Perforated Colorectal Cancer Research Articles

Obstruction and perforation in colorectal adenocarcinoma: An analysis of prognosis and current trends

Background: In adenocarcinoma of the colon and rectum, obstruction and perforation may occur either alone or together at the site of the neoplasm or proximally. Both events carry a poor prognosis. This retrospective study sought to determine whether a correlation exists between perforation and obstruction, and between these conditions and different clinicopathological factors in colorectal adenocarcinoma. Methods: The medical records of 1950 patients with colorectal adenocarcinoma treated in our hospital during a 7-year period were retrospectively analyzed. One hundred patients (5%) were excluded from this study because of a loss of follow-up. Data on clinicopathological factors including age, sex, tumor location, surgical mortality, pathological type, stage, and long-time cancer-free rate were simultaneously analyzed. Patients were grouped as follows: Group 1, complete colonic obstruction without perforation (n = 120); Group 2, complete obstruction with perforation at the site of the cancer (n = 35); Group 3, complete obstruction with perforation proximal to the cancer (n = 13); and Group 4, nonobstructing, nonperforated cancers (n = 1682). Results: When compared with Group 4, Group 1 had a more advanced Dukes' stage, older age, greater incidence of colonic versus rectal cancers, and a poorer cancer-free survival ( P ≤ .005). Groups 2 and 3 had a greater incidence of colonic versus rectal cancers ( P ≤ .004), and Group 3 had a greater operative mortality ( P <.001). No significant differences were found between Groups 1, 2, and 3. Multivariate analysis revealed that the independent factors favorable to cancer-free survival (>5-year survival) were female gender ( P = .035), well-differentiated pathology ( P < .001), uncomplicated cases ( P = .004), colon versus rectal location ( P < .001), and early stage ( P < .001). Conclusions: The perioperative mortality rate for perforated colorectal cancer at the site of the cancer was 9%; for obstructive colorectal cancer, 5%. Perioperative mortality was much greater for perforations of the colon and rectum occurring proximal to the cancer (31%). Survival was worse ( P < .001) for patients with obstruction (33%) or perforation proximal to the cancer (33%). The site of perforation did not appear to impact the 5-year survival, although the numbers are relatively small. (Surgery 2000;127:370-6.)

Use of intraperitoneal 5-fluorouracil and chlorhexidine for prevention of recurrence of perforated colorectal carcinoma in a rat model.

Colorectal cancer is a prevalent and mortal disease, resulting in nearly 55,000 deaths in the United States annually. Preoperative or intraoperative spillage of tumor cells because of perforation occurs in up to 10 percent of cases. When this spillage occurs, the chance of recurrence and death is dramatically increased. In an effort to reduce the chance of recurrence and death, we used a rat model to evaluate the efficacies of intraperitoneal 5-fluorouracil and chlorhexidine in reducing the incidence of recurrence. Rats were injected with 10 mg/kg azoxymethane subcutaneously weekly for 12 weeks to induce colorectal cancers. At 20 weeks, subtotal colectomies were performed on rats with colorectal tumors and without peritoneal implants or liver metastases. At the time of surgery, a cut portion of the tumor was placed in the abdomen for 30 minutes; the rats then randomly received peritoneal irrigation with 5-fluorouracil, chlorhexidine, or sterile water (control). Eight weeks postoperatively a necropsy was performed. At that time, obvious and suspected recurrences and the anastomotic area were sampled for histologic evaluation. Significant differences were seen with chlorhexidine vs. water for gross tumor (P = 0.05) and microscopic tumor (P < 0.05). 5-Fluorouracil showed a greater rate of abscess formation vs. both control and chlorhexidine (P > 0.05). Use of chlorhexidine intraperitoneal therapy at the time of the operation for perforated colorectal cancer significantly decreases the frequency of gross tumor recurrence but not total recurrences. Intraperitoneal 5-fluorouracil does not significantly decrease recurrence and may increase the risk of abscess when used intraoperatively.

Perforated colorectal cancer.

Perforations are rare but serious complications of colorectal cancer, with mortality rates of 30 to 40 percent. The aim of this retrospective study was to investigate possible indicators of prognosis and causes of death and to evaluate the risk of this complication by comparing results in perforated tumors with uncomplicated cancers or large-bowel perforations attributable to benign causes. Data of postoperative and long-term results of 35 patients with perforated colorectal cancers were compared in 868 patients with uncomplicated cancers and 130 patients with large-bowel perforations attributable to benign diseases. Postoperative survival in perforated cancers (mortality, 40 percent) was determined by degree of peritonitis, septic state, and tumor stages. Comparison of the three groups demonstrated advanced tumor stages, a higher rate of septic organ failures, and higher mortality rates for perforated cancers. Long-term survival depended on tumor stages but did not differ in perforated and uncomplicated cancers. A cumulative effect of malignancy and sepsis may be responsible for the high postoperative mortality in malignant perforation. Patients with perforated cancers represent the highest risk group in colonic perforation.

STUDY ON EMERGENCY OPERATION CASES OF COLORECTAL CANCER

Operative procedure and clinicopathological features were studied in patients undergoing emergency operation for colorectal cancer. Subject were 29 patients with intestinal obstruction due to colorectal cancer and 10 patients with perforated colorectal cancer out of 290 patients operated on for colorectal cancer at the department from 1980 to 1991. In a comparison with patients undergoing elective operation, no significant difference was noted in age, sex, histological type, and macroscopic morphology, however, there was a tendency to have deeper invasion depth into the wall or to have other organ metastasis in emergency ones. Emergency operation cases were commonly in an advanced stage at the onset of the disease. That might be a probable reason for its lowered incidence of curative resection. However, if curative resection could be performed in emergency cases, the 5-year survival rate of them did not significantly differ from that of elective operation cases. The prognosis was not necessarily poor for even emergency operation cases. Some cases were capable of undergoing radical operation. Pre and intraoperative correct diagnosis and appropriate selection of operative procedure would promise some emergency cases a favorable prognosis of the same length as that of elective operation cases.

CLINICAL STUDY OF PERFORATION OF THE LARGE INTESTINE

Thirty-nine cases of perforation of the large intestine were subjected to a retrospective study of the cause, site of perforation, clinical findings, prognosis, and operative results and prognosis of perforated colo-rectal cancer patients who were in the greatest frequency were discussed. Seventy four percent of them occurred in sigmoid colon and sigmoid segment of the rectum. These perforations were caused by colo-rectal cancer (38%) and diverticulum of large intestine (36%), namely, the both causes accounted for 74% of all cases. The appearance rate of intraperitoneal free air, which is an evidence for definitive diagnosis, was as low as 49%. Irrespective of causes of perforations, preoperative shock state, free perforation, and intraperitoneal coproplanesia were the risk factors for perforation of the large intestine. The mortality directly related to operation was 21%. Fifteen cases of perforation caused by colo-rectal cancer represented 2.1% of 717 cases operated on for colo-rectal cancer, and were predominantly comprised of advanced cases, in which curative resection rate was as low as 47% and 5-year survival rate in curative resectin cases was as poor as 34.3%. For such cases antishock treatments starting in a preoperative period is important. On the cases of perforated colo-rectal cancer patients, it should be considered to be resected in one staged with lymphnode dissection.