Paula Ferrada1, Mayur B Patel, Vitaliy Poylin, Brandon R Bruns, Stefan W Leichtle, Salina Wydo, Shahnaz Sultan, Elliott R Haut, Bryce Robinson. 1. From the Virginia Commonwealth University (P.F.), Richmond Virginia; Vanderbilt University Medical Center, Departments of Surgery and Neurosurgery; Nashville VA Medical Center, Tennessee Valley Healthcare System (M.B.P.), Nashville, Tennessee; Beth Israel Deaconess Medical Center (V.P.), Boston Massachusetts; Division of Acute Care Surgery, University of Maryland Medical Center (B.R.B.); and Johns Hopkins (E.R.H.), University Bloomberg School of Public Health, Baltimore, Maryland; LAC+USC Medical Center (S.W.L.), University of Southern California, Los Angeles, California; Cooper University Hospital (S.W.), Philadelphia, Pennsylvania; University of Florida (S.S.), Gainesville, Florida; and University of Washington (B.R.), Harborview Medical Center, Seattle, Washington.
Abstract
BACKGROUND: Colonic obstruction is a surgical emergency, and delay in decompression results in added morbidity and mortality. Advances have led to less invasive procedures such as stenting as a bridge for definitive surgery. The aim of this article was to perform a systematic review regarding colon obstruction (malignant or benign) and to provide recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. METHODS: A systematic literature review was conducted using the PubMed, EMBASE, and the Cochrane Library databases of published studies. The search was last performed on January 2, 2015. Two independent reviewers extracted the desired variables from the studies. For our meta-analysis, we used Review Manager X.6 (RevMan). Recommendations are provided using GRADE methodology. A single POPULATION, Intervention, Comparator, Outcome (PICO) question with two outcomes was addressed as follows: POPULATION: in adult patients with a colonic obstruction (malignant or benign). INTERVENTION: should surgery be performed.Comparator: versus endoscopic stenting. OUTCOMES: decreased mortality and decreased emergency, nonplanned procedures? RESULTS: The search yielded 210 results. Screening of the titles excluded 102 articles, leaving 108 for review. After abstract review, 71 additional articles were excluded because of failure to address the PICO questions of this guideline. Thirty-seven articles were reviewed in their entirety, of those six randomized control trials that evaluated the use of stents versus emergency surgery in colonic obstruction caused by malignant disease were included in the final qualitative review. CONCLUSION: We conditionally recommend endoscopic, colonic stenting (if available) as initial therapy for colonic obstruction. In our review, stent use was associated with decreased mortality and rates for emergency, nonplanned procedures to include reoperations. This conditional recommendation is limited to those with malignancy because of the lack of literature supporting this practice in benign colonic disease.
BACKGROUND:Colonic obstruction is a surgical emergency, and delay in decompression results in added morbidity and mortality. Advances have led to less invasive procedures such as stenting as a bridge for definitive surgery. The aim of this article was to perform a systematic review regarding colon obstruction (malignant or benign) and to provide recommendations following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. METHODS: A systematic literature review was conducted using the PubMed, EMBASE, and the Cochrane Library databases of published studies. The search was last performed on January 2, 2015. Two independent reviewers extracted the desired variables from the studies. For our meta-analysis, we used Review Manager X.6 (RevMan). Recommendations are provided using GRADE methodology. A single POPULATION, Intervention, Comparator, Outcome (PICO) question with two outcomes was addressed as follows: POPULATION: in adult patients with a colonic obstruction (malignant or benign). INTERVENTION: should surgery be performed.Comparator: versus endoscopic stenting. OUTCOMES: decreased mortality and decreased emergency, nonplanned procedures? RESULTS: The search yielded 210 results. Screening of the titles excluded 102 articles, leaving 108 for review. After abstract review, 71 additional articles were excluded because of failure to address the PICO questions of this guideline. Thirty-seven articles were reviewed in their entirety, of those six randomized control trials that evaluated the use of stents versus emergency surgery in colonic obstruction caused by malignant disease were included in the final qualitative review. CONCLUSION: We conditionally recommend endoscopic, colonic stenting (if available) as initial therapy for colonic obstruction. In our review, stent use was associated with decreased mortality and rates for emergency, nonplanned procedures to include reoperations. This conditional recommendation is limited to those with malignancy because of the lack of literature supporting this practice in benign colonic disease.