Surgery For Colorectal Cancers During COVID-19 Pandemic at SGE, Max Hosp...

Surgery for colorectal cancer (CRC) with first presentation as bowel obstruction

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 8^th and rectal cancer as 9^th among men and amongst women colon cancer ranks 9^th 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 5^th 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 8^th 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 8^th 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  

5.      Winner M, Mooney SJ, Hershman DL et al. Management and outcome of bowel obstruction in patients with stage IV colon cancer. Dis Colon Rectum. 2013 Jul; 56(7): 834–843.

6.      Wong SK¹, Jalaludin BB, Morgan MJ. Tumor pathology and long term survival in emergency colorerectal cancer. Dis Colon Rectum. 2008 Feb;51(2):223-30

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

www.gicancerindia.com

Outcomes of Colorectal Surgery (CRS) at Department of Surgical Gastroenterology, Max Hospital (Saket): International quality at affordable Indian costs

Our team attended annual conference of the Society of American Gastrointestinal & Endoscopic Surgeons (SAGES) held at Baltimore, USA April 2019. We presented 3 studies including one entitled ‘Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator^’.¹

In the following section we share some of the highlights of this study.

A recent study published in New England Journal of Medicine examined 30 -day readmission data of 479,471 patients from 3004 USA hospitals undergoing six major surgical procedures (colectomy and 5 other surgical procedures). The study concluded that following major surgical procedures, nearly one in seven patients are readmitted to the hospital within 30 days of discharge and readmission data is an indicator of quality of surgical care at any hospital.²

We therefore performed audit of colorectal surgery (CRS) outcomes at our department using American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) risk calculator - one of the most widely utilized and validated universal risk calculator for clinical audits.

The ACS NSQIP risk calculator was developed by utilizing data collected from 4.3 million operations performed across 780 hospitals participating in ACS NSQIP to predict outcomes for 1500 surgical procedures. The risk calculator estimates an individual’s risk of developing 18 different complications within 30 days after surgery.

The risk adjusted scoring systems such as ACS NSQIP risk calculator are important because in heterogeneous cohorts of surgery patients, crude postoperative morbidity and mortality as an outcome measure is misleading. Therefore, for meaningful conclusions from clinical audits and compare outcomes between different units or regions, risk adjusted patient outcomes are essential.

Our single centre observational study included 86 consecutive adult (≥ 18 years) patients who underwent elective or emergency, resective &/or reconstructive CRS from March 2013 to March 2018. Procedures such as appendicectomy, diverting colostomy, laparoscopic rectopexy were excluded from analysis. Data was accessed from institutional electronic health record system and pre-anaesthetic charts. ACS – NSQIP score for each patient was calculated. Actual outcomes were then compared with those predicted by risk calculators.

Of the 86 patients (60 Indians and 26 International) there were 56 males and 30 females with a mean age of 57 (range 18-93) years. Of these 59 (68.6%) underwent elective whereas 27(31.4%) had emergency CRS. We performed complete range of procedures for cancer as well as benign diseases. Sixty-two (72%) and 24 (38%) patients underwent open and minimally invasive procedures (laparoscopic -21 and robotic -3) respectively. The median length of stay was 08 (range 02-40) days. The mortality following elective and emergency operations was 1/59 (1.6%) and 8/27(29.6%) respectively. The readmission rate was 05 (5.8%)

Objective comparison between overall actual outcomes and those predicted by ACS – NSQIP risk calculator revealed no statistically significant difference in any of the parameters studied such as mortality, major complication, anastomotic leak, return to OT, surgical site infection length of stay, and readmission (Figure 1). 

Figure 1. Actual versus predicted outcomes by ACS-NSQIP risk calculator

Additionally there is significant cost advantage - all-inclusive costs of surgery (admission to discharge) were one fifth of the costs incurred for colectomy at comparable US NSQIP hospitals (Figure 2).

Figure 2. Comparison of costs for Colectomy at MSSH & US NSQIP hospitals

In conclusion at Department of Surgical Gastroenterology, Max Super Speciality Hospital, Saket outcomes of colorectal surgery are comparable to best of international centres - US NSQIP hospitals at affordable Indian costs.

References:

1. Vashistha N, Verma A and Singhal D. Outcomes following colorectal surgery: A comparative study CR-POSSUM and ACS-NSQIP risk calculator. Surg Endosc. 2019;33:S241

2. Tsai TC, Joynt KE, Orav EJ et al. Variation in surgical readmission rates and quality of hospital care. N Engl J Med 2013;369:1134-42

      

      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

www.gicancerindia.com

Tips & Tricks for Safe Anastomosis in Minimally Invasive Colorectal Surgery

Part B.   Intraoperative assessment of anastomotic integrity

This is second part in series of the blog 'Tips & tricks for safe anastomosis in minimally invasive colorectal surgery' (https://gicancerindia.blogspot.com/2019/07/tips-tricks-for-safe-anastomosis-in.html).

Anastomotic leak (AL) is the most feared complication of colorectal anastomosis (CRA) with a reported incidence of 8.1% after right hemicolectomy and 5.8% after high anterior resection and 10.8% after low anterior resection¹.

The attributes of 'Safe' intestinal anastomosis include tension free anastomosis between well vascularised bowel segments. In the era of open surgery, surgeons assessed the latter by a combination of observation (' healthy' color and pulastile bleeding at cut end of the bowel) and palpation (arterial pulsations in the mesocolon). In MIS, options available to the surgeons are more limited and viability of the colon following resection and subsequent anastomosis is determined largely by observing the color.

However the predictive accuracy of surgeons' clinical risk assessment for AL is reported to be low and is not influenced by training level (surgeon versus assistant surgeons)².

To make this assessment less observer dependent and to more objectively assess anastomotic integrity and tissue perfusion, several intraoperative tests have been introduced in clinical practice over last few years.

1.       Intraoperative air leak test (ALT): For left sided anastomosis, the test is simple and performed by insufflating the rectum with air while submerging the anastomosis³.

2.       Intraoperative flexible sigmoidoscopy for assessment of colorectal anastomosis (CRA): This is a safe and reliable method for direct assessment of anastomotic integrity as well as bleeding ⁴. More commonly performed in units where surgeons themselves are trained to perform colonoscopy.

3.       Intraoperative Indocyanine Green (ICG) fluorescence imaging: Intraoperative ICG imaging is a simple reproducible technique for real time assessment intestinal perfusion ¹. The data from non randomized studies on the subject suggests decreased anastomotic leak following ICGA^5,6. However results of a recent multicenter randomized controlled trial from Italy suggests that while ICGA can effectively assess vascularisation of the colic stump and anastomosis and led to further proximal resection in 11% of patients, there was no statistically significant reduction of anastomotic leak in the ICGA arm² . Further one multicenter phase II trial investigating the role of ICG imaging in elective CRS has reported that while the technique helped reduce AL rates in left sided resections  - particularly LAR, it did not add any value to outcomes following  ileocolic anastomoses ¹ .

Comments: We routinely do the intraoperative ALT for left sided anastomoses. For the right side, we perform extracorporeal anastomosis and have not introduced ICG fluorescence imaging. For elective CRS the overall AL in our unit is 5.08%

References:

1.       Ris E, Liot E, Buchs NC et al Multicenter phase II trial of near infrared imaging in elective colorectal surgery Br J Surg 2018;105:1359-1367

https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.10844

2.       Karliczek A, Harlaar NJ, Zeebregts CG et al. Surgeons lack predictive accuracy for anastomotic leakage in gastrointestinal surgery. Int J Colorectal Dis 2009;24(5):569-76

https://link.springer.com/article/10.1007%2Fs00384-009-0658-6

3.       Monson JR, Weiser MR, Buie WD et al. Practice parameters for the management of rectal cancer (Revised) Dis Colon Rectum. 2013;56(5):535-50.

https://journals.lww.com/dcrjournal/fulltext/2013/05000/Practice_Parameters_for_the_Management_of_Rectal.2.aspx

4.       Kamal T, Pai A, Velchuru VR et al. Should anastomotic assessment with flexible sigmoidoscopy be routine following laparoscopic restorative left colorectal resection? Colorectal Dis 2015;17(2):160-4

https://onlinelibrary.wiley.com/doi/abs/10.1111/codi.12809

5.       Shen R, Zhang Y, Wang T Indocyanine Green Fluorescence Angiography and the incidence of anastomotic leak after colorectal resection for colorectal cancer: A Meta Analysis. Dis Colon Rectum 2018;61(10):1228-1234

https://journals.lww.com/dcrjournal/fulltext/2018/10000/Indocyanine_Green_Fluorescence_Angiography_and_the.17.aspx

6.       Blanco-Colino R, Espin –Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta- analysis. Tech Coloproctol 2018;22(1):15-23

https://link.springer.com/article/10.1007%2Fs10151-017-1731-8

7.       Nardi De, Elmore U, Maggi G et al. Intraoperative angiography with indocyanine green to assess anastomosis perfusion in patients undergoing laparoscopic colorectal resection: results of a multicenter randomized controlled trial. Surg Endosc 2019;doi:10.1007/s00464-019-06730-0

https://link.springer.com/article/10.1007%2Fs00464-019-06730-0

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

www.gicancerindia.com