Elsevier

Surgical Oncology

Volume 15, Issue 2, August 2006, Pages 91-96
Surgical Oncology

Outcome of acutely perforated colorectal cancers: Experience of a single district general hospital

https://doi.org/10.1016/j.suronc.2006.09.001Get rights and content

Abstract

Introduction

Perforation of colorectal cancer (CRC) is rare and is associated with a significantly high mortality and morbidity. The aim of the current study was to evaluate various factors influencing the outcome in these patients.

Material and Methods

A retrospective analysis of 42 patients with perforated CRC between 1999 and 2003 was performed. A number of variables including age, sex, site of perforation, presence of faecal peritonitis, grade of surgeon, presence of metastasis, stage of tumour, type of surgery, ASA grade and CR POSSUM score were analysed for their influence on the outcome in these patients using MS Excel, MS Access and Stata.

Results

Of the 42 patients 19 were female and 23 were male. The mean age of the patients was 70.5 (range 44–96 yr). Thirty patients had perforation at the tumour, 10 proximal to the tumour, and one distal to the primary tumour. The perforation was localised in 25 patients. However, 17 patients had free perforation with frank faecal peritonitis. Twenty-one patients had resection and anastomosis, 18 patients had resection without restoration of bowel continuity and 3 had palliative colostomy. The in-hospital mortality (within 30 d) was 40.5% (n=17) with only 15 patients being alive at the end of 2 yr with an overall mortality of 64.3% (n=27). The outcome was not altered by variables such as sex, surgeon's grade, surgical procedure, Dukes’ staging or the site of perforation (p>0.5). Univariate analysis showed that advanced age (p<0.01), higher ASA grade (p<0.001), higher CR POSSUM score (p<0.001) and degree of peritonitis (p<0.01) were strongly associated with adverse outcomes. However, in stepwise multivariate logistic regression analysis ASA grade (p=0.01) and CR POSSUM score (p=0.01) were the only significant predictors of in-hospital mortality.

Conclusion

The outcome of perforated colonic cancer continues to be poor. ASA score and CR POSSUM score are good predictors of the short-term outcome.

Introduction

Colorectal cancer (CRC) is the second most common cause of cancer related deaths in the UK. Some 34,000 cases are diagnosed in the UK each year with 60% being colonic and 40% being rectal cancers [1]. Perforation of CRC is an uncommon complication (2.6–9%) [2], [3], [4], [5], but is associated with high mortality and morbidity. In-hospital mortality in cases of perforated CRC has been reported to be between 5% and 40% [4], [6] despite advances in modern management of sepsis and peri- and post-operative intensive care medicine. Studies [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12] have shown various risk factors responsible for the poor outcome of acutely perforated CRC patients and include degree of peritonitis, site of perforation, septic state, stage of the tumour, age and ASA grade of the patient. The aim of this study was to evaluate a number of risk factors that may have a direct bearing on the short and long term outcome of perforated CRC in our hospital.

Section snippets

Method and materials

Data was analysed from a prospectively maintained CRC Database on 762 consecutive patients presented between January 1999 and December 2003. Of these 42 (5.5%) patients presented with acute colorectal (CR) perforation. Diagnosis of perforation was made on the basis of acute presentation and surgical intervention and confirmed by histology. The case notes, operating notes and histopathology reports of these 42 patients were then reviewed in detail and a number of important variables were

Results

Demographic, pre-operative, operative data and Duke's grading are detailed in Table 1. Of the 42 patients with CRC perforation, 23 (55%) were male and 19 (45%) were female with the mean age 70 (range 44–96 yr). In only 5 patients the diagnosis of CRC cancer was known prior to the acute presentation. Thirty-four (81%) patients were admitted directly via the accident and emergency department whereas 5 patients were in-patients in non-surgical wards and were referred to the on-call surgical team

Discussion

As perforated CRCs are quite uncommon (2.6–9%) [2], [3], [4], [5], the majority of the published series span over a long period of time to achieve adequate numbers for any meaningful analysis [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. Our series analysed the 5 yr data on 762 consecutive CRCs which revealed a perforation rate of 5.5%, very much in keeping with the other large-scale series.

A number of previously [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12] published

Conclusion

Perforated CRCs, despite advances in modern management of sepsis and peri- and post-operative intensive care medicine, carry a substaintial mortality. The two major predictors of poor outcome are ASA grade and CR POSSUM. It is recommended that these patients should be managed expeditiously and aggresively with a multidisciplinary approach involving surgeons, anaesthetist and intensivists to optimise their perioperative and postoperative care.

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