Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (48 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
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David E. Beck
Emergency conditions of the large bowel are common and changes in their evaluation and management have continued. Rather than rushing the patient to the operating room after a token resuscitation, current standards suggest that an initial appropriate period of resuscitation along with physiological and radiological evaluation should be undertaken. Many patients with colonic conditions can be managed non-operatively with bowel rest, antibiotics and blood components. Comorbid disease such as cardiac, pulmonary and metabolic conditions are optimised and critically ill patients are monitored in an intensive care setting. If adequate facilities and personnel are not readily available, transfer to a tertiary care facility should be considered if the patient can be readily stabilised.
The operative mortality for emergency colon resections is two to three times that associated with elective resection. As a result, surgeons have investigated ways of stabilising patients in order to convert emergency into more planned, elective procedures. Deciding if and when to operate can be difficult, and active observation and consultation with colleagues is often helpful in the decision-making process. Active participation of the attending/consultant surgeon in both the assessment and operative procedure is essential in this group of very challenging patients.
When emergency surgery is necessary, there has been a clear trend towards single rather than staged procedures for large-bowel disorders. When feasible, this approach reduces the length of hospital stay and avoids the risks of multiple operations. However, in some unfit or acutely septic patients, a staged approach may still be preferable.
Patients should be adequately informed of their likely diagnosis and management options. Alternatives and risks as well as the potential need for a stoma should be explained carefully. Patients requiring emergency large-bowel surgery should be marked for potential stoma sites and if possible participation of a stoma therapist arranged.
The risk of postoperative deep vein thrombosis and pulmonary embolus is substantial in this group of patients, and prophylactic measures are essential. Options include intermittent pneumatic calf compression and subcutaneous low-molecular-weight heparin. Prophylactic antibiotic therapy is standard, with broad-spectrum single-dose therapy as effective as multiple-dose regimens. The duration of prophylactic antibiotics should be less than 24 hours. If significant infection or contamination is found intraoperatively, empirical therapeutic antibiotics may be indicated.
Colonic emergencies can be divided into ischaemia, obstruction, perforation and bleeding. These categories will be discussed in turn, with attention to their pathophysiology, evaluation and management.
Although the colon has a generous overlapping blood supply, any interruption in blood flow produces ischaemia. Anatomical locations that have the potential to be vulnerable to ischaemic disease include: Griffith's point at the splenic flexure (junction of the superior mesenteric artery (SMA) and the inferior mesenteric artery (IMA)); Sudeck's critical point at the mid-sigmoid colon (junction of the IMA and hypogastric vasculature); and the caecum (distal distribution of the SMA).
As outlined in
Box 10.1
, colonic ischaemia can result from a number of conditions.
Box 10.1
Classification of ischaemic colitis
Interruption of flow in large vessels
Following ligation during aortic surgery
Injury secondary to angiographic, blunt or penetrating trauma
Spontaneous thrombosis of large vessels
Intrinsic small-vessel disease
Low-flow state in the critically ill
Spontaneous ischaemic colitis without demonstrable vessel occlusion
Self-limiting without sequelae
With subsequent stricture formation
Miscellaneous
Secondary to luminal obstruction
Young adults
Renal allograft recipients
Interruption of flow in large vessels following aortic surgery varies from 1–2% for elective cases to as high as 60% during emergency aneurysm repair.
1
Sudden occlusion of the IMA can also occur as a result of angiographic trauma with subintimal dissection or as a result of either blunt or penetrating abdominal trauma. Atheromatous narrowing or occlusion of the IMA is not unusual. However, in most cases this occurs gradually, and the collateral circulation from the SMA can compensate for the decrease in flow through collateral circulation via the marginal artery. If the IMA becomes acutely thrombosed or occluded with an embolus and the collateral circulation is inadequate, the clinical picture will be similar to that found after IMA ligation during aortic surgery.
Any of the connective tissue diseases that produce inflammation in the small-intestinal arteries (intrinsic small-vessel disease) can also result in colonic ischaemia.
2
Another variant of ischaemic colitis occurs in patients who are severely ill with conditions that cause hypotension, decreased cardiac output or peripheral vasoconstriction, with a decreased flow to the end organ (low-flow states). This group of patients appears to have a higher incidence of full-thickness necrosis and right-sided involvement than do those with spontaneous ischaemic colitis who were previously well. The mortality associated with colonic infarction in these patients who are severely ill from another disease process is extremely high. In one report of 17 such patients the mortality rate was 57%.
3
One must therefore have a very high index of suspicion for full-thickness necrosis in this group of patients and be ready to intervene early.
Spontaneous ischaemic colitis may occur without any demonstrable vessel occlusion on angiography.
4
The pathological changes seen in the colon are identical to those caused by vessel occlusion and resulting decreased in blood flow to the colon. The spectrum of disease varies from mild submucosal oedema to frank full-thickness necrosis. Most cases are the milder self-limiting variety that are typically seen in middle-aged or elderly patients, often following episodes of dehydration. In younger patients, who are mostly women, there has been an association between ischaemic colitis and the use of oral contraceptive drugs.
5
Colonic ischaemia usually presents in one of two ways. The milder cases are manifest by diffuse and/or bloody diarrhoea. Patients with frank colonic infarction frequently develop acidosis, glucose intolerance, renal failure, obvious sepsis, and abdominal distension or tenderness. The diagnosis of postoperative ischaemia can be made with flexible sigmoidoscopy performed at the bedside. If the symptoms are not explained by flexible sigmoidoscopy, a colonoscopy may occasionally be required to rule out more proximal disease. The endoscopic appearance of colonic ischaemia may range from submucosal oedema with haemorrhage and ulceration to the dusky blue mucosal colour of infarction. Frank gangrene mandates immediate surgery and resection; however, the colon with just mucosal oedema and haemorrhage may be watched closely.
The diagnosis can be made with endoscopy, barium enema or computed tomography (CT). Endoscopy can be performed in the office or at the bedside and the pathological state can be viewed directly (
Fig. 10.1
). CT is rapidly becoming more common and ischaemia presents as thickened bowel wall (
Fig. 10.2
).
Figure 10.1
Endoscopic view of colonic ischaemia.
Figure 10.2
CT scan of colonic ischaemia.
There are three possible outcomes of ischaemic colitis:
Resolution of the process is the most common clinical course.
Progression to full-thickness necrosis is unusual, especially if there is no evidence of gangrenous bowel at the first examination.
The condition may evolve to an ulcerative stage, which may eventually result in stricture formation. During the ulcerative stage the endoscopic and radiographic findings may mimic Crohn's disease. Occasionally the early phases of this disease will go unnoticed or undiagnosed, and the patient will present with a stricture.
Ischaemic colitis may also be associated with a complete or partial bowel obstruction. In one reported series,
6
10% of patients with colonic ischaemia had an associated carcinoma and another 10% had some other condition that potentially interfered with colonic motility. When ischaemic colitis occurs in association with tumour, the ischaemic area is usually proximal to the tumour and may or may not be associated with obstruction. The investigators in this study and others speculated that colonic blood flow could be decreased as a consequence of increased intraluminal pressure, hyperperistalsis with increased muscular spasm, and resultant diminution of blood flow in the colonic wall, or a decrease in aortic blood pressure and vena caval return with straining in obstructive lesions.
7
Knowledge of this association is of obvious importance to avoid using ischaemic bowel for an anastomosis.
If the diagnosis of ischaemic colitis is made early, non-operative treatment is warranted in the first instance. Mild cases can be managed on an outpatient basis with a clear liquid diet, close observation and possibly antibiotic therapy. More serious cases require hospitalisation, bowel rest, nasogastric suction (if there are any signs of ileus), and optimisation of blood flow to the mucosa (intravenous hydration and optimisation of cardiac output). If the patient is receiving digitalis, a serum level should be checked because toxic digitalis levels can have a marked vasoconstrictive effect on visceral circulation. Parenteral antibiotics (such as a second- or third-generation cephalosporin) are used by some surgeons because of the suggestion that colonic ischaemia may allow colonic bacterial transmigration, although there are no strong data to support or refute their use. Patients with ischaemia resulting from arteritides may respond to corticosteroid treatment.
Specific indications for surgery include peritonitis, perforation, sepsis and failure of non-operative therapy. At operation a wide resection of non-viable colon is performed. Primary anastomosis is usually unsafe because of the potential for postoperative progression of the ischaemia. A double-barrel stoma or end stoma and separate mucous fistula is safer and allows assessment of the bowel viability in the postoperative period. The mortality rate for ischaemic colitis among renal transplant patients is 70%.
2
Diagnostic manoeuvres should therefore be initiated at the first suspicion of ischaemia in these high-risk patients, and surgery should be aggressive once the diagnosis is made (resection of any compromised bowel with an end stoma). Primary anastomosis after resection is ill advised in these patients.
Colonic volvulus
Volvulus can be defined as a twisting or torsion of bowel around its mesentery and occurs most commonly in the sigmoid colon (76%), but also in the caecum (22%) and the transverse colon (2%).
8
One report suggested that 40–60% of patients have had previous episodes of obstruction.
9
In the USA, volvulus represents a rare cause of intestinal obstruction, encompassing less than 5% of large-bowel obstructions. However, worldwide it may represent more than 50% of the cases in some countries.
10
The sigmoid colon rotates through 180–720° in either a clockwise or anticlockwise direction to produce the volvulus.
11
A narrowed sigmoid mesocolon provides a pedicle for rotation. The condition is occasionally associated with Chagas' disease and Hirschsprung's disease, in which redundancy of the colon is a feature, in addition to non-specific motility disorders of the colon.
12
A typical patient with a sigmoid volvulus presents with abdominal pain, constipation and feeling bloated. On examination there is marked distension, which is often asymmetrical. Severe pain and tenderness, associated with tachycardia and hypotension, may suggest colonic ischaemia. Patients who develop sigmoid volvulus in the industrialised world tend to be older, and one-third either have mental illness or are institutionalised.
12
Findings on the plain abdominal radiograph are often characteristic. Massive distension of the sigmoid colon is visible; the bowel loses its haustration and extends in an inverted U from the pelvis to the right upper quadrant of the abdomen (
Fig. 10.3
). Fluid levels are seen in both limbs of the loop on the erect film, commonly at different levels (‘pair of scales’). In one-third of patients, the appearances are atypical and a water-soluble contrast enema should be carried out. This may demonstrate narrowing of the contrast column at the point of twisting, which has been described as resembling the beak of a bird of prey.
Figure 10.3
Radiograph of the abdomen demonstrates the characteristic massive dilation of the sigmoid colon arising from the pelvis and extending to the right diaphragm. The arrow points to three lines representing the twisted walls of the sigmoid colon, which converge in the left lower quadrant.
Volvulus patients often present with significant fluid and electrolyte abnormalities, which require careful correction.
Untwisting and decompression
are the initial treatments of choice as long as the patient lacks clinical features suggestive of colonic strangulation. Untwisting has been described using several techniques, including rigid or flexible sigmoidoscopy, colonoscopy, blind passage of a rectal tube, and instillation of rectal contrast during a barium enema examination.
13
–
15
The endoscopic method of decompression has the advantage that decompression can be done under vision, increasing the accuracy of insertion through the twisted segment in the sigmoid colon. In addition, the mucosa of the whole sigmoid loop can be visualised directly and the identification of gangrenous mucosal patches is an indication for operative management.
If symptoms and signs suggest ischaemia of the colon,
laparotomy
should be undertaken after the patient has been adequately resuscitated. Likewise, the patient who has unsuccessful non-operative treatment and those who have clinical features suggestive of colonic ischaemia at colonoscopy should also undergo emergency laparotomy. Since it is likely that resection will be required, the patient should be placed in the lithotomy/Trendelenburg position on the operating table. If colonic distension makes it difficult to handle the colon, a needle inserted obliquely through a taenia coli attached to a suction apparatus aids decompression. If the colon is gangrenous, it should be resected with as little manipulation as possible; the most widely recommended procedure is a segmental colectomy with an end colostomy and closure of the rectal stump (Hartmann's operation). In a prospective randomised trial from West Africa, Bagarani et al. compared the operative treatment in 31 patients with or without gangrene.
16
When gangrene was present, the mortality for Hartmann's procedure was 12.5% compared with 33.3% when resection and anastomosis were performed.
A small number of surgeons have described resection and primary anastomosis with good results. A study from India reported 197 patients with acute sigmoid volvulus treated by single-stage resection and anastomosis, 23 of whom had gangrene of the bowel.
17
Only two patients had anastomotic leaks, both of which responded to non-operative management. The two mortalities occurred in elderly patients who presented with perforations. A study from Ghana reported 21 patients with acute sigmoid volvulus treated by single- stage resection and anastomosis, 15 of whom had gangrene of the bowel.
18
Only one patient had a minor anastomotic leak, which responded to conservative management. However, it is important to stress that the majority of the patients in these studies were young and these results may not be applicable to the typical Western patient. In contrast, a series from the USA with 228 patients reported a mortality rate of 24% for emergency operations and 6% for elective operations. This study found mortality to correlate with emergency surgery and necrotic colon.
14
Intraoperative colonic irrigation may facilitate primary anastomosis in patients with sigmoid volvulus who require emergency operation, since faecal loading proximal to the volvulus may increase the risk of anastomotic dehiscence. However, it is still important that only patients who are generally fit and without systemic sepsis and peritoneal contamination are selected for this procedure.
Because the risk of recurrent volvulus after decompression and de-rotation has been reported to be between 40% and 60%,
9
elective surgery to prevent further volvulus should always be considered. The most widely accepted procedure is resection, which is now associated with an operative mortality of 2–3%. The operation may be performed as a laparoscopic-assisted procedure through a small incision under local anaesthesia if required.
A variety of fixation procedures have been described but have been associated with high recurrence rates.
15
Ileosigmoid knotting is a variant of sigmoid volvulus in which the ileum twists around the base of the mesocolon (
Fig. 10.4
). It is also known as double volvulus. Three factors are responsible for ileosigmoid knotting: (i) a long small-bowel mesentery and freely mobile small bowel; (ii) a long sigmoid colon on a narrow pedicle; and (iii) ingestion of high-bulk diet in the presence of empty small bowel.
19
Figure 10.4
Ileosigmoid knotting.
The condition is characterised by very acute onset of agonising generalised abdominal pain and repeated vomiting. Gangrene of the ileum and sigmoid colon is common. Generalised peritonitis, sepsis and dehydration are recognised complications, with hypovolaemic shock occurring early. The erect plain abdominal radiograph shows a dilated sigmoid colon and fluid levels in the small bowel.
Initial management consists of resuscitation and administration of antibiotics followed by surgical intervention. Resection and anastomosis of the terminal ileum and a Hartmann procedure is the most commonly performed operation. Recent reports suggest that primary colonic anastomosis can be undertaken safely when there is a short history and the colon is clean and well vascularised. The condition unfortunately carries a very high mortality rate, ranging from 15% to 73%.
20
Volvulus affecting the transverse colon is less common than sigmoid volvulus, accounting for only 2.6% of all cases of colonic volvulus in one series.
21
Predisposing conditions include pregnancy, chronic constipation, distal colonic obstruction and previous gastric surgery. The plain abdominal radiograph usually shows gas-filled loops of large intestine with wide fluid levels. The condition is often mistaken for sigmoid volvulus and the diagnosis is rarely made preoperatively. After the operative diagnosis is confirmed and the transverse colon untwisted, evidence of distal obstruction should be sought. Operative choices include a transverse colectomy or an extended right hemicolectomy.
A primary anastomosis after resection is probably safe. However, in the presence of gangrenous bowel and significant peritoneal contamination, the safest approach may be to resect the affected colon and exteriorise both ends.
Volvulus of the caecum is less common than volvulus of the sigmoid colon, representing 28% of all cases of colonic volvulus reported over a 10-year period in Edinburgh.
22
It is likely that incomplete rotation of the midgut leaves the caecum and ascending colon inadequately fixed to the posterior abdominal wall with a substantial length of mesentery. Conditions that alter the normal anatomy may predispose to caecal volvulus. There is an increased risk of caecal volvulus in pregnancy, and some patients are found to have adhesions from previous surgery. There is also an association with distal colonic obstruction. Volvulus usually takes place in a clockwise direction around the ileocolic vessels and, although the term ‘caecal volvulus’ is used, the condition also involves the ascending colon and ileum. As it twists, the caecum comes to occupy a position above and to the left of its original position. A similar condition, which is seen very occasionally, is ‘caecal bascule’. In this condition, the caecum folds upwards on itself, producing a sharp kink in the ascending colon.
It is difficult to differentiate between caecal volvulus and other forms of proximal large-bowel obstruction on clinical grounds. Some patients will have a previous history of episodes of obstruction that subsequently settled with non-operative treatment. The main presenting symptoms are colicky abdominal pain and vomiting. A tympanitic abdominal swelling will usually be present in the mid-abdomen.
On the supine abdominal radiograph, a ‘comma’-shaped caecal shadow in the mid-abdomen or left upper quadrant with a concavity to the right iliac fossa is diagnostic (
Fig. 10.5
) and there may be small-bowel loops lying to the right side of the caecum. A single, long fluid level on the erect film is characteristic. If doubt persists, a contrast enema will show a beaked appearance in the ascending colon at the site of the volvulus (
Fig. 10.6
).
Figure 10.5
Abdominal radiograph demonstrates a massively dilated caecum folded over into the left upper quadrant with distended small bowel.
Figure 10.6
Water-soluble contrast enema demonstrates a beak-like termination at the point of obstruction in the ascending colon with a markedly dilated caecum seen high in the abdomen.
Management depends on the clinical picture. The patient who is unfit for surgical treatment can be considered for colonoscopy since occasional successes have been reported using this method.
23
However, laparotomy is necessary in most patients. If the right colon is gangrenous at operation, the treatment of choice is a right hemicolectomy. A primary anastomosis should be possible in most cases even in the presence of contamination of the peritoneal cavity. It should be remembered that there is a markedly increased mortality in patients who have caecal gangrene. A report from the Mayo Clinic found a mortality rate of 12% in patients with caecal volvulus with a viable caecum, rising to 33% in the presence of colonic gangrene.
24
There is more controversy about the procedure of choice in patients who have a viable caecum after reduction of the volvulus. On the one hand untwisting alone is associated with a high recurrence rate, but on the other hand resection, which avoids all risk of recurrence, carries a small risk of anastomotic leak. However, in one study of 22 patients there was no mortality and no anastomotic leaks. A 14% morbidity included one abdominal wall abscess, one intra-abdominal abscess and one medical complication.
25
The other two procedures commonly performed for caecal volvulus are caecostomy and caecopexy. Reports on the use of caecostomy demonstrate a wide variation in terms of both recurrence (0–25%) and mortality (0–33%). Some authors express concern over the morbidity of caecostomy and the occasional serious complication of abdominal wall sepsis and fasciitis, in addition to the potential for a persistent fistula.
The treatment of caecal volvulus has been reviewed in a large study comprising 561 published cases.
26
This review showed that caecopexy was associated with a mortality rate of 10% and a recurrence rate of 13%. If all circumstances are favourable, resection appears to be a justifiable procedure with minimal risk of recurrence, accepting that there may be a small number of patients who will have increased bowel frequency. In other circumstances, the minimum procedure compatible with survival becomes the goal.