Colostomy for acute tumoral large intestine obstruction in an on-call surgical hospital: clinical recommendations and real-world clinical practice

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Introduction

Every year, 500,000–600,000 new cases of colorectal cancer are registered worldwide. In the Russian Federation, this figure reaches 45,000 cases diagnosed per year, ranking fourth among oncological diseases, surpassed only by lung, stomach, and breast cancer. For a number of organizational reasons, patients with complicated large intestine cancer “fall out” of the established mechanism of specialized oncological care. This is because 30 % of patients with newly diagnosed large intestine cancer will undergo emergency surgery for complications: 80 % will be diagnosed with intestinal obstruction, and 15 % with intestinal perforation [1–3]. Emergency surgical care for patients with complicated colon cancer is mainly provided in general surgical departments by surgeons who do not have special training in oncology and coloproctology, which, according to oncologists, is one of the reasons for tactical and technological errors.

The issues of choosing the extent and type of surgical intervention in this category of patients are currently a hot topic for discussion. However, in accordance with Resolution XV of the Congress of the All-Russian Public Organization “Russian Society of Surgeons named after Academician V.S. Savelyev,” some consensus was reached in 2023. The surgical community agreed on the need to eliminate acute tumor intestinal obstruction through endoscopic stenting or the formation of a decompression intestinal stoma using laparoscopic technologies. At the same time, in severe and unstable patients, extensive resection surgery should be avoided, except in situations where it is the only possible way to save the patient's life. Given the high percentage of intraoperative primary diagnosis of complicated forms of colon cancer in conditions of intestinal obstruction, perforation, or peritonitis, questions regarding the feasibility of laparoscopic interventions and stenting are becoming increasingly relevant [4–6]. It is also worth noting that the further referral of these patients to specialized oncology care depends significantly on postoperative complications, the patient's mindset, and deficiencies in the organization of medical care, which may ultimately lead to unsatisfactory results [7–9].

The aim of the study is to analyze the immediate and long-term results of colostomy in patients with acute tumor-related large bowel obstruction.

Materials and Methods

The study includes the results of examination and treatment of 552 patients diagnosed with “acute obturation intestinal
obstruction” and tumor localization in the descending colon and sigmoid colon, who were hospitalized in on-call surgical units in the Samara region between 2015 and 2020. All patients gave their voluntary informed consent to include the results of their examination and treatment in the study.

The criterion for inclusion of patients in the study was the fact that they had undergone a double-barrel colostomy proximal to the tumor.

The criterion for exclusion from the study was primary resection of the intestine with removal of the tumor.

Study type – non-randomized, multicenter, retrospective, continuous, sequential, controlled.

Two groups of patients were identified from the general group of patients with colostomy: Group I – 117 patients with operable and resectable tumors, who were subsequently
referred for radical surgery at an oncology clinic; Group II – 435 patients with inoperable and unresectable tumors, for whom colostomy was in fact the final surgical intervention.

A comparative analysis of both groups was performed based on key indicators of the patients' initial condition and stratification of the severity of comorbidities.

An analysis was performed of the overall results of patient treatment, hospitalization outcomes, and visits to the Samara Regional Clinical Oncology Dispensary for final specialized treatment.

The inoperability of the tumor was assessed based on signs of distant metastasis and invasion of surrounding organs and tissues.

In accordance with clinical recommendations, colostomy was the surgery of choice for these patients. A double-barrel colostomy was formed as close as possible to the tumor site.

Upon discharge, patients were referred for further examination and treatment at the regional cancer center.

Statistical processing of the data obtained was performed using Microsoft Office 2010, license No. 661988271 (Microsoft, USA). Differences in indicators were considered significant at a probability of an error-free prediction of 95 % or more (p <  0.05).

Results and Discussion

Group I consisted of 63 men (53.8 %) and 54 women (46.2 %), while group II consisted of 261 men (60 %) and 174 women (40 %) (c² = 1.44; p > 0.05). The age of patients ranged from 52 to 94 years. The average age in group I was 62.88 ± 13.43 years, and in group II, it was 71.26 ± 13.14 years (t – Student's = 15.91;
p <  0.05), which indicated a prevalence of older patients in the group with inoperable and advanced tumors.

The severity of comorbidities was stratified using the ASA scale. In group I, the index was 2.71 ± 0.76, and in group II, it was 3.17 ± 1.05
(t-Student = 0.81; p > 0,05). Despite the more advanced oncological process in patients in group II, no statistically significant differences in the assessment of patients' physical status on the ASA scale were found between the groups. However, the overall indicator was quite high, at 2.95 ± 0.94, which indicated a prevalence of patients with ASA III grading (severe systemic diseases).

We analyzed the treatment outcomes for patients in both groups (Table 1).

 

Table 1. Results of treatment of patients with acute tumor-related large bowel obstruction who underwent colostomy

Group of patients	Fatal outcome, abs. (%)	Discharged, abs. (%)	Including patients with repeat surgeries at the cancer center, abs. (%)	Final treatment at the cancer center, abs. (%)
Group I, n = 117 (21.2 %)	15 (12.8)	102 (87.2)	24 (20.51)	20 (19,6)
Group II, n = 435 (78.8 %)	102 (23.5)	333 (76.5)	92 (21.1)	44 (13,2)
Total	117 (21.2)	435 (78.8)	116 (21.01)	64 (14,7)
Criterion	c2 = 6.23.; p <  0.05		c2 = 0.23; p > 0.05	c2 = 2.54; p > 0.05

 

The overall mortality rate in both groups was 21.2 %. In group I, 15 patients (12.8 %) died, and in group II, 102 (23.5 %) died. Statistically significant differences in mortality between the groups are due to the more severe condition of patients with inoperable tumors.

Repeat surgeries were performed on 24 patients (20.51 %) in group I and 92 (21.1 %) in group II. The differences between the groups were not statistically significant (c² = 0.23; p <  0.05), which indicates an equally high probability of early and late complications preventing the timely hospitalization of the majority of patients with colostomy in cancer centers.

The main reasons for repeat operations are presented in Table 2.

 

Table 2. Reasons for repeat surgeries depending on patient group

Group of patients	Reasons for repeat surgeries
	Progressive peritonitis (RSI according to V.S. Savelyev is 13 points or more), abs. (%)	vicious stoma, incompetence, abs. (%)	diastatic rupture in the tumor area, abs. (%)	bleeding from a tumor, abs. (%)
Patients with repeat surgeries from Group I, n = 24	9 (37.5)	7 (29.2)	2 (8.3)	6 (25)
Patients with repeat surgeries from group II, n = 92	20 (21.7)	32 (34.8)	27 (29.3)	13 (14.1)
Total	29 (25)	39 (33.6)	29 (25)	19 (16.4 %)
Criterion	c2 = 2.52; p > 0.05	c2 = 0.27; p > 0.05	c2 = 4.48; p <  0.05	c2 = 1.64; p > 0.05

 

Progressive peritonitis (RSI according to V.S. Savelyev is 13 points or more) was most often detected in patients in Group I, while a vicious stoma and diastatic rupture in the tumor area were most often detected in patients in Group II.

It should be noted that most causes of stoma failure, formation of vicious stomas, and diastatic rupture of the intestine in the tumor area arose as a result of attempts to form a double-barreled colostomy as close to the tumor as possible.

When operating on a patient with large bowel obstruction, the surgeon encounters an overdistended, thinned large intestine, which significantly affects the integrity of the colostomy in the early postoperative period (Fig. 1).

 

Fig. 1. Patient I., 56 years old. Sigmoid colon cancer. Acute colonic tumor obstruction. Distastic stretching of the cecum gut and transverse colon

 

Keeping in mind the aggressive infiltrative process in the tumor growth area and the reduction of the mesentery due to inflammation, the process of colostomy formation requires a balanced approach from the surgeon to determine the safest area for the formation of an external intestinal fistula. This presents a dilemma: on the one hand, a stoma formation that is not close enough to the tumor may contribute to a diastatic rupture of the diverting loop in the tumor area, and on the other hand, attempts to place the stoma as close as possible to the tumor create a risk of its failure, migration into the abdominal cavity, and the development of peritonitis.

Here is a clinical example reflecting one of the variants of the stoma complication that has arisen.

Clinical Case no. 1

Female patient K., 84 years old, MR No. 1244323, was admitted to the emergency surgical ward with acute intestinal obstruction. The diagnosis was confirmed clinically and radiographically. After brief presurgical preparation, the patient underwent laparotomy, and an operable sigmoid colon tumor was identified. A double-barreled sigmoidostoma was performed as close to the tumor as possible. The patient was discharged on the 7th day with improvement and recommendations for further treatment and examination at the oncology clinic. According to the patient, she visited the oncology clinic within a week after discharge, where she was scheduled for examination for planned hospitalization. In the course of regular trips for examination (over 5 weeks), the patient began to notice pain in the stoma area (Fig. 2). After consulting an oncologist, she was referred to an emergency surgical hospital with a diagnosis of “sigmoid stoma migration. Peritonitis?”.

 

Fig. 2. 82-year-old female patient K. Migration of sigmoidostoma. Localized fecal peritonitis

 

The hospital surgeon performed a Hartmann's operation without using radical oncological principles. The patient was discharged on the 12th day with an improvement in her condition and recommendations for further treatment and examination at an oncology clinic. However, there was no evidence of a repeat visit to the oncology clinic.

This clinical example clearly demonstrates the importance of the duration of patient referral to an oncology hospital for further treatment—delays in providing specialized oncological care may lead to complications that could be contraindications for planned surgical intervention.

Only 64 discharged patients (14.7 %) with a colostomy underwent final treatment at an oncology clinic. The operability of the tumor did not statistically significantly affect the continuation of treatment by patients: in Group I 20 (19.6 %) of 102 patients turned to the cancer clinic, in Group II – 44 (13.2 %) of 333 (c² = 2.54; p > 0.05).

A low value for this indicator may be due to various factors: progression of the disease and death before hospitalization, lack of responsibility on the part of the patient for their health, organizational costs associated with preparing for hospitalization in a cancer center, and others. These factors are very real and indicate problems with continuity between surgical hospitals and oncology services [10–12].

The length of hospitalization varied among the 64 patients who visited the cancer center. Within 60 days after discharge from the surgical hospital, 13 patients from both groups (20.3 %) sought treatment at the cancer center, and 51 patients (79.7 %) sought treatment more than 60 days after discharge (Table 3).

 

Table 3. Results of final specialized treatment of patients at the oncology clinic

Patients who have visited the oncology clinic, n = 64	Period of address		Type of treatment
	up to 60 days, abs. (%)	more than 60 days, abs. (%)	radical surgery (resection of the intestine with tumor, resection of the intestine with tumor with D-2 lymphadenectomy), abs. (%)	cytoreductive surgery, abs. (%)
Group I, n = 20	6 (30)	14 (70)	8 (40)	–
Group II, n = 44	7 (15.9)	37 (84.1)	–	33 (75)
Total	13 (20.3)	51 (79.7)	8 (12.5)	33 (51.5)

 

Radical surgery was possible in 8 (40 %) patients from group I (Fig. 3) at the oncology clinic, while cytoreductive surgery was possible in 33 (51.5 %) patients from group II. Unfortunately, the fate of most patients who did not visit the oncology clinic is unknown. However, given the majority of publications reporting 5-year survival rates for patients with complicated forms of colon cancer without specialized treatment, it can be assumed that it was tragic.

 

Fig. 3. Resected intestine with tumor and D-2 lymphadenectomy

 

In our study for the period 2015–2020, the overall mortality rate of patients who underwent colostomy as the treatment of choice in accordance with clinical guidelines was 21.2 %. In the Russian Federation in 2022, the postoperative mortality rate for tumor-related intestinal obstruction was 19.57 % [13–15]. The indexes are comparable, which indicates that the treatment strategy for this group of patients is correct and that preference should be given to unloading proximal colostomies.

However, bearing in mind that only 14.7 % of ostomy patients received final treatment at an oncology clinic, it can be concluded that the results are essentially unsatisfactory and necessitate a search for ways to solve this problem.

We believe that long-term outcomes can be improved in two ways [16–18]. On the one hand, it is necessary to change the principles of organizing cancer care in terms of reducing the time required for preoperative examination and conducting examinations as quickly as possible at the stage of referral to a cancer clinic.

On the other hand, a possible solution to this problem may be primary resection surgery based on oncological principles with the creation of a single-barrel colostomy in an emergency surgical hospital. This will allow the patient, even in the event of a delay in hospitalization at an oncology clinic, to gain time and reduce the frequency of complications from the intestinal stoma [19; 20].

Conclusions

1. Unloading proximal colostomy remains the leading intervention aimed at resolving intestinal obstruction in patients with tumors of the descending colon and sigmoid colon, even in cases where the patient is operable.
2. Delays in hospitalization at the specialized stage of cancer care are related to both medical and organizational aspects, as well as non-medical social and everyday aspects, and affect the subsequent outcome of radical surgery.
3. The principles of organizing cancer care for patients discharged with a colostomy from the emergency surgical hospital and referred for radical surgery need to be revised in order to speed up hospitalization and ensure continuity of specialized care.
4. It is necessary to improve the qualifications of surgeons on duty at surgical hospitals in terms of mastering oncological principles when performing primary resection of the colon if a decision is made on the possibility of its application.

About the authors

E. A. Korymasov

Samara State Medical University; Samara Regional Clinical Hospital named after V.D. Seredavin

Email: Alexey400074@yandex.ru
ORCID iD: 0000-0001-9732-5212
SPIN-code: 9928-6343

DSc (Medicine), Professor, Head of the Department of Surgery with a Course in Cardiovascular Surgery, Honored Scientist of the Russian Federation, Chief Freelance Surgeon of the Ministry of Health of the Samara Region

Russian Federation, Samara; Samara

A. V. Fesyun

Samara State Medical University; Samara Regional Clinical Hospital named after V.D. Seredavin

Author for correspondence.
Email: Alexey400074@yandex.ru
ORCID iD: 0000-0001-6356-8574
SPIN-code: 3824-0937

Surgeon of the Department of Abdominal Surgery

Russian Federation, Samara; Samara

M. Yu. Khoroshilov

Samara State Medical University; Samara Regional Clinical Hospital named after V.D. Seredavin

Email: Alexey400074@yandex.ru
ORCID iD: 0000-0002-9659-8881
SPIN-code: 6048-6009

PhD (Medicine), Associate Professor of the Department of Surgery with a Course in Cardiovascular Surgery, Surgeon of the Department of Abdominal Surgery

Russian Federation, Samara; Samara

References

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