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Zhang HY, Wang ZJ, Han JG. Impact of self-expanding metal stents on long-term survival outcomes as a bridge to surgery in patients with colon cancer obstruction: Current state and future prospects. Dig Endosc 2024. [PMID: 39188169 DOI: 10.1111/den.14905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 07/23/2024] [Indexed: 08/28/2024]
Abstract
Since self-expanding metal stents (SEMS) were first introduced in acute colon cancer obstruction, the increased rate of primary anastomosis and improved quality of life following SEMS placement have been clearly shown. However, it was demonstrated that SEMS are associated with higher recurrence rates. Although several trials have shown that overall and disease-free survival in patients following SEMS placement is similar with patients undergoing emergency surgery, obstruction and a high incidence of recurrence imposed many concerns. The optimal time interval from SEMS to surgery is still a matter of debate. Some studies have recommended a time interval of ~2 weeks between SEMS insertion and elective surgery. A prolonged interval of time from SEMS insertion to elective surgery and the administration of neoadjuvant chemotherapy (NAC) has been proposed. SEMS-NAC might have advantages for improving the surgical and long-term survival outcomes of patients with acute colon cancer obstruction, which is an optional approach in the management of acute colon cancer obstruction.
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Affiliation(s)
- Hao-Yu Zhang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- Department of General Surgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhen-Jun Wang
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jia-Gang Han
- Department of General Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Sullivan J, Donohue A, Brown S. Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes. Surg Clin North Am 2024; 104:631-646. [PMID: 38677826 DOI: 10.1016/j.suc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2024]
Abstract
Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.
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Affiliation(s)
- Joshua Sullivan
- Department of General Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Liberty, NC 28310, USA
| | - Alec Donohue
- Department of General Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Liberty, NC 28310, USA
| | - Shaun Brown
- Department of General Surgery, Womack Army Medical Center, 2817 Reilly Road, Fort Liberty, NC 28310, USA.
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Pavlidis ET, Galanis IN, Pavlidis TE. Management of obstructed colorectal carcinoma in an emergency setting: An update. World J Gastrointest Oncol 2024; 16:598-613. [PMID: 38577464 PMCID: PMC10989363 DOI: 10.4251/wjgo.v16.i3.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 12/06/2023] [Accepted: 01/16/2024] [Indexed: 03/12/2024] Open
Abstract
Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.
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Affiliation(s)
- Efstathios T Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Ioannis N Galanis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- 2nd Propedeutic Department of Surgery, Hippokration General Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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Mauro A, Scalvini D, Borgetto S, Fugazzola P, Mazza S, Perretti I, Gallotti A, Pagani A, Ansaloni L, Anderloni A. Malignant Acute Colonic Obstruction: Multidisciplinary Approach for Endoscopic Management. Cancers (Basel) 2024; 16:821. [PMID: 38398212 PMCID: PMC10887189 DOI: 10.3390/cancers16040821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024] Open
Abstract
Patients presenting with acute colonic obstruction are usually evaluated in the emergency department and multiple specialties are involved in the patients' management. Pre-treatment evaluation is essential in order to establish the correct endoscopic indication for stent implantation. Contrast-enhanced imaging could allow the exclusion of benign causes of colonic obstruction and evaluation of the length of malignant stricture. Endoscopic stenting is the gold standard of treatment for palliative indications whereas there are still concerns about its use as a bridge to surgery. Different meta-analyses showed that stenting as a bridge to surgery improves short-term surgical outcomes but has no role in improving long-term outcomes. Multidisciplinary evaluation is also essential in patients that may be started on or are currently receiving antiangiogenic agents because endoscopic stenting may increase the risk of perforation. Evidence in the literature is weak and based on retrospective data. Here we report on how to correctly evaluate a patient with acute colonic malignant obstruction in collaboration with other essential specialists including a radiologist, surgeon and oncologist, and how to optimize the technique of endoscopic stenting.
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Affiliation(s)
- Aurelio Mauro
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Davide Scalvini
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
- Department of Internal Medicine, PhD in Experimental Medicine Italy, University of Pavia, 27100 Pavia, Italy
| | - Sabrina Borgetto
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Paola Fugazzola
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Stefano Mazza
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Ilaria Perretti
- Institute of Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Anna Gallotti
- Institute of Radiology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Anna Pagani
- Medical Oncology Unit, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Luca Ansaloni
- Department of General Surgery, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
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Giordano A, Podda M, Montori G, Botteri E, Fugazzola P, Ortenzi M, Guerrieri M, Vettoretto N, Agresta F, Sartori A, Bergamini C, Martellucci J, Guariniello A, Fransvea P, Azzinnaro A, Scatizzi M, Catena F, Coccolini F, Ansaloni L, Sartelli M, Sapienza P, Mingoli A, Prosperi P. Colonic Resection, Stoma, or Self-expanding Metal Stents for Obstructive Left Colon Cancer: the CROSCO-1 study protocol. Minerva Surg 2024; 79:7-14. [PMID: 37705392 DOI: 10.23736/s2724-5691.23.09969-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is one of the most common cancers worldwide. There are several causes of a mechanical left bowel obstructive but CRC accounts for approximately 50% of cases and in 10-30% of whom it is the presenting syndrome. In most cases, the left colon is involved. At present, the range of therapeutic alternatives in the management of obstructive left CRC in emergency conditions (primary resection vs. staged resection with applied self-expanding metallic stents) is broad, whereas internationally validated clinical recommendations in each condition are still lacking. This enormous variability affects the scientific evidence on both the immediate and long-term surgical and oncological outcomes. METHODS CROSCO-1 (Colonic Resection, Stoma or Self-expanding Metal Stents for Obstructive Left Colon Cancer) study is a national, multi-center, prospective observational study intending to compare the clinical results of all these therapeutic regimens in a cohort of patients treated for obstructive left-sided CRC. RESULTS The primary aim of the CROSCO-1 study is the 1-year stoma rate of patients undergoing primary emergency surgical resection (Hartmann procedure or primary resection and anastomosis) compared with patients undergoing staged resection. Secondary outcomes are 30-day and 90-day major morbidity and mortality, 1-year quality of life and the timing of chemotherapy initiation in the two groups. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies. CONCLUSIONS The results of a large prospective cohort study which will analyze what really happens in the common clinical practice of managing patients with obstructive left CRC will have the aim of understanding which is the best strategy in terms of surgical and oncological outcomes. Indeed, the CROSCO-1 study will analyze the early surgical outcomes for patients with obstructed left CRC. Future CROSCO studies will follow in which, instead, we will evaluate the long-term oncological outcomes of the two treatment strategies.
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Affiliation(s)
- Alessio Giordano
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy -
| | - Mauro Podda
- General Surgery Unit, Department of Surgery, University Hospital of Cagliari, Cagliari, Italy
| | - Giulia Montori
- Department of General Surgery, ULSS2 Marca Trevigiana, Vittorio Veneto, Treviso, Italy
| | - Emanuele Botteri
- General Surgery Unit, ASST Spedali Civili, Montichiari, Brescia, Italy
| | - Paola Fugazzola
- Division of General Surgery, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Monica Ortenzi
- Department of General Surgery, Polytechnical University of Marche, Ancona, Italy
| | - Mario Guerrieri
- Department of General Surgery, Polytechnical University of Marche, Ancona, Italy
| | - Nereo Vettoretto
- General Surgery Unit, ASST Spedali Civili, Montichiari, Brescia, Italy
| | - Ferdinando Agresta
- Department of General Surgery, ULSS2 Marca Trevigiana, Vittorio Veneto, Treviso, Italy
| | - Alberto Sartori
- Department of General Surgery, Montebelluna Hospital, Montebelluna, Treviso, Italy
| | - Carlo Bergamini
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Jacopo Martellucci
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
| | - Anna Guariniello
- Emergency Surgery Unit, Department of Surgery, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Pietro Fransvea
- Emergency Surgery and Trauma Department, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | | | - Marco Scatizzi
- General Surgery Unit, Department of Surgery, Santa Maria Annunziata and Serristori Hospital, Florence, Italy
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital, Cesena, Italy
| | - Federico Coccolini
- Department of Emergency and Trauma Surgery, Pisa University Hospital, Pisa, Italy
| | - Luca Ansaloni
- Division of General Surgery, IRCCS San Matteo Polyclinic Foundation, Pavia, Italy
| | - Massimo Sartelli
- General Surgery Unit, Department of Surgery, Macerata Hospital, Macerata, Italy
| | - Paolo Sapienza
- Emergency Department, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Andrea Mingoli
- Emergency Department, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Paolo Prosperi
- Emergency Surgery Unit, Emergency Department, Careggi University Hospital, Florence, Italy
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