LEFT SIDED OCCLUSIVE CANCER - SEGMENTAL
RESECTION OR TOTAL COLECTOMY?
Dr. J. Northover
Patients presenting with obstructing cancer of the left colon have a much worse
outlook than those presenting electively; perioperative mortality rates of 30-50%
are reported in the literature, while the five year survival may be around 30%.
This selected group has a series of reasons for having a poorer outlook,
including more advanced pathological stage, older average age, more frequent
intercurrent disease, poorer preoperative state, increased likelihood of
multistage surgery, and potentially a less experienced surgeon. The strategic
aims of surgery in these circumstances, in priority order, are:

to assist the patient to survive the emergency,

to optimise the chance to cure the cancer,

to avoid a permanent stoma,

and to minimise operative morbidity and length of hospital
stay.
It is with this background in mind that we should address the question of the
type of surgery to be preferred in this clinical situation.
From the late 18th century until the 1930s, decompression of the colon was the
main procedure for obstructing cancer, using either caecostomy or transverse
colostomy. Devine described staged resection in 1931, advocating initial
decompression, followed by elective resection and anastomosis, and finally
closure of the initial stoma. The idea of immediate resection of the tumour was
put forward by Wangensteen in 1949, though most surgeons adhered to the
classical three stage approach for several decades thereafter. But the
performance of immediate resection, omitting the first of the three classical
stages, gradually became more widely accepted as parasurgical care improved,
making the use of a major procedure in an acutely ill patient more realistic. The
argument continues, however, as the only major randomised trial in the field,
reported by Kronborg in 1995 (International Journal of Colorectal
Disease, Vol 10, pp 1-5), showed no difference in survival or recurrence rates
between three stage surgery and immediate resection.
The subject of this presentation, however, addresses the question of the
preferred approach to the patient in whom a resection is to be used in the
primary procedure - should the extent of resection be the same as for elective
surgery, or should it be extended to include all the colon proximal to the
tumour? The theoretical reasons for the more extensive procedure relate to the
risks of anastomosis of the unprepared, distended proximal colon; by resecting
back to the terminal ileum, this risk is seen to be avoided, perhaps making
anastomosis technically easier, and avoiding ‘dangerous’ stool threatening the
integrity of the anastomosis.
The comparison, therefore, is between:
Segmental resection, with or without (Hartmann’s procedure) primary
anastomosis
VERSUS
Subtotal (for left colon cancer) or total (for sigmoid cancer) colectomy with ileodistal anastomosis
Segmental resection was first used in this context 50 years ago, at that stage
without anastomosis. Only in the 1980s did surgeons become sufficiently
confident of a safe outcome to include anastomosis, and at that time the
question of the extent of the resection (segmental or total) became an issue.
The concept of total or near total colectomy to minimise anastomotic morbidity
was put forward by the Australian surgeon, ESR Hughes in the 1960s, while the
UK surgeon, Dudley described on-table lavage with semental resection for the
same purpose in 1980. There are no randomised data to allow the most
objective comparison of these two approaches. All that can be examined are
the series presented by the two ‘camps’. Keighley and Williams in their
excellent textbook have done us the service of collecting the various series
published in the past 20 years, examining stoma rates, operative mortality and
morbidity. They located reports of 160 patients undergoing segmental resection
with primary anastomosis, coming from nine publications. Most groups did not
take the option of including a proximal stoma; several series made
anastomoses without bothering with on-table lavage. The mortality and
morbidity rates were just 5% and 16% respectively. Seven publications
described the outcome in 115 patients undergoing subtotal or total colectomy
with ileodistal anastomosis. In this group the mortality and morbidity were 5 and
30%. This more radical approach, besides apparently having increased
operative morbidity, was associated with a higher incidence of diarrhoea and
impaired continence. Thus, on the basis of data which make comparison difficult
and perhaps even misleading, it would appear that there is no clear advantage
for the more radical surgical approach. Segmental resection, with on-table
lavage, is my preferred approach, though there are no randomised data to
support inclusion of lavage.
Having compared the two procedures stipulated in the title, I maintain the view
that the following principles should prevail in the treatment of occlusive left side
cancers:
 the patient should be adequately resuscitated, and operated upon by
the full team during daylight hours, unless there is evidence of actual
or imminent perforation.
 anastomosis in this clinical situation should be performed only by an
experienced surgeon, and only in the patient in whom the general
condition is sufficiently good to warrant the extra operating time.
Even with these caveats, many of these patients will be more safely dealt with
using primary resection, but saving anastomosis for a later procedure.