Primary Anastomosis Without Colonic Lavage for the Obstructed Left Colon

Abstract

Ann R Coll Surg Engl 2008; 90: 302-304 302Obstructing left-sided colonic lesions are associated with a high mortality and morbidity. [1][2][3][4] When emergency surgery is undertaken at night or performed by a registrar or noncolorectal specialist, two-staged Hartmann resections are frequently performed. Whilst this approach provides quick, safe surgery with relatively low complication rates, restoration of bowel continuity is only performed in a proportion and is frequently challenging. Emergency segmental resection with on-table lavage (OTL) and primary anastomosis has been championed since 1967. 5 There are no good randomised trials comparing primary anastomosis versus Hartmann resections and a subsequent reversal with its additional morbidity. Elective, left-sided resection/anastomosis without mechanical bowel preparation has recently been shown not only to be a safe surgical option but also to be associated with reduced morbidity. 6 OTL can be time-consuming, messy and requires a proximal enterotomy and considerable bowel handling, all of which potentially increase morbidity. Sigmoid volvulus has been treated successfully by resection and primary anastomosis without colonic lavage. 7 We have approached our left-sided obstructed patients in a similar manner arguing that, provided mobilisation and blood supply are good, a side-to-side stapled colorectal anastomosis will deal with any size disparity in the bowel and allow a rapid decompression of the system. Our experience is presented. Patients and MethodsWe have undertaken a prospective, observational study of 24 consecutive emergency admissions presenting between November 1996 and November 2004 with left-sided colonic obstruction. Obstruction was confirmed by pre-operative gastrograffin enema. All anaesthetised patients were placed 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.

Surgical practices for malignant left colonic obstruction in Germany

“…Whenever possible, even in emergencies, an oncologically adequate procedure with systematic lymph-node dissection should be aimed at [1]. After removal of the affected section of the bowel, the discontinuity can be treated by Hartmann's procedure, or continuity can be restored by anastomosis, if necessary with the use of a protective stoma [2,3,4,5,6,7,8]. In spite of the repeatedly reported advantages of primary restitution of continuity [3,9,10], the Hartmann operation is still of value [2,4,5,6,7,8].…”

Primary resection and side-to-end anastomosis next to an endcolostomy in the management of acute malignant obstruction of the left bowel: an alternative in selected patients

“…Although resection and primary anastomosis seems to be a safe treatment option in this group of patients [2][3][4], fear of anastomotic leakage often deters surgeons from performing a primary anastomosis. At present no clear guidelines can be based on existing data.…”

“…Today primary resection has become standard practice to treat patients with an obstructed left colon [2][3][4][5][6]. Initial insertion of an enteral stent to decompress the obstructed colon, allowing surgery to be performed electively, is gaining popularity [7], although mature data from large randomized trials are awaited.…”

Surgical treatment of complicated colorectal cancer: tactical aspects (a literature review)

“…При новообразованиях левых отделов толстой кишки с яв-лениями непроходимости формирование межкишеч-ного анастомоза после лаважа является преимуществом данного метода. Методика состоит в полном отмыва-нии приводящего отдела от каловых масс через илео-или аппендикостому -антеградный метод, или через супрастенотический отдел -ретроградный метод [53,54]. Считают, что использование данной методики способствует одномоментной ликвидации повышен-ного внутрикишечного давления, улучшению микро-циркуляции в кишечной стенке и формированию первичного анастомоза в 85 % наблюдений.…”

“…Уровень летальности при данном методе составляет 2-11 %, частота послеоперационных осложнений 3-44 %. Недо-статочность анастомоза развивается в 7-16 % случаев, а при наложении превентивной стомы -в 8 % [53][54][55]. Противники данной методики указывают, что проце-дура интраоперационного лаважа достаточно слож-ная, увеличивает продолжительность оперативного вмешательства, частоту гнойных осложнений в по-слеоперационном периоде и сохраняется риск недо-статочности межкишечного анастомоза [56].…”