Department of General Surgery, Tongji Hospital, Tongji University School of Medicine, 389 Xincun Road, 200065, Shanghai, China.
Department of Colorectal Surgery, Ningbo First Hospital, 315010, Ningbo, China.
BMC Surg. 2021 Mar 20;21(1):148. doi: 10.1186/s12893-021-01144-z.
Bridge to elective surgery (BTS) using self-expanding metal stents (SEMSs) is a common alternative to emergency surgery (ES) for acute malignant left-sided colonic obstruction (AMLCO). However, studies regarding the long-term impact of BTS are limited and have reported unclear results.
A multicenter observational study was performed at three hospitals from April 2012 to December 2019. Propensity score matching (PSM) was introduced to minimize selection bias. The primary endpoint was overall survival. The secondary endpoints included surgical approaches, primary resection types, total stent-related adverse effects (AEs), surgical AEs, length of hospital stay, 30-day mortality and tumor recurrence.
Forty-nine patients in both the BTS and ES groups were matched. Patients in the BTS group more often underwent laparoscopic resection [31 (63.3%) vs. 8 (16.3%), p < 0.001], were less likely to have a primary stoma [13 (26.5%) vs. 26 (53.1%), p = 0.007] and more often had perineural invasion [25 (51.0 %) vs. 13 (26.5 %), p = 0.013]. The median overall survival was significantly lower in patients with stent insertion (41 vs. 65 months, p = 0.041). The 3-year overall survival (53.0 vs. 77.2%, p = 0.039) and 5-year overall survival (30.6 vs. 55.0%, p = 0.025) were significantly less favorable in the BTS group. In multivariate Cox regression analysis, stenting (hazard ratio(HR) = 2.309(1.052-5.066), p = 0.037), surgical AEs (HR = 1.394 (1.053-1.845), p = 0.020) and pTNM stage (HR = 1.706 (1.116-2.607), p = 0.014) were positively correlated with overall survival in matched patients.
Self-expanding metal stents as "a bridge to surgery" are associated with more perineural invasion, a higher recurrence rate and worse overall survival in patients with acute malignant left-sided colonic obstruction compared with emergency surgery.
对于急性恶性左半结肠梗阻（AMLCO），采用自膨式金属支架（SEMS）的择期手术桥接（BTS）是急诊手术（ES）的常见替代方法。然而，关于 BTS 的长期影响的研究有限，且报告结果不一致。
本研究为 2012 年 4 月至 2019 年 12 月在三家医院进行的多中心观察性研究。采用倾向评分匹配（PSM）以最小化选择偏倚。主要终点是总生存率。次要终点包括手术方式、主要切除类型、支架相关总不良事件（AEs）、手术 AEs、住院时间、30 天死亡率和肿瘤复发。
BTS 组和 ES 组各匹配了 49 例患者。BTS 组患者更常接受腹腔镜切除[31 例（63.3%）比 8 例（16.3%），p<0.001]，原发造口术的可能性较小[13 例（26.5%）比 26 例（53.1%），p=0.007]，且更常发生神经周围侵犯[25 例（51.0%）比 13 例（26.5%），p=0.013]。支架置入患者的中位总生存率明显较低（41 个月比 65 个月，p=0.041）。BTS 组的 3 年总生存率（53.0%比 77.2%，p=0.039）和 5 年总生存率（30.6%比 55.0%，p=0.025）明显较低。多变量 Cox 回归分析显示，支架置入（风险比（HR）=2.309（1.052-5.066），p=0.037）、手术 AEs（HR=1.394（1.053-1.845），p=0.020）和 pTNM 分期（HR=1.706（1.116-2.607），p=0.014）与匹配患者的总生存率呈正相关。
与急诊手术相比，自膨式金属支架作为“手术桥接”会导致急性恶性左半结肠梗阻患者的神经周围侵犯更多、复发率更高和总生存率更差。
