Clinical effect and prognosis of laparoscopic surgery on colon cancer complicated with intestinal obstruction patients

Abstract

BACKGROUND

Colon cancer is one of the most common malignancies of the digestive tract, often complicated by intestinal obstruction, which can significantly impact patient outcomes. While traditional laparotomy is the standard treatment, it is associated with large wounds, slower recovery, and higher complication rates. Laparoscopic surgery, a minimally invasive approach, may offer better outcomes for these patients.

AIM

To evaluate the clinical effects and prognosis of laparoscopic surgery in patients with colon cancer complicated by intestinal obstruction compared to traditional laparotomy.

METHODS

A retrospective analysis was conducted on 100 patients diagnosed with colon cancer and intestinal obstruction who underwent surgical treatment between January 2020 and December 2022. Patients were divided into two groups: The control group (CG), treated with traditional laparotomy, and the observation group (OG), treated with laparoscopic surgery. Clinical effects, surgical indicators, postoperative pain, inflammatory response, complication rates, quality of life, and prognosis were assessed and compared between the two groups.

RESULTS

The OG showed superior clinical outcomes compared to the CG (P < 0.05). Patients in the OG had shorter operation times, reduced intraoperative blood loss, faster recovery of intestinal function, earlier mobilization, and shorter hospital stays (P < 0.05). Postoperative pain (numerical rating scale scores) and inflammatory markers [tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP)] were lower in the OG (P < 0.05). The incidence of complications was significantly reduced in the OG (6.00% vs 22.00%, P < 0.05). Quality of life scores, including physical function, psychological state, social communication, and self-care ability, were significantly higher in the OG (P < 0.05). There were no significant differences between groups in abdominal drainage volume, 1-year tumor recurrence or metastasis rates, or 1- and 3-year survival rates (P > 0.05).

CONCLUSION

The OG showed superior clinical outcomes compared to the CG (P < 0.05). Patients in the OG had shorter operation times, reduced intraoperative blood loss, faster recovery of intestinal function, earlier mobilization, and shorter hospital stays (P < 0.05). Postoperative pain (NRS scores) and inflammatory markers (TNF-α, IL-6, CRP) were lower in the OG (P < 0.05). The incidence of complications was significantly reduced in the OG (6.00% vs 22.00%, P < 0.05). Quality of life scores, including physical function, psychological state, social communication, and self-care ability, were significantly higher in the OG (P < 0.05). There were no significant differences between groups in abdominal drainage volume, 1-year tumor recurrence or metastasis rates, or 1- and 3-year survival rates (P > 0.05).

Key Words: Colon cancer; Intestinal obstruction; Laparoscopic surgery; Complication

Core Tip: Laparoscopic surgery offers significant advantages for patients with colon cancer complicated by intestinal obstruction. Compared to traditional open surgery, it results in better clinical efficacy, reduced operation time, less intraoperative blood loss, faster recovery of intestinal function, and shorter hospital stays. Patients experience less postoperative pain, lower levels of inflammatory markers, fewer complications, and improved quality of life. These findings suggest that laparoscopic surgery is an effective and safe alternative, promoting better recovery and outcomes for this patient population.

INTRODUCTION

Colon cancer belongs to a malignant tumor of the digestive tract, which mainly happens in the colon in the gastrointestinal tract of patients, especially at the junction of the sigmoid colon and rectum[1]. Its incidence is extremely high, ranking as high as the third in the ranking of gastrointestinal tumors[2]. Intestinal obstruction is a relatively common complication of colon cancer[3]. The main reason for intestinal obstruction in patients with colon cancer is that the intestinal cavity is usually narrow due to colon cancer, and the stool in the intestine is dry and hard, which leads to the passage of intestinal contents[4]. The early symptoms of acute intestinal obstruction are insidious and difficult to detect, and development of acute intestinal obstruction is rapid after onset, which is easy to lead to death[5]. At present, surgery is often used in the clinical therapy of colon cancer complicated with intestinal obstruction[6], but traditional laparotomy is not only easy to lead to large wounds, but also prone to more complications, which has adverse effects on the rapid recovery of patients[7]. Laparoscopic surgery is increasingly utilized in the treatment of colon cancer complicated by intestinal obstruction, owing to its benefits of reduced postoperative wound size, minimized intraoperative blood loss, fewer postoperative complications, and accelerated recovery times[8]. This study aimed to evaluate the clinical outcomes and prognosis associated with laparoscopic surgery in patients with colon cancer complicated by intestinal obstruction.

MATERIALS AND METHODS

General data

Clinical data from 100 patients diagnosed with colon cancer complicated by intestinal obstruction who underwent surgical treatment at our hospital between January 2020 and December 2022 were retrospectively analyzed. Patients were divided into two groups based on surgical approach: The control group (CG) and the observation group (OG), with 50 patients in each group. Inclusion criteria were: (1) Diagnosis of colon cancer with concurrent intestinal obstruction; and (2) No prior treatment before surgery. Exclusion criteria included: (1) Presence of malignant tumors at other sites; (2) Abnormal cardiac, hepatic, or renal function; (3) Prior open surgery; and (4) Intestinal perforation. Baseline characteristics showed no significant differences between the two groups (P > 0.05), indicating comparability.

Methods

Both groups underwent general anesthesia prior to surgery, and an artificial pneumoperitoneum with a pressure of approximately 15 mmHg was established. Surgical positioning varied according to the location of the tumor and the site of the intestinal obstruction.

The CG underwent a traditional laparotomy. A midline incision was made in the lower abdomen, progressing through successive layers of subcutaneous tissue. The tumor and obstruction sites were carefully examined to assess their size, location, and relation to surrounding tissues, guiding the selection of resection methods for both tumor and lymph nodes. Following resection, hemostasis was confirmed, and the abdominal cavity was irrigated. The incision was closed in layers, and a drainage tube was positioned. Postoperative management included routine anti-infection measures and fluid rehydration.

The OG received laparoscopic surgery. A puncture site was created bilaterally below the umbilicus, each incision measuring approximately 10 mm, allowing for laparoscopic access to the abdomen. Tumor and obstruction sites were visualized laparoscopically. Additional puncture sites were established bilaterally in the upper abdomen, each measuring approximately 5 mm for trocar insertion. The size, location, and adjacent structures of the tumor and obstruction were further assessed, allowing precise placement of primary and secondary operating ports. Through these, intestinal adhesions were lysed, and tumor along with lymph nodes were resected. The abdominal cavity was rinsed with normal saline, and incisions were sutured in layers. Postoperatively, patients received standard anti-infective and rehydration therapy.

Observation indicators

(1) Evaluation of clinical effects. Cure: After treatment, the patient’s clinical symptoms and pathological tumor disappeared, X-ray examination showed no intestinal dilation in the abdomen, incision healing without complications; Improvement: The clinical symptoms were significantly improved, the lesion and tumor were reduced by more than half, and the abdominal intestinal obstruction was partially relieved by X-ray examination. Ineffective: Those who do not meet the above criteria or whose disease worsens. Total effective rate = cure rate + improvement rate; (2) Evaluation of surgical indicators, the operation time, intraoperative blood loss, recovery time of intestinal function, time of getting out of bed and hospital stay of patients were observed and recorded; (3) Pain score was evaluated using numerical rating scale (NRS). The total score was 0-10 points; (4) Inflammatory factors. 5 mL of fasting peripheral blood was gathered from patients before and 3 days after surgery in the morning, respectively. Serum was collected after centrifugation, and the serum levels of TNF-α, IL-6 s well as CRP were examined by help of double-antibody sandwich enzyme-linked immunosorbent assay; (5) The occurrence of complications including pulmonary infection, incision infection, intra-abdominal hemorrhage and anastomotic fistula in both groups was compared; (6) The postoperative quality of life score of the two groups was compared, including physical function, psychological state, social communication, as well as self-care ability, 25 points for each item, the total score of 0-100 points; (7) Postoperative intra-abdominal drainage volume, to compare the postoperative one day, three days, and total intra-abdominal drainage volume between two groups of patients; and (8) Prognostic indicators including postoperative tumor recurrence rate, tumor metastasis rate, survival rate within 1 year after surgery, and survival rate within 3 years after surgery.

Statistical analysis

This experiment was conducted with SPSS 22.0 statistical analysis software. The measurement data of normal distribution were exhibited as mean ± SD, and t-test was adopted for analysis. The count data were expressed as rate (%) and χ² test was performed between groups. P < 0.05 meant the difference was statistically significant.

RESULTS

Clinical effect in both groups

The study results indicated that, in the CG, 20 patients were classified as cured, 22 as improved, and 8 as ineffective, yielding a total effective rate of 84.00% (42 out of 50 patients). In the OG, 26 patients were classified as cured, 23 as improved, and 1 as ineffective, with a total effective rate of 98.00% (49 out of 50 patients). The effective rate in the OG was significantly higher than that in the CG (P < 0.05), as shown in Table 1 and Table 2.

Table 1 General data of patients in both groups, mean ± SD.

Indicators		Control group (n = 50)	Observation group (n = 50)	P value
Gender (male/female)		30/20	29/21	> 0.05
Average age (year)		52.93 ± 8.35	53.06 ± 8.47	> 0.05
TNM stage	Stage I	20	21	> 0.05
	Stage II	25	24
	Stage III	5	5

Table 2 Clinical effect in both groups, n (%).

Groups	n	Cure	Improvement	Ineffective	Total effective rate
Control group	50	20	22	8	42 (84.00)
Observation group	50	26	23	1	49 (98.00)
χ2					5.983
P value					< 0.05

Surgical indicators in both groups

The operation time, intraoperative blood loss, recovery time of intestinal function, time of getting out of bed and hospital stay of patients in the OG presented shorter relative to the CG, the difference is statistically significant (P < 0.05, Figure 1).

Figure 1 Surgical indicators in both groups. ^aP < 0.05.

Degree of pain in both groups

No difference was seen in NRS score between 2 groups before surgery (P < 0.05). After surgery, the NRS score was declined in both groups, and that in the OG presented lower when comparing with the CG (P < 0.05, Figure 2).

Figure 2 Degree of pain in both groups. ^aP < 0.05 vs before surgery; ^bP < 0.05 vs control group. NRS: Numerical rating scale.

Inflammatory response in both groups

There was no difference was seen in tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP) levels between CG and OG before surgery (P < 0.05). After surgery, TNF-α, IL-6 as well as CRP levels were increased in both groups, but those in the OG presented lower when comparing with the CG, the difference is statistically significant (P < 0.05, Figure 3).

Figure 3 Inflammatory response in both groups. ^aP < 0.05 vs before surgery; ^bP < 0.05 vs control group. TNF-α: Tumor necrosis factor-alpha; IL-6: Interleukin-6; CRP: C-reactive protein.

Occurrence of complications in both groups

The results of this study showed that there were 1, 0, 1, and 1 cases of pulmonary infection, incision infection, intra-abdominal bleeding, and anastomotic leakage respectively, the overall incidence of adverse reactions after surgery was 3 (6.00%) in OG. There were 3, 2, 3 and 3 cases of pulmonary infection, incision infection, intra-abdominal bleeding, and anastomotic leakage respectively, and the overall incidence of adverse reactions after surgery was 11 (22.00%). Table 3 displayed that the occurrence of complications in the OG presented lower when comparing with the CG (P < 0.05).

Table 3 Occurrence of complications in both groups, n (%).

Groups	n	Pulmonary infection	Incision infection	Intra-abdominal hemorrhage	Anastomotic fistula	Total incidence rate
Observation group	50	1	0	1	1	3 (6.00)
Control group	50	3	2	3	3	11 (22.00)
χ2						5.316
P value						< 0.05

Quality of life in both groups

After surgery, the quality of life scores including physical function, psychological state, social communication as well as self-care ability in the OG presented higher when comparing with the CG (P < 0.05, Figure 4).

Figure 4 Quality of life in both groups. ^aP < 0.05.

Postoperative drainage volume

There was no significant difference in abdominal drainage volume and total drainage volume between the two groups of patients three days and seven days after surgery (P > 0.05) (Table 4).

Table 4 Postoperative drainage volume, mean ± SD.

	Control group	Observation group	t value	P value
3-day drainage tube drainage volume (mL)	671.03 ± 228.52	670.21 ± 219.15	0.35	0.52
7-day drainage tube drainage volume (mL)	1220.95 ± 506.43	1224.85 ± 503.05	0.63	0.31
Total drainage tube drainage volume(mL)	1652.63 ± 520.15	1662.15± 521.83	0.54	0.37

The prognosis in both groups

The 1-year tumor recurrence rate, 1-year tumor metastasis rate, 1-year survival rate, and 3-year survival rate of the CG were 20% (10/50), 10% (5/50), 90% (45/50), and 64% (32/50), respectively. The OG had a 1-year tumor recurrence rate, tumor metastasis rate, 1-year survival rate, and 3-year survival rate of 14% (7/50), 6% (3/50), 92% (46/50), and 70% (35/50), respectively. There was no significant difference in the 1-year tumor recurrence rate, 1-year tumor metastasis rate, 1-year survival rate, and 3-year survival rate between the two groups (P > 0.05) (Table 5).

Table 5 Occurrence of complications in both groups, n (%).

Groups	n	1-year tumor recurrence rate	1-year tumor metastasis rate	1-year survival rate	3-year survival rate
Observation group	50	17 (14)	3 (6)	46 (92)	35 (70)
Control group	50	10 (20)	5 (10)	45 (90)	32 (64)
χ2		0.638	0.543	0.122	0.407
P value		0.424	0.461	0.727	0.523

DISCUSSION

Intestinal obstruction is one of the most common clinical complications of colon cancer, the cause of which is closely related to postoperative infection and intestinal adhesion in patients with colon cancer[9]. The clinical symptoms are often manifested as abdominal distension, constipation and vomiting, etc.[10]. Because the early symptoms of intestinal obstruction are not easy to detect, and the development rate after the onset of the disease is fast, it possesses a great adverse influence on the survival, quality of life and postoperative recovery of patients[11].

At present, surgery is usually used in clinical therapy of colon cancer complicated with intestinal obstruction, and the curative effect is exact, the tumor can be removed in one time, and the obstruction can be removed in one time[12]. Traditional laparotomy is the main choice for the clinical therapy of colon cancer complicated with intestinal obstruction, which has good therapeutic effect and can effectively remove the tumor and relieve the intestinal obstruction of patients[13]. However, the traditional open surgery will leave a large wound and multiple postoperative complications, resulting in a slow postoperative recovery[14]. Therefore, in the therapy of colon cancer patients with intestinal obstruction, it is particularly important to adopt a surgical treatment with small postoperative wounds, fewer postoperative complications, and rapid postoperative recovery, which not only improves the survival rate of patients, but also promotes the quality of life of patients.

In recent years, minimally invasive surgery has been extensively applied in abdominal surgery, and laparoscopic surgery, as a kind of minimally invasive surgery, has been widely used in clinical treatment for its advantages of small postoperative wound, less intraoperative blood loss, fewer postoperative complications and quick postoperative recovery[15]. In treating colon cancer complicated with intestinal obstruction patients, laparoscopic surgery can observe the patient’s abdominal cavity through the video probe[16]. At the same time, the magnification of laparoscopy can effectively ensure the surgical field of view, so that the patient’s lesion area is fully and clearly exposed[17]. Moreover, laparoscopy has the advantage of multi-angle exploration, so that the positions that are not easily observed in traditional open surgery are also clearly exposed, which is convenient for doctors to carry out detailed and clear surgical operations[18]. In addition, laparoscopic surgery can also effectively decrease the operation time together with postoperative wounds, effectively decline the amount of intraoperative blood loss and postoperative complications, and speed up the postoperative recovery of patients[19].

Our study demonstrated that the overall clinical efficacy was greater in the OG compared to the CG. Patients in the OG experienced shorter operation times, reduced intraoperative blood loss, faster recovery of intestinal function, earlier mobilization, and reduced hospital stays compared to those in the CG. Both groups showed a reduction in NRS pain scores postoperatively; however, the OG reported significantly lower scores than the CG. These findings suggest that laparoscopic surgery may contribute to reduced hospital stays, lower intraoperative blood loss, decreased postoperative pain, enhanced clinical treatment efficiency, and accelerated rehabilitation for patients with colon cancer complicated by intestinal obstruction. This aligns with findings by Ruben Veldkamp et al[20], who reported that laparoscopic colectomy is associated with earlier bowel function recovery, reduced analgesic requirements, and shorter hospital stays compared to open colectomy.

During surgical trauma, patients would also activate the inflammatory response and promote the secretion of inflammatory factors[21]. TNF-α is a pro-inflammatory factor, which is secreted by mononuclear macrophages. IL-6 is an important cytokine, which can not only regulate immunity between cells, but also cooperate with other cytokines in the patient to transmit inflammatory response, which is one of the important indicators to evaluate the degree of surgical trauma in patients[22]. CRP is an important mediator of acute inflammation. When patients suffer from surgical trauma, its level will be significantly increased, which greatly improves the tissue repair ability of patients[23]. However, literatures have found that CRP levels in patients is positively linked to the degree of surgical trauma[24]. Our study indicated that after surgery, TNF-α, IL-6 as well as CRP levels presented increased in both groups, but those in the OG presented lower when comparing with the CG, suggesting that the use of laparoscopic surgery could inhibit the inflammatory response in colon cancer complicated with intestinal obstruction patients. Consistently, it has been reported that the inflammatory response presents lower in laparoscopic rectal surgery when comparing with conventional open surgery[25].The systemic inflammatory response after major surgery is initially the result of a highly conservative innate immune response. Depending on the surgical environment, it varies greatly and is directly proportional to the degree of surgical injury[26]. The relevant molecular patterns are key molecular ligands that trigger inflammatory and immune responses after surgical injury. At the site of injury, DAMPs such as heat shock proteins, S100 proteins, high mobility group B proteins, nucleic acids, DNA, and adenosine triphosphate bind to pattern recognition receptors and send signals to innate immune cells[27]. The activation of pattern recognition receptors induces multiple downstream signaling pathways, leading to the activation of NF-κB, activator protein 1, and interferon regulatory factors[28]. It can also drive the production and release of pro-inflammatory cytokines and chemokines (such as IL-6, TNF-α, IL-1b, IL-8, IL-12, type 1 interferon), leukotrienes (such as leukotriene B4), and DAMPs (such as HMGB1), leading to an increase in the production of neutrophils and monocytes, which are recruited to the site of injury[29,30]. It can also promote NK cell activation, release of reactive oxygen species, increase phagocytosis, and alter endothelial permeability. Inflammation immune response is always balanced because immune suppression and immune activation begin simultaneously. The level of IL-6 is closely related to the severity of injury and the synthesis and release of postoperative CRP[31,32]. However, after binding to IL-1b and TNF-α, it can also stimulate the hypothalamic pituitary adrenal axis, increase cortisol secretion, and affect glucocorticoid mediated immune regulation[33,34]. In addition, when IL-6 reacts with glucocorticoids and anti-inflammatory cytokines (such as IL-4), it can promote the transformation of naive T cells into immunosuppressive type 2 (Th2) phenotype, thereby producing anti-inflammatory cytokines (IL-4, IL-10, IL-13) to suppress cellular immunity. IL-6 can also induce macrophages to release prostaglandin E2, which is a potent immunosuppressant that negatively regulates the function of monocytes, macrophages, and T cells[35,36]. In summary, these functions demonstrate the dual role of IL-6, which serves as a pro-inflammatory cytokine to drive the initial host response, while also promoting immune regulation and inhibition.

The prognosis of general colon cancer patients is closely related to the timing of colon cancer staging at the time of diagnosis. In addition, the pathological type of colon cancer, the location of the lesion, the level of surgery, and the postoperative adjuvant treatment also directly affect the prognosis of colon cancer patients[36,37]. The prognosis of different stages of colon cancer during surgery is significantly different. The five-year survival rate of stage I colon cancer after surgery can reach over 90%, while the five-year survival rate of stage II colon cancer may only be around 70%[38-40]. The five-year survival rate of stage III colon cancer patients after surgery is only about 40%-50%. If stage IV colon cancer is diagnosed with metastasis to distant organs such as the liver and lungs, the prognosis of patients will be even worse, and the survival period will often be significantly shortened[41]. The results of this study show that there was no significant difference in the 1-year tumor recurrence rate, 1-year tumor metastasis rate, 1-year survival rate, and 3-year survival rate between the two groups (P > 0.05). In the pathological grading of colon cancer, the prognosis of poorly differentiated colon cancer is often much worse than that of highly differentiated colon cancer[42]. Patients who can undergo radical surgical resection during surgery often have a better prognosis than those who cannot undergo radical surgical resection. For some patients who require postoperative adjuvant chemotherapy based on pathological reports, if they complete it on time, their survival will be significantly prolonged, longer than those who require postoperative adjuvant chemotherapy without treatment[43]. So the most important thing to improve the prognosis of colon cancer patients is to be able to detect and diagnose early, and provide active treatment early, thereby prolonging the patient's survival time.

CONCLUSION

In addition, our study indicated that the occurrence of complications in the OG presented lower when comparing with the CG, and the quality of life scores including physical function, psychological state, social communication as well as self-care ability in the OG presented higher when comparing with the CG. All above outcomes indicated that the application of laparoscopic surgery could reduce the complications and promote the quality of life of colon cancer complicated with intestinal obstruction patients, which was in line with previous studies[44,45]. In conclusion, laparoscopic surgery has a significant effect in treating colon cancer complicated with intestinal obstruction patients, which can effectively lessen the pain of patients, reduce the inflammatory indicators of patients, decline the postoperative complications of patients, as well as promote the quality of life of patients.