According to international statistics, colorectal
cancer (CRC) is the third most commonly diagnosed cancer in males and second in
females.1 However in India lies, the incidence is lower as compared in
Europe and North America. According to ICMR consensus document on management of
CRC (2014), colon cancer ranks as 8th and rectal cancer as 9th
among men and amongst women colon cancer ranks 9th while cancer rectum
does not figure in top 10 cancers.
First presentation of CRC as emergency – obstruction,
perforation or bleeding is not uncommon. Malignant large bowel obstruction is
reported in 8-13% patients with CRC In Western studies.2,3 Another
multicentre study from UK involving 286591 patients over a 15 year period (1997
– 2012) reported that 24.3%
(69718 patients) needed emergency for CRC and all cause 30 and 90 day mortality
was significantly higher in patients undergoing emergency surgery as compared
to elective surgery.4
Management of
such patients is particularly challenging as they are often elderly with
significant comorbidity and histopathologic diagnosis may not be unavailable.
At surgery large bowel may be hugely distended and complex resections may be
required.
In the following sections, we briefly discuss the
management CRC presenting as emergency through a representative case series of
patients wherein the first presentation was obstruction or perforation.
Case study 1
An elderly woman in her 5th decade
presented with acute intestinal obstruction. Her contrast enhanced abdominal
computed tomography (CT) scan showed mass lesion in cecum – ascending colon
(Figure 1).
Figure 1. Carcinoma right colon with
acute
Intestinal obstruction
She underwent right hemicolectomy with primary anastomosis
and had an uneventful recovery. The biopsy was suggestive of adenocarcinoma
T3N1. She was stared on adjuvant chemotherapy after 3 weeks and is currently
well 4 years after surgery.
Case study 2
An elderly woman in her 8th decade
presented with 6 months history of weight loss and progressive constipation
that for last 4 days had progressed to obstipation. There was no major comorbid
illness and prior to obstipation she was managing her daily activities. Her
abdominal CT scan revealed obstructing lesion in rectosigmoid region with
closed loop obstruction. There were multiple colorectal liver metastases in
segment 2 & 3 (Figure 2 & 3).
Figure 2. Abdominal CT
scan with distended left colon and CLM
Figure 3. Abdominal CT
scan showing closed obstruction of large bowel
At surgery, the whole of whole of large bowel was
massively distended but the cecum was viable. Anterior resection with ascending
colostomy was done. She opted for colostomy closure 8 weeks later but declined further
chemotherapy. Following this second surgery she was restored to good quality of
life and passed away 16 months later.
Case study 3
An elderly male with history of weight loss and
progressive constipation presented to emergency room. He was a known diabetic
and had undergone coronary bypass 1 year ago had low ejection fraction (35%).
Abdominal CT scan is provided in Figure 4. The total white blood cell count was
39,000 mm3
Figure 4. Closed loop obstruction of large bowel with
hugely distended cecum
At surgery, there was an obstructing mass lesion in
sigmoid colon with infiltration of dome of urinary bladder. The cecum appeared
gangrenous. A subtotal colectomy with partial cystectomy was performed.
Reconstruction was by an ileorectal anastomosis with diverting loop ileostomy.
He had an uneventful postoperative recovery and was discharged on 8th
postoperative day. The biopsy reported adenocarcinoma sigmoid colon T4N1 with
all clear surgical margins. The ileostomy was successfully reversed 8 weeks
later.
Discussion
A US study (1991 – 2005) involving 1004 patients ≥65
years with stage IV colon cancer reported that obstruction occurred a median of
7.4 months after colon cancer diagnosis and median survival after obstruction
was approximately 2.5 months.5 Risk factors for presentation with
obstruction included proximal location, high grade tumor, mucinous histological
type and nodal stage N2.3 Another study from Australia has reported
that emergency patients had 5 year survival rate of 39. 2% compared to 64.7%
for elective patients (p< 0.0001) and they also had significantly more
advanced Dukes C & D tumors. Also both emergency Dukes B and C groups had significantly more T4
cases.6
The current treatment options for MLBO include:
1.
Endoscopic stenting with self expanding metallic stent (SEMS)
placement
Endoscopic stenting with SEMS can be
used as a palliative therapy in patients with unresectable primary or
metastatic disease. For patients with malignant large bowel obstruction where a
curative surgery is deemed feasible SEMS is used as a bridge to definitive
surgery thereby avoiding risks of emergency surgery, higher chances of primary
anastomosis and avoiding permanent stomas
in 30-40% patients.7.8 However SEMS placement may result in
perforation rates ranging between 6.9 – 7.7%.8,9
2.
Surgery: This may be done as one, two or 3 stage procedure:
-
Single stage procedure: Oncologic resection + primary
anastomosis.
This is generally acceptable for obstructing carcinoma on the right side
and in select patients on left side in the form of subtotal colectomy with
ileorectal anastomosis.
-
Two stage – (i) Oncologic resection with anastomosis +
proximal diverting stoma (ii) stoma closure
-
Three stage – (i) Proximal diverting stoma (ii) oncologic
resection of the tumor(iii) stoma closure
The choice of treatment depends on the usual
combination of patient factors (e.g. age, comorbidity, hemodynamic stability,
patient preference etc), tumor factors (stage, location, degree of obstruction
– partial or complete, condition of the proximal bowel e.g. bowel dilatation,
viability of cecum) and available local expertise.
Hence for optimal immediate and oncological outcomes
such patients should always be managed by surgical teams experienced in GI
oncosurgery as well as emergency GI surgery.
References
1. Torre LA1, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics
2012. CA Cancer J Clin. 2015 Mar;65(2):87-108
2. Jeanin
E. van Hooft, Joyce V. Veld, 2, Dirk Arnold et al. Self-expandable
metal stents for obstructing colonic and extracolonic cancer: European Society
of Gastrointestinal Endoscopy (ESGE) Guideline –
Update 2020. Endoscopy
3. Winner
M, Mooney SJ, Hershman DL et al. Incidence and predictors of bowel obstruction
in elderly patients with stage IV colon cancer. JAMA Surg 2013;148(8):715-22
4. Askari A, Nachiappan S, Currie A et al. Who requires
emergency surgery for colorectal cancer and can national screening programs
reduce this need. Int J Surg 2017;42:60-68
7. Hsu
J, Sevak S. Malignant large bowel obstruction. Dis Colon Rectum 2019; 62:
1028–1032
8. Amelung FJ, Borstlap WAA, Consten ECJ et al. Propensity
score-matched analysis of oncological outcome between stent as bridge
to surgery and emergency resection in patients
with malignant left-sided colonic obstruction. Br J Surg
2019;106:1075-1086
9. Tan CJ, Dasari BV, Gardiner K Systematic review and meta-analysis
of randomized clinical trials of self-expanding metallic stents as a bridge to
surgery versus emergency surgery for malignant left-sided large bowel
obstruction. Br J Surg 2012;99:469-76
Authors:
Dr Nitin Vashistha, MS, FIAGES, FACS
Dr Dinesh Singhal, MS, FACS, DNB (Surg Gastro)
Department of Surgical Gastroenterology,
Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com
