Treatment of left-sided colonic emergencies: a comparison of US, UK and Australian surgeons

Current practice for the treatment of obstructive left-sided colon cancer in China: a nationwide cross-sectional survey

PURPOSE

This study surveyed the current practice of surgical treatment of obstructive left-sided colon cancer (OLCC) in China.

METHODS

All colorectal surgery departments at tertiary or secondary hospitals in China were invited to complete a web-based questionnaire between August 27 and September 2, 2020.

RESULTS

Overall, completed questionnaire were received from 357 hospitals. Emergency surgery was the mainstay of treatment for OLCC, with the open approach accounting for up to 61.62%. The stoma rate of emergency surgery was up to 80%, mainly due to inadequate bowel preparation and severe edema of colon walls. Hartmann's procedure (61.62%) was the most preferred operation. A total of 243 hospitals (68.7%) reported that they would consider the use of a self-expanding metallic stent (SEMS) as a bridge for elective surgery. More than 50% of the hospitals participating in this study reported the success rate of SEMS placement, as well as the resolution rate of obstruction more than 80%, and the stent-related perforation rate was < 5%. A total of 126 hospitals considered carrying out a strategy of SEMS followed by neoadjuvant chemotherapy prior to elective surgery and believed that it might further improve treatment outcomes.

CONCLUSIONS

SEMS is a feasible option for the treatment of OLCC in addition to traditional emergency surgery, and its clinical benefits have been preliminarily recognized.

Is colonic lavage a suitable alternative for left-sided colonic emergencies?

BACKGROUND

The use of intra-operative colonic lavage (IOCL) with primary anastomosis remains controversial in the emergency left-sided large bowel pathologies, with alternatives including Hartmann’s procedure, manual decompression and subtotal colectomy.

AIM

To compare the peri-operative outcomes of IOCL to other procedures.

METHODS

Electronic databases were searched for articles employing IOCL from inception till July 13, 2020. Odds ratio and weighted mean differences (WMD) were estimated for dichotomous and continuous outcomes respectively. Single-arm meta-analysis was conducted using DerSimonian and Laird random effects.

RESULTS

Of 28 studies were included in this meta-analysis, involving 1142 undergoing IOCL, and 634 other interventions. IOCL leads to comparable rates of wound infection when compared to Hartmann’s procedure, and anastomotic leak and wound infection when compared to manual decompression. There was a decreased length of hospital stay (WMD = -7.750; 95%CI: -13.504 to -1.996; P = 0.008) compared to manual decompression and an increased operating time. Single-arm meta-analysis found that overall mortality rates with IOCL was 4% (CI: 0.03-0.05). Rates of anastomotic leak and wound infection were 3% (CI: 0.02-0.04) and 12% (CI: 0.09-0.16) respectively.

CONCLUSION

IOCL leads to similar rates of post-operative complications compared to other procedures. More extensive studies are needed to assess the outcomes of IOCL for emergency left-sided colonic surgeries.

Evidence-based Clinical Management of Acute Malignant Colorectal Obstruction

Acute malignant colorectal obstruction (AMCO) is an emergency associated with colorectal cancer (CRC). Emergency surgery is standard therapy for AMCO, and 1-stage surgery without colostomy is preferable, but it is occasionally difficult in the emergency setting. A self-expandable metallic stent (SEMS) enables noninvasive colonic decompression and subsequent 1-stage surgery, which has been widely applied for CRC with AMCO. However, recent accumulation of high-quality evidence has highlighted some problems and the limited efficacy of SEMS for AMCO. In palliative settings, SEMS placement reduces hospital stay and short-term complication rates, whereas it increases the frequency of long-term complications, such as delayed perforation. SEMS placement does not seem compatible with recent standard chemotherapy including bevacizumab. As a bridge to surgery, while SEMS placement provides a lower clinical success rate than emergency surgery, it can facilitate primary anastomosis without stoma. However, evidence regarding long-term survival outcomes with SEMS in both palliative and bridge to surgery settings is lacking. The efficacy of transanal colorectal tube placement, another endoscopic treatment, has been reported, but its clinical evidence level is low due to the limited number of studies. This review article comprehensively summarizes the current knowledge about surgical and endoscopic management of CRC with AMCO.

Changes in the surgical approach to colonic emergencies during a 15-year period

PURPOSE

The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years.

MATERIALS AND METHODS

A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed.

RESULTS

Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001).

CONCLUSIONS

Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.

Management of colonic obstruction: a review

Large bowel obstruction is a common problem with many different causes, the most common being colorectal adenocarcinoma, extracolonic adenocarcinoma, diverticular disease, volvulus, and inflammatory bowel disease. The nature of the obstruction can influence the best management. Historically, treatment of obstruction consisted of surgical removal of the obstruction if possible and decompression of the bowel with an ostomy. Other strategies for managing obstruction have evolved as alternatives to stomas, including primary resection with anastomosis and endoscopic stent placement. The choice of treatment can therefore be tailored to the individual patient with good success.