Jung Tak Son and Yong Bog Kim contributed equally to this work as cofirst authors.
This paper was presented as a poster at the meeting of the 53rd Korean Society of Coloproctology Annual Meeting on September 5 to 6, 2020 in Seoul, Korea.
Surgical management of obstructive left colon cancer (OLCC) is still a matter of debate. The classic Hartmann procedure (HP) has a disadvantage that requires a second major operation. Subtotal colectomy/total abdominal colectomy (STC/TC) with ileosigmoid or ileorectal anastomosis is proposed as an alternative procedure to avoid stoma and anastomotic leakage. However, doubts about morbidity and functional outcome and lack of long-term outcomes have made surgeons hesitate to perform this procedure. Therefore, this trial was designed to provide data for morbidity, functional outcomes, and long-term outcomes of STC/TC.
This study retrospectively analyzed consecutive cases of OLCC that were treated by STC/TC between January 2000 and November 2020 at a single tertiary referral center. Perioperative outcomes and long-term outcomes of STC/TC were analyzed.
Twenty-five descending colon cancer (45.5%) and 30 sigmoid colon cancer cases (54.5%) were enrolled in this study. Postoperative complications occurred in 12 patients. The majority complication was postoperative ileus (10 of 12). Anastomotic leakage and perioperative mortality were not observed. At 6 to 12 weeks after the surgery, the median frequency of defecation was twice per day (interquartile range, 1–3 times per day). Eight patients (14.5%) required medication during this period, but only 3 of 8 patients required medication after 1 year. The 3-year disease-free survival was 72.7% and 3-year overall survival was 86.7%.
The risk of anastomotic leakage is low after STC/TC. Functional and long-term outcomes are also acceptable. Therefore, STC/TC for OLCC is a safe, 1-stage procedure that does not require diverting stoma.
Screening programs for the early detection of colon cancer have become common. Nevertheless, 8% to 29% of colon cancer patients visit the hospital with acute colonic obstruction [
Perioperative placement of a self-expandable metallic stent (SEMS) has been used as a bridge to elective surgery and reported with a high success rate of 93.8%. Primary anastomosis was performed in 91.8% of patients and stoma creation was required only in 10.6% to 23.9% of patients [
SC and STC/TC are known to have low mortality and morbidity [
Despite these advantages, STC/TC is not generally chosen for the treatment of obstructive left colon cancer (OLCC). Mege et al. [
This retrospective study was approved by the Institutional Review Board of Kangbuk Samsung Hospital (No. 2020-11-024). The informed consent was waived because of the retrospective nature of the study.
Data were retrospectively collected from the medical records of Kangbuk Samsung Hospital from January 2007 to November 2020.
This study includes patients diagnosed with acute colonic obstruction caused by cancer located from the descending colon to the rectosigmoid colon where STC/TC was undergone. Patients who were diagnosed with combined colonic ischemia or perforation were included. Characteristics of patients including sex, age, American Society of Anesthesiologists (ASA) physical status (PS) classification, and length of hospital stay were collected from the medical records. Tumor location and stage were identified in pathologic and radiologic reports.
All surgeries were performed by 3 colorectal specialists. Laparoscopic or open procedure was selected at the discretion of each surgeon. Distal rectal resection was always above the level above the pelvic promontory to preserve more than 10 cm of the rectum. The terminal ileum was carefully resected within 10 cm in length. If the rectum could not be preserved by more than 10 cm, STC/TC was not chosen, and these patients were excluded from this study. Lymph nodes were always dissected according to oncologic principle. The cases of ileorectal anastomosis after TC were defined as TC group and the cases of ileosigmoid or ileo-descending colon anastomosis with proximal colon resection were defined as STC group.
Collected data were statistically analyzed using IBM SPSS ver. 24.0 (IBM Corp). Results are expressed as median value with interquartile range. Diseasefree survival (DFS) was defined as the time from diagnosis to recurrence or death without evidence of recurrence. Overall survival (OS) was defined as the time from diagnosis to death as a result of all causes. The Kaplan-Meier method was used to construct DFS and OS curves. The log-rank test was used to compare distributions by stage.
During this period, 55 patients met the criteria. Of these, 34 (61.8%) were male and 21 (38.2%) were female. The median age of the enrolled patients was 71 years, and 36 of the patients (65.5%) were of old age (65 years or older). The comorbidities of patients were evaluated by ASA PS classification, and the number of patients with ASA PS classification of III or more was 31 (56.4%).
Of the 55 enrolled patients, 14 patients (25.5%) underwent TC, and 41 patients (74.5%) underwent STC. Stoma was not created in any cases. The median operation time was 175 minutes (range, 155–210 minutes). The median number of harvested lymph nodes was 42.0 (range, 26–61), and the median length of postoperative hospital stay was 11.0 days (range, 9–14 days). The median time required to return to regular diet after surgery was 6.0 days (range, 4–7 days) (
When classified according to tumor location, 25 tumors (45.5%) were located in the descending colon and 30 tumors (54.5%) were located in the sigmoid colon. At the time of operation, 25 (45.5%) patients were diagnosed as stage II, 20 patients (36.4%) were diagnosed as stage III, and 10 patients (18.2%) were diagnosed as stage IV. When each stage was subdivided, 15 (27.3%) were IIA, 6 (10.9%) IIB, 4 (7.3%) IIC, 16 (29.1%) IIIB, and 4 (7.3%) IIIC. When synchronous colon cancer was present, the stage of advanced cancer was applied.
Synchronous colon cancer was identified in 5 cases (9.1%). Combined tubular adenoma was identified in 23 patients (41.8%), and 4 of them were confirmed as high-grade dysplasia. Low-grade mucinous neoplasm of the appendix was identified in one case. Ischemia of the proximal colon was identified in 10 cases (18.2%) and perforation of the colon was identified in 5 patients (9.1%) (
A total of 12 postoperative complications (21.8%) occurred. These included 2 pneumonia and 10 postoperative ileus cases. Nine patients with ileus improved with conservative treatment, but 1 patient needed reoperation. Except for this case, the Clavien-Dindo grades of other surgical complications were all grade II or lower. Anastomotic leakage and perioperative mortality were not observed.
At 6 to 12 weeks postoperatively, the median number of bowel movements was twice per day (interquartile range, 1–3 times per day). At postoperative 6 months, 8 patients (14.5%) complained of diarrhea and needed medications, 14.6% (6 of 41) and 14.3% (2 of 14) in STC and TC group, respectively. Four patients (7.3%) complained of moderate diarrhea which needs antidiarrheal medication at 6 to 12 months postoperatively, 4.9% (2 of 41) and 14.3% (2 of 14) in STC and TC groups, respectively. After 1 year, only 3 of 8 patients still required medication, 2.4% (1 of 41) and 14.3% (2 of 14) in STC and TC groups, respectively. No patients complained of severe diarrhea requiring hospitalization.
Except for 10 stage IV patients, 45 patients were analyzed for DFS. The median follow-up duration was 17.0 months (range, 8.0–45.0 months). Eight tumor recurrences (17.8%) and 3 mortalities (6.7%) were observed during this period. The 3-year DFS was 78.9% in stage II and 66.0% in stage III patients. When both stage II and III patients were included, 3-year DFS was 72.7% (
The median follow-up duration was 18.4 months (range, 7.0–40.0 months). During this period, 8 mortalities (14.5%) were observed and 5 of 8 were caused by progression of colon cancer. In all patients, the 3-year OS was 86.7%. When divided by stage, 3-year OS was 80.0% in stage II, 68.2% in stage III, and 44.4% in stage IV patients (
The rate of morbidity and mortality of emergency surgery for OLCC has been reported as high [
One-stage procedures mainly include segmental resection with perioperative SEMS or intraoperative colonic irrigation and STC/TC. Perioperative placement of SEMS to bridge elective surgery has been used and reports a high success rate of 93.8%. Also, primary anastomosis could be performed in 91.8% of patients, and stoma creation was required only in 10.6% to 23.9% of patients [
SC with intraoperative colonic irrigation and STC/TC are both known to have low mortality and morbidity [
Another problem with SC with intraoperative irrigation is that it is difficult to detect synchronous colon cancer. In colon cancer patients without obstruction, preoperative colonoscopy could detect 5% to 7% of synchronous colon cancers [
STC/TC is a safe 1-stage procedure that does not require a stoma. The rate of anastomotic leakage is reported as 0% to 2.8% [
Compared to other surgeries, STC/TC requires a relatively longer operation time because the area to dissect is larger. In this study, the average length of surgery was 175 minutes (range, 155–210 minutes). Therefore, in hemodynamically unstable patients, primary diverting colostomy would be the safer option relative to STC/TC. Our study did not include hemodynamically unstable patients; however, compared with SC with intraoperative colonic irrigation, the operation time of STC/TC was reported as shorter [
Morbidity and mortality for OLCC operation were reported as high as 28.0% and 7.0%, respectively, and the rate of severe complications (more than Clavien-Dindo grade III) was reported as 7.0% [
Functional aspects are big concerns with respect to the use of STC/TC. In a previous randomized controlled trial, increased bowel frequency (3 or more bowel movements per day) was more common in the STC group than in the SC with intraoperative colonic irrigation group during the immediate postoperative period [
Patients diagnosed with obstructive colon cancer and underwent 1-stage emergency curative treatment were reported with worse long-term survival than patients with nonobstructive lesions [
The number of lymph nodes evaluated after surgical resection of colorectal cancer is a known predictor of survival [
The noncomparative design, small number of included patients, and short period of follow-up are limitations of this study. However, the safety and the benefits of STC/TC were confirmed. In order to verify these results, prospective, large-scale, randomized controlled trials will be needed.
In conclusion, STC/TC for OLCC is a safe, 1-stage procedure that does not require diverting stoma. The advantages of STC/TC also include the elimination of synchronous and potentially metachronous colon tumors and the removal of proximal dilated colon, most importantly, the risk of anastomotic leakage observed is very low. Most patients did not complain of diarrhea or were well controlled with medication and severe diarrhea rarely occurred after surgery. In addition, the 3-year OS and DFS are also acceptable. Therefore, STC/TC is a reasonable treatment option for OLCC.
No potential conflict of interest relevant to this article was reported.
None.
Conceptualization: HOK; Data curation: JTS; Formal analysis: all authors; Investigation: JTS, HOK; Methodology: HOK; Project administration: HOK; Supervision: HOK, HK; Visualization: JTS, YBK; Writing–original draft: JTS, YBK; Writing–review & editing: all authors. All authors read and approved the final manuscript.
Disease-free survival (A) and overall survival (B) of subtotal colectomy for obstructive left colon cancer.
General characteristics of patients (n=55)
Characteristic | Value |
---|---|
Age (yr) | 71 (63–78) |
Sex | |
Male | 34 (61.8) |
Female | 21 (38.2) |
ASA PS classification | |
I or II | 24 (43.6) |
III or IV | 31 (56.4) |
Type of surgery | |
Total colectomy | 14 (25.5) |
Subtotal colectomy | 41 (74.5) |
Length of surgery (min) | 175 (155–210) |
No. of harvested lymph nodes | 42.0 (26–61) |
Total hospital stay (day) | 14.0 (11–17) |
Postoperative hospital stay (day) | 11.0 (9–14) |
Time to tolerance of regular diet (day) | 6.0 (4–7) |
Values are presented as median (interquartile range) or number (%).
ASA, American Society of Anesthesiologists; PS, physical status.
Tumor characteristics and stage (n=55)
Variable | Value |
---|---|
Tumor location | |
Descending colon | 25 (45.5) |
Sigmoid colon | 30 (54.5) |
Combined findings | |
Synchronous colon cancer | 5 (9.1) |
Tubular adenoma | 23 (41.8) |
Appendiceal mucinous neoplasm | 1 (1.8) |
Ischemia of proximal colon | 10 (18.2) |
Perforation of proximal colon | 5 (9.1) |
Stage |
|
II | 25 (45.5) |
IIA | 15 (27.3) |
IIB | 6 (10.9) |
IIC | 4 (7.3) |
III | 20 (36.4) |
IIIB | 16 (29.1) |
IIIC | 4 (7.3) |
IV | 10 (18.2) |
Values are presented as number (%).
When synchronous colon cancer was present, the stage of advanced cancer was applied.