Evolution in the management of left-sided obstructive colon cancer in the Netherlands during a 9-year period

Abstract

Approximately 10% of all patients with colon cancer present with an acute colonic obstruction as the first symptom, although incidence is decreasing as a result of population screening and stage migration.1 Patients with obstructing colon cancer often experience malnutrition and dehydration, and especially elderly patients (age ≥70 years) are at risk for a high rate of postoperative morbidity and mortality.2–5 Emergency resection (ER) has been the mainstay of treatment for left-sided obstructive colon cancer (LSOCC) in many countries worldwide, but is associated with a high postoperative mortality risk.6 There are alternatives available to resolve an acute colonic obstruction in an emergency setting: a decompressing stoma (DS) or a self-expandable metal stent (SEMS).7–9 These decompressing interventions enable optimization of the patients’ condition, complete oncologic staging, improvement of surgical conditions (eg, nondistended bowel), and an elective minimally invasive resection by an optimal surgical team.10 The revised Dutch colorectal cancer guidelines of 2014 recommended bridge to surgery (BTS) with an SEMS or DS as an alternative for ER in elderly patients and/or those with comorbidities.11

We previously described management of LSOCC after guideline revision in the Netherlands. Although a slight decrease of ER in favor of DS and SEMS was observed, still 70% of patients underwent an ER for LSOCC in 2016, with a postoperative mortality rate of 7.2%.12 In another previous national study, we found that patients aged ≥70 years undergoing ER had a 7.4% absolute higher mortality than those aged <70 years following ER; this difference was smaller for SEMS (3.6%) and DS (4.9%).6

The choice between DS or SEMS as a bridging modality depends on several patient and tumor characteristics, but also on the availability of techniques in a certain hospital. However, although SEMS placement requires specific expertise, the formation of a DS should be achievable in every center. The postoperative complication rate after resection following either DS or SEMS does not significantly differ.12 The speed of implementation of new guidelines, such as the recommendation to apply a BTS in elderly patients, not only may be variable between hospitals but also can have consequences for patient outcomes. The aim of this study was to evaluate time trends and interhospital variability in treatment approaches for LSOCC in the Netherlands until 2020, and to compare short-term outcomes between different approaches.