M A R C U S B U R N S T E I N

LARGE BOWEL OBSTRUCTION

MCQ

A 78 yr. old man (HT, DM, 2 coronary stents) has 3 mos. of irregular bowel habits and 72 hrs. of LBO. Distended, non-tender. Normal blood work. Plain xray, CT & colonoscopy à lesion @ DC-sigmoid junction c/w Ca. No mets. The optimal management of this patient is a.  Stent b.  Proximal stoma c.  Extended colectomy, ileocolic

anastomosis d.  Segmental resection, anastomosis (±

loop ileostomy, ± on-table lavage) e.  Hartmann’s

1. MALIGNANT OBSTRUCTION: A practical approach

q  Above the line: RHC, “extended colectomy” … with 10 anastomosis

q  Below the line: ①  Stent now, operate later ②  Operate now:

Diversion alone q  Non-

resectable q  Advanced

rectal q  Unstable

Hartmann’s procedure q  Requires

healthy cecum

Resect and 10 anastomosis ± diversion q  Segmental ±

“clean out” q  Subtotal & IRA

STENT NOW, OPERATE LATER: A growing consensus?

In expert centres: q  Ó10 anastomosis q  Ô length of stay q  Ô mortality q  Ô complications q  Cost-effective

In the real world:

Stent Operation p

Stoma 45% 62% 0.02

10 anastomosis 65% 55% 0.003

Complications 48% 55% ns

Mortality 8% 9% ns

Cirocchi R, et al. Surg Onc 2013;22:14-21

q  Selection: q  Best for rectosigmoid &

sigmoid lesions q  Best for malignant

strictures

q  Complications: q  Perforation ~5% q  Migration ~12% q  Re-obstruction ~7%

Complication rates Ó with time, so “the bridge to surgery” should be short

STENT NOW, OPERATE LATER: A growing consensus?

OPERATIONS FOR THE DISTAL LESION (when stent fails)… how do we chose?

Operation + -

Hartmann’s q  Safe, easy, quick q  Unstable patient q  No leaks! q  No shame!

q  Stoma; >30% not rev’d q  Ó reversal morbidity

STC & IRA q  Nice anastomosis q  Removes the proximal

colon (synchronous lesions; ‘sick’ cecum)

q  One stage, no stoma

q  Not ’quick & easy’ q  Functional disturbance

(ÓBMs, Ô continence) q  Anastomotic leak q  ± Protecting stoma

Segmental Resection

q  Preserves colonic function

q  One stage, no stoma

q  ?Lavage or manual clean out

q  ?Nice anastomosis q  Anastomotic leak q  ± Protecting stoma

q  Weigh the risks and benefits of the various options in the context of: q  Patient factors

q  General health q  ?more likely to get a leak q  ?less able to survive a leak

q  Bowel function, especially continence

q  Disease factors q  Degree of distention and fecal

loading q  Integrity of cecum q  Synchronous lesions q  Cancer vs. benign stricture

Good clinical judgement

Careful patient selection

Individualize therapy

Surgeon experience

IN THE ABSENCE OF CONSENSUS… some ‘evidence’ to help us chose

q STC & IRA vs. Segmental Resection with on-table lavage q  Mortality: no difference (~10%) q  Anastomotic leak: no difference (~5%) q  Wound infection: no difference (~15%) q  Length of stay: no difference q  Quality of life: better after segmental resection

q On-table colonic lavage vs. manual clean-out q  No difference in mortality, leak, and wound infection

q Segmental Resection without lavage or manual clean-out q  Comparable mortality and leak rates to Segmental Resection

with on-table lavage

SOME TRICKS TO HELP US…

① Deflate the distended colon with an angiocath ②  Side to end to overcome luminal discrepancy ③ Don’t do on-table lavage (in general) ④  Scope after anastomosis to deflate, test (±

lavage) ⑤  Still a role for Hartmann’s !!

1.

2. 3. 4.

SIGMOID VOLVULUS

q  Diagnosis… think of it q  Elderly, institutionalized, medicated q  In the rare younger patient, usually part

of colonic inertia ± megacolon q  Treatment

q  Ischemia/infarction à lap à Hartmann’s vs. 10 anastomosis

q  Endoscopic decompression successful ~80%

q  Colonoscopy (if no infarction à rectal tube)

q  Prep à formal colonoscopy à resect q  No resection à Rec Rate up to

70-80% q  ?Timing

SIGMOID VOLVULUS

But these patients are old and frail… can we avoid a G.A. and resection?

q  Endoscopic decompression prn

q  Percutaneous endoscopic colostomy (PEC) tube

q  Laparoscopic-assisted PEC tube(s)

q  Sigmoidopexy q  Sigmoid extra-

peritonealization q  Mesosigmoidoplasty

No G.A.

PEC tube

No good

CECAL VOLVULUS

q  Diagnosis… think of it q  Younger … ave. 50 yrs. q  Many will have had

“recurrent intermittent” before acute obstruction

q  Hospitalized with concurrent illness: 10-30%

q  Colonoscopy not recommended q  Success rate ~30%

q  Treatment: emergency RHC (open or MIS)

bascule

ACUTE COLONIC PSEUDO-OBSTRUCTION

q ~20 % of LBO are not mechanical

q Elderly, often hospitalized, with a wide spectrum of co-morbidities and medications q Affects 0.5-1% of patients

on ortho, neurosurg & burn units

q Mortality > 15% q cecal perforation

②  IV neostigmine: q  1-2mg over 1-5 min q  Monitor HR, BP, EKG q  Rel CI’d: IHD, COPD,

asthma, β blockers, RF q  Success ~80% (repeatable)

①  Supportive care: q  IV, NGT, RT q  Correct lytes q  Stop meds: narcs,

anti-chol, Ca++

blockers, laxatives

q  Monitor cecum

ACUTE COLONIC PSEUDO-OBSTRUCTION: management algorithm

LBO

Acute CPO

Resolution No Resolution X 48 hrs

No Resolution

④  Tube cecostomy

Resection& stomas

Clinical or Radiologic perforation

CT or WSCE or colonoscopy

③  Colonoscopy q  Success ~80% q  Perforation ~2%

LARGE BOWEL OBSTRUCTION

• Mechanical obstruction •  Proximal to the red line… extended colectomy

with ileocolic anastomosis •  Distal to the red line… stent •  If no stent expertise or stent failure •  Transfer •  Operate, but… no consensus on ‘best operation’, &

clinical acumen required

•  Sigmoid volvulus… de-tort then discuss •  Cecal volvulus… RHC

• Acute CPO… lethal condition