AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/codi.15503

The Association of coloproctology of great Britain and Ireland consensus guidelines in emergency colorectal surgery

Emergency surgery (ES) is the standard-of-care for left-sided obstructing colon cancer, with self-expanding metallic stents (SEMSs) and diverting colostomies (DCs) being alternative approaches. The aim of this study was to review the short- and long-term outcomes of SEMS versus ES or DC. Embase and Medline were searched for articles comparing SEMS versus ES or DC. Primary outcomes were survival and recurrence rates. Secondary outcomes were peri- and postoperative outcomes. SEMS-specific outcomes include success and complication rates. Pooled odds ratio and 95% confidence interval were estimated with DerSimonian and Laird random effects used to account for heterogeneity. Thirty-three studies were included, involving 15,224 patients in 8 randomized controlled trials and 25 observational studies. There were high technical and clinical success rates for SEMS, with low rates of complications. Our meta-analysis revealed increased odds of laparoscopic surgery and anastomosis, and decreased stoma creation with SEMS compared to ES. SEMS led to fewer complications, including anastomotic leak, wound infection, ileus, myocardial infarction, and improved 90-day in-hospital mortality. There were no significant differences in 3- and 5-year overall, cancer-specific and disease-free survival. SEMS, compared to DC, led to decreased rates of stoma creation, higher rates of ileus and reoperation, and led to longer hospital stay. SEMS leads to better short-term outcomes but confers no survival advantage over ES. It is unclear whether SEMS has better short-term outcomes compared to DC. There is a lack of randomized trials with long-term outcomes for SEMS versus DC, hence results should be interpreted with caution.

Comparison of colonic stents, stomas and resection for obstructive left colon cancer: a meta-analysis

A large bowel obstruction (LBO) is an emergency condition that requires early diagnosis and prompt treatment, and it is also crucial to identify the cause of the obstruction. Here, we describe a 76-year-old woman who presented to the hospital with a 1-day history of abdominal pain and vomiting and was diagnosed with LBO. Endoscopic findings showed that the cause of the LBO was initially determined to be a Bormann Type I tumour in the sigmoid colon. However, the surgery was performed later; the pathological findings led to the diagnosis of colonic obstruction caused by a colonic polyp in the sigmoid colon narrowed by chronic diverticulitis. Colonic polyps rarely cause LBO. Poor observation due to colonic stenosis can mask the morphology of the lesion. In cases of LBO, colonic polyps should be differentially diagnosed in addition to colon cancer. 

OUP accepted manuscript

For the 8–29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used Despite these attractive outcomes, the superiority of the BTS approach is not clearly established Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches This lack of consensus has spawned differing and sometimes discordant guidelines worldwide In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic We hope that these data will finally converge on a single set of recommendations supporting a management strategy with well-demonstrated superiority

Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?

Objective: Multisystem inflammatory syndrome in children (MIS-C), associated with Coronavirus disease-2019, is defined as the presence of documented fever, inflammation, and at least two signs of multisystem involvement and lack of an alternative microbial diagnosis in children who have recent or current Severe acute respiratory syndrome-Coronavirus-2 infection or exposure. In this study, we evaluated thyroid function tests in pediatric cases with MIS-C in order to understand how the hypothalamus-pituitary-thyroid axis was affected and to examine the relationship between disease severity and thyroid function. Methods: This case-control study was conducted between January 2021 and September 2021. The patient group consisted of 36 MIS-C cases, the control group included 72 healthy children. Demographic features, clinical findings, inflammatory markers, thyroid function tests, and thyroid antibody levels in cases of MIS-C were recorded. Thyroid function tests were recorded in the healthy control group. Results: When MIS-C and healthy control groups were compared, free triiodothyronine (fT3) level was lower in MIS-C cases, while free thyroxine (fT4) level was found to be lower in the healthy group (p<0.001, p=0.001, respectively). Although the fT4 level was significantly lower in controls, no significant difference was found compared with the age-appropriate reference intervals (p=0.318). When MIS-C cases were stratified by intensive care requirement, fT3 levels were also lower in those admitted to intensive care and also in those who received steroid treatment (p=0.043, p<0.001, respectively). Conclusion: Since the endocrine system critically coordinates and regulates important metabolic and biochemical pathways, investigation of endocrine function in MIS-C may be beneficial. These results show an association between low fT3 levels and both diagnosis of MIS-C and requirement for intensive care. Further studies are needed to predict the prognosis and develop a long-term follow-up management plan.

/pdf/are-thyroid-functions-affected-in-multisystem-inflammatory-2lk37qgq.pdf

Are Thyroid Functions Affected in Multisystem Inflammatory Syndrome in Children?

Approximately 20% of patients diagnosed with colorectal cancer will present with left-sided large bowel obstruction. The optimal management of this cohort of patients remains unclear. We aimed to review international guidelines to see if there was a consensus on the treatment of this surgical emergency. The PubMed and Medline databases were searched for guidelines on the management of left-sided, malignant large bowel obstruction (MBO) between 2010 and 2018. Nineteen guidelines were identified spanning a range of continents. There was no clear consensus on the management of potentially resectable disease. Eight guidelines (42%) suggested primary surgery, two guidelines (11%) suggested stenting as a bridge to surgery and nine guidelines (47%) suggested surgery or stenting could be performed. Primary resection with or without anastomosis was the most frequently recommended procedure (n = 6 35%), but over a third of guidelines gave no operative recommendations. There was very limited detail on the stenting procedure and how long elective surgery should be deferred. In the palliative situation, there was general agreement that stents should be offered in preference to surgery. International guidelines offer limited and contrasting recommendations on the management of left-sided MBO. There is a lack of high-quality evidence to support whether emergency surgery or stenting as a bridge to surgery is the optimal procedure in terms of morbidity, mortality and long-term oncological outcome.

/pdf/optimal-management-of-malignant-left-sided-large-bowel-4v28n3b34l.pdf

Optimal management of malignant left-sided large bowel obstruction: do international guidelines agree?

The General Medical Council and Department of Health both recognise that although the acquisition of written informed consent for surgery is not a legal requirement, it remains a good practice.1 2 The use of consent forms enables operation details, including benefits and risks to be discussed and clearly documented. This ensures that patients are fully informed, and reduces the risk of litigation in cases with complications.

One hundred and seven consent forms of patients who underwent colorectal surgery between March 2011 and May 2011 at our teaching hospital were prospectively audited. Areas analysed included patient details, nature of operation, discussion of benefits and risks, details of the …

https://jme.bmj.com/content/medethics/38/9/574.full.pdf

Completion of consent forms in colorectal surgery: are we getting it right?

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Optimal management of malignant left-sided large bowel obstruction: do international guidelines agree?

Completion of consent forms in colorectal surgery: are we getting it right?