We realized an retrospective descriptive study lasting on the later 5 years (2007-2011), considering all cases of colonic cancer treated by surgical intervention in “Colentina” Clinical Surgery (307 patients), based on the analysis of medical papers and operatory registries.
Sex ratio was almost equal, with little predominance of the males (162 cases); as regards the provenience environment, such clear majority of the patients from urban sites could be seen, this being explained by the alimentary habits centered on predominant intake of animal protein diet.
Tumor topography: sigmoid colon - 112 cases, descending colon - 43 cases, transverse colon - 78 cases, cecum and ascending colon - 74 cases. The more frequent localization on left colon, mainly on sigmoid colon could be seen.
In 49 cases, the presentation was made in an emergency status, 39 cases being with acute intestinal occlusion and 10 cases with peritonitis by tumor perforation or by cecum diastatic perforation.
The clinical picture that brought the patient for medical help, except the cases presented in emergency, was carrying the following symptoms and signs (possible association of these):
-alterations of the intestinal transit, with increased constipation or constipation-diarrhea alter-nation: 187 cases;
-abdominal distension: 257 cases;
-abdominal pain: 113 cases;
-anemia of unknown reason: 97 cases;
-weight loss: 215 cases;
-digestive bleeding: 39 cases.
The diagnosis was mainly based, in the great majority of cases (287 cases), on colonoscopy with biopsy and histopathology examination.
The cases of our study group belonged to one of the following evolutionary stages:
- stage I: 34 cases;
- stage II: 75 cases;
- stage III: 135 cases;
- stage IV: 63 cases.
In the great majority of cases, the histopathological result indicated the existence of an adeno-carcinoma with different grades of differentiation.
Information needed for correct tumor staging was offered by investigations like abdominal echography, pulmonary radiography and abdominal computer tomography. The cases presented as emergencies benefited from diagnostic from plain abdominal radiography.
We started lately with such timidity to apply the principles of fast-track surgery, even trying to realize a mechanic preparation of the bowel anytime possible. Regarding the cases operated as emergencies, we practiced intraoperative cleaning of the bowel by washout technique.
The operations proceeded were represented by:
- right hemicolectomy: 86 cases;
- transverse segmental colectomy: 52 cases;
- left hemicolectomy: 48 cases;
- segmental sigmoidectomy: 112 cases;
- subtotal colectomy: 4 cases;
- total colectomy: 5 cases.
Considering the emergency operated cases, they benefited from the following interventions:
- those cases of occlusion by left colonic tumor and those with peritonitis by tumor perforation were solved in seriated interventions, the first time realizing the removal of the tumor with temporary colostomy, the second time for bowel continuity reestablishment being done 3 months later;
- those cases with peritonitis by diastatic cecum perforation were subjected for total colectomy with ileostomy as first operative time, followed 3 months later by reintervention for bowel continuity reestablishment (ileorectostomy).
We should mention here some cases with particular presentation and solution:
- 2 cases of appendical carcinoid that 1 month after the initial intervention (appendectomy), when the histopathological report was ready, needed reintervention for right hemicolectomy with ileotransversostomy;
- 13 cases with preexistent hepatic cirrhosis where the surgical intervention had to face with great hemorrhagic risks and the postoperative period was affected by decompensation of the hepatic function that had to be sustained;
- 5 cases of colonic tumor developed on familial adenomatous polyposis, submitted for subtotal colectomy (3 cases) or total colectomy (2 cases) with ileal pouch;
- 11 cases of splenic flexure colonic tumor with invasion in pancreatic tail and splenic hilum needed association of distal splenopancreatectomy;
- 3 cases of hepatic flexure colonic tumor with duodenal invasion needed reconstructive techniques for duodenum after tumor removal;
- 24 cases with 1-3 hepatic metastases associated wedge resections of the metastases.
In the last period, we started to use the stapler devices in colon-rectal cancer more and more. Thus, from the total of 307 patients operated for colon cancer, we reestablished the bowel continuity by side to end, end to side or side to side anastomoses using the staplers of EEA, TA, GIA or Endo-GIA types. The advantages were represented by shortened duration of the surgical intervention, with accomplishment of surgical sutures that have not produced any postoperative complication until now.
Surgical intervention was done in 5 cases by laparoscopic technique: right hemicolectomy - 2 cases, segmental sigmoidectomy - 2 cases, transversal colectomy - 1 case.
Postoperative complications occurred in 27 cases, being represented by:
- bleeding (3 cases),
- peritoneal abscesses: 5 cases,
- anastomotic fistula: 7 cases,
- wound infections: 12 cases;
11 cases need a surgical re-intervention.
Preoperative mortality was of 13 cases, due to one of the following complications:
- bronchopneumonia: 5 cases;
- IMA: 2 cases;
- hepatic failure: 3 cases;
- sepsis: 3 cases.
All the patients were subsequently submitted for oncologic treatment program with chemo¬therapy having the leading role.
Follow up of operated patients was done by clinical controls every 3 months in the first 2 years and then every 6 months in the next 3 years, colonoscopy, tumor markers and imagistic investigations done every 6 months in the first 2 years and then every year in the next 3 years.