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ORIGINAL ARTICLE
Year : 2019  |  Volume : 15  |  Issue : 2  |  Page : 375-379

The efficacy of endoscopic stenting combined with laparoscopy in the treatment of left colon cancer with obstruction


Department of Acute Abdominal Surgery, First Affiliated Hospital Dalian Medical University, Dalian, Liaoning, China

Date of Web Publication1-Apr-2019

Correspondence Address:
Prof. Guogang Liang
Department of Acute Abdominal Surgery, First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, Liaoning
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_111_18

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 > Abstract 


Context: Endoscopic self-expandable metal stents (SEMSs) are the bridge of obstructive colorectal cancer surgery. The debate is still open on whether the procedure and effects can be the same between the SEMS combined obstructive colon cancer resection and nonobstructive colon cancer resection, both of which were under laparoscopic.
Aims: This retrospective study was designed to compare whether the same effects could be achieved in both resections.
Settings and Design: The retrospective analysis was from September 2016 to November 2017. In the observation group (OG), 20 patients hospitalized for obstruction of the left colon cancer were included, who received obstructive colon cancer laparoscopic resection (LR) combined with SEMS insertion. In control group (CG), 20 patients were randomly selected, who underwent nonobstructive colon cancer LR during this period.
Subjects and Methods: The differences between the two groups were compared, including operation time, intraoperative blood loss, the number of removed lymph nodes, postoperative anal exhaust time, and hospital stay.
Results: Both groups were comparable in the age, gender, weight, the distribution of tumor, lymph node metastasis, tumor, node, and metastasis staging, operation time, intraoperative blood loss, the number of removed lymph nodes, and postoperative anal exhaust time. The hospital stay was 15.2 ± 1.3 days and 14.2 ± 1.5 days in OG and CG, respectively, and it was longer in OG than that of in CG (P = 0.032).
Conclusions: Obstructive colon cancer LR combined with SEMS insertion was a safe and feasible radical treatment strategy. The same level of procedure and effects could be achieved, compared to that of nonobstructive colon cancer LR.

Keywords: Effects, left colon cancer obstructive, self-expandable metal stent


How to cite this article:
Li W, Jin X, Liang G. The efficacy of endoscopic stenting combined with laparoscopy in the treatment of left colon cancer with obstruction. J Can Res Ther 2019;15:375-9

How to cite this URL:
Li W, Jin X, Liang G. The efficacy of endoscopic stenting combined with laparoscopy in the treatment of left colon cancer with obstruction. J Can Res Ther [serial online] 2019 [cited 2019 Jun 18];15:375-9. Available from: http://www.cancerjournal.net/text.asp?2019/15/2/375/255082




 > Introduction Top


Colorectal cancer has been one of the most common malignant tumors worldwide; the technique of laparoscopic treatment of colorectal cancer is mature, with obvious advantages of short recovery time and prolonged survival time. However, about 8%~13% of colorectal cancer patients were concurrent with intestinal obstruction, which was resulted from advanced colon cancer.[1],[2],[3] The left-sided colon was especially common because of the particularity of the anatomy; therefore, the possibility of laparoscopic treatment would be lost or limited. Some patients had to suffer a secondary surgery because of temporary colostomy, which increased the pain and medical expenses. Another problem was that the obstruction leads to unable lymph node dissection regulation and shortened survival time. Since the first report in 1991, the expansion of metal stent (self-expandable metal stents [SEMSs]) was applied as a palliative treatment for colon cancer and satisfactory curative effects were achieved; obstructive colon cancer elective completion of laparoscopic colon cancer surgery has gradually become potential, safe, and effective approach.[4],[5] We performed laparoscopic radical resection of colorectal cancer after placing SEMS under the colonoscopy, and it aimed to relieve the acute intestinal obstruction of colorectal cancer and improve bowel preparation.[6] However, until now, we have not known the different procedures and effects between this type of surgical treatment and nonobstructive left colon cancer laparoscopic radical surgery. In this study, we aimed to analyze whether the obstructive left colon cancer SEMS placement combination laparoscopic radical resection of colon cancer could achieve the surgical procedure and effects compared to nonobstructive left colon cancer laparoscopic radical surgery.


 > Subjects and Methods Top


Clinical data

Retrospective analysis was performed from September 2016 to November 2017. There were 26 patients hospitalized for the obstruction of the left colon cancer, including 19 males and 7 females. The age was ranged 47–83 years old (median age of 69 years), with 9 cases older than 70 years. Distant metastasis without cure was observed in 5 cases; therefore, SEMS in obstruction was only placed for palliative care; in the 6 cases, 1 case of SEMS placement has been failed, instead of emergency enterostomy surgery for palliative care. The remaining 20 patients receiving obstructive colon cancer laparoscopic resection (LR) combined with SEMS were included in the observation group (OG). Besides, randomly selected 20 patients receiving nonobstructive colon cancer LR during this period were included as control group (CG). In the CG, there were 14 male and 6 female, aged 40–80 (median age 64), with 7 cases older than 70 years when they attacked the disease. All the patients in two groups received abdominal enhancement computed tomography (CT) examination, suggesting different occupied sites, and they received laparoscopic radical resection of colorectal cancer finally. The general information of the patients between two groups were compared [Table 1].
Table 1: Comparison of general data between two groups (x¯±s)

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Instrument

This study involved colonoscopy was performed by experienced board-certified gastroenterologists using a video colonoscope (CF-H260 AI and GIF1T240, Olympus Optical), America Boston yellow zebra guidewire (M00556621), diameter of 0.038 inch, length of 260 cm, Straight Tip, the SEMS produced by American COOK company, SEMS were noncoated stents with double bell mouth, inside diameter of 25 mm, length of 6–10 cm, the linear cut stapler(EC60) and intestinal anastomat(CDH29) produced by Johnson and Johnson company.

Treatment

We evaluate the location and size of tumor by imaging data, and selecte the appropriate SEMS for the observation group (OG) patients before operation. First, patients were given distal intestinal cleaning enema, then the colonoscopy was inserted into the distal part of the obstruction and the tumorous tissue biopsy was performed. The yellow zebra guidewire was inserted through the colonoscopic biopsy channel and passed through the narrow part under X-ray monitoring. Then, colonoscopy was withdrawn and catheter was inserted. The iopromide imaging was applied to understand the length and shape of the obstruction section, the catheter was exited, and the SEMS pusher was placed under guidewire, re-entered the colonoscopy, and released the SEMS under the dual surveillance of colonoscopy and X-ray fluoroscopy. It aimed to ensure that the distal SEMS was at least 3 cm beyond the stenosis; after the placement of stent in 24 h, the CT of abdominal was rechecked to know the patency of SEMS.[7] After successful placement of SEMS, preoperative bowel preparation was performed with the laxative (1-day liquid diet, oral laxative, no oral antibiotics, and cleaning enema), then laparoscopic radical surgery was performed 3–7 days after SEMS placement.[8],[9] For the patients in CG, colonoscopy for tumorous tissue biopsy was performed after a preliminary evaluation of tumor location and size with preoperative imaging data. Then, the patients received preoperative bowel preparation (1-day liquid diet, oral laxative, no oral antibiotics, and cleaning enema), preoperative intravenous antibiotics, laparoscopic radical resection of colorectal cancer, and postoperative placement of abdominal drainage tube.

The standard of successful self-expandable metal stent placement

The technical success was defined as the ability to successfully place the colon stents through the obstruction, and the SEMS was fully expanded under the X-ray, and the narrow segment was in the middle of SEMS. The clinical success was defined as intestinal obstruction relief, patient's defecation and exhaust recovery, as well as the remission of abdominal pain, abdominal distention, vomiting, and other symptoms.[10]

Laparoscopic surgery

The operation was performed by a senior surgeon with over 20 years of experience. Conventional intubation general anesthesia was performed, taking the observation hole around the umbilicus, establishing the CO2 pneumoperitoneum, maintaining the pressure at 13 mmHg, taking the operation hole by the tumor location, and adjusting the patient position. Postoperative conventional comprehensive treatment was performed, such as anti-infection and nutritional support. The drainage tube would be removed at 5–7 days postoperatively without special status.

Outcome measures

The general information of patients was observed, including age, body mass index, American Society of Anesthesiologists Classification, lesion location, tumor stage, laparoscopic surgery time, and intraoperative bleeding. The number of postoperative lymph nodes, time of anal exhaust, Clavien–Dindo classification, number of intraoperative removed lymph node, and length of hospital stay was also detected. The results obtained from the selective laparoscopic surgery for the left half colon were compared with that from radical surgery during the same period.

Statistical method

SPSS 22.0 (IBM, Armonk, New York, USA) was applied to analyze the data. The count data were expressed as rate, and Chi-square test was applied for the comparison between the groups. The measurement data were expressed as x¯ ± s, and the independent sample t-test was applied for the comparison between the groups. P < 0.05 indicated statistically significant difference.


 > Results Top


Self-expandable metal stent placement

Among the 26 patients with intestinal obstruction, the lesion site was located in 9 cases of the descending colon (34.62%), 1 case of splenic flexure of colon (3.8%), 10 cases of sigmoid colon (38.5%), and 6 cases of rectum (23.1%). One of the patients (tumor located in the descending colon with distant metastases) had failed in SEMS placement, so descending colon colostomy was performed for palliative care. SEMS was successfully placed in the remaining 25 cases, with the diameter ranged 2.2–2.6 cm and length ranged 8–12 cm. The postoperative image showed that location was satisfactory and the intestinal cavity was smooth. The technical success rate of SEMS placement was 96.15%. For all 25 patients with successful placement of SEMS, within 24 h after surgery, the syndromes of intestinal obstruction were relieved, such as abdominal pain, abdominal distension, stop defecating and exhausting, and better abdominal CT results. There was no exacerbation of intestinal obstruction or colon rupture caused by SEMS. In the 25 cases with successful placement of SEMS, 5 cases were unable to radical operation, only with SEMS for palliative care. For the other 20 cases (OG) with SEMS as a bridge, 3–5 days after the SEMS placement, laparoscopic radical resection of colon cancer and one-stage anastomosis was performed on the left side of the corresponding parts. Intraoperative finding the intestinal cleanliness was good without waste residue; no expanding lumen was observed in the proximal obstruction and the intestinal wall was complete. In addition, there were no obvious postoperative complications.

Comparison of different operations and postoperative conditions

The operation and radical resection of the tumor was successfully completed in both groups, and there was no death during the perioperative period. There was no significant difference between the OG and CG in operative time, intraoperative blood loss, the number of removed lymph nodes, postoperative anal exhaust time, and Clavien–Dindo classification, while the hospital stay of OG was slightly longer than that of in CG (P < 0.05). The operation of the two groups was shown in [Table 2].
Table 2: Comparison of the operation between two groups (x¯±s)

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 > Discussion Top


Over the past decades, the development of computers has changed the way people work, which has also led to increased abdominal obesity. Studies have shown that abdominal obesity may play an important role in the development of colorectal cancer.[11] At present, the technology of laparoscopic colon cancer was easy to grasp and safe to perform in surgical treatment of colorectal cancer.[12] It has the advantages of less trauma, less interference on the organism, fast postoperative rehabilitation, less complications, and its recent effect was better than open surgery, thus it has become the first choice of treatment.[13] Clinically, intestinal obstruction resulted from advanced colon cancer was observed in about 8%~13% of colorectal cancer patients,[1],[2],[3] while studies have shown that more obstruction occurred at the distal colon.[14] The patients' quality of life was reduced by symptoms such as abdominal pain, abdominal distension, and vomiting caused by obstruction, which was also accompanied by severe water and electrolyte imbalance, dilatation of intestine, edema, and even death due to toxic shock. Usually, conservative treatment of obstruction caused by tumor was generally ineffective and more emergency treatment was required. However, the implementation of laparoscopic surgery was limited in treating obstructive left colon cancer. Left colon contained a large number of bacteria, while routine bowel preparation cannot to be performed because of the obstruction. Therefore, to avoid the occurrence of serious complications and reduce the surgical risk, the recommended treatment of left colon cancer with obstruction consisted of first stage of enterostomy surgery and second stage of closure surgery. However, this treatment would increase the patient's trauma and financial burden and cause inconvenience to the patient's life. Hence, for the left colon cancer patients with obstruction, the most ideal treatment was to relieve intestinal obstruction, firstly, and perform adequate preoperative preparation (including bowel preparation, nutritional support and correct water, electrolyte imbalance, etc.). Second, selective laparoscopic radical surgery was performed, to avoid secondary surgery and treat the tumor in one stage with minimally invasive surgery. With the continuously improved technique, SEMS implantation has been more widely applied in clinical practice of treating intestinal obstruction caused by colon cancer. The treatment of left colon cancer obstruction has been recognized, and SEMS has good curative effect and security, as well as small differences in the clinical success rate and safety.[15] According to a retrospective study by Branger et al. in 2010, the technical success rate of SEMS placement in the left colon was 92.5%, the clinical effective was 86%, the incidence of perforation related to SEMS was 4.5%, the incidence of displacement was 3.0%, and the incidence of reclogging was 12%.[16] In the meantime, studies have shown that the case fatality rate of selective operation after placing SEMS and emergency surgery (0% and 10.8%, respectively) and the incidence of major complications (0.8% and 23.9%, respectively) were significantly reduced (P < 0.05).[17] With SEMS, the intestinal obstruction could be safely and effectively relieved, meanwhile reducing the incidence of complications such as anastomotic fistula, disruption of wound, infection and other traumas, risk which may occur in emergency surgery,[18] all of which greatly improved the patients' quality of life. Preoperative SEMS placement could be a reasonable treatment option for patients with SEMS as bridge. There would be several advantages, such as improved general conditions of patients, sufficient preoperative preparation, and reduced postoperative complications, thus reducing patients' pain and shortening hospital stay. This presented a challenge to the traditional concepts of one-stage enterostomy surgery in emergency surgery.

In our hospital, from September 2016 to November 2017, there were 26 patients hospitalized for obstruction of left cancer. Among the 26 cases, SEMS has been successfully placed in 25 cases, and LR was performed in 20 cases after SEMS placement. With high technical success rate and clinical success rate, great clinical efficacy and socioeconomic benefits could be achieved. At the same time, the treatment of SEMS placement provided high safety, and none of the patients show serious complications such as colon perforation, intestinal bleeding, and stent displacement during and after surgery. Compared with CG, the results showed that surgery and radical resection of the tumor were successfully completed in patients of both groups, without perioperative death cases. There was no significant difference between the OG and CG in the operation time, intraoperative blood loss, the number of removed lymph nodes, postoperative anal exhaust time, and Clavien–Dindo classification (P > 0.05). However, the hospital stay in the OG was 15.2 ± 1.3 days, slightly longer than the CG of 14.2 ± 1.5 days (P < 0.05). Although location of colon cancer shows no significant effect on survival,[19] however, from long-term perspective, for the left colon cancer patients with obstruction who performed stent-laparoscopy treatment, we need to pay attention to the safety of SEMS placement, the possibility of increasing the tumor metastasis, and effects on long-term survival rate, etc., Therefore, the long-term follow-up survey and controlled study on the patient who performed stent-laparoscopy treatment should be performed for confirmation. In particular, multicenter studies or prospective comparative studies can be more sufficient to evaluate the effects, safety, and long-term efficacy of stent-laparoscopy treatment of obstructive left colon cancer.[20]


 > Conclusions Top


In summary, the result of this study showed that SEMS placement was safe and effective in relieving obstruction of left colon cancer. Successfully placed SEMS relieved symptoms of intestinal obstruction, intestinal edema, and inflammation, so after intestinal preparation, the nonobstructive left colon cancer elective surgery level could be achieved, without significant effects on the surgical process and effects. In short, it was worth to promote stent laparoscopy in technical.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

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Samper Wamba JD, Fernández Martínez A, González Pastrana L, López González L, Balboa Arregui Ó. Efficacy and complications in the use of self-expanding colonic stents: An analysis of 15 years' experience. Radiologia 2015;57:402-11.  Back to cited text no. 5
    
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Sirikurnpiboon S, Awapittaya B, Jivapaisarnpong P, Rattanachu-ek T, Wannaprasert J, Panpimarnmas S, et al. Bridging metallic stent placement in acute obstructed left sided malignant colorectal cancer: Optimal time for surgery. J Med Assoc Thai 2014;97 Suppl 11:S81-6.  Back to cited text no. 9
    
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