N a d k o V e litc h k o v , J u lia n L o s a n o ff, K irie n K jo s s e v , G e o rg i G rig o ro v , M e g le n a V e z d a ro v a , G u e n o K iro v
Stercoral perforation of the norm al colon:
R eport of five cases
Department
of Emergency
Surgery Military Medical Academy
Sofia, Bulgaria
A se rie s o f five co n se cu tive p a tie n ts w ith ste rco ra l p e rfo ra tio n o f th e co lo n is p re se n te d . F o u r o f th e p a tie n ts h a d fre e p e rfo ra tio n a n d o n e h a d a n a b sce ss b e tw e e n th e sp le n ic fle xu re , sp le e n a n d su rro u n d in g o rg a n s, a ye t u n re p o rte d e n tity. A ll p a tie n ts u n d e rw e n t e m e rg e n cy su rg e ry in clu d in g la p a ro sto m y w ith re p e a te d e xp lo ra tio n s a n d la va g e s in tw o o f th e m . T h e e th io lo g y, p a th o p h ysio lo g y a n d tre a tm e n t o f th e co n d itio n a re u p d a te d . A g ra p h ic a lg o rith m fo r d e cisio n -m a kin g in a p p ro p ria te ly d e a lin g w ith ste rco ra l p e rfo ra tio n o f th e co lo n is p ro p o se d .
U N IT E R M S : S te rco ra l p e rfo ra tio n , co lo n ; p e rito n itis; re se ctio n ; co le cto m y; d ive rsio n ; scyb a la ; in tra o p e ra tive o rth o g ra d e co lo n ic la v-a g e ; v-a lg o rith m .
S
terco ralw h ich h as receiv edp erfo ratio n relativ elyo f th e n o rm al co lo n is an en titylittle atten tio n in b o th th e su rg ical an d m ed ical literatu re. P erh ap s o n e o fth e reaso n s fo r th is is th e rarity o f th e co n d itio n .
N ev erth eless, sterco ral p erfo ratio n o f th e co lo n is im p o rtan t
sin ce it is asso ciated w ith relativ ely h ig h m o rtality
ap p ro ach in g 3 5 p ercen t fo r th o se m an ag ed su rg ically .'
T h is w o rk w as u n d ertak en to rep o rt fiv e n ew cases
o f sterco ral p erfo ratio n o f th e co lo n , to d iscu ss th is u n u su al co n d itio n w ith p articu lar referen ce to its p o ssib le cau satio n
an d to create a g rap h ic alg o rith m fo r d ecisio n -m ak in g
reg ard in g th e o p erativ e strateg y .
A d d re s s fo r c o rre s p o n d e n c e : J u lia n L o s a n o ff
P . 0 . B o x , 1 5 9 S o fia - B u lg a ria - 1 6 0 6
P A T IE N T S A N D M E T H O D S
F iv e p atien ts w ith sterco ral p erfo ratio n o f th e n o rm al co lo n w ere treated at th e D ep artm en t o f E m erg en cy S u rg ery
o f th e M ilitary M ed ical A cad em y o f S o fia, B lilg aria,
b etw een 1 9 7 5 an d 1 9 9 5 . A su m m ary o f th e p rin cip al
fin d in g s in th ese p atien ts is p resen ted in T ab le I. V irtu ally all p atien ts p resen ted an acu te, n o n sp ectic
ab d o m en co n d itio n . P ast m ed ical h isto ry rev ealed th e
fo llo w in g (T ab le 2 ). In all p atien ts th ere w as m ark ed
leu co cy to sis sh ifted to th e left, m ark ed flu id im b alan ce
an d arterial h y p o to n y . A n ab d o m in al x -ray sh o w ed free
air b elo w th e d iap h rag m in all b u t C ase 2 , in w h ich
em erg en cy ab d o m in al u ltraso n o g rap h y rev ealed a larg e
ab scess b etw een th e left co lo n ic flex u re an d th e sp leen
T a b le 1
S u m m a ry o f p rin cip a l fin d in g s in five p a tie n ts w ith ste rco ra l p e rfo ra tio n o f th e n o rm a l co lo n .
P a tie n t A g e ,S e x C o m p la in ts a t P re se n ta tio n
0
a d m issio n(h o u rs)
m a le
75
52
g e n e rize d p e rito n itis2
m a le45
102
le ft u p p e r q u a d ra n t p e rito n itis3
fe m a le80
136
g e n e ra lize d p e rito m itis4
fe m a le76
92
le ft lo w e r q u a d ra n t p e rito m itis5
m a le63
19
R E S U L T S
In a ll fiv e p a tie n ts , th e re s e c te d c o lo n ic s e g m e n ts w e re e x a m in e d b y a p a th o lo g is t, b o th m a c ro s c o p ic a lly a n d h is to lo g ic a lly . M a ro s c o p ic a lly , th e p e rfo ra tio n s h a d n e c ro tic , in fla m m e d e d g e s ; fro m in s id e th e b o w e l, th e re w a s e x te n s i v e n e c ro s is o f m u c o s a c o n s id e ra b ly la rg e r th a n th e s ite o f th e a c tu a l p e rfo ra tio n .M ic ro s c o p ic a lly , n e c ro s is o f p e rfo ra tio n 's e d g e s w a s fo u n d (F ig . 2 ), w ith p h le g m o n o u s in fla m m a tio n o f th e b o w e l w a ll o f d iffe re n t d e g re e s d e p e n d in g o n th e d i's ta 'n c e fro m th e p e rfo ra tio n (F ig . 3 ).
A ll p a tie n ts w h o s u rv iv e d re c ie v e d life -lo n g m e d ic a tio n s w ith m ild a p e rie n ts . N o n e o f th e m p re s e n te d o b s tip a tio n o r c o m p la in ts a ttrib u ta b le to th e p re s e n c e o f fe c a lo m a s in th e c o lo n .
T h e o p e ra tiv e fin d in g s a re lis te d in T a b le 3 . In a ll p a tie n ts , la rg e fe c a lo m a s w e re fo u n d p lu g g in g th e d e fe c ts o f th e c o lo n ic w a lls , in a ll o f th e m th e c o lo n w a s fo u n d to b e fille d w ith m u ltip le fe c a lo m a s o f d iffe re n t s iz e fro m th e ile o c e c a l v a lv e u p to th e re c ta l a m p u la . N o a s s o c ia te d in tra -a b d o m in a l p a th o lo g y w a s fo u n d , in c lu d in g a ll p o s s ib le le s io n s th a t m ig h t c o n trib u te fo r a d iffic u lt g a s tro in te s tin a l p a s s a g e (a d h e s io n s , s tric tu re s , e tc .)
T h e o p e ra tio n s p e rfo rm e d a n d th e fin a l o u tc o m e a re p re s e n te d in T a b le 4 .
F ig u re 1 - A b d o m in a l u ltra so n o g ra p h y re ve a ls,a la rg e a b sce ss b e tw e e n th e le ft co lo n ic fle xu re a n d th e sp le e n .
D IS C U S S IO N
T h e re is a g e n e ra l a g re e m e n t in th e c u rre n t lite ra tu re re g a rd in g th e d e fin itio n o f s te rc o ra l p e rfo ra tio n o f th e n o rm a l c o lo n , n a m e ly " p e rfo ra tio n o f th e b o w e l d u e to p re s s u re n e c ro s is fro m h a rd fe c a l m a s s e s " .1 .2 T h e m o rp h o lo g ic c h a n g e s o f th e b o w e l w a ll a re ty p ic a l: th e p e rfo ra tio n 's e d g e s a re n e c ro tic a n d in tla m m e d ; o fte n a la rg e fe c a lo m a p lu g g s th e d e fe c t (F ig . 4),c o rre s p o n d in g in s iz e to th e p e rfo ra tio n , a n d b o th m a c ro s c o p ic a lly a n d m ic ro s c o p ic a lly th e re is u lc e ra tio n o f th e m u c o s a w ith a c u te a n d c h ro n ic in fla m m a tio n .3 A ll th e p a tie n ts fro m th is
s e rie s fu lfille d th e a b o v e -m e n tio n e d c rite ria s o a s to b e u n d o u b te d ly in c lu d e d in th is c a te g o ry .
T o th e b e s t o f o u r k n o w le d g e , o n ly 6 7 c a s e s o f s te rc o ra l p e rfo ra tio n o f th e n o rm a l c o lo n h a v e b e e n d e s c rib e d to d a te in th e E n g lis h la n g u a g e lite ra tu re .1 .4 .5 P a tie n t's a g e ra n g e b e tw e e n 1 6a n d 8 3 y e a rs (a v e ra g e , 5 9 .3 )
w ith b o th s e x e s b e in g a lm o s t e q u a lly a ffe c te d . T y p ic a lly , p a tie n ts a re e ld e rly a n d in a c tiv e ; a s a ru le , th e re is a lo n g h is to ry o f c o n s tip a tio n o r u s e o f c o n s tip a tin g a g e n ts s u c h a s a n tic h o lin e rg ic s , g a n g lio n ic b lo c k e rs , tric y c lic a n tid e p re s a n ts , p h e n o th ia z in e n e u ro le p tic s a n d s te ro id s , b u t th is d o e s n o t s e e m u n iv e rs a lly v a lid fo r e v e ry c a s e re p o rte d .v ) L o n g ta n d in g o b s tip a tio n h a s b e e n a s c rib e d to b a riu m e n e m a ? a s w e ll. R e c e n tly , s te rc o ra l p e rfo ra tio n o f th e c o lo n h a s b e e n a s c rib e d to in te n s iv e a c tiv a te d c h a rc o a l tre a tm e n t.5 In th is s e rie s , o n ly o n e o f th e p a tie n ts h a d n o h is to ry o f o b s tip a tio n -c a u s in g lo n g -te rm m e d ic a tio n , b u t
sa o P a u lo M e d ica l Jo u rn a l/R P M 1 1 4 (6 ): 1 3 1 7 -1 3 2 3 , 1 9 9 6 V E L IT C H K O V , N .; L O S A N O F F , J.; K JO S S E V , K .; G R IG O R O V , G .; V E Z D A R O V A ,
F igure 2 - H istology from the edges of a stercoral perforation displaying extensive necrosis and acute inflam m atory changes.
H em atoxylin & eosin, x 44.
F igure 3 - H istology from the sam e specim en taken in the close proxim ity of the actual perforation's site and displaying transm ural phlegm onous inflam m ation of the bow el w all. H em atoxylin &eosin,
x 4 4 .
T a b le 2
P a st m e d ica l h isto ry o f th e p a tie n t fro m th e se rie s. in d e e d , th is p a tie n t h a d s u ffe re d
fro m lo n g s ta n d in g o b s tip a tio n
w h ic h m ig h t b e th e lo g ic a l c a u s e
o f h is d is e a s e (C a s e 1 ). T h e re w a s
a h is to ry o f s u c h m e d ic a tio n
a m o n g th e o th e r p a tie n ts (T a b le 2 ),
a s w e ll a s th a t o f lo n g s ta n d i n g
o b s tip a tio n a s th e p o s s ib le re s u lt
o f th is m e d ic a tio n .
T h u s , w e c o n s id e r n e g le c te d
c o n s tip a tio n to b e a t le a s t o n e o f
th e m a jo r c a u s e s o f s te rc o ra l
p e rfo ra tio n o f th e c o lo n , a s
o u tlin e d b y m o s t o f th e o th e r
a u th o rs .I-3.5.C ,.x-" T h e a v o id a n c e o f
c o n s tip a tio n , p a rtic u la rly a m o n g
p a tie n ts tre a te d b y c o n s tip a tiv e
d ru g s , m a y e lim in a te , a t le a s t
th e o re tic a l1 y , th e ris k s o f s te rc o ra l
p e rfo ra tio n o f th e c o lo n . O th e r
fa c to rs th o u g h t to b e im p lic a te d
a re h e rn ia s , h a u s tra e , fo re ig n
b o d ie s , o r in te s tin a l s tric tu re s . lO In
fa c t, s u c h p a th o lo g y w a s n o t
p re s e n t a m o n g o u r p a tie n ts , th u s ,
w e c o n s id e r it to b e o f s e c o n d a ry
im p o rta n c e . A s e x c e p tio n s ,
s te rc o ra l p e rfo ra tio n s c a n b e fo u n d
a m o n g y o u n g p a tie n ts w ith s p in a l
c o rd in ju ry , o r a m o n g p a tie n ts
case
#
1
2
3
4
5
preceding long-term
m edication and other illnesses
uninvestigated, untreated
obstipation /6 years/
obstipation /8 years/ due to
8 years ganglionic blockers
therapy for hypertension
15 years of obstipation; 9
years of tricyclic anti
presants treatm ent for
de-pression
11 years of obstipation; 6
years of anticholinergics
for allergic state
19 years of uninvestigated
obstipation; 8 years of chroniodialysis for renal
insufficiency; 4 years of
phenothiazine neuroleptics
previous operations
appendectom y
22 years previously
hysterectom y
21 years previously
bilateral
nephroli-thotom y, respective Iy 10 and 3 years
4 /3 e m . p e rfo ra tio n o f th e ce cu m ; lo ca l b o w e l p h le g m o n a
su rro u n d in g th e p e rfo ra tio n ; g e n e ra lize d fe cu le n t p e rito n itis
Table 3
Operative findings for five patients with stercoral
perforation of the colon.
1.5/1.5
e m . p e rfo ra tio n o f th e m id sig m o id ; b o w e l p h le g m o n a u p to th e m id tra n sve rse co lo n ; le ft lo w e r q u a d ra n t p u ru le n t p e rito n itisth e re a h isto ry o f m a n ife ste d , p ro lo n g e d fe ca l im p a ctio n ,
w h ich is typ ica l fo r m o st o f th e ca se s fro m th e lite ra tu re .I-J
In p a tie n ts w ith ste rco ra l p e rfo ra tio n o f th e co lo n ,
a cu te a b d o m e n a n d fre e g a s b e lo w th e d ia p h ra g m is th e
u su a l m o d e o f p re se n ta tio n I.2 A IO , a lth o u g h , d e sp ite th e
h isto ry o f lo n g sta n d in g o b stip a tio n , th e co n d itio n is ra re ly
su sp e cte d a n d p a tie n ts a re sch e d u le d fo r e m e rg e n cy
la p a ro to m y fo r a h o llo w o rg a n p e rfo ra tio n . T h is w a s th e
ca se in a ll o u r p a tie n ts, in n o n e o f w h o m w a s th e co rre ct
d ia g n o sis su sp e cte d p re o p e ra tive ly. N e ve rth e le ss, in a
g ive n e ld e rly,. in a ctive p a tie n t w h o h a s a lo n g h isto ry o f
co n stip a tio n , e n o u g h d a ta m ig h t b e p re se n t to su sp e ct th is
e n tity. T h is, in a d d itio n to th e p o sitive fin d in g s o f
p n e u m o p e rito n e u m a n d e ve n tu a lly fe ca lo m a o n p la i n fi 1 m ,
sh o u ld fu rth e r co n trib u te to o n e 's su sp icio n .
E m e rg e n cy su rg e ry is u n d o u b te td Iy th e o n Iy
a p p ro p ria te tre a tm e n t fo r ste rco ra l p e rfo ra tio n o f th e co lo n .
A t o p e ra tio n , m o st p e rfo ra tio n s a re fo u n d to b e sin g le
(79
% ) a n d lo ca te d o n th e a n ti m e se n te ric a sp e ct o f th e sig m o id
a n d re cto sig m o id (1 7 % a n d 3 0 % ,re sp e ctive ly), fo llo w e d
b y th e ce cu m (9 % ), tra n sve rse co lo n
(7 %),
d e sce n d in gco lo n (5 % ), a n d sp le n ic fle xu re (2
%).11
Q u r C a se 2 se e m s e xtre m e ly in te re stin g in re sp e ct
to th e la ck o f fre e p e rfo ra tio n o f th e co lo n b u t o f th e
p re se n ce o f a w e ll-e sta b lish e d a b sce ss fille d w ith p u s a n d
fe ca lo m a s, to o u r kn o w le d g e , a ye t u n re p o rte d co n d itio n .
F in d in g s
1.5/1
e m . p e rfo ra tio n o f th e ce cu m ; p h le g m o n a o f th e b o w e l w a ll u p to th e m id a sce n d in g co lo n ; g e n e ra lize d p u ru le n tp e rito n itis
2/1
e m . p e rfo ra tio n o f th e m id sig m o id ;1/1.5
e m . p e rfo ra tio n o f th e u p p e r re ctu m ; b o w e l p h le g m o n a u p .to th e m id tra n sve rseco lo n ; g e n e ra lize d fe cu le n t p e rito n itis
2/2.5
e m . p e rfo ra tio n o f th e sp le n ic fle xu re ; a b sce ss b e tw e e n th e la sse r, sto m a ch , sp le e n , a n d a b d o m in a l w a ll fille d w ith m u ltip le fe ca lo m a s; se ro u s p e rito n itisFigure 4 -
A rtist's d ra w in g illu stra tin g ste rco ra l p e rfo ra tio n th esig m o id co lo n w ith a la rg e co n g lo m e ra te o f fe ca lo m a s p lu g g in g th e d e fe ct. T h e e n tire co lo n is fille d w ith m u ltip le fe ca lo m a s, fro m th e ile o ce ca l va lve u p to th e re ctu m .
w ith o u t a n y h isto ry o f lo n g sta n d in g o b stip a tio n .5.l) T h e re
a re fe w re p o rts o f a p e rfo ra tio n a m o n g p a tie n ts w ith
ch ro n ic re n a l fa ilu re o r a fte r re n a l tra n sp la n ta tio n . 1.6In o u r
fo u rth ca se , b o th u se o f co n stip a tive a g e n t a n d ch ro n ic
re n a l fa ilu re m a y h a ve co n trib u te d to th e o ccu re n ce o f a
ste rco ra l p e rfo ra tio n . F u rth e rm o re , it
m u st b e n o te d th a t th e
p a th o p h ysio lo g ica l e ffe cts o f b o th
ch ro n ic re n a l fa ilu re a n d p h e n o th ia zin e
n e u ro le p tics a re sim ila r a n d
su p e rim p o sin g , le a d in g ra th e r C a se #
"su cce ssfu lly" to o b stip a tio n a n d
fe ca lo m a fo rm a tio n .
L o g ica lly, ste rco ra l p e rfo ra tio n is
o b vio u sly p re ce d e d b y fe ca l im p a ctio n ,
d e fin e d a s "co lle ctio n o f p u tty-like fe ce s, 2
th a t p ro d u ce s a h a rd e n e d , co n cre te m a ss
a n d b lo cks o r im p e d e s n o rm a l
d e fe ca tio n ".7 F e ca l im p a ctio n is
co n sid e re d to b e e sp e cia lly d a n g e ro u s 3
w h e n p ro lo n g e d ,1 2 a n d a p a rt fro m
. a lte ra tio n s in co lo n ic p a ssa g e , it m a y le a d
to p ro te a n se q u e la e su ch , a s
h yd ro n e p h ro sis7 o r lim b isch e m ia .13 4
P ro m p t re co g n itio n is th u s e xtre m e ly
im p o rta n t a s th e re is a lw a ys a risk o f th e
p a tie n t o f d e ve lo p in g life th re a te n in g
co n d itio n s. In fa ct, a ll o u r p a tie n ts w e re 5
e m e rg e n cy ca se s, w ith p e rfo ra tio n s th a t
a lre a d y h a d o ccu re d . In n o n e o f th e m w a s
sa o P a u lo M e d ica l Jo u rn a l/R P M 1 1 4 (6 ): 1 3 1 7 -1 3 2 3 , 1 9 9 6 V E L IT C H K O V , N .; L O S A N O F F , J.; K JO S S E V , K .; G R IG O R O V , G .; V E Z D A R O V A ,
Table 4
Operative procedures, outcome and duration of follow-up.
C a s e P ro c e d u re O u tc o m e F o llo w -u p
R ig h t c o le c to m y ; d o u b le S u rv iv e d 2 .5 y e a rs ; re s to ra tio n
b a rre lle d ile o tra n s v e r- o f b o w e l c o n tin u ity ,
s o s to m y ; in tra o p e ra tiv e c o lo n o s c o p y
p e rito n e a l a n d o rth o g ra - n e g a tiv e
d e c o lo n ic irrig a tio n
2 L e ft e x te n d e d c o le c to m y , S u rv iv e d 1 3 m o n th s ; re s to ra tio n
s p le n e c to m y ; e n d tra n s - o f b o w e l c o n tin u ity ,
v e rs o s to m y ; d is ta l s ig - c o lo n o s c o p y
m o id m u c o u s fis tu la , n e g a tiv e
. d ra in a g e , in tra o p e ra tiv e
p e rito n e a l irrig a tio n ,a n d
o rth o g ra d e c o lo n ic la v a g e
3 R e s e c tio n o f s ig m o id ; D ie d
H a rtm a n n 's o p e ra tio n ;
m ilk in g o f e n tire c o lo n
th ro u g h th e s to m a , la p a
-ro s to m y
4 R ig h t c o le c to m y , d o u b le - D ie d
b a rre lle d i1 e o tra n s v e
r-s o r-s to m y , m ilk in g o f e n tire
c o lo n , la p a ro s to m y
5 R e s e c tio n o f s ig m o id , S u rv iv e d b o w e l re s to ra tio n n o t
H a rtm a n n 's o p e ra tio n , p e rfo rm e d b e c a u s e
e v a c u a tio n o f p u s w ith o f p o o r ris k ; d ie d o f
d ra in a g e , o rth o g ra d e m y o c a rd ia l in fa rc tio n
c o lo n ic irrig a tio n 2 y e a rs a fte r
I n o u r o p in io n , a n a b s c e s s in tim a te ly a d h e r e n t to th e c o lo n
in a p a tie n t w ith lo n g s ta n d in g c o n s tip a tio n s h o u ld a ls o
a r iz e s u s p ic io n f o r a w a lle d - o f s te r c o r a l p e r f o r a tio n .
T h e in f la m m a to r y p r o c e s s a s a r u le in v o lv e s a w h o le
s e g m e n t o f th e c o lo n2
; th e la tte r is o f te n lo a d e d w ith h a r d
s c ib a la . X .lJ F u r th e r m o r e , th e n e c r o tic c h a n g e s o n th e in n e r
s u r f a c e o f th e b o w e l e x te n d e d w id e f r o m p e r f o r a tio n 's
e d g e s .1 .3 A m o n g th e c a s e s d e s c r ib e d , a ll p r e s e n te d
p h le g m o n o u s in f la m m a tio n o f a w h o le c o lo n ic s e g m e n t,
th e c o lo n o f e a c h w a s f o u n d to b e lo a d e d w ith m u ltip le
f e c a lo m a s , a n d th e n e c r o tic c h a n g e s o n th e in n e r s u r f a c e
o f th e b o w e l e x te n d e d c o n s id e r a b ly f r o m th e a c tu a l
p e r f o r a tio n 's e d g e s . A ll th is s h o u ld b e a lw a y s ta k e n in to
c o n s id e r a tio n in o r d e r to p r e v e n t in a d e q u a te s u r g ic a l
tr e a tm e n t c o n s is tin g o f s im p le c lo s u r e o f th e le s io n o r o f a
lim ite d r e s e c tio n , w ith o u t c le a n in g th e r e s id u a l c o lo n f r o m
a ll th e r e d u n d a n t f e c a l m a te r ia l.
T h e m o s t f r e q u e n tly p e r f o r m e d p r o c e d u r e h a v in g th e
h ig h e s t s u r v iv a l r a te is r e p o r te d to b e r e s e c tio n w ith
c o lo s to m y .3 .6 .x H o w e v e r , in o r d e r to e s c a p e th e r is k o f a
f u r th e r p e r f o r a tio n d u r in g th e p o s to p e r a ti v e p e r io d , c a u s e d
Table
5
Graphic algorithm
fo r d e c is io nmaking in managing patients with stercoral perforation of the colon.
E ld e rly p a tie n t w ith a h is to ry o f lo n g s ta n d in g o b s tip a tio n o r a h is to ry o f lo n g -te rm tre a tm e n t w ith c o n s tip a tiv e a g e n ts , p re s e n tin g a c u te a b d o m e n
s u s p ic io n o f s te rc o ra l p e rfo ra tio n o f th e c o lo n
fre e g a s b e lo w th e d ia p h ra g m
I
I
I
a b d o m in a l x -ra yI
I
n o fre e g a s , n o g a s -flu id le v e ls
e m e rg e n c y la p a ro to m y
p e rfo ra tio n o f:
c e c u m o r a s c e n d in g c o lo n
rig h t c o le c to m y , ile o tra n s v e rs o s to m y a n d G C L
tra n s v e rs e c o lo n
re s e c tio n , tra n s v e rs o s to m y a n d d is ta l m u c o u s fis tu la , G C L o f b o th le ft a n d rig h t c o lo n
c o n s id e rin g o th e r d ia g n o s is + fu rth e r e v a lu a tio n
s p le n ic fle x u re o r d e s c e n d in g c o lo n
le ft c o le c to m y , tra n s v e rs o s to m y a n d d is ta l m u c o u s fis tu la o r H a rtm a n n 's o p e ra tio n , G C L
s ig m o id , re c to s ig m o id o r re c tu m
re s ~ c tio n ,
H a rtm a n n 's o p e ra tio n a n d G C L
a lw a y s c o n s id e r la p a ro s to m y in c a s e s o f d e la y e d o r g e n e ra liz e d p e rito n itis
G C L - o rth o g ra d e c o lo n ic la v a g e
lavage m ust be included as an essential part of the com plex
surgical
treatm ent.
4In tw o of our cases,
m ilking
of the
colon
w as perform ed
instead
of lavage as there w ere no
facilities
for the latter. N evertheless,
the colon of all our
patients
w as cleaned
intraoperatively
and no perforations
occurred
during
the
postoperative
period
nor
w ere
perforations
discovered
at autopsy in the tw o patients w ho
died. T his w as due to their both their advanced
age and
degree
of intoxication
but,
it is our opinion
that,
in
advanced
cases,
laparostom y
w ith
repeat
lavages
and
debridem ent
m ay probably
aid in achieving
a higher
survival
figure.
M ortality
is still unacceptably
high in this condition,
approaching
35% .1-3
P ossible.reasons
for
the
poor
prognosis
include
an older
patient
age
group,
rapid
clinical deterioration
im m ediately
follow ing
perforation,
and
w ell-established
fecal
peritonitis
at the
tim e
of
surgery.
IIT he
results
can
be im proved
only
by rapid
surgical
intervention
and
aggressive
resuscitation.
O therw ise,
longstanding
obstipation
should
never
be
neglected
but instead,
actively
treated.
Interestingly,
no
uniform
guidelines
for surgical
treatm ent
have
been
outlined
to date in the literature.
B ased on our experience
w ith this series of five patients,
and on the data from the
Iiterature,
the
fo 1I0w i ng graph ic algori th m can
be
proposed
to contribute
to m ore appropriately
dealing
w ith
stercoral
perforation
of the colon from the surgical
poi nt
of view (T able 5).
RESUMO
o
tra b a lh o a p re s e n ta u m a s e rie c o n s e c u tiv a d e 5 p a c ie n te s c o m p e rfu ra 9 a o e s te rc o ra l d e c o lo n . Q u a tro p a c ie n te s a p re s e n ta v a mp e rfu ra 9 a o liv re e u m d e le s u m a b s c e s s o e n tre a fle x a o e s p le n ic a , b a 9 0 e o rg a o s v iz in h o s , u m a e n tid a d e a in d a n a o re la ta d a .
T o d o s o s p a c ie n te s fo ra m s u b m e tid o s
a
c iru rg ia d e e m e rg e n c ia , in c lu in d o la p a ro to m ia c o m re p e tid a s e x p lo ra 9 0 e s e la v a g e n se m d o is d e le s . A e tio lo g ia , fis io p a to lo g ia e tra ta m e n to d e s s a a fe c 9 a o fo i re v is a d a .
E
p ro p o s to u m g ra fic o a lg a ritm ic o p a rato m a d a d e d e c is a o e m c a s o s d e p e rfu ra 9 a o e s te rc o ra l d o c o lo n .
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