The Combined Treatment Consisting Of Stent Insertion、Laparoscopic Resection And Neoadjuvant Chemotherapy(NCT) May Be A Good Option For Left-side Colorectal Cancer With Malignant Obstruction

objective:Surgery is still the main treatment for patients who suffered from left-side colorectal cancer with malignant obstruction(LCCO).Conventionally,these patients would undergo emergency surgery with a temporary or permanent colostomy,which would cause poor quality of life and increase their more costs.Moreover,sufficient preoperative bowel preparation,electrolytic disturbance and dehydration correction as well as nutritional support could not be conducted due to the bowel obstruction.Hence,emergency surgery resulted in a higher morbidity and mortality.With the development of endoscopic techniques,the using of colonic stent has been increasing in present years which has received good results.In this study,colon stent was used as a bridge to laparoscopic resection to improve these patients’ poor condition before operation.Then the operations were conducted after fully bowel preparation and preoperative preparation in order to decrease postoperative morbidity and mortality.This study aims to discuss the safety and feasibility of the combined treatment of endoscopic stent insertion and neoadjuvant chemotherapy(NCT)as well as the laparoscopic resection for colorectal cancer with malignant obstruction.Methods :A retrospective analysis was conducted on the data from a total of 95 LCCO patients who admitted to the department of the general surgery of the affiliated hospital of Southwest Medical University from January 2015 to September 2017.Among these patients,49 patients received an emergency surgery directly after the preoperative preparation(emergency group;EG).The other 46 patients were conducted with stent insertion successfully(stent group;SG).Then we try to improve their poor condition before operation by correcting internal milieu disorder and providing nutritional support.Patients in SG subsequently received a course of neoadjuvant chemotherapy(NCT)(Oxaliplatin+Xeloda)when the general condition improved.The specific dose was decided by the patients surface area.Laparoscopic resections were conducted on these LCCO patients after fully preoperative preparation and bowel preparation approximately 2-3 weeks later when time we found that the intestinal dilatation and oedema had basically returned to normal.Detailed data including operation time,harvested lymph nodes,recovery time of bowel function,blood loss during the operation,one-stage anastomosis rate,ICU rate and especially mortality as well as postoperative complications were recorded and compared between these two groups.The distance from tumour to the resection margin and the resection of the intestine were both adapted to the radical standard for all resectable patients in this study.Results:The technical success rate of stent insertion was 100% and the clinical success rate was 97.83% in our study.Only one case(2.2%)of intestinalperforation and no complete stent migration,re-obstruction and death appeared in SG after stent insertion.The preoperative conditions including dehydration,electrolyte disturbance as well as nutritional status had a significant improvement after stent insertion approximately 2 weeks later.The mean operation time and harvested lymph nodes in SG were not significantly different from EG(p>0.05).The mean recovery time of bowel function was3.23±0.57 days in SG and 3.55±0.54 days in EG(p=0.013).The mean blood loss was 57.68±49.19 ml in SG and 80.88±44.78 ml in EG,a significant deference was found in blood loss between these two groups(p=0.029).The rate of ICU after the operation was 6.5% in SG and 20.4% in EG(P=0.049).No death appeared in SG and 4 cases(8.16%)succumbed to acute respiratory distress syndrome(ARDS)or severe electrolytic disturbance in EG,markedly deference in mortality was found between the two groups(p=0.048).The overall postoperative complication rate was 10.9% in SG and40.8% in EG.A significant deference in overall postoperative complications was found between two groups(p=0.001).Only one case of anastomosis leakage appeared in SG and the success rate of one-stage anastomosis was greatly enhanced at 91.3%(42/46)in SG compared to 0% in EG(p<0.001).Patients in EG were only conducted with colostomy operation or a hartma’s operation because of the intestinal dilatation and edema.Moreover,the fully bowel preparation could not be conducted because of the malignant obstruction.Conclusion :Stent insertion combined with NCT and laparoscopic resection had no significant difference in radical resection compared to emergency surgery for LCCO patients.However,it had the characteristics of less trauma,less bleeding and rapid recovery.Patients with stent insertion combined with laparoscopic resection and NCT had lower postoperative morbidity and mortality compared to patients with emergency surgery.Stenting as a bridge to laparoscopic resection greatly improved the onestage anastomosis rate.Preoperative stent implantation combined with NCT and laparoscopic surgery was relatively safe and feasible for LCCO patients in short-term outcome.Oncology safety of preoperative stent insertion requires studies with high-quality and large sample sizes and long-term outcomes also need to be followed up.