Obstructing malignant lesions of the colon

Abstract

Evidence has been presented to suggest that the patient with an obstructed carcinoma of the colon may have a more malignant form of the disease independent of lymph node status or tumor encirclement of the bowel. Rate of tumor growth is never consistent in patients with this disease. Patients who develop colon obstruction early in the course of the disease seem to have more aggressive tumors with rapid growth and a much poorer long-term prognosis. Perforations frequently accompany obstructions of the colon. Patients in this group have a dismal prognosis. Individuals with obstructed carcinoma of the colon have a higher operative mortality and morbidity and a shorter long-term survival. The higher operative mortality and morbidity may depend entirely on the choice of operative procedures. Tumor location affects prognosis. Obstructing tumors in the left colon have a more favorable prognosis than those in the right colon. Obstructing right colon tumors have a much poorer survival (three times worse) than nonobstructing carcinomas of the right colon. Obstructing tumors in the rectum have a very poor prognosis. Evidence exists that resection of the tumor without preliminary proximal decompression may reduce hospital mortality and morbidity and increase long-term survival. In selected cases, primary resection can be done as safely as staged operative procedures. Primary anastomosis with resection of the left colon carries a higher operative mortality because of anastomotic leaks. Resection without anastomosis is much safer. Primary resection with anastomosis is the procedure of choice in obstructing lesions of the right colon. This has a lower operative mortality and morbidity than a staged procedure. This primary resection with anastomosis is certainly as safe as an ileotransverse colostomy. It is important not to abandon the time-honored surgical principle of never suturing obstructed bowel. Primary resection without anastomosis confirms this surgical principle. Meticulous preoperative and postoperative care employing physiological monitoring, multiple antibiotics, total parenteral hyperalimentation, and respiratory and circulatory support will further reduce the hospital mortality and morbidity. Patients who initially appear to be obstructed on barium enema, but who in truth are only partially obstructed, can be properly managed so that an elective primary resection with anastomosis can be done with the same operative mortality and morbidity as in other elective colon cancer patients.