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Journal Reading

Colon Cancer Surgery In Patients


Operated On An Emergency Basis

Ummi Utami
J5100170066
Pembimbing :
Dr. Heru Iskandar, Sp. B

KEPANITERAAN KLINIK ILMU BEDAH RSUD DR. HARJONO PONOROGO


FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH SURAKARTA 2017
The Identity of Journal

Colon Cancer Surgery In Patients


Title Operated On An Emergency Basis

Rodrigo Felippe Ramos, Lucas Carvalho Santos dos-


Authors Reis, Beatriz Esteves Borgeth Teixeira, Igor Maroso
Andrade, Jaqueline Suelen Sulzbach, Ricardo Ary Leal,

Date of 2017
Published
Revista do Colgio Brasileiro de
Published by Cirurgies
ABSTRACT
Objective
To study the epidemiological profile of patients with colorectal cancer operated
on an emergency basis at the Bonsucesso Federal Hospital.
Methods
This is a retrospective study of patients operated between January 1999 and
December 2012. We analyzed the following variables: age, gender, clinical data,
TMN staging, tumor location, survival and types of surgery.
Results
130 patients . The most frequent clinical picture was intestinal obstruction, in
78% of cases. The majority (39%) of the patients had advanced TNM staging.
There were 39 deaths (30%). The most common tumor site was the sigmoid
colon (51%). Adjuvant treatment being performed in 40% of the patients.
Distant metastases were found in 42% of the patients and 10% had
documented disease recurrence. Disease-free survival at two and five years
was 69% and 41%.
Conclusion
there was a high mortality rate and a low survival rate in colorectal cancer
patients operated on urgently.
INTRODUCTION
3rd most common type of cancer among men and 2nd among women
Good prognosis when diagnosed in the early stages.
Most common clinical presentation: obstruction, followed by colon
perforation

Obstructionrisk factor for a worse prognosis, this fact is explained


not only by the patients deterioration of the clinical status due to
the obstructive emergency condition, but also by the advanced stage
of the tumor found in such situations.

Perforationalthough it is a more serious condition and presents


greater postoperative morbidity and mor-tality than colonic
obstruction, survival rates are similar with obstruction
INTRODUCTION
The most commonly used surgical technique in urgently operated
CRC is the Hartmanns procedurebut can causes several problems
of both psychosocial and colostomy-related care demands another
surgical procedure for the reconstruction of intestinal transit, which
also presents considerable morbidity.

Although it is a cancer type with a relatively good prognosis, its


overall mortality remains high, especially in those patients operated
on as an emergencyfailure of CRC screening policies, the diagnosis
often made in advanced stagescomplications such as obstruction
and perforation.
INTRODUCTION
The purpose of this paper is to demonstrate the
reality of a reference hospital of to contribute both
from the epidemiological point of view and in the
pro-motion of protocols for tracking CRC.
METHODS

Design
observational, retrospective,
descriptive study

Place
Surgery Clinic of the
Bonsucesso Federal Hospital

Periode
January 1999 to December
2012
METHODS

Inclusion patients with CRC diagnosis operated on an


Criteria emergency basis.

patients operated due to colon obstruction


or perforation by other diseases or by
tumors not confirmed by
Exclusion
Criteria anatomopathological examination.
patients with medium and low rectum tumors
because of the different treatment modalities
between the colon and rectum tumors.
METHODS
age, gender, clinical data, tumor location, type of
Variables
surgery, whether curative or palliative, TNM staging,
adjuvant treatment, presence of metastases, relapse,
and type of intestinal reconstruction.

Main
Outcomes death and disease-free survival at two and five years.

Software
data collection MS Excel spreadsheet
analyzed with the Bioestat software.

Ethical Clearence
By: Research Committee of the Bonsucesso Federal Hospital
(opinion number 1,183,590).
RESULT
Sample Description

Total Sample 130 patients


Female 55% Male 45%
Mean age 59,5 years old
RESULT
Clinical Presentation

78
72

41
25
15 11
1 2
RESULT
TNM Staging

42

22

13
11
6
3 3

I IIA IIB IIIB IIIC IV -


RESULT
Tumor Location

rectum
6%
cecum
8%
transverse colon
9%

descending colon sigmoid colon


10% 51%

ascending colon
16%
RESULT
Type of Procedure

3%
3%
4%
8% Retrosigmoidectomy
39% right hemicolectomy
left hemicolectomy
14% derivative colostomy
total colectomy
transversectomy
derivative ileostomy

29%
RESULT
anastomosis
with stoma
protection
7% none
7%
derivative terminal
stoma stoma
10% 34%

mucosal
fistula
16% simple
primary
anastomosis
26%
Type of intestinal reconstruction
RESULT
Intention of treatment

undetermine
21%

curative
45%

palliative
34%
RESULT
Adjuvant Treatment

no data
35% yes
40%

no
25%
RESULT
Liver 20%

Peritoneum 11%

Uterus 4%
Distant Metastasis 42%
Abdominal wall 2%

Lung 1%

Other site 4%
RESULT

Recurrence 10%

Recurrancy Not Recurrence 61%

No data 29%
RESULT
Mortality 26 death directly related to CRC
20%

13 death not directly related to CRC


10%
RESULT

Disease-free survival
Two years 69%

Five years 41%


DISCUSSION
CRC high incidencescreening policies
Some studies have already demonstrated the relationship
between the effectiveness of screening policies with
staging of the colorectal tumor at the time of diagnosis,
and consequently the impact on complications such as
obstruction, perforation, and on mortality.
DISCUSSION
7%-40% CRC undergo emergency surgary, e.c obstruction
or perforationmortality 16-38%controversy data (do
not define obstruction degree)discrepancy of mortality
percentage
high mortality in emergency surgeriesmultifactorial
A multivariate analysis revealed, besides surgical urgency,
advanced CRC, age greater than 70 years, presence of
important comorbidities, presence of sepsis and blood
transfusion in the perioperative period
However, among these factors, undoubtedly the one that
has the greatest impact on mortality is staging.
DISCUSSION
The achievement of a temporary derivative stoma for
subsequent elective tumor resection (two-stage surgery) is
not adopted in our service, nor is it recommended by most
authors in the literature.
When the tumor is resected at the first moment, there is
lower postoperative mortality, shorter hospitalization time
and greater disease-free survival in five years, demonstrating
that the main factor related to tumor recurrence is the
adoption of the basic oncological principles, not the
emergency situation itself, when compared with two-time
surgery
DISCUSSION
two-year survival 69%, and 17% survival in five years.
should be viewed with great caution due to the great loss of
follow-up of the patients, and to the small sample.
there was loss of access to patients who died for reasons
other than CRC,
Another study with longer follow-up may provide better
scientific evidence on these variables.
DISCUSSION
Right colon tumors and stable low risk patientprimary
anastomosis
Left colon and high rectum tumor and critically ill patient with
generalized fecal peritonitis hartmanns
procedureproviding R0 resection and no potential of
dehiscence safest in emergency surgery for CRC

Our study allowed us to verify that the mortality in patients


with CRC operated on an emergency basis is still quite high,
with the disease presenting in advanced stages. These data
reflect flaws in CRC screening policies that would make early
diagnosis and treatment of this disease possible.
TERIMAKASIH