Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 598 - файл

In the face of an overall increase in early diagnosis, it is estimated that up to one third of CRC patients would require an emergency intervention upon initial presen­tation [11]. Malignancy represents the leading cause of LBO in adults, and over two thirds of the obstructing tumors occur in the left side of the colon, the majority of which are distal to the splenic exure [12, 13]. Due to the smaller diameter of the bowel, more distal tumors (occurring in the left and sigmoid colon) are more likely to present as an obstruction compared to more proximal cancers. Surgical options in this setting include simple diversion with loop colostomy versus resection with or without primary anastomosis. The creation of a diverting or blowhole colostomy proximal to the tumor presents several advantages: (1) it can be performed quickly, with minimal surgical trauma, potentially even under local anesthesia in particularly frail patients; (2) itis an effective temporizing measure allowing completion of stag­ing and denition of the most appropriate multidisciplinary treatment strategy, while avoiding a resection in the setting of an unprepped colon; (3) itrepresents an effective treatment when a radical resection is not feasible due to the extent of the disease or the tenuous conditions of the patient [4, 14]. However, colostomies are associated with non-trivial complication rates, including prolapse, herniation, necrosis, and infection, and the risk is demonstrably higher when performed in the emergent setting [15]. A loop colostomy negatively affects overall quality of life (QoL) when meant as denitive palliation, and imposes the need for additional operations when used as a bridge to elective resection [16]. The safety of an emer­gency colectomy, when technically feasible, is suggested by several studies in the literature, with reported equal morbidity, mortality and oncologic outcomes com­pared to loop colostomy, and shorter overall length of stay [17, 18]. A segmental resection is the preferred operation, while a subtotal colectomy– reportedly associ­ated with worse functional outcomes- is reserved for those cases where bowel isch­emia or serosal tear/perforation occurs in the proximal colon, or in the presence of synchronous tumors [19]. In a RCT published in 2014, 75 patient with obstructing rectosigmoid cancer were randomized to either loop colostomy or resection with end colostomy (Hartmann’s procedure); after stratifying patients by age and comor­bidities, the two approaches had comparable surgical and non-surgical complication rates, blood transfusion requirement, length of stay, and mortality [20]. Additionally, although the quality of the data is limited, there seems to be a survival benet in resecting the primary tumor even in the presence of synchronous metastases [21]. The feasibility of an oncologically sound resection in the emergent setting was assessed in a retrospective study by Teixeira etal.; 87 patient had an ES (77% of which for bowel obstruction); while the complication rates were higher than those reported for elective procedures (34% morbidity and 20% mortality), the vast majority of the specimens were adequate in terms of surgical margins and lymph node harvest [22]. While a Hartmann’s procedure leaves open the possibility of restoration of bowel continuity, actual colostomy reversal rates are much lower than