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Journal of Medical Cases

Case Report

Volume 12, Number 6, June 2021, pages 248-250

Synchronous Onset of Two Complications in Colon Cancer: A Case Report

As the third most incident malignancy in the world population, colorectal cancer (CRC) is responsible for 11% of all cancer diagnoses per year. Southern Europe, Australia with New Zealand and Northern Europe are the regions of highest incidence if only the colon cancer is considered [1]. With this high incidence among the world population, certain types of complications directly related to colon cancer that require some type of emergency intervention can be expected.

Typical colon cancer complications are bleeding, obstruction and perforation. Up to 33% of the patients with CRC present with some type of these emergencies [2].

Most common is the colon obstruction due to the local tumor growth with incidence ranging between 15% and 29% [3]. Large bowel obstruction is also the most common cause for emergency surgical colon procedures [4].

Second most common complication of CRC is the perforation with overall incidence of 2.6% up to 12% [5]. Colon perforation can occur on tumor site or distantly (proximal to the obstructing tumor). Perforation on tumor site can result in free perforation or a contained one with an abscess formation and is caused by tumor necrosis and tissue friability. Distant perforation occurs due to the increasing intraluminal pressure and consequent wall necrosis and perforation (law of Laplace) in the most wide parts of the colon (cecum, ascending and transverse colon) [6].

Even though bleeding from CRC is reported in up to 50% of cases [2], it is usually occult and self-limited. Acute massive bleeding from CRC is rare [6].

Synchronous occurrence of more than one of the above complications of CRC is rare. Kyllonen reports an overall incidence of tumor perforation with or without obstruction in only 4% of patients [7]. Glenn and McSherry report a dual complication incidence (obstruction and perforation) of 1.7%. Almost in all of their patients, the perforation and obstruction occurred at tumor site. Only one patient with transverse colon cancer had distant (cecal) perforation [8]. In a retrospective study of 1,850 patients with CRC, Chen and Sheen-Chen found 2.6% of patients had obstruction with perforation [9].

We present a case of a 61-year-old female patient that presented to our emergency department. On admission, she was barely standing on her feet and she complained of general weakness, strong pain in the left lumbar region, high fever, absence of flatus and stool passage.

Physical examination revealed clinical signs of bowel obstruction. In the left lumbar region, there was a subcutaneous palpable and painful tumor with local skin inflammation.

Laboratory test showed hemoglobin value of 111 g/L (120.0 - 165.0 g/L), leukocyte count of 17.9 × 10⁹/L (3.8 - 5.8 × 10⁹/L), serum Na⁺ of 132.8 mmol/L (137.0 - 147.0 mmol/L), serum albumin level of 28.7 g/L (35.0 - 52.0 g/L) and C-reactive protein level of 262.4 mg/L (0 - 5.0 mg/L). Other laboratory parameters were within normal limits. Contrast-enhanced computed tomography (CT) scan was previously done in other medical institution. It revealed large bowel obstruction with a site of obstruction at the level of the descending colon where a suspicious neo-infiltrative obstructing lesion was detected (yellow arrow). The scan also showed a retroperitoneal abscess that spreads over the left lumbar region with a bubble-gas level (black arrow) (Fig. 1).

Click for large image

Figure 1. Contrast-enhanced abdominal computed tomography scan with suspicious neo-infiltrative obstructing lesion (yellow arrow) and retroperitoneal abscess that spreads in the left lumbar region with a bubble-gas level (black arrow).

After admission and short resuscitation, the patient was referred to the operating room for an exploratory laparotomy. During exploration, a distended colon was found due to obstructing neo-infiltrative and perforated process of the descending colon. After opening the retroperitoneum, pus was freed from the abscess cavity. Its microbiological analysis showed presence of coliform bacteria. A proper lavage and drainage of the abscess cavity was done. Resection of the descendent colon was followed, with a creation of a terminal transversostomy at the left side of the abdominal wall.

The pathology report showed a moderately differentiated obstructive adenocarcinoma of the descending colon with a 1 cm wide defect on the colon wall. The process invaded the serosa of the colon with pericolic infiltration of the fatty tissue. Only five lymph nodes were yielded and analyzed (one of them had metastatic deposit). The final stage according to the eighth edition of Union for International Cancer Control (UICC) was pT4a pN1c pM0, pL1, pV0, pR0, G2, NG2, stage III B.

The postoperative period of recovery was slow but uneventful. Liquid oral intake started at postoperative day 3 and solid food was administered after the passage of gas through the formed stoma (day 4). The patient was discharged on postoperative day 10. There was no wound infection or any other accompanied postoperative morbidity.

Treatment strategies in the onset of emergency colon cancer are defined. According to the 2017 World Society of Emergency Surgery (WSES) guidelines on colon and rectal cancer emergencies, in cases of transverse/left colon cancer perforation, resection with primary anastomosis should be attempted. Hartmann’s resection is an option, also. As bottom line, the surgeon should decide whether to create stoma or choose a one-stage surgery with primary anastomosis [10].

Fact speaking in favor of diverting stoma creation after the resection is the high mortality rate after single-stage surgery in perforated and/or obstructed colon cancer [11].

Another unfavorable moment for primary anastomosis creation in perforated left colon cancer is the anastomotic leak. The rates range from 3.5% to 30% [12].

When choosing a type of surgery for left colon cancer obstruction, main comparison is made between single-stage surgery and Hartmann’s procedure. Lately, no randomized controlled trials were conducted. Therefore, there is no evidence available and the final choice for the type of the procedure is the surgeon’s one [10].

In our case report, we considered Hartmann’s procedure as the most reasonable and appropriate choice.

Due to the high incidence of colon cancer, its complications are still frequent too. They can be a real obstacle in performing one seriously planned single-stage oncologic surgical procedure with the least possible postoperative adverse events. Therefore, timely diagnosis can result in decreased number of complicated colon cancer cases.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Informed Consent

Not applicable because the manuscript and the images show nothing from the patient’s identity.

Author Contributions

A. Nikolovski and N. Limani were involved in the operation and the postoperative treatment of the patient. A. Nikolovski made the conception and the design of article and drafted the manuscript. A. Lazarova interpreted the CT finding from the other medical institution. All authors read and critically reviewed the report. All authors approved the final submitted version.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.

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