Abstract
Aim
To investigate surgeons' perspectives on the management of right‐sided obstructing colon cancer, with particular focus on their views regarding bridge‐to‐surgery strategies.
Methods
A national cross‐sectional descriptive survey study was conducted in the Netherlands between January and October 2024. Questionnaires were distributed among surgeons with an interest in colorectal surgery and surgical trainees specialising in gastrointestinal surgery.
Results
Fifty completed questionnaires were analysed; 80% of the respondents were surgeons, 20% were surgical trainees. Emergency resection was reported as the sole treatment option for right‐sided obstructing colon cancer in 4% (n = 2), while 64% (n = 32) indicated that emergency resections were performed alongside other treatment strategies. The majority of the respondents preferred a bridge‐to‐surgery strategy, with bowel decompression with nasogastric tube (38%) and ileostomy (38%) being the most favoured strategies. Endoscopic stenting was not offered in 90%, largely due to the lack of trained endoscopists.
Conclusion
Management of right‐sided obstructing colon cancer varies considerably, though most surgeons and surgical trainees favour bridge‐to‐surgery approaches. Greater consistency may be achieved through further research and guideline development.
Keywords: bridge‐to‐surgery, obstructing colon cancer, questionnaire
What does this paper add to the literature?
The optimal management of right‐sided obstructing colon cancer remains uncertain, with guidelines offering limited direction. This study explores surgeons' perspectives on bridge‐to‐surgery strategies, revealing substantial variation in practice and growing support for staged management. These findings highlight the need for clearer evidence and guideline consensus to standardize care.
INTRODUCTION
Colorectal cancer (CRC) is the third most commonly diagnosed malignancy worldwide and the second‐leading cause of cancer‐related mortality [1]. In 10–28% of the cases, patients present with a large bowel obstruction, with a higher incidence in left‐sided tumours compared to right‐sided tumours [2, 3, 4, 5, 6, 7]. Historically, the standard treatment for acute obstructing colon cancer has been an emergency resection, although this has gradually shifted to initial decompression for left‐sided tumour locations in the last decade [8]. For right‐sided tumours, available literature is less conclusive. Dutch and international guidelines suggest that a bridge‐to‐surgery (BTS) approach, such as diverting stoma formation or stent placement, may be considered as alternatives to emergency resection, but without providing firm, standardised guidance [8, 9, 10, 11]. Therefore, management of R‐OCC does not only vary between hospitals, but among surgeons within the same hospital as well.
In recent years, increasing focus has been directed towards optimisation of clinical management of patients with R‐OCC. BTS strategies aim to achieve short‐term relief of the obstruction while postponing the definitive oncological resection. These strategies include bowel decompression through placement of an endoscopic stent, a diverting ileostomy or a nasogastric tube combined with parenteral nutrition [12, 13, 14, 15]. Prior to the definitive oncological resection, patients undergo preoperative optimisation, which includes referral to a dietitian in cases of preoperative malnutrition, advice on maintaining adequate physical activity, smoking cessation advice, and treatment of anaemia when indicated [8, 12, 13, 14, 15]. Postponing the surgery to a (semi)‐elective resection may facilitate laparoscopic surgery by a surgeon specialized in colorectal surgery, rather than by the on‐call surgeon. In selected cases, it may also provide an opportunity for induction or neoadjuvant therapy [15].
To address the variability in the management of R‐OCC and gain further insight into current clinical practice, a questionnaire study has been conducted. The aim of this study was to investigate the perspectives of surgeons and surgical trainees with an interest in colorectal surgery regarding the management of R‐OCC, specifically to describe current practice and identify factors influencing the choice of BTS strategies.
MATERIALS AND METHODS
Study design and population
This cross‐sectional descriptive study using questionnaires was conducted between January and October 2024. The purpose of this study was to gain insight into the treatment strategies followed by surgeons in the Netherlands and the considerations guiding their decision‐making for patients with acute R‐OCC. The questionnaire was administered through the newsletter of a colorectal surgery society and distributed at a national gastrointestinal surgery conference. All surgeons with an interest in colorectal surgery and surgical trainees specialising in gastrointestinal surgery who received the newsletter or attended the conference were invited to complete the questionnaire. Only fully completed questionnaires were included in this study.
Bridge‐to‐surgery
BTS referred to strategies aimed at delaying definitive surgery in patients with R‐OCC to allow intestinal decompression and improvement of the patient's physical and nutritional status prior to (semi‐)elective resection. The BTS approaches considered included nasogastric decompression with parenteral nutrition, diverting ileostomy and right‐sided stenting. While all approaches shared the goal of optimising patient condition before surgery, each had specific advantages and limitations. Nasogastric decompression generally required hospitalisation until resection, whereas ileostomy and stenting typically allowed patients to remain at home. Factors influencing the choice included patient comorbidities, anatomical considerations such as competence of the ileocaecal valve, the need for neoadjuvant chemotherapy and the technical expertise required, particularly for stenting.
Questionnaire
The questionnaire was developed following dedicated qualitative methodological involvement without utilising a standardised template. A multidisciplinary working group of colorectal surgeons and clinical researchers convened to define key domains and concepts relevant to the management of acute R‐OCC. The draft questionnaire underwent internal review by the working group, including both senior surgeons and trainees, to ensure clarity, relevance and face validity. Minor revisions were made based on this feedback. Although no external pilot‐testing or formal validation was performed, the questionnaire was reviewed with participants of varying experience levels within the group, including trainees and consultants, to ensure comprehensibility and applicability. The questionnaire focused on patients with R‐OCC, including tumours in the caecum, ascending colon, hepatic flexure and transverse colon. It concerned patients showing signs of acute obstruction, abdominal pain, nausea, vomiting and constipation, with curable disease, with or without locoregional metastases. The questions did not pertain to patients in a palliative setting, those with suspected peritoneal metastases, signs of perforation (e.g., free air on CT) requiring urgent surgery or cases of imminent obstruction; defined as an endoscopically non‐passable tumour with mild symptoms, no ileus on CT and manageable with conservative measures prior to semi‐elective surgery.
The questionnaire consisted of nine questions, including four multiple‐choice questions that allowed multiple responses and three multiple‐choice questions that required a single response. Additionally, one multiple‐choice question permitted multiple responses, and selecting a specific answer triggered an additional open‐ended question. For Question 4, respondents were allowed to select multiple answers to indicate which treatment options were available in their hospital. In contrast, Question 5 required respondents to select a single option to indicate their preferred treatment strategy. All multiple‐choice questions included an ‘Other’ option, allowing participants to provide additional comments. The questionnaire also contained one fully open‐ended question. The questionnaire required approximately 10 min to complete. A copy of the questionnaire can be found in File S1.
Prior to launch, the study team reviewed survey functionality, ensured compliance with data protection standards, and tested data export procedures. No interviewer training was required as the study involved self‐administered online data entry. The final survey was administered digitally using Castor Electronic Data Capture (EDC). The questionnaire was distributed once through the professional society's newsletter and once via a QR code displayed during the national conference. Data were automatically recorded and securely stored within the Castor platform. Participation was voluntary and anonymous. Completing the online questionnaire implied informed consent. No identifiable personal data were collected, and confidentiality was maintained throughout the study in accordance with national data protection regulations.
Data analysis
This was a descriptive study. For each multiple‐choice question, the frequency with which each answer option was selected was calculated and presented as a percentage of the total number of responses to that question. For categorical variables, chi‐squared and Fisher exact tests were performed. Statistical significance was determined at a level of α = 0.05. Given the exploratory design and small sample size, no adjustment for multiple comparisons was performed. Data analyses were conducted using IBM SPSS Statistics Program version 29. Open‐text responses were collected for selected questions and analysed separately, with qualitative insights summarised alongside quantitative results.
Missing data were minimal as only complete questionnaires were included. No data imputation or weighting procedures were performed. Non‐response bias was minimised by using two separate recruitment channels (newsletter and conference) to reach a broad national sample.
This study was reported in accordance with the CROSS (Checklist for Reporting Of Survey Studies) guidelines.
RESULTS
A total of 68 questionnaires were completed to some degree, of which 50 (74%) were fully completed. The fully completed questionnaires were included in this study. Among the respondents, 40 (80%) were surgeons and 10 (20%) were surgical trainees, with almost all having a subspecialty in colorectal/gastrointestinal surgery (96%) (Table 1, Figures 1, and S1).
TABLE 1.
Question 1–3. Characteristics and areas of expertise among respondents.
| Question 1: Are you a surgeon or surgical trainee | n = 50 | % |
|---|---|---|
| Surgeon | 40 | 80 |
| Surgical trainee | 10 | 20 |
| Other, namely | 0 |
| Years of experience as a surgeon | n = 40 | % |
|---|---|---|
| <5 years of experience | 16 | 41 |
| 5–10 years of experience | 10 | 26 |
| >10 years of experience | 14 | 35 |
| Question 2: What is your area of expertise? | n = 50 | % |
|---|---|---|
| Colorectal/gastrointestinal surgery | 48 | 96 |
| Abdominal wall surgery | 4 | 8 |
| Upper gastrointestinal surgery | 4 | 8 |
| Bariatric surgery | 4 | 8 |
| Hepatobiliary surgery | 3 | 6 |
| Inflammatory bowel diseases | 2 | 4 |
| Neuroendocrine tumours | 1 | 2 |
| Adrenal gland surgery | 1 | 2 |
| Question 3: What type of hospital do you work in? | n = 50 | % |
|---|---|---|
| Teaching hospital | 30 | 60 |
| Regional non‐teaching hospital | 11 | 22 |
| Academic hospital | 9 | 18 |
| Other, namely | 0 |
FIGURE 1.
Available/preferred treatment options for acute right‐sided obstructing colon cancer.
Treatment strategies for acute right‐sided obstructing colon cancer are depicted in Table 2. Among the 50 respondents, 96% (n = 48) reported that one or more BTS approaches were available in their hospital for patients with R‐OCC. Two respondents (4%) indicated that emergency resection was the sole treatment option, with no BTS approach offered. Of the 48 respondents who had BTS options available, 32 (64%) indicated that emergency resections were also performed, yet not as the only available strategy. The remaining 16 respondents (32%) stated that emergency resection was not performed at all for this patient group. When given a choice, the majority of the respondents preferred a BTS strategy, with bowel decompression with nasogastric tube (38%) and ileostomy (38%) being the most favoured strategies. Seven respondents (14%) preferred an emergency resection for patients with R‐OCC, all of them consultant surgeons. None of the surgical trainees selected emergency resection as their preferred treatment. There was no significant association between years of surgical experience and the preference for an emergency resection (<5 years 19%, 5–10 years 10%, >10 years 21%, p = 0.705) (Table 2, Figures 1 and S1).
TABLE 2.
Questions 4, 5, 8 and 9. Treatment for right‐sided obstructing colon cancer.
| Question 4: Which treatment(s) are applied in your hospital for acute right‐sided obstructing colon cancer? | n = 50 | % |
|---|---|---|
| Emergency resection | 34 | 68 |
| Delayed surgical resection: Bowel decompression with a nasogastric tube and parenteral nutrition as a bridge‐to‐surgery | 33 | 66 |
| Delayed surgical resection: Ileostomy as a bridge‐to‐surgery | 43 | 86 |
| Delayed surgical resection: Right‐sided stent as a bridge‐to‐surgery | 5 | 10 |
| Other, namely: diverting bypass | 1 | 2 |
| Question 5: Which treatment do you prefer for acute right‐sided obstructing colon cancer? | n = 50 | % |
|---|---|---|
| Emergency resection | 7 | 14 |
| Delayed surgical resection: Bowel decompression with a nasogastric tube and parenteral nutrition as a bridge‐to‐surgery | 19 | 38 |
| Delayed surgical resection: Ileostomy as a bridge‐to‐surgery | 19 | 38 |
| Delayed surgical resection: Right‐sided stent as a bridge‐to‐surgery | 5 | 10 |
| Other, namely | 0 |
| Question 8: What applies to you/your hospital regarding endoscopic stent placement in the right‐sided colon? | n = 50 | % |
|---|---|---|
| I consider it a good option if the tumour is suitable and the expertise is available | 22 | 44 |
| No endoscopist with relevant expertise is available at my hospital | 26 | 52 |
| I am willing to transfer a patient to another hospital with available expertise | 14 | 28 |
| I consider it as a high‐risk procedure | 13 | 26 |
| Question 9: If you opt for a bridge‐to‐surgery strategy, what additional care do you provide to your patient? | n = 50 | % |
|---|---|---|
| Physiotherapy | 43 | 86 |
| Dietitian | 48 | 96 |
| Other, namely: treatment of anaemia, a complete prehabilitation trajectory, selective digestive decontamination (SDD), ERAS checklist, involvement of other (para)medics: geriatrician, colon care nurses, psychologist | 8 | 16 |
| None | 0 |
Note: Question 4 assessed treatment options available in respondents' hospitals and allowed multiple responses. Question 5 assessed the respondent's preferred treatment strategy and required a single response.
Endoscopic stenting was not offered as a bridge‐to‐surgery option in 90% of hospitals. Over half (52%) cited a lack of trained endoscopists, while 26% considered the procedure high‐risk. Nonetheless, 44% regarded stenting as a viable option if the tumour was suitable and the expertise available. Nearly all respondents would involve a dietitian (96%) and physiotherapist (86%) when opting for a BTS strategy (Table 2).
The preferred timing for an emergency resection or the (semi)‐elective resection following the BTS approach is presented in Table 3. When performing an emergency oncological resection, most respondents do so within 24–48 h. One commented that the timing would depend on the anaesthesiologist. Two surgeons preferred a staged approach and reserved emergency resection for patients with inadequate decompression, aiming to operate within 24–48 h in such situations. In patients managed with nasogastric tube decompression, 53% of the respondents performed the resection 7–14 days after admission. Six respondents did not specify a timeframe, stating that timing depends on factors such as clinical condition, nutrition and logistics.
TABLE 3.
Timeframe for delayed resection among respondents who reported performing a bridge‐to‐surgery approach and/or emergency resection.
| Emergency resection | n = 34 | % |
|---|---|---|
| < 24 h | 7 | 21 |
| 24–48 h | 21 | 62 |
| >48 h | 6 | 18 |
| Bridge‐to‐surgery: Nasogastric tube | n = 32 | % |
|---|---|---|
| 2–6 days | 8 | 25 |
| 7–14 days | 17 | 53 |
| >14 days | 1 | 3 |
| Other | 6 | 19 |
| Bridge‐to‐surgery: Ileostomy | n = 43 | % |
|---|---|---|
| 2–3 weeks | 7 | 16 |
| 3–4 weeks | 8 | 19 |
| 4–6 weeks | 5 | 12 |
| 6–8 weeks | 6 | 14 |
| >8 weeks | 2 | 5 |
| Other | 13 | 30 |
| Missing | 2 | 5 |
| Bridge‐to‐surgery: Right‐sided stent | n = 5 | % |
|---|---|---|
| 3–4 weeks | 2 | 40 |
| 6 weeks | 2 | 40 |
| Missing | 1 | 20 |
Regarding the timing of resection following ileostomy as a BTS, 30% did not define a fixed interval. They indicated it depends on diagnostic work‐up, clinical recovery, prehabilitation, induction/neoadjuvant therapy, and after shared decision‐making with the patient. One respondent cited induction/neoadjuvant therapy as the sole reason for the BTS approach, without specifying a surgical interval. Among those who provided a timeframe, resection timing ranged from 2 to 3 weeks to over 8 weeks. Of the five respondents who reported endoscopic stenting as a treatment option, 40% preferred to perform the oncological resection after 3–4 weeks, and 40% favoured an interval of 6 weeks.
In Questions 6 and 7, respondents were asked to identify both the current and ideal factors influencing the treatment approach for patients with R‐OCC (Table 4). The factors most frequently cited as desirable considerations included patient‐related risk factors (70%), tumour extent (64%) and the possibility of administering induction/neoadjuvant therapy (56%). The respondents felt that the following factors should ideally not influence the treatment strategy: timing of patient's presentation (90%), expertise of the surgeon‐on‐call (88%) and availability of an endoscopist with stenting expertise (78%). Nonetheless, 22% acknowledged that the on‐call surgeon's expertise currently affects decision‐making, despite considering this inappropriate.
TABLE 4.
Question 6 and 7. Current and desirable factors that determine the treatment approach for right‐sided obstructing colon cancer.
| Current and desirable | Current but not desirable | Not current but desirable | Not current and not desirable | |||||
|---|---|---|---|---|---|---|---|---|
| n = 50 | % | n = 50 | % | n = 50 | % | n = 50 | % | |
| Tumour extent (cT2‐3 vs. cT4) | 30 | 60 | 2 | 4 | 2 | 4 | 16 | 32 |
| Patient's age (<70 vs. >70) | 15 | 30 | 7 | 14 | 7 | 14 | 21 | 42 |
| Risk factors (anaemia, >10% weight loss, etc.) | 29 | 58 | 2 | 4 | 6 | 12 | 13 | 26 |
| Tumour location (cecum/ascending vs. hepatic flexure/transverse) | 10 | 20 | 4 | 8 | 5 | 10 | 31 | 62 |
| Suitability of the tumour for stenting | 8 | 16 | 2 | 4 | 14 | 28 | 26 | 52 |
| Availability of an endoscopist with stent expertise | 6 | 12 | 6 | 12 | 5 | 10 | 33 | 66 |
| Time of patient presentation (day, evening, night) | 2 | 4 | 5 | 10 | 3 | 6 | 40 | 80 |
| Expertise of the on‐call surgeon | 5 | 10 | 11 | 22 | 1 | 2 | 33 | 66 |
| Possibility of administering induction/neoadjuvant therapy | 22 | 44 | 4 | 8 | 6 | 12 | 18 | 36 |
Note: Categorised based on whether they (1) currently influence the treatment approach and are considered as desirable, (2) currently influence the approach but are viewed as undesirable influences, (3) are not currently considered but ideally should be and (4) are not considered and are not desirable.
Respondents also cited patient's clinical condition, the degree of bowel dilatation, ileocaecal valve function, and completion of diagnostics as relevant considerations. Overall, treatment decision‐making differed little between trainees and surgeons, except in two areas. Patient age was considered relevant by 70% of trainees versus 38% of surgeons (p = 0.084, 95% CI 0.06–1.15). Additionally, 60% of trainees reported that the availability of an endoscopist with stenting expertise influenced treatment decisions, compared to 15% of consultants (p = 0.007, 95% CI 0.03–0.55).
Respondents whose hospitals performed emergency resections were questioned for their rationale for choosing this approach over a BTS approach in patients without an absolute indication for emergency surgery. Most indicated that the decision depends on clinical context and patient condition, with emergency resection often favoured in patients with good overall health, low risk of complications and adequate nutritional status. Tumour location and the anticipated technical ease of creating an anastomosis were also cited as influencing factors. Some respondents reported negative experiences with BTS strategies, leading them to favour emergency resection. Illustrative comments included: ‘I have encountered problems with diverting ileostomies’, and ‘I have had poor experiences with endoscopic stents placed by endoscopists. Moreover, an ileostomy in patients with a competent ileocaecal valve can lead to complications; therefore, I prefer emergency resection when the patient's condition allows it’. One respondent noted having no experience with obstruction protocols.
DISCUSSION
In this study, we aimed to examine perspectives of surgeons and surgical trainees on the management of R‐OCC, with a specific focus on BTS strategies. The responses to the questionnaire demonstrated considerable variability in both treatment approaches and the preferences regarding the treatment of patients with this disease. Despite this heterogeneity, the majority of the respondents reported working in hospitals where one or more BTS strategies are routinely employed. Only a minority of the surgeons indicated a preference for an emergency resection as their primary treatment option.
Nearly all respondents reported that their hospital offers at least one BTS strategy for the management of R‐OCC. While the majority preferred a BTS approach, the specific type varied, most likely due to the lack of clear guidance in the current guidelines. This lack of definitive guidance likely contributes to variability in clinical practice, with decisions influenced by individual experience and familiarity with available techniques. The Dutch, the American Society of Colon and Rectal Surgeons (ASCRS) and the European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend that, in patients with potentially curable R‐OCC, a bridge‐to‐surgery approach, using either endoscopic stenting or a diverting stoma, may be considered as an alternative to emergency resection. When choosing between these options, clinicians should take into account patient condition and preferences, as well as the technical feasibility and local expertise for stenting. ESGE specifically notes that colonic stenting for proximal malignant obstruction can be considered as a bridge to surgery, but evidence is of low quality and recommendations are weak; ASCRS similarly allows initial colectomy or stent decompression followed by interval colectomy, with a strong recommendation despite low‐quality evidence [8, 10, 11]. Notably, only a few surgeons preferred emergency resection, and none of the surgical trainees selected it as their preferred approach. While these subgroup findings should be interpreted cautiously given the unequal group distribution, the observed pattern may reflect increasing familiarity with BTS techniques among more recently trained clinicians [16, 17].
Previous retrospective studies report substantial variation in the use of BTS strategies for right‐sided colonic obstruction, with stenting used in 1–15%, diverting ileostomies in 4–9% and nasogastric decompression in 1–47%. Emergency resection, however, remains the predominant treatment in these studies (52–93%), although a gradual decline is noted over time in favour of BTS approaches [6, 11, 13, 15, 18]. This shift is likely driven by the unfavourable outcomes associated with emergency resections. A systematic review by Boeding et al. found a mean complication rate of 42% following emergency resection versus 30% after BTS, and mortality rates of 7.2% and 1.2%, respectively [14].
The majority of respondents indicated that endoscopic stenting is not offered as a BTS strategy in their hospital, primarily due to the absence of endoscopists with sufficient expertise and safety concerns. Nonetheless, systematic reviews reported technical success rates for endoscopic stenting between 84% and 96% [14, 19], with significantly lower morbidity and mortality rates compared to emergency resections [19, 20]. Right‐sided stenting is technically more challenging than left‐sided stenting due to factors such as increased bowel tortuosity, greater distance from the anus and limited endoscopic manoeuvrability, meaning that not all practitioners are adequately trained to perform the procedure safely [21]. It should therefore be limited to hospitals with experienced endoscopists [7, 14]. When local expertise is lacking, referral to a specialized centre may be considered; in our survey, a quarter of respondents indicated they would be willing to refer patients. Although current guidelines do not explicitly recommend referral, we suggest that, in settings without adequately trained endoscopists, referral to a specialized centre could help ensure safe and effective treatment.
The reported timing of delayed resection varied across the three BTS strategies, with broad ranges observed for each. A Dutch study presented that a two‐week interval offers an optimal balance between improved surgical outcomes and minimizing stent‐related complications [22], making the longer intervals reported by our respondents notable. However, other studies remain inconclusive; some suggest early surgery (7–10 days) [23, 24], while others report better outcomes with longer delays (>10–15 days or even >4 weeks) [25, 26, 27, 28]. For ileostomy, studies on left‐sided obstructions suggest a 2–4 week interval improves laparoscopic conditions [22], while nasogastric decompression is typically followed by surgery after 8–9.6 days [15, 29].
This study has contributed to future research by highlighting key factors currently influencing treatment decisions for R‐OCC, such as the expertise of the on‐call surgeon and timing of patient presentation. Ideally, these factors should not impact the treatment approach. The findings suggest that clearer, evidence‐based research and updated guidelines would reduce variability in decision‐making among surgeons. With more defined protocols, treatment decisions could be made more consistently, with less reliance on subjective factors like the surgeon's experience, ultimately leading to a more standardized, patient‐centred approach. To obtain more comprehensive data on the use of bridge‐to‐surgery strategies in clinical practice, a nationwide multicentre registry study has been initiated and is currently ongoing (ClinicalTrials.gov ID NCT06338332). This registry aims to offer a clearer understanding of how bridge‐to‐surgery strategies are applied in daily practice, enabling comparisons of outcomes between different approaches and ultimately supporting the development of more consistent, evidence‐based guidelines for the management of acute right‐sided obstructing colon cancer. Additionally, this study revealed that right‐sided stenting is still infrequently used, although there is openness to its application. Further research into this technique, including specific training for endoscopists, is needed to advance future practice and improve treatment outcomes.
A limitation of this study is the potential for selection bias. As participation was voluntary, it is likely that surgeons and surgical trainees with a particular interest in this topic were overrepresented, which may limit the generalisability of the findings. Another limitation is that the exact number of individuals reached is unknown, and therefore a precise recruitment denominator and response rate could not be calculated, while duplicate representation from the same institution cannot be excluded. Only fully completed questionnaires were included in the analysis, which reduced item‐level missingness but may have excluded partially completed responses with potentially relevant perspectives. In addition, with a total of 50 respondents, the results may not fully capture the perspectives of the broader population of surgeons and trainees with an interest in colorectal surgery. Findings from subgroup analyses should be interpreted cautiously, as the small sample size reduces statistical reliability and observed differences may not be robust. In addition, since the responses were collected from individual surgeons rather than from institutions, the reported percentages primarily reflect personal practices or opinions and are not necessarily generalisable to hospital‐level or nationwide practices in the Netherlands. The final limitation is that the questionnaire was not formally validated and did not undergo external pilot testing. Although it was developed through expert consensus and internally reviewed for clarity and face validity, the absence of validation may limit reproducibility and comparability with other studies. Consequently, the findings should be interpreted as exploratory and descriptive, reflecting current clinical perspectives rather than quantitatively validated constructs.
CONCLUSION
Right‐sided obstructing colon cancer is currently managed through either emergency resection or a range of BTS strategies. This survey suggests that BTS approaches are commonly considered by surgeons and surgical trainees with an interest in colorectal surgery; however, considerable variation exists regarding the preferred BTS strategy and timing of resection. To achieve greater uniformity in the treatment of patients with right‐sided obstructing colon cancer, prospective studies are needed to compare BTS strategies, define optimal timing and reduce the impact of logistical factors on treatment decisions.
AUTHOR CONTRIBUTIONS
Research Group OCCBRIGHT: Writing – review and editing; data curation. Pieter J. Tanis: Conceptualization; writing – review and editing; supervision; validation; methodology. Paul D. Gobardhan: Conceptualization; methodology; supervision; writing – review and editing; validation. Jennifer M. J. Schreinemakers: Conceptualization; writing – review and editing; supervision; methodology; validation. Cornelis Verhoef: Conceptualization; writing – review and editing; methodology; supervision; validation. Elize W. Lockhorst: Conceptualization; data curation; formal analysis; visualization; writing – original draft; methodology; investigation; validation; resources; software. Esther C. J. Consten: Conceptualization; methodology; supervision; writing – review and editing; validation.
FUNDING INFORMATION
No funding was received for this study.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
Ethical approval was not required for this study.
PATIENT CONSENT STATEMENT
No patients were involved in this research; informed consent was therefore not applicable.
PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES
No material from other sources requiring permission has been reproduced.
Supporting information
File S1.
Figure S1.
Lockhorst EW, Verhoef C, Tanis PJ, Consten ECJ, Gobardhan PD, Schreinemakers JMJ. Bridge‐to‐surgery in acute right‐sided obstructing colon cancer: A survey of surgeons' perspectives on treatment strategies. Colorectal Dis. 2026;28:e70566. 10.1111/codi.70566
Collaborators OCCBRIGHT Research Group: S. M. Van Aalten (Groene Hart Hospital, Gouda, the Netherlands), R. Barendse (Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands), J. T. M. Blauw (Frisius MC, Heerenveen, the Netherlands), S. O. Breukink (Maastricht University Medical Center, Maastricht, the Netherlands), J. J. van den Broek (Dijklander Hospital, Hoorn, the Netherlands), P. R. A. Buijs (Amstelland Hospital, Amstelveen, the Netherlands), J. P. Bulte (Southern Älvsborg Hospital, Borås, Sweden), S. M. M. De Castro (OLVG, Amsterdam, the Netherlands), S. H. E. M. Clermonts (Ommelander Hospital Groningen and University Medical Centre Groningen, Groningen, the Netherlands), R. J. S. Coelen (Nij Smellinghe Hospital, Drachten, the Netherlands), J. A. van Essen (St. Jans Gasthuis, Weert, the Netherlands), M. Emous (Medical Center Leeuwarden, Leeuwarden, the Netherlands), A. A. W. Van Geloven (TergooiMC, Hilversum, the Netherlands), M. J. P. M. Govaert (Dijklander Hospital, Hoorn, the Netherlands), C. D. P. van ‘t Hullenaar (van Weel‐Bethesda Hospital, Dirksland, the Netherlands), Y. Issa (Leiden University Medical Center, Leiden, the Netherlands), C. S. van Kessel (Reinier de Graaf Gasthuis, Delft, the Netherlands), J. L. M. Konsten (VieCuri Medical Center, Venlo‐Venray, the Netherlands), W. K. G. Leclercq (Maxima Medical Center, Veldhoven, the Netherlands), M. M. N. Leeuwenburgh (Haaglanden Medical Center, the Hague, the Netherlands), H. T. J. Mantel (Ziekenhuis Groep Twente, Hengelo, the Netherlands), H. A. Marsman (OLVG, Amsterdam, the Netherlands), J. Melenhorst (Maastricht University Medical Center, Maastricht, the Netherlands), B. J. Noordman (Erasmus MC, Rotterdam, the Netherlands), J. M. T. Omloo (Gelre Hospitals, Apeldoorn, the Netherlands), C. M. C. Oude Ophuis (Erasmus MC, Rotterdam, the Netherlands), F. B. Poelmann (Nij Smellinghe Hospital, Drachten, the Netherlands), D. J. A. Sonneveld (Dijklander Hospital, Hoorn, the Netherlands), H. A. Swank (Albert Schweitzer Hospital, Dordrecht, the Netherlands), A. K. Talsma (Deventer Hospital, Deventer, the Netherlands), G. H. E. J. Vijgen (Laurentius Hospital, Roermond, the Netherlands), R. J. de Vos tot Nederveen Cappel (Admiraal de Ruyter Hospital, Goes, the Netherlands), F. T. W. E. van Workum (Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands).
Contributor Information
Elize W. Lockhorst, Email: e.lockhorst@erasmusmc.nl.
the OCCBRIGHT Research Group:
S. M. Van Aalten, R. Barendse, J. T. M. Blauw, S. O. Breukink, J. J. van den Broek, P. R. A. Buijs, J. P. Bulte, S. M. M. De Castro, S. H. E. M. Clermonts, R. J. S. Coelen, J. A. van Essen, M. Emous, A. A. W. Van Geloven, M. J. P. M. Govaert, C. D. P. van ‘t Hullenaar, Y. Issa, C. S. van Kessel, J. L. M. Konsten, W. K. G. Leclercq, M. M. N. Leeuwenburgh, H. T. J. Mantel, H. A. Marsman, J. Melenhorst, B. J. Noordman, J. M. T. Omloo, C. M. C. Oude Ophuis, F. B. Poelmann, D. J. A. Sonneveld, H. A. Swank, A. K. Talsma, G. H. E. J. Vijgen, R. J. de Vos tot Nederveen Cappel, and F. T. W. E. van Workum
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
REFERENCES
- 1. Morgan E, Arnold M, Gini A, Lorenzoni V, Cabasag CJ, Laversanne M, et al. Global burden of colorectal cancer in 2020 and 2040: incidence and mortality estimates from GLOBOCAN. Gut. 2023;72(2):338–344. [DOI] [PubMed] [Google Scholar]
- 2. Phillips RK, Hittinger R, Fry JS, Fielding LP. Malignant large bowel obstruction. Br J Surg. 1985;72(4):296–302. [DOI] [PubMed] [Google Scholar]
- 3. Van Leersum NJ, Snijders HS, Henneman D, Kolfschoten NE, Gooiker GA, ten Berge MG, et al. The Dutch surgical colorectal audit. Eur J Surg Oncol. 2013;39(10):1063–1070. [DOI] [PubMed] [Google Scholar]
- 4. Ripamonti C, Bruera E. Palliative management of malignant bowel obstruction. Int J Gynecol Cancer. 2002;12(2):135–143. [DOI] [PubMed] [Google Scholar]
- 5. Jullumstrø E, Wibe A, Lydersen S, Edna TH. Colon cancer incidence, presentation, treatment and outcomes over 25 years. Color Dis. 2011;13(5):512–518. [DOI] [PubMed] [Google Scholar]
- 6. Mege D, Manceau G, Beyer L, Bridoux V, Lakkis Z, Venara A, et al. Right‐sided vs. left‐sided obstructing colonic cancer: results of a multicenter study of the French surgical association in 2325 patients and literature review. Int J Color Dis. 2019;34(6):1021–1032. [DOI] [PubMed] [Google Scholar]
- 7. Yoo RN, Cho HM, Kye BH. Management of obstructive colon cancer: current status, obstacles, and future directions. World J Gastrointest Oncol. 2021;13(12):1850–1862. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. (IKNL) IKN . Colorectaal carcinoom (CRC); Acute presentatie coloncarcinoom. 2022. [updated 05–08–202201‐04‐2025]. Available from: https://richtlijnendatabase.nl/richtlijn/colorectaal_carcinoom_crc/primaire_behandeling_coloncarcinoom_bij_crc/acute_presentatie_coloncarcinoom.html
- 9. Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, et al. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg. 2018;13(1):36. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Vogel JD, Felder SI, Bhama AR, Hawkins AT, Langenfeld SJ, Shaffer VO, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the Management of Colon Cancer. Dis Colon Rectum. 2022;65(2):148–177. [DOI] [PubMed] [Google Scholar]
- 11. van Hooft JE, Veld JV, Arnold D, Beets‐Tan RGH, Everett S, Götz M, et al. Self‐expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) guideline ‐ update 2020. Endoscopy. 2020;52(5):389–407. [DOI] [PubMed] [Google Scholar]
- 12. Boeding JRE, Gobardhan PD, Rijken AM, Seerden TCJ, Verhoef C, Schreinemakers JMJ. Preoptimisation in patients with acute obstructive colon cancer (PREOCC) ‐ a prospective registration study protocol. BMC Gastroenterol. 2023;23(1):186. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Rosander E, Holm T, Sjövall A, Hjern F, Weibull CE, Nordenvall C. Emergency resection or diverting stoma followed by elective resection in patients with colonic obstruction due to locally advanced cancer: a national cohort study. Color Dis. 2021;23(9):2387–2398. [DOI] [PubMed] [Google Scholar]
- 14. Boeding JRE, Ramphal W, Rijken AM, Crolla R, Verhoef C, Gobardhan PD, et al. A systematic review comparing emergency resection and staged treatment for curable obstructing right‐sided colon cancer. Ann Surg Oncol. 2021;28(7):3545–3555. [DOI] [PubMed] [Google Scholar]
- 15. Lockhorst EW, Boeding JRE, Wullaert L, Coebergh van den Braak RRJ, Rijken AM, Verhoef C, et al. Long‐term outcomes after postponing surgery to optimise patients with acute right‐sided obstructing colon cancer. Eur J Surg Oncol. 2025;51(2):109521. [DOI] [PubMed] [Google Scholar]
- 16. Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 2004;13(2):149–157. [DOI] [PubMed] [Google Scholar]
- 17. Spurgeon D. Standard of care by doctors may drop with years spent in practice. BMJ. 2005;330(7488):384. [Google Scholar]
- 18. Boeding JRE, Elferink MAG, Tanis PJ, de Wilt JHW, Gobardhan PD, Verhoef C, et al. Surgical treatment and overall survival in patients with right‐sided obstructing colon cancer‐a nationwide retrospective cohort study. Int J Color Dis. 2023;38(1):248. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Mäder M, Kalt F, Schneider M, Kron P, Ramser M, Lopez‐Lopez V, et al. Self‐expandable metallic stent as bridge to surgery vs. emergency resection in obstructive right‐sided colon cancer: a systematic review and meta‐analysis. Langenbeck's Arch Surg. 2023;408(1):265. [DOI] [PubMed] [Google Scholar]
- 20. Amelung FJ, de Beaufort HW, Siersema PD, Verheijen PM, Consten EC. Emergency resection versus bridge to surgery with stenting in patients with acute right‐sided colonic obstruction: a systematic review focusing on mortality and morbidity rates. Int J Color Dis. 2015;30(9):1147–1155. [DOI] [PubMed] [Google Scholar]
- 21. Kim DH, Lee HH. Colon stenting as a bridge to surgery in obstructive colorectal cancer management. Clin Endosc. 2024;57(4):424–433. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Veld JV, Kumcu A, Amelung FJ, Borstlap WAA, Consten ECJ, Dekker JWT, et al. Time interval between self‐expandable metal stent placement or creation of a decompressing stoma and elective resection of left‐sided obstructive colon cancer. Endoscopy. 2021;53(9):905–913. [DOI] [PubMed] [Google Scholar]
- 23. Abdussamet Bozkurt M, Gonenc M, Kapan S, Kocatasş A, Temizgönül B, Alis H. Colonic stent as bridge to surgery in patients with obstructive left‐sided colon cancer. JSLS. 2014;18(4):e2014.00161. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Broholm M, Kobborg M, Frostberg E, Jeppesen M, Gögenür I. Delay of surgery after stent placement for resectable malignant colorectal obstruction is associated with higher risk of recurrence. Int J Color Dis. 2017;32(4):513–516. [DOI] [PubMed] [Google Scholar]
- 25. de Roos MAJ, Hugen N, Hazebroek EJ, Spillenaar Bilgen EJ. Delayed surgical resection of primary left‐sided obstructing colon cancer is associated with improved short‐ and long‐term outcomes. J Surg Oncol. 2021;124(7):1146–1153. [DOI] [PubMed] [Google Scholar]
- 26. Lee GJ, Kim HJ, Baek J‐H, Lee W‐S, Kwon KA. Comparison of short‐term outcomes after elective surgery following endoscopic stent insertion and emergency surgery for obstructive colorectal cancer. Int J Surg. 2013;11(6):442–446. [DOI] [PubMed] [Google Scholar]
- 27. Matsuda A, Miyashita M, Matsumoto S, Sakurazawa N, Kawano Y, Yamada T, et al. Optimal interval from placement of a self‐expandable metallic stent to surgery in patients with malignant large bowel obstruction: a preliminary study. Surg Laparosc Endosc Percutan Tech. 2018;28(4):239–244. [DOI] [PubMed] [Google Scholar]
- 28. Oh H‐H, Hong J‐Y, Kim D‐H, Myung D‐S, Cho S‐B, Lee W‐S, et al. Differences in clinical outcomes according to the time interval between the bridge to surgery stenting and surgery for left‐sided malignant colorectal obstruction. World J Surg Oncol. 2022;20(1):178. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Suzuki Y, Moritani K, Seo Y, Takahashi T. Comparison of decompression tubes with metallic stents for the management of right‐sided malignant colonic obstruction. World J Gastroenterol. 2019;25(16):1975–1985. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
File S1.
Figure S1.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.