Tube cecostomy and staged resection for obstructing carcinoma of the left colon

Abstract. In July 2008, a 40-year-old man presented to his local physician with diffuse abdominal pain and severe abdominal distension. Impending bowel rupture due to colonic obstruction was strongly suspected. Complete obstruction of the distal sigmoid colon by a tumor was diagnosed, and emergency surgery was performed. A sigmoid colon loop colostomy was created within the range of subsequent resection to relieve the obstruction. After his general condition had improved and the risks were assessed, curative resection including removal of the stoma was performed by hybrid 2-port hand-assisted laparoscopic surgery. The tumor showed invasion of the serosa without lymph node metastasis, and its pathological diagnosis was stage II. Postoperatively, mild wound infection occurred at the hand access site (stoma), but it resolved with conservative treatment, and the patient was discharged on postoperative day 13. This case is reported here because of the good results. IntroductionIn recent years, less invasive laparoscopy-assisted colorectal surgery (LACS) has become very common. The indications for LACS cover a very wide range, from additional procedures after endoscopic mucosal resection (EMR) of stage I early colorectal cancer to curative resection of stage II/III cancer and palliative surgery for advanced stage IV cancer (1-5). Unlike in the West, LACS in Japan does not usually involve hand-assisted laparoscopic surgery (HALS) or hybrid HALS combined with a standard procedure under direct vision (6-9). Instead, LACS is mainly performed with 5-6 ports including the camera port and a small incision of 35-45 mm (10,11). However, such pure LACS is difficult to perform in patients with complete bowel obstruction by left colon cancer or those who require combined resection due to invasion of other organs such as the urinary bladder or other parts of the intestine. Problems with the comparatively long operating time have also been pointed out (5). To solve these problems, we considered the use of hybrid 2-port HALS, in which HALS is combined with open surgery via a small incision (45-55 mm) as the hand access site (5,12,13). Since hybrid 2-port HALS is conducted with a small incision and only two ports, this represents a major difference from pure LACS using 5 to 6 ports. The features of hybrid 2-port HALS are as follows: i) palpation and tactile sensation ensure safe and reliable surgery; ii) protective and smooth procedures can be carried out by manual manipulation, particularly in patients with large and heavy tumors; iii) the procedure can be performed by only two surgeons; iv) it is an extension of standard operation, so the operating time is shorter; and v) there is only a shallow learning curve for the procedure (5,13).It has been reported that initial emergency surgery for complete obstruction of the left colon by cancer should be performed rapidly at any time with minimum invasion in order to relieve the high intraluminal pressure by creation of a safe and reliable temporary loop colostomy or ileostomy (12). We do...

Section: Discussionmentioning

confidence: 99%

Hybrid 2-port hand-assisted laparoscopic surgery for the 2-stage treatment of a complete bowel obstruction by distal sigmoid colon cancer: A case report

Mukai

Kishima²,

Iizuka³

et al. 2009

“…Moreover, when emergency surgery is performed without preoperative bowel lavage, since the bowel contents are not fecal, it is relatively rare for surgeons to feel hesitation about performing anastomosis after one-stage resection of the tumor. Therefore, a complete obstruction of the left colon by cancer is a more serious problem (15)(16)(17)(18). At initial surgery, the radical resection of the primary tumor usually involves the removal of the cancer, followed by bowel anastomosis plus a temporary loop ileostomy and/or right transverse loop colostomy (19)(20)(21).…”

Section: Discussionmentioning

confidence: 99%

Two-port hand-assisted laparoscopic surgery for the 2-stage treatment of a complete bowel obstruction by left colon cancer: A case report

Mukai¹,

Akira²,

Tajima³

et al. 2008

A 69-year-old woman presented to her local clinic with vomiting and abdominal distension. Since a bowel obstruction by left colon cancer was suspected due to a marked dilation of the transverse colon, she was referred to our hospital. On admission, an enema disclosed a complete obstruction at the splenic flexure of the colon. An emergency operation was performed, and a temporary loop colostomy was fashioned on the left side of the transverse colon within the range of resection for 2-stage radical surgery. On hospital day 16, a left hemicolectomy D2 was performed by 2-port hand-assisted laparoscopic surgery (2P-HALS) using the stoma as the hand access site, and the tumor was resected along with the removal of the stoma. After surgery, a slight wound infection occurred at the hand access site, but this healed with conservative management. On day 36, she was discharged from hospital. The histological diagnosis was Type 2 circumferential well-differentiated adenocarcinoma with local peritoneal dissemination. Our experience suggests that 2-stage surgery combined with 2P-HALS is applicable even to a large obstructing left colon cancer. This method is less invasive, safe and achieves excellent results, including a good cosmetic outcome.

“…The surgical procedures employed can be classified into those involving resection of the primary tumor and procedures that only relieve obstruction without removing the primary lesion (16)(17)(18) is followed by anastomosis/reconstruction with construction of a covering colostomy in the right transverse colon, investigation of other tumors and diseases cannot be performed. In addition, the long operating time and highly invasive surgery make it a risky emergency operation (19)(20)(21).…”

Section: Introductionmentioning

confidence: 99%

Two-stage treatment (Mukai's method) with hybrid 2-port HALS (Mukai's operation) for complete bowel obstruction by left colon cancer or rectal cancer

Mukai

Sekido²,

Hoshikawa³

et al. 2010

Abstract. During the initial emergency operation, a temporary loop colostomy (TLC) was constructed at the oral border of the region for subsequent radical resection. Then, radical surgery was performed by hybrid 2-port HALS (Mukai's operation) using the TLC as the hand access site. Left hemicolectomy was done in three patients, sigmoidectomy in two cases, low anterior resection in one case, and Hartmann's operation in one case. Radical surgery was not done in one patient with multiple distant metastases. The mean operating time was 3 h and 7 min (ranging from 1 h and 55 min to 3 h and 47 min), the mean blood loss was 146.4 ml (7-354 ml), the mean duration from TLC to HALS was 11.3 days (8-16 days), and the mean hospital stay after HALS was 13.9 days (9-20 days). Mild wound infection occurred postoperatively in 2/7 patients and ileus occurred in one patient. However, there was no anastomotic leakage/stricture or conversion to conventional laparotomy. These results suggest that 2-stage treatment (Mukai's method with Mukai's operation) is also applicable to large obstructing left colon or rectal cancers. This method is safe, less invasive, and achieves excellent results, including a good cosmetic outcome. IntroductionIn recent years, minimally invasive laparoscopy-assisted colorectal surgery (LACS) has become common, and its indications have expanded considerably from additional resection for early stage I colorectal cancer to radical curative resection of advanced stage II/III cancer and palliative surgery for stage IV patients (1-5). Unlike Western countries, where hand-assisted laparoscopic surgery (HALS) and hybrid-HALS combined with surgery under direct vision are popular (6-9), pure LACS performed via 5-6 ports together with a small incision of 35-45 mm has become the mainstream procedure in Japan (10,11). However, the use of pure LACS is limited in patients with complete bowel obstruction due to left colon cancer, which is an oncologic emergency, and those who need partial resection of tumors infiltrating other organs such as the bladder. In addition, it has been pointed out that the operating time is relatively long (5,(12)(13)(14). In order to solve these problems, we devised hybrid 2-port HALS (Mukai's operation), which involves HALS using a small incision of 45-55 mm as the hand access site, combined with manipulation under direct vision (15). The features of this surgical procedure include the following: i) full grasping manipulation, as well as palpation, can be done with the left hand, enabling protective and smooth handling of even large and heavy tumors; ii) there is little difficulty for anesthesiologists and operating room staff since the procedure is an extension of conventional laparotomy and takes less time than pure LACS and; iii) it is less demanding for surgeons and less time is required to master the procedure, a supervised surgeon who only has experience of standard laparotomy is able to perform it without difficulty. Due to such advantages, hybrid 2-port HALS is applicable to all colorect...