In Emergency department, 70 years old male presents with acute obstruction. He has Ca. descending colon, M/n of choice :
Ans is 'c' ie Hartman's procedure As explained below, a variety of operations can be done in the obstructing lesion of left colon depending on a variety of factors, but Hartman's procedure is the most commonly preferred operation.Management of malignant large bowel obstructionMalignant obstruction is the most common cause of large bowel obstructionThe primary goal of treatment is decompression of the obstructed segment to prevent perforation. Removal of the malignant lesion is the secondary goal but a single operation to accomplish both objectives is preferred whenever possible.There are a variety of operation available and the operative strategy depends on many factors - the patients physical condition & age, location and extent of tumor and the experience of the surgical team.Obstructing lesion of the right colonIf the patient's condition is stable and the remaining bowel appears healthy - resection and ileocolic anastomosis in a single stage is the preferred op.If the patient's condition is unstable or bowel perforation has occurred - lesion is resected but no anastomosis done, an ileostomy is done and anastomosis is performed at a second operation.Nonresectable lesions- are bypassed by diversion procedures (colostomy or cecosigmoidostomy)Obstructing lesion of left colonTraditionally and most commonly performed procedure is - resection of lesion and proximal diversion done with proximal end colostomy or ileostomy (also known as Hartman's procedure)However, there is an increasing trend towards doing & primary anastomosis in a single stage operation. Primary anastomosis done in emergency setting in an unprepared bowel is associated with increased infection and anastomotic failure; but recent techniques of on-table lavage and more liberal application of extended resection coupled with broad-spectrum antibiotics and intensive perioperative care has improved the outcome for primary anastomosis.So in a stable patient with no diffuse peritonitis, no severe bowel injury and a resectable tumor- a resection and primary anastomosis should be preferred.If the patient is unstable, or the bowel is compromised - resection and proximal diversion is done.Another option available for left sided obstructing lesion is- subtotal colectomy with ileorectal anastomosis in one stage. It can be done if the proximal colon looks unhealthy (vascular compromise, serosal tears, perforation).Another option available is a colonic stent placement. This allows for decompression of the obstruction and converts the emergency situation into an elective setting. Stents may also be considered for palliation in patients whose life expectancy is less than 6 months, which is the expected patency of the colonic stent.If lesion is unresectable- a diversion procedure is done with a colostomy (external diversion) or a cecosigmoidostomy (internal diversion)
Defunctioning colostomy
Total Colectomy
Hartmann's procedure
Abdominoperineal resection
Colon and Rectum - Polyps and Carcinoma