1. Surgical Management of Malignant Colonic Obstruction
Joint Hospital Surgical Grand Round
Surgical Management of Malignant Colonic Obstruction
Dennis CK Ng
North District Hospital

2. Introduction Colorectal cancer is common in HK 3519 new cases in 2002
1965 males, 1554 females
M:F = 1.3 to 1
Department of Health, HKSAR 2003

3. Incidence

4. Malignant Colonic Obstruction
8-29% of colorectal cancer presented as obstruction
Ohman 1982, Philips RK 1985
Serpell JW 1989, Setti Carraro 2001
Most are elderly patient
Gerber et al 1962, Anderson 1992

5. Location 12-19% will have a perforation at presentation
Phillips RK 1985
Rovito PF 1990
Sjodahl R 1992
12-19% will have a perforation at presentation
Umpleby HC 1984, Runkel NS 1991

6. Diagnosis

7. Management Depends on location of tumor
Operation remains the main stay of treatment

8. Right Side Obstruction
Right hemicolectomy
Primary anastomosis
Exteriorisation of both ends
Ileotransverse bypass

9. How to Choose?
Emergency right hemicolectomy with primary anastomosis in obstructing tumor
Widely accepted approach in most patient
Irvin 1977, Fielding 1979
Phillips 1985, Runkel 1991, Carty 1992
Exteriorization of both end in less favourable condition
Rarely, bypass only in unresectable locally advanced disease

10. Emergency Right Hemicolectomy
Emergency right hemicolectomy with primary anastomosis in obstructing tumor
Mortality 17%
Anastomosis leak 10%
6% in elective right hemicolectomy
Dudley H 1987
HA COC Surgery 2005
Review on emergency colectomy in 14 HA Hospital
Emergency R hemicolectomy leakage rate ~10-15%

11. Left Side Obstruction Three Stage (1950s, 1960s)
Two Stage (1970s, 1980s, 1990s)
One Stage (1980s, 1990s)

12. Three Stage Defunctioning colostomy Resection of tumor
Closure of colostomy

13. Three Stage Disadvantage Advantage Multiple operations
Decreased long term survival when compared with primary resection
Mortality 20%
Advantage
Short first operation
Frail patient
Defunctioning stoma as protection of anastomosis
Irvin TT 1977, Carson SN 1977

14. Two Stage
Primary tumor resection + Stoma
Closure of stoma

15. Two Stage Still popular in most centers Mortality 10%
Umpleby 1984, Gandrup P 1992
Shorter hospital stay than 3 stage
Ambrosetti P 1989
Problems
Second operation may be difficult
Some will have permanent stoma

16. One Stage
Resection of tumor
+ Primary anastomosis

17. One Stage Avoidance of stoma Mortality 10% Anastomotic leak 4%
Koruth NM 1985
Murray JJ 1991
Deans GT 1994
Anastomotic leak 4%
Konishi F 1988
Longer operation

18. Two Stage vs One Stage “Meta-analysis”
Cochrane Database of Systemic Review
Curative Surgery for Obstruction from Primary Left Colorectal Carcinoma: Primary or Staged Resection
De Salvo et al 2005
Only 1 RCT in literature – poor quality
1 prospective and 3 retrospective case series

19. Conclusion Meta-analysis not performed as only one poor quality RCT
Not possible to draw conclusion from limited number of studies
Need large scale RCT
Inconclusive
De Salvo et al 2005

20. Segmental Resection vs Subtotal Colectomy
Removing synchronous tumors
Reduced metachronous tumors in proximal colon
Increased frequency of post-op diarrhoea
Carty NJ 1993, Hughes ESR 1985, Golighter JC 1975
On-table irrigation with segmental resection
Less disturbance on bowel motion
Time consuming
Complex procedure
Deans GT 1994, Carty NJ 1993, MacKenzie S 1992, Tan SG 1991

21. SCOTIA 1995
Single stage treatment for malignant left-sided colonic obstruction: a prospective randomized clinical trial comparing subtotal colectomy with segmental resection following intraoperative irrigation
British Journal of Surgery 1995; 82:
SCOTIA group 1995

22. Patients 91 patients from 12 centers 47 subtotal colectomy
44 on-table irrigation & segmental colectomy
SCOTIA group 1995

23. Complications
SCOTIA group 1995

24. Stoma Rate
SCOTIA group 1995

25. Bowel Motion Disturbance
SCOTIA group 1995

26. Bowel Motion Disturbance
SCOTIA group 1995

27. Number of Bowel Opening
SCOTIA group 1995

28. Conclusion
No significant difference in operative mortality, hospital stay, anastomosis leakage or wound sepsis
Significantly higher permanent stoma rate in subtotal colectomy group
Significantly more bowel motions in subtotal colectomy group
SCOTIA group 1995

29. Recommendation
Segmental resection following intra-operative irrigation was the preferred treatment for left sided malignant colonic obstruction
Subtotal colectomy for patients with perforated caecum or synchronous neoplasm in proximal colon
SCOTIA group 1995

30. Colonic Stenting “Bridge” to surgery
Mechanical bowel preparation available
Change emergency colectomy to semi-elective operation
Better optimization (hydration, electrolytes, nutrition) before operation
Laparoscopic colectomy possible

31. Colonic Stenting Self expanding metallic stent
Radiologically or endoscopically placed

32. Case Series Mainar A et al 1999 Large multi-center series
Radiological placement of stents
Successful in 93% (66/71)
1 perforation
65 undergo single stage surgery 8.6 days after stents

33. Stents vs Emergency Surgery
Binkert CA et al 1999
Retrospective study
26 patients (13 in stents + elective surgery, 13 emergency surgery)
Stent successful rate 92% (12/13)
Colostomy: 2 in stent group, 10 in surgery group
28.8% cost saving in stents group

34. Stents vs Emergency Surgery
Martinez-Santos et al 2002
Prospective non-randomized study
Radiologically placed stent
72 patients, 43 stent group, 29 control group
Stent successful rate 95% (41/43)
Primary anastomosis in 84.6% of stent group, 41.4% of surgery group
Hospital stay, ICU care and severe complication lower in stents group

35. Conclusion Enables elective colectomy with primary anastomosis
Less stoma rates
Shorter hospital stay
Less ICU care
More cost effective
Need RCTs

36. Summary Right Side Obstruction Left Side Obstruction
Right hemicolectomy
Three Stage
Two Stage
One Stage
Colonic Stent + Surgery
No conclusive evidence which is the bests
Depends on patients condition, bowel viability, degree of contamination, experience of surgeon

37. Thank you

38. Laser Ablation Kiefhaber P 1986 Mansour EG 1992 Nd-YAG laser
75 patient with obstructing tumor
Sussessful in 57 patient
2 patient had perforation
Post-operative mortality 3.7%
Mansour EG 1992
46 patients, 29 had laser before curative resection
1 laser perforation
Postoperative mortality 3.4%