Cecostomy: A Part of an Efficient Method of Decompressing the Colon Obstructed by Cancer

E. S. R. HUGHES, M.D.

Melbourne, Australia

SURCEONS differ in their attitudes toward cecostomy in the management of obstruc- tion of the large bowel caused by carci- noma; some favor cecostomy, some are op- posed to it. This division of opinion is not surprising because obstruction of the colon caused by cancer is relatively uncommon and reliable information, based on broad experience, is not readily obtainable. In some charitable and public institutions, there are records of many patients with ob- struction of the colon of this type, but although the series Of patients may be large, often the surgical management of the pa- tients is conducted by junior surgeons and surve)s of the records must be evaluated with caution.

The objective of this presentation is to add to the record a report of my personal experience with 970 patients with carci- noma of the colon, of which 105 (10.8%) had acute obstruction. (The rectum was involved in 690.) Thirty-four patients un- derwent cecostomy anti the records of these patients form the basis for this report. However, the cecostomy was performed as a part of a special method of decompressing the colon and it is to this procedure that l will devote special attention.

Technic

There is nothing unusual about the per- formance of the cecostomy itself. On all S4 patients, a t~-~be cecoston~y was per- formed as follows:

The abdomen was opened through a

Received for publication April t5, 1963.

left paramedian incision and, after careful exploration, the cecum was delivered into the laparotomy wound, if distention of the bowel made this difficult or impossible, the cecum was brought into a small oblique incision in the right iliac fossa. In either case, a needle was used to puncture the wall of tile cecum, a pursestring was placed around the needle, which was withdrawn and replaced by a tube, 14 ram. in diam- eter, after enlarging the puncture wound. The pursestring was tied snugly around the tube and carried through tire tube it- selL. If the cecum had been delivered into the laparotomy wound, it was then inverted with a second and a third pursestring anti the tube was brought out through a sepa- rate small incision in the right iliac fossa. The wall of the cecum was fixed in close apposition to the parietal peri toneum antl the tube was carried away from the oper- ating table to a suction apparatus which was controlled by an assistant while the colon was manipulated gently by a hand within the peritoneal cavity. Of course, nothing was done intra-abdominally until gloves, gowns anti contaminated instru- ments and drapes had been changed. With only one exception, this method of decom- pressing the colon was quite efficient and within a few days after performing the cecostomy, rectal enemas were utilized to remove residual material from the colon. _~n one patient, there was sc~ch a quantity o[ semiforrned feces that decompression through the cecostomy tube was not pos- sible and a transverse colostomy had to be performed.

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CECOSTOMY

Results

Obstruction of the Right Colon: There were 29 patients with acute obstruction caused by carcinoma of the right colon. Primary resection with anastomosis was performed on 18 patients, and short-circuit- ing ileotransverse anastomosis in eight. In three, cecostomy was performed. One pa- tient with a perforated cecum, caused by carcinoma of the ascending colon, was mor ibund on admission and died soon after the operation. The other two sub- sequently had right hemicolectomies with- out complications.

Obstruct ion of the Upper Left Coton: Twenty-six patients were encountered with obstructing carcinoma of the distal portion of the transverse colon, splenic flexure and descending colon. In two the colon was decompressed by enemas, nine had pr imary resections and three had proximal colos- tomies.

In the remaining 12 patients, cecostomy was performed. One 90-year-old woman was semicomatose at the time of surgery and she survived for only two days. In the other 11, resection and anastomosis was performed. A 75-year-old man had a car- cinoma of the descending colon; another patient had a carcinoma of the rectum and died of b ronchopneumonia three clays after operation. After resection and anastomosis, convalescence was uneventful in the re- maining ten patients.

Obstruction of the Sigmoid Flexure: The re were 29 patients with acute sigmoidal obstruction. Five responded to enemas, three had pr imary resections, and eight had proximal colostomies. In 13, cecostomy was performed. One patient with extensive peritoneal metastasis died after five weeks, despite the fact that the cecostomy had effecfive!y relieved the obstruction. ~n an- other pat ient with liver and peri toneal me- tastasis, resection was performed 13 days after cecostomy, but there was considerable disproport ion in the lumen of the colon

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above and below the obstructing tumor, and a H a r t m a n n resection with colostomy was performed. In the remaining l l pa- tients resection and anastomosis was per- formed after cecostomy without operative mortality.

Obstruction of the Rectum: There were 21 patients with acute obstruction compli- cating carcinoma of the rectum and anal canal. One pat ient was intubated, one underwent immediate resection, one had mult iple polyposis and an ileostomy was required, and 11 had colostomies. One had such extensive peritoneal involvement that nothing could be done. Cecostomy was performed on six patients with relief of the obstruction. In two a combined exci- sion was performed and one patient, 63 years old, died. He was in poor health, suffering from syphilitic aneurysm and gross emphysema (war gas poisoning) The colostomy sloughed, the perineal wound failed to heal and he succumbed from pneu- monia 16 clays after operation. In four patients, resection and intrapelvic anasto- mosis was completed successfully.

Summary and Conclusions

T w o of the 34 patients died soon after performance of the cecostomy. Both were mor ibund at the time of operat ion and the cecostomy was not the cause of death. One died of carcinomatosis five weeks alter ce- costomy, but until her death the cecostomy prevented fur ther episodes of obstruction.

Resection after cecostomy was performed on 31 patients. In t raper i toneal anastomosis was accomplished in 28 patients and one died. Abdominoper ineal and H a r t m a n n ex- cisions with end coIostomies were per- formed on three patients with one death.

Cecostomy was not a blind procedure in this series. Diagnosis -was confirmed at iaparotomy and after the cecostomy was per- formed, decompression was achieved while the abdomen was still open. In only one case was fecal mat te r too solid to be evacu- ated through the tube.

456 H U G H E S

With one exception, a tube cecostomy proved to be neat, clean and comfortable. T h e exceptional pat ient had an obstruction of the ascending colon and there was per- sistent leakage around the tube. For this reason a cecostomy is probably best avoided in patients with right colonic obstructions and fortunately it is rarely indicated.

Muir 2 prefers to use cecostomy only in the more proximally situated obstructions. In this series lesions of the sigmoid flexure and rectum were accepted. Provided imme- diate decompression is obtained and rectal enemas can be given in a few days to clear the left colon, cecostomy is effective in low- lying obstructions.

Smiddy and Golighera considered cecos- tomy a particularly hazardous operat ion "often followed by fatal sepsis." Michel and his colleagues 1 believed that "the rec- ord for cecostomy was not good."

As stated, in this series, two patients died after cecostomy, but both were semicoma- tose at the time of operation; two others died after resection, and a fifth died of carcinomatosiso In none of these cases did the cecostomy appear to be responsible for the fatal outcome.

Some surgeons believe a cecostomy is un- satisfactory because it does not defunction the colon. However, it is accepted that nonobstructive tumors, even though they narrow the lumen of the colon, are suitable for one-stage resection. Once the acute dis-

tention has been relieved by cecostomy, it is possible to prepare the bowel in the usual way.

A transverse colostomy is a safe method of relieving obstruction, bu t a cecostomy can be just as effective. T h e great advan- tage of cecostomy lies in the greater free- dom of activity it permits at the subsequent resection. This freedom is especially advan- tageous in tumors of the u p p e r portion of the left colon. A lesser advantage of the tube cecostomy is its tendency to close spontaneously after removing the tube.

In a series of 84 cases of acute large bowel obstruction caused by carcinoma, a tube cecostomy proved effective° T h e large bowel was decompressed by gentle manip- ulation of the colon, aided by suction ap- plied to the tube, while the abdomen was open. Within a few days, the obstructed lumen reopened and the prepara t ion of the colon for resection proceeded as in nonobstructed patients.

References

1. Michel, M. k., Jr., C. T . T h o m p s o n , t t . W. Reinst ine, Jr., R. R. Senter and D. B'. Dale: Acute obs t ruc t ions of the colon. Ann. Surg. 139: 806, 1954.

2. Muir, E. G.: Carc inoma of tile Colon. l .ondon, Edward Arno ld (Pub| ishers) IAd., 1961, 18l pp.

3. Smiddy, F. G. and J. C. Golighcr: Results nf surgery in the t r ea tment of cancer of the large intest ine. Brit. M. ,]. 1: 793, 1957.