Emergency management with resection versus proximal stoma or stent treatment and planned resection in malignant left-sided colon obstruction

Effects of neoadjuvant chemotherapy for patients with obstructive colon cancer: A multicenter propensity score-matched analysis (YCOG2101)

Aim

Obstructive colon cancer is locally advanced colon cancer with poor prognosis. However, the effect of neoadjuvant chemotherapy (NAC) on obstructive colon cancer remains unclear. Therefore, this study aimed to investigate the safety and efficacy of NAC in patients with obstructive colon cancer.

Methods

From January 2012 to December 2017, we collected patient data for clinical stage II/III obstructive colon cancer at seven Yokohama Clinical Oncology Group (YCOG) institutions. The long-term outcomes of the NAC and non-NAC groups were analyzed retrospectively after adjusting for patients' background characteristics using propensity score matching.

Results

Among the 202 eligible patients, propensity score matching extracted 51 patients each for the NAC and non-NAC groups. After matching, the groups showed no marked differences in the background factors. All the patients in the NAC group underwent diverting stoma construction. Nineteen patients (37.3%) experienced grade 3-4 adverse events during NAC. The incidence of postoperative complications was similar between groups. The 5-year progression-free survival rates were 75.8% in the NAC group and 63.0% in the non-NAC group (p = 0.22, log-rank test). The 5-year overall survival rates were 88.5% in the NAC group and 78.8% in the non-NAC group (p = 0.09, log-rank test).

Conclusion

Although NAC was feasible for obstructive colon cancer after diverting stoma construction, its effects on long-term outcomes could not be proven.

Predicting Mortality Within 90 Days of First Intervention in Patients With Left-Sided Obstructive Colon Cancer

BACKGROUND

Acute resection for left-sided obstructive colon carcinoma is thought to be associated with a higher mortality risk than a bridge-to-surgery approach using decompressing stoma or self-expandable metal stent, but prediction models are lacking.

OBJECTIVE

This study aimed to determine the influence of treatment strategy on mortality within 90 days from the first intervention in patients presenting with left-sided obstructive colon carcinoma.

DESIGN

This was a national multicenter cohort study that used data from a prospective national audit.

SETTINGS

The study was performed in 75 Dutch hospitals.

PATIENTS

Patients were included if they underwent resection with curative intent for left-sided obstructive colon carcinoma between 2009 and 2016.

INTERVENTIONS

First intervention was either acute resection, bridge to surgery with self-expandable metallic stent, or bridge to surgery with decompressing stoma.

MAIN OUTCOME MEASURES

The main outcome measure was 90-day mortality after the first intervention. Risk factors were identified using multivariable logistic analysis. Subsequently, a risk model was developed.

RESULTS

In total, 2395 patients were included, with the first intervention consisting of acute resection in 1848 patients (77%), stoma as bridge to surgery in 332 patients (14%), and stent as bridge to surgery in 215 patients (9%). Overall, 152 patients (6.3%) died within 90 days from the first intervention. A decompressing stoma was independently associated with lower 90-day mortality risk (HR, 0.27; 95% CI, 0.094-0.62). Other independent predictors for mortality were age, ASA classification, tumor location, and index levels of serum creatinine and C-reactive protein. The constructed risk model had an area under the curve of 0.84 (95% CI, 0.81-0.87).

LIMITATIONS

Only patients who underwent surgical resection were included.

CONCLUSIONS

Treatment strategy had a significant impact on 90-day mortality. A decompressing stoma considerably lowers the risk of mortality, especially in older and frail patients. The developed risk model needs further external validation. See Video Abstract at http://links.lww.com/DCR/B975 .PREDICCIÓN DE LA MORTALIDAD A 90 DÍAS POSTERIORES A LA PRIMERA CIRUGÍA EN PACIENTES CON CÁNCER DE COLON OBSTRUCTIVO DEL LADO IZQUIERDOANTECEDENTES:Se cree que la resección aguda para el carcinoma de colon obstructivo del lado izquierdo está asociada con un mayor riesgo de mortalidad que un enfoque puente a la cirugía que utiliza un estoma de descompresión o un stent metálico autoexpandible, pero faltan modelos de predicción.OBJETIVO:Determinar la influencia de la estrategia de tratamiento sobre la mortalidad dentro de los 90 días desde la primera intervención utilizando un modelo de predicción en pacientes que presentan carcinoma de colon obstructivo del lado izquierdo.DISEÑO:Un estudio de cohorte multicéntrico nacional, utilizando datos de una auditoría nacional prospectiva.ENTORNO CLINICO:El estudio se realizó en 75 hospitales holandeses.PACIENTES:Se incluyeron los pacientes que se sometieron a una resección con intención curativa de un carcinoma de colon obstructivo del lado izquierdo entre 2009 y 2016.INTERVENCIONES:La primera intervención fue resección aguda, puente a cirugía con stent metálico autoexpandible o puente a cirugía con estoma descompresor.PRINCIPALES MEDIDAS DE VALORACIÓN:La principal medida de resultado fue la mortalidad a los 90 días después de la primera intervención. Los factores de riesgo se identificaron mediante análisis logístico multivariable. Posteriormente se desarrolló un modelo de riesgo.RESULTADOS:En total se incluyeron 2395 pacientes, siendo la primera intervención resección aguda en 1848 (77%) pacientes, estoma como puente a la cirugía en 332 (14%) pacientes y stent como puente a la cirugía en 215 (9%) pacientes. En general, 152 pacientes (6,3%) fallecieron dentro de los 90 días posteriores a la primera intervención. Un estoma de descompresión se asoció de forma independiente con un menor riesgo de mortalidad a los 90 días (HR: 0,27, IC: 0,094-0,62). Otros predictores independientes de mortalidad fueron la edad, la clasificación ASA, la ubicación del tumor y los niveles índice de creatinina sérica y proteína C reactiva. El modelo de riesgo construido tuvo un área bajo la curva de 0,84 (IC: 0,81-0,87).LIMITACIONES:Solo se incluyeron pacientes que se sometieron a resección quirúrgica.CONCLUSIONES:La estrategia de tratamiento tuvo un impacto significativo en la mortalidad a los 90 días. Un estoma descompresor reduce considerablemente el riesgo de mortalidad, especialmente en pacientes mayores y frágiles. Se desarrolló un modelo de riesgo, que necesita una mayor validación externa. Consulte Video Resumen en http://links.lww.com/DCR/B975 . (Traducción-Dr. Ingrid Melo ).

Which treatment strategy is optimal for acute left-sided malignant colonic obstruction? A Bayesian meta-analysis

PURPOSE

This study aimed to determine the best treatment for acute left-sided malignant colonic obstruction (ALMCO) among emergency surgery (ES), self-expanding metallic stent (SEMS), transanal drainage tube (TD), and decompressive stoma (DS).

METHOD

Articles that compared two or more treatments of ALMCO were searched from PubMed, Cochrane Library, and Embase. Network meta-analyses were performed to calculate the outcomes of primary anastomosis, stoma creation, morbidity, mortality, and 5-year survival.

RESULTS

Fifty-one articles met inclusion criteria. TD was the optimal treatment in performing primary anastomosis [probability of ranking first (Pro-1) 0.96], while ES was the worst [probability of ranking fourth (Pro-4) 0.99]. More permanent stoma was formed in ES and TD groups than in SEMS and DS groups [OR (95%CI): TD vs SEMS: 4.12 (1.89, 9.45); TD vs DS: 3.39 (1.46, 8.75); ES vs DS: 2.55 (1.73, 4.17); SEMS vs ES: 0.33 (0.24, 0.42)]. More morbidity occurred in ES group than in SEMS group [OR (95%CI): ES vs SEMS: 1.44 (1.14, 1.82)]. Besides, SEMS was ranked first in avoiding infection (Pro-4 0.95). For in-hospital mortality, ES was ranked first (Pro-1 0.93). TD was ranked first in recurrence (Pro-1 0.97) and metastasis (Pro-1 0.98). There was no discrepancy in 5-year overall and disease-free survival among all strategies.

CONCLUSION

SEMS as a bridge to surgery reduces stoma formation, and morbidity especially the infection rate with relatively great oncological outcomes. Therefore, SEMS should be recommended first for ALMCO in the medical center with experience and conditions.

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis

BACKGROUND

Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent.

METHODS

Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed.

RESULTS

From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01).

CONCLUSIONS

Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

Oncologic impact of colonic stents for obstructive left-sided colon cancer

Colonic stenting has had a significant positive impact on the management of obstructive left-sided colon cancer (OLCC) in terms of both palliative treatment and bridge-to-surgery (BTS). Notably, many studies have convincingly demonstrated the effectiveness of stenting as a BTS, resulting in improvements in short-term outcomes and quality of life, safety, and efficacy in subsequent curative surgery, and increased cost-effectiveness, whereas the safety of chemotherapy after stenting and the long-term outcomes of stenting as a BTS are controversial. Several studies have suggested an increased risk of perforation in patients receiving bevacizumab chemotherapy after colonic stenting. In addition, several pathological analyses have suggested a negative oncological impact of colonic stenting. In contrast, many recent studies have demonstrated that colonic stenting for OLCC does not negatively impact the safety of chemotherapy or long-term oncological outcomes. The updated version of the European Society of Gastrointestinal Endoscopy guidelines released in 2020 included colonic stenting as a BTS for OLCC as a recommended treatment. It should be noted that the experience of endoscopists is involved in determining technical and clinical success rates and possibly oncological outcomes. This review discusses the positive and negative impacts of colonic stenting on OLCC treatment, particularly in terms of oncology.

Risk factors for a permanent stoma after resection of left-sided obstructive colon cancer - A prediction model

INTRODUCTION

In patients with left-sided obstructive colon cancer (LSOCC), a stoma is often constructed as part of primary treatment, but with a considerable risk of becoming a permanent stoma (PS). The aim of this retrospective multicentre cohort is to identify risk factors for a PS in LSOCC and to develop a pre- and postoperative prediction model for PS.

MATERIALS AND METHODS

Data was retrospectively obtained from 75 hospitals in the Netherlands. Patients who had curative resection of LSOCC between January 1, 2009 to December 31, 2016 were included with a minimum follow-up of 6 months after resection. The interventions analysed were emergency resection, decompressing stoma or stent as bridge-to-elective resection. Main outcome measure was presence of PS at the end of follow-up. Multivariable logistic regression analysis was performed to identify risk factors for PS at primary presentation (T₀) and after resection, in patients having a stoma in situ (T₁). These risk factors were used to construct a web-based prediction tool.

RESULTS

Of 2099 patients included in the study (T₀), 779 had a PS (37%). A total of 1275 patients had a stoma in situ directly after resection (T₁), of whom 674 had a PS (53%). Median follow-up was 34 months. Multivariable analysis showed that older patients, female sex, high ASA-score and open approach were independent predictors for PS in both the T₀ and T₁ population. Other predictors at T₀ were sigmoid location, low Hb, high CRP, cM1 stage, and emergency resection. At T₁, subtotal colectomy, no primary anastomosis, not receiving adjuvant chemotherapy and high pTNM stage were additional predictors. Two predictive models were built, with an AUC of 0.74 for T₀ and an AUC of 0.81 for T₁.

CONCLUSIONS

PS is seen in 37% of the patients who have resection of LSOCC. In patients with a stoma in situ directly after resection, 53% PS are seen due to non-reversal. Not only baseline characteristics, but also treatment strategies determine the risk of a PS in patients with LSOCC. The developed predictive models will give physicians insight in the role of the individual variables on the risk of a PS and help in informing the patient about the probability of a PS.

Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital

INTRODUCTION

Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively.

METHODS

We reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language.

RESULTS

Of 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046).

CONCLUSIONS

Spanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.

Endoscopic stent versus diverting stoma as a bridge to surgery for obstructive colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Self-expandable metallic stent (SEMS), an alternative to diverting stoma (DS), has been used as a "bridge to surgery" (BTS) to decompress acute obstruction of colorectal cancer (CRC) for decades. However, whether SEMS is a safe technique for obstruction of CRC without compromising the long-term survival of patients remains unidentified compared to those of DS. The aim of the present study was to elucidate the safety and survival outcomes of SEMS and DS.

METHODS

Embase, PubMed, and Medline were searched for qualified studies published until October, 2020, in which SEMS or DS was performed as a BTS without resection at the same stage. The last search was on December 5th, 2020. The Newcastle-Ottawa scale (NOS) was used to assess the quality of included studies. The major complication rate, mortality, 3-year overall survival (OS), and permanent stoma rate were estimated as outcomes.

RESULTS

The present study was registered on INPLASY (No. 2020100079). Seven eligible studies were included, involving 646 and 712 patients who underwent SEMS and DS treatments, respectively. The Clavien-Dindo I/II grade complication rate was significantly lower in the SEMS group than in the DS group (8.68 vs. 16.85%; RR, 0.59; 95% confidence interval (CI) 0.41-0.84; P = 0.004). The Clavien-Dindo III/IV grade complication rate was comparable in two groups (7.69 vs. 8.79%; RR, 0.82; 95% CI 0.54-1.27; P = 0.37). There were no statistical differences in the short-term mortality (5.16 vs. 4.53%; RR, 1.25; 95% CI 0.75-2.08; P = 0.39), 3-year OS (71.91 vs. 76.60%; RR, 0.93; 95% CI 0.86-1.01; P = 0.10), and permanent stoma rate (22.08 vs. 27.54%; RR, 0.84; 95% CI 0.67-1.06; P = 0.14) between the two groups.

CONCLUSIONS

To some extent, SEMS is a safe BTS technique for acute obstructive CRC, without significant adverse effect on the survival of patients. Given the advantage of minimal invasion, SEMS may be a better alternative to DS for obstructive CRC. However, the conclusions remain to be discussed because of lacking high-quality randomized controlled trails.

Surgical Dilemmas Associated with Malignant Large Bowel Obstructions

Despite an increase in screening colonoscopy, with the objective to decrease the incidence of colorectal cancer, a third of patients will present with an obstructing cancer. Malignant large bowel obstructions (MLBO) pose a challenging workup and treatment paradigm where an oncologic primary tumor resection must be balanced with relieving the obstruction, functional outcomes, palliation, and consideration for adjuvant therapy. A thorough work up with cross-sectional imaging and medical optimization should be attempted; however, patients may present in extremis and require emergent intervention. The onset of MLBO can be insidious, but result in electrolyte derangements, perforation, small bowel obstruction, hemorrhage, and ischemia. Self-expandable metallic stents have been used as palliation or as a bridge to surgery and have allowed for minimally invasive surgical options as well as a decrease in stoma rates. Patients with signs of colon ischemia or perforation require emergent surgery, which is associated with an increase in stoma formation, morbidity, mortality, and a decrease in overall survival.

Colonic stent as a bridge to surgery versus emergency resection for right-sided malignant large bowel obstruction: a meta-analysis

BACKGROUND

Preoperative colonic stenting for malignant large bowel obstruction (MLBO), also called bridge to surgery (BTS), is considered a great substitute treatment for emergency resection (ER) in the left-sided colon. However, its efficacy in the right-sided colon remains controversial. This systematic review and meta-analysis aimed to compare the postoperative short-term outcomes between BTS and ER for right-sided MLBO.

METHODS

A comprehensive electronic literature search throughout December 2020 was performed to identify studies comparing short-term outcomes between BTS and ER for right-side MLBO. The main outcome measures were postoperative complications and mortality rates. A meta-analysis was performed using a fixed-effect or a random-effect method to calculate odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

Seven studies were included in this meta-analysis, comprising 5136 patients, of whom 1662 (32.4%) underwent BTS and 3474 (67.6%) underwent ER. This meta-analysis demonstrated that BTS resulted in reductions in postoperative complications (OR = 0.78; 95% CI: 0.66-0.92) and mortality (OR = 0.51; 95% CI: 0.28-0.92) than ER.

CONCLUSION

The results of this meta-analysis indicate that BTS for right-sided MLBO confers preferable short-term outcomes as well as for left-sided. This suggests that BTS results in a reduction of postoperative complications and mortality for right-sided MLBO than ER.

Clinical outcome of decompressing colostomy for acute left-sided colorectal obstruction: a consecutive series of 100 patients

PURPOSE

Aim of our study was to evaluate the outcomes of a consecutive series of patients who were treated with a decompressing colostomy (DC) for acute left-sided colorectal obstruction.

METHOD

A consecutive series of 100 patients with acute left-sided colorectal obstruction who underwent DC from January 2015 to August 2020 was retrospectively analyzed. Demographic characteristics, etiology of the obstruction, postoperative morbidity- and mortality rates, DC-related complication and stoma reversal rates were evaluated.

RESULTS

Of the 100 included patients, 64 had malignant- and 36 had benign obstruction. The mean age was 69 years, 42% was male, and the ASA score was 2. Morbidity and mortality rates after DC construction were 20 and 2%, respectively. In 39% of the patients, DC ended up as a permanent stoma and in 61% as bridge to surgery (BtS). DC related complication rate was 32%, with a re-intervention rate of 9%. Elective colorectal resection was performed in 59 cases (59%) with subsequent postoperative morbidity rate of 20%. Stoma reversal rate was 77% for the patients who underwent DC as BtS. Stoma reversal was performed in 66% of the patients with benign obstruction and in 36% for oncological obstruction.

CONCLUSION

DC as bridge to possible elective resection for acute left-sided colorectal obstruction is an effective strategy with low morbidity and mortality rates and a high stoma reversal rate, especially for benign obstruction. However, DC is less appropriate for patients in whom DC turns out to be a permanent stoma due to a relatively high stoma related complications.

Emergency resection or diverting stoma followed by elective resection in patients with colonic obstruction due to locally advanced cancer: a national cohort study

AIM

The aim was to assess long-term prognosis after emergency resection versus primary diverting stoma followed by elective tumour resection.

METHOD

A national-register-based cohort study with retrospective analysis of prospectively collected data was performed. All Swedish patients with non-metastatic obstructive locally advanced colon cancer treated with emergency resection or diverting stoma, followed by an elective resection, between 2007 and 2017 were included. The Kaplan-Meier method and Cox proportional hazards model were used to compare all-cause mortality between patients with emergency resection and elective right- and left-sided resection. The multivariable model was adjusted for year of diagnosis, age at diagnosis, sex, Charlson Comorbidity Index, American Society of Anesthesiologists class, tumour location and pN stage.

RESULTS

In all, 751 patients with a tumour in the right colon and 700 patients with a tumour in the left colon were included. Emergency resection was more common in patients with right-sided colon tumours (681/751) than in patients with left-sided colon tumours (483/700). The 5-year overall survival in patients with right-sided tumours was 25% after emergency resection and 46% after diverting stoma followed by elective resection (log-rank test P = 0.001). The corresponding numbers for patients with left-sided colon tumours were 40% and 64% (P < 0.001). Emergency resection was independently associated with increased all-cause mortality in patients with left-sided tumour (hazard ratio 1.63, 95% CI 1.21-2.19) but not in patients with right-sided tumour (hazard ratio 1.21, 95% CI 0.80-1.81).

CONCLUSION

Diverting stoma followed by elective resection is associated with improved survival compared with emergency resection in patients with left-sided colonic obstruction due to locally advanced tumours.

Time interval between self-expandable metal stent placement or creation of a decompressing stoma and elective resection of left-sided obstructive colon cancer

BACKGROUND

The optimal timing of resection after decompression of left-sided obstructive colon cancer is unknown. Revised expert-based guideline recommendations have shifted from an interval of 5 - 10 days to approximately 2 weeks following self-expandable metal stent (SEMS) placement, and recommendations after decompressing stoma are lacking. We aimed to evaluate the recommended bridging intervals after SEMS and explore the timing of resection after decompressing stoma.

METHODS

This nationwide study included patients registered between 2009 and 2016 in the prospective, mandatory Dutch ColoRectal Audit. Additional data were collected through patient records in 75 hospitals. Only patients who underwent either SEMS placement or decompressing stoma as a bridge to surgery were selected. Technical SEMS failure and unsuccessful decompression within 48 hours were exclusion criteria.

RESULTS

510 patients were included (182 SEMS, 328 decompressing stoma). Median bridging interval was 23 days (interquartile range [IQR] 13 - 31) for SEMS and 36 days (IQR 22 - 65) for decompressing stoma. Following SEMS placement, no significant differences in post-resection complications, hospital stay, or laparoscopic resections were observed with resection after 11 - 17 days compared with 5 - 10 days. Of SEMS-related complications, 48 % occurred in patients operated on beyond 17 days. Compared with resection within 14 days, an interval of 14 - 28 days following decompressing stoma resulted in significantly more laparoscopic resections, more primary anastomoses, and shorter hospital stays. No impact of bridging interval on mortality, disease-free survival, or overall survival was demonstrated.

CONCLUSIONS

Based on an overview of the data with balancing of surgical outcomes and timing of adverse events, a bridging interval of approximately 2 weeks seems appropriate after SEMS placement, while waiting 2 - 4 weeks after decompressing stoma further optimizes surgical conditions for laparoscopic resection with restoration of bowel continuity.

Emergency Management of Obstructive Colorectal Cancer - A Retrospective Study of Efficacy and Safety in Self-expanding Metallic Stents and Trans-anal Tubes

BACKGROUND/AIM

The self-expanding metallic stent (SEMS) has recently been used for obstructive colorectal cancer (OCRC), and reports of its use are increasing. However, the long-term results of OCRC after using SEMS remain unclear. This study investigated the characteristics of SEMS compared to trans-anal tube (TAT) and clarified the long-term results and efficacy of SEMS for OCRC.

PATIENTS AND METHODS

We analyzed 48 patients who required SEMS or TAT for emergent decompression of OCRC and underwent resection for OCRC between 2007 and 2019. The perioperative factors and long-term results in the two groups were evaluated.

RESULTS

Patients with OCRC were divided into the SEMS (n=23) and the TAT group (n=25). No significant differences were seen in background factors, complications and the 5-year overall survival after surgery (p=0.3500) between the two groups. The clinical success of decompression (p=0.0072), oral intake (p<0.0001) and change in serum albumin (p<0.0001) from decompression to surgery were significantly better in the SEMS compares to the TAT group.

CONCLUSION

The long-term outcomes in the SEMS group were not significantly different than in the TAT group, and nutritional status was better in patients with SEMS, suggesting that SEMS is very effective and may be the first-line treatment of OCRC.

Long-term survival after self-expanding metallic stent or stoma decompression as bridge to surgery in acute malignant large bowel obstruction

Aim

Self-expanding metallic stents (SEMS) as bridge to surgery have been questioned due to the fear of perforation and tumour spread. This study aimed to compare SEMS and stoma as bridge to surgery in acute malignant large bowel obstruction in the Swedish population.

Method

Medical records of patients identified via the Swedish Colorectal Cancer Register 2007–2009 were collected and scrutinized. The inclusion criterion was decompression intended as bridge to surgery due to acute malignant large bowel obstruction. Patients who underwent decompression for other causes or had bowel perforation were excluded. Primary endpoints were 5-year overall survival and 3-year disease-free survival. Secondary endpoints were 30-day morbidity and mortality rates.

Results

A total of 196 patients fulfilled the inclusion criterion (SEMS, 71, and stoma, 125 patients). There was no significant difference in sex, age, ASA score, TNM stage and adjuvant chemotherapy between the SEMS and stoma groups. No patient was treated with biological agents. Five-year overall survival was comparable in SEMS, 56 per cent (40 patients), and stoma groups, 48 per cent (60 patients), P = 0.260. Likewise, 3-year disease-free survival did not differ statistically significant, SEMS 73 per cent (43 of 59 patients), stoma 65 per cent (62 of 95 patients), P = 0.32. In the SEMS group, 1.4 per cent (one patient) did not fulfil resection surgery compared to 8.8 per cent (11 patients) in the stoma group (P = 0.040). Postoperative complication and 30-day postoperative mortality rates did not differ, whereas the duration of hospital stay and proportion of permanent stoma were lower in the SEMS group.

Conclusion

This nationwide registry-based study showed that long-term survival in patients with either SEMS or stoma as bridge to surgery in acute malignant large bowel obstruction were comparable. SEMS were associated with a lower rate of permanent stoma, higher rate of resection surgery and shorter duration of hospital stay.

Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression

PURPOSE

After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes.

METHODS

Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated.

RESULTS

36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2 weeks compared to < 2 weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival.

CONCLUSIONS

Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

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.

Diversion, resection, or stenting as a bridge to surgery for acute neoplastic left-sided colonic obstruction: a systematic review and network meta-analysis of studies with curative intent

INTRODUCTION

The debate on the best surgical management strategy for acute malignant left-sided colonic obstruction is ongoing. Decompressing colostomy (DC) and stenting as a bridge to surgery (SBTS) are the currently proposed alternative approaches to emergency colectomy (EC). However, the results of a traditional meta-analysis were inconclusive. Therefore, a network meta-analysis (NMA) was conducted to compare the three approaches for acute left-sided colonic obstruction.

METHODS

A systematic literature search of Embase, PubMed, Google Scholar and the Cochrane library was performed. A traditional meta-analysis and subsequent NMA were conducted.

FINDINGS

A significantly greater number of primary anastomoses were performed in the DC cohort than in the EC and SBTS cohorts. The 90-day mortality rate was significantly lower in the DC cohort than in the EC and SBTS cohorts. Higher costs were associated with the SBTS cohort (by US$2,000) than with the EC cohort. The locoregional recurrence rate was higher for the SBTS cohort than for the EC cohort.

CONCLUSIONS

Evidence from the first NMA suggests there may be some clinical advantages associated with DC as an alternative approach to the EC and SBTS approaches for adequately selected patients with malignant large bowel 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.

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.

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.

Obstructive left side colon cancer: time for a tailored operative approach?

BACKGROUND

Colorectal cancer (CRC) obstruction is frequent but doubts remain on the best treatment. The aim of this study is to analyze the different operative approach used for CRC treatment and evaluate the outcomes for the different cases.

METHODS

Patients were collected from January 2014 to December 2019 and divided in four groups: two "P" groups, namely the Hartmann's procedure (PH) group and the primary anastomosis (PA) group, and two "S" groups, namely the deviating stoma (SD) group and the self-expanding metallic stent (SS) group. The main endpoints were the quality of life and the oncologic safety.

RESULTS

One hundred and eight patients were enrolled. The mean follow-up time was 39 months. The stomas were performed less frequently in SS but lasted more in that group. Only 45% underwent reversal surgery. Cumulative operating time was greater in S versus P groups. The rate of major complications was similar. PA had greater overall survival and disease-free survival rates than PH.

CONCLUSIONS

The various options of treatment should have different indications: primary anastomosis in stable patients, Hartmann in critical cases, SEMS for palliative intent and stoma when neo-adjuvant therapy is needed.

Comparison of short-term outcome between diverting colostomy and colonic stent as a bridge to surgery for left colonic malignant obstruction

The self-expanding metallic stent (SEMS) has been comprehensively investigated as a bridge to surgery. SEMS enables the control of acute colonic obstruction. However, comparison between SEMS and diverting colostomy as another bridge procedure was still challenging issue. Thus, the aim of this study was to compare these 2 procedures.In this retrospective cohort study, patients who received diverting colostomy and SEMS for acute left colonic obstruction between February 2016 and August 2018 were included. They were classified into the colostomy group (n = 27), including 5 patients who had SEMS failure previously, and the SEMS group (n = 23). The clinicopathologic parameters, pathologic results, and short-term outcomes were compared.No significant differences were found in clinicopathologic characteristics and complication rates between the 2 groups. After the bridge procedures, the SEMS group showed a higher rate of laparoscopic colonic resection than the colostomy group (100% vs 76%, P = .023). The colostomy group showed a higher rate of rectal cancer (24.0% vs 9.1%, P = .019) and later recovery of flatus (3 vs 2 days, P = .011) than the SEMS group. Additionally, the length of resected colon was longer in the colostomy group than in the SEMS group (33.9 vs 23.4 cm, P = .007).Although SEMS might permit higher laparoscopic resection rates and faster recovery of bowel habits than diverting colostomy, SEMS showed meaningful failure rate including migration and perforation. In addition, diverting colostomy showed acceptable complication rates and feasible performance. An individualized approach is necessary considering the advantages and disadvantages of both procedures.

Surgical Risk and Pathological Results of Emergency Resection in the Treatment of Acutely Obstructing Colorectal Cancers: A Retrospective Cohort Study

Purpose

The treatment of acutely obstructing colorectal cancers is still a matter of debate. The prevailing opinion is that an immediate resection should be performed whenever possible. This study sought to determine whether immediate resection is safe and oncologically valid.

Methods

We completed a retrospective 2-center cohort study using the medical records of patients admitted for acutely obstructing colorectal cancer under the care of the Colorectal Team, Noble’s Hospital, Isle of Man, and the Emergency Surgery Unit, Umberto I University Hospital, Rome, from March 2013 to May 2017. The primary endpoints were 90-day mortality and morbidity, reoperation rate, and length of stay. The secondary endpoints were status of margins, number of lymph nodes retrieved, and the rate of adequate nodal harvest.

Results

Sixty-three patients were retrospectively enrolled in the study. Mortality was associated with age > 80 years and Dukes B tumors. The length of hospital stay was shorter in patients who had their resection less than 24 hours from their admission, in those who had laparoscopic resection and in those with distal tumors. The number of lymph nodes retrieved and rate of R0 resections were similar to those reported in elective colorectal surgery and were greater in laparoscopic resections and in patients operated on within 24 hours, respectively.

Conclusion

Immediate resection is a safe and reliable option in patients with acutely obstructing colorectal cancer.

Risk factors for non-closure of an intended temporary defunctioning stoma after emergency resection of left-sided obstructive colon cancer

PURPOSE

A substantial part (21-35%) of defunctioning stomas created during resection for colorectal cancer will never be reversed. Known risk factors for non-closure are age, peri- or postoperative complications, comorbidity, and tumor stage. However, studies performed to identify these risk factors mostly focus on rectal cancer and include both preoperative and postoperative factors. This study aims to identify preoperative risk factors for non-reversal of intended temporary stomas created during acute resection of left-sided obstructive colon cancer (LSOCC) with primary anastomosis.

METHODS

All patients who underwent emergency resection for LSOCC with primary anastomosis and a defunctioning stoma between 2009 and 2016 were selected from the Dutch ColoRectal Audit, and additional data were collected in the local centers. Multivariable analysis was performed to identify independent preoperative factors for non-closure of the stoma.

RESULTS

A total of 155 patients underwent acute resection for LSOCC with primary anastomosis and a defunctioning stoma. Of these, 51 patients (32.9%) did not have their stoma reversed after a median of 53 (range 7-104) months of follow-up. In multivariable analysis, hemoglobin < 7.5 mmol/L (odds ratio (OR) 4.79, 95% confidence interval (95% CI) 1.60-14.38, p = 0.005), estimated glomerular filtration rate (eGFR) ≤ 45 mL/min/1.73 m² (OR 4.64, 95% CI 1.41-15.10, p = 0.011), and metastatic disease (OR 6.12, 95% CI 2.35-15.94, p < 0.001) revealed to be independent predictors of non-closure.

CONCLUSIONS

Anemia, impaired renal function, and metastatic disease at presentation were found to be independent predictors for non-reversal of intended temporary stomas in patients who underwent acute resection for LSOCC. In patients who have an increased risk of non-reversal, the surgeon should consider a Hartmann's procedure.

Management of Malignant Large-Bowel Obstruction

An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.

Colonic stenting as a bridge to surgery in malignant large bowel obstruction: oncological outcomes

INTRODUCTION

Stenting of obstructing colorectal cancers obviates the need for emergency surgery, reducing initial morbidity and mortality rate associated with emergency surgery and facilitates full staging of the neoplastic process with an opportunity to optimize the patient for surgery. Some recent publications have suggested however that this approach may be associated with higher local recurrence rates. We examined our outcomes following colonic stenting as a bridge to resection.

METHODS

A database was reviewed (2006-2018) of patients presenting with acute colorectal obstruction that proceeded to endoscopic stenting. We assessed the bridge to surgery strategy, its success, complication rate, and impact on recurrence and survival.

RESULTS

Of a total of 103 patients who presented with acute malignant large bowel obstruction over this time period, 26 patients had potentially curable disease at presentation and underwent stenting as a bridge to surgery. The technical success rate for stenting in those managed as a bridge to surgery was 92% (n = 24/26) with 7.69% (n = 2/26) having a complication. There was one stent-related perforation. Median follow-up of this cohort was 31 months, with a 5-year overall survival of 53.5%.

CONCLUSION

Colorectal stenting as a bridge to resection is a successful management strategy for those presenting with obstructing colorectal obstruction. Selective use is associated with lower rates of stoma formation, greater rates of laparoscopic resections with low complication rates, and acceptable oncological outcomes.

Acute abdominal obstruction: Colon stent or emergency surgery? An evidence-based review

According to the American Cancer Society and Colorectal Cancer Statistics 2017, colorectal cancer (CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018. Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction (MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990s, self-expanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.

[Standardization of surgical care for malignant colonic obstruction]

AIM

To standardize surgical care for malignant colonic obstruction.

MATERIAL AND METHODS

There were 572 patients with malignant colonic obstruction: 247 of them were hospitalized in 2011-2013 (I group); 325 - in 2014-2017 (group II). Forty-six patients underwent medication; 302 - acute resection; 141 - stoma construction; 83 - stent deployment. Elective surgery and radiation or chemotherapy was performed after 0.5-6 months in 110 patients of group II. Acute resection was more common in I group, elective resection - in group II. Early and long-term results including Kaplan-Meier 3-year overall survival were compared in both groups.

RESULTS

Complications occurred in 46.69% (group I) and 21% (group II). Postoperative mortality was significantly higher in group I compared with II group: 26.11 and 10.33%, respectively. Three-year overall survival was higher in group I compared with group II: 0.82 and 0.69, respectively.

CONCLUSION

Advisability of new two-stage surgical standard is confirmed for malignant colonic obstruction. Stoma formation and stenting may be a valid alternative in some patients with malignant colonic obstruction due to significantly lower postoperative mortality.

[The optimal terms of the second stage of treatment of patients with malignant colonic obstruction]

AIM

To determine the optimal terms of the second stage of treatment of patients with malignant colonic obstruction.

MATERIAL AND METHODS

There were 110 patients with colorectal cancer stage T_3-4N₀M₀ (groups I-III, n=69) and T_3-4N_0-2M_0-1 (group IV, n=41). Everybody has been previously treated for colonic obstruction 0,5-6 months ago: stoma in 62 cases, stenting - in 48 cases. Elective radical surgery and radiotherapy and/or chemotherapy were applied in 2 (I group, n=23), 3 (II, n=23), 4 (III, n=23) weeks or 4-6 months (IV, n=41) after colonic decompression. The optimal terms of radical surgery are determined depending on CT-data, histological examination.

RESULTS

Bowel wall thickness was significantly higher in I-II groups compared with III-IV groups: 3.7; 2.5; 1.9; 1.7, respectively (p≤0,5). The maximum number of tumor emboli was found in III-IV groups. Signs of focal colitis were absent in III-IV groups.

CONCLUSION

The expediency of the new surgical standard is confirmed. Bridging strategy (stenting and stoma) may be a valid alternative in some patients with malignant colonic obstruction due to reduced postoperative mortality. The optimal terms for resection in patients with local cancer is 4 weeks after colonic decompression, in locally advanced cancer - 4-6 months.

Colonic stent versus emergency surgery as treatment of malignant colonic obstruction in the palliative setting: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Colorectal cancer (CRC) is the third most common malignancy and the third leading cause of cancer death worldwide. Malignant colonic obstruction (MCO) due to CRC occurs in 8 % to 29 % of patients.The aim of this study was to perform a systematic review and meta-analysis of RCTs comparing colonic SEMS versus emergency surgery (ES) for MCO in palliative patients. This was the first systematic review that included only randomized controlled trials in the palliative setting.

METHODS

A literature search was performed according to the PRISMA method using online databases with no restriction regarding idiom or year of publication. Data were extracted by two authors according to a predefined data extraction form. Primary outcomes were: mean survival, 30-day adverse events, 30-day mortality and length of hospital stay. Stoma formation, length of stay on intensive care unit (ICU), technical success and clinical success were recorded for secondary outcomes. Technical success (TS) was defined as successful stent placement across the stricture and its deployment. Clinical success (CS) was defined as adequate bowel decompression within 48 h of stent insertion without need for re-intervention.

RESULTS

We analyzed data from four RCT studies totaling 125 patients. The 30-day mortality was 6.3 % for SEMS-treated patients and 6.4 % for ES-treated patients, with no difference between groups (RD: - 0.00, 95 % CI [-0.10, 0.10], I 2 : 0 %). Mean survival was 279 days for SEMS and 244 days for ES, with no significant difference between groups (RD: 20.14, 95 % CI: [-42.92, 83.21], I 2 : 44 %). Clinical success was 96 % in the ES group and 86.1 % in the SEMS group (RD: - 0.13, 95 % CI [-0.23, - 0.02], I 2 : 51 %). Permanent stoma rate was 84 % in the ES group and 14.3 % in the SEMS group (RR: 0.19, 95 % CI: [0.11, 0.33], I 2 : 28 %). Length of hospital stay was shorter in SEMS group (RD: - 5.16, 95 % CI: [-6.71, - 3.61], I 2 : 56 %). There was no significant difference between groups regarding adverse events (RD 0.18, 95 % CI: [-0.19, 0.54;]) neither regarding ICU stay. (RD: - 0.01, 95 % CI: [-0.08, 0.05], I 2 : 7 %). The most common stent-related complication was perforation (42.8 % of all AE).

CONCLUSION

Mortality, mean survival, length of stay in the ICU and early complications of both methods were similar. SEMS may be an alternative to surgery with the advantage of early hospital discharge and lower risk of permanent stoma.

Emergency treatment of complicated colorectal cancer

Aim

To find evidence to suggest the best approach in patients admitted as an emergency for complicated colorectal cancer.

Methods

The medical records of 131 patients admitted as an emergency with an obstructing, perforated, or bleeding colorectal cancer to Noble’s Hospital, Isle of Man, and the Umberto I University Hospital, Rome, were retrospectively evaluated. Patients were divided in 3 groups on the basis of the emergency treatment they received, namely 1) immediate resection, 2) damage control procedure and elective or semielective resection, and 3) no radical treatment. Demographic variables, clinical data, and treatment data were considered, and formed the basis for the comparison of groups. Primary endpoints were 90-day mortality and morbidity. Secondary endpoints were length of stay, number of lymph nodes analyzed, rate of radical R0 resections, and the number of patients who had chemoradiotherapy.

Results

Forty-two patients did not have any radical treatment because the cancer was too advanced or they were too ill to tolerate an operation, 78 patients had immediate resection and 11 had damage control followed by elective resection. There was no statistically significant difference between immediate resections and 2-stage treatment in 90-day mortality and morbidity (mortality: 15.4% vs 0%; morbidity: 26.9% vs 27.3%), number of nodes retrieved (16.6±9.4 vs 14.9±5.7), and rate of R0 resections (84.6% vs 90.9%), but mortality was slightly higher in patients who underwent immediate resection. The patients who underwent staged treatment had a higher possibility of receiving a laparoscopic resection (11.5% vs 36.4%).

Conclusion

The present study failed to demonstrate a clear superiority of one treatment with respect to the other, even if there is an interesting trend favoring staged resection.

[Managerial and methodological aspects of emergency surgery for malignant colonic obstruction]

AIM

To determine the most feasible treatment strategy for malignant colonic obstruction.

MATERIAL AND METHODS

There were 427 patients with malignant colonic obstruction who were hospitalized for emergency indications. 30 of them were treated with medical therapy; 286 - underwent acute resection; 43 - stoma construction; 68 - stents deployment. 64 out of 427 patients underwent elective restorative/radical surgery and radio- or chemotherapy in 1-8 months. 3-year Kaplan-Meier survival was assessed.

RESULTS

Complications occurred in 58% after acute resection and in 32.6% and 8.8% after stoma and stent deployment, respectively. Postoperative mortality was significantly lower after palliative surgery (stent or stoma) compared with acute resection: 2.9%, 18.6%, 29.37%, respectively. 3-year survival was higher after elective resections compared with emergency resection group: 0,81 и 0,68 respectively.

CONCLUSION

Bridging strategy (stoma/stents) may be a valid alternative in some patients with malignant colonic obstruction due to significantly reduced postoperative mortality. Acute surgery for malignant colonic obstruction should only be carried out by appropriately trained surgeons at multi-field hospital.

Strategies for diagnosis and treatment of benign and malignant colorectal obstruction

Colorectal obstruction is one of the most common acute abdominal diseases in surgery department. Because of complex etiological factors, severe condition, and rapid progression, timely diagnosis and proper treatment are necessary for colorectal obstruction. By searching the literature and based on our experience in clinical practice, we performed a comprehensive and systematic analysis of the etiology, diagnosis and treatment of benign and malignant colorectal obstruction, and summarize the main points of diagnosis and treatment of benign and malignant colorectal obstruction as follows: identifying the etiology of benign and malignant colorectal obstruction; flexible application of colonography with meglumine diatrizoate, CT virtual endoscopy, and colonoscopy; preoperative colonoscopic drainage as a bridge to surgery; strict control of surgical indication; precise surgical procedures; and active symptomatic treatment. These measures are of important significance in improving the diagnosis and treatment of benign and malignant colorectal obstruction.

Stenting as a bridge to resection versus emergency surgery for left-sided colorectal cancer with malignant obstruction: A systematic review and meta-analysis

PURPOSE

This study aims to discuss the safety and feasibility of a combined treatment consisting of stent insertion and elective surgery for left-sided colorectal cancer with malignant obstruction.

METHODS

Randomized clinical trials (RCTs) that discussed the safety and feasibility of stenting as a bridge to surgery in malignant colorectal cancer were identified in a search of medical databases, including PubMed, Embase, Cochrane Library, and SCIENCE. Each paper's quality was assessed using the Jadad scale. A meta-analysis was conducted using RevMan 5.3, and statistical heterogeneity between RCTs was defined as I²>50%.

RESULTS

Nine RCTs included 594 patients were selected and analyzed. Of the included patients, 281 underwent stent insertion followed by elective surgery (SG group), and 313 underwent emergency surgery (EG group). The meta-analysis revealed that the patients in the SG group had a higher one-stage anastomosis rate. Patients in the SG had lower mortality rates and minor complications. There was no significant difference in anastomotic leakage between the two groups. The funnel plot showed that there was no publication bias in these outcomes.

CONCLUSION

Stenting as a bridge to surgery was safe and feasible in left-sided colorectal cancer with malignant obstruction. Compared with the patients in the EG group, the SG patients had an improved primary anastomosis rate and experienced no increase in the risk of other complications.