Treatment of perforated colon carcinomas-outcomes of radical surgery

Stage IV Colorectal Cancer Management and Treatment

(1) Background: Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer-related mortality worldwide. Up to 50% of patients with CRC develop metastatic CRC (mCRC). Surgical and systemic therapy advances can now offer significant survival advantages. Understanding the evolving treatment options is essential for decreasing mCRC mortality. We aim to summarize current evidence and guidelines regarding the management of mCRC to provide utility when making a treatment plan for the heterogenous spectrum of mCRC. (2) Methods: A comprehensive literature search of PubMed and current guidelines written by major cancer and surgical societies were reviewed. The references of the included studies were screened to identify additional studies that were incorporated as appropriate. (3) Results: The standard of care for mCRC primarily consists of surgical resection and systemic therapy. Complete resection of liver, lung, and peritoneal metastases is associated with better disease control and survival. Systemic therapy now includes chemotherapy, targeted therapy, and immunotherapy options that can be tailored by molecular profiling. Differences between colon and rectal metastasis management exist between major guidelines. (4) Conclusions: With the advances in surgical and systemic therapy, as well as a better understanding of tumor biology and the importance of molecular profiling, more patients can anticipate prolonged survival. We provide a summary of available evidence for the management of mCRC, highlighting the similarities and presenting the difference in available literature. Ultimately, a multidisciplinary evaluation of patients with mCRC is crucial to selecting the appropriate pathway.

Definition and reporting of lymphadenectomy and complete mesocolic excision for radical right colectomy: a systematic review

BACKGROUND

Several procedures have been proposed to reduce the rates of recurrence in patients with right-sided colon cancer. Different procedures for a radical right colectomy (RRC), including extended D3 lymphadenectomy, complete mesocolic excision and central vascular ligation have been associated with survival benefits by some authors, but results are inconsistent. The aim of this study was to assess the variability in definition and reporting of RRC, which might be responsible for significant differences in outcome evaluation.

METHODS

PRISMA-compliant systematic literature review to identify the definitions of RRC. Primary aims were to identify surgical steps and different nomenclature for RRC. Secondary aims were description of heterogeneity and overlap among different RRC techniques.

RESULTS

Ninety-nine articles satisfied inclusion criteria. Eight surgical steps were identified and recorded as specific to RRC: Central arterial ligation was described in 100% of the included studies; preservation of mesocolic integrity in 73% and dissection along the SMV plane in 67%. Other surgical steps were inconstantly reported. Six differently named techniques for RRC have been identified. There were 35 definitions for the 6 techniques and 40% of these were used to identify more than one technique.

CONCLUSIONS

The only universally adopted surgical step for RRC is central arterial ligation. There is great heterogeneity and consistent overlap among definitions of all RRC techniques. This is likely to jeopardise the interpretation of the outcomes of studies on the topic. Consistent use of definitions and reporting of procedures are needed to obtain reliable conclusions in future trials. PROSPERO CRD42021241650.

Risk factors for the recurrence of stage II perforated colorectal cancer: A retrospective observational study

BACKGROUND

Patients with perforated colorectal cancer (PCRC) experience higher recurrence rates than those with non-perforated tissue. We identified the promoting factors of stage II PCRC recurrence after R0 surgery.

METHOD

This retrospective observational study included patients treated for colorectal cancer at a single facility between 2007 and 2016, and compared the clinicopathological features of patients with perforating versus non-perforating stage II tumors who underwent R0 resection, while focusing on recurrences.

RESULTS

Thirty-two and 112 patients (predominantly men) with perforating and non-perforating tumors, respectively, were included. The perforated group had significantly higher proportions of T4 tumors than the non-perforated group (44% vs. 15%). The perforated group had significantly lower numbers of resected lymph nodes than the non-perforated group (6 vs. 17). Seven of 17 patients with follow-up data in the perforated group experienced recurrence (41%), versus 19 of 104 in the non-perforated group (18%). In the non-perforated group, male sex (89% vs. 60%, p = 0.030), T4 stage (32% vs. 9%, p = 0.029), and fewer resected lymph nodes (12.5 vs. 18.6, p = 0.003) were significantly associated with recurrence; however, no such influences on recurrence were observed in the perforated group. The recurrence sites in the perforated group were mostly local (6 patients, 86%). Conversely, recurrences in the non-perforated group were mostly distant; 8 of 19 patients (42%) had liver metastasis and 1 (5%) had lung metastasis.

CONCLUSION

Patients with stage II PCRC experienced higher recurrence rates regardless of clinicopathological features and had high local recurrence rates indicating possible local tumor cell dispersal owing to perforation.

Outcomes of patients with perforated colon cancer: A systematic review

INTRODUCTION

Perforated colon cancer (PCC) is a distinct clinical entity with implications for treatment and prognosis, however data on PCC seems scarce. The aim of this systematic review is to provide a comprehensive overview of the recent literature on clinical outcomes of PCC.

MATERIALS AND METHODS

A systematic literature search of MEDLINE (PubMed), Embase, Cochrane library and Google scholar was performed. Studies describing intentionally curative treatment for patients with PCC since 2010 were included. The main outcome measures consisted of short-term surgical complications and long-term oncological outcomes.

RESULTS

Eleven retrospective cohort studies were included, comprising a total of 2696 PCC patients. In these studies, various entities of PCC were defined. Comparative studies showed that PCC patients as compared to non-PCC patients have an increased risk of 30-day mortality (8-33% vs 3-5%), increased post-operative complications (33-56% vs 22-28%), worse overall survival (36-40% vs 48-65%) and worse disease-free survival (34-43% vs 50-73%). Two studies distinguished free-perforations from contained perforations, revealing that free-perforation is associated with significantly higher 30-day mortality (19-26% vs 0-10%), lower overall survival (24-28% vs 42-64%) and lower disease-free survival (15% vs 53%) as compared to contained perforations.

CONCLUSION

Data on PCC is scarce, with various PCC entities defined in the studies included. Heterogeneity of the study population, definition of PCC and outcome measures made pooling of the data impossible. In general, perforation, particularly free perforation, seems to be associated with a substantial negative effect on outcomes in colon cancer patients undergoing surgery. Better definition and description of the types of perforation in future studies is essential, as outcomes seem to differ between types of PCC and might require different treatment strategies.

Is it possible to adopt the same oncological approach in urgent surgery for colon cancer?

BACKGROUND

Locoregional complications may occur in up to 30% of patients with colon cancer. As they are frequent events in the natural history of this disease, there should be a concern in offering an oncologically adequate surgical treatment to these patients.

AIM

To compare the oncological radicality of surgery for colon cancer between urgent and elective cases.

METHODS

One-hundred and eighty-nine consecutive patients with non-metastatic colon adenocarcinoma were studied over two years in a single institution, who underwent surgical resection as the first therapeutic approach, with 123 elective and 66 urgent cases. The assessment of oncological radicality was performed by analyzing the extension of the longitudinal margins of resection, the number of resected lymph nodes, and the percentage of surgeries with 12 or more resected lymph nodes. Other clinicopathological variables were compared between the two groups in terms of sex, age, tumor location, type of urgency, surgical access, staging, compromised lymph nodes rate, differentiation grade, angiolymphatic and perineural invasion, and early mortality.

RESULTS

There was no difference between the elective and urgency group concerning the longitudinal margin of resection (average of 6.1 in elective vs 7.3 cm in urgency, P = 0.144), number of resected lymph nodes (average of 17.7 in elective vs 16.6 in urgency, P = 0.355) and percentage of surgeries with 12 or more resected lymph nodes (75.6% in elective vs 77.3% in urgency, P = 0.798). It was observed that the percentage of patients aged 80 and over was higher in the urgency group (13.0% in elective vs 25.8% in urgency, P = 0.028), and the early mortality was 4.9% in elective vs 15.2% in urgency (P = 0.016, OR: 3.48, 95%CI: 1.21–10.06). Tumor location (P = 0.004), surgery performed (P = 0.016) and surgical access (P < 0.001) were also different between the two groups. There was no difference in other clinicopathological variables studied.

CONCLUSION

Oncological radicality of colon cancer surgery may be achieved in both emergency and elective procedures.

Is neoadjuvant therapy an alternative strategy to immediate surgery in locally perforated colon cancer?

BACKGROUND

Perforations are a rare but serious complication of colorectal cancer. The current standard of treatment is emergent surgery followed by adjuvant chemotherapy. The concern with this approach is not only the uncertainty of achieving a R0 resection but also potential injury to adjacent vessels, nerves and ureters due to inflamed tissue planes. A subset of this patient population with a contained perforation who are clinically stable may have superior oncological outcomes with local sepsis control, neoadjuvant therapy followed by radical resection. The aim of this study is to report on the pre-operative safety profile for neoadjuvant therapy in the setting of an abscess from colon cancer perforation and the short-term oncological surgical quality outcomes.

METHODS

In this retrospective observational study, all consecutive perforated colon cancer receiving neoadjuvant therapy from Jan 2010 to Dec 2019 were included.

RESULTS

There were 21 patients that met the inclusion criteria. The most common symptom at presentation was abdominal pain (71.4%) and most common site of perforation was sigmoid colon (61.9%). Local sepsis control was achieved with a combination of radiological or surgical drainage, diverting ostomy and/or intravenous antibiotics. Thirteen patients had long-course chemoradiation and eight patients had neoadjuvant chemotherapy. Of these, 13 (61.9%) had tumour regression, with one patient having a pathological complete response. All patients achieved a R0 resection.

CONCLUSIONS

In a small subset of patients with colon cancer perforation, this study has demonstrated the potential safe usage of neoadjuvant therapy first before radical surgery to achieve a clear resection margin.

Perforated Colon Cancer Associated With Post-operative Recurrent Bowel Perforations

Colon perforation is a major life-threatening condition associated with high morbidity and mortality, which often develops secondary to complicated diverticulitis and, less commonly, colon cancer. We describe the case of a 51-year-old female who had perforated colon cancer with concurrent diverticulosis. Based on history, physical exam, laboratory, and computed tomography (CT) findings on initial presentation, the patient was diagnosed with acute complicated diverticulitis. Despite medical treatment, the patient’s condition worsened, warranting exploratory laparotomy and a left hemicolectomy with transverse end colostomy creation. Surgical pathology revealed stage IIIC colon cancer without evidence of diverticulitis. The patient underwent eight cycles of adjuvant chemotherapy with FOLFOX (folinic acid, fluorouracil, and oxaliplatin). Over the next year, the patient experienced recurrent bowel perforations requiring repeated surgeries. Perforations were identified in both the small and large bowel on different occasions. Even though neither presented with a clear etiology, possible ischemic, infectious, erosive, and iatrogenic etiologies were on the differential. Our case exemplifies the mounting complications we should be wary of when performing repeated invasive abdominal operations.

Perforated colorectal cancers: clinical outcomes of 18 patients who underwent emergency surgery

Introduction

Although colon cancer perforations are rare among acute abdominal syndromes, it is a clinical picture with high mortality that requires urgent treatment.

Aim

In this study, the clinical results of patients who were operated in emergency conditions due to colorectal cancer perforation were evaluated.

Material and methods

The data of 18 patients treated for colorectal cancer perforation in our clinic between February 2014 and February 2017 were retrospectively reviewed. The following data were evaluated: demographic features of the patients, location of the tumour, metastasis, stage of the tumour, number of lymph nodes dissected, survival, type, and prognosis of the surgery.

Results

Eight (44%) of 18 patients with perforated colon cancers were female and 10 (56%) were male. The mean age was 65.2 (31-104) years. Four of the patients had liver metastasis only, and 5 had multiple metastases. All cases had sudden abdominal pain and acute abdominal clinical findings. Fourteen of the patients underwent full resection, and 4 of them underwent partial resection and trephine stoma (colostomy). Perioperative mortality was not observed. The long-term mortality rate in our study was 77.7% (n = 14), and the operative mortality rate was 44% (n = 8). Additional organ injuries occurred during resection in 2 patients.

Conclusions

Colorectal cancer perforation seen in advanced ages is one of the causes of acute abdominal syndrome, which can be fatal. The general condition of the patient and the size and localization of the perforation should be taken into consideration in the choice of treatment. Curative surgery can also be performed in perforated colorectal cancers. However, partial resection and trephine colostomy should be performed in patients with multiple metastases and poor general condition.

An Aggressive Liposarcoma Presenting as a Perforated Colon Mass

Dedifferentiated liposarcoma (DDLS) is a high-grade sarcoma that usually arises from a well-differentiated liposarcoma, which most commonly presents as a retroperitoneal mass. DDLS involving the colon is extremely rare, and only a few cases have been reported. We present a case of a DDLS that was found in the cecum and adjacent mesentery. This aggressive sarcoma developed within six months based on computed tomography (CT) findings and initially presented as a perforated colon mass. The patient was taken for emergent exploratory laparotomy including right hemicolectomy with en bloc resection. There was no metastatic disease at time of presentation, but at three-month follow-up, CT scans demonstrated metastatic disease to the liver, lungs, and multiple peritoneal implants. This case highlights a rare form of colon cancer and its aggressive nature of progression.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Colon cancer with perforation

Perforation of the colon is a rare complication for patients with colon cancer and usually requires emergent surgery. The characteristics of perforation differ based on the site of perforation, presenting as either perforation at the cancer site or perforation proximal to the cancer site. Peritonitis due to perforation tends to be more severe in cases of perforation proximal to the cancer site; however, the difference in the outcome between the two types remains unclear. Surgical treatment of colon cancer with perforation has changed over time. Recently, many reports have shown the safety and effectiveness of single-stage operation consisting of resection and primary anastomosis with intraoperative colonic lavage. Under certain conditions, laparoscopic surgery can be feasible and help minimize the invasion. However, emergent surgery for colon cancer with perforation is associated with a high rate of mortality and morbidity. The long-term prognosis seems to have no association with the existence of perforation. Oncologically curative resection may be warranted for perforated colon cancer. In this report, we perform a literature review and investigate the characteristics and surgical strategy for colon cancer with perforation.

Adenocarcinoma of the Colon Disguised as Abdominal Wall Abscess: Case Report and Review of the Literature

Introduction

Abdominal wall invasion by cancerous cells arising from the colon with an overlying secondary infection that presents as an abdominal wall abscess has been encountered previously, but such a symptom is rarely the first presentation of colon cancer. There are very few cases reported in the literature.

Case Presentation

In this case report, we present a case of a 66-year-old male presenting with abdominal wall abscess that was refractory to treatment. The patient later was found to have an abdominal wall invasion by an underlying colonic carcinoma.

Conclusion

The purpose of this review is to set forth the proper approach when encountering such cases and emphasize on the significance of keeping a high index of suspicion. We also highlight the need for utilizing proper diagnostic imaging modalities prior to invasive intervention.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Colon Cancer

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Multivisceral resection for occlusive colorectal cancer: Is it justified?

BACKGROUND

The only possibility of curative surgery in primary T4, locally advanced, adherent colorectal carcinoma (LAACRC) or recurrent disease with infiltration of adjacent organs is the en bloc resection of the invaded structures to achieve clear surgical margins (R0). The role of extended resections for occlusive LAACRC remains unclear. We report on our experience on Multivisceral resections (MVR) for LAACRC patients between 2003 and 2012.

METHODS

Twenty-two patients, who were treated with MVR with curative purpose for non-metastatic disease were recruited. General epidemiologic data, clinical findings, surgical treatment and/or multimodal therapy, histo-pathological examination and follow-up were collected. In addition post-operative complications were classified. Patients with occlusive LAACRC (n = 6) were compared to patients with uncomplicated presentation (n = 16) defined according to the UICC classification.

RESULTS

No statistically significant differences were observed between the two groups, in terms of median age, gender and localization of tumors. R0 resection was performed in 14 (87.5%) patients with uncomplicated tumors and in all patients with occlusive LAACRC. R1 resection was performed in 2/16 (12.5%) patients with uncomplicated disease. No peri-operative mortality was reported in patients of both groups. In the group of uncomplicated tumors, 11 patients (68.7%) were classified as pathological (p)T4 and 5 patients (31.2%) were classified pT3 whereas in the group of occlusive LAACRC the majority of patients were classified as pT4 (83.3%). Lymph node involvement occurred in 9 patients (56.2%) of the fist group and in two patients (33.3%) of the second group, respectively. The 3-year survival rates in all patients with both uncomplicated and occlusive diseases were 58.4% and 33.3%, respectively. The 3-years survival of patients with locally advanced adherent rectal cancer was significantly lower than the observed survival of patients with colon cancer (p < 0.0001).

CONCLUSION

MVR offers cure (R0 resections) in uncomplicated and obstructive LAACRC with three years survival in 40% of patients. Patients affected by rectal cancer with occlusive disease showed significantly decreased survival in comparison with those affected by colon cancer.

Localized peritoneal carcinomatosis mimicking an irreducible left inguinal hernia

Perforated colonic cancers are not rare and leave patients at risk of developing peritoneal carcinomatosis. We present a 68-year-old male patient with a perforated transverse colonic tumour who underwent emergency extended right hemicolectomy. He made an uneventful postoperative recovery, and received adjuvant chemotherapy. Unfortunately, a routine positron emission tomography-computed tomography scan 16 months later demonstrated an fluorodeoxyglucose-avid nodule in the left scrotum associated with an irreducible left inguinal hernia that contained sigmoid colon. At laparotomy, the discovery of isolated peritoneal recurrence in the hernia sac was unexpected, given the absence of local recurrence in the region of the original transverse colon cancer perforation. The etiology therefore remains uncertain, but one may speculate that cell implantation occurred within the hernia sac at the initial emergency laparotomy.

[Management of bleeding and infections in the context of visceral surgery]

Bleeding and vascular infections are serious potential complications during abdominal general surgery. The management of bleeding depends on the extent and localization and can range from the application of hemostatics to vascular sutures, interpositioning and ligatures. The use of prosthetic biomaterials implanted endoluminally or during open reconstruction permits palliation of potentially fatal conditions. The overall incidence of infections involving vascular prostheses is relatively low because of routine antibiotic prophylaxis prior to surgery, refinements in sterilization and packaging of devices and careful adherence to aseptic procedural and surgical techniques. When infections occur detection and definitive therapy of the vascular prosthesis are often delayed and the management is complex and tedious. Infections involving vascular prostheses are difficult to eradicate and in general, surgical therapy is required often coupled with excision of the prosthesis. Keys to success include accurate diagnostics to identify the organism and extent of graft infections, specific long-term antibiotic therapy and well-planned surgical interventions to excise and replace the infected graft and sterilize the local tissue. Regardless of the technique used to eradicate graft infections, success is measured by patient survival, freedom from recurrent infection and patency of revascularization. Even when treatment is successful, the morbidity associated with vascular graft infections is considerable. Aortoenteric fistulas (AEF) are a rare (incidence < 1.5 %) but often fatal complication. Primary diagnosis of AEF remains difficult. Computed tomography (CT) and fluorodeoxyglucose positron emission tomography CT (FDG-PET-CT) are the diagnostic tools of choice. Therapy consists of an urgent individualized interdisciplinary surgical approach with primary axillofemoral bypass and secondary prosthesis explantation or in situ replacement and subsequent bowel resection. Endovascular aortic repair (EVAR) is reserved for primary aortoenteric fistulas in patients with no signs of infection or in emergency cases as a bridging method.