Surgical management of obstructive left colon cancer at a national level: Results of a multicentre study of the French Surgical Association in 1500 patients

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Short-term and long-term outcomes of subtotal/total colectomy in the management of obstructive left colon cancer

Purpose

Surgical management of obstructive left colon cancer (OLCC) is still a matter of debate. The classic Hartmann procedure (HP) has a disadvantage that requires a second major operation. Subtotal colectomy/total abdominal colectomy (STC/TC) with ileo-sigmoid or ileo-rectal anastomosis is proposed as an alternative procedure to avoid stoma and anastomotic leakage. However, doubts about morbidity and functional outcome and lack of long-term outcomes have made surgeons hesitate to perform this procedure. Therefore, this trial was designed to provide data for morbidity, functional outcomes, and long-term outcomes of STC/TC.

Methods

This study retrospectively analyzed consecutive cases of OLCC that were treated by STC/TC between January 2000 and November 2020 at a single tertiary referral center. Perioperative outcomes and long-term outcomes of STC/TC were analyzed.

Results

Twenty-five descending colon cancer (45.5%) and 30 sigmoid colon cancer cases (54.5%) were enrolled in this study. Postoperative complications occurred in 12 patients. The majority complication was postoperative ileus (10 of 12). Anastomotic leakage and perioperative mortality were not observed. At 6 to 12 weeks after the surgery, the median frequency of defecation was twice per day (interquartile range, 1-3 times per day). Eight patients (14.5%) required medication during this period, but only 3 of 8 patients required medication after 1 year. The 3-year disease-free survival was 72.7% and 3-year overall survival was 86.7%.

Conclusion

The risk of anastomotic leakage is low after STC/TC. Functional and long-term outcomes are also acceptable. Therefore, STC/TC for OLCC is a safe, 1-stage procedure that does not require diverting stoma.

Prognostic factors of patients with left-sided obstructive colorectal cancer: post hoc analysis of a retrospective multicenter study by the Japan Colonic Stent Safe Procedure Research Group

Background

There are many reports on the choice of treatment for and prognosis of left-sided obstructive colorectal cancer; however, few studies have focused on the prognostic factors of left-sided obstructive colorectal cancer. Therefore, we analyzed the prognostic factors using a post hoc analysis of a retrospective multicenter study in Japan.

Methods

A total of 301 patients were enrolled in this study to investigate the prognostic factors for relapse-free survival. The relationships between sex, age, decompression for bridge to surgery, depth of invasion, lymph node metastasis, postoperative complications, adjuvant chemotherapy, carcinoembryonic antigen, carbohydrate antigen 19-9, neutrophil-to-lymphocyte ratio, and relapse-free survival were examined.

Results

No change in the decompression method, T3 cancer, negative postoperative complications (grades 0–1 of Clavien-Dindo classification), and adjuvant chemotherapy during Stage III indicated a significantly better prognosis in a Cox univariate analysis. Lymph node metastasis was not selected as a prognostic factor. Excluding patients with <12 harvested lymph nodes (possible stage migration), lymph node metastasis was determined as a prognostic factor. In a Cox multivariate analysis, change in the decompression method, depth of invasion, lymph node metastasis (excluding N0 cases with <12 harvested lymph nodes), and adjuvant chemotherapy were prognostic factors.

Conclusions

Similar to those in nonobstructive colorectal cancer, depth of invasion and lymph node metastasis were prognostic factors in left-sided obstructive colorectal cancer, and patients with <12 dissected lymph nodes experienced stage migration. Stage migration may result in disadvantages, such as not being able to receive adjuvant chemotherapy.

Is Adjuvant Chemotherapy Necessary for Obstructing Stage II Colon Cancer? Results From a Propensity Score Analysis of the French Surgical Association Database

OBJECTIVE

The aim of this study was to compare the survival of patients with stage II obstructing colon cancer (OCC) who had adjuvant chemotherapy with those who did not.

SUMMARY BACKGROUND DATA

The need for adjuvant chemotherapy in stage II colon cancer is still debated.

METHODS

All consecutive patients treated for a stage II OCC in a curative intent (with primary tumor resection) between January 2000 and December 2015 were included in this retrospective, multicenter cohort study which included a propensity score analysis using an odds of treatment weighting (Average Treatment effect on the Treated, ATT). The endpoint was the comparison between the 2 groups for overall survival (OS) and disease-free survival (DFS) according to whether or not patients received adjuvant chemotherapy.

RESULTS

During the study period, 504 patients underwent a curative colectomy for a stage II OCC. Among these patients, 179 (35.5%) had adjuvant chemotherapy and 325 (64.5%) had no adjuvant treatment. Among the 179 patients who received adjuvant chemotherapy, 108 patients (60%) received oxaliplatin based regimen and 99 patients (55%) completed all scheduled cycles. At multivariate analysis, after weighting by the odds (ATT analysis) and adjustment, adjuvant chemotherapy after resection of a stage II OCC was associated with improvements in OS [hazard ratio (HR) = 0.42 (0.17-0.99), P = 0.0498] and DFS [HR = 0.57 (0.37-0.88), P = 0.0116].

CONCLUSION

This study suggests that adjuvant chemotherapy after curative resection of stage II OCC may improve oncological outcomes.

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.

Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association

AIM

It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies.

METHOD

From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively.

RESULTS

In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups.

CONCLUSION

The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

Impact of hospital volume on outcomes after emergency management of obstructive colon cancer: a nationwide study of 1957 patients

PURPOSE

Volume-outcome relationship is well established in elective colorectal surgery for cancer, but little is known for patients managed for obstructive colon cancer (OCC). We aimed to compare the management and outcomes according to the hospital volume in this particular setting.

METHODS

Patients managed for OCC between 2005 and 2015 in centers of the French National Surgical Association were retrospectively analyzed. Hospital volume was dichotomized between low and high volume on the median number of patients included per center during the study period.

RESULTS

A total of 1957 patients with OCC were managed in 56 centers with a median number of 28 (1-123) patients per center: 298 (15%) were treated in low-volume hospitals (LVHs) and 1659 (85%) in high-volume hospitals (HVHs). Patients in LVH were significantly younger, and had fewer comorbidities and synchronous metastases. Proximal diverting stoma was the preferred surgical option in LVH (p < 0.0001), whereas tumor resection with primary anastomosis was more frequently performed in HVH (p < 0.0001). Cumulative morbidity (59 vs. 50%, p = 0.003), mortality (13 vs. 8%, p = 0.03), and length of hospital stay (22 ± 19 vs. 18 ± 14 days, p = 0.002) were significantly higher in LVH. At multivariate analysis, LVH was a predictor for cumulative morbidity (p < 0.0001) and mortality (p = 0.03). There was no difference between the two groups for tumor resection and stoma rates, and for oncological outcomes.

CONCLUSIONS

The hospital volume has no impact on outcomes after the first-stage surgery in OCC patients. When all surgical stages are considered, hospital volume influences cumulative postoperative morbidity and mortality but has no impact on oncological outcomes.

Social deprivation aggravates post-operative morbidity in carcinologic colorectal surgery: Results of the COINCIDE multicenter study

AIM OF THE STUDY

Evaluate the impact of social deprivation on morbidity and mortality in surgery for colorectal cancer.

METHODS

The COINCIDE prospective cohort included nearly 2,000 consecutive patients operated on for colorectal cancer at the Assistance Publique-Hospitals of Paris (AP-HP) from 2008 to 2010. The data on these patients were crossed with the PMSI administrative database. The European Social Deprivation Index (EDI) was calculated for each patient and classified into five quintiles (quintiles 4 and 5 being the most disadvantaged patients). Thirty-day post-operative morbidity was determined according to the Dindo-Clavien classification, with a Had®Hoc re-analysis of each file. Statistical analysis was performed using the proprietary Q-finder® algorithm.

RESULTS

One thousand two hundred and fifty nine curative colorectal resections were analyzed. Mortality was 2.7% and severe morbidity (Dindo-Clavien≥3) occurred in 16.4%. Mortality was not statistically significantly increased among the most disadvantaged who made up almost two thirds of the population (64.2%). Patients in quintiles 4 and 5 had a statistically significant increase in severe morbidity. The relative risk remained 1.5 even after adjustment for the known risk factors found in the analysis: age>70 years, ASA score, urgency, and laparotomy.

CONCLUSIONS

The EDI represents an independent risk factor for severe morbidity after carcinologic colorectal resection. This study suggests that the determinants of health are multidimensional and do not depend solely on the quality and performance of the care system. The inclusion of this index in our surgical databases is therefore necessary, as is its use in health policy for the distribution of resources.

Right-sided vs. left-sided obstructing colonic cancer: results of a multicenter study of the French Surgical Association in 2325 patients and literature review

PURPOSE

Few studies compared management and outcomes of obstructing colonic cancer (OCC), according to the tumor site. Our aim was to compare patient and tumor characteristics, postoperative and pathological results, and oncological outcomes after emergency management of right-sided vs. left-sided OCC.

METHODS

A national cohort study including all consecutive patients managed for OCC from 2000 to 2015 in French surgical centers members of the French National Surgical Association (AFC).

RESULTS

During the study period, 2325 patients with OCC were divided in right-sided (n = 819, 35%) and left-sided (n = 1506, 65%) locations. Patients with right-sided OCC were older, more frequently females, and associated with comorbidities, history of cancer, or previous laparotomy. Surgical management was more frequently performed for right-sided than left-sided OCC (99 vs. 96%, p < 0.0001). Tumor resection was more frequently performed in right-sided OCC (95 vs. 90%, p < 0.0001). Among the resected patients, primary anastomosis was more frequently performed in case of right-sided OCC (86 vs. 62%, p < 0.0001). Definitive stoma rate was lower in right-sided location (17 vs. 46%, p < 0.0001). There was no significant difference between locations in terms of cumulative morbidity, anastomotic leak, unplanned reoperation, and mortality. Five-year overall and disease-free survival rates were significantly lower in right-sided OCC (43 and 36%) than in left-sided OCC (53 and 46%, p < 0.0001 and p = 0.001, respectively).

CONCLUSIONS

Although patients with right-sided OCC are frailer than left-sided OCC, tumor resection and anastomosis are more frequently performed, without difference in surgical results. However, right-sided OCC is associated with worse prognosis than distal location.