Department of Colorectal Surgery, Tallaght University Hospital, Tallaght, Dublin, Ireland.
Trinity College Dublin, College Green, Dublin, Ireland.
Dis Colon Rectum. 2024 Jul 1;67(7):878-894. doi: 10.1097/DCR.0000000000003256. Epub 2024 Apr 1.
The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.
To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.
A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.
Randomized controlled trials and propensity score-matched studies.
Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.
Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.
Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.
There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.
This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.
左侧恶性结肠梗阻的最佳治疗策略仍存在争议。急诊结肠切除术一直是标准的治疗方法；然而，自膨式金属支架作为手术的桥梁可能具有短期优势，尽管存在肿瘤学方面的担忧。减压造口术可能提供了一种有效的替代方法，但证据有限。
对比较左侧恶性结肠梗阻管理方法的研究进行系统评价和贝叶斯臂随机效应模型网络荟萃分析。
从创建到 2023 年 8 月 22 日，对 PubMed、Embase、Cochrane 图书馆和 Google Scholar 数据库进行了系统评价。
随机对照试验和倾向评分匹配研究。
急诊结肠切除术、自膨式金属支架和减压造口术。
肿瘤学疗效、发病率、微创成功手术、一期吻合术和永久性造口术的发生率。
在 5225 篇文章中，有 19 篇符合我们的纳入标准。支架（风险比 0.57；95%可信区间：0.33-0.79）和减压造口术（风险比 0.46，95%可信区间：0.18-0.92）显著降低了永久性造口术的发生率。支架更频繁地促进微创手术（风险比 4.10；95%可信区间：1.45-13.13），总体发病率更低（风险比 0.58；95%可信区间：0.35-0.86）。对一期吻合术的直接分析显示，支架（风险比 1.40；95%可信区间：1.31-1.49）的吻合术发生率高于急诊切除术。支架治疗 90 天死亡率显著降低（风险比 0.63；95%可信区间：0.41-0.95），与切除术相比。无疾病生存率和总生存率分别无差异。
缺乏比较自膨式金属支架与临时性造口术在左侧恶性结肠梗阻中的短期和长期结果的随机对照试验和倾向评分匹配数据。两项试验比较了自膨式金属支架和左侧恶性结肠梗阻中的临时性造口术。
这项研究提供了高级别的证据，表明桥接手术策略对左侧恶性结肠梗阻的管理是安全的，与急诊结肠切除术相比，它可能促进微创手术、增加一期吻合术的比率，并降低永久性造口术的发生率和术后发病率。
