title: Should bypass or stoma creation be undertaken for unresectable stage IV colorectal carcinoma?
abstract: BACKGROUND
  When patients with stage IV colorectal cancer are deemed to have an unresectable primary colorectal cancer or extensive metastases at surgery, bypass or stoma creation may be the only surgical options. Whether this surgical approach provides extra months of life or instead leads to prohibitive post-operative morbidity and mortality has not previously been well characterized. This study was conducted to evaluate early and long-term outcomes for stage IV colorectal cancer patients with unresectable primary tumour.
  
  
  METHODS
  Patients with unresectable colorectal cancer who underwent palliative bypass or stoma creation were identified from a prospective colorectal cancer database. Early and long-term outcomes were evaluated. Survival was determined using Kaplan-Meier survival curves.
  
  
  RESULTS
  From 1980 to 2008, 81 patients with stage IV colorectal cancer had an unresectable primary or extensive metastases and underwent palliative bypass or stoma creation. Mean age was 61.5 ± 13.9 years, 44 (54.3%) were male. Location of the colorectal cancer was left-sided in 82.7%. Of the patients, 38.3% had emergency or urgent surgery. Sixty-two (76.5%) patients underwent a diverting stoma, 15 (18.5%) underwent enteric bypass procedures and 4 (4.9%) had both a diverting stoma and proximal bypass created. Twenty-five complications occurred in 24 patients (29.6%) with 2 patients (2.5%) requiring further re-operation. There was no anastomotic leak. Mean length of hospital stay was 13.8 ± 11.2 days. Thirty-day mortality rate was 16%. The median overall survival was 4.7 months, while the overall survival at 1 year was 24.7%. At 2 years, 6.1% patients were alive, all with a stoma.
  
  
  CONCLUSIONS
  Palliative bypass or stoma creation is associated with survival for several months for a significant proportion of patients with stage IV colorectal cancers, who have unresectable primaries or extensive metastases. The findings of this study support the use of bypass or diversion when faced with an unresectable primary in patients with colorectal cancer with metastases.
authors.affiliation: Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Liang
authors.forename: James M
authors.initials: JM
authors.lastname: Church
authors.forename: Luca
authors.initials: L
authors.lastname: Stocchi
authors.forename: Victor
authors.initials: V
authors.lastname: Fazio
authors.forename: Ravi P
authors.initials: RP
authors.lastname: Kiran
mesh_terms: D000328:Adult; D000368:Aged; D015179:Colorectal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003125:Colostomy; D005260:Female; D006801:Humans; D007081:Ileostomy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010166:Palliative Care / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome
keywords: palliative; stage IV colorectal cancers