热点聚焦——论梗阻性结直肠癌的治疗

Treatment of obstructive colorectal cancer

梗阻性结直肠癌是常见的恶性肠梗阻,急诊手术可能会首选肠造口或切除肿瘤后肠造口,但急诊手术患者的肠道和全身条件往往较差,患者需要接受多次手术,增加手术风险和经济负担,降低患者生活质量,术中视野较差也可能影响手术的根治性。肠梗阻导管可以快速减压、引流,有效解除梗阻症状,提高一期根治性切除手术成功率。肠梗阻导管对肿瘤的挤压较轻,较少引起肿瘤细胞播散,而且价格较低,但管腔较细,容易堵塞,需要繁琐的冲洗或定期更换,目前研究较少。肠梗阻支架可以有效缓解肠梗阻,为择期手术提供较为充分的准备时间,以完善术前检查、充分评估肿瘤,改善患者全身状态,提高患者对根治性手术的耐受性,可以作为梗阻性结直肠癌的重要治疗策略选择。但肠梗阻支架可能对肿瘤产生挤压,导致肿瘤细胞的播散,增加复发率和转移率,降低生存率。而且放入肠梗阻支架后手术时,肠壁水肿依然存在,吻合后造口率高达34%。肠梗阻支架-新辅助化疗的治疗策略,可在有效缓解梗阻后,适当延长手术等待时间2个月左右,有助于肠壁水肿消退和患者全身状态改善,同时,新辅助化疗有助于局部肿瘤和潜在转移病灶的控制,从而提高一期吻合率、手术根治性及患者生存率,有望成为梗阻性左半结肠癌的首选治疗策略。

Obstructive colorectal cancer is a common malignant bowel obstruction.Colostomy or colostomy following tumor resection may be the first choice for emergency surgery.The intestinal and systemic conditions of patients undergoing emergency surgery are often poor,and patients need to undergo multiple operations,which increase the surgical risk and economic burden and reduce the quality of life of patients.Poor intraoperative visualization may also affect the radical operation of emergency surgery.Transanal decompression tube(TDT)can rapidly decompress and drain the obstructed bowel,effectively relieve obstruction symptoms,and improve the success rate of primary radical resection.The TDT squeeze the tumor lightly,causing no spread of tumor cells,and is cheap,but the cavity of transanal decompression tube is small and easily blocked,and requires tedious flushing or regular replacement.Self-expanding metallic stents(SEMS)can relieve intestinal obstruction effectively,provide sufficient preparation time for preoperative examination and improvement of nutritional status.By improving patient's tolerance to radical surgery,SEMS might be used as an important treatment strategy choice for obstructive colorectal cancer.However,SEMS may squeeze the tumor,leading to the spread of tumor cells,increase the recurrence rate and metastasis rate,and reduce the survival rate.Moreover,intestinal wall edema still existed during the operation following SEMS,and the rate of ostomy after anastomosis was as high as 34%.We hypothesized that prolonging the interval between stent insertion and surgery to 2 months,with neoadjuvant chemotherapy administered during this interval(SEMS-neoadjuvant chemotherapy strategy),would help improve outcomes.The SEMS-neoadjuvant chemotherapy strategy is a safe,effective,and well tolerated treatment approach with a high laparoscopic resection rate,low stoma formation rate and improvement in the overall survival for patients with left-sided colon cancer obstruction.The patient physical status is improved,the primary tumor is downstaged,and intestinal wall edema is relieved during the relatively longer interval between SEMS placement and surgery.The SEMS-neoadjuvant chemotherapy strategy may be a preferred therapeutic strategy for obstructive left colon cancer.