Meijer W S, Vermeulen J, Gosselink M P
Medical Center Rijnmond-zuid, Rotterdam, The Netherlands.
Tech Coloproctol. 2009 Jun;13(2):123-6. doi: 10.1007/s10151-009-0468-4. Epub 2009 May 29.
Patients presenting with an acute obstructing carcinoma of the left bowel are a surgical challenge. Under more difficult circumstances with gross distension of the proximal colon many surgeons will decide to defer anastomosis. Hartmann's procedure still represents a valid treatment option. We describe our experience with primary resection and side-to-end anastomosis next to an end-colostomy in the management of acute malignant obstruction of the left bowel.
The surgical procedure involves resection of the tumour and primary stapled side-to-end anastomosis next to a protecting end-colostomy. This type of enterostomy was first described by Santulli and Blanc in 1961. Colostomy closure is possible via a local procedure avoiding relaparotomy. Ten patients (five women) underwent surgery using this technique. Their mean age was 71 years (range 54-88 years). All patients had a massively distended colon. All obstructing lesions were biopsy-proven adenocarcinomas.
There was no postoperative mortality and no anastomotic leakage. The colostomy could be closed without a laparotomy in all patients. The only two complications were one superficial necrosis of the stoma and one wound infection after colostomy closure. In all other patients the postoperative course was uneventful. Wound infection after colostomy closure was seen in the very first patient in whom the wound was closed primarily. In subsequent patients the skin was left open.
The concept of an end-colostomy next to the anastomosis is an alternative approach combining the safety of proximal decompression and the advantages of primary anastomosis. This technique may be considered in patients presenting with a massively distended and faeces-loaded colon caused by an obstructing tumour in the descending or sigmoid colon, when the surgeon would otherwise elect to defer anastomosis.
患有急性左半结肠梗阻性癌的患者是外科手术的一大挑战。在近端结肠严重扩张的更困难情况下，许多外科医生会决定推迟吻合术。哈特曼手术仍然是一种有效的治疗选择。我们描述了我们在左半结肠急性恶性梗阻的治疗中采用一期切除并在端侧吻合旁行末端结肠造口术的经验。
手术步骤包括切除肿瘤并在保护性末端结肠造口旁行一期吻合器端侧吻合。这种类型的肠造口术最早由桑图利和布兰克于1961年描述。结肠造口可以通过局部手术关闭，避免再次开腹。10例患者（5名女性）采用该技术进行手术。他们的平均年龄为71岁（范围54 - 88岁）。所有患者的结肠均有大量扩张。所有梗阻性病变经活检证实为腺癌。
无术后死亡病例，也无吻合口漏。所有患者的结肠造口均可在不开腹的情况下关闭。仅出现了2例并发症，1例造口浅表坏死和1例结肠造口关闭后伤口感染。所有其他患者术后病程平稳。结肠造口关闭后伤口感染出现在第一例直接缝合伤口的患者身上。在随后的患者中，皮肤保持开放。
吻合旁行末端结肠造口术的理念是一种替代方法，它结合了近端减压的安全性和一期吻合的优点。对于因降结肠或乙状结肠梗阻性肿瘤导致结肠大量扩张且充满粪便的患者，当外科医生否则会选择推迟吻合术时，可考虑采用该技术。
