A 60 -year-old man suffering from left colon cancer presented with acute left colonic obstruction and the tre… - Chitranjjan National Cancer Institute Kolkata - 2021

Chitranjjan National Cancer Institute Kolkata - 2021

Medical & Surgical Nursing

Medium

Appeared in: Chitranjjan National Cancer Institute Kolkata - 2021

Explanation

In acute left-sided colonic obstruction, the bowel is unprepared, distended, and edematous, making an immediate anastomosis (re-joining) highly risky.
The Hartmann procedure involves resecting the diseased colon segment, creating an end colostomy, and closing the rectal stump.
This approach removes the cancer and the obstruction in a single emergency operation while avoiding the high risk of anastomotic leak associated with primary anastomosis in an unprepared bowel.
It is considered the safest definitive procedure for most patients in this emergency situation, prioritizing survival over immediate restoration of bowel continuity.

Option B: A defunctioning colostomy only diverts the fecal stream to relieve the obstruction but leaves the cancerous tumor in place. It is not a definitive treatment for cancer.
Option C: A right hemicolectomy is the removal of the right side of the colon. This is anatomically incorrect for a cancer located in the left colon.
Option D: Performing a resection and immediate end-to-end anastomosis in an acutely obstructed, unprepared left colon has a prohibitively high risk of anastomotic leak, which can lead to peritonitis, sepsis, and death.

Clinical Relevance

Nursing practice connection: Use the key finding related to Surgical management of acute malignant large bowel obstruction to guide bedside assessment, documentation, and the next nursing action.
Nurses play a critical role in the care of patients undergoing a Hartmann procedure. This includes pre-operative stoma site marking and education, and extensive post-operative care.
Post-operative nursing priorities include stoma assessment (color, output), skin care around the stoma to prevent breakdown, monitoring for signs of infection or ischemia, and providing emotional support and education to help the patient adjust to living with a colostomy.
What if the patient was young, very stable, and the obstruction was incomplete? In that specific scenario, some surgeons might consider placing a self-expanding metallic stent (SEMS) across the tumor as a 'bridge to surgery'. This would decompress the colon, allowing for bowel preparation and a single-stage elective resection and primary anastomosis a week or two later, avoiding a stoma altogether.

How to Approach the Question

First, identify the core clinical problem: an acute obstruction of the left colon caused by cancer. Recognize this as a surgical emergency.
Analyze the location: 'Left colon' is a key detail. The blood supply and nature of the bowel contents are different on the left side compared to the right, influencing surgical options.
Evaluate the patient's state: 'Acute obstruction' implies an unprepared bowel that is distended and inflamed, which is a hostile environment for healing.
Consider each surgical option in the context of safety. Ask yourself: which procedure best removes the problem (cancer and obstruction) with the lowest risk of a life-threatening complication in this emergency setting?
Eliminate anatomically incorrect options (Right hemicolectomy).
Compare the remaining options based on risk vs. benefit. Weigh the high risk of anastomotic leak (Resection and anastomosis) against the need for a stoma (Hartmann procedure). In an emergency, patient survival is the top priority, making the Hartmann procedure the safest choice.

Concept Tested & Keywords

Concept Tested: Surgical management of acute malignant large bowel obstruction.
Stem keywords: left colon cancer, acute left colonic obstruction, treatment
Lead-in keywords: treatment is
Clinical cues: 60-year-old man: Indicates an adult patient.
Clinical cues: Acute left colonic obstruction: This is an emergency condition requiring urgent intervention.

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E6 Medicine Harrison 22e Part 2 p. 485-487

E6 Gynecology Williams p. 298-363