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Abstract
Large bowel obstruction is a serious and potentially life-threatening surgical emergency which is associated with high morbidity and mortality rate. The most common etiology is colorectal cancer which accounts for over 60% of all large bowel obstructions. Proper assessment, thoughtful decision-making and prompt treatment is necessary to decrease the high morbidity and mortality which is associated with this entity. Knowledge of the key elements regarding the presentation of a patient with a large bowel obstruction will help the surgeon in formulating an appropriate treatment plan for the patient. Comprehensive knowledge and understanding of the various treatment options available is necessary when caring for these patients. This chapter will review the presentation of patients with malignant large bowel obstruction, discuss the various diagnostic modalities available, as well as discuss treatment options and the various clinical scenarios in which they are most appropriately utilized.
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TOPÇU R, YILDIZ BD, AKIN T, BERKEM H, ER S, ULUSOY C, KENDİRCİ M, YÜKSEL BC, ÖZEL İH, HENGİRMEN S. Retrospective analysis of acute left colon obstructions due to colorectal cancers. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2020. [DOI: 10.32322/jhsm.712406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Nguyen HV, Le LH, Do PTT. One-stage operation without intraoperative colonic irrigation for left-sided colonic obstruction: Case series study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Hong Y, Nam S, Kang JG. The Usefulness of Intraoperative Colonic Irrigation and Primary Anastomosis in Patients Requiring a Left Colon Resection. Ann Coloproctol 2017; 33:106-111. [PMID: 28761871 PMCID: PMC5534493 DOI: 10.3393/ac.2017.33.3.106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 05/13/2017] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Youngki Hong
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Soomin Nam
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jung Gu Kang
- Department of Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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Ektov VN. [Enteroenterostomy in surgical treatment of malignant colonic obstruction]. Khirurgiia (Mosk) 2017:43-53. [PMID: 28914832 DOI: 10.17116/hirurgia2017943-53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
AIM To consider surgical tactics and to study the immediate results of primary enteroenterostomy in surgical treatment of malignant colonic obstruction. MATERIAL AND METHODS Radical surgery was performed in 170 (63.9%) out of 266 patients with malignant obstructive colonic obstruction. Colonic resection followed by anastomosis was performed in 68 patients. Conventional hemicolectomy (9 patients) and various original techniques of Y-shaped ileotransversanastomoses (27 patients) were used for right-sided tumor process. In case of left-sided tumor we used intraoperative colonic irrigation with enterosorption (20 operations), Y-shaped anastomoses (9 operations) and subtotal colectomy (3 operations). RESULTS There was significantly increased mortality in patients with sub- and decompensated stages of malignant colonic obstruction. Postoperative mortality after radical surgery was 10.6%, after palliative interventions - 21.9%. There was similar postoperative mortality after various types of radical interventions with/without enteroenterostomy (8.8% and 11.8%, respectively). CONCLUSION In favorable clinical situation radical surgery with tumor removal at the first emergency stage should be preferred for malignant colonic obstruction. At the specialized hospital segmental colonic resection with primary anastomosis is possible after comprehensive assessment of surgical risk, intraoperative colonic irrigation is obligatory for left-sided tumor. This approach increases surgical effectiveness and provides early rehabilitation.
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Affiliation(s)
- V N Ektov
- Department of Surgical Diseases, Burdenko Voronezh State Medical University, Voronezh, Russia
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Bingham JR, Steele SR. Influence of trauma, peritonitis, and obstruction on restoring intestinal continuity—To connect or not to connect? SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Maitra RK, Maxwell-Armstrong CA. Surgical management of obstructed and perforated colorectal cancer: still debating and unresolved issues. COLORECTAL CANCER 2013. [DOI: 10.2217/crc.13.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
SUMMARY Emergency surgery for obstruction and perforation from colorectal cancer (CRC) predicts poorer outcomes compared with elective surgery. For obstructed cancers, the evidence suggests significantly poorer outcomes with multistaged procedures compared with single-stage procedures in this group. Stenting remains an attractive option as a ‘bridge-to-surgery’, with multiple single-center studies demonstrating excellent short-term outcomes. However, contradictory evidence from three randomized trials casts doubts on stenting as the preferred modality for initial management of all curative obstructed CRCs. Results from a UK multicenter randomized controlled trial are still awaited. Palliative stenting shows predominantly positive results and is a valuable option for nonresectable or incurable CRCs. All authors agree on emergency surgery as the primary modality of treatment for perforated malignancies. Short-term outcomes are markedly poorer than the elective surgery group and correlate with the degree of peritoneal contamination. Long-term outcomes are comparable to elective surgery when perioperative deaths are excluded.
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Affiliation(s)
- Rudra K Maitra
- Department of Digestive Diseases & Thoracics Directorate, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, E Floor, West Block, NG7 2UH, UK
| | - Charles A Maxwell-Armstrong
- Department of Digestive Diseases & Thoracics Directorate, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, E Floor, West Block, NG7 2UH, UK
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Büyükgebiz O. Intraoperative underwater colonoscopy with a laparoscope following in-sleeve on-table colonic irrigation in obstructed left colon. SURGICAL PRACTICE 2013. [DOI: 10.1111/1744-1633.12034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Oğuzhan Büyükgebiz
- Department of Surgery; Kocaeli University School of Medicine; Kocaeli; Turkey
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Abstract
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.
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Affiliation(s)
- A Gainant
- Department of Digestive Surgery, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
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Ansaloni L, Andersson RE, Bazzoli F, Catena F, Cennamo V, Di Saverio S, Fuccio L, Jeekel H, Leppäniemi A, Moore E, Pinna AD, Pisano M, Repici A, Sugarbaker PH, Tuech JJ. Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society. World J Emerg Surg 2010. [PMID: 21189148 DOI: 10.1186/1749-7922-5-29.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC. METHODS The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced. RESULTS Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B). CONCLUSIONS Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.
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Affiliation(s)
- Luca Ansaloni
- 1st Unit of General Surgery, Ospedali Riuniti di Bergamo, Italy.
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Ansaloni L, Andersson RE, Bazzoli F, Catena F, Cennamo V, Di Saverio S, Fuccio L, Jeekel H, Leppäniemi A, Moore E, Pinna AD, Pisano M, Repici A, Sugarbaker PH, Tuech JJ. Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society. World J Emerg Surg 2010; 5:29. [PMID: 21189148 PMCID: PMC3022691 DOI: 10.1186/1749-7922-5-29] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 12/28/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Obstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC. METHODS The PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced. RESULTS Hartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B). CONCLUSIONS Loop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.
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Affiliation(s)
- Luca Ansaloni
- 1st Unit of General Surgery, Ospedali Riuniti di Bergamo, Italy
| | | | - Franco Bazzoli
- Department of Internal Medicine and Gastroenterology, University of Bologna, Italy
| | - Fausto Catena
- Unit of General, Emergency and Transplant Surgery, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Vincenzo Cennamo
- Department of Internal Medicine and Gastroenterology, University of Bologna, Italy
| | - Salomone Di Saverio
- Acute Care and Trauma Surgery Unit, Maggiore Hospital Trauma Center, Bologna, Italy
| | - Lorenzo Fuccio
- Department of Internal Medicine and Gastroenterology, University of Bologna, Italy
| | - Hans Jeekel
- Department of Surgery, ZNA Middelheim, Antwerp, Belgium
| | - Ari Leppäniemi
- Department of Surgery, Helsinki University Hospital, Helnsiki, Finland
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, University of Colorado Denver, CO, USA
| | - Antonio D Pinna
- Unit of General, Emergency and Transplant Surgery, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Pisano
- 1st Unit of General Surgery, Ospedali Riuniti di Bergamo, Italy
| | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milano, Italy
| | | | - Jean-Jaques Tuech
- Department of Digestive Surgery, Rouen University Hospital, Rouen, France
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Ciga MA, Oteiza F, Fernández L, de Miguel M, Ortiz H. Comparative study of one-stage colectomy of the descending colon in emergency and elective surgery without mechanical preparation. Dis Colon Rectum 2010; 53:1524-9. [PMID: 20940601 DOI: 10.1007/dcr.0b013e3181f05654] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aim of this study was to compare one-stage colectomy of the descending colon without mechanical preparation in emergency and elective surgery. METHODS From January 2004 to September 2009, 327 consecutive patients underwent surgery in a coloproctology unit for several conditions of the descending colon, 122 on an emergency basis and 205 as elective surgery. In the emergency surgery group, patients with septic shock, multiorgan failure, immunodeficiency or corticoid treatment, ASA IV stage, generalized fecal peritonitis (Hinchey IV stage), nonviable cecum or unresectable tumors were excluded (n = 54). In the elective surgery group, patients who underwent intraoperative colonoscopy, total abdominal colectomy, or an ostomy were excluded (n = 59). In the remaining 214 patients, a colectomy of the descending colon with primary colorectal anastomosis was performed without mechanical bowel preparation, 68 in emergency surgery and 146 in elective surgery. The end points of the study were mortality, anastomotic dehiscence, and surgical site infection. RESULTS No differences were found in mortality (0 in the emergency group vs 3 (2%) in the elective group; P = .571), symptomatic anastomotic dehiscence (1 in the emergency group (1.4%) vs 4 in the elective group (2.7%); P = 1.000), or surgical site infection (7 (10.2%) in the emergency group vs 8 (5.4%) in the elective group; P = .250). CONCLUSIONS In emergencies involving the descending colon one-stage surgery may be performed without colonic preparation as safely as elective surgery in selected patients considered suitable for segmental resection of the descending colon and primary anastomosis.
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Affiliation(s)
- Miguel A Ciga
- Department of Surgery, Virgen del Camino Hospital, Universidad Pública de Navarra, Pamplona, Navarra, Spain.
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Systematic review of intraoperative colonic irrigation vs. manual decompression in obstructed left-sided colorectal emergencies. Int J Colorectal Dis 2009; 24:1031-7. [PMID: 19415306 DOI: 10.1007/s00384-009-0723-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2009] [Indexed: 02/04/2023]
Abstract
AIMS A systematic review was conducted to determine if manual decompression is a safe alternative to intraoperative colonic irrigation prior to primary anastomosis in obstructed left-sided colorectal emergencies. METHODS Search for relevant articles from 1980 to 2007 was conducted on Medline, Embase and the Cochrane Controlled Trials Register using the keywords "colonic lavage, irrigation, decompression, washout, obstructed and bowel preparation", either singularly or in combination. Trials in English publications with similar patient characteristics, inclusion criteria and outcome measures were selected for analysis. Thirty-day mortality, anastomotic leak rates and post-operative wound infection were studied as outcome variables. Analysis was performed with RevMan 4.2 software. RESULTS Seven trials were identified for systematic review, with a total of 449 patients. Data from the single randomised controlled trial and one prospective comparative trial were analysed separately. Results from the remaining five studies were pooled into two arms of a composite series, one with colonic irrigation and one without. Results showed no significant difference in the anastomotic leak rates and mortality rates between the colonic irrigation and manual decompression arms in the randomised and comparative trials. The composite series, however, showed significantly better results with manual decompression (RR 6.18, 95% CI 1.67-22.86). The post-operative infection rate was similar in both groups. CONCLUSION Manual decompression was comparable to colonic irrigation for primary anastomosis in obstructed left-sided colorectal emergencies, with no significant increase in mortality, leak or infection rates.
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Ortiz H, Biondo S, Ciga MA, Kreisler E, Oteiza F, Fraccalvieri D. Comparative study to determine the need for intraoperative colonic irrigation for primary anastomosis in left-sided colonic emergencies. Colorectal Dis 2009; 11:648-52. [PMID: 18624813 DOI: 10.1111/j.1463-1318.2008.01617.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To compare the outcome of resection and primary anastomoses in patients undergoing emergency surgery of the left colon with and without intraoperative colonic irrigation. METHOD From January 2004 to December 2006, 102 consecutive patients with acute occlusion or perforation of the left colon were operated on an emergency basis in two Coloproctology units. According to the sample size calculation, 61 patients from one unit underwent surgery with intraoperative colonic irrigation, whereas 41 patients from the second unit underwent surgery without intraoperative colonic irrigation. The endpoints were mortality and morbidity. RESULTS Thirty (49.2%) patients with intraoperative colonic irrigation and 8 (19.5%) without colonic irrigation developed one or more complications postoperatively (odds ratio 4.0, 95% CI 1.6-10.0, P = 0.002). An increased number of wound infections was seen in the group managed with colonic irrigation 15 vs 3 (P = 0.034). The postoperative mortality rate and the occurrence of dehiscence of the anastomoses were similar in both study groups. CONCLUSION The present findings indicate that resection and primary anastomosis in patients undergoing emergency surgery of the left colon can be safely performed without intraoperative colonic irrigation.
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Affiliation(s)
- H Ortiz
- Department of Surgery, Hospital Virgen del Camino, Universidad Pública de Navarra, Pamplona, Navarra, Spain.
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Trompetas V. Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl 2008; 90:181-6. [PMID: 18430330 DOI: 10.1308/003588408x285757] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress. METHODS A literature search was undertaken using PubMed and the Cochrane Library regarding the options in emergency management of left-sided colonic obstruction focusing on outcomes such as mortality, morbidity, long-term prognosis and cost effectiveness. DISCUSSION Colonic stenting is the best option either for palliation or as a bridge to surgery. It reduces morbidity and mortality rate and the need for colostomy formation. Stenting is likely to be cost effective, but data are variable depending on the individual healthcare system. Nevertheless, surgical management remains relevant as colonic stenting has a small rate of failure, and it is not always available. There are various surgical options. One-stage primary resection and anastomosis is the preferred choice for low-risk patients. Intra-operative colonic irrigation has no proven benefit. Subtotal colectomy is useful in cases of proximal bowel damage or synchronous tumours. Hartmann's procedure should be reserved for high-risk patients. Simple colostomy has no role other than for use in very ill patients who are not fit for any other procedure.
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Affiliation(s)
- Vasileios Trompetas
- Department of Surgery, Eastbourne District General Hospital, Eastbourne, UK.
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Abstract
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.
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Pilot study on one-stage colonic resection without lavage in obstructed left colon in children in an emergency setting. Pediatr Surg Int 2007; 23:1199-202. [PMID: 17968561 DOI: 10.1007/s00383-007-2054-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2007] [Indexed: 10/22/2022]
Abstract
Classically, left-sided colon obstruction is managed by a multi-staged resection and defunctioning colostomy. The purpose of this study was to examine the feasibility of single-stage resection and anastomosis without intraoperative colonic lavage for acute left-sided colonic obstruction in children. Between October 2000 and May 2006, nine consecutive patients who had a one-stage left-sided colon resection without preceding colonic lavage were evaluated. The main outcome measures were anastomotic leakage, wound infection and death. There were nine patients: six were males and three were females (M:F = 2:1). Their ages ranged from 2-10 years (mean age 6 years). The obstruction was due to irreducible colo-colic intussusceptions in two patients and colo-colic intussusceptions with colonic perforation in four patients, and colo-colic intussusceptions with gangrene in three. All the patients had resection and primary anastomosis without on-table colonic lavage. There were no anastomotic leakages or deaths. Postoperative complications included superficial wound infections in two patients and dry cough in four other patients. Three patients were lost to follow up after 3 years of follow up, but the remaining six are presently doing well. Primary anastomosis without colonic lavage is safe for resection of the left colon in children in an emergency setting.
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Govindarajan A, Naimark D, Coburn NG, Smith AJ, Law CHL. Use of colonic stents in emergent malignant left colonic obstruction: a Markov chain Monte Carlo decision analysis. Dis Colon Rectum 2007; 50:1811-24. [PMID: 17899279 DOI: 10.1007/s10350-007-9047-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 04/11/2007] [Accepted: 05/26/2007] [Indexed: 02/08/2023]
Abstract
PURPOSE This decision analysis examines the cost-effectiveness of colonic stenting as a bridge to surgery vs. surgery alone in the management of emergent, malignant left colonic obstruction. METHODS We used a Markov chain Monte Carlo decision analysis model to determine the effect on health-related quality of life of two strategies: emergency surgery vs. emergency colonic stenting as a bridge to definitive surgery. All relevant health states were modeled during a patient's expected lifespan. Outcome measures were mortality, the proportion of patients requiring a colostomy, quality-adjusted life expectancy, and costs. Deterministic and probabilistic sensitivity analyses were performed. RESULTS In our model, colonic stenting was more effective (9.2 quality-adjusted life months benefit) and less costly (CAD dollars 3,763; US dollars 3,135) than emergency surgery. Its benefits were secondary to reductions in acute mortality and in the likelihood of requiring a permanent colostomy. The results were only dependent on the rate of stenting complications (perforation, technical placement failure, and migration) and the patient's risk of surgical mortality, with the benefits being greatest among patients at high risk of operative mortality. CONCLUSIONS Colonic stenting as a bridge to surgery is more effective and less costly than surgery in the treatment of emergent, malignant left colonic obstruction. The benefits are most pronounced in high-risk patients and are diminished by increases in stent placement failure rates and perforation rates. In low-risk patients, the benefits are more modest and may not outweigh the risks.
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Affiliation(s)
- Anand Govindarajan
- Division of General Surgery, University of Toronto, Toronto, Ontario, Canada
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Finan PJ, Campbell S, Verma R, MacFie J, Gatt M, Parker MC, Bhardwaj R, Hall NR. The management of malignant large bowel obstruction: ACPGBI position statement. Colorectal Dis 2007; 9 Suppl 4:1-17. [PMID: 17880381 DOI: 10.1111/j.1463-1318.2007.01371.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- P J Finan
- Department of Colorectal Surgery, General Infirmary at Leeds, Leeds, UK.
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Bianchi A, Pulido L, Espín F, Hidalgo LA, Heredia A, Fantova MJ, Muns R, Suñol J. [Intestinal endometriosis. Current status]. Cir Esp 2007; 81:170-6. [PMID: 17403352 DOI: 10.1016/s0009-739x(07)71296-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Endometriosis affects a wide spectrum of premenopausal women. Intestinal involvement, affecting mainly the large bowel and sometimes the small bowel, is much less frequent. Diagnosis is relatively straightforward in women with long standing pelvic endometriosis but is difficult in acute intestinal obstruction, since a diagnosis of endometriosis is not often considered in this entity. We performed an exhaustive review of the medical literature, including the option of medical treatment, which is rarely effective in intestinal endometriosis. In most patients with intestinal symptoms, the disease is so severe that surgical treatment is required. Recent studies indicate that the most effective approach is laparoscopic. We analyze the most important classical and recent series of patients and discuss treatment results.
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Affiliation(s)
- Alberto Bianchi
- Servicio de Cirugía General, Hospital de Mataró, Consorci Sanitari del Maresme, Mataró, Barcelona, España.
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Abstract
Acute colonic obstruction is a medical emergency because of the potential for bowel ischemia, perforation, and sepsis with peritonitis if not rapidly and appropriately treated. There are numerous causes of acute colonic obstruction, which must be differentiated from colonic pseudo-obstruction, which also is considered a medical emergency. Management options include medical therapy, surgical therapy, endoscopic therapy, and interventional radiologic therapy. Self-expandable metal stents (SEMS) have gained acceptance for alleviating acute malignant colonic obstruction and in some situations for preoperative relief of acute benign colonic obstruction. This article reviews the approach to the patient who has acute colonic obstruction.
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Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology & Hepatology, Mayo Clinic College of Medicine, 200 First Street Southwest, Charlton 8A, Rochester, MN 55905, USA.
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Pavlidis TE, Marakis G, Ballas K, Rafailidis S, Psarras K, Pissas D, Papanicolaou K, Sakantamis A. Safety of bowel resection for colorectal surgical emergency in the elderly. Colorectal Dis 2006; 8:657-62. [PMID: 16970575 DOI: 10.1111/j.1463-1318.2006.00993.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study. PATIENTS AND METHODS In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma. RESULTS The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction. CONCLUSION Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.
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Affiliation(s)
- T E Pavlidis
- Second Surgical Propedeutical Department, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Konstantinoupoleos 49, 54642 Thessaloniki, Greece.
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Poskus E, Jotautas V, Zeromskas P, Stratilatovas E, Stasinskas A, Strupas K. One-Stage Operation for Cancer of the Left Colon with Bowel Obstruction: Do We Need On-Table Wash-Out of the Colon? Visc Med 2006. [DOI: 10.1159/000091660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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