Management of Intestinal Obstruction Due to Rectal Mass
This patient requires urgent surgical decompression with a diverting stoma, NOT resection of the primary tumor, to allow for proper staging and neoadjuvant chemoradiotherapy before definitive oncologic surgery. 1
Immediate Management Priorities
Initial Resuscitation and Assessment
- Request complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactates) to assess the patient's physiologic status and degree of systemic compromise 1
- Initiate antibiotic prophylaxis targeting Gram-negative bacilli and anaerobic bacteria immediately, as bacterial translocation is occurring due to the obstructed bowel 1
- Discontinue prophylactic antibiotics after 24 hours (3 doses maximum) to minimize multidrug-resistant organism development 1
Critical Clinical Decision Point
The imaging demonstrates a locally advanced rectal cancer (5.19 cm circumferential mass causing complete obstruction 7.16 cm from anal verge). Any rectal cancer producing obstruction represents locally advanced disease requiring neoadjuvant therapy for optimal oncologic outcomes 1
Surgical Approach
Primary Recommendation: Decompressive Stoma
Fashion a transverse loop colostomy as the procedure of choice for the following reasons 1:
- Allows complete staging workup and timely initiation of neoadjuvant chemoradiotherapy 1
- Can remain in place to protect the future anastomosis after definitive resection 1
- Easier to create due to transverse colon mobility 1
- Avoids damage to the marginal arcade 1
- Does not alter the left abdomen if permanent end colostomy becomes necessary later 1
Why NOT Self-Expanding Metal Stents (SEMS)
SEMS is contraindicated in this rectal cancer obstruction because 1:
- Causes chronic pain and tenesmus in low rectal cancers, worsening quality of life 1
- Radiation and chemotherapy cause tumor necrosis/shrinkage, increasing risk of stent migration and perforation 1
- Would compromise final oncologic results 1
- Patient will require a stoma anyway at definitive surgery (either APR or diverting stoma with LAR) 1
Alternative Stoma Options (If Transverse Colostomy Not Feasible)
- Loop ileostomy: Only viable if obstruction is incomplete OR ileocecal valve is incompetent; otherwise colonic distension persists 1
- End sigmoid colostomy: Consider if abdominal-perineal resection is predictable based on tumor location (7.16 cm from anal verge suggests this may be necessary) 1
- Trephine left-sided loop colostomy: Reserved for high-risk patients requiring local anesthesia only 1
Critical Pitfalls to Avoid
DO NOT Resect the Primary Tumor
Emergency resection of the obstructing rectal cancer should be avoided because 1:
- Prevents proper staging workup 1
- Eliminates opportunity for neoadjuvant chemoradiotherapy, which significantly improves outcomes in locally advanced rectal cancer 1
- The stoma created during emergency surgery provides only short-term solution and may not be appropriately positioned for the definitive oncologic procedure 1
Timing Considerations
- Proceed to surgery urgently (not emergently unless signs of perforation/peritonitis develop) 1
- The 2-week history without perforation or peritonitis allows time for adequate resuscitation and surgical planning 2
- Goal is stoma creation within hours of adequate resuscitation, not immediate emergency surgery 2
Post-Operative Oncologic Pathway
After stoma creation and recovery 1:
- Complete staging with full colonoscopy (if not done), chest/abdomen/pelvis CT, and MRI pelvis
- Multidisciplinary tumor board discussion
- Neoadjuvant chemoradiotherapy (standard for locally advanced rectal cancer)
- Restaging after neoadjuvant therapy
- Definitive surgical resection (likely low anterior resection with temporary diverting ileostomy vs. abdominoperineal resection given tumor location)
Hemodynamic Instability Protocol
If patient develops instability (pH <7.2, temperature <35°C, BE <-8, coagulopathy, sepsis/septic shock) 1: