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M. Bertucci Zoccali and A. Angistriotis
Recommendations Based ontheData
The recommendations summarized below are based on the data presented in this
chapter and are in keeping with those put forward by the American Society of Colon
and Rectal Surgeons in the current Clinical Practice Guidelines Management of
Rectal Cancer (2020) and Colon Cancer (2022), as well as the ones formulated by
the World Society of Emergency Surgery [4, 69, 78].
In patients with malignant large bowel obstruction secondary to potentially curable left sided disease, stenting as a bridge to surgery is associated with high rates
of technical (>90%) and clinical success (>80%), improved short term outcomes at
the time of surgical resection (particularly in terms of overall complications and
primary anastomosis rates), and lower permanent stoma rates [33, 36, 37, 41, 42].
Concerns remain regarding the reported perforation rates (2–10%) and worse overall recurrence rates with the use of SEMS, while the majority of the literature suggests comparable long term survival rates [35, 36, 38, 39, 41, 42, 48]. Therefore,
patients with obstructing left-sided colon cancer and curable disease, particularly if
averse to diversion, can be management with stenting as bridge to surgery, if properly counselled about the risks (strong recommendation based on high-quality
evidence).
Surgical options in this setting include simple diversion (loop colostomy) versus
resection with or without primary anastomosis and loop ileostomy. Colostomies are
associated with detrimental effects on QoL and, while technically reversible, they
tend to become permanent in the majority of the patients [16, 23]. Evidence has
accumulated in the literature supporting the feasibility of an oncologically sound
emergency colectomy, as well as the safety of primary anastomosis in the acute setting [22, 25, 32]. Hence, in patients undergoing emergency surgery for left sided
malignant obstruction, an oncologic resection (with or without diverting ileostomy)
should be preferred over simple diversion or Hartmann’s procedure, when technically feasible (strong recommendation based on moderate-quality evidence).
For patients with incurable disease, stenting represents an appealing option for
the treatment of obstructing colon cancer, associated with shorter length of stay and
quicker resumption of diet compared to emergent surgery [51, 55, 57]. Surgery,
however, seems to provide longer lasting decompression with less need for repeated
procedures [59, 61]. Based on these considerations, stenting should be considered
the treatment modality of choice for obstructing colon cancer in the palliative setting, especially in patients with poor overall prognosis and performance status
(strong recommendation based on moderate-quality evidence).
Obstructing right sided tumors are generally amenable to primary resection and
anastomosis with acceptable complication rates [4]. While some data exists suggesting a role for stenting as bridge to surgery in this setting to improve surgical
outcomes, more evidence is needed prior to recommending the widespread adoption
of this strategy [44, 68]. Currently, patients with right sided malignant LBO who are
t for surgery should be preferentially managed with primary resection and anastomosis; stenting can be considered as an option for palliation or, in selected cases, as
a bridge to elective surgery (weak recommendation based on low-quality evidence).
13 Surgical Versus Endoscopic Options for Management of Malignant Large Bowel…
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The use of stents for extraperitoneal obstructing rectal cancer or extracolonic
malignancies remains controversial with only low-quality data available in the literature [72–74]. Particularly for rectal cancer, the treatment strategy should prioritize the reliable delivery of optimal oncologic care. Patients with obstructing
extraperitoneal rectal cancer and extracolonic malignancies are best managed with
surgical diversion; stenting can be considered in patients who are poor surgical candidates or with short life expectancy (strong recommendation based on low-quality
evidence).
165
Personal View oftheData
Due to the intrinsically different nature of the associated complications, comparing
the outcomes of endoscopic and surgical treatments is challenging. In particular,
adverse events after stenting might become immediately apparent (for example in
the event of a perforation), while those related to a surgical procedure tend to extend
far beyond the immediate postoperative period, particularly when a diversion is
involved. Additionally, differences in technique, patient selection as well as denition of complications and outcomes can contribute to the inconsistency of the ndings across studies. Lastly, the variability of the clinical presentation, especially in
the emergent setting, along with the varying degree of expertise- a crucial determinant of outcomes- across centers makes any comparison even more challenging.
Currently, a trial is enrolling patients in Goteborg, Sweden comparing emergency surgery versus stenting or stoma prior to elective resection for malignant
LBO, while 2 trials are being conducted in Beijing, China looking at the role of
neoadjuvant chemotherapy after stent placement as a bridge to surgery (www.clini-
caltrials.gov).
These considerations further emphasize the importance of a tailored approach
based on disease stage and presentation, the patient’s overall conditions and goals
of care. When a patient presents with malignant LBO, after appropriate resuscitation and staging imaging, overall goals of treatment should be claried. Most
patients with right sided tumors are best treated with right colectomy and primary
anastomosis. For left sided tumors, granted that the necessary expertise is locally
available, stenting is a valuable treatment to relieve the obstruction and allow for a
subsequent elective resection, particularly in patients who are reluctant to the idea
of a stoma; proper discussion regarding the potential benets as well as the risks
associated with this approach (including iatrogenic perforation and the potential for
suboptimal oncologic outcomes) is crucial. In patients with metastatic disease,
stenting is becoming the treatment modality of choice, both for palliation in patients
with overall poor prognosis, and for those who are good surgical candidates and
could become resectable after systemic treatment. It is worth involving a medical
oncologist in the treatment planning early on, as the use of medications such as antiVEGF agents (Bevacizumab) has been associated with higher rates of stent related
complications. For obstructing tumors of the mid and distal rectum, optimal oncologic treatment almost invariably involves neoadjuvant treatments, hence the acute
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M. Bertucci Zoccali and A. Angistriotis
management should be aimed at achieving reliable, long-lasting resolution of the
obstruction thus minimizing interruptions in the administration of systemic therapy,
and this is usually best accomplished with a proximal diversion.
Summary ofRecommendations
1. Patients with obstructing left-sided colon cancer and curable disease, particu-
larly if averse to diversion, can be managed with stenting as bridge to surgery, if
properly counselled about the risks (strong recommendation based on highquality evidence).
2. In patients undergoing emergent surgery for left sided malignant obstruction, an
oncologic resection (with or without diverting ileostomy) should be preferred
over simple diversion or Hartmann’s procedure, when technically feasible
(strong recommendation based on moderate-quality evidence)
3. Stenting should be considered the treatment modality of choice for obstructing
colon cancer in the palliative setting, especially in patients with poor overall
prognosis and performance status (strong recommendation based on moderatequality evidence).
4. Patients with right sided malignant LBO who are t for surgery should be pref-
erentially managed with primary resection and anastomosis; stenting can be considered as an option for palliation or, in selected cases, as a bridge to elective
surgery (weak recommendation based on low-quality evidence).
5. Patients with obstructing extraperitoneal rectal cancer and extracolonic malig-
nancies are best managed with surgical diversion; stenting can be considered in
patients who are poor surgical candidates or with short life expectancy (strong
recommendation based on low-quality evidence).
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M. Bertucci Zoccali and A. Angistriotis
Metastatic Colorectal Cancer
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intheAsymptomatic Patient: Is There
14
aBenefit inResection ofPrimary Tumor?
PaoloGoffredo andMartinR.Weiser
Approximately 25% of patients with colorectal cancer present with synchronous
metastatic disease at diagnosis, and the primary treatment is chemotherapy [1]. For
patients with limited metastases, complete resection of the primary tumor and distant metastases is associated with a 30–50% increase in the likelihood of 5-year
overall survival, depending on patient and tumor characteristics [2–4]. Primary
tumor resection in medically t patients with resectable metastases, either before or
after chemotherapy, is therefore optimal [5]. Likewise, there is no debate regarding
the need to resect the primary tumor in the setting of metastases if the tumor causes
abdominal pain, gastrointestinal bleeding, or bowel obstruction. For patients with
an asymptomatic primary tumor and unresectable metastases, however, the role of
surgery has been debated. One of the main goals of care for such patients is to maximize survival while maintaining the highest quality of life possible [6–8].
Data from some retrospective studies suggest that in patients with unresectable
metastases, resection of the primary tumor in combination with chemotherapy may
provide a survival benet [9, 10]. However, the benet observed may be associated
with a selection bias in those studies toward younger, healthier patients with good
performance status and low disease burden. Another suggested benet of upfront
resection of an asymptomatic primary tumor is prevention of subsequent development of symptoms, such as bleeding, obstruction, or perforation, which occur in
P. Goffredo
Division of Colon & Rectal Surgery, University of Minnesota, Minneapolis, MN, USA
e-mail: goffr002@umn.edu
M. R. Weiser (*)
Stuart Quan Chair in Colorectal Surgery, Memorial Sloan Kettering Cancer Center,
New York, NY, USA
Weill Cornell Medical College, New York, NY, USA
e-mail: weiser1@mskcc.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
K. Umanskiy, N. Hyman (eds.), Difcult Decisions in Colorectal Surgery,
Difcult Decisions in Surgery: An Evidence-Based Approach,
https://doi.org/10.1007/978-3-031-42303-1_14
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P. Goredo and M. R. Weiser
10–20% of patients [11, 12]. Over the past decade, these considerations led to randomized controlled trials aimed at determining whether resection of an asymptomatic primary tumor in patients with unresectable metastases provides an oncologic
or quality-of-life benet.
Search Strategy
A detailed search of the PubMed, Embase, Medline, and Cochrane databases was
conducted for medical literature published between 2010 and 2022. The following
search terms were employed to identify relevant articles: (“colon” OR “colorectal”
OR “rectal”) AND (“cancer” OR “carcinoma” OR “adenocarcinoma”) AND (“metastatic” OR “Stage IV” OR “Stage 4”) AND “asymptomatic” AND (“surgery” OR
“colectomy” OR “resection”) (Table14.1). The titles and abstracts of English language articles were assessed for relevance. Reasons for exclusion were as follows:
duplicate, not relevant, lack of comparator group (trend analysis), review or opinion
article without primary data, and systematic review or meta-analysis. We sought to
focus our review on the highest-quality evidence, with emphasis on level 1 and
level 2 data.
Table 14.1 PICO table
Patients
Patients with asymptomatic
metastatic colorectal cancer
Intervention Comparator
Primary tumor resection
(colectomy, proctectomy)
Chemotherapy
alone
Outcomes
Overall
survival,
morbidity
14 Metastatic Colorectal Cancer in the Asymptomatic Patient: Is There a Benet…
https://t.me/medicina_free
173
Table 14.2 Results from clinical trials
No. of patients % Survival
Trial
PTR [13] 26 22 70 45 20 23 4 0 18
CAIRO4
[15]
iPACS
[14]
a
PTR, primary tumor resection; CTX, chemotherapy; NA, not available
b
Overall survival at 2years (PTR trial) or 3years (iPACS trial)
c
Within 60days after randomization (CAIRO4 trial) or within 30days after surgery (PTR trial and
iPACS trial)
d
P=0.03
97 99 NA NA 23 30 11 3
81 84 33 33 21 NA 4 0 13
a
% Morbidity
b
grade≥3 % Mortality
% CTX
c
patients
who had
palliative
surgeryPTR CTX PTR CTX PTR CTX PTR CTX
d
NA
Results
Our literature search identied three published multicenter randomized controlled
trials aimed at comparing patients with metastatic colorectal cancer who underwent
primary tumor resection followed by chemotherapy and patients who underwent
chemotherapy alone: the PTR trial (n = 48), the iPACS trial (n = 165), and the
CAIRO4 trial (n= 196) (Table14.2) [13–15]. Four ongoing trials have not yet
reported relevant results: SYNCHRONOUS (ISRCTN 30964555), GRECCAR-8
(NCT 02314182), CLIMAT (NCT 02363049), and the China multicenter study
(NCT 02149784).
Overall Survival
The PTR trial and the iPACS trial found no signicant difference in overall survival
rates between primary tumor resection and chemotherapy alone. The 2-year rates in
the PTR trial were 70 and 45%, respectively (P=0.06) [13]. In the iPACS trial, the
3-year rate was 33% in both groups, with median overall survival of approximately
26months in each (hazard ratio, 1.10; 95% condence interval, 0.76–1.59; P=0.69)
[14, 16]. These results were consistent with the ndings of an analysis of data from
the National Cancer Database [17].
With no level 1 data in favor of primary tumor resection, some relatively weak
evidence supporting primary tumor resection has been reported by retrospective
analyses—a single-institution series from Japan and two population-based cohort
studies from Canada and the United States—which were limited by selection biases
and lack of details on possible confounders [18–20]. A 2018 meta-analysis of
ARCAD database data from eight randomized controlled trials that included patients
with metastatic colorectal cancer found a moderate benet in overall survival:
22.2 months for patients who underwent resection of the primary tumor vs.
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