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Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease

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Abstract

Background: Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis.

Methods: One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin. Variables recorded included duration of the surgical procedure, need for blood transfusion, length of hospital stay, operative mortality and morbidity, staple-ring disruption, and radiologic and clinical leakage. Anastomotic stenosis and recurrence of diverticular disease were noted.

Results: Surgical time was superior in the IMAS group. Radiologic and clinical leakages were significantly higher in group B (P = 0.02, P = 0.03, respectively). In group A a significant lower number of staple-ring disruptions was observed, evolving into clinical dehiscence.

Conclusion: Preserving the natural blood supply to the rectum and the ensuing use of a healthy well-nourished rectal stump are suggested as the main aspects of IMAS in preventing and healing leakage of colorectal anastomosis.

Section snippets

Patients

Between 1982 and 1996, 163 consecutive patients with sigmoid obstruction secondary to diverticulitis were referred for treatment to the Department of Surgery of the University of Cagliari Medical School, to the Department of Surgery and General Thoracic Surgery of the University of Perugia Medical School, or to the 1st Department of Surgery of the University of Rome “La Sapienza” Medical School. Patients with recurrent episodes of inflammation, chronic stricture, and intractable symptoms were

Surgical technique

On entry into the abdomen, blunt dissection of the developmental adhesion between the greater omentum and transverse colon was carried out; the sigmoid, descending colon, splenic flexure, and related mesentery were extensively mobilized. Splenic flexure was mobilized, transverse mesocolon was detached from the inferior pancreatic margin, and then the inferior mesenteric vein doubly ligated and sectioned at its confluence with the splenic trunk.

Patients

Data from the two groups were shown to be homogeneous for sex, age, clinical condition, comorbidity, and timing of presentation (Table 1).

Surgery

The mean surgical time was 158 ± 13.2 minutes in group A and 155 ± 15.8 minutes in group B (P = 0.7). Anastomoses were performed at rectosigmoid junction in all cases. The mean number of transfused blood units was 1.1 ± 0.4 in group A and 1.2 ± 0.5 in group B (P = 0.9).

Early outcome

The mean length of hospital stay was 13.4 ± 2.8 days in group A and 13.6 ± 3.4 days in

Comments

Tension at the anastomotic level, septic contamination of the operative field, structural and ischemic alterations of the anastomotic stumps, and technical flaws are the most important factors affecting the primary healing of intestinal anastomoses [18], [19], [20]. In the current series, in addition to the usual requirements, further technical measures were adopted specifically to enhance the safety of the anastomosis. Coloepiploic detachment has been preferred to the more generally adopted

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