Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma

Emergency subtotal/total colectomyin the management of obstructed left colon carcinoma

Abdei-Hamid A Ghazal, MD; Magdy A Sorour, MD; Mohamed I Kassem, MD

Department of General Surgery, Alexandria University, Egypt.

Abstract

Background: Subtotal colectomy  with ileosigmoid  or ileorectal anastomosis is one of the standard procedures for obstructed tumors of the left colon. Traditionally, left sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. One of the arguments for subtotal colectomy is that this procedure will remove synchronous proximal neoplasms and reduce the risk of subsequent metachronous  tumor. The purpose of this study was to evaluate the procedure of subtotal colectomy in the management  of acute obstructed  carcinoma of the left colon as a single stage operation.

Methods: From January 2009 to December 2011, this study included 60 consecutive patients who underwent emergency operations for obstructing primary  left colorectal cancers  with ileosigmoid or ileorectal anastomosis according to tumor position.

Results: The site of left colon obstruction was the rectosigmoid in 24 patients (40%), sigmoid colon in 28 patients (46.6%), descending colon in 3 patients (5%), and the splenic flexure in 5 patients (8.3%). The histopathology was Dukes B2 in 15 patients (25%), Dukes C in 25 patients (41.66%), Dukes Din 20 patients  (33.33%). Fifty six patients  (93.33%)  had an obstructing cancer. Four patients (6.66%) had synchronous tumors (caecum in two patients; hepatic flexure in one patient and transverse colon in one patient).

Conclusion: This study has shown that patients who present with left sided colonic obstruction

may be safely  treated  by primary  resection and  anastomosis with satisfactory outcomes.

Key words: Intestinal obstruction,  colorectal cancer, ileosigmoid, ileorectal  anastomosis.

Introduction:

Colorectal cancer (CRC) is the second most common cause of cancer mortality among men and women  in the United  States.lAlthough surgery is the first therapeutic option for CRC under elective conditions, a small percentage ofCRC present as a surgical emergency. Over

15%  of colorectal cancers  present  as acute colonic  perforation or obstruction, despite cancer screening programs and routine endoscopy.2,3 For  patients presenting with colorectal cancer as a surgical emergency, the prognosis  is poorer as compared  to patients presenting under  elective  admissions, with higher morbidity and mortality of up to 15%.4,5

Factors contributing to mortality and morbidity in these  patients are old age, co-morbid conditions, diminished vascularity of obstructed bowel, fecal loading, intraoperative contamination, and technical  difficulties in

handling  the distended  colon, and therefore the treatment of acutely obstructed carcinoma of the left colon  still represents a matter of controversy.6

During recent years, extended right hemicolectomy or subtotal colectomy and ileal­ sigmoid or rectal anastomosis has been applied for the treatment of obstructed  carcinoma of the left colon and recto-sigmoid region. The procedure has the advantage of resolving the problem in one operative stage, while offering a low post-operative  morbidity  as a result of immediate removal of the distended, ischemic and full of virulent content colon.7,8 However, when the obstructed  tumor is located  at the recto-sigmoid junction  and  removal  of the upper rectum is mandatory, a small rectal stump with  reduced capacity usually result in increased daily bowel motions and, possibility of faecal incontinence.8

Traditionally, left  sided acute bowel obstruction is treated  by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a  high  complication rate, with  a mortality rate  of 8.2%  after  an emergency operation.9-t2 Additionally, patients undergoing a one-stage emergency curative operation for obstructing tumors will have a lower survival probability than patients with non-obstructing lesions.t3 In some cases, improved  outcome after emergency surgery for colorectal cancer has been reported.14 Elderly patients undergoing elective surgery have  a more  favorable prognosis than age matched  patients having emergency surgery.ts In evaluating risk factors for patients presenting as surgical emergencies due  to CRC,  emergency patients had more advanced tumors, were older, and were much more likely to be widowed.16 Emergency bowel surgery in the elderly is significantly affected by delayed  admission, nature  and extent  of bowel disease, pre-existing cardiopulmonary disease,  presence of generalized peritonitis, requirement of bowel resection and procedure choice.17

Increasingly, studies have been published advocating the advantages of primary resection with  immediate anastomosis, the potential benefits include shorter hospital stay, reduced mortality and morbidity rates, and avoidance of stoma.18-21One of the arguments for subtotal colectomy is that this procedure will remove synchronous proximal neoplasms and reduce the risk of subsequent metachronous tumor development compared with  segmental resection.22-24

A two-stage procedure, involving segmental resection of obstructed bowel  followed by either Hartmann's closure of the distal stump, or exteriorization of the stump as a mucous fistula with proximal bowel exteriorized as an end stoma, is popular because it is quick, does not risk anastomotic leakage, and is technically less demanding than a single-stage operation. The main disadvantages are that up to 60% of stomas are never reversed, the expense and morbidity of  the  takedown procedure are significant, and patients have to make physical and psychological adjustments  to live with a stoma.25 Primary  resection  and anastomosis with a proximal diverting stoma is an alternative

two-stage  procedure  that may be adopted in high risk anastomosis, on the other hand the classic three-stage operation is usually challenged because  of its  high cumulative mortality and morbidity rates and compromised long  term survival resulting from delay  in resection of the tumor.26,27 This procedure is rarely performed any more except in very poor risk patients.

The purpose of this study was to evaluate the procedures of subtotal  colectomy  in the management of acute obstructed carcinoma of the left  colon  as a single stage  operation.

Methods:

From January 2009 to December 2011, 60 consecutive patients who underwent emergency operations for  obstructing primary left colorectal cancers in  the  Department of Surgery, Alexandria Main University Hospital, were included in this study.These patients had clinical features of acute, or sub-acute intestinal obstruction, and the abdominal x-rays showed dilated colon or small bowel with multiple fluid  levels.  These  patients were  admitted through the Emergency Department and underwent emergency operations. Computed tomography (CT) was done for all patients to evaluate the possible cause, site of obstruction, relation and stage of the tumor. In those patients with colonic cutoff on abdominal x-rays and without  clinical  signs  of peritonitis, lower gastrointestinal endoscopy was performed whenever possible to investigate the site and nature of the obstruction. This was performed without  per-oral  bowel preparation.

After initial fluid resuscitation, correction of electrolyte disturbances, appropriate medical consultations, and optimization of medical conditions; informed  consent was taken and surgery was arranged. Prophylactic antibiotics were given at the time of induction of anesthesia and continued. In fact, during this period, one­ stage  resection and  anastomosis (subtotal colectomy) were  often  used  in this  series because past  experience and  publications favored this  procedure, therefore subtotal colectomy was performed for every  patient regardless  of age or gender except for those patients who were hemodynamically unstable or had general peritonitis.

Laparotomy was most often performed through a midline incision. The site and nature of left colon obstruction was confirmed, and when necessary, obstructed large bowel was decompressed by insertion of a needle attached to a suction apparatus. Gaseous decompression of colon allowed access to the rest of the in1ra­ abdominal organs, which were examined. The choice of resection was determined by the following:synchronous pathology, fecal load, colonic perforation, serosal tears of the cecu.m, and massive cecal distension with ischemia. The presence of these features  in a hemodynamically stable patient without diffuse

(A}

peritonitis strongly favored subtotal colectomy with ileorectal anastomosis.

The colon, after mobilization, was resected

from the terminal ileum down to a mjnimum

distance  of  5  em  distal  to  the  tumor Flgures(l,2). If a portion of the sigmoid colon was preserved for distal anastomosis, the origin of the inferior mesenteric artery would be preserved and the left colic artery would be ligated and divided at its origin. The inferior mesenteric vein was ligated and divided near the duodenum, thereby permitting a generous removal   of  mesenteric  lymph   node.

(B)

(C)

Figure(1): Totalcolectomy for cancersigmoid.

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(A)                                                                               (B)

(C)

Figure(2):Obstructing sigmoid cancer.

Results:

A total of 60 patients were treated surgically for left sided malignant colonic obstruction;

38 (63.33%) were females and 22 (36.67%) were males. Average age was 47.5 (38- 67) years. Absolute constipation was the primary complaint of 56 patients with a median time

from onset of obstructive symptoms to presentation of 8 days (range 12 hours to 2 weeks), 4 patients presented with infrequent passage of flatus.Other presenting symptoms included abdominal colicky pain and distension. All patients had used laxatives to treat their constipation.The site ofleft colon obstruction was the rectosigmoid in 24 patients (40%), sigmoid colon in 28 patients (46.6%), descending colon in 3 patients (5%), and the splenic flexure in 5 patients (8.3%). The histopathology was Dukes B2 in 15 patients (25%), Dukes C in 25 patients (41.66%) and Dukes Din 20 patients (33.33%).

Fifty  six patients (93.33%) had an obstructing cancer. Four patients (6.66%) had synchronous tumors (cecum 2;hepatic flexure

1; transverse colon 1). No patients presented

with peritonitis as a result ofbowel perforation.

All  patients underwent   a  one-stage

procedure with  resection and  primary

anastomosis.Of those who underwent primary resection and anastomosis,52 patients (86.66%) had subtotal colectomy with ileorectal anastmosis, while 8 patients (13.33%) had ileosigm.oid anastomosis. Median time taken to complete operation was 186 minutes (range

120 to 330 minutes).Operative blood loss was estimated at a median of 500 mL (range 100 to 1800 mL). Thirty five patients (58.33%) required blood transfusion of 1 to 3 units.

Forty four patients (73.33%) required fresh

frozen plasma and human albumin transfusion. Median hospital stay for the entire group was

10 days (range 6 to 30 days).

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Three postoperative anastomosis leak occurred (5%), the first one was male (subtotal colectomy with ileorectal  anastomosis) with leak  of intestinal content in the  fifth  post operative day that  failed to close with conservative  management. Ultrasound abdomen revealed intra-abdominal collection that required reoperation, exploration revealed disruption of the lateral angle of the ileorectal anastomosis that was treated by repair with proximal ileostomy. The patient improved well and ileostomy  was closed successfully after three months. The second one was female with ileorectal anastomosis, with  smooth post operative recovery.The patient was discharged from hospital, one month later; she developed fever, tachycardia, with abdominal distension and tenderness over the left iliac and lumbar regions. CT abdomen revealed large cystic localized collection, mostly abscess, ultrasound guided  aspiration with  insertion of pig-tail catheter for drainage was done. Three days later,  intestinal  content  came out instead  of pus and the patient became toxic. Abdominal exploration revealed the presence of the drainage tube in a loop of ileum  about 80 em proximal to the site of anastomosis that showed a minute defect as  well; repair of  the anastomotic defect was done  and the injured loop  was brought  out as an ileostomy. The patient's condition improved and  received adjuvant  therapy for one year. CT abdomen later was done and revealed no recurrence nor metastasis, and  ileostomy was   closed.

The last one was female with ileorectal anastmosis, 40 days  after  discharge from hospital; she developed discharge of intestinal content from the site of left-sided  drain, she was  admitted where  ultrasound abdomen revealed no  collection. Conservative management with correction of albumin level for two weeks was done and she was discharged from hospital totally free.

One mortality (1.66%)  was encountered one year post operatively, as a result of multiple liver  deposits  and   brain  metastasis.

Post operative morbidity were encountered either as a complication of surgery itself in the form of wound infection in 6 patients (10%), or systemic complication in the form ofbasal lung collapse  with pneumonia in 2 patients (3.33%).

Discussion:

Colorectal  cancer presenting  as a surgical emergency can  represent a problem  to all surgeons  involved in management of these patients. Initial assessment  and management of the patient should be focused on the patient as  a whole,  taking into  consideration co­ morbidities, risk factors, physical condition, and stage of disease.28 Emergency surgery for colorectal  cancer is associated  with a longer median hospital stay than for elective cases.29

Physical status at presentation is the principal determinant of  outcome after  emergency admission given the poor  conditions of emergency patients.29 The type of surgical procedure for  colorectal cancer depends primarily on the location of the lesion and the ability of a given patient to tolerate a specific procedure.

Resection with anastomosis is not frequently considered for obstructive lesions of the colon, especially in left colon obstruction. Instead, most patients in this situation are traditionally handled by a diverting stoma or resection with a stoma, which necessitates a second or even a third operation in the future  for bowel continuity to be restored. However, one-stage resection and  anastomosis have  several advantages, including the following: saving of time and reduction in hospital costs; avoidance of the risk of a second operation; elimination of  the waiting period  because of a second operation; avoidance of the trouble and embarrassment resulting from a temporary colostomy; offering  a better  quality of the remaining life  for  patients with  incurable malignancies.30

Subtotal colectomy for colorectal cancers presenting as a surgical emergency  has been described for use in a number ofstudies.31-34

The rationale for use of this procedure is based on the fact that the terminal ileum has a rich blood supply.34 The other rationale  is based on the fact there may be synchronous lesions of colorectal cancer at the time of presentation. In a series  by Arnaud et al there were 6.8% synchronous colorectal cancers at the time of acute presentation.34 Thus, the advantages of this procedure includes the lack of necessity for a colostomy, and that the operation deals with any synchronous tumors and minimizes future  colonic tumors.31,33,34   Subtotal

and ensures restoration of gut continuity. The removal of the right colon is based on the premise that the proximal colon when distended and filled with liquid feces, often has dubious viability and signs of impending variability.34,35

Subtotal colectomy was previously thought to require  the intervention of an experienced surgeon and  this concept has  been reiterated.35,36

One  of the major  functional issues  with subtotal colectomy has been  frequency of bowel movements, which average 2-4 bowel movements per day.32-35 In our study, patients with  subtotal colectomy with  ileorectal anastomosis experienced 3-4 bowel motions per day which was in concordance with this result. After subtotal colectomy with ileosigmoid anastmosis which were done for

8 patients (13.33%),  nearly all patients were able  to  pass  1-2  bowel motion per  day.

Our  data showed no  post-operative mortality, only mortality was encountered  in one patient one year after operation as a result of  metastatic deposits. No  difference in resection rate, anastomtic leak rate (3 patients,

1 major leak, 2 minor leak, one of them was

converted to major leak as a result of injury at the time of insertion of beg tail to drain intra­ abdominal abscess) and morbidity (13.33% in the form of wound infection in 6 patients, and pneumonia in 2 patients) are  encountered between our results and those in literatures. Moreover, operative time, operative blood loss, or length of hospitalization encountered in the literature even after segmental  resection,  or resection for obstructing tumor  in the right side  were  in   concordance  with  our

results.30-37

There were multiple associated procedures during colectomy, but  none  of them  were associated with significant morbidity, so they were not likely to be correlated with mortality. Although albumin levels were  always determined, many operations were performed before data on the albumin level were available. Thus, the decision of whether anastomosis can be performed was not dependent on albumin level. There was no direct correlation between albumin level with complications and mortality. It should  be stressed  that a safe  colorectal

a good blood supply, a tensionless anastomosis, and  meticulous technique, but  it  does  not depend on a well prepared colon. One stage resection and anastomosis is feasible in most patients with acute obstruction of the right and left colon, except in those patients  who are hemodynamically unstable or who have severe peritonitis.38

In conclusion, this study has shown  that patients who present  with left sided colonic obstruction may be safely treated by primary resection  and anastomosis with satisfactory outcomes, more over synchronous lesions of colorectal cancer at the time of presentation, or colonic polyps that present in other sites of the  colon were  removed at the  time  of operation. Factors that likely contribute to these results include adequate resuscitation, correction of  albumin  level,  correction of associated anaemia,  and the presence  of an experienced surgical team with adequate assistance. However, elderly patients require careful preoperative evaluation before surgical intervention  to minimize mortality related to associated disease.

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