Obstructed recto sigmoid malignancy

ObstructedRectoSigmoid
Malignancy

Contents
 Introduction
 Epidemiology
 Complications
 Presentation
 Diagnosis
 Treatment
 Loop colostomy
 Hartmann’s procedure
 Stenting
 Summary

Introduction
 Rectosigmoid carcinoma is the most common malignant
gastrointestinal tumour.
 In 2014
 1.23 million rectosigmoid cancers have been diagnosed worldwide.
 Third most commonly diagnosed cancer.
 Accounting for 8% of all cancer deaths.
 In recent estimates the incidence is declining
 Widely applied screening programs in developed countries.
 Estimated 50% reduction in mortality in further years.
Atsushi I, Mitsuyoshi O, Kazuya Y, et al. Long-term outcomes and prognostic factors of patients with obstructive colorectal cancer: A multicenter retrospective cohort study. World Journal of Gastroenterology.
2016;22(22):5237-5245. doi:10.3748/wjg.v22.i22.5237.

Epidemiology
 Causes if intestinal obstruction
 60% of mechanical bowel obstruction is caused by colorectal tumours.
 20% by diverticulosis.
 5% by a colonic volvulus.
 Despite the significant progress made in the field of screening
for early diagnosis
 ~20% of patients with these tumours present with intestinal
obstruction as the first symptom.
 6% to 26% of patients with colorectal cancer develop
obstruction.
Georgios Papadimitriou, Emergency surgery for obstructing colorectal malignancy: prognostic and risk factors, JBUON 2015; 20(2): 406-412

Pathophysiology
 Genetically, rectosigmoid cancer represents a complex disease.
 Genetic alterations are often associated with progression from
adenoma to invasive adenocarcinoma.
 Early event is a mutation of APC (adenomatous polyposis
gene).
 Other pathophysiological causes include
 Lifestyle
 Obesity, smoking, alcohol.
 Diet
 High red meat and animal fat, low-fiber diets.
 Inflammatory bowel diseases.
Ferrari P, Jenab M, Norat T, Moskal A, Slimani N, Olsen A, et al. Lifetime and baseline alcohol intake and risk of colon and rectal cancers in the European prospective investigation into cancer and nutrition (EPIC). Int J Cancer.
2007 Nov 1. 121(9):2065-72.

Pathophysiology
 Adenocarcinomas are the most likely to cause an obstructive
pattern.
 Tumors in the rectosigmoid area commonly have an annular
growth pattern that is constricting.
 Many times the onset of obstruction may be fecal impaction.
Trompetas V. Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl. 2008 Apr. 90(3):181-6.

Complications
 Intestinal obstruction is an acute surgical condition.
 Majority of complications associated with surgery
 Poor 5-year survival.
 High postoperative mortality rates.
 Complications
 Perforation.
 Peritonitis.
 Sepsis.
 Intra-abdominal abscess.
 Pneumonia from aspiration.
 Electrolyte disturbance.
2016;22(22):5237-5245. doi:10.3748/wjg.v22.i22.5237.

Early
presentation
 The early signs of obstruction are usually present.
 But in developing countries like India patient rarely seeks
medical attention.
 Symptoms and signs
 Abdominal cramps.
 Periodic episodes of rectal bleeding.
 Alterations in bowel habits.
 Nausea, vomiting.
 A history of chronic constipation.
2016;22(22):5237-5245. doi:10.3748/wjg.v22.i22.5237.

Stools
 Changes in the patient's caliber of stools strongly suggest
partial obstruction due to carcinoma.
 The recto sigmoid region can squeeze stool through a 1cm
neoplastic stricture for an astonishing time
 But complete obstruction will inevitably occur, usually by
impact ion of a fecal pellet.
 A palpable mass is rarely felt
 Small and sclerotic nature of the tumor.

History
 Complete history of bowel movements at each visit is
important
 Attempt to distinguish complete bowel obstruction from partial
obstruction.
 Fecal consistency.
 Flatus, obstipation.
 Complete obstruction
 Failure to pass either stool or flatus.
 Partial obstruction
 Patient appears obstipated.
 Continues to pass some gas or stools.
 Presence of some stools in rectal lumen.

Late
presentation
 Obstruction of recto sigmoid region is characterized by a slow
onset of symptoms.
 May not cause vomiting despite a markedly distended bowel.
 Vomiting signifies a late stage of obstruction.
 Fistulization of the sigmoid colon to the bladder occurs in late
stage
 Pneumaturia.
 Mucinuria.
 Fecaluria.
 Diminished bowel sounds are seen.

Diagnosis
 Considering the morbidity and mortality associated with
obstruction, approach should be
 Rapid evaluation and prompt surgical intervention.
 Diagnosis should proceed along side the treatment
 Relief of pain.
 Control of vomiting.
 Correction of fluid and electrolyte abnormalities.
 Laboratory studies used to assess
 Degree of dehydration and electrolyte imbalance.
 Evaluate for infection, anemia, and ischemia.
2016;22(22):5237-5245. doi:10.3748/wjg.v22.i22.5237.

Imaging
 Plain radiographs
 Although at times helpful in the evaluation, it is better they are
avoided.
 Contrast radiographs
 Contrast studies include an enema with water-soluble contrast.
 Reveal the site of obstruction.
 Computed tomography
 Imaging of choice if a colonic obstruction is clinically suspected.
 Confirm the diagnosis and helps identify the cause.
 Contrast-enhancedCT (PO and IV) can help to delineate between
partial and complete obstruction.
Jaffe T, Thompson WM. Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology. 2015 Jun. 275(3):651-63.

Contrast
enema
Jaffe T, Thompson WM. Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology. 2015 Jun. 275(3):651-63.

Screening
 Implementation of effective screening procedure is the best
preventive measure for obstructed recto sigmoid malignancy.
 Diagnosis and treatment at a early stage will prevent the
complications.

Management
 Volume resuscitation and nasogastric tube
 Patients with severe vomiting (rarely seen in obstructed recto sigmoid
malignancy).
 Adjuvant chemotherapy
 Use in stage II disease is controversial.
 Chemotherapy rather than surgery after the decompression of
bowel obstruction.
 Metastatic unobstructed cancer.
 Use in partial obstructed cancer is controversial.
 Surgery is the only curative modality for obstructed recto
sigmoid malignancy.
Xu YS, Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction., J Gastrointest Surg. 2015 Dec;19(12):2243-8.

Surgical
management
 General principles for all colorectal tumor operations include
 Removal of the primary tumor with adequate margins.
 Areas of lymphatic drainage.
 To resolve the clinical condition there are several options
 Loop colostomy and subsequent resection (in two or three stages).
 Resection with end colostomy (Hartmann’s procedure).
 Resection and primary anastomosis.
 Endoscopic dilation and stenting.
Villar JM, Martinez AP, Villegas MT, Muffak K, Mansilla A, Garrote D, Ferron JA. Surgical options for malignant left-sided colonic obstruction. Surg Today. 2005;35:275–281.

Surgical
options
 Loop colostomy and Hartmann’s procedure are the most
commonly performed treatment options.
 Poll conducted by the Society ofAmerican Gastrointestinal and
Endoscopic Surgeons
 Preference of surgeons for obstructed recto sigmoid malignancy
Krstic S, Resanovic V, Alempijevic T, et al. Hartmann’s procedure vs loop colostomy in the treatment of obstructive rectosigmoid cancer. World Journal of Emergency Surgery : WJES. 2014;9:52.
67%
26%
7%
%
Hartmanns
procedure
Loop
colostomy
Other
procedures

Hartmann’s
procedure
 Hartmann’s procedure should be preferred to loop colostomy
(level B recommendation II)
 Society of American Gastrointestinal and Endoscopic Surgeons.
 World Society of Emergency Surgery.
 French Association of Surgery investigation.
 Association of Coloproctology of Great Britain and Ireland.
 All the guidelines prefer Hartmann's procedure to loop
colostomy.
2016;22(22):5237-5245. doi:10.3748/wjg.v22.i22.5237.

Loop
colostomy
 Performed for creation of a temporary stoma to divert stool
away from the area of obstruction.
 Surgery brings a loop of bowel through an incision in the
abdominal wall.
 Loop is held in place outside the abdomen by a plastic rod
slipped beneath it.
 Supporting road is removed seven to ten days after surgery.
 Advantages over end colostomy
 Shorter average hospital stay.
 Less intraoperative blood loss.
 Lower complication rate.
 Advantages in a obstructed co morbid patient.

Loop
colostomy

Hartmann’s
procedure
 Surgical resection of the rectosigmoid colon.
 Closure of the rectal stump.
 Formation of an end colostomy.
 Lesion is removed, the distal bowel closed intraperitoneally and
the proximal bowel diverted with a stoma.

Loop
colostomy vs
hartmann’s
procedure
 There is still a considerable controversy when it comes to
urgent surgical treatment of obstructive recto sigmoid
malignancy.
No difference
observed in
surgical
complication
in both groups

Loop
colostomy vs
hartmann’s
procedure
 The preference of the operation to be performed rests with the
operative surgeon.
 Many studies have concluded the following points
 Hartmann’s procedure
 Better suited to older people (highASA grade)
 Malignancy is removed in the one sitting.
 No need for next reconstructive operation.
 Loop colostomy
 Advised for younger, healthy patients
 Ready for immediate definitive surgery (tumor removal).

Predictors of
outcome
 Four important predictors of outcome
 Age.
 ASA score.
 Need for emergency surgery.
 Dukes classification.
 Age
 Increased age is associated with worst outcome.
Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD, the Association of Coloproctology of Great Britain, Ireland. The Association of Coloproctology of Great Britain and Ireland Study of Large Bowel Obstruction Caused by
Colorectal Cancer. Annals of Surgery. 2004;240(1):76-81. doi:10.1097/01.sla.0000130723.81866.75.
Correlation between age and operative mortality

Predictors of
outcome
 American Society of Anesthesiologists (ASA) grade
 Higher grade is associated with more operative mortality.
Correlation between ASA grade and operative mortality

Predictors of
outcome
 Dukes staging
 D subgroup is associated with higher mortality

Predictors of
outcome
Variation of operative mortality by age, ASA grade and operative urgency.The regression lines have been adjusted for age,
ASA, operative urgency using a 3-level hierarchical logistic regression model. Sc, scheduled procedure; Ur, urgent procedure,
Em, emergency procedure.

Stenting
 Endoscopic dilation and stenting of colonic obstruction.
 Self-expandable metal stents (SEMS).
 Helpful in selected cases and an alternative to multistage
surgery.
 Palliative in a high-risk patient with an unresectable
malignancy.
 May be preparatory to surgical resection
 Procedure permits relief of the acute obstruction.
 Resuscitation of the patient.
 Allows for a mechanical bowel preparation.
Geraghty J, Sarkar S, Cox T, et al. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis. 2014 Jun. 16 (6):476-83.

Stenting
 Many studies have been conducted to assess the effectiveness
of stenting.
 Considerable variation in practice exists
 Due to a lack of expertise, technical difficulties and other, as yet ill-
defined features.
Geraghty J, Sarkar S, Cox T, et al. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis. 2014 Jun. 16 (6):476-83.

Stenting
 Good prognostic factors
 Experienced operators (>10 procedures).
 Endoscopy technique (90.3%) versus use of radiologic placement alone
(74.8%).
 Presence of short, malignant strictures with less angulation distal to the
obstruction.
 Poor prognostic factors
 Older patients with American Society ofAnaesthesiologists (ASA)
grade of 3.
 Presence of extracolonic and benign strictures.
 Increased risk of perforation.
Boyle DJ, Thorn C, Saini A, et al. Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis. Dis Colon Rectum. 2015 Mar. 58 (3):358-62.

 60% of mechanical bowel obstruction is caused by colorectal
tumours.
 Despite the progress made in screening 20% patients present
with intestinal obstruction as the first symptom.
 Pain in abdomen & caliber of stools strongly suggest partial
obstruction.
 Contrast enhanced radiographs and CT is modality of choice.
 Hartmann’s procedure is preferred over loop colostomy.
 Stenting relives the obstruction but depends on the experience
of surgeon.

Obstructed recto sigmoid malignancy

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