Obstructing Sigmoid Cancer in a Cardiac Patient: Stent, Stoma or Resection Tonight?
A 79-year-old woman presents with 5 days of absolute constipation, progressive abdominal distension and vomiting. She has ischaemic heart disease with a drug-eluting stent placed 14 months ago, heart failure with an ejection fraction of 35%, and permanent atrial fibrillation on apixaban. She takes no other medication. Blood pressure 128/74 mmHg, heart rate 96/min, temperature 37.4 °C. The abdomen is grossly distended and tympanic; there is mild left-sided tenderness but no guarding or rigidity. Digital rectal examination is empty. CT shows a concentric obstructing mass at the sigmoid colon with proximal colonic dilatation to 10 cm and no free gas or fluid, and no definite distant metastases in the chest, abdomen or pelvis. White cell count 9.8 ×10⁹/L, creatinine 132 µmol/L (baseline 88), potassium 3.2 mmol/L, albumin 29 g/L, lactate 1.9 mmol/L, INR 1.2. The hospital has a 24-hour interventional endoscopy service and a colorectal unit that operates electively.
1. Does she need emergency surgery tonight? Justify your answer by weighing emergency resection against decompression, and state what would change your mind.
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No emergency laparotomy tonight. There is no perforation, no peritonitis, no ischaemia and no haemodynamic instability. An emergency Hartmann procedure in a 79-year-old with an ejection fraction of 35%, a recent drug-eluting stent and a creatinine already above baseline carries a high risk of death, a permanent stoma and a long critical care stay.
What she needs instead: admission, nil by mouth, intravenous fluids with potassium replacement, nasogastric decompression only if vomiting is troublesome (it does not relieve a competent ileocaecal valve), urinary catheter, correction of creatinine with careful hydration, and a bridging self-expanding metal stent within 24–48 hours. This decompresses the colon, allows cardiac and nutritional optimisation, permits completion of staging, and makes a laparoscopic resection with primary anastomosis much more likely.
What would change my mind - and this must be explicit in the notes:
- Free intraperitoneal gas, generalised peritonitis or pneumatosis: proceed to emergency resection.
- Clinical deterioration, rising lactate, or refractory pain suggesting ischaemia.
- Massive caecal distension with a competent ileocaecal valve and impending perforation; a caecum above 12 cm with severe pain and tenderness is an indication to decompress urgently, by stent or tube, not to watch.
- Stent failure or perforation during placement.
One caveat: a 10 cm colon with mild tenderness is a warning, not a licence to wait indefinitely.
2. You elect to place a self-expanding metal stent as a bridge to surgery. Explain the technical and oncological considerations, the risks you consent her for, and how you time the elective resection and manage her apixaban.
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Technical. Place an uncovered or partially covered colonic stent under fluoroscopic and endoscopic guidance over a stiff guidewire, without balloon dilatation, leaving at least 2 cm of margin on either side of the stricture and confirming position and the absence of perforation afterwards. Avoid pre-dilatation, which increases perforation risk.
Oncological considerations. Stenting as a bridge to surgery is acceptable in an obstructed left colon when the goal is a lower-risk elective resection with primary anastomosis. There is debate about tumour seeding and about worse long-term outcomes suggested by some trials; the alternative - an emergency Hartmann procedure - carries its own oncological cost through a permanent stoma and delayed adjuvant therapy. This trade-off should be explicit in the multidisciplinary discussion and in the consent conversation.
Consent. Perforation (5–10%, higher with dilatation), stent migration, failure to deploy or re-obstruction, bleeding, pain, and the possibility of converting to emergency surgery and a stoma.
Timing and anticoagulation. Hold apixaban for 48 hours before the endoscopic procedure with no bridging, then restart after 24–48 hours if there is no bleeding. Aim for resection within 1–2 weeks of stenting, after cardiac optimisation and correction of potassium, creatinine and albumin. If she is judged unfit by cardiology and anaesthetics, the stent may become definitive palliation together with oncology review, and that decision should be shared and documented.
3. Forty-eight hours after stenting she develops sudden severe abdominal pain, tachycardia and free air on CT. Set out your management and explain how this changes her prognosis.
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Immediate management. This is a stented perforation until proven otherwise. Resuscitate with oxygen, two large-bore cannulae, balanced crystalloid and blood products as needed, broad-spectrum antibiotics, urinary catheter and urgent cross-match. Consent for laparotomy and stoma, and warn the family that this is a life-threatening event. Involve cardiology and critical care early.
Operation. Midline laparotomy, washout, resection of the perforated sigmoid segment including the stent, and end colostomy with closure of the rectal stump (Hartmann procedure). Primary anastomosis is not appropriate in a patient with faecal contamination, cardiac failure and a 79-year-old physiology. A damage-control approach with temporary abdominal closure and a second look at 24–48 hours is reasonable if she becomes acidotic, cold or coagulopathic. The stent is retrieved with the specimen and sent with the cancer for histopathology.
How the prognosis changes. Mortality after stented perforation is substantial, in the order of 20–30% in elderly comorbid patients, and much higher than after an elective resection. The likelihood of stoma reversal falls sharply given her cardiac risk, so she and her family should be told to plan on the possibility of a permanent colostomy. Adjuvant chemotherapy is likely to be delayed or not given. This is precisely why the bridge-to-surgery decision, the consent discussion and the threshold for emergency operation in the first place must be documented carefully.