1
|
Ouyang K, Yang Z, Yang Y, Wang J, Wu D, Li Y. Which treatment strategy is optimal for acute left-sided malignant colonic obstruction? A Bayesian meta-analysis. Int J Colorectal Dis 2023; 38:217. [PMID: 37589792 DOI: 10.1007/s00384-023-04489-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 08/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kaibo Ouyang
- Shantou University Medical College, Shantou, 515041, Guangdong Province, People's Republic of China
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Zifeng Yang
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Yuesheng Yang
- Shantou University Medical College, Shantou, 515041, Guangdong Province, People's Republic of China
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Junjiang Wang
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Deqing Wu
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, Guangdong Province, People's Republic of China.
| | - Yong Li
- Department of Gastrointestinal Surgery, Department of General Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, Guangdong Province, People's Republic of China.
| |
Collapse
|
2
|
McKechnie T, Springer JE, Cloutier Z, Archer V, Alavi K, Doumouras A, Hong D, Eskicioglu C. Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis. Surg Endosc 2023; 37:4159-4178. [PMID: 36869265 PMCID: PMC9984133 DOI: 10.1007/s00464-023-09929-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 01/28/2023] [Indexed: 03/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Jeremy E Springer
- Division of Colon and Rectal Surgery, Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | - Zacharie Cloutier
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Victoria Archer
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
| | - Karim Alavi
- Division of Colon and Rectal Surgery, Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, ON, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, ON, L8N 4A6, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, Hamilton, ON, Canada.
| |
Collapse
|
3
|
Bradea C, Tarcoveanu E, Munteanu V, Lupascu CD, Andriesi-Rusu FD, Ciobanu DG, Vasilescu AM. Laparoscopic Hartmann Procedure—A Surgery That Still Saves Lives. Life (Basel) 2023; 13:life13040914. [PMID: 37109443 PMCID: PMC10142299 DOI: 10.3390/life13040914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background: A Hartmann operation, which is the intervention by which the lower part of the sigmoid and the upper part of the rectum are resected with the closing of the rectal stump and end colostomy, has as its indications: advanced or complicated rectosigmoid neoplasm, moderate biological condition of the patient, peritoneal sepsis, intestinal occlusion and fragile colonic wall, especially in the context of inflammatory changes. The Hartmann procedure can save lives even at the cost of a stoma reversal failure. Methods: The cases operated with the Hartmann procedure by an open approach or laparoscopic approach in our clinic, between 1 January 2016 and 31 December 2020, were admitted in this study and their medical records were reviewed, also making a comparison between the two types of approach. Univariate statistical comparisons but also a multivariate analysis was performed. Results: We performed 985 operations for intestinal and colonic occlusion (7.15% of the total operations in the clinic), 531 (54%) were non-tumor occlusions and 454 (46%) were occlusive tumors (88 Hartmann operations). Of these, 7.3% were laparoscopically performed (7 laparoscopic Hartmann operations and 23 diagnostic laparoscopies). A total of 11 cases (18%) also had colonic perforation. We compared laparoscopic Hartmann with open Hartmann and observed the benefits of laparoscopy for postoperative morbidity and mortality. The presence of pulmonary and cardiac morbidities is associated with the occurrence of general postoperative morbidities, while peritonitis is statistically significantly associated with the occurrence of local complications that are absent after the laparoscopic approach. Conclusions: The Hartmann procedure is still nowadays an operation widely used in emergency situations. Laparoscopy may become standard for the Hartmann procedure and reversal of the Hartmann procedure, but the percentage of laparoscopy remains low due to advanced or complicated colorectal cancer, poor general condition both at the first and second intervention, and the difficulties of reversal of the Hartmann procedure.
Collapse
|
4
|
Tao Y, Li GB, Zhang HY, Cao K, Wang ZJ, Han JG. Current practice for the treatment of obstructive left-sided colon cancer in China: a nationwide cross-sectional survey. Surg Today 2022; 53:459-469. [PMID: 36436022 DOI: 10.1007/s00595-022-02623-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
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.
Collapse
|
5
|
Park Y, Choi DU, Kim HO, Kim YB, Min C, Son JT, Lee SR, Jung KU, Kim H. Comparison of blowhole colostomy and loop ostomy for palliation of acute malignant colonic obstruction. Ann Coloproctol 2022; 38:319-326. [PMID: 35255204 PMCID: PMC9441536 DOI: 10.3393/ac.2021.00682.0097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose Surgery to create a stoma for decompression might be required for unresectable stage IV cancer patients with complete colonic obstruction. The aim of this study was to compare the results of blowhole colostomy with those of loop ostomy. Methods Palliative ileostomy or colostomy procedures performed at a single center between January 2011 and October 2020, were analyzed retrospectively. Fifty-nine patients were identified during this period. The demographic characteristics and outcomes between the blowhole colostomy group (n=24) and the loop ostomy group (n=35) were compared. Results The median operative time tended to be shorter in the blowhole colostomy group (52.5 minutes; interquartile range [IQR], 43-65) than in the loop ostomy group (60 minutes; IQR, 40-107), but the difference did not reach statistical significance (P=0.162). The median length of hospital stay was significantly shorter with blowhole colostomy (blowhole, 13 days [IQR, 9-23]; loop, 21 days [IQR, 14-37]; P=0.013). Mean cecum diameter was significantly larger in the blowhole group than in the loop group (8.83±1.91 cm vs. 6.78±2.36 cm, P=0.001), and the emergency operation rate was higher in the blowhole group than in the loop group (22 of 24 [91.7%] vs. 23 of 35 [65.7%], P=0.021). Conclusion In surgical emergencies, diverting a blowhole colostomy can be safe and effective for palliative management of colonic obstruction in patients with end-stage cancer and might reduce the operative time in emergent situations.
Collapse
Affiliation(s)
- Yongjun Park
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Uk Choi
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyung Ook Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Bog Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chungki Min
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Tack Son
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sung Ryol Lee
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hungdai Kim
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
6
|
Surgical treatment of mechanical bowel obstruction: characteristics and outcomes of geriatric patients compared to a younger cohort. Int J Colorectal Dis 2022; 37:1281-1288. [PMID: 35513540 PMCID: PMC9167188 DOI: 10.1007/s00384-022-04152-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Mechanical bowel obstruction (MBO) is one of the most common indications for emergency surgery. Recent research justifies the method of attempting 3-5 days of nonoperative treatment before surgery. However, little is known about specific characteristics of geriatric patients undergoing surgery compared to a younger cohort. We aimed to analyze patients with MBO that required surgery, depending on their age, to identify potential targets for use in the reduction in complications and mortality in the elderly. METHODS Thirty-day and in-hospital mortality were determined as primary outcome. We retrospectively identified all patients who underwent surgery for MBO at the University Hospital of Bonn between 2009 and 2019 and divided them into non-geriatric (40-74 years, n = 224) and geriatric (≥ 75 years, n = 88) patients, using the chi-squared-test and Mann-Whitney U test for statistical analysis. RESULTS We found that geriatric patients had higher 30-day and in-hospital mortality rates than non-geriatric patients. As secondary outcome, we found that they experienced a longer length of stay (LOS) and higher complication rates than non-geriatric patients. Geriatric patients who suffered from large bowel obstruction (LBO) had a higher rate of bowel resection, stoma creation, and a higher 30-day mortality rate. The time from admission to surgery was not shown to be crucial for the outcome of (geriatric) patients. CONCLUSION Geriatric patients suffering from mechanical bowel obstruction that had to undergo surgery had higher mortality and morbidity than non-geriatric patients. Especially in regard to geriatric patients, clinicians should treat patients in a risk-adapted rather than time-adapted manner, and conditions should be optimized before surgery.
Collapse
|
7
|
Veld JV, Beek KJ, Consten EC, ter Borg F, van Westreenen HL, Bemelman WA, van Hooft JE, Tanis PJ. Definition of large bowel obstruction by primary colorectal cancer: A systematic review. Colorectal Dis 2021; 23:787-804. [PMID: 33305454 PMCID: PMC8248390 DOI: 10.1111/codi.15479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/10/2020] [Accepted: 11/29/2020] [Indexed: 12/12/2022]
Abstract
AIM Controversies on therapeutic strategy for large bowel obstruction by primary colorectal cancer mainly concern acute conditions, being essentially different from subacute obstruction. Clearly defining acute obstruction is important for design and interpretation of studies as well as for guidelines and daily practice. This systematic review aimed to evaluate definitions of obstruction by colorectal cancer in prospective studies. METHOD A systematic search was performed in PubMed, Embase and the Cochrane Library. Eligibility criteria included randomized or prospective observational design, publication between 2000 and 2019, and the inclusion of patients with an obstruction caused by colorectal cancer. Provided definitions of obstruction were extracted with assessment of common elements. RESULTS A total of 16 randomized controlled trials (RCTs) and 99 prospective observational studies were included. Obstruction was specified as acute in 28 studies, complete/emergency in five, (sub)acute or similar terms in four and unspecified in 78. Five of 16 RCTs (31%) and 37 of 99 cohort studies (37%) provided a definition. The definitions included any combination of clinical symptoms, physical signs, endoscopic features and radiological imaging findings in 25 studies. The definition was only based on clinical symptoms in 11 and radiological imaging in six studies. Definitions included a radiological component in 100% of evaluable RCTs (5/5) vs. 54% of prospective observational studies (20/37, P = 0.07). CONCLUSION In this systematic review, the majority of prospective studies did not define obstruction by colorectal cancer and its urgency, whereas provided definitions varied hugely. Radiological confirmation seems to be an essential component in defining acute obstruction.
Collapse
Affiliation(s)
- Joyce V. Veld
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Kim J. Beek
- Department of Gastroenterology and HepatologyNWZ AlkmaarAlkmaarThe Netherlands
| | - Esther C.J. Consten
- Department of SurgeryMeander Medical CenterAmersfoortThe Netherlands,Department of SurgeryUniversity Medical Center GroningenGroningenThe Netherlands
| | - Frank ter Borg
- Department of Gastroenterology and HepatologyDeventer HospitalDeventerThe Netherlands
| | | | - Wilhelmus A. Bemelman
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and HepatologyCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands,Department of Gastroenterology and HepatologyLeiden University Medical CenterLeidenThe Netherlands
| | - Pieter J. Tanis
- Department of SurgeryCancer Center AmsterdamAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| |
Collapse
|
8
|
Gavriilidis P, de'Angelis N, Wheeler J, Askari A, Di Saverio S, Davies JR. 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. Ann R Coll Surg Engl 2021; 103:235-244. [PMID: 33682486 DOI: 10.1308/rcsann.2020.7137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | - N de'Angelis
- University Hospital Henri Mondor (AP-HP), Créteil, France
| | - J Wheeler
- Cambridge University Hospitals NHS Foundation Trust, UK
| | - A Askari
- Luton and Dunstable University Hospitals NHS Trust, UK
| | | | - J R Davies
- Cambridge University Hospitals NHS Foundation Trust, UK
| |
Collapse
|
9
|
Farkas N, Conroy M, Harris H, Kenny R, Baig MK. Hartmann's at 100: Relevant or redundant? Curr Probl Surg 2020; 58:100951. [PMID: 34392941 DOI: 10.1016/j.cpsurg.2020.100951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/15/2020] [Indexed: 01/02/2023]
Affiliation(s)
- Nicholas Farkas
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom.
| | - Michael Conroy
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| | - Holly Harris
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| | - Ross Kenny
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| | - Mirza Khurrum Baig
- Department of General Surgery, Worthing Hospital, Western Sussex Hospitals NHS Trust, West Sussex, United Kingdom
| |
Collapse
|
10
|
Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, Agresta F, Allievi N, Bellanova G, Coccolini F, Coy C, Fugazzola P, Martinez CA, Montori G, Paolillo C, Penachim TJ, Pereira B, Reis T, Restivo A, Rezende-Neto J, Sartelli M, Valentino M, Abu-Zidan FM, Ashkenazi I, Bala M, Chiara O, De' Angelis N, Deidda S, De Simone B, Di Saverio S, Finotti E, Kenji I, Moore E, Wexner S, Biffl W, Coimbra R, Guttadauro A, Leppäniemi A, Maier R, Magnone S, Mefire AC, Peitzmann A, Sakakushev B, Sugrue M, Viale P, Weber D, Kashuk J, Fraga GP, Kluger I, Catena F, Ansaloni L. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018; 13:36. [PMID: 30123315 PMCID: PMC6090779 DOI: 10.1186/s13017-018-0192-3] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/28/2018] [Indexed: 02/07/2023] Open
Abstract
ᅟ 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.
Collapse
Affiliation(s)
- Michele Pisano
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Luigi Zorcolo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Cecilia Merli
- Unit of Emergency Medicine Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | | | - Elia Poiasina
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Marco Ceresoli
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | | | - Niccolò Allievi
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | - Federico Coccolini
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| | - Claudio Coy
- 9Colorectal Unit, Campinas State University, Campinas, SP Brazil
| | - Paola Fugazzola
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | | | | | - Ciro Paolillo
- Emergency Department Udine Healthcare and University Integrated Trust, Udine, Italy
| | | | - Bruno Pereira
- 14Department of Surgery, University of Campinas, Campinas, Brazil
| | - Tarcisio Reis
- Oncology Surgery and Intensive Care, Oswaldo Cruz Hospital, Recife, Brazil
| | - Angelo Restivo
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Joao Rezende-Neto
- 16Department of Surgery Division of General Surgery, University of Toronto, Toronto, Canada
| | | | - Massimo Valentino
- 18Radiology Unit Emergency Department, S. Antonio Abate Hospital, Tolmezzo, UD Italy
| | - Fikri M Abu-Zidan
- 19Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | | | - Miklosh Bala
- 21Trauma and Acute Care Surgery Unit Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | | | - Nicola De' Angelis
- 22Unit of Digestive Surgery, HPB Surgery and Liver Transplant Henri Mondor Hospital, Créteil, France
| | - Simona Deidda
- 2Colorectal Unit, Department of Surgery, University of Cagliari, Cagliari, Italy
| | - Belinda De Simone
- Department of General and Emergency Surgery Cannes' Hospital Cannes, Cedex, Cannes, France
| | | | - Elena Finotti
- Department of General Surgery ULSS5 del Veneto, Adria, (RO) Italy
| | - Inaba Kenji
- 25Division of Trauma & Critical Care University of Southern California, Los Angeles, USA
| | - Ernest Moore
- 26Department of Surgery, Denver Health Medical Center, University of Colorado, Denver, CO USA
| | - Steven Wexner
- Digestive Disease Center, Department of Colorectal Surgery Cleveland Clinic Florida, Tallahassee, USA
| | - Walter Biffl
- 28Acute Care Surgery The Queen's Medical Center, Honolulu, HI USA
| | - Raul Coimbra
- 29Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California San Diego Health Sciences, San Diego, USA
| | - Angelo Guttadauro
- 5Department of General Surgery, School of Medicine, University of Milano, Milan, Italy
| | - Ari Leppäniemi
- Second Department of Surgery, Meilahti Hospital, Helsinki, Finland
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Stefano Magnone
- General Surgery Papa Giovanni XXII Hospital Bergamo, Bergamo, Italy
| | - Alain Chicom Mefire
- 32Department of Surgery and Obs/Gyn, Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Andrew Peitzmann
- 33Department of Surgery, Trauma and Surgical Services, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- 34General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery Department, Letterkenny Hospital, Letterkenny, Ireland
| | - Pierluigi Viale
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna, Bologna, Italy
| | - Dieter Weber
- 37Trauma and General Surgeon, Royal Perth Hospital, Perth, Australia
| | - Jeffry Kashuk
- 38Surgery and Critical Care Assuta Medical Centers, Tel Aviv, Israel
| | - Gustavo P Fraga
- 39Division of Trauma Surgery, Department of Surgery, School of Medical Sciences, University of Campinas (Unicamp), Campinas, SP Brazil
| | - Ioran Kluger
- 40Department of General Surgery, Division of Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency Surgery, Parma Maggiore Hospital, Parma, Italy
| | - Luca Ansaloni
- Unit of General and Emergency Surgery, Ospedale Bufalini Cesena, AUSL Romagna, Romagna, Italy
| |
Collapse
|
11
|
Raptis D, Pramateftakis MG, Kanellos I. Our 20-year experience with experimental colonic anastomotic healing. J Med Life 2018; 11:5-14. [PMID: 29696058 PMCID: PMC5909939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Aim: To present our experience with experimental colonic anastomoses and compare it with the results of other experienced researchers. Materials and Method: The published experimental studies of our research group up to 1996, as well as results of other researchers in this field, are demonstrated and discussed. Different actions of administered substances on the anastomotic healing were compared and represented. Various chemotherapeutic agents were evaluated in experimental models without colorectal cancer as independent risk factors for the anastomotic healing. Moreover, numerous pharmaceutical agents such as steroids, immunomodulators, vasodilators and the use of fibrin glue are also assessed in detail. Results: Cytostatics, as well as steroids, impair the colonic anastomotic healing, but the combined administration of other agents can reverse this negative effect. Fibrin glue seems to protect the colonic anastomosis, while iloprost could be a potential candidate for further exploration in patient trials. Tacrolimus, despite its immunosuppressive action, seems to promote the anastomotic healing. This observation could be useful for patients with inflammatory bowel disease under tacrolimus therapy, who undergo a non-elective colectomy. Obstructive conditions predispose to anastomotic insufficiency, and therefore, substances to avoid this threatening complication are also assessed. Tacrolimus and iloprost showed a remarkable action against anastomotic leakage under artificially obstructive conditions. Conclusion: Further studies, especially in forms of clinical protocols, are necessary in order for these results to find their place in safe daily practice.
Collapse
Affiliation(s)
- Dimitrios Raptis
- 4th Surgical Department, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| | | | - Ioannis Kanellos
- 4th Surgical Department, Aristotle University of Thessaloniki, 54124, Thessaloniki, Greece
| |
Collapse
|
12
|
Abstract
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.
Collapse
|
13
|
|