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Primary resection and aseptic anastomosis for lesions of the colon
PRIMARY
RESECTION AND ASEPTIC ANASTOMOSIS LESIONS OF THE COLON*
ARTHUR
B. RAFFL,
M.D. AND WILLIAM J. MICHAELS,
JR.,
FOR
M.D.
Syracuse, New York
A
FTER resecting Iesions of the coIon the surgeon may immediately reestabhsh bowe1 continuity or may eIect to deIay the anastomosis using some modification of the Mikuhcz procedure. Primary resection of Iesions of the coIon and aseptic anastomosis have become increasingIy popuIar in the Iast few years. This is due to a number of factors among which are: greater use of the Wangensteen and MiIIer-Abbott tubes, deveIopment of antibiotics and coIon antiseptics, better knowIedge of the preoperative preparation of patients, refinements in anesthesia and surgical technic and use of bIood and pIasma. Increasing famiIiarity with the procedure has added to its safety. Other Iess scientific reasons for doing primary resections are: avoidance of muItipIe operations and decrease in hospita1 days. These, of course, onIy become important if the safety of the procedure is estabIished. There is common agreement among surgeons that primary resection offers wide remova of the Iesion and its mesentery in addition to the advantages just mentioned. For a Iong period of time primary intraperitonea1 anastomosis of the coIon was avoided because it was dangerous. The earIiest attempts to treat carcinoma of the coIon surgicaIIy were crude attempts at resection and immediate anastomosisusuaIIy open. With no preparation, usually in the face of obstruction, with debiIitated patients and without antibiotics and other surgical adjuvants, the resuIts were disastrous. As Wangensteen14 points out surgery was not yet ready for primary resection. With the deveIopment of the exteriorization principIe by Mikulicz and others, the subsequent drop in mortaIity figures foI-
Iowed. Because of the inauspicious start made by primary resection and anastomosis, there has been an understandabIe reIuctance on the part of surgeons to accept this procedure. It is our purpose in this paper to report brieffy our experiences with primary resection and aseptic anastomoses of the coIon. PREOPERATIVE
PREPARATION
Preoperative treatment of the patients in this series might properIy be considered under three headings: (I) Genera1 considerations; (2) management of the unobstructed case and (3) management of the obstructed case. Many of these General Considerations. patients exhibited chemica1 imbaIances, vitamin deficiencies, anemias and hypoproteinemia. Efforts were concentrated on correcting these states by use of whoIe bIood transfusions, vitamins, IiberaI high protein diets and parentera ffuids incIuding amino acids when indicated. Wherever and whenever possibIe the patients were kept ambuIatory unti1 just before definitive surgery was done. Management
of
the
Unobstructed
Case.
These patients were piaced on a high caIoric, high vitamin, high protein, Iow residue diet. The coIon was prepared using daiIy enemas and saIine catharsis with FIeet’s Phospho-Soda, 2 dr. at g and I I A.M. They were started on suIfasuxidine with an initial dose of 3 to 4 Gm. and then 2 Gm. every four hours. We found that with seven to ten days of such preparation the coIon was bacterioIogicaIIy and physicaIIy ready for surgery. Many surgeons prefer to use suIfathaIidine as a coIon antiseptic and there is IittIe question that it is equaIIy
* From the Department of Surgery of the ColIege of Medicine, Syracuse University, Syracuse, N. Y. 458
American
Journal of Surgery
Ram,
MichaeIs-Lesions
as effective as suIfasuxidine. On occasion, smfasuxidine wiI1 cause miId to moderate diarrhea but we have never encountered a reaction severe enough to cause us to discontinue it. Indeed we believe that this miId diarrheic effect is advantageous and heIps in the preparation of the coIon. We beIieve that the actuaI mechanica cIeansing of the coIon is more important than use of the coIon antiseptics. Much of this portion of the preoperative management of these patients was carried out on an ambulatory basis outside of the hospital. Munagement of the Obstructed Case. Obstruction of the coIon from right-sided maIignant Iesions is rarely encountered. This is due to the Iarger diameter of the right coIon, its Iiquid contents and the nature of the growth. When obstruction of the right coIon does exist, it is of serious prognostic import, usually denoting incurabiIity because of marked IocaI extension or widespread metastases. Often decompression can be accompIished by use of the MiIIerAbbott tube folIowed later by Iow enemas. If after a reasonabIe tria1 the obstruction is not reIieved, then iIeotransverse coIostomy is the procedure of choice. After the iIeotransverse colostomy has been done the usua1 preparation is begun and if possibIe the resection is done as a second stage. With obstruction in the transverse or descending colon, we prefer cecostomy, using a Iarge bore tube and the technic of Lockhart-Mummery.* In our experience this procedure has proved to be most satisfactory. The size of the Iumen of this tube is very important and we have found that a tube with a Iumen diameter measuring 0.73 cm. is ideaI. We find that it furnishes adequate, immediate, safe decompression and the fistuIa cIoses rapidIy once the tube is removed. We irrigate the cecostomy tube with tepid water daiIy, beginning irrigations in about forty-eight hours. We have, on occasion, used a saturated solution of suIfasuxidine instihing it through the tube fohowing irrigation. Often the edema about the lesion subsides and the obstruction is reIieved enough to ahow the October,
I 949
of Colon
459
irrigation to pass per rectum. We have found the average obstructed case requiring cecostomy wiI1 need from ten to fourteen days to decompress adequateIy the coIon and condition the patient for further definitive surgery. The cecostomy does not TABLE
I
Carcinoma..
38
0:
Lymposarcoma of the cecum. TubercuIosis of the cecum.. Carcinoid of the termina1 ileum. Lipoma of the cecum.. .. Diverticulitis of the cecum. . .I Carcinoid of the transverse colon i with jejunocolic k.tuIa.. ( TotaI..
I I I I
,
I
0
I
0
48 :
o 0 0 o
0
~
and shouId not prevent ambulation before the fina procedure. There are many who advocate the use of transverse coIostomy in this situation and we certainIy have no quarre1 with them. However, the patient is then committed to another operative procedure. AI1 patients with Iesions of the cecum or ascending coIon come to the operating room with a MiIIer-Abbott tube in pIace. Patients with lesions elsewhere in the coIon have an inIying gastric tube. For these it has been our poIicy to do a cecostomy at the time of resection, if one had not aIready been done, because often the iIeoceca1 vaIve prevents effective decompression by the MiIIer-Abbott tube. NATURE
AND
LOCATION
OF
LESIONS
A gIance at TabIe I shows that the majority of resections were undertaken for carcinoma. Among the Iesions of the right colon there were four cases of ileocecitis in which we elected resection of the terminal iIeum and right coIon. One patient had tubercuIosis of the cecum necessitating resection. One patient had a carcinoid of the termina1 ileum with metastases to the liver. The IocaI Iesion was resected and the
Rafll, MichaeIs-Lesions
460
patient is alive and working every day eighteen months foIIowing operation. There was one case of Iymphosarcoma and one Iipoma of the cecum. One patient, an eighty-seven year oId maIe, was operated on for acute appendicitis and was found TABLE
of Cases
No.
Total....................................
23 6 7 2 48
to have a mass invoIving the cecum but not the appendix. This was resected without preparation under the impression we were deaIing with a carcinoma. PathologicaIIy it proved to be a Iarge diverticuIum of the cecum. The mass consisted of dense inflammatory tissue surrounding the feca!ith-fiIIed diverticuIum. This patient made a remarkabIe recovery. He was discharged as ambuIatory from the hospita1 on his eighth postoperative day. There were no deaths in this series. A study of Table II reveaIs that the majority of Iesions for which aseptic anastomosis was done were proxima1 to the sigmoid coIon. In our opinion this technic is not appIicabIe to most Iesions of the sigmoid coIon because of the diffIcuIty in appIying the cIamps and of pIacing sutures accurateIy deep in the peIvis. In those Iesions of the sigmoid coIon which are high enough for anterior resection but too Iow for the use of this technic we have used open anastomosis with good resuIts. TYPES
OF
with a MiIIer-Abbott tube in pIace and functioning. In seven cases of unreIieved obstruction it was necessary to do a preIiminary cecostomy as a first-stage procedure foIIowed at a Iater date by resection and anastomosis. TABLE
11
Location of the Lesions Cecum and ascending coIon. Transverse colon.. Splenic flexure.. Descending colon. Sigmoid coIon.
of Colon
OPERATIONS
It wiI1 be seen from TabIe III that tweIve one-stage resections of the cecum and ascending coIon with compIementary iIeostomy were done. These were done earIy in the series. Since then we have done thirteen simiIar resections without iIeostomy but utiIizing a MiIIer-Abbott tube. We beIieve that an iIeostomy is unnecessary
III
No. of Types of Operations Cases One-stage resection of the cecum and ascending I2 colon with iIeostomy One-stage resection of the cecum and ascending I3 coIon without ileostomy One-stage resection of the transverse coIon with cecostomy................................ 4 One-stage resection of the transverse coIon withoutcecostomy........................ z One-stage resection of the splenic flexure with cecostomy................................ 3 Two-stage resection of the splenic Aexure with 4 cecostomy, first-stage.. . . . .. One-stage resection of the descending coIon withcecostomy........................... 4 One-stage resection of the sigmoid coIon with cecostomy................................ 3 Two-stage resection of the sigmoid, cecostomy, first-stage................................ 3 TotaI.
. ..
.. ..
.....
48
It wiI1 be seen from TabIe III that in resection of the transverse, descending and sigmoid coIon we have done a compIementary cecostomy at the time of operation. We beIieve that this is a safety measure of merit. COMPLICATIONS
It was necessary to reoperate upon one patient because of obstruction at the site of the anastomosis. It has been our practice to break in the mucosa1 diaphragm with the index finger and thumb foIIowing compIetion of the anastomosis. In this case the crushed mucosa had remained seaIed and at the second operation an incision was made over the anastomosis IongituduaIIy, the septum was opened and the bowe1 was cIosed transverseIy. The patient made a prompt recovery. There were four intrabdomina1 abscesses occurring postoperatively which we beIieve definiteIy can be attributed to some technica1 error resuIting in a Ieak of coIonic contents. (TabIe IV.) AI1 four of these patients deveIoped septic fevers with paIpaAmerican
Journal
of Surgery
Rafll,
Michaels-Lesions
of CoIon
FIG. I. B, removal of the primary tumor with the gland-bearing mesentery; bfood vessels have been tied.
IA*
shows removal of the primary lesion and the gland-bearing mesentery. FIG.
I. A,
bIe, tender, abdomina1 masses. AI1 were adipose with fat mesenteries, and a11 instances occurred in resections of the right coIon. It was necessary in one case to drain two abscesses through the abdomina1 waI1. The other three patients ran remarkabIy TABLE
IV
Complications Intra-abdominal abscess. . Obstruction at the site of the anastomosis. Wound infection at the site of the ileostomy Wound infection at the site of the cecostomy wound.. Wound infection.. Cystitis.. P neumoma................................. . . Wound dehiscence.
No. of Cases 4
I I I
I 4 1 I
simiIar courses. Each ran a septic fever with a paIpabIe non-pointing intra-abdomina1 mass. SubsequentIy, each had several very Ioose, fouI stooIs containing pus, foIlowing which their temperatures rapidIy returned to normal and the masses disappeared. Three of these patients had both * Figs.
and lesions of the right colon.
October,
IA,
ZA,
I 949
3A,
4A
5A
show the procedure for
penicillin and suIfadiazine postoperatively. One patient had neither and ran essentiaIIy the same course. There was one wound dehiscence in this series. The other compIications were of a minor nature. We had no thrombophIebitis or recognized phIebothrombosis in this series aIthough the average age was fifty-five years. POSTOPERATIVE
CARE
At the time of operation a11 patients were given whoIe blood transfusions. AI1 patients received bIood postoperativeIy when needed. Most patients were pIaced in oxygen immediateIy after operation. FIuid balance was maintained using intravenous ffuids. Plasma proteins were maintained as well as possibIe, using whoIe bIood, pIasma and parentera amino acids. A particular effort was made to prevent postoperative puImonary compIications. The patients were moved frequentIy and encouraged to breathe deeply and to cough when necessary. In addition, at the first evidence of mucous in the air ways which the patient was unable to expectorate, we used intrat Figs. IB, ZB, 3~, 48 and 5~ show procedure for lesions in the transverse, descending and sigmoid colons.
Rafll,
MichaeIs-Lesions
2A
of CoIon
2B
FIG. 2. A, the end of transverse coIon has been closed and the portion of transverse colon to be used for anastomosis with ileum has been clamped with a Stone clamp and the bowe1 walI cut away; B, Stone cIamps rotated outward; posterior serosa1 sutures in place.
3A FIG. 3. A, Stone cIamps rotated outward and posterior muscular basting suture (C and D) of No. oo chromic;
3’3 serosa1 silk sutures in place but not tied; end posterior serosa1 sutures (A and B).
American
B,
Journal
running sero-
of Surgery
Ram,
MichaeIs-Lesions
of CoIon
4B
4.4 FIG. 4. A, posterior and serosal sutures (A and B); running basting seromuscular
suture (C and D) of No. oo chromic which has been taken over the Stone cIamps; the clamps are now ready to be removed; B, clamps have been removed; anastomosis is compIeted and rent in mesentery is to be cIosed.
E-4
$8
shows the cIamps removed and the ends of the running chromic suture being tied to the end posterior serosal sutures; B, rent in mesentery cIosed with sutures of fine siIk. FIG. 5.
A,
trachea1 suction with a soft rubber catheter. Foot exercises were daiIy routine. Since the advent of peniciIIin we have used it routineIy postoperativeIy for the first forty-eight to seventy-two hours. We beIieve that it wiI1 reduce the numbers October, 1949
and severity of pulmonary and urinary comphcations. Intragastric or intra-intestinal suction was maintained unti1 the patient passed gas per rectum. This usuaIIy occurred at seventy-two hours. FoIIowing this the tube
Ram, MichaeIs-Lesions
FIG. 6. CompIetion of anastomosis anteriorly with interrupted serosal sutures of C siIk. A similar posterior layer is applied after rotating the bowel.
was removed and the patient started on Iiquids proceeding as rapidIy as possibIe to a fuII nourishing diet. We aIIowed the patients to be up as soon as was practica1. Most of them were ambuIatory by the fifth postoperative day. If cecostomy had been done as a &St-stage procedure, then the tube was removed after their first norma bowe1 movement. If the cecostomy was done at the time of operation as a compIementary procedure, then the tube was Ieft in pIace about tweIve days before attempting remova1. This period of time is needed to aIIow softening of the catgut sutures so that tearing of the ceca1 waI1 wiI1 not occur upon remova of the tube. FoIIowing its remova1, the cecostomy wound quickIy cIosed. The average stay in the hospita1 of the patient with the uncomplicated case was 15.5 days and of those with compIicated cases 34.0 days. The over-ah average hospita1 stay for the patients in this series was 2 I .6 days. TECHNIC
OF
LESIONS
OPERATIVE OF THE
PROCEDURE RIGHT
FOR
COLON
The abdomen is opened through a generous right rectus, muscIe-spIitting incision. Hemostasis is effected with No. 60 cotton ties. Before proceeding with the surgery a
of Colon
compIete expIoration of the abdomina1 contents is made. The cecum and ascending colon are mobiIized by cutting their IateraI peritonea1 attachments. The ureter, spermatic or ovarian vesseIs, kidney and duodenum are visuaIized and avoided. The iIeocoIic artery is tied near its origin from the superior mesenteric artery. When the right coIic is present and arises from the superior mesenteric artery it is Iikewise tied. The iIeum is then divided with the cautery between Stone and Payr cIamps seIecting a site about IO cm. from the iIeoceca1 vaIve. The transverse coIon is divided with the cautery between Stone and Payr cIamps, seIecting a site we11 beyond the Iesion and, of course, with an adequaebIood suppIy. A wide portion of the mest entery with the regiona Iymph nodes is removed with the primary Iesion. (Fig. IA.) The end of the coIon is first cIosed asepticaIIy using a running atraumatic seromuscuIar suture of No. oo chromic reinforced with interrupted serosa1 sutures of C silk. An area on the anterior aspect of the transverse coIon near the cIosed end is then seIected and ciamped IongitudinaIIy with a Stone clamp removing with the cautery a portion of coIon approximating the transverse diameter of the iIeum. (Fig. 2~.) An aseptic end-to-side iIeotransverse coIostomy is then done over the Stone cIamps. In this series the Stone cIamps were used excIusiveIy and proved to be most satisfactory. The site on the coIon is cIeaned of fat as carefuIIy as possibIe and a number of posterior serosaI sutures, uniting iIeum and coIon, are pIaced but not tied. (Fig. 3~.) When the Iast stitch is pIaced, they are then tied and cut Ieaving the two end sutures Iong. (Fig. 3~.) A running, basting stitch of No. oo chromic is then taken over the cIamps (Fig. 4~), and whiIe the operator puts gentIe traction on the two ends of this suture, the assistant removes the cIamps. This procedure inverts the bowel and you are now ready to pIace the anterior serosa1 Iayer. The ends of the chromic basting stitch are then tied into the end posAmerican
Journal
of Surgery
Radii, MichaeIs-Lesions terior serosaI stitches (Fig. 5~ AC and BD). Inasmuch as the catgut is a running &ding suture, care must be taken at this point not to tie the end sutures too tightly or you wiI1 encroach upon the Iumen of the bowel. The anterior row of interrupted serosa1 sutures of C siIk are pIaced and tied. (Fig. 6~.) To reinforce the posterior row and the corners a cIamp is passed beneath the anastomosis and the opposite end posterior serosa1 suture is seized. The bowe1 is turned by this procedure so that a second Iayer of posterior serosal sutures of C silk may be taken. The angIes are, of course, carefuIly closed. The anterior Iayer is reinforced with a few serosa1 sutures and the rent in the mesentery and mesocolon is closed with a few fine, cautiousIy pIaced sutures of C siIk. PROCEDURE TRANSVERSE,
FOR
LESIONS
DESCENDING
SIGMOID
IN
THE AND
COLONS
In lesions distal to the hepatic ffexure we use end-to-end aseptic anastomosis over Stone cIamps. OccasionaIIy, despite preliminary decompression, we encountered moderate disparity in the size of the bowe1 proxima1 and dista1 to the Iesion. However, we were abIe in a11 cases to perform end-toend anastomosis. We concede that great disparity between the proxima1 and distal coIon wouId demand side-to-side anastomosis. The principIes of technic are exactIy the same as in resection of the right coIon described in the preceding paragraph. (Figs. IB, 2~, 3~, 4~ and SB.) The wounds are closed with interrupted Snead, figure eight, sutures, using as suture materia1 No. 31 stainless stee1 wire or No. 40 cotton doubIed. SUMMARY
AND
CONCLUSIONS*
I. Our experience with forty-eight consecutive primary resections of the coIon are presented. * Since this articIe was submitted for pubIication,
October,1949
of CoIon
2. We beIieve that with careful preparation of the patient, incIuding medica or surgica1 decompression of the bowe1, aseptic primary resection of the coIon is an adequate and safe procedure. REFERENCES I. ALLEX, ARTHUR W. Carcinoma of the colon. Surgery, 14: 350, 1943. 2. ALLEN, ARTHUR W. Carcinoma of the Iarge intestine. S. Clin. North America, 27: 1018, 1947. 3. BEHREND, MOSES. CoIon surgery and the sulfonamide drugs. J. A. M. A., 128:-g, 1943. A. BRUST. JOHN C. M. Carcinoma of the colon: resection and immediate primary anastomosis. New York State J. Med., 46: 2277, 1946. 5. CATTELL, RICHARD B. Carcinoma of the coIon and rectum. Surgery, 14: 1943. 6. HOXWORTH, PAUL I. and MITHOEFER, JAMES. Management of cancer of the coIon. Surgery, 22: 27 I, 1947.
7. JONES, THOMAS E. Consideration of eIective surgica1 procedures in various segments of the colon. Surgery, 14: 342, 1943, 8. LOCKHART-MUMMERY.Diseases of the Rectum and CoIon. 2nd ed., p. 552. WiIIiam Wood & Co. Baltimore, 1934. g. MAYO, C. W. Resection of the right portion of the colon. S. Clin. Nortb America, 23: 1121, 1943. IO. OWINGS, J. C. and STONE, H. B. Technique of anastomosis using the stone clamp. Surg.. Gynec. e* Obst., 68: 95, 1939. II. RANKIN, F. W. The principles of surgery of the COIon. Surg., Gynec. e”pObst., 72: 332, 1941. 12. SINGLETON, ALBERT 0. The blood suppIy of the large bowe1 with reference to resection. Surgery, 14: 328, 1943. 13. STONE, H. B. and MCLANAHAN, S. Resection and immediate asep& anastomosis for carcinoma of the colon. J. A. M. A., 120: 1362, 1942. 14. WANGENSTEEN, OWEN M. Primarvi resection (closed anastomosis) of the colon and rectosigmoid. Surgery, 14: 403, 1943. 15. WAUGH, J. M. and CUSTER, M. D., JR. Segmental resection of Iesions occurring in the Ieft half of the colon with primary end-to-end aseptic anastomosis. Report based on fifty cases. Sure., Gynec. Ed Obst., 81: $93. 1945. 16. WHIPPLE, ALLEN 0. The use of the Miller-Abbott tube in the surgery of the large bowel. Surger,y, 8: 289, 1940. 17. WHIPPLE, ALLEN 0. Surgery of the terminal iIeum, cecum and right coIon. Surgery, 14: 321, 1943. 18. WHITE, W. C. and AMENDOLA, F. IH. The advantages and disadvantages of cIosed resection of the colon. Ann. Surg., 120: 572, 1944. rg. ZINNINGER,M. M. and HOXWORTH, PAUL I. Cancer of the colon. Surgery, 14: 366, 1943. the authors have operated on four additiona without mortality.
patients
RESECTION AND ASEPTIC ANASTOMOSIS LESIONS OF THE COLON*
ARTHUR
B. RAFFL,
M.D. AND WILLIAM J. MICHAELS,
JR.,
FOR
M.D.
Syracuse, New York
A
FTER resecting Iesions of the coIon the surgeon may immediately reestabhsh bowe1 continuity or may eIect to deIay the anastomosis using some modification of the Mikuhcz procedure. Primary resection of Iesions of the coIon and aseptic anastomosis have become increasingIy popuIar in the Iast few years. This is due to a number of factors among which are: greater use of the Wangensteen and MiIIer-Abbott tubes, deveIopment of antibiotics and coIon antiseptics, better knowIedge of the preoperative preparation of patients, refinements in anesthesia and surgical technic and use of bIood and pIasma. Increasing famiIiarity with the procedure has added to its safety. Other Iess scientific reasons for doing primary resections are: avoidance of muItipIe operations and decrease in hospita1 days. These, of course, onIy become important if the safety of the procedure is estabIished. There is common agreement among surgeons that primary resection offers wide remova of the Iesion and its mesentery in addition to the advantages just mentioned. For a Iong period of time primary intraperitonea1 anastomosis of the coIon was avoided because it was dangerous. The earIiest attempts to treat carcinoma of the coIon surgicaIIy were crude attempts at resection and immediate anastomosisusuaIIy open. With no preparation, usually in the face of obstruction, with debiIitated patients and without antibiotics and other surgical adjuvants, the resuIts were disastrous. As Wangensteen14 points out surgery was not yet ready for primary resection. With the deveIopment of the exteriorization principIe by Mikulicz and others, the subsequent drop in mortaIity figures foI-
Iowed. Because of the inauspicious start made by primary resection and anastomosis, there has been an understandabIe reIuctance on the part of surgeons to accept this procedure. It is our purpose in this paper to report brieffy our experiences with primary resection and aseptic anastomoses of the coIon. PREOPERATIVE
PREPARATION
Preoperative treatment of the patients in this series might properIy be considered under three headings: (I) Genera1 considerations; (2) management of the unobstructed case and (3) management of the obstructed case. Many of these General Considerations. patients exhibited chemica1 imbaIances, vitamin deficiencies, anemias and hypoproteinemia. Efforts were concentrated on correcting these states by use of whoIe bIood transfusions, vitamins, IiberaI high protein diets and parentera ffuids incIuding amino acids when indicated. Wherever and whenever possibIe the patients were kept ambuIatory unti1 just before definitive surgery was done. Management
of
the
Unobstructed
Case.
These patients were piaced on a high caIoric, high vitamin, high protein, Iow residue diet. The coIon was prepared using daiIy enemas and saIine catharsis with FIeet’s Phospho-Soda, 2 dr. at g and I I A.M. They were started on suIfasuxidine with an initial dose of 3 to 4 Gm. and then 2 Gm. every four hours. We found that with seven to ten days of such preparation the coIon was bacterioIogicaIIy and physicaIIy ready for surgery. Many surgeons prefer to use suIfathaIidine as a coIon antiseptic and there is IittIe question that it is equaIIy
* From the Department of Surgery of the ColIege of Medicine, Syracuse University, Syracuse, N. Y. 458
American
Journal of Surgery
Ram,
MichaeIs-Lesions
as effective as suIfasuxidine. On occasion, smfasuxidine wiI1 cause miId to moderate diarrhea but we have never encountered a reaction severe enough to cause us to discontinue it. Indeed we believe that this miId diarrheic effect is advantageous and heIps in the preparation of the coIon. We beIieve that the actuaI mechanica cIeansing of the coIon is more important than use of the coIon antiseptics. Much of this portion of the preoperative management of these patients was carried out on an ambulatory basis outside of the hospital. Munagement of the Obstructed Case. Obstruction of the coIon from right-sided maIignant Iesions is rarely encountered. This is due to the Iarger diameter of the right coIon, its Iiquid contents and the nature of the growth. When obstruction of the right coIon does exist, it is of serious prognostic import, usually denoting incurabiIity because of marked IocaI extension or widespread metastases. Often decompression can be accompIished by use of the MiIIerAbbott tube folIowed later by Iow enemas. If after a reasonabIe tria1 the obstruction is not reIieved, then iIeotransverse coIostomy is the procedure of choice. After the iIeotransverse colostomy has been done the usua1 preparation is begun and if possibIe the resection is done as a second stage. With obstruction in the transverse or descending colon, we prefer cecostomy, using a Iarge bore tube and the technic of Lockhart-Mummery.* In our experience this procedure has proved to be most satisfactory. The size of the Iumen of this tube is very important and we have found that a tube with a Iumen diameter measuring 0.73 cm. is ideaI. We find that it furnishes adequate, immediate, safe decompression and the fistuIa cIoses rapidIy once the tube is removed. We irrigate the cecostomy tube with tepid water daiIy, beginning irrigations in about forty-eight hours. We have, on occasion, used a saturated solution of suIfasuxidine instihing it through the tube fohowing irrigation. Often the edema about the lesion subsides and the obstruction is reIieved enough to ahow the October,
I 949
of Colon
459
irrigation to pass per rectum. We have found the average obstructed case requiring cecostomy wiI1 need from ten to fourteen days to decompress adequateIy the coIon and condition the patient for further definitive surgery. The cecostomy does not TABLE
I
Carcinoma..
38
0:
Lymposarcoma of the cecum. TubercuIosis of the cecum.. Carcinoid of the termina1 ileum. Lipoma of the cecum.. .. Diverticulitis of the cecum. . .I Carcinoid of the transverse colon i with jejunocolic k.tuIa.. ( TotaI..
I I I I
,
I
0
I
0
48 :
o 0 0 o
0
~
and shouId not prevent ambulation before the fina procedure. There are many who advocate the use of transverse coIostomy in this situation and we certainIy have no quarre1 with them. However, the patient is then committed to another operative procedure. AI1 patients with Iesions of the cecum or ascending coIon come to the operating room with a MiIIer-Abbott tube in pIace. Patients with lesions elsewhere in the coIon have an inIying gastric tube. For these it has been our poIicy to do a cecostomy at the time of resection, if one had not aIready been done, because often the iIeoceca1 vaIve prevents effective decompression by the MiIIer-Abbott tube. NATURE
AND
LOCATION
OF
LESIONS
A gIance at TabIe I shows that the majority of resections were undertaken for carcinoma. Among the Iesions of the right colon there were four cases of ileocecitis in which we elected resection of the terminal iIeum and right coIon. One patient had tubercuIosis of the cecum necessitating resection. One patient had a carcinoid of the termina1 ileum with metastases to the liver. The IocaI Iesion was resected and the
Rafll, MichaeIs-Lesions
460
patient is alive and working every day eighteen months foIIowing operation. There was one case of Iymphosarcoma and one Iipoma of the cecum. One patient, an eighty-seven year oId maIe, was operated on for acute appendicitis and was found TABLE
of Cases
No.
Total....................................
23 6 7 2 48
to have a mass invoIving the cecum but not the appendix. This was resected without preparation under the impression we were deaIing with a carcinoma. PathologicaIIy it proved to be a Iarge diverticuIum of the cecum. The mass consisted of dense inflammatory tissue surrounding the feca!ith-fiIIed diverticuIum. This patient made a remarkabIe recovery. He was discharged as ambuIatory from the hospita1 on his eighth postoperative day. There were no deaths in this series. A study of Table II reveaIs that the majority of Iesions for which aseptic anastomosis was done were proxima1 to the sigmoid coIon. In our opinion this technic is not appIicabIe to most Iesions of the sigmoid coIon because of the diffIcuIty in appIying the cIamps and of pIacing sutures accurateIy deep in the peIvis. In those Iesions of the sigmoid coIon which are high enough for anterior resection but too Iow for the use of this technic we have used open anastomosis with good resuIts. TYPES
OF
with a MiIIer-Abbott tube in pIace and functioning. In seven cases of unreIieved obstruction it was necessary to do a preIiminary cecostomy as a first-stage procedure foIIowed at a Iater date by resection and anastomosis. TABLE
11
Location of the Lesions Cecum and ascending coIon. Transverse colon.. Splenic flexure.. Descending colon. Sigmoid coIon.
of Colon
OPERATIONS
It wiI1 be seen from TabIe III that tweIve one-stage resections of the cecum and ascending coIon with compIementary iIeostomy were done. These were done earIy in the series. Since then we have done thirteen simiIar resections without iIeostomy but utiIizing a MiIIer-Abbott tube. We beIieve that an iIeostomy is unnecessary
III
No. of Types of Operations Cases One-stage resection of the cecum and ascending I2 colon with iIeostomy One-stage resection of the cecum and ascending I3 coIon without ileostomy One-stage resection of the transverse coIon with cecostomy................................ 4 One-stage resection of the transverse coIon withoutcecostomy........................ z One-stage resection of the splenic flexure with cecostomy................................ 3 Two-stage resection of the splenic Aexure with 4 cecostomy, first-stage.. . . . .. One-stage resection of the descending coIon withcecostomy........................... 4 One-stage resection of the sigmoid coIon with cecostomy................................ 3 Two-stage resection of the sigmoid, cecostomy, first-stage................................ 3 TotaI.
. ..
.. ..
.....
48
It wiI1 be seen from TabIe III that in resection of the transverse, descending and sigmoid coIon we have done a compIementary cecostomy at the time of operation. We beIieve that this is a safety measure of merit. COMPLICATIONS
It was necessary to reoperate upon one patient because of obstruction at the site of the anastomosis. It has been our practice to break in the mucosa1 diaphragm with the index finger and thumb foIIowing compIetion of the anastomosis. In this case the crushed mucosa had remained seaIed and at the second operation an incision was made over the anastomosis IongituduaIIy, the septum was opened and the bowe1 was cIosed transverseIy. The patient made a prompt recovery. There were four intrabdomina1 abscesses occurring postoperatively which we beIieve definiteIy can be attributed to some technica1 error resuIting in a Ieak of coIonic contents. (TabIe IV.) AI1 four of these patients deveIoped septic fevers with paIpaAmerican
Journal
of Surgery
Rafll,
Michaels-Lesions
of CoIon
FIG. I. B, removal of the primary tumor with the gland-bearing mesentery; bfood vessels have been tied.
IA*
shows removal of the primary lesion and the gland-bearing mesentery. FIG.
I. A,
bIe, tender, abdomina1 masses. AI1 were adipose with fat mesenteries, and a11 instances occurred in resections of the right coIon. It was necessary in one case to drain two abscesses through the abdomina1 waI1. The other three patients ran remarkabIy TABLE
IV
Complications Intra-abdominal abscess. . Obstruction at the site of the anastomosis. Wound infection at the site of the ileostomy Wound infection at the site of the cecostomy wound.. Wound infection.. Cystitis.. P neumoma................................. . . Wound dehiscence.
No. of Cases 4
I I I
I 4 1 I
simiIar courses. Each ran a septic fever with a paIpabIe non-pointing intra-abdomina1 mass. SubsequentIy, each had several very Ioose, fouI stooIs containing pus, foIlowing which their temperatures rapidIy returned to normal and the masses disappeared. Three of these patients had both * Figs.
and lesions of the right colon.
October,
IA,
ZA,
I 949
3A,
4A
5A
show the procedure for
penicillin and suIfadiazine postoperatively. One patient had neither and ran essentiaIIy the same course. There was one wound dehiscence in this series. The other compIications were of a minor nature. We had no thrombophIebitis or recognized phIebothrombosis in this series aIthough the average age was fifty-five years. POSTOPERATIVE
CARE
At the time of operation a11 patients were given whoIe blood transfusions. AI1 patients received bIood postoperativeIy when needed. Most patients were pIaced in oxygen immediateIy after operation. FIuid balance was maintained using intravenous ffuids. Plasma proteins were maintained as well as possibIe, using whoIe bIood, pIasma and parentera amino acids. A particular effort was made to prevent postoperative puImonary compIications. The patients were moved frequentIy and encouraged to breathe deeply and to cough when necessary. In addition, at the first evidence of mucous in the air ways which the patient was unable to expectorate, we used intrat Figs. IB, ZB, 3~, 48 and 5~ show procedure for lesions in the transverse, descending and sigmoid colons.
Rafll,
MichaeIs-Lesions
2A
of CoIon
2B
FIG. 2. A, the end of transverse coIon has been closed and the portion of transverse colon to be used for anastomosis with ileum has been clamped with a Stone clamp and the bowe1 walI cut away; B, Stone cIamps rotated outward; posterior serosa1 sutures in place.
3A FIG. 3. A, Stone cIamps rotated outward and posterior muscular basting suture (C and D) of No. oo chromic;
3’3 serosa1 silk sutures in place but not tied; end posterior serosa1 sutures (A and B).
American
B,
Journal
running sero-
of Surgery
Ram,
MichaeIs-Lesions
of CoIon
4B
4.4 FIG. 4. A, posterior and serosal sutures (A and B); running basting seromuscular
suture (C and D) of No. oo chromic which has been taken over the Stone cIamps; the clamps are now ready to be removed; B, clamps have been removed; anastomosis is compIeted and rent in mesentery is to be cIosed.
E-4
$8
shows the cIamps removed and the ends of the running chromic suture being tied to the end posterior serosal sutures; B, rent in mesentery cIosed with sutures of fine siIk. FIG. 5.
A,
trachea1 suction with a soft rubber catheter. Foot exercises were daiIy routine. Since the advent of peniciIIin we have used it routineIy postoperativeIy for the first forty-eight to seventy-two hours. We beIieve that it wiI1 reduce the numbers October, 1949
and severity of pulmonary and urinary comphcations. Intragastric or intra-intestinal suction was maintained unti1 the patient passed gas per rectum. This usuaIIy occurred at seventy-two hours. FoIIowing this the tube
Ram, MichaeIs-Lesions
FIG. 6. CompIetion of anastomosis anteriorly with interrupted serosal sutures of C siIk. A similar posterior layer is applied after rotating the bowel.
was removed and the patient started on Iiquids proceeding as rapidIy as possibIe to a fuII nourishing diet. We aIIowed the patients to be up as soon as was practica1. Most of them were ambuIatory by the fifth postoperative day. If cecostomy had been done as a &St-stage procedure, then the tube was removed after their first norma bowe1 movement. If the cecostomy was done at the time of operation as a compIementary procedure, then the tube was Ieft in pIace about tweIve days before attempting remova1. This period of time is needed to aIIow softening of the catgut sutures so that tearing of the ceca1 waI1 wiI1 not occur upon remova of the tube. FoIIowing its remova1, the cecostomy wound quickIy cIosed. The average stay in the hospita1 of the patient with the uncomplicated case was 15.5 days and of those with compIicated cases 34.0 days. The over-ah average hospita1 stay for the patients in this series was 2 I .6 days. TECHNIC
OF
LESIONS
OPERATIVE OF THE
PROCEDURE RIGHT
FOR
COLON
The abdomen is opened through a generous right rectus, muscIe-spIitting incision. Hemostasis is effected with No. 60 cotton ties. Before proceeding with the surgery a
of Colon
compIete expIoration of the abdomina1 contents is made. The cecum and ascending colon are mobiIized by cutting their IateraI peritonea1 attachments. The ureter, spermatic or ovarian vesseIs, kidney and duodenum are visuaIized and avoided. The iIeocoIic artery is tied near its origin from the superior mesenteric artery. When the right coIic is present and arises from the superior mesenteric artery it is Iikewise tied. The iIeum is then divided with the cautery between Stone and Payr cIamps seIecting a site about IO cm. from the iIeoceca1 vaIve. The transverse coIon is divided with the cautery between Stone and Payr cIamps, seIecting a site we11 beyond the Iesion and, of course, with an adequaebIood suppIy. A wide portion of the mest entery with the regiona Iymph nodes is removed with the primary Iesion. (Fig. IA.) The end of the coIon is first cIosed asepticaIIy using a running atraumatic seromuscuIar suture of No. oo chromic reinforced with interrupted serosa1 sutures of C silk. An area on the anterior aspect of the transverse coIon near the cIosed end is then seIected and ciamped IongitudinaIIy with a Stone clamp removing with the cautery a portion of coIon approximating the transverse diameter of the iIeum. (Fig. 2~.) An aseptic end-to-side iIeotransverse coIostomy is then done over the Stone cIamps. In this series the Stone cIamps were used excIusiveIy and proved to be most satisfactory. The site on the coIon is cIeaned of fat as carefuIIy as possibIe and a number of posterior serosaI sutures, uniting iIeum and coIon, are pIaced but not tied. (Fig. 3~.) When the Iast stitch is pIaced, they are then tied and cut Ieaving the two end sutures Iong. (Fig. 3~.) A running, basting stitch of No. oo chromic is then taken over the cIamps (Fig. 4~), and whiIe the operator puts gentIe traction on the two ends of this suture, the assistant removes the cIamps. This procedure inverts the bowel and you are now ready to pIace the anterior serosa1 Iayer. The ends of the chromic basting stitch are then tied into the end posAmerican
Journal
of Surgery
Radii, MichaeIs-Lesions terior serosaI stitches (Fig. 5~ AC and BD). Inasmuch as the catgut is a running &ding suture, care must be taken at this point not to tie the end sutures too tightly or you wiI1 encroach upon the Iumen of the bowel. The anterior row of interrupted serosa1 sutures of C siIk are pIaced and tied. (Fig. 6~.) To reinforce the posterior row and the corners a cIamp is passed beneath the anastomosis and the opposite end posterior serosa1 suture is seized. The bowe1 is turned by this procedure so that a second Iayer of posterior serosal sutures of C silk may be taken. The angIes are, of course, carefuIly closed. The anterior Iayer is reinforced with a few serosa1 sutures and the rent in the mesentery and mesocolon is closed with a few fine, cautiousIy pIaced sutures of C siIk. PROCEDURE TRANSVERSE,
FOR
LESIONS
DESCENDING
SIGMOID
IN
THE AND
COLONS
In lesions distal to the hepatic ffexure we use end-to-end aseptic anastomosis over Stone cIamps. OccasionaIIy, despite preliminary decompression, we encountered moderate disparity in the size of the bowe1 proxima1 and dista1 to the Iesion. However, we were abIe in a11 cases to perform end-toend anastomosis. We concede that great disparity between the proxima1 and distal coIon wouId demand side-to-side anastomosis. The principIes of technic are exactIy the same as in resection of the right coIon described in the preceding paragraph. (Figs. IB, 2~, 3~, 4~ and SB.) The wounds are closed with interrupted Snead, figure eight, sutures, using as suture materia1 No. 31 stainless stee1 wire or No. 40 cotton doubIed. SUMMARY
AND
CONCLUSIONS*
I. Our experience with forty-eight consecutive primary resections of the coIon are presented. * Since this articIe was submitted for pubIication,
October,1949
of CoIon
2. We beIieve that with careful preparation of the patient, incIuding medica or surgica1 decompression of the bowe1, aseptic primary resection of the coIon is an adequate and safe procedure. REFERENCES I. ALLEX, ARTHUR W. Carcinoma of the colon. Surgery, 14: 350, 1943. 2. ALLEN, ARTHUR W. Carcinoma of the Iarge intestine. S. Clin. North America, 27: 1018, 1947. 3. BEHREND, MOSES. CoIon surgery and the sulfonamide drugs. J. A. M. A., 128:-g, 1943. A. BRUST. JOHN C. M. Carcinoma of the colon: resection and immediate primary anastomosis. New York State J. Med., 46: 2277, 1946. 5. CATTELL, RICHARD B. Carcinoma of the coIon and rectum. Surgery, 14: 1943. 6. HOXWORTH, PAUL I. and MITHOEFER, JAMES. Management of cancer of the coIon. Surgery, 22: 27 I, 1947.
7. JONES, THOMAS E. Consideration of eIective surgica1 procedures in various segments of the colon. Surgery, 14: 342, 1943, 8. LOCKHART-MUMMERY.Diseases of the Rectum and CoIon. 2nd ed., p. 552. WiIIiam Wood & Co. Baltimore, 1934. g. MAYO, C. W. Resection of the right portion of the colon. S. Clin. Nortb America, 23: 1121, 1943. IO. OWINGS, J. C. and STONE, H. B. Technique of anastomosis using the stone clamp. Surg.. Gynec. e* Obst., 68: 95, 1939. II. RANKIN, F. W. The principles of surgery of the COIon. Surg., Gynec. e”pObst., 72: 332, 1941. 12. SINGLETON, ALBERT 0. The blood suppIy of the large bowe1 with reference to resection. Surgery, 14: 328, 1943. 13. STONE, H. B. and MCLANAHAN, S. Resection and immediate asep& anastomosis for carcinoma of the colon. J. A. M. A., 120: 1362, 1942. 14. WANGENSTEEN, OWEN M. Primarvi resection (closed anastomosis) of the colon and rectosigmoid. Surgery, 14: 403, 1943. 15. WAUGH, J. M. and CUSTER, M. D., JR. Segmental resection of Iesions occurring in the Ieft half of the colon with primary end-to-end aseptic anastomosis. Report based on fifty cases. Sure., Gynec. Ed Obst., 81: $93. 1945. 16. WHIPPLE, ALLEN 0. The use of the Miller-Abbott tube in the surgery of the large bowel. Surger,y, 8: 289, 1940. 17. WHIPPLE, ALLEN 0. Surgery of the terminal iIeum, cecum and right coIon. Surgery, 14: 321, 1943. 18. WHITE, W. C. and AMENDOLA, F. IH. The advantages and disadvantages of cIosed resection of the colon. Ann. Surg., 120: 572, 1944. rg. ZINNINGER,M. M. and HOXWORTH, PAUL I. Cancer of the colon. Surgery, 14: 366, 1943. the authors have operated on four additiona without mortality.
patients