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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
OBSTRUCTED RIGHT COLON CANCERM 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. KeywordsRight colon, cancer 3. PatientFemale, 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 examinationThe 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 scanThe 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 1This image demonstrates significant distension of the cecum (a), and confirms a small bowel obstruction. 11. Image 2This 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 3This image demonstrates a distended right colon full of stool (a), followed by an area obstructed by a neoplasm (b). 13. Preoperative diagnosisThere 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 optionsThe therapeutic options are as follows: - right hemicolectomy; - draining cecostomy; - lateral diverting ileostomy; - internal diversion (ileo-transverse colostomy to bypass the tumor); - cholecystectomy. 15. DiscussionDecompressive 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 procedureAfter 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 examWell-differentiated adenocarcinoma stage T3, N1, M0 18. Postoperative follow-upReturn 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. DiscussionThe 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
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