Objective: To explore the short-term efficacy and prognosis of palliative surgical treatment for malignant bowel obstruction (MBO) caused by peritoneal metastasis of colorectal cancer (mCRC). Methods: A retrospective cohort study was conducted. The inclusion criteria for patients were as follows: (1) primary colorectal cancer; (2) massive peritoneal metastasis; (3)obstructive site located below Treitz ligament by imaging; (4) obstruction refractory to conservative treatment; (5) estimated rese survival time more than 2 months; (6) patients and their families had strong willingness for operation; (7) surgical treatment included stoma/bypass and debulking surgery. In accordance with the above criteria, clinicopathological data of 46 patients undergoing palliative surgery at Peking University Gastrointestinal Cancer Center, Unit III from January 2016 to October 2018 were retrospectively collected. Postoperative symptomatic relief rate, morbidity of complication within 30 days, complication classification (Clavien-Dindo classification), mortality and survival after operation were analyzed. Kaplan-Meier method was used to evaluate survival and Cox regression analysis was used to identify prognostic factors. Results: Among 46 patients, 30 were male and 16 were female with median age of 63 (19-87) years; 23 patients received stoma/bypass surgery (stoma/bypass group), and 23 cases received tumor debulking surgery (debulking group). The overall symptom relief rate was 76.1% (35/46), while symptom relief rate in the debulking group was 91.3% (21/23), which was significantly higher than 60.9% (14/23) in the stoma/bypass group (χ(2)=4.301, P=0.038). Postoperative complications occurred in 25 patients. The complication rate was 52.2% (12/23) in the debulking group and 56.5% (13/23) in the stoma/bypass group, without statistically significant difference (χ(2)=0.088, P=0.767). Morbidity of complication beyond grade III was 8.7% (2/23) and 13.0% (3/23) in the debulking group and stoma/bypass group respectively, without statistically significant difference (χ(2)=0.224, P=0.636). Four patients died within 30 days after operation, 2 (8.7%) in each group. Twenty-four patients underwent 1-8 cycles of chemotherapy ± targeting therapy (regimens: CapeOX ± Bevacizumab, FOLFOX/FOLFIRI ± Bevacizumab/Cetuximab), including 10 cases in the stoma/bypass group and 14 cases in the debulking group. Two patients of debulking group received postoperative radiotherapy and chemotherapy (50.6 Gy/22 f, with concurrent oral capecitabine). Till the last follow up of April 2019, 34 patients died (34/46, 73.9%) with a median overall survival time of 6.4 months, and the 6-month and 1-year survival rate was 54.5% and 29.2% respectively. The median survival time in the debulking group was significantly longer than that in the stoma/bypass group (11.5 months vs. 5.2 months, χ(2)=5.117, P=0.024). The median survival time of the 35 patients with symptomatic relief after operation was significant longer than that of 11 patients without relief (7.1 months vs 5.1 months, χ(2)=3.844, P=0.050). Multivariate analysis showed stoma/bypass surgery (HR=2.917, 95%CI:1.357-6.269, P=0.006) and greater omental metastasis (HR=4.060, 95%CI:1.419-11.617, P=0.009) were independent risk factors associated with prognosis of patients with MBO caused by peritoneal mCRC. Conclusions: For patients of MBO caused by peritoneal mCRC, tumor debulking surgery may achieve higher symptom relief rate and prolong survival. Greater omental metastasis indicates poor prognosis.
目的： 探究手术治疗结直肠癌腹腔转移导致的晚期恶性肠梗阻的短期效果及预后。 方法： 采用回顾性队列研究的方法。病例入组标准：（1）原发灶为结直肠癌；（2）存在广泛腹腔转移；（3）影像学上梗阻部位位于Treitz韧带以下；（4）肠梗阻保守治疗无效；（5）预计生存期2个月以上；（6）患者及家属有强烈手术意愿；（7）接受了包括造口/短路手术或减瘤手术治疗。按照上述标准，回顾性收集2016年1月至2018年10月期间北京大学肿瘤医院胃肠中心三病区收治的46例患者临床病理资料，分析术后可经口进固体食物的梗阻症状缓解率、术后30 d内并发症发生率、并发症分级（采用Clavien-Dindo分级）和病死率以及术后生存时间以评价手术效果，同时采用Kaplan-Meier法进行生存分析，采用Cox回归分析筛选结直肠癌腹腔转移导致的恶性肠梗阻的独立预后因素。 结果： 46例患者中男性30例，女性16例；中位年龄63（19~87）岁。其中接受造口或短路手术23例（造口/短路组），接受减瘤手术23例（减瘤手术组）。患者整体术后症状缓解率为76.1%（35/46），造口/短路组为60.9%（14/23），减瘤手术组为91.3%（21/23），减瘤手术组显著高于造口/短路组（χ(2)=4.301，P=0.038）。术后25例患者出现并发症，减瘤手术组和造口/短路组并发症发生率分别52.2%（12/23）和56.5%（13/23），差异无统计学意义（χ(2)=0.088，P=0.767）；Ⅲ级以上并发症发生率分别为8.7%（2/23）和13.0%（3/23），差异也无统计学意义（χ(2)=0.224，P=0.636）。术后30 d内共计4例患者死亡，两组各死亡2例（均为8.7%）。术后有24例患者继续进行1~8周期不等的化疗±靶向治疗（方案有CapeOX±贝伐单抗、FOLFOX/FOLFIRI+西妥昔单抗/贝伐单抗），其中造口/短路组10例，减瘤手术组14例。减瘤手术组另有2例患者接受了术后放化疗（50.6 Gy/22 f，同步口服卡培他滨）截至2019年4月末次随访，全组有34例死亡（34/46，73.9%），中位总生存时间为6.4个月，6个月和1年生存率分别为54.5%和29.2%；减瘤手术组的中位生存期显著长于造口/短路组（11.5个月比5.2个月，χ(2)=5.117，P=0.024）。术后症状改善明显的35例患者中位生存时间长于症状未见明显改善的11例患者（7.1个月比5.1个月，χ(2)=3.844，P=0.050）。多因素分析显示，造口/短路手术（HR=2.917，95%CI：1.357~6.269，P=0.006）和网膜饼形成（HR=4.060, 95%CI：1.419~11.617，P=0.009）是影响患者预后的独立危险因素。 结论： 对于结直肠癌腹腔转移导致的恶性肠梗阻，减瘤手术的方式可以取得良好的症状改善效果，有网膜饼形成的患者预后不佳。.
Keywords: Bowel obstruction, malignant, metastasis; Colorectal neoplasms; Palliative surgery; Prognosis.