EP224 - Resect or Divert? What is the Optimal Management of Malignant Large Bowel Obstruction?

ePoster Presenter(s)

• 

  Moustafa Moussally, MD

  Fellow
  Cleveland Clinic
  Cleveland Clinic
  Cleveland, OH, United States

  Disclosure information not submitted.

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Author(s)

• AM

  April Martinez, MD

  Resident
  Cleveland Clinic
  Cleveland, Ohio, United States

  Disclosure information not submitted.
• AK

  Ajaratu Keshinro, MD

  Colorectal surgeon
  Cleveland Clinic
  Cleveland, Ohio, United States

  Disclosure information not submitted.
• 

  Bradley J. Champagne, MD

  Colorectal Surgeon
  Cleveland Clinic
  Cleveland, Ohio, United States

  Disclosure information not submitted.
• 

  Kristen A. Ban, MD MS FACS FASCRS

  Assistant Professor of Surgery
  Cleveland Clinic
  Fairview Park, Ohio, United States

  Disclosure information not submitted.
• JT

  Joseph Trunzo, MD

  Colorectal Surgeon
  Cleveland Clinic
  Cleveland, Ohio, United States

  Disclosure information not submitted.
• 

  Emre Gorgun, MD, MBA. FACS, FASCRS. (he/him/his)

  Vice Chair, Department of Colorectal Surgery
  Cleveland Clinic
  Cleveland Cliinic
  Cleveland, Ohio, United States

  All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no relevant financial relationships.
• 

  David Liska, MD

  Associate Professor, Chair
  Department of Colorectal Surgery, Cleveland Clinic
  Cleveland Clinic, Cleveland, Ohio
  Cleveland, OH, United States

  All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no relevant financial relationships.

Senior Author(s)

• 

  David R. Rosen, MD

  Colorectal Surgeon
  Cleveland Clinic
  Cleveland Clinic Lerner College of Medicine
  Cleveland, OH, United States

  All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no relevant financial relationships.

Purpose/Background: Colon cancer is the predominant cause of large bowel obstruction (LBO). The optimal surgical management of malignant LBO remains controversial. Initial options include upfront resection or diverting ostomy followed by neoadjuvant chemotherapy and potential interval resection. We hypothesized that diversion with delayed resection would result in greater lymph node harvest and fewer positive margins.

Methods/Interventions: A prospectively maintained institutional cancer database was queried for patients presenting with clinical and radiographic evidence of malignant LBO between January 2020 and August 2025. Patients who underwent self-expanding metal stent placement (n=6) or had rectal cancer were excluded. Demographics, operative details, tumor stage, histopathologic data, and outcomes were reviewed retrospectively. Statistical analyses were performed using SPSS v23.0

Results/Outcomes: A total of 221 patients underwent surgery for malignant large bowel obstruction; 53% were female, with a median age of 70 ± 14.6 years and a median BMI of 26 kg/m². The median follow-up duration was 16.5 months (range 1.5-62.5). Left-sided obstructions (distal to splenic flexure) accounted for 141 (64%) cases. Overall, 188 patients (85%) underwent upfront resection, while 33 (15%) underwent diverting ostomy. High-risk histologic features were present in 124 (63%) specimens. Patients in the diversion group were more likely to have stage IV disease (70% vs 20%, p< 0.01). Among diverted patients, 9/33 (27%) subsequently underwent interval resection after chemotherapy, whereas 24 (73%) received palliative chemotherapy alone. The average lymph node harvest was comparable between the upfront resection and the diversion groups (26 vs 27, p=0.5). The stoma-free rate was higher among patients undergoing upfront resection (62% vs 24%, p< 0.05); however, 89% of diverted patients who later had resection achieved stoma freedom. Positive surgical margins were more frequent following upfront resection (3.7% vs 0%, p=0.5), and distant recurrence rates were similar (25% vs 20%, p=0.7). Overall mortality over our follow up period was 27% in the upfront resection group and 55% in the diversion group (p=0.07).

Conclusion/Discussion: Malignant LBO represents a poor prognostic indicator. The choice between diversion and resection at index operation appears strongly influenced by tumor stage, with stage IV patients more likely to undergo diversion. While nodal harvest and margin status were similar between groups, diversion was more commonly employed in patients with advanced disease achieving comparable oncologic outcomes despite more advanced disease. Optimal management should be individualized, balancing disease burden and long-term quality-of-life considerations.

Table1
Overall Oncologic and Patient Outcomes