Perioperative management - Left hemicolectomy, open, curative

• Colon carcinoma of the descending colon
• Endoscopically non-(completely) resectable polyp with evidence of high-grade intraepithelial neoplasia.
• Presence of a tumorous change whose dignity cannot be clearly determined.
• Stenoses of other genesis, e.g., in Crohn's disease

In the present case, it is a clinically T3 carcinoma just below the left flexure without evidence of distant metastasis in the liver or lung. For this reason, indication for left hemicolectomy. The middle colic artery will not be resected due to the patient's advanced age and the tumor's distant location.

• Severe comorbidity

Limited operability, e.g., due to severe lung disease, heart failure, liver cirrhosis, etc.; whether this comorbidity constitutes a contraindication to surgery must be assessed individually.

• Primary tumor that does not cause symptoms in the case of unresectable metastasis. In this case, initiation of systemic therapy is recommended.

Colon Carcinoma:

• Clinical examination
• Laboratory tests (including tumor markers CEA and CA19-9)
• Complete colonoscopy; if colonoscopy is not possible or cannot be completed due to a stenosis: Pneumocolon CT or repeat colonoscopy 3-6 months postoperatively.
• Biopsies for histological confirmation
• CT thorax/abdomen
• Possibly MRI liver, contrast-enhanced ultrasound liver

Crohn's Disease:

• A Sellink MRI examination is useful to exclude Crohn's involvement with stenoses in the small intestine.

• For carcinomas with an increased risk of recurrence, a recommendation for neoadjuvant systemic therapy is emerging.
• In the case of distant metastases, an interdisciplinary tumor board decides on further therapy.
• Perioperative antibiotic prophylaxis, e.g., with a second or third-generation cephalosporin combined with metronidazole (effective against anaerobes)
• Review of anticoagulant therapy: Perioperative therapy with aspirin can be continued. Clopidogrel (ADP inhibitor) should be paused at least 5 days prior. Vitamin K antagonists should be paused 7 days, NOACs (new oral anticoagulants) at least 3 days preoperatively, bridging with short-acting heparins.
• Preoperative bowel preparation: Current data supports anterograde bowel lavage with the addition of topical antibiotics. See also
• Shaving of the abdominal wall
• Insertion of an indwelling catheter

The most important aspects

• Anastomotic insufficiency
• Septic complications such as intra-abdominal abscess and wound infections
• Injury to the spleen and pancreas
• Injury to the left ureter

Other standard points of clarification are

• Thrombosis and embolism
• Necessary blood transfusions
• Postoperative bleeding
• Incisional hernia