Perforated colonic cancer presenting as intra-abdominal abscess

Size: px

Start display at page:

Download "Perforated colonic cancer presenting as intra-abdominal abscess"

Arleen Matthews
6 years ago
Views:

1 Int J Colorectal Dis (2007) 22: DOI /s ORIGINAL ARTICLE Hsiang-Lin Tsai Jan-Sing Hsieh Fang-Jung Yu Deng-Chyang Wu Fang-Ming Chen Che-Jen Huang Yu-Sheng Huang Tsung-Jen Huang Jaw-Yung Wang Perforated colonic cancer presenting as intra-abdominal Accepted: 5 January 2006 Published online: 20 April 2006 # Springer-Verlag 2006 H.-L. Tsai Division of General Surgery, Department of Surgery, E-Da Hospital/I-Shou University, No. 1, E-Da Road, Jiau-Shu Tsuen, Yan-Chau Shiang, Kaohsiung 824, Taiwan H.-L. Tsai. J.-S. Hsieh. F.-M. Chen. C.-J. Huang. Y.-S. Huang. T.-J. Huang. J.-Y. Wang Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, J.-S. Hsieh. F.-M. Chen. C.-J. Huang. Y.-S. Huang. T.-J. Huang. J.-Y. Wang (*) Division of Gastrointestinal and General Surgery, Department of Surgery, Kaohsiung Medical University Chung-Ho Memorial Hospital, No. 100, Tzyou 1st Road, cy614112@ms14.hinet.net Tel.: Fax: F.-J. Yu. D.-C. Wu Department of Medicine, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, F.-J. Yu. D.-C. Wu Division of Gastrointestinal Medicine, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, No. 100, Tzyou 1st Road, Abstract Background and aims: The various presentations of carcinoma of the colon are well known. Abscess formation occurs in 0.3 to 0.4% and is the second most common complication of perforated lesions. Perforation and penetration of adjacent organs intra-abdominal formation as the initial presentation is uncommon. Materials and methods: A retrospective analysis was made between January 1998 and December 2003 at the Kaohsiung Medical University Hospital. Six colon cancer patients intra-abdominal as the initial presentation were enrolled into this study. Among them, two were men and four were women. Results: During the 6-year period, there were 756 patients colonic carcinoma but only six of those patients (0.79%) presented formation as the initial finding. The initial pre-operative diagnosis was ruptured colonic diverticulitis formation in three patients, and the other three patients were as follows: one ruptured appendicitis, one right subcutaneous inguinal, and one omphalitis abdominal wall. Subsequent colonoscopy was performed in two patients, and colon cancer was recognized. The most common associated symptoms/signs were palpable abdominal mass, abdominal pain, and anemia. All of them underwent a one-stage surgical procedure, and adjuvant chemotherapy was given. One patient died of peritoneal carcinomatosis and liver metastases 1 year post-operatively. The other five patients are still alive. Conclusions: It is difficult to make an accurate diagnosis of formation as the first evidence of colonic carcinoma pre-operatively. The onestage resection of the lesion seems to be an acceptable treatment. For patients intra-abdominal, clinicians should be aware of this differential because it is easily ignored pre-operatively. Keywords Perforated colonic carcinoma. Abscess formation. One-stage surgical resection Introduction Cancer of the colon does not always present the familiar symptoms of rectal bleeding, anemia, change of bowel habits, or abdominal pain [1]. Less common manifestations include perforation and formation, which are usually intra-peritoneal but may also be located in the extra-peritoneal spaces. The incidence of colonic perforation ranges from 2.6 to 10% [2, 3], including cases of free perforation into the peritoneal cavity and those

2 16 Table 1 Reported cases of es as the presenting sign in carcinoma of the colon Patient s number Age/sex 78/male 68/female 76/female 43/female 71/female 46/male Location of LUQ RUQ RLQ LUQ Right groin Periumbilical area abdominal mass Size of abdominal (cm 2 ) Abdominal CT Yes Yes Yes Yes No No Colonoscopy Yes No No No Yes No Initial preoperative diagnosis Diverticulitis rupture Diverticulitis rupture Appendicitis rupture Diverticulitis rupture Right inguinal subcutaneous Date of Jan Feb Oct Jan Aug Dec One-stage Yes Yes Yes Yes Yes Yes Operative method Extended right Extended right Right Extended right Omphalitis abdominal wall Right Extended right Location of the tumor Transverse colon Transverse colon Appendix Transverse colon Cecum Transverse colon Histology Adenocarcinoma, PD Adenocarcinoma, MD Adenocarcinoma, MD Adenocarcinoma, MD Adenocarcinoma, PD Mucinous carcinoma, PD TNM T 3 No Mo T 3 No Mo T 3 N 1 Mo T 3 No Mo T 4 N 2 Mo T 4 No Mo Stage II II III II III II Distant metastases Type of Site of perforation Culturing materials of No No No No No No Intraperitoneal Intraperitoneal Intraperitoneal Intraperitoneal Retroperitoneal abdominal wall involved Proximal to tumor Proximal to tumor Proximal to tumor Proximal to tumor Tumor itself Tumor itself None done Schwanella putrefaciens None done Escherichia coli Escherichia coli Intraperitoneal abdominal wall involved Escherichia coli + Bacteroides fragilis Complications None None Wound infection None None Anastomotic leakage, enterocutaneous fistula Results Alive and well 6 years after Alive and well 6 years after Alive and well 6 years after Alive and well 3 years after Died 1 year after due to carcinomatosis and liver metastases Alive and well 1 year after CT Computed tomography, PD poorly differentiated, MD moderately differentiated

3 17 where the tumor has perforated locally resulting in or fistula formation. In a previous series, formation occurred in 0.3 to 0.4% of colonic carcinoma and is the second most common complication of perforated lesions [4 8]. Kelley et al. [9] reported that perforation is the most lethal complication of colorectal carcinoma, a fourfold operative mortality and a 5-year survival that is one fourth that of the overall population. Perforation and penetration of adjacent organs, formation as the initial presentation, is uncommon. Perforation may occur a distance from the tumor and may be due to the necrosis of stercoral ulcers or increased pressure proximal to an obstructing lesion. Penetration of the wall and the adjacent tissue by the neoplasm is of prime importance in the pathogenesis of adjacent formation [1]. Most of the reported cases of perforated colonic carcinoma presenting as an were not diagnosed pre-operatively. In our data, four of six cases were not appropriately diagnosed pre-operatively even if most of them were evaluated under the initial evaluation of abdominal computed tomography (CT). We report herein six cases of intra-abdominal resulting from perforating carcinoma of the colon and their clinical outcomes. Materials and methods Between January 1998 and December 2003, 756 patients colonic malignancy admitted to Department of Surgery of the Kaohsiung Medical University Hospital were reviewed. Of the 756 patients, six patients formation as the initial presentation of perforated colonic carcinoma were included in our study. All of the medical records of these six patients were reviewed. Characteristics and data, which included commonly associated symptoms/signs, location and size of the palpable abdominal mass, initial diagnosis, location of the colon cancer, histology of the tumor, tumor stage, distant metastases, type of, operative complications, and clinical results were analyzed. Clinical stages and pathological features of the primary tumors were defined according to the criteria of the American Joint Commission on Cancer [10]. Abdominal CT scan was performed pre-operatively for the diagnosis except for two patients. Two of the six patients who received colonoscopy was subsequently diagnosed as colonic cancer after CT-guided percutaneous drainage or incision and drainage under the initial tentative diagnosis of diverticulitis rupture formation and inguinal subcutaneous, respectively. All of the six patients underwent a one-stage surgical resection of the lesion, three who were diagnosed intra-abdominal undergoing in 24 h of admission. Culture samples from materials obtained by surgical method were available for four patients (66.7%). Cultures were made for aerobes, anaerobes, mycobacteria, and fungi examination. Finally, all six patients were contacted, evaluated, and treated 5- fluorouracil (5-FU) (450 mg/m 2 ) plus leucovorin (LV) (200 mg/m 2 ) administered weekly for 6 weeks in an 8- week cycle regularly, an average follow-up of 55 months (range 12 to 87 months). Results Of the six patients, two were men and four were women. Their ages ranged from 43 to 78 years, an average of 63.7 years. Their demography is shown in Table 1. The most frequent pre-operative diagnosis was ruptured colonic diverticulitis formation (three out of six, 50%). The duration of hospitalization was from 15 to 52 days, an average of 30.2 days. All presented a palpable abdominal mass and four had a diagnosis of intraabdominal mass confirmed by abdominal CT before (Fig. 1). However, the other two patients had no abdominal CT done because the initial impression was either subcutaneous or abdominal wall. Both patients were subsequently found to have perforated colonic cancer and intra-abdominal abdominal wall involvement post-operatively. Transverse colon was the most frequent site of the perforated colonic cancer formation in this study (four out of six, 66.7%), and two cases were found to have perforation on the tumor itself and four on the site proximal to the tumor. Four of six were TNM stage II (66.7%) and two were TNM stage III (33.3%). None had distant metastasis. Intra-peritoneal (five out of six, Fig. 1 A 68-year-old female patient was diagnosed intraabdominal formation. Contrast-enhanced CT scan shows a heterogeneous mass (arrowheads) located at the anterior intraperitoneal space. Postoperatively, she was a case of perforated transverse colonic carcinoma formation

4 %) was the most frequent type of formation as the initial presentation and only one patient had a retroperitoneal in our series. The most commonly isolated organism by culture was Escherichia coli (three out four, 75%). The most common symptoms/signs in our cases were abdominal mass (100%), abdominal pain (100%), and anemia (100%). However, the frequent symptom of bowel habit change in most colon cancer patients was not present in our patients. The associated symptoms and signs are summarized in Table 2. All of the six patients underwent a one-stage, which seemed to be an acceptable procedure for the patients. Surgical complications included wound infection (one out of six, 16.7%) and anastomotic leakage entero-cutaneous fistula (one out of six; 16.7%). All were regularly followed-up post-operatively in our hospital, an average follow-up of 55 months. Five of the six are still alive. Discussion The presentation of colorectal cancer can be quite variable and depends on the site of the lesion [11, 12]. This variability is well known and approximately one third of patients colorectal carcinoma will have a major complication of the disease. The most common initial complication is bowel obstruction, occurring in 8 to 21% of patients [9, 13, 14], some authors reporting complete obstruction that range from 8 to 40% [15, 16]. Seventy percent of obstructing lesions is found in the left colon, coinciding the predominance of left-side lesions. Perforation and penetration of adjacent organs formation as the initial presentation of the carcinoma is uncommon, and the incidence of perforation in a previous large series is % [5, 7, 12]. This includes cases of free perforation into the peritoneal cavity and those where the tumor had perforated locally, resulting in or fistula formation. Of our patients, two were found to have Table 2 The associated symptoms/signs Symptoms/signs Number (%) Abdominal mass 6 (100) Abdominal pain 6 (100) Anemia 6 (100) Fever 5 (83.3) Leukocytosis 4 (66.7) Anorexia 4 (66.7) Diarrhea 2 (33.3) Body weight loss 2 (33.3) perforation on the tumor itself and four on the site proximal to the tumor. Abscess formation occurs in 0.3 to 0.4% of colonic carcinoma and is the second most common complication of perforative lesions [4, 7]. The may remain localized in the paracolic area, may extend as a flank, or may track along various tissue planes and present as an at another site, e.g., in the thigh [17] or subcutaneously on the trunk [18]. However, most of the es occur in the intra-abdominal cavity, especially intra-peritoneally, although fistula formation is usually uncommon. In our study, intra-peritoneal is present in five of the six patients (83.3%), which is consistent previous reports. Cross-sectional imaging techniques, such as ultrasound images and abdominal CT, have become the most common techniques for diagnosing intra-abdominal es [19]. With the advent of abdominal computed tomography, it has been possible to identify and accurately determine the location of an intra-abdominal before [20]. However, most of the reported cases of perforated colonic carcinoma presenting as an did not have an accurate diagnosis pre-operatively. In our series, most of them were diagnosed as ruptured diverticulitis formation (three out of six, 50%); but unlike diverticular es, pericolic es caused by carcinomas are rarely small or mobile [21]. General or localized extracolonic spread of infection is more frequently encountered in neoplasm than in inflammatory conditions [1]. CT will frequently be used, as in our cases, and will show the nature, location, and extent of the inflammatory component. However, the source of the inflammation may not be apparent. With recent advances of imaging techniques, the diagnosis of intra-abdominal has improved. In our reported cases, the lack of an accurate pre-operative diagnosis by abdominal CT may be due to the larger intra-abdominal in these patients. Pertinent to this discussion are es which usually develop intra-peritoneally in the pericolic region. This is thought to be related to the efficient walling off and localization by the primary inflammatory process, while tumor penetration is said to be facilitated by the outstripping of its blood supply by rapid growth and subsequent necrosis. In our patients, perforation occurred at the tumor site due to the penetration of the carcinoma through the bowel wall in two of six cases. In most reported cases of colonic carcinoma, perforation is into the peritoneal cavity, which is similar our observation. When this colonic perforation occurs, the findings can be mistaken for diverticulitis, particularly when it occurs on the right side or in the elderly in Asia. Stainland et al. [11] mentioned that the presentation of colorectal cancer can be quite varied and depends on the site of the lesion. Right-sided colonic lesions frequently present symptoms of abdominal pain, palpable mass, or anemia. In this series, all of the six patients had right-

5 19 sided colonic cancer and, therefore, presented the aforementioned symptoms. The anterior abdominal wall is one of the most common presenting points of such es [21]. In our analysis, one case involved the anterior abdominal wall due to a perforated transverse colonic carcinoma an formation. We also have a retro-peritoneal resulting from a perforated cecal carcinoma involving the anterior abdominal wall. Extraperitoneal perforation subsequent formation in the subcutaneous tissue occurs very infrequently. Survival was worse for patients obstructive or perforated cancer [2, 9], and adjuvant chemotherapy was highly recommended for these patients [22]. All of our six patients were administrated 5-FU/LV chemotherapy after the resection of tumors. Despite the previously unfavorable results of colonic cancer perforation, the clinical outcomes of our cases were considerably acceptable after the one-stage operation. The favorable prognosis may be due to the fact that our cases were TNM stage II (66.7%) and III (33.3%). The surgical complications included one wound infection (16.7%) and one anastomotic leakage entero-cutaneous fistula (16.7%). Fortunately, they recovered uneventfully after an exclusively conservative treatment. In conclusion, a one-stage surgical procedure seems feasible for these cases and the clinical outcomes are generally favorable. However, the long-term survival of patients perforated colonic carcinoma remains to be elucidated. References 1. Dean DT, Howard MP (1983) Retroperitoneal : a presentation of colon carcinoma. Gastrointest Radiol 8: Chen HS, Shen-Chen SM (2000) Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery 127: Mandava N, Kumar S, Pizzi WF, Aprile IJ (1996) Perforated colorectal carcinoma. Am J Surg 172: Donaldson GA (1958) The management of perforative carcinoma of the colon. N Engl J Med 258: Miller LD, Boruchow IB, Fitts WT (1986) An analysis of 284 patients perforative carcinoma of the colon. Surg Gynecol Obstet 123: Devitt JE, Roth-Moyo LA, Brown FN (1970) Perforation complicating adenocarcinoma of colon and rectum. Can J Surg 13: Welch JP, Donaldson GA (1974) Perforative carcinoma of colon and rectum. Ann Surg 180: Kobayashi H, Sakurai Y, Shoji M, Nakamura Y, Suganuma M, Imazu H, Hasegawa S, Matsubara T, Ochiai M, and Funabiki T (2001) Psoas and cellulitis of the right gluteal region resulting from carcinoma of the rectum. J Gastroenterol 36: Kelley WE, Brown PW, Lawrence W (1981) Penetrating, obstructing and perforating carcinomas of the colon and rectum. Arch Surg 116: Greene FL, Page DL, Fleming ID, Fritz AG et al (2001) In: AJCC cancer staging handbook. Springer, Berlin Heidelberg New York, pp Stainland JR, Ditchburn J, Dombal FT (1967) Clinical presentation of disease of the large bowel. A detailed study of 642 patients. Gastroenterology 70: Andaz S, Heald RJ (1993) Abdominal wall an unusual primary presentation of a transverse colonic carcinoma. Postgrad Med J 69: Ohman U (1982) Prognosis in patients obstructing colorectal carcinoma. Am J Surg 143: Rovito PF, Verazin G, Prorok I (1990) Obstructing carcinoma of the cecum. J Surg Oncol 45: Kronborg O, Baker O, Sprecjler M (1975) Acute obstruction in cancer of the colon and rectum. Dis Colon Rectum 18: Stower MJ, Hardcastle JD (1986) The results of 1115 patients colorectal cancer treated over an 8-year period in a single hospital. Eur J Surg Oncol 11: Cooke RV (1956) Advanced carcinoma of the colon emphasis on the inflammatory factor. Ann R Coll Surg Engl 18: Shucksmith HS (1963) Subcutaneous as the first evidence of carcinoma of the colon. Br J Surg 50: Gupta H, Dupuy DE (1997) Advances in imaging of the acute abdomen. Surg Clin North Am 77: Haaga JR, Havrilla TR (1997) CT detection and aspiration of abdominal es. Am J Roentgenol 128: John PW (1976) Unusual es in perforating colorectal cancer. Am J Surg 131: Sugarbaker PH, Gianola FJ, Speyer JC, Wesley R et al (1984) Prospective, randomized trial of intravenous versus intraperitoneal 5-fluorouracil in patients advanced primary colon or rectal cancer. Surgery 1985;98:

SUCCESSFUL MANAGEMENT OF PERFORATED DUODENAL DIVERTICULITIS WITH INTRA-ABDOMINAL DRAINAGE AND FEEDING JEJUNOSTOMY: A CASE REPORT AND LITERATURE REVIEW

SUCCESSFUL MANAGEMENT OF PERFORATED DUODENAL DIVERTICULITIS WITH INTRA-ABDOMINAL DRAINAGE AND FEEDING JEJUNOSTOMY: A CASE REPORT AND LITERATURE REVIEW Chin-Fan Chen, 1 Deng-Chyang Wu, 2,5 Chao-Wen Chen,