Optimal management of malignant left-sided large bowel obstruction: do international guidelines agree?
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(2019) 14:23
REVIEW
Open Access
Optimal management of malignant leftsided large bowel obstruction: do international guidelines agree? Peter John Webster1* , Joanna Aldoori2 and Dermot Anthony Burke1
Abstract Background: Approximately 20% of patients diagnosed with colorectal cancer will present with left-sided large bowel obstruction. The optimal management of this cohort of patients remains unclear. We aimed to review international guidelines to see if there was a consensus on the treatment of this surgical emergency. Methods: The PubMed and Medline databases were searched for guidelines on the management of left-sided, malignant large bowel obstruction (MBO) between 2010 and 2018. Results: Nineteen guidelines were identified spanning a range of continents. There was no clear consensus on the management of potentially resectable disease. Eight guidelines (42%) suggested primary surgery, two guidelines (11%) suggested stenting as a bridge to surgery and nine guidelines (47%) suggested surgery or stenting could be performed. Primary resection with or without anastomosis was the most frequently recommended procedure (n = 6 35%), but over a third of guidelines gave no operative recommendations. There was very limited detail on the stenting procedure and how long elective surgery should be deferred. In the palliative situation, there was general agreement that stents should be offered in preference to surgery. Conclusion: International guidelines offer limited and contrasting recommendations on the management of leftsided MBO. There is a lack of high-quality evidence to support whether emergency surgery or stenting as a bridge to surgery is the optimal procedure in terms of morbidity, mortality and long-term oncological outcome. Keywords: Colorectal cancer, Bowel obstruction, Stent, Bridge to surgery
Background Colorectal cancer remains the most common cause of large bowel obstruction in adults [1], and around 20% of patients with colorectal cancer will present with this surgical emergency [2]. For obstructing right-sided colon cancers, there is a general consensus that primary resection and ileocolic anastomosis is the treatment of choice [3]. However, the most common site for malignant large bowel obstruction (MBO) is the sigmoid colon, and over 75% of obstructing cancers occur distal to the splenic flexure [4]. The optimal management of left-sided MBO is less clear [5].
* Correspondence: [email protected] 1 Department of Colorectal Surgery, Leeds Teaching Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF, UK Full list of author information is available at the end of the article
Several surgical options exist for left-sided MBO including primary resection (with or without anastomosis), subtotal colectomy (with or without anastomosis) or defunctioning ileostomy/colostomy with interval resection [4]. Unfortunately, emergency surgery is associated with a high rate of morbidity and mortality [6, 7]. This is due, in part, to this cohort of patients often being elderly, with multiple co-morbidities and re
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