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Williams B, Gupta A, Koller SD, Starr TJ, Star MJH, Shaw DD, Hakim AH, Leinicke J, Visenio M, Perrone KH, Torgerson ZH, Person AD, Ternent CA, Chen KA, Kapadia MR, Keller DS, Elnagar J, Okonkwo A, Gagliano RA, Clark CE, Arcomano N, Abcarian AM, Beaty JS. Emergency Colon and Rectal Surgery, What Every Surgeon Needs to Know. Curr Probl Surg 2024; 61:101427. [PMID: 38161059 DOI: 10.1016/j.cpsurg.2023.101427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 10/17/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Brian Williams
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Abhinav Gupta
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Sarah D Koller
- Division of Colon and Rectal Surgery, University Southern California, Los Angelos, CA
| | - Tanya Jt Starr
- Health Corporation of America, Midwest Division, Kansas City, KS
| | | | - Darcy D Shaw
- Health Corporation of America, Midwest Division, Kansas City, KS
| | - Ali H Hakim
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Leinicke
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Michael Visenio
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Kenneth H Perrone
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | | | - Austin D Person
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Charles A Ternent
- Department of Colon and Rectal Surgery, Creighton University, Omaha, NE
| | - Kevin A Chen
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Muneera R Kapadia
- Division of Gastrointestinal Surgery, University of North Carolina, Chapel Hill, NC
| | - Deborah S Keller
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA; Marks Colorectal Surgical Associates, Wynnewood, PA
| | - Jaafar Elnagar
- Department of Surgery, Lankenau Medical Center, Wynnewood, PA
| | | | | | | | - Nicolas Arcomano
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL
| | - Ariane M Abcarian
- Department of Surgery, University of Illinois College of Medicine at Chicago, Chicago, IL; Cook County Health, Chicago, IL
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CReST Collaborative Group, Hill J, Lee S, Morton D, Parker M, Halligan S, Taylor S, Kay C, Gray R, Handley K, Kaur M, Magill L, Fulcher L, Kaur M, Lilly H, Palmer A, Peters A, Magill L, Sidile C, Wilcockson A, Bensoussane H, Handley K, Marchevsky N, Oliver A, Carlson G, Scott N, Hiller L, Alderson D, Martin D, Yu L, Chokkalingam A, Cross N, Delicata RJ, Edwards P, Sturgeon G, Domingo D, Gutmann J, Huang J, Mills-Baldock T, Mtwana A, Premchand P, Willis N, Cocks S, Curran E, Gall Z, Harris P, Hobbiss J, Lipscomb G, Maxwell A, Patel H, Smith D, Antrum RM, Beckett CG, Davies J, Ghosh T, Gokhale J, Griffith JP, Halstead J, Jackson C, Jowett S, Kay C, Lowe A, May J, McGowan J, Robinson J, Simpson R, Stephenson S, Steward M, Thomas B, Thrower A, Ward K, Dexter J, Doyle T, Farrands P, Hart A, Lamah M, Peterson J, Brown H, Cameron E, Carroll N, Davies J, Fearnhead N, Goodwin K, Liddle A, Miller R, Morton J, Powar M, Read D, Sloan K, Uttridge J, Wheeler J, Bain I, Clark S, Cundall J, Dent J, Green S, Grunshaw N, Gunning K, Howey A, Marsden S, et alCReST Collaborative Group, Hill J, Lee S, Morton D, Parker M, Halligan S, Taylor S, Kay C, Gray R, Handley K, Kaur M, Magill L, Fulcher L, Kaur M, Lilly H, Palmer A, Peters A, Magill L, Sidile C, Wilcockson A, Bensoussane H, Handley K, Marchevsky N, Oliver A, Carlson G, Scott N, Hiller L, Alderson D, Martin D, Yu L, Chokkalingam A, Cross N, Delicata RJ, Edwards P, Sturgeon G, Domingo D, Gutmann J, Huang J, Mills-Baldock T, Mtwana A, Premchand P, Willis N, Cocks S, Curran E, Gall Z, Harris P, Hobbiss J, Lipscomb G, Maxwell A, Patel H, Smith D, Antrum RM, Beckett CG, Davies J, Ghosh T, Gokhale J, Griffith JP, Halstead J, Jackson C, Jowett S, Kay C, Lowe A, May J, McGowan J, Robinson J, Simpson R, Stephenson S, Steward M, Thomas B, Thrower A, Ward K, Dexter J, Doyle T, Farrands P, Hart A, Lamah M, Peterson J, Brown H, Cameron E, Carroll N, Davies J, Fearnhead N, Goodwin K, Liddle A, Miller R, Morton J, Powar M, Read D, Sloan K, Uttridge J, Wheeler J, Bain I, Clark S, Cundall J, Dent J, Green S, Grunshaw N, Gunning K, Howey A, Marsden S, Minty I, Morgan L, Noblett S, Potts K, Scott J, Turnbull D, Varma JS, Wayman L, Welsh S, Anstead A, Bhardwaj R, Edmunds T, Fuller B, Holder P, Lacey L, Parker MC, Ryan R, Smith-Hedges J, Stuart C, Walsh K, Basu A, Omar A, Pitt J, Read G, Ridley P, Spurgeon J, Tricker Y, Bird N, Browell D, Barry C, Cunliffe W, Eltringham M, Katrory M, Mercer-Jones M, Nice C, Scott J, Timmons G, Williams M, Wipat C, Akula J, Caine A, Dawson P, Reese G, Fatola Y, Mazibuko B, Pelling M, Ramos L, Smith GV, Aryal K, Ashraf K, Badreldin R, Brett B, DeSilva A, Gray S, Harman J, Jordon M, Kshatriya KS, Lal R, Perry L, Velchuru V, Williams M, Chung-Faye G, Hansmann A, Leather A, Papagrigoriadis S, Peddu P, Ryan S, Ambrose S, Baker R, Beral D, Botterill I, Burke D, Clarke L, Evans M, Everett S, Finan PJ, Griffiths B, Hamlin J, Hance J, Harris K, Hussain M, Jayne D, Kelly S, Lim M, Maslekar S, Miskovic D, Moriarty C, Priestley M, Rawson S, Sagar PM, Saunders R, Sheridan M, Speight H, Tolan D, White L, Wilkinson L, Wilson T, Burling D, Clark S, Datt P, Fraser C, Gupta A, Jenkins I, Kennedy R, Northover JM, Sakuma S, Saunders BP, Suzuki N, Thomas-Gibson S, Curran F, Hitchen D, Immanuel A, Kirk S, Kushwaha R, Lee S, Parker M, Vanessa A, Butler-Barnes J, Hough C, Khan A, Larcombe T, London I, Selvasekar C, Zaman S, Anderson J, Ball J, Basheer M, Brittenden J, Fawole A, Foster R, Gill K, Hayton-Bott A, Jones A, Kamposioras K, Kerr S, Lowry T, Lupton S, Macklin C, Morrison C, Morrison CP, Narula H, Parchment-Smith C, Rogers M, Shah S, Sivakumar R, Sivaramakrishnan N, Vani D, Verma K, Sivanathan C, Chong P, Duff M, Duffey K, Horgan P, McGregor L, McKee R, Pender J, Viswanathan S, Ashcroft M, Docherty JG, Donaldson A, Lim M, Macleod K, Macleod AJM, Todd A, Walker KG, Watson AJM, Younger H, Brush J, Glancy S, MacRury M, Mander J, Paterson H, Atkin L, Brain C, Brunt S, Burt C, Cheshire H, Clout M, Corderoy H, Dawe C, Dixon AR, Garlicka H, Hopes M, John S, Kirby K, Kirkpatrick S, Law R, Longstaff A, Loveday E, Lyons A, McCarthy K, Pullyblank A, Reilly A, Richmond-Russell K, Roe AM, Saville L, Shelton L, Slack N, Smith C, Solomon L, Treasure A, Agarwal AK, Borowski D, Chilvers A, Dwarakanath D, Essex S, Garg D, Gill T, Jameson E, Jones-King P, Kiddell S, Latif H, Latimer J, Shepherd L, Sinclair S, Tabaqchali MA, Wardle H, Wilson D, Ahmad A, Arain A, Cartmell M, Cross K, Davis A, Groome J, Holbrook B, Ley S, Markham N, Menon M, Taylor J, Thomas F, Koutrik LV, Ahmad SM, Cursley V, Dent K, Martin K, Pai D, Pearson S, Abercrombie JF, Acheson A, Aldred L, Armitage NC, Banerjea A, Coulson C, Eyre M, Maxwell-Armstrong CA, O'Neil R, Ragunath K, Robinson MHE, Scholefield JH, Swinden R, Williams J, Anthony S, Bratby M, Cunningham C, Fourie S, Jones O, Lindsey I, Morrison F, Mortensen NJ, Munday D, Uberoi R, Ahmad F, Chandra N, Conaghan P, Coull D, Foxton J, Gibson M, Hameed W, Jones L, McGrath D, Ramus J, Samakomva T, Speirs A, Walsh K, Arumugam H, Ewiddison A, Faux W, Feldman M, Gopalswamy S, Graves L, Hancock J, Harvey P, Hussaini H, Lloyd-Davies E, Lynn C, Madine JP, Maskell G, Morley N, Pollard K, Prout K, Boorman P, Dickinson B, Guinness R, Hill T, Moran J, Anderson ID, Ashton A, Babbs C, Burnett H, Goulden K, Harrison P, Harter L, Hughes S, Kenyon V, Lee S, Lees N, Lydon A, Ogden A, Ottiwell L, Platt D, Read F, Slade D, Thompson C, Vinod C, Watson D, Brown S, Donnelly D, Hampton J, Eyre-Brook IA, Foot J, Forsyth N, Hunt L, Lowe A, Mackey P, Matull R, Thomas H, Vickery CJ, Caddy G, Foreman J, Hyland M, McCallion K, McFerran E, Tham T, Turkington J, Day S, Francombe J, Murphy P, Simmons E, Sinha R, Bull D, Compson A, Gould M, Ishaq S, Kawesha A, Maleki K, Marriott M, Poutney L, Stonelake PS, Adams C, Brundell S, Coleman M, Congdon H, Douie W, Eastlake L, Evenden L, Fox B, Gandy C, Georgiadis K, Hosie KB, Latchford A, Oppong FC, Pascoe J, Rance M, Shepherd E, Shirley J, Smith H, Appleton B, Bobary C, Feeney M, Gardner A, Krouma F, Richards D, Roche L, Tudor G, Young T, Olufunso A, Alderson D, Atif M, Bach S, Dasgin J, Forde C, Futaba K, Ghods-Ghorbani M, Gourevitch D, Ismail T, Keh C, Manimaran N, McCafferty I, Morton DG, Pandey S, Radley S, Riley P, Royle J, Suggett N, Torrance A, Tucker O, Vohra R, Aldous J, Beal D, Beveridge H, Bradshaw S, Carrick AJ, Coulson C, Dockree J, Fearon M, Hall A, Holding K, Hurst N, Irvine G, Langston K, Lund J, Redfern G, Reeves D, Reynolds JR, Rowntree J, Simmonds K, Singh R, Speake W, Tierney G, Tou S, Worth C, Singh B, Verma R, Allison J, Allison A, Bathurst N, Buckley C, Gotto J, Khan Z, Ockrim J, Rowland-Axe R, Russell A, Spurdle K, Williams-Yesson B, Ames A, Rylance PC, Dyer S, Fletcher J, Kent S, Law N, Macfie J, Mainprize K, Mallinson J, McNaught C, Mitchell C, Nunn A, Renwick IGH. Colorectal Endoscopic Stenting Trial (CReST) for obstructing left-sided colorectal cancer: randomized clinical trial. Br J Surg 2022; 109:1073-1080. [PMID: 35986684 DOI: 10.1093/bjs/znac141] [Show More Authors] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Colorectal cancer often presents with obstruction needing urgent, potentially life-saving decompression. The comparative efficacy and safety of endoluminal stenting versus emergency surgery as initial treatment for such patients is uncertain. METHODS Patients with left-sided colonic obstruction and radiological features of carcinoma were randomized to endoluminal stenting using a combined endoscopic/fluoroscopic technique followed by elective surgery 1-4 weeks later, or surgical decompression with or without tumour resection. Treatment allocation was via a central randomization service using a minimization procedure stratified by curative intent, primary tumour site, and severity score (Acute Physiology And Chronic Health Evaluation). Co-primary outcome measures were duration of hospital stay and 30-day mortality. Secondary outcomes were stoma formation, stenting completion and complication rates, perioperative morbidity, 6-month survival, 3-year recurrence, resource use, adherence to chemotherapy, and quality of life. Analyses were undertaken by intention to treat. RESULTS Between 23 April 2009 and 22 December 2014, 245 patients from 39 hospitals were randomized. Stenting was attempted in 119 of 123 allocated patients (96.7 per cent), achieving relief of obstruction in 98 of 119 (82.4 per cent). For the 89 per cent treated with curative intent, there were no significant differences in 30-day postoperative mortality (3.6 per cent (4 of 110) versus 5.6 per cent (6 of 107); P = 0.48), or duration of hospital stay (median 19 (i.q.r. 11-34) versus 18 (10-28) days; P = 0.94) between stenting followed by delayed elective surgery and emergency surgery. Among patients undergoing potentially curative treatment, stoma formation occurred less frequently in those allocated to stenting than those allocated to immediate surgery (47 of 99 (47.5 per cent) versus 72 of 106 (67.9 per cent); P = 0.003). There were no significant differences in perioperative morbidity, critical care use, quality of life, 3-year recurrence or mortality between treatment groups. CONCLUSION Stenting as a bridge to surgery reduces stoma formation without detrimental effects. Registration number: ISRCTN13846816 (http://www.controlled-trials.com).
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Herzberg J, Khadem S, Guraya SY, Strate T, Honarpisheh H. Intraoperative Colonic Irrigation for Low Rectal Resections With Primary Anastomosis: A Fail-Safe Surgical Model. Front Surg 2022; 9:821827. [PMID: 35465417 PMCID: PMC9023858 DOI: 10.3389/fsurg.2022.821827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/22/2022] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Jonas Herzberg
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
- *Correspondence: Jonas Herzberg
| | - Shahram Khadem
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Salman Yousuf Guraya
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Tim Strate
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Human Honarpisheh
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
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Ng KS, Gladman MA. LARS: A review of therapeutic options and their efficacy. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Lim T, Tham HY, Yaow CYL, Tan IJW, Chan DKH, Farouk R, Lee KC, Lieske B, Tan KK, Chong CS. Early surgery after bridge-to-surgery stenting for malignant bowel obstruction is associated with better oncological outcomes. Surg Endosc 2021; 35:7120-7130. [PMID: 33433675 DOI: 10.1007/s00464-020-08232-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 12/03/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Placement of self-expanding metal stents has been increasingly adopted as a bridge to surgery in patients presenting with obstructed left-sided colorectal cancers. The optimal bridging time has yet to be widely established, hence this retrospective study aims to determine the optimal bridging time to elective surgery post endoluminal stenting. PATIENTS AND METHODS All patients who underwent colorectal stenting for large bowel obstruction in a single, tertiary hospital in Singapore between January 2003 and December 2017 were retrospectively identified. Patients' baseline demographics, tumour characteristics, stent-related complications, intra-operative details, post-operative complications and oncological outcomes were analysed. RESULTS Of the 53 patients who successfully underwent colonic stenting for malignant left sided obstruction, 33.96% of patients underwent surgery within two weeks of stent placement while 66.04% of patients underwent surgery after 2 weeks of stent placement. Univariate analysis between both groups did not demonstrate significant differences in postoperative complications and stoma formation. Significant differences were observed between both groups for stent complications (38.89% vs 8.57%, p = 0.022), on-table decompression (38.89% vs 2.86%, p = 0.001) and systemic recurrence (11.11% vs 40.00%, p = 0.030). Increased bridging interval to surgery (OR 13.16, CI 1.37-126.96, p = 0.026) was a significant risk factor for systemic recurrence on multivariate analysis. CONCLUSIONS Patients undergoing definitive surgery within 2 weeks of colonic stenting may have better oncological outcomes without compromising on postoperative outcomes. Further prospective studies are required to compare outcomes between emergency surgery and different bridging intervals.
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Affiliation(s)
- Tammy Lim
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Hui Yu Tham
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
| | - Clyve Yu Leon Yaow
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ian Jse-Wei Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Dedrick Kok Hong Chan
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ridzuan Farouk
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Kuok Chung Lee
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Bettina Lieske
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ker-Kan Tan
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Choon Seng Chong
- Division of Colorectal Surgery, University Surgical Cluster, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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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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Carr JA. The Dudley colectomy in urgent and emergent situations: a 10 patient case series. J Surg Case Rep 2019; 2019:rjz123. [PMID: 31044065 PMCID: PMC6479186 DOI: 10.1093/jscr/rjz123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/06/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- John Alfred Carr
- St. Joseph Mercy Hospital, 5301 McAuley Drive, Ypsilanti, MI 48197, USA
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Abstract
Preservation of the anal sphincters is now consistent with adequate extirpation of the majority of rectal neoplasms. However, there is still a troublesome incidence of leakage through colorectal anastomoses. A number of different factors, working in combination, are responsible for this. Although most problems have been solved, and the mortality is low, the anastomotic leak rate described in the present series, and in the hands of most surgeons, remains high. Efficient suturing without tension, adequate filling and drainage of the presacral space, and antimicrobial prophylaxis effective enough to abolish abdominal wound sepsis, have been applied. The large vessel arterial blood supply to the suture line is good but the microcirculation of the left colon and rectum, upon which suture line healing ultimately depends, is suspect. Reduction of blood viscosity by deliberate lowering of the haemoglobin level before operation has been practised in the hope of improving the microcirculatory flow. The results so far are encouraging and suggest that the method is worth a continued trial.
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Is patient factor more important than surgeon-related factor in sepsis prevention in colorectal surgery? INTERNATIONAL JOURNAL OF SURGERY OPEN 2018. [DOI: 10.1016/j.ijso.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bendl RF, Bergamaschi R. Do Patients Mandate Resection After a First Episode of Acute Diverticulitis of the Colon with a Complication? Adv Surg 2017; 51:179-191. [PMID: 28797339 DOI: 10.1016/j.yasu.2017.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ryan Francis Bendl
- Department of Surgery, Norwalk Hospital, 30 Stevens Street, Suite D, Norwalk, CT 06856, USA.
| | - Roberto Bergamaschi
- Division of Colorectal Surgery, Department of Surgery, Stony Brook School of Medicine, Stony Brook, NY 11794, USA
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Naso-intestinal tube is more effective in treating postoperative ileus than naso-gastric tube in elderly colorectal cancer patients. Int J Colorectal Dis 2017; 32:1047-1050. [PMID: 28101658 DOI: 10.1007/s00384-017-2760-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/11/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The objective of this study was to compare the effect of naso-intestinal tube and naso-gastric tube in relieving postoperative ileus in elderly patients with colorectal cancer. METHODS Patients (n = 46) with ileus symptom following radical surgery for treating colorectal cancer were placed with either naso-intestinal tube at duodenum or conventional naso-gastric tube. Then, their waist perimeter, intra abdominal pressure, maximum diameter in bowls, length of time to pass flatus or passage of bowel movement or to return to diet, length of hospital stay, daily drainage, serum levels of lactic acid, hemoglobin, and creatinine as well were compared. RESULTS Naso-intestinal tube placement is more effective than naso-gastric tube in relieving intra abdominal pressures, reducing maximum bowl diameter and waist circumference, correcting serum lactic acid levels, alleviating analgesia dependence, regaining serum albumin level, increasing drainage and shortening the time of length of hospital stay, passing flatus or faces, and time to return to diet. CONCLUSION Naso-intestinal tube is effective in treating POI and shows advantage over conventional naso-gastric tube insertion.
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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: 0.6] [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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Faucheron JL, Paquette B, Trilling B, Heyd B, Koch S, Mantion G. Emergency surgery for obstructing colonic cancer: a comparison between right-sided and left-sided lesions. Eur J Trauma Emerg Surg 2017; 44:71-77. [PMID: 28271148 DOI: 10.1007/s00068-017-0766-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/20/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE Few studies compare management and outcomes of obstructive colonic cancer, depending on the tumor site. We aim to evaluate the differences in patient characteristics, tumor characteristics, and outcomes of emergency surgery for obstructive right-sided versus left-sided colonic cancers. METHODS Between 2000 and 2009, 71 consecutive patients had an emergency colectomy following strict and clear definition of obstruction in a single institution. We retrospectively analyzed pre, per, and postoperative data that were prospectively collected. RESULTS There were 31 and 40 patients in the right and left group, respectively. Patients aged over 80 were more frequent in the right group (p = 0.03). At operation, ileocecal valve was less often competent in the right group (p = 0.03). The one-stage strategy was more frequent in the right group (p = 0.008). Patients in the right group had a higher rate of nodes invasion (p = 0.04). One- and two-year mortality rate in the right group had a tendency to be higher. CONCLUSIONS Patients presenting with a right obstructive colonic cancer are older, have a more advanced locoregional disease, and are more often treated in a one-stage strategy than patients with a left obstructive tumor.
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Affiliation(s)
- J-L Faucheron
- Colorectal Unit, Department of Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France.
- University Grenoble Alps, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France.
| | - B Paquette
- Department of Surgery, University Hospital, 25030, Besançon Cedex, France
| | - B Trilling
- Colorectal Unit, Department of Surgery, Grenoble Alps University Hospital, 38000, Grenoble, France
- University Grenoble Alps, UMR 5525, CNRS, TIMC-IMAG, 38000, Grenoble, France
| | - B Heyd
- Department of Surgery, University Hospital, 25030, Besançon Cedex, France
| | - S Koch
- Department of Gastroenterology, University Hospital, 25030, Besançon Cedex, France
| | - G Mantion
- Department of Surgery, University Hospital, 25030, Besançon Cedex, France
- Department of Gastroenterology, University Hospital, 25030, Besançon Cedex, France
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Awotar GK, Guan G, Sun W, Yu H, Zhu M, Cui X, Liu J, Chen J, Yang B, Lin J, Deng Z, Luo J, Wang C, Nur OA, Dhiman P, Liu P, Luo F. Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation. Clin Colorectal Cancer 2017; 16:e89-e103. [PMID: 28254356 DOI: 10.1016/j.clcc.2016.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/01/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported. PATIENTS AND METHODS Patients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant. RESULTS There were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05). CONCLUSIONS Primary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.
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Affiliation(s)
- Gavish Kumar Awotar
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Guoxin Guan
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Wei Sun
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Hongliang Yu
- Department of General Surgery, The Third Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Ming Zhu
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Xinye Cui
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Jie Liu
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Jiaxi Chen
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Baoshun Yang
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Jianyu Lin
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Zeyong Deng
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Jianwei Luo
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Chen Wang
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Osman Abdifatah Nur
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Pankaj Dhiman
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China
| | - Pixu Liu
- Institute of Cancer Stem Cell & College of Pharmacy, Dalian Medical University, Dalian, China
| | - Fuwen Luo
- Department of General Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian City, Liaoning Province, PR China.
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16
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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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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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Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg 2013; 207:127-38. [PMID: 24124659 DOI: 10.1016/j.amjsurg.2013.07.027] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Revised: 07/11/2013] [Accepted: 07/18/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The management of colonic obstruction has changed in recent years. In distal obstruction, optimal treatment remains controversial, particularly after the appearance and use of colonic endoluminal stents. The purpose of this study was to review the current treatment of acute malignant large bowel obstruction according to the level of evidence of the available literature. METHODS A systematic search was conducted in PubMed, MEDLINE, Embase, and Google Scholar for articles published through January 2013 to identify studies of large bowel obstruction and colorectal cancer. Included studies were randomized and nonrandomized controlled trials, reviews, systematic reviews, and meta-analysis. RESULTS After a literature search of 1,768 titles and abstracts, 218 were selected for full-text assessment; 59 studies were ultimately included. Twenty-five studies of the diagnosis and treatment of obstruction and 34 studies of the use of stents were assessed. CONCLUSIONS In view of the various alternatives and the lack of high-grade evidence, the treatment of distal colonic obstruction should be individually tailored to each patient.
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Strategies to evaluate synchronous carcinomas of the colon and rectum in patients that present for emergent surgery. Int J Surg Oncol 2013; 2013:309439. [PMID: 23476758 PMCID: PMC3580935 DOI: 10.1155/2013/309439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 01/10/2013] [Accepted: 01/10/2013] [Indexed: 01/01/2023] Open
Abstract
It is not always possible to evaluate patients that present acutely with carcinoma of the colon and rectum for synchronous lesions. Patients that require emergent surgery necessitate urgent and efficient operation. Patients with lower gastrointestinal bleeding, perforation, or obstruction represent a challenging subset of patients with colorectal cancer. An organized approach to these patients in the effort not to overlook a synchronous carcinoma is important. The present paper provides an evidenced-based approach to this special situation.
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El-labban GM, Saber A. Single-stage procedure in management of uncomplicated acute sigmoid volvulus without colonic lavage. SURGICAL PRACTICE 2010. [DOI: 10.1111/j.1744-1633.2010.00515.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Balogh A. [Surgical treatment of cancer at the beginning of the third millenium--based on the 2004 Krompecher Memorial Lecture of the Society of Hungarian Oncologists]. Magy Onkol 2010; 54:101-15. [PMID: 20576585 DOI: 10.1556/monkol.54.2010.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Adám Balogh
- Szegedi Tudományegyetem, Altalános Orvosi Kar, Szent-Györgyi Albert Klinikai Központ Sebészeti Klinika 6720 Szeged Pécsi u. 6.
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Lu CC, Chen HH, Lin SE. Ischemic Versus Non-ischemic Obstructive Ileocolitis Secondary to Colorectal Cancer: A Review of 393 Cases. Jpn J Clin Oncol 2010; 40:927-32. [DOI: 10.1093/jjco/hyq072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Xu K, Zhang H, Feng Y, Cong JC, Chen CS, Liu EQ. Comparison of the outcomes of preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer: an analysis of 248 cases. Shijie Huaren Xiaohua Zazhi 2010; 18:736-740. [DOI: 10.11569/wcjd.v18.i7.736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of self-expanding metallic stents (SEMSs) and to compare the short- and long-term outcomes of preoperative stent insertion and emergency surgery in the treatment of obstructive left-sided colorectal cancer.
METHODS: Sixty-two patients who underwent SEMS insertion and 186 patients who underwent primary emergency surgery for left-sided colorectal cancer from 2000 to 2008 were retrospectively analyzed.
RESULTS: The SEMSs were placed successfully in 61 patients, of which 14.5% developed complications such as perforating and migration. Primary anastomosis rate was higher in patients undergoing stent insertion than in those undergoing emergency surgery (87.1% vs 34.4%, P = 0.001). The complication rate was higher in patients undergoing emergency surgery than in those undergoing stent insertion (47.3% vs 17.7%, P = 0.000). No significant difference was noted in the survival curve between the two groups (P = 0.497).
CONCLUSION: Preoperative stent insertion is safe and effective in the treatment of obstructive left-sided colorectal cancer and may result in a higher primary anastomosis rate. Stent insertion does not seem to have a deleterious effect on prognosis.
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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: 2.4] [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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Engledow AH, Bond-Smith G, Motson RW, Jenkinson A. Treatment of left-sided colonic emergencies: a comparison of US and UK surgical practices. Colorectal Dis 2009; 11:642-7. [PMID: 18637938 DOI: 10.1111/j.1463-1318.2008.01631.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Surgeons are increasingly considering resection and primary anastomosis when treating left-sided colonic obstruction or perforation in preference to the more traditional staged procedures. Previous studies in the United Kingdom (UK) and United States of America (USA) have suggested a greater interest in single-staged procedures amongst UK surgeons. This study was aimed to directly compare the treatment preferences between UK and US surgeons. METHOD A questionnaire, designed to determine the procedure of choice when faced with left-sided colonic emergencies in patients with good and poor anaesthetic risk, was sent to 500 surgeons in the UK and 500 surgeons in the USA. RESULTS UK surgeons were more likely to perform resection, primary anastomosis and on-table colonic lavage in patients with sigmoid obstruction (good anaesthetic risk: P < 0.0001; poor risk: P < 0.01) and sigmoid perforation (good risk: P < 0.0001). In good-risk patients with sigmoid obstruction, US surgeons were more likely than UK to choose Hartmann's procedure (P < 0.0001). US surgeons performing primary anastomosis were less likely to perform on-table lavage. CONCLUSION Single-stage procedures are widely accepted as viable treatment options in both the UK and the USA when dealing with left-sided colonic emergencies. British surgeons are more likely to favour single-staged procedures, particularly with on-table colonic lavage, when compared with US surgeons.
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Affiliation(s)
- A H Engledow
- Department of Colorectal Surgery, University College Hospital, London, UK.
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Kozman DR, Engledow AH, Keck JO, Motson RW, Lynch AC. Treatment of left-sided colonic emergencies: a comparison of US, UK and Australian surgeons. Tech Coloproctol 2009; 13:127-33. [PMID: 19484347 DOI: 10.1007/s10151-009-0469-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 02/05/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND This study sought to identify and compare the current practice of surgeons in Australia, the UK and the US when presented with a left-sided colonic emergency. METHODS Questionnaires were posted to 500 US, 500 UK and 500 Australian surgeons. Demographic data were collected regarding the surgeon's age and surgical interest, as well as their preferred method of managing left-sided colonic emergencies (namely obstruction and perforation in stable and unstable patients). The results were analysed using the chi-squared test. RESULTS Completed questionnaires were received from 224 UK surgeons (45%), 180 US surgeons (36%) and 259 Australian surgeons (52%). All the US surgeons had an interest in gastrointestinal surgery, while 31% of the UK surgeons and 22% of Australian surgeons had an interest in colorectal surgery. In a haemodynamically stable patient with a good anaesthetic risk presenting with a complete sigmoid obstruction, significantly more UK (84%) and Australian surgeons (70%) would perform a resection and anastomosis than US surgeons (54%, p<0.0001). Of those with a colorectal interest, 97% of UK surgeons and 80% of Australian surgeons would opt for resection and anastomosis. In a haemodynamically stable patient with a good anaesthetic risk with a perforation of the sigmoid colon and purulent peritonitis, 46% of UK surgeons, 32% of Australian surgeons and 33% of US surgeons would opt for resection and anastomosis, and among colorectal surgeons, 68% of UK surgeons and 50% of Australian surgeons would opt for resection and anastomosis. CONCLUSIONS The management of left-sided colonic emergencies varies depending on geographic location and degree of colorectal subspecialization. While the literature suggests that single-stage procedures are accepted and safe, the reasons for this variation are explored.
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Affiliation(s)
- D R Kozman
- Department of Colorectal Surgery, Box Hill Hospital, Vic, Australia.
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Brehant O, Fuks D, Bartoli E, Yzet T, Verhaeghe P, Regimbeau JM. Elective (planned) colectomy in patients with colorectal obstruction after placement of a self-expanding metallic stent as a bridge to surgery: the results of a prospective study. Colorectal Dis 2009; 11:178-83. [PMID: 18477021 DOI: 10.1111/j.1463-1318.2008.01578.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Acute malignant colorectal obstruction (CRO) can be satisfactorily dealt by the placement of a self-expanding metallic stent (SEMS). The aim of this prospective study was to evaluate the rate of elective (planned) colectomy (EPC) in patients with CRO after SEMS placement as a bridge to surgery on an intention-to-treat (ITT) basis. METHOD From 2002 to 2007, 30 SEMS were placed as a bridge to surgery in 30 CRO patients (median age 73 +/- 12 years). The obstructing lesions were located in the right (n = 1), transverse (n = 1) or left colon (n = 24) or the upper third of the rectum (n = 4). RESULTS The SEMS was placed successfully in 25 (83%) patients. Five patients underwent Hartmann's procedure (n = 2) or a diverting colostomy (n = 3). The SEMS was functionally operational in 23 (92%) of the 25 patients. A diverting colostomy was avoided in 23 (77%) of the 30 patients (placement failure n = 5, clinical failure n = 2). There were no complications in 17 (80%) patients. On an ITT basis, 70% of the patients (21 out of 30) underwent an EPC. CONCLUSION On an ITT basis, SEMS placement in CRO patients enabled EPC in 70% of patients.
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Affiliation(s)
- O Brehant
- Federation of Digestive Diseases, Amiens North Hospital, University of Picardy Jules Verne, Amiens Cedex 01, France
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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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Lee KM, Shin SJ, Hwang JC, Cheong JY, Yoo BM, Lee KJ, Hahm KB, Kim JH, Cho SW. Comparison of uncovered stent with covered stent for treatment of malignant colorectal obstruction. Gastrointest Endosc 2007; 66:931-6. [PMID: 17767930 DOI: 10.1016/j.gie.2007.02.064] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 02/19/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Insertion of self-expandable metallic stents (SEMS) can provide rapid relief of malignant colorectal obstruction and can be used as a palliative treatment or as a bridge to surgery. A SEMS can be classified as an uncovered or covered stent. Both types of stents have their own merits and demerits. OBJECTIVE The objectives of this study were to compare success rates, durability, and complication rates of uncovered and covered stent groups of malignant colorectal obstruction. DESIGNS AND SETTING: A nonrandomized prospective, single-center study. METHODS We studied 80 patients with malignant colorectal obstruction: colon cancer in 70 patients, metastatic lesion of advanced gastric cancer in 8 patients, and cervix cancer in 2 patients. Insertion of uncovered stents was attempted in 39 patients (before surgery in 20, palliative in 19), and covered stents were used in 41 (before surgery in 23, palliative in 18). INTERVENTION The stent was inserted into the obstructive sites for preoperative or palliative purposes by using the through-the-scope method. After stent insertion, the patients had regular follow-ups, either as clinical checkups or telephone interviews. MAIN OUTCOME MEASUREMENT Insertion success rate, durability, and complication rate according to stent type. RESULTS Technical and clinical success rates of uncovered and covered stents were not different (100%; 95.1%, P > .05, 100%; 97.4%, P > .05). The early stent migration rate was not different in both groups. The late stent migration was more common in the covered stent group than the uncovered stent group (0% vs 40%, respectively, P = .005). Loss of stent function during the long-term follow-up period was more frequent in the covered stent group than in the uncovered stent group (18.8% vs 60%, respectively, P = .018). LIMITATION This was a small-sized, nonrandomized, prospective, single-center study. Confirmation of large-scale, multicenter, randomized, prospective outcome is required. CONCLUSIONS Insertion of either an uncovered or covered stent is similarly an effective treatment modality of malignant colorectal obstruction for preoperative purposes. However, there are no advantages of covered stents over uncovered stents during the follow-up period in the palliative purpose.
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Affiliation(s)
- Kee Myung Lee
- Department of Gastroenterology Ajou University School of Medicine, Suwon, Korea
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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: 3.0] [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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Mabrut JY, Buc E, Zins M, Pilleul F, Bourreille A, Panis Y. Prise en charge thérapeutique des formes compliquées de la diverticulite sigmoïdienne (abcès, fistule et péritonite). ACTA ACUST UNITED AC 2007; 31:27-33. [DOI: 10.1016/s0399-8320(07)91949-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Acute colonic obstruction due to malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis has traditionally been the treatment of choice. These procedures have been associated with a significant morbidity and mortality rate. Preoperative colonic stenting is effective for decompressing the obstructed colon and may allow for surgery to be performed on an elective basis. RECENT FINDINGS Although randomized clinical data are lacking, the role for preoperative stenting in the emergent management of acute malignant colonic obstruction has been supported by cost-effectiveness analysis studies and several pooled analyses that demonstrate efficacy and safety. SUMMARY This review evaluates the latest developments in colonic stent technology, indications for use in the preoperative setting, and evidence to support their use in this setting.
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Affiliation(s)
- James J Farrell
- Department of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA.
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Breitenstein S, Kraus A, Hahnloser D, Decurtins M, Clavien PA, Demartines N. Emergency left colon resection for acute perforation: primary anastomosis or Hartmann's procedure? A case-matched control study. World J Surg 2007; 31:2117-24. [PMID: 17717625 DOI: 10.1007/s00268-007-9199-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 05/27/2007] [Indexed: 01/25/2023]
Abstract
BACKGROUND The optimal treatment remains controversial for acute left-sided colon perforation. Therefore, the effectiveness and safety of primary anastomosis versus Hartmann's operation (HP) was compared in a case-matched control study. METHODS Thirty consecutive patients with primary anastomosis and protective ileostomy (PAS) were matched to 30 HP patients, controlling for age, gender, American Society of Anesthesiologists (ASA) score, body mass index (BMI), and peritonitis severity (Hinchey). In a second analysis, PAS patients with purulent peritonitis (Hinchey 3) were matched to patients with primary anastomosis without ileostomy (PA). RESULTS Hospital mortality was similar between HP (17%) and PAS (10%). Complication frequency and severity (requiring re-intervention or admission to the Intensive Care Unit [ICU]) were comparable for the first operation (60% versus 56% and 30% versus 32%). The stoma reversal rate was higher in PAS than in HP (96% versus 60%, p = 0.001), with significantly fewer complications (23% versus 66%, p = 0.02), and lower severity (7% versus 33%, p = 0.02). Additional analysis of PAS versus PA showed similar morbidity (52% versus 41%, p = 0.45) and complication severity (18% versus 24%, p = 0.51), whereas overall operation time and hospital stay were significantly shorter in PA (169 versus 320 min, p = 0.003, 17 versus 28 days, p < 0.001). CONCLUSIONS Primary anastomosis and protective ileostomy is a superior treatment to HP in acute left-sided colon perforation. In the absence of feculent peritonitis an ileostomy appears unnecessary.
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Affiliation(s)
- Stefan Breitenstein
- Department of Visceral and Transplantation Surgery, University Hospital, Ramistrasse 100, CH-8091 Zurich, Switzerland.
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Kim MS, Park YJ. Detection and treatment of synchronous lesions in colorectal cancer: The clinical implication of perioperative colonoscopy. World J Gastroenterol 2007; 13:4108-11. [PMID: 17696231 PMCID: PMC4205314 DOI: 10.3748/wjg.v13.i30.4108] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Min Sun Kim
- Department of Surgery, Dongguk University International Hospital, 814 Siksa-dong, Ilsandong-gu, Goyang-si, Gyeonggi-do 410-773, Korea
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Asfar SK, Al-Sayer HM, Juma TH. Exteriorized colon anastomosis for unprepared bowel: An alternative to routine colostomy. World J Gastroenterol 2007; 13:3215-20. [PMID: 17589900 PMCID: PMC4436607 DOI: 10.3748/wjg.v13.i23.3215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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 5th and 7th 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.
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Affiliation(s)
- Sami K Asfar
- Department of Surgery, Faculty of Medicine, Kuwait University and Mubarak Al-Kabeer Hospital, PO Box: 24923, Safat-13110, Kuwait.
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Yokohata K, Sumiyoshi K, Hirakawa K. Merits and faults of transanal ileus tube for obstructing colorectal cancer. Asian J Surg 2006; 29:125-7. [PMID: 16877208 DOI: 10.1016/s1015-9584(09)60070-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We report eight cases of obstructing colorectal cancer successfully managed by preoperative lavage using transanal ileus tube. METHODS Decompression tube was transanally inserted into the colon proximal to the tumour under the guidance of the guide wire. Intestinal lavage with 1,500-2,000 mL of warm water was done every day until surgery. RESULTS There were six men and two women; the mean age was 67 years (range, 50-82 years). Three cancers were in the sigmoid colon and five were in the rectum. Seven patients were treated with a one-stage operation with adequate lymph node dissection. In one patient, only sigmoidostomy was carried out for unresectable huge tumour. In all cases, no dilatation was observed at the proximal colon and no anastomotic failure developed. Four patients suffered from fever of unknown cause after the insertion of the tube. In one patient, the resected specimen showed ulcer by tube compression. In the other patient, the tube penetrated the intestinal wall, which was covered by mesentery. CONCLUSION The transanal ileus tube is effective for the treatment of obstructing colorectal cancer. However, close observation is necessary because of possible perforation.
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Hennekinne-Mucci S, Tuech JJ, Bréhant O, Lermite E, Bergamaschi R, Pessaux P, Arnaud JP. Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma. Int J Colorectal Dis 2006; 21:538-41. [PMID: 16228180 DOI: 10.1007/s00384-005-0048-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2005] [Indexed: 02/04/2023]
Abstract
PURPOSE The treatment of acutely obstructed carcinoma of the left colon still represents a matter of controversy. The aim of the study was to evaluate the results of its management by emergency subtotal or total colectomy with immediate anastomosis without diversion. METHODS An emergency subtotal/total colectomy was performed in 72 patients (mean age 74.9 years). Inclusion criteria were reasonable operative risk, resectable acutely obstructed carcinoma, massively distended colon of dubious viability, and likely to contain ischemic lesions, signs of impending cecal perforation, and masses suggesting synchronous colonic cancers. RESULTS Postoperative mortality was 9.7% (7 patients). An 83-year-old woman died as a result of an anastomotic dehiscence; the six other deaths resulted of cardiopulmonary complications. Postoperative morbidity was 15% (11 patients) including two fistulas, which recovered without surgery. There were eight synchronous colon carcinomas. Six months after surgery, the mean daily stool frequency was two following subtotal colectomy and three after total colectomy. CONCLUSION Emergency subtotal colectomy achieves in one-stage relief of bowel obstruction and tumor resection by encompassing a massively distended and fecal-loaded colon with ischemic lesions and serous tears on the cecum. It ensures restoration of gut contiguity via a "safe" ileocolonic anastomosis and removes occasional lesions proximal to the index cancer.
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Constantinides VA, Tekkis PP, Athanasiou T, Aziz O, Purkayastha S, Remzi FH, Fazio VW, Aydin N, Darzi A, Senapati A. Primary resection with anastomosis vs. Hartmann's procedure in nonelective surgery for acute colonic diverticulitis: a systematic review. Dis Colon Rectum 2006; 49:966-81. [PMID: 16752192 DOI: 10.1007/s10350-006-0547-9] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE This study compares primary resection with anastomosis and Hartmann's procedure in an adult population with acute colonic diverticulitis. METHODS Comparative studies published between 1984 and 2004 of primary resection with anastomosis vs. Hartmann's procedure were included. The primary end point was postoperative mortality. Secondary end points included surgical and medical morbidity, operative time, and length of postoperative hospitalization. Random effects model was used and sensitivity analysis was performed. RESULTS Fifteen studies, including 963 patients (57 percent primary resection with anastomoses, 43 percent Hartmann's procedures), were analyzed. Overall mortality was significantly reduced with primary resection and anastomosis (4.9 vs. 15.1 percent; odds ratio = 0.41). Subgroup analysis of trials matched for emergency operations showed significantly decreased mortality with primary resection and anastomosis (7.4 vs. 15.6 percent; odds ratio = 0.44). No significant difference in mortality was observed in trials matched for severity of peritonitis Hinchey > 2 (14.1 vs. 14.4 percent; odds ratio = 0.85). Sensitivity analysis did not reveal significant heterogeneity between the studies for the primary outcome. CONCLUSIONS Patients selected for primary resection and anastomosis have a lower mortality than those treated by Hartmann's procedure in the emergency setting and comparable mortality under conditions of generalized peritonitis (Hinchey > 2). The retrospective nature of the included studies allows for a considerable degree of selection bias that limits robust and clinically sound conclusions. This analysis highlights the need for high-quality randomized trials comparing the two techniques.
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Affiliation(s)
- Vasilis A Constantinides
- Imperial College of Science, Technology and Medicine, Department of Surgical Oncology and Technology, St. Mary's Hospital, London, United Kingdom
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Durán Giménez-Rico H, Abril Vega C, Herreros Rodríguez J, Concejo Cútoli P, Paseiro Crespo G, Sabater Maroto C, Jadraque Jiménez P, Durán Sacristán H. Hartmann's procedure for obstructive carcinoma of the left colon and rectum: a comparative study with one-stage surgery. Clin Transl Oncol 2006; 7:306-13. [PMID: 16185593 DOI: 10.1007/bf02710270] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES Despite the criticisms from prestigious expert committees, a high percentage of surgeons continue to use, as the technique-of-choice, Hartmann's procedure for acute malignant intestinal obstruction of the distal colon and rectum, without faecal peritonitis. We have reviewed our results with this technique and compared them with other series of patients in the literature undergoing one-stage surgery (resection with primary anastomosis or sub-total colectomy). MATERIAL AND METHODS A retrospective and descriptive study using clinical histories and, from which, the variables studied were: median hospitalisation stay, morbido-mortality and reconstruction index. RESULTS Included in the analysis were 44 patients (24 male; 20 female) with an age range between 37 and 87 years (median age: 67.04 years). The median hospitalisation stay was 15.59 days (range: 8-39). In the 10 patients undergoing reconstruction this was 12.8 days (range: 10-17). The overall stay, therefore, was 28.39 days. The median stay in the series of patients having one-stage surgery was 13.9 days. The morbidity using Hartmann's procedure was 43.18% (19/44) and, in the patients with reconstruction, 40% (4/10). The morbidity in the literature series with one-stage surgery was 22.53%. Mortality in our study was 0%. The mortality in the 16 cases from the literature was close to 5%, although in 3 of the studies this was also 0%. The percentage undergoing reconstruction was 22.72% (10 cases). The median age in the non-reconstructed patients was 71.42 years (range: 46-87) compared to a median age of 52.6 (range 37-67) in the group with reconstruction (p < 0.001). The percentages undergoing reconstruction, according to tumour stage, were Dukes B: 36.84%; Dukes C: 23.07%; Dukes D: 0% (p < 0.001). The median waiting-time for a reconstruction was 15.73 months (range: 8-33). CONCLUSIONS Comparisons of our results with the outcomes in the series of patients in the literature with one-stage surgery indicate that "one-stage surgery" is the more suitable but, however, with two conditions: a sufficient command of the technique so as to minimise complications and a strict patient selection, with the Hartmann's procedure being retained for patients with high anaesthesia risk.
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40
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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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Abstract
Sigmoid volvulus is the third most common cause of colonic obstruction in the United States after cancer and diverticulitis. Etiologic factors include anatomic variation, chronic constipation, neurologic disease, and megacolon. Management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks; the outcome depends on the population and selection of patients. Although volvulus is uncommon, it may be encountered during pregnancy and is a condition that poses significant risk to both mother and fetus requiring a management strategy that varies with each trimester.
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Affiliation(s)
- Sunil K Lal
- Division of Gastroenterology and Hepatology, Drexel University, Philadelphia, PA 19107, USA
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42
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Abstract
Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.
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Affiliation(s)
- Heather Rossi
- Department of Surgery, University of Minnesota Cancer Center, 420 Delaware Street SE, Mayo Mail Code 195, Minneapolis, MN 55455, USA
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43
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Biondo S, Jaurrieta E, Jorba R, Moreno P, Farran L, Borobia F, Bettonica C, Poves I, Ramos E, Alcobendas F. Intraoperative colonic lavage and primary anastomosis in peritonitis and obstruction. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02497.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mitchell JE, Faris I, Aldridge MC, Dudley HAF, Cahill CJ, Bailey ME, Evans HJR, Hudd C, Ribeiro V, Knight M. Correspondence. Br J Surg 2005. [DOI: 10.1002/bjs.1800700425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- J E Mitchell
- Singleton Hospital, Sketty, Swansea, West Glamorgan SA2 8QA
| | - Irwin Faris
- Royal Adelaide Hospital, Adelaide, South Australia 5000 Australia
| | - M C Aldridge
- The Academic Surgical Unit, St Mary's Hospital, London W2
| | - H A F Dudley
- The Academic Surgical Unit, St Mary's Hospital, London W2
| | - C J Cahill
- Royal Surrey County Hospital, Egerton Road, Park Barn, Guildford, Surrey GU2 5XX
| | - M E Bailey
- Royal Surrey County Hospital, Egerton Road, Park Barn, Guildford, Surrey GU2 5XX
| | - H J R Evans
- St George's Hospital, Blackshaw Road, London SW17 0QT
| | - C Hudd
- St George's Hospital, Blackshaw Road, London SW17 0QT
| | - V Ribeiro
- St George's Hospital, Blackshaw Road, London SW17 0QT
| | - M Knight
- St George's Hospital, Blackshaw Road, London SW17 0QT
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Wedell J, Banzhaf G, Chaoui R, Fischer R, Reichmann J. Surgical management of complicated colonic diverticulitis. Br J Surg 2005. [DOI: 10.1046/j.1365-2168.1997.02566.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Biondo S, Parés D, Kreisler E, Ragué JM, Fraccalvieri D, Ruiz AG, Jaurrieta E. Anastomotic dehiscence after resection and primary anastomosis in left-sided colonic emergencies. Dis Colon Rectum 2005; 48:2272-80. [PMID: 16228841 DOI: 10.1007/s10350-005-0159-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE There is no consensus about the risk factors for anastomotic failure after elective or emergency colorectal surgery. The purpose of this study was to analyze the factors that may contribute in anastomotic dehiscence. METHODS A total of 208 patients who underwent left colonic resection and primary anastomosis for distal colonic emergencies were studied. Preoperative and operative variables analyzed for each patient were gender, age, American Society of Anesthesiologists score, comorbidities, indication for surgery, etiology of the disease, presence and grade of peritonitis, preoperative creatinine, hematocrit, hemoglobin, and leukocyte count, need for preoperative and operative transfusion. The end point was the clinical evident incidence of anastomotic leak. Bivariate comparisons of those patients with or without anastomotic leak were unpaired, and all tests of significance were two-tailed. A multivariate analysis, in which presentation of anastomotic leak was the dependent outcome variable, was performed by forward stepwise logistic regression model. RESULTS One hundred five patients (50.4 percent) had one or more complications. Anastomotic leak was diagnosed in 12 patients (5.7 percent). Seventeen patients (8.2 percent) needed a reoperation for complication. The overall mortality was 6.2 percent (13 patients). Obesity was significant as a predictor of anastomotic leak. CONCLUSIONS Obesity is a factor predicting anastomotic leak risk after resection and primary anastomosis for left-sided colonic emergencies.
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Affiliation(s)
- Sebastiano Biondo
- Department of Surgery, Hospital Universitario de Bellvitge, University of Barcelona, Barcelona, Spain.
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Nunes BLBBP, Saad SS, Jucá MJ, Porfírio Z, Matos D. Analysis of bacteremia occurring in the presence of obstruction of the left colon in rats submitted to transoperative antegrade mechanical lavage. J INVEST SURG 2005; 18:233-40. [PMID: 16249166 DOI: 10.1080/08941930500248623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Abstract
BACKGROUND With more and more centres worldwide resorting to primary anastomosis for most left sided colonic pathology, the place for a Hartmann procedure seems to be relegated to surgical history books. However, in our centre it is still being performed on a regular basis. As such, we decided to retrospectively look at our results for the procedure. METHODS All hospital records of patients undergoing the Hartmann procedure between January 1998 and December 2001 were retrospectively analysed looking at demographics, comorbidities and indications of the procedure. RESULTS There were 52 men and 33 women with a median age of 69 years (range 31-96 years). Sixty-six per cent of the patients had medical comorbidities at the time of the operation. The indications for performing the procedure were: 45 patients for cancer (31 patients for obstruction, 11 patients for perforation, two patients for fistulation to other organs and one for uncontrollable bleeding). 19 patients had the procedure for complicated diverticulitis while four patients had anastomotic leaks, which required conversion to the procedure. Other indications include trauma (four patients), ischemic bowel (six patients) and iatrogenic (one patient). Our median operating time was 160 min (range 50-415 min). Our reversal rate was 32%. Our mortality rate for the first stage was 16% and our morbidity, 51%. The morbidity for the reversal was 29%, with no mortalities. CONCLUSION Though the idea of primary anastomosis with on table lavage for left sided anastomosis seems attractive, we think the Hartmann procedure is still useful for selected patients.
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Affiliation(s)
- Dee Wern Seah
- Department of General Surgery, Changi General Hospital, Singapore.
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49
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Kim JH, Shon DH, Kang SH, Jang BI, Chung MK, Kim JH, Shim MC. Complete single-stage management of left colon cancer obstruction with a new device. Surg Endosc 2005; 19:1381-7. [PMID: 16151681 DOI: 10.1007/s00464-004-8232-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2005] [Accepted: 03/28/2005] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- J-H Kim
- Department of Surgery [corrected], College of Medicine, Yeungnam University, 317-1 Daemyungdong Namku, Daegu, 705-717, Korea
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50
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Patriti A, Contine A, Carbone E, Gullà N, Donini A. One-stage resection without colonic lavage in emergency surgery of the left colon. Colorectal Dis 2005; 7:332-8. [PMID: 15932554 DOI: 10.1111/j.1463-1318.2005.00812.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- A Patriti
- General and Emergency Surgery, Department of Surgery, University of Perugia, Perugia, Italy.
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