Ca of the Sigmoid Colon - Forum

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Marcel

Ca of the Sigmoid Colon - Ärzteforum

Post#1 »

I wish to present the following (non trauma) case that was admitted under
my care from the emergency department some two days ago.

This was a 78 year old man who was sent in with a diagnosis of large bowel
obstruction due a Ca of the Sigmoid. He has had symptoms for only two weeks
- increasing constipation - and on admission had a Hb of 10. A CT scan
showed a large 6cm mass of the mid Sigmoid with no evidence of
lymphadenopathy or hepatic metastases. He had gross distension of the colon
with an apparent very competent ileo caecal valve.

He has a past history of chronic obstructive airways disease, hydrocephalus
(with a shunt), peripheral vascular disease, and a repair of an abdominal
aortic aneurysm ten years ago.

At laparotomy that night, I found that the ca of the Sigmoid was invading
the urinary bladder, and the lower anterior abdominal wall. It was fixed
posteriorly and had invaded an adjacent small bowel loop. The liver was
clear.

I resected a ten cms length of small bowel (after I separated it from the
ca by blunt dissection, therefore causing a "perforation"), and I then
performed a relieving transverse colostomy.

He is now in the Intensive Care Unit and is doing well.

Your thoughts would be appreciated on ongoing management.


User avatar
Surgeon

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#2 »

Clinical features + plain AXR suggested to you the dg of large bowel obstruction. Why the CT scan? did it add anything?

Gemcitabine

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#3 »

In a fit patient I would go for resection of the lesion, with a segment of
bladder and the abdominal wall. Whether the bowel resection should be
Hartmann, sigmoidectomy + anastomosis (with or without 'on table' prep) or
subtotal coleclectomy with ileo-rectal anastomosis is CONTROVERSIAL.

But, any of the above may be "too much" at an emergency procedure in an old
-high risk patient. Doing a diverting colostomy at that stage was an
appropriate choice.

forceps

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#4 »

Recover from the operation
Become anabolic
Maximize physiological status

Re-op: resect lesion en-block with anything involved or adherent to.

User avatar
Resident

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#5 »

I am just curious how was the pathologic diagnosis
made that the patient has cancer of the sigmoid colon? Was that diagnosis
known before your (1st) exploratoty/relieving surgery? What did the
pathology of the resected small bowel show?

I assume that it is really cancer. Probably the patient is being by now
prepared for resection including the attached areas of the bladder and
abdominal wall. You'll probably find now more loops of small bowel stuck to
the sigmoid, but this time the loose fibrinous adhesions can be freed (as
opposed to the situation in the first operation). Finally, depending on the
patient's functional status, you may want to consider any role for adjuvant
therapy.

外科医生

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#6 »

1. I was also of the opinion that a subtotal colectomy and ileo-rectal
anastomosis was generally well tolerated until I did a case in
a 50 yo businesswoman with a mid sigmoid cancer and a large sessile cecal
villous adenoma three years ago whose life has since been pretty much
ruined by diarrhea. I haven't done very many of these so I can't really
have an opinion as to its true frequency other than knowing it is definitely
not zero. Neither I or other consultants have found either an effective
remedy nor identified any factors other than a short large bowel segment
as an etiology.

2. I don't do bariatric surgery so can't be accused of making big
bucks preying on desperate people but as I understand the literature
the following are true:

a. Morbid obesity is truly morbid - people die of being
really fat.
b. While complications are not rare, the modern operations,
principally VBG and gastric bypass should be considered
mature procedures with predictable results and M/M rates.
c. Including perioperative mortality the survival of patients
with bone-fide morbid obesity is improved compared to
unoperated.
d. Social and occupational rehabilitation has been demonstrated
as positive consequences of bariatric procedures.
e. Absolutely NOTHING else works.

3. I have been inspecting all my left sided colonic anastomoses with
video flexible endoscopy for at least 15 years. We had a video camera
that attached to the fiberscopes prior to the modern video equipment.
I was taught at the beginning of the mechanically stapled anastomosis
era that you were obliged to observe staple lines for bleeding so this
is an extension of that philosophy. The visualization is more directed
to demonstrating a non-stenotic anastomosis that is not bleeding than
assisting with leak demonstration. I can't imagine that seeing/looking
is harmful. I don't charge extra. There likely is a marginally increased
hospital bill compared to using a catheter. It is cheaper in my hospital
to use the flexible instrument that a disposible rigid sigmoidoscope.

I blow the anastomotic segment up tight and fix any leaks. Leaks are
actually somewhat common especially if you use a double stapled technique
because there is a tendency for the first closure to get caught in the
EEA application. I can't see any reason to do other than fix what is
a technical problem with as many sutures as it takes to fix it - a take
down and a second anastomosis if that is necessary (it usually seems
not to be). The tissues are fresh, well vascularized and minimally
injured by the staple application that for whatever reason proved less
than sufficient. I suppose some day I will have a very low anastomosis
that I just can't fix but that has not yet happened. The only leak
I have had during this time span was one from a Hartman's closure that
was not examined. Using video usually lets me see the anastomosis
without breaking scrub - my family physician assistants all do flex
sigs. I don't see how we could injure the anastomosis since it is
in my hand during scope insertion.

John Dissector

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#7 »

"D" may be true, proving nothing about the worth of the procedure, of course--
But "c" and "e" are NOT true--you should know better than to ever say ALWAYS
or ABSOLUTELY in medicine--show me one prospective randomized study bearing
out your contention, which of course is the only way you could make the claim
in "c".

User avatar
Surgeon

Re: Ca of the Sigmoid Colon - Ärzteforum

Post#8 »

Well, there are a number of studies that show that at 2 years at most 20%
of obese persons who started on a diet plan, any plan, have maintained
weight reduction. Following gastric bypass, that number is around 80-85%,
and for SRVG or more limitted operations it is around 66%. Although there
are no good RCT's, the differences are so large, that they do form good
evidence that maintaining weight reduction is much better with the
operation than without it.

Several problems are clearly ameliorated by bariatric surgery: Diabetes &
HTN becomes easier to control, or disappear completely. Chronic Joint
disease is better tolerated, and sleep apnea is frequently controlled.

I think that barriatric surgery should be offered to obese patients with
any of the above problems.

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