EMERGENCY SURGICAL

MANAGEMENT OF COLORECTAL
CANCER
Dr. dr. I Made Mulyawan, Sp.B, Subsp.BD (K)
INTRODUCTION

Kanker Kolorektal
• Kanker yang dijumpai pada kolon dan
rektum.
• Salah satu kanker yang sering dijumpai di
seluruh dunia.
• Kejadiannya rendah beberapa dekade lalu.
• Sebagian besar pada usia > 50 tahun (75%
kanker rektal dan 80% kanker kolon pada
usia ≥ 60 tahun saat diagnosis).
• Lebih sering pada pria.
• Diperkirakan meningkat menjadi 2,5 juta
kasus pada tahun 2035.
Dekker E, Tanis PJ, et al. Lancet 2019;394:1467-80; Granados-Romero JJ, et al. Int J Res Med Sci. 2017;5(11):4667-76; Marmol I, et al. Int J
Mol Sci. 2017;18:197; Sawicki T, et al. Cancers 2021;13:2025; Kuipers EJ, et al. Nat Rev Dis Primers 2016;1:15065
 Epidemiologi di Indonesia

Indonesia. Globocan 2020.

 Apakah Ada Perbedaan Kanker Kolorektal Kanan & Kiri?

Dekker E, Tanis PJ, et al. Lancet 2019;394:1467-80

EMERGENCY OF COLORECTAL
CANCER
 Colorectal cancer accounts for 50% of all large bowel
obstructions
 Other causes, diverticular disease, Crohns, ischemia, etc
- Can be difficult to distinguish
 Onset usually insidious
- Progressive constipation, narrowed stools (left sided), crampy
abdominal pain (right sided)
 Presentation is variable
- Obstructing colorectal cancer may represent a surgical emergency

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• Most common location of obstructing CRC is sigmoid colon
- 75 % of tumors located distal to splenic flexure
• Perforation at tumor in 70%, and proximal to tumor in 30%
- Perforation at tumor site, contamination often localized
- Perforation proximal, can result in diffuse peritonitis, septic
shock
• Competency of ileocecal valve is critical
- Competent valve results in closed loop obstruction
EMERGENT MANAGEMENT

 Determined by clinical condition of the patient and

acuity of presentation
- Blood work, upright x – ray
- Concern for ischemia, free air with diffuse
peritonitis or sepsis
- Aggressive resuscitation / NGT
- Antibiotics
- OR
 EMERGENT MANAGEMENT

RIGHT SIDED LESION LEFT SIDED LESION

 Sepsis control  Sepsis control
 Right colectomy with end ileostomy if  Hartmann’s procedure if resectable
resectable  Follow oncologic principle
 Follow oncologic principle  +/- mucous fistule
 +/- mucous fistule  Inspect proximal colon for synchronous
 Loop ileostomy if unresectable or clinical disease, injury  STC with end
severe instability ileostomy
 Loop ileostomy if unresectable or clinical
severe instability
NON EMERGENT MANAGEMENT

CT is imaging modality of choice

 Proximal or synchronous lesions, extrinsic disease, closed
loop obstruction, presence of metastatic lesions

Contrast Enema
 Water soluble (Gastrografin)
 Birds beak, apple core
 Insight into role of endoscopic stenting (length / severity of
stricture)

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RIGHT SIDED LESIONS
Resectable
 Follow oncologic principles
 Consider primary anastomosis
 Anastomosis leak rate 2,5-5,2 %
 Need for postoperative chemotherapy
Unresectable
 Stent (SEMS), Bypass
 Loop ileostomy, colostomy
Consider MIS
 Improved outcomes select patients
LEFT SIDED LESIONS
Controversial
 Operative management
 Loop colostomy (transverse)
- Extraperitoneal rectal cancer
 Hartmann’s Procedure
 Resection with primary anastomoses
- +/- fecal diversion
 Self expandable metallic stent
 SEMS
SELF EXPANDABLE METALLIC
STENT (SEMS)
 Emergency management of CRC confers poorer oncologic outcomes and
significant morbidity and mortality
 SEMS used for palliation or Bridge To Surgery (BTS)
 BTS
 Allow for MIS, elective resection with preparation, medically /
nutritionally optimize
 Complications
 Stent failure, migration, re-obstruction, perforation (median risk 4-5%);
immediate / delayed, proximal / site of obstruction
SELF EXPANDABLE METALLIC
STENT (SEMS)
Data on long term oncologic outcomes
unclear
 Concern about radial force of stent
with tumor dissemination into
lymphatics or bloodstream with /
without perforation

Decreased short term morbidity, lower rates of temporary and permanent stoma formation
Analysis of tumor recurrence rate raises concerns about oncologic safety
 LEFT SIDED LESIONS

Resectable lesion (above peritoneal reflection)

 En bloc resection with oncologic principles
 Resection with primary anastomoses
 Carefully selected patients
 Proximal diversion up to surgeon discretion
 Operative mortality 8,1% , anastomotic leak 6,1%
 Hartmann’s
 Evaluate proximal colon for gross injury or synchronous
pathology
 May require subtotal colectomy due to injury to
proximal colon
 OPERATIVE MANAGEMENT
 Unresectable lesions or extraperitoneal lesions
 Proximal diversion (tranverse loop colostomy / blowhole)
 Allows for neoadjuvant XRT
 Avoid risk to marginal arcade, and potential future anastomosis
Pisano, Michele et al. “2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation.” World
20XX Pitch deck title journal of emergency surgery : WJES vol. 13 36. 13 Aug. 2018, 16
doi:10.1186/s13017-018-0192-3
ALGORITM MANAGEMENT CANCER COLON

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MANAGEMENT COLON CANCER :
ESMO

18
CONCLUSIONS
Emergent management of obstructing colorectal cancer
 Sepsis control
 Resection with oncologic principles
 Likely end ileostomy or colostomy formation
Non Emergent management of obstructing colorectal cancer
 Resection with oncologic principles
 Primary anastomosis if condition warrant
 Consider SEMS as BTS with short interval resection at high volume centers
 Loop transverse colostomy / blowhole for extraperitoneal cancers
Need to consider need for adjuvant therapy with management decisions
MATUR SUKSMA