Colonic Obstruction Research Articles

Stent as a bridge to surgery for malignant colonic obstruction: a retrospective study on survival and outcomes

BackgroundIn cases of malignant colonic obstruction (MCO), self-expandable metallic stents (SEMS) are used as a bridge to surgery, offering an alternative to emergency surgery. However, the long-term oncologic outcomes remain debated, particularly in developing countries where the cost of SEMS is a concern. This study aimed to evaluate overall survival (OS) and outcomes associated with SEMS as a bridge to surgery (SBTS) compared to direct emergency surgery (ES) in patients with acute MCO.MethodsA retrospective study was conducted, including patients with potentially curable obstructed colon cancer who were treated with either SBTS or ES at a university hospital in Thailand from 2015 to 2022. We compared OS, 5-year OS rate, disease-free survival (DFS), postoperative morbidity, and complications between the SBTS and the ES groups.ResultsA total of 106 patients were eligible, 29 underwent SBTS, and 77 underwent ES. Baseline characteristics were similar except for ASA classification and chemotherapy rates. The median OS was 56.1 months, with no significant differences in OS (51.4 vs. 61.0 months, p = 0.67) or 5-year DFS (53.8% vs. 59.9%, p = 0.32) between the two groups. The SBTS group had higher rates of minimally invasive surgery (MIS) (65.5% vs. 16.9%, p < 0.001) and shorter postoperative stays (POS) (7 vs. 9 days, p = 0.026). Stage IV cancer and low serum albumin were poor prognostic factors for OS.ConclusionSEMS placement as a bridge to surgery had no significant impact on OS compared to ES, but it was associated with shorter hospital stays and higher rates of MIS.

Oncologic oUTcomes of neoadjuvant chemotherapy for obSTructive colon cAncer after steNt decompression (OUTSTAND trial); A study protocol of multicenter non-inferiority randomized controlled trial.

For obstructive colon cancer, many studies have been conducted on the use of self-expandable metallic stents (SEMS) as a bridge to surgery (BTS). However, there are currently no available prospective data on the impact of bridging period and there is a lack of research on the effects of neoadjuvant chemotherapy during the bridging period. Patients who undergo successful SEMS placement for obstructive left-sided colon adenocarcinoma without metastases will be eligible for this study. This study is a multicenter, non-inferiority, randomized (1:1), open-label, controlled trial. The patients assigned to the control group will undergo curative surgery within two weeks after successful SEMS placement. The patients assigned to the experimental group will undergo three cycles of neoadjuvant FOLFOX chemotherapy within two weeks after successful SEMS placement. Curative surgery will be performed within four weeks of the last administration of neoadjuvant FOLFOX. Circulating tumor DNA (ctDNA) will be collected at specific time points. The optimal time interval for SEMS placement as a BTS can significantly impact long-term oncologic outcomes. In this study, our goal is to identify the optimal time interval for SEMS placement as a BTS. Recently, there has been interest in applying neoadjuvant chemotherapy for locally advanced colon cancer. In the context of early treatment for tumor dissemination following SEMS placement, neoadjuvant chemotherapy may be beneficial for delayed surgery after SEMS placement as a BTS. The results of this trial will be an important reference for the application of neoadjuvant chemotherapy in locally advanced colon cancer. Additionally, researchers will investigate whether ctDNA can serve as a reliable indicator to guide decisions about the timing and type of subsequent treatment. Based on the results of this trial, a patient-tailored treatment strategy can be developed for obstructive colon cancer. This study is registered on ClinicalTrials.gov Identifier: NCT04889820, registered on May 17, 2021 in clinicaltrials.gov; Protocol ID: XC21MIDI0004.

Revisiting Colonic Obstruction Criteria and Optimal Timing for SEMS Placement in Colon Cancer

Revisiting Colonic Obstruction Criteria and Optimal Timing for SEMS Placement in Colon Cancer

Unlocking the Potential of Cecostomies: A Valuable Lifesaving Procedure in Emergency Surgery for Colonic Obstructions.

Colonic obstructions present a serious medical emergency that requires prompt surgical intervention to prevent life-threatening complications. Cecostomy, a procedure involving the creation of an opening in the cecum to decompress the colon, serves as one surgical approach for managing these obstructions. The aim of this review is to evaluate the effectiveness and benefits of cecostomies in emergency surgical settings, with a focus on recent clinical studies and case reports. Cecostomy is highlighted as a bridge procedure in cases such as obstructive carcinomas, providing data on success rates, relative survival, and clinical effectiveness. The importance of the patient's condition and surgeon expertise in selecting cecostomy as a procedure is emphasized. Further comparative research is suggested to optimize the selection criteria, providing a strong, clinically oriented conclusion. A comprehensive literature review was conducted to identify studies and case reports focusing on the application of cecostomies in cases of acute colonic obstruction. Articles were selected based on their relevance to emergency surgery, the effectiveness of cecostomies, and patient outcomes in various clinical scenarios, including obstructive carcinomas and colonic pseudo-obstructions. The analysis reveals that cecostomies provide rapid decompression and effective relief from colonic obstruction, particularly when immediate intervention is needed to prevent bowel perforation or ischemia. In several cases, cecostomies act as a bridge to more definitive surgical treatments, such as resection and anastomosis, and are associated with reduced morbidity and mortality. The selection of cecostomy as a preferred procedure depends on the patient's condition, location of the obstruction, and surgeon expertise. Cecostomies play a crucial role in the emergency management of colonic obstructions, offering a viable and sometimes lifesaving alternative for rapid decompression. Understanding the indications and appropriate use of cecostomies can enhance patient outcomes and provide surgeons with effective strategies for managing acute colonic obstructions. Further research is warranted to refine selection criteria and to compare outcomes between cecostomies and other decompressive techniques in emergency settings.

Colon obstruction due to sunflower seed bezoar: A case report

Colon obstruction due to sunflower seed bezoar: A case report

Managing Complicated Diverticulitis: A Multidisciplinary Approach to Left-Sided Colon Obstruction and Perforation

Colonic diverticulitis has become one of the most prevalent cases that a healthcare professional sees at the hospital, yet some patients with colonic diverticulitis can present with some rare complications such as stenosis, perforation, and abscess formation. We present to you a 52-year-old male who presented to our hospital with severe left-sided abdominal pain, aggravated by oral intake, nausea, and loss of appetite for one month. The patient had a medical history of a sigmoid ulcer with polyps and diverticula. After initial management and multiple diagnostic interventions, including CT scans and colonoscopy, the patient underwent a left-sided colectomy with colostomy. Histologic examination revealed diverticulitis with colonic perforation, fat necrosis, serositis, and abscess formation. Negative for dysplasia or malignancy. Post-operative recovery was complicated by respiratory failure, electrolyte imbalances, and sepsis. The patient required extensive ventilatory support, transfusions, and nutritional management.

Self-Expandable Metal Stents for Obstructing Colon Cancer and Extracolonic Cancer: A Review of Latest Evidence.

Colorectal cancer (CRC) is a leading cause of cancer mortality, with many patients presenting with malignant colorectal obstruction (MCO). Self-expandable metal stents (SEMSs) have emerged as a minimally invasive key intervention, both as a bridge to surgery (BTS) in curative setting sand for palliation in advanced disease. This review aims to provide an evidence-based analysis of SEMS indications, contraindications, and efficacy across curative and palliative contexts, with focus on long-term outcomes. Based on data from recent trials and guidelines, we examine SEMS placement outcomes, focusing on specific scenarios, including BTS for left-sided MCO, chemotherapy (with angiogenic agents) safety during stent therapy, the optimal timing between SEMS placement and surgery, and oncological outcomes. We also discuss the use of SEMSs in challenging contexts such as proximal colon obstruction and extracolonic obstruction, and the relevant technical considerations. Findings indicate that using a SEMS in the BTS setting reduces emergency surgery needs, minimizes complications, and decreases stoma formation. Long-term oncologic outcomes, particularly recurrence, are still debated, but recent evidence shows that SEMS placement is safe, without worsening long term outcomes. Palliative SEMS placement shows high efficacy in symptom relief with manageable adverse events. Success depends on patient selection and technical expertise, with multidisciplinary approaches essential for optimal outcomes.

Caecal Blow-Out – A Case Report

Caecal blow-out is a rare phenomenon that occurs when there is a distal colonic obstruction, leading to the distension of caecum and ascending colon, which in turn thins the walls. If untreated, perforation of the caecum may result. We present here a rare case report of caecal blow-out secondary to distal colonic obstruction due to adenocarcinoma of the descending colon.

Caecal Blow-Out – A Case Report

Caecal blow-out is a rare phenomenon that occurs when there is a distal colonic obstruction, leading to the distension of caecum and ascending colon, which in turn thins the walls. If untreated, perforation of the caecum may result. We present here a rare case report of caecal blow-out secondary to distal colonic obstruction due to adenocarcinoma of the descending colon.

Colonic obstruction from complicated diverticulitis: the role of endoscopic stenting.

Colonic obstruction from complicated diverticulitis: the role of endoscopic stenting.

Beyond Obstruction: Evaluating Self-Expandable Metallic Stents (SEMSs) vs. Emergency Surgery for Challenging pT4 Obstructive Colon Cancer: Multicentre Retrospective Study.

Colon cancer presents as an obstruction in almost 30% of patients. Self-expandable metallic stents emerged as an alternative to emergency surgery, despite early controversies around their use. Improved techniques led to stent incorporation in clinical guidelines. Our objective is to compare colectomies performed after the insertion of self-expandable metallic stents versus emergency surgeries in pT4 obstructive left colon cancer, analysing postoperative and oncological outcomes. This is an observational retrospective multicentre study involving 50 hospitals and analysing data from patients with pT4 obstructive tumours treated for curative intent between 2015 and 2017. Patients with left-sided obstructive colon cancer were included, with exclusion criteria being palliative surgery or incomplete resection. Primary outcomes were local, peritoneal, and systemic recurrence rates, overall survival (OS), and disease-free survival (DFS). Secondary outcomes were postoperative complications and the rate of surgeries without major complications. In total, 196 patients were analysed, 128 undergoing emergency surgery and 68 receiving colonic stents. Stents more frequently allowed for minimally invasive surgeries: 33.8% vs. 4.7% (p < 0.01). The stent group showed fewer major complications (Clavien-Dindo ≥ 3) at 4.5% vs. 22.4% (p < 0.01), fewer infectious complications at 13.2% vs. 23.1% (p = 0.1), and fewer organ-space infections at 3.3% vs. 15.9% (p = 0.03). No significant differences in recurrence rates, 29.4% vs. 28.1% (p = 0.8); disease-free survival, 44.5 vs. 44.3 months (p = 0.5); or overall survival, 50.5 vs. 47.6 months (p = 0.4), were found between groups. Self-expandable metallic stents are a safe alternative for pT4 obstructive left colon cancer, improving postoperative outcomes without compromising short- and medium-term oncological results. Consideration of experienced clinicians and potential referral to centres with advanced stenting capabilities may enhance patient care.

Evolution in the Management of Left-Sided Obstructive Colon Cancer in the Netherlands During a 9-Year Period.

There is growing evidence that bridge to surgery with stent or decompressing stoma for left-sided obstructive colon cancer (LSOCC) is better than emergency resection (ER), especially in elderly patients (age ≥70 years). This was already incorporated in Dutch guideline recommendations in 2014. The aim of this study was to evaluate time trends and interhospital variability in treatment approaches for LSOCC, and to compare short-term outcomes between approaches. Data of patients undergoing resection for LSOCC between 2012 and 2020 were extracted from the Dutch ColoRectal Audit. A total of 4,535 patients were included (3,155 ER, 573 semielective resection [SER], 807 resection after stent or stoma [RSS]). A decrease in ER over time was observed (79.7% in 2012-2014, 68.8% in 2015-2017, and 54.7% in 2018-2020) in favor of RSS (9.2%, 17.9%, and 31.2%, respectively). Compared with SER and RSS, ER was associated with higher 30-day mortality (6.2% ER, 2.8% SER, and 1.0% RSS; P<.001) and complication rates (45.4%, 31.2%, 31.5%, respectively; P<.001). There were still 19 hospitals with >75% ER in 2018-2020. For hospitals with >75% ER, mortality was significantly higher compared with hospitals mainly performing SER and RSS (5.6% vs 4.2%; P=.038). The proportion of ER in patients (age ≥70 years) decreased from 80.7% in 2012-2014 to 54.3% in 2018-2020 (P<.001). Mortality in patients aged ≥70 years was significantly lower after RSS than after ER (1.6% vs 9.5%; P<.001). A significant decrease in ER for LSOCC at a national level was observed, although with a variable degree of adherence to revised guidelines among hospitals. The high risk of mortality after ER, especially in elderly patients, strongly supports the guideline recommendations to perform bridge to surgery in these patients.

Danish guidelines for treating acute colonic obstruction caused by colorectal cancer-a review.

Acute onset of colonic obstruction caused by colorectal cancer occurs in approximately 14% of Danish patients with colon cancer(1). Given that colorectal cancer is a common cancer with about 4,500 new cases annually, acute onset will occur in a reasonably large number of patients in Danish emergency departments, and all surgeons should be familiar with the treatment principles. A revised guideline from the Danish Colorectal Cancer Group is currently underway, and this status article reviews the latest knowledge and recommendations.

BS SO17 - Large Bowel Occlusion as a Manifestation of Gastric Adenocarcinoma in a Patient with Previous Gastric Bypass

Abstract Background Gastric bypass surgery has become one of the hallmarks of the treatment of obesity and metabolic syndrome. Over the last decade, an increasing number of gastric cancer cases have been reported following gastric bypass, particularly in the excluded stomach. The anatomical changes and the difficult access to the excluded stomach via endoscopy hinder the diagnosis and treatment of this cancer. Method Literature review and clinical case analysis through clinical records and exam results. Results A 59-year-old male with a history of gastric bypass 15 years prior was admitted to the emergency department with bowel occlusion. A CT scan revealed colonic obstruction due to invasion by a neoplastic/inflammatory process. Consequently, a right hemicolectomy was performed. Histopathological analysis revealed infiltration of the colonic wall by poorly cohesive gastric carcinoma cells. A follow-up CT scan confirmed a lesion in the excluded stomach. A LAMS (lumen-apposing metal stent) was placed to repermeabilize the excluded stomach, and biopsies confirmed gastric mixed adenocarcinoma. A gastroduodenal stent was placed for antropyloric stenosis. A multidisciplinary team opted for palliative chemotherapy. Conclusion The association between bariatric surgery and gastric cancer remains controversial. As described in previous studies, this clinical case demonstrates that gastric adenocarcinoma in patients who underwent gastric bypass often presents as an aggressive and advanced-stage disease. Given the mortality associated with gastric cancer and the increasing number of bariatric surgeries, this case report highlights the important need to develop patient selection protocols for gastric bypass and respective appropriate follow-up.

Is Butyrate Concentration in the Equine Gastrointestinal Tract Altered During and After Surgery for Treatment of Large Colon Obstruction?

A major cause of morbidity and mortality in horses with large colon obstructive lesions is injury to the colonic mucosal barrier from ischemic injury. Since butyrate has been shown to play a critical role in the maintenance of a healthy mucosal barrier, it may play a role in the recovery process. This study's objective was to determine whether the differences in butyrate concentrations existed between horses with surgical large colon obstructive lesions and healthy horses both during and after surgery. Eleven horses presenting with surgical colic lesions were enrolled; colonic samples were acquired during surgery, and fecal samples were obtained 36 h later. Colonic and fecal samples were also obtained from control groups. Samples were analyzed for butyrate, acetate, and propionate concentrations. There was no significant difference in butyrate content between surgical colonic or fecal samples and controls; however, an alteration in the proportion of SCFAs in relation to one another was noted. These changes in the individual SCFA levels were not statistically significant. The study findings demonstrated that there were no significant differences in butyrate proportions when comparing samples from horses with surgical colic lesions to healthy control horses.

Sevelamer-induced Gastrointestinal Mucosal Injury: A Critical Review for Clinicians.

Sevelamer is a non-absorbable polymer used to treat hyperphosphatemia in individuals with end-stage renal disease (ESRD) undergoing hemodialysis. The deposition of sevelamer crystals in the gastrointestinal (GI) tract, especially in the colon, can cause mucosal inflammation, pseudopolyps, ulceration, ischemia, or necrosis. Owing to its rarity and lack of physician awareness, the actual incidence and prevalence of sevelamer-induced gastrointestinal mucosal injury (SIGMI) remain unknown. The current evidence is retrospective, in the form of observational studies. This systematic review of case reports provides an overview of SIGMI, with a focus on its etiology, signs and symptoms, pathogenesis, diagnosis, and management. Electronic databases, including PubMed, Embase, and Google Scholar, were searched for published case reports, case series, and abstracts from inception to August 2023. The search yielded 1239 articles that were filtered using the study design, English language, and human subjects. After screening for duplicates and irrelevant articles, only 28 articles were included in the final review. Melena and abdominal pain were the most common complaints. Sevelamer was discontinued in all patients, and 27 (75%) experienced clinical improvement or symptom resolution. Eight patients (22%) required colectomy due to colonic perforation, malignant obstruction, or extensive necrosis. SIGMI is a unique complication of sevelamer use in patients undergoing hemodialysis. Prompt diagnosis and management are crucial to prevent life-threatening complications.

Risk of metachronous peritoneal metastases after surgery for obstructive colon cancer: Multivariate analysis from a series of 1,085 patients

BackgroundData in the literature suggest that obstruction is an independent predictor of poor prognosis in colon cancer. Of all possible sites of recurrence, peritoneal metastases are associated with worse survival. Our aim was to report the incidence of metachronous peritoneal metastases from a cohort of patients undergoing resection of obstructive colon cancer with curative intent and to identify predictive factors for metachronous peritoneal metastases. MethodsFrom 2000 to 2015, a total of 2,325 patients were treated for obstructive colon cancer in French surgical centers, members of the French National Surgical Association (AFC). Patients with palliative management, synchronous metastatic disease, and with postoperative mortality were excluded. A multivariate analysis was performed to determine independent predictive factors of metachronous peritoneal metastases. ResultsThe cohort included 1,085 patients. The median follow-up was 21.5 months. Metachronous peritoneal metastases occurred in 12% of patients and were diagnosed after a median interval of 13.5 months. The cumulative 3-year metachronous peritoneal metastasis rate was 10.9%. Three-year overall survival was 85% for patients who did not develop recurrence, 71% for those who develop recurrence without peritoneal metastases, and 56% for those with metachronous peritoneal metastases (P < .0001). In multivariate analysis, 3 variables were identified as independent risk factors for metachronous peritoneal metastases: pT4 stage (odds ratio: 1.98; 95% confidence interval: 1.17–3.36; P = .011), pN2 stage (odds ratio: 2.57; 95% confidence interval: 1.89–4.45; P = .0007), and fewer than 12 lymph nodes examined (odds ratio: 2.01; 95% confidence interval: 1.08–3.74; P = .028). ConclusionThis study showed a significant risk of metachronous peritoneal metastases after curative-intent resection of obstructive colon cancer. The awareness of factors predisposing to metachronous peritoneal metastases could improve the treatment strategy of these patients.

Low-pressure self-expandable metal stent insertion for obstructive colon cancer using water and gel immersion.

Low-pressure self-expandable metal stent insertion for obstructive colon cancer using water and gel immersion.

Appendiceal Mucosal Schwann Cell Proliferation Associated with Incidentally Detected Goblet Cell Adenocarcinoma of Appendix in a Case of Invasive Adenocarcinoma of Sigmoid Colon- A Case Report

Abstract Introduction/Objective Appendiceal mucosal Schwann cell proliferation has been suggested to be a putative histologic marker of appendiceal diverticular disease. Appendiceal Goblet cell adenocarcinoma, (GCA) is amongst the most rare appendiceal tumors with a reported incidence of 0.05 cases per 100,000 population per year in United States. They have features of both neuroendocrine tumors and adenocarcinomas, but behave more similarly to adenocarcinomas. Methods/Case Report Herein, we report a case of appendiceal mucosal schwann cell proliferation associated with incidentally detected Goblet cell adenocarcinoma of appendix in a known case of invasive adenocarcinoma of sigmoid colon. A 75-year-old female presented with sigmoid colon obstruction. Intraoperatively, she was found to have gangrenous and perforated colon, as well as a large obstructing sigmoid mass, and underwent total abdominal colectomy with end-ileostomy. On gross examination, a tan bosselated tumor (up to 3.5 cm) was seen in proximal sigmoid colon. Microscopic examination showed Invasive adenocarcinoma, moderately-differentiated. Appendix was unremarkable on gross examination. Incidentally, the appendix microscopically demonstrated “Goblet cell adenocarcinoma”, histologic grade 1 out of 3 (pathologic stage pTis pN0), present in multiple foci within lamina propria of the distal third of appendix over an area measuring 1.5 cm. Additionally, there were foci of SOX10-positive bland- looking spindle cell proliferation in lamina propria of the appendix. This proliferation is rendered as “Schwann cell proliferation”. Results (if a Case Study enter NA) NA Conclusion One study found that “Schwann cell proliferation” is seen in 42% of appendiceal diverticula cases. It has never been reported in association with “Appendiceal GCA” before. Here we report an intriguing case of Schwann cell proliferation associated with this rare entity of GCA for the first time in literature. Therefore, awareness of such coexistence of these pathologic entities in the same appendix is essential to alert the pathologist to look for GCA, whenever Schwann cell proliferation is encountered in random section of an appendix. This case also emphasizes the importance of being vigilant of the possible presence of other tumors in a specimen with a known tumor.

Impact of a novel-covered colonic stent in obstructive colon cancer.

Although the short-term outcomes of bridge-to-surgery (BTS) procedures using self-expandable metal stents are favorable, concerns remain regarding worsened prognosis due to tissue injury in the tumor area. Herein, we describe a newly developed covered stent, the Kawasumi Jabara colonic stent™, designed to reduce tissue damage/injury associated with stent-related complications in BTS procedures. This study aimed to evaluate the efficacy and safety of the Kawasumi Jabara colonic stent as a BTS for obstructive colorectal cancer (OCC). This multicenter retrospective observational study included 44 OCC patients who underwent BTS with stents at four facilities between September 2020 and November 2022. The groups of patients receiving the Kawasumi Jabara and non-covered colonic stents were designated Groups C and NC, respectively. Treatment outcomes related to stent placement and surgery were compared using propensity score matching (PSM) analysis. Groups NC and C (n = 34 and 10, respectively) showed no significant differences in sex, age, tumor location, histological type, Colorectal Obstruction Scoring System (CROSS) score, or cStage; however, the stent placement duration was shorter in Group C. No significant differences were found in terms of the technical and clinical success rates for stent placement. Stent dislocation was observed in 0 and 2 cases in Groups C and NC, respectively. PSM analysis between eight cases, each from Groups C and NC, revealed no significant differences in stent-related or surgical outcomes between the groups. However, regarding the gross injury score in the resected specimens, Group C had a lower score than Group NC (1.8 vs. 5.5), and the proportion of pathological tissue injury involving deeper layers was also lower in Group C (37.5% vs. 100%). Compared to conventional non-covered stents, the Kawasumi Jabara colonic stent™ demonstrated favorable safety during stent insertion, retention, and surgery, with only mild tissue injury.