Acute colonic pseudo-obstruction in elderly Report of a case.

A case of acute colonic obstruction in an elderly patient is presented, with a brief discussion about peculiar aspects to pseudo-obstruction and particularly chronic idiopathic intestinal pseudo-obstruction (CIIP), in which it was classified by pathologists. Clinical and therapeutic implications of this classification are also discussed. In authors'opinion, interesting aspects of the reported case are represented by the acute presentation, without previous symptoms at medical history and above all by the evidence of a recto-sigmoid junction intraoperatively palpable mass, mimicking ring-like neoplastic disease. The preoperative and intraoperative features led surgeons to perform a total colectomy with ileo-rectal anastomosis and high ligation of mesenteric inferior artery, with complete regional lymphectomy according to oncologic standard, but at histological examination the mass revealed to be due to considerable muscular tissue thickening, therefore to a benign condition. These features probably suggest the need of a better clinical and pathological classification of this difficult and still controversial matter, in order to achieve better outcomes and to avoid misdiagnosis and overtreatment. KEY WORDS: Intestinal obstruction, Pseudo-obstruction, Total colectomy.

Our experience in the management of obstructing colorectal cancer.

AIM: Comparing the different possible surgical procedures and the results in urgent/emergency and in elective surgery for obstructing colorectal cancer. MATERIAL OF STUDY: From 2008 we operated on 238 patients affected by colorectal cancer, 136 complicated tumours, 115 obstructing and 19 perforated. 23 patients had right-sided and 92 left-sided obstructing colonic tumour, divided retrospectively in 4 groups. 18 decompressive colostomy; 32 two-stages procedures: 25 Hartmann's operations and 7 total colectomies with terminal ileostomy; 7 one-stage procedures, with defunctioning ileostomy: 4 total colectomies and 3 colonic resections with wash-out; 35 one-stage procedures with primary anastomosis+wash-out or milking. RESULTS: Operative mortality is 7% in urgent/emergency versus 1% in elective surgery and anastomotic leakage affected 6 /58 cases, 5 requiring additional surgery. Overall, about 2/3 of the perioperative deaths were related to general complications and 1/3 to anastomotic failure. The local recurrence rate was 7% in elective and 11% in urgent/emergency surgery. DISCUSSION AND CONCLUSIONS: Obstructing colorectal cancer is associated with a high operative mortality and a worse prognosis, in terms of recurrence and survival. Actually, immediate resection with primary anastomosis represents the goldstandard in selected patients with a low anaesthetic risk, performing either as a typical resection with wash-out, or a subtotal colectomy; a temporary defunctioning colostomy or ileostomy could be proposed for patients with an intermediate risk; in high-risk cases, advanced obstruction, simultaneous colonic perforation, metastatic or locally advanced disease, Hartmann's operation should be used, as a safer procedure. Colon stenting can be an useful palliative or bridge-to-surgery option. KEY WORDS: Bowel obstruction, Colorectal cancer, Primary anastomosis.