surgical management of malignant colonic obstruction dennis ck ng north district hospital 21-1-2006...
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Surgical Management of Malignant Colonic Obstruction
Dennis CK Ng
North District Hospital
21-1-2006
Joint Hospital Surgical Grand Round
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Introduction
• Colorectal cancer is common in HK
• 3519 new cases in 2002
• 1965 males, 1554 females
• M:F = 1.3 to 1
Department of Health, HKSAR 2003
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Incidence
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Malignant Colonic Obstruction
• 8-29% of colorectal cancer presented as
obstructionOhman 1982, Philips RK 1985
Serpell JW 1989, Setti Carraro 2001
• Most are elderly patientGerber et al 1962, Anderson 1992
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Location
Phillips RK 1985
Rovito PF 1990
Sjodahl R 1992
• 12-19% will have a perforation at presentationUmpleby HC 1984, Runkel NS 1991
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Diagnosis
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Management
• Depends on location of tumor
• Operation remains the main stay of treatment
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Right Side Obstruction
• Right hemicolectomy– Primary anastomosis– Exteriorisation of both ends
• Ileotransverse bypass
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How to Choose?
• Emergency right hemicolectomy with primary anastomosis in obstructing tumor– Widely accepted approach in most patient
Irvin 1977, Fielding 1979
Phillips 1985, Runkel 1991, Carty 1992
• Exteriorization of both end in less favourable condition
• Rarely, bypass only in unresectable locally advanced disease
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Emergency Right Hemicolectomy
• Emergency right hemicolectomy with primary anastomosis in obstructing tumor – Mortality 17%– Anastomosis leak 10%– 6% in elective right hemicolectomy
Dudley H 1987
• HA COC Surgery 2005– Review on emergency colectomy in 14 HA Hospital– Emergency R hemicolectomy leakage rate ~10-15%
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Left Side Obstruction
Three Stage (1950s, 1960s)
Two Stage (1970s, 1980s, 1990s)
One Stage (1980s, 1990s)
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Three Stage
1. Defunctioning colostomy
2. Resection of tumor
3. Closure of colostomy
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Three Stage
• Advantage– Short first operation– Frail patient– Defunctioning stoma
as protection of anastomosis
• Disadvantage– Multiple operations– Decreased long term
survival when compared with primary resection
– Mortality 20%
Irvin TT 1977, Carson SN 1977
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Two Stage
1. Primary tumor resection + Stoma
2. Closure of stoma
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Two Stage
• Still popular in most centers
• Mortality 10%Umpleby 1984, Gandrup P 1992
• Shorter hospital stay than 3 stageAmbrosetti P 1989
• Problems– Second operation may be difficult– Some will have permanent stoma
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One Stage
Resection of tumor
+ Primary anastomosis
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One Stage
• Avoidance of stoma• Mortality 10%
Koruth NM 1985
Murray JJ 1991
Deans GT 1994
• Anastomotic leak 4%Konishi F 1988
• Longer operation
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Two Stage vs One Stage
• “Meta-analysis” • Cochrane Database of Systemic Review
• Curative Surgery for Obstruction from Primary Left Colorectal Carcinoma: Primary or Staged Resection
De Salvo et al 2005
– Only 1 RCT in literature – poor quality– 1 prospective and 3 retrospective case series
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Conclusion
• Meta-analysis not performed as only one poor quality RCT
• Not possible to draw conclusion from limited number of studies
• Need large scale RCT
De Salvo et al 2005
Inconclusive
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Segmental Resection vs Subtotal Colectomy
• Subtotal colectomy– Removing synchronous tumors– Reduced metachronous tumors in proximal colon– Increased frequency of post-op diarrhoea
Carty NJ 1993, Hughes ESR 1985, Golighter JC 1975
• On-table irrigation with segmental resection– Less disturbance on bowel motion– Time consuming– Complex procedure
Deans GT 1994, Carty NJ 1993, MacKenzie S 1992, Tan SG 1991
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SCOTIA 1995
• Single stage treatment for malignant left-sided colonic obstruction: a prospective randomized clinical trial comparing subtotal colectomy with segmental resection following intraoperative irrigation
– British Journal of Surgery 1995; 82: 1622-7
SCOTIA group 1995
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Patients
• 91 patients from 12 centers• 47 subtotal colectomy• 44 on-table irrigation & segmental colectomy
SCOTIA group 1995
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Complications
SCOTIA group 1995
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Stoma Rate
SCOTIA group 1995
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Bowel Motion Disturbance
SCOTIA group 1995
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Bowel Motion Disturbance
SCOTIA group 1995
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Number of Bowel Opening
SCOTIA group 1995
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Conclusion
• No significant difference in operative mortality, hospital stay, anastomosis leakage or wound sepsis
• Significantly higher permanent stoma rate in subtotal colectomy group
• Significantly more bowel motions in subtotal colectomy group
SCOTIA group 1995
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Recommendation
• Segmental resection following intra-operative irrigation was the preferred treatment for left sided malignant colonic obstruction
• Subtotal colectomy for patients with perforated caecum or synchronous neoplasm in proximal colon
SCOTIA group 1995
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Colonic Stenting
• “Bridge” to surgery• Mechanical bowel preparation available• Change emergency colectomy to semi-elective
operation
• Better optimization (hydration, electrolytes, nutrition) before operation
• Laparoscopic colectomy possible
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Colonic Stenting
• Self expanding metallic stent
• Radiologically or endoscopically placed
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Case Series
• Mainar A et al 1999
– Large multi-center series
– Radiological placement of stents
– Successful in 93% (66/71)
– 1 perforation
– 65 undergo single stage surgery
8.6 days after stents
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Stents vs Emergency Surgery
• Binkert CA et al 1999– Retrospective study– 26 patients (13 in stents + elective surgery, 13
emergency surgery)– Stent successful rate 92% (12/13)– Colostomy: 2 in stent group, 10 in surgery
group– 28.8% cost saving in stents group
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Stents vs Emergency Surgery
• Martinez-Santos et al 2002– Prospective non-randomized study– Radiologically placed stent– 72 patients, 43 stent group, 29 control group– Stent successful rate 95% (41/43)– Primary anastomosis in 84.6% of stent group,
41.4% of surgery group– Hospital stay, ICU care and severe
complication lower in stents group
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Conclusion
• Enables elective colectomy with primary anastomosis
• Less stoma rates• Shorter hospital stay• Less ICU care• More cost effective
• Need RCTs
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Summary
• No conclusive evidence which is the bests• Depends on patients condition, bowel viability,
degree of contamination, experience of surgeon
Right Side Obstruction Left Side Obstruction
Right hemicolectomy Three Stage
Two Stage
One Stage
Colonic Stent + Surgery
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Thank you
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Laser Ablation
• Kiefhaber P 1986– Nd-YAG laser– 75 patient with obstructing tumor– Sussessful in 57 patient– 2 patient had perforation– Post-operative mortality 3.7%
• Mansour EG 1992– 46 patients, 29 had laser before curative resection– 1 laser perforation– Postoperative mortality 3.4%