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Modern trends in colon surgery
BtreamlinedIiMcles MODERN TRENDS IN COLON SURGERY FRANK D. CONOLE, M.D. Binghamton, New York
T
HE value of any refinement in surgical technic must be proven. Time alone will give us the answer; the “pull-through” procedure is highly controversiah The indications and contraindications of the various refinements are mentioned. An attitude of fair-mindedness and tolerance will be necessary and helpful until the full value of these procedures has been appraised. ****
During June, 1948, to June, 1949, approximateIy twenty-four surgical operations were performed at the Binghamton City Hospital for malignancy of the large bowel. Over a century ago Reybard’ successfully removed a sigmoidal cancer and restored intestinal continuity by primary anastomosis. Ever since that time surgeons have recognized the challenge and endeavored to accomplish two things: first, resect widely the existing malignancy and, secondly, devise and improve the technical aspects of a necessary anastomosis. It is only in the past ten years that such operative feats have been compatible with Iow operative mortahty. The early mortality has been lowered only in proportion to a necessary knowledge of the basic physiology, biochemistry and refinements in operative technic. About fifty years ago “exas devised by Block, Paul teriorization” and MikuIicz was hailed as the answer. This principle was brought to its highest perfection by Rankin with his so-called “obstructive resection” in 1930. Rapid strides were made during the war years and those of us who were fortunate enough to 820
have used the principle of exteriorization in surgery of the Iarge bowel soon became convinced that the difficulties involved were many. Gibbon and Hodge2 report that the mortality from the exteriorization operation is twice as great as from resection with end-to-end anastomosis. When the malignant lesion to be resected lies between the cecum and rectosigmoid junction, resection with primary anastomosis can usuaIIy be done and is superior to any other method. Preliminary ileostomy, appendicostomy or colostomy is necessary only in compIete obstruction. More than one-half of the lesions (rectum, 69 per cent and coIon, 60.8 per cent) will have metastasized to the regional nodes before the patient comes to surgery. Normal lymph ffow coincides with venous blood flow almost entirely except for some lateral spread. A small-sized lesion can have extensive and far removed metastases. This makes us realize that while lymphatic spread probably accounts for most of the metastases, venous implants do occur. Extension by Iocal growth and wound implants is certainly far less common. The distribution of the twenty-four Iesions encountered and a presentation of the operative procedures used has been tabulated. (TabIe I.) On the right side, from the cecum and ascending colon up to and including the hepatic flexure, it often happens that the local spread is extensive. True, the operative mortality is a bit higher than that for resections on the left side, but the number of five-year survivals is far greater. Because of this onIy a wide resection will satisfy. Excision of the entire right colon American
Journal
of Surgery
ConoIe-Colon
be resected, the blood suppIy preserved and, equally as important, the anastomosis wiI1 not be taut (or under tension). Lesions of the Ieft colon constitute a small number unti1 the rectosigmoid junction is reached. A high spIenic Aexure can
with a portion of the termina1 ileum, hepatic ffexure and transverse colon to the left of the mid-cohc artery should be done. Prehminary iIeotransverse colostomy as a stage procedure with the hope of excision at a later date seldom materiaIizes. Com-
Location
Operative Mortality
of Lesion
TABLE
-
-
age Age (yr.1
cent)
Transverse
I-
colon.
72
81
Descending colon. Sigmoid pelvic colon.
56
Rectum..
71
AverSex
-
-
/ Pathologic
3
hl I ) Adenocarcinoma F 2 M 2 Adenocarcinoma biopsy I F4
3
I
M 6
!
1930
Type of Resection
2
3
pIete obstruction is rarely a factor to be dealt with, but inoperability because of local fixation leaves with one the profound impression of the necessity of early diagnosis. Change in bowel habit, undetermined secondary anemia and weight Ioss are the most common early symptoms. A palpable mass wiI1 not too frequentIy be resectable. The transverse coIon and the sigmoid loop are the two areas in which many surgeons believe that the principle of exteriorization should be used. Jones4 states that he has a bit Iower operative mortality in this area (transverse coIon) by using that procedure. However, the attachments of the gastrocoIic omentum and transverse mesocoIon with their rich Iymphatic and blood supphes caII for a wide resection. Preservation of bIood suppIy to the bowel ends being anastomosed is a fundamental principle. To affect this it sometimes becomes necessary to mobilize the spIenic and hepatic ffexures. This maneuver aIIows for a greater portion of the transverse colon to June,
Diagnosis
Adenocarcinoma
hl F
F
-
-
Aver-
of Cases
Cecum ascending color L
I
T NO.
(per
821
Surgery
8;
no
Adenocarcinoma 4; papillary adenocarcinoma 3; epidermoid carcinoma I
age I-lospita1 Days
Right coIectomy 2; ablaooratomv: dominal patient diedbn table” Mikulicz 3
40
Mikulicz I ; resection and anastomosis 4; loop colostomy 2; inoperabIe r; Miles’ I Divided colostomy z; loop colostomy 3; Babcock pull-through I; inoperable 1; hliles’ I
27
36
4’
be the most difhcuIt area in the entire colon to mobilize, but with adequate abdominal incision and carefu1 dissection one is frequentIy surprised. It is onIy then that the surgeon reaIizes a radicaI excision can be accomplished. The entire left coIon down to the beginning portion of the sigmoid Ioop with a wide swath of the sectiona mesocolon can then be removed and a primary anastomosis between the transverse coIon and sigmoid loop estabIished. Difficulty can be experienced in periotonealizing the area from which the splenic fIexure was removed. It is not good surgery nor is it entirely safe to Ieave this area denuded of its peritonea1 covering. I know of no better use of the MikuIicz pack than in this particuIar locality. The sigmoid Ioop is of great importance because it is here that a Iarge number of lesions are encountered. A stenosing, napkin-ring type is most common. In this same area diverticulitis in its various forms is aIso frequentIy found. When confronted
822
Conole-CoIon
with a differential diagnosis in this area one has a problem of real magnitude. A proximal colostomy would certainly be the ideal answer as a stage procedure if an unequivoca1 diagnosis could be made of diverticulitis. More frequentIy, the typica stenosing lesion of maIignancy is found (it may be small) and one may be surprised to find liver metastases. If no liver metastases are present, a wide resection with remova of the inferior mesenteric group of nodes is indicated. The so-caIIed critica point of Sudeck is a nice academic rehnement, but of more vaIue is the presence of copious bIeeding from the ends of the bowe1 to be anastomosed. In the event of Iiver metastases a paIIiative resection is indicated and is a very worth whiIe procedure. The recta1 ampulla is the most common site in the entire colon to be invaded by neoplastic change. Over 80 per cent of the lesions wiI1 be above the mid-portion of the rectum. DeveIopments unearthed within the past few years (GiIchrist and David,5 McVay,‘j and CoIIer, Kay and McIntyre7) show that it is most unusua1 to find tumor ceIIs 2.5 cm. or I inch below the paIpabIe tumor mass. It is now time to re-evaluate our concepts in regard to Iymphatic spread. The upward spread is extensive and a definite happening; IateraI spread in lesions at the IeveI of the Ievator muscIes is a strong possibiIity. However, true downward spread is unIikeIy. With this thought and a fuI1 realization of a far reaching (not common) upward spread due to venous return, there is no conflict with sphincter-preserving operations. Babcock and Bacon have modified the Hochenegg procedure and do equally as radical a piece of surgery as is possible with MiIes’ operation. I am convinced that the construction of a peritoneal diaphragm carries with it the possibility of recurrence in the form of peritonea1 impIants. The Iow anterior resections as performed by Dixon and Wangensteen are difficuh in a technical way and, if done at a Iow level, proxima1 coIostomy as a temporary measure is mandatory. Both Babcock and Dixon* have a higher percentage of five-year survivaIs
Surgery (58.5 per cent) than those reported from centers doing the orthodox Miles’ operation (46.3 per cent) .y I hold no brief for procedures done from beIow without abdomina expIorations and, strangeIy enough, someone wiIl revive the Lockhart-Mummery (perinea1 excision) operation every now and then. In low-lying lesions MiIes’ (orthodox) abdominoperinea1 resection is the procedure of choice and the operations for sphincter preservation are definitely contraindicated. A fair, non-biased appraisa1 of present day concepts in regard to maIignant Iesions situated in the recta1 ampulIa or rectosigmoid has an ever increasing number of converts to the sphincter-preserving types of operation. Proper preoperative care and chemoand antibiotic therapy now ahow as the procedure of choice open anastomosis. Modifications of the Furniss clamp and the Parker-Kerr basting stitch come close to a cIosed anastomosis, but in so doing only a seromuscular coaptation is achieved. Open anastomosis aIIows not 0nIy for seromuscuIar approximation but aIso, of as great importance, for mucosal approximation. Hemorrhage from the mucosal Iayer has been reported with closed procedures. However, of more importance is failure of accurate approximation of the Iayer of the mucous membrane and in so doing the incidence of stricture formation is very apt to be a factor. The air vent drains as devised by Wangensteen and Chaffin are a great improvement over the Babcock sump drain and of definite value if one decides upon the necessity of drainage. REFERENCES
I.
REYBARD, .I. F. Memorire sur une tumeur concereuse affectant I’iliaque due colon; ablation deIa tumeur et de I’intestin. Bull. acad. de med., Paris, 9: 1031,
‘944. 2. GIBBON, H. J., JR. and HODGE, C. C. Aseptic immediate anastomosis following resection of the colon for carcinoma. Ann. Surg., I 14: 634, 1941. 3. MCKITTRICK, L. S. Principles old and new of resection of the colon for carcinoma. Surg., Gynec. 0 Ok., 87: 15, 1948.
American
Journal
of Surgery
ConoIe-CoIon 4. JONES, T. E. Surgical management of carcinoma of the colon and rectum. S. Clin. North America, 28: 1159. 1948. 5. GILCHRIST, R. K. and DAVID, V. C. Lymphatic spread in carcinoma of the rectum. Ann. Surg., 108: 621, 1938. 6. MCVAY, J. R. InvoIvement of the lymph nodes in carcinoma of the rectum. Ann. Surg., 76: 755, 1922.
Surgery
7. COLLER, F. A., KAY, E. B. and MCINTYRE, R. S. Regional lymphatic metastasis of carcinoma of the rectum. Surgery, 8: 294, 1940. 8. DIXON, C. F. Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann. &i-g., 128: 425, 1948. 9, WHIPPLE, A. 0. et a1. Symposium on the surgical management of malignancy of the coIon. Surgery, ‘4: 321, 1943.
IT is we11 known that many cases of achaIasia of the esophagus go on to irreversibIe esophageal changes. Cardiospasm present is often associated with organic changes in the cardiac portion of the stomach and adjacent esophagus as we11 as with simple imbaIance of the autonomic nervous system. It seems logical, therefore, to recommend surgery when simpIer measures fail to attain success. The narrowed passage may be widened by a technic simiIar to the Finney pyIoropIasty procedure. In other cases, unIess one wishes to resect the stenosed area because of a more advanced pathoIogic condition and do an immediate anastomosis, a successfu1 result can occur following the Heineke-MikuIicz technic. This is done for pyIoric stenosis wherein a Iongitudinal incision is made through the involved area, between stomach and esophagus, and it is cIosed in a transverse manner to make the Iumen more patent. SuccessfuI results can occur after aI1 such procedures whether performed via the transpleural or transperitoneal route. Often, however, fewer complications occur foIIowing the Iatter route and it may be simpIer for genera1 surgeons who do not have too much experience in performing thoracic surgery. (Richard A. Leonardo, M.D.)
June,
1950
823
T
HE value of any refinement in surgical technic must be proven. Time alone will give us the answer; the “pull-through” procedure is highly controversiah The indications and contraindications of the various refinements are mentioned. An attitude of fair-mindedness and tolerance will be necessary and helpful until the full value of these procedures has been appraised. ****
During June, 1948, to June, 1949, approximateIy twenty-four surgical operations were performed at the Binghamton City Hospital for malignancy of the large bowel. Over a century ago Reybard’ successfully removed a sigmoidal cancer and restored intestinal continuity by primary anastomosis. Ever since that time surgeons have recognized the challenge and endeavored to accomplish two things: first, resect widely the existing malignancy and, secondly, devise and improve the technical aspects of a necessary anastomosis. It is only in the past ten years that such operative feats have been compatible with Iow operative mortahty. The early mortality has been lowered only in proportion to a necessary knowledge of the basic physiology, biochemistry and refinements in operative technic. About fifty years ago “exas devised by Block, Paul teriorization” and MikuIicz was hailed as the answer. This principle was brought to its highest perfection by Rankin with his so-called “obstructive resection” in 1930. Rapid strides were made during the war years and those of us who were fortunate enough to 820
have used the principle of exteriorization in surgery of the Iarge bowel soon became convinced that the difficulties involved were many. Gibbon and Hodge2 report that the mortality from the exteriorization operation is twice as great as from resection with end-to-end anastomosis. When the malignant lesion to be resected lies between the cecum and rectosigmoid junction, resection with primary anastomosis can usuaIIy be done and is superior to any other method. Preliminary ileostomy, appendicostomy or colostomy is necessary only in compIete obstruction. More than one-half of the lesions (rectum, 69 per cent and coIon, 60.8 per cent) will have metastasized to the regional nodes before the patient comes to surgery. Normal lymph ffow coincides with venous blood flow almost entirely except for some lateral spread. A small-sized lesion can have extensive and far removed metastases. This makes us realize that while lymphatic spread probably accounts for most of the metastases, venous implants do occur. Extension by Iocal growth and wound implants is certainly far less common. The distribution of the twenty-four Iesions encountered and a presentation of the operative procedures used has been tabulated. (TabIe I.) On the right side, from the cecum and ascending colon up to and including the hepatic flexure, it often happens that the local spread is extensive. True, the operative mortality is a bit higher than that for resections on the left side, but the number of five-year survivals is far greater. Because of this onIy a wide resection will satisfy. Excision of the entire right colon American
Journal
of Surgery
ConoIe-Colon
be resected, the blood suppIy preserved and, equally as important, the anastomosis wiI1 not be taut (or under tension). Lesions of the Ieft colon constitute a small number unti1 the rectosigmoid junction is reached. A high spIenic Aexure can
with a portion of the termina1 ileum, hepatic ffexure and transverse colon to the left of the mid-cohc artery should be done. Prehminary iIeotransverse colostomy as a stage procedure with the hope of excision at a later date seldom materiaIizes. Com-
Location
Operative Mortality
of Lesion
TABLE
-
-
age Age (yr.1
cent)
Transverse
I-
colon.
72
81
Descending colon. Sigmoid pelvic colon.
56
Rectum..
71
AverSex
-
-
/ Pathologic
3
hl I ) Adenocarcinoma F 2 M 2 Adenocarcinoma biopsy I F4
3
I
M 6
!
1930
Type of Resection
2
3
pIete obstruction is rarely a factor to be dealt with, but inoperability because of local fixation leaves with one the profound impression of the necessity of early diagnosis. Change in bowel habit, undetermined secondary anemia and weight Ioss are the most common early symptoms. A palpable mass wiI1 not too frequentIy be resectable. The transverse coIon and the sigmoid loop are the two areas in which many surgeons believe that the principle of exteriorization should be used. Jones4 states that he has a bit Iower operative mortality in this area (transverse coIon) by using that procedure. However, the attachments of the gastrocoIic omentum and transverse mesocoIon with their rich Iymphatic and blood supphes caII for a wide resection. Preservation of bIood suppIy to the bowel ends being anastomosed is a fundamental principle. To affect this it sometimes becomes necessary to mobilize the spIenic and hepatic ffexures. This maneuver aIIows for a greater portion of the transverse colon to June,
Diagnosis
Adenocarcinoma
hl F
F
-
-
Aver-
of Cases
Cecum ascending color L
I
T NO.
(per
821
Surgery
8;
no
Adenocarcinoma 4; papillary adenocarcinoma 3; epidermoid carcinoma I
age I-lospita1 Days
Right coIectomy 2; ablaooratomv: dominal patient diedbn table” Mikulicz 3
40
Mikulicz I ; resection and anastomosis 4; loop colostomy 2; inoperabIe r; Miles’ I Divided colostomy z; loop colostomy 3; Babcock pull-through I; inoperable 1; hliles’ I
27
36
4’
be the most difhcuIt area in the entire colon to mobilize, but with adequate abdominal incision and carefu1 dissection one is frequentIy surprised. It is onIy then that the surgeon reaIizes a radicaI excision can be accomplished. The entire left coIon down to the beginning portion of the sigmoid Ioop with a wide swath of the sectiona mesocolon can then be removed and a primary anastomosis between the transverse coIon and sigmoid loop estabIished. Difficulty can be experienced in periotonealizing the area from which the splenic fIexure was removed. It is not good surgery nor is it entirely safe to Ieave this area denuded of its peritonea1 covering. I know of no better use of the MikuIicz pack than in this particuIar locality. The sigmoid Ioop is of great importance because it is here that a Iarge number of lesions are encountered. A stenosing, napkin-ring type is most common. In this same area diverticulitis in its various forms is aIso frequentIy found. When confronted
822
Conole-CoIon
with a differential diagnosis in this area one has a problem of real magnitude. A proximal colostomy would certainly be the ideal answer as a stage procedure if an unequivoca1 diagnosis could be made of diverticulitis. More frequentIy, the typica stenosing lesion of maIignancy is found (it may be small) and one may be surprised to find liver metastases. If no liver metastases are present, a wide resection with remova of the inferior mesenteric group of nodes is indicated. The so-caIIed critica point of Sudeck is a nice academic rehnement, but of more vaIue is the presence of copious bIeeding from the ends of the bowe1 to be anastomosed. In the event of Iiver metastases a paIIiative resection is indicated and is a very worth whiIe procedure. The recta1 ampulla is the most common site in the entire colon to be invaded by neoplastic change. Over 80 per cent of the lesions wiI1 be above the mid-portion of the rectum. DeveIopments unearthed within the past few years (GiIchrist and David,5 McVay,‘j and CoIIer, Kay and McIntyre7) show that it is most unusua1 to find tumor ceIIs 2.5 cm. or I inch below the paIpabIe tumor mass. It is now time to re-evaluate our concepts in regard to Iymphatic spread. The upward spread is extensive and a definite happening; IateraI spread in lesions at the IeveI of the Ievator muscIes is a strong possibiIity. However, true downward spread is unIikeIy. With this thought and a fuI1 realization of a far reaching (not common) upward spread due to venous return, there is no conflict with sphincter-preserving operations. Babcock and Bacon have modified the Hochenegg procedure and do equally as radical a piece of surgery as is possible with MiIes’ operation. I am convinced that the construction of a peritoneal diaphragm carries with it the possibility of recurrence in the form of peritonea1 impIants. The Iow anterior resections as performed by Dixon and Wangensteen are difficuh in a technical way and, if done at a Iow level, proxima1 coIostomy as a temporary measure is mandatory. Both Babcock and Dixon* have a higher percentage of five-year survivaIs
Surgery (58.5 per cent) than those reported from centers doing the orthodox Miles’ operation (46.3 per cent) .y I hold no brief for procedures done from beIow without abdomina expIorations and, strangeIy enough, someone wiIl revive the Lockhart-Mummery (perinea1 excision) operation every now and then. In low-lying lesions MiIes’ (orthodox) abdominoperinea1 resection is the procedure of choice and the operations for sphincter preservation are definitely contraindicated. A fair, non-biased appraisa1 of present day concepts in regard to maIignant Iesions situated in the recta1 ampulIa or rectosigmoid has an ever increasing number of converts to the sphincter-preserving types of operation. Proper preoperative care and chemoand antibiotic therapy now ahow as the procedure of choice open anastomosis. Modifications of the Furniss clamp and the Parker-Kerr basting stitch come close to a cIosed anastomosis, but in so doing only a seromuscular coaptation is achieved. Open anastomosis aIIows not 0nIy for seromuscuIar approximation but aIso, of as great importance, for mucosal approximation. Hemorrhage from the mucosal Iayer has been reported with closed procedures. However, of more importance is failure of accurate approximation of the Iayer of the mucous membrane and in so doing the incidence of stricture formation is very apt to be a factor. The air vent drains as devised by Wangensteen and Chaffin are a great improvement over the Babcock sump drain and of definite value if one decides upon the necessity of drainage. REFERENCES
I.
REYBARD, .I. F. Memorire sur une tumeur concereuse affectant I’iliaque due colon; ablation deIa tumeur et de I’intestin. Bull. acad. de med., Paris, 9: 1031,
‘944. 2. GIBBON, H. J., JR. and HODGE, C. C. Aseptic immediate anastomosis following resection of the colon for carcinoma. Ann. Surg., I 14: 634, 1941. 3. MCKITTRICK, L. S. Principles old and new of resection of the colon for carcinoma. Surg., Gynec. 0 Ok., 87: 15, 1948.
American
Journal
of Surgery
ConoIe-CoIon 4. JONES, T. E. Surgical management of carcinoma of the colon and rectum. S. Clin. North America, 28: 1159. 1948. 5. GILCHRIST, R. K. and DAVID, V. C. Lymphatic spread in carcinoma of the rectum. Ann. Surg., 108: 621, 1938. 6. MCVAY, J. R. InvoIvement of the lymph nodes in carcinoma of the rectum. Ann. Surg., 76: 755, 1922.
Surgery
7. COLLER, F. A., KAY, E. B. and MCINTYRE, R. S. Regional lymphatic metastasis of carcinoma of the rectum. Surgery, 8: 294, 1940. 8. DIXON, C. F. Anterior resection for malignant lesions of the upper part of the rectum and lower part of the sigmoid. Ann. &i-g., 128: 425, 1948. 9, WHIPPLE, A. 0. et a1. Symposium on the surgical management of malignancy of the coIon. Surgery, ‘4: 321, 1943.
IT is we11 known that many cases of achaIasia of the esophagus go on to irreversibIe esophageal changes. Cardiospasm present is often associated with organic changes in the cardiac portion of the stomach and adjacent esophagus as we11 as with simple imbaIance of the autonomic nervous system. It seems logical, therefore, to recommend surgery when simpIer measures fail to attain success. The narrowed passage may be widened by a technic simiIar to the Finney pyIoropIasty procedure. In other cases, unIess one wishes to resect the stenosed area because of a more advanced pathoIogic condition and do an immediate anastomosis, a successfu1 result can occur following the Heineke-MikuIicz technic. This is done for pyIoric stenosis wherein a Iongitudinal incision is made through the involved area, between stomach and esophagus, and it is cIosed in a transverse manner to make the Iumen more patent. SuccessfuI results can occur after aI1 such procedures whether performed via the transpleural or transperitoneal route. Often, however, fewer complications occur foIIowing the Iatter route and it may be simpIer for genera1 surgeons who do not have too much experience in performing thoracic surgery. (Richard A. Leonardo, M.D.)
June,
1950
823