[The single-stage surgery of colorectal neoplastic occlusion. The experience of 133 cases].Minerva Chir. 1999 Jan-Feb; 54(1-2):37-47.MC
BACKGROUND AND AIM
133 cases of occluded colorectal neoplasms (14% of the entire series): 30 (23%) of the right colon, 103 (77%) of the left colon-rectum; 69 males (52%) and 64 females (48%); mean age 67.5 years old, range 33-91 years. pTNM: stage II, 28 cases (21%); stage III: 43 cases (32%); stage IV, 62 cases (47%). The aim of this study was to resolve the occlusive symptoms and to treat the neoplasm in a single operation.
In the 62 cases at stage IV, surgery was solely palliative: 49 (79%) derivations, 13 (21%) entero-enterostomies and 36 (58%) preternatural anus; 11 (18%) standard hemicolectomies, extended in two cases to hepatic resection, and 2 (3%) Hartmann's operations. In the 71 cases at stages II and III, surgery took the form of standard colic exeresis with primary ligature of the colonic vessels at source and at the outlet; 15 (21%) right colectomies, 50 (70%) left colectomies, extended in 6 cases (8%) to abdomino-perineal amputation; 6 segmentary colectomies, 3 (4%) of the transverse colon and 3 (4%) Hartmann's operations. The following aspects are essential in this single-stage surgery: urgency; massive dose antibiotic treatment limited to the pre- and perioperative stages; peritoneal cleansing using accurate, methodical, repeated and abundant lavage; perioperative colonic preparation using direct colotomic perioperative lavage or using a trans-buccoenteric access (using Grosz-Dennis tube); the peritonisation of the retroperitoneum with the omentum and the protection of the anastomosis using omental wrapping and active lavage and, for colorectal anastomosis, even using the 3-way tube, lavage and active aspiration, in a transanal trans- or sub-anastomotic position. Total parenteral feeding is useful for 6-7 days.
In the 62 cases at stage IV, postoperative morbidity was 3 cases (6%): 3 suppurations of laparotomy, and mortality occurred in 10 cases (16%): one case of anastomotic disunion (pre-Gullino's tube), 3 cases of septic shock and 6 cardiorespiratory failures. Mean postoperative hospitalisation was 14 days. All these patients died owing to the spread of neoplasms within 1-40 months, mean 13 months. The worst results were obtained in entero-enterostomies: 1-9 months, mean 5 months. In the 71 cases at stages II and III, postoperative morbidity was 3 cases (4%): a small anastomotic filtration after right colectomy and 2 suppurations of the laparotomic incision; mortality amounted to 10 cases (14%): one case of septic shock, one of acute hepatitis, one intestinal infarction and one cardiac infarction, 3 pulmonary embolisms and 3 cardiorespiratory failures. Mean postoperative hospitalisation was 13 days, only 10 in cases of left colectomy with anastomosis protected by Gullino's tube. The long-term results were very good in these 71 patients: over 5-year survival of 50% (Kaplan-Meier).
Using this courageous single-stage surgery, the results are optimal even at a distance, together with reduced surgical trauma and a shorter hospital stay.