Management of colonic obstruction
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Colon cancer is one of the most common reasons for colonic obstruction. This presentation focusing on benign as well as malignant diseases with its management. https://drdhavalmangukiya.com/ http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat https://gastrosurgerysurat.blogspot.com/
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Management of colonic obstruction
- 1. Management of Colonic Obstruction Dr Dhaval Mangukiya Dept of GI & HPB Surgery SIDS Hospital & Research Center, Surat
- 2. Causes - Benign Diverticulitis Fecal impaction Hernia Ileus Inflammatory bowel disease Intussusception Pseudo-obstruction Postoperative complication (anastomotic stricture, adhesions) Volvulus
- 3. Causes - Malignant Carcinoid Colorectal adenocarcinoma Gastrointestinal stromal tumor (GIST) Lymphoma Peritoneal carcinomatosis
- 4. Staged Procedure location of the obstructing lesion, condition of the proximal colon, and medical comorbidities of the patient, their life expectancy, goals of care, and presence of proximal perforation 1. Biondo S, Parés D, Kreisler E, et al. Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies. Dis Colon Rectum 2005; 48:2272. 2. De Salvo GL, Gava C, Pucciarelli S, Lise M. Curative surgery for obstruction from primary left colorectal carcinoma: primary or staged resection? Cochrane Database Syst Rev 2004; :CD002101. 3. Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol 2004; 13:149.
- 5. Bowel preparation Not recommend using any type of bowel preparation (preoperative or intraoperative) The absence of mechanical bowel preparation is not a contraindication to primary anastomosis Jiménez Fuertes M, Costa Navarro D. Resection and primary anastomosis without diverting ileostomy for left colon emergencies: is it a safe procedure? World J Surg 2012; 36:1148.
- 6. Bowel preparation Intraoperative colonic lavage (combined antegrade/retrograde technique has been used by some surgeons for hemodynamically stable patients but is generally not necessary Dudley HA, Racliffe AG, McGeehan D. Intraoperative irrigation of the colon to permit primary anastomosis. Br J Surg 1980; 67:80.
- 7. Bowel preparation - On Table Lavage Two small randomized studies comparing decompression alone with on-table lavage (OTL) did not show any benefit for OTL 1. Nyam DC, Seow-Choen F, Leong AF, Ho YH. Colonic decompression without on-table irrigation for obstructing left-sided colorectal tumours. Br J Surg 1996; 83:786. 2. Lim JF, Tang CL, Seow-Choen F, Heah SM. Prospective, randomized trial comparing intraoperative colonic irrigation with manual decompression only for obstructed left-sided colorectal cancer. Dis Colon Rectum 2005; 48:205.
- 8. Bowel preparation - On Table Lavage The disadvantages of performing OTL are that it significantly increases operative time (from 25 to 60 minutes in one study) and may increase soilage Accumulating evidence has determined that primary anastomosis without OTL is safe and associated with acceptable morbidity 1. Torralba JA, Robles R, Parrilla P, et al. Subtotal colectomy vs. intraoperative colonic irrigation in the management of obstructed left colon carcinoma. Dis Colon Rectum 1998; 41:18. 2. Nyam DC, Leong AF, Ho YH, Seow-Choen F. Comparison between segmental left and extended right colectomies for obstructing left-sided colonic carcinomas. Dis Colon Rectum 1996; 39:1000. 3. Ortiz H, Biondo S, Ciga MA, et al. Comparative study to determine the need for intraoperative colonic irrigation for primary anastomosis in left-sided colonic emergencies. Colorectal Dis 2009; 11:648.
- 9. Bowel preparation Numerous studies show that successful bowel preparation with combined oral and mechanical bowel preparation prior to elective colorectal resections decreases rates of deep and superficial surgical site infections, anastomotic leaks, and ileus 1. Kiran RP, Murray AC, Chiuzan C, et al. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg 2015; 262:416. 2. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined Mechanical and Oral Antibiotic Bowel Preparation Reduces Incisional Surgical Site Infection and Anastomotic Leak Rates After Elective Colorectal Resection: An Analysis of Colectomy-Targeted ACS NSQIP. Ann Surg 2015; 262:331.
- 10. Procedures to manage colorectal obstruction - One Stage Curative intent – without proximal fecal diversion. Preferred treatment, in practice, this option is usually chosen for patients with longer life expectancy (based on tumor size, age, comorbidities) The anastomotic leak rate is 2.2 to 6.9 percent Deen KI, Madoff RD, Goldberg SM, Rothenberger DA. Surgical management of left colon obstruction: the University of Minnesota experience. J Am Coll Surg 1998; 187:573. Breitenstein S, Rickenbacher A, Berdajs D, et al. Systematic evaluation of surgical strategies for acute malignant left-sided colonic obstruction. Br J Surg 2007; 94:1451.
- 11. Procedures to manage colorectal obstruction - One Stage Palliative intent – decompressed usually using a transverse loop colostomy or endoscopic stenting
- 12. Procedures to manage colorectal obstruction - Two Stage The obstructing lesion is resected and the colon is either reanastomosed with a proximal diverting loop ostomy or brought out as a colostomy. At a second operation, the ostomy is reversed.
- 13. Procedures to manage colorectal obstruction - Three Stage Hartmann's operation involves only proximal diversion to decompress the obstructed colon Second operation involves resecting the obstructing lesion with either a primary anastomosis with proximal diverting ostomy, or end-colostomy. Third operation is then required to restore gastrointestinal continuity, if not already performed, and to reverse the ostomy. In most series, the mortality rate was approximately 10 percent, and the morbidity rate approximately 30 percent
- 14. Segmental resection versus subtotal colectomy When a distal obstructing lesion presents in combination with a more proximal colonic perforation, serosal tearing or ischemic changes from severe colonic distention, or synchronous polyps (found in up to 11 percent) A primary ileocolonic anastomosis is likely appropriate in this situation, but depending on the clinical circumstances, an end ileostomy might be chosen instead Hennekinne-Mucci S, Tuech JJ, Bréhant O, et al. Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma. Int J Colorectal Dis 2006; 21:538.
- 15. Stapled versus sutured anastomosis 2011 Cochrane review of 11 trials (1125 ileocolic anastomoses; 441 stapled, 684 handsewn) reported fewer leaks following stapled anastomosis than handsewn anastomosis (2.5 versus 6.1 percent) Choy PY, Bissett IP, Docherty JG, et al. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2011; :CD004320.
- 16. Stapled versus sutured anastomosis 1. 2015 European Society of Coloproctology collaborating group. The relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit. Colorectal Dis 2017. 2. Gustafsson P, Jestin P, Gunnarsson U, Lindforss U. Higher frequency of anastomotic leakage with stapled compared to hand-sewn ileocolic anastomosis in a large population-based study. World J Surg 2015; 39:1834. 3. Frasson M, Granero-Castro P, Ramos Rodríguez JL, et al. Risk factors for anastomotic leak and postoperative morbidity and mortality after elective right colectomy for cancer: results from a prospective, multicentric study of 1102 patients. Int J Colorectal Dis 2016; 31:105. 4. Nordholm-Carstensen A, Schnack Rasmussen M, Krarup PM. Increased Leak Rates Following Stapled Versus Handsewn Ileocolic Anastomosis in Patients with Right-Sided Colon Cancer: A Nationwide Cohort Study. Dis Colon Rectum 2019; 62:542. 5. Jessen M, Nerstrøm M, Wilbek TE, et al. Risk factors for clinical anastomotic leakage after right hemicolectomy. Int J Colorectal Dis 2016; 31:1619.
- 17. Intraoperative anastomotic perfusion assessment Indocyanine green (ICG) angiography using near-infrared (NIR) imaging has emerged as a new technology that permits real-time assessment of intestinal microvascularization Shen R, Zhang Y, Wang T. Indocyanine Green Fluorescence Angiography and the Incidence of Anastomotic Leak After Colorectal Resection for Colorectal Cancer: A Meta-analysis. Dis Colon Rectum 2018; 61:1228.
- 18. Primary closure versus ostomy Although a primary anastomosis is the preferred goal for patients with perforated or obstructing lesions, it may not be possible if the patient is too sick to undergo a definitive procedure (eg, intraoperative medical instability, generalized peritonitis), in which case a staged approach may be needed if the latter were used.
- 19. Anastomotic Complications Minor bleeding Does not require blood transfusion and/or intervention approximately 50 percent of patients who present initially with minor bleeding will progress to major bleeding and require a blood transfusion Bleeding occurs secondary to inadequate clearance of the mesentery prior to division and/or stapling of the bowel
- 20. Anastomotic Complications Major bleeding Initial management should be conservative Proctoscopy / Endoscopy Surgery
- 21. Anastomotic Complications Dehiscence and leaks Extraperitoneal leak - percutaneous drainage for a low pelvic abscess, proximal fecal diversion Intraperitoneal leak - broad-spectrum antibiotics and bowel rest, image-guided percutaneous drainage of abscesses, temporary fecal diversion and/or drainage, or resection of the anastomosis
- 22. Leak Rates Leak rates for resection and primary anastomosis are low in modern series at approximately 5 percent for either right or left colectomy, which contrasts sharply with historic series that reported anastomotic leak in up to 50 percent of patients 1. Lee YM, Law WL, Chu KW, Poon RT. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left- sided lesions. J Am Coll Surg 2001; 192:719. 2. Hsu TC. Comparison of one-stage resection and anastomosis of acute complete obstruction of left and right colon. Am J Surg 2005; 189:384. 3. Aslar AK, Ozdemir S, Mahmoudi H, Kuzu MA. Analysis of 230 cases of emergent surgery for obstructing colon cancer--lessons learned. J Gastrointest Surg 2011; 15:110.
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- 32. Condition 6
- 33. Thank you
Editor's Notes
- Whether to choose a staged procedure depends upon the location of the obstructing lesion, condition of the proximal colon, and medical comorbidities of the patient, their life expectancy, goals of care, and presence of proximal perforation [74]. For right-sided lesions, there is general consensus that the most appropriate treatment is resection with primary anastomosis as a single-stage procedure [17]. In general, primary resection and immediate anastomosis is also preferred over staged resection for uncomplicated left-sided obstruction [75]. For larger left-sided lesions, primary anastomosis is more controversial.
- Whenever possible, a one-stage curative procedure is the preferred treatment for right or left-sided colon obstruction, whether benign or malignant [89,90]. ● Curative intent – For a one-stage procedure with curative intent, the obstructing lesion and proximal dilated bowel are resected and re-anastomosed during the initial surgery without proximal fecal diversion. Although this approach should be the preferred treatment, in practice, this option is usually chosen for patients with longer life expectancy (based on tumor size, age, comorbidities) and a strong aversion to a stoma [89,90]. The anastomotic leak rate is 2.2 to 6.9 percent [72,86,91]. (See "Overview of the management of primary colon cancer", section on 'Management of localized disease'.) ● Palliative intent – For palliation, the bowel can be decompressed usually using a transverse loop colostomy or endoscopic stenting. Placement of cecostomy tube is an alternative for gastrointestinal decompression, but this option is rarely used because of issues with ongoing care of the tube, which frequently obstructs [5,92]. Nevertheless, for patients with a short life expectancy who are high-risk surgical candidates, cecostomy may still be a reasonable option (right- or left-sided lesions). The procedure is performed using local anesthetic in an interventional suite or operating room using fluoroscopic guidance. For left-sided lesions, colonic stenting is a better option if the lesion is accessible and providing that an appropriately experienced endoscopist is available to perform the procedure.
- In patients able to tolerate the resection, a two-stage procedure is associated with a quicker recovery compared with a three-stage procedure. This option is appropriate if the risk of anastomotic leak (and the attendant morbidity) is judged to be high. Risk factors for anastomotic leak are described in detail elsewhere for colon and rectal anastomoses.
- subtotal colectomy, rather than a segmental resection, should generally be performed when a distal obstructing lesion presents in combination with a more proximal colonic perforation, serosal tearing or ischemic changes from severe colonic distention, or synchronous polyps (found in up to 11 percent)
- 2011 Cochrane review of 11 trials (1125 ileocolic anastomoses; 441 stapled, 684 handsewn) reported fewer leaks following stapled anastomosis than handsewn anastomosis (2.5 versus 6.1 percent; odds ratio 0.48, 95% CI 0.24-0.95) [49]. A subgroup analysis of cancer patients confirmed that there were also fewer leaks with stapled anastomosis (1.3 versus 6.7 percent; odds ratio 0.28, 95% CI 0.10-0.75). ●
- On the contrary, several observational studies from Europe reported more leaks following stapled anastomosis than handsewn anastomosis [50-54]. As an example, the most recent study from Denmark analyzed 1414 patients who underwent colon surgery for right-sided cancer [53]. The leak rates following stapled and handsewn anastomosis were 5.4 and 2.4 percent, respectively. All of these studies were large (involving from 400 to 3400 patients) and contemporary (published between 2015 and 2019); most patients underwent surgery for cancer or Crohn disease. Stapled anastomosis was associated with more leaks with an odds ratio in the range of 1.43 to 2.41. However, these results should be interpreted with caution as the study populations are heterogeneous, and the surgical techniques are not standardized.
- NIR imaging with ICG has been associated with reduced rates of anastomotic complications in observational studies [55-57] (meta-analyzed in [58]), but not randomized trials. In one study, ICG angiography was successful in all 504 patients who underwent mostly colorectal surgery, and resulted in a change in the site of bowel division in 5.8 percent with no subsequent leaks in those patients [59]. The overall leak rate was lower than that of historic controls at the same centers (2.6 versus 5.8 percent), and the improvements were more significant for left-sided resections (2.6 percent with NIR versus 6.9 percent control) and low anterior resections (3 versus 10.7 percent) than for right-sided resections (2.8 percent with NIR versus 2.6 percent control). If its efficacy in reducing anastomotic complication can be confirmed by randomized trials (at least one is under way [60]), ICG angiography using NIR imaging may become a useful tool for assessing perfusion before and after a bowel anastomosis. (https://www.isrctn.com/ISRCTN13334746? (Accessed on August 08, 2018).
- Minor bleeding — Minor bleeding is defined as bleeding that does not require blood transfusion and/or intervention (endoscopic, angiographic, or surgical). It usually ceases within 24 hours. Minor anastomotic bleeding after hand-sewn or stapled anastomoses is common but rarely reported. It is usually manifested by the self-limited passage of dark blood with the patient's first few bowel movements. It is estimated that approximately 50 percent of patients who present initially with minor bleeding will progress to major bleeding and require a blood transfusion [10]. There are no high-quality data from prospective studies that have addressed this issue. It is hypothesized that anastomotic bleeding occurs secondary to inadequate clearance of the mesentery prior to division and/or stapling of the bowel. The risk of bleeding is increased in patients with a bleeding diathesis. Proposed techniques to reduce minor bleeding include [11]: ● Careful inspection of the staple line, especially for side-to-side and functional end-to-end anastomoses. ● Inversion and inspection of the linear staple line prior to closure of the enterotomy through which a stapling instrument was passed has been advocated by some experts. ● Suture ligation, as opposed to electrocauterization, of significantly bleeding points. ● Utilization of the antimesenteric borders of each limb to construct the anastomosis, thereby avoiding inclusion of the mesentery into the staple line. ● Reinforcement of the anastomosis with an absorbable suture is an option used by some surgeons.
- The management of an extraperitoneal dehiscence includes percutaneous drainage for a low pelvic abscess that is in continuity with anastomotic leak. For patients with a low pelvic abscess in continuity with the anastomotic leak that is not amenable to percutaneous drainage, an examination under anesthesia with transrectal or trans-anastomotic drainage should be performed. Consideration of proximal fecal diversion is warranted in symptomatic patients. ● Options for management of an intraperitoneal dehiscence include conservative management with broad-spectrum antibiotics and bowel rest, image-guided percutaneous drainage of abscesses, temporary fecal diversion and/or drainage, or resection of the anastomosis. Early operative intervention is warranted for patients with generalized peritonitis and sepsis or patients with a free intraperitoneal leak on radiographic imaging.