title: Is an elective diverting colostomy warranted in patients with an endoscopically obstructing rectal cancer before neoadjuvant chemotherapy?
abstract: BACKGROUND
  Many surgeons prefer immediate diversion in patients with endoscopically obstructed rectal cancer before starting neoadjuvant chemotherapy.
  
  
  OBJECTIVE
  The aim of this study was to compare immediate neoadjuvant chemoradiotherapy with diversion for endoscopically obstructed rectal cancer.
  
  
  METHODS
  This study is a retrospective review of patients with rectal adenocarcinoma treated from January 2000 to December 2009. Demographic, tumor, treatment, and outcome data were obtained. Data were analyzed by the use of the Fisher exact probability test and the Student t test.
  
  
  METHODS
  This study was conducted at a tertiary care hospital/referral center.
  
  
  METHODS
  Included were patients with a rectal adenocarcinoma unable to be traversed endoscopically but without clinical evidence of obstruction before the initiation of neoadjuvant chemoradiotherapy. Patients with recurrent tumors or those who did not complete neoadjuvant chemoradiotherapy because of compliance were excluded.
  
  
  METHODS
  The primary outcomes measured were the interval from diagnosis to neoadjuvant chemoradiotherapy initiation and resection and the incidence of complete obstruction.
  
  
  RESULTS
  Eighty-five patients with endoscopically obstructed rectal cancer were identified; 16 underwent immediate diversion before neoadjuvant chemoradiotherapy (diverted group) and 69 were treated with immediate neoadjuvant chemoradiotherapy. Five patients undergoing immediate neoadjuvant chemoradiotherapy presented with bloating and distension; 2 were treated with dietary modification, and 3 (4.3%) progressed to complete obstruction following completion of neoadjuvant chemoradiotherapy and required diversion. Both groups were similar in age, tumor height, and surgical margin status. Patients undergoing diversion required a significantly greater number of permanent stomas and were associated with a higher rate of radical pelvic surgery. There was a significant delay in the initiation of neoadjuvant chemoradiotherapy (p < 0.05) and proctectomy (p < 0.001) from the time of diagnosis in the diverted group compared with the immediate neoadjuvant chemoradiotherapy group. The tumors of patients undergoing diversions were more likely to be unresectable following neoadjuvant chemoradiotherapy.
  
  
  CONCLUSIONS
  This study was limited by its retrospective design and possible selection bias.
  
  
  CONCLUSIONS
  Immediate diversion is unnecessary in endoscopically obstructed rectal cancer without clinical signs of obstruction. There appears to be a relationship between immediate diversion and delay in initiation of neoadjuvant chemoradiotherapy and proctectomy. We conclude that immediate neoadjuvant chemoradiotherapy in patients with endoscopically obstructed rectal cancer is safe and feasible.
authors.affiliation: Section of Colon and Rectal Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA. jpatel@surgery.arizona.edu
authors.forename: Jitesh A
authors.initials: JA
authors.lastname: Patel
authors.forename: James W
authors.initials: JW
authors.lastname: Fleshman
authors.forename: Steven R
authors.initials: SR
authors.lastname: Hunt
authors.forename: Bashar
authors.initials: B
authors.lastname: Safar
authors.forename: Elisa H
authors.initials: EH
authors.lastname: Birnbaum
authors.forename: Anne Y
authors.initials: AY
authors.lastname: Lin
authors.forename: Matthew G
authors.initials: MG
authors.lastname: Mutch
mesh_terms: D000230:Adenocarcinoma / Q000150:complications / Q000175:diagnosis / Q000601:surgery* / Q000628:therapy; D059186:Chemoradiotherapy, Adjuvant; D003125:Colostomy; D016099:Endoscopy, Gastrointestinal; D006801:Humans; D007415:Intestinal Obstruction / Q000175:diagnosis* / Q000209:etiology; D007416:Intestinal Perforation / Q000175:diagnosis / Q000209:etiology; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D010166:Palliative Care; D011183:Postoperative Complications; D012004:Rectal Neoplasms / Q000150:complications / Q000175:diagnosis / Q000628:therapy*