MALIGNANT OBSTRUCTION OF THE LEFT COLON

The management of malignant obstruction of the colon distal to the spl enic flexure is controversial. The 'traditional' three-stage procedure is marred by frequent failure to complete the planned sequence of ope rations and a resulting high permanent stoma rate. At each stage the m ortality rate (7 per cent) and morbidity rate (30 per cent) are signif icant. The mortality rate following primary resection with delayed ana stomosis (Hartmann's procedure) is 10 per cent. However, many patients experience complications and only 60 per cent have the stoma reversed . Primary anastomosis may be performed after subtotal or segmental col onic resection. The reported mortality rate is about 10 per cent with anastomotic leakage in 4-6 per cent, but cases are often carefully sel ected. It is difficult to suggest clear guidelines based on existing d ata. Although there are strong arguments in favour of a single-stage p rocedure, surgeons must decide whether available resources and local c ircumstances permit this. The alternative is Hartmann's procedure or r eferral to a surgeon with an interest in emergency colorectal surgery.