Factors Affecting the Prognosis in the Management of Neoplastic Left Colonic Obstruction

Ayed Karim |

La tunisie chirurgicale - 2019 ; Vol 2019

Resumé

INTRODUCTION

Colon's neoplastic-obstruction is the most common complication of left colonic cancer.

Treatment remains controversial.

The aim of our study is to elaborate the therapeutic modalities in case of a left-colonic-neoplastic occlusion, to identify the predictive factors of morbi-mortality and to evaluate the long-term prognosis in terms of survival.

METHOD

This is a retrospective, descriptive study of patients operated on for left colon adenocarcinoma in occlusion at the general surgery department of the University Hospital Center Habib Bougatfa of Bizerte - Tunisia during a period of 07 years, from 01 January 2008 to 31 December 2015.

RESULT

The study population was characterized by a male predominance with a mean age of 63 years.

All cases underwent a surgical treatment.

 Decompressing stoma as bridge was performed on nine patients while 49 patients underwent a colic-resection procedure.

The morbidity rate was at 39%, the mortality rate was at 10% and the five-year survival rate reached the level of 77%.

In our study, predictive factors for mortality, morbidity, and factors affecting survival were identified.

Decompressing stoma as bridge to the surgery was associated with lower morbidity and better survival.

CONCLUSION

Colonic-neoplastic occlusion is a serious pathology. Decompressing stoma as bridge to the surgery remains the preferred treatment during the first surgical stage allowing a colonic -resection in good conditions and offering the patients a lower rate of morbi-mortality and a better survival.

Mots Clés

obstruction -Colon cancer - Surgical treatment - Prognosis

Introduction :

The colonic neoplastic obstruction is the most common complication of left colonic cancers. It can reveal the cancer from 10% to 19% depending on the series [1]. Its treatment remains a subject of controversy. In fact, if for right colonic tumors in obstruction, right hemicolectomy with immediate recovery of continuity has obtained unanimity of authors, the treatment of left colonic cancers in obstruction is still controversial. Several therapeutic procedures are available. It can consist of either the implementation of a stent followed by a surgical resection or a surgical treatment from the outset. The suggested surgical strategies consist of a first colonic resection with or without anastomosis or a colostomy of discharge followed by a resection.

The aim of this survey is to study therapeutic modalities of left neoplastic colonic obstruction in the general surgery department of the teaching hospital of Bizerte, Tunisia, identify predictive factors of mobi-mortality and evaluate the long-term prognosis in terms of survival and recidivism.

Article

Methods

Study:

It is about a retrospective, descriptive and pronostic study based on patients operated on neoplastic obstruction of the left colon in the general surgery department of Habib Bougatfa teaching hospital, in Bizerte, during the 7 years between January 1, 2008 and December 31, 2015.

Patients:

Inclusion criteria: For the study, we worked on patients who were operated on adenocarcinoma of complicated left colon with colonic obstruction, revealing cancer or occurring on patients with ongoing exploration. The obstruction is defined by a full matter and gas stop for at least 24 hours, associated with on or multiple hydro-aerial in the radiograph of the abdomen with no previous preparation.

Non-inclusion criteria: Patients admitted for right neoplastic occlusion of the colon were not taken for the study, neither those who were admitted for rectal neoplastic obstruction nor patients who underwent a programmed surgery for a left rectal cancer.

Exclusion criteria: The study excludes patients with neoplastic obstruction of left colon, which buckled under gastric suction, medical files that could not be exploited and the other forms of histological adenocarcinoma.

Data collection: In order to study our population and meet suggested goals, a framework of 364 variables has been elaborated. These variables were inputted based on data, operating reports and anatomic pathologies included in patients’ files.

These variables were linked to clinical, para-clinical, anatomic pathologies and surgical aspects as well as data recollected after surgeries and remote monitoring.

Decision criteria that were hold in our study were morbidity, mortality, survival and recurrence. For statistical analysis, we used the SPSS 20.0 software. We did, on the one hand, a descriptive study, and on the other hand, we did an analytical univariate study, then a multivariate. The analytical study aimed to determine predictive factors of morbidity, mortality, recurrence as well as factors influencing survival. The threshold of signification, P, was set at 0.05.

Results:

The subjects of our series is formed by 51 patients. The average age is 63 years old, with a majority of males. The obstruction was cancer revealing for 50 patients (98%) and has occurred during the treatment of a colon cancer for one patient. Not scheduled abdomen x-rays showed pathology for all patients. Abdominal scan was performed on 35 patients, which helped identify the nature of neoplastic obstruction in all these cases. The sigmoid indicated the most common tumor localization. The emergency treatment was surgical in all cases: a colostomy from up-front was conducted for 18% of the patients and a colic-resection was accomplished for 82% of patients. It was segmental for 90% of cases and total for the other 10% of patients who had emergency colic-resection. Immediate recovery of anastomosis occurred for 7% of patients. For 94% of patients, second surgical interventions were performed in order to resect the tumor and/or recover anastomosis. A third surgery time was held for 6% of patients for anastomosis recovery.

On the anatomical pathologies plan, tumor was classified in T3 category for 84% of cases. The average number of ganglions collected was 12. We found node-positive in 61% of cases, vascular embolisms were found with 14% of patients. Resection was of type R2 in 10% of cases.

Post-operation follow-ups were easy in 51% of cases. Global morbidity was of 39% and global mortality was of 10%. Average duration to death was 17 days.

Predictive factors of mortality were in univariate analysis a surgery duration superior to 240 minutes, Hartmann intervention, removal of surrounding organ, tumor intrusion bleeding and intraoperative transfusion, post-operation complications occurrence and medical post-operation complications occurrence (table 1). In multivariate analysis, Hartmann intervention (P=0035; OR=2.69), surrounding organ removal (P=0.04; OR=3.33), tumor intrusion(P = 0,04; OR = 3,33), post-op complications occurrence (P = 0,15; OR = 2,96) were independent factors of predictive mortality.

Global morbiditywas of 39%.

Factors of predictive morbidity were, in univariate study, cardiovascular comorbidity, segmental resection, tumorintrusion, tumor perforation, bleeding and intraoperative transfusion, peritonitis presence and a surgical duration superior to 3 hours. Furthermore, the making of a colostomy  decreased in a significant statistical way the pot-op morbidity. In fact, the global morbidity was 0% for patients who had a colostomy of discharge versus 49% for patients who had a different therapeutic attitude with a P=0.03 (table 2). In multivariate studycardiovascularcomorbidity(P=0,006; OR=2,5), tumor intrusion(P=0,04; OR=2,4) and intraoperative transfusion(P = 0,012; OR =2,24) we independent factors of predictive morbidity.

Global survival, based on the Kaplan Mayer curve was 77% at 5 years (chart 1). Factors affecting global survival in univariate analysis were a duration of admission and surgical intervention superior to ten hours (49.8% vs 93%; P=0.01), the presence of distant metastases (82% vs 22%; P=0.001), invasion of neighboring organs (89% vs 2%; P=0.0001), presence of vascular embolism (89% vs 12%; P=0.03), tumoral resection type R2 (82% vs 22%; P=0.001). These factors decreased, in a significant statistical way, global survival. The making of colostomy of discharge increased, in a significant statistical way, the survival. In multivariate analysis, the presence of vascular embolisms (P=0.038; OR=2.87) (Chart 2), colic resection type R2 (P=0.003; OR=4.48) (Chart 3) and invasion of neighboring organs (P=0.003; OR=5.55) (Chart 4) were independent factors affecting global survival.

The average decline in our study was of 33 months.

Having concluded this study, 53% of patients were alive with no recurrence and no stoma, 10% were alive with no recurrence and with stoma, 10% died and the cause of death was colon cancer, 4% had recurrence and 16% were not seen again.

Discussion:

Colorectal cancer is classified in the third rank of cancers in frequency and it represents the second cause of death by cancer [2].

Colonic obstruction is a particular mode of colonic adenocarcinoma revelation and constitutes a therapeutic emergency.

The urgency of the surgical gesture is associated to a high post-op morbidity and mortality. In our series, global morbidity was 39% and global mortality was 10%. In literature, morbidity is estimated between 38 and 51% whilst 20% and 30% in scheduled oncologic colonic surgery [3], [4], [5].

Mortality forwarding an emergency surgery for colonic cancer is estimated between 10 and 20% whilst for schedueled surgery, it is between 3 and 6%, and this, whatever the type of therapeutic attitude that was adapted [4]. Many factors were incriminated as predictive mortality. The factors most reported to literature are advanced age [3], [8], [9], ASA score [8] and the urgent character of surgical care.

In our series, adavanced age (superior to 65 years old) was not a predictive factor of mortality. Tekkis and Al.fournd that the risk of post-op mortality increased with age [3]. In fact, patients who had colonic neoplastic obstruction whose age was between 65 and 70 years old had a post-op death risk, in multivariate analysis, multiplied by 2.97 comparing to other patients aged by less than 65 years old and patients aged between 75 and 84 years old, had a risk multiplied by 5.87 [3]. Bakker and al found that post-op mortality risk was 2.3% for patients aged less than 73 years old and was 7.3% for patients aged more than 75 years old. In multivariate analysis, age equal or superior to 75 years old remained an independent risk factor of mortality in the global series (OR=2.25 – IC 95% : 2.201 – 2.954).

In this same study, post-op mortality was significantly higher for the group of patients who had emergency operation (8.5% vs 3.4% with P=0.001). Furthermore, the presence of comorbidities determined by the ASA score represents an independent risk factor of post-op mortality, whether it is in colorectal oncological surgery performed in emergency (OR=2.65 – IC 95% : 2.026 - 3.453) [8].

Regarding post-op morbidity, it is mainly related to physiological and hydro electrolytic modifications that the obstruction creates as well as the increased risk of infectious pre and post operations, because of bacterial proliferation driven by stercoral. In addition, the surgery of colonic neoplastic obstructions is frequently performed in the on-duty period of young surgeons. Many studies showed that in these conditions, patients are exposed to a higher risk of post-op colorectal surgery complications [10], [11].

The surgical treatment of left colonic neoplastic obstructions is a subject of multiple controversy and unanimity is way far from happening. Two main categories of intervention are opposed: the surgery of two or three surgical times and the surgery with one surgical time.

In our series, the making of a colostomy followed by a resection was associated with minor morbidity and mortality and with a better survival. This was noted in the study of Chéreau and al. who compared first colostomy, Hartmann intervention and colonic resection with anastomosis from outset in terms of morbidity, mortality and long-term survival. It was found that discharge colostomy had a morbidity (9.8 vs 54.4 vs 45.5%) and mortality (39 vs 45 vs 54%) which is less than other attitudes. In addition, first colostomy is associated to a hospitalization duration shorter than the Hartmann intervention’s (20 vs 27 days).

The number of ganglions collected was higher for patients who had a first colostomy (29 vs 22 ganglions). The average survival (26.1 vs 7 vs 18.1 months) as well as the survival to 5 years (39.2 vs 24.2 vs 20.5%) were better with a stoma rate way lower (7 vs 50%) [12].

Cancers prognostic plosive of colon is unfavorable because, first, from a general precarious state of patients who are often aged, holders of multiple defect and, second, from the urgent character of the surgical intervention that is not always performed in the optimal conditions.

In our study, survival to 5 years was at 77%. It is, in literature, between 19 and 52%. The urgent character of care is one of the major factors for bad prognostic of colonic tumors in obstruction [1], [13], [14], [15]. It often results to a colonic resection type R1 [16]. The survival with no recurrence and global survival are significantly decreased in the case of colonic resection type R1 [17].

The study of Sa Cunha and al. [18] confirmed the severity of left colong cancer in obstruction. In this case, 32% of patients had metastatic from the outset and 36% of tumors were classified T4. The size of the tumor a pejorative factor. Saha and al showed that global survival to 5 years moved from 66% for a tumor size inferior to 2cm to 41% for a tumor size of 6 cm [19].

Regarding the tumor recurrence, we had in our series two cases of loco-regional recurrence. Cortet and al. found in his series that univariate study, the rate of loco-regional recurrence and at a distance of 5 years it was significantly higher for patients with obstruction than those who underwent scheduled intervention (28% vs 2%, P<0.0001). in multivariate study, the occlusive character was an independent bad prognostic factor on the loco-regional recurrence (Odds ratio=1.53, P=0.04) [20].

 

Conclusion:

Optimal surgical treatment of left colon obstructed cancers remains a subject of controversy. The data from literature do not afford a definitive answer with a proof of good level allowing to settle from all different attitudes. All availablestudiescomparingdifferentmodalities are ratherretrospective.

Discharge colostomy is recommended by multiple authors. It allow a lower mortality and morbidity and a better survival. However, the proof level remains low. Multicentric studies are necessary to carry out a factual satisfying answer to better plan therapeutic modalities of patients.

Conflict of interest: No conflict of interest between authors.

 

 

Table 1: Predicitve Factors of Mortality

Factors

Yes

No

P

Invasion of neighboringorgans

6 ( 50%)

45 ( 4%)

0,01

Hartmann Intervention

9 ( 33%)

42 ( 4%)

0,03

Removal of neighboringorgans

3 (100%)

48 ( 48%)

0,001

Intraoperative Tumoral Effraction

4 (75%)

47 ( 4%)

0,004

IntraoperativeBleeding

7 ( 42%)

44 ( 4%)

0,03

Intraoperative Transfusion

7 ( 42%)

44 ( 4%)

0,03

Post-op Coomplications

20 ( 25%)

31 ( 0%)

0,007

 

Table 2: Predictive Factors of Morbidity

Morbidity

Yes

No

P

CardiovascularComorbidity

9 ( 78%)

42 ( 31%)

0,0009

Peritonitis

6 ( 83%)

45(31%)

0,03

Segmental ColonicResection

34 (50%)

17 (19%)

0,03

Tumoral Effraction

4 ( 100%)

47(33%)

0,04

IntraoperativeBleeding

7(86%)

44(29%)

0,04

Intraoperative Transfusion

7 ( 87%)

44 (29%)

0,04

Tumoral Perforation

12 (67%)

39 ( 32%)

0,04

Surgery Duration

> 223 minutes

< 223 minutes

 

 

74%

11%

 

       _

       _

 

0,01

 

Chart 1: Global Survival Based on Kaplan Mayer Curve

 

Chart 2: Survival Curve Based the Presence of Vascular Embolisms

 

Chart 3: SurvivalCurveBased on the Resection Type

Chart 4: SurvivalCurveBased on the Invasion of NeighboringOrgans

Références

1.         Scott NA, Jeacock J, Kingston RD. Risk factors in patients presenting as an emergency with colorectal cancer. Br J Surg. 1995 Mar;82(3):321–3.

2.         Teixeira F, Akaishi EH, Ushinohama AZ, Dutra TC, Netto SD do C, Utiyama EM, et al. Can we respect the principles of oncologic resection in an emergency surgery to treat colon cancer? World J Emerg Surg WJES. 2015;10:5.

3.         Panis Y, Maggiori L, Caranhac G, Bretagnol F, Vicaut E. Mortality after colorectal cancer surgery: a French survey of more than 84,000 patients. Ann Surg. 2011 Nov;254(5):738–43; discussion 743–4.

4.         Sjo OH, Larsen S, Lunde OC, Nesbakken A. Short term outcome after emergency and elective surgery for colon cancer. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2009 Sep;11(7):733–9.

5.         Adloff M, Arnaud JP, Ollier JC, Schloegel M. Les cancers du côlon : étude portant sur 1122 malades opérés. J Chir (Paris). 1990;127(12):565–71.

6.         Runkel NS, Schlag P, Schwarz V, Herfarth C. Outcome after emergency surgery for cancer of the large intestine. Br J Surg. 1991 Feb;78(2):183–8.

7.         Tekkis PP, Kinsman R, Thompson MR, Stamatakis JD, Association of Coloproctology of Great Britain, Ireland. The Association of Coloproctology of Great Britain and Ireland study of large bowel obstruction caused by colorectal cancer. Ann Surg. 2004 Jul;240(1):76–81.

8.         Bakker IS, Snijders HS, Grossmann I, Karsten TM, Havenga K, Wiggers T. High mortality rates after nonelective colon cancer resection: results of a national audit. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2016 Jun;18(6):612–21.

9.         Gainant A. Prise en charge en urgence des occlusions coliques par cancer. J Chir Viscérale. 2012;149(1):3–11.

10.       Borowski DW, Bradburn DM, Mills SJ, Bharathan B, Wilson RG, Ratcliffe AA, et al. Volume-outcome analysis of colorectal cancer-related outcomes. Br J Surg. 2010 Sep;97(9):1416–30.

11.       Harmon JW, Tang DG, Gordon TA, Bowman HM, Choti MA, Kaufman HS, et al. Hospital volume can serve as a surrogate for surgeon volume for achieving excellent outcomes in colorectal resection. Ann Surg. 1999 Sep;230(3):404–11; discussion 411–3.

12.       Chéreau N, Lefevre JH, Lefrancois M, Chafai N, Parc Y, Tiret E. Management of malignant left colonic obstruction: is an initial temporary colostomy followed by surgical resection a better option? Colorectal Dis Off J Assoc Coloproctology G B Irel. 2013 Nov;15(11):e646–53.

13.       Ratto C, Sofo L, Ippoliti M, Merico M, Doglietto GB, Crucitti F. Prognostic factors in colorectal cancer. Literature review for clinical application. Dis Colon Rectum. 1998 Aug;41(8):1033–49.

14.       McArdle CS, Hole DJ. Emergency presentation of colorectal cancer is associated with poor 5-year survival. Br J Surg. 2004 May;91(5):605–9.

15.       Chapuis PH, Dent OF, Fisher R, Newland RC, Pheils MT, Smyth E, et al. A multivariate analysis of clinical and pathological variables in prognosis after resection of large bowel cancer. Br J Surg. 1985 Sep;72(9):698–702.

16.       ASGE Standards of Practice Committee, Harrison ME, Anderson MA, Appalaneni V, Banerjee S, Ben-Menachem T, et al. The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction. Gastrointest Endosc. 2010 Apr;71(4):669–79.

17.       Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K, Association Française de Chirurgie. Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study. Arch Surg Chic Ill 1960. 2005 Mar;140(3):278–83, discussion 284.

18.       Rault A, Collet D, Sa Cunha A, Larroude D, Ndobo’epoy F, Masson B. [Surgical management of obstructed colonic cancer]. Ann Chir. 2005 Jun;130(5):331–5.

19.       Saha S, Shaik M, Johnston G, Saha SK, Berbiglia L, Hicks M, et al. Tumor size predicts long-term survival in colon cancer: an analysis of the National Cancer Data Base. Am J Surg. 2015 Mar;209(3):570–4.

20.       Cortet M, Grimault A, Cheynel N, Lepage C, Bouvier AM, Faivre J. Patterns of recurrence of obstructing colon cancers after surgery for cure: a population-based study. Colorectal Dis Off J Assoc Coloproctology G B Irel. 2013 Sep;15(9):1100–6.