Indications for colectomy include benign and malignant diseases (Table 1). The most common benign conditions are diverticulitis, lower gastrointestinal (GI) hemorrhage, ulcerative colitis, sigmoid volvulus, and penetrating trauma. The most common malignant condition is adenocarcinoma of the colon.
Colectomy is the standard of care for adenocarcinoma of the colon. Most segmental colectomies for carcinoma are performed with intent to cure the patient. Even with advanced (metastatic) disease, colectomy may be required to palliate bleeding or obstruction.
When colectomy is being considered for benign conditions many variables are considered prior to recommending surgery. For example, in cases of sigmoid diverticulitis or sigmoid volvulus, recurrence rates are important. After one episode of sigmoid diverticulitis, the risk of a second episode is about 15-20%. However, if a patient has a second episode, the risk of subsequent attacks of diverticulitis rises to about 50%. Therefore, most surgeons recommend elective segmental colectomy after resolution of a second episode.
Conversely, with sigmoid volvulus recurrence rate after a first episode is 40-80%. Therefore, if a patients is fit enough to tolerate surgery, sigmoid resection is recommended after one episode of sigmoid volvulus. The general medical condition of the patient is important in all of these decisions.
In patients over 50 yr of age, significant lower GI hemorrhage is frequently a result of a bleeding colonic diverticula or a vascular ectasia (1). Bleeding from the right colon (ascending colon and cecum) is more common than bleeding from the left colon (descending and sigmoid colon). The bleeding stops spontaneously in more than 70% of patients. Efforts are made to identify the precise area of hemorrhage. In patients where hemorrhage has stopped, colonoscopy may identify the pathology. In patients with ongoing bleeding, a tagged RBC nuclear scan +/or angiography are utilized to localize the bleeding. Localization is important in order to limit the extent of colonic resection, should the patient come to operation. Patients with active bleeding, massive bleeding (requiring greater than 4 U of blood transfusion in 24 h) or recurrent bleeding are considered for surgery. Patients with lower GI bleeding who are in prohibitive medical condition for surgery may be considered for embolization therapy via a selective mesenteric angiogram.
Ulcerative colitis is a surgically curable disease via total colectomy. The patient may then have a permanent ileostomy (see chapter on small intestine) or an ileo-anal anastomosis. Unlike ulcerative colitis, granulomatous colitis may be appropriately treated by segmental colectomy (2).
Urgent colonic surgery may not allow for bowel preparation. Examples would include massive lower GI hemorrhage or colonic obstruction. In the former case, some "bowel preparation" has been accomplished by the cathartic effect of blood in the GI tract. With colonic obstruction however, the surgeon faces a colon full of solid stool with the highest bacterial counts. With urgent colon surgery on unprepped colon, a surgeon may need to perform a colostomy in order to prevent infectious complications, particularly leakage of an anastomosis. The patient should be forewarned of this distinct probability.
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