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Large bowel obstruction

  • 15% colorectal cancers present with obstruction
  • Most patients are over 70 years old
  • Risk of obstruction greatest with left sided lesions
  • Usually present at a more advanced stage
  • 25% have distant metastases at presentation
  • Perforation can occur at site of tumour or in a dilated caecum

Clinical presentation

  • Caecal tumours present with small bowel obstruction
    • Colicky central abdominal pain
    • Early vomiting
    • Late absolute constipation
    • Variable extent of distension
  • Left sided tumours present with large bowel obstruction
    • Change in bowel habit
    • Absolute constipation
    • Abdominal distension
    • Late vomiting

Investigation

  • Plain supine abdominal x-ray will show dilated large bowel
  • Small bowel may also be dilated depending on competence of ileocaecal valve

Plain abdominal xray showing dilated small and large intestine due to a proximal sigmoid carcinoma

  • Added value of erect film debatable
  • If doubt over diagnosis or site of obstruction consider a water soluble contrast enema

Management

  • All patients require
    • Adequate resuscitation
    • Prophylactic antibiotics
    • Consenting and marking for potential stoma formation
  • At operation
    • Full laparotomy should be performed
    • Liver should be palpated for metastases
    • Colon should be inspected for synchronous tumours
  • Appropriate operations include
  • Right sided lesions – right hemicolectomy
  • Transverse colonic lesion – extended right hemicolectomy
  • Left sided lesions – various options

Three-staged procedure

  • Defunctioning colostomy
  • Resection and anastomosis
  • Closure of colostomy

Two-staged procedure

  • Hartmann’s procedure
  • Closure of colostomy

One-stage procedure

  • Resection, on-table lavage and primary anastomosis
  • Three stage procedure will involve 3 operations!
  • Associated with prolonged total hospital stay
  • Transverse loop colostomy can be difficult to manage
  • With two-staged procedure only 60% of stomas are ever reversed
  • With one-stage procedure stoma is avoided
  • Anastomotic leak rate of less than 4% have been reported
  • Irrespective of option total perioperative mortality is about 10%

Bibliography

Carty N J,  Ravichandram D.  The management of malignant large bowel obstruction.  In: Johnson C D  Taylor I eds. Recent advances in Surgery 19. Churchill Livingstone, London 1996: 1 -18.

Deans G T, Krukowski Z H,  Irwin S T.  Malignant obstruction of the left colon.  Br J Surg 1994:  81: 1270 - 1276.

Lopez-Kostner F,  Hool G R,  Lavery I C.  Management and causes of acute large bowel obstruction.  Surg Clin N Am 1997;  77: 1265-1587.

 

 
 

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