Sigmoid volvulus: long-term clinical outcome and review of the literature.
Abstract: 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.
Article Type: Report
Subject: Aged (Health aspects)
Excision (Surgery) (Health aspects)
Intestines (Obstructions)
Intestines (Patient outcomes)
Intestines (Care and treatment)
Intestines (Research)
Authors: Suleyman, Ozdemir
Kessaf, Aslar A.
Ayhan, Kuzu M.
Pub Date: 02/01/2012
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
Accession Number: 281375515
Full Text: 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. (4-9)

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.

Results

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.

Discussion

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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