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Surgical Versus Endoscopic Options for Management of Malignant Large Bowel Obstruction

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Difficult Decisions in Colorectal Surgery

Part of the book series: Difficult Decisions in Surgery: An Evidence-Based Approach ((DDSURGERY))

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Abstract

The incidence of colorectal cancer has been steadily increasing overtime, representing the fourth most common malignancy and the third leading cause of cancer related death worldwide. With advances in early diagnosis and treatment strategies, colorectal cancer mortality has progressively decreased, with a reported 64% 5-year relative survival rate for all colon cancer stages combined in the US. Elective colon resection remains the mainstay of treatment for locoregional disease, with low morbidity and mortality rates, particularly after the widespread adoption of minimally invasive techniques. Despite the intensification of screening, large bowel obstruction is still the initial presentation of up to 30% of colon cancers. Emergency surgery has traditionally represented the treatment of choice for these patients, with reported higher complication rates and worse oncologic outcomes compared to elective operations. In an effort to avoid the morbidity associated with emergency surgery, the use of endoscopically placed self-expanding metal stents has been proposed and implemented over the last 3 decades for the restoration of intestinal flow in patients presenting with malignant large bowel obstruction. While initially proposed as definitive palliation for unresectable tumors or in patients unfit for surgery, overtime stents have been commonly used as a bridge to surgery, with the aim of converting a surgical emergency into a condition amenable to a safer elective procedure. Despite some concerns related to potentially worse oncologic outcomes in the event of an iatrogenic perforation during stent placement, this approach has gained popularity, as data regarding its safety and efficacy, particularly in avoiding the need for a stoma, has accumulated in the literature. This chapter provides a critical review of the current literature on the topic, discussing advantages and disadvantages of the use of stents over emergency surgeries in the setting of malignant bowel obstruction, with some special considerations for right sided and rectal cancers as well as extracolonic malignancies.

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  1. Division of Colorectal Surgery, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, NY, USA

    Marco Bertucci Zoccali & Athanasios Angistriotis

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  1. Marco Bertucci Zoccali
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  1. Medical Center, University of Chicago, Chicago, IL, USA

    Konstantin Umanskiy

  2. Medical Center, University of Chicago, Chicago, IL, USA

    Neil Hyman

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Bertucci Zoccali, M., Angistriotis, A. (2023). Surgical Versus Endoscopic Options for Management of Malignant Large Bowel Obstruction. In: Umanskiy, K., Hyman, N. (eds) Difficult Decisions in Colorectal Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-031-42303-1_13

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