Pavlidis Efstathios T, Galanis Ioannis N, Pavlidis Theodoros E
2 Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece.
World J Gastrointest Oncol. 2024 Mar 15;16(3):598-613. doi: 10.4251/wjgo.v16.i3.598.
Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.
结直肠癌很常见，尤其是在左侧。20%的患者中，梗阻和肠梗阻可能是进展期（II期、III期甚至IV期）癌的首发临床表现。诊断基于临床表现、腹部平片、计算机断层扫描（CT）、CT结肠成像和正电子发射断层扫描/CT。就短期手术或介入以及长期肿瘤学结局而言，最佳管理策略仍不明确。对于最常见的左侧梗阻，首选应是急诊手术或通过自膨式金属支架或导管进行内镜减压。手术方案应为一期或二期切除。一期切除并在台上进行肠减压和冲洗，可伴有或不伴有近端去功能化造口（结肠造口术或回肠造口术）。一期吻合更方便，但吻合口漏和发病率的风险增加。二期切除（哈特曼手术）更安全且应用最广泛，尽管会暂时影响生活质量。高危体弱患者的损伤控制手术较少进行，因为它可成功地被内镜支架置入或置管替代。对于不太常见的右侧梗阻，一期手术切除比内镜减压更有益。微创手术（腹腔镜或机器人手术）的作用存在争议。急诊腹腔镜辅助管理在一定程度上具有优势，但由于解剖扩张结肠存在固有困难以及破裂和随后脓毒症并发症的风险，需要很多专业知识。减压支架作为择期手术的桥梁，比急诊减压手术更能显著降低发病率和死亡率风险，且中期总生存率和无病生存率相当。其与新辅助化疗或放疗联合可能对长期肿瘤学结局有积极影响。管理计划至关重要，必须个体化以更好地适应每个病例。
