Journal of Gastrointestinal Surgery

, Volume 15, Issue 12, pp 2232–2238

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

  • Martin D. Zielinski
  • Amit Merchea
  • Stephanie F. Heller
  • Y. Nancy You
Original Article

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.

Keywords

Complicated colon cancer Peforated viscous Long-term outcomes Septic shock Intensive care 

References

  1. 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.PubMedCrossRefGoogle Scholar
  2. 2.
    The United States Center for Disease Control.Google Scholar
  3. 3.
    Gunnarsson H, Holm T, Ekholm A, et al. Emergency presentation of colon cancer is most frequent during summer. Colorectal Dis. 13:663–668,2010PubMedCrossRefGoogle Scholar
  4. 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.PubMedCrossRefGoogle Scholar
  5. 5.
    Smothers L, Hynan L, Fleming J, et al. Emergency surgery for colon carcinoma. Dis Colon Rectum. 46:24–30,2003.PubMedCrossRefGoogle Scholar
  6. 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.PubMedCrossRefGoogle Scholar
  7. 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.PubMedGoogle Scholar
  8. 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.PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. 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.PubMedCrossRefGoogle Scholar
  11. 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.PubMedCrossRefGoogle Scholar
  12. 12.
    Welch JP, Donaldson GA. Perforative carcinoma of colon and rectum. Ann Surg. 180:734–740,1974.PubMedCrossRefGoogle Scholar
  13. 13.
    Murphy JE, Ryan DP. American Society of Clinical Oncology 2010 colorectal update. Expert Rev Anticancer Ther. 2010 Sep;10(9):1371–3.PubMedCrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. 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.PubMedCrossRefGoogle Scholar
  16. 16.
    Badia JM, Sitges-Serra A, Pla J, et al. Perforation of colonic neoplasms. A review of 36 cases. Int J Colorectal Dis. 2:187–189,1987PubMedCrossRefGoogle Scholar
  17. 17.
    Chen HS, Sheen-Chen SM. Obstruction and perforation in colorectal adenocarcinoma: an analysis of prognosis and current trends. Surgery. 127:370–376,2000.PubMedCrossRefGoogle Scholar
  18. 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.PubMedCrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 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.PubMedCrossRefGoogle Scholar
  21. 21.
    Khan S, Pawlak SE, Eggenberger JC, et al. Acute colonic perforation associated with colorectal cancer. Am Surg. 67:261–264,2001.PubMedGoogle Scholar
  22. 22.
    Mandava N, Kumar S, Pizzi WF, et al. Perforated colorectal carcinomas. Am J Surg. 172:236–238,1996.PubMedCrossRefGoogle Scholar
  23. 23.
    Kriwanek S, Armbruster C, Dittrich K, et al. Perforated colorectal cancer. Dis Colon Rectum. 39:1409–1414,1996.PubMedCrossRefGoogle Scholar
  24. 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.PubMedCrossRefGoogle Scholar
  25. 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.PubMedCrossRefGoogle Scholar
  26. 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.PubMedCrossRefGoogle Scholar
  27. 27.
    Cuffy M, Abir F, Audisio RA, et al. Colorectal cancer presenting as surgical emergencies. Surg Oncol. 13:149–157,2004.PubMedCrossRefGoogle Scholar
  28. 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.PubMedCrossRefGoogle Scholar
  29. 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.PubMedCrossRefGoogle Scholar
  30. 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: 780–784CrossRefGoogle Scholar
  31. 31.
    Crowder VH, Cohn I. Perforation in cancer of the colon and rectum. Dis Colon Rectum. 10:415–420,1967.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2011

Authors and Affiliations

  • Martin D. Zielinski
    • 1
    • 2
  • Amit Merchea
    • 1
  • Stephanie F. Heller
    • 1
  • Y. Nancy You
    • 1
  1. 1.Department of SurgeryMayo ClinicRochesterUSA
  2. 2.Division of Trauma, Critical Care and General Surgery, Mary Brigh 2-810St. Mary’s Hospital, Mayo ClinicRochesterUSA

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