Management of obstructive colorectal cancer with endoscopic stenting followed by single-stage surgery: open or laparoscopic resection? Surg Endosc. 2008;22:1477-1481. [PMID: 18027039 DOI: 10.1007/s00464-007-9654-5]

Laparoscopic versus open surgery in obstructive colorectal cancer patients following stents placement: a comprehensive meta-analysis of cohort studies

BACKGROUND

Over the past decade, the use of stent placement as a bridge to surgery (BTS) has emerged as an alternative to emergency surgery for patients with (OCRC). However, the optimal surgical approach remains indeterminate. This study seeks to evaluate the safety and feasibility of a combined treatment modality involving stent placement and laparoscopic surgery for OCRC presenting with malignant obstruction.

METHODS

A comprehensive search of PubMed, Cochrane Library, EMBASE, Web of Science, and ClinicalTrials.gov was conducted until June 2023 to identify studies that compared laparoscopic to open surgery in patients with OCBC following stent insertion.

RESULTS

The meta-analysis incorporated 12 cohort studies, encompassing 933 patients. There was no statistically significant difference in the 30-day mortality rates between the two groups (relative risk [RR], 1.09; 95% confidence interval [CI] 0.26 to 4.48; P = 0.95). Compared to the laparoscopic approach group, the open approach group had a higher rate of overall postoperative complications (POCs) (RR 0.52; 95% CI 0.37 to 0.72, P < 0.0001). There was no significant variance in lymph node (LN) dissection number between the groups (mean differences [MD], 1.64; 95% CI - 1.51 to 4.78; P = 0.31). Notably, laparoscopic surgery resulted in less intraoperative blood loss (MD, - 25.84 ml; 95% CI - 52.16 to 0.49; P = 0.05) and a longer operation time (MD, 20.99 mins; 95% CI 2.31 to 39.44; P = 0.03). The laparoscopic approach was associated with a shorter length of hospital stay (LOS) (MD - 3.29 days; 95% CI - 5.27 to 1.31; P = 0.001). Conversely, the open approach group had a higher rate of postoperative surgical site infection (SSI) (RR 0.47; 95% CI 0.23 to 0.96, P = 0.04). Although the number of included studies was insufficient to conduct a meta-analysis, several of them imply that laparoscopic surgery may yield more favorable outcomes in terms of the 3-year overall survival rate (OS), 3-year disease-free survival rate (DFS), 5-year OS, and 5-year DFS when compared to open surgery. It is worth noting that these differences lack statistical significance.

CONCLUSION

In patients with OCRC subjected to stent insertion, laparoscopic surgery arguably presents a modest superiority over open surgery by diminishing the overall postoperative risk and potentially reducing the LOS.

Fluoroscopic Stent Placement as a Bridge to Surgery for Malignant Colorectal Obstruction: Short- and Long-Term Outcomes

Purpose

To assess the outcomes of single-stage surgery following fluoroscopic stent placement for malignant colorectal obstruction.

Materials and Methods

This retrospective study included 46 patients (28 male and 18 female; mean age, 67.2 years) who had undergone fluoroscopic stent placement followed by laparoscopic resection (n = 31) or open surgery (n = 15) for malignant colorectal obstruction. The surgical outcomes were analyzed and compared. After a mean follow-up of 38.9 months, the recurrence-free and overall survival were estimated, and prognostic factors were evaluated.

Results

The mean interval between stent placement and surgery was 10.2 days. Primary anastomosis was possible in all patients. The mean postoperative length of hospitalization was 11.0 days. Bowel perforation was detected in six patients (13.0%). During the follow-up, ten patients (21.7%) developed recurrence; these included five of the six patients with bowel perforation. Bowel perforation had a significant effect on recurrence-free survival (p = 0.010).

Conclusion

Single-stage surgery following fluoroscopic stent placement may be effective for treating malignant colorectal obstruction. Stent-related bowel perforation is a significant predictive factor for tumor recurrence.

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.

Biopsy sampling during self-expandable metallic stent placement in acute malignant colorectal obstruction: a narrative review

BACKGROUND

Histopathology is a crucial part of diagnosis and treatment guidance of colorectal cancer. In Denmark, it is not routine to biopsy during self-expandable metallic stent (SEMS) placement as a treatment option for acute colorectal obstruction of unknown etiology. This is due to lack of knowledge about the risks of hemorrhage, and thus the risk to aggravate the deteriorating overview conditions. Therefore, the aim of this study is to investigate whether there is evidence to avoid biopsy sampling during acute SEMS placement.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies. Studies were included if they described biopsy sampling in relation to SEMS placement. Additionally, national and international guidelines were scrutinized on Google and by visiting the websites of national and international gastrointestinal societies.

RESULTS

In total, 43 studies were included in the review. Among these, one recommended biopsy during SEMS placement, three advised against biopsy, 23 just reported biopsy was performed during the procedure, and 16 reported biopsy before or after the procedure, or the timing was not specified. Among the 12 included guidelines, only two described biopsy during SEMS placement.

CONCLUSION

The literature on the subject is limited. In 24 of the 43 included studies, biopsy sampling was done during SEMS placement without reporting a decrease in the technical success rate. The included guidelines were characterized by a general lack of description of whether biopsy during SEMS placement should be performed or not. Prospective studies are needed in order to establish the real risk of hemorrhage, if any, when a biopsy is obtained.

Short- and long-term outcomes after colonic self-expandable metal stent placement for malignant large-bowel obstruction as a bridge to surgery focus on the feasibility of the laparoscopic approach: a retrospective, single center study

Purpose

Malignant large-bowel obstruction (MLBO) is a highly urgent condition in colorectal cancer with high complication rates. Self-expandable metal stent (SEMS) placement in MLBO is a new decompression treatment in Japan. Preoperative stent placement (bridge to surgery: BTS) avoids emergency surgery, but oncological influences of stent placement and post-BTS surgical approach remain unclear. We examined short- and long-term results of surgery for MLBO after SEMS placement in our hospital.

Methods

We retrospectively reviewed 75 patients with MLBO who underwent resection after SEMS placement at our hospital from June 2013 to December 2018. Postoperative morbidity and mortality were evaluated by comparison with the surgical approach.

Results

Tumor location was significantly higher in the left-side colon and rectum (n = 59, 78.7%) than right-side colon (n = 16, 21.3%). Technical and clinical success rates for SEMS placement were 97.3% and 96.0%, respectively. Laparoscopic surgery was performed in 54 patients (69.0%), and one-stage anastomosis was performed in 73 (97.3%). Postoperative complications were similar in the open surgery (open) group (n = 5, 23.8%) and laparoscopic surgery (lap) group (n = 7, 13.0%), with no severe complications requiring reoperation. Three-year overall survival (OS) and relapse-free survival (RFS) rates were not significantly different in the lap vs open group (67.5% vs 66.4%; 82.2% vs 62.5%).

Conclusion

Preoperative stent treatment avoids stoma construction but allows anastomosis. One-time surgery was performed safely contributing to minimally invasive treatment and acceptable short- and long-term results.

A Comparison of Open and Laparoscopic-assisted Colectomy for Obstructive Colon Cancer

BACKGROUND/AIM

We performed a retrospective multi-center cohort analysis to compare the outcomes of laparoscopic surgery vs. open surgery for obstructive colon cancer.

PATIENTS AND METHODS

A total of 455 patients with colon cancer with ileus underwent surgery at Yokohama City University Hospital and four related institutions from April 2000 to March 2016.

RESULTS

There were 414 cases in the open surgery group and 41 cases in the laparoscopic surgery group with no marked differences in the gender or age. The postoperative complication rate, according to the Clavien-Dindo classification, was lower in the laparoscopic group compared to the open surgery group. The postoperative hospital stay was 16 days in the open surgery group and 9 days in the laparoscopic surgery group (p=0.004). Among the various factors examined, the operation approach was identified as a statistically significant independent risk factor for postoperative complications (p=0.015).

CONCLUSION

Preoperative treatment for colon cancer with ileus and elective laparoscopic surgery are thought to be useful for achieving curative treatment, avoiding colostomy, and shortening the length of hospital stay.

Short-term outcomes of laparoscopic approach to colonic obstruction for colon cancer

BACKGROUND

We speculated that a laparoscopic approach to emergent/urgent partial colectomy for colonic obstruction would be associated with less morbidity and shorter length of stay with similar mortality to open colectomy. We compared the outcomes of laparoscopic and open approaches to emergent/urgent partial colectomy for colonic obstruction from colonic cancer using data from the National Surgical Quality Improvement Program (NSQIP) database for the period of 2012-2017.

METHODS

Multivariate analysis compared NSQIP data points following laparoscopic, laparoscopic converted to open, and open colectomy for emergent/urgent colectomy for colonic obstruction from colon cancer from 2012 to 2017.

RESULTS

A total of 1293 patients who underwent emergent colectomy for colon obstruction from colon cancer during 2012-2017 were identified within the NSQIP database. Laparoscopic approach was used for colonic obstruction in 19.3% of operations with a conversion rate of 28.5%. A laparoscopic approach to obstructing colonic cancers was associated with lower morbidity (50% vs. 61.8%, AOR: 0.67, P = 0.01) and shorter hospitalization length (10 days vs. 13 days, mean difference: 3 days, P < 0.01) compared with an open approach. However, the mean operation duration was longer in laparoscopic operations than open operations (159 min vs. 137 min, P < 0.01).

CONCLUSION

A laparoscopic approach to malignant colonic obstruction is associated with decreased morbidity. This suggests that efforts should be directed towards increasing the utilization of laparoscopic approaches for the surgical treatment of colonic obstruction.

Colon metal stents as a bridge to surgery had no significant effects on the perineural invasion: a retrospective study

Purpose

The long-term oncological effects of self-expandable metallic stent (SEMS) as a “bridge to surgery” are contradictory, and perineural invasion was supposed to be enhanced by the stenting. In this retrospective study, we compared the perineural invasion and the oncological outcomes between the stent as a bridge to surgery (SBTS)- and emergency surgery (ES)-treated patients to evaluate the results of stenting on the perineural invasion.

Methods

The clinical data of patients with acute intestinal obstruction caused by colorectal cancer from January 2013 to January 2017 were retrospectively collected. Forty-three patients underwent semi-elective curative resection after endoscopic SEMS insertion, and sixty-three underwent ES. The adverse events and long-term follow-up outcomes were assessed. The clinicopathological characteristics, perineural invasion rates, and survival rates were compared between the two patient groups.

Results

Stent insertion resulted in significantly lower stoma rate (32.6% vs 46%; P = 0.03), post-operative overall complication rate (11.6% vs 28.6%, P = 0.038), and total hospital stay (17.07 ± 5.544 days vs 20.48 ± 7.372 days, P = 0.042). Compared with the ES group, there was no significant increase in the incidence of peripheral invasion in the SBTS group (39.5% vs 47.6%, P = 0.411). No significant difference was noted in the survival rate and long-term prognosis between the SEMS and ES groups (P = 0.964). The technical success rate was 95.6%, and the clinical success rate was 97.7%.

Conclusions

Preoperative colon stenting was an effective transitional method for colorectal cancer patients with complete obstruction. Short-term stent implantation had no significant effect on perineural invasion in patients with CRC.

Successful single-stage laparoscopic surgery using a preoperative self-expanding metallic stent in patients with obstructive colorectal cancer

INTRODUCTION

Although a self-expanding metallic stent (SEMS) or a transnasal or transanal decompression tube is sometimes used as a bridge to surgery in patients with obstructive colorectal cancer, the optimal decompression procedure to achieve successful laparoscopic surgery remains unclear.

METHODS

Forty-two patients with obstructive colorectal cancer who were preoperatively decompressed by using SEMS (the SEMS group, n = 20) or a decompression tube (the DT group, n = 22) between January 2010 and February 2017 were included in this retrospective study.

RESULTS

In the SEMS group, 20 patients (100%) were able to eat and 17 patients (85%) were able to undergo total colonoscopy preoperatively, but no patients could do so in the DT group (P < 0.01 and P < 0.01, respectively). The serum albumin level increased in the time between admission and just before surgery in five patients in the SEMS groups (25%), whereas it decreased in all patients in the DT group (P = 0.037). Laparoscopic surgery was performed more frequently in the SEMS groups (19 patients, 95%) than in the DT group (13 patients, 59.1%) (P = 0.018). Primary anastomosis without stoma was also achieved more frequently in the SEMS groups (19 patients, 95%) than in the DT group (15 patients, 68.2%) (P = 0.047). Anastomotic leakage did not occur in the SEMS group, but it did occur in one patient in the DT group. The recurrence-free survival rate did not differ between the groups (median follow-up period: 21 months).

CONCLUSION

In patients with obstructive colorectal cancer, SEMS appears to be more effective than a decompression tube as a preoperative treatment to achieve successful laparoscopic resection without stoma.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

ᅟ

Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Feasibility of laparoscopic surgery after stent insertion for obstructive colorectal cancer

INTRODUCTION

A growing number of patients with obstructive colorectal cancer are being treated with self-expanding metallic stents (SEMS) followed by laparoscopic resection. The aim of this study was to assess the feasibility of stent insertion and laparoscopic surgery for obstructive colorectal cancer and to compare these outcomes to regular laparoscopic surgery for non-obstructive colorectal cancer.

METHODS

We retrospectively analyzed the outcomes of patients with a malignant colonic obstruction who underwent SEMS placement followed by elective laparoscopic resection. The comparison was made between stent-laparoscopy and laparoscopy alone for non-obstructive colorectal cancer.

RESULTS

Colonic stenting as a bridge to surgery was successful in 97.1% of all cases. Fifteen patients underwent an elective laparoscopic surgery for left-sided colon and rectal cancer after SEMS. The mean interval from SEMS insertion to laparoscopic surgery was 21.5 days. There was no conversion to open surgery and no need for a diverting stoma. One patient (6.7%) experienced paralytic ileus. Our comparison of stent-laparoscopy to regular laparoscopy for non-obstructive colorectal cancer treatment showed comparable short-term postoperative outcomes with the exception of blood loss, which was greater in the stent-laparoscopy group.

CONCLUSION

Elective laparoscopic surgery after colonic stenting is a safe and feasible strategy for the treatment of an acute malignant colonic obstruction.

Should patients With obstructing colorectal cancer have proximal diversion?

BACKGROUND

Up to 20% of patients with colorectal cancer present with obstruction. The goal of this study was to compare the short-term outcomes of patients with obstructing colon cancer who underwent resection and primary anastomosis with or without proximal diversion.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program Procedure Targeted Colectomy databases from 2012 to 2014 were reviewed. Patients undergoing colorectal resection with or without diverting ostomy for obstructing colorectal cancer were analyzed. Propensity score-matched cohorts of diverted and nondiverted patients were created accounting for patient characteristics. The primary outcomes were 30-day mortality, postoperative complications, and readmission.

RESULTS

There were 2,323 patients (92%) with no proximal diversion and 204 patients (8%) with proximal diversion. In univariate analysis, patients with colorectal resection with diversion were significantly more likely to have any complication (P = .001), sepsis (P = .01), and blood transfusion (P = .001). Diversion patients were also significantly more likely to be readmitted to the hospital within 30 days of the index procedure (P = .02). Proximal diversion was associated with any complication (P = .01), failure to wean off ventilator (P = .05), and longer length of stay (P = .01) in matched cohorts.

CONCLUSIONS

Proximal diversion in the setting of obstructive colorectal cancer is associated with higher rates of any complication, deep wound infection, sepsis, and readmission. Surgeons who perform a primary anastomosis with diversion for obstructing colorectal cancer should take into account the significant risk for postoperative complications.

Open surgery versus laparoscopic surgery after stent insertion for obstructive colorectal cancer

PURPOSE

To compare the outcomes of laparoscopic surgery vs. open surgery after insertion of a colonic stent for obstructive colorectal cancer.

METHODS

Between April 2005 and August 2013, 58 patients underwent surgery after the insertion of a colonic stent for obstructive colorectal cancer. We analyzed the outcomes of the patients who underwent laparoscopic surgery vs. those who underwent open surgery.

RESULTS

We compared blood loss, operative time, hospital stay, and complications in 26 patients who underwent laparoscopic surgery and 32 patients who underwent open surgery. Blood loss was significantly less in the laparoscopic surgery group, but operative time was significantly shorter in the open surgery group. The length of hospital stay was shorter in the laparoscopic surgery group than in the open surgery group, but the difference was not significant. There was no significant difference in postoperative surgical complications between the groups.

CONCLUSION

The patients who underwent laparoscopic resection had less blood loss, although no significant difference was found in postoperative morbidity or mortality. Thus, laparoscopic resection after stent insertion is a feasible and safe option for patients with obstructive colorectal cancer.

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

BACKGROUD

The efficacy and safety of self-expandable metallic stents (SEMSs) as a bridge for patients with acute malignant colorectal obstructions (AMCOs) are still controversial. We conducted this study to evaluate the outcomes of patients with AMCOs treated by different strategies.

METHODS

From January 2010 to March 2014, a total of 171 patients with AMCOs from Zhongshan Hospital were retrospectively enrolled in this study. One hundred twenty patients successfully received stent placement followed by one-stage laparoscopic or open resection in the stent group, and 51 patients received emergency operations in the emergency group.

RESULTS

The operation duration and postoperative hospital stay were significantly shorter in the stent group (114.51 ± 28.65 vs. 160.39 ± 58.94 min, P < 0.001; 8.00 ± 3.97 vs. 12.59 ± 9.07 days, P = 0.001). The stent group also had significantly reduced intraoperative blood loss and the incidence of postoperative complications compared with the emergency group (61.00 ± 43.70 vs. 121.18 ± 85.90 ml, P < 0.001; 16.7 vs. 37.3%, P = 0.003). Kaplan-Meier survival curves showed that the median survival time in the stent group was significantly longer than that in the emergency group (53 vs. 41 months, P = 0.034). In subgroup analysis of stent group, the stent laparoscopy group had significantly decreased postoperative complications (P = 0.025), and similar long-term survival (P = 0.81).

CONCLUSIONS

Stent placement as a bridge to surgery is a safe and feasible procedure and provides significant advantages in terms of short-term outcomes and favorable prognoses for patients with AMCOs. Laparoscopic surgery could be considered as an optimal treatment after stent placement.

Role of self-expanding metal stents in patients with malignant colorectal obstruction: A systematic review and meta-analysis

AIM: To assess the safety and efficacy of self-expandable metal stents (SEMSs) for malignant colorectal obstruction.

METHODS: Data regarding technical success, clinical success, and procedure related complications were collected from included studies. DerSimonian-Laird random effects model was used to generate the overall outcome. Thirty international studies with a total of 2058 patients with malignant colorectal obstruction were included.

RESULTS: The technical and clinical success rates for SEMS placement were 94% (95%CI: 92-96) and 91% (95%CI: 88-93), respectively. Overall complication rate for SEMS was 23% (95%CI: 18-29). Stent migration 8% (95%CI: 6-10) and stent obstruction 8% (95%CI: 6-11) were the most common complications, followed by perforation 5% (95%CI: 4%-7%). Surgical or endoscopic re-interventions were needed in 14% (95%CI: 10-18) of patients. Endoscopic repeat stent placement was required in 8% (95%CI: 6-10), while surgical intervention was needed in 6% (95%CI: 4-8).

CONCLUSION: SEMS are effective when used as palliation or bridge to surgery for malignant colorectal obstruction with high technical and clinical success. About 14% of patients require repeat endoscopic or surgical intervention for stent failure or to manage stent related complications.

Comparative Study on Therapeutic Efficacy Between Hand-Assisted Laparoscopic Surgery and Conventional Laparotomy for Acute Obstructive Right-Sided Colon Cancer

INTRODUCTION

This retrospective study aims to compare open colectomy and hand-assisted laparoscopic surgery (HALS) in the management of acute obstructive right-sided colon cancer and to analyze and evaluate the feasibility and safety of HALS.

PATIENTS AND METHODS

Ten consecutive patients who underwent hand-assisted laparoscopic right hemicolectomy due to acute obstructive right-sided colon cancer were retrospectively well matched with 25 patients scheduled for a conventional laparotomy during the same time. Demographic, intraoperative, and postoperative data were assessed.

RESULTS

The HALS group had the advantage in the length of incision (5.8±0.7 cm) over the conventional group (16±2.3 cm) (P<.05), and the mean blood loss during the operations was significantly less in the HALS group (30±15.2 mL) than in the laparotomy group (90±29.4 mL) (P<.05). Moreover, the time of postoperative ambulation was earlier (2.5±0.8 days versus 3.2±0.9 days) (P<.05). Seven cases underwent intestinal decompression for severe intestinal dilatation and had a satisfactory result. The hand-assisted device can fairly meet the demands of a minimally invasive operation and can protect the abdominal incision and avoid infection. There was no intergroup difference in complication rate, although the conventional group had a higher rate.

CONCLUSIONS

In this study, compared with conventional laparotomy for acute obstructive right-sided colon neoplasm, HALS is associated with less blood loss, shorter incision, and earlier ambulation. Emergency laparoscopic-assisted right hemicolectomy can be safely performed in patients with obstructing right-sided colonic carcinoma. If practiced more, it might be advocated as a bridge between the conventional open approach and traditional laparoscopic surgery.

Systematic review of emergent laparoscopic colorectal surgery for benign and malignant disease

Laparoscopic surgery has become well established in the management of both and malignant colorectal disease. The last decade has seen increasing numbers of surgeons trained to a high standard in minimally-invasive surgery. However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery. There is a perception that emergent surgery is technically more difficult and may lead to worse outcomes. The present review aims to provide a comprehensive and critical appraisal of the available literature on the use of laparoscopic colorectal surgery (LCS) in the emergency setting. The literature is broadly divided by the underlying pathology; that is, inflammatory bowel disease, diverticulitis and malignant obstruction. There were no randomized trials and the majority of the studies were case-matched series or comparative studies. The overall trend was that LCS is associated with shorter hospital stay, par or fewer complications but an increased operating time.Emergency LCS can be safely undertaken for both benign and malignant disease providing there is appropriate patient selection, the surgeon is adequately experienced and there are sufficient resources to allow for a potentially more complex operation.

Colorectal stenting: An advanced approach to malignant colorectal obstruction

Some colorectal cancer (CRC) patients present symptoms of bowel obstruction, which is considered a surgical emergency. Because of poor medical condition and high incidence of post-surgical complications, there has been increasing use of self-expanding metal stents (SEMS) for the purpose of palliation or as a bridge to surgery with some benefits, including shorter hospital stays, lower rates of adverse events, and one-stage surgery. However, with increasing survival of CRC patients, there have been controversial data on clinical outcomes and complications, compared between SEMS use and surgery for treatment of malignant bowel obstruction. We review recent clinical data on clinical outcomes of SEMS use compared to surgery, including complications.

Palliative care and end-stage colorectal cancer management: The surgeon meets the oncologist

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Perforation in colorectal stenting: a meta-analysis and a search for risk factors

BACKGROUND

Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement.

OBJECTIVE

To identify risk factors for perforation from colonic stenting.

DESIGN

A meta-analysis of 86 studies published between 2005 and 2011.

SETTING

Multicenter review.

PATIENTS

All patients who underwent colorectal stent placement.

INTERVENTION

Colorectal stent placement.

MAIN OUTCOME MEASUREMENTS

The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab.

RESULTS

A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%).

LIMITATIONS

Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis.

CONCLUSIONS

The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.

Short- and long-term outcomes after laparoscopic versus open emergency resection for colon cancer: an observational propensity score-matched study

BACKGROUND

Case series suggest the feasibility and safety of emergency resection of colon cancer by laparoscopy. The present study compares short- and long-term outcomes of laparoscopic and open resection for colon cancers treated as emergencies.

METHODS

The study was a propensity score-matched design based on a prospective database. From October 2006 to December 2011, emergency laparoscopic colon cancer resections were 1:2 propensity score-matched to open cases. Covariates for match-estimation were age, gender, American Society of Anesthesiologists grade, procedure type, tumor site, and reason for emergency surgery. Short-term outcomes included oncological quality surrogates (lymph node harvest and R stage), need for a stoma, length of hospital stay, and postoperative complications. For long-term outcomes, overall and recurrence-free survival rates were analyzed with Kaplan-Meier curves.

RESULTS

During the study period, a total of 217 colon cancers were resected (181 open and 36 laparoscopic) as emergencies. The laparoscopic cases were matched to 72 open cases. Median follow-up was 3.6 [95 % confidence interval (CI) 2.3-4.3] years. The overall 3-year survival rate was 51 % (95 % CI 35-76) in the laparoscopic group versus 43 % (95 % CI 32-58) in the open group (p = 0.24). The 3-year recurrence-free survival rate in the laparoscopic group was 35 % (95 % CI 20-60) versus 37 % (95 % CI 27-50) in the open group (p = 0.53). Median lymph node harvest (17 vs. 13 nodes; p = 0.041) and median length of hospital stay (7.5 vs. 11.0 days; p = 0.019) favored laparoscopy.

CONCLUSIONS

Our data suggest that selective emergency laparoscopy for colon cancer is not inferior to open surgery with regard to short- and long-term outcomes. Laparoscopy resulted in a shorter length of hospital stay.

Status and literature review of self-expandable metallic stents for malignant colorectal obstruction

Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.

Self-expanding metallic stents for palliation and as a bridge to minimally invasive surgery in colorectal obstruction

Self-expanding metallic stents are effective for the palliation of malignant obstruction. This study indicates that stents for bowel obstruction may allow for minimally invasive surgical intervention with a shorter hospital stay, lower stoma rate, and earlier chemotherapy administration.

Background and Objectives:

Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. Emergency procedures had an associated mortality rate of 10% to 30%. This encouraged development of other options, most notably self-expanding metallic stents. The primary endpoint of this study to is to report our group's experience.

Methods:

We performed a retrospective review of 37 patients who underwent self-expanding metallic stent placement for colorectal obstruction between July 2000 and May 2012. Data collected were age, comorbidities, diagnosis, intent of intervention (palliative vs bridge to surgery), complications, and follow-up.

Results:

The study comprised 21 men (56.76%) and 16 women (43.24%), with a mean age of 67 years. The intent of the procedure was definitive treatment in 22 patients (59.46%) and bridge to surgery in 15 (40.54%). The highest technical success rate was at the rectosigmoid junction (100%). The causes of technical failure were inability of the guidewire to traverse the stricture and bowel perforation related to stenting. The mean follow-up period was 9.67 months. Pain and constipation were the most common postprocedure complications.

Discussion:

The use of a self-expanding metallic stent has been shown to be effective for palliation of malignant obstruction. It is associated with a lower incidence of intensive care unit admission, shorter hospital stay, lower stoma rate, and earlier chemotherapy administration. Laparoscopic or robotic surgery can then be performed in an elective setting on a prepared bowel. Therefore the patient benefits from advantages of the combination of 2 minimally invasive procedures in a nonemergent situation. Further large-scale prospective studies are necessary.

Self-expandable metallic stent placement plus laparoscopy for acute malignant colorectal obstruction

AIM: To investigate the clinical advantages of the stent-laparoscopy approach to treat colorectal cancer (CRC) patients with acute colorectal obstruction (ACO).

METHODS: From April 2008 to April 2012, surgery-related parameters, complications, overall survival (OS), and disease-free survival (DFS) of 74 consecutive patients with left-sided CRC presented with ACO who underwent self-expandable metallic stent (SEMS) placement followed by one-stage open (n = 58) or laparoscopic resection (n = 16) were evaluated retrospectively. The stent-laparoscopy group was also compared with a control group of 96 CRC patients who underwent regular laparoscopy without ACO between January 2010 and December 2011 to explore whether SEMS placement influenced the laparoscopic procedure or reduced long-term survival by influencing CRC oncological characteristics.

RESULTS: The characteristics of patients among these groups were comparable. The rate of conversion to open surgery was 12.5% in the stent-laparoscopy group. Bowel function recovery and postoperative hospital stay were significantly shorter (3.3 ± 0.9 d vs 4.2 ± 1.5 d and 6.7 ± 1.1 d vs 9.5 ± 6.7 d, P = 0.016 and P = 0.005), and surgical time was significantly longer (152.1 ± 44.4 min vs 127.4 ± 38.4 min, P = 0.045) in the stent-laparoscopy group than in the stent-open group. Surgery-related complications and the rate of admission to the intensive care unit were lower in the stent-laparoscopy group. There were no significant differences in the interval between stenting and surgery, intraoperative blood loss, OS, and DFS between the two stent groups. Compared with those in the stent-laparoscopy group, all surgery-related parameters, complications, OS, and DFS in the control group were comparable.

CONCLUSION: The stent-laparoscopy approach is a feasible, rapid, and minimally invasive option for patients with ACO caused by left-sided CRC and can achieve a favorable long-term prognosis.

Clinical and oncologic safety of laparoscopic surgery for obstructive left colorectal cancer following transanal endoscopic tube decompression

BACKGROUND

Little information has been available concerning the safety of laparoscopic resection of obstructive colorectal cancer after transanal endoscopic tube decompression (TETD). The aim of this study was to assess the short- and long-term outcomes of laparoscopic surgery following TETD for such advanced colorectal cancer.

METHODS

A retrospective review was performed of 40 patients with obstructive left colorectal cancer whose distended bowels were treated with TETD before laparoscopic surgery, between January 2001 and March 2011 (TETD group). The elective surgery resulted in potentially curative resection of the tumor in all cases. Their clinical records were compared to those of 80 matched controls with nonobstructive left colorectal cancer resected laparoscopically during the same period (control group).

RESULTS

Operative time, blood loss, and the rate of conversion to laparotomy were comparable between the two groups. There were no significant between-group differences in morbidity rates. Five-year overall survival rates in the TETD and control groups were 71.9 and 75.4%, respectively, with no statistical difference. Disease-free survival rates after 5 years were also similar (TETD group, 64.5% vs. control group, 66.3%). There were no significant differences between the two groups in recurrence rates and patterns.

CONCLUSION

These results suggest that laparoscopic surgery following TETD is clinically and oncologically safe and could be a treatment of choice for obstructive left colorectal cancer.

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

BACKGROUND

The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.

METHODS

Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.

RESULTS

Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %.

CONCLUSIONS

In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

Non-resection versus resection for an asymptomatic primary tumour in patients with unresectable stage IV colorectal cancer

BACKGROUND

In a majority of patients with stage IV colorectal cancer, the metastatic disease is not resectable and the focus of management is on how best to palliate the patient. How to manage the primary tumour is an important part of palliation. A small proportion of these patients present with either obstructing or perforating cancers and require urgent surgical care. However, a majority are relatively asymptomatic from their primary cancer. Chemotherapy has been shown to prolong survival in this group of patients, and a majority of patients would be treated this way. Nonetheless, A recent meta-analysis (Stillwell 2010) suggests an improved overall survival and reduced requirement for emergency surgery in those patients who undergo primary tumour resection. This review was also able to quantify the mortality and morbidity associated with surgery to remove the primary.

OBJECTIVES

To determine if there is an improvement in overall survival following resection of the primary cancer in patients with unresectable stage IV colorectal cancer and an asymptomatic primary who are treated with chemo/radiotherapy.

SEARCH METHODS

In January 2012 we searched for published randomised and non-randomised controlled clinical trials without language restrictions using the following electronic databases: CENTRAL (the Cochrane Library (latest issue)), MEDLINE (1966 to date), EMBASE (1980 to date), Science Citation Index (1981 to date), ISI Proceedings (1990 to date), Current Controlled Trials MetaRegister (latest issue), Zetoc (latest issue) and CINAHL (1982 to date).

SELECTION CRITERIA

Randomised controlled trials and non-randomised controlled studies evaluating the influence on overall survival of primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who are treated with palliative chemo/radiotherapy.

DATA COLLECTION AND ANALYSIS

We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group. "Review Manager 5" software was used.

MAIN RESULTS

A total of 798 studies were identified following the initial search. No published or unpublished randomised controlled trials comparing primary tumour resection versus no resection in asymptomatic patients with unresectable stage IV colorectal cancer who were treated with chemo/radiotherapy were identified. Seven non-randomised studies, potentially eligible for inclusion, were identified: 2 case-matched studies, 2 CCTs and 3 retrospective cohort studies. Overall, these trials included 1.086 patients (722 patients treated with primary tumour resection, and 364 patients managed first with chemotherapy and/or radiotherapy).

AUTHORS' CONCLUSIONS

Resection of the primary tumour in asymptomatic patients with unresectable stage IV colorectal cancer who are managed with chemo/radiotherapy is not associated with a consistent improvement in overall survival. In addition, resection does not significantly reduce the risk of complications from the primary tumour (i.e.  obstruction, perforation or bleeding). Yet there is enough doubt with regard to the published literature to justify further clinical trials in this area. The results from an ongoing high quality randomised controlled trial will help to answer this question.

Colorectal stents: do we have enough evidence?

BACKGROUND

The use of colonic stents has significantly evolved over the last few years. Emergency surgery for colonic obstructions is usually associated with significant mortality, morbidity and often stoma formation. Colonic stents provide an alternative way to relieve colonic obstruction, and hence avoiding the risks associated with emergency surgery. This literature review aims to summarize the important current evidence regarding colorectal stenting and show whether further evaluation of the procedure is required.

RESULTS

The available large number of non-randomized studies suggests that Self-Expandable-Metal-Stents (SEMS) placement for acute colonic obstruction could be considered as safe and effective alternative to surgery in experienced hands either as a bridge to surgery or as a palliative measure. This evidence has led to SEMS being widely adopted. However, randomized evidence has begun to show the defects that are inherent in the low level evidence that has so far supported SEMS use and it may be that reports of randomized controlled trials may clarify the patient population where SEMS placement is appropriate.

CONCLUSION

While we are still waiting for the outcome of the multicentre randomized controlled trials in the UK and Europe, clinicians must be aware of the current evidence limitations and apply SEMS use pragmatically.

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.

Hybrid approach for left-sided colonic carcinoma obstruction; a case report

Traditionally, there are several approaches to manage left-sided colonic carcinoma obstruction, such as tumor resection with primary anastomosis, tumor resection with end-colostomy and loop-colostomy. Recently, colonic stent insertion was introduced as a bridge prior to definite surgery. We demonstrated a hybrid approach for obstructed sigmoid carcinoma using colonic stent, followed by single incision laparoscopic colectomy (SILC). A 58 year-old man presented with complete left-sided colonic obstruction. He underwent emergency colonoscopy with metallic stent placement. One week later, he was performed SILC. He recovered well after the operation without any postoperative complications. The pathological result showed adequacy of oncologic resection. This hybrid approach of colonic stent insertion and SILC can be safely performed.

Efficacy and safety of colonic stenting for malignant disease in the elderly

BACKGROUND

Self-expandable metal stents (SEMS) are an accepted palliation for malignant colorectal obstruction. Outcomes of stent insertion solely in older patients are unknown.

OBJECTIVE

To compare outcomes of SEMS insertion for malignant colorectal disease, in older versus younger patients.

METHODS

Forty-three patients were retrospectively identified as having undergone SEMS insertion for obstructing colorectal cancer. Of these, 24 were > or = 70 years of age (older patient group) and 19 were <70 years of age (younger patient group).

RESULTS

There was no significant difference in successful SEMS insertion between the groups (88% in older versus 100% in younger patients, p > 0.05). Furthermore, the complication rate was similar in both groups (12.5% versus 26%, p > 0.10). There was no difference in median survival (113 days versus 135 days, p > 0.09).

CONCLUSION

Colorectal stenting for malignant disease in older patients is both safe and effective with comparative success and complication rates to a younger population.

CT colonography after metallic stent placement for acute malignant colonic obstruction

PURPOSE

To evaluate the feasibility of using computed tomographic (CT) colonography for preoperative examination of the proximal colon after metallic stent placement in patients with acute colon obstruction caused by colorectal cancer.

MATERIALS AND METHODS

Institutional review board approval was obtained, and patient informed consent was waived. Fifty patients (mean age +/- standard deviation, 58.5 years +/- 11.7), who demonstrated no postprocedural complication after successful placement of self-expandable metallic stents to treat acute colon obstruction caused by cancer, underwent CT colonography 1-43 days (median, 5 days) after stent placement. CT colonography was performed after cathartic preparation by using magnesium citrate (n = 20) or sodium phosphate (n = 3), combined with oral bisacodyl, or by using polyethylene glycol (n = 27). Fecal/fluid tagging was achieved by using 100 mL of meglumine diatrizoate. The colon was distended by means of pressure-monitored CO(2) insufflation. The sensitivity and specificity of CT colonography in evaluating the colon proximal to the stent and CT colonography-related complications were assessed. The 95% confidence intervals (CIs) were calculated for proportional data.

RESULTS

Per-lesion and per-patient sensitivities of CT colonography for lesions 6 mm or larger in diameter in the colon proximal to the stent were 85.7% (12 of 14 lesions; 95% CI: 58.8%, 97.2%) and 90% (nine of 10 patients; 95% CI: 57.4%, 99.9%), respectively. CT colonography depicted all synchronous cancers (two lesions) and advanced adenomas (five lesions). Per-patient specificity for lesions 6 mm and larger in the proximal colon was 85.7% (18 of 21 patients; 95% CI: 64.5%, 95.9%). CT colonography did not generate any false diagnosis of synchronous cancer. False-positive findings at CT colonography did not result in a change in surgical plan for any patients. No CT colonography-associated stent dislodgment/migration or colonic perforation occurred in any patient (95% CI: 0%, 6.2%).

CONCLUSION

CT colonography is a safe and useful method for preoperative examination of the proximal colon after metallic stent placement in patients with acute colon obstruction caused by cancer. (c) RSNA, 2010.

Role of self-expanding metallic stents in the management of malignant obstruction of the proximal colon

PURPOSE

Expandable metal stents have been shown to be effective in the management of malignant large-bowel obstruction. However, right colonic lesions account for less than 5% of all reported cases of colonic stenting. This study was performed to determine the outcomes following stenting for lesions proximal to the splenic flexure.

METHODS

The hospital records of patients undergoing stenting for large-bowel obstruction at a district general hospital in northeastern England from 2003 to 2008 were reviewed retrospectively. Data were analyzed to identify patient characteristics, site of obstructing lesion, intent for stenting, and outcomes measured including relief of obstruction, hospital stay, and complications.

RESULTS

Stenting was attempted in 97 patients with malignant large-bowel obstruction. Of these, 16 (16.5%) patients had lesions proximal to the splenic flexure: 8 patients had lesions in the ascending colon and 8 patients had lesions in the transverse colon. Self-expanding metal stents were successful in relieving obstruction in 14 (88%) patients with proximal colonic lesions. Stenting was attempted as a bridge to definitive surgery in five patients and for palliation in nine patients. One patient had poststent bleeding that was managed conservatively, and there were no perforations or stent dislodgements. The mean postprocedure hospital stay was 1.6 days.

CONCLUSIONS

Self-expanding metal stents are safe and effective in the management of malignant large-bowel obstruction proximal to the splenic flexure. The technical and clinical success rates are comparable with those reported for stenting distal colonic lesions.

Endoscopic treatment of colonic obstruction

PURPOSE OF REVIEW

Over the past 15 years, great strides have been made in the nonsurgical management of malignant large bowel obstruction. Progress continues, particularly in the area of self-expanding metal stents. The purpose of this review is to assess the available endoscopic techniques for colonic decompression and document the inexorable trend toward supremacy of the self-expanding metal stent in this arena.

RECENT FINDINGS

Stents are being designed with the structure and function of the colon in mind allowing better and longer-lasting palliation. Improvement in the design of the colonic decompression tube allows a low-tech approach to the palliation of colonic obstruction. Argon plasma coagulation is helpful in restoring continuity of the obstructed colonic lumen in certain circumstances.

SUMMARY

As a consequence of technological innovation and growing expertise in the community, gastroenterology is becoming the go to specialty in the early management and palliation of malignant bowel obstruction.