Simultaneous operation for cancer‐related sigmoid colon perforation and abdominal aortic aneurysm of 76 mm in diameter

Abstract

Case

A 92‐year‐old woman was emergently admitted to our hospital for peritonitis caused by sigmoid colon cancer perforation, with a coexistent abdominal aortic aneurysm of 76 mm in diameter.

Outcome

A 92‐year‐old woman was admitted to the hospital with a complaint of abdominal pain and fever of 24‐h duration. On physical examination, severe tenderness with muscular defense and a palpable, pulsating mass were detected in the upper abdomen. The patient was diagnosed as having panperitonitis caused by sigmoid colon perforation. Computed tomography also revealed an infrarenal abdominal aortic aneurysm of 76 mm in diameter. We performed endovascular aneurysm repair to prevent aneurysmal rupture in the perioperative period and simultaneously performed intra‐abdominal drainage and Hartmann's operation. The patient's postoperative course was uneventful.

Conclusion

Simultaneous endovascular aneurysm repair and operation for peritonitis is considered a possible treatment strategy for patients at high risk of abdominal aortic aneurysm rupture.

Introduction

In elderly patients, acute surgical abdomen, such as peritonitis, is rarely associated with abdominal aortic aneurysm (AAA). Emergent operation for acute surgical abdomen is indicated as an initial treatment, with the AAA treated secondarily as an elective surgery. However, large AAAs have a risk of rupture during the perioperative period.1, 2 Recently, endovascular aneurysm repair (EVAR) has been reported as a convenient and safe treatment for AAA. We present a case of sigmoid colon perforation associated with an AAA of 76 mm in diameter, for whom EVAR, hemicolectomy, and drainage were simultaneously performed.

Case

A 92‐year‐old woman was admitted to the hospital by ambulance with a complaint of abdominal pain and fever of 24‐h duration. On physical examination, severe tenderness with muscular defense and a palpable, pulsating mass were detected in the upper abdomen. She was alert and her body temperature was 37.7°C; blood pressure, 148/80 mmHg; and heart rate, 95 b.p.m. The leukocyte count was 8,700/μL, and the C‐reactive protein level was 15.8 mg/dL. Prothrombin time – international normalized ratio was 1.28, and activated partial thromboplastin time was 36.1 s. The pH, PaCO₂, PaO₂, and other arterial blood gas analysis parameters were within normal limits. Abdominal computed tomography revealed free air in the peritoneal cavity and signs of inflammation in the adipose tissue surrounding the sigmoid colon, with an infrarenal AAA of 76 mm in diameter (Fig. 1A,B). The patient was diagnosed as having panperitonitis caused by sigmoid colon perforation. Although she was considered to be suffering from peritonitis, her vital signs were relatively favorable. Therefore, we decided to carry out simultaneous operations consisting of EVAR followed by surgery for peritonitis, to avoid rupture of the AAA in the abdominal surgery. The Endurant (Medtronic, Minneapolis, MN, USA) stent graft main body (ENBF2516C145EJ) was introduced from the left common femoral artery to the pararenal aorta (Fig. 1C). The contralateral limb was inserted from the right common femoral artery to the main body. The main body and contralateral limb were then deployed. The EVAR was completed without complications and with an operation time of 1 h 46 min; heparin was used to prevent thrombosis.

Figure 1.

Abdominal computed tomography scan before surgery in a 92‐year‐old woman diagnosed with panperitonitis caused by sigmoid colon perforation. A, An inflammatory reaction was suspected in the adipose tissue surrounding the sigmoid colon (within dashed circle line). There was no obvious finding of intestinal necrosis. B, Infrarenal abdominal aortic aneurysm (76 mm in diameter, within dashed circle line) and free air in the peritoneal cavity was identified. C, Enhanced computed tomography examination on the seventh postoperative day. There was no endoleakage from the graft.

Following EVAR, we proceeded with surgery for the panperitonitis. Before we started the operation, we used protamine to neutralize the effect of heparin and control bleeding. After laparotomy, wall thickening and perforation (10 mm in diameter) were identified in the sigmoid colon. Solid stool and purulent ascites were confined to the area surrounding the sigmoid colon and the retroperitoneal cavity (Fig. 2A). The sigmoid colon near the perforation was tightly adhered to the transverse colon and the adhesion was considered to be caused by inflammation or cancer invasion. We then performed left hemicolectomy and transverse colostomy (Hartmann's operation; operation time, 2 h 42 min). Total amount of bleeding from the two operations was 150 mL.

Figure 2.

Intraoperative findings in a 92‐year‐old woman diagnosed with panperitonitis caused by sigmoid colon perforation. A, Wall thickening and perforation of 1 cm in diameter (arrow) were found in the sigmoid colon. Solid stool and purulent ascites were confined to the area surrounding the sigmoid colon and the retroperitoneal space. B, Perforation of the sigmoid colon (a). Early colon cancer (well‐ to moderately differentiated adenocarcinoma) was found on the side opposite the sigmoid colon perforation (b).

The patient was moved to the intensive care unit (ICU) postoperatively under ventilation, and received direct hemoperfusion with an immobilized polymyxin‐B fiber column for approximately 48 h continuously (from immediately after admission to ICU to the second postoperative day). The patient was extubated and discharged from the ICU on the third postoperative day, and enhanced computed tomography examination on the seventh postoperative day confirmed that there was no endoleakage from the graft (Fig. 1C). The patient's postoperative course was uneventful and she was transferred to another hospital on the 15th postoperative day in a wheelchair to continue rehabilitation. Pathological examination revealed early colon cancer (well‐ to moderately differentiated adenocarcinoma) on the side opposite the sigmoid colon perforation (Figs. 2B, 3A,B). The cancer was widespread, involving multiple venous thromboemboli and the entire thickness of the colonic wall (Fig. 3). We suspected that the venous invasion caused congestion that resulted in ischemia and perforation of the colonic wall.

Figure 3.

Microscopic findings of the resected specimen from a 92‐year‐old woman who underwent simultaneous operation for sigmoid colon perforation and abdominal aortic aneurysm. A, Hematoxylin and eosin staining of the resected specimen showing early colon cancer involving massive venous invasion on the side opposite the sigmoid colon perforation (magnification, ×40). B, Magnified image of the cancer (well‐ to moderately differentiated adenocarcinoma) (magnification, ×40). C, Magnified image of the venous invasion.

Discussion

We report a patient who underwent simultaneous operations for sigmoid colon perforation and a very large AAA. Generally, the initial treatment for patients with peritonitis complicated by AAA is determined by the severity of each disease. Our patient required emergency surgery for peritonitis because it has been reported that peritonitis caused by colon perforation is associated with a high mortality of approximately 17%.3 The additional concern was that the complicating AAA was considered to have a risk of rupture in the perioperative period. Robinson et al. reported that 2 of 10 cases with colorectal cancer and complicating AAA greater than 60 mm experienced AAA rupture after colorectal surgery before AAA treatment.2 Morris et al. reported that blood pressure change and collagenase activation in the perioperative period increased the risk of rupture.1 We decided to perform simultaneous operation for both diseases.

Endovascular aneurysm repair enables safe and simple AAA treatment without laparotomy. Prinssen et al. carried out a randomized controlled trial comparing the clinical results of abdominal surgery for AAA with those with EVAR, and EVAR was revealed to be associated with a significantly lower incidence of mortality versus abdominal surgery (4.6% versus 1.2%, respectively), as well as morbidity (9.8% versus 4.7%, respectively).4 In our case, conventional AAA treatment (graft replacement surgery) would have been extremely invasive and carried a high risk of graft infection if carried out simultaneously with surgery for colonic perforation. The reported mortality of graft infection after surgery is approximately 17%;5 therefore, we performed EVAR prior to peritonitis surgery to avoid both rupture of the AAA and graft infection.

Operative findings revealed that purulent ascites and solid stool were confined to the area surrounding the sigmoid colon, and the retroperitoneal space, because of severe inflammation and adhesion. This was the suspected reason that the patient was relatively stable. If the patient had a more severe condition due to peritonitis, we would have carried out minimally invasive peritonitis surgery prior to EVAR.

Although the etiology of colonic perforation was not confirmed during the operation, the pathological diagnosis revealed that perforation was caused by sigmoid colon cancer. The rate of colorectal cancer complicated by AAA is reported to be approximately 0.5–1.4%,2, 6 and we found several published case reports.1, 2, 6, 7 In those reports, the decisions to treat which disease first, or to treat simultaneously, were based on the patients' general status, cancer prognosis, and AAA condition. Generally, when the diameter of the AAA was greater than 60 mm, AAA was treated first to avoid perioperative rupture. We found no previous reports of simultaneous operation for gastrointestinal perforation caused by cancer complicated with AAA. We found one case report by Pitoulias et al. discussing a 78‐year‐old woman with acute cholelithiasis and an AAA of 62 mm in diameter, who underwent one‐stage operation with EVAR and laparoscopic cholecystectomy.8 In cases of peritonitis associated with risky, large AAAs, one‐stage operation with EVAR is considered to be a safe and effective treatment to avoid perioperative AAA rupture.

Conclusion

In cases of peritonitis complicated with a large AAA with tolerable general condition, simultaneous operation consisting of EVAR for AAA and peritonitis operation is considered to be an effective treatment strategy to avoid rupture of the AAA.

Conflict of Interest

None.