22C. Mahabier, J. D. K. Munting and C. J C.Mahabier, J.D.K.Munting and C.J.van Duin (Heerlen), Intraoperative colon irrigation permitting safe primary resection and anastomosis in the unprepared left colonResection and anastomosis of the colon distal to the splenic flexure without any bowel preparation is commonly accepted as being unsafe. In cases of obstructing tumours in this part of the colon, a staged surgical management is generally the method of choice. This includes the performance of a diverting colostomy, with the intention of removing the tumour at a second operation and closing the colostomy at a third (or performing the Hartmann procedure).With intraoperative colon irrigation it is feasible to perform a primary resection and anastomosis in most cases in which the colon in unprepared. The technique of the intraoperative colon irrigation and some modifications with newly developed instruments (making the procedure safer and easier) were demonstrated.Thirty eight patients with a mean age of 65 years underwent intraoperative colon irrigation for various reasons, followed by resection and primary anastomosis of the left colon. A ‘protective’ diverting colostomy was used in two patients with technically imperfect low anterior anastomoses. Uneventful anastomotic healing occurred in all patients, except in two with peritonitis carcinomatosa who developed clinical leakages. One radiological leakage occurred without any clinical consequence. No patients died due to the complications of anastomotic leakage but two patients died postoperatively from cardiac disease.The intraoperative colon irrigation enabled us to create an elective environment at ‘non elective’ times in colorectal surgery, permitting a safe one-stage operation in most patients with obstructions. The mortality is comparable to any other staged surgical procedure. However the morbidity after this procedure will always be lower which is the greatest advantage, especially when the age of the patients is taken into account.
25Review Ann R Coll Surg Engl. 2008 Apr;90(3):181-6. Emergency management of malignant acute left-sided colonic obstruction.Trompetas V.SourceDepartment of Surgery, Eastbourne District General Hospital, Eastbourne, UK.AbstractINTRODUCTION:The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress.METHODS:A literature search was undertaken using PubMed and the Cochrane Library regarding the options in emergency management of left-sided colonic obstruction focusing on outcomes such as mortality, morbidity, long-term prognosis and cost effectiveness.DISCUSSION:Colonic stenting is the best option either for palliation or as a bridge to surgery. It reduces morbidity and mortality rate and the need for colostomy formation. Stenting is likely to be cost effective, but data are variable depending on the individual healthcare system. Nevertheless, surgical management remains relevant as colonic stenting has a small rate of failure, and it is not always available. There are various surgical options. One-stage primary resection and anastomosis is the preferred choice for low-risk patients. Intra-operative colonic irrigation has no proven benefit. Subtotal colectomy is useful in cases of proximal bowel damage or synchronous tumours. Hartmann's procedure should be reserved for high-risk patients. Simple colostomy has no role other than for use in very ill patients who are not fit for any other procedure.
26Ann R Coll Surg Engl. 2008 May;90(4):302-4. Primary anastomosis without colonic lavage for the obstructed left colon.Cross KL, Rees JR, Soulsby RH, Dixon AR.SourceDepartment of Colorectal Surgery, North Bristol NHS Trust, Frenchay Hospital, Bristol, UK.AbstractINTRODUCTION:Resection, on-table lavage (OTL) and primary anastomosis is the treatment of choice for the obstructed left colon. OTL is time-consuming, requires considerable mobilisation/bowel handling, an enterotomy and potentially exposes the patient to mesenteric vascular injury, faecal contamination and a prolonged ileus. We have assessed outcome following primary resection and anastomosis without prior lavage.PATIENTS AND METHODS:Twenty-four consecutive, obstructed patients underwent splenic flexure mobilisation and high anterior resection (concomitant small bowel resection in 2) with primary side-to-side colorectal anastomosis without either prior lavage or covering stoma. Outcome was audited.RESULTS:Twenty-four patients, 17 female aged years (median. 76 years) presented with left-sided obstruction due to carcinoma (Dukes' B , C , D ) or chronic diverticulitis (14). Median operative time was 85 min (range, min). Colonic ileus resolved on day 2 (29%) and day 3 (58%). Median hospital stay was 7 days (range, 6-72 days); 92% discharged by day 10. There were no deaths or re-admissions. A return to theatre followed a reactionary haemorrhage in one. This latter patient's anastomosis leaked on day 4 (no faecal contamination) and was converted to an end stoma. Urinary and wound infections were seen in two. Late complications comprised two anastomotic strictures; both responded to balloon dilatation at 5 months.CONCLUSIONS:Resection and primary anastomosis without on-table lavage is an easy, practical, predictable and safe treatment option for left-sided colonic obstruction with minimal complications.
27Dis Colon Rectum. 2012 Jan;55(1):72-8. One-stage segmental colectomy and primary anastomosis after intraoperative colonic irrigation and total colonoscopy for patients with obstruction due to left-sided colorectal cancer.Sasaki K, Kazama S, Sunami E, Tsuno NH, Nozawa H, Nagawa H, Kitayama J.SourceDepartment of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan.AbstractBACKGROUND:Intraoperative colonic irrigation and intraoperative on-table colonoscopy may be useful for a more accurate diagnosis of colorectal cancer before colectomy in patients with obstructive left-sided colorectal cancer, but the clinical benefit of this technique has not been investigated in large-scale studies.OBJECTIVE:The aim of this study was to evaluate the usefulness of intraoperative colonic irrigation with a Y-shaped irrigation device and intraoperative colonoscopy in the management of obstructive colorectal cancer in patients undergoing elective surgery.DESIGN AND SETTING:This was a retrospective cohort study of patients undergoing surgical treatment at a single tertiary care institution in Japan.PATIENTS AND INTERVENTION:Among 715 consecutive patients with left-sided colorectal cancer, 101 patients (14.1%) with obstructing tumor received intraoperative colonic irrigation and intraoperative colonoscopy before colectomy and primary anastomosis, and 614 patients with nonobstructive colorectal cancer underwent preoperative colonoscopy with mechanical bowel preparation.MAIN OUTCOME MEASURES:Detection rates of proximal synchronous lesions, occurrence of postoperative complications, and changes in the surgical procedure prompted by the results of the intraoperative colonoscopy were evaluated.RESULTS:Intraoperative colonoscopy detected synchronous adenomatous polyps in 27 patients (26.8%), carcinoma in 4 patients (4%), and obstructive colitis in 2 patients (2%). Findings of the intraoperative colonoscopy prompted changes in surgical procedure in 9 patients (8.9%). The overall morbidity in the intraoperative group was 17%, with anastomotic leakages in 3 patients, wound infection in 5, and postoperative ileus in 3 patients. The risk of these complications was not increased in patients with intraoperative colonoscopy with intraoperative colonic irrigation compared with those receiving preoperative colonoscopy with mechanical bowel preparation. The operation time was 28 minutes longer in the intraoperative than in the preoperative group, but neither the time to start of oral intake nor the length of postoperative hospital stay was significantly different between the 2 groups.LIMITATIONS:The study is limited by its retrospective nature.CONCLUSIONS:: In patients with obstructive colorectal cancer, intraoperative colonic irrigation with intraoperative colonoscopy is a useful strategy for detecting synchronous lesions located proximally to the obstructing tumor, without increasing patient morbidity.