One stage procedure in the management of acute sigmoid volvulus without colonic lavage.

BACKGROUND: There is a growing acceptance of one-stage primary resection and anastomosis of left-sided colon obstruction with on-table antegrade colonic lavage to reduce the risk of post-operative infectious complications and anastomotic dehiscence. The purpose of this study was to evaluate the safety of single-stage resection and anastomosis for acute left-sided colonic obstruction due to acute sigmoid volvulus, without intraoperative colonic lavage, in a consecutive series of patients admitted to our department. METHODS: Emergency resection of acute sigmoid volvulus was performed by an experienced senior surgeon (consultant grade). This was followed by primary anastomosis without on-table colonic lavage after a manual decompression. RESULTS: A total of 21 patients underwent bowel decompression, resection and primary colorectal anastomosis. Two of the patients who had ileosigmoid knotting and gangrenous bowel had double resection with primary ileoileal and colorectal anastomosis. There were two superficial wound infections. No death or clinical anastomotic failure were recorded in this series. The mean hospital stay was 10.3 days. CONCLUSION: Our results suggest that resection of acute sigmoid volvulus and primary anastomosis after decompression alone can be carried out safely in reasonably fit patients.     

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

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

Primary anastomosis in emergency distal colonic surgery after on-table colonic lavage

The traditional operative management of emergency distal colon pathology has involved staged procedures, but recently Hartmann's operation has gained popularity. The indications for primary anastomosis without covering colostomy have remained controversial, but the technique of on-table lavage has extended the use of this approach in the acute setting. A series of seven patients having this procedure for diverticular abscess (three), obstructing colonic carcinoma (one), perforating colonic carcinoma (one) and sigmoid volvulus (two) is presented. The saline irrigation is introduced by a Foley catheter inserted via the appendix stump and the effluent is diverted from the proximal colon by anaesthetic scavenger tubing. The lavage is continued until the effluent is clear and anastomosis performed with one-layer interrupted absorbable sutures. There were no deaths in the series; one patient developed a wound infection and average hospitalization was 16 days (range: 6-31 days). Immediate anastomosis in selected cases of emergency distal colonic pathology is thus feasible and safe following on-table colonic lavage.     

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

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

Emergency surgery for obstructing colorectal cancers: a comparison between right-sided and left-sided lesions

BACKGROUND:

Fifteen to twenty percent of patients with primary colorectal cancers present with intestinal obstruction. Traditionally, different approaches have been used in the management of right-sided and left-sided colonic obstruction. Recently, single-stage resection with primary anastomosis in left colonic obstruction has been shown to have good results. The objective of this study was to compare the operative results of patients who had emergency operations for right-sided and left-sided obstructions from primary colorectal cancers.

STUDY DESIGN:

This is a retrospective study including 243 patients who underwent emergency operations for obstructing colorectal cancers from 1989 to 1997. Primary resection of the tumor-bearing segment followed by primary anastomosis was attempted when the conditions were feasible. The operative results of patients with right-sided tumors were compared with those of patients with left-sided tumors.

RESULTS:

One hundred seven patients had obstruction at or proximal to the splenic flexure (right-sided lesions), and 136 had lesions distal to the splenic flexure (left-sided lesions). The primary resection rate was 91.8%. Of the 223 patients with primary resection, primary anastomosis was possible in 197 patients. Among the 101 primary anastomoses in patients with left-sided obstruction, segmental resection with on-table lavage was performed in 75 patients and subtotal colectomy was performed in 26. The overall operative mortality rate was 9.4%, although that of the patients with primary resection and anastomosis was 8.1%. The anastomotic leakage rate for those with primary resection and anastomosis was 6.1%. There were no differences in the mortality or leakage rates between patients with right-sided and left-sided lesions (mortality: 7.3% versus 8.9%, P = 0.79; leakage: 5.2% versus 6.9%, P = 0.77). Colocolonic anastomosis did not show a significant difference in leakage rate when compared with ileocolonic anastomosis (6.1% versus 6.0%, P = 1.0).

CONCLUSIONS:

This study showed that primary resection and anastomosis for left-sided malignant obstruction, either by segmental resection with on-table lavage or subtotal colectomy, was not more hazardous than primary anastomosis for right-sided obstruction. The single-stage procedure should be the objective for the treatment of patients with obstructing colorectal cancers, except when patients are hemodynamically unstable during surgery or when the condition of the bowel is not optimal for primary anastomosis.     

Surgical options for left-sided large bowel emergencies.

Current choices of operation for left-sided large bowel emergencies have been established by a questionnaire sent to 218 consultant surgeons asking which operation they would perform under varying circumstances for obstructing sigmoid carcinoma and diverticular disease. A 92% response rate was obtained. Hartmann's procedure (with or without a mucus fistula) is the most popular operation for all conditions. Sigmoid colectomy with primary anastomosis is performed by 40% of surgeons for obstructing carcinomas, but less commonly in other situations. On-table lavage is rarely used, and the majority of anastomoses are not protected by a proximal stoma. Subtotal colectomy is very seldom employed, except when caecal perforation results from an obstructing carcinoma. Some surgeons perform a defunctioning colostomy alone even in the presence of a perforation.     

Surgical treatment of complicated sigmoid diverticulitis: our experience

Traditionally, surgical sigmoid diverticular emergencies used to be treated in stages, but more recently there has been a trend towards definitive surgery with immediate resection plus anastomosis under certain conditions. The aim of this study was to define the morbidity and mortality of resection plus anastomosis with on-table antegrade irrigation and of the Hartmann procedure for complicated sigmoid diverticulitis in relation to the type of peritonitis and to the American Society of Anesthesiologists (ASA) grade of the patients. From April 1999 to April 2002, 38 emergency operations for complicated sigmoid diverticulitis were performed at the San Sebastiano Hospital in Caserta. Six patients underwent operations for obstructions and 32 for perforation (19 Hinchley stage III and 13 Hinchley stage IV). Surgical therapy for obstruction consisted in 4 resections plus anastomosis, 1 subtotal colectomy and 1 Hartmann procedure. Surgical therapy for perforation consisted in 14 resections plus anastomosis and 18 Hartmann procedures. There was 1 case (5%) of anastomotic dehiscence out of 19 primary anastomoses versus 2/19 surgical complications (10%) after the Hartmann procedure. The mortality amounted to 1 death out of 38 (2.6%) in a patient treated with the Hartmann procedure. Left-sided colonic obstruction should be treated by resection plus anastomosis or by subtotal colectomy for ASA II-III patients and by Hartmann's procedure for ASA IV-V patients. ASA II-III patients with localised or generalised non-faecal peritonitis should be treated by resection plus anastomosis, while a Hartmann procedure should be the reasonable option for generalised faecal peritonitis and for ASA IV-V patients with localised or generalised non-faecal peritonitis.     

A simplified operative technique for single-staged resection of left-sided colon obstructions: report of a 9-year experience

Purpose: The operative strategy for left-sided large bowel obstruction remains controversial. Because a safe and definitive single-staged operation that avoided a colostomy would clearly be in the patients' best interest, we conducted a prospective study to compare the efficacy of single-staged surgery (SSS) supplemented by the milking and swabbing technique (MST), with the conventional Hartmann's procedure (HP). Methods: In group 1 (n = 37) we performed traditional HP by resecting the site of obstruction and constructing an end colostomy. In group 2 (n = 33), after resecting the site of obstruction, instead of on-table lavage, we cleaned out the fecal content from the proximal and distal parts of the obstruction by milking the colon with the fingers, then swabbing the proximal and distal 10 cm of lumen of the colonic anastomosis with povidone iodinized stick sponges. Finally, we performed a primary one-layer anastomosis without fecal diversion. Results: The mortality, morbidity, and postoperative hospital stay after emergency left-side colonic resection and primary anastomosis by MST was comparable with those after HP (P > 0.05). Conclusions: We believe that SSS with MST is a viable choice in the surgical management of selected patients with obstructing lesions of the left colon. The advantages of SSS with MST lie in its good long-term results, and short-term reduced surgical intervention and hospital stay. Received: November 12, 2001 / Accepted: May 7, 2002 Reprint requests to: M. Turan, Inonu Muzesi Yani, K. Kazancilar Sok. No 1/4, 58070 Sivas, Turkey     

One-stage resection without colonic lavage in emergency surgery of the left colon

OBJECTIVE: Intra-operative colonic lavage is a widespread procedure introduced to decompress and clean the colon of its faecal load during emergency surgery of the left colon in order to perform a safe anastomosis. This type of lavage is never performed at our institution. The aim of this study was to evaluate the safety and acceptability of emergency left-sided colectomy without colonic lavage in a consecutive series of patients admitted at our department for perforation and obstruction of the left colon. PATIENTS AND METHODS: All 44 patients (29 with obstruction and 15 with perforation) on whom a one-stage left-sided colon resection was performed without colonic lavage between January 1998 and June 2004 were evaluated in a retrospective review. During this period all patients with acute disease of the left colon underwent a one stage resection without colonic lavage. The only exclusion criteria for anastomosis were: haemodynamic instability, ASA > 3, unresectable tumour. Death, anastomotic leakage and wound infection were main outcome measures. RESULT: The leak rate was 4.5% and mortality 2.3% due to one case of postoperative myocardial infarction. A 16% morbidity rate was recorded due to 4 wound infections and 3 minor complications. CONCLUSION: The procedure is safe. The low morbidity and mortality of one stage resection without colonic lavage can justify future prospective studies enrolling a large number of patients to compare its results with those obtained by one stage resection with colonic lavage.     

Which surgeons avoid a stoma in treating left-sided colonic obstruction? Results of a postal questionnaire.

There is now good evidence to indicate that the majority of patients with large bowel obstruction can be safely managed by resection and immediate anastomosis, but have surgeons embraced this policy? A postal survey has been performed to ascertain the opinions of consultant general surgeons within the Wessex region regarding the management of left-sided large bowel obstruction. Of 47 questionnaires sent, 42 replies could be analysed. In patients of good anaesthetic risk, 90% would perform resection with primary anastomosis if the lesion was at the splenic flexure, and 62% would adopt this policy for a rectosigmoid obstruction. In patients of higher anaesthetic risk these figures fell to 71% and 31%, respectively. Surgeons with a gastrointestinal interest were more likely to recommend resection with primary anastomosis. However, this trend reached statistical significance only for splenic flexure and descending colon lesions in good-risk patients. Most surgeons would avoid a stoma in the presence of liver metastases, and only three would be more likely to create a stoma in this situation.     

Preoperative colonic lavage and one-stage excision-anastomosis in obstruction of the left colon

In a retrospective series of 95 patients requiring emergency surgery for distal colonic obstruction, primary bowel resection followed by immediate anastomosis after intraoperative colonic irrigation was performed. Carcinoma was the cause of obstruction in 81 cases (85%); 13 patients had diverticulitis, and 1 had sigmoid volvulus. The technique of on-table lavage was similar to that described by Dudley in 1980: a caecostomy tube was used in 86 patients (90%) and was removed on the tenth postoperative day. 4 patients died, none from complications of anastomotic leakage. There were three anastomotic leakages (3.1%) and 10 radiologic leaks were observed. 3 patients were reoperated. The mean hospital stay was 23 days. The results of this study suggest that intraoperative colonic irrigation is an effective method, enabling the surgeon to perform primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.     

Should primary anastomosis and on-table colonic lavage be standard treatment for left colon emergencies?

All patients with left colon obstruction or infection admitted under the care of one surgical firm over a 2.5-year period underwent on-table colonic lavage and primary anastomosis. Results were compared with all other similar patients treated during the same period in the same health district (involving a stoma in all cases). No significant difference in perioperative mortality or morbidity between primary anastomosis and Hartmann''s groups was demonstrated. Hartmann''s procedure necessitated a stoma for over 2 months with an 11% incidence of stoma-related complications. The stoma was not reversed in 25% of cases. Total inpatient stay was an average of 14 days shorter (95% CI 4.7-22.7 days) for primary anastomosis compared with Hartmann''s patients. On-table lavage with primary anastomosis should be standard treatment for left colon emergencies.     

Single stage primary anastomosis without colonic lavage for left-sided colonic obstruction due to acute sigmoid volvulus: a prospective study of one hundred and ninety-seven cases

Background: The purpose of this study was to examine the feasibility of single‐stage resection and anastomosis for acute left‐sided colonic obstruction due to acute sigmoid volvulus without intraoperative lavage. Mechanical bowel preparation has been shown to be unnecessary for elective colorectal surgery. Colonic decompression without intraoperative lavage may simplify operations in acute left‐sided colorectal obstruction. Methods: Emergency resection of acute sigmoid volvulus was performed. This was followed by primary anastomosis without on‐table lavage after closed bowel decompression. Results: A total of 197 patients underwent bowel decompression, resection and primary colonic anastomosis. Two patients developed anastomosis leak, requiring re‐laparotomy, Hartmann's procedure and delayed closure. Two deaths occurred postoperatively; these were unrelated to the nature of the surgery. The mean hospital stay was 9.8 days. Conclusion: Primary colonic anastomosis can be safely done for obstructed left colon due to acute sigmoid volvulus without intraoperative colonic lavage.     

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

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

Emergency management of acute colonic cancer obstruction

Emergency management of obstructing colonic cancer depends on both tumor location and stage, general condition of the patient and surgeon's experience. Right sided or transverse colon obstructing cancers are usually treated by right hemicolectomy-extended if necessary to the transverse colon-with primary anastomosis. For left-sided obstructing cancer, in patients with low surgical risk, primary resection and anastomosis associated with on-table irrigation or manual decompression can be performed. It prevents the confection of a loop colostomy but presents the risk of anastomotic leakage. Subtotal or total colectomy allows the surgeon to encompass distended and fecal-loaded colon, and to perform one-stage resection and anastomosis. Its disadvantage is an increased daily frequency of stools. It must be performed only in cases of diastatic colon perforation or synchronous right colonic cancer. In patients with high surgical risk, Hartmann procedure must be preferred. It allows the treatment of both obstruction and cancer, and prevents anastomotic leakage but needs a second operation to reverse the colostomy. Colonic stenting is clinically successful in up to 90% in specialized groups. It is used as palliation in patients with disseminated disease or bridge to surgery in the others. If stent insertion is not possible, loop colostomy is still indicated in patients at high surgical risk.     

Rectal carcinoma. Optimizing the procedures in an emergency]

Emergency conditions in rectal cancer can happen pre-, intra-, and postoperatively. Preoperative emergencies are perforation and obstipation. Spontaneous intraperitoneal perforations have a mortality of 17 to 33% and a five year survival of only 7 to 10%. The site of the perforation is not identical with the the site of the tumor. Due to fecal peritonitis a defunctioning stoma and planned repeat laparotomies are indicated. Initial fecal diversion is followed by tumor resection with anastomosis when the peritonitis has subsided. Iatrogenic perforations from endoscopy or barium enema examination are rare (0.09 to 0.004%). Tumor obstruction occurs in 15% of colorectal cancers. Immediate resection with primary anastomosis is deemed to be feasible if preceded by on-table colonic lavage. Immediate resection has a lower mortality (13.6%) than two staged fecal diversion and resection (35.5%). Intraoperative emergency conditions are bleeding and tumor cell spillage. Bleeding from the presacral veins will be controlled with the hemorrhage occluder pin. Inadvertent perforation of the tumor leads to dissemination of tumor cells. In case of spillage local recurrence was seen in 39% of resections within five years. Multivisceral resection and precise preparation with respect to anatomical planes may prevent damage of the rectum. The leading postoperative emergency condition is anastomotic leak. The incidence of clinical leaks is 6%. In diffuse peritonitis the anastomosis should be taken down and planned repeat laparotomy should be performed. This concept reduces the mortality down to 18.7%.     

Primary anastomosis without colonic lavage for the obstructed left colon

INTRODUCTION

Resection, on-table lavage (OTL) and primary anastomosis is the treatment of choice for the obstructed left colon. OTL is time-consuming, requires considerable mobilisation/bowel handling, an enterotomy and potentially exposes the patient to mesenteric vascular injury, faecal contamination and a prolonged ileus. We have assessed outcome following primary resection and anastomosis without prior lavage.

PATIENTS AND METHODS

Twenty-four consecutive, obstructed patients underwent splenic flexure mobilisation and high anterior resection (concomitant small bowel resection in 2) with primary side-to-side colorectal anastomosis without either prior lavage or covering stoma. Outcome was audited.

RESULTS

Twenty-four patients, 17 female aged 48–92 years (median. 76 years) presented with left-sided obstruction due to carcinoma (Dukes'' B [3], C [6], D [1]) or chronic diverticulitis (14). Median operative time was 85 min (range, 40–105 min). Colonic ileus resolved on day 2 (29%) and day 3 (58%). Median hospital stay was 7 days (range, 6–72 days); 92% discharged by day 10. There were no deaths or re-admissions. A return to theatre followed a reactionary haemorrhage in one. This latter patient''s anastomosis leaked on day 4 (no faecal contamination) and was converted to an end stoma. Urinary and wound infections were seen in two. Late complications comprised two anastomotic strictures; both responded to balloon dilatation at 5 months.

CONCLUSIONS

Resection and primary anastomosis without on-table lavage is an easy, practical, predictable and safe treatment option for left-sided colonic obstruction with minimal complications.     

Colonoscopic perforations: a review of 30,366 patients

Background Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. Methods A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients’ demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. Results In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. Conclusion Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.     

Oncologic emergencies in colorectal cancer patients

The management of obstruction and perforation, which are representative of primary oncologic emergencies in colorectal cancer patients, is outlined. In the management of obstructing colorectal carcinoma, primary resection and anastomosis can be performed in elective conditions with favorable outcomes with preoperative decompression of the obstruction using decompression tubes or self-expanding stents and is the treatment of choice. Even in patients in whom the obstruction fails to improve, the current trend favors intraoperative on table lavage followed by primary resection and anastomosis, except when patients are hemodynamically unstable during surgery or when the condition of the bowel is not optimal for primary anastomosis. For patients with colorectal perforation, the treatment of first choice is primary resection of the septic focus at the perforation site plus colostomy. Single-stage surgery (primary anastomosis after resection of the perforation site) or primary resection of the tumor in patients with perforation occurring far proximal to the cancer should be avoided to reduce the risk of postoperative complications, especially in patients with serious conditions. Intensive management to prevent sepsis including continuous blood purification methods such as polymixin B-immobilized fiber hemofiltration and continuous hemodiafiltration is required to improve the perioperative mortality rate.