were enrolled. Technical success rates and procedure times were recorded. Clinical and interventional parameters were investigated for their potential effect on procedure time by univariate and multivariate analyses.
Technical success rate of SEMS placement was 98%. Median procedure time was 30 (range, 4-170) min. In 27% of patients, procedure time exceeded 45 min, indicating technically difficult placement. Multivariate analyses showed significant associations between technically difficult placement and a ColoRectal Obstruction Scoring System (CROSS) score of 0 before SEMS placement (odds ratio [OR], 1.6; P < 0.05), tumor site in the right colon (OR, 2.5; P < 0.0001), stricture length ≥5 cm (OR, 2.2; P < 0.001), peritoneal carcinomatosis (OR, 1.7; P < 0.05), and multiple SEMS placement (OR, 8.0; P < 0.01).
Clinicians must anticipate technical challenges in cases with peritoneal carcinomatosis, a CROSS score of 0, or expansive strictures; such cases require experienced clinicians to carry out SEMS placement.
结直肠癌患者常伴有大肠梗阻。选择性放置自膨式金属支架（SEMS）可缓解梗阻，但可能具有挑战性。既往研究仅通过结局比较病例，但本研究仅调查成功病例，以确定与恶性结肠梗阻患者 SEMS 放置时间延长和困难相关的因素。
对 2012 年 3 月至 2013 年 10 月在日本 46 家机构进行的多中心临床试验（UMIN000007953）进行了一项事后分析；共纳入 511 例因急性结直肠梗阻或恶性肿瘤引起的症状性狭窄而需要 SEMS 放置的患者。记录技术成功率和手术时间。通过单变量和多变量分析，研究了临床和介入参数对手术时间的潜在影响。
SEMS 放置的技术成功率为 98%。中位手术时间为 30（范围 4-170）min。27%的患者手术时间超过 45min，表明手术难度较大。多变量分析显示，SEMS 放置前 CROSS 评分（ColoRectal Obstruction Scoring System）为 0（优势比 [OR]，1.6；P<0.05）、肿瘤位于右半结肠（OR，2.5；P<0.0001）、狭窄长度≥5cm（OR，2.2；P<0.001）、腹膜转移（OR，1.7；P<0.05）和多次 SEMS 放置（OR，8.0；P<0.01）与技术难度较大的放置显著相关。
对于伴有腹膜转移、CROSS 评分 0 或广泛狭窄的患者，临床医生必须预计到技术挑战；此类病例需要有经验的临床医生进行 SEMS 放置。
