Complete single-stage management of left colon cancer obstruction with a new device

Definition of large bowel obstruction by primary colorectal cancer: A systematic review

AIM

Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies.

METHOD

A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements.

RESULTS

A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07).

CONCLUSION

In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.

Intraoperative Colonoscopy During Colorectal Surgery Does Not Increase Postoperative Complications: An Assessment From the ACS-NSQIP Procedure-targeted Cohort

Intraoperative colonoscopy (IOC) is an adjunct in colorectal surgery to detect the location of the lesions and assessing anastomotic integrity. The authors aimed to evaluate the safety and feasibility and postoperative morbidity of IOC in left-sided colectomy patients for colorectal cancer. Patients undergoing elective left-sided colectomy without any proximal diversion for colorectal cancer between 2013 and 2016 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program procedure-targeted database. Demographics, comorbidities, short-term outcomes, and postoperative morbidity of patients were evaluated. A total of 8811 patients were identified and IOC was performed for 1143 (12.97%) patients. There was no significant difference in postoperative complications between the IOC and non-IOC groups. Patients with IOC had shorter total hospital length of stay. The use of IOC does not adversely affect short-term outcomes after colorectal resections. Surgeons may utilize IOC liberally for left-sided colorectal resections.

Quality of Life for Patients With Incurable Stage IV Colorectal Cancer: Randomized Controlled Trial Comparing Resection Versus Endoscopic Stenting

BACKGROUND/AIM

A prospective randomized open label parallel trial, comparing the quality of life (QoL) after endoscopic placement of a self-expandable metal stent or primary tumor resection, in patients with stage IV colorectal cancer was performed.

PATIENTS AND METHODS

Thirty-three patients affected with stage IV colorectal cancer and unresectable metastases were randomly assigned into two groups: Group 1 (16 patients), that underwent self-expandable metal stent positioning and Group 2 (17 patients), in which primary tumor resection was performed. Karnofsky performance scale and QoL assessment using the EQ-5D-5L™ questionnaire was administered before treatment and thereafter at 1, 3 and 6 months.

RESULTS

At 1 month, index values showed a statistically significant deterioration of the QoL in patients of Group 2 when compared to those of Group 1 (p=0.001; 95%CI=0.065-0.211) whereas, at 6 months, index values showed a statistically significant deterioration of the QoL in patients of Group 1 (p<0.025; 95%CI=0.017-0.238).

CONCLUSION

QoL in patients affected with stage IV colorectal cancer has a bimodal fluctuation pattern: at 1-month it was better in patients that received stent, but at 6-months it was significantly better in patients submitted to surgical resection.

Feasibility and Safety of Intraoperative Colonoscopy after Segmental Colectomy and Primary Anastomosis

Patients presenting with near-obstructing colon lesions requiring segmental colectomy may benefit from intraoperative colonoscopy (IOC) after primary anastomosis for a more timely and accurate diagnosis of synchronous lesions. The aim of this study is to demonstrate the feasibility and safety of this technique. A retrospective cohort study of patients undergoing single-stage segmental colectomy and anastomosis at a single tertiary care institution from 2011 to 2013 was performed. One Hundred and sixty-eight consecutive patients underwent segmental colectomy and primary anastomosis of which 78 (46%) were unable to receive preoperative colonoscopy (POC) because of near-obstructing lesions and received IOC after the anastomosis. IOC detected synchronous adenomatous polyps in 24.4 per cent, diverticular disease in 19 per cent, and colitis/proctitis in 2.5 per cent. The IOC group was not significantly different from the POC group with regard to overall morbidity (31% vs 39% P = 0.45), anastomotic leakage (1.3% vs 0%, P = 0.46), or wound infection (5.1% vs 1.1%, P = 0.18). Operation time was 19 minutes longer in the intra-operative group, but overall length of hospital stay was not significantly different (6.4 ± 2.9 days vs 7.3 ± 4.6 days). In patients unable to receive POC because of partial obstruction, IOC after primary anastomosis is both feasible and safe for detecting proximal synchronous lesions.

Comparative study of postoperative complications in patients with and without an obstruction who had left-sided colorectal cancer and underwent a single-stage operation after mechanical bowel preparation

Purpose

The purpose of this study is to compare postoperative complications for single-stage surgery after mechanical bowel preparation in patients who experienced obstruction and those who did not.

Methods

From 2000 to 2011, 1,224 patients underwent a single-stage operation for left colorectal cancer after bowel preparation. Nonobstruction (NOB) and obstruction (OB) colorectal cancer patients were 1,053 (86.0%) and 171 (14.0%), respectively. Postoperative morbidity and mortality were compared between groups.

Results

The OB group had poor preoperative conditions (age, white blood cell, hemoglobin, albumin level, and advanced tumor stage) compared with the NOB group (P < 0.05). Mean on-table lavage time for the OB group was 17.5 minutes (range, 14-60 minutes). Mean operation time for the OB group was statistically longer than that of the NOB group (OB: 210 minutes; range, 120-480 minutes vs. NOB: 180 minutes; range, 60-420 minutes; P < 0.001). Overall morbidity was similar between groups (NOB: 19.7% vs. OB: 23.4%, P = 0.259). Major morbidity was more common in the OB group than in the NOB group, but the difference was without significance (OB: 11.7% vs. NOB: 7.6%, P = 0.070). Postoperative death occurred in 16 patients (1.3%), and death in the OB group (n = 7) was significantly higher than it was in the NOB group (n = 9) (4.1% vs. 0.9%, P = 0.001). Twelve patients had surgical complications, which were the leading cause of postoperative death: postoperative bleeding in five patients and leakage in seven patients.

Conclusion

Postoperative morbidity for a single-stage operation for obstructive left colorectal cancer is comparable to that for NOB, regardless of poor conditions of the patient.

Long-term fecal diverting device for the prevention of sepsis in case of colorectal anastomotic leakage: an animal experiment

BACKGROUND

A new fecal diverting device (FDD) was fabricated for fecal diversion from the proximal colon above the anastomosis to outside the anus for protecting the rectal anastomosis. The aim of the study is to evaluate the safety and effectiveness of the FDD.

METHODS

After a pilot study, a prospective observational trial was performed in 34 mongrel dogs. The experiment comprised of segmental resection and anastomosis of the colon, fixation of the FDD, and observation for 3 weeks (n = 15) and more than 3 weeks (n = 19) without initiation of parenteral nutrition.

RESULTS

Four cases of perioperative death unrelated to the FDD were excluded. Twenty-six (87 %) of the 30 dogs survived. Sixteen (53 %) dogs were able to retain the FDD for more than 3 weeks until 82 days. The autopsy findings revealed that four (15 %) dogs showed colonic wall erosions and mucosal scarring respectively at the band fixation area without evidence of serious septic complications. The surviving dogs retained the FDD for more than 6 days. Mortality occurred in four of the five dogs that expelled the FDD within three postoperative days. A closed abscess cavity as the evidence of anastomotic leakage was noted in seven (23 %) of the surviving dogs.

CONCLUSIONS

The newly designed fecal diverting device can be retained for more than 3 weeks until 82 days without any serious complications. The FDD may prevent sepsis in case of anastomotic leakage if it is retained for more than 6 days.

One-stage segmental colectomy and primary anastomosis after intraoperative colonic irrigation and total colonoscopy for patients with obstruction due to left-sided colorectal cancer

BACKGROUND

Intraoperative colonic irrigation and intraoperative on-table colonoscopy may be useful for a more accurate diagnosis of colorectal cancer before colectomy in patients with obstructive left-sided colorectal cancer, but the clinical benefit of this technique has not been investigated in large-scale studies.

OBJECTIVE

The aim of this study was to evaluate the usefulness of intraoperative colonic irrigation with a Y-shaped irrigation device and intraoperative colonoscopy in the management of obstructive colorectal cancer in patients undergoing elective surgery.

DESIGN AND SETTING

This was a retrospective cohort study of patients undergoing surgical treatment at a single tertiary care institution in Japan.

PATIENTS AND INTERVENTION

Among 715 consecutive patients with left-sided colorectal cancer, 101 patients (14.1%) with obstructing tumor received intraoperative colonic irrigation and intraoperative colonoscopy before colectomy and primary anastomosis, and 614 patients with nonobstructive colorectal cancer underwent preoperative colonoscopy with mechanical bowel preparation.

MAIN OUTCOME MEASURES

Detection rates of proximal synchronous lesions, occurrence of postoperative complications, and changes in the surgical procedure prompted by the results of the intraoperative colonoscopy were evaluated.

RESULTS

Intraoperative colonoscopy detected synchronous adenomatous polyps in 27 patients (26.8%), carcinoma in 4 patients (4%), and obstructive colitis in 2 patients (2%). Findings of the intraoperative colonoscopy prompted changes in surgical procedure in 9 patients (8.9%). The overall morbidity in the intraoperative group was 17%, with anastomotic leakages in 3 patients, wound infection in 5, and postoperative ileus in 3 patients. The risk of these complications was not increased in patients with intraoperative colonoscopy with intraoperative colonic irrigation compared with those receiving preoperative colonoscopy with mechanical bowel preparation. The operation time was 28 minutes longer in the intraoperative than in the preoperative group, but neither the time to start of oral intake nor the length of postoperative hospital stay was significantly different between the 2 groups.

LIMITATIONS

The study is limited by its retrospective nature.

CONCLUSIONS

: In patients with obstructive colorectal cancer, intraoperative colonic irrigation with intraoperative colonoscopy is a useful strategy for detecting synchronous lesions located proximally to the obstructing tumor, without increasing patient morbidity.

Detection and treatment of synchronous lesions in colorectal cancer: The clinical implication of perioperative colonoscopy

AIM: To evaluate the clinical significance of pre- and intra-operative colonoscopy for the detection of synchronous lesions in colon cancer.

METHODS: Two hundred and sixty-five pre-operative and 51 intra-operative colonoscopic evaluations were performed in 316 colorectal cancer patients who underwent curative resection from January 2001 to June 2006. The incidence and characteristics of synchronous lesions and their influence on surgery were evaluated.

RESULTS: Two hundred and eighty-two synchronous lesions were detected in 124 (39.2%) of 316 patients including all lesions regardless of their histologic type. True adenomatous polyps were found in 91 (28.8%) of 316 patients, and 17 (5.4% of all patients) patients had synchronous colon cancers. The preoperative identification of synchronous lesions altered the planned surgery in 37 (14.0%) of 265 patients. In 18 patients among the surgically removed cases, the lesions were removed by extending the resection range. Further segmental resection or polypectomy through enterotomy was necessary in 19 patients. Nineteen (37.2%) of 51 intraoperative colonoscopy cases had synchronous lesions. Additional surgical procedures including segmental bowel resection and polypectomy with enterotomy were necessary in 7 (13.7%) of 51 intraoperative colonoscopy cases to remove the lesions.

CONCLUSION: Synchronous colorectal polyps or cancer are frequent and their preoperative detection is important for optimal surgical planning and treatment. Intraoperative colonoscopy is a useful option in cases where a preoperative colonoscopy is not feasible.