Endoscopic decompression procedure in acute obstructing colorectal cancer

Endoscopic Management of Colonic Obstruction

Large bowel obstruction is a serious event that occurs in approximately 25% of all intestinal obstructions. It is attributed to either benign, malignant, functional (pseudo-obstruction), or mechanical conditions. Benign etiologies of colonic obstructions include colon volvulus, anastomotic strictures, radiation injury, ischemia, inflammatory processes such as Crohn's disease, diverticulitis, bezoars, and intussusception.

Self-expanding metal stents versus decompression tubes as a bridge to surgery for patients with obstruction caused by colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Using self-expanding metal stents (SEMS) and decompression tubes (DT) as a bridge-to-surgery (BTS) treatment may avoid emergency operations for patients with colorectal cancer-caused obstructions. This study aimed to evaluate the efficacy and safety of the two approaches.

METHODS

We systematically retrieved literature from January 1, 2000, to May 30, 2023, from the PubMed, Embase, Web of Science, SinoMed, Wanfang Data, Chinese National Knowledge Infrastructure, and Cochrane Central Register of Clinical Trials databases. Randomized controlled trials (RCTs) or cohort studies of SEMS versus DT as BTS in colorectal cancer obstruction were selected. Risks of bias were assessed for RCTs and cohort studies using the Cochrane Risk of Bias tool version 2 and Risk of Bias in Nonrandomized Studies of Interventions. Certainty of evidence was determined using the Graded Recommendation Assessment. Odds ratio (OR), mean difference (MD), and 95% confidence interval (95% CI) were used to analyze measurement data.

RESULTS

We included eight RCTs and eighteen cohort studies involving 2,061 patients (SEMS, 1,044; DT, 1,017). Pooled RCT and cohort data indicated the SEMS group had a significantly higher clinical success rate than the DT group (OR = 1.99, 95% CI 1.04, 3.81, P = 0.04), but no significant difference regarding technical success (OR = 1.29, 95% CI 0.56, 2.96, P = 0.55). SEMS had a shorter postoperative length of hospital stays (MD = - 4.47, 95% CI - 6.26, - 2.69, P < 0.00001), a lower rates of operation-related abdominal pain (OR = 0.16, 95% CI 0.05, 0.50, P = 0.002), intraoperative bleeding (MD = - 37.67, 95% CI - 62.73, - 12.60, P = 0.003), stoma creation (OR = 0.41, 95% CI 0.23, 0.73, P = 0.002) and long-term tumor recurrence rate than DT (OR = 0.47, 95% CI 0.22, 0.99, P = 0.05).

CONCLUSION

SEMS and DT are both safe as BTS to avoid emergency surgery for patients with colorectal cancer obstruction. SEMS is preferable because of higher clinical success rates, lower rates of operation-related abdominal pain, intraoperative bleeding, stoma creation, and long-term tumor recurrence, as well as a shorter postoperative length of hospital stays. Trial registration CRD42022365951 .

Long-term and short-term outcomes of laparoscopic versus open resection following tube decompression for obstructive colorectal cancer: a single-center retrospective study

PURPOSE

The benefits of laparoscopic surgery over open surgery are well documented; however, the suitability of laparoscopic surgery for obstructive colorectal cancer is still controversial. The aim of this retrospective study was to compare the clinical benefits of laparoscopic surgery vs. open surgery for obstructive colorectal cancer after tube decompression.

METHODS

We analyzed the outcomes of patients who underwent laparoscopic surgery vs. open surgery for curative resection after tube decompression for obstructive colorectal cancer at our hospital between January, 2007 and March, 2018.

RESULTS

This study comprised 67 patients: 29 patients who underwent open surgery and 38 patients who underwent laparoscopic surgery. The morbidity within 30 days after surgery was comparable between the groups. The 3-year overall survival rates of the open and laparoscopic groups were 83.3 and 79.4%, respectively (p = 0.6244), and the 3-year disease-free survival rates were 59.3 and 71.2%, respectively (p = 0.3200). Multivariate analysis showed that nodal stage (p = 0.021) was an independent prognostic factor for OS and sex (p = 0.010) and side-ness (p = 0.048) were independent prognostic factors for DFS.

CONCLUSION

If adequate decompression is achieved, laparoscopic resection following tube decompression for obstructive colorectal cancer can be a safe alternative to open surgery.

2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation

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Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).

Methods

The literature was extensively queried for focused publication until December 2017. Precise analysis and grading of the literature has been performed by a working group formed by a pool of experts: the statements and literature review were presented, discussed and voted at the Consensus Conference of the 4th Congress of the World Society of Emergency Surgery (WSES) held in Campinas in May 2017.

Results

CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted.

With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.

Clinical scenarios in the case of perforation might be dramatic, especially in case of free faecal peritonitis. The importance of an appropriate balance between life-saving surgical procedures and respect of oncologic caveats must be stressed. In selected cases, a damage control approach may be required.

Medical treatments including appropriate fluid resuscitation, early antibiotic treatment and management of co-existing medical conditions according to international guidelines must be delivered to all patients at presentation.

Conclusions

The current guidelines offer an extensive overview of available evidence and a qualitative consensus regarding management of large bowel obstruction and perforation due to colorectal cancer.

Long-term Outcomes of One Stage Surgery Using Transanal Colorectal Tube for Acute Colorectal Obstruction of Stage II/III Distal Colon Cancer

Purpose

Since oncological outcomes of transanal colorectal tube (TCT) placement, an endoscopic treatment for colorectal cancer (CRC) with acute colorectal obstruction (ACO), remain unknown, this study analyzed long-term outcomes of TCT placement for stage II/III CRC with ACO.

Materials and Methods

Data were retrospectively reviewed from consecutive patients with distal stage II/III CRC who underwent surgery between January 2007 and December 2011 at two Japanese hospitals. One hospital conducted emergency surgery and the other performed TCT placement as the standard treatment for all CRCs with ACO. Propensity score (PS) matching was used to adjust baseline characteristics between two groups.

Results

Among 754 patients with distal stage II/III CRC, 680 did not have ACO (non-ACO group) and 74 had ACO (ACO group). The PS matching between both hospitals identified 234 pairs in the non-ACO group and 23 pairs in the ACO group. In the non-ACO group, the surgical quality was equivalent between the two institutions, with no significant differences in overall survival (OS) and disease-free survival (DFS). In the ACO group, the rate of primary resection/anastomosis was higher in the TCT group than in the surgery group (87.0% vs. 26.1%, p < 0.001). No significant differences were noted between the surgery and the TCT groups in OS (5-year OS, 61.9% vs. 51.5%; p=0.490) and DFS (5-year DFS, 45.9% vs. 38.3%; p=0.658).

Conclusion

TCT placement can achieve similar long-term outcomes to emergency surgery, with a high rate of primary resection/anastomosis for distal stage II/III colon cancer with ACO.

Naso-intestinal tube is more effective in treating postoperative ileus than naso-gastric tube in elderly colorectal cancer patients

OBJECTIVE

The objective of this study was to compare the effect of naso-intestinal tube and naso-gastric tube in relieving postoperative ileus in elderly patients with colorectal cancer.

METHODS

Patients (n = 46) with ileus symptom following radical surgery for treating colorectal cancer were placed with either naso-intestinal tube at duodenum or conventional naso-gastric tube. Then, their waist perimeter, intra abdominal pressure, maximum diameter in bowls, length of time to pass flatus or passage of bowel movement or to return to diet, length of hospital stay, daily drainage, serum levels of lactic acid, hemoglobin, and creatinine as well were compared.

RESULTS

Naso-intestinal tube placement is more effective than naso-gastric tube in relieving intra abdominal pressures, reducing maximum bowl diameter and waist circumference, correcting serum lactic acid levels, alleviating analgesia dependence, regaining serum albumin level, increasing drainage and shortening the time of length of hospital stay, passing flatus or faces, and time to return to diet.

CONCLUSION

Naso-intestinal tube is effective in treating POI and shows advantage over conventional naso-gastric tube insertion.

Clinical application of transanal ileal tube placement using X-ray monitoring

Colorectal cancer, which includes colon and rectal cancer, is a common digestive tract tumor. Although surgery is the primary form of treatment, there are a number of drawbacks, including patients experiencing considerable pain and high cost. The present study was undertaken to examine the clinical value of transanal ileal tube placement under X-ray monitoring. Thirty-six cases of left colon obstruction presenting to our hospital between July 2011 and February 2014, underwent transanal ileal tube placement using a single-curve catheter guided by a guidewire under X-ray monitoring. An ileal tube was successfully inserted into 32 patients. Clinical symptoms were alleviated effectively within 48 h. Indwelling catheter decompression time was 4–9 days with an average of 5.61 days. In two cases, the colon guidewire perforated into the abdominal cavity. Repeated exploration resistance of the guidewire and catheter indicated stenosis at this position owing to obstruction. In conclusion, transanal placement of the ileal tube through X-ray monitoring is capable of effectively alleviating the symptoms of ileus. Thus, this constitutes a safe, effective, and economical method that is acceptable to patients.

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.

Risk model for right hemicolectomy based on 19,070 Japanese patients in the National Clinical Database

BACKGROUND

Right hemicolectomy is a very common procedure throughout the world, although this procedure is known to carry substantial surgical risks. The present study aimed to develop a risk model for right hemicolectomy outcomes based on a nationwide internet-based database.

METHODS

The National Clinical Database (NCD) collected records on over 1,200,000 surgical cases from 3,500 Japanese hospitals in 2011. After data cleanup, we analyzed 19,070 records regarding right hemicolectomy performed between January 2011 and December 2011.

RESULTS

The 30-day and operative mortality rates were 1.1 and 2.3 %, respectively. The 30-day mortality rates of patients after elective and emergency surgery were 0.7 and 6.0 %, respectively (P < 0.001). The odds ratios of preoperative risk factors for 30-day mortality were: platelet <50,000/μl, 5.6; ASA grade 4 or 5, 4.0; acute renal failure, 3.2; total bilirubin over 3 mg/dl, 3.1; and AST over 35 U/l, 3.1. The odds ratios for operative mortality were: previous peripheral vascular disease, 3.1; cancer with multiple metastases, 3.1; and ASA grade 4 or 5, 2.9. Sixteen and 26 factors were selected for risk models of 30-day and operative mortality, respectively. The c-index of both models was 0.903 [95 % confidence interval (CI) 0.877-0.928; P < 0.001] and 0.891 (95 % CI 0.873-0.908; P < 0.001), respectively.

CONCLUSION

We performed the first reported risk stratification study for right hemicolectomy based on a nationwide internet-based database. The outcomes of right hemicolectomy in the nationwide population were satisfactory. The risk models developed in this study will help to improve the quality of surgical practice.

Management of obstructive colorectal cancer: evaluation of preoperative bowel decompression using ileus tube drainage

PURPOSE

This study evaluated a better treatment for patients with obstructive colorectal cancer (CRC) that have a poor prognosis.

METHOD

This study compared the outcomes of 138 patients with obstructive CRC, including 70 primary resections, 50 resections after bowel decompression using an ileus tube, and 18 delayed resections after colostomy.

RESULTS

The ileus tube and delayed resection groups included more left-sided primary lesions. The physiologic POSSUM, types 3-4, tumor size, CEA, and hospital stay of the delayed resection group were different, in comparison to both the primary resection and ileus tube groups. The histopathological type and depth of invasion of the delayed resection group included less well types and more T4 than those of the ileus tube group. The operative blood loss of the delayed resection group was more than that of the ileus tube group. There were no differences in the overall and disease-free survival among the three groups.

CONCLUSION

Separately analyzing the data of the right-sided cancer group and the left-sided cancer group demonstrated that primary resection might be acceptable for right-sided obstructive CRC and delayed resection might be done for patients with poorer general conditions (high PPS) and poorer oncological prognostic factors such as more type 3/type 4 cases, a larger tumor size, a less well-differentiated histopathological type, more T4 cases, and a higher CEA level.

Mechanical obstruction of the small bowel and colon

Mechanical obstruction of the small bowel and colon is moderately common, accounting for several hundred thousand admissions per year in the United States. Patients generally present with abdominal pain, nausea and emesis, abdominal distention, and progressive obstipation. Clinical findings of high fever, localized severe abdominal tenderness, rebound tenderness, severe leukocytosis, or metabolic acidosis suggest possible complications of bowel necrosis, bowel perforation, or generalized peritonitis. Differentiation of total mechanical obstruction from partial mechanical obstruction and pseudo-obstruction is important because total mechanical obstruction is generally treated surgically,whereas the other two entities are usually treated medically. Mechanical obstruction is usually suggested by plain abdominal radiographs, and confirmed by small bowel follow through,abdominal CT, or CT enteroclysis.

Transanal endoscopic tube decompression of acute colonic obstruction: experience with 51 cases

BACKGROUND

Acute colorectal obstruction is a potentially life-threatening emergency that requires immediate surgical treatment. To avoid major postoperative complications, most surgeons advocate two-step surgery despite the increase in patient discomfort and cost. Various methods for performing one-step surgery have been reported including intraoperative colonic lavage, decompression with self-expandable metal stents, and transanal tube decompression.

METHODS

The authors present their experience performing transanal colonic decompression for 51 patients.

RESULTS

Endoscopic tube placement was successful for 43 (84%) of the 51 patients. The emergency clinical situation could be converted to semielective treatment in 37 cases (73%) (30 operations and 6 nonoperative interventions), and to an elective operation in 1 case. After successful colonic decompression, the rate of one-stage operations was 93% (28/30), as compared with 40% (4/10) if the decompression failed.

CONCLUSION

Endoscopic tube decompression of acute colonic obstruction is an easy and cost-effective possibility for avoiding emergency operations with all their sequelae. Emergency surgery can be converted to semielective or elective surgery, markedly reducing the rate of staged operations.

Merits and faults of transanal ileus tube for obstructing colorectal cancer

BACKGROUND

We report eight cases of obstructing colorectal cancer successfully managed by preoperative lavage using transanal ileus tube.

METHODS

Decompression tube was transanally inserted into the colon proximal to the tumour under the guidance of the guide wire. Intestinal lavage with 1,500-2,000 mL of warm water was done every day until surgery.

RESULTS

There were six men and two women; the mean age was 67 years (range, 50-82 years). Three cancers were in the sigmoid colon and five were in the rectum. Seven patients were treated with a one-stage operation with adequate lymph node dissection. In one patient, only sigmoidostomy was carried out for unresectable huge tumour. In all cases, no dilatation was observed at the proximal colon and no anastomotic failure developed. Four patients suffered from fever of unknown cause after the insertion of the tube. In one patient, the resected specimen showed ulcer by tube compression. In the other patient, the tube penetrated the intestinal wall, which was covered by mesentery.

CONCLUSION

The transanal ileus tube is effective for the treatment of obstructing colorectal cancer. However, close observation is necessary because of possible perforation.