Guidelines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society
1 1st Unit of General Surgery, Ospedali Riuniti di Bergamo, Italy
2 Department of Surgery, Linköping University Hospital, Sweden
3 Department of Internal Medicine and Gastroenterology, University of Bologna, Italy
4 Unit of General, Emergency and Transplant Surgery, St Orsola-Malpighi University Hospital, Bologna, Italy
5 Acute Care and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy
6 Department of Surgery, ZNA Middelheim, Antwerp, Belgium
7 Department of Surgery, Helsinki University Hospital, Helnsiki, Finland
8 Department of Surgery, Denver Health Medical Center, University of Colorado Denver, CO, USA
9 Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milano, Italy
10 The Washington Cancer Institute, Washington Hospital Center
11 Department of Digestive Surgery, Rouen University Hospital, Rouen, France
World Journal of Emergency Surgery 2010, 5:29 doi:10.1186/1749-7922-5-29Published: 28 December 2010
Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.
The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.
Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).
Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.