Curative surgery for obstruction from primary left colorectal carcinoma: Primary or staged resection?

 

Abstract

Background

In 8 to 29% of patients with colorectal carcinoma, obstruction is the main symptom at diagnosis, and 85% of patients undergoing emergency colorectal surgery have obstruction from colorectal carcinoma. The prognosis of patients who undergo emergency surgery for obstruction is often poor. So far, two types of surgical approach have been used for this condition: primary resection (primary anastomosis or Hartmann's procedure) with simultaneous treatment of carcinoma and obstruction, or staged resection (treatment of the obstruction prior to resection).
However, neither strategy has been found to have any advantages over the other.

Objectives

To ascertain whether primary resection in patients with obstruction from left colorectal carcinoma has advantages over staged resection in terms of morbidity and mortality.

Search methods

Electronic database searches of Cochrane Controlled Trials Register, Medline, Cancerlit, Embase. Hand searching of the most important journals in the fields of oncology and surgery from 2003 and onward until the time of writing.

Selection criteria

Randomised Clinical Trials (RCT) and Controlled Clinical Trials (CCT), in which a group of patients who undergo primary resection for intestinal obstruction from left primary colorectal carcinoma is compared with a group of patients who undergo staged resection for the same condition. Since only one study of this type was available, we considered all other studies, except for case-controls, on the basis of the best possible available evidence.
Studies were considered without language restrictions.

Data collection and analysis

Two reviewers (GLDS, CG) examined all the citations and abstracts derived from the electronic search strategy. Reports of potentially relevant trials were retrieved in full. Both reviewers independently applied the selection criteria to trials reports. Reviewers were not blind to the names of institutions, journals or authors of trials. A third opinion (SP, ML) was obtained to resolve disagreements.

Main results

We identified 2043 citations: Medline 1205, Embase 635, Cancerlit 203. One study for potential inclusion was identified, but was then excluded (Kronborg 1995).

Authors' conclusions

The limited number of identified trials together with their methodological weaknesses do not allow a reliable assessment of the role of either therapeutic strategy in the treatment of patients with bowel obstruction from colorectal carcinoma. It would appear advisable to conduct high quality large scale RCT to establish which treatment is more effective. However, it is doubtful whether they could be carried out in a timely and satisfactory way in this particular surgical context.

 

Plain language summary

Curative surgery for obstruction from primary left colorectal carcinoma: Primary or staged resection?

No strong evidence about whether removal of bowel obstruction and cancer should be done in one step or as a staged procedure, when people have cancer in the left colon. Colorectal (bowel) cancer is common. It can obstruct the bowel, causing severe dilation of the intestine and the stomach, pain and vomiting. Surgery is used to try to remove the obstruction, as well as the cancer. When the cancer is in the right colon, the obstruction and cancer are usually removed simultaneously. If the cancer is in the left colon or in the rectum, however, it may be better for the patient to have the obstruction and the cancer removed in separate surgical procedures.
This review found no evidence in comparative trials indicating which of these techniques is preferable for people with cancer in the left colon. More research is therefore needed.

 

摘要

背景

針對原發性左側大腸直腸癌導致的腸阻塞所做的治癒性手術，應該單次完成或分階段完成？

大腸直腸癌中有8至29%的病患在診斷時是以腸阻塞為主要症狀；需要緊急手術的大腸直腸癌病患中，有85%是為了腸阻塞而做緊急手術。這類病人的預後通常較差。目前為止，這類病人的手術方式有兩種：一階段切除(同時切除腫瘤並做腸吻合或腸造口)，同時治療腫瘤及阻塞；或兩階段切除(先做腸造口解除腸阻塞，再做第二次手術切除腫瘤)。然而，兩種手術治療策略並無明顯的優劣。

目標

為了確定左側大腸直腸癌引起腸阻塞之病患，一階段切除在後遺症和死亡率方面是否優於兩階段切除手術。

搜尋策略

搜尋電子資料庫Cochrane Controlled Trials Register、Medline、Cancerlit、Embase。人工搜尋從2003年至文章撰寫時，在腫瘤學及外科學中最重要的期刊。

選擇標準

選擇研究設計為隨機臨床試驗和控制臨床試驗。病患族群為罹患原發性左側大腸直腸癌導致腸阻塞，在同一情形下比較一階段切除手術和兩階段切除手術的預後。因為搜尋結果只有一個研究符合，基於最佳可得證據，除病例對照研究設計外，再將其他種研究設計方式也列入考慮。不限發表文獻的語言種類。

資料收集與分析

兩位評讀者(GLDS、CG)審視了電子期刊搜尋策略中所有的引用文獻和摘要。符合要求的期刊文章會進行全文審視。兩位評讀者根據評選標準各自獨立進行評讀。評讀者可以看到研究機構名稱、期刊名稱以及研究作者姓名。當不一致意見出現時，由第三方(SP、ML)解決。

主要結論

我們找出了2,043個引用文獻：1,205篇來自Mediline，635篇來自Embase，203篇來自Cancerlit。搜尋時找出一篇1995年由Kronborg領導的研究，但經審查後被排除。

作者結論

搜尋出來的研究數目相當有限，因為其研究方法有缺陷，對大腸直腸癌引起腸阻塞患者，關於施行不同治療策略而言，無法得到可信賴的結果。故建議針對上述問題進行高品質的大型隨機臨床試驗，來驗證何種手術策略較為有效。然而，是否能做出及時且符合實證要求的研究是令人質疑的。

翻譯人

本摘要由臺北榮民總醫院呂慧君翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於左側大腸直腸腫瘤合併腸阻塞進行一次性手術或分階段手術，目前無強烈證據顯示孰優孰劣。大腸直腸癌發生率高，且可能造成腸阻塞，導致嚴重的小腸及胃部擴張、疼痛及嘔吐。進行手術是希望能解除腸阻塞和切除腫瘤。當腫瘤長在右側大腸時，通常會在手術時會一併解決腸阻塞及切除腫瘤。然而，腫瘤長在左側大腸或直腸時，分階段手術也許對病人較好。本文獻回顧沒有找到證據，關於罹患左側大腸癌的較佳治療策略。故需要更多的研究。