Prevention of acute resection in obstructive colorectal cancer using a four-stage obstruction protocol

Malignant bowel obstruction is common in colorectal cancer and may require high-risk emergency surgery. A structured four-stage obstruction protocol may improve outcomes through early decompression and optimisation, thereby preventing deterioration, reducing acute resections and stoma formation, and minimising morbidity and mortality. This study evaluated clinical outcomes of this protocol.

The protocol categorises patients by symptom severity and colonic distension, with stage-specific management and routine reassessment for improvement or deterioration. Deterioration was defined as worsening of symptoms requiring escalation to a higher stage and more intensive care. This retrospective study included patients treated between 2018 and 2024.

Of 319 patients, 236 received curative and 83 palliative treatment. Stage distribution (curative/palliative): stage 1 (184/59), stage 2 (19/11), stage 3 (20/6), stage 4 (13/7). (Semi-)acute resections occurred more frequently in higher stages: 1% (stage 1), 6% (stage 2), 25% (stage 3), 15% (stage 4) (p < 0.001). Overall, 6% of curative patients deteriorated: 3% (stage 1), 5% (stage 2), 30% (stage 3), and 8% (stage 4). In curative stage 3, acute resection was avoided in 75% treated with stenting or nasogastric decompression. In the palliative group, all stage 3-4 patients received a stent or stoma without deterioration.

The four-stage obstruction protocol effectively manages colorectal cancer-related obstruction. In 94% of curative patients, deterioration was prevented, avoiding emergency surgery and its risks. While emergency resection was previously considered standard in stage 3, the protocol avoided this in most patients. Accurate staging and close monitoring remain essential to prevent deterioration.