Acute Colonic Obstruction Research Articles

Opioid-sparing effect of selective cyclooxygenase-2 inhibitors on surgical outcomes after open colorectal surgery within an enhanced recovery after surgery protocol.

To evaluate the opioid-sparing effect of selective cyclooxygenase-2 (COX-2) inhibitors on short-term surgical outcomes after open colorectal surgery. Patients undergoing open colorectal resection within an enhanced recovery after surgery protocol from 2011 to 2015 were reviewed. Patients with combined general anesthesia and epidural anesthesia, and those with acute colonic obstruction or perforation were excluded. Patients receiving selective COX-2 inhibitor were compared with well-matched individuals without such a drug. Outcome measures included numeric pain score and morphine milligram equivalent (MME) consumption on postoperative day (POD) 1-3, gastrointestinal recovery (time to tolerate solid diet and time to defecate), complications and length of postoperative stay. There were 75 patients in each group. Pain score on POD 1-3 was not significantly different between two groups. However, MME consumption and MME consumption per kilogram body weight on POD 1-3 was significantly less in patients receiving a selective COX-2 inhibitor (P < 0.001). Median MME consumption per kilogram body weight on POD 1-3 was 0.09, 0.06 and nil, respectively in patients receiving a selective COX-2 inhibitor and 0.22, 0.25 and 0.07, respectively in the comparative group (P < 0.001), representing at least 59% opioid reduction. Patients prescribing a selective COX-2 inhibitor had a shorter median time to resumption of solid diet [1 (IQR 1-2) d vs 2 (IQR 2-3) d; P < 0.001] and time to first defecation [2 (IQR 2-3) d vs 3 (IQR 3-4) d; P < 0.001]. There was no significant difference in overall postoperative complications between two groups. However, median postoperative stay was significantly 1-d shorter in patients prescribing a selective COX-2 inhibitor [4 (IQR 3-5) d vs 5 (IQR 4-6) d; P < 0.001]. Perioperative administration of oral selective COX-2 inhibitors significantly decreased intravenous opioid consumption, shortened time to gastrointestinal recovery and reduced hospital stay after open colorectal surgery.

Role of colonic stents in the management of colorectal cancers.

Colorectal cancer is one of the commonly encountered cancers across the Western World. In United Kingdom, this constitutes third most common ranked cancer and second most common ranked cause of cancer related deaths. Its acute presentation as a malignant colonic obstruction imposes challenges in its management. Colonic stent has been used for many years to alleviate acute obstruction in such cases allowing optimisation of patient's physiological status and adequate staging of cancer. In this review, current literature evidence regarding use of colonic stent in acute malignant colonic obstruction is critically appraised and recommendations on the use of colonic stent are advocated.

Comparison of primary resection and anastomosis with hartmanns procedure in management of acute sigmoid volvulus

Background: Sigmoid volvulus is a common surgical emergency in many regions of the world, with significant morbidity and mortality. Volvulus occurs when an air-filled segment of the colon twists about its mesentery. In developing countries it is a major cause of colonic obstruction. The sigmoid colon is involved in up to 90% of cases. It can be present as acute, sub-acute or chronic. Emergency operation is needed in acute sigmoid volvulus. Various methods are used in the management. The purpose of our study was to evaluate the comparative study of single-stage resection and anastomosis with Hartmann’s procedure for management of acute left-sided colonic obstruction due to acute sigmoid volvulus. Methods: This retrospective study was conducted in a consecutive series of 122 patients, admitted to M. K. C. G. Medical College in the department of general surgery, with acute sigmoid volvulus. Then laparotomy were carried out in all 122 patients, primary resection of the affected sigmoid colon with anastomosis were done in 87 patients and the surgical resection of the recto-sigmoid colon with closure of the rectal stump and formation of an end colostomy (Hartmann's procedure) in 35 patients were done in different groups. Outcome of the two procedures analyzed in terms of mortality, post-operative complications, and hospital stay. Results: This study clearly showed that there is no such statistically significant result compared to both groups. Except little bit longer hospital stay in resection and anastomosis group than Hartmann’s group. Conclusions: This study demonstrated that outcome of two procedures are same. Resection and anastomosis should be done in uncomplicated acute sigmoid volvulus safely, but in case of complicated patients Hartmann’s procedure is the choice of operation.

A NEW METHOD OF DECOMPRESSION BY MALIGNANT LARGE BOWEL OBSTRUCTION

Purpose: improve the immediate results of treatment of patients with acute colonic obstruction of tumor genesis through the use of a new method of colon decompression. Materials and methods: the study included 35 patients who were divided into 2 groups. The control group consisted of 9 patients who were formed from a double-barreled colostomy minimal access without removing the contents of the large intestine and the rehabilitation of its lumen.The main group consisted of 26 patients,which after the application of double-barreled loop ileostomy through minimal access for the removal of intestinal contents was used a new method of colon decompression. Results: in the main group was noted more rapid normalization of basic clinical and laboratory parameters, as well as indicators of abdominal pressure. Complications were found in the main group in 1 (3.8%) patient, in the control group in 3 (33.3%) patients. Summary: а new method reduces the number of complications and deaths compared with conventional double-barreled ileostomy,due to forced removal of colon content and readjustment of its lumen, leading to a more rapid normalization of the major clinical and laboratory parameters as well as parameters of intraabdominal pressure.

Гипербарическая оксигенация в комплексе лечения острой толстокишечной непроходимости

Гипербарическая оксигенация в комплексе лечения острой толстокишечной непроходимости

Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction

PurposeThe aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. MethodsFrom January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7–9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed. ResultsTwenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1). ConclusionDecompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.

Endoscopic stent placement in the management of malignant colonic obstruction: Experiences from two centers.

Intestinal obstruction due to colorectal tumors requires immediate surgical decompression. Endoscopic stent placement for acute malignant colonic obstruction is gaining widespread acceptance as an alternative to emergency surgery. Our aim in this study was to evaluate the success and complication rates of endoscopic stenting for malignant colonic obstruction. Patients with acute malignant colonic obstruction who underwent endoscopic stenting between 2011-2014 were retrospectively reviewed. Data included demographic features, localization of obstruction, endoscopic stenting indications, rate of technical and clinical success, complications, morbidity and mortality. Endoscopic stent was successfully placed in 77 out of 82 procedures (93.9%). A colostomy was placed in five cases in which endoscopic stent could not be inserted. There were complications in seven patients with technically successful stents (9.0%). These included three stent migrations, one perforation, and rectal hemorrhage in three patients. There were no stent-related deaths. The mortality rate of emergency surgery for malignant bowel obstruction is relatively high. The use of colonic stents can avoid surgery in patients who are not suitable for emergency surgery and may allow adequate time for preoperative preparation, counseling and staging for those who are suitable for further intervention. We believe that self-expandable metallic stent placement is a safe, effective, and minimal invasive alternative treatment method for malignant colonic obstruction.

Progress in the management of obstructing cancer of the left colon

Obstructing colorectal cancer is one of the acute abdominal diseases which are common in clinical practice. The initial symptoms of 8.0%–33.9% patients with obstructing colorectal cancer are complete or incomplete acute colonic obstruction. Seventy percent of obstructing colorectal cancer located at the left colon. There are no standard treatment methods for obstructed left colonic carcinoma (OLCC) . Previously, a staged procedure was recommended. With the improvement of the intestinal surgical techniques, one-stage resection and anastomosis including intraoperative colonic irrigation, subtotal colectomy, metal stents placement and transanal drainage tube placement were preferred by most of the surgeons. In addition, metal stents placement and transanal drainage tube placement can reduce bowel pressure, which creates the possibility for the treatment of malignant colorectal obstruction by laparoscopes. Key words: Colonic neoplasms; Bowel obstruction; One-stage surgery

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Endoscopic Management of Gastrointestinal Emergencies

Gastrointestinal endoscopy in the last years has become from a purely diagnostic to a largely therapeutic procedure. Endoscopic therapy has rapidly become the treatment of choice for many acute conditions including non-variceal and variceal GI bleeding, foreign body impaction, caustic agents and acute biliary and colonic obstruction, narrowing the role of surgery and interventional radiology in the acute setting. The development of new tools and techniques have reduced the rebleeding and mortality rate but the comorbidity remain an important factor that impact on the patient outcome. In this issue of Journal of Gastroenterology and Hepatology research I have brought together a group of distinguished experts in their respective fields to review the literature and share their approach to endoscopic emergencies. I asked the authors to review and update the evidence regarding their subsequent topics as well as offer some clinical and practical advice, which would be useful tool to approach the GI emergiencies. I wish to thank Dr. Sung J for the invitation to participate as editor of this edition of the Journal of Gastroenterology and Hepatology research. We’d also like to thank each of the authors contributing to this edition for their efforts on this project. We hope the readers will find this issue as informative and enjoyable to read.

Efficacy of Self-expanding Metallic Stent for Right-sided Colonic Obstruction Due to Carcinoma Before 1-Stage Laparoscopic Surgery

The aim of this small study was to assess the clinical outcomes of self-expanding metallic stent (SEMS) placement followed by 1-stage laparoscopic resection for treatment of acute right-sided colonic obstruction due to carcinoma. From January 2012 to December 2012, we performed 1-stage laparoscopic colectomy after placement of SEMS for right-sided obstructive colon carcinoma in 4 patients. SEMS placement was technically successful in all cases and symptoms were immediately relieved. The presence of the endoluminal stent did not prevent a laparoscopic approach; moreover, decompression of the bowel obstruction provided a wide field of view and working space for the laparoscopic procedure. There were no cases of conversion to laparotomy and no intraoperative complications. One-stage laparoscopic surgery, as a minimally invasive therapy, can be safely performed by SEMS placement in patients with acute right-sided colonic obstruction due to carcinoma. A large sample study is required to confirm the efficacy of this procedure.

Long-term results of palliative stent placement for acute malignant colonic obstruction.

Endoscopic placement of self-expanding-metal-stents (SEMS) is widely performed as palliative treatment for acute malignant colonic obstruction. There is ongoing debate regarding risks and benefits associated with SEMS placement. This study aimed to evaluate long-term outcomes of palliative SEMS placement in patients presenting with acute malignant colonic obstruction. A prospectively collected patient cohort (2005-2013) from a general teaching hospital was used. In this hospital, all consecutive patients presenting with acute malignant large bowel obstruction are treated with endoscopic SEMS placement. Only colon cancer patients who underwent palliative SEMS placement were selected. In total, 48 patients were included. The technical and short-term clinical success rates were 91 % (44/48) and 85 % (36/48), respectively. SEMS-related mortality occurred in 6/48 patients (13 %) (early n = 4, late n = 2) and was caused by SEMS-related perforation in all cases. The SEMS-related morbidity rate was 38 % (18/48) (early n = 7, late n = 11). Endoscopic re-intervention was performed 14 times and 13 patients eventually underwent surgical treatment during follow-up. The stoma-formation rate was 15 % (7/48). Long-term clinical success was 48 % (23/48). The estimated stent patency rate (95 % confidence interval) was 69 % (52-79) at 1 month, 54 % (37-66) at 6 months and 50 % (33-62) at 12 months. Palliative SEMS placement provides rapid relief of obstruction and avoids a stoma in most patients with acute colonic obstruction caused by incurable or inoperable colon cancer. However, these benefits should be weighed against mortality and morbidity related to SEMS placement.

Short-term outcomes following the use of self-expanding metallic stents in acute malignant colonic obstruction – A single centre experience

Background: Colonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients in whom a definitive surgical approach is unsuitable. We evaluated short-term outcomes of malignant colorectal obstructive patients who underwent SEMS insertion in our institution over a 3-year period. Methods: A prospectively maintained database was reviewed to identify all patients who presented to our institution with AMCO between August 2010 and 2013 and who were treated with a SEMS either temporarily or permanently. Additional data was retrieved from chart reviews and operation notes. Results: Sixteen patients (12 males, 4 females) each had a single stent inserted during the study period, either palliatively (n = 11) or as a BTS (n = 5). The technical and clinical success rates were both 87.5% (14/16). The two unsuccessful stenting cases both had disseminated disease and required emergency surgery while five patients with curable disease proceeded to elective resections. There was no procedure-related mortality or stent-related perforations. The mean (standard deviation) length of stay post acute surgery was longer than elective surgery [45 ± 21.2 vs. 15.8 ± 4.0, days]. All patients in the BTS group were stoma-free post-operatively, while both patients who had emergency surgery ended up with permanent stomas. Finally, the stent complication rate was 6.2% (1/16), secondary to migration. Conclusions: Although limited by a small sample size, the study shows that SEMS have favourable short-term outcomes. Further adequately powered trials are needed to confirm those findings.

Acute Bowel Obstruction Due to Endometriosis Treated With Colonic Stent

Introduction: Endometriosis is defined as the presence of extrauterine endometrium. It affects up to 8% of premenopausal women. Intestinal involvement is the most common extrapelvic site, affecting 5.4% of women with endometriosis, and out of which rectosigmoid endometriosis comprises 90%. Endometriosis is an extremely rare cause of large bowel obstruction. Urgent surgical intervention carries high morbidity and mortality, and operative intervention can be more difficult in extensive pelvic endometriosis. Less invasive alternatives can be considered in this situation. Case Report: A 35-year-old female presented with 2 weeks of progressive abdominal pain, nausea, and constipation. She denied hematochezia and reported no other gastrointestinal problem. She was afebrile, hemodynamically stable, and in moderate distress due to abdominal pain. Abdomen was diffusely tender, distended, and bowel sounds were present. Rectal exam revealed no abnormality. WBC count was 15 K. CT abdomen showed distended large bowel and colonic obstruction due to distal sigmoid colon stricture. A discrete mass was not seen. Colonoscopy showed tight colonic stricture with sharp angle at 18 cm above dentate line, unable to pass endoscope. The edge of the stricture was biopsied. A guide wire was advanced into the dilated colon proximal to stricture. Contrast injection revealed a 2.5-cm-long stricture. A 2.5-cm x 8-cm uncovered stent was deployed after consulting with the surgical team. Pathology showed benign edematous colonic mucosa. She did well for 2 days with scant semi-formed stools, but her symptoms got worse, and she ultimately underwent surgery. Upon initial inspection of bowel during surgery, the cecum and sigmoid colon were very dilated. The cecum was ischemic in appearance with splitting of the serosa in several areas. There was a hard, obstructing lesion in the proximal rectum, just distal to the confluence of tenia. The proximal sigmoid was resected. The initial surgical impression was diverticular disease, but pathology revealed extensive sigmoid colon endometriosis. Discussion: It is very rare to have endometriosis leading to bowel obstruction without any prior symptoms or history of endometriosis. This is the second reported case of acute bowel obstruction treated initially with colonic stent. Colonic stenting is currently widely used in malignant obstruction. The use of self expanding metallic stents to treat benign conditions is controversial; however, due to associated long-term complications. This case demonstrates that stenting can provide a bridge to major surgery in the rare event of acute endometriotic colonic obstruction. The initial treatment with stent can provide time to prepare and medically optimize the patient for surgery.

Long‐term outcome of stenting as a bridge to surgery for acute left‐sided malignant colonic obstruction

This study aimed to evaluate both the short- and long-term outcomes associated with colonic stenting as a bridge to surgery in patients with obstructing adenocarcinoma of the colon. Patients with potentially curable acute left-sided colonic obstruction treated with stenting as a bridge to surgery (n = 28) or with emergency surgical resection (n = 39) from January 1998 to December 2008 were identified from a prospectively maintained database. Short-term data on postoperative mortality, morbidity, necessity of intensive care and length of hospital stay were compared. Overall survival and disease-free survival were also analysed. Patients in the two study arms had similar demographic profiles. Those receiving preoperative stenting had a higher likelihood of a laparoscopic resection (P < 0.001). The emergency surgery group had a higher rate of postoperative complications (P = 0.024), rate of intensive care unit admission (P = 0.013) and longer total length of hospital stay (9 vs 12 days, P = 0.001). With a median follow-up of 26.5 and 31.3 months for the stenting and surgical resection groups, there was no difference in overall and disease-free survival (overall survival 30 vs 31 months, P = 0.858; disease-free survival 13 vs 12 months, P = 0.989). There was no difference in the rate of systemic recurrence (8 vs 13, P = 0.991). Stenting as a bridge to surgery is a safe strategy for acute left-sided colonic obstruction with improved short-term outcome and comparable long-term oncological results.

Medical economics and safety analysis of colonic stenting and emergency surgery for resectable acute colonic cancer obstruction

Objective To compare the medical economics and safety of colonic metallic stent implantation as a bridge to elective resection with traditional emergency resection. Methods Data of colonic cancer obstruction cases in emergency room from 2008 to 2013 were retrospectively analyzed and divided into stent group（ colonic stent as a bridge to surgery） and control group （emergency surgery）. Main parameters between the two groups were compared, including surgery-associated mortality and morbidity, colostomy rate and re-anastomosis rate, ICU admitted rate, average days and costs in hospital, and colonic stent insertion associated clinical success rate and mortality. Results Ten and 11 patients were included in stent group and control group respectively. Surgery associated morbidity and eolostomy rates were both 0 in stent group, and 18.2% and 100.0% in control group. Days of hospitalization and costs were 23 days and 67 742 Yuan in stent group, and 49 days and 92 553 Yuan in control group. The surgery associated mortality rates both were 0 in the two groups. ICU admitted rates were 20% and 18% respectively. Conclusion Colonic stenting as a bridge to surgery has a high clinical success rate and has a lower morbidity and colostomy rate, shorter hospitalization days, less cost compared with traditional emergency surgery. This strategy for colonic cancer obstruction is of safety and great health economic value. Key words: Colonic neoplasms ; Intestinal obstruction ; Stents ; Economics, medical

Patients who failed endoscopic stenting for left-sided malignant colorectal obstruction suffered the worst outcomes.

Reported outcomes of patients followed failed endoscopic stenting for acute left-sided malignant colonic obstruction remained lacking. This study aims to compare the outcomes between endoscopic stenting and emergency surgery in patients with acute left-sided malignant colonic obstruction and to identify factors that predict failed stenting. A retrospective review of all patients with acute left-sided malignant colonic obstruction in the National University Hospital, Singapore was performed. From January 2007 to October 2013, 165 patients, with a median age of 68 years (range, 25-96), formed the study group. Sixty-nine (41.8 %) patients underwent immediate surgery. Endoscopic stenting was attempted in 96 (58.2 %) patients and was successful in 76 (79.2 %). The remaining 20 (20.8 %) failed the procedure and were operated immediately. Three of the patients who were successfully stented but did not improve clinically also required emergency surgery. Patients that failed stenting were 13.3 (95 % confidence interval (CI), 3.61-48.8; p < 0.001) times more likely to develop severe adverse events than those who were successfully stented. The group of patients who failed stenting was also 3.3 (95 % CI, 1.19-9.20; p = 0.026) times more likely to develop severe adverse events than those operated immediately. The only factor that predicted failure of stenting was a more acute angulation between the tumour and the distal lumen. Patients who failed endoscopic stenting fared worse than those who were successfully stented and also those who underwent emergency surgery upfront. Identification of factors that predict failures may be vital to minimise morbidity in these high-risk patients.

PWE-017 Short Term Outcomes Following The Use Of Self Expanding Metallic Stents In Acute Malignant Colonic Obstruction

IntroductionColonic self-expanding metallic stents (SEMS) may provide prompt relief of acute malignant colorectal obstruction (AMCO) and are increasingly used either palliatively or as a bridge to surgery (BTS) in patients...

Factors associated with mortality risk for malignant colonic obstruction in elderly patients.

BackgroundAcute colonic obstruction is the most common complication of colorectal cancer (CRC) in elderly patients. Medical treatment has been associated with higher perioperative morbidity and mortality rates. There is a need for identification of elderly CRC patients who will do poorly so that results can be improved. The purpose of this study is to assess the 30-day outcome of elderly patients undergoing malignant colonic obstruction procedures and identify the associated factors of mortality.MethodsA review of 233 elderly patients who received medical procedures for malignant colonic obstruction between April 2000 and April 2012 was conducted. Data regarding clinical variables, surgical procedures and outcomes, complications, and mortality were studied. Univariate and logistic regression analyses were performed on mortality risk factors.ResultsPatients had a mean age of 78.2 years (range 70–95). A total of 126 (54.1%) patients were classified ASA III and above. Eighty (34.3%) patients had right-sided colonic obstruction. In the 153 (65.7%) patients with left-sided colonic obstruction, 40 patients received self-expandable metallic stent (SEMS) treatment and 193 patients received surgery. A total of 62.2% (n = 145) patients had post operation complications. The overall 30-day mortality was 24.5% (n = 57). ASA grading, peritonitis and Dukes staging were independent risk factors for mortality.ConclusionsMedical procedures in elderly patients with malignant colonic obstruction are associated with significant complications and mortality. Identifying these high-risk patients and treating promptly may improve outcomes. SEMS treatment provides a useful alternative to surgical intervention.

Meta-Analysis of Complications of Colonic Stenting Versus Emergency Surgery for Acute Left-sided Malignant Colonic Obstruction

Left-sided malignant colonic obstruction is one of the most difficult clinical problems, whereas both emergency operations and colonic stenting may have their own advantages and disadvantages. The purpose of this study was to evaluate the complications of colonic stenting versus emergency surgery for acute left-sided malignant colonic obstruction. Medline, Embase, and the Cochrane Library were searched. Only prospective randomized controlled trials that compared the 2 methods were included. Evaluation indexes in our study involved hospital death rates and complications. No significant difference in either hospital death rates or the overall complications between the 2 groups was found. Heterogeneity analysis found that there was no significant heterogeneity. Removing individual studies from the data editor did not substantially change the RR or the level of heterogeneity of significance for our 2 outcome measures. Testing for publication bias showed that hospital death rates and the overall complications had no serious publication bias. Colonic stenting was no better than emergency surgery, and should be only used as an alternative to emergency surgery carefully.