Original article
Differences between proximal and distal obstructing colonic
cancer after curative surgery
R. Frago, S. Biondo, M. Millan, E. Kreisler, T. Golda, D. Fraccalvieri, B. Miguel and E. Jaurrieta
Department of Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, Barcelona, Spain
Received 6 October 2010; accepted 10 December 2010; Accepted Article online 12 March 2011
Abstract
Aim To study any possible differences in morbidity,
mortality and overall survival rate after curative surgery
for obstructive colon cancer according to tumour loca-
tion.
Method From January 1994 to December 2006,
patients with colonic cancer presenting as obstruction
were analysed. The two groups were defined as proximal
and distal according to the tumour location with respect
to the splenic flexure. In relation to the surgeon
specialization, patients were operated on by a colorectal
surgeon and by a general surgeon. Postoperative mor-
bidity and mortality and cancer-related survival at 3 years
were analysed.
Results Of the 377 patients included in the study, there
were 173 patients (45.9%) in the proximal group and 204
patients (54.1%) in the distal group. The global morbid-
ity was 54.9% without differences in postoperative mor-
bidity except for anastomotic leakage, which was higher
in the proximal group (P < 0.014). No differences in
postoperative mortality were observed. After patients
were stratified by the tumour node metastasis system, the
Introduction
Colonic obstruction represents between 2% and 4% of
admissions for acute abdomen, and in most cases requires
surgery [1,2]. The most common cause is colorectal
cancer, located in 75% of cases distal to the splenic flexure
of the colon [3].
Although patients with obstructing colonic cancer are
a heterogeneous group, it occurs equally in both genders
[4], most commonly affects elderly patients with comor-
bidities [5], and is associated with locally advanced or
Correspondence to: Sebastiano Biondo MD, Bellvitge University Hospital,
Department of Surgery, C ⁄ Feixa Llarga s ⁄ n, L’Hospitalet de Llobregat, 08907
Barcelona, Spain.
E-mail: sebastianobiondo@yahoo.com
e116 Colorectal Disease  2011 The Association of Coloproctology of Great Britain and Ireland. 13, e116–e122
doi:10.1111/j.1463-1318.2010.02549.
differences between the groups, with respect to 3-year
overall survival, cancer-related survival and probability of
being free from recurrence, did not reach statistical
significance. The overall survival after radical surgery for
colonic obstruction was 57.6%.
Conclusion Mortality and morbidity after emergency
surgery for obstructing colon cancer are high. Special-
ization in colorectal surgery influences postoperative
results in terms of lower anastomotic dehiscence rate
after emergency proximal colon resection. After radical
surgery, tumour location does not appear to influence the
prognosis of obstructive colon cancer.
Keywords Colonic cancer, obstruction, survival, surgical
specialization, prognostic factors
What is new in this paper?
There are no differences between proximal and distal
obstructive colonic cancer in terms of oncological results.
Proximal colonic resection presents a significantly higher
anastomotic leakage rate compared with distal colonic
resections in complicated obstructing tumours.
metastatic neoplastic disease [2,6]. Emergency surgery
has been the traditional treatment of the obstructive
syndrome and tumour, and is associated with a high
mortality and morbidity [7–9]. In tumours proximal to
the splenic flexure, colonic resection with primary anas-
tomosis is widely accepted as the treatment of choice
[10]. In distal colonic obstruction, treatment options are
broader, and continue to be a source of controversy:
surgical resection with primary anastomosis, Hartmann’s
procedure and, more recently, the use of colonic stents as
an initial treatment for the obstruction, and as a ‘bridge’
for subsequent surgical resection [11].
Previous studies have shown that obstructive tumours
are more aggressive and present worse outcomes than
nonobstructive tumours [12], but few studies have
analysed differences in the rate of survival between
 2011 The Authors
R. Frago et al.
proximal and distal obstructive cancers [13,14]. Recent
publications have suggested that proximal tumours seem
to have a better prognosis [12].
The aim of the present study was to analyse any possible
differences in postoperative morbidity, mortality and
survival rate after curative surgery for obstructing colon
cancer according to tumour location (proximal or distal).
Method
A retrospective observational study was designed to
analyse the results of surgical management of patients
presenting with obstructing colorectal cancer from
January 1994 to December 2006.
The hospital treats patients from a defined geograph-
ical area with approximately 1 250 000 inhabitants.
The diagnosis of colonic obstruction was established
in patients with clinical symptoms of intestinal obstruc-
tion, as defined in previous publications, accompanied by
plain abdominal radiographic findings of large-bowel
obstruction [9]. The diagnosis was confirmed either by
gastrografin (Bayer S.L., Barcelona, Spain) enema or
abdominal computed tomography (CT). All patients
underwent emergency surgery within 24 h after admis-
sion or surgical consultation.
All patients with bowel obstruction due to a colorectal
neoplasm who were operated on in the study period and
who underwent resection of the primary tumour without
leaving any visible residual cancer were included in the
analysis.
Cases of extrinsic compression of the colon, nonco-
lorectal neoplasms, nonresectable tumours and stage IV
patients with unresectable metastases, in whom a self-
expanding metallic stent was placed in the obstructing
lesion, were excluded from the analysis.
Demographic information, hospital length of stay and
postoperative morbidity and mortality were obtained
from a prospectively maintained database of all patients
treated for colorectal diseases at our institution.
Two groups were defined according to the location of
the tumour: proximal and distal. Proximal obstruction
was defined as an obstructing tumour proximal to or at
the splenic flexure; and distal obstruction was defined as
an obstructing tumour distal to the splenic flexure.
The choice of operation depended on the site of the
obstructive lesion, the general condition of the patient
and the surgical findings. In patients with proximal
lesions, a right or extended right colectomy with primary
anastomosis was the operation of choice. If the lesion was
located at the splenic flexure, a subtotal colectomy was
performed. In left colonic obstruction, the first-choice
operation was resection and primary anastomosis with
on-table antegrade lavage, as described previously [1].
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Colorectal Disease  2011 The Association of Coloproctology of Great Britain and Ireland. 13, e116–e122
Proximal and distal colonic obstruction
At present, colonic lavage is no longer routinely used,
and we only use decompression when the bowel shows
important distension and before any mobilization of the
colon. Decompression is achieved by caecal puncture
with an intramuscular needle connected to the suction.
The proximal colon is transected near the site chosen for
anastomosis and a manual retrograde milking of the
colonic content is performed in the distal 5 cm. A purse-
string suture keeps the colon closed around the anvil used
for circumferential mechanical anastomosis.
Total colectomy was performed when there was
proximal colonic ischaemia ⁄ perforation or a synchronous
tumour. In patients at high risk because of renal failure,
ASA IV patients, or patients with faecal peritonitis or
haemodynamic instability, a Hartmann’s procedure in
distal lesions or a total or subtotal colectomy with
terminal ileostomy in proximal lesions was performed,
respectively.
During the study period, 38 surgeons were involved in
the treatment of obstructing colon cancer, eight colorec-
tal surgeons (CS) and 30 general surgeons (GS).
A surgeon was defined as a colorectal surgeon if, after
having completed general surgery training, he or she had
undergone a training period of at least 1 year in the
Colorectal Unit of Bellvitge University Hospital or in
another national or international colorectal referral cen-
tre. The rest of the surgeons were considered as general
surgeons independently of the unit of the Department of
Surgery where they usually worked. Surgeons with less
than 1 year of practice after their training in general
surgery were considered trainees. Operations were per-
formed by CS, GS or trainees assisted by either CS or GS
[15].
Anastomotic leakage was defined as purulent or faecal
drainage through the drains, radiological signs of leakage
(gas or an abscess adjacent to the suture), or evidence of
leakage at reoperation or autopsy.
Morbidity was defined as any complication occurring
within the first 30 days after surgery, and postoperative
mortality was defined as death within the first 30 days
after surgery. Tumour stage was classified according to
the tumour node metastasis (TNM) system. [16]. Overall
survival at 3 years was considered as the crude survival
rate including all causes of death for stage I-II or III
colorectal cancer and stage IV cases in which the primary
tumour and the metastases were resected. Patients who
died in the postoperative period were included in this
survival analysis. The probability of being free from
recurrence was equivalent to the disease-free survival and
represents the chance of not developing a first recurrence.
Cancer-related survival was defined as the time from the
date of first treatment to the date of death as a
consequence of cancer recurrence.
e117
Proximal and distal colonic obstruction
Statistical analysis
Continuous variables are expressed as the mean, median
and range between brackets. Categorical variables are
presented as absolute numbers and by percentages.
Comparative analysis of the quantitative data was per-
formed using the Student t-test or nonparametric test
when needed (Mann–Whitney U-test). The v2 test for
proportions or Fisher’s exact test was used in the analysis
as appropriate. Survival analysis was performed using the
Kaplan–Meyer actuarial method and survival curves were
compared using the log-rank method. Statistical signif-
icance was determined a priori at P < 0.05. Stepwise
logistic regression was performed using SAS V9.1 (SAS
Institute, Cary, North Carolina, USA).
Results
Four hundred and eighty-three patients presented with a
colonic obstruction in the study period. One-hundred
and six were excluded from the analysis: 95 did not
undergo tumour resection (39 patients with unresectable
stage IV disease in whom a stent was placed, and 56
palliative patients in whom a colostomy or bypass was
performed) and 11 patients were excluded due to
deficiencies in the completion of the database (Fig. 1).
483 cases of obstructive colorectal cancer
---- 106 patients excluded
377 patients with tumour resection
Proximal obstruction (173 patients) Distal obstruction (204 patients)
Stage I–II III IV I–II
Patients 66 66 41 72
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R. Frago et al.
After excluding patients without tumour resection,
377 patients were included in the analysis of outcome:
173 (45.9%) had obstructing cancers at or proximal to
the splenic flexure, and 204 (54.1%) had lesions distal to
the splenic flexure.
Age, sex, American Society of Anesthesiologists score,
comorbidity, tumour site, type of surgery, TNM classi-
fication of the two groups of patients treated by curative
surgery, and their differences are shown in Table 1.
The types of operations performed are listed in
Table 2. An anastomosis was possible in 171 of 173
patients (98.8%) in right-sided tumours, and in 169 of
204 patients (82.8%) in left-sided tumours (P < 0.001).
The postoperative morbidity rate was 54.3% (94
patients) in the proximal cancer group and 55.4% (113
patients) in the distal cancer group; there were no
statistical differences between the two groups with regard
to this variable when the overall anastomotic leakage rate
was excluded. The leakage rate was 16.4% (28 patients) in
the proximal group and 7.7% (13 patients) in the distal
group. The prevalence of anastomotic leakage was
significantly higher for right-sided tumours than for
left-sided tumours (P = 0.014). The types of morbidity
are listed in Table 3.
When we analysed the differences between the type of
surgeon and the type of resection, we observed a
III IV
77 55 Figure 1 Distribution of patients.
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R. Frago et al. Proximal and distal colonic obstruction

Table 1 Comparison between proximal and distal obstructing Table 3 Causes of morbidity.
tumours.
Proximal (%) Distal (%)
Proximal (%) Distal (%) 173 204 P
173 patients 204 patients P
Incisional surgical site complications
Gender Abscess (superficial 16 (9.2%) 28 (13.7%) 0.177
Female 63 (36.4) 91 (44.6) 0.107 and deep)
Male 110 (63.6) 113 (55.4) Incisional hernia 4 (2.3%) 5 (2.5%) 1*
ASA Organ-space surgical site complications
I 14 (8.1) 28 (13.7) 0.317 Abscess 10 (5.8%) 11 (5.4%) 0.870
II 87 (50.3) 102 (50.0) Generalized 4 (2.3%) 11 (5.4%) 0.127
III 49 (28.3) 48 (23.5) peritonitis
IV 23 (13.3) 26 (12.7) Reoperations 30 (17.3%) 22 (10.8%) 0.066
Anastomosis Anastomotic leakage 28 (16.4%) 13 (7.7%) 0.014
No 2 (1.2) 35 (17.2) < 0.001 Extra-surgical site complications
Yes 171 (98.8) 169 (82.8) Respiratory failure 13 (7.5%) 17 (8.3%) 0.770
Comorbidity and pneumonia
No 48 (27.7) 71 (34.8) 0.142 Cardiac failure, 4 (2.4%) 8 (4%) 0.502*
Yes 125 (72.3) 133 (65.2) arrhythmia
Stage Upper digestive 2 (1.2%) 4 (2%) 0.691*
I 3 (1.7) 6 (3.0) 0.739 bleeding
II 63 (36.4) 66 (32.3) Prolonged ileus 9 (9.2%) 15 (7.4%) 0.394
III 66 (38.2) 77 (37.7) Mean hospital stay (range) 20.4 days 19.3 days 0.575
IV 41 (23.7) 55 (27.0) (7–191) (5–90)
Mortality 25 (14.5%) 30 (14.7%) 0.944

*Fisher exact test.

Table 2 Surgical procedures.
tory failure (32.7%), septic complications (16.4%), mul-
Patients %
tiorgan failure (27.3%) and other causes (9.1%).
The mortality varied according to the ASA score and
Proximal tumour
the location of resection. In the distal colon the sickest
Right ⁄ extended right colectomy 151* 87.3
Subtotal colectomy 19 11
patients did not undergo anastomosis, and therefore we
Subtotal colectomy with loop ileostomy 3 1.7 did not analyse the ASA score in relation to anastomotic
Distal tumour leakage. In the proximal resections, the postoperative
Left colectomy with anastomosis 102 50 mortality rate was 11.9% in ASA I-II patients and 18.1%
Anterior resection 22 10.8 in ASA III-IV patients. In the distal resections, mortality
Total colectomy with anastomosis 45 22.1 in ASA I-II patients was 4.0% after left colectomy and
Total colectomy with ileostomy 6 2.9 primary anastomosis, 6.7% after anterior resection and
Hartmann’s procedure 29 14.2 11.1% after Hartmann’s procedure. The mortality rates in
*All patients but two underwent primary anastomosis. high-risk ASA III-IV patients were 5.9%, 4.5% and 44.8%,
respectively.
After the patients were stratified according to tumour
statistically significant difference in the leakage rate stage, no statistical differences were found between the
between CS (5.8%) and GS (21%) for proximal colonic two groups in 3-year overall survival. While the 3-year
resections (P = 0.007). However, in distal resections no survival rate for stage I -II cancers in the proximal group
differences were observed between the two groups of was 74.2%, in the distal group it was 68.5% (P = 0.159)
surgeons: 6.3% and 8.9%, respectively (P = 0.896). (Fig. 2). The survival rate in stage III patients in the
The mean hospital stay was 20.4 days (range, 7– proximal group was 67.5%, and in the distal group it was
191 days) in the proximal group and 19.3 days (range, 75.1% (P = 0.932) (Fig. 3). Finally, in stage IV cancers
5–90 days) in the distal group (P = 0.538). the survival rate in the proximal group was 22.6%, and
The postoperative mortality rate was 14.5% (25 26.6% in the distal group (P = 0.249); all of these
patients) in the proximal cancer group and 14.7% (30 patients had resectable metastases that were resected in
patients) in the distal cancer group (P = 0.944). The a second surgery. The overall survival rate after radical
causes of mortality were cardiac failure (14.5%), respira- surgery for colonic obstruction was 57.6%.

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Colorectal Disease  2011 The Association of Coloproctology of Great Britain and Ireland. 13, e116–e122 e119
Proximal and distal colonic obstruction R. Frago et al.

Stage I–II have on cancer prognosis should not be underestimated

[17]. Although our study provides descriptive data, it
1.0 Proximal
Distal may contribute as a reminder that colon obstruction
remains a common clinical manifestation of colon cancer.
0.8
Cumulative survival

Most cases of colon cancer arise sporadically and

follow the classical adenoma-carcinoma sequence, which
0.6
takes years to develop [18]. Despite this slow growth,
about 20% of patients present with a colonic obstruction
0.4
[2]. This presentation is more common in tumours distal
to the splenic flexure and in elderly patients, often with
0.2
associated comorbidities [5]. In our series, 54.1% of the
patients had distal obstruction, and the sigmoid colon
0.0 (39.5% of cases) was the most common site of obstruc-
0 12 24 36 48 tion.
Time (months) Large bowel obstruction can cause an important
Figure 2 Kaplan–Meier estimates of 3-years overall survival in destabilization of underlying diseases, especially in elderly
stage I–II. patients with significant cardiovascular or respiratory
dysfunction [19]. Consideration of the known predictive
Stage III factors for postoperative mortality, such as age over
70 years, ASA score (III–IV) or preoperative renal failure
1.0 Proximal
Distal among other factors, and the optimization and the
suitable preoperative resuscitation of patients, have been
0.8
Cumulative survival

proven to be useful in the management of these patients

0.6
0.4
0.2
0.0
0 12 24 36
Time (months)
Figure 3 Kaplan–Meier estimates of 3-years overall survival in
stage III.
No differences were found in terms of cancer-related
survival: in stage I-II it was 90.8% and 91.9% in the
proximal and distal groups, respectively (P = 0.201); in
stage III it was 84.7% in the proximal group and 81.1% in
the distal group (P = 0.417). No differences were found
in the probability of being free from recurrence: in stage
I–II the probability was 82.4% in the proximal group and
77.0% in the distal group (P = 00.171); in stage III it was
70.5% in the proximal group and 75.1% in the distal
group (P = 0.980).
Discussion
Current literature on cancer prognosis often focuses on
the understanding of molecular carcinogenesis and the
possibility of developing molecular markers to predict
outcome. Nevertheless, the influence that clinical factors
[9,20]. A CT scan, whenever available, should be
performed to complete the study of patients with
suspected large bowel obstruction; it has been shown to
confirm the diagnosis of colonic obstruction in over 90%
of patients, locate the correct site of obstruction, detect
metastatic disease, and even evaluate the resectability of
the tumour in some cases [21].
For over four decades, the treatment of proximal
48
obstructive colorectal neoplasms focused on attempting
resolution of symptoms, primary tumour resection and
reconstruction of intestinal continuity. A right hemi-
colectomy or extended right hemicolectomy is accepted
as the standard treatment of proximal obstruction [10].
In the distal colon, although several studies refer to
one-stage resection with primary anastomosis as a safe
technique in most patients with obstruction [9,22],
Hartmann’s procedure remains widely used [10]. At
present, the literature reflects a trend towards attempts to
resolve the obstruction by placing self-expanding metallic
stents as a ‘bridge’ until tumour resection [10,23].
Following our protocol for colonic obstruction [9], our
standard treatment during the period included in the
present study was resection of the obstructing tumour
with primary anastomosis whenever possible. Intestinal
continuity was preserved in 98.8% of proximal obstruc-
tions and in 82.8% of distal obstructions (P < 0.001).
Colonic stents were reserved for some ASA IV patients
and unresectable stage IV colorectal cancer [24].
The high morbidity observed in emergency surgery
of the colon is constant [4,10]. Unlike other studies

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e120 Colorectal Disease  2011 The Association of Coloproctology of Great Britain and Ireland. 13, e116–e122
R. Frago et al.
published [10,25], we found statistically significant
differences in the anastomotic leakage rate between
proximal and distal obstruction (P = 0.014); there were
significantly more anastomotic leaks in the proximal
colonic anastomoses.
These outcomes could be explained by the fact that
primary anastomosis was performed in most patients with
proximal obstruction. There was no protocol to change
the surgical strategy depending on predictive factors for
postoperative morbidity and mortality in large bowel
obstruction [9]. Moreover, we also observed that surgical
specialization influenced the outcomes of emergency
colorectal surgery in terms of lower postoperative mor-
bidity and mortality rates [15].
Although there is a higher rate of anastomotic leakage
in proximal colonic obstruction, our results showed no
statistical differences in postoperative mortality between
the groups (14.5% in the proximal cancer group and
14.7% in the distal cancer group). Mortality remains
lower than 20%, which remains within the recommenda-
tions of the Royal College of Surgeons of England [26].
In order to improve our outcomes, at present we use
the same criteria in the selection of patients for a primary
anastomosis in both proximal and distal tumours. In
high-risk patients with proximal obstruction, we perform
a loop ileostomy after anastomosis. In distal obstruction,
we consider self-expanding metallic stents as a bridge to
surgery after resuscitation. The mortality rate in our
institution after stenting is 6.1%, as described in a recent
study [24].
Several studies have referred to obstruction as a sign of
poor prognosis for colorectal cancer, even after data
stratification by TNM stage. Moreover, it has been
previously reported that obstructive right colon tumours
have a worse prognosis than distal tumours [14]. The use
of the 3-year disease-free survival rate is a reasonable
indicator for cure owing to the relatively small increase in
recurrence after that period of time [27]. When the
patients were stratified according to tumour stage, no
statistical differences were observed for overall survival,
cancer-related survival and the probability of being free
from recurrence between proximal and distal obstructing
tumours. The overall survival rate after curative surgery
for colonic obstruction was 57.6%, worse than our own
previously published results in elective surgery [28],
probably due to the inclusion of stage IV patients, who
present an overall survival rate of 24.7%.
Conclusions
In conclusion, surgery for proximal as well as distal
obstructive colonic cancer presents high postoperative
morbidity and mortality rates. In our experience, there is
 2011 The Authors
Colorectal Disease  2011 The Association of Coloproctology of Great Britain and Ireland. 13, e116–e122
Proximal and distal colonic obstruction
a high rate of anastomotic leakage in surgery for proximal
obstructive colonic cancer. A strict selection of high-risk
patients with proximal obstruction should be made in
order to offer them safe surgical options, such as resection
and primary anastomosis with a diverting ileostomy.
Specialization in colorectal surgery influences postoper-
ative results in terms of lower anastomotic dehiscence rate
after emergency proximal colon resection. After curative
surgery, tumour location does not appear to influence the
prognosis of obstructive colon cancer.
Conflicts of interest
No conflicts of interest are declared.
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