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

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.

Clinical research of the surgical timing for resectable colorectal cancer complicated with obstructions after implantation of SEMS / 中国实用外科杂志

OBJECTIVE: To compare the clinical outcomes of endoscopic intestinal stenting combined with elective surgery and emergency surgery at the same time for resectable left colon cancer or rectal cancer with intestinal obstruction and to explore the best time for reoperation after stent implantation. METHODS: The clinical data of 82 cases who underwent endoscopic intestinal stenting in the First Affiliated Hospital of China Medical University for the treatment of left colon cancer and rectal cancer with intestinal obstruction from March 2014 to September 2018 were analyzed retrospectively. Treatments were defined as effective only if primary anastomosis was received without a stoma,and those clinical outcomes were analyzed by receiver operator characteristic(ROC)curve. Another 44 patients diagnosed with colorectal cancer complicated with intestinal obstruction underwent emergency surgery during the same period were the control group. The differences in the first-stage surgical anastomosis rate,average operation time,total hospitalization time,total hospitalization expenses,and postoperative complications between two groups were compared.RESULTS: The area under the ROC curve(AUC)was 0.693 with a certain degree of accuracy(P<0.05). Compared to those within 8 days,the rate of primary anastomosis was significantly higher in those received elective surgery over 8 days,the average operation time was significantly decreased,and the ICU utilization rate was also significantly decreased(P<0.05).Compared with the emergency operation group,the stent group had a significantly higher rate of primary anastomosis,and the average operation time was significantly lower. The postoperative ICU utilization rate and the incidence of diarrhea were significantly lower,but the total hospitalization days and total hospitalization expenses were significantly increased(P <0.05).CONCLUSION: Endoscopic intestinal stenting combined with elective surgery for left colon cancer and rectal cancer intestinal obstruction is safe and feasible,and elective surgery should be implemented over 8 days for its security.

Surgical treatment of left colon cancer complicated with acute abdomen / 国际外科学杂志

Objective To study the surgical treatment of left colon cancer complicated with acute abdo-men.Methods From January 2000 to Dcember 2008,the clinic data of 36 patients with left colon cancer complicated by acute abdomen were analyzed retrospectively.All cases have been chosen emergency opera-tion.One-stage colectomy and annstomosis were performed in 28 cases,Hartmann in 5 cases and palliative colostomy in 3 cases.Results Anastomic leakage was found in one case after operation,infection of inci-sion happended in 4 cases,infection of lung happened in 2 cases,the times of defecation rised in one case,one patient died.Conclusion More attention shoud be paid to left colon cancer complicated by acute abdo-men.According to the patients'status,different operative manners were chosen.One-stage operation should be chosen firstly to improve quality of life and avoid staged operation.

IMA-origin Lymph Node Metastasis in Left Colon Cancer

PURPOSE: Although an extended colon resection with high ligation of the inferior mesenteric artery (IMA) generally has been recommended as curative surgery for advanced left colon cancer (LCC), it shows little or no survival advantage over segmental resection with low ligation of IMA. The present study is to determine the risk factors associated with IMA-origin lymph-node (LN) metastasis and to clarify the implication of IMA-origin LN metastasis. METHODS: We examined the clinicopathological results of 200 cases of LCC. LN dissection was performed as follows: D2 en-bloc resection of the primary tumor, IMA-origin LN dissection, and paraaortic LN dissection. RESULTS: The incidence of IMA-origin LN metastasis of LCC was 4.5% (9 cases), and all cases involved sigmoid colon cancer. The independent risk factors of IMA-origin LN metastasis were four or more regional LN metastases (hazard ratio: 16.51, 95% confidence interval: 1.60~164.12) and a preoperative CEA level of greater than 6 ng/ml of (hazards ratio: 6.63, 95% confidence interval: 1.06~41.32). The incidence of IMA-origin LN metastasis among stage IIIC patients was 26.7%. Five of the 9 (55.6%) cases of IMA-origin LN metastasis had a concomitant paraaortic LN metastasis. CONCLUSIONS: The incidence of IMA-origin LN metastasis among patients with LCC was low; however, IMA-origin LN metastasis should be considered as a systemic metastasis.

Complete Single Stage Management of Left Colon Cancer Obstruction with a New Devices

Intraoperative antegrade colonic irrigation for single stage procedure in left colon cancer obstruction is a preferred technique recently however, synchronous pathology cannot be detected. A new device that enables easy intraoperative irrigation and colonoscopy before resection of tumor was devised. PURPOSE: To evaluate the efficacy of the new device for single stage procedure in left colon cancer obstruction. METHODS: The new device (NICI; MITech co., Ltd, Seoul, Korea) consists of a Y-shaped teflon tube of maximum diameter 2.9, 3.5 and 4.1 cm, one proximal end is designed to connect with the dilated colon just proximal to the lesion. Two distal branches are for drainage of fecal matter and for retrograde insertion of irrigation catheter and subsequent colonoscope respectively. RESULTS: There were 53 patients (27 male, median age 64, range; 28~82) who underwent this procedure. No extraintestinal leaks were encountered. The volume of saline used was 12 (range; 6 to 27) Liters over 14 (range; 9 to 22) minutes. Subsequent colonoscopic examination added 10 (range, 8 to 15) minutes to the entire operation in 28 patients. There were one anastomotic leakage and 2 wound infections, however, there was no operative mortality. On-table colonoscopy resulted in extended resection in 3 cases because of synchronous malignancy in frozen biopsy and found synchronous polyps in 13 of 28 cases. CONCLUSIONS: The new device enabled safe, simple and time saving single stage surgical management of left colon cancer obstruction. The ability to perform on-table colonoscopy enabled treatment of synchronous bowel pathology.

Surgical Treatment for Obstructing Carcinomas of the Left Colon and Rectum

PURPOSE: There have been many different kinds of operations for obstructing left colon (distal to splenic flexure) cancer and rectal cancer because immediate resection and anastomosis was known to cause many complications. We performed this study to analyse operative cases and evaluate which procedure had the better result. METHODS: Thirty-six cases of left colon cancer and rectal cancer with complete obstruction were analysed from April 1990 to January 2001 and those cases were divided into two groups, the group of staged procedure and the group of primary resection. 28 cases were curative operations and 8 cases were palliative operations. RESULTS: The group of staged procedures had 17 cases of curative operations with 1st. stage-colostomy and 2nd. stage-cancer resection. And the group of primary resection had 11 cases of curative operations, 6 cases of Hartmann's procedures, 2 cases with intraoperative colonic lavage and resection and 3 cases with cancer resection, anastomosis and proximal colostomy. There were no differences in the distribution of age and cancer stage between two groups. In both groups, the sigmoid colon was the most prevalent obstruction site. The staged procedure group had higher operative mortality (25%) than the primary resection group (8%). And 5-year survival rate of the primary resection group was higher than that of the staged procedure group (45%: 33%), but there was no statistical significance. CONCLUSIONS: We think that the primary resection is the better surgical procedure because of shorter hospital stay and fewer operations in the treatment of obstructing left colon and rectal cancer.

The Safety of Intraoperative Colonic Irrigation for Single Stage Procedure in Emergency Based Left Colonic Pathology

Staged procedures are preferred to single stage procedures in emergency based left colonic obstruction or perforation because of the safety. PURPOSE: To evaluate whether the single stage procedure in emergency based left colonic pathology is not safe. METHODS: We compared medical records of single stage procedure (SP, n=22 male; 10, mean age: 60+/-17, range: 26-82 Yrs) with Hartmanns procedure (HP, n=23 male; 13, mean age: 58+/-16, range: 18-90 Yrs) and diverting loop colostomy (DC, n=19, male; 12, mean age: 59+/-19, range: 19-80 Yrs) in these 4 years. All the patients were admitted via emergency room. Intraoperative colonic irrigation method with newly developed irrigation device (MITech co., Ltd, Seoul, Korea) was used for SP. APACHE III scoring system was applied to evaluate the physiologic status of the patients. Preoperative data were compared with the 1st and 3rd postoperative day (POD). RESULTS: There were no statistically significant differences in patient demographics and preoperative APACHE III scores. The improvement of APACHE III score was significant in SP and DC on the 3rd POD from 29.6+/-20.9 to 22.9+/-10.2 and 25.7+/-13.3 to 21.4+/-14.8 (P<0.05). There was also a significant improvement in DC (25.7+/-13.3 to 21.9+/-12.9, P<0.05) on the 1st POD, however, there was only a tendency of improvement in SP (29.6+/-20.9 to 26.1+/-12.3) without statistical significance. The scores in HP showed no improvement on the 1st and 3rd POD. There were 3 operative mortalities in HP and one in DC. CONCLUSIONS: Our results suggest that the safety of the single stage procedure with newly developed colonic irrigation device is comparable to palliative decompressive loop colostomy and better than Hartmanns procedure in emergency based left colonic pathology.