标题：自膨胀金属支架在左侧大肠癌伴急性梗阻中的应用价值

      作者：张守亮 1，谢黎 1，姚俊 2    (镇江市第一人民医院胃肠外科 1、消化内科 2，江苏 镇江 212000)

      卷次： 2018年29卷20期

      【摘要】 目的 探讨内镜下植入自膨胀金属支架在左侧大肠癌伴急性梗阻患者中的应用价值。方法 回顾性分析2016年3月至2018年6月镇江市第一人民医院胃肠外科收治的40例左侧大肠癌伴急性梗阻患者经内镜植入自膨胀金属支架的临床效果，其中18例未能手术，1例术中发现肠系膜转移结节仅行结节活检，21例完成肠癌切除。将21例支架植入后肠梗阻缓解、限期行肠癌根治性切除的患者作为支架+手术组，同时间段20例单纯行肠癌根治性切除的患者作为单纯手术组。比较两组患者的性别、年龄、肿瘤位置、肿瘤直径、手术方式、肠造口率、术中失血、pTNM分期、术后住院天数、总住院天数、并发症发生率和一期吻合率。结果 支架+手术组和单纯手术组在性别、年龄、肿瘤位置、肿瘤直径、手术方式、pTNM分期、术后住院天数、总住院天数方面比较，差异均无统计学意义(P>0.05)；与单纯手术组比，支架+手术组患者的肠造口率更低(9.5% vs 40.0%)、总并发症发生率更低(4.8% vs30.0%)、一期吻合率更高(90.5% vs 60.0%)、术中失血量更低[(38.6±18.2) mL vs (83.0±63.8) mL]，差异均有统计学意义(P<0.05)；而在未能手术的18例中，1例高龄患者因肠梗阻未缓解放弃进一步治疗，9例肝或和肺转移患者接受化疗，8例无转移患者接受化疗或中药治疗，梗阻缓解率为94.4% (17/18)。结论 对于左侧大肠癌伴急性梗阻患者先行内镜下自膨胀金属支架植入，待梗阻缓解后再行肠癌根治性切除可减少肠造口率、总并发症发生率和术中失血量，增加一期吻合率，是一种安全可行的治疗方法。对于高龄、远处转移且拒绝手术的患者，支架植入作为姑息性治疗可缓解肠梗阻症状，改善生活质量。
      【关键词】 自膨胀金属支架；左侧大肠癌；急性梗阻；疗效
      【中图分类号】 R735.3+4 【文献标识码】 A 【文章编号】 1003—6350（2018）20—2859—04

Application value of self-expandable metal stent in patients of left-side colorectal cancer with acute obstruction.ZHANG Shou-liang 1, XIE Li 1, YAO Jun 2.
Department of Gastrointestinal Surgery 1, Department of Gastroenterology 2,Zhenjiang First People's Hospital, Zhenjiang 212000, Jiangsu, CHINA
【Abstract】 Objective To explore the application value of self-expandable metal stent implantation under en-doscopy in patients of left-side colorectal cancer with acute obstruction. Methods The clinical therapeutic effect of 40patients of malignant left-side colorectal cancer with obstruction who underwent self-expandable metal stent (SEMS) in-sertion in Department of Gastrointestinal Surgery of Zhenjiang First People's Hospital were retrospectively analyzedfrom March 2016 to June 2018. Among them, 18 cases did not received surgery, 1 case only underwent nodule biopsy be-cause of mesenteric implant nodules, and 21 had colorectal cancer radical resection. The 21 patients undergoing stent im-plantation and radical resection were enrolled as the stent+surgery group, and 20 patients receiving colorectal cancer radi-cal resection only were included in teh simple surgery group in the same period. Patients in the two groups were com-pared for gender, age, tumor location, tumor diameter, surgical method, colostomy rate, intraoperative blood loss, pTNMstage, postoperative hospitalization days, total hospitalization days, complications rate and first-stage anastomosis rate.Results There was no statistically significant difference in gender, age, tumor location, tumor diameter, surgical meth-od, pTNM stage, postoperative hospitalization days and total hospitalization days between the stent+surgery group andthe simple surgery group (P>0.05). Compared with the simple surgery group, the stent+surgery group had significantlylower colostomy rate (9.5% vs 40.0%), lower total complication rate (4.8% vs 30.0%), higher first-stage anastomosis rate(90.5% vs 60.0%), less intraoperative blood loss (38.6±18.2) vs (83.0±63.8), with statistically significant differences (P<0.05). Among the 18 cases that did not underwent operation, 1 elderly patient gave up further treatment because ileuswas not relieved, 9 cases were treated with adjuvant chemotherapy due to liver or/and lung metastasis, and 8 cases with-out liver or lung metastasis were treated with chemotherapy or Chinese herbs, with the obstruction remission rate of94.4% (17/18). Conclusion For patients of left-side colorectal cancer with acute obstruction, endoscopic self-expand-able metal stent implantation was recommended to be performed first, and then radical resection of colorectal cancer wascarried out after relief of obstruction. The therapy could reduce the incidence of colostomy rate, total complications andintraoperative blood loss, and obviously increase the first-stage anastomosis rate, which is safe and feasible. For elderlypatients with distant metastasis who refuse surgery, stent implantation as a palliative treatment can alleviate the symp-toms of intestinal obstruction and improve the quality of life.
      【Key words】 Self-expandable metal stent (SEMS)