Rectal cancer. Optimal management in emergency conditions

Emergency conditions in rectal cancer can happen pre-, intra-, and postoper atively. Preoperative emergencies are perforation and obstipation. Spontane ous intraperitoneal perforations have a mortality of 17 to 33 % and a five year survival of only 7 to 10 %. The site of the perforation is not identic al with the the site of the tumor. Due to fecal peritonitis a defunctioning stoma and planned repeat laparotomies are indicated. Initial fecal diversi on is followed by tumor resection with anastomosis when the peritonitis has subsided. Iatrogenic perforations from endoscopy or barium enema examinati on are rare (0.09 to 0.004 %). Tumor obstruction occurs in 15 % of colorect al cancers. Immediate resection with primary anastomosis is deemed to be fe asible if preceded by on-table colonic lavage. Immediate resection has a lo wer mortality (13.6 %) than two staged fecal diversion and resection (35.5 %). Intraoperative emergency conditions are bleeding and tumor cell spillag e. Bleeding from the presacral veins will be controlled with the hemorrhage occluder pin. Inadvertent perforation of the tumor leads to dissemination of tumor cells. In case of spillage local recurrence was seen in 39 % of re sections within five years. Multivisceral resection and precise preparation with respect to anatomical planes may prevent damage of the rectum. The le ading postoperative emergency condition is anastomotic leak. The incidence of clinical leaks is 6 %. In diffuse peritonitis the anastomosis should be taken down and planned repeat laparotomy should be performed. This concept reduces the mortality down to 18.7 %.