支架联合腹腔镜手术治疗梗阻性左半结肠癌的初步探讨

A preliminary study of stenting followed by laparoscopic surgery for obstructing left-sided colon cancer

目的 探讨左半结肠癌并肠梗阻患者腔内支架置入后再行腹腔镜手术的疗效及手术时机的选择.方法 前瞻性将49例左半结肠癌并梗阻患者由计算机随机分入支架联合腹腔镜手术组（29例,其中支架后3 d手术15例、10 d后手术14例）和开腹手术组（20例）,对比分析3组患者一期手术吻合成功例数、中转开腹率、手术时间、住院时间、术中失血量、疼痛评分、永久造口率和术后并发症发生情况.结果 与开腹组比较,支架联合腹腔镜手术组患者一期手术吻合成功率高（62.1%比35.0%,P=0.004）,永久造口率低（6.9%比35.0%,P=0.024）,失血量少（15～200 ml比120～610 ml,P=0.000）,疼痛轻（术后疼痛评分2.5分、3.0分比8.0分,P=0.000）,相关并发症少（5例次比10例次）.支架联合腹腔镜手术两组之间,与3 d后手术组比较,10 d后手术组患者一期手术吻合成功率高（85.7%比40.0%,P=0.001）中转开腹率低（14.3%比46.7%,P=0.046）.结论 左半结肠癌并梗阻患者放置腔内支架后的腹腔镜手术是可行的,放置支架后10 d行腹腔镜手术较为合适.

Objective To study the efficacy of stenting followed by laparoscopic surgery in the treatment of obstructing left-sided colon cancer. Methods Forty-nine patients with obstructing left-sided colon cancer were prospectively randomized into two groups. Twenty patients received emergent open surgery, while 15 underwent laparoscopic surgery 3 days after placement of the self-expanding metal stent （SEMS） and 14 of them received laparoscopic surgery 10 days after placement of SEMS. Outcomes evaluated included 1-stage operation rate, conversion rate, operative time, length of hospital stay,blood loss, postoperative pain score and use of analgesics, rates of permanent stoma, and postoperative complications. Results Compared with emergent open surgery, patients undergoing laparoscopic surgery had significantly less blood loss （P=0.000）, lower permanent stoma rate （P=0.024）, less pain （P=0.000）, and lower incidence of postoperative complications. Laparoscopic surgery was associated with a significantly higher rate of 1-stage operation （P=0.004）. Compared with patients undergoing laparoscopic surgery 3 days after SEMS placement, patients who underwent laparoscopic surgery 10days after SEMS placement had a significantly hihger 1-stage operation rate （P=0.001） and a lower conversion rate（P=0.046）. Conclusions Self-expanding metal stenting is a safe and effective bridge to laparoscopic surgery in patients with obstructing left-sided colon cancer. Laparoscopic surgery 10 days after SEMS placement may be more appropriate.