The surgical management of left-sided colon emergencies such as diverticular disease and colorectal cancer is moving towards a single surgical procedure but patient selection for a single or staged procedure appears to remain controversial. The choice of operative procedure depends on the patient's health and a single-stage operation is preferable and often achievable even in elderly people with peritonitis, as a result of the advances in intensive care medicine and the management of peritoneal sepsis. Improvement in morbidity, mortality and stoma formation rates is enhanced by the grade of surgeon operating.
In a retrospective study covering 10 years by Zorcolo et al. (2003), 336 patients in a large UK hospital, who presented with an acute abdomen, underwent surgery for left-sided diverticular disease or colorectal cancer without bowel preparation. Patients were operated on by surgeons whose major interest was either colorectal surgery or upper gastrointestinal conditions. Patients were assigned to a particular surgeon by chance, although the colorectal surgeons tended to diagnose and treat more cases.
Of the 336 patients, 65.8% were operated on by the colorectal surgeons and 34.2% by the upper gastrointestinal team. Complicated diverticular disease was present in 58.6% of patients; 193 patients were operated on within 24 hours of admission and the remainder were operated on within 48 hours. Within the whole cohort consultants were present in 197 of the cases, operating in 115 cases and assisting in 82 cases. Registrars were unsupervised in 139 cases. Of the 336 cases, primary anastomosis was made in 184 cases and 15 had a defunctioning stoma. More patients with colorectal cancer had a primary anastomosis compared with those with diverticular disease. Primary anastomosis frequency was indicated by the experience of the operator, with consultants achieving 699% and trainees 47%. In patients with diverticular disease the figures were more marked, with consultants achieving 72.7% and trainees 29.8% for a primary anastomosis. In patients who had diverticular disease complicated by peritonitis, a one-stage operation was performed by colorectal surgeons in 37.7% as against 11.5% by non-colorectal surgeons (Zorcolo et al., 2003).
There is an obvious advantage in a one-stage procedure even if sepsis is present, provided that the patient is appropriately selected. Primary anastomosis excludes the high complication rate of reversing a Hartmann's procedure and closing a colostomy. The data from this study suggest that colorectal emergencies have a better outcome if managed by specialist surgeons, reducing stoma rates and complication rates, and with lower mortality rates.
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