Primary resection and side-to-end anastomosis next to an end-colostomy in the management of acute malignant obstruction of the left bowel: an alternative in selected patients.
ABSTRACT Patients presenting with an acute obstructing carcinoma of the left bowel are a surgical challenge. Under more difficult circumstances with gross distension of the proximal colon many surgeons will decide to defer anastomosis. Hartmann's procedure still represents a valid treatment option. We describe our experience with primary resection and side-to-end anastomosis next to an end-colostomy in the management of acute malignant obstruction of the left bowel.
The surgical procedure involves resection of the tumour and primary stapled side-to-end anastomosis next to a protecting end-colostomy. This type of enterostomy was first described by Santulli and Blanc in 1961. Colostomy closure is possible via a local procedure avoiding relaparotomy. Ten patients (five women) underwent surgery using this technique. Their mean age was 71 years (range 54-88 years). All patients had a massively distended colon. All obstructing lesions were biopsy-proven adenocarcinomas.
There was no postoperative mortality and no anastomotic leakage. The colostomy could be closed without a laparotomy in all patients. The only two complications were one superficial necrosis of the stoma and one wound infection after colostomy closure. In all other patients the postoperative course was uneventful. Wound infection after colostomy closure was seen in the very first patient in whom the wound was closed primarily. In subsequent patients the skin was left open.
The concept of an end-colostomy next to the anastomosis is an alternative approach combining the safety of proximal decompression and the advantages of primary anastomosis. This technique may be considered in patients presenting with a massively distended and faeces-loaded colon caused by an obstructing tumour in the descending or sigmoid colon, when the surgeon would otherwise elect to defer anastomosis.
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ABSTRACT: Traditionally, left-sided colon obstruction is managed by a multistaged defunctioning colostomy and resection. However, there is growing acceptance of one-stage primary resection and anastomosis with on-table antegrade irrigation. This paper presents a series of patients managed prospectively by primary anastomosis without intraoperative colonic lavage. Emergency resection of acutely obstructed left-sided colonic carcinomas was performed. This was followed by primary anastomosis without on-table lavage after bowel decompression using a new technique. Fifty-eight consecutive, unselected patients underwent bowel decompression, resection and primary colocolic anastomosis. Only one patient developed a leak at the anastomotic site, requiring pelvic abscess drainage and transverse loop colostomy. One death occurred 12 h following surgery. Autopsy confirmed that this was due to myocardial infarction. Mean hospital stay was 9.8 days. Emergency surgery on the obstructed left colon can be carried out safely after decompression alone, without intraoperative colonic lavage.British Journal of Surgery 11/1999; 86(10):1341-3. · 4.84 Impact Factor
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ABSTRACT: Reversal of Hartmann's is a major surgical procedure and associated with substantial morbidity and mortality. This study retrospectively analysed the data at a single centre over an eight-year period to assess the clinical results and morbidity of reversal of Hartmann's. One hundred and ten Hartmann's procedures were performed during the period. Only 66 (61%) of patients had a reversal. Advanced age and comorbidity were the primary reasons for not reversing. Complications among the 66 patients (36 males and 30 females) who underwent reversal occurred in 26 (41%). There were no deaths. Patients who underwent reversal were ASA 2 (60%), ASA 3 (25%) and ASA 4 (4.6%). Univariate analysis demonstrated a significant association between complications following reversal and ASA grade (P =0.01), and hypertension (P = 0.03) There was no correlation between the patient variables and anastomotic leakage. Multiple logistic regression analysis showed a significant influence of hypertension, smoking and ASA grade on complications. About 40% of patients who undergo Hartmann's procedure will not have a reversal. Reversal is a feasible operation for selected patients, but there is a high complication rate.Colorectal Disease 10/2005; 7(5):454-9. · 2.08 Impact Factor
- Annals of Surgery 04/1957; 145(3):410-4. · 6.33 Impact Factor