Colon obstruction due to cancer
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.
I’m surprised with your excellent results and I congratulate you for them.It’s amazing that 3 out of 6 cases of total obstructive colon cancer were located in the right colon, that means also cecum and ascendent colon? It’s so unusual to see total obstructive lesions in such locations ’cause of anatomical reasons that undoubtedly you perfectly know.
All you’ve done is quite unusual in front of a colon obstructive emergency due to cancer and widespread as you say.I hope survival will be satisfactory though I’m sure your attitude had to do with saving their lifes. excellent results!
What an excellent timing but, using stapplers what means a significant increase in costs sometimes unreachable for our patients here in Chile. A colon cancer resection in 10 to 15 minutes (excluding opening and closure)!.It’s really amazing.Hope you are not making publicity or propaganda to those devices.
In general, and in emergency, we are quite fearful of colon resections in particular when there’s a complete bowel obstruction and no colonic preparation and we prefer to divert transit with any adequate ostomy(we use frequently Hartmann’s operation in the left side) as we are sure that the colon is by no means prepared,clean and aseptic, with great dilation of the proximal segment what means serious compromise of parietal vascularity and eventual permeation of bacterias into the peritoneal cavity and that means a great risk of contamination and septic peritoneal postop. complications.
Again I must ask you if you are not trying to popularize the use of mecanical suture devices.They are precise,mecanic and automatic but that doesn’t mean that by times they fail and leakage may appear and even peritonitis or fistulae can develop.We use them but they are quite expensive so we continue to trust in the surgeon’s hand (that must be able to) and complications are not greater though time required is undoubtedly longer.
You have sounded as a school master but as a very good one so thank you for your summer lessons and accept my comments as modest opinions.Since short time ago I’m trying to be as polite as I can what doesn’t mean that I’ll try always to say what I really think even if I’m mistaken, what is quite human and quite common.Here in Chile,we are in the middle of winter,quite mild fortunately though some rain, which we had been expecting for some years, fell and paliated the damages drought had made during the last years.
I would like to congratulate you for your good outcomes and say that in general I agree with your approach to malignant colon obstruction. Unfortunately, here in Brazil we also have no conditions ($$$) to use liberally the staplers, so the majority of vascular ligatures and anastomoses are still hand-made. And maybe because that, when you say
>Rely on the stapler, they were made with greater precision than surgeons.
I do not agree, staplers can be faster, butare always the same, do always the same thing, and conditions of tissues are not. So I think surgeons are still more precisious then staplers.
We see things from a same perspective as both belonging to countries of subdeveloped condition (much more us than you). Your statement that “machine can’t do better than hand” is particularly applyable to “obstructive colon emergencies” where the findings during the op can be so diverse : bowel full of gas and contents, parietal distension with compromise of vascularity as I said before in a message, bacterial permeation, etc., but, the most important when you must decide if hand or mecanic anast. should be performed is the condition of the bowel wall and,as you say, the hand (with the brain) can perform the more adecuated suture, thing that can’t be accomplished by the stappler and so there can be frequent failures such as leakage,fistulae or dehiscence as described in literature. We don’t choose primary anast. when total obstructive cancer is present and we carry out a resection and an ostomy leaving transit reconstruction to a second time.
I see your point and it is well taken. However, I am a stapler fan regarding them as one of the few major advances in the handicraft of surgery in recent years. And staplers are not that new, the first being made just after the turn of this century. Like all new technology it takes time to get the necessary experience. The big difference is with emergency surgery but to master the technique one must practice on elective cases. Laparoscopic surgery made it quicker at higher price and possibly at lesser benefit than staplers for open surgery.
There will be a lot more time for the operation, mobilising the peritoneal reflections I mentioned, and for evacuation of the bowel. But, once you are ready to resect the staplers very quickly accomplish transection of bowel, mesentery, and fashion an anastomosis. And I never re-enforce a stapled anastomosis with sutures, and I never close the mesentery which saves time and makes the operation simpler.
Staplers help turning emergency resection into a much cleaner operation than it would be with open techniques. It is one reason to use them, apart from the greater precision afforded. It is not so common that the bowel is distended with faeces but most often it is gas and simple to decompress. However I fully agree with you that if there is uncertainty do a Hartmann.
Septic complications is something about which I wish I had better understanding. My general understanding is that minor contamination is of no consequence unless there is blood or damaged tissue left. I do not believe that a decompressed colon translocate to any significance. And thinking about it most patients with obstruction has had it for hours or even days without showing signs of infection. So I am more inclined to believe that it is the surgery that is the risk.
You also asked how frequent obstructions are on the right side. I would say probably one third of the cases have obstruction in the right colon. But they are often not reported because the main problem is with tumours obstructing the left side. However I am not so sure about that. The reason is that I seem to see a correlation between the distension of the small bowel and the patient’s condition and course. A distended colon does not seem to cause as much illness in the patient.
I operated on 2 very old (91 with senile dementia) and 86 ladies with obstructing mid right colon cancers (which is a little unusual, since as Per-Olof and others mentioned, right colon cancers usually do not obstruct).
I did right hemicolectomies with hand-sewn anastomoses and placed combined feeding jejunostomy decompressive gastrostomy tubes. Both did well.
I also had a fascinating case: 76 year old female smoker post abdominal aortic aneurysmorrhaphy and coronary artery bypass graft and extremely stubborn (which is why some of the history came out after surgery instead of before) came to ER after 3 week trip to San Antonio and return via Sioux Falls SD (all places with fine medical care) having adamantly refused to see a doctor. She walked in alert and oriented with a blood pressure of 50, blood urea nitrogen of 212 and creatinine of 9.4. She related a little bright red blood in her stool and diarrhea, with some suggestion of upper gastrointestinal bleeding (I think she vomited a little old blood but I have forgotten that part of her story) (which to her internist explained the blood urea nitrogen and creatinine). The internist rapidly infused 3 liters crystalloid, just barely getting her blood pressure over 90 (she as most elderly smoking vascular patients was on multiple anti-hypertensives, so hypotension was quite unusual for her).
He consulted me and I decided to do upper GI endoscopy and colonoscopy. On upper GI endoscopy, I found diffuse gastritis and old blood. I started colonoscopy, but could not get above 20 cm and her abdomen immediately blew up, became hard and she started moaning with pain. At this point, I thought I must have perforated her, even though, perforating at 20 cm without undue force would be odd.
I rushed her to surgery, where the anesthetist gave her another 8 liters crystalloid plus 3 Units blood in a short time (under 3 hours). Every time he turned on any anesthetic, her blood pressure plummeted to 50–60 systolic. When he turned the anesthetic off, her pressure returned to just above 90.
I found a cecal volvulus down in the left lower abdomen/left pelvis with appendicitis (white cells in the lumen) most likely due to obstruction. The cecal volvulus was probably also due to obstruction. She had a tight fixed stricture of the sigmoid with microperforations and abscesses.
I did a right hemicolectomy plus Hartmann’s procedure. I hand sewed a right colon anastomosis.
Post-op, her blood urea nitrogen and creatinine rapidly returned to normal. She did require a few more liters of crystalloid in the first 24 hours because of hypotension.
Surprisingly, she did quite well post-op.
I found out the following after surgery:
She had been sick since December.
She came to ER in Feb with diarrhea and signed out against medical advice after giving them stool specimens.
She could not eat without her abdomen blowing up (marked distention).
Feeding jejunostomy -what for? Did you resect his mouth or removed his stomach as well?
Decompressive gastrostomy-what for? Decompress what and why?
The less unnecessary tubes one places the better.
You mention that the “cecal volvulus” or what you thought to be one was due to the left colon obtruction. Be it as it may the options would have been as following:
1. In the absence of vascular compromise of the cecum you could just resect the left lesion and decompress the cecum -adding a few sutures for cecopexy.
2. Otherwise a subtotal colectomy would have been a “better” option. In a stabe/well nurished patient I would have continued with a ileo-rectal anastomosis.
Your patient had 2 anastomoses (the ileotransverse and Hartmann pouch) and a colostomy; he could have instead only 1 anastomosis without a colostomy.
He probably will agree with me that a Hartmann for an obstructing lesion is slowsly becoming a thing of the past.