Obstructive left-sided colon cancer (OLCC) is the primary cause of acute malignant colonic obstruction, with an incidence rate ranging from 58% to 80% [
This study was designed to identify the risk factors for 3-year overall survival (OS) and 3-year disease-free survival (DFS) for ES and SEMS placement. We primarily explored the indications for the use of alternative methods in OLCC patients based on the stratification analysis of long-term survival.
All patients (
Patients who primarily manifested complete or incomplete bowel obstructive syndrome were enrolled in this study. All diagnoses of left-sided colorectal obstruction were confirmed by emergency abdominal computed tomography (CT), and diagnoses of malignancy were confirmed by pathological examination; all stage IV patients underwent radical resection for distant metastasis lesions. Seventy-eight patients were excluded from this study, including 43 with right-side OCC, 10 with rectal cancer, 8 with acute peritonitis with perforation, and 17 who underwent surgery without radical dissection intent. Detailed information on our classification criteria is shown in Figure
Patient inclusion flowchart. OCC: obstructive colorectal cancer; SEMS: self-expandable metal stent; BTS: bridge to surgery; ES: emergency surgery; PSM: propensity score matching.
Isoperistaltic lavage or manual decompression for intraoperative clearance was performed as described previously [
Stent placement was performed by an endoscopist who had previously performed more than 400 endoscopic retrograde cholangiopancreatography (ERCP) procedures [
Left-sided colon cancers were defined as locations including the splenic flexure, descending colon, sigmoid colon, and distal intestine up to 10 cm from the anal verge. The pathological tumor stage was diagnosed according to the American Joint Committee on Cancer (AJCC), Cancer Staging Manual, 7th edition [
Perioperative complications were subdivided into five grades according to the Clavien-Dindo classification system [
All patients were followed up 1 month after surgery, every subsequent 3 months during the first postoperative year, and every 6 months thereafter until 36 months after surgery or until death. At each follow-up visit, routine blood tests, serum CEA level, and computed tomography (CT) were performed. Outcomes were overall survival (OS) and disease-free survival (DFS). Of the 72 included patients, 69 (95.83%) accept follow-up visit and 3 (4.17%) were lost as they were involuntary to follow-up visit.
Propensity scores for all patients were estimated via a logistic regression model, which consisted of all covariates that might have affected patient short-term and survival outcomes (Figure
Between-group differences in qualitative variables were compared using the chi-squared test or Fisher’s exact test, and quantitative variables were compared using
Of 162 patients who underwent surgery for OCC at our center between January 2008 and October 2014, 84 with OLCC were recruited in this study according to the strict selection criteria. Of these 84 OLCC patients, 44 underwent ES with intraoperative irrigation or manual decompression and the other 40 underwent SEMS placement as a BTS. Thirty-six patients were included in each group. After PSM, clinical parameters, including age, sex, ASA grades, pT stage, pN stage, and cM stage, as well as the location of the tumor and the rates of adjuvant chemotherapy, were precisely compared between the 2 groups (Table
Clinical characteristics of patients.
Before propensity matching | After propensity matching | |||||
---|---|---|---|---|---|---|
SEMS | ES | SEMS | ES | |||
Characteristics | ( |
( |
( |
( |
||
Age, | 0.932 | 1.000 | ||||
<60 y | 16 (40.0) | 18 (40.9) | 15 (41.7) | 15 (41.7) | ||
≥60 y | 24 (60.0) | 26 (59.1) | 21 (58.3) | 21 (58.3) | ||
Sex, | 0.770 | 0.804 | ||||
Men | 27 (67.5) | 31 (70.5) | 23 (63.9) | 24 (66.7) | ||
Women | 13 (32.5) | 13 (29.5) | 13 (36.1) | 12 (33.3) | ||
ASA grade, | 0.434 | 0.772 | ||||
<III | 32 (80.0) | 32 (72.7) | 28 (77.8) | 29 (80.6) | ||
≥III | 8 (20.0) | 12 (27.3) | 8 (22.2) | 7 (19.4) | ||
pT stage, | 0.421 | 0.810 | ||||
T1-3 | 22 (55.0) | 28 (63.6) | 22 (61.1) | 21 (58.3) | ||
T4 | 18 (45.0) | 16 (36.4) | 14 (38.9) | 15 (41.7) | ||
pN stage, | 0.165 | 0.437 | ||||
N0 | 9 (22.5) | 16 (36.4) | 9 (25.0) | 12 (33.3) | ||
N1-2 | 31 (77.5) | 28 (63.6) | 27 (75.0) | 24 (66.7) | ||
cM stage, | 0.226 | 1.000 | ||||
M0 | 34 (85.0) | 41 (93.2) | 33 (91.7) | 33 (91.7) | ||
M1 | 6 (15.0) | 3 (6.8) | 3 (8.3) | 3 (8.3) | ||
pTNM stage | 0.303 | 0.718 | ||||
I | 0 (0.0) | 2 (4.5) | 0 (0.0) | 2 (5.6) | ||
II | 8 (20.0) | 12 (27.3) | 8 (22.2) | 8 (22.2) | ||
III | 26 (65.0) | 27 (61.4) | 25 (69.4) | 23 (63.9) | ||
IV | 6 (15.0) | 3 (6.8) | 3 (8.4) | 3 (8.4) | ||
Lymph nodes, counts | 0.939 | 0.991 | ||||
Location of tumor, | 0.601 | 0.456 | ||||
Splenic colon | 5 (12.5) | 10 (22.7) | 5 (13.9) | 10 (27.8) | ||
Descending colon | 9 (22.5) | 10 (22.7) | 9 (25.0) | 9 (25.0) | ||
Sigmoid colon | 22 (55.0) | 19 (43.2) | 18 (50.0) | 15 (41.7) | ||
Rectum | 4 (10.0) | 5 (11.4) | 4 (11.1) | 2 (5.6) | ||
Adjuvant chemotherapy, |
20 (50.0) | 28 (63.6) | 0.207 | 18 (50.0) | 23 (63.9) | 0.234 |
Comorbidities | 0.054 | 0.096 | ||||
With | 22 (55.0) | 15 (34.1) | 19 (52.8) | 12 (33.3) | ||
Without | 18 (45.0) | 29 (65.9) | 17 (47.2) | 24 (66.7) |
SEMS: self-expanding metal stents; ES: emergency surgery. All
Stent-related adverse events occurred in 11 of 36 (30.6%) patients in the SEMS group, including 6 (16.7%) with difficulty in positioning the guidewire in the lumen of the tumor, 3 (8.3%) with pathologically verified microperforation after stent placement, and 2 (5.6%) with clinical reobstruction (Table
Characteristics of patients with stent-related adverse events in the SEMS group.
No. | Adverse events | pT stage | Location | Stoma | Treatment |
---|---|---|---|---|---|
1 | Failure | 4 | Descending colon | None | Emergency surgery |
2 | Failure | 4 | Sigmoid colon | Construction | Emergency surgery |
3 | Failure | 3 | Sigmoid colon | Construction | Emergency surgery |
4 | Failure | 4 | Descending colon | None | Emergency surgery |
5 | Failure | 4 | Descending colon | Construction | Emergency surgery |
6 | Failure | 3 | Descending colon | Construction | Emergency surgery |
7 | Microperforation | 4 | Sigmoid colon | None | Conservative |
8 | Reobstruction | 4 | Sigmoid colon | Construction | Change schedule |
9 | Microperforation | 3 | Sigmoid colon | Construction | Conservative |
10 | Reobstruction | 3 | Sigmoid colon | Construction | Change schedule |
11 | Microperforation | 4 | Sigmoid colon | None | Conservative |
Increased surgical time (
Comparison of surgical- and pathological-related outcomes between the SEMS and ES groups.
Characteristics | SEMS ( |
ES ( |
|
---|---|---|---|
Surgical time (mins) | 0.422 | ||
Blood loss (ml) | 0.326 | ||
Number of LNs ( |
0.991 | ||
Time to flatus (days) | 0.278 | ||
Time to semifluid (days) | 0.931 | ||
Total hospital stay (days) | 0.988 | ||
Stoma construction, |
10 (27.8) | 6 (16.7) | 0.257 |
CD classification system, | 1.000 | ||
Grade I | 11 (30.6) | 11 (30.6) | |
Grade II | 15 (41.7) | 14 (38.9) | |
Grade III | 8 (22.2) | 8 (22.2) | |
Grade IV | 2 (5.6) | 3 (8.3) | |
Incision infection, |
6 (16.7) | 6 (11.1) | 0.496 |
ICU intervention, |
2 (5.6) | 1 (2.8) | 1.000 |
30 days-mortality, |
0 (0.0) | 1 (2.8) | 1.000 |
Histology, | 0.659 | ||
Well differentiated | 0 (0.0) | 1 (2.8) | |
Moderate differentiated | 26 (72.2) | 24 (66.7) | |
Poorly differentiated | 1 (2.8) | 3 (8.3) | |
Signet ring | 9 (25.0) | 8 (22.2) | |
Stent related adverse events, |
11 (30.6) | ||
Failure | 6 (54.5) | ||
Perforation | 3 (27.3) | ||
Reobstruction | 2 (18.2) | ||
Surgical intervals (days) | 10.07 |
LN: lymph node; SEMS: self-expanding metal stents; ES: emergency surgery. All
The 3-year OS and 3-year DFS were analyzed for all patients enrolled in this study. The 3-year OS was not significantly different between the SEMS (73.5%) and ES (60.0%) groups (
Overall (a) and disease-free survival (b) after surgery between the SEMS and ES groups.
Univariate and multivariate analyses of risk factors on prognosis in OLCCs.
OLCCs | 3-year DFS | 3-year OS | ||||||
---|---|---|---|---|---|---|---|---|
Univariate | Multivariate | Univariate | Multivariate | |||||
Characteristic | Hazard ratio (95% CI) | Hazard ratio (95% CI) | Hazard ratio (95% CI) | Hazard ratio (95% CI) | ||||
Age (≥60 vs <60 years) | 1.90 (0.64, 5.68) | 0.251 | — | — | 1.75 (0.62, 4.92) | 0.288 | — | — |
Sex (male vs female) | 1.13 (0.42, 3.01) | 0.813 | — | — | 0.52 (0.19, 1.44) | 0.205 | — | — |
ASA ( |
0.75 (0.20, 2.88) | 0.673 | — | — | 1.34 (0.42, 4.22) | 0.622 | — | — |
Group (ES vs SEMS) | 1.34 (0.51, 3.51) | 0.550 | — | — | 1.58 (0.66, 3.81) | 0.308 | — | — |
pT stage (pT4 vs pT1-3) | 3.12 (1.15, 8.48) | 0.026 | 3.88 (1.54, 9.77) | 0.004 | 3.64 (1.31, 10.11) | 0.013 | 4.04 (1.66, 9.86) | 0.002 |
pN stage (pN+ vs pN0) | 1.60 (0.49, 5.24) | 0.441 | — | — | 1.14 (0.38, 3.44) | 0.811 | — | — |
Metastasis (cM1 vs cM0) | — | — | — | — | 2.70 (0.86, 8.47) | 0.088 | — | — |
Comorbidity (with vs without) | 1.41 (0.50, 4.00) | 0.522 | — | — | 0.95 (0.33, 2.71) | 0.918 | — | — |
All factors where the
Univariate and multivariate analyses of risk factors on prognosis in the SEMS group.
SEMS group | 3-year DFS | 3-year OS | ||||||
---|---|---|---|---|---|---|---|---|
Univariate | Multivariate | Univariate | Multivariate | |||||
Characteristic | Hazard ratio (95% CI) | Hazard ratio (95% CI) | Hazard ratio (95% CI) | Hazard ratio (95% CI) | ||||
Age (≥60 vs <60 years) | 4.98 (0.52, 47.47) | 0.163 | — | — | 1.68 (0.35, 8.00) | 0.514 | — | — |
Sex (male vs female) | 5.88 (0.24, 142.85) | 0.276 | — | — | 1.05 (0.11, 9.98) | 0.968 | — | — |
ASA ( |
12.66 (0.73, 218.60) | 0.081 | — | — | 7.97 (0.84, 75.78) | 0.071 | — | — |
pT stage (pT4 vs pT1-3) | 47.51 (2.10, 1075.38) | 0.015 | 7.54 (1.51, 37.70) | 0.014 | 47.04 (3.34, 663.62) | 0.004 | 15.42 (1.92, 123.79) | 0.010 |
pN stage (pN+ vs pN0) | 8.12 (0.32, 204.56) | 0.203 | — | — | 5.45 (0.43, 69.34) | 0.192 | — | — |
Metastasis (cM1 vs cM0) | — | — | — | — | 1.35 (0.09, 20.91) | 0.832 | — | — |
Comorbidity (with vs without) | 0.54 (0.10, 3.04) | 0.483 | — | — | 0.24 (0.05, 1.21) | 0.083 | — | — |
All factors where the
Univariate and multivariate analyses of risk factors on prognosis in the ES group.
ES group | 3-year DFS | 3-year OS | ||||||
---|---|---|---|---|---|---|---|---|
Univariate | Multivariate | Univariate | Multivariate | |||||
Characteristic | Hazard ratio (95% CI) | Hazard ratio (95% CI) | Hazard ratio (95% CI) | Hazard ratio (95% CI) | ||||
Age (≥60 vs <60 years) | 1.61 (0.33, 7.98) | 0.559 | — | — | 2.18 (0.49, 9.68) | 0.304 | — | — |
Sex (male vs female) | 1.11 (0.33, 3.80) | 0.867 | — | — | 0.61 (0.16, 2.36) | 0.477 | — | — |
ASA ( |
0.20 (0.02, 1.76) | 0.148 | — | — | 0.67 (0.16, 2.84) | 0.588 | — | — |
pT stage (pT4 vs pT1-3) | 2.01 (0.52, 7.71) | 0.311 | — | — | 1.34 (0.39, 4.57) | 0.644 | — | — |
pN stage (pN+ vs pN0) | 0.75 (0.12, 4.74) | 0.756 | — | — | 0.43 (0.10, 2.28) | 0.325 | — | — |
Metastasis (cM1 vs cM0) | — | — | — | — | 4.15 (0.84, 20.61) | 0.082 | 8.92 (2.08, 38.18) | 0.003 |
Comorbidity (with vs without) | 4.14 (0.88, 19.55) | 0.073 | 3.13 (1.01, 9.75) | 0.049 | 3.24 (0.59, 17.85) | 0.177 | — | — |
All factors where the
Due to the discrepancy in risk factors for 3-year DFS and 3-year OS in the 2 groups, stratification analysis was performed in OLCC patients. Subgroup analysis of the pT stage resulted in differences in the 3-year DFS rate and 3-year OS rate between the SEMS group and ES group. Patients with non-pT4 stages in the SEMS group showed significantly better 3-year OS (95.0%) than those in the ES group (70.0%,
Kaplan-Meier stratification survival curves for patients in the SEMS and ES groups according to different parameters (log-rank test). (a) 3-year OS in different pT categories.
Stratification analysis of oncological and survival outcomes on prognosis in OLCCs.
OLCCs with pT stage | |||||
Rates (95% CI) | OLCCs with pT stage | Rates (95% CI) | |||
0.39 (0.25, 0.52) | 0.001 | 0.43 (0.30, 0.56) | 0.001 | ||
0.70 (0.59, 0.80) | 0.108 | 0.70 (0.60, 0.80) | 0.043 | ||
0.40 (0.27, 0.53) | 0.001 | 0.47 (0.34, 0.60) | 0.001 | ||
0.90 (0.83, 0.97) | — | 0.95 (0.90, 0.99) | — | ||
OLCCs with comorbidity | |||||
Rates (95% CI) | OLCCs with cM stage | Rates (95% CI) | |||
0.71 (0.62, 0.80) | 0.027 | — | — | ||
0.77 (0.66, 0.87) | 0.030 | 0.74 (0.66, 0.82) | 0.001 | ||
0.71 (0.60, 0.82) | 0.033 | 0.67 (0.40, 0.94) | 0.197 | ||
0.36 (0.22, 0.51) | — | 0.66 (0.57, 0.74) | 0.001 |
All
This study reveals similar 3-year DFS and 3-year OS rates between the SEMS and ES groups. The independent risk factors included the status of metastasis and comorbidities in the ES group and the pT stage in the SEMS group. Through stratification survival analysis, we determined that only certain subgroups of OLCC patients would benefit from SEMS placement or ES, which might explain why controversial data have been presented in recent studies.
Concerning the negative oncological outcome in the further analysis of the SEMS group, macroscopic and microscopic perforations have been described in several studies, partly due to the stiffness of the guide wire and older age of patients [
The operative risk of patients in the ES group and the concern for oncological outcomes in the SEMS group were areas of focus. The high risk of intraoperative complications and postoperative mortality were considered more threatening than the risk of stent-related perforation [
The volume of the center greatly affects the efficacy of SEMS placement and ES for OLCC patients [
However, this is a PSM analysis study of a cohort at one center, and thus, a prospective multicenter study should be performed in the future. In addition, the sample size was not large and additional samples are required in future research. Accounting for the above limitations, this study suggests a similar survival benefit for SEMS placement as a BTS and ES in patients with OLCC. Specifically, patients in the high-operative risk group with existing severe comorbidities could acquire more survival benefits from the SEMS strategy. As a supplement for the latest ESGE guideline, the indication for the use of SEMSs in OLCC patients may be elaborated to patients without locally advanced invasion such as the non-pT4-stage status.
The findings of the present study suggest that SEMS might be preferred for patients of obstructive left-sided colorectal cancer in the “high-operative risk group” with existing comorbidities or those without locally advanced invasion, such as non-pT4-stage status.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors declare that they have no conflicts of interest.
Jun-rong Zhang, Ping Hou, and Xian-qiang Chen conceived the study, analyzed the data, and drafted the manuscript; Bing-qiang Lin helped revise the manuscript critically for important intellectual content; Yong Wei and Tian-ran Liao helped collect data and design the study. All authors read and approved the final manuscript.
We thank all the participants of this study and the nursing and department staff of Fujian Medical University Union Hospital. This study was supported by the Construction Project of Fujian Province Minimally Invasive Medical Center (no. [2017]171).