结肠镜非透视下自扩张金属支架在处理梗阻性结直肠癌中的临床应用研究

Clinical study of the application of self-expanding metal stents without fluoroscopic monitoring for malignant colorectal obstruction

目的：比较肠镜非透视下金属支架置入序贯手术（SEMS组）与急诊手术（ES组）治疗梗阻性结直肠癌的临床效果。方法回顾性分析2007年10月至2012年12月第二军医大学附属长海医院、解放军第四一三医院收治的60例接受手术治疗的梗阻性结直肠癌患者，SEMS组（27例）接受了金属支架置入序贯手术治疗，ES组（33例）接受了急诊手术治疗。对比分析2组患者的一期切除吻合率、肠造口率、腹腔镜手术率、术后病死率、并发症发生率、ICU转入率、淋巴结清扫数量、手术时间、住院时间、住院费用等指标。所有患者术前均由多学科团队讨论、制定治疗方案。结果 SEMS组患者一期切除吻合率92．6％（25／27），高于ES组的66．7％（22／33），差异有统计学意义（P＝0．015）；SEMS组造口率7．4％（2／27），明显低于ES组的45．5％（15／33），差异有统计学意义（P＝0．001）；SEMS组的腹腔镜手术率14．8％（4／27），高于ES组的0％（0／33），差异有统计学意义（P＝0．035）；SEMS组术后ICU转入率7．4％（2／27），低于ES组的33．0％（11／33），差异有统计学意义（P＝0．015）；SEMS组患者淋巴结清扫数量[（17．52±4．00）枚]，多于ES组[（13．73±6．12）枚]，差异有统计学意义（P＝0．008）；SEMS组患者手术时间（117．22±6．42）min，明显短于ES 组的（173．64±8．32）min，差异有统计学意义（P＜0．01）；SEMS组患者中位住院时间9 d，明显短于ES组的14 d，差异有统计学意义（P＜0．01）；SEMS组患者中位住院费用39183．33元，明显少于ES组的53675．58元，差异有统计学意义（P＜0．001）。SEMS组术后30 d死亡率0％（0／27）、围手术期相关并发症发生率7．4％（2／27），低于ES组的3．0％（1／33）、21．2％（7／33），差异无统计学意义（P＞0．05）。结论 SEMS可有效解除结直肠癌合并的急性肠梗阻，将急诊手术转变为限期手术，为海上医疗后送或转诊提供条件、创造时间，获得更好的术后结果，具有良好的应用价值。

Objective To compare the clinical effect of self-expanding metal stents as a bridge to surgery （the SEMS group）with those of emergency surgery （the ES group）for malignant colorectal obstruction （MCO）.Methods A retrospective analysis was made on the 60 cases of MCO that received surgical treatment in Changhai Hospital of the Second Military Medical University and No.413 Hospital from October 2007 to＆amp;nbsp;December 2012.The SEMS group （27 cases）received self -expanding metal stents,while the ES group （33 cases）was treated with emergency surgery.Indexes,such as primary anastomotic rate,stoma rate, laparoscopic surgical rate,death rate after surgery,postoperative complication rate,ICU transfer rate,the number of lymph nodes cleared,surgical time,length of hospital stay and hospitalization cost,were compared between the 2 groups. Before surgery, the medical team consisting of multidisciplinary specialists held discussions on the treatment schemes and appropriate surgical protocols were developed pertaining to individual cases.Results Primary anastomotic rate of the patients in the SEMS group （92.6%,25/27）was significantly higher than that of the patients in the ES group （66.7%,22/33）（P=0.015）.Stoma rate of the SEMS group （7.4%,2/27）was significantly lower than that of the ES group （45.5%,15/33）（P=0.001）.Laparoscopic surgical rate of the SEMS group （14.8%,4/27）was obviously higher than that of the ES group （0%,0/33） （P=0.035）.ICU transfer rate of the SEMS group （7.4%,2/27）was significantly lower than that of the ES group （33.3%,11/33）（P=0.015）.The number of lymph nodes cleared for the SEMS group（17.52 ± 4.00）was larger than that for the ES group （13.73 ±6.12）（P=0.008）.Surgical time for the SEMS group （117.22 ±6.42）min was significantly shorter than that for the ES group （173.64 ±8.32）min （P〈0.01）. Length of hospital stay for the SEMS group （9 d）was significantly shorter than that for the ES group （14 d） （P〈0.01）.The median hospitalization cost for the SEMS group （39183.33 RMB）was significantly less than that for the ES group （53675.58 RMB）（P〈0.01）.Death rate 30 days after surgery and complication rate during perioperative period for the SEMS group [（0%,0/27）,（7.4%,2/27）]were lower than those for the ES group [（3.0%,1/33 ）,（21.2%,（7/33 ）],and no statistical significance could be noted when comparisons were made between them （P〈0.05 ）.The postoperative morbidity in the SEMS group was lower than that in the ES group （3.0% vs 21.2%）,without significant statistical difference （P ＆lt;0.05 ）. Conclusions SEMS could effectively relieve the obstruction caused by colorectal cancer,and change the traditional emergency surgery into a selective surgery with better outcomes.This technique could offer better chances for medical transfer at sea or medical transformation to higher echelon care and seemed to have good promise for further clinical application.