Management of patients with OCC is a challenge. Different treatment options, risk factors and improvements in postoperative care for OCC have been evaluated over the years. [
4,
32‐
36] Treatment for OCC can be divided roughly into two main options: 1) emergency resection or 2) staged treatment (alleviation of the obstruction with secondary resection of the tumour). It has been shown that emergency resection has poor outcomes compared to elective colorectal surgery.
Emergency resection & staged treatment
Emergency resection was the most commonly performed treatment for left-sided OCC. [
6] However, in the Netherlands, there has been a paradigm shift away from emergency resection for left-sided OCC. This while emergency resection has been associated with an increased risk of postoperative mortality, morbidity and permanent stoma rates. Mortality rates after emergency surgery for OCC can increase up to 41% in elderly patients with multiple comorbidities. [
2‐
4,
6,
16] In right sided OCC, the most commonly used treatment is still emergency resection, [
37] despite the poor outcome on morbidity and mortality compared to patients treated electively. [
4,
5,
32,
36,
38].
Different treatment strategies avoiding emergency resection in OCC (e.g. loop colostomy, stent placement and tube decompression) have been mainly analysed for left-sided OCC. [
17,
37]. Over the years, positive results for left-sided OCC treated with decompressing ileostomy or self-expandable metallic stents (SEMS) as a bridge to surgery, such as improved short-term mortality and morbidity compared to emergency surgery have been reported. [
16,
39,
40] For right-sided OCC the literature is far less extensive, compared to left-sided OCC. However the high postoperative mortality and morbidity rates after emergency surgery for right-sided OCC, compared to patients treated electively for CRC, indicate the need for alternative treatment options. Much room for improvement remains in patients with OCC.
Optimisation
New insights show that the preoperative health status in elective CRC treatment is of importance to the postoperative outcome. [
18‐
21] Promising data in postoperative recovery, after prehabilitation programs in elective abdominal and colorectal operations, have been released, as well as for other elective surgical procedures. [
22‐
28] A recent Dutch trial by van Berkel et al. demonstrated the value of prehabilitation in elective colon resection while it reduces the risk of postoperative complications in high-risk patients. [
41].
The worse clinical status in patients presenting with OCC is probably one of the main causes of the poor short-term compared to non-obstructing OCC. Obstruction of the colon is often accompanied by symptoms such as nausea, abdominal pain, and vomiting, leading to altered intake or no intake. This may lead to malnutrition and a poor physical health status at time of presentation. The preoperative timeframe, which is needed for preoptimisation, is often short or non-existent in patients with OCC. However, staged treatment to avert emergency surgery, creates a preoperative time frame providing a chance for optimisation of the patient’s medical condition before tumour resection and allowing to do a complete preoperative screening of the patient’s health status and examine possible concomitant illnesses. The influence of optimisation in OCC may be of great value in case of reducing postoperative complications, morbidity and mortality.
Refraining from emergency surgery in OCC can be a barrier for professionals because of concern for complications due to the distended (small) bowel and colon. Adequate management of the obstruction is crucial, while left untreated the obstruction could lead to bowel necrosis, perforation, and ultimately death. [
42] However, the feasibility of different staged procedures has been demonstrated over the years, such as SEMS and decompressing ileo- or (transverse) colostomy for left-sided OCC. Non-surgical bowel decompression by nasogastric tube for (right-sided) OCC has not yet been proved in large studies. We realise that concerns may be raised over the strategy to decompress the small bowel and proximal colon in patients with an imminent or complete obstruction in OCC. Therefore, daily assessment of the patients with right-sided OCC in this study is crucial. In case a caecum dilation > 10 cm, decompression is immediately needed, while this extensive diameter is often accompanied by a competent ileocecal valve. Clinical and biochemical values need to be monitored carefully, and immediate interference is needed in case of abdominal pain, increase of leukocytes or C-reactive protein, to prevent bowel necrosis, perforation of a blowout. The feasibility of postponing surgery without decompressing stent or ileostomy as a bridge to surgery has recently be confirmed in a recent study of Fahim et al.. This study included all consecutive bowel obstruction patients treated with dietary adjustments, laxatives and prehabilitation before resection. In this study a total of 24 patients with bowel distention receiving TPN, reported emergency surgery in only 25% of the patients, while 75% of these patients were treated electively after 7–10 days of prehabilitation. [
43] This study differs from this study protocol while they also included benign disease. However, the feasibility of postponing surgery without SEMS or decompressing ileostomy was showed. In addition to this study, a retrospective pilot study performed in the Amphia hospital confirmed the feasibility of postponing surgery as well. In a total of 16 patients presenting with right-sided OCC, bowel decompression using a nasogastric tube was performed and emergency interference was not needed.
Another barrier for postponing emergency resection in OCC may be the uncertainty concerning oncological outcome. This while postponing resection may lead to tumour treatment delay. However, recent studies in patients treated with SEMS as bridge to surgery in left-sided OCC showed that the oncological outcomes were comparable with those from emergency surgery. [
44,
45] Even though the oncological outcome in optimisation of OCC patient is unknown, optimisation may influence postoperative outcome positively. While high rates of postoperative complications after emergency surgery may lead to prolonged hospital stay and time to recovery. [
3,
7,
46] The increased recovery time may lead to delayed adjuvant chemotherapy treatment, or no adjuvant treatment at all which has been associated with significantly worse overall survival and a higher recurrence rate. [
47].
The aim of this study is to determine whether optimisation in patients presenting with OCC is feasible, with special interest for right-sided OCC. We believe that this preoptimisation is beneficial for the majority of the patients. Next to a poor nutritional status and physical condition, it is often necessary to restore the fluid- and electrolyte balance. By adopting this strategy, there is time to improve these factors. Because of the acute setting, we do not think it is possible to define a homogeneous group that can be treated with preoptimisation or other valid treatment procedures (acute resection or diverting stoma). This is why randomisation, according to our opinion, is not a preferred option in our study.