Colorectal stapled anastomoses

PURPOSE: Stapled anastomoses are currently an established technique in colorectal surgery. Larger series about the use of circular staplers in rectal anastomoses within daily clinical routine are rare. METHODS: We evaluated the morbidity, clinical leakage rate, and mortality in an unselected population of a teaching hospital after elective, left-sided colorectal resections with stapled rectal anastomoses. In the course of our study, manually sewn rectal anastomoses were not performed. All anastomoses were tested intraoperatively by instillation of liquid. RESULTS: A total of 615 elective colorectal resections with stapled rectal anastomoses was performed by 18 surgeons from 1984 to 1993. A protective colostomy was created in 2.9 percent (n=16) of all patients. Clinical anastomotic leakage occurred in nine patients (1.5 percent). The mortality rate was 1 percent (n=6). CONCLUSION: Use of the stapling technique facilitates the performance of anastomoses, particularly in regions with difficult anatomy. The rate of local complications is low, and protective colostomy can thus be dispensed with in most cases.     

Anastomotic Dehiscence After Resection and Primary Anastomosis in Left-Sided Colonic Emergencies

PURPOSE There is no consensus about the risk factors for anastomotic failure after elective or emergency colorectal surgery. The purpose of this study was to analyze the factors that may contribute in anastomotic dehiscence. METHODS A total of 208 patients who underwent left colonic resection and primary anastomosis for distal colonic emergencies were studied. Preoperative and operative variables analyzed for each patient were gender, age, American Society of Anesthesiologists score, comorbidities, indication for surgery, etiology of the disease, presence and grade of peritonitis, preoperative creatinine, hematocrit, hemoglobin, and leukocyte count, need for preoperative and operative transfusion. The end point was the clinical evident incidence of anastomotic leak. Bivariate comparisons of those patients with or without anastomotic leak were unpaired, and all tests of significance were two-tailed. A multivariate analysis, in which presentation of anastomotic leak was the dependent outcome variable, was performed by forward stepwise logistic regression model. RESULTS One hundred five patients (50.4 percent) had one or more complications. Anastomotic leak was diagnosed in 12 patients (5.7 percent). Seventeen patients (8.2 percent) needed a reoperation for complication. The overall mortality was 6.2 percent (13 patients). Obesity was significant as a predictor of anastomotic leak. CONCLUSIONS Obesity is a factor predicting anastomotic leak risk after resection and primary anastomosis for left-sided colonic emergencies. Reprints are not available.     

Risk factors for rectal cancer morbidity and mortality in patients with familial adenomatous polyposis after colectomy and ileorectal anastomosis

PURPOSE: The aims of the study were to investigate the effects of ileorectal anastomosis and the follow-up program on rectal cancer morbidity and mortality and to identify risk factors that predict the fate of the rectal stump. METHODS: One hundred ninety-five patients with familial adenomatous polyposis on whom an ileorectal anastomosis was performed between 1957 and the end of 1995 were included. Median follow-up time was 14 (range, 1-39) years. The cumulative risks of rectal cancer and rectal excision were estimated using survival analysis. RESULTS: Eighteen patients (9.2 percent) developed cancer, 17 in the retained colorectal segment and one on the ileal side of the anastomosis, and nine died of their cancer during the study period. The cumulative rectal cancer morbidity and mortality 20 years after ileorectal anastomosis was 12.1 percent (95 percent confidence interval = 5.7-18.5) and 7 percent (95 percent confidence interval = 2-12), respectively. The cumulative age-dependent risk of rectal cancer was 22.9 percent (95 percent confidence interval = 11.4-34.5) and 25.7 percent (95 percent confidence interval = 13.2-38.2) at the ages of 60 and 70 years, respectively. The corresponding cumulative mortality was 11.1 percent (95 percent confidence interval = 2.9-19.3) at the age of 70 years. Patients with dense polyposis at colectomy had an increased risk for cancer in the retained colorectal segment compared with patients with intermediate or sparse polyposis (P = 0.04). Sixty-six patients (34 percent) had their rectum removed, and the cumulative rectal excision rate 35 years after ileorectal anastomosis was 65.5 percent (95 percent confidence interval = 53-78). CONCLUSION: Patients on whom ileorectal anastomosis was performed had, despite the high rectal excision rate, a substantial risk of developing cancer in the retained colorectal segment, with an ensuing high mortality. Our results indicate that patients with dense polyposis should undergo restorative proctocolectomy as primary operation for familial adenomatous polyposis. In younger patients with intermediate or sparse polyposis and good expected follow-up compliance, ileorectal anastomosis still is an alternative.     

Simultaneous versus staged liver resection of synchronous liver metastases from colorectal cancer

Background and aims The surgical strategy for treatment of synchronous liver metastases from colorectal cancer remains controversial. This retrospective analysis was conducted to compare the postoperative outcome and survival of patients receiving simultaneous resection of liver metastases and primary colorectal cancer to those receiving staged resection. Materials and methods Between January 1988 and September 2005, 219 patients underwent liver resection for synchronous colorectal liver metastases, of whom, 40 patients received simultaneous resection of liver metastases and primary colorectal cancer, and 179 patients staged resections. Patients were identified from a prospective database, and records were retrospectively reviewed. Patient, tumor, and operative parameters were analyzed for their influence on postoperative morbidity and mortality as well as on long-term survival. Results Simultaneous liver resections tend to be performed for colon primaries rather than for rectal cancer (p = 0.004) and used less extensive liver resections (p < 0.001). The postoperative morbidity was comparable between both groups, whereas the mortality was significantly higher in patients with simultaneous liver resection (p = 0.012). The mortality after simultaneous liver resection (n = 4) occurred after major hepatectomies, and three of these four patients were 70 years of age or older. There was no significant difference in long-term survival after formally curative simultaneous and staged liver resection. Conclusion Simultaneous liver and colorectal resection is as efficient as staged resections in the treatment of patients with colorectal cancer and synchronous liver metastases. To perform simultaneous resections safely a careful patient selection is necessary. The most important criteria to select patients for simultaneous liver resection are age of the patient and extent of liver resection.     

Early complications after low anterior resection for rectal cancer using the EEATM stapling device

Complications following 178 low anterior resections for rectal carcinoma with the EEA autosuture device are reported prospectively. The operative mortality was 2.8 percent. Clinical anastomotic leakage developed in 27 patients, but in none of the 30 patients over 76 years of age. Two of the five hospital deaths were related to leakage. Long-term steroid treatment and previous pelvic radiotherapy were associated with increased risk of leakage. Severe stenosis following anastomotic leakage was seen in one patient. Intraoperative diverting colostomy was done in 16 patients, but no benefit could be demonstrated. It was concluded that use of the upper sigmoid colon for anastomosis probably is not associated with a higher mortality and morbidity than that after more extensive resections reported in the literature. Future randomized trials should exclude very old patients, in whom no leak was seen, when the upper sigmoid colon was used for stapling after low anterior resection. Supported by The Danish Cancer Society     

Self-expandable stent before elective surgery vs. emergency surgery for the treatment of malignant colorectal obstructions: comparison of primary anastomosis and morbidity rates

PURPOSE: At present there are not enough studies that demonstrate the usefulness of self-expandable stents in patients with left-sided malignant colon and rectal obstruction. We evaluated primary anastomosis and morbidity rates obtained with this method in comparison with the results of the emergency surgical treatment. METHODS: From February 1994 to November 1999, 72 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Forty-three patients were assigned to the study group (preoperative stent and elective surgical treatment or palliative stent, depending on the assessment of the stage of the tumor) and 29 to the control group (emergency surgical treatment). The resection was not indicated in 18 cases in the study group (after preoperative staging in 17 and intraoperative staging in 1) and in 3 cases in the control group. RESULTS: In the study group, the obstruction was relieved in 41 cases (95 percent) after the stent placement. Of 26 patients who underwent surgical treatment, a primary anastomosis was possible in 22 (84.6 vs. 41.4 percent in the control group, P = 0.0025), with lower need for a colostomy (15.4 vs. 58.6 percent in the control group). The anastomotic failure rate was similar and the reintervention rate was lower (0 vs. 17 percent, P = 0.014). The total stay (14.23 vs. 18.52 days; P = 0.047), the intensive care unit stay (0.3 vs. 2.9 days; P = 0.015), and the number of patients with severe complications (11.6 vs. 41.2 percent; P = 0.008) were significantly lower in the study group. CONCLUSIONS: In our patients with left-sided malignant colon and rectal obstruction, placement of a preoperative stent prevented 17 (94 percent) of 18 of unnecessary operations and a large number of colostomies after elective surgery. These results were obtained with a lower severe complication rate as well as a shorter hospital stay.     

Early experience of the compression anastomosis ring （CAR~（TM） 27） in left-sided colon resection

AIM: To evaluate clinical validity of the compression anastomosis ring (CAR™ 27) anastomosis in left-sided colonic resection.METHODS: A non-randomized prospective data collection was performed for patients undergoing an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27 between November 2009 and January 2011. Eligibility criteria of the use of the CAR™ 27 were anastomoses between the colon and at or above the intraperitoneal rectum. The primary short-term clinical endpoint, rate of anastomotic leakage, and other clinical outcomes, including intra- and postoperative complications, length of operation time and hospital stay, and the ring elimination time were evaluated.RESULTS: A total of 79 patients (male, 43; median age, 64 years) underwent an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27. Colectomy was performed laparoscopically in 70 patients, in whom two patients converted to open procedure (2.9%). There was no surgical mortality. As an intraoperative complication, total disruption of the anastomosis occurred by premature enforced tension on the proximal segment of the anastomosis in one patient. The ring was removed and another new CAR™ 27 anastomosis was constructed. One patient with sigmoid colon cancer showed postoperative anastomotic leakage after 6 d postoperatively and temporary diverting ileostomy was performed. Exact date of expulsion of the ring could not be recorded because most patients were not aware that the ring had been expelled. No patients manifested clinical symptoms of anastomotic stricture.CONCLUSION: Short-term evaluation of the CAR™ 27 anastomosis in elective left colectomy suggested it to be a safe and efficacious alternative to the standard hand-sewn or stapling technique.     

Safe resection for diverticular disease of the colon

A retrospective study of 83 patients undergoing surgery for diverticular disease over two years at a colorectal specialty hospital was undertaken to assess the safety of resection. No patient had free perforation. Eightynine percent of 46 patients with neither abscess nor fistula underwent resection and primary anastomosis, the remainder undergoing other resectional therapy; there was no mortality in this group. Of the 37 patients with abscesses, fistulas, or both, all had resections with or without primary anastomoses and one of these 37 patients died (2.7 percent mortality). In the entire series of 83 patients, the operative mortality was 1.2 percent, although 69 percent had morbidity. Resection can be performed safely for diverticulitis, and primary anastomosis can be safely added in uncomplicated and selected complicated cases.     

Outcomes for Abdominoperineal Resections Are Not Worse Than Those of Anterior Resections

Purpose Local recurrence and cure rates following abdominoperineal resections have been reported to be much worse than sphincter-preserving anterior resections. We compared the oncologic outcomes of patients treated by abdominoperineal resections with those following sphincter-preserving anterior resections. Methods The medical records of patients who underwent radical rectal resection for rectal carcinoma at the Colorectal Surgery Department, Singapore General Hospital, during the period from April 1989 to April 2002 were reviewed. A total of 791 cases were studied. Operative procedures were classified as either abdominoperineal resections or anterior resections with either straight or pouch anastomosis. Total mesorectal excision was routinely performed for carcinomas of the lower middle and lower third of the rectum. Sentinel events, including local and systemic recurrences or morbidity and mortality, were tracked prospectively. Results There were a total of 93 abdominoperineal resections (12.1 percent), 547 anterior resections with straight anastomoses (71 percent), and 130 anterior resections with pouch anastomoses (16.9 percent). Postoperative mortality was 2.6 percent and postoperative morbidity was 13.6 percent with an overall anastomotic leakage rate of 2.5 percent. The cumulative five-year local recurrence rate was 5.4 percent for abdominoperineal resections, 3.6 percent for anterior resections with straight anastomoses, and 3.8 percent for anterior resections with pouch anastomoses (P = 0.73 by log-rank test). The median time to local recurrence also did not differ significantly between the different procedures (abdominoperineal resections, 17 months, anterior resections with straight anastomoses, 18 months, anterior resections with pouch anastomoses, 13 months). Independent predictors for local recurrence included advanced tumor stage, tumor depth, and poorly differentiated tumors. The five-year cancer-specific survival was 70 percent. The type of anastomosis did not influence disease-free survival with median disease-free survival for patients who underwent abdominoperineal resections being 100 months, survival of anterior resections with straight anastomoses being 135 months, and survival of anterior resections with pouch anastomoses being 121 months (P = 0.33 by log-rank test). The independent factors for poor survival were age greater than 65 years, advanced tumor stage, tumor depth, and poorly differentiated tumors. Conclusion Both abdominoperineal resections and sphincter-preserving anterior resections can be performed safely with low morbidity and mortality in a specialized high-volume hospital unit without compromising oncologic outcomes. With appreciation of the anatomic relations in total mesorectal excision and standardized consistent surgical technique, the oncologic outcomes of patients treated by abdominoperineal resections are not worse than those treated by sphincter-preserving anterior resections. Reprints are not available.     

Anastomotic Leak and the Loop Ileostomy: Friend or Foe?

Purpose Anastomotic disruption is an uncommon but morbid complication of colon and rectal surgery. This study was designed to evaluate the use of proximal diversion and surgical drainage as an alternative to anastomotic resection in the operative management of patients with anastomotic complications. Methods A retrospective chart review was undertaken of all patients on the colon and rectal surgery service at an academic medical center requiring operative intervention for an anastomotic complication between 1998 and 2005. Demographic data, operative management, morbidity, and mortality were collected and analyzed for each patient. Results Twenty-seven patients with anastomotic leaks were included in the study. Nineteen patients were managed with proximal diversion and surgical drainage, six patients had resection of their anastomosis and creation of an end colostomy, and two patients were treated by primary reanastomosis. There was 0 percent mortality. Sixty-three percent of the patients treated with proximal diversion had restoration of intestinal continuity vs. 33 percent of the patients who had the anastomosis resected. Of the 13 patients treated with proximal diversion who underwent fluoroscopic evaluation, 92 percent were normal without evidence of persistent leak or stricture. Conclusions Based on this retrospective study, proximal diversion without resection of the anastomosis seems to be a safe and effective alternative for the treatment of anastomotic complications. Sepsis is well controlled with limited mortality and there is a high rate of anastomotic salvage. Prospective studies are needed to further delineate the optimal management for this complicated patient population. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.     

One-stage resection and anastomosis for acute obstruction of the left colon

PURPOSE: The purpose of this study was to analyze a single surgeon's experience with one-stage resection with primary anastomosis in acute obstruction of the left colon, emphasizing intraoperative decompression before the anastomosis. METHOD: From January 1986 to September 1996, 91 patients received one-stage resection with primary anastomosis for acute obstruction of the left colon. Eighty-five of these 91 patients were operated on for carcinoma of the colon and rectum. Subtotal colectomies were performed in 20 patients, left hemicolectomies in 21 patients, sigmoid colectomies in 34 patients, and anterior resections in 16 patients. The preoperative serum albumin level was less than 3 gm/dl in 17 patients (less than 2.5 gm/dl in 10 patients). Four patients had associated abscesses, and one patient had colonic perforation with peritonitis before operative colonoscopy. Neither antegrade nor retrograde irrigation was performed. RESULTS: Operative mortality rate was 2.2 percent. There were two cases (2.2 percent) of anastomotic leakages. Other common complications included wound infection (11 cases), urinary tract infection (5 cases), intestinal obstruction (6 cases), and respiratory failure (3 cases). CONCLUSION: This experience suggests that an anastomosis can be performed more safely in patients with acute obstruction of the left colon than in those with an anastomosis in the nondiverted colon. Neither intraoperative irrigation nor routine subtotal colectomy was found to be necessary. Anastomosis below the peritoneal reflection is also not a contraindication.     

Altered microperfusion at the rectal stump is predictive for rectal anastomotic leak

PURPOSE: The aim of this study was to evaluate the reliability of intraoperative laser-Doppler measurements in predicting the occurrence of anastomotic leak in patients with colorectal cancer undergoing stapled straight anastomosis to the rectum. METHODS: A prospective study was undertaken on 55 patients with rectal cancer or distal sigmoid cancer programmed for elective curative surgery. In all patients transmural colonic blood flow was measured by laser-Doppler flowmetry technique before bowel manipulation (baseline measurement) and after vascular ligation and division. Comorbidities at admission, intraoperative events, associated surgical procedures, and clinical outcome were tested for any association with anastomotic leak. RESULTS: Postoperative mortality was 1.8 percent (1/55 patients), and the overall morbidity was 21.3 percent. Anastomotic leak occurred in eight patients (14.5 percent). After colonic division a blood flow reduction at the rectal stump was observed in 42 patients (76.3 percent) as compared with baseline measurement. The mean rectal stump flow reduction was 6.2 percent in patients without anastomotic leak, whereas in patients who developed anastomosis breakdown it was 16 percent (P<0.001). Mean proximal stump flow reduction was 5.1 percent in the uncomplicated patients, whereas in patients who had an anastomosis breakdown it was 12.9 percent (P<0.01). A positive linear correlation was found between decrease in blood flow and rate of anastomotic leak. CONCLUSION: Blood flow reduction at the rectal stump is associated with an increased risk of anastomotic leak.Presented in part at the XVII Biennial Congress of the International Society of University Colon and Rectal Surgeons, Malmö, Sweden, June 7 to 11, 1998.     

Surgical treatment of left colon malignant emergencies. A new tool for operative risk evaluation

BACKGROUND/AIMS: The surgical treatment of left colon and rectal cancer emergencies is still controversial. In our opinion the choice is to be based on the general health status of each patient. METHODOLOGY: We retrospectively analyzed our series of 57 patients who underwent immediate resection and anastomosis. RESULTS: Factors significantly related to short-term results were chronic renal failure, heart disease, low albumin serum levels and colonic perforation. The presence of a diverting colostomy did not result in being a protective factor toward anastomotic dehiscence. We constructed a Colorectal Tumors Emergencies Score made of the identified four factors in which the score of each factor is the approximated odds ratio (chronic renal failure 7 points, low albumin serum levels 6 points, heart disease 5 points, colon perforation 4 points). Each patient was classified as Low Risk (CTES < 4), Moderate Risk (CTES 4-12) and High Risk (CTES > 12), mortality and morbidity being 4.3% and 21.7%, 24.0% and 60.0%, 88.9% and 88.9%, respectively. CONCLUSIONS: High-risk patients may undergo a staged procedure. Moderate risk patient may be treated by immediate resection of the tumor, without anastomosis. Immediate resection and anastomosis may be reserved to low-risk patients.     

Single-layer continuous colon and rectal anastomosis using monofilament absorbable suture (Maxon®)

PURPOSE: The study purpose was to evaluate the results of continuous, single-layer colon and rectal anastomoses using a monofilament absorbable suture material (Maxon®). METHODS: Four hundred ninety-two consecutive patients undergoing five hundred colon and rectal anastomoses with the above technique were evaluated for outcome, including anastomotic leakage, stricture, and other complications, by means of chart review. RESULTS: Three patients (0.6 percent) died after surgery and 7 (1.4 percent) developed clinical evidence of anastomotic leakage. Twenty-four percent developed some postoperative complications, most of which were minor. CONCLUSIONS: Continuous, single-layer colorectal anastomosis using monofilament absorbable suture can be performed safely, quickly, and with a favorable cost ratio. Handsewn anastomoses should still be part of the armamentarium of the well-trained surgeon.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Risk Factors for Anastomotic Leakage After Left-Sided Colorectal Resection With Rectal Anastomosis

PURPOSE: To identify the risk factors for anastomotic leakage after left-sided colorectal resections with rectal anastomosis. METHODS: Forty-four patients with anastomotic leakage identified from a computer-generated database were compared with 44 control patients standardized for gender, age, and operative indication. RESULTS: The mean hospital stay was significantly prolonged in the leakage group, which resulted in a higher total cost of hospital treatment. The preoperative variables significantly associated with anastomotic leakage included malnutrition, weight loss, hypoalbuminemia, cardiovascular disease, two or more underlying diseases, and use of alcohol. The surgery-related factors that turned out to be significant were The American Society of Anesthesiologists physical status, operation time greater than two hours, multiple blood transfusions, intraoperative contamination of the operative field, and a short distance of the anastomosis to the anal verge. Obesity, body mass index, diabetes, smoking, serum hemoglobin, serum creatinine, serum bilirubin, bowel preparation, mode of antibiotic prophylaxis, type of anastomosis, technique of stapling, size of stapler used, and use of drain were nonsignificant variables. Malnutrition, weight loss, use of alcohol, intraoperative contamination, long operation time, and multiple blood transfusions remained significant in logistic regression model. Eighty-six percent of the patients with three or more risk factors of anastomotic leakage belonged to the leakage group. CONCLUSIONS: Patients with multiple risk factors have higher risk for anastomotic leakage. When patients have three or more risk factors, the creation of a protective stoma should be considered in cases with a low rectal anastomosis, and all these patients should be carefully monitored postoperatively for signs of possible leak.     

Avoidance of anastomotic complications in low anterior resection of the rectum

PURPOSE: This retrospective study was designed to evaluate the efficacy of suction-irrigation drainage systems in reducing anastomotic complications. The current trend for lesions of the upper and middle rectum emphasizes maintaining an intact anal sphincter mechanism as long as limits of resection are not compromised. Removal of the rectosigmoid colon with an anastomosis below the peritoneal reflection accomplishes this goal but with appreciable morbidity and mortality, which is in great part related to subsequent anastomotic breakdown and resultant pelvic abscess and fecal fistula formation. The presence of collections of blood, serum, and cellular debris contribute significantly to anastomotic disruption by serving as a culture medium in which bacteria may thrive, leading to abscess formation with subsequent deleterious effects on the integrity of the adjacent low lying anastomosis. Many surgeons accepted this risk and routinely performed diverting colostomies to minimize the consequences of anastomotic disruption below the peritoneal reflection. The authors felt that if this risk could be sufficiently reduced, it would obviate the need for a protecting stoma. METHODS: From 1980 to 1988, 60 consecutive patients were subjected to anterior or low anterior resections in which a closed Shirley sump irrigation system was used to facilitate postoperative drainage of the pelvis and thus avoid hematoma formation. Since this original study group of 60 patients, another 100 consecutive patients have been entered into this study. This cohort group again consisted of patients with lesions of the upper, middle, and lower rectum who underwent anterior or low anterior resections of the rectum. RESULTS: Fifty-three of the original 60 patients did not have protecting stomas. Clinical leak rate for this series was 1.67 percent. Clinical leak rate for this updated series of 100 patients was 1 percent, with overall clinical leak rate of 1.25 percent in 160 consecutive patients. There were no deaths in the series, and overall morbidity was 7.5 percent. CONCLUSIONS: The authors felt that removing blood, serum, and cellular debris from the pelvis following resections of all or part of the rectum minimizes the risk of anastomotic disruption. With this routine, covering colostomies are no longer required for most patients undergoing anterior or low anterior resections of all or part of the mesorectum.     

An Algorithm for the Management of Sigmoid Colon Volvulus and the Safety of Primary Resection: Experience with 827 Cases

Purpose This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus. Methods The records of 827 patients were reviewed retrospectively. Results The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann’s procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent. Conclusions Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.     

Prospective, Randomized Trial Comparing Intraoperative Colonic Irrigation With Manual Decompression Only for Obstructed Left-Sided Colorectal Cancer

BACKGROUND This is a prospective, randomized, controlled trial comparing the outcome of intraoperative colonic irrigation with that of manual decompression for acutely obstructing colorectal cancers distal to the splenic flexure.METHODS All patients admitted to our department from June 1999 to August 2002 with obstructing left-sided colorectal cancers were recruited. Patients were randomized intraoperatively and were excluded if deemed unsuitable for segmental resection and primary anastomosis. Twenty-five patients were randomized to receive colonic irrigation and twenty-eight to receive manual decompression. Perioperative parameters and outcome including mortality and anastomotic leak were recorded.RESULTS Both groups of patients were comparable in terms of gender and age. The time taken for mobilization, decompression, and irrigation in the colonic irrigation group (median, 31 minutes) was significantly longer than that for the manual decompression group (median, 13 minutes) (P; = 0.0005). However, the total time of the operation was similar for both groups. Times for recovery of bowel function, of wound infection, and until discharge from the hospital were also similar. In the manual decompression group there were two cases of anastomotic leak (8 percent, 2/25) requiring reoperation but none (0/24) in the colonic irrigation group. However, this difference was not statistically significant.CONCLUSION Manual decompression of proximal colon without irrigation is as safe as colonic irrigation in one-stage surgical management of obstructing left-sided colorectal cancer.Published online: 28 January 2005.     

Results of reoperations in colorectal anastomotic strictures

PURPOSE: The incidence of colorectal anastomotic strictures varies from 3 to 30 percent. Most of these anastomotic strictures are simple narrowings shorter than 1 cm that can be successfully treated by dilation or endoscopic alternatives. However, up to 28 percent of patients will require surgical correction. This can be technically difficult, with the possibility of a permanent colostomy. This study reports the outcomes after operative treatment of severe strictures of colorectal anastomoses. METHODS: From August 1992 to October 1996, 27 patients were referred for surgical treatment of severe rectal anastomotic strictures. The reasons for the initial surgery were as follows: rectal cancer (13), diverticular disease (7), Hirschsprung's disease (2), rectal endometriosis (2), uterine carcinoma with rectal invasion (1), ruptured abdominal aortic aneurysm with rectosigmoid necrosis (1), and rectovaginal fistula (1). There were 15 (56 percent) stapled anastomoses, and 21 (78 percent) patients had developed a postoperative leak. RESULTS: The median time between initial surgery and diagnosis of the stenosis was 7.2 (range, 1–24) months and between the last operation and referral was 15.1 (range, 1–44) months. Stenosis was located at a mean distance of 9.5 (range, 4–15) cm from the anal verge. Eleven patients (41 percent) had been unsuccessfully dilated before referral. Surgical correction of the stenosis required 7 colorectal anastomoses for upper rectal anastomotic strictures and 20 coloanal anastomoses for middle and lower rectal strictures (19 Soave's procedures and 1 colon J-pouch-anal anastomosis). Intestinal continuity was restored in all cases. After a mean follow-up of 28.7±14 months, no recurrences were detected and functional results were satisfactory. CONCLUSIONS: Resection of the stenosis and construction of a new colorectal anastomosis can be performed successfully for upper rectal anastomotic stricture. For a stenosis located in the middle and lower rectum, Soave's procedure offers a good alternative, with satisfactory long-term functional results. Whichever technique is used, a permanent colostomy should rarely be required.Presented at the meeting of the European Council of Coloproctology, Edinburgh, Scotland, June 17 to 19, 1997     

Staged liver resection for colorectal metastases:a valuable strategy or a waste of time?

BACKGROUND:The use of staged liver resections for colorectal metastases has been increasing in recent times.The aim of this study was to determine the practices and outcomes of those surgeons attending the Australia and New Zealand Hepatic, Pancreatic and Biliary Association(ANZHPBA)meeting in 2008 who perform staged resections. METHODS:A questionnaire was sent to all members of the ANZHPBA and the international faculty who were invited to attend the annual meeting held in Coolum,Queensland, Australia in October 2008. RESULTS:There were 30 responses from 7 centres across the UK,Germany and Australia.Twenty-eight patients completed treatment.The study population was predominantly male (n=20,67%),with an average age of 59.4 years.All patients had bilobar disease.A right-sided first resection was planned in 39%of cases.Seventeen percent of patients underwent portal vein embolization prior to first resection.A second operation was performed at an average of 2.8 months from the first resection.Overall,50%(n=14)of patients eventually achieved a complete(R0)staged procedure.Twelve complications after the first resection were seen in 32%patients(n=9).Twenty- three patients underwent a second liver resection.Twenty-five complications after the second resection were present in 57% (n=13). CONCLUSIONS:Two-stage liver resections are beneficial if both stages are completed and an R0 resection is achieved. While there is increased morbidity and mortality,we believe that staged liver resection for colorectal metastases is a valuable strategy in selected cases.