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 Table of Contents  
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 35-39

Curative management of malignant left-sided colorectal obstruction

1 Department of General Surgery, Colorectal Unit, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
2 Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
3 Department of General Surgery, Colorectal Unit, The Alfred Hospital, Monash University; Division of Cancer Surgery, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia

Date of Web Publication27-Jun-2019

Correspondence Address:
Dr. Wen-Shen Lee
Department of General Surgery, Colorectal Unit, The Alfred Hospital, Monash University, 55 Commercial Road, Melbourne, Victoria 3004
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/WJCS.WJCS_44_18

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Left-sided malignant colonic obstruction remains a challenging surgical problem despite recent advances. We aim to provide a concise overview of the relevant surgical options for this condition in the curative setting. A literature search of MedLine, PubMed, and Embase was performed to elucidate the latest evidence in the management of malignant left-sided colorectal obstruction, focusing on the risks and benefits of each approach and the appropriate patient selection. Primary resection and anastomosis are the intervention of choice for low-risk patients in the curative setting. Delayed resection with a bridge to surgery should be considered in unwell patients requiring medical optimization. While stenting has gained popularity, the risk of stent perforation carries a poor prognosis and must be carefully considered. Hartmann's procedure should be considered in high-risk elderly patients. Subtotal colectomy is preferred over segmental colectomy when there is extensive proximal colon damage but results in more frequent bowel actions postoperatively.

Keywords: Colectomy, colorectal neoplasms, colostomy, intestinal obstruction, stents

How to cite this article:
Lee WS, Kong JC, Carne P, Bell S, Warrier SK. Curative management of malignant left-sided colorectal obstruction. World J Colorectal Surg 2019;8:35-9

How to cite this URL:
Lee WS, Kong JC, Carne P, Bell S, Warrier SK. Curative management of malignant left-sided colorectal obstruction. World J Colorectal Surg [serial online] 2019 [cited 2021 Aug 2];8:35-9. Available from: https://www.wjcs.us.com/text.asp?2019/8/2/35/261547

  Introduction Top

Colorectal cancer is the second most common cancer diagnosed in Australia, with an estimated 16,500 new cases per year, constituting 12.4% of all new cancer diagnoses. It is also the leading cause of cancer-related death,[1] and can be anatomically defined as cancer in the colon or rectum. Left-sided cancers are defined as those located between the splenic flexure and upper third of the rectum. Due to the smaller caliber of the bowel lumen on the left side of the colon, cancers in this region are more likely to cause bowel obstruction,[2],[3] with the splenic flexure being the most common site of the occlusion.[4],[5]

Left-sided tumors represent 60%–80% of all colorectal cancers.[6],[7],[8] Malignant large bowel obstruction is a well-recognized complication, with rates as high as 33% reported in the literature.[5],[9] It carries a significant postoperative mortality risk in the order of 25%–40%,[2] as opposed to elective surgery with an estimated risk between 2% and 5%.[10],[11] These tumors are often diagnosed at a late stage, with a higher incidence of lymphatic and distant metastases, and a poorer prognosis compared to patients with nonobstructing cancers.[2],[4],[12],[13] Due to the significant mortality and morbidity associated with obstructive colorectal cancer, the focus of this systematic review is to present the current evidence on the management of left-sided malignant bowel obstruction in the patient with curative goals of therapy.

  Materials and Methods Top

A search for medical literature was conducted on MedLine, PubMed, and Embase using the following keywords: “colorectal neoplasms” and “obstruction.” Text terms, including “stents,” “colonic irrigation,” “Hartmann's procedure,” “colostomy” and “anastomosis,” were also used in combination to investigate the respective topics. All suitable articles were fully analyzed and their appropriate reference sources were reviewed similarly, to ensure that discussion revolved primarily around the curative management of left-sided colonic and upper rectal disease and that separate conclusions were drawn if there was discussion about right-sided colonic cancer, or if the study involved palliative patients. There was no language restriction. Our discussion also involves some guidelines and conclusions from professional associations and reviews. The final date of the literature search was June 20, 2018.

  Discussion Top

The traditional teaching for the emergent management of left-sided malignant colonic obstruction has been the use of a two-or three-stage surgical approach, involving either a Hartmann's procedure or a diverting colostomy performed in the emergent setting and restoration of bowel continuity done at a later date. However, primary resection and anastomosis(PRA) have become a popular approach, with some authors recommending it as the approach of choice in certain patients.[14],[15],[16] The use of stents as a bridge to surgery has gained popularity in recent years but remains a controversial topic that we will discuss.[17],[18],[19] The palliative treatment of obstructing cancers differs from the curative approach and will not be covered in this review. Therefore, patients should be appropriately staged with computerized tomography at admission to evaluate for metastatic disease, with extensive multidisciplinary involvement to determine the goals of care. The therapeutic approach to patients with perforation resulting from obstruction will also not be discussed.

Segmental versus total or subtotal colectomy

The extent of surgical resection for left-sided colonic obstruction is an important consideration and depends on the location of the tumor. Surgical options include the left hemicolectomy, subtotal colectomy, and anterior resection. The surgical conundrum lies with true splenic flexure cancers, and the decision on the type of resection would depend on patient factors such as age, comorbidities, and long-term prognosis.

A subtotal colectomy involves extensive removal of colonic length but does attain several advantages. These include the removal of the poor quality proximal colon from dilatation and ischemia, a lower frequency of wound contamination and anastomotic leakage, while maintaining an adequate oncologic resection margin including the entire draining lymph node basin with a shorter operative duration.[20] While a subtotal colectomy confers no difference in mortality and morbidity, it does, however, cause adverse functional outcomes, with patients complaining of increased daily bowel movements.[21],[22] Similar outcomes were observed in the subtotal colectomy versus on-table irrigation and anastomosis (SCOTIA) trial in 1995, which to date is the only randomized controlled trial on the subject. Patients undergoing segmental resection had better functional outcomes with fewer daily bowel movements, prompting the authors to conclude that segmental colectomy should be the preferred option when possible due to the functional benefits. The authors commented that subtotal colectomy has the theoretical benefit of removing synchronous tumors and reducing the risk of subsequent metachronous tumors, but the long-term outcomes were not assessed.[22]

Intraoperative colonic irrigation versus manual decompression

In the setting of emergency colectomy where mechanical bowel preparation is not possible, intraoperative colonic irrigation can be performed to remove fecal and bacterial matter from the colon, allowing for a primary anastomosis with a lower risk of anastomotic dehiscence.[23] While irrigation is associated with a longer operative time, it is not associated with a prolonged hospital stay or increased in postoperative morbidity.[24] Alternatively, manual decompression of the affected colon can be performed as an equally safe option in single-stage management of obstructing colonic cancer, with shorter operating time and no difference in complication rates.[25] Till date, only one systematic review has been published comparing these two options and they were deemed equivalent with similar mortality and morbidity rates.[26]

Primary anastomosis and appropriate patient selection

There has been a shift away from the traditional approach of Hartmann's procedure as the intervention of choice for left-sided colonic obstruction. It is now recognized that a subset of emergency patients can be considered for PRA.[27] This approach offers the benefit of a shorter hospital length of stay and avoiding problems associated with a colostomy.[28] The added benefits were also shown by Mochizuki etal., who reported that patients undergoing primary anastomosis compared to a staged procedure with diverting stoma had lower rates of wound infection, anastomotic complications, and an increased in cumulative survival curve.[14] However, it must be weighed against a higher risk of anastomotic dehiscence when two ends of dilated, inflamed colon are anastomosed emergently.[29] While conventional teaching suggests that a defunctioning stoma may help facilitate anastomotic healing and decrease the risk of dehiscence, a study by Kube etal. found that the use of a protective stoma did not decrease the rate of such incidents in patients with malignant left colonic obstruction undergoing PRA.[30] Routine defunctioning stoma formation is, therefore, not recommended in patients undergoing PRA for malignant left-sided bowel obstruction.

There are several surgical and patient-related factors that should be considered when choosing the appropriate surgical technique. PRA should not be offered in patients who had a perforation at the tumor site, extreme colonic dilatation, proximal-bowel atony, severe hyponatremia, and anemia.[31] It is favorable in patients who are younger and those with low postoperative risk.[15],[28],[30],[31],[32] A study by Tekkis etal. aimed to identify important predictors of patient outcome for malignant bowel obstruction, and they reported that increasing age, the American Society of Anesthesiologists(ASA) grading, Duke's stage, and the urgency of intervention were independent predictors for adverse outcome.[33] These are the patients that should not be offered a primary anastomosis. In younger patients with fewer comorbidities with minimal colonic distension, PRA can be considered as the treatment modality of choice.

Staged procedure

A staged procedure is defined as one where resection and anastomosis are not performed in the same operation. The options for staged surgery include:(i) Hartmann's procedure: Immediate resection and a stoma formation followed by an anastomosis with or without a diverting loop ileostomy performed 3–6months later and(ii) delayed resection where a stoma is formed, or stent is inserted emergently as a temporizing measure to relieve the obstruction[Figure1]. The delayed approach permits the conversion of an emergency procedure in a compromised patient into a semi-elective one, allowing for patient optimization before definitive surgery.{Figure1}

Emergent resection with end stoma formation

A Hartmann's procedure with a diverting end colostomy after resection should be considered in older patients with multiple comorbidities and significant bowel distension where colonic viability is potentially compromised.[30] In more proximal tumors, a subtotal colectomy with end ileostomy may be performed instead. The formation of an end stoma allows for inflammation to subside before a definitive anastomosis is performed. However, there are disadvantages associated with a Hartmann's procedure, including complications related to stoma formation with multiple significant negative repercussions on the quality of life,[34],[35] as well as medical complications, including parastomal hernia, volume depletion, stomal obstruction, necrosis, and prolapse. Furthermore, due to the potential risk of Hartmann's reversal, many patients are not offered a chance for a reversal. Some studies have shown the reversal rate to be as low as 20%, with the risk of surgical mortality cited as the primary reason for this.[36]

Benefits of delayed resection

Various studies have revealed better outcomes in delayed resection when compared to primary anastomosis,[29],[37],[38],[39] including better lymph node harvest, reduced rates of local recurrence, and longer 5-year disease-free survival. Delayed resection is performed through a bridge-to-surgery, either by maturing a diverting stoma or insertion of a self-expanding metallic stent(SEMS) to relieve the obstruction. This allows the clinician to revert a medically compromised patient closer to baseline, perform oncologic staging and allow time for colonic decompression. This can be accomplished as a two-stage procedure where the anastomosis and closure of the diverting stoma are performed in the second surgery or as a three-stage procedure where the stoma is only closed several months after the resection anastomosis.

Patients with malignant bowel obstruction often present late with rapid progression of obstructive symptoms. Asignificant proportion will be malnourished and cachexic with severe colonic damage and distension at the time of presentation.[40] These patients often have higher mortality and morbidity associated with emergency surgery.[29],[40],[41],[42] Other advantages of delayed resection include a higher lymph node harvest,[42] and the option of a minimally invasive approach.[40],[43] Studies have reported similar 5-year overall survival in patients undergoing PRA(between 31.8% and 63%) compared to patients with staged surgical procedure with reported rates of 7.7%–67%.[14],[44],[45],[46],[47],[48] The mortality rate of the two approaches is also similar, with 2%–31.3% for PRA compared to 0%–27.8% in staged resection patients.[14],[15],[16],[42],[44],[47],[48],[49]

The consequences of a staged procedure include a technically demanding second operation due to the formation of dense adhesions, longer hospital stay, and colostomy-associated morbidity.[15] A delayed resection should be the preferred treatment modality in patients with a high ASA score in the emergent setting but are likely to benefit from a quick emergency procedure that relieves the obstruction and allows for medical and nutritional support before undergoing definitive treatment.

Bridge to surgery via diverting stoma

Loop colostomy in the acute setting was the standard of care for obstructing left-sided colonic cancer. Emergency colostomy allows for exploration and the assessment of the intra-abdominal cavity including the liver for any metastases while relieving the obstruction. However, there are risks associated with anesthesia and surgery, with documented long-term medical and psychological morbidity associated with stoma.[50] It remains a safe surgical option, and should always be considered, especially when expertise for stenting is not available.

Bridge to surgery using self-expanding metallic stents

The role of SEMS as a bridge to surgery has remained controversial due to the risk of perforation, which would drastically worsen outcomes of patients who originally had an oncologically favorable prognosis.[51] Trials assessing the safety of stenting in malignant colorectal obstruction is increasing, with evidence from small cohort studies showing a safe and effective means to relieve the obstruction, while avoiding the need for a stoma and its associated medical and psychological repercussions.[39],[52],[53],[54] This strategy allows for resection to be postponed to the semi-elective period, where bowel preparation can be performed after the relief of obstruction, allowing for a safer resection with a reduced risk of postoperative complications.

A clinical success rate of over80% for stent placement has been reported.[17],[19],[55],[56],[57],[58] Recently, a prospective, single-arm multicenter trial in Japan of 327patients performed by Saito etal. showed a success rate of 98%.[19] Delayed surgery after stenting does not adversely affect hospital length of stay and major complication rate including anastomotic dehiscence. Other benefits of stenting include a lower rate of stoma formation, reduced need for intensive care unit admission, and earlier initiation of adjuvant chemotherapy.[17] However, one must consider the perforation risk reported at between 1% and 12.8%.[17],[19],[39],[58],[59],[60],[61] Datye and Hersh reported in 2011 that the administration of chemoradiotherapy and steroids are risk factors for perforation.[60] In such patient groups, stenting should not be offered if the goal of treatment is curative. The disastrous consequences of stent perforation must be discussed extensively with patients or their treatment decision-makers, and centers without significant SEMS expertise should not be offering this as a first-line option in patients undergoing curative treatment. Even where expertise is available, the perforation risk must be carefully considered on a case-by-case basis, and multi-professional discussion is highly recommended.

  Conclusion Top

Malignant left-sided colorectal obstruction remains a challenging surgical emergency with a wide variety of surgical approaches for management. The viability of each approach discussed in this paper depends heavily on the clinical scenario. Careful assessment of patients' clinical state, disease progression, and medical comorbidities are of utmost importance in determining the optimal management strategy for patients with malignant left-sided bowel obstruction.

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Conflicts of interest

There are no conflicts of interest.

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