C in palliation SEMS + surgery vs. surgery Total of studies RCT 1 [9] 0 1 [25] 1 [29] 3 [36–38] 1 [52] 9 PNRS/OS 1 [10] 6 [5, 6, 12–14, 23] 1 [26] 3 [30–32] 0 3 [50, 53, 54] 14 CSR 1 [11] 0 0 0 0 0 1 SR 0 0 0 1 [34] 4 [43–46] 0 5 MA 0 0 0 0 0 1 [55] 1 Cost analysis 0 0 0 0 0 5 [36, 58–61] 5 [references] All the participants at APR-246 consensus conference agree that the literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A. To help in decision making the authors wish to suggest surgeons to consider 3 further key points approaching OLCC: patient stratification according to the ACPGBI

rules; clinical environment; surgeon skill. The target as usual is to offer the best option for the patient; starting from this point of view also historical surgical option could still play a valid role. The staged procedure, with preference to the two stages, should be reserved when multimodality therapy is expected or in case of “”dramatic”" scenarios. PRA with manual decompression is a safe option and appears to be associated with best outcomes. HP might still have a role in patients at high risk for anastomotic dehiscence. TC is an appealing

option in case of synchronous polyps or CP673451 cancer and/or impending or actual perforation of the right colon. SEMS represent a valuable option both for palliation and as a bridge to elective surgery. Obviously high clinical and technical expertise is mandatory to safely and successfully treat colonic obstruction by stents: due to this consideration routine use in practice is still limited. However we strongly support a judicious application of the procedure and encourage increased

use of stents after adequate training in referral hospitals with a goal of further testing this modality. Acknowledgements The Authors would like thank Marco Valerio Melis, MD for his help in reviewing the manuscript No financial support was required and the job has been done on a voluntary basis References 1. Phillips RK, Hittinger R, Fry JS, Fielding LP: Malignant large bowel obstruction. Br J Surg Parvulin 1985, 72:296–302.CrossRefPubMed 2. Mella J, Biffin A, Radcliffe AG, Stamatakis JD, Steele RJC: Population-based audit of colorectal cancer management in two UK learn more health regions. Br J Surg 1997, 84:1731–1736.CrossRefPubMed 3. Serpell JW, McDermott FT, Katrivessis H, Hughes ESR: Obstructing carcinomas of the colon. Br J Surg 1989, 76:965–969.CrossRefPubMed 4. Umpleby HC, Williamson RCN: Survival in acute obstructing colorectal carcinoma. Dis Colon Rectum 1984, 27:299–304.CrossRefPubMed 5. Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD: The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg 2004, 204:76–81.CrossRef 6.