Guideline

The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction

Colon and rectal surgical emergencies are a frequent cause for urgent surgical consultation. The resources available to diagnose and treat these emergencies vary widely depending on location. This review seeks to help guide all surgeons (general surgeons, acute care surgeons, colon and rectal surgeons, etc.) through pre-operative decision-making, intra-operative management, and post-operative considerations for the most common colon and rectal surgery emergencies. The common denominator across all of the colon and rectal surgery emergencies is the importance of a careful history and physical exam, appropriate diagnostic work up, prompt recognition of life-threatening emergencies, and expeditious management.

Hemorrhoids:

When discussing colorectal surgical emergencies, anorectal diseases must also be considered. Anorectal emergencies describe anorectal disorders presenting with alarming symptoms such as acute anal pain and bleeding which may require immediate management. Hemorrhoids are one of the most common anorectal disorders. Distinguishing the etiology of internal versus external disease and timeframe of symptoms is critical for proper management. Distinguishing incarcerated prolapsed internal hemorrhoids from incarcerated rectal prolapse is key to planning appropriate operative treatment.

Rectal Prolapse:

When the rectum drops down below the anal sphincters, an incarceration or strangulation may occur. It is imperative for the surgical team to plan for immediate reduction and/or resection of the prolapsed rectum to prevent further demise of the patient. Early recognition and reduction of incarcerated full thickness rectal prolapse (FTRP) using hyperosmotic solutions is critical in an emergency setting. Failure to reduce incarcerated FTRP may lead to strangulation. Immediate surgical repair is reserved for strangulated prolapse. Elective perineal or abdominal repair of FTRP are reasonable approaches in successfully reduced cases.

Fournier's Gangrene:

Early identification of necrotizing perineal infections (Fournier's gangrene) is paramount to optimal management and outcomes. Previously FG had a high mortality rate and was seen as uniformly fatal. Advancements in medical knowledge and treatment with multidisciplinary care teams have allowed full recovery after infection with FG to become the norm. The blood supply to the perineum is robust, thus with aggressive debridement, antibiotics, and diligent wound care, full closure of even quite extensive wounds that have undergone multiple debridements is possible.

Lower Gastrointestinal (LGI) Bleed:

Massive lower gastrointestinal (LGI) bleeding is a medical and surgical emergency. While management has become increasingly non-surgical due to the evolution of endoscopic and endovascular hemorrhage control, surgery remains an important option for refractory localized bleeding or persistent unlocalized hemorrhage. Due to the range of treatments available and depending on facility resources, massive LGI bleed requires a multidisciplinary approach that may involve gastroenterologists, surgeons, interventional radiologists, and surgical intensivists. Furthermore, cases of hemorrhagic shock and profound physiologic derangement will require a large number of resources, a blood bank capable of massive transfusion protocols, and constant multidisciplinary communication. Diverticulosis, followed by ischemic colitis, are the most common reasons for massive lower GI bleed. The majority of lower GI bleeds, even those rapidly bleeding, will typically be self-limiting. Physical exam remains the most important first step in diagnosis and localization. CT angiography and colonoscopy have become mainstays for diagnosis and localization. Make every effort to perform bowel prep prior to colonoscopy to aid in identification of lesion. Stable patients should undergo CT angiography as it is rapid, minimally invasive, and has a high rate of hemorrhage localization. Unstable patients with unlocalized colonic bleeding benefit from a total abdominal colectomy with end ileostomy (after small bowel bleeding terminal ileum has been ruled out through inspecting the terminal ileum). There is no role for segmental resection unless there is successful localization. Diagnostic and therapeutic options must be tailored to local context and available resources. Hemodynamically unstable patients, or patients with an on-going bleed resistant to colonoscopy might benefit from procedural intervention.

Acute and Toxic Megacolon:

Toxic megacolon is a rare but severe complication of colitis and carries a mortality rate of about 10%. Toxic megacolon is defined as colonic distension (>6cm in the transverse colon) in the presence of systemic sepsis. Treatment requires aggressive medical and potentially surgical intervention to prevent morbidity and mortality. The etiology largely guides the diagnostic approach and management of toxic megacolon.

Malignant Large Bowel Obstructions (LBO):

Malignant LBO can be a challenging scenario for surgeons. The individual patient's acuity of presentation and clinical status will determine how urgently an intervention is needed. There are numerous ways to approach a malignant LBO, including diversion alone, upfront resection, or stent placement. The surgeon's comfort with these various methods, as well as the patient's clinical and tumor characteristics, will determine which intervention is employed. The primary goal should be to adequately address the obstruction, using a method with the lowest risk of complications, to enable patients to receive systemic therapy, if needed, as expeditiously as possible. Ultimately, prolonging the patient's life, as well as preserving their quality of life, are of paramount importance.

Regarding surgical management, damage control techniques should be utilized if the patient is critically ill. In addition, restoration of intestinal continuity should be the ultimate goal of management if feasible. If a patient is determined to require emergent or urgent intervention, but is not critically ill, there are multiple options for definitive management, but proceeding to the operating room should be prioritized to minimize the risk of sequalae such as perforation, feculent peritonitis, and bowel ischemia. Overall, colonic stenting can be a useful bridge to surgery and should be considered on an individual basis. Because it requires interventional endoscopists who can utilize both endoscopic and fluoroscopic techniques, it is not widely used in the community. Management decisions should be tailored to each patient's needs and goals of care.

Non-Malignant Large Bowel Obstruction (LBO):

Large bowel obstruction (LBO) account for 25% of bowel obstruction. Malignant large bowel obstruction account for >60% of large bowel obstruction. Although they represent a minority of cases, non-malignant LBO remain an important cause of bowel obstruction. Frequent etiologies include diverticulitis, volvulus, inflammatory bowel disease (IBD), anastomotic or ischemic strictures, and radiation enteritis. Obstructions can be partial or complete. Unlike a small bowel obstruction (SBO), which is commonly managed with decompression and bowel rest to give the obstruction the opportunity to resolve, the presence of a competent ileocecal valve significantly alters the management of LBOs. A competent ileocecal valve creates closed loop obstruction when there is a complete blockage of enteric contents in the colon. As gas and stool continue to enter, the colon becomes more and more distended. Eventually, the colon will become overly distended and perforate. The timing of perforation can vary with more chronic obstructions allowing the colon to slowly distend over time and accommodate a larger diameter prior to perforation. Decompression options can include surgical resection, or endoscopic techniques including stenting.

Perforated Feculent Diverticulitis:

Surgical management of fecal peritonitis requires prompt evaluation and extremely prudent decision-making, with intraoperative factors often finalizing the choice of operation. Multiple factors including a patient's overall health, comorbidities, disease severity, and hemodynamic status guide decision-making.

Increasing evidence favors primary anastomosis over Hartmann's procedure, particularly with improved stoma reversal rates. However, surgeon judgment and patient factors such as metabolic strain, comorbidities, and intraoperative findings should still help guide the choice of operation. Though primary anastomosis is gaining traction, the practice of Hartmann's remains relevant in specific cases, with the option of referral for reversal surgery.

Surgeons have a role in observing, detect abnormalities, disease, and other deficiencies in function which could be treated. Diagnosing and treating back days were challenging for many reasons. However, technology's innovation enhances surgeons' ability to treat their patients. The term endoscopy refers to the Greek prefix endo- (“within”) and the verb skopein (“to view or observe”). Endoscopy is practical both in the diagnosis and treatment of various pathologies. Technological advances, especially in endoscopy, gradually progress and discover many possibilities which allow rapid advancement. Endoscopy development aims to assess human orifice that has not been inspected, probed, and examined over the centuries. Endoscopy over these decades is improving, which led to new problem solving using advanced technological approaches. Thus, a surgeon can solve any issues from examination, diagnosis, and treatment using progressive endoscopy evolution. This review delivers a brief history of advances in surgical endoscopy and describes current endoscopy development.

Colonic stent placement can avoid urgent surgery for large bowel obstruction in selected patients. Population-wide stent utilization patterns and outcomes are unknown.

Using retrospective, population-based, Nationwide Inpatient Sample data, we studied patients with colonic stents discharged during 2010-2015. The primary outcome was ostomy creation during the same hospitalization. Other outcomes were perforation or peritonitis, and in-hospital death. Associations of outcomes with stent indication were investigated, adjusting for patient-, admission-, and hospital characteristics. We estimated annual population-wide stent use volumes.

Of 4257 patients with stent placement (52% male, mean age 64.6 years), 9.9% had non-metastatic colon cancer, 12.9% metastatic colon cancer, 37.8% extracolonic malignancy (ECM), and 39.3% had benign obstruction. In 8.1% of patients, ostomy creation surgery was performed. Perforation or peritonitis occurred in 16.7%, and in-hospital death in 4.5%. Relative to ECM, ostomy creation was several-fold more likely among nonmetastatic colon cancer (adjusted odds ratio (OR) 3.4; 95%CI, 2.1-5.5), metastatic colon cancer (adjusted OR 2.5; 95%CI, 1.7-3.7), and benign obstruction patients (adjusted OR 3.1; 95%CI, 2.1-4.7). Benign obstruction was associated with high risk of perforation/peritonitis (adjusted OR 3.1 relative to non-metastatic CC (95%CI, 2.1-4.5)). Perforation/peritonitis was highly associated with inpatient death (adjusted OR 6.8 (95%CI, 4.9-9.5)). Annually, about 3,580 patients underwent stent placement, with benign obstruction showing an increasing trend (P=0.0002).

Over 75% of stent placements were done for patients with benign disease and ECM obstruction. Subsequent ostomy creation during the hospitalization was least likely among ECM patients. Rates of perforation/peritonitis in benign obstructions were concerningly high. (22.2%).