Comparison between one stage operation for obstructed left colon cancer and Hartmann's procedure

Comparison between one stage operation for obstructed left colon cancer and Hartmann's procedure

Mohammad MAli, MD; Hosam F Abdelhameed, MD;

Samir A abdelmegeed, MD

Department of General Surgery, Sohag University Hospital, Egypt.

Abstract

Background: Although acute obstruction of the right colon is usually dealt with by primary anastomosis following resection, many surgeons are reluctant to offer one stage resection and anastomosis to patients with obstructive lesions of the left colon.

Aim: The aim of the study is to compare the result of one stage resection and anastomosis for patients with acute complete obstruction due to left colon cancer versus Hartman's procedure.

Patients and methods: Eighty four patients with acute left colonic obstruction presented to Sohag University Hospital between march 2008 and February 2012. The diagnosis was based on clinical evidence of obstruction and radiological features of left colonic obstruction on plain x-ray abdomen. No pre-operative histopathological  confirmation   of  the diagnosis was done for all patients. Thirty eight patients were managed by one stage left colectomy  without intra­ operative lavage (only manual evacuation of colon and mobbing of the two ends of anastomosis). Hartmann's  procedure was performed in thirty four patients. Twelve patients were excluded from the study according to the following criteria: 1- patients with inoperaple tumors (liver metastasis, peritoneal seedling, haemorrhagic ascitis or unresectable). 2-medically unfit or haemodynamiclly  unstable patients. 3- colonic perforation or peritonitis.

Results: As regards the post operative complications related to left sided colonic surgery (wound   sepsis,  intra-peritoneal   sepsis,  anastomotic   leakage),   there  were  no  significant difference between the two techniques.

Introduction:

Colorectal  cancer is common in developed countries   and   about   15%-20%  of  patients present with an intestinal  obstruction needing emergency  surgery.1,2  Obstructing  tumors are generally  more  advanced, with   a higher incidence of local extension and distant metastasis than  non-obstructing neoplasmes. Also emergency surgery  on a distended and unprepared bowel in high risk patients results in high morbidity and mortality  rates.3

Until  recently, the obstructing left sided colonic   lesions   were  traditionally  managed by  either  three  stage  surgery,  consisting of diverting colostomy,  colonic  resection  and colostomy closure4  or two stage surgery; consisting of     resection  with  proximal colostomy or Hartman's procedure followed

by later reconstruction.5,6

Nowadays,    there     are    surgical techniques that allow colonic  resection and reconstruction to  be  performed in  a  single stage  procedure,  consisting of resection and primary  anatomists with or without  intra­ operative   colonic   irrigationJ-11  One  of  the most  advantage  of  this  type   of  procedure is that it eliminates the need for temporary stoma.  In  our  hospital, emergency surgery for  obstructed  colorectal  cancer   is  carried out by  general  surgeons, and the techniques used  for  resection   are  therefore  dependent on  the  attending surgeon's  experience  and the patient's specific  condition. In our study we compared  and analyzed  the results of two different   techniques to  determine  if  single stage    procedure   (without   intra-operative

lavage) is associated with higher post operative morbidity and consumption of resources than the more conservative Hartman's technique.

Patients and  methods:

Eighty  four  patients  with  acute  left colonic obstruction presented to Sohag University   Hospital   between   march   2008 and   February   2012.   The   diagnosis   was based  on  clinical  evidence  of  obstruction and radiological features of left colonic obstruction on plain x-ray abdomen. No pre­ operative     histopathological     confirmation of the diagnosis was done for all patients. Thirty eight patients were managed by one stage left colectomy without intra-operative lavage (only manual evacuation of colon and mobbing of the two ends of anastomosis). Hartman's   procedure    was   performed    in thirty four patients. Twelve patients were excluded from the study according to the following criteria: 1- patients with inoperaple tumors (liver metastasis, peritoneal seedling, haemorrhagic      ascttls     or     unresectable).

2- medically unfit or haemodynamically unstable patients. 3- colonic perforation or peritonitis.

Results:

There   were   eighty   four   patients   with acutely obstructive carcinomas that required emergency surgery. Only seventy two patients were included in the study. There were forty

Table (1): The demographic data of patients.

six men and twenty  sex women  with mean age of 61.8 years old (ranging from 38-83 years). The demographic data ofthe patients who had tumors at left side of colon and underwent one stage and two stage operation were shown in Table(l).

The tumors  of both groups  were mainly in Duke C (26/34 patients  or 76.4%  in two stage group and 32/38 or 84.2% in one stage operation group).

As regards tumor histology, there was no

difference in both groups except the higher number of tumor with poor differentiation  in two stage group.

Sites of tumors in one stage group were mainly in proximal descending colon and proximal  sigmoid  colon  (26/38  patients  or

68.3%)  while  most tumors in the two  stage

operation were in distal sigmoid colon and rectosegmoid  area (30/34  patient or 88.2%). All patients of one stage group underwent immediate primary colonic anatomists without colostomy after resection and without intra­ operative lavage (only  manual evacuation of the proximal distended colon and cleaning of the two ends of anatomists with saline wet gauzes).  In the two stage group, Hartmann's operation was done Table(2).

There    was    no    statistical     difference in wound  sepsis, intra-operative sepsis, anastomotic leakage and thirty days mortality in both groups after the operations Table(3).

Table(2): Site of tumors in one stage group and two stage group.

Table (3):

Discussion:

The choice of treatment for obstructed carcinomas of left sided colon is still debated because   of  its  high   associated   morbidity and mortality and the number of different surgical   options   available.1,2   Some  times the patient's local or general condition can simplify the decision making process. Most patients with a very high surgical risk or unresectable  neoplasms will  be treated  with decompressive colostomy, whereas coecal ischemia  and perforation  or synchronus tumors in the right colon are strong indication for subtotal colectomy. On the other hand, subtotal  colectomy  is contraindicated  in patients with pre-operative sphencteric dysfunction.3,4 The attending surgeon may decide to  delay the  surgery, trying  to  carry out an intestinal preparation, with or without the placement of a self-expanding endo­ luminal  prothesis to  allow colonic resection on an elective basis.12-14 On the other hand in   an   emergency   operation   the   surgeon may decide on Hartman's procedure, single stage  subtotal colectomy, or colectomy  with primary  anatomosis  (CPA)  with  or  without intra operative colonic irrigation.9-ll

The post operative morbidity after surgery

for malignant left sided colonic obstruction is high8,11,13 being about (43%) in many series and the complications such as anastomotic leakage and post operative infections were mainly related to the surgical technique used.

Although the incidence of complications after  colectomy   and   primary   anastomosis with  intra-operative  lavage  was  lower than that after other techniques, the difference was not significant.

In our study, the post operative mortality

was  7.9%  in  one  stage  group  and  11.8% in  Hartman's  procedure  and  this  came  in accordance  with that  of other  recent  series ranging   from   2%-12%.1,3,8,13  Anastomotic leakage      affected      (5.3%)      of       patiens who      underwent                    pnmary                        anastomosis without  intra-operative  lavage  which  is  in accordance  with that  reported  in literatures with       segmental        resection           and       primary anastomosis   with  intra-operative                 colonic irrigation   and  total  or  subtotal   colectomy while   anastomotic   leakage   is  avoided   in Hartmann's procedure but it is associated with short-term  complicatins  such  as  colostomy necrosis  which  occurred  in  (10.2%)  in  our study.  Moreover the creation of a stoma has obvious reprecussion  on the patient's  quality

Am-Shams] Surg 2013; 6(1):27-30