c l i n i c a l f o l i o s : d i s c u s s i o n



Sigmoid Perforation

 

 

Related narrative: Perforated Sigmoid Carcinoma

Colon perforation in the elderly is due to diverticular disease and colon cancer in about equal proportion (about 40% each), with the remainder due to mechanical trauma (15%), ischemia (4%) and ulceration (1%). Emergency surgery for colon cancer is more often for obstruction (75%) than for perforation (15% proximal to the tumor, 10% at the tumor). The majority of perforations result in localized fluid collections/abscess, with the minority resulting in free perforation and generalized peritonitis. There has been a trend toward primary resection of the diseased colon. However, there is an overall 25% mortality for any emergency abdominal surgery in the elderly, and comorbid factors must be considered in selecting the optimal procedure for particular patients. Primary resection is feasible in only about half of patients with complicated colon cancer (obstruction/perforation). Most patients with perforation require resection despite the higher risk, and therefore have a higher postoperative mortality (up to 74%) than patients who have primary resection for obstructing lesions (28%). Poor long term survival rate for patients with perforated colon cancer has led to the use of adjuvant chemotherapy (5FU/levamisole or 5FU/leucovorin) and/or adjuvant radiotherapy for local control.

Primary closure of an abdomen under tension can result in intraabdominal hypertension (IAH) which can lead to organ damage (abdominal compartment syndroma/ACS). Abdominal compartment syndrome consists of increased intraabdominal pressure, increased pulmonary airway pressure, hypoxia, hypercarbia, and decreased renal function. A variety of conditions such as ascites, hemoperitoneum, giant hernia repair, or bowel edema as in trauma and in this case can result in IAH. The critical level of intraabdominal pressure ranges between 10 and 30 mm of Hg in the literature, with organ damage reported as low as 10mm. For patients with closed abdominal pressure increases, indirect bladder monitoring via Foley catheter is a simple diagnostic measure. Loose abdominal closure with prosthetic material is the best prophylactic measure for the open abdomen, especially in a sick patient. Synthetic mesh (polyglactin) is well tolerated in the presence of infection and is relatively safe to place directly on bowel. It can be separated easily at 7-10 days if primary or flap closure is feasible at that time, or can accept a split thickness skin graft. Dual sided mesh with an abdsorbable inner layer has the advantage of long term abdominal support without hernia formation.

References:

Sabiston: Textbook of Surgery, 15th ed., Copyright 1997 W. B. Saunders Company :497-8.

Emergency abdominal surgery in the elderly.
McIntyre R - J R Coll Surg Edinb - 1997 Jun; 42(3): 173-8

Emergency surgery for colon cancer in the aged.
Koperna T - Arch Surg - 1997 Sep; 132(9): 1032-7

Perforated carcinoma of the colorectum. Computerized tomography findings.
Catalano O - Radiol Med (Torino) - 1997 Jan-Feb; 93(1-2): 83-6

Improved outcome after emergency surgery for cancer of the large intestine.
Runkel NS - Br J Surg - 1998 Sep; 85(9): 1260-5

Perforated colonic cancer. Evolution and prognosis.
Alcobendas F - Rev Esp Enferm Dig - 2000 May; 92(5): 326-33

Perforated colorectal cancer.
Kriwanek S - Dis Colon Rectum - 1996 Dec; 39(12): 1409-14

Surgical treatment of the perforated colon with peritonitis.
Faltyn J - Ann Ital Chir - 1996 Mar-Apr; 67(2): 211-3

Adjuvant therapy for colon cancer.
Macdonald JS - CA Cancer J Clin - 1997 Jul-Aug; 47(4): 243-56

Does postoperative irradiation play a role in the adjuvant therapy of stage T4 colon cancer?
Willett CG - Cancer J Sci Am - 1999 Jul-Aug; 5(4): 242-7

Synthetic graft placement in the treatment of fascial dehiscence with necrosis and infection.
McNeeley SG Jr - Am J Obstet Gynecol - 1998 Dec; 179(6 Pt 1): 1430-4

Intra-abdominal hypertension and the abdominal compartment syndrome.
Ivatury RR - Surg Clin North Am - 1997 Aug; 77(4): 783-800


This page was last modified on 17-Jan-2001.