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Bowel Obstruction –
Investigation and
Management Options
March 10, 2009
Lee Brewster
Toowoomba Base Hospital
Malignant Large Bowel Obstruction
Obstruction of large bowel due to
a malignant neoplastic process
Intramural (eg. Colorectal cancer)
Extramural (eg. Compression from disseminated
peritoneal deposits eg. ovarian cancer)
Epidural blockade
Endoscopic decompression
Manual decompression
Surgery (usually a right hemicolectomy, sometimes
a caecostomy)
Acute Colonic Pseudo-Obstruction:
Indications for surgery
Ongoing caecal distension despite
maximal medical therapy
Caecal tenderness
Perforation
Radiological Investigation
Aimed at confirming the presence
of mechanical obstruction and site
of obstruction
Plain AXR
Water Soluble Contrast Enema
CT with oral / rectal contrast
Flexible Sigmoidoscopy
Colonoscopy
Plain AXR
Easy to obtain
Fast
Gas pattern seen will
depend on the site of
obstruction and if the
ileocaecal valve is
competent
Hard to distinguish
mechanical from
pseudo-obstruction
Water-soluble contrast enema
Distinguishes pseudo-
obstruction from
mechanical obstruction
May be ‘therapeutic’ in
pseudo-obstruction
Barium contra-indicated
Study by Koruth et. al
CT
Getting easier to obtain in many
centres
IV/Oral/Rectal contrast
Provides information about
concurrent metastatic disease /
other pathology
? Sensitivity in diagnosing
pseudo-obstruction
Endoscopy
Flexible sigmoidoscopy /
colonoscopy
Can distinguish pseudo
obstruction from mechanical
obstruction
Visualize any mucosal lesions
distal to the obstruction
Equipment may not be easily
available in the emergency
department / after hours
Management Options
Operative or Non-operative
Curative or Palliative
Decision making based on :
Site of obstruction
Disease load
Patient factors
Available expertise
Institutional facilities
Operative
Management
Operative Management – Additional
Considerations
Periop mortality 2-3 times higher
than elective resections
Morbidity 6 – 40%
Right side vs.. left side
One stage procedures vs..
two/three stage procedures
Perforation / peritonitis
Predictive Factors Mortality of Large
Bowel Obstruction
Biondo et.al
Age> 70 years (>75 up to 5 x increased
risk) – this is associated with increased
co-morbidities
ASA score III – IV
Preoperative renal failure (creat > 120
umol/L)
Presence of proximal colon damage
(ischaemic or necrotic lesions) with or
without peritonitis
Perforation (up to x4 increased mortality)
:
Operative Management
Debated Issues
Previously, debate centred around
whether primary resection of tumour
(Hartmann's’) or simple decompression
was the management of choice at initial
presentation
Subsequent debate about primary
anastomosis vs.. two – stage
procedures
Increasing evidence and trend towards
primary resection and anastomosis in
appropriate patients in high – volume
centres
Operative Management: Left sided malignant large bowel obstruction
Three-stage procedure
Standard approach until 1970’s /
1980’s
Defunctioning colostomy – usually
transverse (stage 1), Resection of
tumour (stage 2), Closure of
colostomy (stage 3)
Advantages:
Defunctioning colostomy a
relatively minor procedure in an
unstable patient
Operative Management: Left sided malignant large bowel obstruction
Three-stage procedure
Disadvantages
Transverse colostomy difficult to
manage and has a higher rate
parastomal hernia
Many patients not fit enough to
have further surgery
Mortality rates from 3 procedures
combined (20% in 1970’s – 11-
12% 1980’s)
Longer combined hospital stay
(30 – 55 days)
Operative Management: Left sided malignant large bowel obstruction
Advantages:
Tumour is resected at first operation
Anastomosis with its associated risks
avoided
Shorter time on operating table
Operative Management: Left sided malignant large bowel obstruction
Single-stage procedures
Resection of tumour and primary
anastomosis in one procedure
Subtotal colectomy with ileo-colic
or ileo-rectal anastomosis, or
Segmental colectomy and colo-
colic/rectal anastomosis
Much evidence suggests that in
appropriate circumstances, it is no
more hazardous than resections
for right sided tumours
Lee et al, Hsu
Operative Management: Left sided malignant large bowel obstruction
Single-stage procedures
Advantages
Avoids stoma
Decreased cumulative mortality
compared with multi-stage
procedures
Avoids need for further surgery in
patients with incurable disease
Decreased cumulative hospital
stay
Operative Management: Left sided malignant large bowel obstruction
Single-stage procedures
Disadvantages
Risk associated with anastomosis
Theoretically, higher risk of
anastomotic complications in an
unprepared, obstructed colon.
Not suitable for unstable patients
Requires confidence with
procedure
Longer operating time
Single-Stage Operations for Left sided obstruction:
Segmental Colectomy
Usually performed with on-table
lavage or manual decompression
of proximal colon
Anastomotic leak rate 4 – 8 %
Perioperative mortality 10%
Proximal bowel needs to be viable
Less diarrhoea than subtotal
Single-Stage Operations for Left sided obstruction:
On-table lavage vs. manual decompression
Theoretically a higher risk of
anastomotic complications when
colon is dilated and unprepared :
Decompressed colon reduces tension on
anastomosis
Anastomotic collagen metabolism and healing may be
compromised if faecal material is incorporated into the
anastomosis
Palliation
Liver mets present in 27%
Presence of liver metastases should not
preclude palliative resection if it is possible
Disseminated intraperitoneal metastases
present a difficult problem
Options:
As previously discussed
Bypass surgery (eg. Ileo-transverse colon
bypass)
Defunctioning stoma / caecostomy (used
rarely)
Non-Operative
Management
Non Operative Management
Complications
Perforation : 5%
Immediate or delayed
More common in left colon
Increased risk if subsequent radiotherapy
May cause dissemination of an otherwise
resectable tumour
Most important risk factor is balloon dilatation
Migration 11 – 40%
Bleeding
Abdominal pain
Diarrhoea
Non-Operative Management: SEMS
Complications
Failure to achieve decompression
– 6%
Late recurrence of obstruction 4 –
25%– (tumour ingrowth)
Non Operative Management : SEMS
Advantages – Palliative
Allows time to stabilise / further
evaluate patient for curative
resection
Avoid unnecessary surgery in
patients with unresectable /
disseminated disease
Shorter Hospital stay
Non Operative Management : SEMS
Advantages - Palliative
Lower procedural related mortality
Fewer medical complications
Reduced stoma formation
Non Operative Management : SEMS
Disadvantages - Palliative
In patients who are otherwise
healthy apart from their locally
advanced disease, stent insertion
may be more likely to complicated
by tumour ingrowth
?Better treated by palliative
resection after relief of initial
obstruction in patients with a
longer life expectancy
Covered Stents
Non-Operative Management : SEMS
Farrell, J, et al. Pre-operative colonic stenting: how, when and why?. Endoscopy
2007: 23; 544 – 549.
Koruth NM, et. al. The place of contrast enema in the management of large bowel
obstruction. J R Coll Surg Edinb 1985: 30: 258 – 260.
The SCOTIA Study Group. Single stage treatment for malignant left sided colonic
obstruction: a prospective randomised clinical trial comparing subtotal
colectomy with segmental resection following intraoperative irrigation. Br J
Surg 1995; 82: 1622-7.
References
Jiang, JK et. al Primary vs Delayed Resection for Obstructive Left-Sided Colorectal
Cancer: Impact of Surgery on Patient Outcome. Dis Colon Rectum 2008. 51;
306 – 311
Hsu, T. One-Stage Resection and Anastomosis for Acute Obstruction of the Left
Colon. Dis Colon Rectum. 1998 41: 28 – 32
Pain, J and Cahill, J. Surgical Options for left-sided large bowel emergencies.
Annals of Royal College of Surgeons of England. 1991. 73: 394 – 297.
Carty, N and Corder, A. Which surgeons avoid a stoma in treating left-sided colonic
obstruction? Results of a postal questionnaire. Annals of the Royal College of
Surgeons of England. 1992: 74; 391 – 394.