Br. J. Surg. 1991, Vol. 78, February, 183-1 88
Outcome after emergency surgery for cancer of the large intestine The data f o r 77 patients with colorectal cancer who underwent emergency surgery .for acute intestinal obstruction (57 patients) or perforation (20 patients) within 24 h of admission were evaluated. The patients were older and had more advanced disease than patients undergoing elective surgery f o r colorectal cancer. Emergency surgery f o r carcinoma of the right colon consisted of primary resection in 9.5 per cent of cases and was followed bv a 28 per cent mortality rate. Perforated tumours of the left colon and rectum were managed by primary resection in 82 per cent of cases with a 22 per cent mortality rate. In contrast, obstructing tumours of the left colon and rectum were treated by primary resection in 38 per cent of cases with a 6 per cent mortality rate, and by primary decompression in 62 per cent of cases with a 2.5 per cent mortality rate. The overall postoperative mortality rate was 23 per cent and increased with advanced tumour disease, perforation and peritonitis. Cardiac decompensation and intraabdominal sepsis were the major causes of death. Although the long-term survival rate following emergency surgery was worse than after elective surgery, improvements in outcome should be achieved by better management of the initial emergency situation.
N. S. Runkel, P. Schlag, V. Schwarz and C. Herfarth Department of Surgery, Section of Surgical Oncology, University of Heidelberg. lm Neuenheimer Feld 7 10, 6900 Heidelberg. Germany Correspondence to:
Professor P. Schlag
About 15 per cent of patients with carcinoma of the large intestine present as surgical emergencies, the great majority with acute intestinal obstruction, perforation at the site of the tumour, or a combination of both when perforation occurs in distended colon proximal to the obstructing cancer. Traditionally, the surgical procedure of choice for these emergencies consisted of an initial decompression of the proximal colon followed by resection after an interval of weeks or months. Over the last two decades, the attitude of most surgeons has changed towards a more aggressive initial approach. Emergency resection for cancer of the right hemicolon is now a generally accepted procedure and a primary ileocolonic anastomosis is performed in almost all of these cases'-3. Similarly, discontinuity resection for perforated tumours of the left colon has emerged as a standard surgical p r ~ c e d u r e ~ . ~ . Current controversy concerns the treatment of obstructing carcinomas of the distal large bowel. In 1979 a major study demonstrated an improved outcome after primary resection'. Since then, primary resection has been performed with increasing frequency. Recent results, however, show no difference in the early outcome between primary and staged procedures', and the long-term prognosis may even be worse after primary resection'. This study analysed the outcome after emergency laparotomy for obstructing and perforated colorectal cancer in this department between January 1982 and December 1987.
Patients and methods All patients with malignancies have been computer documented in our department. In addition, basic clinical data from all colorectal cancer patients were prospectively collected and registered. More detailed information about the clinical course was obtained from hospital records, the follow-up records of the oncology outpatient department, or directly from thc patient's general practitioner. Between 1982 and 1987,923patients underwent surgical treatment for primary colorectal carcinoma in our institution. Emergency laparotomy within 24 h of admission was performed for large bowel obstruction or perforation in 77 (8 per cent) patients. All of the other 846 (92 per cent) patients
.
0007-1323/91/020183 06
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are referred to as elective cases in this study, which analysed the relationship between the variables of age, sex, tumour stage and location. surgical treatment, postoperative morbidity and mortality, and long-term survival. The tumour stage was classified using the postsurgical histopathological tumour node metastasis (pTNM) classification of the Union International Contra Le Cancrum'. The xz test was applied for statistical analyses of the contingency tables. The survival curves were calculated with the Kaplan-Meier method'. The log rank test was used to check for significant differences between the Kaplan-Meier estimates".
Results Patients and tunrour cliuracteristics Of the 77 emergency laparotomies. 57 (74 per cent) were performed for obstruction and 20 (26 per cent) for perforation including five (6 per cent) for a combination of obstruction and perforation. The median age of the patients was 67 years in the elective group, 76 years in the group with obstruction and 79 years in the group with perforation. A third of all emergency laparotomies were performed in patients over 80 years of age (Figure I ) . The sex distribution was similar in the elective (47 per cent men) and the emergency group (51 per cent men). The incidence of emergency surgery varied with tumour location. Obstruction occurred more frequently in cancer of the descending (19 per cent) and sigmoid colon (12 per cent) than in cancer of the right hemicolon ( 5 per cent). In contrast, perforation was more frequently found in tumours of the right hemicolon ( 5 per cent) than in tumours of the descending (2 per cent) or sigmoid colon ( 2 per cent). Rectal carcinomas rarely presented with large bowel obstruction (3 per cent) or perforation ( 1 per cent).
I)iagnosis Intestinal obstruction was diagnosed clinically and confirmed by plain abdominal films in all 57 patients. A combined large and small bowel ileus was present in 57 per cent of cases. Five (9 per cent) of the underlying carcinomas had already been diagnosed before emergency admission. In all other cases,
. -.~
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183
Emergency surgery for colorectal cancer: N. S. Runkel e t at.
obstruction was the first presented symptom of colorectal cancer. Digital examination or Gastrografin a enema (Schering AG, Berlin, Germany; 27 investigations) established the diagnosis of cancer in 29 (51 per cent) patients before surgery. Flexible endoscopy had no role in the detection of tumour obstruction. Rigid endoscopy was performed twice and failed to demonstrate both sigmoid lesions. Forty per cent of patients underwent exploratory laparotomy . All 20 patients with colonic perforation presented with clinical signs of localized (25 per cent) or generalized (75 per cent) peritonitis. Ninety per cent of these patients underwent immediate laparotomy without knowledge of the underlying cancer or further diagnostic workup. A Gastrografin enema was performed in one patient and revealed a sigmoid lesion with retroperitoneal perforation. Another tumour had already been detected before emergency admission. Endoscopy was not performed in these patients with peritonitis. Laparotomy demonstrated perforation at the site of the tumour in 75 per cent of patients and in the distended prestenotic colon in 25 per cent of patients. Free rupture caused diffuse o r localized peritonitis in 50 per cent and 25 per cent of patients, respectively. Gross faecal contamination of the peritoneal cavity was apparent in 40 per cent of cases. The rupture was concealed with abscess formation and localized peritonitis in 20 per cent of cases. Five per cent of patients presented with a secondary free rupture of a concealed abscess leading to diffuse purulent peritonitis. Table 1 compares 'T' and 'N' stages and shows that there were more locally advanced tumours in the emergency group than in the elective group. In addition. distant metastases ( M , ) were found in 29 per cent of patients presenting on an emergency basis compared to 14 per cent of the elective patients (P
Outcome after emergency surgery for cancer of the large intestine The data f o r 77 patients with colorectal cancer who underwent emergency surgery .for acute intestinal obstruction (57 patients) or perforation (20 patients) within 24 h of admission were evaluated. The patients were older and had more advanced disease than patients undergoing elective surgery f o r colorectal cancer. Emergency surgery f o r carcinoma of the right colon consisted of primary resection in 9.5 per cent of cases and was followed bv a 28 per cent mortality rate. Perforated tumours of the left colon and rectum were managed by primary resection in 82 per cent of cases with a 22 per cent mortality rate. In contrast, obstructing tumours of the left colon and rectum were treated by primary resection in 38 per cent of cases with a 6 per cent mortality rate, and by primary decompression in 62 per cent of cases with a 2.5 per cent mortality rate. The overall postoperative mortality rate was 23 per cent and increased with advanced tumour disease, perforation and peritonitis. Cardiac decompensation and intraabdominal sepsis were the major causes of death. Although the long-term survival rate following emergency surgery was worse than after elective surgery, improvements in outcome should be achieved by better management of the initial emergency situation.
N. S. Runkel, P. Schlag, V. Schwarz and C. Herfarth Department of Surgery, Section of Surgical Oncology, University of Heidelberg. lm Neuenheimer Feld 7 10, 6900 Heidelberg. Germany Correspondence to:
Professor P. Schlag
About 15 per cent of patients with carcinoma of the large intestine present as surgical emergencies, the great majority with acute intestinal obstruction, perforation at the site of the tumour, or a combination of both when perforation occurs in distended colon proximal to the obstructing cancer. Traditionally, the surgical procedure of choice for these emergencies consisted of an initial decompression of the proximal colon followed by resection after an interval of weeks or months. Over the last two decades, the attitude of most surgeons has changed towards a more aggressive initial approach. Emergency resection for cancer of the right hemicolon is now a generally accepted procedure and a primary ileocolonic anastomosis is performed in almost all of these cases'-3. Similarly, discontinuity resection for perforated tumours of the left colon has emerged as a standard surgical p r ~ c e d u r e ~ . ~ . Current controversy concerns the treatment of obstructing carcinomas of the distal large bowel. In 1979 a major study demonstrated an improved outcome after primary resection'. Since then, primary resection has been performed with increasing frequency. Recent results, however, show no difference in the early outcome between primary and staged procedures', and the long-term prognosis may even be worse after primary resection'. This study analysed the outcome after emergency laparotomy for obstructing and perforated colorectal cancer in this department between January 1982 and December 1987.
Patients and methods All patients with malignancies have been computer documented in our department. In addition, basic clinical data from all colorectal cancer patients were prospectively collected and registered. More detailed information about the clinical course was obtained from hospital records, the follow-up records of the oncology outpatient department, or directly from thc patient's general practitioner. Between 1982 and 1987,923patients underwent surgical treatment for primary colorectal carcinoma in our institution. Emergency laparotomy within 24 h of admission was performed for large bowel obstruction or perforation in 77 (8 per cent) patients. All of the other 846 (92 per cent) patients
.
0007-1323/91/020183 06
~
(
~
-
~
~
I991 Rutterworth-Heinemann Ltd
are referred to as elective cases in this study, which analysed the relationship between the variables of age, sex, tumour stage and location. surgical treatment, postoperative morbidity and mortality, and long-term survival. The tumour stage was classified using the postsurgical histopathological tumour node metastasis (pTNM) classification of the Union International Contra Le Cancrum'. The xz test was applied for statistical analyses of the contingency tables. The survival curves were calculated with the Kaplan-Meier method'. The log rank test was used to check for significant differences between the Kaplan-Meier estimates".
Results Patients and tunrour cliuracteristics Of the 77 emergency laparotomies. 57 (74 per cent) were performed for obstruction and 20 (26 per cent) for perforation including five (6 per cent) for a combination of obstruction and perforation. The median age of the patients was 67 years in the elective group, 76 years in the group with obstruction and 79 years in the group with perforation. A third of all emergency laparotomies were performed in patients over 80 years of age (Figure I ) . The sex distribution was similar in the elective (47 per cent men) and the emergency group (51 per cent men). The incidence of emergency surgery varied with tumour location. Obstruction occurred more frequently in cancer of the descending (19 per cent) and sigmoid colon (12 per cent) than in cancer of the right hemicolon ( 5 per cent). In contrast, perforation was more frequently found in tumours of the right hemicolon ( 5 per cent) than in tumours of the descending (2 per cent) or sigmoid colon ( 2 per cent). Rectal carcinomas rarely presented with large bowel obstruction (3 per cent) or perforation ( 1 per cent).
I)iagnosis Intestinal obstruction was diagnosed clinically and confirmed by plain abdominal films in all 57 patients. A combined large and small bowel ileus was present in 57 per cent of cases. Five (9 per cent) of the underlying carcinomas had already been diagnosed before emergency admission. In all other cases,
. -.~
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183
Emergency surgery for colorectal cancer: N. S. Runkel e t at.
obstruction was the first presented symptom of colorectal cancer. Digital examination or Gastrografin a enema (Schering AG, Berlin, Germany; 27 investigations) established the diagnosis of cancer in 29 (51 per cent) patients before surgery. Flexible endoscopy had no role in the detection of tumour obstruction. Rigid endoscopy was performed twice and failed to demonstrate both sigmoid lesions. Forty per cent of patients underwent exploratory laparotomy . All 20 patients with colonic perforation presented with clinical signs of localized (25 per cent) or generalized (75 per cent) peritonitis. Ninety per cent of these patients underwent immediate laparotomy without knowledge of the underlying cancer or further diagnostic workup. A Gastrografin enema was performed in one patient and revealed a sigmoid lesion with retroperitoneal perforation. Another tumour had already been detected before emergency admission. Endoscopy was not performed in these patients with peritonitis. Laparotomy demonstrated perforation at the site of the tumour in 75 per cent of patients and in the distended prestenotic colon in 25 per cent of patients. Free rupture caused diffuse o r localized peritonitis in 50 per cent and 25 per cent of patients, respectively. Gross faecal contamination of the peritoneal cavity was apparent in 40 per cent of cases. The rupture was concealed with abscess formation and localized peritonitis in 20 per cent of cases. Five per cent of patients presented with a secondary free rupture of a concealed abscess leading to diffuse purulent peritonitis. Table 1 compares 'T' and 'N' stages and shows that there were more locally advanced tumours in the emergency group than in the elective group. In addition. distant metastases ( M , ) were found in 29 per cent of patients presenting on an emergency basis compared to 14 per cent of the elective patients (P
