Intraoperative colonic lavage in emergency surgical treatment of left-sided colonic obstruction

Overuse of Proximal Fecal Diversion in Colorectal Surgery

Many surgeons tend to overuse proximal fecal diversion in the setting of colonic surgery. The decision to proximally divert an anastomosis should be made with careful consideration of the risks and benefits of proximal diversion. Proximal diversion does not decrease the rate of anastomotic leak, but it does decrease the severity of leaks. Anastomotic height for low pelvic anastomoses, hemodynamic instability, steroid use, male sex, obesity, malnutrition, smoking, and alcohol abuse increase the rate of anastomotic leak. Biologics, most immunosuppressive agents, unprepped colons, and radiation for rectal cancer do not contribute to increased rates of anastomotic leak. Proximal fecal diversion creates additional potential morbidity, higher rates of readmission, and need for a subsequent hospitalization and operation for reversal. Additionally, diverted patients have higher rates of anastomotic stricture and delayed recognition of chronic leaks. These downsides to diversion must be weighed with a patient's perceived ability to handle the physiologic stress and consequences of a severe leak if reoperation is required. When trying to determine which patients can handle a leak, the modified frailty index can help to objectively determine a patient's risk for increased rate of morbidity and failure to rescue in the event of a leak. While proximal diversion is still warranted in many cases, we find that certain clinical scenarios often lead to overuse of proximal diversion. The old surgical adage "If you are considering diverting, you should probably do it" should be tempered by an understanding of the risk and benefits of diversion.

Intraoperative Colonic Irrigation for Low Rectal Resections With Primary Anastomosis: A Fail-Safe Surgical Model

Aim

Regardless the technological developments in surgery, the anastomotic leakage (AL) rate of low rectal anastomosis remains high. Though various perioperative protocols have been tested to reduce the risk for AL, there is no standard peri-operative management approach in rectal surgery. We aim to assess the short-term outcome of a multidisciplinary approach to reduce the rates of ALs using a fail-safe-model using preoperative and intraoperative colonic irrigation in low rectal resections with primary anastomosis.

Methods

Between January 2015 and December 2020, 92 patients received low rectal resections for rectal cancer with primary anastomosis and diverting ileostomy. All these patients received pre-operative mechanical bowel preparation (MBP) without antibiotics as well as intraoperative colonic irrigation. The intraoperative colonic irrigation was performed via the efferent loop of the ileostomy. All data were analyzed by SPSS for descriptive and inferential analyses.

Results

In the study period, 1.987 colorectal surgical procedures were performed. This study reports AL in 3 (3.3%) of 92 recruited patients. Other postoperative complications (Dindo-Clavien I-IV) were reported in 25 patients (27.2%), which occurred mainly due to non-surgical reasons such as renal dysfunction and sepsis. According to the fail-safe model, AL was treated by endoscopic or re-do surgery. The median postoperative length of hospitalization was 8 days (4–45) days.

Conclusion

This study validates the effectiveness of a multi-disciplinary fail-safe model with a pre-operative MBP and an intraoperative colonic irrigation in reducing AL rates. Intraoperative colonic irrigation is a feasible approach that lowers the AL rates by reducing fecal load and by decontamination of the colon and anastomotic region. Our study does not recommend a pre-operative administration of oral antibiotics for colorectal decontamination.

Is colonic lavage a suitable alternative for left-sided colonic emergencies?

BACKGROUND

The use of intra-operative colonic lavage (IOCL) with primary anastomosis remains controversial in the emergency left-sided large bowel pathologies, with alternatives including Hartmann’s procedure, manual decompression and subtotal colectomy.

AIM

To compare the peri-operative outcomes of IOCL to other procedures.

METHODS

Electronic databases were searched for articles employing IOCL from inception till July 13, 2020. Odds ratio and weighted mean differences (WMD) were estimated for dichotomous and continuous outcomes respectively. Single-arm meta-analysis was conducted using DerSimonian and Laird random effects.

RESULTS

Of 28 studies were included in this meta-analysis, involving 1142 undergoing IOCL, and 634 other interventions. IOCL leads to comparable rates of wound infection when compared to Hartmann’s procedure, and anastomotic leak and wound infection when compared to manual decompression. There was a decreased length of hospital stay (WMD = -7.750; 95%CI: -13.504 to -1.996; P = 0.008) compared to manual decompression and an increased operating time. Single-arm meta-analysis found that overall mortality rates with IOCL was 4% (CI: 0.03-0.05). Rates of anastomotic leak and wound infection were 3% (CI: 0.02-0.04) and 12% (CI: 0.09-0.16) respectively.

CONCLUSION

IOCL leads to similar rates of post-operative complications compared to other procedures. More extensive studies are needed to assess the outcomes of IOCL for emergency left-sided colonic surgeries.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

The Dudley colectomy in urgent and emergent situations: a 10 patient case series

Left-sided colon pathology that needs to be treated in an emergency situation usually requires a partial colectomy and colostomy with a Hartmann’s pouch. Primary anastomosis is avoided with an unprepped left colon due to the risk of post-operative anastomotic leakage. In this series, 10 patients were treated with on-table lavage to wash out the colon, and left colectomy with primary anastomosis in urgent and emergent situations without a protective ileostomy (the Dudley colectomy). All patients acutely recovered and none had an anastomotic leak. There was a single superficial wound infection, and a single late mortality due to heart failure. On-table colonic lavage and left colectomy with primary anastomosis without a protective ileostomy is a safe and effective way to treat left-sided colon emergencies without a protective ileostomy.

The Usefulness of Intraoperative Colonic Irrigation and Primary Anastomosis in Patients Requiring a Left Colon Resection

PURPOSE

The aim of this study is to assess the short-term outcome of intraoperative colonic irrigation and primary anastomosis and to suggest the usefulness of the procedure when a preoperative mechanical bowel preparation is inappropriate.

METHODS

This retrospective study included 38 consecutive patients (19 male patients) who underwent intraoperative colonic irrigation and primary anastomosis for left colon disease between January 2010 and December 2016. The medical records of the patients were reviewed to evaluate the patients' characteristics, operative data, and postoperative short-term outcomes.

RESULTS

Twenty-nine patients had colorectal cancer, 7 patients had perforated diverticulitis, and the remaining 2 patients included 1 with sigmoid volvulus and 1 with a perforated colon due to focal colonic ischemia. A diverting loop ileostomy was created in 4 patients who underwent a low anterior resection. Complications occurred in 15 patients (39.5%), and the majority was superficial surgical site infections (18.4%). Anastomotic leakage occurred in one patient (2.6%) who underwent an anterior resection due sigmoid colon cancer with obstruction. No significant difference in overall postoperative complications and superficial surgical site infections between patients with obstruction and those with peritonitis were noted. No mortality occurred during the first 30 postoperative days. The median hospital stay after surgery was 15 days (range, 8-39 days).

CONCLUSION

Intraoperative colonic irrigation and primary anastomosis seem safe and feasible in selected patients. This procedure may reduce the burden of colostomy in patients requiring a left colon resection with an inappropriate preoperative mechanical bowel preparation.

One-stage segmental colectomy and primary anastomosis after intraoperative colonic irrigation and total colonoscopy for patients with obstruction due to left-sided colorectal cancer

BACKGROUND

Intraoperative colonic irrigation and intraoperative on-table colonoscopy may be useful for a more accurate diagnosis of colorectal cancer before colectomy in patients with obstructive left-sided colorectal cancer, but the clinical benefit of this technique has not been investigated in large-scale studies.

OBJECTIVE

The aim of this study was to evaluate the usefulness of intraoperative colonic irrigation with a Y-shaped irrigation device and intraoperative colonoscopy in the management of obstructive colorectal cancer in patients undergoing elective surgery.

DESIGN AND SETTING

This was a retrospective cohort study of patients undergoing surgical treatment at a single tertiary care institution in Japan.

PATIENTS AND INTERVENTION

Among 715 consecutive patients with left-sided colorectal cancer, 101 patients (14.1%) with obstructing tumor received intraoperative colonic irrigation and intraoperative colonoscopy before colectomy and primary anastomosis, and 614 patients with nonobstructive colorectal cancer underwent preoperative colonoscopy with mechanical bowel preparation.

MAIN OUTCOME MEASURES

Detection rates of proximal synchronous lesions, occurrence of postoperative complications, and changes in the surgical procedure prompted by the results of the intraoperative colonoscopy were evaluated.

RESULTS

Intraoperative colonoscopy detected synchronous adenomatous polyps in 27 patients (26.8%), carcinoma in 4 patients (4%), and obstructive colitis in 2 patients (2%). Findings of the intraoperative colonoscopy prompted changes in surgical procedure in 9 patients (8.9%). The overall morbidity in the intraoperative group was 17%, with anastomotic leakages in 3 patients, wound infection in 5, and postoperative ileus in 3 patients. The risk of these complications was not increased in patients with intraoperative colonoscopy with intraoperative colonic irrigation compared with those receiving preoperative colonoscopy with mechanical bowel preparation. The operation time was 28 minutes longer in the intraoperative than in the preoperative group, but neither the time to start of oral intake nor the length of postoperative hospital stay was significantly different between the 2 groups.

LIMITATIONS

The study is limited by its retrospective nature.

CONCLUSIONS

: In patients with obstructive colorectal cancer, intraoperative colonic irrigation with intraoperative colonoscopy is a useful strategy for detecting synchronous lesions located proximally to the obstructing tumor, without increasing patient morbidity.

Prospective, controlled, randomized study of intraoperative colonic lavage versus stent placement in obstructive left-sided colonic cancer

BACKGROUND

The main aim of this study was to compare short-term results and long-term outcomes of patients who underwent intraoperative colonic lavage (IOCL) with primary anastomosis with those who had stent placement prior to scheduled surgery for obstructive left-sided colonic cancer (OLCC).

METHODS

We conducted a prospective, controlled, randomized study of patients diagnosed with OLCC. Patients were divided into two groups: stent and deferred surgery (group 1) and emergency IOCL (group 2). Demographic variables, risk prediction models, postoperative morbidity and mortality, staging, complications due to stent placement, surgical time, clinical follow-up, health costs, and follow-up of survival were recorded.

RESULTS

Twenty-eight patients (15 group 1 and 13 group 1) were enrolled. The study was suspended upon detecting excess morbidity in group 2. The two groups were homogeneous in clinical and demographic terms. Overall morbidity in group 1 was 2/15 (13.3%) compared with 7/13 (53.8%) in group 2 (p = 0.042). None of the 15 patients in group 1 presented anastomotic dehiscence compared with 4/13 (30.7%) in group 2 (p = 0.035). Surgical site infection was detected in 2 (13.3%) patients in group 1 and in 6 (46.1%) in group 2 (p = 0.096). Postoperative stay was 8 days (IQR 3, group 1) and 10 days (IQR 10, group 2) (p = 0.05). The mean follow-up period was 37.6 months (SD = 16.08) with no differences in survival between the groups.

CONCLUSION

In our setting, the use of a stent and scheduled surgery is safer than IOCL and is associated with lower morbidity, shorter hospital stay, and equally good long-term survival.

[Surgical treatment of cancer at the beginning of the third millenium--based on the 2004 Krompecher Memorial Lecture of the Society of Hungarian Oncologists]

The author presents a historical overview of cancer surgery of the last century. At the last quarter of the century the main characteristic of this process has been the significant extension of surgical radicality. Three new surgical methods appeared and have been routinely used at the Surgical Clinic of the Szeged University School, to increase surgical radicality, to improve survival rate without impairing the postoperative quality of life. 1.) Subtotal colectomy (STC) involves an extended resection of the colon over the splenic flexure. In a period of 8 years a total of 72 STCs were performed for the treatment of large bowel obstructions or symptomatic stenosis caused by cancer of the left colon. STC offers: a) one stage treatment for colonic obstruction in emergency surgery, b.) removal of the tumor with sufficient oncological radicality, c.) primary reconstruction of the digestive tract, with a safe ileocolic anastomosis even in emergency cases. Based on a study about postoperative quality of life of STC operated patients, it proved to be normal. 2.) The author reports a total of 108 middle and low third rectal cancer cases operated on by total mesorectal excision (TME) by the method of Heald. The oncological basis of this procedure is the horizontal regional metastatization of rectal cancer. The author succeeded in 60% of cases to perform an anterior resection with preservation of the anal sphincter, and to decrease the early (within two years after surgery) local recurrence rate from 14.5% to 6.4%, compared to the group of patients operated on by traditional technic. 3.) A total of 154 patients with locally advanced - stage IV - colorectal cancer underwent extended surgery of multivisceral resections as a treatment of cancer process involving adjacent abdominal organs. Surgery was performed to treat advanced cancer of the colon in 112 cases and the one of the rectum in 42 cases. The mortality rate was 7% in the colon cancer group, and 12% in the group of rectal cancer patients. In their tumor-free postoperative period 90% of colon cancer patients and 95% of rectal cancer patients had an improved quality of life. The 5 years survival rate was 40% in the colon group and 22% in the rectal cancer group. In the group of patients having more than 3 simultaneously tumorous organs, in spite of the multiple organ resections, no 5 years survival has been recorded.

Comparison of one-stage managements of obstructing left-sided colon and rectal cancer: stent-laparoscopic approach vs. intraoperative colonic lavage

PURPOSE

We evaluated the operative outcomes of laparoscopic surgery following self-expandable metallic stent compared to one-stage emergency surgical treatment.

METHODS

From April 1996 to October 2007, 95 consecutive patients with left-sided malignant colorectal obstruction were enrolled. Twenty-five patients were assigned to the preoperative stenting and elective laparoscopic surgical treatment group (SLAP) and 70 to the emergency open surgery with intraoperative colon lavage group (OLAV).

RESULTS

Among the 25 patients in the SLAP group, a primary anastomosis was possible in all patients and a diverting stoma was needed in one patient. The operative time was shorter in the SLAP group (198.53 vs. 262.17 min, P = 0.002). Tumor size, number of retrieved lymph nodes, and pathological stage were similar in both groups. The rate of anastomotic failure was similar and postoperative complications occurred less in the SLAP group (5.9% vs. 31.4%, P = 0.034). The passage of flatus and oral intake were resumed earlier in the SLAP group (2.88 vs. 3.68 days, P = 0.046 and 5.18 vs. 6.65 days, P < 0.001, respectively). The postoperative hospital stay was shorter in the SLAP group (10 vs. 15.4 days, P = 0.013).

CONCLUSIONS

In patients with left-sided malignant colon and rectal obstruction, laparoscopic surgery after SEMS could be safely performed with successful early postoperative outcomes.

[Total colectomy--options in management of acute obstruction of the left-side colon]

INTRODUCTION

Emergency colorectal surgery has been associated with a high morbidity and mortality rate. The current trend for the management of obstruction of left-sided colorectal carcinoma favours primary resection and anastomosis, as a safe and acceptable approach to selected patients.

METHOD

Retrospective review of 81 patients (46 male and 35 female, mean 64 years).

RESULTS

Morbidity after emergency total colectomy was 21%, and mortality was 6%. There were 6 anastomotic complications (2 anastomotic disruptions and 4 anastomotic leaks). Mean hospital stay was 13 days. 82% patients had adequate continence.

DISCUSSION

Traditional approach for left-sided colon obstruction is three-stage procedure (Bloch-Paul-Mikulicz). The idea of removing dilated colon proximal to an obstructing tumor is not new, since Lane suggested this option in 1914. In 1965 Hughes and Cuthberson described their experience with 12 patients. At the moment of laparotomy 20% patients had advanced malignant disease. The cumulative morbidity and mortality are high in three-stage procedure. Three-stage approach is associated with high permanent colostomy rate. One-stage resection with primary anastomosis of the obstructed left-sided colon is a safe alternative to staged procedures. Emergency radical resection can be safely performed in majority of patients with left-colon obstruction.

CONCLUSIONS

Total colectomy with anastomosis is a suitable procedure for treating left-sided colonic obstruction provided that pelvic floor is adequate. Total colectomy has low mortality, acceptable morbidity and good quality of life. The success of the surgery depends on the selection of patients.

Detection and treatment of synchronous lesions in colorectal cancer: The clinical implication of perioperative colonoscopy

AIM: To evaluate the clinical significance of pre- and intra-operative colonoscopy for the detection of synchronous lesions in colon cancer.

METHODS: Two hundred and sixty-five pre-operative and 51 intra-operative colonoscopic evaluations were performed in 316 colorectal cancer patients who underwent curative resection from January 2001 to June 2006. The incidence and characteristics of synchronous lesions and their influence on surgery were evaluated.

RESULTS: Two hundred and eighty-two synchronous lesions were detected in 124 (39.2%) of 316 patients including all lesions regardless of their histologic type. True adenomatous polyps were found in 91 (28.8%) of 316 patients, and 17 (5.4% of all patients) patients had synchronous colon cancers. The preoperative identification of synchronous lesions altered the planned surgery in 37 (14.0%) of 265 patients. In 18 patients among the surgically removed cases, the lesions were removed by extending the resection range. Further segmental resection or polypectomy through enterotomy was necessary in 19 patients. Nineteen (37.2%) of 51 intraoperative colonoscopy cases had synchronous lesions. Additional surgical procedures including segmental bowel resection and polypectomy with enterotomy were necessary in 7 (13.7%) of 51 intraoperative colonoscopy cases to remove the lesions.

CONCLUSION: Synchronous colorectal polyps or cancer are frequent and their preoperative detection is important for optimal surgical planning and treatment. Intraoperative colonoscopy is a useful option in cases where a preoperative colonoscopy is not feasible.

Exteriorized colon anastomosis for unprepared bowel: An alternative to routine colostomy

AIM: To see the possibility of avoiding routine colostomy in patients presenting with unprepared bowel.

METHODS: The cohort is composed of 103 patients, of these, 86 patients presented as emergencies (self-inflected and iatrogenic colon injuries, stab wounds and blast injury of the colon, volvulus sigmoid, obstructing left colon cancer, and strangulated ventral hernia). Another 17 patients were managed electively for other colon pathologies. During laparotomy, the involved segment was resected and the two ends of the colon were brought out via a separate colostomy wound. One layer of interrupted 3/0 silk was used for colon anastomosis. The exteriorized segment was immediately covered with a colostomy bag. Between the 5^th and 7^th postoperative day, the colon was easily dropped into the peritoneal cavity. The defect in the abdominal wall was closed with interrupted nonabsorbable suture. The skin was left open for secondary closure.

RESULTS: The mean hospital stay (± SD) was 11.5 ± 2.6 d (8-20 d). The exteriorized colon was successfully dropped back into the peritoneal cavity in all patients except two. One developed a leak from oesophago-jejunostomy and from the exteriorized colon. She subsequently died of sepsis and multiple organ failure (MOF). In a second patient the colon proximal to the exteriorized anastomosis prolapsed and developed severe serositis, an elective ileo-colic anastomosis (to the left colon) was successfully performed.

CONCLUSION: Exteriorized colon anastomosis is simple, avoids the inconvenience of colostomy and can be an alternative to routine colostomy. It is suitable where colostomy is socially unacceptable or the facilities and care is not available.

Analysis of bacteremia occurring in the presence of obstruction of the left colon in rats submitted to transoperative antegrade mechanical lavage

With the objective of determining the association between bacteremia and transoperative antegrade mechanical lavage of the colon in an experimental model of obstruction of the left colon in rats, 40 male Wistar rats aged between 90 and 120 days were divided randomly into four groups: A, with intestinal obstruction and with mechanical lavage of the colon; B, with intestinal obstruction and without mechanical lavage of the colon; C, without intestinal obstruction and with mechanical lavage of the colon; and D, without intestinal obstruction and without mechanical lavage of the colon. Analysis of the results showed that there was no bacteremia in the animals in the sham group. On the other hand, bacterial growth in blood cultures was found in three animals (30%) in group C and in four animals (40%) in group B. Positive blood culturing was presented by eight animals (80%) of the rats in group A, and variance analysis on this finding was statistically significant (p = .0029). It can be concluded that, in this experimental model, intestinal obstruction causes a fourfold increase in the risk of bacteremia, while lavage causes an almost threefold increase in the chance of bacterial dissemination into the blood stream. This explains why there was greater incidence of bacteremia in the animals with obstruction and with lavage.

Complete single-stage management of left colon cancer obstruction with a new device

BACKGROUND

A newly developed device that enables easy intraoperative colonic irrigation and subsequent colonoscopy was introduced recently.

METHODS

To evaluate the efficacy of the single-stage procedure with a new device and the significance of on-table colonoscopy, 112 patients with obstructive left colon cancer were recruited.

RESULTS

Primary anastomosis after tumor resection was performed in 104 cases. The volume of saline used for irrigation averaged 13.5 l over 12.1 min. Subsequent colonoscopic examination added an average of 10.4 min to the operative time. There were three anastomotic leaks, two wound infections, four acute renal failures, and two operative mortalities. On-table colonoscopy resulted in extended resection in 17 cases.

CONCLUSIONS

The new device enabled safe, simple, and time-saving, single-stage surgical management of left colon cancer obstruction. The ability to perform on-table colonoscopy enabled treatment and recognition of synchronous bowel pathology.

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.

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.

Hartmann's colectomy and reversal in diverticulitis: a population-level assessment

PURPOSE

This study was designed to assess the costs and outcomes of colostomy and colostomy reversal in patients with diverticulitis and examine the impact of such procedures on the health care system.

METHODS

We employed a retrospective design and used a Washington State administrative database to identify patients undergoing operations with colostomy (1987-2002) who were followed over time. Descriptive and comparative analysis was performed, focusing on patients with diverticulitis.

RESULTS

There were 16,556 patients who underwent colostomy and 5,420 (32.7 percent) were for diverticulitis and its related complications (mean age, 64.8 +/- 15.1 years; 53.2 percent female). In patients with diverticulitis, the rate of colostomy reversal was 56.3 percent (80 percent in patients less than 50 years, and 30 percent in patients over 77 years). The in-hospital mortality rate after colostomy reversal was 0.36 percent, and was 2.6 percent in those over 77 years of age. After colostomy reversal a second stoma was used in 3.4 percent, reoperation was required for bleeding complications in 0.6 percent, and infectious complications were noted in 2 percent. The length of time from colostomy to its reversal was approximately five months (138.1 +/- 164 days; interquartile range, 72-156). The relationship between the length of time from colostomy to reversal was evaluated and the adjusted odds of a second stoma being used at the time of colostomy reversal were 45 percent higher (odds ratio, 1.45; 95 percent confidence interval, 1.22, 1.73) for each increase in time interval (<3, 6-9, 9-12, >12 months).

CONCLUSIONS

One-third of all colostomies were related to diverticulitis and only 56 percent were reversed. We identified a higher than expected mortality rate among older patients undergoing colostomy reversal. The impact of colostomy and reversal operations on both patients and the health care system is significant.

Intraoperative colonic lavage in emergency surgical treatment of left-sided large bowel lesions

There has been a trend towards resection and primary anastomosis after on-table lavage in patients with left sided colonic emergencies. This study will analyse the outcome in our centre. Thirty-two patients underwent the operation for various lesions of the left colon and the rectum between December 1998 and December 2002. The mean age of the patients was 37.7+/-11.1 years. Mean extra time for the procedure was 37.4+/-5.2 min. The mean hospital stay was 11.2+/-2.9 days. Postoperative complications included four cases (12.5%) of wound infection, and one (3.1%) right sub-phrenic abscess. No clinical anastomotic leakage or mortality was recorded. This study shows that primary anastomosis with on-table colonic lavage can be a safe procedure in selected, low risk patients.

Prospective, randomized trial comparing intraoperative colonic irrigation with manual decompression only for obstructed left-sided colorectal cancer

BACKGROUND

This is a prospective, randomized, controlled trial comparing the outcome of intraoperative colonic irrigation with that of manual decompression for acutely obstructing colorectal cancers distal to the splenic flexure.

METHODS

All patients admitted to our department from June 1999 to August 2002 with obstructing left-sided colorectal cancers were recruited. Patients were randomized intraoperatively and were excluded if deemed unsuitable for segmental resection and primary anastomosis. Twenty-five patients were randomized to receive colonic irrigation and twenty-eight to receive manual decompression. Perioperative parameters and outcome including mortality and anastomotic leak were recorded.

RESULTS

Both groups of patients were comparable in terms of gender and age. The time taken for mobilization, decompression, and irrigation in the colonic irrigation group (median, 31 minutes) was significantly longer than that for the manual decompression group (median, 13 minutes) (P; = 0.0005). However, the total time of the operation was similar for both groups. Times for recovery of bowel function, of wound infection, and until discharge from the hospital were also similar. In the manual decompression group there were two cases of anastomotic leak (8 percent, 2/25) requiring reoperation but none (0/24) in the colonic irrigation group. However, this difference was not statistically significant.

CONCLUSION

Manual decompression of proximal colon without irrigation is as safe as colonic irrigation in one-stage surgical management of obstructing left-sided colorectal cancer.

Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review

PURPOSE

This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis.

METHODS

This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity.

RESULTS

Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent.

CONCLUSIONS

Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.

Primary anastomosis after intraoperative colonic lavage vs. Hartmann's procedure in generalized peritonitis complicating diverticular disease of the colon

BACKGROUND AND AIMS

For complicated diverticulitis Hartmann's procedure remains the favored option in patients with acute complicated sigmoid disease, but there has been increasing interest in primary resection and anastomosis with intraoperative colonic lavage. This study compared primary resection with intraoperative colonic lavage and Hartmann's procedure.

PATIENTS AND METHODS

Between January 1994 and November 2001, 60 patients underwent emergency laparotomy for diverticular peritonitis (Hinchey stages III and IV). Primary resection and anastomosis with intraoperative colonic lavage was performed in 27 patients and Hartmann's procedure in 33. All data were collected prospectively on a standardized form.

RESULTS

Mortality with intraoperative colonic lavage was 11% and with Hartmann's procedure 12%. The incidence of postoperative complication was significantly higher after Hartmann's procedure. The mean hospital stay was significantly longer after Hartmann's procedure than after primary resection with intraoperative colic lavage.

CONCLUSION

Primary resection with intraoperative colonic lavage compares favorably with Hartmann's procedure for diffuse purulent peritonitis in complicated diverticulitis. It should be an alternative to Hartmann's procedure in stercoral peritonitis.

Safety of primary anastomosis in emergency colo-rectal surgery

BACKGROUND

The surgical management of left-sided large bowel emergency patients remains controversial. There has been an increasing trend towards primary reconstructive surgery. The main dilemma remains appropriate patient selection for primary anastomosis.

METHODS

The records of 323 patients who presented as acute emergencies and underwent surgery between January 1990 and December 2000 for left-sided colorectal cancer and diverticular disease were reviewed, to compare the outcome of resection and primary anastomosis with Hartmann's procedure. Patients were stratified into 3 groups according to whether the presentation was with localized or generalized peritonitis, or with obstruction.

RESULTS

Resection and anastomosis was carried out in 176 (55.7%) patients with a 30-day mortality of 5.7%. Anastomotic dehiscence occurred in 9 (5.1%) patients, with no difference between the three groups. Wound sepsis occurred in 8 (4.5%) patients, and the median hospital stay was 13 days. Hartmann's resection was associated with a higher incidence of systemic and surgical morbidity (39.5% and 24.3%, respectively). The mortality rates in those selected for primary anastomosis (5.7%) compared favourably with those undergoing Hartmann's resections (20.4%) (P < 0.001).

CONCLUSION

Emergency primary anastomosis in left-sided disease can be performed with a low morbidity and mortality in selected patients, even in the presence of a free perforation with diffuse peritonitis. Patients selected for staged resection, were those with major comorbid disease.

[Comparison between resection and primary anastomosis and staged resection in obstructing adenocarcinoma of the left colon]

BACKGROUND

The surgical option to deal with obstruction of the left side of the large bowel is still controversial.

OBJECTIVE

To report the experience of our group in the treatment of malignant left-sided colonic obstruction focusing on the immediate results using either one-stage resection and primary anastomoses or staged resection.

PATIENTS/METHODS

Twenty-three patients (median age = 52 (39-84) years; 10 males and 13 females) with potentially resectable obstructed adenocarcinomas of the left colon entered the study. The patients were submitted to different surgical procedure: 14 (60,9%) underwent one stage colonic resection (intra-operative lavage of colon (n = 10) or subtotal colectomy (n = 4); resection and primary anastomoses group) and 9 patients (39,1%) underwent staged resection (Hartmann's operation (n = 4) or loop colostomy (n = 5); staged resection group).

RESULTS

Two patients (8,7%) died. All were from the staged resection group. Four patients (44,4%) of staged resection group did not complete the treatment with the closing of the colostomy. The incidence of complications was 28,6% in resection and primary anastomoses group (4/14) and 66,7% in staged resection group (6/9). Hospital stay was 15 (9-45) in staged resection patients and 8 (6-20) in resection and primary anastomoses group. There was one case (7,1%) of anastomotic dehiscence in resection and primary anastomoses group and two cases (22,2%) in staged resection group.

CONCLUSIONS

The treatment of obstruction of left colon in one stage is safe and may be indicated for the management of the majority of cases.

Sigmoid volvulus in rural Bengal

Between January 1995 and December 2000, 197 patients (44.97%) were treated for sigmoid volvulus at Bankura Medical College and Hospital, Bankura, West Bengal, India. The mean age was 45.06 years and the male to female ratio was 2.07:1. The various aetiological factors, clinical features and management have been reviewed. Abdominal distension with obstipation was the common clinical presentation. Straight X-ray of the abdomen suggested the diagnosis. Management included celiotomy and primary resection and anastomosis without intra-operative lavage in 196 patients and sigmoidopexy in one patient. The overall mortality rate was 1.01%. There was only one recurrence in the patients who had undergone sigmoidopexy. Primary resection and anastomosis at initial presentation proved a safe operative treatment and avoided unnecessary repeated hospitalization.

One-stage procedure in non-elective surgery for diverticular disease complications

OBJECTIVE

Admission of patients with acute complications of diverticular disease is frequent and operative management remains controversial. The aim of this study was to investigate the efficacy and safety of resection, intra-operative colonic lavage and primary anastomosis in patients who require urgent laparotomy to treat complications of diverticular disease.

PATIENTS AND METHODS

From January 1992 to December 1999, 124 surgical patients underwent emergency operation for complicated diverticular disease. Resection, intra-operative colonic lavage and primary anastomosis were carried out in 55 patients: four with obstruction, two with massive bleeding and 49 with diverticulitis. In the diverticulitis group, 33 (67.3%) patients presented with localized peritonitis and 16 (32.7%) with generalized purulent peritonitis. No patient with faecal peritonitis was treated by a one-stage procedure.

RESULTS

One or more complications were detected in 25 patients (45.4%). Four patients (7.2%) required reintervention. Mortality occurred in four patients (7.2%). Two patients (3.6%) presented with anastomotic leakage. Wound infection was detected in 16 cases (29%). The overall mean (s.d.) Hospital stay was 18.5 (12.1) days.

CONCLUSION

Resection, intra-operative colonic lavage and primary anastomosis provide an alternative procedure for achieving one-stage resection in selected patients who require emergency operation for complication of diverticular disease.

Self-expanding metallic stent in the treatment of colonic obstruction caused by advanced malignancies

INTRODUCTION

The treatment of malignant obstruction of the left colon or rectum usually requires emergency surgery on poor-risk patients, and the creation of a stoma is usually inevitable. With the use of self-expanding metallic stents, the prompt relief of large-bowel obstruction without surgery has become possible. This report describes our results in the use of self-expanding metallic stents in the treatment of left-sided colonic obstruction resulting from advanced malignancies.

METHODS

From November 1997 to March 1999, insertion of self-expanding metallic stents was attempted in 24 patients with acute left-sided colonic obstruction caused by primary or recurrent malignancies. All the procedures were performed by colorectal surgeons. The guidewire was inserted through the channel of the endoscope, and its position was confirmed with fluoroscopy. Uncovered Wallstent esophageal endoprostheses were used in all except the first case. The insertion and deployment of the stents were under both endoscopic and fluoroscopic guidance.

RESULTS

There were 24 patients (15 males) with a mean age of 63.6 (range, 36-98) years. Thirteen patients had primary colorectal cancer and 11 had recurrent cancers (colorectal cancer, 5; gastric cancer, 5; other, 1). In the treatment of primary colorectal cancer, seven procedures were palliative, and no subsequent surgery was planned because of extensive liver metastasis or poor medical risk. The other six patients underwent elective resection after mechanical bowel preparation. There was no mortality related to the procedure. Stenting was successful in the relief of obstruction in 23 patients. Perforation of the colon occurred in one patient, and an emergency Hartmann's operation was performed. Migration of the stents occurred in three patients. Only 3 of the 18 patients in the palliation group required the subsequent creation of stomas.

CONCLUSION

The use of the self-expanding metallic stents can achieve rapid and effective nonsurgical means to relieve left-sided colonic obstruction. It provides good palliation for unresectable advanced tumors that cause colonic obstruction. It may also have a role in the temporary relief of obstruction so that subsequent colonic resection can be performed under elective conditions.

Role of resection and primary anastomosis of the left colon in the presence of peritonitis

BACKGROUND

Classically a primary colonic anastomosis is not performed in the presence of left colonic peritonitis. Recently there has been a trend towards resection and anastomosis in selected patients, but no prospective study concerning the safety of this approach has been published. The objective of this study was to define the role of intraoperative colonic lavage with resection and primary anastomosis (RPA) in left colonic peritonitis, and to evaluate the differences in outcome in patients with diffuse or localized peritonitis.

METHODS

Between January 1994 and December 1998, 127 patients underwent emergency operation for a distal large bowel perforation. RPA was the operation of choice and was performed in 61 patients, 38 with localized and 23 with diffuse peritonitis. Septic shock, faecal peritonitis, immunocompromised status and American society of Anesthesiologists grade IV were contraindications to the one-stage procedure. Alternative operations used in high-risk patients were Hartmann's procedure in 55 patients, subtotal colectomy in eight and colostomy in three.

RESULTS

There were two deaths (3 per cent) among 61 patients treated by RPA and one (2 per cent) case of clinical anastomotic dehiscence. Overall morbidity was 39 per cent and the overall mean(s.d.) hospital stay was 18(15) days. No statistical differences were observed between patients with localized and diffuse peritonitis treated by RPA.

CONCLUSION

RPA may be the operation of choice in selected patients with left colonic diffuse peritonitis.

Usefulness of preoperative colonic lavage using transanal ileus tube for obstructing carcinoma of left colon: device to perform one-stage operation safely

Surgical treatments for patients with obstructing carcinoma of the left colon still remain controversial, and many devices to perform a one-stage operation for such cases have been reported. The aim of the current study was to demonstrate the usefulness of preoperative colonic lavage using a transanal ileus tube to perform a one-stage operation for patients with obstructing carcinoma of the left colon. Five patients with intestinal obstruction due to advanced carcinoma of the left colon were investigated. An ileus tube was transanally inserted and placed in the colon proximal to the tumor under the guidance of a colonoscope and guidewire. Preoperative colonic lavage was done with oral administration of an irrigating solution over several days. By using a transanal ileus tube, preoperative colonic lavage can be done, which enables us to safely perform a one-stage operation for patients with obstructing carcinoma of the left colon with no increase in complications or anastomotic leakage.

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.