Emergency General Surgery

IKEA’s Instructions for Building Noah’s Ark

If you dam a river it stagnates. Running water is beautiful water. So be a channel.

English Proverb

Hello guys… Today we are going to talk about a common surgical problem, which is the emergency presentation of a more complex and challenging pathology…

But let’s start with a typical clinical case…

It’s about 6 PM, and your shift in the Surgery Department will finish in 2 hours. The ED doctor rings you up for a new patient. It’s about a 65 yo man, without a particular medical history, who’s complaining about abdominal distension and constipation evolving since 3-4 days, and a vomiting episode this morning.

On clinical examination, the abdomen is distended, with tenderness on the right lower quadrant and hyperactive bowel sounds. Rectal digital exploration reveals an empty and wide ampulla, with traces of liquid stool on the glove.

Laboratory exams: Hb 11.4 g/dL; WCC 12’300/mm3; CRP 4 mg/dL, Creat 1.4 mg/dL.

A plain abdominal X-ray shows abnormal colic distension.

And Now? How do you go on? Which exams do you think will be useful for diagnosis?

Introduction

In our clinical practice, this is the typical presentation of left-sided malignant colon obstruction. The emergency outset is not uncommon if we consider that 30% of colorectal cancer presents in that way, and that large bowel obstruction represents about 80% of colorectal cancer emergencies.

Considering presenting signs and symptoms, abdominal pain and distension, inability to pass stool or flatus, nausea and vomiting are the most common. Another frequent sign is the change of bowel movements (absence or hyperactivity). In the case of rectal obstruction, the lesion can be palpable during the rectal digital exploration.

Laboratory test results alterations, if present, are those typical for intestinal obstruction (e.g. electrolyte imbalances, acute renal failure, and metabolic alkalosis consequent to recurrent vomiting and dehydration).

When a patient with a story of constipation arrives with an acute clinical picture, the differential diagnosis is between a benign cause, such as bowel volvulus, diverticular sigmoiditis, adhesive bowel obstruction, and a malignant one. In this second hypothesis, knowing the level of the neoplastic obstruction is mandatory to choose the correct therapeutic pathway.

The first imaging that may be used in the ED should be an ultrasound (US). We do not advocate the use of plain abdominal X-ray because cannot give you any of the information you need. Remember that if you are not proficient with the use of US and you want to exclude the presence of bowel perforation, a chest X-ray is far better than a plain abdominal X-ray to make the diagnosis.

However, the contrast-enhanced abdominal CT scan is certainly the gold standard because it’s able to provide a lot of information: cancer localization, possible cancer-related complications (e.g. grade of bowel dilatation, perforation, bleeding), and cancer staging.

Neoplastic large bowel obstruction has always a surgical indication, but the surgical strategy can significantly vary upon tumor localization and patint’s general clinical conditions.

Let’s take a look!

Obstructive Right-Sided Colon Cancer

For right colon cancers with an obstructive presentation, the management is quite simple: a right colectomy with primary anastomosis should be the first option. For many reasons, this procedure has a low risk of complications. First of all, the hepatic flexure is usually easy to mobilize; second, performing an ileocolic anastomosis doesn’t require adjunctive surgical maneuvers, thanks to the mobility of the small bowel; third, the ileocolic anastomosis benefits from an optimal blood supply. There are many anastomotic techniques, including hand-sewn and stapled sutures. A recent ESCP snapshot audit of 3208 patients reported a slightly increased anastomotic leak rate from stapled anastomoses. Moreover, in an emergency setting, the leak rate is important, exceeding 14%. Advanced age, ASA III-IV, and preoperative renal failure appear to be risk factors for the anastomotic leak in an Asiatic population study.

In general, in patients with “heavy” comorbidities and advanced age, the opportunity of a primary ileocolic anastomosis must be carefully evaluated, in alternative to colic resection and terminal ileostomy along with colonic fistula. In this second option, the major postoperative risk is electrolyte imbalance.

In the case of advanced-staged cancer with intra-abdominal tumor dissemination and/or direct infiltration of other viscera, the simplest and the least invasive solution could be an internal ileocolic bypass.

An endoscopic metal stent is indicated only in a few cases and has very limited application in expert hands.

Obstructive Left-Sided Colon Cancer

For left colon cancer obstruction, the management becomes more complex.

The first option, if the patient is hemodynamically stable, is to determine the precise site of colonic obstruction with endoscopy. This allows making biopsies, especially when surgery is not expected in the very short term.

The subsequent strategy depends on curative or palliative intent.

In a palliative context, with unresectable tumors and/or peritoneal carcinomatosis, self-expandable metallic stent (SEMS) placement is the treatment of choice and it should be preferred to colostomy because it is associated with similar mortality and morbidity rates, but a shorter hospital stay. When chemotherapy with bevacizumab is possible, an alternative to SEMS should be considered, because of the high risk of tumor perforation during the therapy.

Conversely, when the aim is curative, we have more surgical solutions. In the absence of risk factors, colon resection with primary anastomosis should be the preferred option for uncomplicated left-sided colon malignant obstruction. In this case, it is indicated to clean up the colon intra-operatively. In this setting, two procedures are possible: colonic irrigation, usually performed through the appendicular base (after the appendectomy, of course!) in an anterograde way; or manual decompression, which is a shorter and simpler procedure. In both cases, surgeons must pay attention not to contaminate the abdominal field during the procedure. To avoid contamination, homemade solutions are usually adopted, for example connecting a plastic bag (e.g. laparoscopic camera or ultrasound probe cover) to the colon in order to empty the content directly in the waste bin.

In the emergency setting, when patients have a high surgical risk for anastomotic leak, the best intervention is the Hartmann’s procedure. The Hartmann’s procedure should be preferred to simple colostomy because the latter is associated with a longer overall hospital stay and the need for multiple operations since it does not provide resection of the tumor.

For all procedures, the laparoscopic approach cannot be always recommended as the first choice but should be reserved for specialized centers.

The use of SEMS as a bridge to surgery in curative intent has been considered in the last 20 years. Several RCT and meta-analyses compared SEMS to emergency surgery in patients with left-sided colon cancer obstruction. The results demonstrated that SEMS offers a better short-term outcome than surgery. In fact, the complications are comparable, but the long-term stoma rate is significantly inferior in the SEMS arm. Moreover, SEMS enables a laparoscopic approach for the subsequent elective surgery. On the other hand, oncologic long-term results remain uncertain. Some studies suggest that the use of SEMS could increase the rate of tumor ulceration, perineural invasion, lymph node invasion, and, above all, the risk of tumor perforation, which may affect long-term survival. However, the debate of which one is the best option has not been settled yet.

Another possible clinical presentation is the association of left-sided obstruction and right-sided diastatic perforation, usually involving the caecum. In this case, surgery is mandatory and both issues must be solved during the same procedure. To achieve this, a subtotal colectomy with an ileorectal anastomosis is usually required.

Obstructive Rectal Cancer

When the cancer obstruction involves the extra-peritoneal rectum, the therapeutic strategy changes again. As a matter of fact, obstructive rectal cancer is locally advanced by definition. At this stage, as known, the best choice is a multimodal approach, and neoadjuvant chemoradiotherapy is commonly indicated.

In case of acute obstruction, resection of the primary tumor should be avoided in favor of a decompressive stoma to allow a prompt beginning of the neoadjuvant therapy and to limit possible local complications during the entire treatment. A right-sided loop transverse colostomy appears to be the best option. In fact, if the ileocecal valve is continent, a loop ileostomy cannot solve the colonic distension and its consequent risk of diastatic perforation. Moreover, this type of colostomy, compared with a sigmoidostomy, can be left in place as protecting diversion after planned rectal resection.

The use of SEMS is contraindicated in the rectum, because of its high risk of migration and its associated symptoms, such as chronic pain and tenesmus.

Flowchart by Pisano M, et al.
Unstable Patients

When we face instability in clinical conditions, damage control (DC) strategies must be considered. The damage control approach is targeted to restore the normal patient physiology and not to provide definitive treatment (the basic principles are the same as in trauma surgery; Find it out here).

We can define as unstable a patient with at least one of the following clinical findings:

  • pH <7.2;
  • BE <-8;
  • Core temperature <35 °C;
  • Laboratory or clinical evidence of coagulopathy;
  • Signs of sepsis or septic shock, including the necessity of inotropic support.

These conditions constitute the so-called “lethal triad” (i.e. acidosis, hypothermia, coagulopathy; Read our previous post if you want to know more). This situation, in association with septic conditions, identifies decompensated patients. The reasons behind the hemodynamic instability can be recognized in fluid and electrolyte imbalances, bacterial overgrowth with translocation across the intestinal wall, peritonitis, and associated pre-existing medical comorbidities.

The main goal of damage control surgery (DCS) is to remove the cause of the instability (i.e. bowel obstruction and peritoneal contamination). Even if this should be achieved as soon as possible, the patient needs to be adequately resuscitated first. In fact, differently from the trauma setting, the application of DCS in septic patients requires an initial period of resuscitation to prevent hemodynamic instability during the induction of anesthesia. In 6 hours top, we must re-establish adequate organ perfusion and start broad-spectrum antibiotic therapy (For more information on sepsis management Click Here).

When performing DCS in patients with colonic cancer obstruction, we have different options depending on cancer localization. The basic treatment is always colonic resection, and it may be associated either with a terminal ostomy (ileostomy for right colectomy, colostomy in case of Hartmann’s procedure) or with an open abdomen. In all cases, anastomosis should not be performed, because of the high risk of anastomotic leakage and the prolonged surgical times.

After an open abdomen, the planned relook laparotomy should be performed in 24-48 h and the definitive abdominal closure should be achieved within 7 days from the first operation.

Finally, it is important to emphasize that, in the case of DCS, intraoperative communication between surgeon, anesthetist, and nurses is essential to decide together the best therapeutic approach to the patient.

That’s it!

We hope that now you are ready to adequately manage a patient with colorectal obstruction.

See you next time for a new post!

References
  1. Pisano M, et al. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018;13:36.
  2. Miller AS, et al. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021;23:476-547.
  3. Veld JV, et al. Definition of large bowel obstruction by primary colorectal cancer: A systematic review. Colorectal Dis 2021;23:784-804.
  4. Ramsay G, et al. Causes of death after emergency general surgical admission: population cohort study of mortality. BJS Open 2021;DOI: https://doi.org/10.1093/bjsopen/zrab021.
  5. Arezzo A, et al. Stent as bridge to surgery for left-sided malignant colonic obstruction reduces adverse events and stoma rate compared with emergency surgery: results of a systematic review and meta-analysis of randomized controlled trials. Gastrointest Endosc 2017;86:416-26.
How to Cite This Post

Parini D, Bellio G, Marrano E. Ikea’s Instructions for Building Noah’s Ark. Surgical Pizza. Published on June 12, 2021. Accessed on July 31, 2021. Available at [https://surgicalpizza.org/emergency-surgery/ikea-instructions-for-building-noah-ark/].

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