Primary colon resection or Hartmann's procedure in malignant left-sided large bowel obstruction? The use of stents as a bridge to surgery

Abstract

There is still significant debate regarding the best surgical treatment for malignant left-sided large bowel obstruction. Primary resection and anastomosis offers the advantages of a definite procedure without need for further surgery. Its main disadvantages are related to the increased technical challenge and to the potential higher risk of anastomotic leakage that occurs in the emergency setting. Primary resection with end colostomy (Hartmann's procedure) is considered the safer option. Tan et al compared in a systematic review and meta-analysis the use of self-expanding metallic stents (SEMS) as a bridge to surgery vs emergency surgery in the management of acute malignant left-sided large bowel obstruction. The authors concluded that the technical and clinical success rates for stenting were lower than expected. SEMS was associated with a high incidence of clinical and silent perforation. Stenting instead of loop colostomy can be recommended only if the appropriate expertise is available in the hospital. The goal of stenting, a decrease of the stoma rate, may be advocated only if the complication rates of stenting are lower than those of stoma creation in the emergency situation. Until now, this was not demonstrated in a prospective randomized trial. COMMENTARY ON HOT TOPICSThere is still significant debate regarding the best surgical treatment for malignant left-sided large bowel obstruction. In a multicenter German observation study, out of 15 911 patients with cancer of the left colon a total of 743 patients (4.7%) underwent emergency surgery, performed as a radical resection. In 57.9% (n = 430) a one-stage operation, in 11.7% (n = 87) a primary anastomosis with protective stoma, and in 30.4% (n = 226) Hartmann's procedure (HP) were performed [1] . The morbidity and hospital mortality rates (overall hospital mortality, 7.7%, n = 57) did not differ significantly between the groups. With comparable mortality, HP was recommended for high risk patients in the emergency situation. On the basis of a literature search, Trompetas [2] came to a similar conclusion: primary resection with end colostomy (HP) is considered the safest option in malignant left-sided colonic obstruction. The main advantages are that there is no risk of anastomotic dehiscence and the operation can be performed by less experienced and non-specialist surgeons. The main disadvantages of HP are the need for a second major operation to reverse the colostomy, and the fact that 40%-60% of patients do

Safety and Efficacy of Percutaneous Cecostomy/Colostomy for Treatment of Large Bowel Obstruction in Adults with Cancer

“…Endoscopic interventions are widely acknowledged as alternatives to surgery for colonic obstruction. A number of recent studies have established endoscopic stent placement as a valid primary or "bridging" therapy in the setting of malignant bowel obstruction (22)(23)(24)(25)(26). However, as evident in the present study, many patients with cancer are not appropriate candidates for endoscopic stent placement, and some who appear to be may not show any improvement after endoscopic intervention.…”

Painless removal of suction drains

“…It is especially useful for debilitated patients who would not tolerate a midline laparotomy and for malignant disease that requires specialist expertise (that is not immediately available), further staging or neoadjuvant treatment. 2…”

Comparative Study of Postoperative Complications in Patients With and Without an Obstruction Who Had Left-Sided Colorectal Cancer and Underwent a Single-Stage Operation After Mechanical Bowel Preparation

“…Primary resection with an anastomosis offers the advantage of a definite procedure without the need for further surgery. However, the limitations of this procedure are the technical challenge and the potential risk of a high postoperative complication rate, depending on the general preoperative conditions or fecal-loading status of the colon [ 15 ]. The present study revealed that postoperative morbidity for left-colon OB patients who underwent a single-stage operation after on-table lavage did not significantly differ from that for NOB patients, despite the poor preoperative condition of the patients [ 16 ].…”