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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 40-43

Experience with on-table colonic lavage using low-cost indigenous technique in obstructive left-sided colorectal pathology: A prospective study


1 Department of Surgery, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
2 Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
3 Department of Pediatric Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Web Publication14-Jul-2014

Correspondence Address:
Shehtaj Khan
Department of Surgery, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh - 202 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.136712

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  Abstract 

Background: Preoperative mechanical bowel preparation (MBP) for elective colorectal surgery has been criticized, but is still in use because of fear of fecal load and peritoneal contamination. Experience with an indigenous low cost technique for on-table colonic lavage (OTCL) in obstructive left-sided colonic pathology has been described. OTCL would be a step towards discouraging MBP before colorectal surgery.
Patients and Methods: Fourteen patients for elective colorectal surgery without preoperative bowel preparation were evaluated and found with impacted fecal matter and loaded colon intraoperatively. Instead of two-stage procedure, we did OTCL by our own devised method followed by a single-stage curative resection.
Results: All patients had successful resection and primary anastomosis of their lesions. Mean time for lavage was 21 min. There was no peritoneal contamination. No postoperative anesthesia or procedure-related complication was encountered. No clinical anastomotic leak or mortality was encountered. In one patient, surgical site wound infection occurred.
Conclusion: In cases where bowel preparation is not done preoperatively and single-stage procedure discredited only because of impacted fecal matter, OTCL should be taken into account. Our technique of OTCL should be employed as it is simple, safe, and cheap and would prove to be a step towards discouraging preoperative MBP for elective colorectal surgery, especially in resource limited setting.

Keywords: Colonic lavage, colorectal surgery, mechanical bowel preparation


How to cite this article:
Bansal J, Khan S, Jenaw R, Ahmad R. Experience with on-table colonic lavage using low-cost indigenous technique in obstructive left-sided colorectal pathology: A prospective study. Arch Int Surg 2014;4:40-3

How to cite this URL:
Bansal J, Khan S, Jenaw R, Ahmad R. Experience with on-table colonic lavage using low-cost indigenous technique in obstructive left-sided colorectal pathology: A prospective study. Arch Int Surg [serial online] 2014 [cited 2024 Mar 1];4:40-3. Available from: https://www.archintsurg.org/text.asp?2014/4/1/40/136712


  Introduction Top


Mechanical bowel preparation (MBP) before elective abdominal surgery was introduced in the late 20 th century, and is regarded as one of the most important factors for safe elective colorectal surgery. [1] Patients with acute malignant colonic obstruction, diverticulitis, sigmoid volvulus, and penetrating colonic injuries were often managed by the traditional method in emergency situation either as three- or two-stage procedure (Hartmann's) because MBP was almost impossible in such cases. It was only after Muir in 1968, who introduced cleansing the colon at operation table, that single-stage surgery became possible in these situations where condition permitted. [2] The Cochrane review concluded that there is no convincing evidence that MBP is associated with reduced rates of anastomotic leakage after elective colorectal surgery. [3] On the contrary, there is evidence that this intervention may be associated with an increased rate of anastomotic leakage and wound complications. [3] Although in a recent survey of members of the American Society of Colon Rectum Surgeons, 99% of respondents routinely use MBP, although 10% question its benefits. [4]

In our center routine MBP is not done, but in cases of obstructive left-sided colonic lesions intra-operative colonic lavage is done to cleanse the bowel of impacted fecal matter to prevent peritoneal spillage. Here we describe our experience with an indigenous, low cost technique of on-table colonic lavage (OTCL) for bowel cleansing used in 14 patients with left-sided obstructive colonic lesions.


  Patients and Methods Top


From July 2010 to June 2011, 16 consecutive patients with left-sided obstructive colorectal pathology were operated in our center using the procedure described below. Preoperative MBP was not done as a routine and loaded colon with impacted fecal matter was encountered intraoperatively. We devised an indigenous technique for OTCL with slight modification of Dudley original description. [5] Resection with primary anastomosis was done in all cases. Two patients got diverting ileostomy because in one lower doughnut was incomplete with circular stapler anastomosis and in the other one to protect ultra-low anterior resection and were excluded from the study.

All patients were given intravenous antibiotics at the induction of anesthesia and were continued for 48 h postoperatively. Wound infection was defined as serous or purulent discharge from the incision. Anastomotic dehiscence was diagnosed on clinical grounds alone. Institutional review board approval for the study was obtained.

At laparotomy, the pathological lesion and adjacent colon were mobilized, the colon was divided distal to the pathological lesion taking adequate safe margins. Four to six centimeters proximal to growth bowel was divided and resected specimen taken out. Proximal cut end was cannulated with sterile, long, corrugated washing machine hosepipe and secured with autoclaved simple thread. The other end of hose pipe drained into the bucket. After executing appendectomy, 16 Fr Ryle's tube was inserted into the lumen of large bowel through appendicular stump and secured with simple suture. The Ryle's tube was connected to transurethral resection (TUR) set, which was connected to the suspended 2 L warmed normal saline bottles. Irrigation was started and with little manipulation all the impacted bowel content emptied in the bucket through hose pipe. Once effluent became clear, irrigation was stopped, Ryle's tube removed and appendicular stump closed securely. At the end of procedure, two bowel clamps were applied 4-6 cm proximal to the proximal level of resection on the hosepipe side. Bowel was divided in between clamps, hosepipe discarded with devitalized bowel segment, and that bowel segment sent for histopathological examination (HPE) along with previously resected specimen after marking them appropriately. Both cut ends were anastomosed either using circular stapler or hand sewn with interrupted single layer suture. In the immediate postoperative period, two finger dilatation of anal sphincter was done to relive postoperative spasm with gloved finger lubricated with lignocaine jelly. Single senior surgeon executed all operative procedure and OTCL in all these 14 patients. Washing machine hosepipe was disinfected by keeping it in glutaraldehyde solution for 20 min. Oral feeding was allowed on return of bowel activity.


  Results Top


Fourteen patients were studied prospectively. Age ranged from 22 to 70 (mean 50.6) years; of these, six were males and eight females. Rectum was the commonest site (seven, 50%), followed by rectosigmoid (35.72%), sigmoid (7.14%), and descending colon (7.14%). Pathology as confirmed by HPE was adenocarcinoma rectum (seven), adenocarcinoma rectosigmoid (four), adenocarcinoma sigmoid (one), adenocarcinoma descending colon (one), and inflammatory stricture rectosigmoid (one). All the patients had undergone single-stage curative resection. Average time for OTCL was 21.21 ± 2.88 min (ranging 17-27 min) and total operative time was 121.78 ± 18.77 min. On an average, 5 L of normal saline was sufficient for colonic lavage, but in one patient we required 10 L saline. Total cost of OTCL was about 5 US dollar only. This included the cost of Ryle's tube, TUR set, washing machine hose pipe, and normal saline and was quite affordable.

No adverse event related to anesthesia or surgical procedure was encountered in the immediate postoperative period. Mean duration of hospital stay was 7 days ranging from 5 to 10 days. Superficial wound infection occurred only in one patient (7.14%) that required initiation of antibiotic treatment as per culture sensitivity report. No clinical anastomotic leak and postoperative mortality was noted.


  Discussion Top


Early observational studies and long-standing clinical experience have shown that removal of fecal matter from the bowel lumen prior to surgery has been associated with decreased patient morbidity and mortality. [3] There is, however, a paucity of data showing that MBP by itself, separately from other operative and perioperative measures, actually reduces the rate of infectious complications. [6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] This is in keeping with common belief that clinical practice of MBP often is not evidence based, but is based on tradition, previous teaching, and anecdotal.

The major advantage of per-operative colonic lavage is that it enables primary anastomosis after curative resection of pathology in single stage. It results in decreased associated morbidity and shorter hospital stay than a multistage procedure. On-table lavage after the anastomosis is constructed has also been described. [17] Dafnis described an uncomplicated and safe way to perform OTCL [18] and Khaira and Jewkes described rapid OTCL with minimal risk of peritoneal contamination. [19] Büyükgebiz described a novel technique of in-sleeve on-table colonic irrigation in telescopic fashion and intraoperative colonoscopy and concluded that it is safe, easy to apply, shortens the operative period, and also allows a convenient route for intraoperative colonoscopy. [20] Despite the extensive variation and methodology, on-table lavage did not gain widespread acceptance among surgeons. Previously, it was argued that colonic lavage takes more time, so only decompression was advised rather than lavage; but colon, loaded with impacted fecal matter, might be too cumbersome to empty alone by decompression. Moreover, it may lead to unexpected iatrogenic injury and predispose patient to postoperative ileus. [21]

Colon is known for its precarious blood supply, so extensive dissection and mobilization of colon to accomplish on-table colonic irrigation predispose the colon to mesenteric vascular ischemia. In our method, minimal manipulation of the bowel was done, there was no procedure-related obstacle like spillage of fecal content, contamination of operative field, blockage of tube, slippage of ligature, or difficulty in executing the procedure. This was because we used the hosepipe of a washing machine with a large bore to avoid blockage and having corrugation to avoid slippage of ligature, hence, no consequent spillage of fecal content into the operative field. This washing machine hosepipe was easily available and disinfected.


  Conclusion Top


In cases where bowel preparation is not done preoperatively and single-stage procedure discredited only because of impacted fecal matter, OTCL should be taken into account. Our technique of OTCL should be employed as it is simple, safe, and cheap and would prove to be a step towards discouraging preoperative MBP for elective colorectal surgery, especially in a resource-limited setting.

 
  References Top

1.Zmora O, Pikarsky AJ, Wexner SD. Bowel preparation for colorectal surgery. Dis Colon Rectum 2001;44:1537-49.  Back to cited text no. 1
    
2.Muir EG. Safety in colonic resection. Proc R Soc Med 1968;61:401-8.  Back to cited text no. 2
    
3.Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2005;CD001544.  Back to cited text no. 3
    
4.Zmora O, Wexner SD, Hajjar L, Park T, Efron JE, Nogueras JJ, et al. Trends in preparation for colorectal surgery: Survey of members of the American Society of Colon and Rectal Surgeons. Am Surg 2003;69:150-4.  Back to cited text no. 4
    
5.Dudley HA, Radcliffe AG, McGeehan D. Intraoperative irrigation of the colon to permit primary anastomosis. Br J Surg 1980;67:80-1.  Back to cited text no. 5
    
6.Zmora O, Mahajna A, Bar-Zakai B, Rosin D, Hershko D, Shabtai M, et al. Colon and rectal surgery without mechanical bowel preparation: A randomized prospective trial. Ann Surg 2003;237:363-7.  Back to cited text no. 6
    
7.Santos JC JR, Batista J, Sirimarco MT, Guimarães AS, Levy CE. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg 1994;81:1673-6.  Back to cited text no. 7
    
8.Bucher P, Gervaz P, Soravia C, Mermillod B, Erne M, Morel P. Randomized clinical trial of mechanical bowel preparation versus no preparation before elective left-sided colorectal surgery. Br J Surg 2005;92:409-14.  Back to cited text no. 8
    
9.Fa-Si-Oen P, Roumen R, Buitenweg J, van de Velde C, van Geldere D, Putter H, et al. Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery. Dis Colon Rectum 2005;48:1509-16.  Back to cited text no. 9
    
10.Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg 2005;140:285-8.  Back to cited text no. 10
    
11.Jung B, Pahlman L, Nystrom PO, Nilsson E; Mechanical Bowel Preparation Study Group. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg 2007;94:689-95.  Back to cited text no. 11
    
12.Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical bowel preparation for elective colorectal surgery. Arch Surg 2004;139:1359-64.  Back to cited text no. 12
    
13.Platell C, Hall J. What is the role of mechanical bowel preparation in patients undergoing colorectal surgery? Dis Colon Rectum 1998;41:875-82.  Back to cited text no. 13
    
14.Slim K, Vicaut E, Panis Y, Chipponi J. Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg 2004;91:1125-30.  Back to cited text no. 14
    
15.Pineda CE, Shelton AA, Hernandez-Boussard T, Morton JM, Welton ML. Mechanical bowel preparation in intestinal surgery: A meta-analysis and review of the literature. J Gastrointest Surg 2008;12:2037-44.  Back to cited text no. 15
    
16.Scabini S1, Rimini E, Romairone E, Scordamaglia R, Damiani G, Pertile D, et al. Colon and rectal surgery for cancer without mechanical bowel preparation: One-center randomized prospective trial. World J Surg Oncol 2010;8:35.  Back to cited text no. 16
    
17.Sitzler PJ, Stephenson BR, Nicholls RJ. On-table colonic lavage: An alternative. J R Coll Surg Edinb 1998;43:276-7.  Back to cited text no. 17
    
18.Dafnis G. An uncomplicated and safe way to perform on-table colonic lavage. Tech Coloproctol 2004;8:189-91.  Back to cited text no. 18
    
19.Khaira HS, Jewkes A. Rapid on-table colonic lavage with minimal mess. Ann R Coll Surg Engl 1999;81:399-400.  Back to cited text no. 19
    
20.Büyükgebiz O. In-sleeve on-table colonic irrigation in telescopic fashion and intraoperative colonoscopy: A novel technique. Ulus Travma Acil Cerrahi Derg 2010;16:323-6.  Back to cited text no. 20
    
21.Naraynsingh V, Rampaul R, Maharaj D, Kuruvilla T, Ramcharan K, Pouchet B. Prospective study of primary anastomosis without colonic lavage for patients with an obstructed left colon. Br J Surg 1999;86:1341-3.  Back to cited text no. 21
    




 

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Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References

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