Endo-Laparoscopic Approach Versus Conventional Open Surgery in Obstructing Left-sided Colon Cancer: RCT
Endo-Laparoscopic Approach Versus Conventional Open Surgery in Obstructing Left-sided Colon Cancer: RCT
Objective: Whether temporary endoscopic decompression by Self-expanding metal stents (SEMS)
 could allow these patients to undergo successful laparoscopic resection (endo-laparoscopic
 approach) has never been previously studied. This randomized trial aims to compare this
 approach with emergency open surgery in the management of obstructing left-sided colon
 cancer.
Introduction:

 First reported in 1991, laparoscopic assisted colectomy is increasingly practised world-wide.
 Abundant evidence exists in the literature suggesting laparoscopic assisted colectomy, when
 compared with its open counterpart, is associated with more favourable short-term outcomes,
 better cosmesis, and better patient's satisfaction. Moreover, recent reports from large-scale
 randomized trials support the use of this minimally invasive technique in the treatment of
 colorectal cancer, a malignant condition common in many parts of the world. However, around
 8-29% of patients with colorectal cancer present as acute large bowel obstruction, a
 condition used to be considered as a contraindication to laparoscopic surgery due to poor
 exposure and potential hazard of injury to the distended bowel. Thus, most cases of malignant
 large bowel obstruction mandate an emergency open surgery to relieve the obstruction and
 resect the tumour, with many patients, especially those with obstructing left-sided colon
 cancer, ending up with temporary or permanent stoma which can adversely affect their
 health-related quality of life.

 Self-expanding metal stents (SEMS) was first described by Dohmoto in 1991 as an endoscopic
 palliative alternative for treating inoperable colon cancer. Three years later, Tejero et al.
 published a preliminary report of using SEMS as a 'bridge' to surgery in two patients with
 colonic obstruction 13. Since then, a number of publications as well as systemic review have
 shown that endoluminal stenting is a relatively simple and safe alternative to standard
 surgical management of acute malignant obstruction of the left colon, thereby obviating the
 need of emergency surgery or colostomy. However, whether temporary endoscopic bowel
 decompression by SEMS could allow patients with malignant left colonic obstruction to undergo
 successful laparoscopic resection (endo-laparoscopic approach) has never been studied in
 detail before. We therefore conducted the current trial to study the outcomes of this
 endo-laparoscopic approach in patients with obstructing left-sided colon cancer.

 Patients and Methods:

 This study is a randomized controlled trial designed to evaluate the outcomes of the
 endo-laparoscopic approach for patients with obstructing left-sided colon cancer, using
 patients undergoing emergency open surgery as controls. Only patients with obstructing
 left-sided colon cancer were studied because of the reported high incidence of stoma creation
 in this condition10,11, and because a homogeneous group of patients could be ensured to
 facilitate comparison of the two different approaches. A single surgical team consisting of
 two surgeons (C.C.C. and M.K.W.L.) and one camera assistant in the case of laparoscopic
 resection performed all operations with the patient under general anesthesia. The study was
 approved by the hospital ethical committee and was not supported by any commercial funds or
 sponsorship.
Inclusion Criteria:

 -  Consecutive adult patients (aged 18 or above) presenting with clinical features of
 left colonic obstruction were potential candidates.

 -  In the absence of peritonitis, right lower quadrant tenderness or grossly distended
 caecum (10cm or above in maximal dimension) on plain abdominal radiograph, an urgent
 water-soluble single contrast enema was performed to determine the level of
 obstruction within 24 hours of admission.

 -  Patients were recruited if the lower border of an obstructing tumour was found between
 the splenic flexure and rectosigmoid junction.

 -  Informed consent was obtained from every patient recruited in the trial.

 Exclusion Criteria:

 -  Patients who did not give informed consent

 -  Patients who were considered unfit for operative treatment

 -  Patients with previous laparotomy

 -  Patients with clinically palpable tumor on abdominal examination.