Sigmoid volvulus: long-term clinical outcome and review of the literature.
Objective. Little has been published regarding long-term surgical
outcome after the initial management of acute sigmoid colon volvulus.
Methods. Patients undergoing primary resection and anastomosis (PRA) or Hartmann's procedure (HP) for sigmoid volvulus between September 1992 and August 2000 were reviewed. Eligible patients who had had the initial procedure at least 5 years previously were contacted and completed a questionnaire regarding recurrence, current symptoms and bowel habits.
Results. Data on 42 PRA patients and 36 HP patients were analysed. Follow-up (mean 7.2 years, range 5-11 years) was completed for 63 patients (37 PRA, 26 HP). Restoration of bowel continuity was successfully performed in 25 of 26 HP patients. No patient had megacolon. Constipation was reported by 83% of PRA and 65% of HP patients. Of these patients, 51% regularly used laxatives. No patient complained of incontinence, and no recurrences of sigmoid volvulus were recorded during the follow-up period.
Conclusion. Sigmoidectomy with primary anastomosis is a good option for the definitive management of sigmoid volvulus. Despite the high constipation rate, no recurrence occurred during long-term follow-up.
Excision (Surgery) (Health aspects)
Intestines (Patient outcomes)
Intestines (Care and treatment)
Kessaf, Aslar A.
Ayhan, Kuzu M.
|Publication:||Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 South African Medical Association ISSN: 0038-2361|
|Issue:||Date: Feb, 2012 Source Volume: 50 Source Issue: 1|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: Turkey Geographic Code: 7TURK Turkey|
Sigmoid colon volvulus is still one of the most frequent reasons
for emergency large-bowel surgery in certain parts of the world. (1-3)
This condition may result in acute large-bowel obstruction and has the
potential for high morbidity and mortality, especially in the elderly.
Numerous surgical and non-surgical treatments have been described to relieve this condition. (10-19) Surgical procedures may be non-resective or resective, but lack of randomised trials has led to controversy regarding the optimal treatment for sigmoid volvulus. Non-operative management of acute sigmoid volvulus offers a potentially better treatment option in frail patients. (6) However, since the recurrence rate is high and this conservative approach is not curative, many surgeons resort to subsequent operative treatment. (5,20-24) Simple operative detorsion, various methods of sigmoid fixation, extraperitonealisation of non-gangrenous sigmoid volvulus, mesosigmoidoplasty (-pexy), percutaneous sigmoidostomy, and primary resection with or without anastomosis have all been advocated as surgical treatments for sigmoid volvulus. (16,18,19,21,25,26)
Although morbidity and mortality figures play an important role in determining the safety of a surgical procedure, information regarding long-term clinical outcome strongly influences wide acceptance of a surgical technique. The ideal treatment in large-bowel obstruction due to sigmoid volvulus should result not only in low mortality and morbidity in the short term, but also in low recurrence rates in the long term. The purpose of this prospective study was to assess the clinical outcomes of patients who had undergone emergency primary resection of the acute sigmoid volvulus with or without anastomosis and were followed up for more than 5 years. In addition, a comprehensive literature review was performed to assess rates of recurrence and constipation reported in other publications on the emergency management of acute sigmoid volvulus.
Patients and methods
Patients who had undergone emergency resection for acute sigmoid volvulus between September 1992 and August 2000 at a large government teaching hospital (Ankara Numune Training and Research Hospital, Ankara, Turkey) or between June 1998 and August 2000 at a large university hospital (University of Ankara) were approached and asked to participate in the study. The early surgical outcome of these patients following emergency primary resection with or without anastomosis has been reported previously. (27) The participants answered a questionnaire to assess their clinical outcome at least 5 years after surgery, with special attention to recurrence and functional outcomes. The study was approved by the ethics committees of the two hospitals, and written informed consent was obtained from participants.
Eligible patients were contacted either by letter or telephone to determine their willingness to participate in the study. When a patient agreed to participate, a clinic appointment was arranged, at which the patient completed a questionnaire as described below.
The following were recorded for each patient: age, gender, symptoms, concurrent diseases (hypertension, atherosclerotic heart disease, diabetes mellitus, chronic obstructive respiratory disease, chronic renal failure or chronic liver disease), the patient's previous operation notes (primary resection and anastomosis (PRA) or Hartmann's procedure (HP)), Hartmann's reversal operation notes, major morbidity (anastomotic leakage, wound infection, intra-abdominal abscess, re-operation, stoma revision) and mortality following Hartmann's reversal, recurrence rate and functional outcome. Functional outcome was evaluated using a non-validated survey created for this study. This survey assessed the number of bowel movements per 24 hours, constipation, faecal incontinence and medications for the control of bowel movements, i.e. laxatives and enemas. Constipation and faecal incontinence were defined according to the Rome II criteria. (28)
In order to assess the morbidity and mortality of Hartmann's reversal, wound infection was defined as pus in the wound or a positive culture from a serous or serosanguinous discharge that needed drainage and packing. Anastomotic dehiscence was diagnosed clinically on the basis of evidence of a faecal fistula, leakage of faeces from the drain, local or generalised peritonitis or evidence of anastomotic dehiscence at re-operation, or by water-soluble radiological studies. Length of stay in hospital was calculated as the period from the day of surgery until discharge. Hospital death was defined as death from any cause within 30 days of hospitalisation for Hartmann's reversal.
In order to compare the long-term postoperative rates of recurrence and constipation in our patients with those of previous studies, a comprehensive literature search was carried out. All randomised trials, controlled clinical trials or case series regarding the treatment of acute sigmoid volvulus were included in our PubMed literature search of the English literature from 1960 to 2009. Searches were carried out using medical subject headings (MeSH) and free textwords including sigmoid colon volvulus. The reference lists of all relevant articles were searched for other relevant studies. Selected articles and reviews were scanned for citations and categorised according to type of treatment. Studies in our review were included if they included at least five participants, specified the follow-up period, and recorded the specific operative procedure. Treatment modalities were classified as non-operative, non-resectional and resectional. Non-operative procedures included decompression by rigid or flexible sigmoidoscopy or colonoscopy and barium enema; non-resectional procedures included operative detorsion, mesosigmoidoplasty, colopexy and extraperitonealisation; and resectional procedures included PRA, HP, Mikulicz resection, exteriorisation and subtotal colectomy.
Patients who underwent emergency resection for acute sigmoid volvulus between 1992 and 2000 at the two hospitals (N=106) were eligible for inclusion in this study, and their charts were abstracted to obtain data on the initial procedure and short-term complications, if any. Of the 106 eligible patients, none had megacolon, 7 died during the first admission, and 21 could not be contacted, leaving 78 who were approached after the first admission for participation in this longer-term study; all gave their consent. PRA was performed in 42 patients and HP in 36 patients. Five Patients in the PRA and 10 in the HP group died during the follow-up period; none of these deaths was related to the primary procedure or to the Hartmann's reversal surgery. Results were therefore analysed from 63 patients (37 PRA, 26 HP), with a median follow-up of 7.2 years (Fig. 1).
Patient demographics and postoperative outcomes for patients in the PRA and HP groups are shown in Table 1. All 26 patients in the HP group underwent Hartmann's reversal. One patient with anastomotic dehiscence required re-operation and was treated by HP. Four patients had major wound infection, and 3 of these had respiratory complications. All were treated conservatively and discharged without further complications or death. The mean length of hospital stay for HP patients on their second admission was 8.8 days (range 5-15 days).
Constipation was reported by 31 of 37 PRA patients (83%) and 17 of 26 HP patients (65%). Half (51%) of the patients overall used a laxative regularly. None of the patients complained of incontinence. No recurrences of sigmoid volvulus were recorded during the follow-up period (median 7.2 years, range 5-11 years).
Our PubMed literature search identified 733 studies, of which 91 met inclusion criteria for review. Studies were excluded because of non-English language (N=174), article type (review article, N=55), or fewer than 5 participants. The 91 studies we reviewed included 6 120 patients (number of patients per study ranged from 5 to 827), but because of the great heterogeneity in patient populations and data, we were unable to perform a meta-analysis. Twelve of these studies were prospective, 35 were retrospective, and the remaining 44 studies did not report whether the data were obtained prospectively or retrospectively. The majority of the studies described the technique used for treatment of acute sigmoid volvulus. Peri-operative treatment of patients was not described in detail in most of the trials. In nearly all the studies, early outcome parameters such as mortality, morbidity, anastomotic leakage and hospital stay were reported. Long-term recurrence rates were published in only 28 studies, and mean follow-up duration was given in only 23 of these. Long-term results with regard to bowel habits were mentioned in only 7 studies.
Nearly all studies reported using interventional techniques in addition to endoscopic decompression. Decompression only was performed in 509 acute sigmoid volvulus patients reported in 31 studies. Their average mortality rate was 7.5%, and in the 310 patients available for follow-up, the average recurrence rate was 45% (range 11-85%).
Forty-four non-resectional and 78 resectional studies were found, which included 1 171 and 3 672 patients, respectively. Their average mortality rates were 8% and 12%, respectively. In the 768 non-resectional surgical patients who were followed up, the recurrence rate was 20% (range 0-64%). In the 857 resectional surgical patients who were followed up, the recurrence rate was 3% (range 0-37%). Recurrence after sigmoid resection occurred in 27 of 857 patients, and megacolon or megarectum was noted in 21 of these 27 patients (77%). The outcomes of non-operative, non-resectional and resectional treatment modalities are summarised in Tables 2, 3 and 4, respectively.
Owing to the paucity of prospective randomised trials, controversy still exists regarding the optimal treatment of acute sigmoid volvulus. To date, no prospective study has reported the long-term results (recurrence and bowel habits) of sigmoid colon resection with PRA or HP. Because sigmoid resection eliminates any anatomical factors that predispose to volvulus, our surgical department has been performing primary resection for years as our first choice for this life-threatening emergency condition. The present study revealed that primary resection with or without anastomotis was associated with no recurrence over a mean follow-up of more than 5 years. However, over 80% of PRA patients complained of constipation, whereas only 65% of HP patients reported this problem. As a remedy, more than half of the patients used laxatives.
[FIGURE 1 OMITTED]
Non-operative management of acute sigmoid volvulus is usually a better treatment option for frail patients. Furthermore, this approach has the advantage that emergency surgery can be changed to a semi-elective procedure if the colon is still non-gangrenous. However, high recurrence rates are the major drawback of this technique, (5,8,23,29) the average recurrence rate during the first 3 months after the operation being as high as 45%. (23,30) Some patients refuse definitive surgery after their obstructive symptoms are relieved with decompression, which is another disadvantage of this procedure. The temporary resolution of symptoms may also result in a delay in the diagnosis of recurrence, thus increasing morbidity and mortality. Several studies have reported that approximately 50% of patients refused surgery after endoscopic decompression. (2,23,31) The mortality rate in such patients is between 20% and 40%, (8,32-34) but increases to 80% if the colon is gangrenous. (7,35)
A non-resective procedure in a patient with a non-gangrenous colon has the advantage of avoiding an anastomosis under emergency conditions. However, the surgical mortality and long-term recurrence rates of non-resective procedures are not better than those obtained after primary resection. Simple operative detorsion and various methods of sigmoid fixation have been advocated in the past, but have largely been abandoned because of recurrence rates of up to 64%. (36) Although the other alternative, extraperitonealisation, has been reported to have satisfactory surgical outcomes, this operation is not universally accepted as a standard approach because of its complicated technique. (18,37,38) Another widely used alternative is mesosigmoidoplasty, but its results are also conflicting. (19-21) The only prospective, randomised study in the literature found that, in the presence of a viable colon, a sigmoid resection, performed either as an HP or as a one-stage definitive operation, had a lower rate of recurrence than mesosigmoidoplasty. (39) Our literature review revealed an overall recurrence rate of 20% and generally poor outcomes in patients who underwent non-resective procedures.
Some surgeons are reluctant to perform a definitive operation in the unprepared bowel of an elderly frail patient because of the relatively high incidence of anastomotic complications. HP is still one of the best operative alternatives, especially in the presence of peritonitis and/or a necrotic bowel. However, multistage procedures can be poorly tolerated and also carry a higher risk of mortality and morbidity. Nevertheless, in our series bowel continuity was successfully restored in 25 out of 26 patients with a morbidity of 36% without any deaths. Wound infection occurred in 15% of our patients, the mean length of stay for the second admission was 9 days, and anastomotic dehiscence occurred in one patient who required repeat colostomy. These results are well within the range of those reported in the literature. (40-42)
Even though the traditional method for preventing recurrence of sigmoid volvulus is primary resection of the diseased colon, our literature review found a recurrence rate of 3% after resection. The mean interval between surgery and recurrence was reported in two studies to be 76 (standard deviation (SD) 17) months (range 1-156 months) and 27 months, respectively. (22,23) While the exact pathological mechanism of recurrence is still unclear, the main factor for recurrence was reported to be the presence of concomitant megacolon or megarectum. (22,23,43) Morrissey et a1. (22) reported that the recurrence rate was 6% if the disease was limited to the sigmoid, but rose to 82% if megacolon was present. Other factors associated with recurrence include insufficient resection, (4) bulky diets and motility disorders. (33,44) Absence of ganglionic cells in the colon segment manifests as chronic constipation, and is another cause of recurrence. (22,45) However, a recent study revealed no relationship between functional bowel movement disorders (elongation of the bowel in sigmoid volvulus and re-volvulus) and the number of ganglion cells in Auerbach's or Meissner's plexus. (46) Although constipation was not reported in some series, (19,47) it is still an important issue for the majority of our patients. Routine constipation occurs following primary resection in 45-64% of patients, but authors state that this was not the cause or result of the recurrence. (23,29) Moreover, constipation is not a problem peculiar to resection; it occurs in 9-77% of patients after extraperitonealisation, and in 13% after mesosigmoidoplasty. (37,38,48)
The long-term clinical outcome of a procedure strongly influences its wide acceptance as a treatment for a particular condition. In our patient population, with a mean follow-up period of over 7 years, primary resection of the sigmoid colon or resection by HP resulted in no recurrence of sigmoid colon volvulus. Our extensive literature review also revealed that resection procedures have a better outcome than the alternatives, especially in the absence of megacolon.
Conflict of interest. The authors declare that there is no conflict of interest.
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Ozdemir Suleyman, M.D.
Department of Surgery, University of Ufuk, Ankara, Turkey
Aslar A. Kessaf, M.D.
Ankara Numune Training and Research Hospital, Ankara
Kuzu M. Ayhan, M.D., F.A.C.S.
Department of Surgery, University of Ankara
TABLE 1. DEMOGRAPHICS AND OUTCOME OF OUR 63 PATIENTS WHO UNDERWENT A RESECTIONAL PROCEDURE FOR SIGMOID COLON VOLVULUS AND WERE AVAILABLE FOR FOLLOW-UP OVER 5 YEARS LATER PRA N 37 Mean age (yrs) at the end of follow-up period (median 67.2 (46--81) (range)) Gender (male/female) 25/12 Concomitant disease * 26 Restoration of bowel NA Complications in the second admission NA Wound infection Pulmonary complication Anastomotic leakage Transient ischaemic attack Mortality in the second admission NA Length of stay (d) in the second admission (median NA (range)) Constipation (N (%)) 31(83%) Recurrence 0 Median follow-up period (yrs) 7.4 HP N 26 Mean age (yrs) at the end of follow-up period (median 68.2 (50--83) (range)) Gender (male/female) 22/4 Concomitant disease * 16 Restoration of bowel 25 Complications in the second admission Wound infection Pulmonary complication Anastomotic leakage Transient ischaemic attack 4 3 Mortality in the second admission 0 Length of stay (d) in the second admission (median 8.8(5-15) (range)) Constipation (N (%)) 17(65%) Recurrence 0 Median follow-up period (yrs) 7.1 * Concomitant disease included hypertension, atherosclerotic disease, diabetes mellitus, chronic obstructive pulmonary disease and chronic renal failure. PRA = primary resection and anastomosis; HP = Hartmann's procedure; NA = not applicable. TABLE 2. MORTALITY AND RECURRENCE RATES OF PATIENTS UNDERGOING A NON-SURGICAL PROCEDURE FOR SIGMOID COLON VOLVULUS IN STUDIES WITH 5 OR MORE PATIENTS Author, year of publication Study design Drapanas et al., 1961 (24) Retrospective Taha et al., 1980 (49) Retrospective Knight et al., 1980 (50) Retrospective Anderson and Lee, 1981 (51) Retrospective Schagen van Leeuwen, 1985 (52) Retrospective Ballantyne et al., 1985 (9) Retrospective Bak and Boley, 1986 (8) Retrospective Friedman et al., 1989 (29) Retrospective Hiltunen et al., 1992 (4) Retrospective Chung et al., 1999 (23) Prospective Grossmann et al., 2000 (32) Retrospective Lau et al., 2006 (30) Retrospective Larkin et al., 2009 (5) Retrospective Safioleas et al., 2007 (35) Retrospective Oren et al., 2007 (21) Retrospective Tanga, 1974 (11) Retrospective Jagetia et al., 1998 (26) Retrospective Daniels et al., 2000 (13) Prospective Baraza et al., 2007 (12) Prospective Author, year of publication Treatment modality N Drapanas et al., 1961 (24) Decompression 10 Taha et al., 1980 (49) Decompression 10 Knight et al., 1980 (50) Decompression 14 Anderson and Lee, 1981 (51) Decompression 20 Schagen van Leeuwen, 1985 (52) Decompression 26 Ballantyne et al., 1985 (9) Decompression 8 Bak and Boley, 1986 (8) Decompression 33 Friedman et al., 1989 (29) Decompression 7 Hiltunen et al., 1992 (4) Decompression 17 Chung et al., 1999 (23) Decompression 14 Grossmann et al., 2000 (32) Decompression 50 Lau et al., 2006 (30) Decompression 14 Larkin et al., 2009 (5) Decompression 11 Safioleas et al., 2007 (35) Decompression 26 Oren et al., 2007 (21) Barium enema 13 Tanga, 1974 (11) Catheterisation of colon 10 Jagetia et al., 1998 (26) Tube sigmoidostomy 17 Daniels et al., 2000 (13) PEC with temporary tubes 8 PEC with permanent tubes 5 Baraza et al., 2007 (12) PEC 19 Mortality Recurrence Follow-up Author, year of publication rate (%) rate (%) period Drapanas et al., 1961 (24) 0 50 NR Taha et al., 1980 (49) 0 21 NR Knight et al., 1980 (50) 21 42 NR Anderson and Lee, 1981 (51) 10 50 1-13 yrs Schagen van Leeuwen, 1985 (52) 0 19 NR Ballantyne et al., 1985 (9) 0 14 49 mo. Bak and Boley, 1986 (8) 21 69 NR Friedman et al., 1989 (29) 0 75 NR Hiltunen et al., 1992 (4) 11 29 49 mo. Chung et al., 1999 (23) 16 85 2.8 mo. Grossmann et al., 2000 (32) 12 23 NR Lau et al., 2006 (30) 0 43 84 d Larkin et al., 2009 (5) 36.4 71.4 NR Safioleas et al., 2007 (35) 3 41 NR Oren et al., 2007 (21) 7.7 11.1 Early Tanga, 1974 (11) 0 0 2 yrs Jagetia et al., 1998 (26) 0 0 18 mo. Daniels et al., 2000 (13) 0 37 0 0 12.6 mo. Baraza et al., 2007 (12) 5 10 35 mo. NR= not reported; PEC = percutaneous endoscopic colostomy. TABLE 3. MORTALITY AND RECURRENCE RATES OF PATIENTS UNDERGOING A NON-RESECTIONAL SURGICAL PROCEDURE FOR SIGMOID COLON VOLVULUS IN STUDIES WITH 5 OR MORE PATIENTS Author, year of publication Study design Sutcliffe, 1968 (36) Retrospective Taha and Suleiman, 1980 (49) Retrospective Ballantyne et al., 1985 (9) Retrospective Pahlman et al., 1989 (53) Retrospective Shepherd, 1971 (25) Retrospective Oren et al., 2007 (21) Retrospective Hiltunen et al., 1992 (4) Retrospective Agaoglu et al., 2005 (54) Retrospective Anderson and Lee, 1981 (51) Retrospective Salim, 1991 (47) Prospective Khanna et al., 1999 (55) Retrospective Subrahmanyam et al., 1992 (20) Prospective Bagarani et al., 1993 (39) Prospective Akgun et al., 1996 (48) Prospective Bach et al., 2003 (19) Retrospective Khanna et al., 1995 (37) Prospective Avisar et al., 1997 (38) Retrospective Bhatnagar and Sharma, 1998 (18) Prospective Author, year of publication Treatment modality N Sutcliffe, 1968 (36) Operative detorsion 19 Taha and Suleiman, 1980 (49) Operative detorsion 10 Ballantyne et al., 1985 (9) Operative detorsion 9 Pahlman et al., 1989 (53) Operative detorsion 9 Shepherd, 1971 (25) Operative detorsion 49 Fixation 213 Oren et al., 2007 (21) Operative detorsion 46 Mesosigmoidoplasty 56 Hiltunen et al., 1992 (4) Detorsion with or without sigmoidopexy 21 Agaoglu et al., 2005 (54) Detorsion and sigmoidopexy 7 Anderson and Lee, 1981 (51) Sigmoid colopexy 6 Salim, 1991 (47) Colopexy with banding 20 Khanna et al., 1999 (55) Colocolopexy 13 Extraperitonealisation 44 Subrahmanyam et al., 1992 (20) Mesosigmoidoplasty 126 Bagarani et al., 1993 (39) Mesosigmoidoplasty 7 Akgun et al., 1996 (48) Mesosigmoidoplasty 15 Bach et al., 2003 (19) Modified mesosigmoidoplasty 12 Khanna et al., 1995 (37) Extraperitonealisation 88 Avisar et al., 1997 (38) Extraperitonealisation 11 Bhatnagar and Sharma, 1998 (18) Extraperitonealisation 84 Recur Mortality rence Follow-up Author, year of publication rate (%) rate (%) period Sutcliffe, 1968 (36) 10 64 NR Taha and Suleiman, 1980 (49) 0 40 NR Ballantyne et al., 1985 (9) 11 22 NR Pahlman et al., 1989 (53) 0 44 NR Shepherd, 1971 (25) 16 42 NR 8 41 Oren et al., 2007 (21) 10.9 36 26.4 yrs 5.4 16 24.7 yrs Hiltunen et al., 1992 (4) 14 23 NR Agaoglu et al., 2005 (54) 14 29 27 mo. Anderson and Lee, 1981 (51) 16 33 NR Salim, 1991 (47) 0 0 1 yr. Khanna et al., 1999 (55) 7 38 NR 0 0 Subrahmanyam et al., 1992 (20) 0.7 1 8.2 yrs Bagarani et al., 1993 (39) 0 28.5 NR Akgun et al., 1996 (48) 6 0 28 mo. Bach et al., 2003 (19) 0 8 4 mo. Khanna et al., 1995 (37) 0 0 3.2 yrs Avisar et al., 1997 (38) 0 0 4.5 yrs Bhatnagar and Sharma, 1998 (18) 9 0 6.6 yrs NR= not reported. TABLE 4. MORTALITY AND RECURRENCE RATES OF PATIENTS UNDERGOING A RESECTIONAL SURGICAL PROCEDURE FOR SIGMOID COLON VOLVULUS IN STUDIES WITH 5 OR MORE PATIENTS Author, year of Treatment publication Study design modality N Anderson and Lee, Retrospective PRA 68 1981 (51) HP 3 Mikulicz 30 resection Ballantyne et al., 1985 (9) Retrospective PRA 25 HP 10 Friedman et al., 1989 (29) Retrospective PRA 12 HP 5 Subtotal 4 colectomy Pahlman et al.,1989 (53) Retrospective PRA 23 Hiltunen et al., 1992 (4 *) Retrospective PRA 19 Bagarani et al., 1993 (39) Prospective PRA 16 HP 8 Morrissey et al., 1994 Retrospective PRA 19 (22) ([dagger]) HP 5 Subtotal 4 colectomy Chung et al., 1999 (23 *) Prospective PRA 25 HP 2 Subtotal 2 colectomy Khanna et al., 1999 (55) Retrospective PRA 29 HP 17 De et al., 2003 (41) Prospective PRA 197 Agaoglu et al., 2005 (54) Retrospective PRA 9 HP 16 Oren et al., 2007 (21) Retrospective PRA 126 HP 146 Mikulicz 14 resection Heis et al., 2008 (56) Retrospective PRA 28 HP 4 Kuzu et al., 2002 Prospective PRA 57 (27) ([double dagger]) HP 49 Author, year of Mortality Recurrence Follow-up publication rate (%) rate (%) period Anderson and Lee, 14 0 NR 1981 (51) 0 0 NR 30 0 NR Ballantyne et al., 1985 (9) 0 0 NR 0 0 NR Friedman et al., 1989 (29) 0 8 37.9 mo. 0 0 50 0 Pahlman et al., 1989 (53) 0 0 NR Hiltunen et al., 1992 (4 *) 21 5 NR Bagarani et al., 1993 (39) 25 0 NR 12.5 0 NR Morrissey et al., 1994 0 37 76 mo. (22) ([dagger]) 0 20 76 mo. 25 0 7.3 yrs Chung et al., 1999 (23 *) 4 24 27 mo. 0 0 0 0 Khanna et al., 1999 (55) 13 0 NR 11 0 De et al., 2003 (41) 1 0 2 yrs Agaoglu et al., 2005 (54) 0 0 26.7 mo. 6 0 Oren et al., 2007 (21) 14 0 15.8 yrs 19.2 0 22.1 yrs 21 0 22.8 yrs Heis et al., 2008 (56) 7 0 16 mo. 0 0 Kuzu et al., 2002 5 0 7.2 yrs (27) ([double dagger]) 8 0 * Limited resection. ([dagger]) Presence of megacolon or megarectum. ([double dagger]) Patients in the present study. PRA = primary resection and anastomosis; HP = Hartsmann's procedure; NR = not reported.
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