The effect of intraoperative colonic lavage withN G -nitro-l-arginine methyl ester (l-NAME) on anastomotic healing in the presence of left-sided colonic obstruction in the rat

-arginine methyl ester (L-NAME) on the healing of colonic anastomosis in the presence of a left-sided obstruction in the rat was investigated. Left-sided colonic obstruction was created in 144 Wistar rats. The obstruction site was excised 24 h later and anastomosis was performed after either no irrigation or colonic lavage with either saline, povidone iodine (PI), short-chain fatty acids (SCFA), L-NAME, or glutamine, in 24 animals each. Animals were killed on days 3 and 6, and a 4-cm colonic segment with the anastomosis at the center was excised. Bursting pressure (BP) and hydroxyproline (HP) content were measured. In the saline, PI, and SCFA groups, BP was higher (P < 0.05, P < 0.05, and P < 0.001, respectively) and HP concentration was similar compared with controls. Both the BP and HP concentrations were higher in the glutamine group compared with controls (P < 0.001). BP was lower (P < 0.05) and HP concentration was similar in the L-NAME group compared with the control group. Colonocyte nutrition and tissue perfusion are the mainstays of anastomotic healing. Intraoperative colonic lavage with L-NAME suppresses colonic anastomotic healing in the presence of a left-sided obstruction. (Received for publication on Mar. 29, 1999; accepted on Nov. 11, 1999)     

Treatment of left-sided colonic emergencies: a comparison of US and UK surgical practices

Background  Surgeons are increasingly considering resection and primary anastomosis when treating left-sided colonic obstruction or perforation in preference to the more traditional staged procedures. Previous studies in the United Kingdom (UK) and United States of America (USA) have suggested a greater interest in single-staged procedures amongst UK surgeons. This study was aimed to directly compare the treatment preferences between UK and US surgeons.
Method  A questionnaire, designed to determine the procedure of choice when faced with left-sided colonic emergencies in patients with good and poor anaesthetic risk, was sent to 500 surgeons in the UK and 500 surgeons in the USA.
Results  UK surgeons were more likely to perform resection, primary anastomosis and on-table colonic lavage in patients with sigmoid obstruction (good anaesthetic risk: P  < 0.0001; poor risk: P  < 0.01) and sigmoid perforation (good risk: P  < 0.0001). In good-risk patients with sigmoid obstruction, US surgeons were more likely than UK to choose Hartmann's procedure ( P  < 0.0001). US surgeons performing primary anastomosis were less likely to perform on-table lavage.
Conclusion  Single-stage procedures are widely accepted as viable treatment options in both the UK and the USA when dealing with left-sided colonic emergencies. British surgeons are more likely to favour single-staged procedures, particularly with on-table colonic lavage, when compared with US surgeons.     

Role of protective colostomy in colorectal surgery. Apropos of 68 cases

A retrospective study was made from the records of 68 patients who had temporary loop colostomy with left colectomy between 1975 and 1985. Six fecal fistula occurred. Two of these patients died in spite of the colostomy. The colostomy closure was complicated by six leakages and four wound infections. The results are compared with those from literature. Finally loop colostomy for protecting an anastomosis keeps good indications with sub-obstructions and acute obstructions without large colectasia, infections without abscess, bowels no or bad prepared, and some low colo-rectal anastomosis. Large bowel obstruction with megacolon, and peritonitis avoid all kind of anastomosis. The colostomy closure is a high colonic surgery procedure. It must occur three months after its formation. A barium enema is necessary before loop colostomy closure.     

Effects of pneumoperitoneum with or without colostomy on rat colonic anastomotic healing

Background: Elevated intra‐abdominal pressure and colostomy have adverse effects on colonic anastomoses. The aim of the present study was to investigate the effects of laparoscopic colon surgery with and without diverting colostomy on healing of colonic anastomoses in an experimental model. Methods: Thirty‐six male rats were divided into three equal groups: group 1, control (colonic anastomosis and anaesthesia for 180 min only); group 2, 180 min pneumoperitoneum and colonic anastomosis; and group 3, similar to group 2 with a proximal colostomy. On day 7, bursting pressures, tissue hydroxyproline and nitric oxide concentrations and histopathological inflammation scores were determined and compared. Results: Mean bursting pressures were higher in the control group than the two pneumoperitoneum groups (P = 0.0003). Mean tissue hydroxyproline concentrations showed no difference (P > 0.05). Mean tissue nitric oxide concentrations were significantly increased in the control group (P = 0.0013). Histopathological scores demonstrated increased inflammatory response in group 3 compared to the controls (P = 0.0009). Conclusion: Pneumoperitoneum delays collagen maturation and impairs anastomotic strength in the colon. Following pneumoperitoneum, performance of a diverting loop colostomy to protect the anastomosis will not have additional detrimental effects on anastomotic healing.     

改良式顺行结肠灌洗法在梗阻性左半结肠癌术中的应用

目的探讨在左半结肠癌并肠梗阻术中采用改良式顺行灌洗法行一期吻合的效果。方法对112例左半结肠癌并肠梗阻患者在术中采用左半结肠拖出无菌塑料袋中,以保护手术野免于污染,然后从阑尾插管顺行灌洗肠道后,行一期切除吻合术。结果112例行肿瘤切除、结肠一期吻合术。术后1例发生肠漏,经再次手术行结肠近端造瘘治愈。1例死亡。结论改良式顺行灌洗法操作简便,肠道减压迅速,基本无污染,肠道清洁质量高,灌洗后行左半结肠癌一期切除吻合安全可行。     

Endoluminal stenting for benign colonic obstruction

We report a case of complete descending colon obstruction due to diverticular disease that was initially managed by endoscopic stent placement followed by single-stage left colectomy with primary anastomosis. Traditional management of complete large bowel obstruction, whether due to benign or malignant disease, most often requires a temporary colostomy because of unprepared colon. In this case, preparation of the colon was accomplished by successful stenting of the benign colonic obstruction. We believe that endoscopic colonic stenting is an effective way of avoiding a temporary colostomy in patients with complete large bowel obstruction. Received: 10 June 1997/Accepted: 1 July 1997     

Endoscopic-laparoscopic treatment of neoplastic occlusion of the left colon

About a third of patients with colorectal carcinoma have acute colonic obstruction requiring emergency surgery. The surgical options are: intraoperative lavage and resection of the colonic segment involved with primary anastomosis; subtotal colectomy with primary anastomosis; colostomy followed by resection; and resection of the colonic segment involved with an end colostomy (Hartman's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and are associated with a poor quality of life. Endoscopic colonic stent insertion effectively decompresses the obstructed colon allowing bowel preparation and elective resection. In this article we present 2 cases successfully treated with the use of stents followed by a laparoscopic resection. We also describe technical details concerning the endoscopy and laparoscopy procedure, discuss the advantages of this treatment and present a review of the literature. One patient underwent a left hemicolectomy; while the other was treated with splenic flexure resection. No complications occurred after surgery. Histological staging revealed a pT3 pNO pMx G2 and a pT4 pN1 pM1 G2 adenocarcinoma, respectively. This initial experience shows that endoscopic colonic stent insertion can effectively resolve the neoplastic obstruction, allowing safe elective surgery. The use of stents does not prevent a laparoscopic approach.     

Comparison of Defecatory Function After Colonic J-Pouch Anastomosis and Straight Anastomosis for Stapled Low Anterior Resection: Results of a Prospective Randomized Trial

Purpose. Although defecatory function after low anterior resection for rectal cancer is reported to be better following colonic J-pouch than straight anastomosis, few prospective randomized trials comparing the two forms of anastomosis have been reported. We performed a prospective randomized trial comparing straight anastomosis with colonic J-pouch anastomosis both clinically and physiologically in patients undergoing stapled low colorectal anastomosis. Methods. A total of 42 consecutive patients were intraoperatively randomized to undergo either straight anastomosis or colonic J-pouch anastomosis. Clinical defecatory function was evaluated by a questionnaire answered preoperatively, then 6 and 12 months postoperatively. Anorectal physiological assessment was also carried out before surgery, then 12 months postoperatively. Results. The clinical defecatory function assessed 6 months and 12 months after surgery did not differ between the two groups. However, while the length of high-pressure zone was significantly shortened, and (neo)rectal capacity was significantly reduced postoperatively in the straight group, none of these physiological parameters were significantly altered in the pouch group. Conclusion. Although the aim of colonic J-pouch to preserve reservoir function was physiologically achieved, the improvement in clinical defecatory function was not significant. Thus, further prospective studies are needed to confirm the functional superiority of colonic J-pouch anastomosis for stapled low colorectal anastomosis after low anterior resection. Received: January 17, 2001 / Accepted: July 17, 2001     

Side-to-end anastomosis in a colostomy for acute malignant large-bowel obstruction: Side-to-end anastomosis with a colostomy (STEC procedure)

This report describes the use of side-to-end anastomosis in a colostomy for an acute malignant large-bowel obstruction. A 59-year-old man presented with a colonic obstruction due to advanced descending colon cancer. The preoperative imaging studies revealed a complete obstruction of the descending colon at the site of the splenic flexure, a remarkably dilated transverse colon, and no other metastatic lesions. Side-to-end anastomosis was performed with the colostomy because of the high comorbidity associated with such cases. When the patient’s general condition improved, a stoma closure was performed under local anesthesia. In conclusion, a side-to-end anastomosis with a colostomy (STEC procedure) was found to be a simple, useful, and cost-effective technique for an acute malignant large-bowel obstruction, particularly in a high-risk patient.     

Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon.

BACKGROUND: Traditionally, left-sided colon obstruction is managed by a multistaged defunctioning colostomy and resection. However, there is growing acceptance of one-stage primary resection and anastomosis with on-table antegrade irrigation. This paper presents a series of patients managed prospectively by primary anastomosis without intraoperative colonic lavage. METHODS: Emergency resection of acutely obstructed left-sided colonic carcinomas was performed. This was followed by primary anastomosis without on-table lavage after bowel decompression using a new technique. RESULTS: Fifty-eight consecutive, unselected patients underwent bowel decompression, resection and primary colocolic anastomosis. Only one patient developed a leak at the anastomotic site, requiring pelvic abscess drainage and transverse loop colostomy. One death occurred 12 h following surgery. Autopsy confirmed that this was due to myocardial infarction. Mean hospital stay was 9.8 days. CONCLUSION: Emergency surgery on the obstructed left colon can be carried out safely after decompression alone, without intraoperative colonic lavage.     

Left colectomy with immediate anastomosis in emergency surgery

PURPOSE OF THE STUDY: A retrospective study of our experience with one-stage left colectomy for acute diverticulitis and obstruction with a review of the literature to more clearly define the indications of this procedure. PATIENTS AND METHODS: 30 patients were operated for acute diverticulitis (group 1) and 47 for obstruction (group 2). Only 7 patients (23%) of group 1 had an intraoperative colonic lavage while this was performed for all the patients of group 2. RESULTS: The postoperative morbidity and mortality for the patients of group 1 and 2 were 37 and 28%, and 7 and 11% respectively. None of the patients of group 1 had clinical anastomotic leak, while this occurred in 2 patients (4%) of group 2. The mean hospital stay was 26 days for patients of group 1 and 17 days for patients of group 2. CONCLUSIONS: Bowel obstruction should be treated by one-stage left colectomy and intraoperative colonic lavage for patients with low anaesthetic risks (ASA 1 and 2). Immediate anastomosis protected by colostomy or ileostomy could be proposed for patients with an intermediate risk (ASA 3). Patients with acute diverticulitis and a localized abscess or peritonitis should be treated with one-stage colectomy; an immediate protected anastomosis could be performed in patients with generalized purulent peritonitis while a Hartmann's type colectomy should be the reasonable option for fecal generalized peritonitis. Intraoperative colonic lavage does not seem mandatory.     

Current practices in left-sided colonic emergencies: a survey of US gastrointestinal surgeons.

BACKGROUND: The paradigms in the surgical management of obstruction and perforation of the left colon - once considered absolute contraindications to primary resection and anastomosis - are changing. The aim of this survey was to poll American Gastrointestinal surgeons on their current approach to left colonic emergencies. METHODS: A questionnaire was sent to 500 US-based surgeons, randomly selected members from the membership list of the Society for Surgery of the Alimentary Tract. It surveyed the surgeons on how they would approach 'good-risk' and 'poor-risk' patients with left colonic obstruction or perforation. RESULTS: 215 (43%) surgeons responded to the questionnaire; 180 fully completed questionnaires (36%) were analyzed. Sigmoid obstruction: 96 responders (53%) selected a one-stage procedure in 'good-risk' patients; 78 preferred sigmoid resection with (n = 46) or without (n = 32) 'on-table' colonic lavage and 18 opted for a subtotal colectomy and ileo-rectal anastomosis. Most (94%) responders preferred a staged procedure in 'high-risk' patients: a Hartmann resection (n = 120) or a transverse colostomy (n = 46). Sigmoid diverticular perforation: only one third of the responders recommended a one-stage procedure in 'good-risk' patients: 58 would perform a sigmoidectomy with (n = 19) or without (n = 39) 'on-table' colonic lavage; only two opted for subtotal colectomy with ileo-rectal anastomosis. In 'high-risk' patients most surgeons opted for a Hartmann's (88%) procedure or a diverting colostomy (7%). CONCLUSIONS: This survey suggests that a half and one-third of the responders would perform a one-stage resection and anastomosis in 'good-risk' patients with left colonic obstruction and perforation, respectively. In 'poor-risk' patients most responders would still opt for a staged procedure.     

Interposition of a Jejunal Segment as an Alternative One-Stage Operation for Acute Left Colon Obstruction

Purpose: Much debate surrounds the one-stage surgical management of acute left colon obstruction. Many surgeons are still reluctant to perform primary anastomosis in unprepared bowel fearing the risk of anastomotic dehiscence. Although intraoperative lavage and subtotal colectomy have recently proved effective for preventing fecal loading, both of these procedures have drawbacks and the search for additional alternative surgical procedures continues. We conducted an experimental study to examine a new one-stage operation, consisting of the interposition of a jejunal segment to the resection site of the colon, to manage acute left colon obstruction. Methods: The colons of 20 domestic pigs were obstructed, and 2 days later, segmental resection and either primary colo-colonic anastomosis or interposition of a jejunal segment was performed. Autopsies were done 6 weeks after the operations and the anastomotic regions were subjected to bursting pressure analysis. Results: The operating time was longer in the interposition group at 49 ± 14 vs 38 ± 12 min (P < 0.01). There was no mortality or clinical signs of anastomotic dehiscence in either group. A perianastomotic abscess was detected on autopsy in one animal from the primary colo-colonic anastomosis group. The bursting pressures of the jejunocolic anastomoses were significantly higher (P < 0.001) than those of the primary colo-colonic anastomoses. Conclusions: These experimental results suggest that jejunal interposition may be a feasible alternative to primary colonic anastomosis to create intestinal continuity after resection for acute obstruction of the left colon. Received: September 20, 2001 / Accepted: March 5, 2002     

Left colon anastomotic healing following colostomy closure. An experimental study on rats

The impact of colostomy closure on the healing of a left colonic anastomosis performed 4 weeks earlier was studied in rats. Colostomy closure could be safely accomplished but in 3 of 25 rats was followed by faecal obstruction due to narrowing of the primary left colonic anastomosis. After colostomy closure the gain in anastomotic strength was slow and did not exceed the outset value until after 3 weeks. After colostomy closure, accumulation of collagen in the anastomotic region increased earlier than anastomotic strength, indicating delay in collagen maturation.     

Sixty-one cases of acute obstructions of the colon caused by cancer. Indications for emergency surgery]

Sixty-one cases of acute malignant colonic obstruction were operated upon within 24 hours after the patient's admission, between 1979 and 1989: 10 for a right colon carcinoma, 51 for a left-sided lesion. Indications, for emergency operation were: complete clinical obstruction, iliac tenderness, radiologic ileal fluid levels and arrest on barium enema. The initial procedures consisted of 8 right hemicolectomies, and for the left-sided obstructions, 32 colostomies, 7 colectomies with immediate anastomosis, and 12 colectomies without anastomosis. Overall mortality was nil for the right side and 4% left-sided obstructions. The current surgical procedures of choice according to the authors are: right hemicolectomy for right-sided obstruction; elective colostomy for the left side. In case of doubt about the mechanism of obstruction or vitality of the colon, a midline approach for operative exploration, followed by colectomy without anastomosis is recommended. Colectomy with immediate anastomosis is possible in rare favourable cases. Subtotal colectomy is indicated in cases of ischemic lesions, caecal perforation or other colonic tumours. Intraoperative irrigation of the colon is rarely permitted in this particular variety of acute obstruction.     

Stenting or stoma creation for patients with inoperable malignant colonic obstructions? Results of a study and cost-effectiveness analysis

Background: The aim of the present study was to compare the efficacy, safety, and cost of endoscopic palliative treatment with selfexpanding metallic stents with that of stoma creation in the management of inoperable malignant colonic obstructions. Methods: A total of 30 patients with inoperable malignant partial obstruction (due to metastases, hemodynamic instability, or pulmonary instability) in the left colon unsing from colorectal or ovarian cancer were included in the study. Fifteen were randomized to undergo palliative metallic colonic stent placement and 15 to undergo stoma creation. The efficacy and safety of the two methods was compared. A cost-effectiveness analysis was also performed, including the cost of postinterventional care. Results: Stents were placed successfully in 14 of 15 patients. In one patient with obstruction of a tortuous rectosigmoid flexure colon, stenting was not possible; this patient was excluded from the study. During the follow-up period, a moderate, nonocclusive ingrowth of tumor into the stent lumen was observed in six patients; they were all treated with internal laser ablation. The cost-effectiveness analysis showed that although the stoma creation procedure was less expensive, the total difference in average costs for the two methods was 6.9% (132 Euros). Conclusions: Self-expanding metallic stent placement is a palliative alternative to colostomy for patients with inoperable malignant colonic strictures. This treatment option provides a better quality of life for the patient, without the psychological repercussions of a colostomy, and it appears to be cost-effective.     

Primary Anastomosis and Diverting Colostomy in Diffuse Diverticular Peritonitis

Background: Despite the well documented morbidity associated with its reversal, Hartmann’s procedure remains the favoured option in patients with complicated diverticular disease in the presence of diffuse peritonitis. A prospective study was conducted to determine whether primary anastomosis with diverting colostomy constitutes a valid alternative to the Hartmann procedure.

Methods: Between 1994 and 1998, all patients with diffuse peritonitis due to perforated diverticulitis of sigmoid origin underwent resection and primary anastomosis with diverting colostomy. Restoration of colonic continuity was programmed six weeks later, after verification of the anastomose by gastrograffin enema. The group included 5 men and 15 women with a mean age of 72 years (32-97 years). The ASA classification of the patients was as follows: ASA II (n = 2), ASA III (n = 12), ASA IV (n = 3), ASA V (n = 3). The mean delay between onset of symptoms and surgery was 74 hours (8–215 hours).

Results: Operative mortality and morbidity was 15% (n = 3) and 50% respectively. No patients showed signs of suture disruption and this was confirmed by routine radiological controls of the anastomoses. Mean length of hospitalization was 20 ± 10 days (SD; median: 18 days). Closure of the colostomy using a small peristomal incision was performed in all surviving patients after a mean delay of 45 ±9 days (range 28-67 days). Mean length of hospitalization for colostomy closure was 7 ±3 days (range 3-18 days) without mortality.

Conclusions: Applied systematically to all patients with diffuse peritonitis due to perforated diverticular disease, primary anastomosis was found to be as safe as the Hartmann procedure but appears to be superior in terms of total length of hospital stay, interval to stoma closure and rates of stoma closure. Primary anastomosis with diverting colostomy could constitute a valid alternative to the Hartmann procedure in selected patients with complicated diverticular disease, even in the presence of diffuse peritonitis.     

Anorectal malformation,associated with colon atresia and intestinal malrotation,a case report

Introduction and importanceIn this case report from Muhimbili National Hospital, Dar es salaam, Tanzania, we present the unexpected findings of anorectal malformation, colonic atresia, and intestinal malrotation in a 2-day old neonate. This combination is exceedingly rare, with only case reports published in the literature. We describe the challenges in diagnosis and offer our insights based on this experience and review of the literature.Case presentationOur patient was a male born at term, weighing 2600 g, diagnosed clinically with a high anorectal malformation. He was planned for colostomy, and we unexpectedly found a collapsed descending colon. Exploration revealed intestinal malrotation and three segments of type I colonic atresia from the mid transverse colon to the sigmoid colon in addition to the high anorectal malformation.Clinical discussionCreating a colostomy in a high anorectal malformation and failure to identify proximal intestinal atresia would result in potentially devastating consequences. Colonic atresia and anorectal malformation will both present as large bowel obstruction. In the extremely rare situation, when occurring in combination, the obvious clinical diagnosis of anorectal malformation will mask the clinical suspicion of the possibility of colonic atresia. Finding a distal bowel air bubble above the pubococcygeal line on an invertogram is useful in identifying proximal atresia preoperatively.ConclusionThe current report emphasizes the importance of maintaining an awareness of possible associated colonic atresia in neonates with anorectal malformation. An invertogram and intraoperative finding of a collapsed descending colon should prompt evaluation for a proximal obstructing lesion.     

肠道支架联合腹腔镜在急性梗阻性左半结肠癌治疗中的初步应用

目的:探讨腹腔镜结肠癌Ⅰ期切除吻合术中置入肠道支架的短期疗效。方法:回顾分析2013年6月至2016年5月收治的27例中老年急性梗阻性左半结肠癌患者的临床资料。入院常规行全腹部增强CT检查,排除同时性结肠癌远处转移。常规行胃肠减压,纠正电解质紊乱、贫血及低蛋白血症。对照组(n=16)于24~48 h内急诊行左半结肠癌根治术,视术中情况选择性行近端结肠造瘘或Ⅰ期结肠吻合术;支架组(n=11)入院后先通过超细内镜引导下置入肠道支架解除梗阻,梗阻状况及全身情况改善后进一步行腹腔镜辅助左半结肠癌根治+Ⅰ期吻合术。结果:支架组无死亡病例,未行结肠残端造口,未出现术后吻合口瘘。两组淋巴结廓清数量、首次住院时间、首次住院费用差异无统计学意义(P0.05)。支架组手术时间、术中出血量、预防性造口率少于对照组(P0.05)。结论:超细内镜结肠支架置入术联合腹腔镜结肠癌根治术治疗急性梗阻性左半结肠癌短期疗效显著。