modern trends in the surgery of the colon · 53 modern trends in the surgery of the colon by sir...

53

MODERN TRENDS IN THE SURGERY OFTHE COLON

BY SIR HUGH DEVINE, M.S.(Melb.), Hon. F.R.C.S.(Eng.)Melbourne, Australia

Carcinoma of the ColonEarlier Methods of Operating on the Colon

If, as a background to the study of the moderntrends in the surgery of carcinoma of the colonwe take the evolution of the surgery of this organ,we shall better appreciate its modern drift.At the turn of the century the feeling was that

if an end-to-end anastomosis gave satisfactoryresults in the small intestine it should be a correctprocedure in the large intestine. The method,therefore, came to be the routine for operations onthe large intestine which required a resection.The majority of the patients, however, died ofperitonitis.

It took some time to dawn on surgeons that thebiological conditions of the large intestine werevery different from those of the small intestine.'The bacterial content was high. The colonic wallin the presence of surgical interference offered avery slender barrier to the migration of germs intothe peritoneal cavity. The vitality of the colonwall was very poor since, in most cases, thepatients were old and these operations were donefor late malignancies. The vascularity of the thincolonic wall was frail and the small vessels wereeasily occluded by sutures when a piece-mealnecrosis occurred. These were the adverse bio-logical conditions the importance of which werenot fully recognized.

In the last two decades there has been a gradualevolution in the surgery of the colon in which mostof its adverse surgical conditions have beeneliminated and its high mortality rate reduced tosomething within the bounds of surgery of otherparts of the alimentary canal. During thisevolution, various principles in regard to pre-operative, operative and post-operative methods,which are relevant to the practice of moderncolonic surgery, have been developed. The use ofmany of these principles permits of that individual-istic surgical treatment of the various phases ofcolonic disease which is the secret of consistentsuccess in colon surgery. For example, anoperator may select that method which will bestcope with the particular pattern of colonic diseasethat he encounters; or he may choose that type

of operation which, taking into account his ownsurgical capabilities, is most likely to be successful.

In England, Paul (I895) was one of the first tobreak away from the accepted end-to-end anasto-motic method. He made an anastomosis withoutsutures; he did this with a crushing clamp in theway that we all know. No peritonitis occurred ini6 out of 17 cases. This extraperitoneal approach,regarded as rather crude at the time, marked adistinct advance. It carried a message, establisheda principle; it showed one way in which peritonitiscould be avoided in the case of a colonicanastomosis. The operation, however, was notradical enough. In the less mobile sections of thecolon it did not permit of a radical extirpation ofthe secondary glands, but the principle on whichthe operation was based still has a most importantuse in modern surgery.

In 1928, I93I, 194I and also in 1948, theauthor reported the following additions and im-provements to this ' spur and enterotome' extra-peritoneal method of operation in order to make itcomply with the requirements for a completelyradical operation for carcinoma of not only thedistal, but also of the proximal colon.

i. Mobilization of the whole of the right sideof the colon to the mid line for a right-sided lesion(Fig. i), or the whole of the left side of the colonto the same extent for a left-sided lesion (Fig. 2),so that it would be possible to make a completeremoval of the mesentery and its glands in eachcase. This extensive stripping of the coloncentrally to its arterial attachments to the aorta iseasy and causes little shock.

2. Modification of the spur and enterotometechnique which this principle embodies so that itcould be applied to join the small intestine to thetransverse colon on the right side in the case ofan ileocolectomy (Fig. 3), and the small intestineto the mobilized rectum on the left side in a near-colectomy (Fig. 4). Fig. 5 and Fig. 6 show themethod of extraperitoneal operation devised for theremoval of carcinoma of the descending colon orof the sigmoid flexure.

3. Extensive modification of the technique so astoi m )dify the artificial anus with a view to lessen-

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54 POSTGRADUATE MEDICAL JOURNAL February I950

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FIG. i.-The ileocolic segment extensively mobilized.A, muscles of the posterior abdominal wall; B,kidney; C, ureter; D, duodenum; E, posterioraspect of the mesentery of the proximal colon withvessels; F, mobilized proximal colon; G, appen-dix; H, terminal ileum; I, liver.

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FIG. 2.-Shows insertion of operating frame,clamping on the edges of wound onoperation covers. A, incision of peri-toneum lateral to descending colon andabove the splenic flexure; B, 'parking'with mechanical hands the small intes-tine into the right side of the abdomen;C, sigmoid flexure; D, exposure of thesplenic flexure.

ing its unpleasantness and rendering its closureeasy and consistent.

Operation on the Defunctioned Left ColonThere were, however, many cases of disease in

the left half of the colon which required resectionbut in which this extraperitoneal method was im-practicable. For these the author originated andpractised a twro-stage method: ' Operation on adefunctioned dlistal colon.'The principles on which this operation is based

are that if you completely isolate and deprive thedistal colon of its function, which is largely con-cerned with bacterial activity, it will slowly losethe greater part of this bacterial content; anyinflammation in the colonic wall will slowly re-solve, faecal lumps can be removed, and thissegment of colon can be subjected to directchemotherapy. A resection can then be carriedout and an anastomosis allowed to heal in cir-cumstances where the bowel wall is healthy, atrest, and where there is little infection and nocontents. In such circumstances there is practic-ally no danger of peritonitis (Figs. 7 and 8).

This method was originally designed for thosecases of diverticular obstruction which wereassociated with extensive colonic cellulitis and

which, because of the rigid inflammatory colonicwalls, did not permit of a safe sutured anastomosis.Its particular application to these cases was that,because of their innocency, the full value of thedefunctioning of the bowel could be obtained,for it could be defunctioned for many months.The bowel was defunctioned by using the type ofdisconnecting anus as shown in Fig. 8-an anuswhich is small, which completely disconnects thesegments of right and left parts of the colon andwhich is easily closed.

In later years, the author used this method incases of cancer of the colon with which wereassociated special surgical difficulties-especiallyin cases of carcinoma of the descending colon andin the lower part of the sigmoid colon.The special value of the method is shown by the

fact that in particularly complicated cases in whichit was used, leaks occurred in the anastomosis, butno peritonitis followed. Indeed, it was difficult totell that a leak had occurred. Its only evidencewas a muco-purulent discharge from the abdominaldrainage tube track and the fact that a salineenema came through this track. If the openingsin the anastomosis were not big, they closed intime, after which the faecal stream was restored tothe defunctioned colon.



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Febrdary 1950 DEVINE: Modern Tren(ds in the Surgery of the Colont 55

Aseptic Methods of AnastomosisIn the effort to get better results in the surgery

of the colon, there arose another line of thought,namely, the use of various clamps and gadgetswith the idea of achieving an aseptic or ' closed'anastomosis in contrast to the usual ' open'anastomosis. With these aseptic methods thenames of Rankin, Wangensteen, Gibbons, Hart,Stone, Cope and others have been associated. Ofthemselves, as methods of operation, these so-called' aseptic 'methods do not seem to have madeany epoch-making improvements in the safety ofcolonic operations. In conjunction with the useof modern chemotherapeutic drugs, however,these methods may have a place in present-daysurgery, since, apart from their object of attainingasepsis, they achieve an exactitude in making ananastomosis.

End-to-End or Side-to-Side Anastomoses Com-bined with Caecostomy

This type of operation is mentioned because itmay be regarded as a standard textbook method.As an operation for general application in all thevarious phases of colonic disease, and unfortifiedby the use of sulpha and antibiotic drugs, itcarried too high a mortality rate. The caecostomy,which is spurless, has little action in defunctioningthe colon, for the physiology of the colon is suchthat most of the faeces will by-pass such an open-ing. Its only function is to drain the excess offaeces in cases of intestinal obstruction. With theadvent of chemotherapy, however, the applicationof this operation has, today, become wider and itsmortality rate much lower.

One-Stage Resection and Anastomosis of the ColonThe discovery of sulphathaladine and sulpha-

succidine, drugs which have a strong selectiveaction on the bacterial content of the colon (Poth,Moore and Miller, I942), marked a turning pointin the surgery of the colon. It has led to the re-vival of the discarded end-to-end anastomosisuncombined with any bowel vent, that is, to aone-stage resection and anastomosis of the colon.Based on the good results of American clinics,this operation threatens to become a surgicalvogue. In this attitude of mind, namely a primaryresection or nothing, the idealized operation,notwithstanding adverse or unexpected surgicalcircumstances, lies a definite danger. It must beremembered that its good results-and earlypublished results of advances in surgery byreason of a combination of circumstances arealways good-have been obtained by expertsurgeons working in highly-organized clinics,specializing in and therefore performing largenumbers of this type of operation.

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FIG. 3.-Fashioning of the long spur and the divisionof the ileocolic artery and of the mesenteric leaf.A, division of ileocolic artery; B, leng suturedspur; C, proximal part of transverse colon; D,small bowel; E, ileocolic mesentery; F, ileum;G, ascending colon; H, caecum; I, appendix.

Many factors have contributed to make thisoperation possible:-the discovery by Whipplethat he could decompress the colon by continuoussuction with the Miller-Abbott tube; the advent ofchemotherapy, particularly of the sulphonamides,sulphathalidine and sulphasuccidine, drugs whichcan lower the bacterial content of the bowel to avery great degree in pre-operative and post-operative treatment; the discovery of antibiotics;the organization of nursing teams specially trainedin the art of emptying the large bowel; therecognition of the importance of restoring thevitality of the colonic wall by raising the patient'sprotein, haemoglobin and vitamin levels; thepreservation of full vitality of the bowel edges bythe avoidance of crushing clamps; improvementsin anaesthetic methods; and finally a piinstakingtechnique in making the anastomosis in whichfine mattress stitches are carefully placed and tiedto avoid an embarrassment of the circulation.These were the advances and discoveries whichmade one-stage resection and anastomosis of thecolon practicable.The published mortality rate varies from 5 per

cent. to Io per cent. In implementing the con-cepts of this operation it does not seem to matterwhether the anastomosis is made by the ' open'or by the ' closed ' method. In point of fact, mostsurgeons preftr the former.

Prominent among the exponents of this one-stage method are: Dickson, McPhee, Wangen-,



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POSTGRADUATE MEDICAL JOURNAL February 1950

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FIG. 4.-Shows the ileum joined to the mobilizedrectum by the spur and enterotome method. Asmall fragment of the lower end of the sigmoid isretained in continuity with the rectum to permitthe use of this method. A is spur clamp; B theileal limb of the spur; C the sigmoid limb of thespur; D the mobilized rectum.

steen, White and Amendover, McNeilly andLands, Stone and McLauabank, Waugh andCuster.

The Choice of Operation in Colon SurgeryThe approach to the surgery of the colon should

be made with the feeling that there can be noroutine operation for an organ which presents somany phases of disease, each with its own par-ticular problem; that is, in the choice of operationthere are factors in the surgery of the colon otherthan the septic condition of its contents, whichdemand individualistic operative treatment andoften preclude the ideal primary resection andarastomosis.The first of these factors is that the healing

power of the colonic wall can be inadequate. Thevitality of the colonic tissues can be so lowered thatthe use of sutures in an anastomosis could lead topet itonitis, notwithstanding the use of chemo-therapy which can only bring about a very materiallowering of the bacterial content, not a completesterilization. The combination of old age, of thesystemic effect on tissues of advanced carcinomaand of the local action on the bowel wall of anacute intestinal obstruction can cause such a de-vitalization of bowel tissue that it cannot beadequately restored by the most elaborate pre-operative preparation. We see this particularlyin cases of late and highly cellular carcinoma of thecaecum, and in the late growths in the ileocaecalregion associated with acute obstruction. Herean extraperitoneal operation (Figs. i and 2) willsave the life of a patient who would be lost by themore spectacular prim'ry resection and anasto-mosis.David (I943) uses an extraperitoneal operation

in all but 5 to io per cent. of cases, and Lahey(1946) in all but io to I5 per cent. of cases. In

the author's practice the use of ileocolectomy bythe extraperitoneal method for over 25 years hasgiven a mortality rate of 5 per cent. Perhaps themost important advantage of this method is thatthe convalescence is so entirely devoid of in-cident, so smooth. In our practice there were nocases of local peritonitis from the anastomosis,no distensions that gave anxiety, no local abscessesand other complications which are so often seenin the one-stage operation and which frequentlylead to secondary operations.Lahey (1946) in his last 500 cases had a mortalitv

rate of 2 per cent.On the other hand it must be recognized that

ileocaecal growths, in a reasonable early stage intheir course even if associated with moderateobstruction, are suitable for primary resection andanastomosis.A second factor is that the tissues of the colon

wall can be acutely and incurably inflamed. Inulcerative colitis, for instance, a sutured anasto-mosis may not heal or may be followed by aperitonitis as a result of sutures in the highly-infected tissues. Here no lowering of the bacterialcontent, even if it could be obtained, would avail.For colectomy in such circumstances we use theextraperitoneal method to anastomose the ileum,through the medium of a terminal segment of thesigmoid, to a fully-mobilized rectum (Fig. 4). Inthese cases, the worst possible risks, there was notone complication of peritonitis arising from theanastomosis.The condition of the bowel wall in cass3 of

obstructive diverticular tumour associated withextensive cellulitis of the adjoining colon may,too, be a bar to primary resection and anasto-mosis. So also may the chronic proliferative in-flammation of the colonic wall which sometimesfollows unskilful pelvic operations with extensive



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February I950 DEVINE: Modern Trends in the Surgery of the Colon 57

injury to the sigmoid. Here primary resection isimpossible and good results can only be obtainedby ' operation on the defunctioned colon' (Figs.7 and 8). The bowel may have to be defunctionedfor i2 months before the inflammation will resolveand the bowel will become supple enough to makea safe sutured anastomosis.The following case histories are examples of the

value of using these conservative methods wherethey are indicated rather than the more modernprimary resection.

Obstructive diverticular tumour and coloniccellulitis.-A woman, aged 50, suffered from anobstructive diverticular tumour in the lower partof the sigmoid colon with much inflammation andrigidity of the adjoining colon. The distal colonwas defunctioned for eight months. The opera-tion which was then undertaken showed that thebowel had lost most of its rigidity and that a re-section and sutured anastomosis was feasible.However, notwithstanding the most careful tech-nique, on the eighth day it was found that therewas a leak in the anastomosis (a saline enemaflowed through the abdominal drainage tubetrack). The only evidence of the leak was amuco-purulent discharge through this track. Theabdominal wall was soft and the patient was com-fortable. The leak was allowed to heal in theisolated and defunctioned distal colon. In sixweeks it had completely healed and then, but not

till then, the faecal stream was returned to thedistal colon. Had this leak occurred in a primaryresection and anastomosis, a peritonitis or localizedabscess formation would have followed.

Sigmoid colon injury.-A woman had a gynaeco-logical operation. Following this she developedall the manifestations of peritonitis and was on theverge of death. Finally her abdominal woundopened and from it issued pus and faeces. Eventu-ally, over a period of two years, she becameemaciated, exhausted and bedridden, with manyabdominal sinuses discharging faeces, withchronically inflamed, rigid and adherent in-testines. X-ray showed three large openings inthe sigmoid colon. At a preliminary operationto ' soften' the general chronic inflammatoryhyperplasia, the distal colon was completely de-functioned. The contents of the colon werecleared out and the distal colon and the sinusesantiseptically treated. The patient was then senthome for nine months. After this period thepatient had greatly improved and at the sub-sequent operation adhesions had largely dis-appeared, the intestinal wall had become soft andsuturable and the faecal fistulae were easily dis-sected out. The ' defunctioning' had made theoperation easy and safe.A further factor in the choice of operation is

the situation of a carcinomaA growth in the descending colon, at the

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Vlc. 5.-Drawn from X-ray studies in the live body.In this it will be seen how the proximal sigmoidwill come up to its vascular pedicle A, and how thedistal part of the transverse colon will swing downto its vascular pedicle B. It will also be seen howmuch closer together these parts are in life thanthey are found in anatomical studies.

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FIG. 6.-Shows how the vascular supply usually per-mits the formation of a long spur between the distalcolon and the proximal sigmoid. Note the longspur at A. The neck of the loop is shown suturedinto the parietal peritoneum and the wound. Theloop of bowel and mesenteric leaf removed is in-included in dotted lines. A, ileocolic vascularpedicle; B, mid-colic pedicle.



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POSTl'GRADUAT'E MEDICAL JOURNAL February 1950

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FIG. 7.-Diagram to show the method of com-plete isolation and defunctioning of thedistal colon. A is the widely separated cutends of bowel; B, tube in rectum; C, thegrowth in the distal colon. Funnels showwash-out of isolated bowel from above andbelow growth.

FIG. 8.-Shows how the small anusesare so separated that no faeces canpass over and reinfect the distalcolon after it has been more or less'debacterialized.'

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February I950 DEVINE: Modern Trends in the Surgery qf the Colon 59

splenic flexure or in the vicinity of the recto-sigmoid junction, may make a primary resectionand anastomosis inadvisable. Here the extra-peritoneal operation pictured in Fig. 4, forsplenic flexure and descending colon growths and' operation on the defunctioned colon' for recto-sigmoid growths, are safer procedures thanprimary resection, and therefore can be said to bea modern trend.

Finally, in the choice of operation, there is thehuman factor. A medical man, unskilled insurgery, who is confronted with an intestinalobstruction caused by a distal colon carcinoma-certainly in our far-out Australian country dis-tricts-can not only save his patient's life, butcan carry out the first stage of the operation for itsremoval by placing and making an artificial anusas pictured in Fig. 8. He can carry out the firststage of ' operation on a defunctioned distal colon 'at the same time as he relieves the patient's acuteintestinal obstruction.

The Choice ofOperation for Carcinoma in theVicinity of the Rectosigmoid JunctionHere there are two questions. Firstly, should a

rectosigmoid resection be performed rather thanan abdominoperineal operation ? Secondly, if arectosigmoid resection is feasible, should a primaryresection and anastomosis be carried out, eitherwith or without a bowel vent, or should the moreconservative two-stage method, ' operation in a

defunctioned and prepared colon,' as shown inFigs. 7 and 8, be used ? The answer to thisproblem depends on the particular circumstancesof the case. In the earlier years of the author'scolon surgery, an abdominoperineal operationwas our choice for a carcinomatous lesion in thelower end of the sigmoid. In common with othersurgeons we felt that the vascularity of the rectalstump could not be trusted in a rectosigmoidanastomosis. It was felt, however, that the use ofan abdominoperineal operation as a routine ofteninflicted on patients an artificial anus which arectosigmoid resection could safely have avoided.Thus, in 1938, we showed that carefully-selected

lesions in the rectosigmoid region could be radicallyremoved by a rectosigmoid resection; that the vas-cularity of the rectal stump as studied in the livebody (Devine, 1941) could, in most cases, be trustedto make a safe anastomosis; and that the way toensure safety in this operation, in the case ofvascular anomaly, which is not uncommon, was tomake an anastomosis in a defunctioned andantiseptically-prepared colon (Figs.7 and 8, andFigs. 9, io and ii). The patients in which thismethod was used were carefully selected; theirgrowths had to be early and localized. Heyd(I945) and others published cases satisfactorilyoperated on by this method and used it as a routine.

Since I940, when Dixon and other Americansurgeons published a series of good results fromprimary rectosigmoid resection and anastomosis,

FIG. 9.-Showing illustration of rectosigmoid re-section taken from our article in Americanjournal Surgery, I938. Here the rectum hasbeen mobilized preparatory to resection of therectosigmoid segment containing the growth.

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6o POSTGRAD)UATE MEDICAL JOURNAL February 1950

1tVFIG. io.-Showing method of making rectosigmoid

anastomosis. Inset shows method of insertingmattress sutures.

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FIG. i i.-Shows divisionof inferior mesentericand last sigmoid artery.A, rectum; B, inferiormesenteric artery; C,last sigmoid artery.

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FIG. I2.-This diagrammatic illustration shows a stage in a near-colectomy,in which the colon and all but a fragment of the terminal sigmoid havebeen removed. The sectioned ileum is joined to the mobilized rectumto make a spur so that an ileo-rectal anastomosis can be made on thespur-and-enterotome principle. Before the ends B and C are closed, thepolyps in the upper part of the rectum and the sigmoid fragment and alsothe polyps in the lower part of the rectum (through the anus) are re-moved by a diathermy snare applied through a sigmoidoscope. A is thesnare; B the cut-end of the ileum; C the cut-end of the sigmoid fragment;D the sigmoidoscope, and E the mobilized rectum with its attachedsigmoid fragment which facilitates the ileo-rectal anastomosis.



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lFebruary 1950 DEVINE: Modern Tre'nds in the Surgery of the Colon6

this operation has been practised, in some caseswith, in others without, a bowel vent.Our experience of rectosigmoid resection,

covering now about I5 years, would lead us tocounsel conserva,ism in the use of this operation,especially where it is used as a single-stage opera-tion uncombined with a bowel vent. Our reasonsare these:

In the first place, since its use.has become rathera vogue, it has been employed for growths whichare, perhaps, too far advanced or too active atype of carcinoma. Here its use l,as,been followedby rapid recurrences, 'sometimes within a year,which shows that this operation was an unwisechoice; the method is not as radical as theabdominoperineal operation. In this relation,too, may be quoted Allen' of Boston, who has wideexperience in colon surgery and is noted for hissound judgment. He writes:-' The' trend tosave the patient's sphincteric control may lead toinadequate removal and therefore to' recurrence.'

In the second 'place, where a rectosigmoid' re-section is carried out as a primary resection andanastomosis, ccnsistent results are not obtained.Leaks occur nct so much from septic contepts asfrom vascular deficiencies. From these peritonitisand death may occur, or sinuses and abscessformation may develop and be almost surgicallyuncurable. ;Even in theauthor's own cases' inwhich the 'sutured rectosigmoid anastomosis wasmade under the; most ideal conditions, leaksoccurred. Since however the anastomosis wasalways made in a distal colon which had beencompletely isolated, washed out and treated withchemotherapy, nothing untoward happened; noperitonitis followed. There was a discharge ofmucus and pus, but the opening, if not too big,always healed, whereafter the faecal current wasrestored to the distal colon. If, however, theopening did not close because it was too big, andthis did occur, it was not a difficult operation to re-open the abdomen and resuture the bowel endswhich, by this time, had a well ' determined'circulation. The special point to be made is thatif, under these ideal conditions-far more idealthan primary resection and anastomosis protectedby the use of sulpha drugs-a carefully-suturedrectosigmoid anastomosis can leak and givetrouble, risks from primary rectosigmoid anasto-mosis will be found to be much greater thanreports would have us believe.

In the third place, figures are coming to lightwhich show that retrograde metastases areoccurring after rectosigmoid resection for car-cinoma below the promontary of the sacrum; andthat lesions which are situated at or below theperitoneal reflection have a high incidence of localand hepatic recurrence. In this situation, too,

some figures show that where lymph node meta-stases were found in the surgical specimens, 23per cent. developed local recurrences within fiveyears.

It is true to write that the more experience theauthor has had with rectosigmoid resection themore conservative he has become in its use. Itwill, therefore, be gleaned that his feelings arethat primary rectosigmoid resection and anasto-mosis, with or without a vent, is an operation whichdemands much experience and sound judgmentand is a dangerous operation to put into the handsof the average surgeon. It should be sparingly used.

The Application of One-Stage Resection andAnastomosis

Having pointed out therefore how many phasesof colonic disease do not lend themselves to thepractice of primary resection and anastomosis,attention must now be drawn to the considerablefield of colonic disease to which such trkeatmerii iseminently applic .ble.

A. Stephens Graham writes: ' Of 50 surgeonsin America with relatively large and prolongedexperience in the field of colon surgery, 72 percent. have performed primary resection andanastomosis in 50 per cent. of cases.' He furtherwrites: ' Of ten surgeons selected for their pre-eminence in colon surgery, six estimate that theyperform primary resection and anastomosis in notmore than 25 per cent. of cases.' In these opinionswe have some guide to the use we should make ofthis operation. We should not be too impressedby the many publications which feature smallseries of successful cases.

Special points in the performance of primary re-section and anastomosis are: there should be nocomplications; any obstruction should be com-pletely decompressed. The intestine must beviable and free from circulatory disturbance. Nooperation must be attempted until adverse con-ditions are corrected. There should be a com-plete mechanical cleansing of the bowel by purga-tives and enemas followed by oral sulphasuccidineand sulphathalidine and a low residue diet. Thereshould be careful protection of the wound edges,two rows of inverting mattress sutures; a change ofgloves and instruments on the completion, of the-first row of sutures.

In the case of anastomosis in the vicinity, of the-rectosigmoid junction, a tube should be passedithrough the anastomosis. The ' open' operationis preferable because of the accuracy with; which,sutures can be placed, and because of the fact-thatthe full vitality of the wound edges can, be re-tained; in this case rubber-covered clampsshould be used to avoid soiling Qf the operationfield by faecal contents.



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62 POSTGBADUATE MIEDICAL JOURNAL Fehbruarv I950

Complications. Some notion ot the frequencyof complications after this operation may beobtained from published results. One series of79 cases, taken at random, showed the followingcomplications. There were three cases ofperitonitis; six of intestinal obstruction; four offailure of the anastomosis to function; one ofurinary fistula; one of general sepsis; one ofwound infections; two of phlebothrombosis; andthree of coronary thrombosis. In general, a highincidence of complications when compared withthose following the extraperitoneal and the two-stage operation. Many of these complications en-tailed secondary operations.

Transplantation of the Proximal Colon intothe Anal Canal after Removal ofthe DistalColon and RectumBacon and Smith (1947) report eight cases in

which they removed the left half of the colon withthe rectum and transplanted the proximal partof the transverse colon into the anal canal withpreservation of the sphincter. They write: ' Thepatients were well satisfied with the continenceobtained. There was no mortality in the eightcases. The operation was a formidable one.'

In this type of operation it should be recognizedthat its potentiality to confer a satisfactory con-tinence is not great because of the destructionof the autonomic nerve supply of the rectum.

Colostomy ClosureSince the advent of sulphasuccidine and sulpha-

thalidine it has become the custom of somesurgeons to close colostomies by an end-to-endanastomosis; that is, by an intraperitoneal insteadof an extraperitoneal operation.

Serious Injuries of the ColonLate injuries of the colon, especially in the

sigmoid region, which sometimes follow un-skilful pelvic operations, provide some of the mostdifficult operations in colonic surgery. Thepatients may come under notice with severalopenings in the abdominal wall pouring faeces andpus, with little or no faeces passing by the rectum,and with all the outward appearance of being veryill. In these cases faecal fistulae with induratedwalls lead down through rigid and adherent in-testines to the wound in the wall of the injuredsigmoid; chronic abscesses form between theintestinal loops in the vicinity of the bowel wound,and intestinal loops adhere to the parietalperitoneum and to one another. The wall of thesigmoid is rigid and thick as the result of long-standing chronic inflammation, and the mucousmembrane prolapses through the wound in thebowel and curls over and becomes adherent insuch a way that natural healing is impossible.

In these cases the surest way to effect a surgicalcure lies in a delayed approach. The distal colonmust be completely isolated, ' defunctioned,' bvmaking a disconnecting artificial anus (Figs. 7and 8). It then receives chemotherapy and isallowed to rest over a period of perhaps 12 months.It will then be found that gradually the chronicinflammation in the walls of the small intestine, inthe sinuses and in the sigmoid will resolve, thatmost of the adhesions will disappear, that thewalls of the sigmoid will lose their rigidity andbecome supple enough to suture, and that theoperation becomes reasonably easv.

DiverticulitisBabcock (1941) points out that radical surgery,

for the early stages of diverticulitis is curative, hasa low mortality and should be practised moreoften than it is.

Diverticulitis with inflammatory infiltration(tumefaction) usually requires surgical inter-vention. The filling defect when seen in theX-ray is characteristic. It is much longer thanthat of a malignancy. Diverticula may not showin its neighbourhood because the ostia may beclosed by oedema of the bowel wall.Where a diverticular tumour causes obstruction,

part of the obstructive process may be due tooedema and therefore relievable by treatment ofthe inflammation. Thus, sometimes a defunction-ing transverse colostomy may not only relieve theacute obstruction but also it may effect to a largeextent a cure of the obstructive process. In ourpractice we have, in some old and feeble patientswho have suffered from an acute obstructive pro-cess, been able, after defunctioning the bowel forI2 months, to close their colostomies.As a rule, however, these diverticular tumours

have to be resected. Our method of doing thishas already been described in dealing with'operation on the defunctioned distal colon.'

In cases of diverticulitis where perforation of adiverticulum occurs, a defunctioning transversecolostomy should be made and the segment inwhich the diverticulum is situated exteriorized.This must be done because the inflammation ofthe tissue surrounding the perforation makessuture impossible. If the peritonitis remainslocal the patient recovers, and, if the perforationis not big, it will heal. It may, however, benecessary, where a fistula persists, to resect theaffected segment and carry out an end-to-endanastomosis.Where diverticulitis becomes complicated by a

vesico-colic fistula a serious operative problem ispresented. The distal colon must be completelyisolated and treated with chemotherapy for per-haps I2 months. After this period it will be found



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February 1950 I)EVINE: Modern Trends in the Surgery of the Colon 63

that it is surprisingly easy to dissect out thefistulous track and close the openings in bowel andbladder.

PolypsHelwig's observations show that adenoma is the

most common form of polyp and that adenomasoccur most 'frequently in the sigmoid region.David (I943) believes, as does Lahey, that anadenoma is a definitely precancerous lesion-; this,too, is our own feeling. It is generally agreed thatwhere a polyp is to be removed locally a biopsyshould be made and that the section of tissueshould be taken from the base of the polyp. It isalso accepted that it is impossible to make adiagnosis of the pathological nature of a polypexcept by microscopical examination.

Pedunculated polyps, if few in number, maybe removed through one or more colostomies with,of course precautions in regard to malignancy. Inorder to distinguish between a colonic polyp anda lump of faeces, Dixon, after darkening the room,holds a cold light behind the bowel.

Familial PolyposisFor this condition, after appropriate preparatory

treatment, we remove the colon. If the rectum isextensively involved we remove it at a later stageand leave the patient with an ileostomy. Wherethe rectum is not extensively affected we endeavourto put off the evil day when the rectum may haveto be resected by removing the polyps with asigmoidoscope, as shown in Fig. 12.

Conclusions

i. During the last two decades advances in thesurgery of the colon have so changed its outlookthat it no longer holds the fears for patient andsurgeon that it did in earlier years.

2. In these advances early diagnosis of malig-nancy of the large bowel has been one of the bigfeatures.

3. Many of the conservative operative methodswhich came into use in this period still have aplace in modern surgery.

4. The modern methods of primary one-stageresection and anastomosis of the colon, if appliedwith discretion, mark a spectacular advance in thesurgery of the large bowel.

BIBLIOGRAPHY

BABCOCK, W. W. (I94l), Rev. Gastroenterology, 8, 77.BACON, H. E., and SMITH, C. H. (I947), J. Int. Coil. Surg.,

1O, 66i.DAVID, V. C. (1943), Surgery, 14, 387.DEVINE, H. B (1928), 'Colon Surgery in the Debilitated,' _. Coll.

Surg., Australasia, I, 173.DEVINE, H. B. (93I), ' Safer Colon Surgery,' The Lancet, I, 627.DEVINE, H. B. (1938), 'Operation on the Defunctioned Colon,'

Surgery, 3, I65.DEVINE, H. B. (I941), 'Surgery of the Alimentary Tract,' John

Wright & Sons.DEVINE, H. B., and DEVINE, J. B. (1948), 'Rectum and Colon,'

John Wright & Sons.DIXON, C. F. (I944), Surgery, I5, 367.DIXON, C. F., and BENSON, R. E. (I944), Annals of Surgery,

I20, 562.

GRAHAM, A. STEPHENS (1949), Surg. Gyn. and Obst., 88, 264.HEYD, C. G. (I945), Am. J. Surg., 67, 479.LAHEY, F. H. (1946), S. Clin. N. America, 26, 6io.McNEALY, R. W., and LANDS, V. G. (I947), Surgery, 21, 283.MACFEE, W. F. (I947), Annals of Surgery, 126, 125.PAUL, F. T. (I895), Liverpool Med. Chir. J., 15, 409.POTH, E. J. (I945), Surgery, 17, 773.STONE, H. B., and McLANAHAN, S. (I942), J. Am. Med. Ass.,

120, 1362.WANGENSTEEN, 0. H. (1945), Surg. Gyn. and Obst., 8g, 1-24.WAUGH, J. M., and CUSTER, M. D. (1945), Ibid., 8i, 593.WHIPPLE, A. O. (1940), Surgery, 8, 289.WHIPPLE, A. 0. (I943), Ibid., 14, 321.WHITE, W. C., and AMENDOLA, F. H. (1944), Ann. .Strg., 120

572-

A Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). TheClinic is provided with a staff of doctors, technicians and nurses.

The surroundings are beautiful. The climate is mild. There is central heating throughout. The annualrainfall is 30.5 inches, that is, less than the average for England.

The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Tegraus: Carst, Ruthim. Telephone: Ruthin g

The illustrations of this article are from Sir Hugh and John Devine's book,The Surgery of the Colon and Rectum. They are reproduced here by courtesy ofthe publishers, Messrs. John Wright and Sons Ltd., Bristol.



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