Stercoral perforation of the colon. Concepts of operative management

Stercoral perforation of the colon is a direct result of ischemic pressure necrosis by a stercoraceous mass. In over 90 per cent of cases, the perforation will involve either the sigmoid or rectosigmoid colon and is consistently centrally located within a region of mucosal ulceration of varying diameter and magnitude. A review of 33 surgically treated cases from the literature along with four cases presented here, support resection, end colostomy, and either mucous fistula or Hartmann's procedure as the operation of choice with the lowest operative mortality (23%) when compared to those patients treated by either loop colostomy or exteriorization (71%) or proximal colostomy with plication of the perforation (44%). Irrigation of the distal rectal segment as that for penetrating rectal injury is also recommended.     

Colon perforation after kidney transplantation.

Between 1962 and 1977 approximately 2% of Denver kidney transplant patients developed colon perforation. The single commonest cause was diverticulitis of the left colon (6/13 cases). In spite of drastic reduction or discontinuation of immunosuppression, only 5/13 patients survived for more than 90 days after operation. Analysis of this experience suggests that the high mortality rate associated with this complication can be reduced by early operation which removes the perforation from the peritoneal cavity (either exteriorization or resection) without primary intestinal reanastomosis. We believe that candidates for kidney transplantation with a history of previously symptomatic diverticulosis coli should have elective colon resection prior to transplantation. Any kidney transplant patient with lower abdominal signs should be investigated and treated aggressively.     

Bile peritonitis in acute cholecystitis

A review of all patients treated for acute cholecystitis (n = 5848) during an 18-year period (1969-1986) at two hospitals (one practising early surgery in patients with acute cholecystitis and the other not) disclosed that 104 (1.8%) had bile within the abdominal cavity at surgery; 71 with a visible perforation of the gallbladder and 33 without. The bile was infected in 82% of performed cultures (most commonly with Escherichia coli). Mortality was 7.7% (8/104 patients), being 20% (4/20) in the hospital practising delayed surgery and 5% (4/84) in the hospital practising early surgery (p less than 0.10). Infectious complications were responsible for the deaths by leading to multiple organ failure with pulmonary or renal insufficiency or gastro-intestinal bleeding. The timing of surgery was the only factor that had prognostic significance, i.e. the longer the hospital delay before surgery the higher the mortality, although elderly patients or patients with perforation tended to have a worse prognosis. In conclusion, the results of this study indicated that early surgery is important in patients with acute cholecystitis as a means of lowering mortality in bile peritonitis in this condition.     

Typhoid perforation of the bowel. Experiences in 78 cases.

Seventy-eight patients ranging from four to 65 years of age were treated for typhoid perforation of the bowel. Sixty-one patients (78%) were males. The average time from perforation to admission was 56 hours. The mortality rate was 32% and was adversely influenced by the duration of illness, duration of perforation, shock, uremia, encephalopathy and fecal peritonitis. Forty-nine patients were treated by closure of the perforation, resection or miscellaneous procedures; the other 29 by closure of the perforation combined with an end-to-end ileotransverse colostomy. Although mortality was the same in both groups, those undergoing bypass had a significantly smoother postoperative course.     

Spectrum of Perforation Peritonitis in Delhi: 77 Cases Experience

Perforation peritonitis is the most common surgical emergency encountered by surgeons all over the world as well in India. The spectrum of etiology of perforation peritonitis in tropical countries continues to differ from its western counterpart. This study was conducted at Hindu Rao Hospital, Municipal Corporation of Delhi, New Delhi, India, designed to highlight the spectrum of perforation peritonitis in the eastern countries and to improve its outcome. This prospective study included 77 consecutive patients of perforation peritonitis studied in terms of clinical presentations, causes, site of perforation, surgical treatment, postoperative complications, and mortality at Hindu Rao Hospital, Delhi, from March 1, 2011 to December 1, 2011, over a period of 8 months. All patients were resuscitated and underwent emergency exploratory laparotomy. On laparotomy cause of perforation peritonitis was found and controlled. The most common cause of perforation peritonitis noticed in our series was perforated duodenal ulcer (26.4 %) and ileal typhoid perforation (26.4 %), each followed by small bowel tuberculosis (10.3 %) and stomach perforation (9.2 %), perforation due to acute appendicitis (5 %). The highest number of perforations was seen in ileum (39.1 %), duodenum (26.4 %), stomach (11.5 %), appendix (3.5 %), jejunum (4.6 %), and colon (3.5 %). Overall mortality was 13 %. The spectrum of perforation peritonitis in India continuously differs from western countries. The highest number of perforations was noticed in the upper part of the gastrointestinal tract as compared to the western countries where the perforations seen mostly in the distal part. The most common cause of perforation peritonitis was perforated duodenal ulcer and small bowel typhoid perforation followed by typhoid perforation. Large bowel perforations and malignant perforations were least common in our setup.     

The management of colon injuries.

Surgical management of colon injuries was assessed in 97 patients. Injuries comprised stab wounds (88 cases), blunt trauma (5 cases), and gunshot wounds (4 cases). Injury involved the right colon in 52,6% and the left colon in 47,4% of patients. Fifty-eight per cent had associated major visceral injury. Patients were divided into two categories; those in whom proximal colostomy or exteriorisation of the perforation was performed constituted the one group, and those who had primary closure, the other. Analysis of results were made with regard to the incidence of wound infection, intra-abdominal abscess formation, peritonitis, and other postoperative complications. Seventeen patients had exteriorisation of the colon performed. Colostomy and colostomy closure had a significant morbidity rate, with a mean total period of hospitalisation of 58,5 days. Eighty patients were treated by primary closure. Septic complications occurred in 36,7% of cases. An analysis of the factors influencing mortality and morbidity was made, with reference to the side of the colon involved, the time interval between injury and surgery, faecal contamination of the peritoneal cavity, associated visceral injury and the presence of more than one colonic perforation. Increased morbidity was noted when the operative delay exceeded 6 hours and when faecal contamination of the peritoneal cavity was marked. Primary closure of a lacerated colon is safe provided that careful consideration is given to the above factors.     

Short-and long-term outcomes of surgery for diffuse peritonitis in patients 80 years of age and older

Purpose We evaluated the impact of advanced age on the morbidity, mortality, and long-term outcome after emergency surgery for diffuse peritonitis. Methods We retrospectively evaluated the mortality and morbidity rates in 36 patients who were 80 years of age or older and who had undergone emergency surgery for diffuse peritonitis, and calculated 5-year survival by the Kaplan-Meier method. Factors compromising prognosis were identified by univariate and multivariate analyses. Results The median patient age was 84 years (range, 80–97 years); 16 patients were men and 20 were women. Preoperative concomitant disease was present in 81% of patients; cardiac disease was most common. Sites of visceral perforation were in the upper gastrointestinal tract in five patients, colon or rectum in 30, and gallbladder in 1. The postoperative morbidity rate was 72%, the surgical mortality rate was 11%, and the in-hospital mortality rate was 28%. The median hospital stay was 56 days. The median survival was 41 months, with a 5-year survival rate of 23%. A multivariate analysis identified number of failing organs as the only independent adverse prognostic factor (P < 0.001; relative risk 5.51, 95% confidence interval 1.97–15.4). Conclusions Elderly patients with diffuse peritonitis had an unsatisfactory rate of short-term morbidity and mortality compared with those undergoing elective surgery. Postoperative organ failure was most likely to compromise survival.     

Longitudinal outcomes of intra-abdominal infection complicated by critical illness

BACKGROUND: Critically ill surgical patients remain at high risk of adverse outcomes as a result of intra-abdominal infections, including prolonged length of stay, organ dysfunction, and death despite advances in critical care and innovations in management of the peritoneal cavity. We evaluated the causes and consequences of intra-abdominal infections among critically ill surgical patients in a single tertiary-care intensive care unit (ICU) over a decade. METHODS: Prospective study of 465 critically ill surgical patients with hollow viscus perforation and peritonitis or abscess from 1991-2002. Data collected were age, gender, admission APACHE III score, multiple organ dysfunction score, ICU and hospital length of stay, abscess (yes/no), site and type of perforation (colon vs. other), de novo vs. nosocomial origin, and mortality. Statistical analysis was by univariate ANOVA for coordinate data, Fisher exact test for continuous data, and logistic regression analysis. RESULTS: The incidence of intra-abdominal infection was 5.75%, 73.7% of the patients developed organ dysfunction, and mortality was 22.6%. Females comprised 46.8% of the patients. De novo infection represented 71.8% of cases, whereas nosocomial infection comprised 28.2% of cases. Perforations were of the colon (including the appendix) 49.9% of the time. An abscess formed in 22.3% of patients; the remainder had peritonitis but no abscess. Patients in the cohort with peritonitis were older (p = 0.0157), sicker on admission (p = 0.0411) and developed more organ dysfunction (p = 0.0072), but had the same rate of mortality. Despite steadily increasing acuity since 1991 (r(2) = .71, p < 0.0001), the magnitude of organ dysfunction (r(2) = 0.11) and the mortality rate remained constant (r(2) = .01). By logistic regression, abscess correlated with less severe organ dysfunction (score > or = 5 [odds ratio 0.54, 95% CI 0.33-0.90] and > or =9 points [odds ratio 0.38, 95% CI 0.20-0.74]), and increasing magnitude of organ dysfunction was associated with mortality (each point [odds ratio 1.46, 95% CI 1.32-1.61]). CONCLUSIONS: Although outcomes are improving, generalized peritonitis still causes high organ dysfunction-related mortality among critically ill surgical patients. Further improvements in resuscitation, surgical technique, and pharmacotherapy of severe intra-abdominal infections are needed.     

Causes and treatment outcome of perforation peritonitis in north eastern Nigeria

Background: Intestinal perforations cause generalized peritonitis and overwhelming sepsis resulting in high morbidity and mortality. The purpose of the present study was to review the causes and treatment outcome of non-traumatic perforation peritonitis in a government referral hospital in north-eastern Nigeria. Patients and Methods: In a retrospective study, the clinical records of 153 patients with intraoperative diagnosis of non-traumatic perforation associated peritonitis managed in the Federal Medical Centre, Azare, Nigeria between June 2004 and May 2009 were reviewed. Results: One hundred and fifty-three patients, comprising 112 males (73.2%) and 41 females were operated for perforation peritonitis, including 31 (20.3%) children. The mean age was 21.88 years ± 14.51 (range 4–70). The mean time lapse between onset of symptoms and presentation to hospital was 5.4 ± 3.7 days (range 0.75–21). Forty-eight (31.4%) of the patients were operated within 24 h of presentation and 105 (68.3%) after 24 h. The main symptoms were abdominal pain in 150 (98.9%), fever in 108 (70.6%), and abdominal distention in 108 (70.6%). The main causes of perforation peritonitis were typhoid ileal perforation in 98 (64.0%), perforated peptic ulcer in 25 (16.3%) and perforated appendix in 22. Tuberculous ileal perforation was seen in one (0.6%) patient. Wound infection 39 (25.5%) and wound dehiscence 15 (9.8%), were the most common postoperative complications. Enterocutaneous fistula was seen in 21 (13.7%) of the patients and was associated with mortality in nine (42.8%) patients. The overall mortality rate was 26.1%, mainly from overwhelming sepsis and severe electrolyte derangement. Conclusion: The outcome of perforation peritonitis depended on the underlying cause, the duration of symptoms before treatment, and the general health of the patient. Typhoid ileal perforation is the most common cause of perforation peritonitis in our environment.     

Outcome after emergency surgery for cancer of the large intestine

The data for 77 patients with colorectal cancer who underwent emergency surgery for acute intestinal obstruction (57 patients) or perforation (20 patients) within 24 h of admission were evaluated. The patients were older and had more advanced disease than patients undergoing elective surgery for colorectal cancer. Emergency surgery for carcinoma of the right colon consisted of primary resection in 95 per cent of cases and was followed by a 28 per cent mortality rate. Perforated tumours of the left colon and rectum were managed by primary resection in 82 per cent of cases with a 22 per cent mortality rate. In contrast, obstructing tumours of the left colon and rectum were treated by primary resection in 38 per cent of cases with a 6 per cent mortality rate, and by primary decompression in 62 per cent of cases with a 25 per cent mortality rate. The overall postoperative mortality rate was 23 per cent and increased with advanced tumour disease, perforation and peritonitis. Cardiac decompensation and intraabdominal sepsis were the major causes of death. Although the long-term survival rate following emergency surgery was worse than after elective surgery, improvements in outcome should be achieved by better management of the initial emergency situation.     

The outcome of surgery in fulminant Clostridium difficile colitis

BACKGROUND: The clinical presentation of Clostridium difficile infection ranges from asymptomatic carriage, colitis with or without pseudomembranes, to fulminant colitis. Although not common, fulminant C. difficile colitis can result in bowel perforation and peritonitis with a high mortality rate. Colectomy is often indicated in these cases. METHODS: We retrospectively analysed the outcome of 14 patients who underwent surgery for fulminant C. difficile colitis in the period 1996-2003 in our Unit. RESULTS: The indications for surgery were systemic toxicity and peritonitis (n = 10), radiological and clinical evidence of progressive toxic colonic dilatation (n = 3) and progressive colonic dilatation with bowel perforation (n = 1). C. difficile infection as the cause of colitis was diagnosed pre-operatively in seven (50%) patients, six of whom underwent a total colectomy and one a right hemicolectomy. Overall mortality in our series was 35.7%. Total colectomy was associated with a lower mortality rate of 11.1% (1/9) when compared with left hemicolectomy was 100% (4/4) (P = 0.01). One patient who underwent a right hemicolectomy (on the basis of deceptively normal external appearance of the rest of the colon intra-operatively) survived after a prolonged hospital stay. CONCLUSIONS: Early or pre-operative microbiological diagnosis of C. difficile infection can be difficult in patients with a fulminant presentation. Those patients with C. difficile colitis, who develop signs of toxicity, peritonitis or perforation, should undergo a total colectomy as the operation of choice.     

Experimental evaluation of ileal patch in delayed primary repair of penetrating colon injuries: An animal study

Primary repair of traumatic colonic perforation is progressively gaining acceptance as the best method of management. However, when delayed, the risk of infection-related complications may increase. Here, we present a new method of repairing colon perforation in the presence of peritonitis. Acute colon injury was simulated in 22 German shepherd dogs. The dogs were randomly divided into two groups of 11 and after 24 hours they were operated on. The perforations were repaired by subserosal suture technique. In the first group (group A), ileal patch was used. In the other group (group B), the colon was closed by debridement and anastomosis. After 6 weeks, the repairs were assessed on the basis of survival, gross and histological assessments. Nine (82%) dogs in group A and six (56%) in group B survived. Ileal patch utilization significantly decreased the mortality rate (p < 0.05). The cause of death in two group A dogs and five group B dogs was peritonitis and intra-abdominal abscess formation. None of the surviving dogs showed evidence of anastomotic leakage or breakdown. Small bowel patch used in primary repair of colon injury in the presence of peritonitis may decrease the risk of postoperative infection-related complications and the mortality rate.     

Acute diverticulitis with colon perforation in renal transplantation

INTRODUCTION: Acute diverticulitis with colon perforation is a serious condition in transplant recipients. The aim of this study was to analyze our experience with colon perforations among 875 renal transplant recipients between January 1986 and September 2004. METHODS: Patients were analyzed by age, gender, steroid dosage, time interval from the transplantation, delay between symptoms and surgery, clinical presentation, surgical procedure, graft and patient outcomes. RESULTS: We identified 8 patients with colon perforation. The incidence of perforation was 0.9%. Mean age at the the time of perforation was 58.5 years. Fever, abdominal pain, localized or diffuse signs of peritonitis, and leukocytosis were present in 7 patients (87.5%). Three patients (37.5%) were on steroid-free immunosuppression, whereas in 2 cases (25%) the steroid dosage was >20 mg/d. The mean interval between transplantation and perforation was 4.1 years. Two episodes (25%) occurred within 1 month following transplantation and the other 6 (75%) between 1 and 15 years. The interval between the onset of symptoms and surgery was longer than 48 hours in 1 patient (12.5%). In 5 cases (62.5%), a Hartmann procedure was performed; in 2 patients (25%), a resection with primary anastomosis was preferred. The last patient had a direct suture of the colon. Mortality rate was 12.5%. At a median follow-up of 6.1 years, 6 patients (75%) are alive with 5 functioning grafts. CONCLUSIONS: Colon perforations in renal transplant recipients remain a challenging surgical problem. An aggressive diagnostic attitude and an immediate surgical treatment may contribute to significantly decrease the incidence and the mortality of this complication.     

Peritonitis in diverticulitis: the Bern concept

INTRODUCTION: The colon is the most frequent origine for a diffuse peritonitis and diverticular perforation is again the most common source of a spontaneous secondary peritonitis. This paper first focuses on the treatment of peritonitis and secondly on the strategies of source control in peritonitis with special emphasis on the tactics (primary anastomosis vs. Hartmann procedure with colostomy) for surgical source control. PATIENT AND METHODS: Prospective analysis of 404 patients suffering from peritonitis (11/93-2/98), treated with an uniform treatment concept including early operation, source control and extensive intraoperative lavage (20 to 30 liters) as a standard procedure. Other treatment measures were added in special indications "on demand" only. Peritonitis was graded with the Mannheim Peritonitis Index (MPI). Tactics of source control in peritonitis due to diverticulitis were performed according to "general condition" respectively the MPI of the patient. RESULTS: The 404 patients averaged a MPI of 19 (0-35) in "local" peritonitis and a MPI of 26 (11-43) in "diffuse" peritonitis. The colon as a source of peritonitis resulted in MPI of 16 (0-33) in the case of "local" respectively 27 (11-43) in "diffuse" peritonitis. From 181 patients suffering from diverticulitis 144 needed an operation and in 78 (54%) peritonitis was present. Fourty-six percent (36) of the patients suffered from "local", 54% (42) from "diffuse" peritonitis. Resection with primary anastomosis was performed in 26% (20/78) whereas in 74% (58/78) of the patients a Hartmann procedure with colostomy was performed. The correlating MPI was 16 (0-28) vs. 23 (16-27) respectively. The analysis of complications and mortality based on the MPI showed a decent discrimination potential for primary anastomosis vs Hartmann procedure: morbidity 35% vs. 41%; reoperation 5% vs. 5%; mortality 0% vs. 14%. CONCLUSION: In case of peritonitis due to diverticulitis the treatment of peritonitis comes first. Thanks to advances in intensive care and improved anti-inflammatory care, a more conservative surgical concept nowadays is accepted. In the case of diverticulitis the MPI is helpful to choose between primary anastomosis vs. Hartmann procedure with colostomy as source control. The MPI includes the "general condition" of the patient into the tactical decision how to attain source control.     

Ischaemic necrosis of lesser curve of stomach after proximal gastric vagotomy.

Of 483 patients treated by proximal gastric vagotomy (PGV) between 1972 and 1986 four (0.8%) developed lesser curve necrosis with perforation and one died of diffuse peritonitis. Gastroscopy 3-6 days after PGV in 26 patients between November 1985 and May 1987 showed that five had developed ischemic ulcers on the lesser curve (19%). One further patient developed lesser curve necrosis with perforation before endoscopy, giving a total of six lesser curve lesions after 26 vagotomies (23%). Endoscopy also showed that most patients had some gastric retention. Ulcers with maximal diameters of 0.4-2 cm were asymptomatic. One patient with a large ischaemic ulcer (3 cm) had an abrupt fall in haemoglobin concentration (from 148 to 73 g/l) as did two patients who developed lesser curve necrosis with perforation and peritonitis (143 to 93, and 159 to 71, respectively). We conclude that ischemic ulcers are relatively common after PGV, that small ulcers are asymptomatic and do not perforate, and that an upper GI bleeding after PGV strongly suggests that lesser curve necrosis has developed.     

Impact of primary resection on the outcome of patients with perforated diverticulitis

BACKGROUND: Primary resection has replaced the conventional drainage procedure in the management of patients with generalized peritonitis complicating diverticular disease of the colon. This study investigates the impact of primary resection on operative mortality, identifies predictors of mortality, and compares the results with those of our earlier experience. HYPOTHESIS: Primary resection of the perforated diseased segment of the colon is associated with lower mortality rates than the drainage procedure in patients with Hinchey stages 3 and 4 diverticulitis. DESIGN: Retrospective analysis. SETTING: Tertiary care referral center. PATIENTS: We included 138 consecutive patients who underwent emergent operation for generalized peritonitis complicating diverticular disease of the colon (Hinchey stages 3 and 4) during a period of 16 years (January 1983 to May 1999). MAIN OUTCOME MEASURES: The 30-day mortality rate was analyzed and predictors of mortality identified. RESULTS: Patients were classified as having spreading purulent peritonitis (n = 44, 31.9%), diffuse peritonitis (n = 64, 46.4%), or fecal peritonitis (n = 30, 21.7%). One hundred thirty-one patients (94.9%) underwent primary resection, 6 patients (4.3%) underwent resection and primary anastomosis, and 1 patient required total colectomy and end ileostomy. Thirteen of the 138 patients in the present group died (1983-1998), representing a perioperative mortality rate of 9%. There was no significant difference in mortality when compared with our earlier study (1972-1982), which had a mortality rate of 12%, considering that more than 25% of the patients in that group were managed by colostomy and drainage alone. Factors identified univariately as predictors of mortality were age of more than 70 years (P = .047), 2 or more comorbid conditions (P<.01), obstipation at initial examination (P = .02), use of steroids (P = .01), and perioperative sepsis (P<.001). CONCLUSIONS: Primary resection has become the standard practice for patients with generalized peritonitis complicating diverticulitis. Mortality rates have not significantly declined despite more aggressive surgical management of the septic source. Because advanced age, comorbid conditions, and perioperative sepsis predict mortality, it is suggested that further reduction in mortality will require improvement in medical management of perioperative sepsis and comorbid conditions.     

Status of resection-anastomosis in emergency left-sided colon surgery

Resection and primary anastomosis (RPA) in emergency left-side colon surgery is not universally performed because of anastomotic healing difficulties of unprepared, dilated, or inflamed colons. Ninety-three patients underwent emergency surgery for left-side colon disease. Sixty-three primary anastomoses were performed with a 16% mortality rate and a 6% incidence of anastomotic leakage. These results are similar to those reported in the literature, depending upon the pathology involved, and appear to justify resection and primary anastomosis in case of hemorrhage, trauma, and left-colonic obstruction. As for diverticular perforation with localized peritonitis, RPA can be attempted in some instances, if a protective stoma is added. Finally, in case of diffuse peritonitis, the Hartmann procedure still remains the safest method.     

Emergency operations for nondiverticular perforation of the left colon

OBJECTIVE: Although diverticulitis is the most common cause of large bowel perforation, other disease may result in left colonic peritonitis. The aim of this study was to evaluate and compare the incidence, management, and outcome of patients with different causes of nondiverticular left colonic perforations. PATIENTS AND METHODS: From January 1992 to September 2000, 212 surgical patients underwent emergency operation for distal colonic peritonitis. Perforations were caused by diverticulitis in 133 patients (63%) and by a nondiverticular process in 79 (37%). Mortality and morbidity in patients with nondiverticular perforation of the distal large bowel its relationship with the general conditions, the grade and the cause of peritonitis were analysed. Four types of surgical procedures were used. Hartmann's procedure was performed in 40 patients (51%); intraoperative colonic lavage, resection, and primary anastomosis (ICL) in 27 patients (34%); colostomy in 7 (9%); and subtotal colectomy in 5 (6%). RESULTS: Perforated neoplasm, the most common cause of peritonitis, was observed in 30 patients, colonic ischemia in 20, iatrogenia in 13, and other causes in 16 patients. One or more complications were observed in 57 patients (72%); among causes of perforation, colonic ischemia was significantly associated with the longest hospital stay and highest mortality. Eighteen patients (23%) died. CONCLUSIONS: Left large bowel perforation by nondiverticular disease is associated with high mortality and morbidity. The prognosis of patients is determined by the development of septic shock and colonic ischemia, as underlying disease, may influence patient survival.     

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE: Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study. PATIENTS AND METHODS: In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma. RESULTS: The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction. CONCLUSION: Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.     

Surgical treatment of Crohn's disease complications. Our experience

Thirty-five patients with Crohn's Disease (CD) were observed: 18 have been treated with medical therapy and 17 (48.6%) underwent to surgical treatment : 1) intolerance to the medical treatment in 5.9% (1 case); 2) local complications in 94.1% (16 cases: 6 stenosis, 2 occlusions, 3 abscesses, 3 fistulas, 1 perforation with peritonitis, 1 case toxic megacolon). The operations have been 19: resective interventions 14 (bowel and/or colon resections), conservative interventions 5. The mortality was 0, the morbidity 35,29%. The incidence of the recurrences in a follow up of 5 year was 42,9%. The Authors conclude that the surgery, indicated for the treatment of complications, can be resective surgery (perforating Crohn disease: fistulas, abscess) or conservative surgery (stenosing Crohn disease: stenosis). Recently the conservative intervention are proposed in the treatment of fistulas and abscesses too, but when the inflammation is mild and in patients that underwent to extensive intestinal resection with risk of short bowel syndrome.