Management of Large Bowel Obstruction
The optimal management approach for large bowel obstruction requires cause-specific treatment, with endoscopic detorsion followed by same-admission sigmoid colectomy for sigmoid volvulus without ischemia, immediate right hemicolectomy for cecal volvulus, and resection with primary anastomosis for malignant obstruction in low-risk patients. 1
Initial Assessment and Management
- Begin with supportive care including intravenous crystalloid fluid resuscitation, nasogastric tube decompression, and Foley catheter insertion to monitor urine output 1
- Multidetector CT scan with intravenous contrast is the diagnostic modality of choice to determine cause, location, and complications of the obstruction 1
- Water-soluble rectal contrast can be administered when diagnosis remains uncertain 2
- Monitor closely for signs of ischemia or perforation through clinical assessment, laboratory values (white blood cell count, lactate), and imaging findings 1
Cause-Specific Management
Sigmoid Volvulus
- For sigmoid volvulus without ischemia or perforation: endoscopic detorsion followed by same-admission sigmoid colectomy with primary anastomosis 2, 1
- Endoscopic detorsion alone should be reserved only for high-surgical-risk patients, though recurrence rates are high 2, 3
- Immediate surgery is necessary for ischemic volvulus or failed derotation 2, 1
- Laparoscopic approach has limitations due to absence of fixation and excessive length of the sigmoid colon 2, 1
Cecal Volvulus
- Right hemicolectomy is the only treatment option for cecal volvulus 2, 1, 4
- Endoscopy has no therapeutic role in cecal volvulus, unlike in sigmoid volvulus 4
- For viable cecum, resection with primary anastomosis provides the best long-term outcomes 4
Diverticular Obstruction
- Resection with primary anastomosis is the preferred approach after successful conservative management, regardless of bowel preparation status 2, 1
- Conservative therapy or Hartmann procedure may be more appropriate for high-risk patients 2, 1
- Diverticular obstruction often resolves with conservative treatment as it is usually incomplete 2
Malignant Obstruction
- Self-expanding metallic stents as a bridge to elective surgery offers better short-term outcomes than emergency surgery for left-sided colonic cancer 1
- Resection with primary anastomosis is recommended for patients without significant risk factors or perforation 2, 1
- For high-risk patients or those with perforation, a staged procedure such as Hartmann procedure is preferred 2, 1
- For extraperitoneal rectal cancer, postpone primary tumor resection and create a diverting stoma to allow proper staging and appropriate neoadjuvant treatment 2, 1
- Anastomotic leak rates in emergency surgery for malignant large bowel obstruction range from 2.2-12%, comparable to the 2-8% rate after elective procedures 2, 1
Timing of Intervention
- Prompt intervention (within 2 days of admission) results in decreased length of stay and greater likelihood of discharge to home 5
- Immediate surgery is necessary if signs of clinical deterioration develop in patients managed conservatively 1
- Regular reassessment is essential to determine if surgical intervention becomes necessary 1
Special Considerations
- Laparoscopic approach should be limited to selected cases in specialized centers for malignant large bowel obstruction 2, 1
- Stents are becoming increasingly important in managing malignant large bowel obstruction, converting emergency operations to elective cases with decreased complications and stoma formation 2, 1
- Colonic pseudo-obstruction should be distinguished from mechanical obstruction as it can usually be managed without surgery 3
- For tumors up to and including the splenic flexure, an extended right hemicolectomy is advisable as it offers adequate tumor removal and allows an immediate safe ileocolic anastomosis 3