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Subtotal colectomy for obstructing carcinoma of the left colon
Subtotal Colectomy for Obstructing Carcinoma of the Left Colon
Robert L. Glass, MD, FACS, MC, USNR, Bethesda, Maryland Lee E. Smith, MD, FACS, MC, USN, Bethesda, Maryland Robert C. Cochran, MD, FACS, Bethesda, Maryland
Overall 5 year survival for patients with obstructing carcinoma of the left half of the colon is 10 to 16 percent [I ,z]. The poor results are primarily due to the advanced stage of the disease at the time of treatment [3], but even those patients resected for cure have a lower survival than those with nonobstructing tumors. Obstructed patients resected for cure have 5 year survival rates of about 25 percent when the standard three-stage surgical technique is used [I ,3]. Primary resection with colostomy has been proposed as a better alternative [4], but the morbidity of a colostomy and the need for a second operation for closure detract from the palliative value in patients who ultimately die from recurrent cancer. Primary colocolostomy in the distended and unprepared bowel has high mortality and complication rates because the distended colon has a poor blood supply and is likely to develop an anastomotic leak. The terminal ileum has a richer blood supply and emergency right hemicolectomy with immediate ileotransverse colostomy has been an acceptable procedure for many years. The use of subtotal colectomy with primary ileoproctostomy for obstructing cancer of the left colon has been reported by others [5] and may be the procedure of choice for many patients. Material
and Methods
Between 1975 and 1982, seven unselected patients presented with complete obstruction of the left half of the colon and were subjected to subtotal colectomy and primary ileorectal anastomosis. The patients were either private patients of one of us (RLG) or patients referred to the National Naval Medical Center. The surgery was performed by or under the direct supervision of one of us. The From the Department of Sugary. NaticmalNaval Medical Center. Bethesda. Maryland. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the view of the Navy Department or the Naval sewice at large. Request for reprints should be addressed to Robert L. Glass, MD. MC. USNR. Department of Swgery/C61, National Naval Medical Center. Betfwsde. Maryland 20814.
Volume 145, March 1983
distal rectosigmoid segment was cleansed with saline enemas and a Betadinb enema immediately before surgery and the terminal ileum was decompressed through a proximal enterotomy and then lavaged with 1 percent neomycin solution or Betadine. A single layer end-to-end or side-to-end anastomosis was carried out, and the anastomosis was wrapped with a pedicle of omentum.
Results The 14 percent operative mortality compares favorably with other reports of staged and primary resections (Table I). The patients generally had from two to four soft stools per day and only occasionally used antidiarrhea medications after the first 8 weeks. One patient had a second primary cancer in the cecum and another had many polyps in the resected specimen. Comments Resection of a potentially curable cancer at the time of first operation should theoretically cure more cancers because the tumor is removed during the period of postoperative depression of tumor-directed cell-mediated immunity [6]. Results of several uncontrolled studies [I ,7] suggest that this is true. Using the terminal ileum rather than the colon as the proximal limb of the anastomosis should result in fewer anastomotic dehiscences due to better blood supply in the ileum, but as much ileum as possible should be preserved to prevent postoperative diarrhea. The occasional second primary tumor [8] is treated at the same time, and the remaining colorectal mucosa can be easily inspected at regular intervals with a sigmoidoscope to detect new primary tumors early. Summary This retrospective review of seven patients with completely obstructing cancers of the left half of the colon, in addition to other reports in the literature, suggests that subtotal colectomy with primary ileal
335
Glass et al
TABLE I
Clinical Data on Seven Patients Who Underwent Subtotal Colectomy for Obstructing Carcinoma of the Left Colon: 1975-1982 Age WI
Patient
and Sex
Tumor Location
1
68, F
Descending
10 days
2
71, F
Sigmoid
22 days
3
73, F
Sigmoid
...
4
66, F
Descending
8mo
5
72, M
Sigmoid
11 days
6
66. M
Sigmoid
28 days
7
78, M
Left transverse
34 days
Hospital Stay
Comments AandW40mo postop AandW 18mo postop AandW5yr postop Dead from complications Incidental cecal cancer; A and W 3 mo postop Alive with metastasis 16 mo postop Many other Polyps; A and W 9 mo POStOD
A and W = alive and well.
proctostomy may be the treatment of choice for those lesions that are technically resectable and located high enough to permit an intraperitoneal ileal proctostomy. The morbidity and mortality is less than that seen with the staged approach and the length of hospitalization is shorter. By eliminating a second or third hospitalization and a temporary colostomy, palliation is better in those patients who ultimately die from recurrent cancer. Furthermore, those patients resected for cure may have increased rates of long-term survival.
References 1. Fielding LP, Wells BW. Survival after primary and after staged resection for large bowel obstruction caused by cancer. Br J Surg 1974;61:16-8.
336
2. Ohman ULF. Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982;143:742-7. 3. Ragland JJ, Londe AM, Spratt JS. Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathological variables. Am J Surg 1971;121:552-6. 4. Clark J, Hall AW, Moossa AR. Treatment of obstructing cancer of the colon and rectum. Surg Gynecol Obstet 1975;141: 541-4. 5. Klatt GR, Martin WH, Gillespie JT. Subtotal colectomy with primary anastomosis without diversion in the treatment of obstructing carcinoma of the left colon. Am J Surg 1981;141: 577-80. 6. Co&ran AJ, Spilg WGS, Mackie RM, Thomas CE. Postoperative depression of tumor directed cell-mediated immunity in patients with mabgnant disease. Br Med J 1972;4:67-70. 7. Carson EN, Poticha SM, Shiekfs TW. Carcinoma obstructing the left side of the colon. Arch Surg 1977;112:523-6. 8. Lee TK. Barringer M, Myers RJ, Sterchi JM. Multiple primary carcincmas of the colon and associated extracolonic primary malignant tumors. Ann Surg 1982;195:501-7.
The American Journal 01 Surgery
Robert L. Glass, MD, FACS, MC, USNR, Bethesda, Maryland Lee E. Smith, MD, FACS, MC, USN, Bethesda, Maryland Robert C. Cochran, MD, FACS, Bethesda, Maryland
Overall 5 year survival for patients with obstructing carcinoma of the left half of the colon is 10 to 16 percent [I ,z]. The poor results are primarily due to the advanced stage of the disease at the time of treatment [3], but even those patients resected for cure have a lower survival than those with nonobstructing tumors. Obstructed patients resected for cure have 5 year survival rates of about 25 percent when the standard three-stage surgical technique is used [I ,3]. Primary resection with colostomy has been proposed as a better alternative [4], but the morbidity of a colostomy and the need for a second operation for closure detract from the palliative value in patients who ultimately die from recurrent cancer. Primary colocolostomy in the distended and unprepared bowel has high mortality and complication rates because the distended colon has a poor blood supply and is likely to develop an anastomotic leak. The terminal ileum has a richer blood supply and emergency right hemicolectomy with immediate ileotransverse colostomy has been an acceptable procedure for many years. The use of subtotal colectomy with primary ileoproctostomy for obstructing cancer of the left colon has been reported by others [5] and may be the procedure of choice for many patients. Material
and Methods
Between 1975 and 1982, seven unselected patients presented with complete obstruction of the left half of the colon and were subjected to subtotal colectomy and primary ileorectal anastomosis. The patients were either private patients of one of us (RLG) or patients referred to the National Naval Medical Center. The surgery was performed by or under the direct supervision of one of us. The From the Department of Sugary. NaticmalNaval Medical Center. Bethesda. Maryland. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the view of the Navy Department or the Naval sewice at large. Request for reprints should be addressed to Robert L. Glass, MD. MC. USNR. Department of Swgery/C61, National Naval Medical Center. Betfwsde. Maryland 20814.
Volume 145, March 1983
distal rectosigmoid segment was cleansed with saline enemas and a Betadinb enema immediately before surgery and the terminal ileum was decompressed through a proximal enterotomy and then lavaged with 1 percent neomycin solution or Betadine. A single layer end-to-end or side-to-end anastomosis was carried out, and the anastomosis was wrapped with a pedicle of omentum.
Results The 14 percent operative mortality compares favorably with other reports of staged and primary resections (Table I). The patients generally had from two to four soft stools per day and only occasionally used antidiarrhea medications after the first 8 weeks. One patient had a second primary cancer in the cecum and another had many polyps in the resected specimen. Comments Resection of a potentially curable cancer at the time of first operation should theoretically cure more cancers because the tumor is removed during the period of postoperative depression of tumor-directed cell-mediated immunity [6]. Results of several uncontrolled studies [I ,7] suggest that this is true. Using the terminal ileum rather than the colon as the proximal limb of the anastomosis should result in fewer anastomotic dehiscences due to better blood supply in the ileum, but as much ileum as possible should be preserved to prevent postoperative diarrhea. The occasional second primary tumor [8] is treated at the same time, and the remaining colorectal mucosa can be easily inspected at regular intervals with a sigmoidoscope to detect new primary tumors early. Summary This retrospective review of seven patients with completely obstructing cancers of the left half of the colon, in addition to other reports in the literature, suggests that subtotal colectomy with primary ileal
335
Glass et al
TABLE I
Clinical Data on Seven Patients Who Underwent Subtotal Colectomy for Obstructing Carcinoma of the Left Colon: 1975-1982 Age WI
Patient
and Sex
Tumor Location
1
68, F
Descending
10 days
2
71, F
Sigmoid
22 days
3
73, F
Sigmoid
...
4
66, F
Descending
8mo
5
72, M
Sigmoid
11 days
6
66. M
Sigmoid
28 days
7
78, M
Left transverse
34 days
Hospital Stay
Comments AandW40mo postop AandW 18mo postop AandW5yr postop Dead from complications Incidental cecal cancer; A and W 3 mo postop Alive with metastasis 16 mo postop Many other Polyps; A and W 9 mo POStOD
A and W = alive and well.
proctostomy may be the treatment of choice for those lesions that are technically resectable and located high enough to permit an intraperitoneal ileal proctostomy. The morbidity and mortality is less than that seen with the staged approach and the length of hospitalization is shorter. By eliminating a second or third hospitalization and a temporary colostomy, palliation is better in those patients who ultimately die from recurrent cancer. Furthermore, those patients resected for cure may have increased rates of long-term survival.
References 1. Fielding LP, Wells BW. Survival after primary and after staged resection for large bowel obstruction caused by cancer. Br J Surg 1974;61:16-8.
336
2. Ohman ULF. Prognosis in patients with obstructing colorectal carcinoma. Am J Surg 1982;143:742-7. 3. Ragland JJ, Londe AM, Spratt JS. Correlation of the prognosis of obstructing colorectal carcinoma with clinical and pathological variables. Am J Surg 1971;121:552-6. 4. Clark J, Hall AW, Moossa AR. Treatment of obstructing cancer of the colon and rectum. Surg Gynecol Obstet 1975;141: 541-4. 5. Klatt GR, Martin WH, Gillespie JT. Subtotal colectomy with primary anastomosis without diversion in the treatment of obstructing carcinoma of the left colon. Am J Surg 1981;141: 577-80. 6. Co&ran AJ, Spilg WGS, Mackie RM, Thomas CE. Postoperative depression of tumor directed cell-mediated immunity in patients with mabgnant disease. Br Med J 1972;4:67-70. 7. Carson EN, Poticha SM, Shiekfs TW. Carcinoma obstructing the left side of the colon. Arch Surg 1977;112:523-6. 8. Lee TK. Barringer M, Myers RJ, Sterchi JM. Multiple primary carcincmas of the colon and associated extracolonic primary malignant tumors. Ann Surg 1982;195:501-7.
The American Journal 01 Surgery