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Emergency Management of Perforated Colon Cancers: How Aggressive Should We Be?

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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Emergency treatment of perforated colon cancer has traditionally been linked with dismal outcomes due to the double jeopardy of a septic insult combined with a malignant disease, leaving unclear how aggressive emergency surgical procedures should be. We aimed to define short- and long-term outcomes in the current era of critical care support and oncologic advances, to provide updated data for decision making.

Study Design

Patients with perforations associated with a primary colon cancer were identified. Peri-operative and long-term survival were compared among free (FP; n = 41) and contained perforations (CP; n = 45) and to age-, stage-, and resection status case-matched, non-perforated (NP; n = 85), controls.

Results

Tumors were completely resected in 67% of FP but fewer lymph nodes were harvested (median, 11 vs. 11 and 16 in CP and NP; p = 0.21 and p < 0.001). Peri-operative mortality was highest in FP: 19% vs. 0% and 5% in CP and NP (p = 0.038), respectively. After adjusting for peri-operative mortality, 5-year overall survival was comparable: 55%, 59%, and 54% for FP, CP, and NP, respectively. Advanced age, higher ASA class, presence of residual disease, and advanced stage, but not perforation, were independent predictors of poorer long-term overall survival.

Conclusions

Patients with malignant colonic perforation face high risk of peri-operative death, making septic source control the priority in the acute setting. Pursuit of an oncologically oriented resection and long-term cancer-directed treatments, however, may lead to improved long-term outcomes.

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References

  1. Edwards, BK, Ward, E, Kohler, BA, et al. Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer. 116:544–573,2010.

    Article  PubMed  Google Scholar 

  2. The United States Center for Disease Control.

  3. Gunnarsson H, Holm T, Ekholm A, et al. Emergency presentation of colon cancer is most frequent during summer. Colorectal Dis. 13:663–668,2010

    Article  PubMed  Google Scholar 

  4. Bass G, Fleming C, Conneely J, et al. Emergency first presentation of colorectal cancer predicts significantly poorer outcomes: a review of 356 consecutive Irish patients. Dis Colon Rectum. 52:678–684,2009.

    Article  PubMed  Google Scholar 

  5. Smothers L, Hynan L, Fleming J, et al. Emergency surgery for colon carcinoma. Dis Colon Rectum. 46:24–30,2003.

    Article  PubMed  Google Scholar 

  6. Runkel NS, Hinz U, Lehnert T, et al. Improved outcome after emergency surgery for cancer of the large intestine. Br J Surg. 85:1260–1265,1998.

    Article  PubMed  CAS  Google Scholar 

  7. Kelley WE Jr., Brown PW, Lawrence W, Jr., et al. Penetrating, obstructing, and perforating carcinomas of the colon and rectum. Arch Surg. 116:381–384,1981.

    PubMed  Google Scholar 

  8. Cheung HY, Chung CC, Tsang WW, et al. Endolaparoscopic approach vs conventional open surgery in the treatment of obstructing left-sided colon cancer: a randomized controlled trial. Arch Surg. 144:1127–1132,2009.

    Article  PubMed  Google Scholar 

  9. Lim JF, Tang CL, Seow-Choen F, et al. Prospective, randomized trial comparing intraoperative colonic irrigation with manual decompression only for obstructed left-sided colorectal cancer. Dis Colon Rectum. 48:205–209,2005.

    Article  PubMed  CAS  Google Scholar 

  10. Breitenstein S, Rickenbacher A, Berdajs D, et al. Systematic evaluation of surgical strategies for acute malignant left-sided colonic obstruction. Br J Surg. 94:1451–1460,2007.

    Article  PubMed  CAS  Google Scholar 

  11. Tilney HS, Lovegrove RE, Purkayastha S, et al. Comparison of colonic stenting and open surgery for malignant large bowel obstruction. Surg Endosc. 21:225–233,2007.

    Article  PubMed  CAS  Google Scholar 

  12. Welch JP, Donaldson GA. Perforative carcinoma of colon and rectum. Ann Surg. 180:734–740,1974.

    Article  PubMed  CAS  Google Scholar 

  13. Murphy JE, Ryan DP. American Society of Clinical Oncology 2010 colorectal update. Expert Rev Anticancer Ther. 2010 Sep;10(9):1371–3.

    Article  PubMed  Google Scholar 

  14. Dellinger RP, Levy MM for the International Surviving Sepsis Campaign Guidelines Committee. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med (2008) 34:17–60.

    Article  PubMed  Google Scholar 

  15. Gunderson LL, Jessup JM, Sargent DJ, et al. Revised TN categorization for colon cancer based on national survival outcomes data. J Clin Oncol. 28:264–271,2010.

    Article  PubMed  Google Scholar 

  16. Badia JM, Sitges-Serra A, Pla J, et al. Perforation of colonic neoplasms. A review of 36 cases. Int J Colorectal Dis. 2:187–189,1987

    Article  PubMed  CAS  Google Scholar 

  17. Chen HS, Sheen-Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery. 127:370–376,2000.

    Article  PubMed  CAS  Google Scholar 

  18. Biondo S, Kreisler E, Millan M, et al. Differences in patient postoperative and long-term outcomes between obstructive and perforated colonic cancer. Am J Surg. 195:427–432,2008.

    Article  PubMed  Google Scholar 

  19. Abdelrazeq AS, Scott N, Thorn C, et al. The impact of spontaneous tumour perforation on outcome following colon cancer surgery. Colorectal Dis. 10:775–780,2008.

    Article  PubMed  CAS  Google Scholar 

  20. Anwar MA, D’Souza F, Coulter R, et al. Outcome of acutely perforated colorectal cancers: experience of a single district general hospital. Surg Oncol. 15:91–96,2006.

    Article  PubMed  Google Scholar 

  21. Khan S, Pawlak SE, Eggenberger JC, et al. Acute colonic perforation associated with colorectal cancer. Am Surg. 67:261–264,2001.

    PubMed  CAS  Google Scholar 

  22. Mandava N, Kumar S, Pizzi WF, et al. Perforated colorectal carcinomas. Am J Surg. 172:236–238,1996.

    Article  PubMed  CAS  Google Scholar 

  23. Kriwanek S, Armbruster C, Dittrich K, et al. Perforated colorectal cancer. Dis Colon Rectum. 39:1409–1414,1996.

    Article  PubMed  CAS  Google Scholar 

  24. Lee IK, Sung NY, Lee YS, et al. The survival rate and prognostic factors in 26 perforated colorectal cancer patients. Int J Colorectal Dis. 22:467–473,2007.

    Article  PubMed  Google Scholar 

  25. Wong SK, Jalaludin BB, Morgan MJ, et al. Tumor pathology and long-term survival in emergency colorectal cancer. Dis Colon Rectum. 51:223–230,2008.

    Article  PubMed  Google Scholar 

  26. Tan KK, Hong CC, Zhang J, et al. Surgery for perforated colorectal malignancy in an Asian population: an institution’s experience over 5 years. Int J Colorectal Dis. 25:989–995,2010.

    Article  PubMed  Google Scholar 

  27. Cuffy M, Abir F, Audisio RA, et al. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 13:149–157,2004.

    Article  PubMed  Google Scholar 

  28. Carraro PG, Segala M, Orlotti C, et al. Outcome of large-bowel perforation in patients with colorectal cancer. Dis Colon Rectum. 41:1421–1426,1998.

    Article  PubMed  CAS  Google Scholar 

  29. Jestin P, Nilsson J, Heurgren M, Påhlman L, Glimelius B, Gunnarsson U. Emergency surgery for colonic cancer in a defined population. Br J Surg. 2005 Jan;92(1):94–100.

    Article  PubMed  CAS  Google Scholar 

  30. Lehnert T, Buhl K, Dueck M, Hinz U, Herfarth C. Two-stage radical gastrectomy for perforated gastric cancer. Eur J Surgical Oncology 2000; 26: 780–784

    Article  CAS  Google Scholar 

  31. Crowder VH, Cohn I. Perforation in cancer of the colon and rectum. Dis Colon Rectum. 10:415–420,1967.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Mayo Clinic, Rochester, MN, USA

    Martin D. Zielinski, Amit Merchea, Stephanie F. Heller & Y. Nancy You

  2. Division of Trauma, Critical Care and General Surgery, Mary Brigh 2-810, St. Mary’s Hospital, Mayo Clinic, 1216 Second St. SW, Rochester, MN, 55902, USA

    Martin D. Zielinski

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  1. Martin D. Zielinski
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  2. Amit Merchea
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  3. Stephanie F. Heller
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  4. Y. Nancy You
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Correspondence to Martin D. Zielinski.

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Zielinski, M.D., Merchea, A., Heller, S.F. et al. Emergency Management of Perforated Colon Cancers: How Aggressive Should We Be?. J Gastrointest Surg 15, 2232–2238 (2011). https://doi.org/10.1007/s11605-011-1674-8

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  • DOI: https://doi.org/10.1007/s11605-011-1674-8

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