ORIGINAL ARTICLE
Colon Esquerdo (distal)
Laparoscopic Management for Acute Malignant
Colonic Obstruction todos a esquerda
Fan-Ming Chen, MD, Tzu-Chieh Yin, MD, Wen-Chieh Fan, MD, Che-Jen Huang, MD,
and Jan-Sing Hsieh, MD
Purpose: We aimed to evaluate the feasibility of staged laparo-
scopic colectomy for acute malignant colon obstruction.
Methods: Through a laparoscopic approach, emergency blowhole
colostomy and subsequent elective resection were performed.
Results: There were 14 men and 8 women, ages ranging from 42 to
79 years. All patients underwent laparoscopic blowhole colostomy
for fecal diversion. Of these stomas, 6 were located at the splenic
flexure, 7 at the descending colon, and 9 at the sigmoid colon.
Subsequently, 20 of the 22 patients achieved an elective laparo-
scopic resection including takedown of the stoma. They were left
hemicolectomy in 11 and anterior resection in 9. The mean total
length of hospital stay was 20 ± 4.6 days (range, 16 to 33 d) in these
20 patients. The remaining 2 patients did not undergo reversal of
the colostomy. The median follow-up period was 23 months. Seven
patients died of disease progression and 15 patients remained alive
and well.
Conclusions Our results suggest that staged laparoscopic colon re-
section is a feasible and effective technique for acute malignant
colonic obstruction. The length of hospital stay is justified as
compared with conventional single-staged resection. Our technique
can also be recommended when colonic stenting is not available.
Key Words: acute malignant colonic obstruction, blowhole colo-
stomy, laparoscopy, staged colon resection
(Surg Laparosc Endosc Percutan Tech 2012;22:210–214)
A cute colonic obstruction is frequently caused by colo-
rectal cancer and requires emergent management to
resolve the obstruction.1–4 However, the general condition
of the patients and the clinical and pathologic stages of the
tumors vary greatly. The best strategy for acute malignant
large-bowel obstruction remains controversial. Although
with progression of medical care, primary resection with
anastomosis is more widely used than before in selected
patients, a major radical colectomy may be contraindicated
in patients who are debilitated by unstable hemodynamics
and concomitant medical illness. It is recommended to
perform a timely decompressed colostomy for fecal di-
version before definite surgery.5,6 However, staged proce-
dures for left-sided colonic obstruction are not currently
popular due to prolonged hospitalization and the need for
Received for publication April 13, 2011; accepted January 13, 2012.
From the Department of Surgery, Faculty of Medicine, Kaohsiung
Medical University, Kaohsiung Medical University Hospital,
Kaohsiung, Taiwan.
The author declares no conflicts of interest.
Reprints: Jan-Sing Hsieh, MD, Department of Surgery, Kaohsiung
Medical University, Kaohsiung Medical University Hospital, No.
100, Tzyou 1st Road, Kaohsiung City 807, Taiwan (e-mail:
h660016@gmail.com).
Copyright r 2012 by Lippincott Williams & Wilkins
210 | www.surgical-laparoscopy.com Surg Laparosc Endosc Percutan Tech
multiple operations. Although self-expanding metallic
stents have been used to replace emergency colostomy for
acute colonic obstruction with relative safety, they are not
widely available.7,8
The potential advantages of a laparoscopic approach
may make intestinal stoma creation more acceptable for
fecal diversion in acute malignant colonic obstruction.
Moreover, subsequent definitive surgery may be performed
electively under laparoscopic assistance if the tumor is
evaluated to be resectable after detailed investigations.
Thus, the disadvantages of conventional-staged surgery can
be reduced as much as possible. Herein, we intend to report
the efficacy and safety of laparoscopic-staged resection for
the treatment of acute malignant colon obstruction.
PATIENTS
Between January 2006 and December 2009, 22 patients
diagnosed with acute complete colonic obstruction were
included for a laparoscopic-staged resection for colon
cancer. The diagnosis of acute complete colonic obstruction
was made on the basis of the clinical manifestations and
findings of the abdominal radiography. The site of ob-
struction was confirmed by abdominal computed tomo-
graphy (CT) or colonoscopy. They were all located in
the left-sided colon. Patients were excluded from the study
if there was clinical or radiographic evidence of bowel
perforation.
Laparoscopic-assisted Blowhole Colostomy
After admission, fluid and electrolyte resuscitation was
carried out to stabilize the hemodynamic condition and
a nasogastric tube was inserted for decompression.
Subsequently, all the patients underwent surgery without
colonic preparation. The intended area for blowhole co-
lostomy was preoperatively estimated by abdominal CT.
The procedures of blowhole colostomy have been described
in the illustrations (Figs. 1–3).
Laparoscopic Colon Resection
Before laparoscopic procedures, the colostomy was
closed first and the exteriorized segment was returned into
the intraperitoneal cavity. For anterior resection, cephalic
mobilization of the sigmoid mesocolon was completed in a
medial to lateral direction. Ligation of the inferior mesen-
teric vessels was performed. The rectum and the meso-
rectum were sharply dissected and transected > 5 cm below
the tumor, using a laparoscopic stapler. The distal specimen
was retrieved and exteriorized through the previous stoma
wound (Fig. 4) while the abdominal wall was protected with
a drape. The cancer-bearing and colostomy segments were
then resected. Finally, intestinal reconstruction was estab-
lished by intracorporeal anastomosis using the circular sta-
pling device (SDH 29; Ethicon Endo-Surgery, Cincinnati).
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Surg Laparosc Endosc Percutan Tech  Volume 22, Number 3, June 2012
FIGURE 1. A portion of the dilated colon is exteriorized through
a laparoscopic aid and a catheter is inserted for instant decom-
pression.
For left colectomy, the area between the distal half of the
transverse colon to the proximal end of the sigmoid colon
including the cancer-bearing segment was dissected. Mobi-
lization of the left colon, lymph node dissection, and excision
of the mesentery were performed laparoscopically in the same
manner as described above. Reconstruction was completed
by manual anastomosis extracorporeally through the pre-
vious stoma wound in the left upper quadrant.
RESULTS
First-stage Surgery
There were 14 men and 8 women, mean age 61 ± 8.8
years (range, 42 to 79 y). Among these 22 patients, 7 had
concomitant medical diseases and 2 were in septic
condition. The demographic characteristics and clinical
features of these patients are listed in Table 1. Under lap-
aroscopic control, the blowhole colostomy was successfully
created in all these 22 patients within the first 24 hours after
admission. Of these stomas, 6 were located at the splenic
flexure, 7 at the descending colon, and 9 at the sigmoid
FIGURE 2. A blowhole colostomy is successfully performed.
r 2012 Lippincott Williams & Wilkins
Laparoscopic Resection of Colon Cancer Obstruction
FIGURE 3. Second-staged laparoscopy showing the constricted
site of an obstructed sigmoid colon cancer.
colon. The mean operative time was 43 ± 6.8 minutes
(range, 35–65 min). Intraoperative complications, such as
bleeding, perforation, or taking the wrong segment, were
not encountered, and there was no death related to lapa-
roscopic surgery. There was no case of conversion from
laparoscopy to laparotomy. All the stomas functioned
well soon after surgery, and in most patients, abdominal
distension subsided within 2 to 3 days postoperatively.
The patients resumed oral intake soon after abdominal
distension subsided.
Second-stage Surgery
The timing of the second surgery was determined de-
pending on the patient’s general conditions, recovery of
intestinal obstruction, and nutritional status. Seven to 17
days later, 20 of the 22 patients achieved an elective lapa-
roscopic resection. Among them, 11 had left hemicolectomy
and 9 had anterior resection. The remaining 2 patients did
not undergo reversal of the colostomy, because one of them
suffered from a previous cerebral vascular disorder with
conscious disturbance whereas the other patient showed
deterioration due to progressive liver metastasis. In these 20
patients with staged surgery, the timing of procedures and
the length of hospital stay are listed in Table 2. All patients
had at least a T2 tumor and the great majority of tumors
FIGURE 4. The wound for the blowhole colostomy and sub-
sequent tissue retrieval in staged laparoscopic colon resection.
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Chen et al Surg Laparosc Endosc Percutan Tech  Volume 22, Number 3, June 2012

TABLE 1. The Demographic Characteristics and Clinical Features TABLE 3. Clinical Pathologic Features of Resected Specimens in
of the Patients (n = 22) Acute Malignant Colonic Obstruction (n = 20)
Age 61 ± 8.8 (42-79 y) Tumor invasion n
Sex (male:female) 14:8 T2 1
Concomitant medical illness n T3 13
Cerebral vascular disease 1 T4 6
Cardiovascular disease 2 Lymph node involvement
Diabetes mellitus 3 N0 4
Pulmonary disease 1 N1 12
Septic condition 2 N2 6
Location of obstruction n Distant metastasis
Splenic flexure 6 Liver 2
Descending colon 7 Omentum 1
Rectosigmoid 9 Staging of colon cancer
II 4
III 15
were classified as stage III. Only 4 patients were free from IV 3
regional lymph node involvement. The clinical pathologic
feature and staging are listed in Table 3.
DISCUSSION
Complication and Mortality Traditional colostomies are usually associated with
In the first-staged surgery, 2 patients had prolonged high morbidity rates and an incidence of 34% has been
ileus due to small stoma, postoperatively. There were 2 reported in a retrospective study of 1616 patients with
patients with a wound infection at the site of previous co- stoma placement.9 However, intestinal stoma creation
lostomy and one with a urinary tract infection in the second through a laparoscopic approach for fecal diversion is
surgery. Complications related to anastomotic dehiscence considered to be a safe, feasible, and effective procedure
were not encountered. There was no hospital mortality in that can be performed with low morbidity.10,11 Compared
this series. with conventional techniques, the advantages of laparo-
scopic surgery have been well documented including faster
Adjuvant Therapy postoperative recovery, reduction of postoperative mor-
Postoperatively, adjuvant therapy was given to 16 bidity, shortened hospital stay, and reduced incidence of
patients with systemic intravenous 5-fluorouracil-based adhesions and small-bowel obstruction. In our experience,
chemotherapy. laparoscopic blowout colostomy can be successfully per-
formed within an extremely short time with an effective
Follow-up function for decompression. All risks related to resection
Postoperatively, complete follow-up was carried out and anastomosis of a dilated and unprepared colon can be
in all patients and the median follow-up period was 23 avoided. There was no surgical mortality, and postoperative
months. Seven patients died due to disease progression and morbidity was not significant in this study. Intraoperative
15 patients remained alive at the completion of this study. complications such as hemorrhage, colon perforation, or
The 1-year and 3-year survivals were 81% and 52%, taking the wrong segment were not encountered. This
respectively. The disease-free survival curve is depicted procedure also provides a chance to facilitate hemodynamic
in Figure 5. Of the 20 patients undergoing surgical re- stabilization, enhance enteral nutritional support and allow
section, 15 are alive at this writing. In these 15 patients, 1 complete clinical evaluation and tumor staging, and, most
patient underwent a second surgery for recurrent disease 12 importantly, enable subsequent elective resection lapa-
months after the first colon resection and is disease free roscopically after adequate bowel preparation. Fur-
after 14 months. A further 2 patients had recurrent colon
disease and received more aggressive systemic chemo-
therapy. The remaining 5 died due to progressive disease.

TABLE 2. The Timing of Surgical Procedures and Length of

Hospital Stay
Time of blowhole colostomy 43 ± 6.8 (35-65 min)
Second-staged procedure n
Laparoscopic left hemicolectomy 11
Laparoscopic anterior resection 9
No 2
Total length of hospital stay 20 ± 4.6 (16-33 d)
First stage 10 ± 2.4 (7-17 d)
Second stage 10 ± 3.2 (7-21 d)
Complication n
Ileus 2
Wound infection 2
Urinary tract infection 1 FIGURE 5. The disease-free survival curve for 22 patients with
acute malignant colon obstruction.

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Surg Laparosc Endosc Percutan Tech  Volume 22, Number 3, June 2012
thermore, because the degree of intraperitoneal adhesion is
minimal, the procedure of staged laparoscopic resection can
be easily and successfully accomplished.
Primary colonic resection has been adopted as the
standard treatment for acute left-sided colonic obstruction
by most surgeons. Although primary resection with end
colostomy (Hartmann operation) is considered the safest
option,12,13 single-staged resection and primary anasto-
mosis remains the preferred treatment in selected patients.14
However, it has been reported that primary resection in
emergency conditions had significantly higher mortality
rates than that of elective surgery, ranging from 23% to
50%.1,15–18 Therefore, patients with high surgical risks
should be carefully stratified before making a selection of
the optimal procedure.19,20 Several important predictors
related to outcome for acute malignant colorectal ob-
struction have been identified, including age, ASA grade,
operative urgency, and Dukes’ stage.19 Primary resection
and anastomosis is a definite procedure that does not re-
quire further surgery. However, it may include some dis-
advantages because the operating time is relatively long and
there is a risk of extensive surgical invasion, especially in the
elderly ill patients.21 In fact, the advantages of primary
resection for obstruction from primary left colon or rectal
carcinoma have yet to be proven. A Cochrane systematic
review indicates that neither strategy has been found to
have an advantage over the other in terms of morbidity and
mortality.6
The main advantages of the Hartmann procedure are
that there is no risk of anastomotic dehiscence and the
operation can be performed by less experienced and non-
specialist surgeons. However, it is sometimes very difficult
to perform a reanastomosis operation because of the
comorbidities in the elderly or multiple adhesions in the
intraperitoneal cavity. The reversal rate after Hartmann
procedure for colon cancer may be as low as < 20%.3,22 It
may minimize surgical trauma, which is of particular im-
portance in debilitated patients,5 and reduces the risk of
contamination due to an unprepared bowel. A recent study
in favor of the staged procedure concludes that a safer and
better oncologic outcome can also be achieved compared
with primary resection in obstructive left-sided colorectal
cancer under emergency situations.23 In a questionnaire
survey in 2001, a proportion (26%) of American gastro-
intestinal surgeons indicated that they would perform a
simple colostomy in a high-risk patient.24 Another UK
study also reported that 24.3% of patients with malignant
large-bowel obstruction underwent either Hartmann pro-
cedure or creation of a palliative stoma.19
Previous reports have described that there is an in-
creased risk of surgical mortality, a higher incidence of
lymph node metastasis, and a decreased curative resection
rate in patients with obstructing colorectal cancer.3,4,18
However, in patients with acute obstructing colon cancer
that is judged to be locally advanced during diagnostic
laparoscopy or abdominal CT, preoperative concurrent
chemoradiotherapy (CCRT) after a stoma creation can be
performed to downstage the tumor and increase the re-
sectablility. In this small series, 6 of the 22 patients were
classified as T4 by abdominal CT but no patient underwent
preoperative CCRT. Four of these 6 patients who were
judged to be resectable achieved complete curative resection
finally. The remaining 2 patients had severe concomitant
medical disease and rapid deterioration of metastatic lesion,
and CCRT was not indicated for them.
r 2012 Lippincott Williams & Wilkins
Laparoscopic Resection of Colon Cancer Obstruction
Staged procedures for left-sided colonic obstruction
have been criticized for prolonged hospitalization in several
studies. It has been reported that after primary or staged
resection for a left-sided tumor, the median hospital stays
were 19 and 41 days, respectively.25 A similar result was
found in a randomized trial where the only advantage of
primary over-staged resection was a shorter hospital stay.26
Contrary to previous findings, our study revealed that the
total hospital stay of laparoscopic-staged resection for ob-
structing left-sided colon cancer was relatively short. In this
study, the mean total hospital stay of the first and the
second surgery was 20 ± 4.6 days, which is comparable
with that of single-staged colon resection for an obstructing
lesion through the conventional open approach. In addi-
tion, the short-term outcome of our patients is also
acceptable as compared with that of patients treated by
primary resection and anastomosis. There are few data in
the literature regarding the laparoscopic management of
colonic obstruction. In our study, there was no hospital
mortality and no anastomotic leak. It is known that an
emergency operation for left-sided obstructive malignancy
has a significantly higher morbidity rate than elective sur-
gery.27,28 Our overall complication rates are significantly
lower than the reported morbidity rates in patients with
primary emergency resection.23,27,28 The relatively low
morbidity can be related to the documented advantages of
laparoscopic colorectal resection including reduction of
perioperative complications and faster postoperative re-
covery. The most important benefit of staged procedure in
patients presenting with acute large-bowel obstruction is
that curative resection can be performed as an elective
surgery after successful fecal diversion, resulting in less
overall complications.
In recent years, metallic colonic and rectal stents have
been used for palliation in patients who have inoperable
cancer or as a bridge to elective surgery. Recent systematic
reviews have shown that colonic stenting is a relatively safe
technique, with high success rates of up to 91%.29–31 Al-
though some might consider stenting as a bridge to surgery
is the preferred approach, to date, solid evidence of
randomized, prospective clinical trials examining the utility
of stent placement is awaited. In addition, the cost effec-
tiveness of colonic stent and the widespread availability of
out-of-hours stenting are other parameters to be consid-
ered.8,32 In conclusion, our results suggest that management
of acute malignant colonic obstruction with laparoscopic-
staged resection is a safe, feasible, and effective technique.
The length of hospital stay is justified as compared with
conventional single-staged resection. The advantages of
laparoscopic-staged resection are low morbidity and no
procedure-related mortality, although multiple operations
are required. As the current series is neither controlled
nor randomized, laparoscopic-staged resection cannot be
recommended as a surgical standard, but is at least an
alternative to open stoma construction. It can also be
recommended when colonic stenting is not available.
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