Evidence-Based Management of Acute Malignant Colorectal Obstruction: Diverting Colostomy as a Bridge to Elective Surgery is a Valid Alternative

Abstract

Colorectal cancer presents relatively often as acute bowel obstruction, which requires immediate intervention. Operative morbidity and mortality are increased by deterioration of the patient and the commonly poor condition of the proximal bowel. The optimal curative approach for obstructing colorectal carcinoma continues to be a topic of discussion and is the subject of this literature review. The pros and cons of the various strategies based on data provided by clinical studies are discussed. Primary decompression of the bowel with a colostomy or stent and delayed colectomy has the advantage of providing time for improvement of the patient’s general condition, recovery of the initially dilated large bowel, accurate disease staging, planning of preoperative treatment and resection by an experienced surgeon. In the absence of significantly dilated bowel the definitive surgical procedure may be performed laparoscopically. Since placement of a self-expanding metallic stent as a bridge to elective surgery is associated with a high complication rate, and probably with impaired oncological outcome, it should be considered only as an alternative to emergency surgery in those patients who have an increased surgical risk, or as a palliative procedure. Local availability and expertise, and high costs are further issues that need to be considered. The creation of diverting colostomy as a bridge to elective surgery is a safe and valid alternative. Although a second operation is required, the overall morbidity and mortality are no higher than for primary resection, while the rate of permanent colostomy is significantly lower, and there is evidence that the two-stage approach is associated with a better oncological outcome.