Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon

Acute sigmoid volvulus is commonest in the Western world among the elderly and the institutionalised. Given the significant co-morbidity in this population and the perceived risks associated with definitive surgery, many surgeons elect to manage this condition conservatively with colonoscopic decompression alone. Non-operative management of acute sigmoid volvulus potentially obviates surgical morbidity in high-risk elderly and frail patients with distended, unprepared bowel. However, because recurrence rates (55-90%) and mortality rates (40%) are high, conservative treatment should be used predominantly to move patients from emergency surgery status to semi-elective surgery status.1-8 Indeed, following initial resuscitation of patients with acute sigmoid volvulus, including an attempt to detort the volvulus colonoscopically where appropriate, definitive surgery may prevent the significant morbidity and mortality associated with subsequent episodes of volvulus. We reviewed our unit's experience with non-operative and operative management of this condition. Patients and MethodsThe records of all patients who underwent emergency nonoperative or operative treatment for acute sigmoid volvulus in the Department of Surgery, Mayo General Hospital, during an 11-year period between January 1996 and December 2006, were reviewed retrospectively. The age, gender, co-morbid problems, ASA score, clinical presentation, indication, nonoperative or operative procedures, mortality, morbidity, hospitalisation period, and recurrence rates were considered.Patients were identified from the operating theatre register and admissions office records. PATIENTS AND METHODS We reviewed our unit's experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions. RESULTS Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group. CONCLUSIONS Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mor...

Section: Discussionmentioning

confidence: 99%

Recurrent Sigmoid Volvulus – Early Resection may Obviate Later Emergency Surgery and Reduce Morbidity and Mortality

Larkin

Thekiso

Waldron

et al. 2009

“…[18][19][20][21] This idea was supported by various RCTs comparing mechanical bowel preparation, with no preparation in elective open colonic surgery. The results were separately examined in a Cochrane systematic review of 9 RCTs 22 and in a metaanalysis of 7 RCTs.…”

Section: Primary Resectionmentioning

confidence: 95%

“…Other non-randomised studies or case series have shown manual decompression to be safe. [18][19][20] Although one-stage resection and anastomosis is considered to be a better option than Hartmann's procedure in left-sided colonic obstruction, this is not true for all patients, and other parameters should be examined before choosing the operation. 5,13,24 Patients should be stratified according to risk.…”

Section: Primary Resectionmentioning

confidence: 99%

Emergency Management of Malignant Acute Left-Sided Colonic Obstruction

Trompetas

2008

The searches showed one Cochrane systematic review, two further systematic reviews, one meta-analysis, two decision 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.

“…Naraynsingh et al 14 reported only one leak and one postoperative death in 58 consecutive patients with left-sided malignant colonic obstruction who underwent decompression without irrigation, followed by resection and primary colocolic anastomosis.…”

Section: Discussionmentioning

confidence: 99%

Primary Anastomosis Without Colonic Lavage for the Obstructed Left Colon

Cross

Rees

Soulsby

et al. 2008

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.