Surgical management of large bowel obstruction due to colonic cancer

Factors associated with failure of Enhanced Recovery After Surgery (ERAS) in colorectal and gastric surgery

Background: The Enhanced Recovery After Surgery (ERAS) pathway is widely applied in the perioperative period of stomach and colorectal surgery, and can decrease the length of hospital stay of the patients without compromising the safety of the patients. However, some patients are removed from this pathway for various reasons. Here we found some factors that taking the patients out from the procedures. Methods: A retrospective analysis of collected data of 550 patients over a 3-year period was conducted, with 292 in the ERAS group and 258 in the conventional care group. Then various basic elements were analyzed to explore the reasons for the failure to complete the ERAS program. Results: Total length of hospital stay after surgery was significantly shorter in the ERAS group, and a similar incidence of complication rates were observed in the two groups. In this study, the significant factors that associated with complications were advanced age (OR 2.18; p = .031), history of abdominal surgery (OR 2.03; p = .04), incomplete gastrointestinal obstruction (OR 3.42; p < .001), laparoscopic surgery (OR 0.39; p = .004) and intraoperative neostomy (OR 2.37; p = .006). Conclusions: We found that advanced age (>80 years old), history of abdominal surgery, gastrointestinal obstruction and stoma formation were the risk factors. We anticipated to design a risk assessment system upon the high-risk patients from the present ERAS pathway, and make a modified ERAS pathway for those patients.

Enhanced recovery after surgery vs conventional care in emergency colorectal surgery

AIM: To investigate the feasibility and beneficial effects of enhanced recovery after surgery (ERAS) programme in the setting of emergency colorectal surgery.

METHODS: Between January 2011 and October 2013, patients undergoing emergency resection for obstructing colorectal cancer at the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand using ERAS programme were compared with those using conventional care (1:2 ratio). They were matched for their age, gender, ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity score, and type of surgery. Primary outcomes were length of hospital stay and postoperative morbidity. Secondary outcomes included gastrointestinal recovery, 30-d readmission, and time interval from surgery to chemotherapy.

RESULTS: Twenty patients treated with ERAS programme were compared with 40 patients receiving conventional postoperative care. Median of hospital stay was shorter in the ERAS group: 5.5 d (range: 3-16) vs 7.5 d (range: 5-25), P = 0.009. The ERAS group had a non-significant reduction in the incidence of postoperative complication (25% vs 48%, P = 0.094). No 30-d mortality and readmission occurred. Patients with ERAS programme had a shorter time to first flatus (1.6 d vs 2.8 d, P < 0.001) and time to resumption of normal diet (3.5 d vs 5.5 d, P = 0.002). Time interval between operation and initiation of adjuvant chemotherapy was significantly shorter in the ERAS group (37 d vs 49 d, P = 0.009).

CONCLUSION: The ERAS programme in the setting of emergency colorectal surgery was safe and feasible. It achieved significantly shorter hospitalisation and faster recovery of bowel function.

Outcome of emergency one-stage resection and anastomosis procedure for patients with obstructed colorectal cancer

PURPOSES

The purpose of this study was to verify the outcome of the emergency one stage resection and anastomosis procedure for patients with obstructed colorectal cancer.

METHODS

An emergency one stage resection and anastomosis procedure was performed for 40 patients with obstructive colorectal cancer. The outcome was verified and compared dividing into two groups. 17 patients under the age of 70 in (Group A), 23 patients 70 years and over in (Group B).

RESULTS

The operative mortality rate in both groups was 0%. As a result, postoperative complications were not significantly different between the two groups. The overall survival rate after a 5-year period in both groups was 41.8%, regarding all patients and the survival curves for the two groups, was not significantly different. The 5 year survival rate in stage II or III showed no differences between the two groups.

CONCLUSION

The one-stage resection and anastomosis of the large bowel could be applied safely to emergency patients, which in turn allows for excellent short-term operative results in both groups mentioned. This particular procedure should be positively enforced, even in elderly patients in their 70's.

CT diagnosis of the nature of bowel obstruction: morphological evaluation of the transition point

PURPOSE

This study evaluated transition-point morphology for defining the nature of bowel obstructions.

MATERIALS AND METHODS

Computed tomography (CT) examinations of 95 patients affected by severe bowel obstruction (23 neoplastic, 72 nonneoplastic) were retrospectively reviewed.

RESULTS

The transition point was identified in 89 patients (94%); morphology in relation to the proximal loop was concave in 64 cases (68%), linear in five (5%) and convex in 20 (21%). Concave transition-point morphology was indicative of a nonneoplastic condition, with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy values of 89%, 100%, 100%, 74% and 92%, respectively. A linear shape had almost identical incidence among neoplastic (60%) and nonneoplastic (40%) conditions. A convex appearance correlated with neoplastic disease with sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 87%, 100%, 100%, 96% and 97%, respectively.

CONCLUSIONS

In the case of bowel obstruction, transitionpoint detection indicates the obstruction site, whereas its morphological evaluation can contribute to defining the nature of the obstruction. A concave morphology indicates a nonneoplastic condition with a high probability; a convex morphology correlates with neoplastic disease, whereas linearity is not significant.

Value of "protruding lips" sign in malignant bowel obstructions

OBJECTIVE

This study aims to evaluate the diagnostic accuracy of a new CT sign in order to define or exclude a malignant aetiology of bowel obstruction.

MATERIALS AND METHODS

CT scans of 137 patients affected by bowel obstruction were reviewed. Colonic obstruction occurred in 47 (34%) cases, small bowel obstruction in 90 (66%). Neoplastic aetiology was found in 42 cases (31%), while in the remaining 95 (69%) obstruction was caused by non-neoplastic conditions. Definitive diagnosis was surgically confirmed in all patients. CT images were evaluated searching for bowel obstruction's signs and for the presence of the "protruding lips" sign on the proximal surface of stenosis, which is represented by the evidence of a protrusion within the dilated loop.

RESULTS

The sign was found in 31 (23%) cases, all of neoplastic origin. When malignant obstruction was diagnosed, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy values of the described sign were 74%, 100%, 100%, 90% and 92%, respectively.

CONCLUSIONS

The "protruding lips" sign represents an alteration to be searched when bowel obstruction is diagnosed by CT examination. Its evidence correlates to a malignant condition with a 100% probability and when it is not found, the probability of a non-neoplastic condition is 90%.

Prognostic value of MDCT in malignant large-bowel obstructions

PURPOSE

This study aimed to correlate multidetector-row computed tomography (MDCT) findings and postoperative prognosis in malignant large-bowel obstructions.

MATERIALS AND METHODS

Twenty-seven patients affected by malignant colonic obstruction underwent MDCT examination and were analysed for obstruction site, colon-wall morphology, intestinal content alterations and transverse diameter of ascending colon.

RESULTS

Obstruction site was recognised in all cases (5/27 ascending colon; 1/27 transverse colon; 11/27 descending colon; 10/27 sigma-rectum). Intestinal content consisted of mainly air in 3/27 patients, mainly fluid in 11/27 and air-fluid levels in 13/27. In 9/27 cases, pneumatosis intestinalis was found. Mean maximum diameter of the ascending colon was 8.2 cm. Overall mortality rate was 37%. An intestinal content mainly consisting of air (3/3 living patients) or fluid (7/11 living patients) were indicative of good prognosis. Air-fluid level detection indicated poor prognosis in 7/13 cases. Pneumatosis intestinalis (7/9 deceased patients) and ascending colon diameter values > or =10 cm (7/7 deceased patients) were indicative of poor prognosis.

CONCLUSIONS

MDCT can identify the presence and site of malignant large-bowel obstructions and may provide useful prognostic information.

Surgery for obstructed colorectal malignancy in an Asian population: predictors of morbidity and comparison between left- and right-sided cancers

INTRODUCTION

Surgical treatment of obstructed colorectal cancers has been associated with significant perioperative morbidity and mortality. This study was performed to review the spectrum of surgery and early outcome of patients with acutely obstructed colorectal cancers. The secondary aims were to compare right- and left-sided obstruction and to identify factors predicting morbidity and mortality in these patients.

METHODS

A retrospective review of all patients who underwent operative intervention for acute obstruction from colorectal malignancy from February 2003 to April 2008 was performed. Patients were identified from the hospital's operating records based on postoperative diagnosis codes of colorectal malignancy. The diagnosis of acute obstruction was confirmed through clinical assessment, radiological investigations, and surgical findings. All the complications were graded according to the classification proposed by Clavien and group.

RESULTS

Out of a total of 1,268 patients who underwent surgery for colorectal malignancy, 134 (10.6%) patients with a median age of 71 years (range, 34-97 years) were operated for acute obstruction. Left-sided malignancy accounted for 79.9% of the obstruction, with sigmoid colon being the most common site in 54 (40.3%) patients. A significant proportion (77.6%) of our patients had associated perioperative morbidity, and the mortality rate was 11.9%. Worse complications (grades of complications III to V) were more frequent in patients who had a higher American Society of Anesthesiologists score (3-4), are > or = 60 years old, and had preoperative renal impairment. Stoma was created more frequently in left-sided pathology.

CONCLUSION

In an Asian population, surgery in patients with acute colorectal malignant obstruction is associated with significant morbidity and mortality rates. Though left-sided malignant obstruction occurs more frequently and is associated with a higher incidence of stoma creation, primary resection and anastomosis is a safe option in selected patients.

[Intestinal endometriosis. Current status]

Endometriosis affects a wide spectrum of premenopausal women. Intestinal involvement, affecting mainly the large bowel and sometimes the small bowel, is much less frequent. Diagnosis is relatively straightforward in women with long standing pelvic endometriosis but is difficult in acute intestinal obstruction, since a diagnosis of endometriosis is not often considered in this entity. We performed an exhaustive review of the medical literature, including the option of medical treatment, which is rarely effective in intestinal endometriosis. In most patients with intestinal symptoms, the disease is so severe that surgical treatment is required. Recent studies indicate that the most effective approach is laparoscopic. We analyze the most important classical and recent series of patients and discuss treatment results.