Intraoperative Colonic Irrigation Research Articles

3 Years Chronic Simultaneous Separated Triple Large Bowel Volvulus in a Middle Age Female, Very Rare Patient: A Case Report

This case report has been reported in line with the SCARE 2020 criteria. Volvulus of transverse colon is rare when compared to cecal and sigmoid volvulus. Cases involving simultaneous volvulus of the transverse colon and another colonic segment are extremely rare. In adolescent’s sigmoid volvulus is rare and because of this diagnosis is usually missed or delayed. Volvulus is commonly defined as a twisted loop of the intestinal bowel and associated mesentery around a fixed point at its base. Surgery is the main course of treatment for Volvolus, ranging from simple detorsion to right colectomy. Sigmoid volvulus remains an uncommon cause of intestinal obstruction among the adolescent age group. A high index of suspicion is necessary to reach a diagnosis and manage accordingly. Delay in diagnosis can lead to complications such as necrosis and perforation of the twisted colon. Caecal volvulus is a rare cause of bowel obstruction, mainly caused by an exceedingly mobile caecum. Early diagnosis can be difficult due to its unspecific symptoms. Computed tomography plays a major role in a positive diagnosis. The main course of treatment is surgical, and modalities depend on various factors such as patient status and perioperative findings. Nowadays laparoscopic evolution continues to reduce postoperative morbidity. Transverse colon volvulus is an uncommon cause of intestinal obstruction. It is a surgical emergency that can lead to bowel infarction, peritonitis, and death. Our case was a 52 female just with abdominal distention and we performed CT for her and we find Triple volvulus of large bowel that in history she has signs for 10 days in 3 years before. We operate him and Total colectomy was done and anastomosis of small bowel to rectum and discharge her healthy. The surgical options in the management of acute large bowel obstruction, as a consequence of transverse colon volvulus, are one- or two-stage procedures. A one-stage procedure includes intraoperative colonic irrigation, resection of non-viable bowel, and primary anastomosis to avoid stoma creation. In a two-stage procedure, two options are available: (1) bowel is resected; the proximal end is brought out as terminal colostomy and distal end as a mucus fistula; 2–3 months’ post-surgery, end-to-end anastomosis is performed and (2) bowel is resected and end-to-end anastomosis is performed; a defunctioning colostomy or a loop ileostomy is fashioned to protect the anastomosis, which is closed 3–4 weeks later. Colonic volvulus usually occurs as a single event that can affect various parts of the colon. The usual sites affected being the sigmoid colon (75%) and the caecum (22%). The phenomenon of multiple sites simultaneously undergoing volvulus is an extremely rare occurrence. The dual location of strangulation makes this situation a major surgical emergency with a high risk of gangrene and septic shock. Colectomy with delayed anastomosis should be preferred in the treatment. Overall, metachronous colonic volvulus must be considered in the differential diagnosis of bowel obstruction, particularly in patients with significant risk factors. Early surgical intervention is essential for better outcome and avoiding complications. A metachronous transverse colonic volvulus is uncommon. Preoperative diagnosis is challenging as there are no defining radiographic features compared to the volvulus of the sigmoid colon with the classical omega sign. Most cases are diagnosed intra-operatively. Bowel resection and anastomosis in a single stage is a safe option. We report this case because in literature we did not find triple and chronic volvulus.

Intraoperative Colonic Irrigation for Low Rectal Resections With Primary Anastomosis: A Fail-Safe Surgical Model.

AimRegardless the technological developments in surgery, the anastomotic leakage (AL) rate of low rectal anastomosis remains high. Though various perioperative protocols have been tested to reduce the risk for AL, there is no standard peri-operative management approach in rectal surgery. We aim to assess the short-term outcome of a multidisciplinary approach to reduce the rates of ALs using a fail-safe-model using preoperative and intraoperative colonic irrigation in low rectal resections with primary anastomosis.MethodsBetween January 2015 and December 2020, 92 patients received low rectal resections for rectal cancer with primary anastomosis and diverting ileostomy. All these patients received pre-operative mechanical bowel preparation (MBP) without antibiotics as well as intraoperative colonic irrigation. The intraoperative colonic irrigation was performed via the efferent loop of the ileostomy. All data were analyzed by SPSS for descriptive and inferential analyses.ResultsIn the study period, 1.987 colorectal surgical procedures were performed. This study reports AL in 3 (3.3%) of 92 recruited patients. Other postoperative complications (Dindo-Clavien I-IV) were reported in 25 patients (27.2%), which occurred mainly due to non-surgical reasons such as renal dysfunction and sepsis. According to the fail-safe model, AL was treated by endoscopic or re-do surgery. The median postoperative length of hospitalization was 8 days (4–45) days.ConclusionThis study validates the effectiveness of a multi-disciplinary fail-safe model with a pre-operative MBP and an intraoperative colonic irrigation in reducing AL rates. Intraoperative colonic irrigation is a feasible approach that lowers the AL rates by reducing fecal load and by decontamination of the colon and anastomotic region. Our study does not recommend a pre-operative administration of oral antibiotics for colorectal decontamination.

The Use оf Intraoperative Colonic Irrigation in Surgical Treatment 
 of Obstructing Cancer of the Left Colon

Purpose. Study of technical options and immediate results of primary anastomoses using intraoperative colonic irrigation in the surgical treatment of left-sided colonic tumor obstruction.Material and methods. Of the 128 patients with left-sided colonic obstruction, 20 patients underwent surgery with intraoperative colonic lavage and the formation of a primary colonic anastomosis. The mean age was 61.7 1.4 years. In 5 patients, the compensated stage of colonic malignant obstruction was detected, in 8 patients - subcompensated, in 7 patients - decompensated. Colon icirrigation was carried out by means of antegrade jet injection of 8 -10 liters of isoosmolar solution of electrolytes and was terminated by the introduction of enterosorbent microsorb-P. In 11 cases left-sided hemicolectomy was performed in patients and in 9 cases - resection of the sigmoid colon with primary anastomosis.Results. After surgical interventions various complications were observed in 7 patients. In 2 patients afailure of anastomosis was revealed, the successful treatment of which did not require repeated surgical procedures. In the postoperative period 1 (5.0%) patient died on the 4th day after surgical intervention from cardiopulmonary insufficiency on the basis of concomitant pathology.Conclusion. In the conditions of specialized surgical hospitals after careful evaluation of operational risk with obstructing cancer of the left colon it is possible to use segmental resections of the colon with the imposition of a primary anastomosis with mandatory use of intraoperative colonic lavage . This tactic helps to increase the effectiveness of surgical interventions and provides early rehabilitation of operated patients.

One-stage operation without intraoperative colonic irrigation for left-sided colonic obstruction: Case series study

BackgroundTo perform a one-stage operation safely in selected patients with left-sided colonic obstruction, many surgeons have considered intraoperative colonic irrigation as an indispensable step. Recently, studies have shown that step is unnecessary. The aim of this study was to identify the early results of a one-stage operation without intraoperative colonic irrigation in the treatment of left-sided colonic obstruction. MethodsThis case series included patients who had resectable left-sided colonic obstruction and were admitted to Nhan Dan Gia Dinh Hospital from January 2008 to December 2018. All patients were treated by one-stage operation without intraoperative colonic irrigation. The early results were described, focusing on mortality, anastomotic-related complications, operative time and length of hospital stay. ResultsThere were 74 patients with a mean age of 50 years (range 20–81 years). Colorectal cancer accounted for 86.4% of cases. The median operative time was 158 ± 42 min (range 65–285 min). One patient (1.4%) died on postoperative day 6 due to pneumonia and multiorgan failure. Three patients (4.1%) had major anastomotic leakage, 4 patients (5.4%) had minor anastomotic leakage, 9 patients (12.2%) had wound infection, 4 patients (5.4%) had intraabdominal fluid collection, and 1 patient (1.4%) had an early adhesive small bowel obstruction. The median length of hospital stay was 9 ± 3 days (range 5–24 days). The method was successful in 70/74 patients (94.6%). ConclusionsWith properly selected patients and experienced GI surgeons, a one-stage operation without intraoperative colonic irrigation is an effective and safe alternative for resectable left-sided colonic obstruction.

The Usefulness of Intraoperative Colonic Irrigation and Primary Anastomosis in Patients Requiring a Left Colon Resection.

PurposeThe aim of this study is to assess the short-term outcome of intraoperative colonic irrigation and primary anastomosis and to suggest the usefulness of the procedure when a preoperative mechanical bowel preparation is inappropriate.MethodsThis retrospective study included 38 consecutive patients (19 male patients) who underwent intraoperative colonic irrigation and primary anastomosis for left colon disease between January 2010 and December 2016. The medical records of the patients were reviewed to evaluate the patients' characteristics, operative data, and postoperative short-term outcomes.ResultsTwenty-nine patients had colorectal cancer, 7 patients had perforated diverticulitis, and the remaining 2 patients included 1 with sigmoid volvulus and 1 with a perforated colon due to focal colonic ischemia. A diverting loop ileostomy was created in 4 patients who underwent a low anterior resection. Complications occurred in 15 patients (39.5%), and the majority was superficial surgical site infections (18.4%). Anastomotic leakage occurred in one patient (2.6%) who underwent an anterior resection due sigmoid colon cancer with obstruction. No significant difference in overall postoperative complications and superficial surgical site infections between patients with obstruction and those with peritonitis were noted. No mortality occurred during the first 30 postoperative days. The median hospital stay after surgery was 15 days (range, 8–39 days).ConclusionIntraoperative colonic irrigation and primary anastomosis seem safe and feasible in selected patients. This procedure may reduce the burden of colostomy in patients requiring a left colon resection with an inappropriate preoperative mechanical bowel preparation.

Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation

BackgroundThe management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported. Patients and MethodsPatients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant. ResultsThere were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05). ConclusionsPrimary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.

Enteroenterostomy in surgical treatment of malignant colonic obstruction

To consider surgical tactics and to study the immediate results of primary enteroenterostomy in surgical treatment of malignant colonic obstruction. Radical surgery was performed in 170 (63.9%) out of 266 patients with malignant obstructive colonic obstruction. Colonic resection followed by anastomosis was performed in 68 patients. Conventional hemicolectomy (9 patients) and various original techniques of Y-shaped ileotransversanastomoses (27 patients) were used for right-sided tumor process. In case of left-sided tumor we used intraoperative colonic irrigation with enterosorption (20 operations), Y-shaped anastomoses (9 operations) and subtotal colectomy (3 operations). There was significantly increased mortality in patients with sub- and decompensated stages of malignant colonic obstruction. Postoperative mortality after radical surgery was 10.6%, after palliative interventions - 21.9%. There was similar postoperative mortality after various types of radical interventions with/without enteroenterostomy (8.8% and 11.8%, respectively). In favorable clinical situation radical surgery with tumor removal at the first emergency stage should be preferred for malignant colonic obstruction. At the specialized hospital segmental colonic resection with primary anastomosis is possible after comprehensive assessment of surgical risk, intraoperative colonic irrigation is obligatory for left-sided tumor. This approach increases surgical effectiveness and provides early rehabilitation.

Outcomes in Colorectal Surgeon-Driven Management of Obstructing Colorectal Cancers

Emergency surgery for obstructing colorectal cancer is associated with high mortality and morbidity rates. The purpose of this study was to assess outcomes of emergency surgery for obstructing colorectal cancer in a single hospital, where care was primarily provided by colorectal surgeons. This was a retrospective cohort study. The study was conducted at the Toyonaka Municipal Hospital. The study included 208 consecutive patients who underwent emergency surgery for obstructing colorectal cancer between 1998 and 2013. Surgical outcomes, including mortality and morbidity, were evaluated. The obstructing cancers involved the right colon, left colon, and rectum in 78, 97, and 33 of the included patients. Many patients had poor performance indicators, such as age ≥75 years (42%), ASA score of III or more (38%), stage IV colorectal cancer (39%), obstructive colitis (12%), and perforation or penetration (9.6%). Colorectal surgeons performed the operations in all but 5 of the patients. Primary resection and anastomosis were accomplished in 96%, 70%, and 27% of cases involving the right colon, left colon, and rectum. Intraoperative colonic irrigation (n = 32), manual colonic decompression (n = 11), and subtotal or total colorectal resection (n = 34) were performed before left-sided anastomoses. Anastomotic leak was reported in only 2 patients. The in-hospital mortality and morbidity rates were 1.3% and 34.0%. This study was a retrospective analysis of data from a single hospital. Surgical outcome analysis for obstructing colorectal cancers managed by specialized colorectal surgeons demonstrates low mortality and morbidity rates. Therefore, we concluded that our management of this condition is safe and feasible.

Progress in the management of obstructing cancer of the left colon

Obstructing colorectal cancer is one of the acute abdominal diseases which are common in clinical practice. The initial symptoms of 8.0%–33.9% patients with obstructing colorectal cancer are complete or incomplete acute colonic obstruction. Seventy percent of obstructing colorectal cancer located at the left colon. There are no standard treatment methods for obstructed left colonic carcinoma (OLCC) . Previously, a staged procedure was recommended. With the improvement of the intestinal surgical techniques, one-stage resection and anastomosis including intraoperative colonic irrigation, subtotal colectomy, metal stents placement and transanal drainage tube placement were preferred by most of the surgeons. In addition, metal stents placement and transanal drainage tube placement can reduce bowel pressure, which creates the possibility for the treatment of malignant colorectal obstruction by laparoscopes. Key words: Colonic neoplasms; Bowel obstruction; One-stage surgery

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

Mo1628 One-Stage Colectomy With Intraoperative Colonic Irrigation for Acute Left-Sided Malignant Colonic Obstruction

One-Stage Segmental Colectomy and Primary Anastomosis After Intraoperative Colonic Irrigation and Total Colonoscopy for Patients With Obstruction Due to Left-Sided Colorectal Cancer

Intraoperative colonic irrigation and intraoperative on-table colonoscopy may be useful for a more accurate diagnosis of colorectal cancer before colectomy in patients with obstructive left-sided colorectal cancer, but the clinical benefit of this technique has not been investigated in large-scale studies. The aim of this study was to evaluate the usefulness of intraoperative colonic irrigation with a Y-shaped irrigation device and intraoperative colonoscopy in the management of obstructive colorectal cancer in patients undergoing elective surgery. This was a retrospective cohort study of patients undergoing surgical treatment at a single tertiary care institution in Japan. Among 715 consecutive patients with left-sided colorectal cancer, 101 patients (14.1%) with obstructing tumor received intraoperative colonic irrigation and intraoperative colonoscopy before colectomy and primary anastomosis, and 614 patients with nonobstructive colorectal cancer underwent preoperative colonoscopy with mechanical bowel preparation. Detection rates of proximal synchronous lesions, occurrence of postoperative complications, and changes in the surgical procedure prompted by the results of the intraoperative colonoscopy were evaluated. Intraoperative colonoscopy detected synchronous adenomatous polyps in 27 patients (26.8%), carcinoma in 4 patients (4%), and obstructive colitis in 2 patients (2%). Findings of the intraoperative colonoscopy prompted changes in surgical procedure in 9 patients (8.9%). The overall morbidity in the intraoperative group was 17%, with anastomotic leakages in 3 patients, wound infection in 5, and postoperative ileus in 3 patients. The risk of these complications was not increased in patients with intraoperative colonoscopy with intraoperative colonic irrigation compared with those receiving preoperative colonoscopy with mechanical bowel preparation. The operation time was 28 minutes longer in the intraoperative than in the preoperative group, but neither the time to start of oral intake nor the length of postoperative hospital stay was significantly different between the 2 groups. The study is limited by its retrospective nature. : In patients with obstructive colorectal cancer, intraoperative colonic irrigation with intraoperative colonoscopy is a useful strategy for detecting synchronous lesions located proximally to the obstructing tumor, without increasing patient morbidity.

Guidelines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society

BackgroundObstructive left colon carcinoma (OLCC) is a challenging matter in terms of obstruction release as well of oncological issues. Several options are available and no guidelines are established. The paper aims to generate evidenced based recommendations on management of OLCC.MethodsThe PubMed and Cochrane Library databases were queried for publications focusing on OLCC published prior to April 2010. A extensive retrieval, analyses, and grading of the literature was undertaken. The findings of the research were presented and largely discussed among panellist and audience at the Consensus Conference of the World Society of Emergency Surgery (WSES) and Peritoneum and Surgery (PnS) Society held in Bologna July 2010. Comparisons of techniques are presented and final committee recommendation are enounced.ResultsHartmann's procedure should be preferred to loop colostomy (Grade 2B). Hartmann's procedure offers no survival benefit compared to segmental colonic resection with primary anastomosis (Grade 2C+); Hartmann's procedure should be considered in patients with high surgical risk (Grade 2C). Total colectomy and segmental colectomy with intraoperative colonic irrigation are associated with same mortality/morbidity, however total colectomy is associated with higher rates impaired bowel function (Grade 1A). Segmental resection and primary anastomosis either with manual decompression or intraoperative colonic irrigation are associated with same mortality/morbidity rate (Grade 1A). In palliation stent placement is associated with similar mortality/morbidity rates and shorter hospital stay (Grade 2B). Stents as a bridge to surgery seems associated with lower mortality rate, shorter hospital stay, and a lower colostomy formation rate (Grade 1B).ConclusionsLoop colostomy and staged procedure should be adopted in case of dramatic scenario, when neoadjuvant therapy could be expected. Hartmann's procedure should be performed in case of high risk of anastomotic dehiscence. Subtotal and total colectomy should be attempted when cecal perforation or in case of synchronous colonic neoplasm. Primary resection and anastomosis with manual decompression seems the procedure of choice. Colonic stents represent the best option when skills are available. The literature power is relatively poor and the existing RCT are often not sufficiently robust in design thus, among 6 possible treatment modalities, only 2 reached the Grade A.

Comparative study to determine the need for intraoperative colonic irrigation for primary anastomosis in left‐sided colonic emergencies

To compare the outcome of resection and primary anastomoses in patients undergoing emergency surgery of the left colon with and without intraoperative colonic irrigation. From January 2004 to December 2006, 102 consecutive patients with acute occlusion or perforation of the left colon were operated on an emergency basis in two Coloproctology units. According to the sample size calculation, 61 patients from one unit underwent surgery with intraoperative colonic irrigation, whereas 41 patients from the second unit underwent surgery without intraoperative colonic irrigation. The endpoints were mortality and morbidity. Thirty (49.2%) patients with intraoperative colonic irrigation and 8 (19.5%) without colonic irrigation developed one or more complications postoperatively (odds ratio 4.0, 95% CI 1.6-10.0, P = 0.002). An increased number of wound infections was seen in the group managed with colonic irrigation 15 vs 3 (P = 0.034). The postoperative mortality rate and the occurrence of dehiscence of the anastomoses were similar in both study groups. The present findings indicate that resection and primary anastomosis in patients undergoing emergency surgery of the left colon can be safely performed without intraoperative colonic irrigation.

Primary resection and anastomosis without intraoperative colonic irrigation in left colonic cancer with complete obstruction

Objective To assess the value of primary resection and anastomosis without intraoperative irrigation in the patients with obstructive left colonic cancer. Method Between January 2000 and January 2008, 93patients underwent primary resection and anastomosis for colonic cancers were analyzed retrospectively. Primary resection and anastomosis without intraoperative colonic irrigation (decompression by manual defecation) was performed in 43 patients with obstructive left colonic caner and traditional left-sided colectomy in 50 cases without obstruction. Both groups of patients were comparable in terms of gender, nutritional status, underlaying disease, tumor location and stage, etc ( P = 0.83,0.13,0.29,0.51,0.38). The average age of the patients with colonic obstruction was significant older than that of the cases without obstruction (61.2 ± 8.6 vs. 58.1 ±7.8, P =0.010).The operative results were compared between patients with obstructive colonic cancer and cases without obstruction.Results The mean hospital stay of the primary anastomosis group and traditional left-sided colectomy group were (16.6±7.8) d and (12.4±5.4) d respectively, and the former was significant longer than the latter (P =0.002). The costs of hospitalization in the two groups were (50192.8 ± 39727.4) RMB and (46489.3 ±29543.1)RMB respectively (P = 0.04) . The morbidity and mortality in the two groups were 25.6% (11/43) vs. 18%(9/50) (P =0.375) and 2.3% (1/43) vs. 2.0% (1/50) (P =0.714) respectively, and there were no significant difference between the two groups. Conclusions Primary resection and anastomosis without intraoperative colonic irrigation (decompression by manual defecation) compares favorably with traditional left-sided colectomy in safety and efficiency for left colonic cancer with obstruction. Key words: Colonic carcinoma; Intestinal obstruction; Treatment

Systematic review of intraoperative colonic irrigation vs. manual decompression in obstructed left-sided colorectal emergencies

A systematic review was conducted to determine if manual decompression is a safe alternative to intraoperative colonic irrigation prior to primary anastomosis in obstructed left-sided colorectal emergencies. Search for relevant articles from 1980 to 2007 was conducted on Medline, Embase and the Cochrane Controlled Trials Register using the keywords "colonic lavage, irrigation, decompression, washout, obstructed and bowel preparation", either singularly or in combination. Trials in English publications with similar patient characteristics, inclusion criteria and outcome measures were selected for analysis. Thirty-day mortality, anastomotic leak rates and post-operative wound infection were studied as outcome variables. Analysis was performed with RevMan 4.2 software. Seven trials were identified for systematic review, with a total of 449 patients. Data from the single randomised controlled trial and one prospective comparative trial were analysed separately. Results from the remaining five studies were pooled into two arms of a composite series, one with colonic irrigation and one without. Results showed no significant difference in the anastomotic leak rates and mortality rates between the colonic irrigation and manual decompression arms in the randomised and comparative trials. The composite series, however, showed significantly better results with manual decompression (RR 6.18, 95% CI 1.67-22.86). The post-operative infection rate was similar in both groups. Manual decompression was comparable to colonic irrigation for primary anastomosis in obstructed left-sided colorectal emergencies, with no significant increase in mortality, leak or infection rates.

One-stage treatment of left-sided large bowel emertencies

To evaluate the safety and benefits of left-sided colectomy and primary anastomosis without intraoperative colonic irrigation in the management of patients with colorectal emergencies. Prospective descriptive analysis of patients with emergency left-sided colonic and rectal lesions requiring resection and primary anastomosis. Setting A hospital based cohort over a five and a half year period at Jos University Teaching Hospital, Jos, Nigeria. A total of 42 patients with left sided and rectal emergency lesions. Their ages ranged from 9-65 years with a mean of 43.1 years. Twenty patients had sigmoid colectomy and primary colorectal anastomosis for sigmoid volvulus. Two patients with compound sigmoid volvulus had sigmoid colectomy as well as ileal resection and primary colorectal and ileoileal anastomosis. Transverse colectomy and primary colocolic anastomosis was carried out in six patients who had transverse colon tumour from gastric neoplasia. These six patients had in addition distal partial gastrectomy and gastrojejunal anastomosis to remove the primary gastric neoplasia. One patient had transverse colectomy and another four left hemicolectomy and primary colocolic anastomosis for trauma. Left colectomy and colocolic anastomosis was performed in three patients with left colon tumour while anterior resection and colorectal anastomosis for rectosigmoid cancer was carried out in six patients. Manual decompression of the colon is as good as antegrade colonic irrigation in the management of left-sided large bowel emergency conditions in selected patients when undertaken by dedicated experienced surgeons. There was one clinical anastomostic leak presenting as enteric fistula on the sixth postoperative day. The discharge was bilious and occurred in a patient with gastric mesenchymal stromal tumour who had distal partial gastrectomy and gastrojejunal anastomosis. He had no features of generalised peritonitis nor residual intra-abdominal abscesses. The fistula was managed non-operatively. A 12% wound infection rate was recorded. All infections were superficial and healed with conservative measures. We had no mortality in our series. The hospital stay ranged from 6 to 21 days with a mean of 7.5 days. Manual decompression of the colon alone is as good as colonic irrigation in the management of left-sided large bowel emergencies. However, on-table antegrade colonic irrigation should be reserved for the loaded colon that may interfere with the use of a stapling instrument, when the resection margins are limited as in low anterior resections and when left-side colonic emergencies are undertaken by non-dedicated, less experienced surgeons.

Emergency Management of Malignant Acute Left-Sided Colonic Obstruction

The management of acute left-sided colonic obstruction still remains a challenging problem despite significant progress. 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. 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.

Colonic Obstruction Caused by Sigmoid Volvulus Combined with a Transomental Hernia: A Case Report

The case of sigmoid volvulus combined with a transomental hernia is reported. A 70-year-old man was admitted to our hospital with mild abdominal pain and distension. Although no signs of peritoneal irritation were apparent, a plain abdominal X-ray showed a markedly dilated loop of the sigmoid colon, and CT revealed a whirl pattern of the sigmoid mesentery. These findings suggested sigmoid volvulus. Colonoscopic reduction was attempted as an initial nonoperative treatment, and an urgent laparotomy was performed after the reduction failed. The sigmoid loop was herniated through the great omentum, with torsion in the clockwise direction. The colon was manually untwisted in the counter-clockwise direction, and the sigmoid loop was released by dividing the great omentum. During this one- stage operation, intraoperative colonic irrigation, sigmoid resection, and primary anastomosis were performed. The postoperative course was uneventful. Although sigmoid volvulus combined with a transomental hernia is rare, urgent surgical intervention is essential on failure of endoscopic reduction.

Intra-operative colonic irrigation in the management of left-sided large bowel emergencies.

In a consecutive series of 93 patients who required emergency surgery for distal colonic lesions, 61 had primary bowel resection with immediate anastomosis after intra-operative antegrade colonic irrigation. The operative mortality was 8 per cent, anastomotic leakage rate 7 per cent and superficial wound infection occurred in 3 per cent of patients. The mean hospital stay was 13 days. Of the remaining 32 patients, 3 did not have a resection and 29 had a primary resection and end colostomy without anastomosis: bowel continuity was later restored in 17 of 28 survivors (61 per cent) but 11 (39 per cent) were left with a permanent colostomy. The hospital mortality in this group was 6 per cent, superficial wound infection rate 14 per cent and the mean hospital stay 26 days. The results of this study suggest that intra-operative colonic irrigation is an effective method enabling the surgeon to perform a primary anastomosis with reasonable safety after emergency resection of selected distal colonic lesions.

Intraoperative colonic irrigation in the treatment of acute sigmoid volvulus.

Intraoperative colonic irrigation in the treatment of acute sigmoid volvulus.