SURGICAL APPROACHES OF LEFT SIDED LARGE GUT OBSTRUCTION DUE TO MALIGNANT LESION OF IT

Md. Khalilur Rahman Khabir*, Md. Ashraful Islam, Akram Hossain Khan, Mohammad Tawfik Aziz Shaon, Md. Saidul Anwar and Tanveer Ahmed

ABSTRACT

Background: The rising incidence of colorectal cancer is a well-known phenomena. Two third of the cancer is located in the left side of the colon and the remaining one third is located in the right. Large gut obstruction is a common complication that the patients with left sided colorectal cancer presented with. The surgical treatment of acutely obstructed left colon cancer is still a debatable issue for the surgeons because of its high associated morbidity and mortality and availability of different surgical options. Therefore, the data generated from the present study might be helpful to identify the appropriate surgical option for the patients with left sided large gut obstruction due to its malignancy, thus reducing the postoperative mortality and morbidity of the patients with dilemma of surgeons about surgical approaches as well. Objective: To propose a preliminary guideline for selection of surgical option for patients with left sided large gut obstruction due to its malignant lesion. Methods: It was a prospective observational study. The study was carried out in the department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka Medical College Hospital and Shaheed Suhrawardi Medical College Hospital, Dhaka; during the period of september 2013 to march 2014. Demographic data of the patients as well as clinical presentations of them, diagnostic procedures, parameters relating to surgical approaches, early post-operative complications were retrieved. Results: A total of 50 patients of left sided obstructing colorectal cancer were studied. The mean age of the patients was 49.78 years with a male female ratio of 1.3:1. All patients presented with abdominal pain, constipation, abdominal distension and absence of bowel sound. Sigmoid colon was the commonest site of lesion (42%) followed by recto sigmoid junction (22%), rectum (16%), splenic flexure (12%) and descending colon (8%). Three patients of in this series presented in Dukes' stage A (6%) while 22 patients presented in stage B (44%). Stage C and stage D constituted 36% and 14% respectively. Primary resection and anastomosis with covering ilesotomy was done in 12% patents, who belonged Dukes' stage A&B and ASA score <3. 52% were underwent primary resection and end colostomy (Hartmann’s procedure) and belonged mostly Dukes' stage C&D and ASA ≥3, and the rest 36% were undergone loop colostomy and belonged Duke stage C&D and ASA ≥3. Conclusion: Primary resection and end colostomy (Hartmann's procedure) is the appropriate surgical option for high risk patients for malignant left sided large gut obstruction and it is opted for most of the patients. Again, loop colostomy is recommended for patients who are in extremely high risk and not fit for prolong surgery. Whereas, primary resection and anastomosis with covering ileostomy is recommended for low-risk patients.

Keywords: Colorectal cancer, Morbidity, Mortality, Loop colostomy.