Surgical Management of Malignant Colonic Obstruction

Dennis CK Ng

North District Hospital

21-1-2006

Joint Hospital Surgical Grand Round

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

Incidence

Malignant Colonic Obstruction

• 8-29% of colorectal cancer presented as

obstructionOhman 1982, Philips RK 1985

Serpell JW 1989, Setti Carraro 2001

• Most are elderly patientGerber et al 1962, Anderson 1992

Location

Phillips RK 1985

Rovito PF 1990

Sjodahl R 1992

• 12-19% will have a perforation at presentationUmpleby HC 1984, Runkel NS 1991

Diagnosis

Management

• Depends on location of tumor

• Operation remains the main stay of treatment

Right Side Obstruction

• Right hemicolectomy– Primary anastomosis– Exteriorisation of both ends

• Ileotransverse bypass

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

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%

Left Side Obstruction

Three Stage (1950s, 1960s)

Two Stage (1970s, 1980s, 1990s)

One Stage (1980s, 1990s)

Three Stage

1. Defunctioning colostomy

2. Resection of tumor

3. Closure of colostomy

Three Stage

• Advantage– Short first operation– Frail patient– Defunctioning stoma

as protection of anastomosis

• Disadvantage– Multiple operations– Decreased long term

survival when compared with primary resection

– Mortality 20%

Irvin TT 1977, Carson SN 1977

Two Stage

1. Primary tumor resection + Stoma

2. Closure of stoma

Two Stage

• Still popular in most centers

• Mortality 10%Umpleby 1984, Gandrup P 1992

• Shorter hospital stay than 3 stageAmbrosetti P 1989

• Problems– Second operation may be difficult– Some will have permanent stoma

One Stage

Resection of tumor

+ Primary anastomosis

One Stage

• Avoidance of stoma• Mortality 10%

Koruth NM 1985

Murray JJ 1991

Deans GT 1994

• Anastomotic leak 4%Konishi F 1988

• Longer operation

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

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

De Salvo et al 2005

Inconclusive

Segmental Resection vs Subtotal Colectomy

• 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

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: 1622-7

SCOTIA group 1995

Patients

• 91 patients from 12 centers• 47 subtotal colectomy• 44 on-table irrigation & segmental colectomy

SCOTIA group 1995

Complications

SCOTIA group 1995

Stoma Rate

SCOTIA group 1995

Bowel Motion Disturbance

SCOTIA group 1995

Bowel Motion Disturbance

SCOTIA group 1995

Number of Bowel Opening

SCOTIA group 1995

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

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

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

Colonic Stenting

• Self expanding metallic stent

• Radiologically or endoscopically placed

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

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

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

Conclusion

• Enables elective colectomy with primary anastomosis

• Less stoma rates• Shorter hospital stay• Less ICU care• More cost effective

• Need RCTs

Summary

• No conclusive evidence which is the bests• Depends on patients condition, bowel viability,

degree of contamination, experience of surgeon

Right Side Obstruction Left Side Obstruction

Right hemicolectomy Three Stage

Two Stage

One Stage

Colonic Stent + Surgery

Thank you

Laser Ablation

• Kiefhaber P 1986– 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%