Comparison of Emergency Resection, Self-Expanding Metallic Stents and Decompressing Stoma for Left-Sided Obstructive Colon Cancer: A Protocol for Systematic Review and Network Meta-Analysis

Background: The optimal management strategy for patients with left-sided obstructive colon cancer remains unclear. The aim of this study is to compare the efficacy and safety of emergency resection (ER), self-expanding metallic stents (SEMS) and decompressing stoma (DS) for left-sided obstructive colon cancer.Methods: Electronic searches by titles/abstracts of ER, SEMS and DS for left-sided obstructive colon cancer will be performed using the following electronic bibliographic databases: PubMed, Cochrane Library, Embase and clinical trials. The protocol of this network meta-analysis has been registered on PROSPERO (CRD42021243097). The primary outcomes are the oncological outcomes such as local recurrence rate and overall and disease-free survival. Secondary outcomes of this study include peri- and postoperative outcomes, successful primary anastomosis, temporal and permanent stoma. Included randomized controlled trials will be evaluated on their risk of bias with the Cochrane Collaboration’s risk of bias tool. The quality of observation studies will be assessed using Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. The overall quality of the evidence will be judged based on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria in the network meta-analysis. Heterogeneity, publication bias, subgroup analysis and sensitivity analysis will be explored.Discussion: Considering the importance of acute intestinal obstruction in left-sided colon cancer, we hope that this network meta-analysis can aid and accelerate the consolidation of evidence, such that health-care professionals and patients are provided with high-quality evidence to facilitate decisions on how to manage patients with left-sided obstructive colon cancer. We will conduct subgroup and sensitive analysis to determine the potentially appropriate population for either ER or a bridge to surgery (SEMS or DS) and provide a foundation for future studies from our network meta-analysis.

Sigmoid volvulus in children

Sigmoid volvulus in paediatric patients is a rare but potentially life-threatening condition. Since 1940, only 100 cases have been reported. There are no consensual guidelines for juvenile sigmoid volvulus unlike in adults, where the condition and the treatment is well described. We report a case of a 12-year-old patient, who presented with uncharacteristic symptoms of mild abdominal discomfort and lack of passage of stool. A CT-scan showed a sigmoid volvulus and emergency resection was performed with placement of a colostomy. With this case, we want to emphasise juvenile sigmoid volvulus as a probable differential diagnosis when symptoms of abdominal distress and constipation occur.

Laparoscopic Lavage in the Management of Hinchey III/IV Diverticulitis

Diverticulitis manifestations may cover a spectrum of mild local inflammation to diffuse feculent peritonitis. Up to 35% of patients presenting with diverticulitis will have purulent (Hinchey grade III) or feculent (Hinchey grade IV) contamination of the abdomen, with a high-associated morbidity and mortality. Surgical management may involve segmental resection with or without restoration of bowel continuity. However, emergency resection for diverticulitis can be associated with high mortality rates, as well as low stoma reversal rates at 1 year. Therefore, laparoscopic peritoneal lavage has been proposed for use in selected patients with purulent peritonitis. The topic of laparoscopic peritoneal lavage for the treatment of perforated diverticulitis in the literature has been controversial. Our review of the recent data show that laparoscopic lavage may be safe and feasible in select patients with similar rates of mortality and major morbidity. There is, however, a concern regarding an associated higher rate of postoperative abscess and early reintervention risk.

Is routine colonoscopy necessary for patients who have an unequivocal computerised tomography diagnosis of acute diverticulitis?

Aims To assess the incidence of underlying colorectal malignancy in patients admitted as an emergency with a CT diagnosis of acute diverticulitis and determine the need for routine follow up colonoscopy Methods A retrospective study was performed on all patients who had been admitted to our surgical unit with CT diagnosed diverticulitis from September 2016 to September 2018 (n = 125). Results 11 patients (8.8%) required emergency resection with no underlying malignancy found. 76 patients (61%) had a follow up colonoscopy after being discharged. 4 patients were found to have an underlying colorectal malignancy, one of them suspected on CT and another an incidentally detected caecal polyp cancer. Therefore 3/87(3.4%) had an unexpected cancer diagnosis and all those in the diseased segment were within complicated diverticulitis. Conclusion Nowadays, multi-slice CT scanners are so good at giving an accurate assessment of colonic pathology. In our study, 96.6% of the patients with a CT diagnosis of acute diverticulitis had no underlying malignancy in the diseased segment with all the cancers within complicated diverticulitis. With such a low yield of underlying malignancy in uncomplicated diverticulitis, we question the need for routine follow up colonoscopy when there is no CT suspicion of malignancy in these patients