Primaryvs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV)

PURPOSE: Our hypothesis was that in patients with perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV) a one-stage sigmoid colon resection is safe and cost effective when performed by an experienced colorectal surgeon. We evaluated outcome and cost of one-stagevs. two-stage sigmoid colon resection after diverticulitis perforation and peritonitis. METHODS: Patients undergoing emergency resection for perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV). Outcome, costs, and insurers reimbursement were compared between 13 patients undergoing sigmoid colon resection and primary anastomosis (Group A) and 42 patients undergoing sigmoid colon resection with Hartmann's procedure and secondary descendorectostomy (Group B). RESULTS: Group A patients were comparable to Group B patients in age, gender, preoperative risk and severity of peritonitis (Mannheim Peritonitis Index and C-reactive protein). Operating room time for sigmoid colon resection with primary anastomosis (3.3±1.2 hours) was identical to the time for sigmoid colon resection with colostomy (3.3±1 hour), and morbidity and mortality, intensive care unit, and in-hospital stay were not significantly different between the two groups. In Group B patients' intestinal continuity was restored 169±74 days after the primary resection in 32 of 42 patients only (78 percent). The second procedure took on average 1.4 hours longer than the first procedure. Patients in Group B received more antibiotics (2.2vs. 2) albeit for a shorter period of time (4.5vs. 5.7 days,P = not significant). Overall expenses for restoration of intestinal continuity were between 74 and 229 percent higher for Group B patients than for Group A patients. Reimbursement was 18,191±16,761 SFr (Group A) and 41,321±26,983 SFr (Group B) respectively. CONCLUSION: With meticulous surgical technique and extensive intraoperative lavage, perforated sigmoid colon diverticulitis with peritonitis can be treated by a one-stage sigmoid colon resection and anastomosis with a low mortality and morbidity. A one-stage procedure is considerably cheaper and patients are rehabilitated faster and to a higher percentage.Presented in part at the Mittelrheinischer Chirurgenkongress, Pforzheim, Germany, September 22 to 23, 2000.     

A comparison of emergency resection and staged management in perforated diverticular disease

This retrospective view examines the outcome of surgical treatment of perforated diverticular disease in one hospital in the period 1976 to 1983. Of the 78 patients, 38 underwent emergency colonic resection (group A) whereas 40 (group b) were treated by proximal colostomy and drainage (37 patients) or suture of the perforation with drainage (three patients). There was no significant difference between groups A and B in terms of operative mortality (21 percentvs. 24 percent, respectively). Mortality rates were highest in patients with generalized peritonitis treated by colostomy and drainage (36 percent), whereas those with localized disease undergoing resection had a mortality rate of 17 percent (P<.05). Eight of the 40 patients in group B developed fistulas whereas none of the group A patients had this complication. Only four (16 percent) of the surviving group A patients were left with a permanen colostomy as opposed to 15 (56 percent) of their counterparts in group B. In the presence of perforated diverticular disease, emergency resection carries a lower morbidity than colostomy and drainage, although the present review shows no statistically significant differences in terms of mortality.     

Complications and Survival After Surgery for Rectal Cancer in Patients Younger Than and Aged 75 Years or Older

PURPOSE: An increasing number of rectal cancer patients are elderly and have comorbid medical diseases. This study was designed to compare perioperative morbidity, mortality, and survival after surgery for rectal cancer in patients younger than and aged 75 years or older.METHODS: Between 1980 and 1997, 294 patients with rectal cancer were admitted to the Fourth Department of Surgery, Helsinki University Central Hospital. Of these, 95 (32 percent) were aged 75 or older and comprise the elderly group.RESULTS: Major curative operation was possible in 59 of 95 patients in the elderly group and in 147 of 199 patients in the younger age group. Among those operated on with curative intent, 20 of 59 patients (34 percent) in the older age group and 39 of 147 patients (27 percent) in the younger age group had complications (P = 0.31). Thirty-day mortality was 2 percent (n = 1) and 0, respectively. Although five-year crude survival was significantly lower in the older age group (43 vs. 65 percent, P = 0.01), five-year cancer-specific survival (60 vs.70 percent, P = 0.6) and disease-free, five-year survival (60 vs. 69 percent, P = 0.4) were similar in both groups. Patients (n = 17) treated with local excision had a cancer-specific survival of 81 and 83 percent in younger and older age groups, respectively. After palliative resection, the two-year survival was similar (20 vs. 24 percent) in both age groups. Ten elderly patients (11 percent) were not operated on at all in contrast to two patients (1 percent) younger than aged 75 years (P = 0.003).CONCLUSIONS: Major, curative, rectal cancer surgery in selected elderly patients can be performed with similar indications, perioperative morbidity, and mortality, as well as five-year, cancer-specific and disease-free survival as in younger patients.Presented at the meeting of the Finnish Surgical Society, Helsinki, Finland, December 20 to 22, 2002.Reprints are not available.     

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.     

Sigmoid volvulus in West Africa: A prospective study on surgical treatments

To evaluate the efficacy of different types of surgery, we performed a prospective, randomized trial in 31 consecutively hospitalized patients with sigmoid volvulus. These patients represented 8 percent of 377 cases of emergency surgery. At the time of surgery, the patients were divided into two groups according to the absence (Group A) or presence (Group B) of bowel gangrene. At random, each group was assigned two surgical treatments. Seventeen patients entered Group A and underwent mesosigmoidopexy (seven patients) or resection and primary anastomosis (10 patients). Fourteen patients entered Group B and underwent Hartmann's procedure (eight patients) or resection and primary anastomosis (six patients). Overall mortality was four patients among 31 (13 percent), with a significant prevalence in the group with gangrene (21.4 percent vs.5.8 percent). In Group A, the rate of success in patients treated with resection-anastomosis was higher than that in patients undergoing mesosigmoidopexy (90 percent vs.71.5 percent). In Group B, a meaningful difference was observed between the rate of success of patients undergoing Hartmann's procedure and that of those undergoing resection and primary anastomosis (87.5 percent vs.50 percent). The mortality rates were 12.5 percent and 33.3 percent, respectively. The results of our study show that the therapeutic approach to sigmoid volvulus should be diversified according to the absence or presence of gangrenous colon. The treatment of choice seems to be resection with primary anastomosis in patients with viable colon and Hartmann's procedure in patients with gangrenous colon.This study was supported by medical cooperation between Kamsar Hospital (Kamsar, Guinea) and Subiaco Hospital (Rome, Italy).     

Toward Lowering Morbidity,Mortality, and Stoma Formation in Emergency Colorectal Surgery: The Role of Specialization

INTRODUCTION: Surgical management of left-sided large bowel emergencies has been evolving toward single-staged procedures. Selection for single or staged resection remains the most controversial issue. METHODS: The results from a series of 336 emergency colorectal procedures performed between January 1990 and December 2000 for cancer and diverticular disease by two different surgical units in one hospital are reported: one with a specific interest in colorectal surgery, and one specialized in upper gastrointestinal surgery. RESULTS: A primary anastomosis was performed in 142 (64.3 percent) patients by colorectal surgeons and in 42 (36.5 percent) by noncolorectal surgeons (P < 0.0001). The overall morbidity and mortality rates were lower for colon and rectal surgeons (14.5 vs. 24.3 percent and 10.4 vs. 17.4 percent, respectively). Trainees were more likely to perform anastomoses when assisted by colorectal consultants (72.1 percent of cases) than when a noncolorectal consultant was present (47.5 percent of cases; P < 0.05). The 30-day mortality for patients with primary anastomosis was 6 percent, and anastomotic dehiscence occurred in nine (4.9 percent) patients. The mortality for patients undergoing staged resections (21.1 percent) was significantly higher than those who had primary resections performed (P < 0.001). CONCLUSIONS: Primary anastomosis for left-sided colorectal diseases can be performed with low morbidity and mortality in selected patients. Specialization increased anastomotic rates and reduced morbidity. This study suggests that colon and rectal surgeons should manage colorectal emergencies, and trainees should not be left unsupervised.     

Large Bowel Obstruction: Predictive Factors for Postoperative Mortality

PURPOSE The aims of this study were to assess the prognostic value for mortality of several factors in patients with colonic obstruction and to study the differences between proximal and distal obstruction.METHODS Two-hundred and thirty-four consecutive patients who underwent emergency surgery for colonic obstruction were studied. Patients with an obstructive lesion distal to the splenic flexure were assessed as having a distal colonic obstruction. Resection and primary anastomosis was the operation of choice in selected patients. Alternative procedures were Hartmanns procedure in high-risk patients, subtotal colectomy in cases of associated proximal colonic damage, and colostomy or intestinal bypass in the presence of irresectable lesions. Obstruction was considered proximal when the tumor was situated at the splenic flexure or proximally and a right or extended right colectomy was performed. A range of factors were investigated to estimate the probability of death: gender, age, American Society of Anesthesiologists score, nature of obstruction (benign vs. malign), location of the lesion (proximal vs. distal), associated proximal colonic damage and/or peritonitis, preoperative transfusion, preoperative renal failure, and laboratory data (hematocrit 30 percent, hemoglobin 10 g/dl, and leukocyte count >15,000/mm³). Univariate and multivariate forward steptwise logistic regression analysis was used to study the prognostic value of each significant variable in terms of mortality.RESULTS One or more complications were detected in 109 patients (46.5 percent). Death occurred in 44 patients (18.8 percent). No differences were observed between proximal and distal obstruction. Age (>70 years), American Society of Anesthesiologists III–IV score, preoperative renal failure, and the presence of proximal colon damage with or without peritonitis were significantly associated with postoperative mortality in the univariate analysis. Only American Society of Anesthesiologists score, presence of proximal colon damage, and preoperative renal failure were significant predictors of outcome in multivariate logistic regression.CONCLUSION Large bowel obstruction still has a high of mortality rate. An accurate preoperative evaluation of severity factors might allow stratification of patients in terms of their mortality risk and help in the decision-making process for treatment. Such an evaluation would also enable better comparison between studies performed by different authors. Principles and stratification similar to those of distal lesions should be considered in patients with proximal colonic obstruction.Reprints are not available.     

Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years

Background

Sigmoid volvulus describes the wrapping of the sigmoid colon around itself and its mesentery, causing an intestinal obstruction. The aim of this study was to assess the outcomes of 952 patients treated for sigmoid volvulus over a period of 46.5 years.

Methods

Clinical records were reviewed retrospectively.

Results

Nonsurgical detorsion was performed in 686 patients with 77.1 % success, 2.5 % morbidity, 0.7 % mortality, and 4.5 % early recurrence rates; emergency surgical procedures were performed in 447 patients with 35.3 % morbidity, 16.1 % mortality, 0.7 % early recurrence, and 7.4 % late recurrence rates, while elective surgical treatment was performed in 104 patients with 12.5 % morbidity, no mortality, and no recurrence.

Conclusions

The principal strategy in the treatment for sigmoid volvulus is early nonsurgical detorsion followed by elective surgery in uncomplicated patients, while emergency surgical treatment is performed for patients with bowel gangrene, perforation, or peritonitis, other difficulties with diagnosis, unsuccessful nonsurgical detorsion, and early recurrence.     

Outcomes after medical and surgical treatment of diverticulitis: a systematic review of the available evidence

There is still controversy regarding the appropriate management of diverticulitis of the colon in cases when both surgical and conservative treatment may be an option. We performed a systematic review of the available evidence regarding the outcomes after medical and surgical treatment of diverticulitis from studies published after 1980 and indexed in the PubMed database. We included original studies that reported comparative data for at least one outcome in medically- and surgically-treated patients with transverse or left colon diverticulitis. The main outcomes of interest were mortality, morbidity, and recurrence of diverticulitis after medical or surgical treatment. There were 21 studies fulfilling our inclusion criteria out of 1360 initially identified as possibly relevant. More patients were treated conservatively in the included studies compared to emergency surgery (24 862 vs 6504). Emergency surgery was the main option for patients with severe complications of diverticular disease, including peritonitis. In most studies, in-hospital mortality for patients treated surgically was generally higher than that of patients treated medically, whereas there were insufficient comparative data regarding mortality during follow up. However, readmission to the hospital due to diverticular disease during follow up was more common in the group of patients treated conservatively compared to those treated surgically (4358/23 446 [18.6%]vs 22/359 [6.1%]). Conservatively-treated patients, with a first or second episode of diverticulitis, required surgery for recurrent disease during follow up in a maximum of 45% of cases, with larger studies reporting percentages lower than 11%. It should be emphasized that medical and surgical treatments have not ever been compared in a randomized controlled trial in patients with diverticulitis (without generalized peritonitis that is a surgical emergency). Although medical treatment results in more readmissions due to recurrence, it may be reasonable to avoid surgical therapy in the vast majority of patients with acute diverticulitis. It is unclear what the best treatment option is for younger patients (<50 years), namely whether elective surgery should be considered with the first episode of diverticulitis.     

Primary vs. secondary anastomosis after sigmoid colon resection for perforated diverticulitis (Hinchey Stage III and IV): a prospective outcome and cost analysis

PURPOSE: Our hypothesis was that in patients with perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV) a one-stage sigmoid colon resection is safe and cost effective when performed by an experienced colorectal surgeon. We evaluated outcome and cost of one-stage vs. two-stage sigmoid colon resection after diverticulitis perforation and peritonitis. METHODS: Patients undergoing emergency resection for perforated sigmoid colon diverticulitis and peritonitis (Hinchey Stage III and IV). Outcome, costs, and insurers reimbursement were compared between 13 patients undergoing sigmoid colon resection and primary anastomosis (Group A) and 42 patients undergoing sigmoid colon resection with Hartmann's procedure and secondary descendorectostomy (Group B). RESULTS: Group A patients were comparable to Group B patients in age, gender, preoperative risk and severity of peritonitis (Mannheim Peritonitis Index and C-reactive protein). Operating room time for sigmoid colon resection with primary anastomosis (3.3 +/- 1.2 hours) was identical to the time for sigmoid colon resection with colostomy (3.3 +/- 1 hour), and morbidity and mortality, intensive care unit, and in-hospital stay were not significantly different between the two groups. In Group B patients' intestinal continuity was restored 169 +/- 74 days after the primary resection in 32 of 42 patients only (78 percent). The second procedure took on average 1.4 hours longer than the first procedure. Patients in Group B received more antibiotics (2.2 vs. 2) albeit for a shorter period of time (4.5 vs. 5.7 days, P = not significant). Overall expenses for restoration of intestinal continuity were between 74 and 229 percent higher for Group B patients than for Group A patients. Reimbursement was 18,191 +/- 16,761 SFr (Group A) and 41,321 +/- 26,983 SFr (Group B) respectively. CONCLUSION: With meticulous surgical technique and extensive intraoperative lavage, perforated sigmoid colon diverticulitis with peritonitis can be treated by a one-stage sigmoid colon resection and anastomosis with a low mortality and morbidity. A one-stage procedure is considerably cheaper and patients are rehabilitated faster and to a higher percentage.     

Postoperative morbidity and mortality following resection of the colon and rectum for cancer

PURPOSE: The aim of this study was to report the prevalence of postoperative complications and mortality of patients with colorectal cancer when treated by conventional surgery. METHODS: Morbidity and mortality following open resection for colorectal cancer were analyzed in 1,846 patients whose clinical, operative, and pathology data were prospectively documented over a 20-year period. RESULTS: Mortality following elective resection of the left and right colon was low, whereas overall morbidity was high (37.2 percent). Respiratory and cardiac complications were especially common. Incidence of clinically significant leakage was similar following right (0.5 percent) or left (1.1 percent) hemicolectomy. Incidence of anastomotic leakage was significantly higher after emergency right hemicolectomy (4.3 percent). Overall morbidity following excision of the rectum was high (40.2 percent). Respiratory and cardiac complications predominated. Incidence of clinically significant anastomotic leakage following anterior resection was low (2.9 percent). Over the years, there has been a decline in the number of patients with tumor demonstrated histologically in a line of resection, suggesting an improved local surgical clearance. CONCLUSIONS: These results following conventional surgery may be useful when evaluating new techniques.     

Resection enterostomy versus Hartmann’s procedure for emergency colonic resections

Background

If a primary anastomosis is considered too risky after emergency colon resection either a resection enterostomy or an end stoma with closure of the distal bowel (Hartmann’s procedure) is possible. This study analyzes the rate of restoration of intestinal continuity and other surgical outcomes after resection enterostomy placement versus Hartmann’s procedure for emergency colon resections.

Methods

All patients who underwent emergency colorectal resections between August 2009 and June 2014 at the University Medical Center Mannheim were reviewed in regard to therapeutic approach, rate of restoration of bowel continuity, and surgical morbidity after the primary operation and after reversal surgery.

Results

Fifty-five patients in whom both studied interventions would have been technically feasible were further analyzed. The rate of revisional surgery was significantly higher in the resection enterostomy cohort after the primary operation. There were no significant differences regarding morbidity, mortality, and the rate of restoration of intestinal continuity. Overall, bowel continuity could be restored in 63% (29/46) of the surviving patients. The median time of surgery of the initial as well as of the reversal surgery was significantly longer in the Hartmann’s group. Five of 13 patients underwent protective ileostomy placement in the Hartmann’s group at the time of the reversal (vs. none in the resection enterostomy group).

Conclusions

The bowel continuity can be restored in the majority of patients after emergency colonic resection. Conclusive evidence which surgical option should be preferred when a primary anastomosis is considered too risky—Hartmann’s procedure or resection enterostomy—is still lacking.

     

Surgical management of isolated retroperitoneal recurrences of colorectal carcinoma

PURPOSE: Isolated locoregional disease accounts for approximately 20 percent of recurrences after treatment for colorectal cancer. It has been suggested that complete resection of these recurrences can result in increased survival. The value of surgery for isolated retroperitoneal recurrences has not been well defined. We have sought to characterize outcome and survival in patients undergoing resection for isolated retroperitoneal recurrences of colorectal cancer. METHODS: From a prospective database, 25 patients were identified as having undergone surgical exploration with curative intent for isolated retroperitoneal recurrences of colorectal cancer between 1988 and 1999. Variables studied included age, gender, location and size of the tumor, extent of resection, disease-free interval, and morbidity and mortality. Statistical analyses were performed using the log-rank test and Kaplan-Meier estimates, with overall survival as the primary end point. RESULTS: The study population consisted of 25 patients (13 males), with a median age of 55 years and a median follow-up of 29 (range, 1–151) months. The median time to first retroperitoneal recurrence was 23 (range, 3–72) months. Twenty patients underwent resection, whereas five patients were deemed unresectable at the time of operation. The median survival in patients who underwent resection patients was 31 months compared with 3 months in those patients who did not undergo resection (P = 0.0001). Analysis of the entire group demonstrated a disease-free interval of greater than 24 months to be a positive predictor of outcome (median survival, 30 vs. 48 months; P = 0.02). For patients undergoing resection, the presence of positive margins (P = 0.01) and tumor size 5 cm (P = 0.008) predicted a worse prognosis. In patients who underwent resection, the two-year and five-year overall survival rates were 60 and 15 percent, respectively. CONCLUSIONS: Patients with isolated retroperitoneal recurrences of colorectal cancer generally have a poor prognosis. However, a longer disease-free interval, complete negative-margin resection, and smaller tumor size are associated with long-term survival in selected patients.     

Operative mortality rates among surgeons

PURPOSE: The original Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and the more recent Portsmouth predictor equation for mortality scoring systems were developed to provide risk-adjusted mortality rates in general surgery. The aim of this study was to compare crude and risk-adjusted operative mortality rates among four surgeons using the above scoring systems and assess their applicability for patients scored retrospectively. METHODS: A total of 505 consecutive patients undergoing major gastrointestinal surgery were analyzed; 65 percent underwent colorectal, 27.5 percent underwent upper gastrointestinal, and 7.5 percent underwent small-bowel surgery. The observed:predicted mortality ratios using the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity and Portsmouth predictor equation for mortality scoring systems were calculated for each surgeon. RESULTS: The actual overall operative mortality rate was 11.1 percent (elective was 3.9 percent, and emergency was 25.1 percent). The Portsmouth predictor equation for mortality equation predicted a mortality rate of 11.3 percent (P=0.51). However, the Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity scoring system was found to overpredict death by a factor of two: 21.5 percent (P<0.001). Mortality rates among the four surgeons varied from 7.6 to 14.7 percent but depended on the proportion of electivevs. emergency surgery. The observed:predicted ratio for Portsmouth predictor equation for mortality was close to unity (0.905–1.067) for all surgeons, but it was 0.45 to 0.56 for Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. CONCLUSION: The Portsmouth predictor equation for mortality equation seems to be a more accurate predictor of mortality in gastrointestinal surgery. It would seem to provide the best choice for analyzing operative mortality rates for individual surgeons, taking into account variation in case mix and fitness of patients even when scored retrospectively. This has important implications for the future assessment of surgeons' clinical standards and the assessment of quality of surgical care.Supported by the Department of Clinical Audit, Maidstone Hospital, Kent, United Kingdom.Presented at the Association of Coloproctologists of Great Britain and Ireland Annual Scientific Meeting, Southport, United Kingdom, June 9 to 11, 1999. Published in abstract form inColorectal Disease 1999;1(Suppl 1):7.     

En bloc resection of colon carcinoma adherent to other organs: An efficacious treatment?

From 1977 to 1984, 56 patients with colon cancer adherent to other organs were operated upon. Twenty-three (41 percent) underwent palliative treatment without resection. The mean survival in this group was 6 months. The results of en bloc resection were evaluated in 33 patients (59 percent) with colon carcinoma and tumor growth in adjacent organs. Pathologic staging was based on Dukes' (Astler and Coller) classification. Dukes' B carcinoma was shown in 15 patients. Dukes' C in 14 patients, and Dukes' D in four patients. The 4-year survival rate was as follows: Dukes' B, 47 percent; Dukes' C, 29 percent; and Dukes' D, 0 percent. The 4-year survival rate for the whole group was 33 percent. The postoperative morbidity and mortality were 6 percent and 3 percent, respectively. Colon cancer with involvement of adjacent structures should not be regarded as an incurable Dukes' D carcinoma; en bloc resection is indicated and can be performed with acceptable morbidity and mortality.     

Sigmoid volvulus in Department of Veterans Affairs Medical Centers

PURPOSE: Sigmoid volvulus is the third leading cause of large-bowel obstruction. The optimal management strategy remains controversial. This study was undertaken to evaluate the care of patients with sigmoid volvulus recently treated at Department of Veterans Affairs hospitals. METHODS: All patients with the International Classification of Diseases, Ninth Revision, Clinical Modification, Third Edition code for colonic volvulus during the period 1991 to 1995 were identified in the computerized national Department of Veterans Affairs database. Data on patient demographics, clinical course, and outcomes were analyzed. RESULTS: Two hundred twenty-eight patients had volvulus of the sigmoid colon and sufficient clinical data for evaluation. The mean age was 70; all were males. Endoscopic decompression was attempted in 189 of 228 (83 percent) patients and was successful in 154 of 189 (81 percent). Management included celiotomy in 178 of 228 (78 percent) patients. There were no intraoperative deaths. Twenty-five of 178 (14 percent) patients died within 30 days of surgery. The mortality rate was 24 percent for emergency operations (19/79), and 6 percent for elective procedures (6/99). Mortality was correlated with emergent surgery (P<0.01) and necrotic colon (P<0.05). Among those 50 patients managed by decompression alone, six (12 percent) died during the index admission. Ten of the remaining 44 (23 percent) patients eventually developed recurrent volvulus requiring further treatment, and 2 of 10 (20 percent) patients died. CONCLUSIONS: In this cohort sigmoid volvulus often presents as a surgical emergency. Initial endoscopic decompression resolves the acute obstruction in the majority of cases. Surgical intervention carries a substantial risk of mortality, particularly in the setting of emergent surgery or in the presence of necrotic colon.     

Colorectal Surgery in Cirrhotic Patients: Assessment of Operative Morbidity and Mortality

Purpose  The morbidity from colorectal surgery can be high and increases for patients with cirrhosis of the liver. This study was designed to assess morbidity, mortality, and prognostic factors for patients with cirrhosis undergoing colorectal surgery. Methods  From 1993 to 2006, 41 cirrhotic patients underwent 43 colorectal procedures and were included. Both univariate and multivariate analyses were performed to identify variables influencing morbidity and mortality. Results  Postoperative morbidity was 77 percent (33/43). Postoperative mortality was 26 percent (11/43) among whom six patients (54 percent) underwent emergency surgery. Four factors influenced mortality on univariate analysis: presence of peritonitis (P < 0.05), postoperative complications (P < 0.04), postoperative infections (P < 0.01), and total colectomy procedures (P < 0.02). On multivariate analysis, the only factor influencing mortality was postoperative infection (P < 0.04). The only factor influencing morbidity was the existence of preoperative ascites (P < 0.04). Conclusions  Colorectal surgery for cirrhotic patients has a high risk of morbidity and mortality. This risk is associated with the presence of infection, ascitic decompensation, and the urgent or extensive nature of the procedure. The optimization of patients through selection and preparation reduces operative risk.     

Colorectal cancer in patients over 80 years of age

Between January 1, 1973, and December 31, 1986, 1,734 patients underwent colorectal resections for carcinoma. Patients were divided into two groups: Group I included 163 patients aged 80 years on first presentation; Group II comprised 1,571 patients aged <80 years. The total perioperative mortality rates for the elderly and young group were 15.3 percent and 5 percent, respectively (P <0.001). The surgical mortality rates after elective operations in Groups I and II were 7.4 and 4.5 percent, respectively, and were not statistically different. Emergency surgery was associated with a significantly higher incidence of perioperative deaths at any age (P <0.001). In the elderly group, most deaths (88 percent) resulted from complications of coexisting medical disorders or thromboembolic complications. The 5-year survival for the young and elderly group were 46.2 percent and 35 percent, respectively (P <0.05). However, excluding patients dying from nonmalignant disease, the 5-year survival rate did not differ significantly between the two groups of patients (49.5 percent vs. 41.2 percent).     

Emergency subtotal/total colectomy with anastomosis for acutely obstructed carcinoma of the left colon

PURPOSE: The operation of choice for acutely obstructed carcinoma of the left colon is controversial. The aim of the study was to evaluate the results of its management by emergency subtotal/total colectomy with immediate anastomosis without diversion. METHODS: An emergency subtotal/total colectomy was performed in 44 patients (mean age, 72.4 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS: Postoperative mortality was 6.8 percent. Two patients over 90 years of age died postoperatively as a result of cardiopulmunary complications. An 83-year-old female died as a result of an anastomotic dehiscence. Morbidity was 6.8 percent including one fistula which recovered without surgery. There were three synchronous colon cancers. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION: Emergency subtotal colectomy achieves in one stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serosal tears on the cecum, ensures restoration of gut contiguity via a “safe” ileocolonic anastomosis, and removes occasional lesions proximal to the index cancer. It is a safe procedure given that operative mortality rates are as low as with elective surgery.     

Primary Resection With Anastomosis vs. Hartmann’s Procedure in Nonelective Surgery for Acute Colonic Diverticulitis: A Systematic Review

Purpose This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. Methods Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. Results Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. Conclusions Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.