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RESECTIONS
mycin intraperitoneally prior to wound clo-
sure. Intraperitoneal or intraluminal neo-
mycin was rarely given. All patients re-
ceived massive wide-spectrum antibiotic
agents postoperatively. Of the 19 patients
who underwent non-planned colon resec-
tion, no preoperative antibiotics were ad-
ministered, and preparation was limited to FLAMMATORY VASCULAR
an enema given 12 hours prior to operation. DISEASE COMPOMISE
Because of differences among the 111 pa- FIG. 3.
tients in primary diseases warranting col-
ectomy, evaluation of the group in a single Of the 31 emergency colectomies, 24
category is impossible. Therefore, patients were right colon. In 20 the indication for
were separated into five categories for operation was acute intestinal obstruction.
analysis: 1) malignant and benign neo- Following right colectomy, intestinal conti-
plasms; 2) inflammatory diseases; 3) vascu- nuity was re-established by end-to-end ileo-
lar occlusions; 4) trauma; and 5) hemor- transverse colostomy. Four right colec-
rhage (Fig. 3). tomies were performed for acute perfora-
tion; one adenocarcinoma of the cecum,
Resection for Malignant and one malignant lymphoma, and 2 carcinoids
Benign Neoplasms of the appendix. All four patients had signs
of peritoneal irritation.
Of 40 patients in this group, 31 had col- Four emergency transverse colectomies
ectomies as emergencies, and nine as non- were performed for perforated carcinomas
planned operations. In 36 cases the neo- of the mid-transverse colon. One 84-year-
plasm was malignant (35 adenocarcinoma old woman had an obstructing carcinoma
and 1 lymphoma), and in four benign (1 of the transverse colon with a competent
cecal lipoma, 1 cecal leiomyoma, and 2 ileocecal valve and cecal gangrene. Right
carcinoids of the appendix). and transverse colectomy were performed
with a smooth postoperative recovery. One
MORTALITY RATE patient underwent a radical right, trans-
EMERGENCY AND NON-PLANNED COLECTOMY verse, and proximal left colectomy for an
III PATIENTS obstructing neoplasm of the splenic flexure.
One patient had left colectomy for adeno-
92 Patients TOTAL MORTALITY carcinoma of the sigmoid.
RATE: 6.3 %
Of nine non-planned colonic resections,
three were transverse colectomies during
gastric resections for gastric cancers which
had invaded the transverse colon. One car-
cinoma of the mid-transverse colon was
19 Patients found incidentally and resected at opera-
tion for cholecystitis. Two left colectomies
7 DEATHS NO DEATHS were performed for carcinomas which had
EM ERGENCY NON-PLANNED been misdiagnosed as left ovarian masses.
FIG. 2. One left colectomy was done for a left
HERRINGTON, LAWLER, THOMAS AND GRAVES Annals of Surgery
712 MIay 1967
upper quadrant carcinoma thought preop- no peritonitis at autopsy. Two elderly pa-
eratively to have been a ruptured spleen. A tients, one having emergency right colec-
sigmoid carcinoma was found incidentally tomy and the other radical right, trans-
in a left inguinal hernial sac in one patient, verse, and proximal left colectomy for ob-
and during resection of an aortic aneurysm structing carcinomas, died of pulmonary
in another. Left colon resections were car- embolism on the sixth and tenth days re-
ried out in both patients (Fig. 4). spectively. There was no peritoneal sepsis
Postoperatively, there were three wound at autopsy. The sixth death followed emer-
infections and one wound disruption. Two gency right colectomy for obstruction in an
wound infections followed resection of the 86-year-old man. He had a fatal coronary
left colon, and one after transverse colec- thrombosis, and autopsy showed the ab-
tomy. There were six postoperative deaths dominal cavity free of sepsis (Fig. 5).
among the 40 patients. The average post-
operative hospital stay among surviving pa- Resections for Inflammatory Disease
tients was 14 days. A 60-year-old man who Of 43 patients, 34 underwent emergency
had undergone right colectomy for a per- colonic resections, and nine non-planned
forated lymphoma of the ascending colon resections. Twenty-seven had right colec-
died of azotemia and cardiopulmonary tomies, and the preoperative diagnoses
complications on the seventh postopera- were in most instances acute appendicitis.
tive day. At necropsy the intestinal suture In several cases the preoperative diagnosis
line was intact, and there was no perito- of small intestinal obstruction or perforated
neal sepsis. A 77-year-old woman, in ex- neoplasm was made. The pathologic diag-
tremis at the time of right colectomy for nosis in the 27 patients was perforated
obstructing carcinoma, died 24 hours post- cecal or ascending colonic diverticula in
operatively. Necropsy showed no anasto- eight, perforated appendices in five, ileo-
motic leak. One elderly patient died in the cecal tuberculosis with perforation in three,
early postoperative period following emer- and granulomatous ileitis with obstruction
gency transverse colectomy, and there was or perforation in 11. The diverticular and
20 Aute OstructioI 4
rfPration FIG. 4.
RIGHT T TRANSVERSE
COLECTOMY (SLpet )
Obstruction
(Suspeted)
ObstructionPrfrto
Volume 165 COLON RESECTION WITH PRIMARY ANASTOMOSIS
Number 5 713
COMPLICATIONS IN
RESECTION FOR NEOPLASM
- 40 PATIENTS -
SUPERFICIAL WOUND
WOUND INFECTION DISRUPTION
75 %
FIG. 5.
NONE
AGE: 60 77 80 60 71 86
15%
4FATAL COMPLICATIONS ( 6 Patients)
appendiceal perforations were either in- for perforated sigmoid diverticulitis with
tense phlegmons about the cecum indistin- localized abscesses. Two had been errone-
guishable from neoplasms, or large blow- ously diagnosed preoperatively as twisted
outs in the cecal wall requiring right col- ovarian cysts. One, at repair of a left scrotal
ectomy. hernia, had acute sigmoid diverticulitis
One patient had an acute abdomen and with abscess in the sliding hernial sac. In
a ruptured diverticulum of the transverse another patient a sigmoid diverticulitis was
colon for which limited mid-transverse co- discovered at time of gastric re-resection
lonic resection was performed. Six patients for marginal ulcer. Two non-planned right
had sigmoid resections for diverticulitis colectomies were performed, one for a non-
with perforation and localized abscesses. specific granulomatous cecal mass encoun-
Four of the six were known to have sigmoid tered at vagotomy-antrectomy. In the other,
diverticula prior to operation. All four had exploration of a small sinus tract of the ab-
recently been at another hospital for pe- dominal wall following appendectomy re-
riods of 48 to 72 hours, and tenderness, vealed extensive ileocolitis requiring right
fever, and abdominal discomfort had in- colon resection. Three transverse colon re-
creased. In the other two preoperative sections were carried out at time of gastric
diagnoses of acute appendicitis were made resections for greater curve ulcers adherent
and acute sigmoid diverticulitis with lo- to the transverse colon (Fig. 6).
calized abscesses without peritonitis were There were four postoperative wound in-
found. fections. Two followed right colonic resec-
Nine of the 43 patients underwent non- tions, one after left colectomy, and one
planned colonic resection. Four were sig- after transverse colonic resection. One small
moid resections with primary anastomosis fecal fistula which subsequently closed re-
714 HERRINGTON, LAWLER, THOMAS AND GRAVES Annals of Surgery
May 1967
Perforated
Diverticulum
r~~~~~~~~~~~
:4r:
DiverticulitiseG
(Perforated with Abscess) (Suspected)
FIG. 6.
sulted from right colectomy for perforated right, transverse, and left colon were per-
appendicitis. There was one hospital death formed. Six of the right colectomies were
(2.3%o mortality), on the fourth postopera- in infants and young children for ileocolic
tive day in a patient who underwent trans- intussusception with gangrene. Two in-
verse colonic resection for a perforated di- stances of cecal volvulus with gangrene,
verticulum. At autopsy it was found that a and one of cecal gangrene in a strangulated
suture line leak caused widespread perito- hernia accounted for three emergency re-
neal sepsis (Fig. 7). sections. Two additional right colectomies
were for a large twisted mesenteric cyst
Resection for Vascular Occlusions which had compromised blood supply to
the ileocecal area in one, and for localized
In this group of 14 patients there were infarction of the terminal ileum and right
13 in whom colonic resection was an emer- colon in another elderly patient. One left
gency, and in one non-planned. Of the colonic resection and anastomosis was per-
13 emergencies, the preoperative diagno- formed for gangrenous volvulus. A final
sis was most often intestinal obstruction. emergency resection was in a 42-year-old
Eleven right colectomies, one left colon re- man who was admitted in peripheral vascu-
section, and one radical resection of the lar collapse with a rigid abdomen. The
Volume 165 COLON RESECTION WITH PRIMARY ANASTOMOSIS 715
Number 5
diagnosis of perforated ulcer was made, of 14 patients. The average postoperative
but at laparotomy there were multiple hospital stay was 11 days (Fig. 8).
areas of focal gangrene involving the right,
transverse, and left colon without occlusion Resection for Trauma
of the blood supply. Radical subtotal col- There were nine patients in this group,
ectomy was carried out, and the patient eight of whom had penetrating abdominal
had a normal recovery. This case has been wounds, and one blunt abdominal trauma.
reported elsewhere.'9 All were operated upon soon after hospital
Only one patient was subjected to non- admission. Five had right colectomies for
planned resection. This was a 38-year-old large blast injuries involving the cecum and
woman with a uterine myoma. She was ascending colon. One severe injury involv-
known to have a redundant sigmoid colon, ing transverse and left colon required ex-
and had episodes suggesting recurrent vol- tensive resection. Two transverse colec-
vulus. While being prepared for hysterec- tomies were necessary for large penetrat-
tomy, she had severe abdominal pain. ing wounds, and one patient required left
Twelve hours later at operation, partial colectomy. One patient operated upon for
volvulus of the sigmoid was encountered. blunt trauma had a large cecal perforation.
The bowel was hyperemic but viable. Hys- Most of the patients also had small bowel
terectomy and left colectomy were per- perforations which required closure or re-
formed. section. Fecal spillage was moderate to se-
There were no significant postoperative vere in several cases. Intraperitoneal anti-
complications and no deaths in this group biotic drugs were used in most instances
COMPLICATIONS IN
RESECTION FOR INFLAMMATORY DISEASE
- 43 PATIENTS -
FIG. 7.
EMERGENCY (13)
RIGHT, TRANSVERSE a
RIGHT COLECTOMY LEFT COLECTOMY LEFT COLECTOMY
2-Cecal Volvulus 1-Mesentiric Cyst,
with Gangrene Gangrene of Cecum
I-Cecal Gangrrnev J Gangrene, Terminal
')_Tleum
(Hernial Sac) a Right Colon I
6- Ileocolic Intussusception Volvulus of Sigmoid Multiple Segmental
with Gangrene with Gangrene I n farctions
FIG. 9.