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.     

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.     

Role of emergency subtotal colectomy in neoplastic obstructions of the left colon]

From 1984 to 1990, 60 patients underwent emergent surgery for a neoplastic obstruction of the left colon. We performed 19 colostomies without initial exeresis and 41 immediate tumoral resections. In the latter group, five subtotal colectomies (S.T.C.) were performed, including four with immediate mechanical anastomosis. Two patients had synchronous cancers and three had pre-perforating cecal lesions. Three patients had an associated general peritonitis. Three of the patients treated with STC died. These were these patients with general peritonitis, two of whom also had hepatic metastases. The data found in the literature on neoplastic obstructions of the left colon treated with STC with immediate anastomosis (227 cases are published) show an overall mortality rate of 8.4% with 24% morbidity, a complication of the anastomosis occurring in 4.5% of all cases.     

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.     

Intraoperative colonic irrigation in emergency colorectal surgery

Bowel preparation is frequently impossible in various acute colonic diseases, such as left-sided colonic obstruction. The goal of intraoperative colonic irrigation is to obtain, during surgery, a bowel preparation offering the possibility of primary resection with immediate anastomosis, when pre-operative bowel preparation has not been feasible. Technical aspects of intra-operative colonic irrigation are described. Indications for this method are presented: left-sided obstructing carcinomas, diverticulitis, more rarely inflammatory stenosis or functional 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.     

Anastomotic leakage after elective right versus left colectomy for cancer: prevalence and independent risk factors

BACKGROUND: Anastomotic leakage in colorectal surgery remains a major challenge because of its early and late consequences. STUDY DESIGN: To determine whether prevalence and risk factors for anastomotic leakage (AL) differed between right and left elective colectomy for cancer, we conducted univariate and multivariate analyses and compared 33 variables (15 preoperative, 18 intraoperative) culled prospectively for 520 right and 1,230 left colectomies, followed by immediate anastomosis in 1,750 adult patients with or without AL. RESULTS: The overall AL rate was 4% (71 of 1,750) and was significantly lower (p < 0.0001) for right (7 of 520=1.35%) than for left colectomy (64 of 1,230=5.20%). Overall mortality was 4.1% (68 of 1,750), and was not statistically different (p=0.50) between right (4.6%, 24 of 520) and left (3.6%, 44 of 1,230)) colectomy. In right colectomy, differences in associated mortality rates with (14.3%, 1 of 7) and without (4.5%, 23 of 513) AL were not statistically significant (p=0.28), but in left colectomy, associated mortality was statistically significantly higher (p < 0.006) with AL (10.9%, 7 of 64) than without it (3.2%, 37 of 1,166). Independent risk factors for AL were preoperative in right colectomy: loss of weight (> 10%), odds ratio (OR)=5.62, with 95% CI 1.06 to 29.8; and intraoperative in left colectomy: palliative resection (OR=2.12; 95% CI 1.06 to 4.23), "poor" colonic cleanliness (OR=2.4; 95% CI 1.34 to 4.28), proximal colorectal anastomosis (OR=1.34; 95% CI 1 to 1.8), and distal colorectal anastomosis (OR=3.91; 95% CI 1.64 to 9.81). CONCLUSIONS: In right colectomy for cancer, preoperative nutritive support leading to regain of lost weight could reduce postoperative morbidity. Concerning left colectomy, if colonic cleanliness is poor, intraoperative colonic lavage should be done. When poor colonic cleanliness is associated with palliative resection and low distal rectal anastomosis, a protective stoma should be considered.     

Primary anastomosis in the neoplastic colonic obstruction

The authors report their own experience on the treatment of large bowel obstruction caused by a neoplastic stenosis. During a 36-month period 110 operations for emergency large bowel obstructions were performed: 59 (53.6%) underwent primary anastomosis without colostomy (28 right colectomy, 16 left colectomy, 9 sub-total and 6 total colectomy). Total group post-operative mortality was 2.9% as a result of cardio-pulmonary complications. Morbidity was 19.8%, included a 3% of anastomotic leak underwent surgical treatment. Our results suggest that resection and primary anastomosis can be performed with acceptable morbidity and mortality in a high proportion of cases of emergency large bowel obstructions.     

Surgical Options for Malignant Left-Sided Colonic Obstruction

Purpose We evaluated the clinical results of different techniques of resection for malignant left-sided colonic obstruction.Methods The subjects of this prospective nonrandomized study were 63 consecutive patients who underwent surgery between 1995 and 2000 at a single institution. Patients with nonprimary colonic tumors, lesions located proximally to splenic flexure, peritonitis, perforation, or cecal necrosis were excluded.Results Segmental colectomy with primary anastomosis (CPA) was performed in 35 patients; with intraoperative colonic irrigation (ICI) in 19, and without ICI in 16. Total or subtotal colectomy (TSC) was performed in 8, and Hartmanns procedure (HP) was performed in 20. There were no differences in age, sex, comorbidity, time of symptoms, preoperative hospital stay, or tumor staging among the groups of patients defined by the different surgical techniques. The overall incidence of postoperative complications was 43%; postoperative mortality, 5%; anastomotic dehiscence, 12%; urgent reoperations, 12%; and readmissions, 5%, without significant differences among the treatment groups. However, the postoperative and total hospital stay were significantly shorter after ICI (P = 0.016 and P = 0.012, respectively). The overall 5-year survival was 42.7%.Conclusions We think that segmental colectomy with anastomosis after intraoperative colonic irrigation is the most effective operative treatment for neoplastic left-sided colonic obstructions, considering its safety and cost-effectiveness.     

Intestinal obstruction due to perforated cecal volvulus. Case report

Cecal volvulus is an uncommon cause of large-bowel obstruction. Its developement is due to an abnormal mobility of the ileocecal loop because of lacking attachement of ascending colon. Clinical features are frequently aspecific and should be differentiated from sigmoid volvulus and neoplastic obstruction. Therapy depends on visceral circulatory conditions at the moment of diagnosis. Possible options include endoscopic decompression, cecopexy with or without cecostomy, right colectomy with immediate or delayed anastomosis. The present paper reports the case of cecal volvulus in a 44 year old woman, successfully treated with right colectomy and primary anastomosis.     

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。     

Surgical approach to right colon cancer:From open technique to robot.State of art

This work is a topic highlight on the surgical treatment of the right colon pathologies,focusing on the literature state of art and comparing the open surgery to the different laparoscopic and robotic procedures.Different laparoscopic procedures have been described for the treatment of right colon tumors: Totally laparoscopic right colectomy,laparoscopic assisted right colectomy,laparoscopic facilitated right colectomy,hand-assisted right colectomy,single incision laparoscopic surgery colectomy,robotic right colectomy.Two main characteristics of these techniques are the different type of anastomosis: Intracorporeal(for totally laparoscopic right colectomy,single incision laparoscopic surgery colectomy,laparoscopic assisted right colectomy and robotic technique) or extracorporeal(for laparoscopic assisted right colectomy,laparoscopic facilitated right colectomy,hand-assisted right colectomy and open right colectomy) and the different incision(suprapubic,median or transverse on the right side of abdomen).The different laparoscopic techniques meet the same oncological criteria of radicalism as the open surgery for the right colon.The totally laparoscopic right colectomy with intracorporeal anastomosis and even more the single incision laparoscopic surgery colectomy,remain a technical challenge due to the complexity of procedures(especially for the single incision laparoscopic surgery colectomy) and the particular right colon vascular anatomy but they seem to have some theoretical advantages compared to the other laparoscopic and open procedures.Data reported in literature while confirming the advantages of laparoscopic approach,do not allow to solve controversies about which is the best laparoscopic technique(Intracorporeal vs Extracorporeal Anastomosis) to treat the right colon cancer.However,the laparoscopic techniques with intracorporeal anastomosis for the right colon seem to show some theoretical advantages(functional,technical,oncological and cosmetic advantages) even if all studies conclude that further prospective randomized trials are necessary.Robotic technique may be useful to overcome the problems related to inexperience in laparoscopy in some surgical centers.     

Ruptured giant colonic diverticulum

Giant colonic diverticulum (GCD) is a rare complication of diverticular disease with less than 150 cases reported in the English literature. The clinical presentation ranges from asymptomatic to that of an acute abdomen. In most cases, giant colonic diverticulum is found in the sigmoid colon. The ideal treatment is elective resection of the sigmoid colon with primary anastomosis. When the diverticulum presents with perforation or obstruction, however, the treatment is a sigmoid colectomy with diverting colostomy (Hartmann procedure).     

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。     

Definitive one-stage emergency large bowel surgery

During a 30-month period, 126 operations for emergency large bowel conditions were performed: 57 were for colonic carcinoma, 26 for acute diverticulitis, 14 for colonic ischaemia, 13 for complications of inflammatory bowel disease, and 16 for other conditions. Sixty-eight patients had peritonitis. One hundred and ten patients (87.3 per cent) underwent immediate resection. Of these, 83 (65.9 per cent of the overall group) had colonic resection with primary anastomosis but without a colostomy, 56 of which were left-sided colonic resections. Excluding 9 of the 68 patients with peritonitis, who had a total colectomy, 66 per cent also underwent resection, anastomosis and no colostomy. Total group mortality was 14.3 per cent: 12.7 per cent in the immediate resection group, 9.6 per cent in those with primary anastomosis and no colostomy, 5.2 per cent in the group with peritonitis undergoing resection and anastomosis, and 25 per cent in those having non-resectional surgery. Complications included an overall wound infection rate of 10.3 per cent and a clinical anastomotic leak rate of 7.2 per cent in those who had anastomosis without colostomy. Our results suggest that resection and primary anastomosis can be performed with acceptable morbidity and mortality in a high proportion of cases of emergency large bowel conditions, irrespective of underlying pathology, site of disease or the presence of peritonitis.     

Primary restorative colectomy in malignant left-sided large bowel obstruction.

A series of 18 consecutive patients who underwent primary resection and immediate anastomosis as the treatment for malignant left-sided large bowel obstruction are presented. Intraoperative mechanical preparation of the colon was omitted. There was no clinical evidence of anastomotic dehiscence or wound infection. The mean duration of hospital stay was 11 days. It is suggested that colonic continuity can be restored immediately and safely without mechanical bowel preparation, providing attention is directed to constructing an anastomosis that has a good blood supply and is free from tension.     

Obstructing carcinoma of the left colon managed by subtotal colectomy

Obstructing carcinomas of the left colon are traditionally managed with a staged resection, as immediate colonic anastomosis is associated with a high risk of anastomotic dehiscence. We have prospectively performed total or subtotal colectomy in 18 consecutive patients presenting with obstruction at or distal to the splenic flexure. The operative mortality was 11%, which compared favourably with the results of other methods of surgical management. The procedure is safe and no cases of anastomotic dehiscence occurred. Subtotal colectomy achieves in a single procedure relief of the obstruction, tumour resection and restoration of gut continuity whilst allowing resection of synchronous lesions and eliminating the risk of metachronous tumour. Frequent liquid stool was not a significant sequel of a subtotal colectomy in this series.     

The intraoperative colonic irrigation in emergency surgery

Bowel preparations is frequently impossible in various ante colonic diseases, such as left-sided colonic obstruction. The goal of intraoperative colonic irrigation is to obtain, during surgery, a bowel preparation offering the possibility of primary resection with immediate anastomosis, when preoperative bowel preparation has not been feasible. Technical aspects of intra-operative colonic irrigation are described. Indications for this methods are presented: left-sided obstructing carcinomas, diverticulitis, more rarely inflammatory stenosis or functional obstruction. The surgical management of left colonic emergencies has evolved in the past few decades. Recently, there has been increasing interest in resection with primary anastomosis in selected cases. The post operative mortality rate was 13 per cent. The incidence of clinical anastomotic leakage was 6.65 per cent.     

Intraoperative orthograde intestinal irrigation. On a method used in colonic surgical emergencies

With the help of intraoperative orthograde irrigation of the colon it is possible to handle emergency abdominal colectomies like elective operations of the colon. The resection of the large bowel following the intraoperative orthograde irrigation is determined by the causal malady as cancer, diverticulitis and perforation. Lymphadenectomy and colonic resection with primary anastomosis succeeded without preventative colostomy. One of the nine, mostly geriatric patients undergoing an emergency resection of the left colon or rectosigmoid died of pulmonary embolism. No typical complications as anastomotic leakage or disturbance of wound healing ensued, common morbidity came to four of the nine patients. For the intraoperative orthograde irrigation of the colon accurate surgical engineering and tactics are absolutely necessary as described. It is possible to renounce the radical colectomy, colostomy and staged procedures in the treatment of emergency colon resection.     

肠道支架联合腹腔镜在急性梗阻性左半结肠癌治疗中的初步应用

目的:探讨腹腔镜结肠癌Ⅰ期切除吻合术中置入肠道支架的短期疗效。方法:回顾分析2013年6月至2016年5月收治的27例中老年急性梗阻性左半结肠癌患者的临床资料。入院常规行全腹部增强CT检查,排除同时性结肠癌远处转移。常规行胃肠减压,纠正电解质紊乱、贫血及低蛋白血症。对照组(n=16)于24~48 h内急诊行左半结肠癌根治术,视术中情况选择性行近端结肠造瘘或Ⅰ期结肠吻合术;支架组(n=11)入院后先通过超细内镜引导下置入肠道支架解除梗阻,梗阻状况及全身情况改善后进一步行腹腔镜辅助左半结肠癌根治+Ⅰ期吻合术。结果:支架组无死亡病例,未行结肠残端造口,未出现术后吻合口瘘。两组淋巴结廓清数量、首次住院时间、首次住院费用差异无统计学意义(P0.05)。支架组手术时间、术中出血量、预防性造口率少于对照组(P0.05)。结论:超细内镜结肠支架置入术联合腹腔镜结肠癌根治术治疗急性梗阻性左半结肠癌短期疗效显著。