“Obstruction and perforation due to colorectal cancer represent challenging matters in terms of diagnosis, life-saving strategies, obstruction resolution and oncologic challenge. The aims of the current paper are to update the previous WSES guidelines for the management of large bowel perforation and obstructive left colon carcinoma (OLCC) and to develop new guidelines on obstructive right colon carcinoma (ORCC).”
“CT scan is the best imaging technique to evaluate large bowel obstruction and perforation. For OLCC, self-expandable metallic stent (SEMS), when available, offers interesting advantages as compared to emergency surgery; however, the positioning of SEMS for surgically treatable causes carries some long-term oncologic disadvantages, which are still under analysis. In the context of emergency surgery, resection and primary anastomosis (RPA) is preferable to Hartmann’s procedure, whenever the characteristics of the patient and the surgeon are permissive. Right-sided loop colostomy is preferable in rectal cancer, when preoperative therapies are predicted. With regards to the treatment of ORCC, right colectomy represents the procedure of choice; alternatives, such as internal bypass and loop ileostomy, are of limited value.”

“Conclusions: grey areas and opportunities for improvements

We found some limitations within the present guidelines:

– They fail to cover all the possible abdominal scenarios when colon cancer occurs as an
emergency: for example, associated resections were not taken into considerations, neither we discussed about therapeutic strategies in case of evidence of peritoneal carcinomatosis.
– Despite our attempts to underline suggestions in case of low technical resources, the present guidelines are generally oriented toward hospitals with high level of resources.

On the other side, in our opinion, the current guidelines suggest some stimuli for doctors involved in this field:

– To review the approach to patient suffering from abdominal pain by introducing and promoting the use of bedside abdominal US.
– To bear in mind that the emergency surgeon should have a strong oncologic background or that the specialised colorectal surgeon should have a strong background of surgical pathophysiology, emergency surgery and damage control philosophy.
– To promote the use of clinical pathways within singular Hospitals”

Pisano M, et al 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg. 2018 Aug 13;13:36. Free Full Text