Guidelines on the management of large bowel perforation, obstructive left colon carcinoma, and obstructive right colon carcinoma were released on August 13, 2018, by the World Society of Emergency Surgery.
If colon obstruction is suspected, CT scan can provide diagnostic confirmation better than abdominal ultrasound, which is better than plain abdominal radiograph.
In stable patients, direct visualization of the colonic obstruction should be considered when colonoscopy is available. Biopsies should be obtained when endoscopic stent is planned.
In stable patients, in cases of diagnosis of perforation on abdominal US or radiograph, abdominal CT scan should be considered.
When diffuse peritonitis occurs in cases of cancer-related colon perforation, the priority is control of the sepsis source.
In the case of perforation at the tumor site, resection consists of formal resection with or without anastomosis, with or without stoma.
In the case of perforation proximal to the tumor site, resection consists of simultaneous tumor resection and management of proximal perforation. A subtotal colectomy may be required depending on the condition of the colon wall,
The Hartmann procedure should be preferred to simple colostomy because colostomy appears to be associated with longer hospital stay, multiple operations, and no decrease in morbidity. Loop colostomy should be reserved for unresectable tumors in severely ill patients who cannot undergo major surgical procedures or general anesthesia.
Resection and primary anastomosis (RPA) should be the preferred option for uncomplicated malignant left-sided large bowel obstruction in the absence of other risk factors. Patients with high surgical risk are better managed with the Hartmann procedure.
Total colectomy should not be preferred over segmental colectomy in the absence of cecal tears or perforation, evidence of bowel ischemia, or synchronous right colonic cancers, because the former does not reduce morbidity and mortality, and it is associated with higher rates of impaired bowel function.
Laparoscopy cannot be recommended for emergency treatment of obstructive left colon carcinoma (OLCC); it should be reserved for favorable cases in specialized centers.
Locally advanced rectal cancers are better treated with a multimodal approach, including neoadjuvant chemoradiotherapy. If there is acute obstruction, avoid resection of the primary tumor, and a stoma should be created.
If right-sided colon cancer is causing acute obstruction, the preferred option is right colectomy with primary anastomosis. A terminal ileostomy with colonic fistula is an alternative if primary anastomosis is considered unsafe.
For unresectable right-sided colon cancer, a side-to-side anastomosis can be performed between the terminal ileum and the transverse colon (internal bypass); as an alternative, a loop ileostomy can be created.
For right-sided obstruction, right colectomy with terminal ileostomy should be considered the procedure of choice, and severely unstable patients should be treated with a loop ileostomy.
For right-sided perforation, right colectomy with terminal ileostomy should be considered the procedure of choice, and if an open abdomen has to be considered, stoma creation should be delayed.
For left-sided obstruction, the Hartmann procedure should be considered the procedure of choice, and severe unstable patients should be treated with loop transverse colostomy.
For left-sided perforation, the Hartmann procedure should be considered the procedure of choice, and if an open abdomen has to be considered, stoma creation should be delayed.
In patients with perforation/obstruction due to colorectal lesions, an open abdomen should be considered if abdominal compartment syndrome is expected, and bowel viability should be reassessed after resection. Open abdomen should be closed within 7 days.
In patients with colorectal carcinoma obstruction and no systemic signs of infection, antibiotic prophylaxis is recommended that mainly targets gram-negative bacilli and anaerobic bacteria because of potential bacterial translocation. Prophylactic antibiotics should be discontinued after 24 hours or 3 doses.
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Cite this: Colon and Rectal Cancer Emergencies Clinical Practice Guidelines (2018) - Medscape - Sep 14, 2018.