How to manage a patient with severe aortic stenosis and bowel obstruction from colon cancer requiring urgent surgery?

Management of a Patient with Severe Aortic Stenosis and Bowel Obstruction from Colon Cancer Requiring Urgent Surgery

For patients with severe aortic stenosis and bowel obstruction from colon cancer requiring urgent surgery, a damage control approach with initial focus on relieving the bowel obstruction while minimizing cardiac stress is recommended, followed by definitive cardiac and oncologic management.

Patient Assessment and Stabilization

• Evaluate patient stability using criteria such as pH < 7.2, core temperature < 35°C, base excess < -8, evidence of coagulopathy, or signs of sepsis/septic shock including need for inotropic support 1
• Assess for signs of peritonitis, sepsis, and hemodynamic instability which would necessitate immediate intervention 1
• Perform close monitoring of cardiac function with consideration of invasive hemodynamic monitoring during surgery 1

Management Algorithm

Step 1: Determine Patient Stability and Urgency

For Unstable Patients (Septic Shock, Peritonitis, Complete Obstruction):

• Immediate damage control surgery should be prioritized 1
• Right-sided colon cancer with obstruction:
  • Right colectomy with terminal ileostomy is the procedure of choice 1
  • Severely unstable patients should be treated with a loop ileostomy 1
• Left-sided colon cancer with obstruction:
  • Hartmann's procedure is the procedure of choice 1
  • Severely unstable patients should be treated with a loop transverse colostomy 1

For Stable Patients with Partial Obstruction:

• Consider colonic stenting as a bridge to definitive surgery 2, 3
• Self-expandable metallic stents (SEMS) can relieve obstruction and allow time for cardiac optimization 2
• SEMS is particularly useful in high-risk patients with severe aortic stenosis 1

Step 2: Cardiac Management Options

After initial management of bowel obstruction:

• Option 1: Transcatheter Aortic Valve Implantation (TAVI)

  • Preferred for high-risk surgical patients with severe aortic stenosis 2, 3
  • Allows for definitive colon cancer surgery 12-22 days after TAVI 2, 3
  • Avoids risks associated with extracorporeal circulation in patients with malignancy 2

• Option 2: Balloon Aortic Valvuloplasty (BAV)

  • Can be considered as a bridge to definitive surgery in urgent cases 4
  • However, clinical outcomes may be similar to conservative management 4

• Option 3: Surgical Aortic Valve Replacement

  • Consider for lower-risk patients who can tolerate open heart surgery 5
  • May be performed as a staged procedure before definitive cancer surgery 5

Step 3: Definitive Colon Cancer Surgery

• After cardiac optimization, proceed with definitive colon cancer surgery 3
• For right-sided colon cancer:
  • Right colectomy with primary anastomosis is preferred if patient is stable 1
  • Consider terminal ileostomy if primary anastomosis is unsafe 1
• For left-sided colon cancer:
  • Hartmann's procedure is often safest in this high-risk population 1
  • Primary anastomosis may be considered in selected stable patients 1

Special Considerations

• Antibiotic therapy targeting gram-negative bacilli and anaerobic bacteria is recommended due to potential bacterial translocation 1
• Close communication between surgeon, anesthesiologist, and cardiologist is essential to assess effectiveness of resuscitation and determine optimal treatment 1
• Laparoscopic approaches may be considered in hemodynamically stable patients to reduce length of stay and morbidity 1, 6
• Avoid prolonged hypotension during surgery as it may precipitate cardiac events in patients with severe aortic stenosis 1

Pitfalls to Avoid

• Delaying intervention in patients with complete obstruction or signs of peritonitis 1
• Attempting primary anastomosis in hemodynamically unstable patients 1
• Underestimating the cardiac risk during non-cardiac surgery in patients with severe aortic stenosis 4
• Performing extensive cancer surgery before addressing severe aortic stenosis in stable patients 2, 3
• Creating stomas in patients who may require open abdomen management (delay stoma creation in these cases) 1