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Malignant Large

Bowel Obstruction –
Investigation and
Management Options
March 10, 2009
Lee Brewster
Toowoomba Base Hospital
Malignant Large Bowel Obstruction
 Obstruction of large bowel due to
a malignant neoplastic process
 Intramural (eg. Colorectal cancer)
 Extramural (eg. Compression from disseminated
peritoneal deposits eg. ovarian cancer)

 Main focus of this presentation will


be obstruction due to colorectal
cancer
Malignant Large Bowel Obstruction
 Between 8 – 20% of pts with
colorectal cancer present with
obstruction
 Left sided cancers are more likely
to obstruct:
 Largest % of malignant LBO’s are
in sigmoid
 Approx 12 -19% will have an
associated perforation
Malignant Large Bowel Obstruction
Cheynel et al. looked at trends:

 Often treated outside of tertiary


institutions
 Surgical morbidity/mortality is
higher in low-volume,
nonspecialised hospitals
 Does not appear to be any
change in the frequency of
malignant LBO in past 25 years
Acute Colonic Pseudo-Obstruction
 Symptoms and examination findings
mimic mechanical large bowel
obstruction
 Can lead to perforation
 Usually due to an underlying condition
 Management is non-operative except
when perforation has occurred
 High mortality rate – resulting from
underlying disorders but also failure to
recognise the condition leading to
inappropriate operation
 Important to distinguish from mechanical
obstruction
Acute Colonic Pseudo-Obstruction:
Predisposing Conditions
 Sepsis eg. Chest infection
 MI
 CVA
 Renal Failure
 Electrolyte disturbances
 Orthopaedic trauma
 Puerperium
 Retroperitoneal malignancy –
“Ogilve’s syndrome”
Acute Colonic Pseudo-Obstruction:
Treatment
 Enemas
 Adrenergic blockers / cholinergic
agents (risk of bradycardia – ? Risk decreased with
administration of gylcopyrrolate)

 Epidural blockade
 Endoscopic decompression
 Manual decompression
 Surgery (usually a right hemicolectomy, sometimes
a caecostomy)
Acute Colonic Pseudo-Obstruction:
Indications for surgery
 Ongoing caecal distension despite
maximal medical therapy
 Caecal tenderness
 Perforation
Radiological Investigation
 Aimed at confirming the presence
of mechanical obstruction and site
of obstruction
 Plain AXR
 Water Soluble Contrast Enema
 CT with oral / rectal contrast
 Flexible Sigmoidoscopy
 Colonoscopy
Plain AXR
 Easy to obtain
 Fast
 Gas pattern seen will
depend on the site of
obstruction and if the
ileocaecal valve is
competent
 Hard to distinguish
mechanical from
pseudo-obstruction
Water-soluble contrast enema
 Distinguishes pseudo-
obstruction from
mechanical obstruction
 May be ‘therapeutic’ in
pseudo-obstruction
 Barium contra-indicated
 Study by Koruth et. al
CT
 Getting easier to obtain in many
centres
 IV/Oral/Rectal contrast
 Provides information about
concurrent metastatic disease /
other pathology
 ? Sensitivity in diagnosing
pseudo-obstruction
Endoscopy
 Flexible sigmoidoscopy /
colonoscopy
 Can distinguish pseudo
obstruction from mechanical
obstruction
 Visualize any mucosal lesions
distal to the obstruction
 Equipment may not be easily
available in the emergency
department / after hours
Management Options
 Operative or Non-operative
 Curative or Palliative
 Decision making based on :
 Site of obstruction
 Disease load
 Patient factors
 Available expertise
 Institutional facilities
Operative
Management
Operative Management – Additional
Considerations
 Periop mortality 2-3 times higher
than elective resections
 Morbidity 6 – 40%
 Right side vs.. left side
 One stage procedures vs..
two/three stage procedures
 Perforation / peritonitis
Predictive Factors Mortality of Large
Bowel Obstruction
Biondo et.al
 Age> 70 years (>75 up to 5 x increased
risk) – this is associated with increased
co-morbidities
 ASA score III – IV
 Preoperative renal failure (creat > 120
umol/L)
 Presence of proximal colon damage
(ischaemic or necrotic lesions) with or
without peritonitis
 Perforation (up to x4 increased mortality)
:
Operative Management

Right Sided Colonic Obstruction


 Less debated than management
of left sided lesions
Options:
 Right Hemicolectomy / Extended
Right Hemicolectomy and primary
anastomosis
 Right Hemicolectomy and
exteriorisation of bowel ends /
abcarian stoma / end ileostomy
Operative Management : Right sided colonic obstruction

Right Hemicolectomy / Extended Right


Hemicolectomy
 Not without complications
 Mortality rates as high as 17%
reported
 Mortality & morbidity often
related to anastomotic
dehiscence / leak
 Leak rate 10% in surgery for
obstruction vs.. 4 - 6% in non-
obstructed patients
 ? Exteriorisation of bowel ends
in unstable patients
Operative Management : Right sided colonic obstruction

Right Hemicolectomy / Extended Right


Hemicolectomy
 For lesions in caecum / ascending colon
 Extended right for transverse colon /
splenic flexure lesions
 Consider decompression prior to
mobilisation if competent ileocaecal valve
 Anastomotic technique – staples / hand
sewn
 Ileo-colic anastomosis – better blood
supply / better bowel ‘quality’ (i.e. – not
dilated)
:
Operative Management

Left Sided Malignant Obstruction


 Wider range of surgical options, and
thus debate
 Single – stage procedures vs. multi
stage procedures
 Intact proximal colon vs. perforated
/necrotic proximal colon
 Peritonitis vs. relatively stable pt
 Combined non operative / operative
approaches now possible with advent
of endoscopic stenting
Operative Management: Left sided malignant large bowel obstruction

Debated Issues
 Previously, debate centred around
whether primary resection of tumour
(Hartmann's’) or simple decompression
was the management of choice at initial
presentation
 Subsequent debate about primary
anastomosis vs.. two – stage
procedures
 Increasing evidence and trend towards
primary resection and anastomosis in
appropriate patients in high – volume
centres
Operative Management: Left sided malignant large bowel obstruction

Three-stage procedure
 Standard approach until 1970’s /
1980’s
 Defunctioning colostomy – usually
transverse (stage 1), Resection of
tumour (stage 2), Closure of
colostomy (stage 3)
Advantages:
 Defunctioning colostomy a
relatively minor procedure in an
unstable patient
Operative Management: Left sided malignant large bowel obstruction

Three-stage procedure
Disadvantages
 Transverse colostomy difficult to
manage and has a higher rate
parastomal hernia
 Many patients not fit enough to
have further surgery
 Mortality rates from 3 procedures
combined (20% in 1970’s – 11-
12% 1980’s)
 Longer combined hospital stay
(30 – 55 days)
Operative Management: Left sided malignant large bowel obstruction

Hartmann’s Procedure (a two-stage procedure)


 Became popular in 1970’s
 Still the operation of choice for many
surgeons in the setting of a range of
circumstances
 Operation of choice in an unstable
patient

Advantages:
 Tumour is resected at first operation
 Anastomosis with its associated risks
avoided
 Shorter time on operating table
Operative Management: Left sided malignant large bowel obstruction

Hartmann’s Procedure - Reversal


 Only 60% - 70% of patients will be
able to have reversal
 Often technically difficult –
particularly if rectum had to be
divided below peritoneal reflection
 May require covering ileostomy
 Has been performed
laparoscopically
 Timing of reversal
Operative Management: Left sided malignant large bowel obstruction

Single-stage procedures
 Resection of tumour and primary
anastomosis in one procedure
 Subtotal colectomy with ileo-colic
or ileo-rectal anastomosis, or
 Segmental colectomy and colo-
colic/rectal anastomosis
 Much evidence suggests that in
appropriate circumstances, it is no
more hazardous than resections
for right sided tumours
 Lee et al, Hsu
Operative Management: Left sided malignant large bowel obstruction

Single-stage procedures
Advantages
 Avoids stoma
 Decreased cumulative mortality
compared with multi-stage
procedures
 Avoids need for further surgery in
patients with incurable disease
 Decreased cumulative hospital
stay
Operative Management: Left sided malignant large bowel obstruction

Single-stage procedures
Disadvantages
 Risk associated with anastomosis
 Theoretically, higher risk of
anastomotic complications in an
unprepared, obstructed colon.
 Not suitable for unstable patients
 Requires confidence with
procedure
 Longer operating time
Single-Stage Operations for Left sided obstruction:

Segmental Colectomy
 Usually performed with on-table
lavage or manual decompression
of proximal colon
 Anastomotic leak rate 4 – 8 %
 Perioperative mortality 10%
 Proximal bowel needs to be viable
 Less diarrhoea than subtotal
Single-Stage Operations for Left sided obstruction:
On-table lavage vs. manual decompression
 Theoretically a higher risk of
anastomotic complications when
colon is dilated and unprepared :
 Decompressed colon reduces tension on
anastomosis
 Anastomotic collagen metabolism and healing may be
compromised if faecal material is incorporated into the
anastomosis

• On table lavage can be time-


consuming, messy and require
mobilisation of whole colon
Single-Stage Operations for Left sided obstruction:
On-table irrigation vs. Manual
Decompression
Evidence to suggest manual
decompression of colon just
as good:
Manual decompression
possibly associated with
higher wound infection rate
(Hsu, 1997)
Single-Stage Operations for Left sided obstruction:
Subtotal colectomy
 Operative mortality 3 – 11%
Potential Advantages
 Better blood supply to anastomosis
 Removes synchronous tumours in
proximal colon
 Consider if familial colorectal cancer
suspected
 Not dependent on proximal bowel
viability
 Does not require irrigation or
decompression of colon
Single-Stage Operations for Left sided obstruction:
Subtotal colectomy
Potential Disadvantages
 Diarrhoea / increased frequency of
bowel motions
 May not be appropriate in elderly /
patients with history of pre-morbid
incontinence or decreased anal
sphincter tone
Single-Stage Operations for Left sided obstruction
Segmental Resection or Subtotal colectomy?
 Several studies comparing the two
 No difference between anastomotic
leak rates, periop mortality or
hospital stay
 Torralba et. al suggested subtotal
colectomy over segmental resection
except it obstruction was at
rectosigmoid junction
 SCOTIA study group suggested
segmental resection over subtotal
because of improved stoma rate and
bowel function
Study: Which surgeons avoid a stoma in
treating left-sided colonic obstruction?
 One-stage resection and
anastomosis in pts good
anaesthetic risk
Operative Management:

Palliation
 Liver mets present in 27%
 Presence of liver metastases should not
preclude palliative resection if it is possible
 Disseminated intraperitoneal metastases
present a difficult problem
Options:
 As previously discussed
 Bypass surgery (eg. Ileo-transverse colon
bypass)
 Defunctioning stoma / caecostomy (used
rarely)
Non-Operative
Management
Non Operative Management

SEMS – Self-Expanding Metal Stents


 Definitive palliative procedure, or
bridge to curative surgery
 Extrinsic malignant obstruction
 Technique of Insertion
 Available Stents
Non Operative Management : SEMS
Limitations
 Most data on left sided lesions
 Placement of stents proximal to
splenic flexure associated with a
higher failure rate because of
redundancy of these parts of
colon
 Rectal obstructions may be
unsuitable for stenting due to the
higher rate stent migration and
post – procedural pain
Non Operative Management : SEMS
Limitations
 Requires specialised equipment
and availability of persons with
expertise
Non-Operative Management: SEMS

Complications
 Perforation : 5%
Immediate or delayed
More common in left colon
Increased risk if subsequent radiotherapy
May cause dissemination of an otherwise
resectable tumour
Most important risk factor is balloon dilatation
 Migration 11 – 40%
 Bleeding
 Abdominal pain
 Diarrhoea
Non-Operative Management: SEMS

Complications
 Failure to achieve decompression
– 6%
 Late recurrence of obstruction 4 –
25%– (tumour ingrowth)
Non Operative Management : SEMS
Advantages – Palliative
 Allows time to stabilise / further
evaluate patient for curative
resection
 Avoid unnecessary surgery in
patients with unresectable /
disseminated disease
 Shorter Hospital stay
Non Operative Management : SEMS
Advantages - Palliative
 Lower procedural related mortality
 Fewer medical complications
 Reduced stoma formation
Non Operative Management : SEMS
Disadvantages - Palliative
 In patients who are otherwise
healthy apart from their locally
advanced disease, stent insertion
may be more likely to complicated
by tumour ingrowth
 ?Better treated by palliative
resection after relief of initial
obstruction in patients with a
longer life expectancy
 Covered Stents
Non-Operative Management : SEMS

Advantages – Bridge to Curative surgery


 Allows time to stabilise patient
 May allow endoscopic
assessment of proximal colon
 Mean interval between stenting
and surgery 11 days (Stipa et. Al)
 Reduces probability of requiring
stoma by 83%
Non-Operative Management

Advantages – Bridge to Curative surgery

 No difference in 3 year survival (50%


vs. 48%) or 5 year survival (44% vs.
40%) when compared with immediate
operative resection
 23% Fewer operative procedures
 Lower procedure – related mortality (5
vs. 11%)
 Shorter cumulative hospital stay and
thus reduction of costs
 May allow use of laparoscopic
techniques
Non-Operative Management: SEMS

Disadvantages – Bridge to Curative surgery


 If perforation occurs during
insertion of stent, a previously
curable tumour may be
disseminated
 Stents make colonic segment
more bulky and thus technically
challenging to resect
laparoscopically
Other Non-Operative Techniques
Described
 Laser therapy
(neodymium-yttrium aluminum garnet laser Nd –
YAG)
 Transanal endoscopic
decompression tube

 Palliation with medication /


conservative measures
Points to Consider
 Is Obstruction an independent
factor in long-term outcome?
 Is there any affect on long term
oncological outcomes in the
various operative choices?
 Weaknesses in literature
 Stent-in 2 study
Conclusions
 Multiple factors influence decision
making
 Rule out pseudo-obstruction
 Choose safest option within own abilities
and institutions capabilities
 In presence of perforation / peritonitis a
two stage operative procedure is safest
 In appropriate circumstances, one-stage
operative resection and anastomosis is
safe
 Advent of SEMS may prevent
unnecessary surgery and allow delayed
laparoscopic resection of tumour
References
Core Topics in General and Emergency Surgery Edited by Simon
Paterson Brown
Elsevier Sauders: The Netherlands, 2006

Sung, JS et.al Clinical Application of Self-Expandable Metal Stent for


Treatment of Colorectal Obstruction Caused by Extrinsic Invasive
Tumous. Dis Colon Rectum 2008; 51: 578 – 583

Torralba, J. A et al, Subtotal Colectomy vs. Intraoperative Colonic


Irrigation in the Management of Obstructed Left Colon Carcinoma.
Dis Colon Rectum . 1998; 41: 18 – 22

Lim J. F. et, al. Prospective, Randomized Trial Comparing Intraoperative


Colonic Irrigation With Manual Decompression Ony for Obstructed
Left-Sided Colorectal Cancer, Dis Colon Rectum. 2005; 48: 205 –
209

Martinez-Santos, C et. Al, Self-Expandable Stent Before Elective


Surgery vs. Emergency Surgery for the Treatment of Malignant
Colorectal Obstructions: Comparison of Primary Anastomosis and
Morbidity Rates. Dis Colon Rectum 2002; 45 401 - 406
References
Tilney, H. S. et al, Comparison of colonic stenting and open surgery for malignant
large bowel obstruction. Surg Endosc 2007 21: 225 – 233

Stipa, F. et. Al . Management of Obstructive colorectal cnacner with endoscopic


stenting followed by single-stage surgery: open or laparoscopic resection. Surg
Endosc 2008 22: 1477 – 1481

Farrell, J, et al. Pre-operative colonic stenting: how, when and why?. Endoscopy
2007: 23; 544 – 549.

Lee, Y. M et al, Emergency Surgery for Obstructing Colorectal Cancers; A


Comparison Between Right-sided and Left-sided lesions. J Am Coll Surg
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Koruth NM, et. al. The place of contrast enema in the management of large bowel
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Biondo, S. et. al Large Bowel Obstruction : Predictive Factors for Postoperative


Mortality. Dis Colon Rectum. 2004; 47: 1889 – 1897.

The SCOTIA Study Group. Single stage treatment for malignant left sided colonic
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References
Jiang, JK et. al Primary vs Delayed Resection for Obstructive Left-Sided Colorectal
Cancer: Impact of Surgery on Patient Outcome. Dis Colon Rectum 2008. 51;
306 – 311

Hsu, T. One-Stage Resection and Anastomosis for Acute Obstruction of the Left
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