自扩张金属支架在左侧结肠癌或直肠癌合并急性肠梗阻中的应用价值

Value of self-expanding metallic stent for obstructing left-sided colon cancer or rectal cancer

目的探讨自扩张金属支架（SEMS）在可切除的左侧结肠癌（或直肠癌）合并急性肠梗阻中的治疗价值。方法回顾性分析2007年5月至2012年1月首都医科大学附属北京朝阳医院普外科收治的73例左侧结肠癌（或直肠癌）合并急性肠梗阻患者，按治疗方法的不同分为SEMS组（34例）和急诊手术组（39例）。SEMS组患者均先放置SEMS解除梗阻，再限期手术。比较2组患者的一期切除吻合率、肠造口率、腹腔镜手术率、术后病死率和总并发症率、ICU住院率、ICU停留时间、住院时间和住院费用。结果SEMS组患者一期切除吻合率（97．1％）明显高于急诊手术组（56．4％）（χ2=16．256，P〈0．01），而保护性造口率（33．3％）和永久性造口率（2．9％）均低于急诊手术组（分别为86．3％、43．6％）（χ2=14．972、16．156，P〈0．001）。SEMS组接受腹腔镜手术的患者（47．1％）明显多于急诊手术组（0）（χ2=23．505，P〈0．001）。2组患者术后病死率（SEMS组2．9％，急诊手术组10．3％）的差异无统计学意义。SEMS组术后总并发症率为35．3％，低于急诊手术组（66．7％）（χ2=7．163，P=0．007），切口感染率（17．6％）低于急诊手术组（38．5％），但差异无统计学意义（χ2=3．840，P=0．050）。与急诊手术组比较，SEMS组术后ICU住院率（24．2％）低（χ2=6．972，P=0．008），ICU停留时间[（69．5±7．4）h]短（t=-20．23，P〈0．001），平均住院时间[（19．6±4．8）d]少（t=-2．90，P=0．005），平均住院费用[（45383±15648）元]低（t=-3．74，P〈0．001）。结论SEMS可有效解除左侧结肠癌（或直肠癌）合并的急性肠梗阻，将急诊手术转变为限期手术，从而获得更好的术后结果，具有良好的应用价值。

Objective To investigate the therapeutic value of self-expanding metallic stent （SEMS） for resectable obstructing left-sided colon cancer or rectal cancer. Methods Clinical data of 73 patients who had acute obstruction due to left-sided colon cancer or rectal cancer during May 2007 to January 2012 were retrospectively analyzed. The patients were divided into 2 groups： SEMS group （34 cases ） underwent surgical resection after insertion of SEMS; emergency surgery group （39 cases ） underwent emergency operation. The 2 group patients were compared for the incidence of primary anastomosis, stoma rate, laparoscopic surgery rate, mortality, postoperative morbidity, ICU admission rate, length of ICU stay, hospital stay, and hospitalization costs. Results The incidence of primary anastomosis in SEMS group was significantly higher than that in emergency surgery group （97.1% vs. 56. 4%, X2 = 16. 256, P 〈0. 001 ）, and the protective stoma rate and permanent stoma rate in SEMS group were both lower than those in emergency surgery group （33.3% vs. 86. 3% , 2.9% vs. 43.6%, χ2 value were 14. 972 and 16. 156, both P 〈0. 001 ）. Patients in SEMS group underwent significantly more laparoscopic surgery than in emergeney surgery group （47. 1% vs. 0, χ2 = 23. 505, P 〈 0. 001 ）. There were no significant difference in postoperative mortality （2. 9% vs. 10. 3%, P = 0. 364）. The postoperative morbidity in SEMS group was significantly lower than that in emergency surgery group （35.3% vs. 66. 7% , P =0. 007）. Incisional infection was the most common complication in both groups, and the incidence of which seemed to be more higher in emergency surgery group （ 17.6% vs. 38. 5% , χ2 =3. 840, P =0. 050）. There was a lower ICU admission rate in SEMS group （24. 2% vs. 53.9% , χ2 = 6. 972,P = 0. 008）, and the mean length of ICU stay and hospital stay were both shorter in SEMS group （69. 5 ± 7. 4） hours vs. （ 114. 3 ± 10. 9） hours, t = -20.23, P〈0. 001; （19.6±4.8） days vs. （23.4±6.2） days, t= -2.90, P=0.005）. The cost of hospitalization was less in SEMS group （45 383 ± 15 648 vs. 61 485 ± 20 380, t = - 3.74, P 〈 0. 001 ）. Conclusions SEMS can effectively relieve the large intestinal obstruction caused by left-sided colon cancer or rectal cancer, and change the traditional emergency surgery into a selective surgery with better outcomes. SEMS appears to be a valuable technique for resectable obstructing left-sided colorectal cancer.