LARGE BOWEL OBSTRUCTION MARCUS BURNSTEIN

LARGE BOWEL OBSTRUCTION MARCUS BURNSTEIN

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 1 0 anastomosis q Below the line: 1 Stent now, operate later 2 Operate now: Diversion alone q Nonresectable q Advanced rectal q Unstable Hartmann s procedure q Requires healthy cecum Resect and 1 0 anastomosis ± diversion q Segmental ± clean out q Subtotal & IRA

STENT NOW, OPERATE LATER: A growing consensus? In expert centres: q Ó 1 0 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 1 0 anastomosis 65% 55% 0.003 Complications 48% 55% ns Mortality 8% 9% ns Cirocchi R, et al. Surg Onc 2013;22:14-21

STENT NOW, OPERATE LATER: A growing consensus? 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

OPERATIONS FOR THE DISTAL LESION (when stent fails) how do we chose? Operation + - q Weigh the risks and benefits of the various Good Hartmann s q Safe, easy, quick q Stoma; >30% not rev d options in the context of: clinical q Unstable patient q Ó reversal judgement morbidity q Patient factors q No leaks! q General q health No shame! q?more likely to get a leak Careful STC & IRA q Nice anastomosis q Not quick & easy q?less able q Removes to survive the proximal a leak patient q Functional selection disturbance q Bowel function, colon especially (synchronous (Ó BMs, Ô continence) continence lesions; sick cecum) q Anastomotic leak q Disease factors q One stage, no stoma q ± Protecting stoma Individualize q Degree of distention and fecal therapy Segmental loading q Preserves colonic q?lavage or manual Resection q Integrity of function cecum clean out q Synchronous q One lesions stage, no stoma q?nice anastomosis q Cancer vs. benign stricture q Anastomotic Surgeon leak q ± Protecting experience stoma

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. 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!! 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. 1 0 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 extraperitonealization q Mesosigmoidoplasty No G.A. No good PEC tube

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 comorbidities and medications q Affects 0.5-1% of patients on ortho, neurosurg & burn units q Mortality > 15% q cecal perforation

ACUTE COLONIC PSEUDO-OBSTRUCTION: management algorithm CT or WSCE or colonoscopy LBO Acute CPO Clinical or Radiologic perforation Resection & stomas Resolution 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) No Resolution X 48 hrs No Resolution 4 Tube cecostomy 1 Supportive care: q IV, NGT, RT q Correct lytes q Stop meds: narcs, anti-chol, Ca ++ blockers, laxatives q Monitor cecum 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