Colon Resection with Primary Anastomosis Performed

as an Emergency and as a Non-Planned Operation

J. LYNWOOD HERRINGTON, JR., M.D., MARION LAWLER,* M.D.,
THOMAS V. THOMAS,** M.D., HERSCHEL A. GRAVES, JR., M.D.
From the Department of Surgery, Vanderbilt University Medical Center, the
Surgical Services of St. Thomas Hospital and Mid-State Baptist Hospital,
and the Edwards-Eve Clinic, Nashville, Tennessee

THE MAJORITY of patients with lesions of In 1951 Woodhall and Ochsner,47 in

the colon are subjected to elective primary
resection and anastomosis after adequate
bowel preparation consisting of mechanical
cleansing and intestinal antibiotics. Cur-
rently, there is controversy as to the merits
of preoperative enteric antibiotic agents.1
Five to twenty per cent of patients with
colonic lesions have complications of ob-
struction, perforation, acute inflammation,
hemorrhage or vascular compromise in
whom little or no time is available for pre-
operative preparation. In addition a small
number of asymptomatic colonic lesions are
discovered at laparotomy for unrelated dis-
ease and bowel preparation has been in-
adequate.
Until recently emergency operations per-
formed for complications of colonic lesions
and operations for colonic disease found
incidentally at laparotomy consisted of
staged procedures with proximal colos-
tomy, side tracking operations, or exteriori-
zation as the initial stage. Surgeons were
reluctant to perform primary resection with
anastomosis on unprepared bowel for fear
of sepsis and suture line leaks.
Presented at the Annual Meeting of the South-
ern Surgical Association, December 6-8, 1966,
Boca Raton, Florida.
* Assistant Resident Surgeon, Vanderbilt Uni-
versity Hospital.
* Former Surgical Resident, St. Thomas Hos-
pital, at present Fellow, Cardiovascular Surgery,
University of Louisville Medical School.
709
evaluating management of perforating in-
juries to the colon, demonstrated the feasi-
bility of primary resection and anastomosis
in specific circumstances. Since their report
and particularly during the past 10 years
with the advent or refined surgical tech-
nics, excellent anesthesia, antibiotics, blood
replacement, and improved postoperative
care, methods of surgical management of
acute colonic emergencies have been re-
evaluated.'3, 21, 35, 37, 46
Patterson32 in 1955 showed the desira-
bility of right colectomy in cecal cancer
discovered unexpectedly at operation for
acute appendicitis. Gregg 15 challenged the
wisdom of staged operations in all early
obstructive and perforated lesions of the
colon. He also suggested re-evaluation of
surgical principles, in that there was a
better chance for recovery if the source of
contamination were eliminated. Crile and
others 8, 24 stressed the dangers of conserva-
tive operations in abdominal emergencies.
Donaldson 9 in a study of perforated carci-
noma of the colon at the Massachusetts
General Hospital over 20 years found the
highest mortality in patients receiving the
operation of lesser magnitude. Madden 26 27
recently demonstrated the superiority of
primary resection to staged procedures.
Other surgeons 2, 3, 11, 12, 14, 18, 23, 33, 36, 38, 39, 40,
41, 45 have also shown the advantages of
primary resection as opposed to multiple
710 HERRINGTON, LAWLE]R,
operations in certain colonic emergencies.
Donavan and Berne'0 reported 20 selected
cases of emergency resection of the right
colon. Thirteen of the 20 patients had ob-
structing carcinomas, and four died. Post-
operative intraperitoneal sepsis was not en-
countered in this group, death was due to
vascular or pulmonary complications. None
of seven patients undergoing emergency
resection for inflammatory disease died. In
comparison 50 patients underwent elective
right colectomy during the same time in-
terval, and eight deaths (16%o) resulted.
Currently indications for emergency and
non-planned resection of the right colon
and proximal transverse colon are more
liberal than are those for the left colon.
There is increasing evidence, however, to
show that emergency and non-planned left
colectomy with primary anastomosis is
justifiable in selected cases.4-7 15 27,42
In a review of more than 700 cases of
large bowel carcinoma at Vanderbilt Uni-
versity Medical Center from 1925 through
1960, McSwain25 found emergency opera-
tion was necessary in 70 (10%o). These pro-
cedures were for the most part of lesser
magnitude and were not directed toward
removal of the disease and there was an
8% mortality. Twelve patients of the 70
had primary resection and anastomosis (10
COLON RESECTIONS
January, 1955 through December, .1965
TOTAL: 1257
11 i (10%) EMERGENCY a
NON-PLANNED RESECTIONS
56 Males -55 Females
471
Average Age:44 Years
268
44
VANDERBILT ST. THOMAS
HOSPITAL
FM.- 1.
THOMAS AND GRAVES Annals ofMaySurgery
1967
right colectomies, 2 left colectomies) with
no deaths and no significant complications.
Experience
During the past 11 years, January 1955
through December 1965, a total of 1,257
patients in three Nashville hospitals (Van-
derbilt University, St. Thomas, and Mid-
State Baptist) were subjected to resection
of the colon. Patients with rectal and anal
lesions were not considered. In 111 (10%)
of the 1,257, resection of the colon with pri-
mary anastomosis was carried out either as
an emergency or as a non-planned opera-
tion (Fig. 1). Only a small number of the
111 resections were performed during the
late 1950's; the majority were performed
between 1960 and 1965. Primary indications
for operation were complications of ma-
lignant and benign tumors, and acute in-
flammatory disease. Secondary indications
were external trauma, vascular occlusions,
and massive hemorrhage.
Ninety-two of the 111 patients under-
went colon resection within one to 24 hours
following hospital admission. Nineteen pa-
tients were subjected to non-planned colon
resections when primary colonic disease or
secondary colonic involvement was found
unexpectedly at laparotomy. There were
seven hospital deaths (6.3%o mortality) all
of which occurred in patients subjected to
emergency resection of the colon. There
was no mortality among 19 patients under-
going non-planned colectomy (Fig. 2).
S18
There were 12 non-fatal significant post-
operative complications, the majority of
which were related to wounds, and eight
of the 12 complications occurred in resec-
tions of the colon carried out as an emer-
gency procedure.
Of 92 patients who had emergency col-
423
ectomy, electrolyte replacement, plasma,
BAPTIST
Dextran, or blood were given in sufficient
quantities for replacement prior to opera-
tion. Only a few patients received anti-
biotic drugs preoperatively, and rarely anti-
Volume 165 COLON RESECTION WITH PRIMARY ANASTOMOSIS
Number 5
biotic agents were given intravenously
during operation. Approximately one-third
of the patients received penicillin-strepto-
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
an enema given 12 hours prior to operation.
Because of differences among the 111 pa-
tients in primary diseases warranting col-
ectomy, evaluation of the group in a single
category is impossible. Therefore, patients
were separated into five categories for
analysis: 1) malignant and benign neo-
plasms; 2) inflammatory diseases; 3) vascu-
lar occlusions; 4) trauma; and 5) hemor-
rhage (Fig. 3).
Resection for Malignant and
Benign Neoplasms
Of 40 patients in this group, 31 had col-
ectomies as emergencies, and nine as non-
planned operations. In 36 cases the neo-
plasm was malignant (35 adenocarcinoma
and 1 lymphoma), and in four benign (1
cecal lipoma, 1 cecal leiomyoma, and 2
carcinoids of the appendix).
MORTALITY RATE
EMERGENCY AND NON-PLANNED COLECTOMY
III PATIENTS
92 Patients TOTAL MORTALITY
RATE: 6.3 %
19 Patients
7 DEATHS NO DEATHS
EM ERGENCY NON-PLANNED
FIG. 2.
711
INDICATIONS
- III PATIENTS
EMERGENCY a NON-PLANNED
RESECTIONS
FLAMMATORY VASCULAR
DISEASE COMPOMISE
FIG. 3.
Of the 31 emergency colectomies, 24
were right colon. In 20 the indication for
operation was acute intestinal obstruction.
Following right colectomy, intestinal conti-
nuity was re-established by end-to-end ileo-
transverse colostomy. Four right colec-
tomies were performed for acute perfora-
tion; one adenocarcinoma of the cecum,
one malignant lymphoma, and 2 carcinoids
of the appendix. All four patients had signs
of peritoneal irritation.
Four emergency transverse colectomies
were performed for perforated carcinomas
of the mid-transverse colon. One 84-year-
old woman had an obstructing carcinoma
of the transverse colon with a competent
ileocecal valve and cecal gangrene. Right
and transverse colectomy were performed
with a smooth postoperative recovery. One
patient underwent a radical right, trans-
verse, and proximal left colectomy for an
obstructing neoplasm of the splenic flexure.
One patient had left colectomy for adeno-
carcinoma of the sigmoid.
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
found incidentally and resected at opera-
tion for cholecystitis. Two left colectomies
were performed for carcinomas which had
been misdiagnosed as left ovarian masses.
One left colectomy was done for a left
 HERRINGTON, LAWLER, THOMAS AND GRAVES
712
upper quadrant carcinoma thought preop-
eratively to have been a ruptured spleen. A
sigmoid carcinoma was found incidentally
in a left inguinal hernial sac in one patient,
and during resection of an aortic aneurysm
in another. Left colon resections were car-
ried out in both patients (Fig. 4).
Postoperatively, there were three wound
infections and one wound disruption. Two
wound infections followed resection of the
left colon, and one after transverse colec-
tomy. There were six postoperative deaths
among the 40 patients. The average post-
operative hospital stay among surviving pa-
tients was 14 days. A 60-year-old man who
had undergone right colectomy for a per-
forated lymphoma of the ascending colon
died of azotemia and cardiopulmonary
complications on the seventh postopera-
tive day. At necropsy the intestinal suture
line was intact, and there was no perito-
neal sepsis. A 77-year-old woman, in ex-
tremis at the time of right colectomy for
obstructing carcinoma, died 24 hours post-
operatively. Necropsy showed no anasto-
motic leak. One elderly patient died in the
early postoperative period following emer-
gency transverse colectomy, and there was
RESECTION FOR NEOPLASM
- 40 PATI E NTS -
AGES l7-84 YEARS (AVERAGE AGE:'58 YEARS)
EMERGENCY (31)
RIGHT COLECTOMY TRANSVERSE COLECT6MY
20 Aute OstructioI 4
rfPration
RIGHT T TRANSVERSE
COLECTOMY
Obstruction
RIGHT, TRANSVERSE LEFT
PROXIMAL LEFT'COLECTOMY COLECTOMAY
(D
ObstructionPrfrto
Annals of Surgery
MIay 1967
no peritonitis at autopsy. Two elderly pa-
tients, one having emergency right colec-
tomy and the other radical right, trans-
verse, and proximal left colectomy for ob-
structing carcinomas, died of pulmonary
embolism on the sixth and tenth days re-
spectively. There was no peritoneal sepsis
at autopsy. The sixth death followed emer-
gency right colectomy for obstruction in an
86-year-old man. He had a fatal coronary
thrombosis, and autopsy showed the ab-
dominal cavity free of sepsis (Fig. 5).
Resections for Inflammatory Disease
Of 43 patients, 34 underwent emergency
colonic resections, and nine non-planned
resections. Twenty-seven had right colec-
tomies, and the preoperative diagnoses
were in most instances acute appendicitis.
In several cases the preoperative diagnosis
of small intestinal obstruction or perforated
neoplasm was made. The pathologic diag-
nosis in the 27 patients was perforated
cecal or ascending colonic diverticula in
eight, perforated appendices in five, ileo-
cecal tuberculosis with perforation in three,
and granulomatous ileitis with obstruction
or perforation in 11. The diverticular and
NON-PLANNED (9) -
TRANSVERSE COLECTOM LEFT COLECTOMY
FIG. 4.
(SLpet )
(Suspeted)
Volume 165 COLON RESECTION WITH PRIMARY ANASTOMOSIS
Number 5 713
COMPLICATIONS IN
RESECTION FOR NEOPLASM
- 40 PATIENTS -

10% | NON-FATAL COMPLICATIONS (4 Patients)

SUPERFICIAL WOUND
WOUND INFECTION DISRUPTION
75 %
FIG. 5.
NONE

AZOTEMIA, VASCULAR PULMONARY PULMONARY CORONARY

CARDIAC DIS. COLLAPSE CARDIAC DIS. EMBOLUS THROMBUS

AGE: 60 77 80 60 71 86
15%
4FATAL COMPLICATIONS ( 6 Patients)

appendiceal perforations were either in-
tense phlegmons about the cecum indistin-
guishable from neoplasms, or large blow-
outs in the cecal wall requiring right col-
ectomy.
One patient had an acute abdomen and
a ruptured diverticulum of the transverse
colon for which limited mid-transverse co-
lonic resection was performed. Six patients
had sigmoid resections for diverticulitis
with perforation and localized abscesses.
Four of the six were known to have sigmoid
diverticula prior to operation. All four had
recently been at another hospital for pe-
riods of 48 to 72 hours, and tenderness,
fever, and abdominal discomfort had in-
creased. In the other two preoperative
diagnoses of acute appendicitis were made
and acute sigmoid diverticulitis with lo-
calized abscesses without peritonitis were
found.
Nine of the 43 patients underwent non-
planned colonic resection. Four were sig-
moid resections with primary anastomosis
for perforated sigmoid diverticulitis with
localized abscesses. Two had been errone-
ously diagnosed preoperatively as twisted
ovarian cysts. One, at repair of a left scrotal
hernia, had acute sigmoid diverticulitis
with abscess in the sliding hernial sac. In
another patient a sigmoid diverticulitis was
discovered at time of gastric re-resection
for marginal ulcer. Two non-planned right
colectomies were performed, one for a non-
specific granulomatous cecal mass encoun-
tered at vagotomy-antrectomy. In the other,
exploration of a small sinus tract of the ab-
dominal wall following appendectomy re-
vealed extensive ileocolitis requiring right
colon resection. Three transverse colon re-
sections were carried out at time of gastric
resections for greater curve ulcers adherent
to the transverse colon (Fig. 6).
There were four postoperative wound in-
fections. Two followed right colonic resec-
tions, one after left colectomy, and one
after transverse colonic resection. One small
fecal fistula which subsequently closed re-
714 HERRINGTON, LAWLER, THOMAS AND GRAVES
RESECTION FOR INFLAMMATORY DISEASE-
- 43
AGES 18-76 YEARS
EMERGENCY (34)
RIGHT COLECTOMY
8 - Perforoted Diverticulum
5 - Perforated Appendix
7 3- Perforated Ileocecal Tbc
11 - Perforated or Obstructed
Granulomatous Ileitis
TRANSVERSE COLECTOMY SIGMOID COLECTOMY
Perforated
Diverticulum
r~~~~~~~~~~~
:4r:
DiverticulitiseG
(Perforated with Abscess)
FIG. 6.
sulted from right colectomy for perforated
appendicitis. There was one hospital death
(2.3%o mortality), on the fourth postopera-
tive day in a patient who underwent trans-
verse colonic resection for a perforated di-
verticulum. At autopsy it was found that a
suture line leak caused widespread perito-
neal sepsis (Fig. 7).
Resection for Vascular Occlusions
In this group of 14 patients there were
13 in whom colonic resection was an emer-
gency, and in one non-planned. Of the
13 emergencies, the preoperative diagno-
sis was most often intestinal obstruction.
Eleven right colectomies, one left colon re-
section, and one radical resection of the
Annals of Surgery
May 1967
PATI E NTS -
(AVERAGE AGE: 50 YEARS)
NON-PLANNED (9)
RIGHT COLECTOMY
2 - Granulomatous Ileocolitis
/ v
I
o oA
TRANSVERSE COLECTOMY SIGMOID COLECTO.MY
(Suspected)
right, transverse, and left colon were per-
formed. Six of the right colectomies were
in infants and young children for ileocolic
intussusception with gangrene. Two in-
stances of cecal volvulus with gangrene,
and one of cecal gangrene in a strangulated
hernia accounted for three emergency re-
sections. Two additional right colectomies
were for a large twisted mesenteric cyst
which had compromised blood supply to
the ileocecal area in one, and for localized
infarction of the terminal ileum and right
colon in another elderly patient. One left
colonic resection and anastomosis was per-
formed for gangrenous volvulus. A final
emergency resection was in a 42-year-old
man who was admitted in peripheral vascu-
lar collapse with a rigid abdomen. The
Volume 165 COLON RESECTION WITH PRIMARY ANASTOMOSIS
Number 5
diagnosis of perforated ulcer was made,
but at laparotomy there were multiple
areas of focal gangrene involving the right,
transverse, and left colon without occlusion
of the blood supply. Radical subtotal col-
ectomy was carried out, and the patient
had a normal recovery. This case has been
reported elsewhere.'9
Only one patient was subjected to non-
planned resection. This was a 38-year-old
woman with a uterine myoma. She was
known to have a redundant sigmoid colon,
and had episodes suggesting recurrent vol-
vulus. While being prepared for hysterec-
tomy, she had severe abdominal pain.
Twelve hours later at operation, partial
volvulus of the sigmoid was encountered.
The bowel was hyperemic but viable. Hys-
terectomy and left colectomy were per-
formed.
There were no significant postoperative
complications and no deaths in this group
715
of 14 patients. The average postoperative
hospital stay was 11 days (Fig. 8).
Resection for Trauma
There were nine patients in this group,
eight of whom had penetrating abdominal
wounds, and one blunt abdominal trauma.
All were operated upon soon after hospital
admission. Five had right colectomies for
large blast injuries involving the cecum and
ascending colon. One severe injury involv-
ing transverse and left colon required ex-
tensive resection. Two transverse colec-
tomies were necessary for large penetrat-
ing wounds, and one patient required left
colectomy. One patient operated upon for
blunt trauma had a large cecal perforation.
Most of the patients also had small bowel
perforations which required closure or re-
section. Fecal spillage was moderate to se-
vere in several cases. Intraperitoneal anti-
biotic drugs were used in most instances

COMPLICATIONS IN
RESECTION FOR INFLAMMATORY DISEASE
- 43 PATIENTS -

NON-FATAL COMPLICATIONS ( 5 Patients )

WOUND INFECTION FECAL FISTULA

FIG. 7.

= FFATAL COMPLICATION (I Patient) ANASTOMOTIC

2.3% LEAK
716 HERRINGTON, LAWLER, THOMAS AND GRAVES Annals of Surgery
May 1967

*RESECTION FOR VASCULAR COMPROMISE

- 14 PATIENTS -

AGES 10 Months-86 Years (Average Age: 33 Years)

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

NON-PLANNED (1) NO DEATHS

LEFT COLECTOMY
Recurrent
Volvulus of
Sigmold
FIG. 8.
following peritoneal saline irrigations. In
the four patients undergoing transverse and
left colon resection, cecostomy for decom-
pression was performed in two.
One superficial wound infection occurred,
and one patient developed renal failure
which responded to treatment. One patient
with a blast injury of the right colon along
with osseous and soft tissue injuries de-
veloped a fecal fistula which subsequently
required re-resection of the ileum and
transverse colon. There were no postopera-
tive deaths. The average postoperative hos-
pital stay was 14 days except for the pa-
tient with the fecal fistula who Nvas hos-
pitalized 180 days (Fig. 9).
Resection for Hemorrhage
Five patients underwent emergency re-
section for massive rectal bleeding. Multi-
ple diverticula of the right colon with
NO SIGNIFICANT
COMPLICATIONS
hemorrhage required right colectomy to
prevent exsanguination in one patient. An-
other patient bled profusely from a large
varix of the cecal wall, and right colectomy
was performed in this case. Three patients
bled massively from sigmoid diverticulosis
and received from 12 to 17 units of blood
preoperatively; left colectomies were per-
formed. In two patients sigmoid diverticula
were known to exist preoperatively. No sig-
nificant complications and no deaths oc-
curred in this group (Fig. 10).
Discussion
The objections to colon resection with
primary anastomosis performed as an emer-
gency, or on a patient for whom colectomy
was not planned, have been fear of peri-
toneal sepsis from suture line leaks and
faulty healing of the anastomosis. For these
reasons staged operations were advocated
Volume 16S
Number S
COLON RESECTION WITH PRIMARY ANASTOMOSIS
RESECTIO-N FOR TRAUMA
- 9 PATIENTS -
AVERAGE AGE: 25 Years
RIGHT COLECTOMY TRANSVERSE COLECTOMY
Infection Shutdown
NON-FATAL COMPLICATIONS (3)
until recent years. Recent evidence shows
that in selected cases emergency colonic
resection with anastomosis can be per-
formed with low operative mortality and
in certain instances is the procedure of
choice.
There is agreement that indications for
emergency and non-planned resection of
the right and proximal transverse colon are
more liberal than those for resection of the
left colon. For perforated lesions of the
right colon right hemicolectomy and ileo-
transverse colostomy are now accepted.
Experiences in World War II and the Ko-
rean conflict demonstrated poor results fol-
lowing exteriorization of perforated right
colon because of loss of intestinal fluids.
Recent experiences also show that obstruc-
tive lesions of the proximal transverse and
right colon may be treated by primary re-
section and anastomosis in selected cases.
When there is a competent ileocecal valve
with right colonic obstruction, terminal
small bowel and colon distal to the ob-
structive site are usually normal and suit-
able for primary anastomosis. With right
717
TRANSVERSE a
LEFT COLECTOMY
FIG. 9.
Fistula
colonic obstruction and an incompetent
ileocecal valve, dilated terminal small
bowel can be adequately decompressed in
most instances. Following decompression
the bowel usually regains tone and may be
utilized for ileocolonic anastomosis. In right
colonic obstruction of long standing with
an incompetent ileocecal valve and massive
small bowel distention in the poor risk pa-
tient, emergency ileotransverse colostomy
with cecostomy is the procedure of choice.
The current low mortality following right
colectomy for perforation and for selected
cases of obstruction is undoubtedly due to
rapid preoperative correction of hypovo-
lemia, improved anesthesia, skillful tech-
nics, and intensive postoperative antibiotic
therapy.
Some surgeons are reluctant to perform
emergency and non-planned left colonic re-
sections with primary anastomosis under
any circumstances. Others are less re-
stricted. In perforated lesions of the left
colon recent emphasis has been directed
toward removal of the source of contami-
nation. Concomitantly there has been a
 HERRINGTON, LAWLER, THOMAS AND GRAVES
718
RESECTION FOR HEMORRHAGE
- 5 PATIENTS -
AGES 36-88 Years ( Average Age 66 Years )
RIGHT COLECTOMY LEFT COLECTTOMY
3
I - OtVERTICULA 3 -DIVERTICULOSIS
I - VARIX OF CECUM
NO DEATHS
NO SIGNIFICANT COMPLICATIONS
FIG. 10.
trend away from three-stage operations,
because of inadequacies and high mor-
tality. According to Byrne8 the requisites
for emergency and non-planned left colec-
tomy with primary anastomosis are a rela-
tively empty colon, absence of gross fecal
spillage, and absence of peritonitis in a
patient of good risk. Madden's indications
are more liberal, and he has performed
emergency left colectomy for perforated
lesions with diffusing peritonitis, with good
results. Another accepted method for per-
forated left colonic lesions with generalized
peritonitis is primary resection with proxi-
mal colostomy and closure of the rectal
stump (Hartmann procedure). Exterioriza-
tion may be an alternative, particularly in
the poor risk patient, but this procedure is
inadequate if the perforated lesion should
be malignant. Proximal colostomy with
drainage is usually restricted to long stand-
ing perforations with chronic abscesses and
fistulae.
Madden28 cited a 7% mortality among
27 patients subjected to left colectomy and
primary anastomosis for perforated carci-
noma or diverticulitis. In contrast there was
a 35% mortality in a comparable group of
20 patients undergoing staged operations.
Madden collected 110 patients subjected to
Annals of Surgery
May 1967
emergency left colectomy with a mortality
of 9.1%. In contrast there was a mortality
of 46.3% in 287 patients undergoing staged
operations. Thus, there was a five-fold in-
crease in mortality with conservative or
staged planned procedures. Snyder40 like-
wise perforned left colectomy for perfora-
tion as an emergency procedure with good
results. Gregg'5 cited 16 cases of perfora-
tion and early obstruction treated by emer-
gency colectomy with no deaths. There
were 25 staged operations with 6 deaths.
Gregg 17 in a personal communication re-
ports 25 emergency colonic resections per-
formed for perforation, obstruction, or ab-
scess formation with one death. Thirteen
of the resections were for diverticulitis, ten
of which were perforated; two had ab-
scesses, and one had early obstruction.
Twelve resections were for complications
of carcinoma, eight for acute obstruction,
and four for perforation. Most obstructions
were in the proximal two-thirds of the
colon, and only one in the sigmoid colon.
Of the four cases of perforation, two were
in the right colon, and two in the left colon.
In 10 of the 25 resections a complementary
transverse colostomy was performed. One
fatality was due to an anastomotic leak,
and in this case no proximal diverting col-
ostomy was performed.
Gregg believes that early colonic perfora-
tion resulting either from carcinoma or di-
verticulitis is best treated by resection with
primary anastomosis, and a complementary
transverse colostomy when left colectomy
is performed. Gross fecal spillage or puru-
lent peritonitis from left colon perforation
is a contraindication to primary anastomo-
sis, and in such circumstances resection and
proximal colostomy may be used. For acute
obstructions of the right, transverse, and
for selected cases of the proximal left colon,
Gregg advocates resection with primary
anastomosis. In 111 patients here reported
there was an operative mortality rate of
6.3%. All deaths followed 92 emergency
operations; no deaths followed 19 non-
Volume 165 COLON RESECTION WITH PRIMARY ANASTOMOSIS
Number
planned colectomies. The mortality rate
compares with that following planned
colon resection reported by others.16 20 22 43
Anastomotic leak with peritoneal sepsis
was the cause of death in only one of the
seven patients who died. The remaining
six deaths were in patients in the 6th, 7th,
and 8th decades who had cardiopulmonary
or renal complications. There were no anas-
tomotic leaks found at autopsy. Two addi-
tional patients developed anastomotic leaks
with fistula formation. One fistula subse-
quently closed spontaneously, and the other
required operation. Six of the seven pa-
tients who died had either perforated or
obstructing malignant neoplasms.
There were 22 patients (20%) who un-
derwent left colon resection with no mor-
tality (Fig. 11). Among these patients,
complementary cecostomy or transverse
colostomy was frequently employed. The
significant non-fatal complications were ap-
proximately equal among right and left co-
lonic resections (Fig. 12).
Summary
During a recent 11-year-period, 1,257 co-
lonic resections were carried out in three
Nashville hospitals. One hundred-eleven of
the 1,257 resections were performed as
SUMMARY OF LOCATION
- 'II PATIENTS -
RIlG HT RIGHT a
TRANSVERSE TANSVERE
64%
I Patient 14 PatienXt
71 PatIents
RIGHT, TRANSVERSE TRANSVERSE LE FT
a LEFT a LEFT
2 Patients I Patient 22 Patients
FIG. 11.
719
SUMMARY OF COMPLICATIONS
III PATIENTS -
5
4 4
3
2
0 0
FATAL NON-FTAL FATAL NO-FATAL FATAL MON-FATAL
OWN-FATAL FATAL
RIGHT TRANSVERSE COMPLETE(Near) LEFT
COLON LOCATION
FIG. 12.
emergency or non-planned operations for
perforations and obstructions due to benign
and malignant neoplasms, inflammatory
disease, vascular impairment, trauma, and
hemorrhage. There were seven deaths
(6.3%) among the 111 cases. One of the
seven deaths was associated with an anas-
tomotic leak found at necropsy. This mor-
tality rate compares with the reported mor-
tality rates following planned colon resec-
tion.
This study is in agreement with those
who believe that perforated lesions and
certain obstructing lesions of the right
colon may be treated by resection with pri-
mary anastomosis with low operative mor-
tality.
Indications for emergency and non-
planned left colectomy with primary anas-
tomosis are more strict, but in selected
cases the operation may be performed with
safety.
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