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Evidence-based treatment of patients with acute large bowel obstruction caused by colon cancer of the left colon: Applying a clinical decision guideline

ABSTRACT: Interventions: 1. Patients younger than 70 years will have surgical resection. Exceptions can be made for those who have (1) an indication for neo-adjuvant treatment, (2) severe comorbidities, and (3) incurable metastatic disease; they should receive a decompressing intervention. 2. Patients aged 70 years and older without incurable metastatic disease will initially have non-resectional decompression followed by elective resection (bridge to surgery treatment): A) Patients with a malignant stenosis < 40 mm are eligible for colonic stent placement, which will be performed by an experienced gastroenterologist. B) If stent insertion failed, if stricture characteristics are unfavourable for stent placement, or if systemic anti-angiogenic therapy is intended, a minimally invasive transverse loop colostomy is constructed. Patients eligible for elective resection will be operated at least 7 days after initial decompression and no later than 4 weeks after initial presentation. 3. Patients of all ages with incurable extensive metastatic disease or patients who are unfit to undergo surgical resection will be treated palliatively by stent placement or a diverting colostomy. Patients who are fit enough to have palliative chemotherapy are best treated with a colostomy in case anti-angiogenic therapy will be administered because of the risk of tumour perforation when having a stent in situ. Primary outcome(s): In-hospital and 30-day mortality rate in the elderly patients (≥ 70 years). Study Design: Non-randomized controlled trial, Open (masking not used), N/A , unknown, Other

DISEASE(S): Colon Cancer, Malignant Large Bowel Obstruction, Stent, Elderly Patients.dutch: Obstructief Coloncarcinoom, Stent, Ouderen

PROVIDER: 18885 | ecrin-mdr-crc |

REPOSITORIES: ECRIN MDR

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Project description:Colorectal cancer is the fourth most common cancer in China. Up to 30% of patients with colorectal cancer present with an emergency obstruction of the large bowel at the time of diagnosis, and 70% of all malignant obstruction occurs in the left-sided colon. Patients with obstruction are associated with worse oncologic outcomes compared with those having nonobstructive tumors. Conventionally, patients with malignant large bowel obstruction receive emergency surgery, with morbidity rates of 30%-60% and mortality rates of 7-22%, and about two-thirds of such patients end up with a permanent stoma. Self-expanding metallic stents (SEMS) haven been used as a bridge to surgery (to relieve obstruction prior to elective surgery) in patients with potentially resectable colorectal cancer. Several clinical trials demonstrate that SEMS as a bridge to surgery may be superior to emergency surgery considering the short-term outcomes. SEMS is associated with lower morbidity and mortality rate, increased primary anastomosis rate, and decreased stoma creation rate. Although about half of patients can achieve primary anastomosis after stent placement, the primary anastomosis rate is still significantly lower compared with nonobstructing elective surgery. The interval between stent placement and surgery may be not long enough that bowel decompression is insufficient at the time of operation. Furthermore，the long-term oncologic results regarding SEMS as a bridge to surgery are still limited and contradictory. Sabbagh et al. suggest worse overall survival of patients with SEMS insertion compared with emergency surgery, the 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively, P=0.02). One interpretation is that tumor cells may disseminate during the procedure of colonic stenting placement. We hypothesis that immediate chemotherapy after stenting may improve overall survival by eradicating micrometastasis. Moreover, neoadjuvant chemotherapy prolongs the interval between stent placement and surgery, and the time for bowel decompression is more sufficient, which may increase the success rate of primary anastomosis and decrease risk of stoma formation.

Project description:Patients with obstruction are associated with worse oncologic outcomes compared with those having nonobstructive tumors. Conventionally, patients with malignant large bowel obstruction receive emergency surgery, with morbidity rates of 30%-60% and mortality rates of 7-22%, and about two-thirds of such patients end up with a permanent stoma. Self-expanding metallic stents (SEMS) haven been used as a bridge to surgery (to relieve obstruction prior to elective surgery) in patients with potentially resectable colorectal cancer. Several clinical trials demonstrate that SEMS as a bridge to surgery may be superior to emergency surgery considering the short-term outcomes. SEMS is associated with lower morbidity and mortality rate, increased primary anastomosis rate, and decreased stoma creation rate. Although about half of patients can achieve primary anastomosis after stent placement, the primary anastomosis rate is still significantly lower compared with nonobstructing elective surgery. The interval between stent placement and surgery may be not long enough that bowel decompression is insufficient at the time of operation. Furthermore#the long-term oncologic results regarding SEMS as a bridge to surgery are still limited and contradictory. Sabbagh et al. suggest worse overall survival of patients with SEMS insertion compared with emergency surgery, the 5-year cancer-specific mortality was significantly higher in the SEMS group (48% vs 21%, respectively, P=0.02). One interpretation is that tumor cells may disseminate during the procedure of colonic stenting placement. Immunotherapy has proven to be highly effective as first-line treatment of metastatic colorectal cancer (CRC). And immunotherapy also has emerged as a neoadjuvant approach, possibly changing treatment strategy for both primary resectable and metastatic CRC. We hypothesis that, regardless of the MSI state, immunotherapy (Camrelizumab, an anti-PD-1 antibody) combined with chemotherapy after stenting may improve overall survival by eradicating micrometastasis. Moreover, immunotherapy (Camrelizumab, an anti-PD-1 antibody) combined with neoadjuvant chemotherapy prolongs the interval between stent placement and surgery, and the time for bowel decompression is more sufficient, which may increase the success rate of primary anastomosis and decrease risk of stoma formation, and furthermore, improve OS and PFS.

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Evidence-based treatment of patients with acute large bowel obstruction caused by colon cancer of the left colon: Applying a clinical decision guideline

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