Introduction
Colorectal cancer is one of the most common malignant tumors. The incidence and mortality of colorectal cancer are increasing in China [
1]. Colorectal cancer complicated with acute intestinal obstruction is one of the common acute abdominal diseases in surgery. About 7–29% of colorectal cancer patients present with acute complete or incomplete intestinal obstruction symptoms [
2,
3]. Approximately 70% of colorectal malignant obstruction is in the left half of the colon [
4]. The scope of the left colon generally includes the left half of the transverse colon, the splenic flexure of the colon, the descending colon, and the sigmoid colon, and the upper part of the rectum also belongs to the category of the left colon in a broad sense [
5]. Complete obstruction of left hemicolon cancer is categorized as a closed-loop obstruction, which necessitates immediate treatment to alleviate the obstruction. If left untreated, this obstruction can lead to various severe complications such as water and electrolyte imbalance, acid–base disorders, intestinal wall ischemia, necrosis, and perforation. It may also result in conditions like acute diffuse peritonitis, septic shock, and other life-threatening complications. Additionally, it is worth noting that patients with proximal colon obstruction often exhibit dilation and edema due to the lack of routine preoperative bowel preparation in these cases. The diameter difference between proximal and distal intestinal tubes is significant, which is not conducive to anastomosis. In addition, anatomical and physiological factors such as a relatively thin wall of the left colon, poor blood supply of the colon, and many bacteria were found. Additionally, most patients were elderly, often complicated with various underlying diseases, long course of the disease, anemia, hypoproteinemia, and internal environmental disorders [
4,
6]. There is a high risk of postoperative complications, especially anastomotic leakage [
6]. Therefore, the safety of primary tumor resection and anastomosis is still controversial [
4,
6,
7].
There is no unified standard for treating acute left-sided colon cancer obstruction. Traditional surgery is mainly based on open surgery, and staging surgery is primarily used ((1) The two-stage operation was Hartmann’s procedure, the first emergency operation of stage I tumor resection and relief of intestinal obstruction, proximal colostomy, distal closure, and then stage II colostomy closure. (2) Three-stage surgery, including stage I proximal colostomy to relieve intestinal obstruction, stage II tumor resection, and stage III closed stoma) or intraoperative irrigation with one-stage anastomosis. The former Hartmann’s procedure will cause the trauma of the second operation, prolong the patient’s recovery period, and increase the overall treatment cost. At the same time, the abdominal stoma also increases the psychological burden and pain of the patient, and the second operation also increases the difficulty and risk of the surgeon. However, the three-stage surgery, with the same surgical trauma and many complications, not only increases the pain and economic burden of patients but also increases the risk of tumor spread, making some patients lose the opportunity for radical surgery [
4‐
6,
8].
Moreover, it is difficult or even impossible to close the stoma in 40–60% of patients after staged surgery, resulting in permanent stoma [
9]. The latter is not recognized by most clinicians because intestinal lavage prolongs the operation time and increases the chance of abdominal cavity contamination. At the same time, due to intestinal wall edema and hypoproteinemia, postoperative complications such as anastomotic leakage, abdominal cavity, and wound infection are as high as about 30% [
8,
10].
None has yet been accepted as the best treatment for left-sided colon cancer obstruction. The ideal treatment method is to solve the obstruction of the left colon without surgery, or at least surgery should be performed with proper bowel preparation and good general condition for selective surgical resection and essential anastomotic connection. The placement of metal stents under endoscopy combined with X-ray fluoroscopy has made it possible. In many cases of malignant digestive tract obstruction, this method has become a partial alternative to surgery.
Discussion
Colorectal cancer is currently one of the most common malignancies in the world, and current data show that the incidence of colorectal cancer has become the third most common malignancy worldwide [
12]. In China, the incidence of colorectal cancer is the fourth highest among women and the fifth highest among men [
13]. In our country, patients with colon cancer are often in the progressive stage at the time of diagnosis, and some patients with left-sided colon cancer present with acute bowel obstruction as the primary presentation [
14]. Since complete obstruction of left hemicolon cancer belongs to closed-loop intestinal obstruction, emergency treatment is needed to relieve the obstruction. If left untreated, this obstruction can lead to various severe complications such as water and electrolyte imbalance, acid–base disorders, intestinal wall ischemia, necrosis, and perforation. It may also result in conditions like acute diffuse peritonitis, septic shock, and other serious complications.
For treating acute right hemicolectomy with intestinal obstruction, there is a consensus that a stage I right hemicolectomy + ileocolonic anastomosis should be performed if the tumor is resectable [
15]. However, whether to perform one-stage tumor resection and anastomosis for acute left-sided colon cancer obstruction is still controversial [
4,
6,
7]. Because there is no preoperative bowel preparation in such patients, the proximal colon of obstruction is usually dilated and edematous, the diameter of the distal and proximal bowel is quite different, and the intestinal wall of the left colon is relatively thin, the blood supply of the bowel is poor, and the amount of bacteria is large. In addition, most patients are elderly, often with various underlying diseases, a long course of disease, and many adverse factors such as low nutritional status and internal environmental disorders [
4,
6]. In addition, intraoperative intestinal lavage is required before one-stage anastomosis, which prolongs the operation time and increases the chance of abdominal contamination [
8,
10]. There is often a high risk of postoperative complications, especially anastomotic leakage [
6]. It has been reported that the mortality rate of such emergency surgery is 15–20%, and the incidence of complications is as high as 40–50% [
16].
Therefore, most scholars still advocate staging surgery [
17]. Traditional staged surgery is mainly based on open surgery, and the surgical method is mostly used in two-stage surgery. Often Hartmann’s procedure, that is, emergency surgery, is performed. First, the tumor is removed, and the intestinal obstruction is relieved. The proximal colostomy is performed, the distal closure is performed, and the colostomy is withdrawn in the second stage. However, the Hartmann’s procedure will cause the trauma of the second operation for patients, prolong the recovery period of patients, and increase the overall treatment cost. At the same time, abdominal stoma also increases patients’ psychological burden and pain. For surgeons, the second operation also increases the difficulty and risk of the operation. However, stage III surgery, namely stage I proximal colostomy to relieve intestinal obstruction, stage II tumor resection, and stage III closed colostomy, has the same surgical trauma and many complications, which not only increases the pain and economic burden of patients but also increases the risk of tumor spread. Some patients have tumor metastasis and dissemination during reoperation and lose the opportunity for radical surgery [
4‐
6,
8]. Therefore, three-stage surgery has been gradually abandoned. Moreover, it is difficult or even impossible to close the stoma in 40–60% of patients after staged surgery, resulting in permanent stoma [
9].
Endoscopic placement of metal stents for malignant colorectal obstruction is a further development following the application of metal stents for malignant diseases of the esophagus, cardiac, and biliary tract. In 1991, Dohmoto et al. [
18] first reported colon stent and applied it to treat acute left hemicolon obstruction caused by colonic tumors. Subsequently, many research groups in Europe, America, Japan, and other countries affirmed the application value of colon stents in treating colon cancer complicated with intestinal obstruction [
19‐
21]. In the past 20 years, this treatment method has been promoted and improved worldwide. The clinical application of metal stent implantation under endoscopy combined with X-ray fluoroscopy can effectively relieve acute intestinal obstruction so that the surgeon can obtain sufficient preoperative preparation time, correct the patient’s nutritional status and water and electrolyte balance disorders, reduce intestinal inflammation and edema, and then perform the one-stage anastomosis. It acts as a “bridge” for one-stage anastomosis and turns emergency surgery into a limited operation. As a result, the incidence of stoma and infection and the burden of secondary closure of stoma were significantly reduced [
4,
22,
23]. At present, the technology of colorectal stent implantation is becoming more and more mature. It is reported that the technical and clinical success rates of colorectal stent implantation are 90–100% and 84–94%, respectively [
6,
24,
25]. In this study, the technical and clinical success rates of 23 experimental group patients were 100% (23/23). Therefore, gastrointestinal endoscopists are required to have relatively skilled operation experience.
The early complications of stent implantation are mainly bleeding, perforation, stent displacement or slippage, and abdominal pain caused by intestinal wall injury, among which intestinal wall perforation is the most serious, which is easy to cause severe abdominal infection and secondary septic shock, so emergency surgery is required [
26]. This study had no apparent complications except for two patients with rectosigmoid junction cancer who had stent migration. In the two patients, the symptoms of intestinal obstruction were gradually relieved during the transitional period before the migration of the inserted stent, and the subsequent laparoscopic surgery was successfully performed. Laparoscopic colorectal cancer surgery has the advantages of less trauma and rapid postoperative recovery and has gradually become the standard mainstream operation for colorectal cancer treatment. Corresponding randomized controlled studies worldwide have shown that compared with open surgery for colon cancer. Laparoscopic surgery has obvious short-term efficacy advantages, such as less intraoperative blood loss, less postoperative pain, faster recovery of intestinal function, and shorter hospital stay [
27].
Moreover, the long-term follow-up results of these studies found no significant difference in the 3-year disease-free survival rate and 3-year overall survival rate between laparoscopic and open colon cancer surgery, and the stratified analysis according to tumor stage did not reflect the difference between the two [
28]. Stent implantation does not affect the subsequent laparoscopic operation and the survival rate of patients, so laparoscopic surgery after stent implantation has good safety and short-term efficacy in treating left-sided colon cancer obstruction [
29]. Of the 23 patients in the experimental group, 22 patients successfully underwent laparoscopic left hemicolectomy and primary anastomosis, and only one 81-year-old female patient underwent laparoscopic radical resection of sigmoid colon cancer + distal closure + proximal ostomy due to poor bowel preparation and general condition deviation.
This study also showed no significant differences in operation time, intraoperative blood loss, number of harvested lymph nodes, and postoperative anal exhaust time between the two groups (all P > 0.05). However, the overall postoperative complication rate and hospital stay in the metal stent implantation combined with the laparoscopic surgery group were significantly lower than those in the Hartmann’s surgery group (P < 0.05). Further subgroup analysis of the overall incidence of postoperative complications in the two groups showed that the traditional Hartmann’s procedure group was likelier to have an incomplete intestinal obstruction (P < 0.05). It was considered that although the intestinal tumor had been removed and the complete obstruction had been relieved after the emergency Hartmann’s operation, the large range of intestinal dilatation and inflammatory edema in the state of intestinal obstruction still needed to continue for some time to disappear completely. So our research results also verify the metal stent implantation under endoscopy combined with X-ray fluoroscopy joint the feasibility of laparoscopic surgery in treating acute left half colon cancer obstruction, compared with the traditional emergency laparotomy, which is more minimally invasive, safe, and effective. Moreover, this combined technology can avoid the traditional second or even third-surgical trauma and improve patients’ quality of life so that patients can recover faster after surgery, to benefit patients.
This study also found no significant differences in overall survival and recurrence-free survival between the observation and control groups (all
P > 0.05). Therefore, there is no significant difference in the long-term prognosis between the endoscopic and X-ray-guided metal stent placement combined with laparoscopic surgery for acute left colon cancer obstruction and the traditional Hartmann surgery group. In a study conducted by Takahashi et al., it was found that there is no significant variance in long-term survival rates between patients who underwent stenting and those who chose surgical intervention for palliation in cases of obstructing unresectable colon cancer. Interestingly, stenting seemed to correlate with more favorable patient prognoses [
30]. Similarly, the work of Ueki et al. indirectly implied that the overall survival rates and recurrence-free survival rates were similar between patients who had stent placement and those who did not [
31]. Building upon these findings, our research, in conjunction with the study conducted by Verstockt et al., further supports the notion that utilizing stenting as a bridge to surgery for obstructing colorectal cancer does not lead to inferior survival outcomes for patients treated with curative intent [
32]. These results highlight the positive impact of stenting as a viable treatment option for patients with obstructing colorectal cancer. Because our sample size is small, more studies with larger sample sizes will be needed to ascertain our results further.
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