Obstructive Colon Cancer, a Bridge to Surgery in Right Sided Obstructive Colon Cancer

Rationale: Approximately 13% (range 10-28%) of all colorectal cancer patients (CRC) present with an acute obstruction. Postoperative mortality after an emergency resection is known for its high risk of morbidity and mortality. Different options can be considered in the management of obstructing right sided CRC: 1) primary resection, simultaneous treatment of obstruction and tumour resection, or 2) staged treatment of the obstruction with secondary resection of the tumour. Currently, in the Netherlands, an emergency resection has been judged to be inferior to postponing surgery. Patients who present with right sided obstructive colon cancer at one of the participating hospitals are subjected to a bridge to surgery (BTS) protocol. Objective: The primary objective of this study is to determine the feasibility of BTS protocols in right sided obstructive colon cancer and reduce mortality- and morbidity (stoma rates, major- and minor complications) rates in potentially curable patients presenting with acute obstructing colon cancer. Study design: This is a multicentre, prospective registration study Study population: All patients presenting with high clinical suspicion or histologically proven right sided colon cancer and signs of obstruction of the large bowel. Intervention: Prospective registration of the implementation of bridge to surgery protocols in patients with (acute) malignant right sided obstruction of the colon, without suspicion of perforation (tumour perforation or blow out) in order to optimize patients preoperatively. The BTS approach encompasses the utilization of either ileostomy creation, stent placement or nasogastric tube for decompression, which is subsequently followed by definitive surgical treatment at a later stage. BTS also involves pre-optimization, prior to the surgical procedure, with the following approach: optimizing the nutritional health status improving the physical health status of the patient. Main study parameters/endpoints: The primary endpoint is complication-free survival (CFS) at 90 days after hospitalization. Complication is defined here as mortality and/or development of a major complication (Clavien-Dindo classification ≥3). With a total follow up of three years. Secondary endpoints: overall mortality, morbidity (stoma rates, minor complications), in hospital stay, oncologic quality of resection and other occurring adverse events.

Sex

All

Minimum age

18 Years

Inclusion Criteria:

* Patients age is 18 years or older
* Patients presenting with symptoms of obstruction (including cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon) caused by (high suspicion or histologically proven) colonic cancer.
* Patient presenting with symptoms of partial obstruction (abdominal pain, nausea, vomiting, diarrhoea) confirmed by the presence of a dilated colon or ileum with a computed tomography (CT-scan).
* Treatment with curative intent.

Exclusion Criteria:

* Obstruction of the colon pathologically caused by benign disease.
* Obstruction of the colon caused by an extra-colonic malignancy.
* Suspicion of emergency complications caused by peritonitis due to perforation (tumour or blow out) or sepsis.
* Patients with advanced disease who will undergo a palliative trajectory.
* Rectal cancer

• BACKGROUNDBoeding JRE, Cuperus IE, Rijken AM, Crolla RMPH, Verhoef C, Gobardhan PD, Schreinemakers JMJ. Postponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study. Eur J Surg Oncol. 2023 Sep;49(9):106906. doi: 10.1016/j.ejso.2023.04.005. Epub 2023 Apr 9. PMID 37061403
• BACKGROUNDBarberan-Garcia A, Ubre M, Roca J, Lacy AM, Burgos F, Risco R, Momblan D, Balust J, Blanco I, Martinez-Palli G. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann Surg. 2018 Jan;267(1):50-56. doi: 10.1097/SLA.0000000000002293. PMID 28489682
• BACKGROUNDvan Rooijen SJ, Molenaar CJL, Schep G, van Lieshout RHMA, Beijer S, Dubbers R, Rademakers N, Papen-Botterhuis NE, van Kempen S, Carli F, Roumen RMH, Slooter GD. Making Patients Fit for Surgery: Introducing a Four Pillar Multimodal Prehabilitation Program in Colorectal Cancer. Am J Phys Med Rehabil. 2019 Oct;98(10):888-896. doi: 10.1097/PHM.0000000000001221. PMID 31090551
• BACKGROUNDLi C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, Kim DJ, Vassiliou MC, Feldman LS. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013 Apr;27(4):1072-82. doi: 10.1007/s00464-012-2560-5. Epub 2012 Oct 9. PMID 23052535
• BACKGROUNDNishiyama VKG, Albertini SM, Moraes CMZG, Godoy MF, Netinho JG. MALNUTRITION AND CLINICAL OUTCOMES IN SURGICAL PATIENTS WITH COLORECTAL DISEASE. Arq Gastroenterol. 2018 Oct-Dec;55(4):397-402. doi: 10.1590/S0004-2803.201800000-85. PMID 30785525
• BACKGROUNDBarao K, Abe Vicente Cavagnari M, Silva Fucuta P, Manoukian Forones N. Association Between Nutrition Status and Survival in Elderly Patients With Colorectal Cancer. Nutr Clin Pract. 2017 Oct;32(5):658-663. doi: 10.1177/0884533617706894. Epub 2017 May 23.