Original article doi:10.1111/j.1463-1318.2008.01631.x Treatment of left-sided colonic emergencies: a comparison of US and UK surgical practices A. H. Engledow*, G. Bond-Smith*, R. W. Motson† and A. Jenkinson‡ *Department of Colorectal Surgery, University College Hospital, London, UK, †Department of Laparoscopic Surgery, Colchester Hospital, UK and ‡Department of Biatric Surgery, The Homerton Hospital, London, UK Received 13 March 2008; accepted 2 June 2008 Abstract Background Surgeons are increasingly considering resection and primary anastomosis when treating left- sided colonic obstruction or perforation in preference to the more traditional staged procedures. Previous studies in the United Kingdom (UK) and United States of America (USA) have suggested a greater interest in single-staged procedures amongst UK surgeons. This study was aimed to directly compare the treatment preferences between UK and US surgeons. Method A questionnaire, designed to determine the procedure of choice when faced with left-sided colonic emergencies in patients with good and poor anaesthetic risk, was sent to 500 surgeons in the UK and 500 surgeons in the USA. Results UK surgeons were more likely to perform resection, primary anastomosis and on-table colonic lavage in patients with sigmoid obstruction (good anaesthetic risk: P < 0.0001; poor risk: P < 0.01) and sigmoid perforation (good risk: P < 0.0001). In good- risk patients with sigmoid obstruction, US surgeons were more likely than UK to choose Hartmann’s procedure (P < 0.0001). US surgeons performing pri- mary anastomosis were less likely to perform on-table lavage. Conclusion Single-stage procedures are widely accepted as viable treatment options in both the UK and the USA when dealing with left-sided colonic emergencies. British surgeons are more likely to favour single-staged proce- dures, particularly with on-table colonic lavage, when compared with US surgeons. Keywords Left-sided, colonic, emergencies Introduction Left-sided colonic obstruction or perforation remains common surgical emergencies. Colonic carcinoma, with an annual incidence of 32 per 100 000 population [1] accounts for 90% of obstructive episodes. Approximately 15% of patients with colonic tumours present with obstruction [2,3], the majority of these being distal to the splenic flexure. Perforation of the distal colon secondary to sigmoid diverticular disease occurs in 4 per 100 000 patients per year [4]. It is noteworthy that localized perforation related to an obstructing lesion is not the only site of perforation but distant perforation can also occur. An obstructing lesion in the distal colon can create increasing proximal pressure. If the ileocaecal valve remains competent and does not allow the release of this intraluminal pressure into the small bowel, then the proximal colon and caecum will pathologically dilate and ultimately perforate. The most common site of distant perforation is the caecum. Both conditions are life-threatening if not treated by prompt surgical intervention and affect predominantly elderly patients with limited physiological reserve. How- ever, the optimal treatment of individual patients pre- senting with these conditions remains controversial with no consensus of opinion between surgeons. Traditional surgical teaching suggested that, in the presence of obstruction or abdominal sepsis, a bowel anastomosis should not be attempted [5]. Nevertheless, mortality rates for Hartmann’s procedure approached 20% with defunctioning colostomy and staged resection for obstruction faring little better [6]. More recently surgeons have increasingly performed primary resection with immediate anastomosis in selected patients with good results [7,8]. Extended right haemicolectomy or segmental colonic resection and Correspondence to: Mr Alec H. Engledow, University College Hospital, 235 Euston Road, London NW1 2BU, UK. E-mail: alecengledow@hotmail.com 642 Ó 2009 The Authors. Journal Compilation Ó 2009 The Association of Coloproctology of Great Britain and Ireland. Colorectal Disease, 11, 642–647