Two-Stage Operations in Patients with Acute Right-sided Colonic Obstruction: a 15-year Single Institution Experience

Nien-Ying Tsai; Chun-Wei Yu; Cheng-Wen Hsiao; Shu-Wen Jao; Cheng-Hsiang Lo; Chih-Wei Yang; Yi-Chiao Cheng

doi:10.20883/medical.e732

Authors

Nien-Ying Tsai Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Chun-Wei Yu Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Cheng-Wen Hsiao Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Shu-Wen Jao Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Cheng-Hsiang Lo Department of Radiation Oncology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Chih-Wei Yang Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
Yi-Chiao Cheng Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

DOI:

https://doi.org/10.20883/medical.e732

Keywords:

colon cancer, ileostomy, obstruction, two-stage resection

Abstract

Objective

The aim of the study was to review the characteristics, surgical outcomes, complications, and long-term outcomes of two-stage operations for acute right-sided colonic obstruction (RSCO) in a single institution.

Summary background data

Although patients with acute RSCO can be treated by resection of the tumor with a primary anastomosis, longer procedure times and bigger wounds can result in more mortality and complications. A two-stage operation by diverting loop ileostomy was another surgical option. However, the outcomes of two-stage operations are lacking.

Methods

The retrospective study reviewed the patients who underwent emergency surgery for acute RSCO in a tertiary center from 2004-2018. First-stage operations other than diverting loop ileostomy, incomplete obstructions that could be treated medically, or pathologies other than adenocarcinomas were excluded. Perioperative data such as first and second operations, operative times, lengths of stay, harvested lymph nodes, and any complications were included. We assessed overall survival (OS) and disease-free survival (DFS) for the oncologic outcomes.

Results

Sixty-nine patients were included. Seven patients had surgical complications related to ileostomy. Three of them died within 30 days of first admission. Thirty-one patients received a second-stage operation by right hemicolectomy. None had anastomosis leakage or 30-day mortality. Only 9.7% of patients had fewer than 12 harvested lymph nodes. One-year OS was 34% in the patients who received only ileostomy, and 89% in those who received two-stage operations (P < 0.001). Among 26 patients who underwent curative resection of tumor, 3-year DFS was 61.5%.

Conclusions

A two-stage operation is associated with low mortality and morbidity rates in an emergency setting. The subsequent right hemicolectomy can harvest more lymph nodes than emergency resection. Long-term survival benefits can be expected.

Downloads

Download data is not yet available.

References

The Global Cancer Observatory. (2019). Available at: https://gco.iarc.fr/today/data/factsheets/cancers/10_8_9-Colorectum-fact-sheet.pdf.

Faucheron JL, Paquette B, Trilling B, Heyd B, Koch S, Mantion G. Emergency surgery for obstructing colonic cancer: a comparison between right-sided and left-sided lesions. Eur J Trauma Emerg Surg 2018;44:71-7.

Aslar AK, Ozdemir S, Mahmoudi H, Kuzu MA. Analysis of 230 cases of emergent surgery for obstructing colon cancer--lessons learned. J Gastrointest Surg 2011;15:110-9.

Pisano M, Zorcolo L, Merli C, Cimbanassi S, Poiasina E, Ceresoli M, Agresta F, Allievi N, Bellanova G, Coccolini F, Coy C, Fugazzola P, Martinez CA, Montori G, Paolillo C, Penachim TJ, Pereira B, Reis T, Restivo A, Rezende-Neto J, Sartelli M, Valentino M, Abu-Zidan FM, Ashkenazi I, Bala M, Chiara O, De' Angelis N, Deidda S, De Simone B, Di Saverio S, Finotti E, Kenji I, Moore E, Wexner S, Biffl W, Coimbra R, Guttadauro A, Leppaniemi A, Maier R, Magnone S, Mefire AC, Peitzmann A, Sakakushev B, Sugrue M, Viale P, Weber D, Kashuk J, Fraga GP, Kluger I, Catena F, Ansaloni L. 2017 WSES guidelines on colon and rectal cancer emergencies: obstruction and perforation. World J Emerg Surg 2018;13:36.

Lyra A, Forssten S, Rolny P, Wettergren Y, Lahtinen SJ, Salli K, Cedgard L, Odin E, Gustavsson B, Ouwehand AC. Comparison of bacterial quantities in left and right colon biopsies and faeces. World J Gastroenterol 2012;18:4404-11.

Cuffy M, Abir F, Audisio RA, Longo WE. Colorectal cancer presenting as surgical emergencies. Surg Oncol 2004;13:149-57.

Mege, Diane, et al. "Surgical management of obstructive right-sided colon cancer at a national level results of a multicenter study of the French Surgical Association in 776 patients." European Journal of Surgical Oncology 44.10 (2018): 1522-1531.

Gessler B, Eriksson O, Angenete E. Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. International journal of colorectal disease 2017;32:549-56.

Nors J, Sommer T, Wara P. Leakage Rate After Laparoscopic Ileocolic Intracorporeal Anastomosis. J Laparoendosc Adv Surg Tech A 2018;28:1287-93.

Vasiliu EC, Zarnescu NO, Costea R, Neagu S. Review of Risk Factors for Anastomotic Leakage in Colorectal Surgery. Chirurgia (Bucharest, Romania : 1990) 2015;110:319-26.

Nasiri S, Mirminachi B, Taherimehr R, Shadbakhsh R, Hojat M. The Effect of Omentoplasty on the Rate of Anastomotic Leakage after Intestinal Resection: A Randomized Controlled Trial. The American surgeon 2017;83:157-61.

Chiorean, E. Gabriela, et al. Treatment of patients with late-stage colorectal cancer: ASCO resource-stratified guideline. JCO Global Oncology 6, 2020: 414-438.

Rajan, Ruben, and David A. Clark. Current management of large bowel obstruction: a narrative review. Annals of Laparoscopic and Endoscopic Surgery, 2022, 7.

Gainant, A. Emergency management of acute colonic cancer obstruction. Journal of visceral surgery, 2012, 149.1: e3-e10.

Basili G, Lorenzetti L, Biondi G, Preziuso E, Angrisano C, Carnesecchi P, Roberto E, Goletti O. Colorectal cancer in the elderly. Is there a role for safe and curative surgery? ANZ J Surg 2008;78:466-70.

Finan PJ, Campbell S, Verma R, MacFie J, Gatt M, Parker MC, Bhardwaj R, Hall NR. The management of malignant large bowel obstruction: ACPGBI position statement. Colorectal Dis 2007;9 Suppl 4:1-17.

Ishihara S, Nishikawa T, Tanaka T, Tanaka J, Kiyomatsu T, Kawai K, Hata K, Nozawa H, Kazama S, Yamaguchi H, Sunami E, Kitayama J, Sugihara K, Watanabe T. Benefit of primary tumor resection in stage IV colorectal cancer with unresectable metastasis: a multicenter retrospective study using a propensity score analysis. International journal of colorectal disease 2015;30:807-12.

Ishihara S, Hayama T, Yamada H, Nozawa K, Matsuda K, Miyata H, Yoneyama S, Tanaka T, Tanaka J, Kiyomatsu T, Kawai K, Nozawa H, Kanazawa T, Kazama S, Yamaguchi H, Sunami E, Kitayama J, Hashiguchi Y, Sugihara K, Watanabe T. Prognostic impact of primary tumor resection and lymph node dissection in stage IV colorectal cancer with unresectable metastasis: a propensity score analysis in a multicenter retrospective study. Ann Surg Oncol 2014;21:2949-55.

Lee WS, Baek JH, Kang JM, Choi S, Kwon KA. The outcome after stent placement or surgery as the initial treatment for obstructive primary tumor in patients with stage IV colon cancer. Am J Surg 2012;203:715-9.

Lee YM, Law WL, Chu KW, Poon RT. Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions. J Am Coll Surg 2001;192:719-25.

Frago R, Biondo S, Millan M, Kreisler E, Golda T, Fraccalvieri D, Miguel B, Jaurrieta E. Differences between proximal and distal obstructing colonic cancer after curative surgery. Colorectal Dis 2011;13:e116-22.

Biondo S, Pares D, Frago R, Marti-Rague J, Kreisler E, De Oca J, Jaurrieta E. Large bowel obstruction: predictive factors for postoperative mortality. Diseases of the colon and rectum 2004;47:1889-97.

Chin CC, Wang JY, Changchien CR, Huang WS, Tang R. Carcinoma obstruction of the proximal colon cancer and long-term prognosis--obstruction is a predictor of worse outcome in TNM stage II tumor. International journal of colorectal disease 2010;25:817-22.

Babcock BD, Aljehani MA, Jabo B, Choi AH, Morgan JW, Selleck MJ, Luca F, Raskin E, Reeves ME, Garberoglio CA, Lum SS, Senthil M. High-Risk Stage II Colon Cancer: Not All Risks Are Created Equal. Ann Surg Oncol 2018;25:1980-5.

Reha J, Mukkamalla SKR, Rathore R, Somasundar PS. Adequate lymph node evaluation in the elderly is associated with improved survival in patients with stage I-III colon cancer: A validation study using the National Cancer Data Base. Eur J Surg Oncol 2018;44:148-56.

Yang Z, Wang L, Kang L, Xiang J, Peng J, Cui J, Huang Y, Wang J. Clinicopathologic characteristics and outcomes of patients with obstructive colorectal cancer. J Gastrointest Surg 2011;15:1213-22.

Arnold D, Lueza B, Douillard JY, Peeters M, Lenz HJ, Venook A, Heinemann V, Van Cutsem E, Pignon JP, Tabernero J, Cervantes A, Ciardiello F. Prognostic and predictive value of primary tumour side in patients with RAS wild-type metastatic colorectal cancer treated with chemotherapy and EGFR directed antibodies in six randomized trials. Ann Oncol 2017;28:1713-29.

Ji WB, Kwak JM, Kang DW, Kwak HD, Um JW, Lee SI, Min BW, Sung NS, Kim J, Kim SH. Clinical benefits and oncologic equivalence of self-expandable metallic stent insertion for right-sided malignant colonic obstruction. Surg Endosc 2017;31:153-8.

Yoon JY, Jung YS, Hong SP, Kim TI, Kim WH, Cheon JH. Clinical outcomes and risk factors for technical and clinical failures of self-expandable metal stent insertion for malignant colorectal obstruction. Gastrointest Endosc 2011;74:858-68.

Cho YK, Kim SW, Lee BI, Lee KM, Lim CH, Kim JS, Chang JH, Park JM, Lee IS, Choi MG, Choi KY, Chung IS. Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction. Gut Liver 2011;5:165-70.

Sloothaak DA, van den Berg MW, Dijkgraaf MG, Fockens P, Tanis PJ, van Hooft JE, Bemelman WA, collaborative Dutch Stent-In study g. Oncological outcome of malignant colonic obstruction in the Dutch Stent-In 2 trial. The British journal of surgery 2014;101:1751-7.

Maruthachalam K, Lash GE, Shenton BK, Horgan AF. Tumour cell dissemination following endoscopic stent insertion. The British journal of surgery 2007;94:1151-4.

Steinert EM, Schwartz RH, Singh NJ. At low precursor frequencies, the T-cell response to chron