Application of Enhanced Recovery after Surgery Protocols in Colorectal Cancer, Complicated by Malignant Bowel Obstruction: a Review of the Literature

Summary Enhanced recovery after surgery (ERAS) protocols are standard in elective colorectal surgery. They lead to decreasing postoperative complications and shorten the hospital stay and the recovery period. Following these protocols is associated with better short-term results and better and disease-free survival in cases of respectable colorectal carcinomas. There is clear evidence of the beneficial effect of the protocols in reducing the rate of postoperative complications and shortening the hospital stay after elective colorectal surgery. There remains the question of whether these protocols are applicable effective in patients after emergency colorectal surgery. Over the last years, safe and effective ERAS protocols have been reported in patients with life-threatening conditions such as colorectal obstruction and intraabdominal infection.

Self-Expanding Metal Stent Insertion by Colorectal Surgeons Using a Two-Person Approach Colonoscopy Without Fluoroscopic Monitoring in the Management of Acute Colorectal Obstruction: A 14-Year Experience

Background Placement of a self-expanding metal stent (self-expanding metal stent, SEMS) in patients presenting with kinds of colorectal disease as an acute colorectal obstruction (acute colorectal obstruction, ACO) may obviate emergency surgery(emergency surgery, ES), potentially effectively palliating incurable tumours, acting as a bridge to surgery (bridge to surgery, BTS) in patients with operable or potentially operable tumours and achieving effective decompression of other colorectal obstruction diseases. We present our experience with SEMS insertion by colorectal surgeons without fluoroscopic monitoring for ACO especially for acute malignant colorectal obstruction (acute malignant colorectal obstruction, AMCO) nearly a 14-year period (2007–2020).Methods We retrospectively reviewed the medical records of patients to identify all patients presenting to our unit with ACO especially with AMCO who had stenting carried out to achieve colonic decompression. All 434 procedures were performed by colorectal surgeons using a two-person approach colonoscopy and a conventional endoscope without fluoroscopic monitoring. Results The overall technique success rate by SEMS insertion was (428/434, 98.6%), the overall clinic success rate by SEMS insertion was (412/434, 94.9%), and the overall incidence of complications was (19/434, 4.4%). The complications included clinical perforation (6/434, 1.4%), stent migration (2/434, 0.5%), one of which re-stent; stent detachment (fell off)(3/434, 0.7%), none of them with re-stent; stool impaction (6/434, 1.4%), 1 of which re-stent; abdominal pain or anal pain (2/434, 0.5%). There was no hemorrhage in any of the 434 patients. Conclusions SEMS insertion is a relative safe and effective technique for colonic decompression in the dealing with ACO as either a bridge to subsequent resection surgery or as palliative measure, or solution to other causes such as recurrent tumor、benign diseases or extra-luminal compression. Therefore, ES was largely avoided.

Biopsy sampling during self-expandable metallic stent placement in acute malignant colorectal obstruction: a narrative review

Background Histopathology is a crucial part of diagnosis and treatment guidance of colorectal cancer. In Denmark, it is not routine to biopsy during self-expandable metallic stent (SEMS) placement as a treatment option for acute colorectal obstruction of unknown etiology. This is due to lack of knowledge about the risks of hemorrhage, and thus the risk to aggravate the deteriorating overview conditions. Therefore, the aim of this study is to investigate whether there is evidence to avoid biopsy sampling during acute SEMS placement. Methods The PubMed, Embase, and Cochrane Library databases were searched for relevant studies. Studies were included if they described biopsy sampling in relation to SEMS placement. Additionally, national and international guidelines were scrutinized on Google and by visiting the websites of national and international gastrointestinal societies. Results In total, 43 studies were included in the review. Among these, one recommended biopsy during SEMS placement, three advised against biopsy, 23 just reported biopsy was performed during the procedure, and 16 reported biopsy before or after the procedure, or the timing was not specified. Among the 12 included guidelines, only two described biopsy during SEMS placement. Conclusion The literature on the subject is limited. In 24 of the 43 included studies, biopsy sampling was done during SEMS placement without reporting a decrease in the technical success rate. The included guidelines were characterized by a general lack of description of whether biopsy during SEMS placement should be performed or not. Prospective studies are needed in order to establish the real risk of hemorrhage, if any, when a biopsy is obtained.

Long-term trends in colorectal cancer: incidence, localization, and presentation

Background The purpose of this study was to assess trends in incidence and presentation of colorectal cancer (CRC) over a period of 37 years in a stable population in Mid-Norway. Secondarily, we wanted to predict the future burden of CRC in the same catchment area. Methods All 2268 patients diagnosed with CRC at Levanger Hospital between 1980 and 2016 were included in this study. We used Poisson regression to calculate the incidence rate ratio (IRR) and analyse factors associated with incidence. Results The incidence of CRC increased from 43/100,000 person-years during 1980–1984 to 84/100,000 person-years during 2012–2016. Unadjusted IRR increased by 1.8% per year, corresponding to an overall increase in incidence of 94.5%. Changes in population (ageing and sex distribution) contributed to 28% of this increase, whereas 72% must be attributed to primary preventable factors associated with lifestyle. Compared with the last observational period, we predict a further 40% increase by 2030, and a 70% increase by 2040. Acute colorectal obstruction was associated with tumours in the left flexure and descending colon. Spontaneous colorectal perforation was associated with tumours in the descending colon, caecum, and sigmoid colon. The incidence of obstruction remained stable, while the incidence of perforation decreased throughout the observational period. The proportion of earlier stages at diagnosis increased significantly in recent decades. Conclusion CRC incidence increased substantially from 1980 to 2016, mainly due to primary preventable factors. The incidence will continue to increase during the next two decades, mainly due to further ageing of the population.