Surgical Care

Surgical care is directed at relieving the obstruction. In most patients, the obstructing lesion is resected. Because the colon has not been cleansed, anastomosis often is risky. After resection, most surgeons perform a proximal colostomy if the obstruction is on the left side or ileostomy if it is on the right side.

In patients with substantial comorbidity and surgical risk or in the presence of an unresectable tumor, a diverting proximal colostomy or ileostomy may be performed without resection.

A diverting transverse loop colostomy may be the least invasive procedure for a very ill patient with a left colonic obstruction. It permits relief of the obstruction and further resuscitation without compromising chances for a subsequent resection.

A sigmoid colostomy without resection may be employed in patients with rectal obstruction that cannot be managed without a combined abdominoperineal approach.

Cecostomy should not be performed because the diversion is inadequate.

In younger patients some surgeons would consider primary anastomosis, rather than ileostomy, in the right colon, assuming no intraoperative hypotension, blood loss, or other complications are present.

If resection and proximal colostomy or ileostomy is performed, a mucous fistula generally is extracted from the distal end, unless the obstruction is rectosigmoid, in which case the distal end may be oversewn or stapled and left to drain transanally.

If the cause of the obstruction can be relieved nonsurgically, through procedures such as decompressign a volvulus, or if the obstruction is only partial, deferring surgery temporarily and supporting the patient while the large bowel is cleansed so that primary anastomosis may be performed more safely is preferable.