“To stent or not to stent?”: immediate emergency surgery with laparoscopic radical colectomy with CME and primary anastomosis is feasible for obstructing left colon carcinoma

Salomone Di Saverio, Arianna Birindelli, Edoardo Segalini, Matteo Novello, Anna Larocca, Francesco Ferrara, Gian Andrea Binda, Marco Bassi

Great debate exists in the initial acute management of large bowel obstruction from obstructing left colon carcinoma. While endoscopic stenting is well established as the first approach in the setting of palliative care of patients with advanced metastatic disease as well as a bridge to elective surgery in elderly patients who have an increased risk of postoperative mortality (age >70 years and/or ASA status ≥3), controversies exist regarding oncological safety and long-term outcomes of endoscopic colonic stenting in younger patients and ESGE Guidelines do not recommend SEMS placement in patients <70 and fit for curative surgery. Particularly, the Consensus Panelists currently state that SEMS placement as a bridge to surgery is not recommended as the standard treatment because (1) it does not reduce the postoperative mortality in the general population, (2) SEMS may be associated with an increased risk of tumor recurrence, and (3) acute resection is feasible in young and fit patients, with an acceptable postoperative mortality rate. A 32-year-old lady was admitted with complete LBO from obstructing sigmoid carcinoma. Initial i.v. CE-CT scan detected a large bowel partial obstruction with fecal impaction in the entire colon until sigmoid with some mildly dilated SB loops. The presence of a thickened area in the colonic wall could not be assessed because the patient was young and thin and in such patients the CT appearance of bowel wall cannot be clearly appreciated. She was initially managed with laxatives and gastrografin. The patient's obstruction did not improve and abdominal distension worsened with nausea and colicky pain. Urgent endoscopy detected a friable mass, consistent with completely obstructing carcinoma of the mid sigmoid. Biopsies were taken and distal ink marking was made. Whole-body urgent CT scan with i.v. contrast was performed in order to obtain full preoperative staging and to rule out distant metastases. CT scan and the previously given oral gastrografin confirmed complete large bowel obstruction with a tight stricture in the sigmoid. Cecum was markedly distended.