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Subtotal colectomy with cecorectal anastomosis for multiple adenomas of the colon
Subtotal Colectomy with Cecorectal Anastomosis for Multiple Adenomas of the Colon PETER A. ROSI,
M.D.
AND WILLIAM J. CAHILL,
From tbe Department of Surgery, Nortbwestern versity, School of Medicine, Chicago, Illinois.
Uni-
Chicago, Illinois
noma was 2 per cent whereas in 539 patients with poIyps the incidence of carcinoma was 5.8 per cent or practicaIIy three times more frequent. In patients who had poIyps removed the recurrence rate of new poIyps was high, especiaIIy if the poIyps were multipIe at the time of the initia1 diagnosis. In an anaIysis of the recurrence rates of poIyps foIIowing previous polypectomy, these investigators found a rate of 38.5 per cent in patients who had polypectomy for singIe poIyps and 55.7 per cent in patients who had had muItipIe poIyps excised. Benign adenomas of the rectum, whether singIe or multiple, which are within the reach of the 25 cm. sigmoidoscope are best treated from below, after the histoIogy is definitely estabIished [3,6,7]. Patients with a singIe benign adenoma above the Ievel of the sigmoidoscope are best treated by Iaparotomy and removal of the tumor [2-4,6]. This can be accomplished by coIotomy and poIypectomy for a peduncuIated adenoma, or by conservative Iocal resection in a patient with a sessiIe adenoma. Because of the high recurrence rate of poIyps in patients with muItipIe poIyps, and because of the diffkuIty in determining cIinicaIIy the histoIogic character of polyps above the reach of the sigmoidoscope, an operation is needed that wiI1 greatIy reduce the incidence of recurrence and malignancy, and yet leave the patient with a minima1 disturbance of bowe1 function. The idea1 operation must have two quaIifications: (I) Reduction of the length of the colon so that the portion of the bowe1 remaining can be examined by proctoscopy periodically in order to detect and fulgurate or excise any new polyps that may deveIop, and
of the major probIems in the management of multipIe poIyps of the coIon is the extent of resection of the coIon that is necessary in order to effect a cure and prevent future recurrences. Excision of polyps of the coIon, either by polypectomy, segmenta resection or subtota1 colectomy is justified onIy if maIignancy is present or suspected. Polyps of the coIon or rectum may be primariIy benign, benign with malignant degeneration or primarily maIignant. In the absence of histoIogic study of the entire poIyp it is impossible to differentiate cIinicaIIy between them. Extirpation of poIyps of the coIon or rectum is based on this concept. That benign polyps can undergo maIignant change is generally accepted [I-41. However, there is some difference of opinion whether a mahgnant poIyp begins as a malignancy or is due to maIignant changes in a previously benign poIyp [5]. For poIyps within the reach of the proctoscope, histologic examination of biopsy specimens from them will heIp to estabIish the true character of the poIyp. Polyps above the reach of the proctosigmoidoscope, that can be seen only on roentgenographic examination of the coIon, must be treated as potentiaIIy maIignant tumors since cIinicaIIy it is impossibIe to differentiate between the benign, the benign with maIignant changes or the primariIy maIignant polyps. Rider and his coIIeagues [I], in a study of polyps of the coIon at the University of Chicago, showed that in a survey of 9,132 patients without poIyps the incidence of carci-
0
M.D.,
NE
75
American
Journal
of Surgery,
Volume
103, January
1962
Rosi
and
(2) cause the Ieast possibIe disturbance of the physioIogy of the colon. AIthough subtotal coIectomy with ileosigmoidostomy or ileoproctostomy fuIfiIIs the frrst qualilication and is the operation performed most frequentIy for muItipIe poIyps of the colon, it faiIs to fuIfil1 the second quaIification of Ieaving the patient with a minima1 disturbance of bowe1 function. In the physiology ofthe normal intestinal tract, water is most effectively absorbed in the Iower part of the iIeum, cecum and ascending coIon after soIutes in the intestinal cana have been removed in the upper reaches of the smaI1 intestine [lo,lr]. In this procedure those areas are removed, therefore, frequent loose stooIs may develop (a compIication which is often resistant to the usual forms of therapy). Subtotal coIectomy (Fig. I) with cecorecta1 anastomosis, originaIIy suggested by WangenSteen [8], fuIfiIls both quaIifications: (I) the portion of the coIon containing the poIyp is removed and the tota Iength of 25 cm. of the rectum and cecum which remains can be examined periodicahy with a standard Iength proctoscope. (2) The more effective water absorption properties of the terminal ileum and cecum and the function of the ileoceca1 vaIve which governs the physioIogic fIow of iIea1 contents into the cecum are retained [IO]. The cecum also can assume the storage function of the lower Ieft portion of the colon and rectum. In one constipated patient in our series the stoolfiIled cecum reached midway from the pubis to the umbilicus. The presence of the iIeoceca1 vaIve and the anal sphincter leaves the patient with a greatIy foreshortened, aIthough functionahy normaI, colon and rectum. Patients who are thought to have polyps, or who present themselves with the diagnosis of singIe or muItiple poIyps of the colon, are thoroughIy examined by pIain barium and aircontrast enemas, as well as by proctoscopy, in an attempt to determine as accurately as possibIe the number and distribution of the poIyps in the coIon and rectum. AI1 polyps within the reach of the sigmoidoscope are destroyed by electrocoagulation after biopsy has confirmed their benign nature. Recently two cases of postcoIectomy regression of adenomatous poIyps of the rectum were reported [g]. This regression followed ileoproctostomies and was attributed to the chemica1 nature of the intestinal conWe beIieve that eIectrocoagulation tents. through the sigmoidoscope before surgery is
CahiIl the best method of removing tumors in the rectal stump. In preparation for surgery, the patients are given a cIear liquid diet for five days and a tota of 8 gm. of Neomycin during the fortyeight hours preceding surgery in the dosage of I gm. every six hours. In addition, 2 ounces of castor oi1 are given twenty-four hours before surgery to insure proper mechanical cleansing. For further cleansing saline enemas are given the afternoon and evening preceding the operation. AI1 this is required in order to obtain a coIon free of stoo1 so that coIoscopy can be carried out properIy and effectively. Preoperative bIood volume determination and other base Iine bIood and bIood chemical determinations are made. The operation is performed usuaIIy with continuous epidural or spina anesthesia through a Iong Ieft paramedian incision. In a11 cases when onIy a smal1 number of polyps have been seen on the roentgenograms or when they are Iocalized to a smaI1 area, routine coIoscopy of the entire colon is performed. We have found, as have others [4,6], that the number of actuapolyps as determined by coIoscopy or examinal tion of resected coIon specimens may be four or five times larger than the number seen on the roentgenogram. CarefuI coIoscopy of the entire colon shouId be carried out on all patients with colorectal adenomas, whether single or muItipIe, as advocated and described by Deddish [2], Bacon [j], McLanahan [4] and others. It is accomplished by cutting the lateral peritonea attachments of the sigmoid, descending and ascending coIon as we11 as the cecum. The spIenic and hepatic ffexures are mobiIized, maintaining great care not to injure adjacent parenchymatous organs. Frequently, it is possible to examine the entire coIon from the ileoceca1 vaIve to the ana cana with just two coIotomies after this procedure has been carried out. (Figs. 2 and 3.) Soft intestina1 clamps are appIied across the termina1 iIeum in order to prevent the escape of inflated air from the coIon into the smaI1 bowel. The bowe1 is then opened by a smaII transverse incision along the antimesenteric border of the colon. The 25 or 40 cm. sigmoidoscope is introduced under direct vision to its fuI1 length. As air is being insufFlated into the coIon and the sigmoidoscope sIowly withdrawn, the entire bowel waI1 can be examined for more poIyps. In this way the exact number and distribution of the
76
SubtotaI
CoIectomy
for Adenomas
of Colon
FIG. 2. CoIotomy sites for proctoscopic examination of the colon: A, base of the appendix for examination of the ascending colon. B, midtransverse, for examination of the right transverse, ascending coIon, caccum and the left transverse coIon. C, spIenic fIexure, for examination of the transverse coton and occasionally the ascending &on and caecum. AIso for examination of the descending coIon and occasionaIIy the sigmoid and rectum. D, descending colon, for examination of the descending coton and sigmoid.
FIG. I. Segment of the coIon to be removed incIudes ascending colon, transverse colon, descending colon and sigmoid coIon. The appendix is removed.
polyps can he determined. If there are more than three or four polyps distributed widely throughout the colon, or if a Iarge number of poIyps are Iocalized to a smaIIer area, subtotal colectomy is indicated. However, before this is performed, any adenomas in the cecal pouch are removed either by excision or electrocoaguIation. The colotomy openings are then closed. The entire coIon is mobilized by incising the lateral peritonea1 reflection of the cecum, ascending, descending and sigmoid colon. The transverse colon and omentum are freed from the stomach by dividing the gastrocolic omentum in order to preserve the gastroepipIoic vessels aIong the greater curvature of the stomach. The mesenter,y of the colon is then divided just distal to the origin of the iIeoceca1 artery around the colon in order to divide the right an d middle colic arteries at the base of the mesentery and the Ieft coIic and sigmoid arteries distal to their origin from the inferior mesenteric artery. The superior hemorrhoida branch of the inferior mesenteric artery is preserved. Al1 attachments of the cecum are divided so that the cecum can be moved freel>-. The appendix is removed. If the patient were to have an acute appendicitis with the cecum in its new position, it would be diffkult, if not
FIG. 3. Visualization of the entire colon through a single colotomy site in the spIenic flexure is occasionaNy possibIe.
77
Rosi and CahiIl
FIG. 4. Frontal anastomosis.
view
of
the
completed
cecorectal
impossibIe, to estabIish the diagnosis. The ascending coIon is divided 3 cm. beyond the iIeoceca1 vaIve in an area in which the bIood suppIy is adequate, as evident by visibIe puIsations in the termina1 arteries entering the bowe1 at the site of the proposed anastomosis. The anastomosis is to be performed end to end between the ceca1 pouch and the rectum at the IeveI of the sacra1 prominence. This wiI1 give a tota cecorectal segment of approximateIy 25 cm. (Figs. 4 and 5.) The superior hemorrhoidal artery to the rectum is preserved as the bowel waI1 is cIeared. The cecum is swung
FIG. 6. CountercIockwise
rotation
FIG. 5. Lateral view of the completed
anastomosis.
over to the midIine whiIe it is being rotated in a countercIockwise manner. (Fig. 6.) This is a continuation of the countercIockwise rotation the cecum undergoes in embryonic deveIopment and prevents twisting of its mesentery [ 121. This maneuver is accompIished by retracting the smaI1 bowe1 to the Ieft and cephaIad
FIG. 7. Examination of the ceca1 recta1 pouch with a standard 25 cm, proctoscope.
of the cecum to an
upright position.
78
SubtotaI
CoIectomy
for Adenomas TABLE
-
/ Case NO.
Age (yr.)
-
I
No. of PoIyp~
6”
7 ‘5
j0
i 58
6
~ 57
8
~ 56
4
i 88
4
6”
4
4 IO
I2
6
‘5
/
j6
(
MULTIPLE
ADENOMAS
of CoIon
I OF THE
COLON
Location
Course
Hepatic Aexure, descending and sigmoid coIon Descending colon, sigmoid, ascending &on and rectum Sigmoid, transverse, cecum nnd descending colon Descending coIon, splenic ffexure ascending coIon and cecum Left transverse and descending coIon and hepatic ffexure Sigmoid, right transverse, spIenic Aexure and ascending coIon SpIenic ffexure, descending coIon and transverse colon Sigmoid, transverse and hepatic fIexure Rectum, descending colon, transverse and ascending coIon Throughout coIon rectum and transverse Sigmoid, cecum, coIon Descending, sigmoid and hepatic ffexure Siamoid. transverse and ascending coIon Trksveke, hepatic flexure, sigm;d, rectum and descending colon Ascending, spIenic flcxure, rectum and sigmoid colon
and moving the cecum from its normal position counterclockwise down to the Ieft across the pelvic brim. In this manner the ileum and mesentery of the cecum remain free and there is no disturbance of the bIood suppIv. The anastomosis is carefuhy carried out in two layers with interrupted No. 4-0 chromic catgut in the mucosa and interrupted No. 5-o black silk sutures in the seromuscuIar Iayer. The defect between the mesenteric border of the cecum, which now lies to the right side of the cecum, and the adjacent posterior abdominal waI1 is closed with interrupted silk sutures in order to prevent interna herniation. The abdomina1 walI is then cIosed. BJood volume determinations are obtained in all patients immediateJy after surgery and thereafter to determine their bIood and fluid requirements. Postoperatively these patients are examined at six to tweIve month intervals. The cecal rectal pouch is then carefuhy examined by means of a 25 cm. proctoscope for the
No. of Stools DaiIy
Norma1 Normal Normal
2
Norma1
I
Norma1 Norma1
1
FistuIa developed on abdomina1 wall; closed SpontaneousIy Norma1 Normal
or
2
2
Norma1 Norma1 Norma1 Norma1 Normal Norma1
or
2
T OF
2
I
presence of new polyps which, if present, are biopsied and fuIgurated. (Fig. 7.) In the past. eighteen months we have used this procedure on fifteen patients with muItipIe benign adenomas. There have been no mortaIities. In fourteen patients the postoperative course has been uneventfu1. In the other patient, who was operated upon in rg4g for coIotomy and excision of poIyps, a smaI1 IistuIa deveIoped on the lower abdomina1 waI1. This fistuIa cIosed spontaneously. A11 the patients had Ioose diarrhea1 stooIs at the time of their bowel movements following the procedure. However, there was a progressive reduction in the frequency and Jooseness of the stools and by the fourteenth postoperative day alJ patients were passing one or two semisolid or soIid stooIs daily. After four weeks, a11 patients reported passing normaI, formed stooIs, once or twice daily. (TabIe I.) Two patients have complained of constipation after three months. Four patients surpassed their preoperative
79
Rosi and
CahiII tion of the bowe1. The iIeoceca1 artery remains free, the termina1 iIeum untwisted and the cecum in direct continuity with the rectum.
weight. The mortaIity and morbidity rates for this smaI1 seIection of patients seem to indicate that it is better to treat patients who are considered good surgica1 risks with a singIe safe procedure than to subject them to muItipIe procedures. Patients who, because of advanced age and coincidenta degenerative disease, are considered poor surgical risks and in whom, because of Iimited Iife expectancy, the risk of recurrent disease is Iess, might better be treated with muItipIe coIostomies and poIypectomy if any surgery is indicated at aI1.
REFERENCES I. RIDER, J. A., KIRSNER, J. B., MOELLER, H. C. and PALMER, W. L. Polyp of the coIon and rectum. J. A. M. A., 170: 633, 1959. 2. DEDDISH, M. E. and HERTZ, R. E. Colotomy and coloscopy in management of mucosa1 poIyps and cancer of colon. Am. J. Surg., go: 846, 1955. 3. BACON, H. E. and PEALE, A. R. Appraisal of adenomatous polyps of coIon, their histopathology and surgical management. Ann. Surg., 144: g,
SUMMARY
Subtotal colectomy with anastomosis of the cecum to the rectum was carried out upon fifteen patients with muItipIe poIyposis of the colorectum. This procedure gives patients who have muItipIe benign adenomas of the COIOrectum the greatest protection against recurrence of polyps and the fewest undesirable side effects. Preservation of the water absorptive areas of the ileum and cecum and the function of the iIeoceca1 vaIve, reduces the incidence of frequent and Ioose stooIs. The 25 cm. segment of coIon and rectum that remains is adequate to fuIfiI1 the storage function of the Iarge bowe1 so that these patients pass onIy one or two formed stooIs daiIy. The anastomosis of the cecum to the rectum is carried out by mobilization and counterclockwise rotation of the cecal pouch, which is a continuation of the earIy embryoIogic rota-
80
1956. 4. MCLANAHAN, S. and MARTIN, R. E. CoIotomy, coIoscopy, and coIectomy in the management of poIyp of the Iarge intestine. Ann. Surg., 145: 689, 1957. 5. SPRAT~, J. S., ACKERMAN, I. V. and MOYER, C. A. PoIyps of the coIon. Ann. Surg., 148: 682, 1958. 6. TURRELL, R. Management of adenomatous poIyps of coIon and rectum. S. Clin. Nortb America, December rg5g. 7. MCMILLAN, F. L. and JAMIESON, R. W. Errors in the diagnosis and treatment of adenomatous poIyps of the coIon and rectum. S. Clin. Nortb America, p. 267, February 1958. 8. LILLEHEI, R. C. and WANGENSTEEN, 0. H. Bowel function after colectomy for cancer, poIyps and diverticuhtis. J. A. M. A., 159: 163, 1955. g. COLE, J. W. and HILDEN, W. Post-coIectomy regression of adenomatous polyps of the rectum. .kgery, 41: 385, 1959. 10. BYKOV, K. M. Textbook of Physiology. Moscow, 1958. Foreign Languages Publishing House. (Translated from Russian.) I I. FULTON, J. F. Textbook of PhysioIogy. PhiIadelphia, 1959. W. B. Saunders Co. 12. AREY, L. B. DeveIopmentaI Anatomy. PhiIadeIphia, 1958. W. B. Saunders Co.
M.D.
AND WILLIAM J. CAHILL,
From tbe Department of Surgery, Nortbwestern versity, School of Medicine, Chicago, Illinois.
Uni-
Chicago, Illinois
noma was 2 per cent whereas in 539 patients with poIyps the incidence of carcinoma was 5.8 per cent or practicaIIy three times more frequent. In patients who had poIyps removed the recurrence rate of new poIyps was high, especiaIIy if the poIyps were multipIe at the time of the initia1 diagnosis. In an anaIysis of the recurrence rates of poIyps foIIowing previous polypectomy, these investigators found a rate of 38.5 per cent in patients who had polypectomy for singIe poIyps and 55.7 per cent in patients who had had muItipIe poIyps excised. Benign adenomas of the rectum, whether singIe or multiple, which are within the reach of the 25 cm. sigmoidoscope are best treated from below, after the histoIogy is definitely estabIished [3,6,7]. Patients with a singIe benign adenoma above the Ievel of the sigmoidoscope are best treated by Iaparotomy and removal of the tumor [2-4,6]. This can be accomplished by coIotomy and poIypectomy for a peduncuIated adenoma, or by conservative Iocal resection in a patient with a sessiIe adenoma. Because of the high recurrence rate of poIyps in patients with muItipIe poIyps, and because of the diffkuIty in determining cIinicaIIy the histoIogic character of polyps above the reach of the sigmoidoscope, an operation is needed that wiI1 greatIy reduce the incidence of recurrence and malignancy, and yet leave the patient with a minima1 disturbance of bowe1 function. The idea1 operation must have two quaIifications: (I) Reduction of the length of the colon so that the portion of the bowe1 remaining can be examined by proctoscopy periodically in order to detect and fulgurate or excise any new polyps that may deveIop, and
of the major probIems in the management of multipIe poIyps of the coIon is the extent of resection of the coIon that is necessary in order to effect a cure and prevent future recurrences. Excision of polyps of the coIon, either by polypectomy, segmenta resection or subtota1 colectomy is justified onIy if maIignancy is present or suspected. Polyps of the coIon or rectum may be primariIy benign, benign with malignant degeneration or primarily maIignant. In the absence of histoIogic study of the entire poIyp it is impossible to differentiate cIinicaIIy between them. Extirpation of poIyps of the coIon or rectum is based on this concept. That benign polyps can undergo maIignant change is generally accepted [I-41. However, there is some difference of opinion whether a mahgnant poIyp begins as a malignancy or is due to maIignant changes in a previously benign poIyp [5]. For poIyps within the reach of the proctoscope, histologic examination of biopsy specimens from them will heIp to estabIish the true character of the poIyp. Polyps above the reach of the proctosigmoidoscope, that can be seen only on roentgenographic examination of the coIon, must be treated as potentiaIIy maIignant tumors since cIinicaIIy it is impossibIe to differentiate between the benign, the benign with maIignant changes or the primariIy maIignant polyps. Rider and his coIIeagues [I], in a study of polyps of the coIon at the University of Chicago, showed that in a survey of 9,132 patients without poIyps the incidence of carci-
0
M.D.,
NE
75
American
Journal
of Surgery,
Volume
103, January
1962
Rosi
and
(2) cause the Ieast possibIe disturbance of the physioIogy of the colon. AIthough subtotal coIectomy with ileosigmoidostomy or ileoproctostomy fuIfiIIs the frrst qualilication and is the operation performed most frequentIy for muItipIe poIyps of the colon, it faiIs to fuIfil1 the second quaIification of Ieaving the patient with a minima1 disturbance of bowe1 function. In the physiology ofthe normal intestinal tract, water is most effectively absorbed in the Iower part of the iIeum, cecum and ascending coIon after soIutes in the intestinal cana have been removed in the upper reaches of the smaI1 intestine [lo,lr]. In this procedure those areas are removed, therefore, frequent loose stooIs may develop (a compIication which is often resistant to the usual forms of therapy). Subtotal coIectomy (Fig. I) with cecorecta1 anastomosis, originaIIy suggested by WangenSteen [8], fuIfiIls both quaIifications: (I) the portion of the coIon containing the poIyp is removed and the tota Iength of 25 cm. of the rectum and cecum which remains can be examined periodicahy with a standard Iength proctoscope. (2) The more effective water absorption properties of the terminal ileum and cecum and the function of the ileoceca1 vaIve which governs the physioIogic fIow of iIea1 contents into the cecum are retained [IO]. The cecum also can assume the storage function of the lower Ieft portion of the colon and rectum. In one constipated patient in our series the stoolfiIled cecum reached midway from the pubis to the umbilicus. The presence of the iIeoceca1 vaIve and the anal sphincter leaves the patient with a greatIy foreshortened, aIthough functionahy normaI, colon and rectum. Patients who are thought to have polyps, or who present themselves with the diagnosis of singIe or muItiple poIyps of the colon, are thoroughIy examined by pIain barium and aircontrast enemas, as well as by proctoscopy, in an attempt to determine as accurately as possibIe the number and distribution of the poIyps in the coIon and rectum. AI1 polyps within the reach of the sigmoidoscope are destroyed by electrocoagulation after biopsy has confirmed their benign nature. Recently two cases of postcoIectomy regression of adenomatous poIyps of the rectum were reported [g]. This regression followed ileoproctostomies and was attributed to the chemica1 nature of the intestinal conWe beIieve that eIectrocoagulation tents. through the sigmoidoscope before surgery is
CahiIl the best method of removing tumors in the rectal stump. In preparation for surgery, the patients are given a cIear liquid diet for five days and a tota of 8 gm. of Neomycin during the fortyeight hours preceding surgery in the dosage of I gm. every six hours. In addition, 2 ounces of castor oi1 are given twenty-four hours before surgery to insure proper mechanical cleansing. For further cleansing saline enemas are given the afternoon and evening preceding the operation. AI1 this is required in order to obtain a coIon free of stoo1 so that coIoscopy can be carried out properIy and effectively. Preoperative bIood volume determination and other base Iine bIood and bIood chemical determinations are made. The operation is performed usuaIIy with continuous epidural or spina anesthesia through a Iong Ieft paramedian incision. In a11 cases when onIy a smal1 number of polyps have been seen on the roentgenograms or when they are Iocalized to a smaI1 area, routine coIoscopy of the entire colon is performed. We have found, as have others [4,6], that the number of actuapolyps as determined by coIoscopy or examinal tion of resected coIon specimens may be four or five times larger than the number seen on the roentgenogram. CarefuI coIoscopy of the entire colon shouId be carried out on all patients with colorectal adenomas, whether single or muItipIe, as advocated and described by Deddish [2], Bacon [j], McLanahan [4] and others. It is accomplished by cutting the lateral peritonea attachments of the sigmoid, descending and ascending coIon as we11 as the cecum. The spIenic and hepatic ffexures are mobiIized, maintaining great care not to injure adjacent parenchymatous organs. Frequently, it is possible to examine the entire coIon from the ileoceca1 vaIve to the ana cana with just two coIotomies after this procedure has been carried out. (Figs. 2 and 3.) Soft intestina1 clamps are appIied across the termina1 iIeum in order to prevent the escape of inflated air from the coIon into the smaI1 bowel. The bowe1 is then opened by a smaII transverse incision along the antimesenteric border of the colon. The 25 or 40 cm. sigmoidoscope is introduced under direct vision to its fuI1 length. As air is being insufFlated into the coIon and the sigmoidoscope sIowly withdrawn, the entire bowel waI1 can be examined for more poIyps. In this way the exact number and distribution of the
76
SubtotaI
CoIectomy
for Adenomas
of Colon
FIG. 2. CoIotomy sites for proctoscopic examination of the colon: A, base of the appendix for examination of the ascending colon. B, midtransverse, for examination of the right transverse, ascending coIon, caccum and the left transverse coIon. C, spIenic fIexure, for examination of the transverse coton and occasionally the ascending &on and caecum. AIso for examination of the descending coIon and occasionaIIy the sigmoid and rectum. D, descending colon, for examination of the descending coton and sigmoid.
FIG. I. Segment of the coIon to be removed incIudes ascending colon, transverse colon, descending colon and sigmoid coIon. The appendix is removed.
polyps can he determined. If there are more than three or four polyps distributed widely throughout the colon, or if a Iarge number of poIyps are Iocalized to a smaIIer area, subtotal colectomy is indicated. However, before this is performed, any adenomas in the cecal pouch are removed either by excision or electrocoaguIation. The colotomy openings are then closed. The entire coIon is mobilized by incising the lateral peritonea1 reflection of the cecum, ascending, descending and sigmoid colon. The transverse colon and omentum are freed from the stomach by dividing the gastrocolic omentum in order to preserve the gastroepipIoic vessels aIong the greater curvature of the stomach. The mesenter,y of the colon is then divided just distal to the origin of the iIeoceca1 artery around the colon in order to divide the right an d middle colic arteries at the base of the mesentery and the Ieft coIic and sigmoid arteries distal to their origin from the inferior mesenteric artery. The superior hemorrhoida branch of the inferior mesenteric artery is preserved. Al1 attachments of the cecum are divided so that the cecum can be moved freel>-. The appendix is removed. If the patient were to have an acute appendicitis with the cecum in its new position, it would be diffkult, if not
FIG. 3. Visualization of the entire colon through a single colotomy site in the spIenic flexure is occasionaNy possibIe.
77
Rosi and CahiIl
FIG. 4. Frontal anastomosis.
view
of
the
completed
cecorectal
impossibIe, to estabIish the diagnosis. The ascending coIon is divided 3 cm. beyond the iIeoceca1 vaIve in an area in which the bIood suppIy is adequate, as evident by visibIe puIsations in the termina1 arteries entering the bowe1 at the site of the proposed anastomosis. The anastomosis is to be performed end to end between the ceca1 pouch and the rectum at the IeveI of the sacra1 prominence. This wiI1 give a tota cecorectal segment of approximateIy 25 cm. (Figs. 4 and 5.) The superior hemorrhoidal artery to the rectum is preserved as the bowel waI1 is cIeared. The cecum is swung
FIG. 6. CountercIockwise
rotation
FIG. 5. Lateral view of the completed
anastomosis.
over to the midIine whiIe it is being rotated in a countercIockwise manner. (Fig. 6.) This is a continuation of the countercIockwise rotation the cecum undergoes in embryonic deveIopment and prevents twisting of its mesentery [ 121. This maneuver is accompIished by retracting the smaI1 bowe1 to the Ieft and cephaIad
FIG. 7. Examination of the ceca1 recta1 pouch with a standard 25 cm, proctoscope.
of the cecum to an
upright position.
78
SubtotaI
CoIectomy
for Adenomas TABLE
-
/ Case NO.
Age (yr.)
-
I
No. of PoIyp~
6”
7 ‘5
j0
i 58
6
~ 57
8
~ 56
4
i 88
4
6”
4
4 IO
I2
6
‘5
/
j6
(
MULTIPLE
ADENOMAS
of CoIon
I OF THE
COLON
Location
Course
Hepatic Aexure, descending and sigmoid coIon Descending colon, sigmoid, ascending &on and rectum Sigmoid, transverse, cecum nnd descending colon Descending coIon, splenic ffexure ascending coIon and cecum Left transverse and descending coIon and hepatic ffexure Sigmoid, right transverse, spIenic Aexure and ascending coIon SpIenic ffexure, descending coIon and transverse colon Sigmoid, transverse and hepatic fIexure Rectum, descending colon, transverse and ascending coIon Throughout coIon rectum and transverse Sigmoid, cecum, coIon Descending, sigmoid and hepatic ffexure Siamoid. transverse and ascending coIon Trksveke, hepatic flexure, sigm;d, rectum and descending colon Ascending, spIenic flcxure, rectum and sigmoid colon
and moving the cecum from its normal position counterclockwise down to the Ieft across the pelvic brim. In this manner the ileum and mesentery of the cecum remain free and there is no disturbance of the bIood suppIv. The anastomosis is carefuhy carried out in two layers with interrupted No. 4-0 chromic catgut in the mucosa and interrupted No. 5-o black silk sutures in the seromuscuIar Iayer. The defect between the mesenteric border of the cecum, which now lies to the right side of the cecum, and the adjacent posterior abdominal waI1 is closed with interrupted silk sutures in order to prevent interna herniation. The abdomina1 walI is then cIosed. BJood volume determinations are obtained in all patients immediateJy after surgery and thereafter to determine their bIood and fluid requirements. Postoperatively these patients are examined at six to tweIve month intervals. The cecal rectal pouch is then carefuhy examined by means of a 25 cm. proctoscope for the
No. of Stools DaiIy
Norma1 Normal Normal
2
Norma1
I
Norma1 Norma1
1
FistuIa developed on abdomina1 wall; closed SpontaneousIy Norma1 Normal
or
2
2
Norma1 Norma1 Norma1 Norma1 Normal Norma1
or
2
T OF
2
I
presence of new polyps which, if present, are biopsied and fuIgurated. (Fig. 7.) In the past. eighteen months we have used this procedure on fifteen patients with muItipIe benign adenomas. There have been no mortaIities. In fourteen patients the postoperative course has been uneventfu1. In the other patient, who was operated upon in rg4g for coIotomy and excision of poIyps, a smaI1 IistuIa deveIoped on the lower abdomina1 waI1. This fistuIa cIosed spontaneously. A11 the patients had Ioose diarrhea1 stooIs at the time of their bowel movements following the procedure. However, there was a progressive reduction in the frequency and Jooseness of the stools and by the fourteenth postoperative day alJ patients were passing one or two semisolid or soIid stooIs daily. After four weeks, a11 patients reported passing normaI, formed stooIs, once or twice daily. (TabIe I.) Two patients have complained of constipation after three months. Four patients surpassed their preoperative
79
Rosi and
CahiII tion of the bowe1. The iIeoceca1 artery remains free, the termina1 iIeum untwisted and the cecum in direct continuity with the rectum.
weight. The mortaIity and morbidity rates for this smaI1 seIection of patients seem to indicate that it is better to treat patients who are considered good surgica1 risks with a singIe safe procedure than to subject them to muItipIe procedures. Patients who, because of advanced age and coincidenta degenerative disease, are considered poor surgical risks and in whom, because of Iimited Iife expectancy, the risk of recurrent disease is Iess, might better be treated with muItipIe coIostomies and poIypectomy if any surgery is indicated at aI1.
REFERENCES I. RIDER, J. A., KIRSNER, J. B., MOELLER, H. C. and PALMER, W. L. Polyp of the coIon and rectum. J. A. M. A., 170: 633, 1959. 2. DEDDISH, M. E. and HERTZ, R. E. Colotomy and coloscopy in management of mucosa1 poIyps and cancer of colon. Am. J. Surg., go: 846, 1955. 3. BACON, H. E. and PEALE, A. R. Appraisal of adenomatous polyps of coIon, their histopathology and surgical management. Ann. Surg., 144: g,
SUMMARY
Subtotal colectomy with anastomosis of the cecum to the rectum was carried out upon fifteen patients with muItipIe poIyposis of the colorectum. This procedure gives patients who have muItipIe benign adenomas of the COIOrectum the greatest protection against recurrence of polyps and the fewest undesirable side effects. Preservation of the water absorptive areas of the ileum and cecum and the function of the iIeoceca1 vaIve, reduces the incidence of frequent and Ioose stooIs. The 25 cm. segment of coIon and rectum that remains is adequate to fuIfiI1 the storage function of the Iarge bowe1 so that these patients pass onIy one or two formed stooIs daiIy. The anastomosis of the cecum to the rectum is carried out by mobilization and counterclockwise rotation of the cecal pouch, which is a continuation of the earIy embryoIogic rota-
80
1956. 4. MCLANAHAN, S. and MARTIN, R. E. CoIotomy, coIoscopy, and coIectomy in the management of poIyp of the Iarge intestine. Ann. Surg., 145: 689, 1957. 5. SPRAT~, J. S., ACKERMAN, I. V. and MOYER, C. A. PoIyps of the coIon. Ann. Surg., 148: 682, 1958. 6. TURRELL, R. Management of adenomatous poIyps of coIon and rectum. S. Clin. Nortb America, December rg5g. 7. MCMILLAN, F. L. and JAMIESON, R. W. Errors in the diagnosis and treatment of adenomatous poIyps of the coIon and rectum. S. Clin. Nortb America, p. 267, February 1958. 8. LILLEHEI, R. C. and WANGENSTEEN, 0. H. Bowel function after colectomy for cancer, poIyps and diverticuhtis. J. A. M. A., 159: 163, 1955. g. COLE, J. W. and HILDEN, W. Post-coIectomy regression of adenomatous polyps of the rectum. .kgery, 41: 385, 1959. 10. BYKOV, K. M. Textbook of Physiology. Moscow, 1958. Foreign Languages Publishing House. (Translated from Russian.) I I. FULTON, J. F. Textbook of PhysioIogy. PhiIadelphia, 1959. W. B. Saunders Co. 12. AREY, L. B. DeveIopmentaI Anatomy. PhiIadeIphia, 1958. W. B. Saunders Co.