INTRODUCTION

Malignant gastrointestinal obstruction is an important issue in advanced cancer and occurs in approximately 30% of patients with gastrointestinal cancer[1]. Gastrointestinal obstruction causes oral intake impairment, nausea, vomiting, and abdominal pain and also poses a risk of gastrointestinal perforation. Primary therapy involves fasting, intravenous hydration, and nasogastric tube or ileus tube placement for bowel rest and decompression[2,3]. In secondary therapy, complete surgical resection is performed for resectable malignant gastrointestinal obstruction; palliative surgery, including bypass and stoma surgery or self-expandable metal stent (SEMS) placement, is performed at one or more points of unresectable malignant gastrointestinal obstruction (Figure 1).

Chemotherapy after palliative surgery or SEMS placement is a particularly challenging clinical issue. Although it can improve overall survival[4-6], little is known regarding the difference in overall survival between patients undergoing chemotherapy treatment and those receiving best supportive care (BSC). In addition, the risk of gastrointestinal perforation is a concern for treatment involving chemotherapy combined with SEMS[7,8]. However, previous studies on the safety of chemotherapy in this situation were limited by small sample sizes.

宣教前，有633例患者了解肺炎疫苗，有622例患者認(rèn)知疫苗能預(yù)防肺炎，有439例患者愿意接種，分別 占 63.30%（633/1 000）、62.20%（622/1 000）、43.90%（439/1 000）；宣教后，有711例患者了解肺炎疫苗，有703例患者認(rèn)知疫苗能預(yù)防肺炎，有524例患者愿意接種，分別占 71.10%（711/1 000）、70.30%（703/1 000）、52.40%（524/1 000）；組間比較，患者宣教后的了解肺炎疫苗率、疫苗能預(yù)防肺炎率、愿意接種率均更高于宣教前，差異有統(tǒng)計(jì)學(xué)意義（P＜0.05）。 見表2。

We performed a large multicenter cohort study to evaluate the effectiveness and safety of chemotherapy after palliative surgery or SEMS placement compared with BSC in patients with unresectable malignant gastrointestinal obstructions. In addition, we aimed to identify the optimal population for chemotherapy after palliative surgery or SEMS placement.

From the database, we identified patients who had undergone palliative surgery or SEMS placement for gastrointestinal obstruction, including esophageal bypass surgery, gastrojejunostomy, duodenojejunostomy, intestinal bypass surgery, stoma surgery, esophageal stenting, gastroduodenal stenting, or colonic stenting, who did not undergo gastrointestinal tract resection thereafter. We excluded patients without malignant disease, those with a history of gastrointestinal perforation or fistula, and patients with multifocal gastrointestinal obstructions. The codes used for patient selection are listed in Supplementary Table 1.

MATERIALS AND METHODS

Study design, setting, and participants

We performed a retrospective cohort study using the diagnostic procedure combination (DPC) databases of nine hospitals between January 2014 and March 2019. The combined database comprised the records of all inpatients and outpatients at the University of Tokyo Hospital, Shuto General Hospital, Fukui Prefectural Hospital, Nerima Hikarigaoka Hospital, St. Luke’s International Hospital, Toyonaka Municipal Hospital, Ishikawa Prefectural Central Hospital, and Nagasaki Minato Medical Center and of inpatients at Tonan Hospital. The database included diagnoses, comorbidities, and adverse events using the International Classification of Diseases, 10th revision and Japanese original disease codes. It also included the cancer stage according to the Union for International Cancer Control classification system[9], Japanese original medication and procedure codes, and Barthel index (BI)[10].

1.2.6 RT-qPCR Trizol法提取細(xì)胞總RNA并測(cè)定RNA濃度和純度,調(diào)整樣品濃度后按照RT Mix試劑說明書反轉(zhuǎn)錄合成cDNA，PCR反應(yīng)體系為5 μL SYBR、3.6 μL DEPC水、0.4 μL引物與1 μL cDNA。內(nèi)參GAPDH引物序列為5′-AGAAGGCTGGGGC-TCATTTG-3′和5′-AGGGGCCATCCACAGTCTT-C-3′；Atg5引物序列為5′-GCTTCGAGATGTGTGG-TTTG-3′和5′-CAGTGGTGTGCCTTCATATT-3′，其相對(duì)表達(dá)量用2-ΔΔCt表示。

以人參皂苷Rb1為例，一級(jí)質(zhì)譜信息顯示該化合物在負(fù)離子模式下響應(yīng)較好，并得到m/z 1107.592 29的準(zhǔn)分子離子峰 [M－H]?，經(jīng)Xcalibar軟件擬合其分子式為C54H91O23。該化合物的二級(jí)質(zhì)譜信息主要有m/z 945.543 21 [M－H－Glc]?、m/z 783.492 43 [M－H－2Glc]?、m/z 621.437 26 [M－H－3Glc]?、m/z 459.386 08 [M－H－4Glc]?。發(fā)現(xiàn)其斷裂方式符合皂苷類化合物的裂解規(guī)律，通過與文獻(xiàn)報(bào)道[21]進(jìn)行比較后，最終確定該化合物為人參皂苷Rb1，人參皂苷Rb1的質(zhì)譜裂解途徑見圖6。

We selected the chemotherapy group (patients who received any chemotherapy drugs after the intervention) with the BSC group (patients who did not receive chemotherapy drugs after the intervention) (Figure 1). The follow-up period was from the date of the intervention to death or the final visit. The end of follow-up was March 2019, and loss to follow-up was defined as the date of the final visit. The study was approved by the Institutional Review Board of the University of Tokyo Hospital (No. 2019161NI).

Outcomes and variables

We performed a subgroup analysis to identify the optimal population for chemotherapy because this study included heterogenous patients with various cancers and obstruction sites, which could influence the effectiveness of chemotherapy. The effectiveness of chemotherapy after the intervention for overall survival and patency duration was consistent among the cancer types and obstruction sites. Especially in cases of pancreatic cancer and gastroduodenal obstruction, chemotherapy might be more beneficial. The effectiveness of chemotherapy after the intervention was similar among the cancer types and obstruction sites. Especially in cases of pancreatic cancer and gastroduodenal obstruction, chemotherapy may be more beneficial. These findings will help guide future research on treatment approaches and precision medicine. Currently, overall survival and recurrence risk are predicted based on limited data such as pathological findings. However, recent biological research has suggested potential biomarkers, including circulating tumor DNA and micro-RNA, as well as microbiome profiling, to predict overall survival and recurrence. In the near future, these precision medicine methods are expected to contribute to cancer therapies including molecular targeted anti-cancer drugs, monoclonal antibody therapy, and antibiotic therapies.

王貴春知道，如果丈夫動(dòng)手打人，按照現(xiàn)在的法律，法律責(zé)任是逃不了的，“萬一打出問題，丈夫甚至有可能被判刑”。進(jìn)一步，萬一丈夫打了人，“‘青楞’狠心伺機(jī)報(bào)復(fù)，向魚塘里下毒，以后家里的經(jīng)濟(jì)也毀了”。也就是說，王貴春并非欠缺“基礎(chǔ)性知識(shí)”的“挑戰(zhàn)性法盲”[30]，而是無法使心中的“氣”按照常規(guī)的方式排泄出來，于是“氣不過”，激動(dòng)之下，便選擇了自殺。

我父親1918年初生人，屬馬。要是活著今年整一百歲了。我奶奶家當(dāng)年是做生意的，經(jīng)濟(jì)上挺富裕。1916年她16歲那年，在讀私塾的時(shí)候認(rèn)識(shí)了我爺爺。當(dāng)時(shí)我爺爺家境并不好，只因?yàn)樗迨迨墙虝壬?，他才能跟著讀私塾。那個(gè)年代婚姻都是家長(zhǎng)做主，可我奶奶有大小姐脾氣，再加上民國(guó)了讀書了，思想相對(duì)開放了，非要嫁我爺爺不可。一來二去，家里看實(shí)在攔不住了，只能勉強(qiáng)同意。轉(zhuǎn)年，我爺爺家下了聘禮，我奶奶下嫁了我爺爺。

We evaluated the following clinical factors: Age, sex, comorbidities, BI, medication use, cancer type, cancer stage, obstruction site, chemotherapy before the intervention, and intervention type. Age was categorized into < 75 years and ≥ 75 years. Comorbidities were evaluated by the Charlson comorbidity index (CCI)[11] and categorized as < 3 and ≥ 3. BI was categorized as ≥ 60, < 60, and missing. We evaluated the use of aspirin, thienopyridine, warfarin, direct oral anticoagulants (including dabigatran, rivaroxaban, apixaban, and edoxaban), other antiplatelet drugs (including dilazep hydrochloride hydrate, dipyridamole, trapidil, cilostazol, limaprost alfadex, ethyl icosapentate, beraprost sodium, sarpogrelate hydrochloride, and ozagrel sodium), nonsteroidal anti-inflammatory drugs, and steroids. The cancer type was categorized into esophageal cancer, gastric cancer, pancreatic cancer, colorectal cancer, and other cancers. The cancer stage was categorized into stage I–III, stage IV or recurrence, and missing. The obstruction site was categorized as esophageal obstruction, gastroduodenal obstruction, or lower gastrointestinal obstruction. The intervention type was categorized as palliative surgery or SEMS placement. The International Classification of Diseases, 10th revision codes of primary cancers and comorbidities are listed in Supplementary Table 3, and the medication codes are shown in Supplementary Table 4.

Statistical analysis

The results of a subgroup analysis of adjusted HRs for overall survival and patency duration were consistent with those of the overall analysis (Table 4).

Categorical data were compared by the chi-squared test or Fisher’s exact test and continuous data by the Wilcoxon rank-sum test. A

value < 0.05 was considered indicative of statistical significance. Statistical analysis was performed using SAS software v. 9.4 (SAS Institute, Cary, NC, United States).

To our knowledge, this is the first study of the effectiveness and safety of chemotherapy after palliative surgery or SEMS placement for various types of unresectable malignant gastrointestinal obstruction. In addition, our finding showed that chemotherapy was associated with prolongs gastrointestinal patency. However, this study has several limitations. First, it was a retrospective study. Although we used multivariate Cox proportional hazard models to reduce the effects of confounding factors, some bias may remain because the decision to undergo chemotherapy depends on so many factors including unmeasured confounders. It is difficult to evaluate the effect of chemotherapy more accurately in our setting. Second, our study included patients with different types of cancer, and there were different numbers of patients among the cancer groups. Third, the DPC database lacked information on potential prognostic factors such as radiotherapy history and pathological findings.

RESULTS

Patient characteristics

Fourteen hundred forty patients who had undergone palliative surgery or SEMS placement for unresectable gastrointestinal obstruction were extracted from the DPC database. After excluding patients without malignant disease (

= 234), those with a history of gastrointestinal perforation or fistula (

= 74), and patients with multifocal gastrointestinal obstructions (

= 10), the remaining 1122 patients were analyzed. In total, 470 patients who received chemotherapy drugs after the intervention (chemotherapy group) and 652 patients who did not receive chemotherapy drugs after the intervention (BSC group) were analyzed (Figure 2). The patients’ baseline characteristics are listed in Table 1. The age, CCI, BI, medication, cancer type, and cancer stage distributions were significantly different between the groups. The chemotherapy group had higher rates of < 75 aged patients, CCI ≥ 3, BI ≥ 60, and stage IV or recurrence.

Overall survival and patency duration

During the follow-up period of 54.1 mo, the median overall survival durations were 19.3 mo (95%CI: 16.2-25.9 mo) in the chemotherapy group and 5.4 mo (95%CI: 3.6-7.6 mo) in the BSC group (log-rank test,

< 0.01; Figure 2). The median patency durations were 9.7 mo (95%CI: 7.7-11.5 mo) in the chemotherapy group and 2.5 mo (95%CI: 2.0-2.9 mo) in the BSC group (log-rank test,

< 0.01; Figure 3).

Factors affecting overall survival and patency duration

The factors affecting overall survival are shown in Table 2. Multivariate analysis showed that the factors affecting overall survival were chemotherapy after the intervention (aHR, 0.36), CCI ≥ 3 (aHR, 1.56), BI < 60 (aHR, 2.04), gastric cancer compared with esophageal cancer (aHR, 0.64), colorectal cancer compared with esophageal cancer (aHR, 0.47), stage IV or recurrence compared with stage I–III (aHR, 1.79), chemotherapy before the intervention (aHR, 1.66), and SEMS placement compared with palliative surgery (aHR, 1.63).

2.技術(shù)資源。網(wǎng)絡(luò)信息技術(shù)是當(dāng)前全球研發(fā)投入最集中、創(chuàng)新最活躍、應(yīng)用最廣泛、輻射帶動(dòng)作用最大的技術(shù)創(chuàng)新領(lǐng)域，不斷發(fā)展的網(wǎng)絡(luò)信息技術(shù)將為政府治理創(chuàng)新提供源源不斷的技術(shù)資源。

The factors affecting patency are shown in Table 3. Multivariate analysis showed that the factors affecting patency duration were chemotherapy after the intervention (aHR, 0.49), CCI ≥ 3 (aHR, 1.41), BI < 60 (aHR, 1.55), colorectal cancer

esophageal cancer (aHR, 0.67), stage IV or recurrence compared with stage I–III (aHR, 1.65), chemotherapy before the intervention (aHR, 1.64), and SEMS placement compared with palliative surgery (aHR, 2.48).

Overall survival and patency durations were estimated by the Kaplan–Meier method and were compared by log-rank test. Data were censored at the date of the final visit. Univariate Cox proportional hazards models were used to estimate crude hazard ratios and 95% confidence intervals (CIs). The multivariate Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) using age, sex, cancer type, cancer stage, CCI, BI, and intervention type.

Adverse events

The rates of adverse events are listed in Table 5. The perforation rate was 1.3% (6/470) in the chemotherapy group (3 gastric cancers, one colorectal cancer, 1 breast cancer, and 1 unclassifiable cancer) and 0.9% (6/652) in the BSC group (3 colorectal cancers, 2 gastric cancers, and 1 esophageal cancer) (

= 0.567). In 4 of the 6 perforation cases in the chemotherapy group, perforation occurred a mean of 137 d after chemotherapy initiation.

The gastrointestinal bleeding rate was 1.5% (7/470) in the chemotherapy group (4 gastric cancers, 1 esophageal cancer, 1 pancreatic cancer, and o1colorectal cancer) and 0.5% (3/652) in the BSC group (1 esophageal cancer and 2 pancreatic cancers) (

= 0.105). In 4 of 7 bleeding cases in the chemotherapy group, gastrointestinal bleeding occurred a mean of 294 d after chemotherapy initiation.

環(huán)境細(xì)節(jié)描寫能襯托人物形象，推動(dòng)故事情節(jié)的發(fā)展，突出人物的精神品質(zhì)。如《一夜的工作》中“我走進(jìn)總理的辦公室。那是一間高大的宮殿式的房子，室內(nèi)陳設(shè)極其簡(jiǎn)單，一張不大的寫字臺(tái)，兩把小轉(zhuǎn)椅，一盞臺(tái)燈，如此而已?！薄皹O其簡(jiǎn)單”就是簡(jiǎn)單到不能再簡(jiǎn)單，“寫字臺(tái)”“臺(tái)燈”“轉(zhuǎn)椅”這幾樣是工作必不可少的辦公設(shè)備，“如此而已”更加強(qiáng)調(diào)了陳設(shè)的簡(jiǎn)單?！案叽蟮膶m殿式的房子”與極其簡(jiǎn)單的擺設(shè)形成了鮮明的對(duì)比，反映出周總理的生活極其簡(jiǎn)樸。

DISCUSSION

（2）活性材料投加量的確定。取3號(hào)廢泥漿樣品加入 AP2.0%、水泥20.0%、促凝增強(qiáng)劑CA 5.0%及相應(yīng)添加劑，HHJ投加量不同，考察固化改良后浸出液主要指標(biāo)，試驗(yàn)結(jié)果見表9。通過數(shù)據(jù)分析可以看出，當(dāng)HHJ投加量達(dá)到10.0%時(shí)，固化改良物浸出液的各項(xiàng)指標(biāo)都能夠到要求。再增加投加量，處理效果變化不大，因此選擇HHJ活性材料的加量為10.0%。

The chemotherapy group showed longer overall survival and patency durations. We suggest three reasons for these findings. First, chemotherapy drugs may prolong overall survival and patency duration even in patients with malignant gastrointestinal obstruction. We performed a multivariate analysis to reduce the influence of confounders; chemotherapy after the intervention was an independent factor for overall survival and patency duration. Previous studies reported similar results. Nomoto

[6] reported that chemotherapy after bypass surgery for esophageal cancer improved the prognosis. Cho

[4] showed that chemotherapy after SEMS placement for gastric cancer was a significant prognostic factor for patency duration. Ahn

[5] reported that chemotherapy after palliative surgery or SEMS placement for colorectal cancer significantly improved survival. Second, bias in terms of patient characteristics may have influenced the results. The chemotherapy group included younger patients, those of higher BI, and more nonsteroidal anti-inflammatory drugs users. This suggests that the chemotherapy group may have previously been treated for other diseases. In turn, this may have increased palliative surgery performance and improved the patency and survival durations. Third, chemotherapy was not associated with increased perforation, which is a fatal complication. The risk of gastrointestinal perforation after SEMS placement is a matter of great concern, particularly when chemotherapy is combined with SEMS. The 2019 clinical guidelines of the Japanese Society for Cancer of the Colon and Rectum[2] does not recommend SEMS placement for patients with colonic obstruction who are indicated for systemic chemotherapy. However, available data on the safety of chemotherapy after palliative surgery or SEMS placement are limited. In this study, the rate of perforation was < 2% in the chemotherapy and BSC groups; however, the definition of perforation was major perforation that required surgery.

The primary outcome was overall survival. The secondary outcomes were patency duration and adverse events, including perforation and gastrointestinal bleeding. Patency duration was defined as the time between the first food intake after the intervention and reintervention, stopping food intake, or death. Perforation was defined as surgery for suture, drainage, or intra-abdominal lavage. Gastrointestinal bleeding was defined as any gastrointestinal bleeding requiring endoscopic hemostasis. The procedure codes for outcomes are listed in Supplementary Table 2.

身材削瘦的女生建議選擇寬大的毛衣，可以增添整體飽滿感。如果身材本身是瘦的，但可能會(huì)有點(diǎn)小肚子的女生，也不必發(fā)愁，選擇一款寬大的毛衣，就可以很好地遮蓋小肚子了；瘦小又肩窄的女生也適合寬大的毛衣，可以增加肩膀的厚度，不會(huì)看起來很弱小，并且寬大的版型也更保暖。另外，穿寬大的毛衣可以露出小細(xì)腿，不僅保暖更顯瘦。

聯(lián)合國(guó)副秘書長(zhǎng)拉克魯瓦對(duì)中國(guó)對(duì)聯(lián)合國(guó)維和事業(yè)的貢獻(xiàn)給予高度評(píng)價(jià)。認(rèn)為中國(guó)履行承諾，為聯(lián)合國(guó)維和行動(dòng)提供高素質(zhì)軍隊(duì)和警察；中國(guó)是安理會(huì)五常中最大的出兵國(guó)，也是世界第二大出資國(guó)；中國(guó)支持聯(lián)合國(guó)的性別倡議，更多中國(guó)女性進(jìn)入聯(lián)合國(guó)特派團(tuán)。最近，聯(lián)合國(guó)對(duì)中國(guó)3000人的待命部隊(duì)進(jìn)行了評(píng)估，高水平建設(shè)給人印象深刻。中國(guó)還幫助聯(lián)合國(guó)維和行動(dòng)進(jìn)行能力建設(shè)，開展各種培訓(xùn)。中國(guó)在技術(shù)領(lǐng)域的支持也很重要，如在無人機(jī)、民航、醫(yī)療、工程、后勤等方面提供了技術(shù)支持。聯(lián)合國(guó)維和行動(dòng)順利開展，得益于與中國(guó)的密切合作。

Chemotherapy after palliative surgery or SEMS placement for unresectable malignant gastrointestinal obstruction was associated with improved overall survival and patency duration and not associated with increased perforation or gastrointestinal bleeding compared with BSC. In addition, its effectiveness for overall survival and patency duration was consistent among cancer types and obstruction sites.

CONCLUSION

In conclusion, chemotherapy after palliative surgery or SEMS placement for unresectable malignant gastrointestinal obstruction was associated with increased overall survival and patency duration independent of the cancer type and obstruction site, and it was not associated with an increased rate of gastrointestinal perforation.

ARTICLE HIGHLIGHTS

Research conclusions

Chemotherapy after interventions for unresectable malignant gastrointestinal obstruction was associated with increased overall survival and patency duration.

Research perspectives

Our results showed that chemotherapy may be more beneficial in cases of pancreatic cancer and gastroduodenal obstruction. These findings will help guide future research on treatment approaches and precision medicine. In the near future, these precision medicine methods are expected to contribute to cancer therapies including molecular targeted anti-cancer drugs, monoclonal antibody therapy, and antibiotic therapies.

FOOTNOTES

All authors contributed to the acquisition of data for this study; Fujisawa G analyzed the data and wrote the draft manuscript; Niikura R designed the research study; Kawahara T contributed data analysis; Honda T, Hasatani K, Yoshida N, Nishida T, Sumiyoshi T, Kiyotoki S, Ikeya T, Arai M, Hayakawa Y, Kawai T, and Fujishiro M performed the research; All authors have read and approved the final manuscript.

the Tokyo Medical University Cancer Research Foundation, No. 2021; and KAKENHI Grants-in-Aid for Scientific Research, No. 20K08375.

This study was approved by the Institutional Review Board of the University of Tokyo Hospital (No. 2019161NI) and conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Informed consent was obtained in the form of opt-out on the website.

The authors declare that they have no conflicts of interest.

No additional data are available.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Japan

Gota Fujisawa 0000-0002-0218-200X; Ryota Niikura 0000-0001-5047-6195; Takuya Kawahara 0000-0002-3859-2756; Tetsuro Honda 0000-0001-9402-5417; Kenkei Hasatani 0000-0002-7465-4715; Naohiro Yoshida 0000-0002-7867-8490; Tsutomu Nishida 0000-0003-4037-9003; Tetsuya Sumiyoshi 0000-0002-9390-8477; Shu Kiyotoki 0000-0002-6417-4638;Takashi Ikeya 0000-0003-4838-2207; Masahiro Arai 0000-0002-6312-6319; Yoku Hayakawa 0000-0002-3988-2499; Takashi Kawai 0000-0002-5320-8134; Mitsuhiro Fujishiro 0000-0002-4074-1140.

上述神話表明文字作為人類文明的劃時(shí)代標(biāo)志，它是文明與野蠻的區(qū)別。從空間上看，不同人群是否掌握了文字和書寫能力，成為統(tǒng)治與被統(tǒng)治的一個(gè)工具，無文字的族群被貼上“野蠻人”或“落后”的標(biāo)簽。奇怪的事，神話敘事的主體是無文字民族，這似乎表明他們接受了無文字帶來的后果，自責(zé)及接受“神授”安排的無奈。

Yan JP

Filipodia

Yan JP

1 Cousins SE, Tempest E, Feuer DJ. Surgery for the resolution of symptoms in malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer.

2016 ; CD002764 [PMID: 26727399 DOI:10 .1002 /14651858 .CD002764 .pub2 ]

2 Hashiguchi Y, Muro K, Saito Y, Ito Y, Ajioka Y, Hamaguchi T, Hasegawa K, Hotta K, Ishida H, Ishiguro M, Ishihara S,Kanemitsu Y, Kinugasa Y, Murofushi K, Nakajima TE, Oka S, Tanaka T, Taniguchi H, Tsuji A, Uehara K, Ueno H,Yamanaka T, Yamazaki K, Yoshida M, Yoshino T, Itabashi M, Sakamaki K, Sano K, Shimada Y, Tanaka S, Uetake H,Yamaguchi S, Yamaguchi N, Kobayashi H, Matsuda K, Kotake K, Sugihara K; Japanese Society for Cancer of the Colon and Rectum. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer.

2020 ; 25 : 1 -42 [PMID: 31203527 DOI: 10 .1007 /s10147 -019 -01485 -z]

3 van Hooft JE, Veld JV, Arnold D, Beets-Tan RGH, Everett S, G?tz M, van Halsema EE, Hill J, Manes G, Meisner S,Rodrigues-Pinto E, Sabbagh C, Vandervoort J, Tanis PJ, Vanbiervliet G, Arezzo A. Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2020 . Endoscopy 2020 ; 52 : 389 -407 [PMID: 32259849 DOI: 10 .1055 /a-1140 -3017 ]

4 Cho YK, Kim SW, Hur WH, Nam KW, Chang JH, Park JM, Lee IS, Choi MG, Chung IS. Clinical outcomes of selfexpandable metal stent and prognostic factors for stent patency in gastric outlet obstruction caused by gastric cancer.

2010 ; 55 : 668 -674 [PMID: 19333756 DOI: 10 .1007 /s10620 -009 -0787 -3 ]

5 Ahn HJ, Kim SW, Lee SW, Lim CH, Kim JS, Cho YK, Park JM, Lee IS, Choi MG. Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent

surgery.

2016 ; 30 : 4765 -4775 [PMID: 26895922 DOI: 10 .1007 /s00464 -016 -4804 -2 ]

6 Nomoto D, Baba Y, Akiyama T, Okadome K, Uchihara T, Harada K, Eto K, Hiyoshi Y, Nagai Y, Ishimoto T, Iwatsuki M,Iwagami S, Miyamoto Y, Yoshida N, Watanabe M, Baba H. Outcomes of esophageal bypass surgery and self-expanding metallic stent insertion in esophageal cancer: reevaluation of bypass surgery as an alternative treatment.

2020 ; 405 : 1111 -1118 [PMID: 32860110 DOI: 10 .1007 /s00423 -020 -01969 -x]

7 Datye A, Hersh J. Colonic perforation after stent placement for malignant colorectal obstruction--causes and contributing factors.

2011 ; 20 : 133 -140 [PMID: 20929424 DOI: 10 .3109 /13645706 .2010 .518787 ]

8 Imbulgoda A, MacLean A, Heine J, Drolet S, Vickers MM. Colonic perforation with intraluminal stents and bevacizumab in advanced colorectal cancer: retrospective case series and literature review.

2015 ; 58 : 167 -171 [PMID:25799132 DOI: 10 .1503 /cjs.013014 ]

9 Brierley JD, Gospodarowicz MK, Wittekind C. TNM classification of malignant tumours. 8 th ed. Wiley-Blackwell, 2017

10 Mahoney FI, Barthel DW. Functional Evaluation: The Barthel Index. Md State Med J 1965 ; 14 : 61 -65 [PMID: 14258950 ]

11 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.

1987 ; 40 : 373 -383 [PMID: 3558716 DOI:10 .1016 /0021 -9681 (87 )90171 -8 ]