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WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

OBSTRUCTED RIGHT COLON CANCER


M Simone, MD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This illustrated case describes a colon obstruction secondary to a cancer at the hepatic flexure. Radiologic studies are typical. The choice of urgent therapeutic intervention is discussed within the context of the patient’s age (92 years old).

2. Keywords


Right colon, cancer

3. Patient


Female, 92-year-old

4. Past medical history


- ischemic cardiomyopathy;
- two myocardial infarctions in the last 3 years;
- senile dementia.

5. History of present illness


- abdominal pain;
- no passage of gas nor bowel movements for the last 48 hours.

6. Clinical examination


The abdomen is tense, tympanic, and there is asymmetry of the abdominal wall greater on the right.
The intestinal loops are visible on the abdominal wall. Palpation and digital rectal exam are within normal limits.

7. Laboratory data


- WBC 13K;
- CRP 30;
- SGOT, SGPT, GGT, are within normal limits;
- alkaline phosphatase is elevated 3X normal.

8. Abdominal X-ray (without preparation)


The plain, flat abdominal X-ray reveals multiple air-fluid levels.

9. CT scan


The CT scan reveals a thickening at the right colon angle in a subhepatic position with a stenosis of the intestinal lumen, which is clearly identified. The right colon is very dilated. Diverticula as well as gallstones are also identified.

10. Image 1


This image demonstrates significant distension of the cecum (a), and confirms a small bowel obstruction.

11. Image 2


This image shows the right colon full of stool (a) with air located in the intestinal wall above a thickened bowel wall at the right angle of the transverse colon (b). A gallstone is visible.

12. Image 3


This image demonstrates a distended right colon full of stool (a), followed by an area obstructed by a neoplasm (b).

13. Preoperative diagnosis


There is evidence of a bowel obstruction caused by a neoplasm at the right angle of the occluded transverse colon. Another possibility could be the migration of a gallstone due to the presence of gallstones and elevated liver enzymes.

14. Therapeutic options


The therapeutic options are as follows:
- right hemicolectomy;
- draining cecostomy;
- lateral diverting ileostomy;
- internal diversion (ileo-transverse colostomy to bypass the tumor);
- cholecystectomy.

15. Discussion


Decompressive interventions for the bowel can be imagined for an elderly patient in a poor state of general health. However the cecostomy is not well suited because it does not remove the source of the obstruction. In an inoperable patient, an ileostomy under local anesthesia can be considered. If general anaesthesia is possible, it is preferable to at least perform an internal anastomosis to give maximal comfort to the patient and then if possible to resect the tumor.

16. Operative procedure


After a preoperative anesthesia evaluation, it is decided to perform a surgical intervention under general anesthesia. An exploratory laparotomy is performed. It confirms the existence of a pre-perforation dilatation of the right colon, with a 15 cm diameter and a serosal tear of 10 cm. These findings necessitated a right hemicolectomy. A cholecystectomy was performed at the same operation.

17. Pathological exam


Well-differentiated adenocarcinoma stage T3, N1, M0

18. Postoperative follow-up


Return of bowel function occurred on POD 3, and oral intake was started on the fourth postoperative day. The hospital stay was uneventful and the patient was discharged on the 10th postoperative day.

19. Discussion


The therapeutic options considered essentially depend on the general state of health of the patient. The decision to perform an operation under general anesthesia must consider the operation, which will offer the optimal quality of life to the patient. The resection of the tumor followed by immediate anastomosis represented the ideal solution in this case. The decision to perform an operation under general anesthesia must take into account which surgical intervention will offer the best quality of life to the patient.
Adenocarcinoma represents 95% of tumors of the colon and is the third most frequently occurring cancer in females. It also represents the third leading cause of death by cancer. The positive diagnosis of a colonic tumor is usually realized during the evaluation of common symptoms. The location of colon cancer occurs 51% in the sigmoid colon, 10% in the left colon, 7% in the transverse colon, and between 3% to 4% at the splenic or hepatic flexures and in 25% in the right colon with a division of 15% in the cecum and 10% in the ascending colon.

The most frequent symptoms include bleeding (58%), abdominal pain (52%), changes in bowel habits (51%), and anemia (57% of cases). The presence of occult blood in the stool is found in up to 77% of the cases. The duration of symptoms before diagnosis is usually 14 weeks. There is no concordance between the duration of symptoms, the stage of disease, the age of the patient or tumor location. As in the observation presented, the late discovery of a right colon cancer is a relatively frequent occurrence in particular in elderly patients due to the lack of clinical signs.

20. References


  1. Demers RY, Severson RK. Incidence of colorectal adenocarcinoma by anatomic subsite. Cancer 1997;79 :441-7.
  2. Gorski TF, Rosen L, Riether R, Stasik J, Khubchandani I. Colorectal cancer after surveillance colonoscopy: false-negative examination or fast growth? Dis Colon Rectum 1999;42:877-80.
  3. Majumdar SR, Fletcher RH, Evans AT. How does colorectal cancer present? Symptoms, duration, and clues to location. Am J Gastr 1999; 94:3039-45.
  4. Miller A, Gorska M, Bassett M. Proximal shift of colorectal cancer in the Australian Capital Territory over 20 years. Aust N Z J Med 2000;30:221-5.
  5. Scott NA. Treating colorectal cancer: chances in front of goal. BMJ 2000;320:949.