Feasibility,Safety And Cost Effectiveness Of Open Surgery Following Sems As A Bridge To Surgery For The Treatment Of Acute Left Malignant Colorectal Obstruction

INTRODUCTION: Colorectal cancer(CRC)is the 5th most prevalent cancer and the 5th leading cause of all cancer cognate deaths in China.CRC remain unnoticed,until it causes acute colorectal obstruction(ACO)in approximately 7%-29% cases.Acute left malignant colorectal obstruction(ALMCO)is a life-threatening emergency with controversial management.Emergency surgeries for ALMCO are associated with high morbidity,mortality and colostomy creation rate.Endoscopic colorectal self-expandable metallic stent(SEMS),introduced in early 90's,has provided an alternative less invasive and non-surgical way to decompress the obstructed bowel.We aimed to compare the clinical efficacy and cost effectiveness of endoscopic colonic SEMS as bridge to open surgery(BTS)with 2 types of emergency surgeries i.e Hartmann's procedure and a single-stage colonic resection with primary anastomosis following intraoperative colonic irrigation.METHODS: A retrospective study from Jan,2010 to Dec,2016 was conducted at the Second Affiliated Hospital of Dalian Medical University and all the registered CRC cases complicated by obstruction were identified.After meeting the inclusion and exclusion criteria,the patients were forficate into 3 groups: GROUP SEMS,GROUP ICI and GROUP HP,depending on the intervention they underwent.Patients having SEMS insertion with an intent to act as a bridge to elective open surgery were allotted to GROUP SEMS,whereas GROUP HP and GROUP ICI were assigned to patients who underwent and emergent Hartmann's procedure and a single-stage emergent colonic resection following intraoperative colonic irrigation,respectively.RESULTS: 82(36.12%)out of 227 patients with left colorectal obstruction were selected.GROUP SEMS,GROUP ICI and GROUP HP had 10,23 and 49 patients,respectively.Males covered the majority of population i.e.64.6%,whereas female population covered only 35.4%,with a median age of 69.50 years(range: 60.75-77.25).Sigmoid colon lesions cases were most common i.e.63.4% and 98.8% of lesions were adenocarcinoma.SEMS cognate technical and clinical success rates were 100% and 90%,respectively,and only 1 patient experienced stent-related perforation.GROUP SEMS had significantly(P<0.05)shorter surgery duration,more primary anastomosis and less stoma creation rate than the other 2 groups,whereas GROUP HP had significantly(P<0.05)shorter time to 1st flatus passage and 1st oral intake and lowest treatment cost than the other 2 groups.There were 2 anastomotic leakage cases in GROUP ICI and 2 deaths in GROUP HP,but postoperative morbidity and mortality rates were not statistically different(P>0.05).CONCLUSION: 1.Colorectal SEMS as BTS is a safer,less invasive and effective treatment for bowel decompression prior to the surgery in patients with ALMCO.2.Elective surgery following SEMS insertion is superior to the emergency surgeries,with acceptable postoperative morbidity and mortality rates.