ORIGINAL ARTICLE

Laparoscopic Colectomy for Obstructive Colorectal Carcinoma Iku Abe, MD, Yutaka J. Kawamura, MD, and Fumio Konishi, MD

Abstract: Laparoscopic surgery for obstructive colorectal carcinoma is a controversial issue. Defining the obstructive carcinoma as colonoscopic impassability, the patients with obstructive carcinoma were managed according to the treatment algorithm, by which the indication of open or laparoscopic surgery was determined. As a result, 31 patients with obstructive colorectal carcinoma underwent laparoscopic surgery. The location of the tumor was in the right side in 10 patients and in the left in 21 patients. Preoperatively, all cases were managed by restriction of oral intake and/or decompression. Laparoscopic surgery was completed in 26 cases and colonic obstruction was the direct cause of the conversion in only 1 case. Regarding postoperative complications, there were 3 surgical site infections and 3 instances of postoperative prolonged ileus but no mortality. Oncologically, the primary tumor was completely resected in each case and lymph node harvest (26.6) was adequate. Key Words: laparoscopic colectomy, obstructive colorectal carcinoma, perioperative management, decompression, conversion

(Surg Laparosc Endosc Percutan Tech 2013;23:518–523)

T

he management of obstructive colorectal carcinoma is challenging; prompt and precise decision making and meticulous application of necessary measures including endoscopic and surgical intervention are mandatory, with the life of the patient often at stake.1,2 Because of the difficulty and complexity of the management, it seems that the indication of less invasive surgery for obstructive colorectal carcinoma has not yet been definitely established. In fact, for instance, patients complicated with obstructive colorectal carcinoma were excluded from large-scale randomized controlled trials such as COST, COLOR, and CLASSIC, in which oncological as well as short-term outcome of open and laparoscopic surgery was investigated.3–7 The perioperative management strategy for obstructive colorectal carcinoma seems to be not definitively established, either. Previous studies exclusively focused on emergent treatment for those with complete obstruction accompanied by obstruction-indicating symptoms, not for those without symptoms or those who were supposedly at risk of immediate obstruction. If adequately managed, the less invasive laparoscopic surgery instead of conventional open surgery might be a preferable choice for these patients. In this study, we reviewed 31 cases with Received for publication May 16, 2012; accepted January 27, 2013. From the Department of Surgery, Jichi Medical University Saitama Medical Center, Saitama, Japan. The authors declare no conflicts of interest. Reprints: Iku Abe, MD, Department of Surgery, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Omiya-ku, Saitama-shi, Saitama 330-8503, Japan (e-mail: m03102_iku@ yahoo.co.jp) Copyright r 2013 by Lippincott Williams & Wilkins

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obstructive colorectal carcinoma, who underwent laparoscopic surgery in our department, aiming to demonstrate the safety and technical feasibility of laparoscopic colectomy for obstructive colon carcinoma under an adequate management strategy.

MATERIALS AND METHODS From August 2002 to December 2011, 189 patients with colorectal carcinoma complicated with obstruction were treated in the Department of Surgery, Jichi Medical University Saitama Medical Center. The patients were managed according to our algorithm for obstructive colorectal carcinoma (Fig. 1), which included, under certain circumstances, the indication of oncological laparoscopic surgery. As a result, 31 patients underwent laparoscopic surgery and were included in this study. In this study, the tumorous obstruction of the large intestine was defined as narrowing of the lumen to the extent that a colonoscope with a diameter of 10 mm (PCF240I, PCF-240ZI, or PCF-240AZI; Olympus, Tokyo, Japan) could not pass, irrespective of the symptoms of the patients. If obstruction was suspected before colonoscopy, either clinically or radiologically, colonoscopy was subsequently performed after necessary resuscitation; and the narrowing of the lumen was endoscopically confirmed. The management algorithm for obstructive colorectal carcinoma in our Department is presented in Figure 1. One fundamental principle of this algorithm includes pathologic confirmation of malignancy. Therefore, patients who presented with obstructive symptoms were subjected to emergent or urgent colonoscopy after initial resuscitation. Whether the patient was subjected to the treatment algorithm or not was determined according to the presence or absence of an obstruction, which was defined by impassability of the colonoscope. Patients without severe stenosis were excluded from the algorithm and were managed as ordinary cases, meaning elective surgery after evaluation of surgical risk factors. In our algorithm, patients with obstruction, both those who were diagnosed by emergent or urgent colonoscopy in our Department and those who were referred to our Department due to malignant obstruction diagnosed previously in another hospital, were divided according to the presence or absence of symptom and dilatation of the proximal bowel. If the patients were symptomatic or complicated with a dilated proximal bowel, as demonstrated in Figure 2, immediate decompression was performed, principally by using a retrograde transanal drainage tube. Successful decompression, which was later confirmed by plain abdominal x-ray (Fig. 3) or abdominal CT, was followed by further examination for possible simultaneous pathology in the proximal colon. In the case of patients for

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FIGURE 1. Management algorithm for obstructive colon carcinoma.

whom decompression was thought to be unsuccessful, emergent open surgery was performed. Asymptomatic patients without proximal bowel dilatation were managed with bowel rest varying from nothing by mouth to liquid or low residual meal, which was determined according to the condition of the patient. Then, the proximal bowel was examined for simultaneous lesions except for those patients with right side colon carcinoma, in which case the entire proximal colon was resected. The surveillance of the proximal colon was done by means of either a water-soluble enema study or CT colonography. If the examination revealed no abnormalities necessitating intervention, the patient was considered as a possible candidate for laparoscopic surgery. Then, finally, the indication of laparoscopic surgery in each case was determined with consideration of the following exclusion criteria for laparoscopic surgery in our Department: (a) apparent invasion to adjacent organ(s), (b) tumor >8 cm, (c) perforation or penetration, and (d) history of major abdominal surgery. r

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Urgent laparoscopic surgery was carried out either by the standard procedure using 5 ports or by reduced-port surgery using 3 or 4 ports. All operations were performed or supervised by experienced laparoscopic surgeons who were certified by the Japan Society of Endoscopic Surgery (Y.J.K. and F.K.). In general, lymph node dissection including high tie of the corresponding vessels was performed followed by simultaneous bowel reconstruction. Clinicopathlogic characteristics of the patients, preoperative management, and short-term surgical outcomes were retrospectively analyzed. The rate of conversion to open surgery was compared with that of patients without obstruction who underwent laparoscopic surgery for colon cancer during the study period. This study was approved by the Institutional Review Board of Jichi Medical University Saitama Medical Center.

RESULTS Patients’ backgrounds are shown in Table 1. Their mean age was 68 years, and location of the tumor was on www.surgical-laparoscopy.com |

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TABLE 1. Patients’ Characteristics N Sex Male/Female Age (y) Location of the tumor Cecum Ascending colon Transverse colon Descending colon Sigmoid colon Rectosigmoid Rectum TNM stage I II III IV FIGURE 2. Obstructive colon carcinoma with dilated proximal intestines. CT-visualized tumor located in the ascending colon and dilated proximal intestines. If the imaging study revealed a dilated intestine, as in this case, immediate decompression was performed irrespective of the presence or absence of symptoms due to obstruction.

the right side (cecum, ascending and transverse colon) in 10 patients and on the left side (descending or sigmoid colon, rectosigmoid or rectum) in 21 patients. Twenty-seven patients with TNM stage II or III disease underwent potentially curative surgery with oncological lymph node dissection. Of the 4 patients with TNM stage IV disease, 3 of them underwent laparoscopic surgery with oncological dissection followed by subsequent resection of distant

31 18/13 68 ± 12 (mean ± SD) 1 8 1 2 13 5 1 0 12 15 4

metastasis. The surgery was palliative for the remaining stage IV patient. A summary of perioperative management is presented in Table 2 and Figure 4. Eight patients were emergently hospitalized, most of whom had either symptoms associated with obstruction or dilated proximal intestines. Decompression was performed in 6 cases including 1 case in which a self-expandable metallic stent (SEMS) was introduced. Otherwise decompression was achieved by use of a transanal drainage tube. In 29 patients, oral intake was restricted according to the decision of the attending physician based on patients’ condition. As a result, 25 patients were successfully prepared for surgery without decompression. In all cases, histologic diagnosis of colorectal carcinoma was preoperatively confirmed by endoscopic biopsy. Details of the surgical procedures are shown in Table 3. The median duration of the operation was 173 minutes (range, 92 to 360 min). The rate of conversion to open surgery was 16.1% (5 cases), which was higher than that for the cases without obstruction who underwent laparoscopic surgery during the study period (8.4%, 50/598). However, the difference was not statistically significant (P = 0.14, w2 test). With respect to oncological lymph node dissection, all but 1 patient underwent high tie of the corresponding artery. The mean number of harvested lymph nodes was 26.6 ± 12.2. The causes of conversion to open surgery are listed in Table 4. The dilatation of the intestines was the immediate

TABLE 2. Perioperative Management

n (%)

FIGURE 3. Preoperative plain abdominal x-ray for evaluation of effect of the decompression. Abdominal x-ray confirmed successful decompression, which indicated possible application of the laparoscopic procedure.

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Emergent admission Symptoms associated with stenosis Present/absent Oral intake Nothing by mouth Fluid only Low residual meal No restriction Total parenteral nutrition Dilatation of the proximal intestine Decompression None Retrograde long tube Ileus tube Stent

r

8 (25.8) 8 (25.8)/23 (74.2) 2 20 7 2 15 5

(6.5) (64.5) (22.6) (6.5) (48.4) (16.1)

25 4 1 1

(80.6) (12.9) (3.2) (3.2)

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FIGURE 4. Flowchart of patients with an obstructive tumor.

cause of the conversion in only 1 case. In this case, the inferior mesenteric artery was injured because of a limited operative view, and so the laparoscopic surgery was converted to open surgery. There were no other significant intraoperative complications. In the 4 other cases of conversion, the reasons were not directly associated with the obstruction. With regard to postoperative complications, there were 2 cases with superficial surgical site infection and 2 cases with prolonged postoperative ileus. In addition, in the conversion cases, there was 1 case with surgical site infection and 1 case with prolonged postoperative ileus, none of which necessitated surgical treatment; and there was no mortality.

DISCUSSION Laparoscopic surgery is widely accepted as a standard procedure for colorectal carcinoma since randomized r

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controlled studies revealed noninferiority of laparoscopic surgery over open surgery with respect to long-term oncological outcome as well as superiority in short-term outcome.3–7 However, eligibility criteria of earlier studies excluded those patients with obstruction, who consist of approximately 30% of patients with colorectal carcinoma,1,8,9 due to technical difficulty in maintaining a proper operative view owing to interference by a dilated bowel. Other than these large-scale randomized controlled studies, the lack of definitive scientific evidence regarding the indication of laparoscopic surgery for those with obstructive colorectal carcinoma is apparent. There is only a single previously reported randomized controlled trial scrutinizing the outcome of laparoscopic surgery for obstructive colorectal carcinoma,10 in which laparoscopic surgery after stenting for obstructive left-sided colon www.surgical-laparoscopy.com |

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TABLE 3. Surgical Outcomes Surgery Laparoscopic ileocecal resection Laparoscopic right colectomy Laparoscopic transverse colectomy Laparoscopic left colectomy Laparoscopic sigmoid colectomy Laparoscopic anterior resection Operation time (min) [median (range)] Bleeding (g) [median (range)] Conversion to open surgery Lymph node dissection High tie Low tie Lymph node harvest [median (range)]

n 2 7 0 1 12 4 173 30 5

(%) (7.7) (26.9) (0) (3.8) (46.2) (15.4) (92-360) (0-850) (16.1)

30 (96.8) 1 (3.2) 26 (7-55)

carcinoma was compared with emergent open surgery. That study examined the clinical outcome of a homogenous group of patients (left side lesion with complete obstruction) treated by a single strategy (stenting followed by laparoscopic surgery), not reflecting the complexity of treatment strategy for obstructive colorectal carcinoma. The reasons for the lack of evidence are considered to be, in addition to the already mentioned poor visibility of the operative field during laparoscopic surgery, the wide variety of presentation of patients, of treatment of choice, and of difficulty of decision making, all of which contribute to the complexity of developing protocols for a prospective study. Even in retrospective studies, it is usually the case that only a selected population among those with obstructive colorectal carcinoma was included.11–13 The definition of obstruction in previous studies was often rather indistinct. A typical definition is “obstructing symptoms associated with typical finding by emergent water-soluble enema,” which lacks the description of the actual diameter or length of the narrowed lumen. Furthermore, as symptoms are subjective, if used in a scientific study, a detailed definition, preferably a quantitative one, would seem to be necessary. Such was apparently not the case in previous studies. Moreover, there were no statistical data regarding the correlation between symptoms of the patients and the actual diameter or length of the stenosis or severity of the obstruction. In this present study, we objectively defined the obstruction in terms of the impassability of a colonoscope having a diameter of 10 mm, which would include patients with severe, but not complete obstruction, in an attempt to include those individuals with a potentially hazardous risk of developing symptoms of complete obstruction. It should be noted that the treatment strategy for those patients with impending obstruction has not been definitively established. Emergent or urgent surgery might be a treatment of choice. However, drawbacks of an emergent or

TABLE 4. Reasons for Conversion

Conversion Rate Dilatation of the intestines Invasion to adjacent organs Adhesions Tumor size

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5/31 (16.1) [n (%)] 1 2 1 1

(20) (40) (20) (20)



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urgent operation sometimes overweigh the benefits, especially in elderly patients and in those with comorbidities, for whom careful perioperative evaluation and management are essential. In our Department, once patients with obstruction, either impending or complete, are identified, they are managed according to the algorithms for obstructive colorectal carcinoma. Considering the complexity and poor outcome of treatment after the development of obstructive symptoms,1,2 our algorithms were developed with precautions involving preventive measures including hospitalization and restriction of oral intake. As a result, most of the patients with obstruction were successfully managed without decompression. As to the technical aspect of decompression, the majority of patients are treated by use of a retrograde transanal drainage tube.14 The quality of life might be better if a SEMS is used, as there is no need for a drainage tube extending from the anus. However, the use of a SEMS was not approved by Ministry of Health, Labor and Welfare of Japan during the study period; and, furthermore, we believe that the cost is too high (250,000 Japanese Yen, US$3300) to use it as a bridge to surgery, which usually lasts

Laparoscopic colectomy for obstructive colorectal carcinoma.

Laparoscopic surgery for obstructive colorectal carcinoma is a controversial issue. Defining the obstructive carcinoma as colonoscopic impassability, ...
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