Self-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction

Self-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Self-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction Bing Li, Shi-Lun Cai, Zhen-Tao Lv, Ping-Hong Zhou, Li-Qing Yao, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-33526/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Dec, 2020 Read the published version in BMC Surgery → Version 3 posted 9 You are reading this latest preprint version Show more versions Abstract Background: The use of a self-expandable metallic stent (SEMS) as a bridge to surgery has increased for patients with obstructing colorectal cancer. However, relatively few reports have compared SEMS as a bridge to elective surgery for acute malignant obstruction of the right-sided colon (MORC) vs. emergency surgery (ES). This study aimed to evaluate the benefits of elective surgery after SEMS placement vs. ES for patients (including stage IV cases) with acute MORC. Methods: Patients with acute MORC who underwent radical resection for a primary tumour from July 2008 to November 2016 at Zhongshan Hospital of Fudan University were retrospectively enrolled. Postoperative short-term outcomes, progression-free survival (PFS), and overall survival (OS) were compared between the SEMS and ES groups. Results: In total, 107 patients with acute MORC (35 in the SEMS group and 72 in the ES group) were included for analysis. The Intensive Care Unit admission rate was lower (11.4% vs. 34.7%, P = 0.011), the incidence of complications was reduced (11.4% vs. 29.2%, P = 0.042), and the postoperative length of hospitalisation was significantly shorter (8.23 ± 6.50 vs. 11.18 ± 6.71 days, P = 0.033) for the SEMS group. Survival curves showed no significant difference in PFS ( P = 0.506) or OS ( P = 0.989) between groups. Also, there was no significant difference in PFS and OS rates between patients with stage II and III colon cancer. After colectomy for synchronous liver metastases among stage IV patients, the hepatectomy rates for the SEMS and ES groups were 85.7% and 14.3%, respectively ( P = 0.029). The hazard ratio for colectomy alone vs. combined resection was 3.258 (95% CI 0.858–12.370; P = 0.041). Conclusion: Stent placement offers significant advantages in terms of short-term outcomes and comparable prognoses for acute MORC patients. For synchronous liver metastases, SEMS placement better prepares the patient for resection of the primary tumour and liver metastasis, which contribute to improved survival. Surgery General Surgery Right-sided colon cancer Obstruction Self-expandable metallic stent Liver metastases Figures Figure 1 Figure 1 Figure 2 Figure 2 Figure 3 Figure 3 Background Colorectal cancer (CRC) is the fourth most commonly diagnosed cancer and the second leading cause of cancer-related death in both males and females [1]. Approximately 8%–13% of patients with advanced colon cancer present with an obstruction of the large bowel [2-4] . A self-expandable metallic stent (SEMS) is widely used for obstructive left-sided colon cancer to allow for an easy endoscopic approach to the lesion and to facilitate patient recovery from the acute status with reduced risks of postoperative complications and mortality [5-7]. However, fewer than 10% of reported cases of colonic stenting have involved the right colon [8]. Some studies have reported insertion of a SEMS for acute malignant obstruction of the right-sided colon (MORC) could benefit patients with severe comorbidities, advanced age, or complete obstruction [9, 10]. Moreover, the technical success rate in experienced centres has improved to > 96%, similar to that reported for stenting of distal colon lesions [11]. Thus, the present retrospective study included more cases than previous reports of the advantages of SEMS as a bridge to elective surgery as compared to emergency surgery (ES) for CRC patients with a proximal malignant obstruction of the large bowel. In addition, bowel obstruction is often accompanied by distant metastasis, as the liver is the most common site of CRC metastasis [4, 12]. Here, we report our experience and results with the use of colonic stenting of patients, including those with stage IV CRC, an area of the published data that remains severely limited. Therefore, the aim of the present study was to evaluate the benefits of elective surgery after SEMS placement vs. ES for patients (including stage IV cases) with acute MORC. Methods Ethics statement The study protocol was approved by the Institutional Review Board of Zhongshan Hospital and conducted in accordance with the tenets of the Declaration of Helsinki. Informed consent was obtained from all patients prior to treatment. This retrospective observational study was conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines [13]. Patients The study cohort was limited to patients with acute right-sided bowel obstruction caused by malignant CRC who underwent radical resection for the primary tumour from July 2008 to November 2016 at Zhongshan Hospital of Fudan University (Shanghai, China). Right-sided colon cancer was defined as any tumour arising in the cecum, ascending colon, hepatic flexure or transverse colon. MORC was clinically defined as symptoms of abdominal pain, distension, vomiting, and no passage of stool or flatus, and radiologically defined as severe dilatation of the proximal colon due to suspected colon cancer by abdominal X-ray and/or contrast-enhanced computed tomography (CT). Radical surgery was performed if no distant metastasis was observed either pre- or intra-operatively. However, if distant metastasis was found, radical resection was performed for the primary tumour, while sites of metastasis were treated by synchronous or two-stage resection, or other non-surgical treatments. The patients were assigned to one of two groups: the ES group, which consisted of patients who underwent radical resection within 24 h after visiting the hospital and received no other treatments for primary causes, or the SEMS group, which consisted of patients who underwent colonic stent placement followed by surgery within 2 weeks after stent placement. The strategy to choose ES or SEMS placement as a bridge to surgery was mainly based on the following considerations: 1) the tumor locations differed significantly between the SEMS and ES groups, as stenting was not appropriate for an obstruction in the cecum; 2) low-pressure enema intestinal cleaning could be completed to facilitate stricture visualization and stent placement; 3) there were no signs of peritonitis or perforation in the SEMS group; 4) if ES was considered too risky or when the disease was very advanced and palliation was needed, stent placement as a bridge to surgery was considered; and 5) the final choice of treatment (ES or SEMS placement) was mostly dependent on a consensus among the surgeons, the endoscopists and the patient or patient's family. Procedure All stent placement procedures were performed by experienced endoscopists at the Endoscopy Centre of Zhongshan Hospital with experience and competence in both colonoscopy and fluoroscopic techniques and who performs colonic stenting on a regular basis. Briefly, the stent placement procedures consisted of four steps: 1) determining the site and aetiology of the acute bowel obstruction by colonoscopy combined with fluoroscopy; 2) a hydrophilic biliary guidewire was introduced through the tumour beyond the point of obstruction; 3) injection of water-soluble contrast medium proximally to the stricture; and 4) insertion and placement of suitable stents under fluoroscopic guidance. The immediate escape of air and liquid faeces through the stent indicated successful decompression. Afterward, a series of examinations, including chest X-ray, abdominal ultrasound or abdominal CT, and blood tests, were performed. At 7 to 14 days after the colon obstruction was relieved, mechanical bowel preparation was performed using polyethylene glycol or sodium phosphate and one-stage surgery. Staging assessment and follow-up Pathological tumour-node-metastasis staging was performed in accordance with the guidelines of the Union for International Cancer Control, eighth edition. For all patients, routine clinical follow-up data were obtained. CT, abdominal ultrasound, chest X-ray, and blood tests were performed every 3 months for the first year and then every 6 months thereafter. Colonoscopic surveillance was performed every 6 months for the first year and then once per year thereafter. Diagnoses of relapse and metastasis were based on imaging studies and biopsy, if necessary. The follow-up period was defined as the date of surgery to either the date of death or August 2018, whichever occurred first. Data collection and analysis In addition to clinicopathological data (i.e., age, sex, tumour characteristics, histopathology and surgical information), short-term postoperative outcomes and long-term prognoses were collected for analysis. The short-term postoperative outcomes mainly consisted of admission to the Intensive Care Unit (ICU), adverse events, and mortality within 30 days after surgery. The primary endpoints of long-term outcomes were progression-free survival (PFS) and overall survival (OS). Data were primarily obtained from medical records. For patients who had moved away, attempts were made to obtain outcome details by telephone contact with the patient or a family member. Comparisons between groups were performed using the Student's t -test, chi-squared test, or Fisher’s exact test and rank-sum test, as appropriate. Kaplan–Meier curves were constructed to analyse rates of survival, recurrence, and metastasis. The log-rank test was used to evaluate the significance of differences between curves. All statistical analyses were performed using SPSS for Windows, version 16.0. (SPSS Inc., Chicago, IL, USA). A probability ( P ) value of < 0.05 was considered statistically significant. Results Baseline characteristics From July 2008 to November 2016, 107 patients with acute MORC (35 patients in the SEMS group and 72 in the ES group) underwent radical resection at Zhongshan Hospital. The median patient age was 66 (range 23–94) years. As shown in Table 1, there were no major differences in baseline and oncologic characteristics, with the exception of tumour location, between the SEMS and ES groups. No stent migration or perforation was observed, although one patient experienced re-obstruction after initial successful stenting. As of the last follow-up on August 2018, the overall median follow-up duration was 35 (range 0.1–120) months. Of the 107 patients, 13 (12.1%) were lost to follow-up. However, there was no significant difference in the rate of patients lost to follow-up between the SEMS and ES groups (11.4% [4/35] vs 12.5% [9/72], respectively; P > 0.99). Characteristics of the procedures and postoperative short-term outcomes The characteristics of the surgical procedures and short-term postoperative outcomes of the two groups are shown in Table 2. Although open surgery was the primary approach, laparoscopic procedures were performed more frequently in the SEMS group than the ES group (11.4% vs. 0%, respectively; P = 0.010). In regard to intraoperative findings, the incidence of ascites was greater in the ES group than the SEMS group (52.8% vs. 20.0%, respectively; P = 0.001), while perforation occurred in four (5.6%) patients in the ES group. The need for intraoperative transfusion tended to be lower in the SEMS group than the ES group, but the difference was not statistically significant (2.9% vs. 13.9%, respectively; P = 0.098). In the SEMS group, jejunostomy was performed for one patient, as partial duodenectomy was required due to intraoperative findings that the tumor had invaded the duodenum. The postoperative ICU admission rate was significantly lower in the SEMS group than the ES group (11.4% [4/35 vs. 34.7% [25/72], respectively; P = 0.011). Moreover, the complication rate was significantly lower in the SEMS group than the ES group (11.4% [4/35] vs. 29.2% [21/72], respectively; P = 0.042). The most common postoperative complications in both groups were wound infection, pulmonary infection, and anastomotic leakage, but there was no significant difference in the incidence of complications between the two groups ( P > 0.05). One patient in the ES group died due to multiple organ dysfunction syndrome on postoperative day 3. Moreover, the average duration of postoperative hospitalization was significantly shorter in the SEMS group than the ES group (8.23 ± 6.50 vs. 11.18 ± 6.71 days, respectively; P = 0.033). After excluding tumors located in the cecum from the ES group, the characteristics of the surgical procedures and postoperative short-term outcomes of the two groups were compared. The results in Supplementary Table 1 show the advantages of stent placement in terms of lower ICU admission rate, reduced complication rates, and shorter postoperative hospital stays. Long-term outcome s of all populations in the SEMS and ES groups Kaplan–Meier curves of PFS for all patients are presented in Fig. 1A. The hazard ratio (HR) for PFS between the ES vs. SEMS groups was 1.235 (95% confidence interval [CI] 0.674–2.263; P = 0.506). The 5-year PFS rate was greater in the SEMS group than the ES group (54.0% [95% CI 34.20%–73.80%] vs. 49.1% [95% CI 35.97%–62.23%], respectively). The Kaplan–Meier curves of OS for all patients are presented in Fig. 1B. The HR for OS between the ES and SEMS group was 0.995 (95% CI 0.520–1.907; P = 0.989). The 5-year OS rate was lower in the SEMS group than the ES group (56.0% [95% CI 36.40%–75.60%] vs. 61.6% [95% CI 49.25%–73.95%], respectively). Subgroup analyses based on tumor stage Comparison of stage II and III disease between the SEMS and ES groups During the follow-up period, disease progression, defined as local site recurrence and distant metastasis, was observed in 27 (29.0%) patients with stage II and III disease. There was no significant difference in the distant metastasis rate between the SEMS and ES groups (21.4% [6/28] vs. 18.5% [12/65], respectively; P = 0.740) or in the rate of local relapse (7.1% [2/28] vs . 10.8% [7/65], respectively; P = 0.719). At the time of analysis, a total of 31 (33.3%) patients died during the follow-up period. However, there was no significant difference in the mortality rate between the SEMS and ES groups (32.1% [9/28] vs . 33.8% [22/65], respectively; P = 0.873) (Table 3). PFS curves of the 93 patients with stage II and III disease are shown in Fig. 2A. As the HR for the ES vs . SEMS groups was 1.543 (95% CI 0.774–3.075; P = 0.253), the 5-year PFS rate was 64.5% (95% CI 43.53–85.47) for the SEMS group and 52.6% (95% CI 38.64–66.52) for the ES group. The Kaplan–Meier curves of OS are presented in Fig. 2B. The HR for the ES vs. SEMS group was 1.217 (95% CI 0.559–2.646; P = 0.619), when the 5-year OS rate was 68.2% (95% CI 47.82–88.58) for the SEMS group and 64.2% (95% CI 51.46–76.94) for the ES group. Long-term outcomes of patients with stage IV disease Table 4 shows the clinicopathological characteristics and long-term prognostic outcome data of 14 patients with stage IV colon cancer in the two groups. The SEMS and ES groups both had seven CRC patients with synchronous liver metastases. After colectomy, the synchronous or two-stage hepatectomy rates was significantly greater in the SEMS group than the ES group (85.7% [6/7] vs. 14.3% [1/7], respectively; P = 0.029). The remaining patients received chemotherapy, transcatheter arterial chemoembolisation or other palliative treatments. To determine the advantages of different therapeutic regimens, survival outcomes of patients who underwent colectomy only vs. colectomy combined with hepatectomy were compared. Kaplan–Meier curves of OS are shown in Fig. 3. The data showed that median OS was superior for those who underwent combined resection as compared to colectomy alone (42 vs. 6 months, respectively), and the HR for colectomy only vs combined resection was 3.258 (95% CI 0.858–12.370; P = 0.041). Discussion In fact, since Campbell et al . reported the efficacy and safety of successful SEMS placement in MORC patients in 1997 [14], this technique has gained more and more attention. Repici et al . reported that the success rate for SEMS insertion for right-sided malignant colonic obstruction was 95% (20/21), with resolution of obstructive symptoms and no immediate complications in 85% of cases (17/20) [15]. Similarly, another recent study reported a success rate of 87.5% and symptom relief rate of 100% with no immediate complications [16]. In the present study, re-obstruction as a long-term complication occurred in only one patient. Collectively, these findings confirm the feasibility of SEMS placement for treatment of MORC. Considering the higher morbidity and mortality rates as compared with elective surgery [17, 18], successful SEMS placement can provide sufficient preoperative preparation for patients with acute malignant colorectal obstruction prior to open or laparoscopic one-stage colectomy [19, 20]. In the present study, 35 patients initially underwent SEMS placement as a bridge to elective surgery, while 72 patients underwent ES. Although open colectomy accounted for the majority of surgeries, laparoscopic colectomy, as opposed to ES, tended to be implemented in the SEMS group. As compared to open surgery, the advantages of laparoscopic approach include faster recovery and lower postoperative morbidity in the SEMS group. However, prior to 2016, colorectal surgeons at our center had limited experience with the laparoscopic approach, which explains the low rate of laparoscopic surgery, as it takes time to incorporate a new technology. In regard to the intra-operative findings, the incidence of ascites was greater in the ES group (52.8%, 38/72) than the SEMS group (20.0%, 7/35), indicating that the physical status of patients in the SEMS group was better than that of the ES group. Likewise, in the present study, short-term outcomes were better in the SEMS group than the ES group. In addition, the ICU admission rate was significantly lower in the SEMS group (11.4%, 4/35) than the ES group (34.7%, 25/72), suggesting that the main advantages of stent placement were a reduced incidence of postoperative complications and shorter hospital stay. Other studies reported similar conclusions. One study reported shorter postoperative hospital stays and time to resume oral food intake in the SEMS group, suggesting better recovery from surgery [16]. The long-term prognosis of stent placement for MORC as a bridge to surgery was an important focus of the present study. Considering the differences in treatment methods and survival results, the PFS and OS rates were separately compared between the SEMS and ES groups in terms of stage IV disease and other stages. The results showed no significant differences in PFS and OS rates between patients with stage II and III colon cancer. A multicentre retrospective study also indicated that the long-term oncologic outcome of the SEMS group was similar or slightly better than that of the ES group among all patients with stage II or III colon cancer [21]. According to a meta-analysis of 11 studies, which included 1136 patients with left-sided or right-sided obstructive colon cancer, stenting as a bridge to surgery was oncologically comparable to ES with respect to OS, disease-free survival, and recurrence [22]. Moreover, Li et al . and Gianotti et al . reported improved survival of the SEMS group throughout the follow-up period [23, 24]. For patients with CRC, the liver is the most common site of metastasis and hepatic metastasis during the course of disease is the main cause of death [25, 26]. Of the 93 patients with stage II or III disease in the present study, liver metastasis occurred in eight (8.6%) after surgery. In cases of synchronous CRC liver metastases (CRCLM), the prognosis of untreated patients is poor, as fewer than 30% had survived at 1 year and fewer than 5% at 5 years after diagnosis [27]. Surgical resection is the most effective treatment for CRCLM, as the 5-year survival rate after liver resection reportedly ranges from 44% to 57% [28, 29]. In the present study, 14 patients had right-sided colorectal obstructions with synchronous metastasis. In the SEMS group, six (95.7%) of seven patients underwent resection of the primary tumour and the metastatic sites of the liver, while only one patient in the ES group underwent combined resection and the other seven underwent colectomy for severe obstruction. Thus, we inferred that SEMS improved the suitability of patients with stage IV disease for radical resection. Among the patients who underwent liver surgery, median survival was 42 months, which is comparable to the survival duration of 36 to 57 months in other reports [29, 30]. Based on these survival data of different treatment regimens, it is obvious that patients could benefit from resection of both the primary tumour and sites of metastasis. There were several limitations to this study. First, in terms of baseline characteristics, SEMS was not employed in the cecum due to differences in tumour location. The main reason for this imbalance is that stent placement in the cecum of the right-sided colon is more technically challenging, as the stent should preferably extend beyond the stricture at both ends by 1.5–2cm. Of course, the results of the present study were limited by the relatively small number of patients, especially those with liver metastases, and the single-centre retrospective study design. The small sample number was also a limit to the research on learning curve of right colon stenting. Nonetheless, future studies with larger numbers of subjects and longer follow-up periods are warranted. Conclusion In conclusion, stent placement as a bridge to surgery followed by selective surgery provides significant advantages in terms of short-term outcomes as compared to ES, but with comparable prognoses for patients with acute MORC. For patients with synchronous liver metastases, stent placement provides more opportunities for resection of the primary tumour and sites of metastasis in the liver, which can further improve survival. Abbreviations SEMS, self-expandable metal stents; MORC, malignant obstruction of right-sided colon; PFS, progression-free survival; OS, overall survival; ES, emergency surgery; ICU, Intensive Care Unit; HR, hazard ratio; CRC, colorectal cancer; CT, computed tomography; MODS, multiple organ dysfunction syndrome; AHF, acute heart failure; CI, confidence interval; TACE, transcatheter arterial chemoembolization; ESGE, European Society of Gastrointestinal Endoscopy; CRCLM, CRC liver metastases. Declarations Ethics approval and consent to participate This study was approved by the institutional review board of Zhongshan Hospital of Fudan University (approval number 09-135). Written informed consent for treatment and use of their clinical data was obtained from all participants. Consent for publication Written informed consent for publication of their clinical details was obtained from all patients. Availability of data and materials The datasets used and analysed during this study are available from the corresponding author upon reasonable request. Competing interests The authors have no competing interests to declare. Funding This work was supported by grants from the National Natural Science Foundation of China (grant no. 81672329), and the Dawn Program of the Shanghai Education Commission (grant no. 18SG08). The funders had no role in the study design, data collection/analysis, decision to publish, or preparation of the manuscript. Authors’ contributions Conception and design: J-MX, Y-SZ. Acquisition of data: BL, Z-TL, QS, Z-PQ, DS, S-LC, AY, E-PX. Analysis and interpretation of the data: BL, L-QY, P-HZ, S-LC, AY, J-MX, Y-SZ. Drafting of the article: BL, S-LC. Critical revision of the article for important intellectual content: S-LC, Z-TL. Final approval of the article: BL, S-LC, Z-TL, QS, Z-PQ, DS, AY, E-PX, L-QY, P-HZ, J-MX, Y-SZ. All authors read and approved the final manuscript. Acknowledgments Not applicable. References Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018. Cheynel N, Cortet M, Lepage C, Benoit L, Faivre J, Bouvier AM. Trends in frequency and management of obstructing colorectal cancers in a well-defined population. Dis Colon Rectum. 2007;50(10):1568-75. Jullumstro E, Wibe A, Lydersen S, Edna TH. 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Self-expandable metallic stent as a bridge to elective surgery versus emergency surgery for acute malignant colorectal obstruction. Int J Colorectal Dis. 2016;31(3):561-70. Gianotti L, Tamini N, Nespoli L, Rota M, Bolzonaro E, Frego R, et al. A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction. Surg Endosc. 2013;27(3):832-42. Van Cutsem E, Nordlinger B, Adam R, Kohne CH, Pozzo C, Poston G, et al. Towards a pan-European consensus on the treatment of patients with colorectal liver metastases. Eur J Cancer. 2006;42(14):2212-21. Sorski L, Melamed R, Levi B, Matzner P, Lavon H, Rosenne E, et al. Prevention of liver metastases through perioperative acute CpG-C immune stimulation. Cancer Immunol Immunother. 2020. Manfredi S, Lepage C, Hatem C, Coatmeur O, Faivre J, Bouvier AM. Epidemiology and management of liver metastases from colorectal cancer. Ann Surg. 2006;244(2):254-9. Morris EJ, Forman D, Thomas JD, Quirke P, Taylor EF, Fairley L, et al. Surgical management and outcomes of colorectal cancer liver metastases. Br J Surg. 2010;97(7):1110-8. Noren A, Eriksson HG, Olsson LI. Selection for surgery and survival of synchronous colorectal liver metastases; a nationwide study. Eur J Cancer. 2016;53:105-14. de Jong MC, Pulitano C, Ribero D, Strub J, Mentha G, Schulick RD, et al. Rates and patterns of recurrence following curative intent surgery for colorectal liver metastasis: an international multi-institutional analysis of 1669 patients. Ann Surg. 2009;250(3):440-8. Tables TABLE 1. Baseline and oncologic characteristics of the included patients SEMS group (n=35) Emergency group (n=72) P Baseline characteristics Age, y 0.144 Median 66 67 Range 24-92 23-94 Sex, no. (%) 0.131 Male 21 (60.0%) 32 (44.4%) Female 14 (40.0%) 40 (55.6%) Comorbidity, no. (%) Hypertension 10 (28.6%) 14 (19.4%) 0.288 Diabetes mellitus 5 (14.3%) 11 (15.3%) 0.893 Cardiovascular disease 3 (8.6%) 6 (8.3%) 1.000 Pulmonary disease 2 (5.7%) 2 (2.8%) 0.596 Neurologic disease 1 (2.9%) 2 (2.8%) 1.000 Other malignancy 2 (5.7%) 3 (4.2%) 0.661 Renal disease 0 (0%) 1 (1.4%) 1.000 Oncologic characteristics Tumor size, mean(± SD), cm 7.71±3.70 5.85±2.58 0.216 Tumor location, no. (%) 0.022 Cecum 0 (0%) 11 (15.3%) Ascending colon 12 (34.3%) 26 (36.1%) Hepatic flexure 7 (30.0%) 17 (23.6%) Transverse colon 16 (45.7%) 18 (25.0%) Pathology, no. (%) 0.893 Adenocarcinoma 30(85.7%) 61 (84.7%) Well differentiated 2(5.7%) 3 (4.2%) Moderately differentiated 26(74.3%) 54 (75.0%) Poorly differentiated 2(5.7%) 4 (5.5%) Mucinous 5(14.3%) 11 (15.3%) Lymphovascular involvement, no. (%) Yes 13(37.1%) 17(23.6%) 0.144 No 22(62.9%) 55(76.4%) pTNM stage 0.240 II 16(45.7%) 31(43.1%) III 12(34.3%) 34(47.2%) IV 7(20.0%) 7(9.7%) Abbreviations: SEMS , self-expandable metal stents. TABLE 2. Characteristics of the surgical procedures and postoperative short-term outcomes SEMS group (n=35) Emergency group (n=72) P Operation method, no. (%) 0.010 Laparoscopy 4 (11.4%) 0 (0%) Open 31 (88.6%) 72 (100%) Operation findings, no. (%) Ascites 7 (20.0%) 38 (52.8%) 0.001 Perforation 0 (0%) 4 (5.6%) 0.301 Stoma formation 1 (2.9%) 0 (0%) 0.327 Transfusion, no. (%) 1 (2.9%) 10 (13.9%) 0.098 Blood loss, mean(± SD), ml 70.00±39.92 77.22±50.94 0.414 Operation time, mean(± SD), min 118.14±29.95 147.14±43.77 0.052 Positive margin, no. (%) 0 (0%) 0 (0%) / No. of retrieved LNs, mean(± SD) 21.09±9.89 19.96±9.53 0.766 No. of metastatic LNs, mean(± SD) 1.86±3.91 1.89±2.69 0.573 ICU stay, no. (%) 4 (11.4%) 25 (34.7%) 0.011 ICU stay time, mean(± SD), day 4.25±2.87 3.96±2.81 0.882 Postoperative complication, no. (%) 4 (11.4%) 21 (29.2%) 0.042 Wound infection 1 (2.9%) 5 (6.9%) 0.661 Pneumonic infection 2 (5.7%) 11 (15.3%) 0.217 Anastomotic leakage 0 (0%) 3 (4.2%) 0.549 Gastric retention 0 (0%) 1 (1.4%) 1.000 MODS 0 (0%) 1 (1.4%) 1.000 AHF 1 (2.9%) 0 (0%) 0.327 30-days mortality, no. (%) 0 (0%) 1 (1.8%) 1.000 Hospital stay, mean(± SD), day 8.23±6.50 11.18±6.71 0.033 Abbreviations: SEMS , self-expandable metal stents; LN , lymph node; ICU , intensive care unit; MODS , multiple organ dysfunction syndrome; AHF, acute heart failure. TABLE 3. Long-term prognosis outcomes on patients with stage II and stage III disease in the SEMS group and emergency group SEMS group (n=28) Emergency group (n=65) P Distant metastasis, no. (%) 6 (21.4%) 12 (18.5%) * 0.740 Liver 1 (3.6%) 7 (10.8%) 0.427 Others 5 (17.9%) 8 (12.3%) 0.522 Lungs 2 (7.1%) 4 (6.2%) Peritoneum 2 (7.1%) 3 (4.6%) Bone 0 (0%) 1 (1.5%) Adrenal gland 1 (3.6%) 0 (0%) Local site relapse, no. (%) 2 (7.1%) 7 (10.8%) 0.719 Death 9 (32.1%) 22 (33.8%) 0.873 * Two patient developed liver metastases and lungs metastases, and one patient developed liver metastases and bone metastases at the same time during follow-up. TABLE 4. The clinicopathological characteristics and long-term prognosis outcomes data on patients with stage IV disease No. SEMS Patient Lesion Outcomes Age, years Sex location Pathology Lymphovascular involvement Metastatic site Synchronous or two-stage hepatectomy Date of colectomy Recurrence/ metastasis Death #1 Yes 63 F Transverse colon Adenocarcinoma Yes Liver Yes Aug 2009 Yes Jan 2013 #2 Yes 54 M Ascending colon Adenocarcinoma No Liver No, chemotherapy Mar 2010 / Aug 2010 #3 Yes 67 M Ascending colon Adenocarcinoma Yes Liver Yes Sep 2010 Loss to follow-up / #4 Yes 66 M Transverse colon Mucinous No Liver Yes Oct 2011 Yes Jul 2014 #5 Yes 73 M Ascending colon Adenocarcinoma Yes Liver Yes Aug 2012 Yes Aug 2013 #6 Yes 64 M Hepatic flexure Adenocarcinoma No Liver Yes May 2013 Yes Jun 2016 #7 Yes 47 M Ascending colon Adenocarcinoma No Liver Yes Jan 2015 No No #8 No 49 M Ascending colon Adenocarcinoma No Liver Yes Dec 2010 No No #9 No 64 F Transverse colon Adenocarcinoma Yes Liver No, chemotherapy Dec 2010 / Aug 2015 #10 No 64 F Ascending colon Adenocarcinoma Yes Liver No, chemotherapy Feb 2013 / Nov 2013 #11 No 77 F Ascending colon Adenocarcinoma No Liver No Oct 2013 Loss to follow-up / #12 No 64 F Cecum Adenocarcinoma Yes Liver No Jan 2014 / Jun 2014 #13 No 62 F Cecum Adenocarcinoma No Liver No, TACE Aug 2015 / Nov 2015 #14 No 48 F Cecum Adenocarcinoma Yes Liver No May 2016 / Dec 2016 Abbreviations: SEMS , self-expandable metal stents; TACE , transcatheter arterial chemoembolization. Supplementary Files SupplementaryTable1.docx SupplementaryTable1.docx STROBEchecklistv4combined.doc STROBEchecklistv4combined.doc Cite Share Download PDF Status: Published Journal Publication published 10 Dec, 2020 Read the published version in BMC Surgery → Version 3 posted Editorial decision: Accept 29 Nov, 2020 Reviewer # 2 agreed at journal 28 Nov, 2020 Review # 2 received at journal 28 Nov, 2020 Review # 1 received at journal 23 Nov, 2020 Editor assigned by journal 22 Nov, 2020 Reviewers invited by journal 22 Nov, 2020 Reviewer # 1 agreed at journal 22 Nov, 2020 Submission checks completed at journal 22 Nov, 2020 Editor invited by journal 22 Nov, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":212273,"visible":true,"origin":"","legend":"(A) PFS and (B) OS outcomes of the SEMS and ES groups.","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/805fcbdaab3829d04973dfba.png"},{"id":4202506,"identity":"59e301c7-a425-48ab-9494-7951957e8c74","added_by":"auto","created_at":"2020-12-11 18:18:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":225002,"visible":true,"origin":"","legend":"(A) PFS and (B) OS of patients with stage II and III disease in the SEMS and ES groups.","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/de66e82b5bd6c0939490859b.png"},{"id":4202500,"identity":"59d1bbe2-64c3-4753-820d-0c59166c8a9e","added_by":"auto","created_at":"2020-12-11 18:18:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":225002,"visible":true,"origin":"","legend":"(A) PFS and (B) OS of patients with stage II and III disease in the SEMS and ES groups.","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/ac213f55797685362ca492ad.png"},{"id":4202508,"identity":"ff37fde1-e0fa-466d-82a9-9dd530a4d962","added_by":"auto","created_at":"2020-12-11 18:18:21","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":39634,"visible":true,"origin":"","legend":"OS curves of patients with stage IV disease treated by colectomy combined with hepatectomy and colectomy alone.","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/afaeefdf9b47ee5c45b3f39c.jpg"},{"id":4202502,"identity":"21da43dc-c758-4992-b5ef-5b5e59ccec37","added_by":"auto","created_at":"2020-12-11 18:18:15","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":39634,"visible":true,"origin":"","legend":"OS curves of patients with stage IV disease treated by colectomy combined with hepatectomy and colectomy alone.","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/eb6431db0f5084491d8fcaab.jpg"},{"id":13632172,"identity":"e11caf7f-e506-4686-b5fc-0a189b9faeb7","added_by":"auto","created_at":"2021-09-17 08:19:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":910858,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/0d1bf616-bf1f-48a4-b856-51c0e6d5c70e.pdf"},{"id":4202504,"identity":"0c7a7b36-f991-41bc-a756-1334e49ec10f","added_by":"auto","created_at":"2020-12-11 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18:18:21","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":96768,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistv4combined.doc","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/5a926584fe97b27563b444db.doc"},{"id":4202501,"identity":"dcd8464d-ca5c-4537-bb64-aec40015cdd0","added_by":"auto","created_at":"2020-12-11 18:18:14","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":96768,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistv4combined.doc","url":"https://assets-eu.researchsquare.com/files/rs-33526/v3/f66d0c61a62b7f32ceb4864e.doc"}],"financialInterests":"","formattedTitle":"\u003cp\u003eSelf-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eColorectal cancer (CRC)\u0026nbsp;is the fourth most commonly diagnosed cancer and the second leading cause of cancer-related death in both males and females\u0026nbsp;[1]. Approximately 8%\u0026ndash;13% of patients with advanced colon cancer present with an obstruction of the large bowel\u0026nbsp;[2-4]\u0026nbsp;. A self-expandable metallic stent (SEMS)\u0026nbsp;is widely used\u0026nbsp;for obstructive left-sided colon cancer\u0026nbsp;to allow for an easy endoscopic approach to the lesion and to facilitate patient recovery from the acute status with reduced risks of postoperative complications and mortality\u0026nbsp;[5-7]. However, fewer than 10% of reported cases of colonic stenting have involved the right colon\u0026nbsp;[8].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome studies have reported insertion of a SEMS for acute malignant obstruction of the right-sided colon (MORC) could benefit patients with severe comorbidities, advanced age, or complete obstruction [9, 10]. Moreover, the technical success rate in experienced centres has improved to \u0026gt; 96%, similar to that reported for stenting of distal colon lesions [11]. Thus, the present retrospective study included more cases than previous reports of the advantages of SEMS as a bridge to elective surgery as compared to emergency surgery (ES) for CRC patients with a proximal malignant obstruction of the large bowel. In addition, bowel obstruction is often accompanied by distant metastasis, as the liver is the most common site of CRC metastasis [4, 12]. Here, we report our experience and results with the use of colonic stenting of patients, including those with stage IV CRC, an area of the published data that remains severely limited. Therefore, the aim of the present study was to evaluate the benefits of elective surgery after SEMS placement vs. ES for patients (including stage IV cases) with acute MORC.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Review Board of Zhongshan Hospital and conducted in accordance with the tenets of the Declaration of Helsinki.\u0026nbsp;Informed consent was obtained from all patients prior to treatment. This retrospective observational study was conducted in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines\u0026nbsp;[13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study cohort was limited to patients with acute right-sided bowel obstruction caused by malignant CRC who underwent radical resection for the primary\u0026nbsp;tumour from July 2008 to November 2016\u0026nbsp;at Zhongshan Hospital of Fudan University\u0026nbsp;(Shanghai, China). Right-sided colon cancer was defined as any tumour arising in the cecum, ascending colon, hepatic flexure or transverse colon. MORC was clinically defined as symptoms of abdominal pain, distension, vomiting, and no passage of stool or flatus, and radiologically defined as severe dilatation of the proximal colon due to suspected colon cancer by abdominal X-ray and/or contrast-enhanced\u0026nbsp;computed tomography (CT).\u0026nbsp;Radical surgery was performed\u0026nbsp;if no distant metastasis was observed either pre- or intra-operatively. However, if distant metastasis was found, radical resection was performed for the primary tumour, while sites of metastasis were treated by synchronous or two-stage resection, or other non-surgical treatments.\u003c/p\u003e\n\u003cp\u003eThe patients were assigned to one of two groups: the ES group, which consisted of patients who underwent radical resection within 24 h after visiting the hospital and received no other treatments for primary causes, or the SEMS group, which consisted of patients who underwent colonic stent placement followed by surgery within 2 weeks after stent placement. The strategy to choose ES or SEMS placement as a bridge to surgery was mainly based on the following considerations: 1) the tumor locations differed significantly between the SEMS and ES groups, as stenting was not appropriate for an obstruction in the cecum; 2) low-pressure enema intestinal cleaning could be completed to facilitate stricture visualization and stent placement; 3) there were no signs of peritonitis or perforation in the SEMS group; 4) if ES was considered too risky or when the disease was very advanced and palliation was needed, stent placement as a bridge to surgery was considered; and 5) the final choice of treatment (ES or SEMS placement) was mostly dependent on a consensus among the surgeons, the endoscopists and the patient or patient\u0026apos;s family.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll stent placement procedures were performed by experienced\u0026nbsp;endoscopists at the\u0026nbsp;Endoscopy Centre of\u0026nbsp;Zhongshan Hospital\u0026nbsp;with experience and competence in both colonoscopy and fluoroscopic techniques and who performs colonic stenting on a regular basis. Briefly, the stent placement procedures consisted of four steps:\u0026nbsp;1) determining the site and aetiology of the acute bowel obstruction by colonoscopy combined with fluoroscopy; 2) a hydrophilic biliary guidewire was introduced through the tumour beyond the point of obstruction; 3) injection of water-soluble contrast medium proximally to the stricture; and 4) insertion and placement of suitable stents under fluoroscopic guidance. The immediate escape of air and liquid faeces through the stent indicated successful decompression.\u003c/p\u003e\n\u003cp\u003eAfterward, a series of examinations, including chest X-ray, abdominal ultrasound or abdominal CT, and blood tests, were performed. At 7 to 14 days after the colon\u0026nbsp;obstruction was relieved, mechanical bowel preparation was performed using polyethylene glycol or sodium phosphate and one-stage surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaging assessment and follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePathological tumour-node-metastasis staging\u0026nbsp;was performed in accordance with the guidelines of the Union for International Cancer Control, eighth edition. For all patients, routine clinical follow-up data were obtained. CT, abdominal ultrasound, chest X-ray, and blood tests were performed every 3 months for the first year and then every 6 months thereafter. Colonoscopic surveillance was performed every 6 months for the first year and then once per year thereafter. Diagnoses of relapse and metastasis were based on imaging studies and biopsy, if necessary. The follow-up period was defined as the date of surgery to either the date of death or August 2018, whichever occurred first.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection and analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; In addition to clinicopathological data (i.e., age, sex, tumour characteristics, histopathology and surgical information),\u0026nbsp;short-term postoperative outcomes and long-term prognoses were collected for analysis. The short-term postoperative outcomes mainly consisted of admission to the\u0026nbsp;Intensive Care Unit (ICU), adverse events, and mortality within 30 days after surgery. The primary endpoints of long-term outcomes were\u0026nbsp;progression-free survival (PFS)\u0026nbsp;and\u0026nbsp;overall survival (OS).\u0026nbsp;Data were primarily obtained from medical records. For patients who had moved away, attempts were made to obtain outcome details by telephone contact with the patient or a family member.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eComparisons between groups were performed using the Student\u0026apos;s \u003cem\u003et\u003c/em\u003e-test, chi-squared test, or Fisher\u0026rsquo;s exact test and rank-sum test, as appropriate. Kaplan\u0026ndash;Meier curves were constructed to analyse rates of survival,\u0026nbsp;recurrence, and metastasis. The log-rank test\u0026nbsp;was used to evaluate the significance of differences between curves. All statistical analyses were performed using\u0026nbsp;SPSS for Windows, version 16.0. (SPSS Inc., Chicago, IL, USA). A probability (\u003cem\u003eP\u003c/em\u003e) value of \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom July 2008 to November 2016,\u0026nbsp;107 patients\u0026nbsp;with acute MORC (35 patients in the SEMS group and 72 in the\u0026nbsp;ES group) underwent radical resection at Zhongshan Hospital.\u0026nbsp;The median patient age was 66 (range 23\u0026ndash;94) years. As shown in Table 1, there were no major differences in baseline and oncologic characteristics, with the exception of tumour location,\u0026nbsp;between the SEMS and ES groups. No stent migration or perforation was observed, although one patient experienced re-obstruction after initial successful stenting. As of the last follow-up on August 2018, the overall median follow-up duration was 35 (range 0.1\u0026ndash;120) months. Of the 107 patients, 13 (12.1%) were lost to follow-up. However, there was no significant difference in the rate of patients lost to follow-up between the SEMS and ES groups (11.4% [4/35] \u003cem\u003evs\u003c/em\u003e 12.5% [9/72], respectively; \u003cem\u003eP\u003c/em\u003e \u0026gt; 0.99).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCharacteristics of the procedures and postoperative short-term outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eThe characteristics of the surgical procedures and short-term postoperative outcomes of the two groups are shown in Table 2. Although open surgery was the primary approach, laparoscopic procedures were performed more frequently in the SEMS group than the ES group\u0026nbsp;(11.4% vs. 0%, respectively; P = 0.010). In regard to intraoperative findings, the incidence of ascites was greater in the ES group than the SEMS group (52.8% vs. 20.0%, respectively; P = 0.001), while perforation occurred in four (5.6%) patients in the ES group. The need for intraoperative transfusion tended to be lower in the SEMS group than the ES group, but the difference was not statistically significant\u0026nbsp;(2.9% vs. 13.9%, respectively; P = 0.098). In the SEMS group, jejunostomy was performed for one patient, as partial duodenectomy was required due to intraoperative findings that the tumor had invaded the duodenum.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The postoperative ICU admission rate\u0026nbsp;was significantly lower in the SEMS group than the ES group (11.4% [4/35 vs. 34.7% [25/72], respectively; \u003cem\u003eP\u003c/em\u003e = 0.011).\u0026nbsp;Moreover, the complication rate was significantly lower in the SEMS group than the ES group (11.4% [4/35] vs. 29.2% [21/72], respectively; \u003cem\u003eP\u003c/em\u003e = 0.042). The most common postoperative complications in both groups were wound infection, pulmonary infection, and anastomotic leakage, but there was no significant difference in the incidence of complications between the two groups (\u003cem\u003eP\u003c/em\u003e \u0026gt; 0.05). One patient in the ES group died due to multiple organ dysfunction syndrome\u0026nbsp;on postoperative day 3. Moreover, the average duration of postoperative hospitalization was significantly shorter in the SEMS group than the ES group (8.23 \u0026plusmn; 6.50 vs. 11.18 \u0026plusmn; 6.71 days, respectively; \u003cem\u003eP\u003c/em\u003e = 0.033).\u0026nbsp;After excluding tumors located in the cecum from the ES group, the characteristics of the surgical procedures and postoperative short-term outcomes of the two groups were compared. The results in Supplementary Table 1 show the advantages of stent placement in terms of lower ICU admission rate, reduced complication rates, and shorter postoperative hospital stays.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLong-term outcome\u003c/strong\u003e\u003cstrong\u003es of all populations in the SEMS and ES groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKaplan\u0026ndash;Meier curves of PFS for all patients are presented in Fig. 1A. The hazard ratio (HR) for PFS between the ES vs. SEMS groups was 1.235 (95%\u0026nbsp;confidence interval [CI]\u0026nbsp;0.674\u0026ndash;2.263; \u003cem\u003eP\u003c/em\u003e = 0.506). The 5-year PFS rate was greater in the SEMS group than the ES group (54.0% [95% CI 34.20%\u0026ndash;73.80%] vs. 49.1% [95% CI 35.97%\u0026ndash;62.23%], respectively). The Kaplan\u0026ndash;Meier curves of OS for all patients are presented in Fig. 1B. The HR for OS between the ES and SEMS group was 0.995 (95% CI 0.520\u0026ndash;1.907; \u003cem\u003eP\u003c/em\u003e = 0.989). The 5-year OS rate was lower in the SEMS group than the ES group (56.0% [95% CI 36.40%\u0026ndash;75.60%] vs. 61.6% [95% CI 49.25%\u0026ndash;73.95%], respectively).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubgroup analyses based on tumor stage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eComparison of stage II and III disease between the SEMS and ES groups\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the follow-up period, disease progression, defined as local site recurrence and distant metastasis, was observed in 27 (29.0%)\u0026nbsp;patients with stage II and III disease.\u0026nbsp;There was no significant difference in the\u0026nbsp;distant\u0026nbsp;metastasis rate between the SEMS\u0026nbsp;and\u0026nbsp;ES groups (21.4% [6/28] vs. 18.5%\u0026nbsp;[12/65], respectively; \u003cem\u003eP\u003c/em\u003e = 0.740)\u0026nbsp;or in the rate of local relapse (7.1% [2/28] vs\u003cem\u003e.\u003c/em\u003e 10.8% [7/65], respectively; \u003cem\u003eP\u003c/em\u003e = 0.719). At the time of analysis, a total of 31 (33.3%) patients died during the follow-up period. However, there was no significant difference in the mortality rate between the SEMS and ES groups (32.1% [9/28] vs\u003cem\u003e.\u003c/em\u003e 33.8% [22/65], respectively;\u0026nbsp;\u003cem\u003eP\u003c/em\u003e = 0.873)\u0026nbsp;(Table 3).\u003c/p\u003e\n\u003cp\u003ePFS curves of the 93 patients\u0026nbsp;with stage II and III\u0026nbsp;disease are shown in Fig. 2A. As the\u0026nbsp;HR for the ES vs\u003cem\u003e.\u003c/em\u003e SEMS groups was 1.543\u0026nbsp;(95% CI 0.774\u0026ndash;3.075; \u003cem\u003eP\u003c/em\u003e = 0.253), the 5-year PFS rate was 64.5% (95% CI 43.53\u0026ndash;85.47)\u0026nbsp;for the\u0026nbsp;SEMS\u0026nbsp;group and\u0026nbsp;52.6% (95% CI 38.64\u0026ndash;66.52) for the\u0026nbsp;ES\u0026nbsp;group.\u0026nbsp;The Kaplan\u0026ndash;Meier curves of OS are presented in Fig. 2B. The HR for the ES vs.\u0026nbsp;SEMS\u0026nbsp;group\u0026nbsp;was 1.217\u0026nbsp;(95% CI 0.559\u0026ndash;2.646; \u003cem\u003eP\u003c/em\u003e = 0.619), when the 5-year OS\u0026nbsp;rate was\u0026nbsp;68.2% (95% CI 47.82\u0026ndash;88.58)\u0026nbsp;for the\u0026nbsp;SEMS\u0026nbsp;group and 64.2% (95% CI 51.46\u0026ndash;76.94)\u0026nbsp;for the\u0026nbsp;ES\u0026nbsp;group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLong-term outcomes of patients with stage IV disease\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 shows the clinicopathological characteristics and long-term prognostic outcome data of 14 patients with stage IV colon cancer in the two groups. The SEMS and ES groups both had seven CRC patients with synchronous liver metastases. After colectomy, the synchronous or two-stage\u0026nbsp;hepatectomy\u0026nbsp;rates was significantly greater in the SEMS group than the ES group (85.7% [6/7] vs. 14.3% [1/7], respectively; \u003cem\u003eP\u003c/em\u003e = 0.029). The remaining patients received chemotherapy, transcatheter arterial chemoembolisation\u0026nbsp;or other palliative treatments.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo determine the advantages of different therapeutic regimens, survival outcomes of patients who underwent colectomy only vs. colectomy combined with hepatectomy were compared. Kaplan\u0026ndash;Meier curves of OS are shown in Fig. 3. The data showed that median OS was superior for those who underwent combined resection as compared to colectomy alone (42 vs. 6 months, respectively),\u0026nbsp;and the HR for colectomy only \u003cem\u003evs\u003c/em\u003e combined resection was 3.258 (95% CI 0.858\u0026ndash;12.370; P = 0.041).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn fact, since\u0026nbsp;Campbell \u003cem\u003eet al\u003c/em\u003e. reported the efficacy and safety of successful SEMS placement in MORC patients\u0026nbsp;in 1997\u0026nbsp;[14], this technique has gained more and more attention.\u0026nbsp;Repici \u003cem\u003eet al\u003c/em\u003e. reported that the success rate for SEMS insertion for right-sided malignant colonic obstruction was 95% (20/21), with resolution of obstructive symptoms and no immediate complications in 85% of cases (17/20)\u0026nbsp;[15]. Similarly, another recent study reported a success rate of 87.5% and symptom relief rate of 100% with no immediate complications\u0026nbsp;[16]. In the present study, re-obstruction as a long-term complication\u0026nbsp;occurred in only one patient. Collectively, these findings confirm the feasibility of SEMS placement for treatment of MORC.\u003c/p\u003e\n\u003cp\u003eConsidering the higher morbidity and mortality rates as compared with elective surgery\u0026nbsp;[17, 18], successful SEMS placement can provide sufficient preoperative preparation for patients with acute malignant colorectal obstruction prior to open or laparoscopic one-stage colectomy\u0026nbsp;[19, 20]. In the present study, 35 patients initially underwent SEMS placement as a bridge to elective surgery, while 72 patients underwent ES. Although open colectomy accounted for the majority of surgeries, laparoscopic colectomy, as opposed to ES, tended to be implemented in the SEMS group. As compared to open surgery, the advantages of laparoscopic approach include faster recovery and lower postoperative morbidity in the SEMS group. However, prior to 2016, colorectal surgeons at our center had limited experience with the laparoscopic approach, which explains the low rate of laparoscopic surgery, as it takes time to incorporate a new technology. In regard to the intra-operative findings, the incidence of ascites was greater in the ES group (52.8%, 38/72) than the SEMS group (20.0%, 7/35), indicating that the physical status of patients in the SEMS group was better than that of the ES group. Likewise, in the present study, short-term outcomes were better in the SEMS group than the ES group.\u0026nbsp;In addition, the ICU admission rate was significantly lower in the SEMS group (11.4%, 4/35) than the ES group (34.7%, 25/72), suggesting that the main advantages of stent placement were a reduced incidence of postoperative complications and shorter hospital stay.\u0026nbsp;Other studies reported similar conclusions. One study reported shorter postoperative hospital stays and time to resume oral food intake in the SEMS group, suggesting better recovery from surgery\u0026nbsp;[16].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The long-term prognosis of stent placement for MORC as a bridge to surgery was an important focus of the present study. Considering the differences in treatment methods and\u0026nbsp;survival results, the PFS and OS rates were separately compared between the SEMS and ES groups in terms of stage IV disease\u003cem\u003e\u0026nbsp;\u003c/em\u003eand other stages. The results showed\u0026nbsp;no significant differences in PFS and OS rates between patients with stage II and III colon cancer. A multicentre retrospective study also indicated that the long-term oncologic outcome of the SEMS group was similar or slightly better than that of the ES group among all patients with stage II or III colon cancer\u0026nbsp;[21]. According to a meta-analysis of 11 studies, which included 1136 patients with left-sided or right-sided obstructive colon cancer, stenting as a bridge to surgery was oncologically comparable to ES with respect to OS, disease-free survival, and recurrence\u0026nbsp;[22]. Moreover, Li \u003cem\u003eet al\u003c/em\u003e. and Gianotti \u003cem\u003eet al\u003c/em\u003e. reported improved survival of the SEMS group throughout the follow-up period\u0026nbsp;[23, 24].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor patients with CRC, the liver is the most common site of metastasis and hepatic metastasis during the course of disease is the main cause of death\u0026nbsp;[25, 26]. Of the 93 patients with stage II or III disease in the present study, liver metastasis occurred in eight (8.6%) after surgery. In cases of synchronous CRC liver metastases (CRCLM), the prognosis of untreated patients is poor, as fewer than 30% had survived at 1 year and fewer than 5% at 5 years after diagnosis\u0026nbsp;[27]. Surgical resection is the most effective treatment for CRCLM, as the 5-year survival rate after liver resection reportedly ranges from 44% to 57%\u0026nbsp;[28, 29]. In the present study, 14 patients had right-sided colorectal obstructions with synchronous metastasis. In the SEMS group, six (95.7%) of seven patients underwent resection of the primary tumour and the metastatic sites of the liver, while only one patient in the ES group underwent combined resection and the other seven underwent colectomy for severe obstruction. Thus, we inferred that SEMS improved the suitability of patients with stage IV disease for radical resection. Among the patients who underwent liver surgery, median survival was 42 months, which is comparable to the survival duration of 36 to 57 months in other reports\u0026nbsp;[29, 30]. Based on these survival data of different treatment regimens, it is obvious that patients could benefit from resection of both the primary tumour and sites of metastasis.\u003c/p\u003e\n\u003cp\u003eThere were several limitations to this study. First, in terms of baseline characteristics, SEMS was not employed in the cecum due to differences in tumour location. The main reason for this imbalance is that stent placement in the cecum of the right-sided colon is more technically challenging, as the stent should preferably extend beyond the stricture at both ends by 1.5\u0026ndash;2cm. Of course, the results of the present study were limited by the relatively small number of patients, especially those with liver metastases, and the single-centre retrospective study design. The small sample number was also a limit to the research on learning curve of right colon stenting. Nonetheless, future studies with larger numbers of subjects and longer follow-up periods are warranted.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, stent placement as a bridge to surgery followed by selective surgery provides significant advantages in terms of short-term outcomes as compared to ES, but with comparable prognoses for patients with acute MORC. For patients with synchronous liver metastases, stent placement provides more opportunities for resection of the primary tumour and sites of metastasis in the liver, which can further improve survival.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSEMS, self-expandable metal stents; MORC, malignant obstruction of right-sided colon; PFS, progression-free survival; OS, overall survival; ES, emergency surgery; ICU, Intensive Care Unit; HR, hazard ratio; CRC, colorectal cancer; CT, computed tomography; MODS, multiple organ dysfunction syndrome; AHF, acute heart failure; CI, confidence interval; TACE, transcatheter arterial chemoembolization; ESGE, European Society of Gastrointestinal Endoscopy; CRCLM, CRC liver metastases.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional review board of Zhongshan Hospital of Fudan University (approval number 09-135). Written informed consent for treatment and use of their clinical data was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their clinical details was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the National Natural Science Foundation of China (grant no. 81672329), and the Dawn Program of the Shanghai Education Commission (grant no. 18SG08). The funders had no role in the study design, data collection/analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design: J-MX, Y-SZ.\u003c/p\u003e\n\u003cp\u003eAcquisition of data: BL, Z-TL, QS, Z-PQ, DS, S-LC,\u0026nbsp;AY, E-PX.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnalysis and interpretation of the data: BL, L-QY, P-HZ, S-LC,\u0026nbsp;AY, J-MX, Y-SZ.\u003c/p\u003e\n\u003cp\u003eDrafting of the article: BL, S-LC.\u003c/p\u003e\n\u003cp\u003eCritical revision of the article for important intellectual content: S-LC, Z-TL.\u003c/p\u003e\n\u003cp\u003eFinal approval of the article: BL, S-LC, Z-TL, QS, Z-PQ, DS, AY, E-PX, L-QY, P-HZ, J-MX, Y-SZ. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018.\u003c/li\u003e\n\u003cli\u003eCheynel N, Cortet M, Lepage C, Benoit L, Faivre J, Bouvier AM. Trends in frequency and management of obstructing colorectal cancers in a well-defined population. Dis Colon Rectum. 2007;50(10):1568-75.\u003c/li\u003e\n\u003cli\u003eJullumstro E, Wibe A, Lydersen S, Edna TH. Colon cancer incidence, presentation, treatment and outcomes over 25 years. Colorectal Dis. 2011;13(5):512-8.\u003c/li\u003e\n\u003cli\u003eWinner M, Mooney SJ, Hershman DL, Feingold DL, Allendorf JD, Wright JD, et al. 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Gastrointest Endosc. 2017;86(3):416-26.\u003c/li\u003e\n\u003cli\u003eIversen LH, Bulow S, Christensen IJ, Laurberg S, Harling H, Danish Colorectal Cancer G. Postoperative medical complications are the main cause of early death after emergency surgery for colonic cancer. Br J Surg. 2008;95(8):1012-9.\u003c/li\u003e\n\u003cli\u003eWang B, Lu S, Song Z, Li F, Ma J, Ma Y, et al. Comparison of Clinical Outcomes and Pathological Characteristics of Self-Expandable Stent Bridge to Surgery and Emergency Surgery in Obstructive Colon Cancer. Cancer Manag Res. 2020;12:1725-32.\u003c/li\u003e\n\u003cli\u003eOrmando VM, Palma R, Fugazza A, Repici A. Colonic stents for malignant bowel obstruction: current status and future prospects. Expert Rev Med Devices. 2019;16(12):1053-61.\u003c/li\u003e\n\u003cli\u003eKye BH, Lee YS, Cho HM, Kim JG, Oh ST, Lee IK, et al. Comparison of Long-Term Outcomes Between Emergency Surgery and Bridge to Surgery for Malignant Obstruction in Right-Sided Colon Cancer: A Multicenter Retrospective Study. Ann Surg Oncol. 2016;23(6):1867-74.\u003c/li\u003e\n\u003cli\u003eMatsuda A, Miyashita M, Matsumoto S, Matsutani T, Sakurazawa N, Takahashi G, et al. Comparison of long-term outcomes of colonic stent as \"bridge to surgery\" and emergency surgery for malignant large-bowel obstruction: a meta-analysis. Ann Surg Oncol. 2015;22(2):497-504.\u003c/li\u003e\n\u003cli\u003eLi ZX, Wu XH, Wu HY, Chang WJ, Chang XJ, Yi T, et al. Self-expandable metallic stent as a bridge to elective surgery versus emergency surgery for acute malignant colorectal obstruction. Int J Colorectal Dis. 2016;31(3):561-70.\u003c/li\u003e\n\u003cli\u003eGianotti L, Tamini N, Nespoli L, Rota M, Bolzonaro E, Frego R, et al. A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction. Surg Endosc. 2013;27(3):832-42.\u003c/li\u003e\n\u003cli\u003eVan Cutsem E, Nordlinger B, Adam R, Kohne CH, Pozzo C, Poston G, et al. Towards a pan-European consensus on the treatment of patients with colorectal liver metastases. Eur J Cancer. 2006;42(14):2212-21.\u003c/li\u003e\n\u003cli\u003eSorski L, Melamed R, Levi B, Matzner P, Lavon H, Rosenne E, et al. Prevention of liver metastases through perioperative acute CpG-C immune stimulation. Cancer Immunol Immunother. 2020.\u003c/li\u003e\n\u003cli\u003eManfredi S, Lepage C, Hatem C, Coatmeur O, Faivre J, Bouvier AM. Epidemiology and management of liver metastases from colorectal cancer. Ann Surg. 2006;244(2):254-9.\u003c/li\u003e\n\u003cli\u003eMorris EJ, Forman D, Thomas JD, Quirke P, Taylor EF, Fairley L, et al. Surgical management and outcomes of colorectal cancer liver metastases. Br J Surg. 2010;97(7):1110-8.\u003c/li\u003e\n\u003cli\u003eNoren A, Eriksson HG, Olsson LI. Selection for surgery and survival of synchronous colorectal liver metastases; a nationwide study. Eur J Cancer. 2016;53:105-14.\u003c/li\u003e\n\u003cli\u003ede Jong MC, Pulitano C, Ribero D, Strub J, Mentha G, Schulick RD, et al. Rates and patterns of recurrence following curative intent surgery for colorectal liver metastasis: an international multi-institutional analysis of 1669 patients. Ann Surg. 2009;250(3):440-8.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"553\"\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 1. \u003c/strong\u003e\u003cstrong\u003eBaseline and oncologic characteristics \u003c/strong\u003e\u003cstrong\u003eof the included patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eSEMS group (n=35)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eEmergency group\u003c/strong\u003e\u003cstrong\u003e (n=72)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"553\"\u003e\n\u003cp\u003eBaseline characteristics\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eAge, y\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.144\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;Median\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;Range\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e24-92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e23-94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eSex, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.131\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;Male\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e21 (60.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e32 (44.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;Female\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e14 (40.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e40 (55.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eComorbidity, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;Hypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e10 (28.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e14 (19.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.288\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;Diabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e5 (14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e11 (15.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.893\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;Cardiovascular disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e3 (8.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e6 (8.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003ePulmonary disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e2 (5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e2 (2.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.596\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eNeurologic disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e1 (2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e2 (2.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eOther malignancy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e2 (5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e3 (4.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.661\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;Renal disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e1 (1.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"553\"\u003e\n\u003cp\u003eOncologic characteristics\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eTumor size, mean(\u0026plusmn; SD), cm\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e7.71\u0026plusmn;3.70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e5.85\u0026plusmn;2.58\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.216\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eTumor location, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.022\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eCecum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e11 (15.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e12 (34.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e26 (36.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eHepatic flexure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e7 (30.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e17 (23.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eTransverse colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e16 (45.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e18 (25.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;Pathology, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.893\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp; Adenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e30(85.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e61 (84.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Well differentiated\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e2(5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e3 (4.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Moderately differentiated\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e26(74.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e54 (75.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Poorly differentiated\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e2(5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e4 (5.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp; Mucinous\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e5(14.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e11 (15.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eLymphovascular\u003c/p\u003e\n\u003cp\u003einvolvement, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e13(37.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e17(23.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.144\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp;No\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e22(62.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e55(76.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003epTNM stage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.240\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp; II\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e16(45.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e31(43.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp; III\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e12(34.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e34(47.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"198\"\u003e\n\u003cp\u003e\u0026nbsp; IV\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e7(20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e7(9.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: \u003cem\u003eSEMS\u003c/em\u003e, self-expandable metal stents.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"553\"\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 2. \u003c/strong\u003e\u003cstrong\u003eCharacteristics of the \u003c/strong\u003e\u003cstrong\u003esurgical\u003c/strong\u003e\u003cstrong\u003e procedures and postoperative short-term outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eSEMS group (n=35)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eEmergency group\u003c/strong\u003e\u003cstrong\u003e (n=72)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eOperation method, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.010\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;Laparoscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e4 (11.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;Open\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e31 (88.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e72 (100%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eOperation findings, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eAscites\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e7 (20.0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e38 (52.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003ePerforation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e4 (5.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.301\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eStoma formation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1 (2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.327\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eTransfusion, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1 (2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e10 (13.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.098\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eBlood loss, mean(\u0026plusmn; SD), ml\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e70.00\u0026plusmn;39.92\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e77.22\u0026plusmn;50.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.414\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eOperation time, mean(\u0026plusmn; SD), min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e118.14\u0026plusmn;29.95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e147.14\u0026plusmn;43.77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.052\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003ePositive margin, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eNo. of retrieved LNs, mean(\u0026plusmn; SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e21.09\u0026plusmn;9.89\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e19.96\u0026plusmn;9.53\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.766\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eNo. of metastatic LNs, mean(\u0026plusmn; SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1.86\u0026plusmn;3.91\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e1.89\u0026plusmn;2.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.573\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eICU stay, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e4 (11.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e25 (34.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.011\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eICU stay time, mean(\u0026plusmn; SD), day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e4.25\u0026plusmn;2.87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e3.96\u0026plusmn;2.81\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.882\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003ePostoperative complication, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e4 (11.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e21 (29.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.042\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eWound infection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1 (2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e5 (6.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.661\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003ePneumonic infection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e2 (5.7%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e11 (15.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.217\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eAnastomotic leakage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e3 (4.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.549\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;Gastric retention\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e1 (1.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eMODS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e1 (1.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eAHF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1 (2.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.327\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e30-days mortality, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e1 (1.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e1.000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eHospital stay, mean(\u0026plusmn; SD), day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e8.23\u0026plusmn;6.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e11.18\u0026plusmn;6.71\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.033\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: \u003cem\u003eSEMS\u003c/em\u003e, self-expandable metal stents; \u003cem\u003eLN\u003c/em\u003e, lymph node; \u003cem\u003eICU\u003c/em\u003e, intensive care unit; \u003cem\u003eMODS\u003c/em\u003e, multiple organ dysfunction syndrome; \u003cem\u003eAHF,\u003c/em\u003e acute heart failure.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" width=\"553\"\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 3. \u003c/strong\u003e\u003cstrong\u003eLong-term prognosis outcomes\u003c/strong\u003e\u003cstrong\u003e on patients with stage II and stage III disease in the SEMS group and emergency group\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eSEMS group (n=28)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e\u003cstrong\u003eEmergency group (n=65)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eDistant metastasis, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e6 (21.4%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e12 (18.5%)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.740\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;Liver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1 (3.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e7 (10.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.427\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp;Others\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e5 (17.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e8 (12.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.522\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp; Lungs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e2 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e4 (6.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp; Peritoneum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e2 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e3 (4.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp; Bone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e1 (1.5%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003e\u0026nbsp; Adrenal gland\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e1 (3.6%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e0 (0%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eLocal site relapse, no. (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e2 (7.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e7 (10.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.719\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"208\"\u003e\n\u003cp\u003eDeath\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e9 (32.1%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"161\"\u003e\n\u003cp\u003e22 (33.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"52\"\u003e\n\u003cp\u003e0.873\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eTwo patient developed liver metastases and lungs metastases, and one patient developed liver metastases and bone metastases at the same time during follow-up.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"12\" width=\"916\"\u003e\n\u003cp\u003e\u003cstrong\u003eTABLE 4.\u003c/strong\u003e \u003cstrong\u003eThe clinicopathological characteristics and long-term prognosis outcomes data on patients with stage IV disease\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"57\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"64\"\u003e\n\u003cp\u003e\u003cstrong\u003eSEMS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"120\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"6\" width=\"517\"\u003e\n\u003cp\u003e\u003cstrong\u003eLesion\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"157\"\u003e\n\u003cp\u003e\u003cstrong\u003eOutcomes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003eAge,\u003c/p\u003e\n\u003cp\u003eyears\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eSex\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003elocation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003ePathology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eLymphovascular\u003c/p\u003e\n\u003cp\u003einvolvement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eMetastatic\u003c/p\u003e\n\u003cp\u003esite\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eSynchronous or two-stage hepatectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eDate of colectomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eRecurrence/\u003c/p\u003e\n\u003cp\u003emetastasis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eDeath\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eTransverse colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eAug 2009\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eJan 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e54\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo, chemotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eMar 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eAug 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eSep 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eLoss to follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eTransverse colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eMucinous\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eOct 2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eJul 2014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eAug 2012\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eAug 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eHepatic flexure\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eMay 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eJun 2016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e47\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eJan 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e49\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eDec 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eTransverse colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo, chemotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eDec 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eAug 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo, chemotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eFeb 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNov 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e77\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eAscending colon\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eOct 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eLoss to follow-up\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e64\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eCecum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eJan 2014\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eJun 2014\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e62\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eCecum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo,\u003c/p\u003e\n\u003cp\u003eTACE\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eAug 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eNov 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"57\"\u003e\n\u003cp\u003e#14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"64\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"62\"\u003e\n\u003cp\u003e48\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"58\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"73\"\u003e\n\u003cp\u003eCecum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"106\"\u003e\n\u003cp\u003eAdenocarcinoma\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"104\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"75\"\u003e\n\u003cp\u003eLiver\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"90\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"70\"\u003e\n\u003cp\u003eMay 2016\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e/\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"78\"\u003e\n\u003cp\u003eDec 2016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: \u003cem\u003eSEMS\u003c/em\u003e, self-expandable metal stents; \u003cem\u003eTACE\u003c/em\u003e, transcatheter arterial chemoembolization.\u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Right-sided colon cancer, Obstruction, Self-expandable metallic stent, Liver metastases","lastPublishedDoi":"10.21203/rs.3.rs-33526/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-33526/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe use of a self-expandable metallic stent (SEMS) as a bridge to surgery has increased for patients with obstructing colorectal cancer. However, relatively few reports have compared SEMS as a bridge to elective surgery for acute malignant obstruction of the right-sided colon (MORC) vs. emergency surgery (ES). This study aimed to evaluate the benefits of elective surgery after SEMS placement vs. ES for patients (including stage IV cases) with acute MORC.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003ePatients with acute MORC who underwent radical resection for a primary tumour from July 2008 to November 2016 at Zhongshan Hospital of Fudan University were retrospectively enrolled. Postoperative short-term outcomes, progression-free survival (PFS), and overall survival (OS) were compared between the SEMS and ES groups.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e In total, 107 patients with acute MORC (35 in the SEMS group and 72 in the ES group) were included for analysis. The Intensive Care Unit admission rate was lower (11.4% vs. 34.7%, \u003cem\u003eP\u003c/em\u003e = 0.011), the incidence of complications was reduced (11.4% vs. 29.2%, \u003cem\u003eP\u003c/em\u003e = 0.042), and the postoperative length of hospitalisation was significantly shorter (8.23 ± 6.50 vs. 11.18 ± 6.71 days, \u003cem\u003eP\u003c/em\u003e = 0.033) for the SEMS group. Survival curves showed no significant difference in PFS (\u003cem\u003eP\u003c/em\u003e = 0.506) or OS (\u003cem\u003eP\u003c/em\u003e = 0.989) between groups. Also, there was no significant difference in PFS and OS rates between patients with stage II and III colon cancer. After colectomy for synchronous liver metastases among stage IV patients, the hepatectomy rates for the SEMS and ES groups were 85.7% and 14.3%, respectively (\u003cem\u003eP\u003c/em\u003e = 0.029). The hazard ratio for colectomy alone vs. combined resection was 3.258 (95% CI 0.858–12.370; \u003cem\u003eP\u003c/em\u003e = 0.041).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eStent placement offers significant advantages in terms of short-term outcomes and comparable prognoses for acute MORC patients. For synchronous liver metastases, SEMS placement better prepares the patient for resection of the primary tumour and liver metastasis, which contribute to improved survival.\u003c/p\u003e","manuscriptTitle":"Self-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-12-11 18:18:12","doi":"10.21203/rs.3.rs-33526/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-11-30T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-29T00:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-11-29T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nPlease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\nPlease overwrite this text when adding your comments to the authors.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-11-24T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nI am satisfied with the changes made* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **None**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorAssigned","content":"","date":"2020-11-23T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-11-23T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-11-23T00:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-11-22T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-11-22T23:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-10-14 15:48:11","doi":"10.21203/rs.3.rs-33526/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-11-10T00:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nDear Authors,\nthank you for your satisfactory answers.\nPlease, add in your discussion the reason why there is a low rate of laparoscopic right colectomy in your study: this is a bias of your work and it can help in planning further studies.\nBest Regards\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"decision","content":"Minor revision","date":"2020-11-10T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-10-27T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nThe present study has greatly improved.\n\nHowever:\n\n- Authors should better describe the limitations of the study. \"The results of the study may....\". not may are limited.\n- The references of the STROBE guidelines are not reported\n- The STROBE guidelines checklist was not uploaded* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **None**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-10-24T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-10-22T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-10-22T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-28T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-27T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-27T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-07-16 13:54:09","doi":"10.21203/rs.3.rs-33526/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-09-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-16T12:00:00+00:00","index":3,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nDear Colleaugues,\nI found your retrospective study very interesting for the topic: for obstructive right sided colon cancer, in clinical practice the treatment of choice is often emergency surgery in laparoscopic or open approach according to skills of the surgeon and the hemodynamic and nutritional status of the patient. Your results show that placement of SEMS could be considered as an alternative to emergency surgery for all stage of the cancer with advantages in terms of lenght of hospital stay and ICU admission rate.\nThe only data that leaves me surprised is the low rate of laparoscopic approach in the SEMS group: can you explain it? For the size of the tumor? For the absence of a laparoscopic surgeon? Patients were scheduled for elective right colectomy and despite it, they were treated by laparotomy, I can't understand. Can you explain also what happened with patient (1) with stoma formation in the SEMS group? Add it in the main text, please.\nWhich is the learning curve of right colon stenting in your hospital?Is there an endoscopist on call at night?\nAnyway, if skills are available, and the emergency surgery can be delayed until SEMS placement, it can be a valid option even in righ sided obstructive colon cancer, because it allows the preparation of the patient to elective surgery or for palliation in patients unfit for surgical treatment.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"editorInvitedReview","content":"","date":"2020-08-11T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nNo further amendments are requested.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-04T12:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-02T12:00:00+00:00","index":1,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThis is a retrospective case series regarding Self-expandable metallic stenting as a bridge to elective surgery versus emergency surgery for acute malignant right-sided colorectal obstruction.\n\nI have the following comments and suggestions:\n\nABSTRACT\nThe background it is inappropriate and should be rewritten.\nThe abstract is completely unbalanced. It is necessary to reduce the section dedicated to the results.\n\nThe whole paper should be shortened (introduction, procedure etc.). Above all, the discussion should be reduced by half (at least).\nThe aim of the study must be added in the introduction being consistent with the one reported in the abstract.\nPlease add the STROBE statement in the methods section.\n\nOn what basis were patients subjected to resection or stent placement? this is the key point of the study and represents the major bias.\n\nThe two groups are not clearly comparable considering the diversity of location (Table 1). Inter alia, patients undergoing ES are more than twice.\n\nThe results are interesting but too dispersed and not focused on the main topic.\nThe discussion is too preliminary to be reviewed.\n\nFigures 1 and 2 are not readable.\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **none**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **No**\n"},{"type":"reviewerAgreed","content":"","date":"2020-07-27T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-07-26T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-26T12:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-07-03T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-07-02T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-07-02T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c0cfba7-bff5-40e6-a8ce-1629bc7c3738","owner":[],"postedDate":"December 11th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":1441772,"name":"Surgery"},{"id":1441773,"name":"General Surgery"}],"tags":[],"updatedAt":"2020-12-13T15:02:47+00:00","versionOfRecord":{"articleIdentity":"rs-33526","link":"https://doi.org/10.1186/s12893-020-00993-4","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2020-12-10 15:01:17","publishedOnDateReadable":"December 10th, 2020"},"versionCreatedAt":"2020-12-11 18:18:12","video":"","vorDoi":"10.1186/s12893-020-00993-4","vorDoiUrl":"https://doi.org/10.1186/s12893-020-00993-4","workflowStages":[]},"version":"v3","identity":"rs-33526","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-33526","identity":"rs-33526","version":["v3"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}