In the past couple of months I have operated six patients (five in July) for complete colon obstruction due to cancer. It is an unusual number for me which prompts some reflections and sharing experiences.
Their age ranged from 45 years to 94 years. Three cancers were in the right colon and three sigmoid. Three cancers were local and three had spread beyond surgical cure. All patients survived the operation, none was reoperated or spent time in the ICU. All went home in regular time without any particular complication. Also this is a bit besides usual experiences.
The tumors on the right side were resected with primary anastomosis. One tumour on the left side (the 94 yo lady) had multiple metastases in the omentum and a primary at the rectosigmoid junction engaging the ovary and uterus, and beginning necrosis of caecum. I took out the entire colon, omentum, and ovary, and closed the rectum and fashioned an ileostomy. The other two had sigmoid resections with primary anastomosis on unprepared colon.
I use the linear Ethicon TLC 55 with intestinal cartridges (blue) and vascular cartridges (white) for these resections. The anastomosis is completely fashioned with the stapler on the right side while a circular stapler is used on the left side most of the time. There is not a single ligature and not a suture used for the entire intraabdominal operation. For those of you who are not used to these staplers – they are a pure marvel that increase precision and speed up the operation fantastic. Blood loss can be kept at 50 or 100 ml. It becomes possible to resect ( and I mean a cancer resection) and anastomose in ten to fifteen minutes. The larger part of the operation is spent on open and close, lateral mobilisation of peritoneal reflections, and evacuation of the small bowel (yes, not the large bowel).
A few reflections:
The distension of the small bowel in those with incompetent ileocaecal valve is a problem. Patients get sicker if the small bowel is distended, and they remain sicker after the operation. I therefore evacuate the small bowel, through the staple line in right resections and through enterotomies with tumours on the left side. I have probably never experienced a problem with these enterotomies on the small bowel, and I use them for SBOs as well. I use an ordinary nasogastric tube for the evacuation. I believe it is important to handle the bowel with light hands, very light indeed, not to cause more injury to the bowel than you attempt to relieve by the evacuation.
I frequently evacuate the right colon through a caecal enterotomy in left obstructions. It cannot be done very complete but there remains no pressure inside the colon. I evacuate the left colon through the staple line in sigmoid tumours, and again not very complete.
I do not think I have used on-table large bowel lavage in the last ten years. I did not like it.
For tumors from right to, and including, the descendens I do subtotal colectomy because most patients will do well with an ileo-sigmoid anastomosis. In patients with sigmoid tumours, or rectosigmoid, I do local resection with colorectal anastomosis or a Hartman closure and sigmoidostomy. I never oversew the staple line in the rectal stump. If you do the reversal of the Hartman will be difficult. Rely on the stapler, they were made with greater precision than surgeons.
What are the aims with the operation?
The pathomechanism is obstruction. The first aim is to decompress, both small bowel and colon. Second, it is a cancer disease. Always remove the cancer with a perfect cancer operation. The tumour may be incurable but remain true to cancer surgery for the local process. It is usually the easiest. Third, restore continuity. This comes only third. Most of the time it is the best solution but do not go for it if there is a problem doing it. On-table bowel lavage is a problem: too cumbersome, sloppy, and time consuming. For many a patient a good sigmoidostomy is a good solution. Do not hesitate if you think a good sigmoidostomy is better than a bad anastomosis. Having said that, I do primary anastomosis on unprepared but decompressed colon.
I never use protective ostomy which I think is a complete misconception. It protects nothing but fools the surgeon and the nurses in the ward. I have seen one patient die from it this year. Do a Hartman instead. There are a few patients after right resection where you may be uncertain about the anastomosis. Then do a combined ileo-colostomy. It is an ileostomy but a small opening in the colon; it looks lika a loop-ileostomy and is as easily closed.
I am sorry if I sounded like a school master. There is one correction to the above. I suture the enterotomies for decompression (with Maxon single layer), and a purse string suture for the circular stapler.