Large bowel obstruction

Section: Colorectal Sub-section: Acute colorectal Curriculum: Curriculum, page 24

Aetiology

Type

• Partial or complete
• Intrinsic or extrinsic
• Adynamic or mechanical

Causes

• Intrinsic:
  • Neoplasm
  • Diverticulitis
  • Stricture
  • Faecal impaction
  • Inflammatory/ischaemia
  • Intussusception
• Extrinsic:
  • Volvulus
  • Hernia
  • Endometriosis
  • Adhesions
• Adynamic
  • Colonic pseudo-obstruction

Management by Cause

Neoplastic

Stents

• Bridge to surgery or palliation
• Complications: stent migration, obstruction/occlusion and perforation (including microperforation with oncological concerns)
• Benefits - lower stoma rates, facilitates a laparoscopic approach
• According to ESGE and ASGE:
  • Prophylactic stents not recommended
  • Self-expandable metal stents (SEMS) not recommended as bridge to elective surgery in left-sided malignant obstruction
  • SEMS recommended for palliation except patients treated with anti-angiogenic drugs
• Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial
  • https://pubmed.ncbi.nlm.nih.gov/35986684/ - BJS 2022
    • Decrease stoma rate
    • Same mortality at 3 years

Operative

• Resection
  • Can be single or multiple stages.
  • If primary anastomosis, can be with or without protective diverting ostomy.
  • Decompression may be required, can use needle, suction, lavage and endoscopic. On table lavage does not decrease anastomotic complications.
  • Need to evaluate for synchronous tumours, liver metastasis, local invasion and presence of peritoneal carcinomatosis.
• Diverting stoma
  • Loop colostomy or ileostomy
  • Rectal cancer = stoma as neoadjuvent treatment typically indicated

Diverticular

• Can use stent as bridge to surgery if partial obstruction.
• Operative
  • Difficult to tell if malignant preoperatively so principles should follow oncological resection.
  • Hartmans is the safest option