Comparison of one-stage resection and anastomosis of acute complete obstruction of left and right colon

BACKGROUND: Although acute obstruction of the right colon is usually handled by primary anastomosis following resection, many surgeons are reluctant to offer one-stage resection and anastomosis to patients with obstructive lesions of the left colon. The aim of the study is to compare the immediate result of one-stage resection and anastomosis for patients with acute complete obstruction of the right colon versus left colon. METHODS: From January 1986 to December 2003, 214 cases of acute colonic obstruction were managed with one-stage resection and anastomosis by a single surgeon. Eighty patients were operated on for obstructive lesions of the right colon, 71 of them for carcinoma of the colon. Operative mortality was 10% (8/80); all except 2 patients died of respiratory failure. There were 2 cases (2.5%) of anastomotic leakage. One hundred thirty-four patients were operated on for obstructive lesions of the left colon, 127 of them for carcinomas of the colon and rectum. Operative mortality was 1.5% (2/134); both patients died of metastasis from the colorectal cancer following surgery. There were 3 cases (2.3%) of anastomotic leakage. CONCLUSION: This experience suggests that an anastomosis can be performed as safely in patients with acute obstruction of the left colon as in those with acute obstruction of the right colon. Mortality following resection and anastomosis is actually lower in left than right colonic obstruction. Neither intraoperative irrigation nor routine subtotal colectomy was found to be necessary in patients with acute colonic obstruction. Intraoperative decompression should be considered in left and also right colonic obstruction prior to the anastomosis following colonic resection.     

一期切除吻合术治疗左半结肠癌并急性肠梗阻临床疗效观察（附46例报告）

目的 探讨左半结肠癌并急性肠梗阻行一期切除吻合术的安全性及其临床应用.方法 对46例左半结肠癌并梗阻患者行一期肠切除肠吻合术,术中进行有效的结肠减压及清洁灌洗,术后观察疗效.结果 有31例患者左半结肠恶性梗阻患者经保守治疗肠梗阻缓解改限期手术行一期肠切除吻合术,其余15例患者一般情况较好,经全结肠灌洗后一期肠切除吻合术,所有手术均顺利完成,术后并发切口感染8例（17.4％）,吻合口漏4例（8.7％）,经保守治疗痊愈.结论 左半结肠癌并发急性肠梗阻患者行一期肿瘤切除吻合术是安全有效的.     

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.     

Safety of colonic anastomosis following portal triad occlusion in rats

Traumatic colon injuries frequently coexist with liver injury. Stopping the bleeding from hepatic pool may require complete portal triad occlusion. The possible effects of portal venous occlusion on healing of colonic anastomosis were examined using a rat model. A colo-colonic anastomosis following resection of a 1 cm segment of the transverse colon was done with just a simple manipulation on the liver and portal triad in the group A. In the group B the portal triad was clamped for 15 minutes. Then, the clamp was released for a thirty minutes reperfusion time. Subsequently, the same technique in the control group for colonic resection and anastomosis was applied. Ischemia/reperfusion resulted in histologically proven alterations in the large bowel in the group B. However, colonic tissue superoxide dismutase values showed no significant differences between the groups. On day 7, no differences were recorded in bursting pressures of the anastomoses and the hydroxyprolene levels of the anastomotic tissues of the two groups. These findings suggest that colonic anastomosis after portal triad occlusion is safe in the absence of peritonitis.     

左半结肠切除术中高渗灌洗液的应用观察

目的 总结在左半结肠切除一期肠吻合术中高渗液甘露醇结肠灌洗的临床效果.方法 我院对31例左半结肠切除患者,术中依次行生理盐水、甲硝唑和20%甘露醇结肠灌洗,病变切除再行一期肠吻合.结果 除3例切口感染外,其余病例均在4～5天后开始进食,未发生吻合口瘘,痊愈出院.结论 左半结肠梗阻性病变需行结肠切除时,采用生理盐水、甲硝唑和甘露醇结肠灌洗,再行一期吻合术,术后肠功能恢复快,可防止吻合口瘘的发生.     

Healing of experimental colonic anastomoses. I. Bursting strength of the colon after left colon resection and anastomosis.

Mechanical strength of the left colon with anastomosis and the intact transverse colon was studied by the bursting strength technic from four to fourteen days after standardized left colon resection in the rat. Two different single layer inverting suture technics were used, continuous suture and interrupted sutures. Bursting strength was tested by determinations of both bursting pressure and bursting wall tension, both of which provided the same information concerning mechanical strength of the colon. The bursting strength test measures the anastomotic strength only during the early stages of healing, since more than 90 per cent of the left colon segments ruptured outside the anastomosis as early as day 7. The two different suture technics resulted in the same bursting strength of the left colon segment with anastomosis. Both types of anastomoses showed a moderate narrowing at the anastomotic line upon inflation. This was due to the fact that the anastomosis constituted a relatively firm fibrotic ring from day 7, and both types of anastomoses had an equal inner diameter at that time. By supporting the colonic wall above and below the anastomosis, it could be calculated that the anastomosis on day 7 withstood at least 50 per cent higher circular wall tension than the surrounding colonic wall.There was no correlation between collagen concentration of the colonic wall and bursting strength of the colon either in unoperated controls or after resection and anastomosis. When interrupted sutures were used for anastomosis of the left colon, bursting strength of the intact transverse colon was significantly higher on day 7 than when continuous suture was used. It actually exceeded that of the transverse colon in unoperated controls by almost 50 per cent on the seventh postoperative day, although the collagen concentration in the transverse colon was within normal range. This finding indicated changes in the proximal colonic wall after left colon resection, which are probably related to changes in the structure or arrangement of collagen.     

一期切除术在急性大肠梗阻中的应用

作者报告了手术治疗急性大肠梗阻２８３例，其中结直肠癌引起的梗阻２５５例，良性病变引起的梗阻２８例。行一期切除术２０１例，其中行一期切除近端结肠造口二期肠造口闭合术４４例，一期切除吻合术１５７例。行分期手术５２例。术后生存率一期切除术优于分期手术。作者认为：（１）左侧结直肠癌梗阻情况允许时应尽量争取一期切除术，条件许可时行一期吻合术，如不能吻合则行近端结肠造口二期肠造口闭合术，一期切除吻合加保护性横结肠造口术不宜采用；（２）术中结肠灌洗对左侧结肠梗阻一期切除吻合具有重要意义；（３）结肠次全切除术适合于横结肠左侧至降结肠部位的梗阻。     

左半结肠癌并急性肠梗阻16例一期切除治疗体会

目的 探讨左半结肠癌并急性肠梗阻一期切除吻合术的安全性及临床应用体会。方法 回顾分析2008年7月至2011年5月我科收治的左侧结肠癌并急性肠梗阻16例患者的临床资料。所有患者应用术中结肠减压灌洗并一期切除吻合,结合术后应用抗生素及全胃肠外营养等综合治疗。结果 16例患者中,行一期根治性切除吻合术15例,姑息性切除1例。所有患者全部治愈,无吻合口瘘,腹腔脓肿等并发症发生,仅一例发生术后切口感染,经换药治疗痊愈。结论 正确把握手术适应症,术中有效地的肠道灌洗,重视围术期综合治疗,左半结肠癌致急性肠梗阻患者行一期根治性切除吻合是一种安全可行的手术方式,值得临床应用推广。     

左半结直肠癌致急性肠梗阻的急诊治疗策略

目的探讨左半结、直肠癌致急性肠梗阻的急诊治疗策略。方法回顾性分析2000-2006年哈尔滨医科大学附属第一医院收治的36例左半结、直肠癌致急性肠梗阻的病例资料。结果行一期肠切除吻合27例,行姑息性结肠造口4例,另5例经肛门插入型肠梗阻导管减压去污后行一期手术。术后切口感染2例,无吻合口漏发生,无手术死亡病例。结论左半结、直肠癌致急性肠梗阻的急诊治疗中,对于选择性病人,一期肠切除吻合术是安全可行的;经肛门插入型肠梗阻导管结肠减压、灌洗去污是对一期肠切除吻合术的有效补充。     

一期肿瘤切除肠吻合术治疗直肠癌急性肠梗阻临床疗效分析（附28例报告）

目的探讨一期肿瘤切除肠吻合术治疗直肠癌急性肠梗临床疗效。方法回顾分析我院2002年1月至2007年1月收治的直肠癌急性肠梗阻28例临床资料。结果本组33例中,28例行一期肿瘤切除肠吻合术,无一例出现肠吻合口漏。结论直肠癌急性肠梗阻在结肠充分灌洗清洁的情况下,行一期直肠肿瘤切除肠吻合术是可行的。     

Colonic interposition for reconstruction after resection of cancer in the esophagus and gastroesophageal junction.

In 26 patients with carcinoma of the esophagus or gastroesophageal junction, intestinal interposition was performed in post-resection reconstruction, using left colon in 21 cases, right colon in one and a long jejunal segment in four cases. The tumor involved the gastric cardia in 16 patients with colonic interposition and five underwent palliative resection. Infectious pulmonary and abdominal complications were common. Three patients required reoperation, for empyema, ischemic colonic segment and subphrenic abscess, respectively. Ischemia of the interposed segment occurred in two patients, necessitating removal of the segment in one. There was no anastomotic dehiscence and no tumor in the margins of the resected tissue. The 30-day postoperative mortality was 1/22 and the mean postoperative hospital stay 24 days, with 11 patients discharged directly to their homes. The functional results 6 months postoperatively were favorable in most survivors, and only three complained of dysphagia.     

改良式顺行结肠灌洗法在梗阻性左半结肠癌术中的应用

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

右半结肠与左半结肠肿瘤性肠梗阻一期切除吻合的比较

目的:比较右半结肠与左半结肠癌肠梗阻一期切除吻合的近期结果.方法:回顾分析80例结肠癌肠梗阻行一期切除吻合患者的临床资料.结果:37例右半结肠癌及43例左半结肠癌肠梗阳患者行一期手术,2组患者平均住院时间为(31.6±12.8)d vs(29.6±14.8)d,P=0.518,平均住院费用为(52794.9±60 804.3)元vs(50 192.8±39 727.4)元,P=0.817,并发症率分别为21.6%(8/37)vs 25.6%(11/43),P=0.678,病死率为5.4%(2/37)vs2.3%(1/44),P=0.593,差异均无统计学意义.2组中各有1例发生吻合口瘘.结论:一期切除吻合对右半或左半结肠癌肠梗阻者同样安全.左半结肠吻合前,充分的结肠减压是必须的.     

老年人左半结肠癌并急性肠梗阻Ⅰ期切除吻合疗效观察(附46例报告)

目的 探讨老年人左半结肠癌急性肠梗阻行I期切除吻合手术的临床疗效.方法 对46例老年左半结肠癌急性梗阻患者行急诊I期切除吻合术,术中充分肠道减压和结肠灌洗使肠道空虚、清洁、吻合口双层缝合.结果 无死亡病例,肺部感染6例,切口感染5例,其中2例切口裂开,吻合口瘘2例.结论 左半结肠癌急性梗阻,只要严格掌握手术指征,I期手术是安全有效的.     

左半结肠癌性梗阻术中肠道灌洗Ⅰ期手术的应用

目的探讨术中结肠灌洗在左半结肠癌并急性梗阻Ⅰ期切除吻合中的应用价值。方法对32例左半结肠癌致肠梗阻行一期切除吻合临床资料进行回顾性分析。结果 32例中根治性切除29例,姑息性切除3例,均行一期切除吻合。腹部切口感染2例,经换药治愈;未发生肠瘘,无死亡病例。结论在做好急诊手术前准备,恰当的术中术后处理,有效的抗生素联合应用基础及肠外营养支持治疗,左半结肠癌并急性肠梗阻患者行一期左半结肠切除术是安全可行的。     

对不同部位结肠癌性肠梗阻术式选择的临床研究

目的探讨不同部位结肠癌性肠梗阻的术式选择。方法回顾性分析我院2007年7月至2012年12月期间手术治疗76例结肠癌性肠梗阻的临床资料。结果Ⅰ期肿瘤切除60例,占78.9%(60/76),其中Ⅰ期吻合55例,占91.7%(55/60)。左半结肠癌占60%(33/55),其中Ⅰ期左半结肠切除吻合术51.5%(17/33),I期扩大右半结肠切除吻合术27.3%(9/33),经内镜支架置入过渡后行I期左半结肠切除吻合术18.2%(6/33);Hartmann手术5例,占6.5%(5/76),Ⅰ期单纯造瘘9例(5例Ⅱ期切除),总切除率78.9%(60/76),术后并发吻合口漏1例,治愈75例,住院死亡1例(1.3%)。结论对结肠癌急性结肠梗阻应综合分析,选择适当术式,个体化治疗。     

左半结肠癌致急性肠梗阻I期手术的治疗分析

目的探讨术中结肠灌洗在左半结肠癌并急性梗阻性Ⅰ期切除吻合术中的应用。方法 对收治的38例急性梗阻性左半结肠癌患者,分为灌洗组和对照组。灌洗组采用术中结肠灌洗后,再行Ⅰ期肠切除吻合术。对照组术中不采用结肠灌洗行Ⅰ期肠切除吻合术。对治疗效果及并发症进行分析。结果灌洗组患者治疗时间短、费用低、效果好、并发症少。结论术中结肠灌洗行Ⅰ期左半结肠切除吻合术安全、可靠。     

左半结肠癌合并急性肠梗阻Ⅰ期吻合手术治疗体会

目的 探讨左半结肠癌合并急性肠梗阻手术治疗方法 及结局。方法 选取我院收治35例左半肠癌合并急性肠梗阻的患者,术中采取肠道充分灌洗处理,均行一期吻合术。结果 所有患者手术过程顺利,未发生围手术期死亡病例,吻合口漏1例（2.9%）,经通畅引流、冲洗、加强营养等治疗后痊愈出院。左半结肠癌伴急性梗阻患者平均住院时间为14.5（9～24）天,3例患者发生切口感染或液化（8.6%）,经换药等处理后愈合。发生肺部感染4例（11.4%）,经抗感染治疗痊愈。结论 左半结肠癌合并急肠梗阻进行术中结肠灌洗并行Ⅰ期肠切除吻合是可行的。     

Effects of locally applied recombinant human granulocyte-macrophage colony-stimulating factor on ischemic bowel anastomoses in rat

BACKGROUND: Ischemia is one of the most common causes of anastomosis disruption. In the present study we investigated the effect of locally injected recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) on ischemic bowel anastomosis in rats. METHODS: 144 male Sprague-Dawley rats were randomized into four groups: in group 1, colon anastomoses were performed; in group 2, anastomoses were performed then 50 microg rhGM-CSF was injected subserosally into the perianastomotic area; in group 3, anastomoses were performed on ischemic colon segments, and in group 4, colon anastomoses were performed on ischemic segments and then 50 microg rhGM-CSF was injected subserosally into the perianastomotic area. On the 3rd and 7th post-operative days, the rats were sacrificed and anastomotic bursting pressures were measured. Hydroxyproline contents were studied on the tissues from the anastomotic line. Three anastomotic segments were saved from each group for histopathological studies before bursting pressure measurement. RESULTS: The bursting pressure in group 3 was significantly weaker than in the other groups. There were no significant differences between the bursting pressures in groups 1 and 4. The levels of hydroxyproline content in group 4 were significantly greater than in group 3. CONCLUSIONS: These data suggest that the local injection of rhGM-CSF improves the healing of ischemic and even normal colon anastomoses.     

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.