Management of obstructed and perforated large bowel carcinoma.

Obstructed large bowel carcinoma is a disease of the aged, often with concomitant disease and also advanced malignancy. The immediate mortality rate of operation is high and long-term prognosis is poor in comparison with elective surgery. It is important before operation that the diagnosis be established by sigmoidoscopy and emergency contrast studies. Staged procedures based on considerations of safety have given way to immediate resection. For right-sided colonic obstruction immediate resection and anastomosis is now almost universal and for left-sided tumours primary resection has overtaken staged resection in the UK. An anticipated survival advantage for primary resection has not, however, been confirmed. Obstruction complicated by perforation is an absolute indication for resection. After left-sided resection, making an anastomosis is associated with higher risk of leakage than after an elective operation. In the most adverse circumstances of associated sepsis, Hartmann's operation retains its place but immediate anastomosis is the most frequent option for many. Additional manoeuvres to make this safe include peroperative antegrade colonic irrigation and subtotal colectomy, although segmental resection with anastomosis and without bowel preparation is also practised and may be safe in selected patients. When major resectional surgery is undertaken in aged patients at high risk of mortality, the rule that the operator should be fully trained in elective large bowel surgery is incontrovertible. It is at least equally important that the anaesthetist is experienced and capable of instituting, interpreting and acting upon sophisticated cardiopulmonary monitoring.