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The left-sided colon
THE LEFT/SIDED COLON* DAVID
A.
SUSNOW,
San Francisco,
T
HE term left-sided colon refers to that condition in which the entire colon including the cecum lies in the left side of the abdominal cavity. It results from a failure of the midgut to rotate in the second stage of rotation. This condition is of interest not only to the embryologist and anatomist but also to the surgeon as we11 because the latter may find himself unexpectedly faced with this unusual situation. Until recentIy the Ieft-sided colon was recognized only post-mortem or during an abdominal operation. Today we appreciate the surgica1 importance of anomalies of intestinal rotation and no longer regard them as mere anatomic curiosities. During surgery the Ieftsided coIon may be discovered as a totally unahied condition or as the cause of an acute abdominal emergency to which anomalies of intestinal rotation give rise. Of forty-eight cases collected by Dott’ thirty-five left-sided colons were discovered accidentally and thirteen patients presented symptoms relevant to the anomaly. In thirty-three cases collected by Haymond and Dragstedt” eighteen patients gave a history of gastric distress due to the anomaly and nine patients made no mention of abdominal discomfort. The left-sided colon was first observed radiologicalIy in 1921 by Hurst.” Rubin” has given an excellent description of its radiologic aspects. Embryology.6 In the earliest days of development the alimentary cana consists of a tube suspended in the midline of the abdominal cavity by a ventral and dorsal mesentery. By the end of the fifth week of intra-uterine life the alimentary cana is divided into the folIowing which forms the three parts : the foregut stomach and duodenum down to the entrance of the bile duct, the midgut which extends from the ampulla of Vater to the junction of the middle with the left third of the transverse colon, and the hindgut which extends from the left third of the transverse colon down to the anus. The extremities of the midgut are firmly tixed by the upper duodenum above and the
M.D.
Calijornia
cohc angle below. These two fixed points are close together and form the duodenocolic isthmus. The midgut forms a convex loop forward. Because of the rapid growth of the midgut and liver by the fifth week the midgut is forced into the root of the umbilical cord which forms a temporary developmental umbilical hernia. (Fig. I .) The midgut carries with it its artery, the superior mesenteric, which terminates at the apex of the extruded gut, the site of the vitelline duct. The superior mesenteric artery runs from the aorta through the duodenocohc isthmus to the apex of the cxtruded gut sending off branches forward to the prearteria1 segment of the midgut loop and backward to the postarteria1 segment. ROTATION
OF THE
MIDGU’I
The first stage of rotation takes place between the fifth to tenth week whiIe the loop lies in the umbilical cord, during which time the ends of the midgut loop rotate through 90 degrees in an anticlockwise direction (as one faces the fetus). The second stage of rotation commences at the beginning of the tenth week. (Fig. 2.) In this stage the midgut returns to the abdominal cavity and in so doing continues to rotate countercIockwise to a full 270 degrees. Frazer and Robbin expIain this return by the reIatively decreased growth of the hver which makes room for the midgut in the abdomen. Due to the fact that it is not possible for the bulky hernial contents to return en masse through the narrow umbilical orifice, the contents are returned in a definite order. The cecum especiahy offers resistance to this passage. Because of the greater growth of the prearteria1 segment the proxima1 loops of small intestine are reduced first. WhiIe the prearterial Ioops are returning, the superior mesenteric artery is firmly fixed to the umbilicus by its termination; and it is therefore stretched like a cord from beginning to end. The returning small intestine enters the abdomen to the right of the superior mesenteric artery. Because of
* From the Proctology Clinic, Department of Surgery, Mt. Zion Hospital, San Francisco, Calif. January,
1950
129
130
Susnow-Left-sided
the Iimited space the coiIs first reduced are pushed to the Ieft behind the taut artery by those foIlowing. They displace the dorsal rnesentery of the hindgut, which occupies the midIine, before them so that the descending colon comes to occupy the left hank and the
Colon
mesenteric artery; (2) the transverse coIon crosses in front of the superior mesenteric (3) the descending colon has been artery; pushed into the left flank; (4) the cecum is in the right Ioin under the liver and (5) the loops of small intestine extend from the left upper
I-KS. I to 3. Schematic drawing of normal dcvclopmcnt, rotation and attachment of the midgut. The midgut in each sketch is that part included between the dotted lines and represents that portion of the alimentary tract from duodenum to midtransverse colon which is supplied by the superior mesenteric artery. (From “Abdomina1 Surgery of Infancy and ChiIdhood,” L-add and Gross.) Figure I, fifth week of fetal life; lateral view; the foregut, midgut and hindgut with their respective bIood supplies are indicated. Rlost of the midgut is extruded into the base of the umbilical cord where it normaIIy resides from about the fifth to the tenth week. Figure 2, tenth week of feta1 life; anterior view; the intestine is elongating and the hindgut is displaced to the Ieft side of the abdomen. The developing, intraabdominal intestines come to lie behind the superior mesenteric artery. A portion of the midgut stiI1 protrudes through the umbilical orifice into the base of the cord. Figure 3, eleventh week of fetal life; a11 of the alimentary tract is withdrawn into the abdomen. The cecum Iies in the epigastrium beneath the stomach. A, aorta; C, cecum; CA, ceIiac axis; D, descending colon; F, foregut; I-I, hindgut; IhZA, inferior mesenteric artery; SRIA, superior mesenteric artery; 170. umbilical orifice and VD, vitelIinc duct.
colic angle is pushed up to form the future splenic ffexure. The Iast loop of ileum carries the superior mesenteric artery with it as it is reduced. The cecum and right half of the coIon are reduced. The cecum lies free in the region of the umbilicus on a plane anterior to the small intestines and the superior mesenteric artery; from there it can pass in any direction. The colon tending to straighten out carries the cecum upward and to the right and crosses the pedicIe of the smaII intestine at the point of origin of the superior mesenteric artery from the aorta. (Fig. 3.) Subsequent growth and elongation pushes the cecum into the right Ioin under the liver. Thus when the second stage of rotation is compIeted, the following normal conditions are present: (I) The duodenum crosses behind the upper part of the superior
to
the
right
lower
abdominal
quadrants.
(Fig. 4.) The third stage of rotation is concerned with the descent of the cecum and the fixation and fusion of various portions of the intestines to the posterior abdominal wall. The cecum descends from its position under the Iiver down into the right iliac fossa. (Fig. 5.) Theprimitive mesentery of the small gut becomes adherent to the posterior abdominal wall along a broad, obIique Iine from the Ieft upper to the right lower quadrant. (Fig. 6.) The postarterial mesentery of the transverse colon persists as the transverse mesocolon. The mesenterv of the cecum, ascending colon, hepatic hexure and hindgut becomes completely obIiterated by fusion with the posterior parieta1 peritoneum
American
Journal
of Surger),
Susnow-Leftexcept in the case of the pelvic colon where the mesentery persists as the future mesocolon. Because of the complex nature of the processes involved in attaining its normal position it is readily understandable why abnormaIities of location of the alimentary tract are almost entirely confined to the midgut.
-sided
Colon
131
ileum occupy the right hypochondrium, lumbar and iIiac regions; (4) the termination of the ileum may cross the midline to reach a Ieft iliac cecum or it may terminate about the midline in a pelvic cecum; (5) the colon is confined to the Ieft side of the abdomen; (6) the cecum is reversed and the ileum enters it from the
FIC:S. 1 to 6. Late in eleventh week of fetal life; the colon is rotating so that the cecum Iies in the right upper quadrant of the abdomen. Figure 5, rotation of the colon is compIete and the cccum lies in a norma position. There is a common mesentery, the mewcolon of the ascending colon being continuous \vith the rnesentcry of the ileum. There is no posterior attachment of this common mesentcry except at the origin of the superior mesenteric artery. Figure 6, final stage in attachment of the mesenteries; the stippled portions become fused and anchored to the posterior abdominal waI1 so that the ascending and descending parts of the coIon are anchored and the mesentery of the jejunum and ileum have a posterior attachment from the origin of the superior mesenteric artery obliqurl,v downward to the cecum. (For further explanation see Figures I to 3.) NON-ROTATION
OF
MIDGUT
The chief factor which determines a normal second stage of rotation is the sequence in which the midgut is returned from the umbiIica1 cord to the abdomina1 cavity. It depends on the buIk of the cecum retaining it to the Iast in the hernia1 sac in the umbiIicus while the more easiIy reducibIe smaI1 intestine enters first. However, in the presence of a lax umbilical ring the coIon and cecum return first carrying with them the lower end of the iIeum and the superior mesenteric artery. The smaI1 intestine immediateIy following wiI1 not tend to pass behind the artery, since the latter is not now held forward to the umbilicus, but rather to displace it and the large intestine to the left. The following features of non-rotation of the midgut according to Dott’ are thereby produced (Fig. 7): (I) The small intestine Iies chiefly to the right of the midline; (2) the duodenum passes down the right side of superior mesenteric artery; (3) the jejunum and
January,
I 950
right side; (7) the ascending colon passes upward from the cecum, usuaIIy a short distance to the left of the midIine, to reach a position behind the greater curvature of the stomach; between this point and the normally placed splenic Aexure a narrow U-shaped Ioop of transverse coIon goes for a variable distance; (8) reIation of the transverse colon to the greater omentum is normal and (9) the descending and pelvic colons take their usual course. In these abnormal sites the viscera undergo a great variety of secondary fixation by mesenteric adhesions which tends to be imperfect.
CONSEQUENCES
OF
LEFT-SIDED
COLON
Pathologic consequences arising from a leftsided colon are not due to its anomalous location but rather to the abnormal attachment and fixation and the inefficient fixation that so frequently accompanies the anomaly. Thus
132
Susnow-Left-sided
interference with motihty and kinks and compression of the bowel may result. Secondary volvulus is the common pathologic consequence of a left-sided colon. This is due to the fact that because the whole of the midgut shares a common mesentery, unless the
Colon result from inefficient or abnormal fixation of the various portions of the midgut. Symptoms may be vague in character or may be those of a typica partial or complete bowel obstruction depending upon the nature and extent of the secondary involvement. Because a percentage will come under observation for symptoms which they have had since early childhood, the anomaly m these cases usually will be discovered by x-ray; but others will not be found until a bowel obstruction necessitates emergency surgery. Some will be discovered during the course of an examination or surgery for a totalIy unallied condition. The value of preoperative knowledge of the anomaly is evident. With this information the surgeon is in a better position to make a correct diagnosis and to pIan and perform his operation accordingly. In those cases in which the surgeon finds himself confronted unexpectedly with the anomoIy during surgery for a condition either directly reIated or totally unallied to the left-sided colon, it is manifest that the surgeon who is familiar with anomalies of intestinal rotation is at an advantage. (Table I.) Lack of knowledge predisposes to errors in procedure or injurious proIongation of the operation or its abandonment. CASE REPORTS
FIG. 7. Schematic drawing of the left-sided colon; the colon occupies the left half or less of the abdominal cavity. The small intestine lies to the right side. The duodenum is elongated and its mesentery usually persists. The colon does not cross ventral to any part of the small intestine. The superior mesenteric artery lies dorsal to the duodenum sending branches to the small intestines from its right side and colic branches from its left side.
ascending coIon forms its secondary attachments, the smaIl intestine, ascending coIon and proximal half of the transverse colon may be freely suspended in their common mesentery by a narrow pedicle which is an idea1 condition for volvuIus. Extensive volvulus is characteristic in early life, usuaIly shortly after birth. In Iater Iife voIvolus of the ileocecal segment is typical. DIAGNOSIS
Symptoms which accompany the Ieft-sided colon are not due primarily to the misplacement but to the pathologic consequences which may
CASE I. Z. Y., a thirty-five year old white married woman was seen whose chief complaints were occasiona bright red bIood with bowe1 movements, constipation and abdomina1 distress. She was born with a cleft palate and an umbilical hernia. PIastic surgery was performed for the cIeft palate when she was an infant and the umbilical hernia was repaired when she was thirty years of age. The patient had recta1 bleeding with bowel movements off and on for severa years associated with painful, protruding hemorrhoids. She had attacks of vague abdomina1 distress ever since she could remember. AbdominaI pain at times was quite severe and constipation and distention developed. Attacks seemed to be brought on by dietary indiscretions and were relieved by enemas. Recta1 examination showed moderateIy-sized, protruding interna hemorrhoids. Proctosigmoidoscopy for a distance of 24 cm. from the anaI verge was essentially negative as was the abdominal examination. There was no recurrence of umbiIica1 hernia. Because of the compIaint referrabIe to the abdomen a gastrointestinal x-ray examination was done with the foIIowing results: A gastrointestina1 x-ray was taken on ApriI 17,
American
Journal
of Surgery
Susnow-Left-sided 1947. (Figs. 8, g and IO.) FIuoroscopy showed the chest was normaI; the esophagus and stomach also were normal. The duodena1 cap was spastic but otherwise normaI. At six hours the stomach was empty and barium had reached the descending coIon; the cecum Iay deep in the peIvis to the Ieft side and the remainder of the coIon was to the Ieft
I .ocation of Incision
I
-i-
Anomalies to Be Considered
Findings
‘33
of the midIine. Loops of smaI1 bowe1 containing barium were present in the peIvis and in the right abdomen. Opaque enema with air contrast, ApriI 19, 1947, confirmed the previous finding of the position of the coIon. The conclusion was Ieft-sided coIon; no intrinsic organic Iesion was present. This patient has been seen since from time to
TABLE
-
CoIon
DifferentiaI
Diagnoses
.Right iliac region
Large intestine bc found
cannot
i_
.I.
II:ailure of descent o cecum
Upper abdomen
Transverse apparent
colon not
Non-rotation
-____ Reversed
rotation
_ Left iliac region
Large bowel is paralIe1 to the descending coton
Duodenum passes down the right side of the root of the mesentery; duodenum not covered by coIon or mesocoton
Non-rotation
Non-rotation
fl Large
intestine crosses duodenum; cecum found in subhepatic region or is foIded back toward splenic Aexure
Duodenum not covered by colon or mesocolon; duodenum has free mesentery and passes down right side of root of mesentery; ascending colon passes up the Ieft side of the vertebral coIumn; no duodenojejunal IIexure; upper loop of jejunum in right hypochondrium Jejunum passes in front of mesenteric vessels from right to Ieft; transverse coIon behind origin of superior mesenteric artery; ascending colon in norma position; no duodenojejunal ffexure; upper Ioop of jejunum in about midline in front of mesenteric root Abnormal colon, probably the ascending colon, passes up from a Ieft-sided cecum on the Ieft side of the vertebral coIumn
8 IO 9 FIG. 8. Opaque enema showing short transverse coIon and dista1 portion of ascending colon. Case 1. FIG. 9. Opaque enema after evacuation; cecum is deep in peIvis to Ieft side; coIon to left of midIine; loops of small bowe1 in right abdomen and peIvis. Case I. FIG. 10. Opaque enema with air contrast cIearIy demonstrating position of entire coIon. Case 1.
January,
I 950
Susnow-Left-sided
‘34
FIG. I I. Opaque enema before evacuation. Case 11. time. She has been on a smooth diet and does not permit herseIf to become constipated. There have hcen no further severe attacks of abdominat pain although at times she has vague epigastric distress. CASE II.* M. K. L., a white maIe forty-seven years of age, compIained of itching about the anus of twelve years’ duration. In Igzg he had pains in his stomach when it became empty. This pain was reIieved by food and aIkaIis. No x-rays were taken at that time but he was treated for a peptic uIcer. There was a trace of sugar in the urine. The patient had itching about the anus for the past tweIve years which was not reIieved by Iow carbohydrate diet or various medications. His boweIs had been normaI. There was occasional anaI discomfort with bow4 movements and occasiona epigastric distress which was reIieved by alkalis. Examination showed simple fistuIa-in-ano at the posterior commissure with an associated anal fissure. Proctosigmoidoscopy and abdominal examination were negative; urinalysis and a gIucose toIerance test were normaI. Because of the history of a possible peptic ulcer and the occasiona epigastric distress a gastrointestina1 x-ray examination was done with the foIIowing resuIts: The upper gastrointestina1 tract was normaI. The opaque enema (Figs. I I and 12) took a course obliquely upward to the Ieft then looped downward before again turning upward to the spIenic ffexure. From this Iatter part the transverse colon fiIIing was entireIy to the left of the spine, the short ascending coIon and cecum with the partiaIIy fiIIed appendix being Iocated in the peIvis. Scattered gas in the right abdomen represented Ioops of smaI1 bowel. The conclusion was left-sided coIon. * Courtesy of Dr. E. A. French.
CoIon
FIG. 12. Opaque enema after evacu3tion. Case II. COMMENT
The two foregoing cases fall into that group of left-sided colons which is discovered accidentalIy. To date neither patient has presented signs and symptoms requiring surgery for any of the compIications incident to the anomaly. The patient in Case I may eventuaIly require surgery because the occasiona attacks which she has experienced are suggestive of partial obstruction due to voIvuIus. The patient in Case II wiI1 probably live out his normal span of years without any diffIcuIties relevant to his Ieft-sided colon. In any event, armed with the knowIedge of the existing anomalies the surgeon confronted with signs of obstruction in these cases wiI1 be in a better position to make a preoperative diagnosis and so can treat the condition adequately and satisfactorily. It shouId be noted that the patient in Case I had an umbiIica1 hernia which required surgery. This fits in with the theory that a relaxed umbiIica1 ring makes it possible for the cecum and coIon to be reduced before the small intestine and to lay the groundwork for non-rotation and a Ieft-sided coIon. SUMMARY The colon cance lined.
embryoIogic explanation of the left-sided has been presented. Its cIinicaI signifiand surgical importance has been outTwo cases of left-sided colon have been
presented Ieft-sided
in which no surgery reIevant to the colon has been necessary to date. American
Journal of Surgery
Susnow-Left-sided REFERENCES I. DOTT, N.
M. AnomaIies of intestinal
rotation: their and surgical aspects: with report of five c-asesrrit. J. S&g., I I i 25 I, 1923. _ I. HAYMOND. H. E. and DRAGSTEDT. L. R. Anomalies of intesknal rotation. Surg., G&. & Ok., 53: 316-329, 1937. 3. IIURST, P. F. and JOHNSTON,T. B. Left-sided colon. Guy’s Hosp. Rep., I : 369, 1921. _c. RUBIN, E. L. Radiological aspects of intestina1 rotation. Lance& 2: 1222, 1935. 5. MCGREGOR, A. L. A Synopsis of Surgical Anatomy, Rotation of the Gut. Chap. 12, Anatomy of Congenita1 Errors. BaItimore, 1943. The WiIIiams & Wilkins Co. 6. FRAZER, J. E. and ROBBINS, R. H. On the factors concerned in causing rotation of the intestines in man. J. Amt. & Physiol., 50: 75. ,915. embryology
DISCUSSION
AHTHUR A. GLADSTONE (Burlington, Vt.): pIeased that the condition known as Ieft-sided
I am
coIon has been bl-ought to the attention of the society, because the surgeon who meets its complications may be embarrassed unIess hc is quite famiIiar with it. Doctor Susnow has succeeded in reviewing for us the stages in rotation in a very concise, clear manner and according to the most accepted Embryology is something one reads, theories. understands and soon forgets; at Ieast that is the way with me. But one should remember and understand thcsc steps because otherwise he cannot understand the pathologic findings be may encounter asscjciatcd with these abnormahties in rotation. In other bvords, Dr. Susnow did not present a11 this embryology just out of theoretic concern but because it has a very practical significance and apptication in the operative treatment and managemcnt of this probIem. It is true that the condition is not too common. It has, howcvcr, been recognized for a Iong time; medic\-a1 anatomists described it. Besides the few cases of my own 1 am familiar with other such cases in our Iittlc state of Vermont, so I have a feeIing that the condition is not as uncommon as the number of reported cases in the Iiterature might lead us to beIieve. Since the problem, as Dr. Susnow expIains, usuaIIy presents itself as a duodena1 obstruction or volvulus, it is more apt to come to a genera1 surgeon than to a proctoIogist; but if you happen to be in the hospital, in the next operating room or anywhere around when some surgeon who is not too familiar lv’ith this condition encounters a compIication associated with a non- or maIrotation, he wiII be very apt to catI you in for advice. That is the way I came to see the first case. Not aI1 the patients are as tortunate as the ones in the cases Dr. Susnow
Januay,
1950
Colon
‘35
reported who did not require surgery. I would Iikr to tell you about one of my patients. An attending surgeon in our hospital was asked to see a baby five days oId who began to vomit twenty-four hours after birth. Physical examination revealed upper abdomina1 distention; a peristaItic wave could be seen across the upper abdomen and the referring doctor thought hc couId feel a mass in the pyIoric region. The surgeon, however, couId feel no mass; and because the vomiting started so soon after birth and because bile was present in the vomitus, he did not accept the diagnosis of the referring doctor of pyIoric hypertrophy. He thought the baby might have some anomaty, congenita1 band, obstruction to the duodenum from the superior mesentery or perhaps some stenosis. After the usua1 preparation, paying attention to hydration, blood changes, decompression of dilated stomach etc., the baby was operated upon. A right rectus incision was made; on entering the abdomen the surgeon was surprised when he couId see no smaI1 intestine. At this point I was calted in to help in the interpretation of findings. The cecum was Iow in the midIine and the iIeum was seen to enter it from the right side. The ascending coIon was to the Ieft of the midIinc and, of course, no transverse coIon was seen covering the duodenum. Everything from the duodcnojejuna1 junction down seemed to be in a sac. WC could trace the terminal iIcum back a short distance from the cecum before it entered the sac. At first I thought we had a large rctroperitonea1 hernia but then reasoned that since the jejuna1 and iIca1 ends entered at different pIaces and, further, since KC found that the posterior parieta1 peritoneum was distinct from the posterior waII of the sac, rve \vert not deaIing with a hernia through the duodenol jejunal fossa. I Iater found simiIar cases described in the Iiterature. It seems this sac is a ballooned-out pouch of mesentery of the Iower position of the i1eum. When this sac was entered, coiIs of small intestine seemed moderately diIated and sIightIy dusky in color. By pIacing a finger at the duodenojejunal junction, a sort of band was feIt which proved to be a twist of the short mesentery that goes with this malrotation. Part of the smaII intestine had to be eviscerated before we couId interpret what we had and untwist the voIvuIus. We aIso found a band of peritoncat retlexion that seemed to obstruct the duodenum and was probabIy as much responsible for the troubIe as the partia1 twist of voIvuIus. Eighteen months have ctapsed since the operation and the baby has done weI1 except for two nonsustained bouts of vomiting. What we fear is a recurrence of the voIvuIus on that abnormaIIy short mesenteric root. It is very possible that the bouts of vomiting were due to a recurrence of the incompIete voIvuIus which corrected itself.
136
Susnow-Left-sided
One case I had which was discovered only with a routine roentgen exam was that of a man of forty. It is interesting because he presented upper abdomina1 symptoms for years simiIar to the case of Dr. Susnow’s. He was treated for a duodena1 uIcer but none was ever discovered by x-ray examination. It may be we11 to remember that it is the usua1 thing and not the exception for patients’ symptoms to be referred to the upper abdomen in coIonic obstruction. Dr. Susnow mentioned the importance of keeping left-sided,appendicitis in mind. A friend of mine had such a case in which diverticuIitis and salpingitis were being considered in the differentia1 diagnosis. Since both these conditions do not require immediate surgery, the danger of overIooking Ieft-sided appendicitis is very possible. To repeat, we must be aware of the probIem and its comphcation because operation is our onIy hope of cure and mortality wiI1 onIy mount with deIay. In the case I cited we might have overIooked a voIvuIus of the entire mesentery if we were not aware of the pathoIogic condition invoIved and if we had not made a complete expIoration. M. H. HOLEHAN (Memphis, Tenn.): I think Dr. Susnow has put much thought and study in his paper and the embryoIogic maneuvers that the gut goes through to get to the norma anatomic position. I wiI1 not try to enIarge upon this nor the anomaIies that occur when this pattern is not fobowed. The two case reports Ieave nothing to be added. From a surgical standpoint it is we11 to know a11 of these conditions so that if an intra-abdomina1 pathoIogic condition arises and the physica facts and symptoms are somewhat pecuIiar, it may heIp you in making a more accurate diagnosis and correcting the condition. PersonaIIy I have not treated any Ieft-sided coIons and, therefore, I have taken the Iiberty of borrowing two from the John Gaston HospitaI of Memphis. The first case is that of a twenty year oId white female who had been in John Gaston HospitaI on
CoIon
two previous occasions, one for a norma deIivery and the other a pregnancy at time that was deIivered by cesarean section due to a ruptured uterus. After Ieaving the hospita1 the patient was later seen in the outpatient cIinic numerous times. Her chief compIaints were indigestion, constipation, intermittent cramping over peIvic region and severe aching pains usuaIIy foIIowing urination. She was again admitted to the hospita1 and a gastrointestina1 series was done and the foIlowing noted. The duodena1 Ioop appeared abnorma1 and did not present the usua1 conhguration; it appeared to pass to the right directly with the jejunum without being attached to the ligament of Triste. Abnormality in the Iocation of the cecum was also noted in the one-hour fiIm. This was at a Iater date folIowed with a barium enema and the abnormality of the position of the right coIon was cIearIy visuaIized. This patient had severe cystitis which was treated; the constipation was corrected and she was discharged. She has had no symptoms since. The second case is that of a white male twentyeight years of age. He had an essentiaIIy negative history except occasiona attacks of pain in the Ieft Iower quadrant which were graduaIIy getting worse and were causing him to Iose time from work. A barium enema was given and the right colon was found to be on the Ieft side. Later an appendectomy was performed and patient made an uneventful recovery. DAVID A. SUSNOW(cIosing): I have been asked what the incidence of the Ieft-sided coIon is. FrankIy, I do not know; I have not been abIe to get any figures. However, in poIIing a number of surgeons and proctoIogists I was amazed to find how few men have seen even one case during many years of practice. In poIIing roentgenoIogists the average man may have seen onIy two or three cases in a Iifetime. As a practica1 point shouId one encounter a Ieftsided coIon during surgery for voIvuIus, it is almost aIways necessary to eviscerate a11 of the mass onto the abdomina1 waI1 so that the point of voIvuIus can bc demonstrated.
American
Journal
of Surgery
A.
SUSNOW,
San Francisco,
T
HE term left-sided colon refers to that condition in which the entire colon including the cecum lies in the left side of the abdominal cavity. It results from a failure of the midgut to rotate in the second stage of rotation. This condition is of interest not only to the embryologist and anatomist but also to the surgeon as we11 because the latter may find himself unexpectedly faced with this unusual situation. Until recentIy the Ieft-sided colon was recognized only post-mortem or during an abdominal operation. Today we appreciate the surgica1 importance of anomalies of intestinal rotation and no longer regard them as mere anatomic curiosities. During surgery the Ieftsided coIon may be discovered as a totally unahied condition or as the cause of an acute abdominal emergency to which anomalies of intestinal rotation give rise. Of forty-eight cases collected by Dott’ thirty-five left-sided colons were discovered accidentally and thirteen patients presented symptoms relevant to the anomaly. In thirty-three cases collected by Haymond and Dragstedt” eighteen patients gave a history of gastric distress due to the anomaly and nine patients made no mention of abdominal discomfort. The left-sided colon was first observed radiologicalIy in 1921 by Hurst.” Rubin” has given an excellent description of its radiologic aspects. Embryology.6 In the earliest days of development the alimentary cana consists of a tube suspended in the midline of the abdominal cavity by a ventral and dorsal mesentery. By the end of the fifth week of intra-uterine life the alimentary cana is divided into the folIowing which forms the three parts : the foregut stomach and duodenum down to the entrance of the bile duct, the midgut which extends from the ampulla of Vater to the junction of the middle with the left third of the transverse colon, and the hindgut which extends from the left third of the transverse colon down to the anus. The extremities of the midgut are firmly tixed by the upper duodenum above and the
M.D.
Calijornia
cohc angle below. These two fixed points are close together and form the duodenocolic isthmus. The midgut forms a convex loop forward. Because of the rapid growth of the midgut and liver by the fifth week the midgut is forced into the root of the umbilical cord which forms a temporary developmental umbilical hernia. (Fig. I .) The midgut carries with it its artery, the superior mesenteric, which terminates at the apex of the extruded gut, the site of the vitelline duct. The superior mesenteric artery runs from the aorta through the duodenocohc isthmus to the apex of the cxtruded gut sending off branches forward to the prearteria1 segment of the midgut loop and backward to the postarteria1 segment. ROTATION
OF THE
MIDGU’I
The first stage of rotation takes place between the fifth to tenth week whiIe the loop lies in the umbilical cord, during which time the ends of the midgut loop rotate through 90 degrees in an anticlockwise direction (as one faces the fetus). The second stage of rotation commences at the beginning of the tenth week. (Fig. 2.) In this stage the midgut returns to the abdominal cavity and in so doing continues to rotate countercIockwise to a full 270 degrees. Frazer and Robbin expIain this return by the reIatively decreased growth of the hver which makes room for the midgut in the abdomen. Due to the fact that it is not possible for the bulky hernial contents to return en masse through the narrow umbilical orifice, the contents are returned in a definite order. The cecum especiahy offers resistance to this passage. Because of the greater growth of the prearteria1 segment the proxima1 loops of small intestine are reduced first. WhiIe the prearterial Ioops are returning, the superior mesenteric artery is firmly fixed to the umbilicus by its termination; and it is therefore stretched like a cord from beginning to end. The returning small intestine enters the abdomen to the right of the superior mesenteric artery. Because of
* From the Proctology Clinic, Department of Surgery, Mt. Zion Hospital, San Francisco, Calif. January,
1950
129
130
Susnow-Left-sided
the Iimited space the coiIs first reduced are pushed to the Ieft behind the taut artery by those foIlowing. They displace the dorsal rnesentery of the hindgut, which occupies the midIine, before them so that the descending colon comes to occupy the left hank and the
Colon
mesenteric artery; (2) the transverse coIon crosses in front of the superior mesenteric (3) the descending colon has been artery; pushed into the left flank; (4) the cecum is in the right Ioin under the liver and (5) the loops of small intestine extend from the left upper
I-KS. I to 3. Schematic drawing of normal dcvclopmcnt, rotation and attachment of the midgut. The midgut in each sketch is that part included between the dotted lines and represents that portion of the alimentary tract from duodenum to midtransverse colon which is supplied by the superior mesenteric artery. (From “Abdomina1 Surgery of Infancy and ChiIdhood,” L-add and Gross.) Figure I, fifth week of fetal life; lateral view; the foregut, midgut and hindgut with their respective bIood supplies are indicated. Rlost of the midgut is extruded into the base of the umbilical cord where it normaIIy resides from about the fifth to the tenth week. Figure 2, tenth week of feta1 life; anterior view; the intestine is elongating and the hindgut is displaced to the Ieft side of the abdomen. The developing, intraabdominal intestines come to lie behind the superior mesenteric artery. A portion of the midgut stiI1 protrudes through the umbilical orifice into the base of the cord. Figure 3, eleventh week of fetal life; a11 of the alimentary tract is withdrawn into the abdomen. The cecum Iies in the epigastrium beneath the stomach. A, aorta; C, cecum; CA, ceIiac axis; D, descending colon; F, foregut; I-I, hindgut; IhZA, inferior mesenteric artery; SRIA, superior mesenteric artery; 170. umbilical orifice and VD, vitelIinc duct.
colic angle is pushed up to form the future splenic ffexure. The Iast loop of ileum carries the superior mesenteric artery with it as it is reduced. The cecum and right half of the coIon are reduced. The cecum lies free in the region of the umbilicus on a plane anterior to the small intestines and the superior mesenteric artery; from there it can pass in any direction. The colon tending to straighten out carries the cecum upward and to the right and crosses the pedicIe of the smaII intestine at the point of origin of the superior mesenteric artery from the aorta. (Fig. 3.) Subsequent growth and elongation pushes the cecum into the right Ioin under the liver. Thus when the second stage of rotation is compIeted, the following normal conditions are present: (I) The duodenum crosses behind the upper part of the superior
to
the
right
lower
abdominal
quadrants.
(Fig. 4.) The third stage of rotation is concerned with the descent of the cecum and the fixation and fusion of various portions of the intestines to the posterior abdominal wall. The cecum descends from its position under the Iiver down into the right iliac fossa. (Fig. 5.) Theprimitive mesentery of the small gut becomes adherent to the posterior abdominal wall along a broad, obIique Iine from the Ieft upper to the right lower quadrant. (Fig. 6.) The postarterial mesentery of the transverse colon persists as the transverse mesocolon. The mesenterv of the cecum, ascending colon, hepatic hexure and hindgut becomes completely obIiterated by fusion with the posterior parieta1 peritoneum
American
Journal
of Surger),
Susnow-Leftexcept in the case of the pelvic colon where the mesentery persists as the future mesocolon. Because of the complex nature of the processes involved in attaining its normal position it is readily understandable why abnormaIities of location of the alimentary tract are almost entirely confined to the midgut.
-sided
Colon
131
ileum occupy the right hypochondrium, lumbar and iIiac regions; (4) the termination of the ileum may cross the midline to reach a Ieft iliac cecum or it may terminate about the midline in a pelvic cecum; (5) the colon is confined to the Ieft side of the abdomen; (6) the cecum is reversed and the ileum enters it from the
FIC:S. 1 to 6. Late in eleventh week of fetal life; the colon is rotating so that the cecum Iies in the right upper quadrant of the abdomen. Figure 5, rotation of the colon is compIete and the cccum lies in a norma position. There is a common mesentery, the mewcolon of the ascending colon being continuous \vith the rnesentcry of the ileum. There is no posterior attachment of this common mesentcry except at the origin of the superior mesenteric artery. Figure 6, final stage in attachment of the mesenteries; the stippled portions become fused and anchored to the posterior abdominal waI1 so that the ascending and descending parts of the coIon are anchored and the mesentery of the jejunum and ileum have a posterior attachment from the origin of the superior mesenteric artery obliqurl,v downward to the cecum. (For further explanation see Figures I to 3.) NON-ROTATION
OF
MIDGUT
The chief factor which determines a normal second stage of rotation is the sequence in which the midgut is returned from the umbiIica1 cord to the abdomina1 cavity. It depends on the buIk of the cecum retaining it to the Iast in the hernia1 sac in the umbiIicus while the more easiIy reducibIe smaI1 intestine enters first. However, in the presence of a lax umbilical ring the coIon and cecum return first carrying with them the lower end of the iIeum and the superior mesenteric artery. The smaI1 intestine immediateIy following wiI1 not tend to pass behind the artery, since the latter is not now held forward to the umbilicus, but rather to displace it and the large intestine to the left. The following features of non-rotation of the midgut according to Dott’ are thereby produced (Fig. 7): (I) The small intestine Iies chiefly to the right of the midline; (2) the duodenum passes down the right side of superior mesenteric artery; (3) the jejunum and
January,
I 950
right side; (7) the ascending colon passes upward from the cecum, usuaIIy a short distance to the left of the midIine, to reach a position behind the greater curvature of the stomach; between this point and the normally placed splenic Aexure a narrow U-shaped Ioop of transverse coIon goes for a variable distance; (8) reIation of the transverse colon to the greater omentum is normal and (9) the descending and pelvic colons take their usual course. In these abnormal sites the viscera undergo a great variety of secondary fixation by mesenteric adhesions which tends to be imperfect.
CONSEQUENCES
OF
LEFT-SIDED
COLON
Pathologic consequences arising from a leftsided colon are not due to its anomalous location but rather to the abnormal attachment and fixation and the inefficient fixation that so frequently accompanies the anomaly. Thus
132
Susnow-Left-sided
interference with motihty and kinks and compression of the bowel may result. Secondary volvulus is the common pathologic consequence of a left-sided colon. This is due to the fact that because the whole of the midgut shares a common mesentery, unless the
Colon result from inefficient or abnormal fixation of the various portions of the midgut. Symptoms may be vague in character or may be those of a typica partial or complete bowel obstruction depending upon the nature and extent of the secondary involvement. Because a percentage will come under observation for symptoms which they have had since early childhood, the anomaly m these cases usually will be discovered by x-ray; but others will not be found until a bowel obstruction necessitates emergency surgery. Some will be discovered during the course of an examination or surgery for a totalIy unallied condition. The value of preoperative knowledge of the anomaly is evident. With this information the surgeon is in a better position to make a correct diagnosis and to pIan and perform his operation accordingly. In those cases in which the surgeon finds himself confronted unexpectedly with the anomoIy during surgery for a condition either directly reIated or totally unallied to the left-sided colon, it is manifest that the surgeon who is familiar with anomalies of intestinal rotation is at an advantage. (Table I.) Lack of knowledge predisposes to errors in procedure or injurious proIongation of the operation or its abandonment. CASE REPORTS
FIG. 7. Schematic drawing of the left-sided colon; the colon occupies the left half or less of the abdominal cavity. The small intestine lies to the right side. The duodenum is elongated and its mesentery usually persists. The colon does not cross ventral to any part of the small intestine. The superior mesenteric artery lies dorsal to the duodenum sending branches to the small intestines from its right side and colic branches from its left side.
ascending coIon forms its secondary attachments, the smaIl intestine, ascending coIon and proximal half of the transverse colon may be freely suspended in their common mesentery by a narrow pedicle which is an idea1 condition for volvuIus. Extensive volvulus is characteristic in early life, usuaIly shortly after birth. In Iater Iife voIvolus of the ileocecal segment is typical. DIAGNOSIS
Symptoms which accompany the Ieft-sided colon are not due primarily to the misplacement but to the pathologic consequences which may
CASE I. Z. Y., a thirty-five year old white married woman was seen whose chief complaints were occasiona bright red bIood with bowe1 movements, constipation and abdomina1 distress. She was born with a cleft palate and an umbilical hernia. PIastic surgery was performed for the cIeft palate when she was an infant and the umbilical hernia was repaired when she was thirty years of age. The patient had recta1 bleeding with bowel movements off and on for severa years associated with painful, protruding hemorrhoids. She had attacks of vague abdomina1 distress ever since she could remember. AbdominaI pain at times was quite severe and constipation and distention developed. Attacks seemed to be brought on by dietary indiscretions and were relieved by enemas. Recta1 examination showed moderateIy-sized, protruding interna hemorrhoids. Proctosigmoidoscopy for a distance of 24 cm. from the anaI verge was essentially negative as was the abdominal examination. There was no recurrence of umbiIica1 hernia. Because of the compIaint referrabIe to the abdomen a gastrointestinal x-ray examination was done with the foIIowing results: A gastrointestina1 x-ray was taken on ApriI 17,
American
Journal
of Surgery
Susnow-Left-sided 1947. (Figs. 8, g and IO.) FIuoroscopy showed the chest was normaI; the esophagus and stomach also were normal. The duodena1 cap was spastic but otherwise normaI. At six hours the stomach was empty and barium had reached the descending coIon; the cecum Iay deep in the peIvis to the Ieft side and the remainder of the coIon was to the Ieft
I .ocation of Incision
I
-i-
Anomalies to Be Considered
Findings
‘33
of the midIine. Loops of smaI1 bowe1 containing barium were present in the peIvis and in the right abdomen. Opaque enema with air contrast, ApriI 19, 1947, confirmed the previous finding of the position of the coIon. The conclusion was Ieft-sided coIon; no intrinsic organic Iesion was present. This patient has been seen since from time to
TABLE
-
CoIon
DifferentiaI
Diagnoses
.Right iliac region
Large intestine bc found
cannot
i_
.I.
II:ailure of descent o cecum
Upper abdomen
Transverse apparent
colon not
Non-rotation
-____ Reversed
rotation
_ Left iliac region
Large bowel is paralIe1 to the descending coton
Duodenum passes down the right side of the root of the mesentery; duodenum not covered by coIon or mesocoton
Non-rotation
Non-rotation
fl Large
intestine crosses duodenum; cecum found in subhepatic region or is foIded back toward splenic Aexure
Duodenum not covered by colon or mesocolon; duodenum has free mesentery and passes down right side of root of mesentery; ascending colon passes up the Ieft side of the vertebral coIumn; no duodenojejunal IIexure; upper loop of jejunum in right hypochondrium Jejunum passes in front of mesenteric vessels from right to Ieft; transverse coIon behind origin of superior mesenteric artery; ascending colon in norma position; no duodenojejunal ffexure; upper Ioop of jejunum in about midline in front of mesenteric root Abnormal colon, probably the ascending colon, passes up from a Ieft-sided cecum on the Ieft side of the vertebral coIumn
8 IO 9 FIG. 8. Opaque enema showing short transverse coIon and dista1 portion of ascending colon. Case 1. FIG. 9. Opaque enema after evacuation; cecum is deep in peIvis to Ieft side; coIon to left of midIine; loops of small bowe1 in right abdomen and peIvis. Case I. FIG. 10. Opaque enema with air contrast cIearIy demonstrating position of entire coIon. Case 1.
January,
I 950
Susnow-Left-sided
‘34
FIG. I I. Opaque enema before evacuation. Case 11. time. She has been on a smooth diet and does not permit herseIf to become constipated. There have hcen no further severe attacks of abdominat pain although at times she has vague epigastric distress. CASE II.* M. K. L., a white maIe forty-seven years of age, compIained of itching about the anus of twelve years’ duration. In Igzg he had pains in his stomach when it became empty. This pain was reIieved by food and aIkaIis. No x-rays were taken at that time but he was treated for a peptic uIcer. There was a trace of sugar in the urine. The patient had itching about the anus for the past tweIve years which was not reIieved by Iow carbohydrate diet or various medications. His boweIs had been normaI. There was occasional anaI discomfort with bow4 movements and occasiona epigastric distress which was reIieved by alkalis. Examination showed simple fistuIa-in-ano at the posterior commissure with an associated anal fissure. Proctosigmoidoscopy and abdominal examination were negative; urinalysis and a gIucose toIerance test were normaI. Because of the history of a possible peptic ulcer and the occasiona epigastric distress a gastrointestina1 x-ray examination was done with the foIIowing resuIts: The upper gastrointestina1 tract was normaI. The opaque enema (Figs. I I and 12) took a course obliquely upward to the Ieft then looped downward before again turning upward to the spIenic ffexure. From this Iatter part the transverse colon fiIIing was entireIy to the left of the spine, the short ascending coIon and cecum with the partiaIIy fiIIed appendix being Iocated in the peIvis. Scattered gas in the right abdomen represented Ioops of smaI1 bowel. The conclusion was left-sided coIon. * Courtesy of Dr. E. A. French.
CoIon
FIG. 12. Opaque enema after evacu3tion. Case II. COMMENT
The two foregoing cases fall into that group of left-sided colons which is discovered accidentalIy. To date neither patient has presented signs and symptoms requiring surgery for any of the compIications incident to the anomaly. The patient in Case I may eventuaIly require surgery because the occasiona attacks which she has experienced are suggestive of partial obstruction due to voIvuIus. The patient in Case II wiI1 probably live out his normal span of years without any diffIcuIties relevant to his Ieft-sided colon. In any event, armed with the knowIedge of the existing anomalies the surgeon confronted with signs of obstruction in these cases wiI1 be in a better position to make a preoperative diagnosis and so can treat the condition adequately and satisfactorily. It shouId be noted that the patient in Case I had an umbiIica1 hernia which required surgery. This fits in with the theory that a relaxed umbiIica1 ring makes it possible for the cecum and coIon to be reduced before the small intestine and to lay the groundwork for non-rotation and a Ieft-sided coIon. SUMMARY The colon cance lined.
embryoIogic explanation of the left-sided has been presented. Its cIinicaI signifiand surgical importance has been outTwo cases of left-sided colon have been
presented Ieft-sided
in which no surgery reIevant to the colon has been necessary to date. American
Journal of Surgery
Susnow-Left-sided REFERENCES I. DOTT, N.
M. AnomaIies of intestinal
rotation: their and surgical aspects: with report of five c-asesrrit. J. S&g., I I i 25 I, 1923. _ I. HAYMOND. H. E. and DRAGSTEDT. L. R. Anomalies of intesknal rotation. Surg., G&. & Ok., 53: 316-329, 1937. 3. IIURST, P. F. and JOHNSTON,T. B. Left-sided colon. Guy’s Hosp. Rep., I : 369, 1921. _c. RUBIN, E. L. Radiological aspects of intestina1 rotation. Lance& 2: 1222, 1935. 5. MCGREGOR, A. L. A Synopsis of Surgical Anatomy, Rotation of the Gut. Chap. 12, Anatomy of Congenita1 Errors. BaItimore, 1943. The WiIIiams & Wilkins Co. 6. FRAZER, J. E. and ROBBINS, R. H. On the factors concerned in causing rotation of the intestines in man. J. Amt. & Physiol., 50: 75. ,915. embryology
DISCUSSION
AHTHUR A. GLADSTONE (Burlington, Vt.): pIeased that the condition known as Ieft-sided
I am
coIon has been bl-ought to the attention of the society, because the surgeon who meets its complications may be embarrassed unIess hc is quite famiIiar with it. Doctor Susnow has succeeded in reviewing for us the stages in rotation in a very concise, clear manner and according to the most accepted Embryology is something one reads, theories. understands and soon forgets; at Ieast that is the way with me. But one should remember and understand thcsc steps because otherwise he cannot understand the pathologic findings be may encounter asscjciatcd with these abnormahties in rotation. In other bvords, Dr. Susnow did not present a11 this embryology just out of theoretic concern but because it has a very practical significance and apptication in the operative treatment and managemcnt of this probIem. It is true that the condition is not too common. It has, howcvcr, been recognized for a Iong time; medic\-a1 anatomists described it. Besides the few cases of my own 1 am familiar with other such cases in our Iittlc state of Vermont, so I have a feeIing that the condition is not as uncommon as the number of reported cases in the Iiterature might lead us to beIieve. Since the problem, as Dr. Susnow expIains, usuaIIy presents itself as a duodena1 obstruction or volvulus, it is more apt to come to a genera1 surgeon than to a proctoIogist; but if you happen to be in the hospital, in the next operating room or anywhere around when some surgeon who is not too familiar lv’ith this condition encounters a compIication associated with a non- or maIrotation, he wiII be very apt to catI you in for advice. That is the way I came to see the first case. Not aI1 the patients are as tortunate as the ones in the cases Dr. Susnow
Januay,
1950
Colon
‘35
reported who did not require surgery. I would Iikr to tell you about one of my patients. An attending surgeon in our hospital was asked to see a baby five days oId who began to vomit twenty-four hours after birth. Physical examination revealed upper abdomina1 distention; a peristaItic wave could be seen across the upper abdomen and the referring doctor thought hc couId feel a mass in the pyIoric region. The surgeon, however, couId feel no mass; and because the vomiting started so soon after birth and because bile was present in the vomitus, he did not accept the diagnosis of the referring doctor of pyIoric hypertrophy. He thought the baby might have some anomaty, congenita1 band, obstruction to the duodenum from the superior mesentery or perhaps some stenosis. After the usua1 preparation, paying attention to hydration, blood changes, decompression of dilated stomach etc., the baby was operated upon. A right rectus incision was made; on entering the abdomen the surgeon was surprised when he couId see no smaI1 intestine. At this point I was calted in to help in the interpretation of findings. The cecum was Iow in the midIine and the iIeum was seen to enter it from the right side. The ascending coIon was to the Ieft of the midIinc and, of course, no transverse coIon was seen covering the duodenum. Everything from the duodcnojejuna1 junction down seemed to be in a sac. WC could trace the terminal iIcum back a short distance from the cecum before it entered the sac. At first I thought we had a large rctroperitonea1 hernia but then reasoned that since the jejuna1 and iIca1 ends entered at different pIaces and, further, since KC found that the posterior parieta1 peritoneum was distinct from the posterior waII of the sac, rve \vert not deaIing with a hernia through the duodenol jejunal fossa. I Iater found simiIar cases described in the Iiterature. It seems this sac is a ballooned-out pouch of mesentery of the Iower position of the i1eum. When this sac was entered, coiIs of small intestine seemed moderately diIated and sIightIy dusky in color. By pIacing a finger at the duodenojejunal junction, a sort of band was feIt which proved to be a twist of the short mesentery that goes with this malrotation. Part of the smaII intestine had to be eviscerated before we couId interpret what we had and untwist the voIvuIus. We aIso found a band of peritoncat retlexion that seemed to obstruct the duodenum and was probabIy as much responsible for the troubIe as the partia1 twist of voIvuIus. Eighteen months have ctapsed since the operation and the baby has done weI1 except for two nonsustained bouts of vomiting. What we fear is a recurrence of the voIvuIus on that abnormaIIy short mesenteric root. It is very possible that the bouts of vomiting were due to a recurrence of the incompIete voIvuIus which corrected itself.
136
Susnow-Left-sided
One case I had which was discovered only with a routine roentgen exam was that of a man of forty. It is interesting because he presented upper abdomina1 symptoms for years simiIar to the case of Dr. Susnow’s. He was treated for a duodena1 uIcer but none was ever discovered by x-ray examination. It may be we11 to remember that it is the usua1 thing and not the exception for patients’ symptoms to be referred to the upper abdomen in coIonic obstruction. Dr. Susnow mentioned the importance of keeping left-sided,appendicitis in mind. A friend of mine had such a case in which diverticuIitis and salpingitis were being considered in the differentia1 diagnosis. Since both these conditions do not require immediate surgery, the danger of overIooking Ieft-sided appendicitis is very possible. To repeat, we must be aware of the probIem and its comphcation because operation is our onIy hope of cure and mortality wiI1 onIy mount with deIay. In the case I cited we might have overIooked a voIvuIus of the entire mesentery if we were not aware of the pathoIogic condition invoIved and if we had not made a complete expIoration. M. H. HOLEHAN (Memphis, Tenn.): I think Dr. Susnow has put much thought and study in his paper and the embryoIogic maneuvers that the gut goes through to get to the norma anatomic position. I wiI1 not try to enIarge upon this nor the anomaIies that occur when this pattern is not fobowed. The two case reports Ieave nothing to be added. From a surgical standpoint it is we11 to know a11 of these conditions so that if an intra-abdomina1 pathoIogic condition arises and the physica facts and symptoms are somewhat pecuIiar, it may heIp you in making a more accurate diagnosis and correcting the condition. PersonaIIy I have not treated any Ieft-sided coIons and, therefore, I have taken the Iiberty of borrowing two from the John Gaston HospitaI of Memphis. The first case is that of a twenty year oId white female who had been in John Gaston HospitaI on
CoIon
two previous occasions, one for a norma deIivery and the other a pregnancy at time that was deIivered by cesarean section due to a ruptured uterus. After Ieaving the hospita1 the patient was later seen in the outpatient cIinic numerous times. Her chief compIaints were indigestion, constipation, intermittent cramping over peIvic region and severe aching pains usuaIIy foIIowing urination. She was again admitted to the hospita1 and a gastrointestina1 series was done and the foIlowing noted. The duodena1 Ioop appeared abnorma1 and did not present the usua1 conhguration; it appeared to pass to the right directly with the jejunum without being attached to the ligament of Triste. Abnormality in the Iocation of the cecum was also noted in the one-hour fiIm. This was at a Iater date folIowed with a barium enema and the abnormality of the position of the right coIon was cIearIy visuaIized. This patient had severe cystitis which was treated; the constipation was corrected and she was discharged. She has had no symptoms since. The second case is that of a white male twentyeight years of age. He had an essentiaIIy negative history except occasiona attacks of pain in the Ieft Iower quadrant which were graduaIIy getting worse and were causing him to Iose time from work. A barium enema was given and the right colon was found to be on the Ieft side. Later an appendectomy was performed and patient made an uneventful recovery. DAVID A. SUSNOW(cIosing): I have been asked what the incidence of the Ieft-sided coIon is. FrankIy, I do not know; I have not been abIe to get any figures. However, in poIIing a number of surgeons and proctoIogists I was amazed to find how few men have seen even one case during many years of practice. In poIIing roentgenoIogists the average man may have seen onIy two or three cases in a Iifetime. As a practica1 point shouId one encounter a Ieftsided coIon during surgery for voIvuIus, it is almost aIways necessary to eviscerate a11 of the mass onto the abdomina1 waI1 so that the point of voIvuIus can bc demonstrated.
American
Journal
of Surgery