Does Stenting as a Bridge to Surgery in Left-Sided Colorectal Cancer Obstruction Really Worsen Oncological Outcomes?

Management Strategies for Malignant Left-Sided Colonic Obstruction: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials and Propensity Score Matching Studies

BACKGROUND

The optimal treatment strategy for left-sided malignant colonic obstruction remains controversial. Emergency colonic resection has been the standard of care; however, self-expanding metallic stenting as a bridge to surgery may offer short-term advantages, although oncological concerns exist. Decompressing stoma may provide a valid alternative, with limited evidence.

OBJECTIVE

To perform a systematic review and Bayesian arm random-effects model network meta-analysis comparing the approaches for management of malignant left-sided colonic obstruction.

DATA SOURCES

A systematic review of PubMed, Embase, Cochrane Library, and Google Scholar databases was conducted from inception to August 22, 2023.

STUDY SELECTION

Randomized controlled trials and propensity score-matched studies.

INTERVENTIONS

Emergency colonic resection, self-expanding metallic stent, and decompressing stoma.

MAIN OUTCOME MEASURES

Oncologic efficacy, morbidity, successful minimally invasive surgery, primary anastomosis, and permanent stoma rates.

RESULTS

Nineteen of 5225 articles identified met our inclusion criteria. Stenting (risk ratio 0.57; 95% credible interval, 0.33-0.79) and decompressing stomas (risk ratio 0.46, 95% credible interval: 0.18-0.92) resulted in a significant reduction in the permanent stoma rate. Stenting facilitated minimally invasive surgery more frequently (risk ratio 4.10; 95% credible interval, 1.45-13.13) and had lower overall morbidity (risk ratio 0.58; 95% credible interval, 0.35-0.86). A pairwise analysis of primary anastomosis rates showed increased stenting (risk ratio 1.40; 95% credible interval, 1.31-1.49) compared with emergency resection. There was a significant decrease in the 90-day mortality with stenting (risk ratio 0.63; 95% credible interval, 0.41-0.95) compared with resection. There were no differences in disease-free and overall survival rates, respectively.

LIMITATIONS

There is a lack of randomized controlled trials and propensity score matching data comparing short-term and long-term outcomes for diverting stomas compared to self-expanding metallic stents. Two trials compared self-expanding metallic stents and diverting stomas in left-sided malignant colonic obstruction.

CONCLUSIONS

This study provides high-level evidence that a bridge-to-surgery strategy is safe for the management of left-sided malignant colonic obstruction and may facilitate minimally invasive surgery, increase primary anastomosis rates, and reduce permanent stoma rates and postoperative morbidity compared with emergency colonic resection.

Colonic stent as a bridge to surgery versus emergency rection for malignant left-sided colorectal obstruction: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The role of self-expanding metal stent (SEMS) implantation as a bridge to surgery in malignant left-sided colorectal obstruction (MLCO) remains controversial.

OBJECTIVE

To evaluate the safety of SEMS implantation versus emergency surgery (ER) in the treatment of MLCO.

METHODS

Four major literature databases (Cochrane Library, Embase, PubMed, and Web of Science) were searched to collect articles published before April 20, 2023. After determining random or fixed-effect models based on heterogeneity tests, odds ratios (RR) or standardized mean differences (SMD) with their respective 95% confidence intervals (CI) were calculated.

RESULTS

Nineteen randomized controlled studies were included. The main outcomes included overall tumor recurrence rate, 30-day mortality rate, and overall incidence of complications. Secondary outcomes included mortality-related indicators, tumor recurrence-related indicators, surgery-related indicators, and other relevant indicators. The study found that there was no significant difference in the 30-day mortality rate between the SEMS group and the er group. However, the SEMS group had a lower overall incidence of complications (RR = 0.787, P = .004), lower incision infection rate (RR = 0.472, P = .003), shorter operation time (SMD = -0.591, P = .000), lower intraoperative blood loss (SMD = -1.046, P = .000), lower intraoperative transfusion rate (RR = 0.624, P = .021), lower permanent stoma rate (RR = 0.499, P = .000), lower overall stoma rate (RR = 0.520,P = .000), shorter hospital stay (SMD = -0.643, P = .014), and more lymph node dissections during surgery (SMD = 0.222, 95% CI: 0.021-0.423, P = .031), as well as a higher primary anastomosis rate (RR = 0.472, 95% CI: 0.286-0.7 77, P = .003), among other advantages. However, the SEMS group had a higher overall tumor recurrence rate (RR = 1.339, P = .048).

CONCLUSION

SEMS has significant advantages over er in relieving clinical symptoms and facilitating postoperative recovery in MLCO, but does not reduce the tumor recurrence rate. Neoadjuvant chemotherapy combined with SEMS may provide a new approach to the treatment of MLCO.

Comparison of the prognosis of four different treatment strategies for acute left malignant colonic obstruction: a systematic review and network meta-analysis

Background

There is controversy regarding the efficacy of different treatment strategies for acute left malignant colonic obstruction. This study investigated the 5-year overall survival (OS) and disease-free survival (DFS) of several treatment strategies for acute left malignant colonic obstruction.

Methods

We searched for articles published in PubMed, Embase (Ovid), MEDLINE (Ovid), Web of Science, and Cochrane Library between January 1, 2000, and July 1, 2020. We screened out the literature comparing different treatment strategies. Evaluate the primary and secondary outcomes of different treatment strategies. The network meta-analysis summarizes the hazard ratio, odds ratio, mean difference, and its 95% confidence interval.

Results

The network meta-analysis involved 48 articles, including 8 (randomized controlled trials) RCTs and 40 non-RCTs. Primary outcomes: the 5-year overall survival (OS) and disease-free survival (DFS) of the CS-BTS strategy and the DS-BTS strategy were significantly better than those of the ES strategy, and the 5-year OS of the DS-BTS strategy was significantly better than that of CS-BTS. The long-term survival of TCT-BTS was not significantly different from those of CS-BTS and ES. Secondary outcomes: compared with emergency resection (ER) strategies, colonic stent-bridge to surgery (CS-BTS) and transanal colorectal tube-bridge to surgery (TCT-BTS) strategies can significantly increase the primary anastomosis rate, CS-BTS and decompressing stoma-bridge to surgery (DS-BTS) strategies can significantly reduce mortality, and CS-BTS strategies can significantly reduce the permanent stoma rate. The hospital stay of DS-BTS is significantly longer than that of other strategies. There was no significant difference in the anastomotic leakage levels of several treatment strategies.

Conclusion

Comprehensive literature research, we find that CS-BTS and DS-BTS strategies can bring better 5-year OS and DFS than ER. DS-BTS strategies have a better 5-year OS than CS-BTS strategies. Without considering the hospital stays, DS-BTS strategy is the best choice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-021-00355-2.

Comparison of safety between self-expanding metal stents as a bridge to surgery and emergency surgery based on pathology: a meta-analysis

BACKGROUND

To explore the long-term oncological safety of using self-expanding metal stents (SEMS) as a bridge to surgery for acute obstructive colorectal cancer by comparing the pathological results of emergency surgery (ES) with elective surgery after the placement of SEMS.

METHODS

Studies comparing SEMS as a bridge to surgery with emergency surgery for acute obstructive colorectal cancer were retrieved through the databases of Pubmed, Embase, and Cochrane libraries, and a meta-analysis was conducted based on the pathological results of the two treatments. Risk ratios (OR) or mean differences (MD) with 95% confidence intervals (CI) were calculated for the outcomes under random effects model.

RESULTS

A total of 27 studies were included, including 3 randomized controlled studies, 2 prospective studies, and 22 retrospective studies, with a total of 3737 patients. The presence of perineural invasion (RR = 0.58, 95% CI 0.48, 0.71, P < 0.00001), lymphovascular invasion (RR = 0.68, 95% CI 0.47, 0.99, P = 0.004) and vascular invasion (RR = 0.66, 95% CI 0.45, 0.99, P = 0.04) in SEMS group were significantly higher than those in ES group, and there was no significant difference in lymphatic invasion (RR = 0.92, 95% CI 0.77, 1.09, P = 0.33). The number of lymph nodes harvested in SEMS group was significantly higher than that in ES group (MD = - 3.18, 95% CI - 4.47, - 1.90, P < 0.00001). While no significant difference was found in the number of positive lymph nodes (MD = - 0.11, 95% CI - 0.63, 0.42, P = 0.69) and N stage [N0 (RR = 1.03, 95% CI 0.92, 1.15, P = 0.60), N1 (RR = 0.99, 95% CI 0.87, 1.14, P = 0.91), N2 (RR = 0.94, 95% CI 0.77, 1.15, P = 0.53)].

CONCLUSIONS

SEMS implantation in patients with acute malignant obstructive colorectal cancer may lead to an increase in adverse tumor pathological characteristics, and these characteristics are mostly related to the poor prognosis of colorectal cancer. Although the adverse effect of SEMS on long-term survival has not been demonstrated, their adverse effects cannot be ignored. The use of SEMS as the preferred treatment for patients with resectable obstructive colorectal cancer remains to be carefully weighed, especially when patients are young or the surgical risk is not very high.

Long-term outcomes of stent-related perforation in malignant colon obstruction: a systematic review and meta-analysis

PURPOSE

The placement of self-expandable metallic stents as a bridge to surgery in malignant colon obstruction is concerning due to the long-term oncological results reported in recent published studies. The aim of this study was to evaluate the oncological consequences of stent-related perforations in patients with malignant colon obstruction and potentially curable disease.

METHODS

MEDLINE, Cochrane Library, Ovid and ISRCTN Registry were searched, with no restrictions. We performed five meta-analyses to estimate the pooled effect sizes by using a random-effect model. The outcomes were global, locoregional and systemic recurrence rate and 3 and 5 year-survival rate depending on the presence or absence of stent-related perforation.

RESULTS

Thirteen studies (950 patients) were included. The overall rate of stent-related perforation was 8.9%. The global recurrence rate was significantly higher in stent-related perforation group (41.2 vs. 30.8%; OR 1.70; 95%CI: 1.02-2.84; p = 0.04). Locoregional recurrence rate was higher in the perforated group than in the non-perforated group (26.6 vs. 12.5%), with statistically significant differences (OR 2.41; 95% CI:1.33-4.34; p = 0.004). No significant differences were found in systemic recurrence rate (13.6 vs. 20.5%; OR 0.77; 95%CI: 0.35-1.7; p = 0.51); 3-year overall survival rate (65.4 vs. 74.8%; OR 0.63; 95% CI:0.29-1.39; p = 0.25) and 5-year overall survival rate (48.3 vs. 58.6%; OR 0.67; 95%CI: 0.27-1.65; p = 0.38).

CONCLUSION

Stent-related perforation is associated with an increased risk of global and locoregional recurrence. The successful placement of the stent as a bridge to surgery in the curative purpose of patients with obstructed colon cancer does not exclude the presence of underlying perforation, with the consequent danger of disease spread. PROSPERO registration number: CRD42020152817.

Comparison of colonic stents, stomas and resection for obstructive left colon cancer: a meta-analysis

BACKGROUND

Emergency surgery (ES) is the standard-of-care for left-sided obstructing colon cancer, with self-expanding metallic stents (SEMSs) and diverting colostomies (DCs) being alternative approaches. The aim of this study was to review the short- and long-term outcomes of SEMS versus ES or DC.

METHODS

Embase and Medline were searched for articles comparing SEMS versus ES or DC. Primary outcomes were survival and recurrence rates. Secondary outcomes were peri- and postoperative outcomes. SEMS-specific outcomes include success and complication rates. Pooled odds ratio and 95% confidence interval were estimated with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Thirty-three studies were included, involving 15,224 patients in 8 randomized controlled trials and 25 observational studies. There were high technical and clinical success rates for SEMS, with low rates of complications. Our meta-analysis revealed increased odds of laparoscopic surgery and anastomosis, and decreased stoma creation with SEMS compared to ES. SEMS led to fewer complications, including anastomotic leak, wound infection, ileus, myocardial infarction, and improved 90-day in-hospital mortality. There were no significant differences in 3- and 5-year overall, cancer-specific and disease-free survival. SEMS, compared to DC, led to decreased rates of stoma creation, higher rates of ileus and reoperation, and led to longer hospital stay.

CONCLUSIONS

SEMS leads to better short-term outcomes but confers no survival advantage over ES. It is unclear whether SEMS has better short-term outcomes compared to DC. There is a lack of randomized trials with long-term outcomes for SEMS versus DC, hence results should be interpreted with caution.

Long-term tumour outcomes of self-expanding metal stents as 'bridge to surgery' for the treatment of colorectal cancer with malignant obstruction: a systematic review and meta-analysis

PURPOSE

To explore the long-term oncological results of self-expanding metal stents (SEMS) as a surgical transition compared with those of simple emergency surgery.

METHODS

A systematic review of studies involving long-term tumour outcomes comparing SEMS with emergency surgery was conducted. All studies included information on 3-year and 5-year survival rates, 3-year and 5-year disease-free survival (DFS) rates, and local and overall recurrence rates; the results were expressed as odds ratios.

RESULTS

Overall, 24 articles and 2508 patients were included, including 5 randomised controlled trials, 3 prospective studies, and 16 retrospective studies. The 3-year survival rate (odds ratio (OR) = 0.88, 95% confidence interval (CI) 0.69-1.12, P = 0.05), 5-year survival rate (OR = 0.91, 95% CI 0.70-1.17, P = 0.67), 3-year DFS rate (OR = 1.14, 95% CI 0.91-1.42, P = 0.65), 5-year DFS rate (OR = 1.35, 95% CI 0.91-2.02, P = 0.17), overall recurrence rate (OR 1.04, 95% CI 0.77-1.41, P = 0.14), and local recurrence rate (OR 1.37, 95% CI 0.84-2.23, P = 0.92) were determined. There was no significant difference between the randomised and observational studies in the subgroup analysis, and the 5-year survival rate was higher in studies with a stent placement success rate of ≥ 95%.

CONCLUSION

SEMS implantation was a viable alternative in malignant left colon obstruction as a transition to surgery; its long-term survival results, including 5-year DFS and overall survival, were equivalent to those of emergent surgery.

Efficacy of intestinal obstruction stent combined with laparoscopic surgery and neoadjuvant chemotherapy in patients with obstructive colorectal cancer

There is still controversy on the surgical treatment of obstructive colorectal cancer worldwide. No accurate research has been reported to propose which method is the most suitable for patients with obstructive colorectal cancer. Therefore, comparison of efficacy of intestinal stent and trans-anal ileus catheter combined with laparoscopic surgery and neoadjuvant chemotherapy respectively in patients with obstructive colorectal cancer was carried out to provide reference and guidance for the selection of surgical schemes for patients with obstructive colorectal cancer. In total 89 patients with obstructive colorectal cancer treated in the Taizhou Hospital of Zhejiang Province, Wenzhou Medical University, from February 2016 to March 2017 were selected for retrospective analysis. Forty-nine cases treated with intestinal metal stent implantation combined with laparoscopic surgery and neoadjuvant chemotherapy were the stent group. The other 40 cases treated with trans-anal ileus catheter combined with laparoscopic surgery and neoadjuvant chemotherapy were the catheter group. The intestinal preparation time, surgical duration, intraoperative blood loss, open surgery rate, postoperative exhaust time and adverse reaction rate were compared between the two groups. All the patients were followed up with reexamination at 1 year in hospital to record the local recurrence rate and tumor implantation rate of incision. The intestinal preparation time in the stent group was shorter than that in the catheter group (P<0.001). The surgical duration in the stent group was longer than that in the catheter group (P<0.001). The intraoperative blood loss in the stent group was higher than that in the catheter group (P<0.001). However, there was no significant difference in open surgery rate, postoperative exhaust time, adverse reaction rate, local recurrence rate or incision tumor implantation rate between the two groups (all P>0.05). Therefore, intestinal metal stent implantation can effectively relieve intestinal obstruction, while trans-anal ileus catheter has higher safety in laparoscopic surgery. Their combination with neoadjuvant chemotherapy and laparoscopic surgery for obstructive colorectal cancer has high value and clinical effect. The best treatment plan should be selected according to the patient's condition.

Optimal management of malignant left-sided large bowel obstruction: do international guidelines agree?

Background

Approximately 20% of patients diagnosed with colorectal cancer will present with left-sided large bowel obstruction. The optimal management of this cohort of patients remains unclear. We aimed to review international guidelines to see if there was a consensus on the treatment of this surgical emergency.

Methods

The PubMed and Medline databases were searched for guidelines on the management of left-sided, malignant large bowel obstruction (MBO) between 2010 and 2018.

Results

Nineteen guidelines were identified spanning a range of continents. There was no clear consensus on the management of potentially resectable disease. Eight guidelines (42%) suggested primary surgery, two guidelines (11%) suggested stenting as a bridge to surgery and nine guidelines (47%) suggested surgery or stenting could be performed. Primary resection with or without anastomosis was the most frequently recommended procedure (n = 6 35%), but over a third of guidelines gave no operative recommendations. There was very limited detail on the stenting procedure and how long elective surgery should be deferred. In the palliative situation, there was general agreement that stents should be offered in preference to surgery.

Conclusion

International guidelines offer limited and contrasting recommendations on the management of left-sided MBO. There is a lack of high-quality evidence to support whether emergency surgery or stenting as a bridge to surgery is the optimal procedure in terms of morbidity, mortality and long-term oncological outcome.

Self-expanding metallic stent as a bridge to surgery versus emergency surgery for acute obstructive colorectal cancer: a retrospective study

Purpose: Acute obstructive colorectal cancer is a common emergency that requires decompression immediately. The aim of the study was to compare short-term and long-term results of acute obstructive colorectal cancer treated by the self-expanding metallic stent (SEMS) as a bridge to surgery (BTS) versus emergency surgery.

Patients and methods: We retrospectively reviewed 78 patients who were diagnosed as acute obstructive colorectal cancer that underwent elective surgery after stent insertion (stent group, N=37) or emergency surgery (emergency group, N=41) from January 2013 to October 2016. The Kaplan–Meier method was conducted to calculate overall survival. Univariate analyses were performed using the Mann–Whitney U analysis, Pearson’s chi-square test, and Fisher’s exact test. In addition, continuous variables were compared using the Student’s t-test.

Results: The baseline characteristics were not significantly different between the two groups. The stent group had increased preoperative serum albumin level and decreased ASA risk score. In addition, operation time, diet time, harvested lymph nodes and total stoma creation of the stent group were better than that of the emergency group. The complications and mortality during hospitalization were not significantly different between the two groups. The overall survival was not significantly different while the quality of life of survival patients in the stent group was better than that of the emergency group.

Conclusion: For acute obstructive colorectal cancer, a stent as a BTS seems to be a safe and feasible alternative option for emergency surgery in the management of acute obstructive colorectal cancer.

Is bridge to surgery stenting a safe alternative to emergency surgery in malignant colonic obstruction: a meta-analysis of randomized control trials

BACKGROUND

Despite studies showing superior results in terms of reduced stoma rate and higher primary anastomosis rate, the safety of bridge to surgery stenting (BTS stent) for left-sided malignant colonic obstruction, especially in oncological terms, remains a concern.

AIM

The aim of this meta-analysis was to evaluate whether BTS stent is a safe alternative to emergency surgery (EmS).

METHODS

Randomized control trials (RCTs) comparing BTS stent and EmS for left-sided colonic obstruction caused by primary cancer of the colon, up to Sep 2018, were retrieved from the Pubmed, Embase database, clinical trials registry of U. S. National Library of Medicine and BMJ and Google Search.

RESULTS

There were seven eligible RCTs, involving a total of 448 patients. Compared to EmS, BTS stent had a significantly lower risk of overall complications (RR = 0.605; 95% CI 0.382-0.958; p = 0.032). However, the overall recurrence rate was higher in the BTS stent group (37.0% vs. 25.9%; RR = 1.425; 95% CI 1.002-2.028; p = 0.049). BTS stent significantly increased the risk of systemic recurrence (RR = 1.627; 95% CI 1.009-2.621; p = 0.046). This did not translate into a significant difference in terms of 3-year disease-free survival or 3-year overall survival.

CONCLUSION

BTS stent is associated with a lower rate of overall morbidities than EmS. However, BTS stent was associated with a greater chance of recurrence, especially systemic recurrence. Clinicians ought to be aware of the pros and cons of different interventions and tailor treatments for patients suffering from left-sided obstructing cancer of the colon.

Long-term outcomes after stenting as a bridge to surgery in patients with obstructing left-sided colorectal cancer

PURPOSE

Self-expandable metallic stents (SEMS) may be used in acute, obstructing, left-sided colorectal cancer (CRC) to avoid high-risk emergency surgery. However, the data regarding the long-term effects of SEMS as a bridge to surgery are limited and contradictory. Our aim is to analyze the long-term oncological outcomes of SEMS compared with surgery.

METHODS

Between January 2006 and November 2013, a total of 855 patients with stage III CRC were regularly followed at the CRC clinic of Severance Hospital, Seoul, Korea. We retrospectively evaluated their 5-year disease-free survival (DFS), 5-year overall survival (OS), and 5-year cancer-specific survival (CSS).

RESULTS

There were 94 patients in the SEMS group, 17 in the emergent-surgery group, and 744 in the elective-surgery group. In the short term, the rate of permanent stoma formation was significantly higher in the emergent-surgery group than in the SEMS group (p = 0.030), although the median hospital stay and overall complication rate were comparable. During the long-term follow-up period, oncological outcomes including 5-year DFS (70.2 vs 52.9%; p = 0.210), OS (70.2 vs 52.9%; p = 0.148), and CSS (79.8 vs 70.6%; p = 0.342) were not different between the SEMS group and the emergent-surgery group. Multivariate analysis showed emergent operation to be a significant risk factor of DFS (hazard ratio [HR], 3.117; 95% confidence interval [CI], 1.498-6.489; p = 0.002).

CONCLUSIONS

Preoperative SEMS insertion does not adversely affect long-term oncological outcomes or patient survival.

Ten-year survival after endoscopic stent placement as a bridge to surgery in obstructing colon cancer

BACKGROUND AND AIMS

Self-expandable metal stents are used increasingly in the treatment of obstructing colorectal cancer (CRC). Although endoscopic colon stenting is widely accepted in palliation, disagreement exists about its role in a curative setting. This study aims to describe long-term survival data in a large patient group treated with colon stenting as a bridge to surgery for CRC.

METHODS

This prospective study included 97 patients who presented in a Belgian hospital between 1998 and 2013 with obstructing, although potentially curable, CRC. All patients underwent endoscopic stenting as a bridge to surgery. Procedure-related adverse events and long-term follow-up data were retrospectively collected and compared with the CRC mortality in Belgium in the same time span.

RESULTS

Overall survival in this observational cohort did not differ significantly from survival in all Belgian patients with CRC in the same period (P = .14). One-year, 5-year, and 10-year survival rates were similar in both groups (95.9% vs 79.0%; 54.7% vs 51.2%; 41.0% vs 35.6%, respectively). The technical success rate was 94.8%. Seventy-three patients did not experience any adverse event. Stent migration occurred in 9 patients, whereas micro-perforations and macro-perforations were observed in 14 patients, without influence on survival. Incidence rates of peritoneal metastases did not differ between patients with and without any type of perforation (22.2% vs 15.2%, respectively; P = .47). The type of stent influenced the overall adverse event risk, mainly driven by a significant increase in stent migration in case of Wallstent enteral (Boston Scientific Corporation, Natick, Mass).

CONCLUSIONS

Colon stenting before surgery is effective and did not worsen the survival outcome in patients with obstructing CRC who were treated with curative intent, which affirms the role for stenting as a bridge to surgery.

Long-term oncologic outcomes of stent as a bridge to surgery versus emergency surgery in malignant left side colonic obstructions: a meta-analysis

Background

The placement of a metallic stent as a bridge to surgery (SBTS) could represents an option for the treatment of left-sided malignant colonic obstruction in centres with adequate skills. Several meta-analyses demonstrated better short-term outcomes after SBTS when compared with emergency surgery (ES); however, some studies reported a higher local recurrence rate. The aim of the present review is to investigate the long-term outcomes of stent bridge to surgery as compared to ES.

Methods

A systematic review was performed to retrieve studies comparing long-term oncologic outcomes of SBTS and ES. Local and overall recurrence rate, overall and disease-free survival were retrieved and results were expressed as risk ratios.

Results

Seventeen studies and a total of 1,333 patients were included in the analysis. No significant differences were reported in recurrence rate [risk ratio (RR) =1.11; 95% confidence interval (95% CI): 0.84-1.47, P=0.47], 3-year mortality (RR =0.90; 95% CI: 0.73-1.12, P=0.34) and 5-year mortality (RR =1.00; 95% CI: 0.82-1.22, P=0.99). There were no differences among randomized and observational studies.

Conclusions

SBTS has similar long-term oncologic outcomes to ES and in centres with appropriate skill should be considered the best treatment option for left-sided malignant colonic obstructions.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Colon Cancer

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Emergency Presentations of Colorectal Cancer

Many colorectal carcinomas will present emergently with issues such as obstruction, perforation, and bleeding. Emergency surgery is associated with poor short- and long-term outcomes. For abnormality localizing to the colon proximal to the splenic flexure, surgical management with hemicolectomy is often a safe and appropriate approach. Obstructions are more common in the distal colon, however, where there is an evolving spectrum of surgical and nonsurgical options, most notably by the development of endoluminal stents. Perforation and bleeding are managed similarly to benign causes, as malignancy may be only part of a differential diagnosis at the time of an operation.