Division of Gastroenterology, Hepatology, and Nutrition. The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
Baylor College of Medicine, Houston, Texas, USA.
Gastrointest Endosc. 2019 Jul;90(1):116-124. doi: 10.1016/j.gie.2019.02.016. Epub 2019 Feb 21.
The aim of this study was to examine clinical outcomes and adverse events (AEs) of self-expandable metal stents (SEMSs) in the management of malignant colonic obstruction (MCO).
Patients with SEMSs for MCO treated at our institution from 2007 to 2016 were included. Clinical success was defined as successful oral intake after the procedure and technical success as stent deployment across the stricture in the desired location.
Of 199 patients, the mean age was 58, 54% were men, and 99% had stage IV cancer. MCO etiology was colorectal cancer in 82% and extrinsic compression in 17%. Technical success was achieved in 99.5% and clinical success in 89%. The SEMSs were palliative in 97% and were a bridge to surgery in 4%. MCO occurred in the left side of the colon in 90%, transverse in 4.5%, and ascending colon in 5.5%. SEMSs were placed in curved segments in 30% and straight segments in 70%. Tandem SEMSs were required in 27 patients. Forty-six patients had 48 AEs (24%), including 2% periprocedure, 15% postprocedure, and 83% after 72 hours. Stent-related AEs (n = 25) included persistent obstruction (n = 14), occlusion (n = 10), and failure of expansion (n = 1). Procedural AEs (n = 23) included minor bleeding (n = 2), perforations (n = 4), abdominal pain (n = 12), stent migration (n = 4), and respiratory insufficiency (n = 1). Repeat procedures were performed in 21 of 46 patients. After SEMSs, 48 patients underwent surgery, including resection with primary anastomosis (n = 8), resection with definitive stoma (n = 18), and diverting stoma without resection (n = 19). Mean time to surgery after SEMS placement was 175 days. Postsurgical AEs occurred in those with resections (leak, 2; infection, 2). Of 104 receiving bevacizumab, 22% had AEs, including 1 perforation compared with 3 in the nonbevacizumab group (P = .549). Mean overall survival was 5.6 months. Extrinsic compression and curved strictures were associated with poor clinical success by univariate analysis and etiology (noncolonic with poor outcome) by multivariate analysis.
SEMSs for MCO has high technical but suboptimal clinical success. Curved strictures and extrinsic compression are associated with poor outcomes. The perforation rate was not higher in the bevacizumab compared with the nonbevacizumab group, although this should be further validated in a larger population.
本研究旨在探讨自膨式金属支架（SEMS）在治疗恶性结肠梗阻（MCO）中的临床疗效和不良事件（AEs）。
纳入 2007 年至 2016 年在我院接受 SEMS 治疗的 MCO 患者。临床成功定义为术后成功口服，技术成功定义为支架在预期位置穿过狭窄部位。
199 例患者中，平均年龄为 58 岁，54%为男性，99%为 IV 期癌症。MCO 的病因是结直肠癌占 82%，外压性占 17%。技术成功率为 99.5%，临床成功率为 89%。SEMS 为姑息性治疗，占 97%，桥接手术占 4%。MCO 发生在结肠左侧占 90%，横结肠占 4.5%，升结肠占 5.5%。SEMS 放置在弯曲段占 30%，直段占 70%。27 例患者需要双支架。46 例患者出现 48 例 AEs（24%），包括围手术期 2%，术后 15%，术后 72 小时 83%。支架相关 AEs（n=25）包括持续性梗阻（n=14）、闭塞（n=10）和扩张失败（n=1）。手术相关 AEs（n=23）包括轻微出血（n=2）、穿孔（n=4）、腹痛（n=12）、支架移位（n=4）和呼吸功能不全（n=1）。46 例患者中有 21 例重复进行了手术。SEMS 后 48 例患者接受了手术，包括根治性切除+一期吻合术（n=8）、根治性切除+确定性造口术（n=18）和无切除的转流性造口术（n=19）。SEMS 放置后至手术的平均时间为 175 天。接受贝伐单抗治疗的 104 例患者中有 22%发生 AEs，包括 2 例渗漏和 2 例感染。贝伐单抗组有 1 例穿孔，而非贝伐单抗组有 3 例穿孔（P=0.549）。总生存时间的平均值为 5.6 个月。单因素分析显示，外压性和弯曲狭窄与临床成功率差有关，多因素分析显示病因（非结直肠癌与不良结局）与临床成功率差有关。
SEMS 治疗 MCO 的技术成功率高，但临床成功率不理想。弯曲狭窄和外压性与不良结局有关。贝伐单抗组的穿孔率与非贝伐单抗组无差异，但这仍需要在更大的人群中进一步验证。
