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Benign tumors of the cecum
BENIGN TUMORS OF THE CECUM THEIR DIFFERENTIATION
JOHN J. MCGRATH,
AND TREATMENT, M.D.,
F.A.C.S.
AND STANLEY
NEW YORK
A
BENIGN tumor of the intestine is a distinctIy rare finding. Yet the variety of neopIasms which can arise in this location is surprising, and in addition, there are other conditions which simuIate neopIasms with diagnosticaIIy confusing resuIts. The 2 cases here reported were of totaIIy different histoIogica1 character, yet their manifestations were simiIar and the preoperative diagnosis much the same. Moreover, the operative measures seIected were necessariIy aImost identica1, and IastIy, and most important, the resuIts proved equaIIy good. The first case was one of muItipIe Iipoma of the cecum, preoperatively diagnosed as carcinoma of the sigmoid or transverse coIon with probabIe metastases. The second wouId have been considered a possible carcinoma, had not the youth of the patient argued strongIy against it. In the absence of positive evidence of tubercuIous infection, the real condition of hyperpIastic tubercuIosis of the Iarge intestine did not at first suggest itseIf. Comfort’ says that “a diagnosis of Iipoma of the gastrointestina1 tract has been made before operation onIy in exceptiona1 instances.” Rankin and Mayo, in discussing carcinoma of the smaI1 intestine, note that IocaIized tubercuIosis of the ileum can hardIy be differentiated from carcinoma except by operation. A search of recent Iiterature seems to indicate that these benign Iesions of the bowe1 are very apt to bring about diagnostic diffIcuIties. This situation can onIy be improved by accumuIation of a Iarge voIume of cIinica1 data. It is in the hope
WITH REPORT
OF TWO CASES*
EISS, M.D., F.A.C.S.
CITY
of making a worthwhiIe contribution such materia1 that the present paper offered.
to
is
LIPOMA OF THE INTESTINE Fatty tumors of the intestine may be either submucous or subserous; occasionaIIy both varieties wiI1 appear in the same subject. The submucous variety is, however, much more frequentIy reported than any other. Comfort found 181 cases in the Iiterature, to which he added 28 taken from the records of the Mayo CIinic. The majority of these growths were discovered at autopsy, having produced no recognizable symptoms during life. In a comparatively few instances they were reveaIed at operation for an obstruction in the intestina1 tract, the exact nature of which couId not be preoperativeIy ascertained. It is generaIIy impossibIe, though a neoplastic growth can be unquestionably made out, to hazard a guess as to its structure or nature. When the abdomen is opened, it is usuaIIy because symptoms suggesting intussusception have been manifested. CriIe and McCIintock,2 in a recent report on fibroma of the coIon, cite CIifton and Landry as having noted that intussusception was found at operation in 3 out of every 4 cases, which, in the opinion of the CIeveIand CIinic authors “represents fairIy accurateIy the usua1 diagnostic reason for opening the abdomen in cases where benign tumors are reaIIy the basic cause of troubIe.” They add significantly : The history of recurrent attacks of Iocalized colic or pain with nausea and vomiting, shouId
* From the Department of Surgery, New York Polyclinic Medical SchooI and HospitaI. 88
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suggest the possibihty of benign intestinal tumors. It is to be remembered that in aduIts the most frequent cause for intussusception is the presence of a tumor, and, further, that it is not the rule for maIignant growths to cause this condition. It has been remarked by Erdmann3 that ahhough “we recognize the frequent association of intestina1 polyps with intussusception, intestina1 obstruction, and a variety of vague abdominal symptoms . . . unti1 the presence of these intestinal polyps is signahzed by some acute abdominal caIamity, they are regarded as of Iittle cIinica1 or pathoIogica1 importance.” Stewart4 differentiates between Iipomata and poIypi, but as in the same paragraph he refers to “adenomatous poIypi,” we may perhaps assume that he is mereIy drawing a distinction between adenoma and Iipoma. He has found non-maIignant adenomata to be the most common benign Iesions of the intestina1 tract, with Iipomata next in and frequency. Dewis, whom Erdmann Morris quote, coIIected 219 cases of benign tumors of the gastrointestina1 tract from the Iiterature up to 1906, and found that 127 were adenomata and 44 Iipomata, 57.9 and 20 per cent respectiveIy. Erdmann and Morris further state that anaIysis of the series of Dewis shows that whiIe polypi in genera1 present themseIves as soIitary, or a few scattered tumors, adenomatous poIypi are frequentIy muItipIe and widely disseminated. “There were but two cases of muItipIe dissemination recorded in the entire group of non-adenomatous tumors-one among the Iipomata and one among the fibromata.” When Iipomata occur as a disseminated poIyposis, they present the same form as the soIitary specimens, that is, rounded or ovoid, with pedicIe attachment to the waI1 of the intestine. As a rule they have their origin in the submucous Iayer and the direction of their growth is inward, toward the Iumen of the gut. Sex Incidence: The statistics given by recent writers vary greatIy in regard to sex incidence and site of prediIection. CriIe2
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says, “Benign
tumors are more frequent in the Iarge bowe1 and occur more commonIy in women.” Erdmann found that t,he patient presenting the adoIescent or congenita1 disseminated type of intestina1 poIyposis was “usuaIIy a maIe.” In Crile’s group of 45 fibromata of the coIon, there were 25 femaIes and 20 maIes, while in the series at the Mayo CIinic studied by Comfort1 the cases were about evenly divided between the sexes, there being 81 in maIes and 72 in femaIes among I 53 cases in which the sex was mentioned. As to locution, it is very generaIIy
agreed that the Iarge intestine is a far more frequent site for both muItipIe poIyposis and singIe benign growths. Most writers seem to think that the trauma incident to the passage of hard feca1 masses is accountabIe for the higher incidence in the colon, especiaIIy the sigmoid and transverse coIon. Next in order is the cecum, .where the lesions were found in our patient. As Erdmann says, “the sequence of irritation, inff ammation, reaction, mucous membrane hyperpIasia and polyp formation is readiIy acceptabIe.” The tabIe which Comfort compiIed from the records of the Mayo CIinic in regard to the site of Iipomata offers an interesting confirmation of the findings aIready cited. Lipomata were about 50 per cent more frequent in the Iarge intestine than in the smaI1, and moreover, those in the Iarge intestine were aImost twice as IikeIy to produce symptoms as those in the smaI1 intestine. A natura1 coroIIary to this wouId be that the ones discovered at autopsy which had never produced symptoms during Iife were more IikeIy to be in the smaI1 intestine than in the Iarge. And this proved to be true in the cases Comfort gathered from the literature. But in the Mayo CIinic series those found at ne’cropsy . . . were equaIIy divided between the smaI1 and Iarge intestine. Lipomata in the smaI1 intestine are most common in the iIeum, and least common in the jejunum; in the Iarge intestine, they are most common in the cecum and ascending colon, and next most common in the
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sigmoid. . . . It seems that Iipomata tend to occur more commonly in those segments of the gastrointestina1 tract composed of the stomach and duodenum, and of the Iower part of the iIeum? cecum and ascending coIon.
gut, so that its serosa comes in contact with that at the base of the tumor. These two Iayers of serosa wiI1 soon become joined together, and wiI1 push in between the Iayers of muscIe which the increased size This author remarks that his experience is of the invading neopIasm has incIuded in the tumor mass. diametricaIIy opposed to that of Stetten, Continued peristaItic action, which beiyho found that Iipomata were about evenIy divided between the smaI1 and comes more and more irreguIar and powerfu1 as the obstruction grows Iarger, and Iarge bowe1, or of NothnageI, who cIaimed interferes with the norma action of the that their favorite site was the rectum or Iower part of the iIeum, and coincides stiI1 intestina1 muscIes, is IikeIy to bring about intussusception, Iess with that of Virchow, whose excepas in the case here reported. In the Mayo CIinic series the tionaIIy extensive pathoIogica1 experience bowe1 was “teIescoped” in 26 out of the Ied him to decIare that Iipomata are more 2g cases of Iipoma of the smaI1 intestine, common in the stomach and upper parts and in 33 among the 62 cases where of the smaI1 intestine. the neopIastic growth was in the Iarge Pathology: Fat ceIIs are normaIIy found intestine. beneath the mucosa of the gastrointestina1 In generaI, when an abdomina1 tumor tract, but in very smaI1 numbers. When can be paIpated at the first examination, abnorma1 conditions produce them in Iarge intussusception has probabIy taken place. amount, they wiI1 sometimes be apparent In George Webb’s5 case, where the growth to the unaided eye, giving a yeIIowish cast was entireIy within the cecum, in a Iocation to the mucous membrane, often constitutsimiIar to that in our case, the cecum was ing a fatty infiItration without actua1 gIued to the parieta1 peritoneum and the Iipoma formation. Those tumors which are mass firmIy attached to its posterior so smaI1 as to be visibIe onIy under the aspect, though the anterior waI1 couId microscope are mereIy embedded in the be freeIy moved over the surface of the connective tissue Iying beneath the mucosa. tumor. The iIeoceca1 region was sIightIy But as the growths increase in size, the invaginated into the ascending coIon. As fatty structures are more sharpIy demarthis patient was but thirty-four years oId, cated from this connective tissue and the existence of marked tenderness over graduaIIy assume definite capsuIes formed McBurney’s point and other abdomina1 from the submucosa1 connective tissue. manifestations Ied to a preoperative diagEven smaI1 Iipomata wiI1 be divided by thin but perfectIy definite septa into a nosis of appendicitis. This emphasizes the Iimitations to the series of IobuIes, and the very Iarge fatty arriva1 at a definite diagnosis of intestina1 tumors even take on definite fibrous charIipoma which Comfort has Iaid down. OnIy acteristics which bring them close to the when the tumor is far enough down to be cIassification of fibromata. If the tumors or after it grow very Iarge, the muscuIar Iayer wiI1 seen through the proctoscope, has proIapsed externaIIy and presents a be found much thinner and the yeIIow typica appearance (by no means invariabIy coIor decidedIy more pronounced, a differthe case), or when biopsy can be made ential point of vaIue to the operating from a recta1 Iipoma or from a Iipoma surgeon. attached to the apex of an area of intusAs Iipomata increase in size, they bring susception which proIapses into the rectum, about marked pathoIogica1 and physiois there IikIihood of a correct preoperative IogicaI aIterations in the intestine. The diagnosis. pressure induced pushes out the waI1 of the
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CASE
McGrath
& Eiss-Tumors
REPORT
Mrs. M. P., a tiny, emaciated Italian woman, aged sixty-four years, when examined on January 24, 1932, gave a history of severe abdominaI pain and obstinate constipation of one week’s duration. The constipation was of Iongstanding, but had become much worse recentIy. There had been sweIIing of the abdomen, ribbon-like stools, anorexia and much eructation of gas, but no vomiting. There was no history of bIood or mucus in the stoo1, or of diarrhea. Inspection showed symmetrica swelhng of the Iower abdomen, and on paIpation a mass about the size of a grapefruit couId be made out at the midhne. This mass was hard and tender, but did not appear to have any definite attachment. Consideration of the woman’s age and the Iocation of the mass gave an impression of carcinoma of the transverse coIon, or possibly of the sigmoid, with metastases. Operation the foIIowing day was carried out through an incision through the rectus muscIe, to the right of the midIine. When the tumor mass was brought through the incision, it was found to consist of the transverse coIon, into which had teIescoped the ascending coIon, the cecum with its appendix, and about 4 inches of the iIeum. Reduction presented no especial diffrcuIty. When the cecum had been freed, a semisolid mass about 2 inches in diameter was feIt within it, which was assumed to be a carcinoma. The ascending coIon, the cecum, and 4 or 5 inches of the ileum were resected, the mesentery tied off, and the severed portions of the bowe1 removed. The ends of both transverse coIon and iIeum were cIosed with two Iayers of sutures, and a IateraI anastomosis made between transverse coIon and iIeum, with an opening about 3 inches in Iength. After a cigarette drain had been pIaced just beneath the Iiver in the deepest part of the abdominal cavity, the incision was cIosed about it Iayer by Iayer, using pIain catgut for the peritoneum, chromic catgut for the aponeurosis, and interrupted sutures for the skin. Pathologist’s Report: The specimen consisted of a portion of the cecum some 14 cm. in length, together with about 7 cm. of the ileum. The ceca1 content was stained with bile. Adjacent to the iIeoceca1 vaIve there was a large tumor about 3 by 4 cm. in extent, Iving between mucosa and muscularis. Its
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shape was roughIy spherical, and the surface showed no evidence of uIceration. On posterior section through the muscle waI1, this tumor was found to be encapsuIated and composed entireIy of fatty tissue. A similar, smaher tumor was found about 4 cm. farther down the lumen of the cecum. MicroscopicaIIy, the appendix showed obhteration of the lumen and marked fatty infiItration, with a definite, Iow-grade inffammation. The entire tumor consisted of Iipomatous tissue. Diagnoses: Lipoma of cecum; low-grade
chronic appendicitis. The postoperative
course
was somewhat
sIow, but uneventfu1, and the patient was dismissed on the thirtieth day. When seen last, more than a year and a haIf after remova of the tumor, the woman was in excehent health and had gained 16 pounds in weight. HYPERPLASTIC
TUBERCULOSIS
OF THE
LARGE
BOWEL
The type of intestina1 tubercuIosis which is IikeIy to cause confusion with intestinal neopIasia is the hyperplastic, or, as some writers have termed it, intestinal tuberculoma. There seems to be a genera1 impression that this is an excessiveIy rare form of tubercuIosis, as it does not appear as a compIication secondary to a focus in the Iungs, but is IikeIy to be found in subjects in whom no manifestations of tubercuIous infection have previousIy appeared. AIthough the smaI1 intestine is very seIdom affected with tuberculosis (onIy 9 cases having been reported in the Iiterature), a study of avaiIabIe cIinica1 reports shows that the Iarge intestine not infrequentIy becomes infected by tubercle baciIIi independentIy of the occurrence of the disease eIsewhere in the same su.bject. In the Iast decade of the nineteenth century, severa European surgeons, BiIIroth and Hartmann among them, described tumor formations occurring in the Iarge bowe1 which produced symptoms aad gave a clinica picture identica1 with that of carcinoma but on pathoIogica1 examination proved to be tuberculous in origin. In 1906, Hartmann made a report on 2 19 operated
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cases. In nearIy a11 the reports the cecum is overwheImingIy the favored Iocation. Of IOO cases Iisted by Mummery in his textbook, 87 were either entireIy within the cecum or in cecum and ascending coIon. Etiology: As in cases of carcinoma simiIarIy Iocated, the causa1 factors favoring the estabIishment of a tubercuIous Iesion in this particuIar part of the body are obscure. PossibIy the theory of continued trauma from hard feca1 masses, which has been advanced in the instance of newgrowths of the Iarge bowe1, may be appIicabIe to invasion by tubercIe baciIIi. Linthicum6 thinks that the most pIausibIe expIanation of Iarge gut invoIvement in the hyperpIastic type of tubercuIosis is the ingestion of a weak or attenuated organism which Iodges in a spot favorable for its propagation during its passage through the Iower bowe1. IndividuaIs who are resistant to inhaIed tubercIe baciIIi might succumb to those entering the digestive tract. Thus a primary tubercuIous focus might be estabIished in the Iarge intestine, “in which the usua1 warfare goes on between . . . the tubercIe baciIIus and the individua1, with the resuIt that an inffammatory reaction is set up, with the production of fibrous tissue, which is the heaIing.” norma . . . tubercuIous Some of the difI?cuIties in Diagnosis: diagnosis have aIready been pointed out. Many of the symptoms are common to a variety of diseases, so that none can be considered pathognomonic. Progressive Ioss of strength and weight extending over a considerabIe period, if occurring in a young subject, suggests tuberculosis rather than maIignancy; yet there are enough records of abdomina1 carcinoma occurring in young persons to cause doubt. If the Iesion attains considerabIe size, it wiI1 produce symptoms characteristic of partia1 occIusion of the bowe1 Iumen, chief among which are sweIIing of the abdomen and increase in intestina1 peristaIsis, with severe paroxysma pain. In some cases these attacks may simuIate renaI coIic, and the confusion with appendicitis is so frequent that in nearIy a11 the reported cases appen-
dectomy had been previousIy performed. Linthicum suggests that differentiation from appendicitis may be accompIished by noting that there is no characteristic painfu1 spot, nor genera1 distention of the abdomen, nor the rise of temperature reguIarIy attending acute inff ammation of the appendix. The tumor, moreover, is not fixed, but is aIways more or Iess mobiIe, steadiIy increasing in size, often muItipIe, and apt to assume a cyIindrica1 form. If the possibiIity of tubercuIous infection shouId be suggested, appropriate tests wouId soon offer a substantia1 basis for diagnosis, but the rarity of the Iesion makes its detection before operative intervention practicaIIy impossibIe. CASE
REPORT
Mrs. B. K., a young married woman of twenty-three, was first admitted December 19, 1932. At that time she compIained of abdominaI pain, which she beIieved had begun after she had been in swimming some three months before. Pain had been aImost continuous for the intervening three months, with occasional vomiting and aImost compIete Ioss of appetite. However, the boweIs were said to have moved reguIarIy. There had been an appendectomy two years before, and the pain was partiaIIy referred to the site of this operation. About three weeks before, the old scar had opened and discharged about a cupfu1 of pus. At the time of entrance the fistuIa had closed. Investigation of this operative record showed that the origina appendectomy incision had remained open for five months, so that a secondary intervention was required to cIose it. The Iungs were cIear, but the patient compIained of chronic cough with morning expectoration. There was no other suggestion of tuberculosis in either the past or present history. Examination of the abdomen showed the scar of the appendectomy with evidence of extensive drainage. In the right lower quadrant a mass as Iarge as a grapefruit couId be made out. This was somewhat tender on pressure, but the abdomina1 waI1 was not rigid. The abdomen was opened on December 2, 1932, and the mass found to be denseIy adherent to the surface of the peritoneum. When exposed by both bIunt and sharp dissection, it proved
NE\~’
SI~K,ES
to be a
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greatly thickened portion of the cecum, the mesentery especiaIIy being very hyperpIastic. The underIying portion of the mass appeared to be diseased Iymph nodes. A search was made for the appendix under the hypothesis that it might not have been removed entire at the preceding intervention, or that an abscess might have formed at the site of its remova1. Nothing of the sort was found; neither was there any evidence of a local abscess coIIection in the posterior aspect of the cecum, after it had been mobilized. The abdomen was closed in Iayers about a cigarette drain, using continuous pIain catgut sutures for the peritoneum, continuous chromic catgut for the aponeurosis, with interrupted fine silk sutures for the skin. WhiIe the appearance of the mass in the cecum might easiIy have been taken for that of maIignancy, the fact that the patient was but twenty-four years of age argued strongIy in favor of its being the product of a chronic inflammatory process, invoIving connective tissue and gIanduIar structure in the retroceca1 region as we11 as the lymph nodes aIong the course of the iIiac vesseIs. For this reason it was deemed advisabIe to confine the intervention merely to drainage of the affected area. On JuIy 18, 1933, seven months after this operation, the patient re-entered, compIaining that there was a fistuIa at the site of incision from which very profuse drainage had continued. She had aIso experienced some pain in the old wound. The abdomen was reopened by an incision running from above the umbiIicus downward toward the symphysis pubis, which reveaIed a mass some 4 by 6 inches in diameter, presenting in the iIiac fossa. This mass was firmly adherent to the waI1 of the peIvis and adjacent parts. ApparentIy it aIso involved the waIIs of the cecum and ascending coIon, as weI1 as the adjacent mesenteric grands. After being freed a11 around and brought up into the incision, it was recognized as the head of the cecum and ascending coIon. By section across the iIeum near the iIeoceca1 junction and at the hepatic fIexure, the mass was removed and a lateral anastomosis made Jletween the iIeum and the transverse coIon, using the suture method without cIamps which the senior author’ has described in his textbook. The incision was cIosed Iayer by Iayer, using the same method of cIosure as in the previous operation, with the cigarette drain emerging from the lower angIe of the wound.
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Pathological Report: The specimen consisted of a section of intestine so matted together as to be no more than 20 cm. in Iength. If straightened out, it wouId have been about 35 cm. in Iength. There was a separate smaI1 specimen of skin and sinus tract. About 11 cm. of the Length was made up of iIeum, the remainder cecum. At the iIeoceca1 junction there was an induratecl, anguIar, buIky tumor-like mass invoIving the waI1. About 6 cm. beyond the junction there was a soft, somewhat uIcerated area. In one portion of the tissue there was a smaI1 diverticuIum, and at another point what appeared to be the stump of the appendix. Above the previousIy mentioned area, another smaI1 point of uIceration appeared. The 1:ymph gIands in the fatty tissue were much enIarged. MicroscopicaIIy, there was evidence of a chronic inflammatory process with considerabIe fibrosis. In some areas an occasiona multinucIeated giant-ceI1 couId be made out. Nothing about the sIide couId be pointed out as tvpica1 of tubercuIosis, but there was a possibiI&y of tuberculosis in the background. It appeared more IikeIy, however, that it was essentialIy an inff ammatory condition arising around the diverticuIum and the stump of the appendix. The lymph glands were Iarge and showed a we11 marked simpIe Iymphadenitis. There was no evidence of maIignancy. REFERENCES I. COMFORT, M. W.
Submucous Iipomata of the gastrointestina1 tract. Surg. Gynec. Obst., 52: 101, 1931. 2. CRILE, G. W.. and MCCLINTOCK. J. C. Fibroma of the c0I0n. AM. J. SURG., n.s. 21: 82, 1933. 3. ERDMANN, J. F., and MORRIS, J. H. Polyposis coIon. Surg. Gynec. Obst., 40: 460, 1925.
of the
4. STEWART, W. H., and II-LICK, H. E. Lipoma of the coIon; report of two cases. Am. J. Roentgenol., 23: 308, ‘930. 5. WEBB, G. Two
cases of Iipoma. AM. J. SURG., n.s. 16: 522, 1932. 6. LINTHICUM,G. M. TubercuIosis of the large intestine. AM. J. SURG., n.s. 16: 471, 1932. 7. MCGRAT~I, J. J. Operative Surgery. Phila., Davis, 1913. Further
References
CUNNINGHAM,J. J., and SNEIERSON,H. Chronic hyperplastic tubercuIosis of the iIeum. AM. J. SURG., n.S. 12: 131, 1931. DOWDLE, E. Tuberculoma of the descending colon. Ann. Surg., 91: 786, 1930. FITZGIBBON and RANKIN. PoIvnosis of the coIon. J. A. M. A., 97: 575, 1931.“HERRICK, F. C. TubercuIoma of the cecum, hyperpIastic tubercuIosis. Ann. Surg., 81: 801, 1925. RATCLIFF, R. A. Submucous Iipoma of colon. Cq’s Hosp. Rep., 80: 453, 1930.
JOHN J. MCGRATH,
AND TREATMENT, M.D.,
F.A.C.S.
AND STANLEY
NEW YORK
A
BENIGN tumor of the intestine is a distinctIy rare finding. Yet the variety of neopIasms which can arise in this location is surprising, and in addition, there are other conditions which simuIate neopIasms with diagnosticaIIy confusing resuIts. The 2 cases here reported were of totaIIy different histoIogica1 character, yet their manifestations were simiIar and the preoperative diagnosis much the same. Moreover, the operative measures seIected were necessariIy aImost identica1, and IastIy, and most important, the resuIts proved equaIIy good. The first case was one of muItipIe Iipoma of the cecum, preoperatively diagnosed as carcinoma of the sigmoid or transverse coIon with probabIe metastases. The second wouId have been considered a possible carcinoma, had not the youth of the patient argued strongIy against it. In the absence of positive evidence of tubercuIous infection, the real condition of hyperpIastic tubercuIosis of the Iarge intestine did not at first suggest itseIf. Comfort’ says that “a diagnosis of Iipoma of the gastrointestina1 tract has been made before operation onIy in exceptiona1 instances.” Rankin and Mayo, in discussing carcinoma of the smaI1 intestine, note that IocaIized tubercuIosis of the ileum can hardIy be differentiated from carcinoma except by operation. A search of recent Iiterature seems to indicate that these benign Iesions of the bowe1 are very apt to bring about diagnostic diffIcuIties. This situation can onIy be improved by accumuIation of a Iarge voIume of cIinica1 data. It is in the hope
WITH REPORT
OF TWO CASES*
EISS, M.D., F.A.C.S.
CITY
of making a worthwhiIe contribution such materia1 that the present paper offered.
to
is
LIPOMA OF THE INTESTINE Fatty tumors of the intestine may be either submucous or subserous; occasionaIIy both varieties wiI1 appear in the same subject. The submucous variety is, however, much more frequentIy reported than any other. Comfort found 181 cases in the Iiterature, to which he added 28 taken from the records of the Mayo CIinic. The majority of these growths were discovered at autopsy, having produced no recognizable symptoms during life. In a comparatively few instances they were reveaIed at operation for an obstruction in the intestina1 tract, the exact nature of which couId not be preoperativeIy ascertained. It is generaIIy impossibIe, though a neoplastic growth can be unquestionably made out, to hazard a guess as to its structure or nature. When the abdomen is opened, it is usuaIIy because symptoms suggesting intussusception have been manifested. CriIe and McCIintock,2 in a recent report on fibroma of the coIon, cite CIifton and Landry as having noted that intussusception was found at operation in 3 out of every 4 cases, which, in the opinion of the CIeveIand CIinic authors “represents fairIy accurateIy the usua1 diagnostic reason for opening the abdomen in cases where benign tumors are reaIIy the basic cause of troubIe.” They add significantly : The history of recurrent attacks of Iocalized colic or pain with nausea and vomiting, shouId
* From the Department of Surgery, New York Polyclinic Medical SchooI and HospitaI. 88
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suggest the possibihty of benign intestinal tumors. It is to be remembered that in aduIts the most frequent cause for intussusception is the presence of a tumor, and, further, that it is not the rule for maIignant growths to cause this condition. It has been remarked by Erdmann3 that ahhough “we recognize the frequent association of intestina1 polyps with intussusception, intestina1 obstruction, and a variety of vague abdominal symptoms . . . unti1 the presence of these intestinal polyps is signahzed by some acute abdominal caIamity, they are regarded as of Iittle cIinica1 or pathoIogica1 importance.” Stewart4 differentiates between Iipomata and poIypi, but as in the same paragraph he refers to “adenomatous poIypi,” we may perhaps assume that he is mereIy drawing a distinction between adenoma and Iipoma. He has found non-maIignant adenomata to be the most common benign Iesions of the intestina1 tract, with Iipomata next in and frequency. Dewis, whom Erdmann Morris quote, coIIected 219 cases of benign tumors of the gastrointestina1 tract from the Iiterature up to 1906, and found that 127 were adenomata and 44 Iipomata, 57.9 and 20 per cent respectiveIy. Erdmann and Morris further state that anaIysis of the series of Dewis shows that whiIe polypi in genera1 present themseIves as soIitary, or a few scattered tumors, adenomatous poIypi are frequentIy muItipIe and widely disseminated. “There were but two cases of muItipIe dissemination recorded in the entire group of non-adenomatous tumors-one among the Iipomata and one among the fibromata.” When Iipomata occur as a disseminated poIyposis, they present the same form as the soIitary specimens, that is, rounded or ovoid, with pedicIe attachment to the waI1 of the intestine. As a rule they have their origin in the submucous Iayer and the direction of their growth is inward, toward the Iumen of the gut. Sex Incidence: The statistics given by recent writers vary greatIy in regard to sex incidence and site of prediIection. CriIe2
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says, “Benign
tumors are more frequent in the Iarge bowe1 and occur more commonIy in women.” Erdmann found that t,he patient presenting the adoIescent or congenita1 disseminated type of intestina1 poIyposis was “usuaIIy a maIe.” In Crile’s group of 45 fibromata of the coIon, there were 25 femaIes and 20 maIes, while in the series at the Mayo CIinic studied by Comfort1 the cases were about evenly divided between the sexes, there being 81 in maIes and 72 in femaIes among I 53 cases in which the sex was mentioned. As to locution, it is very generaIIy
agreed that the Iarge intestine is a far more frequent site for both muItipIe poIyposis and singIe benign growths. Most writers seem to think that the trauma incident to the passage of hard feca1 masses is accountabIe for the higher incidence in the colon, especiaIIy the sigmoid and transverse coIon. Next in order is the cecum, .where the lesions were found in our patient. As Erdmann says, “the sequence of irritation, inff ammation, reaction, mucous membrane hyperpIasia and polyp formation is readiIy acceptabIe.” The tabIe which Comfort compiIed from the records of the Mayo CIinic in regard to the site of Iipomata offers an interesting confirmation of the findings aIready cited. Lipomata were about 50 per cent more frequent in the Iarge intestine than in the smaI1, and moreover, those in the Iarge intestine were aImost twice as IikeIy to produce symptoms as those in the smaI1 intestine. A natura1 coroIIary to this wouId be that the ones discovered at autopsy which had never produced symptoms during Iife were more IikeIy to be in the smaI1 intestine than in the Iarge. And this proved to be true in the cases Comfort gathered from the literature. But in the Mayo CIinic series those found at ne’cropsy . . . were equaIIy divided between the smaI1 and Iarge intestine. Lipomata in the smaI1 intestine are most common in the iIeum, and least common in the jejunum; in the Iarge intestine, they are most common in the cecum and ascending colon, and next most common in the
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sigmoid. . . . It seems that Iipomata tend to occur more commonly in those segments of the gastrointestina1 tract composed of the stomach and duodenum, and of the Iower part of the iIeum? cecum and ascending coIon.
gut, so that its serosa comes in contact with that at the base of the tumor. These two Iayers of serosa wiI1 soon become joined together, and wiI1 push in between the Iayers of muscIe which the increased size This author remarks that his experience is of the invading neopIasm has incIuded in the tumor mass. diametricaIIy opposed to that of Stetten, Continued peristaItic action, which beiyho found that Iipomata were about evenIy divided between the smaI1 and comes more and more irreguIar and powerfu1 as the obstruction grows Iarger, and Iarge bowe1, or of NothnageI, who cIaimed interferes with the norma action of the that their favorite site was the rectum or Iower part of the iIeum, and coincides stiI1 intestina1 muscIes, is IikeIy to bring about intussusception, Iess with that of Virchow, whose excepas in the case here reported. In the Mayo CIinic series the tionaIIy extensive pathoIogica1 experience bowe1 was “teIescoped” in 26 out of the Ied him to decIare that Iipomata are more 2g cases of Iipoma of the smaI1 intestine, common in the stomach and upper parts and in 33 among the 62 cases where of the smaI1 intestine. the neopIastic growth was in the Iarge Pathology: Fat ceIIs are normaIIy found intestine. beneath the mucosa of the gastrointestina1 In generaI, when an abdomina1 tumor tract, but in very smaI1 numbers. When can be paIpated at the first examination, abnorma1 conditions produce them in Iarge intussusception has probabIy taken place. amount, they wiI1 sometimes be apparent In George Webb’s5 case, where the growth to the unaided eye, giving a yeIIowish cast was entireIy within the cecum, in a Iocation to the mucous membrane, often constitutsimiIar to that in our case, the cecum was ing a fatty infiItration without actua1 gIued to the parieta1 peritoneum and the Iipoma formation. Those tumors which are mass firmIy attached to its posterior so smaI1 as to be visibIe onIy under the aspect, though the anterior waI1 couId microscope are mereIy embedded in the be freeIy moved over the surface of the connective tissue Iying beneath the mucosa. tumor. The iIeoceca1 region was sIightIy But as the growths increase in size, the invaginated into the ascending coIon. As fatty structures are more sharpIy demarthis patient was but thirty-four years oId, cated from this connective tissue and the existence of marked tenderness over graduaIIy assume definite capsuIes formed McBurney’s point and other abdomina1 from the submucosa1 connective tissue. manifestations Ied to a preoperative diagEven smaI1 Iipomata wiI1 be divided by thin but perfectIy definite septa into a nosis of appendicitis. This emphasizes the Iimitations to the series of IobuIes, and the very Iarge fatty arriva1 at a definite diagnosis of intestina1 tumors even take on definite fibrous charIipoma which Comfort has Iaid down. OnIy acteristics which bring them close to the when the tumor is far enough down to be cIassification of fibromata. If the tumors or after it grow very Iarge, the muscuIar Iayer wiI1 seen through the proctoscope, has proIapsed externaIIy and presents a be found much thinner and the yeIIow typica appearance (by no means invariabIy coIor decidedIy more pronounced, a differthe case), or when biopsy can be made ential point of vaIue to the operating from a recta1 Iipoma or from a Iipoma surgeon. attached to the apex of an area of intusAs Iipomata increase in size, they bring susception which proIapses into the rectum, about marked pathoIogica1 and physiois there IikIihood of a correct preoperative IogicaI aIterations in the intestine. The diagnosis. pressure induced pushes out the waI1 of the
NE\Y SERIES VOL. XXIV,
No. i
CASE
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REPORT
Mrs. M. P., a tiny, emaciated Italian woman, aged sixty-four years, when examined on January 24, 1932, gave a history of severe abdominaI pain and obstinate constipation of one week’s duration. The constipation was of Iongstanding, but had become much worse recentIy. There had been sweIIing of the abdomen, ribbon-like stools, anorexia and much eructation of gas, but no vomiting. There was no history of bIood or mucus in the stoo1, or of diarrhea. Inspection showed symmetrica swelhng of the Iower abdomen, and on paIpation a mass about the size of a grapefruit couId be made out at the midhne. This mass was hard and tender, but did not appear to have any definite attachment. Consideration of the woman’s age and the Iocation of the mass gave an impression of carcinoma of the transverse coIon, or possibly of the sigmoid, with metastases. Operation the foIIowing day was carried out through an incision through the rectus muscIe, to the right of the midIine. When the tumor mass was brought through the incision, it was found to consist of the transverse coIon, into which had teIescoped the ascending coIon, the cecum with its appendix, and about 4 inches of the iIeum. Reduction presented no especial diffrcuIty. When the cecum had been freed, a semisolid mass about 2 inches in diameter was feIt within it, which was assumed to be a carcinoma. The ascending coIon, the cecum, and 4 or 5 inches of the ileum were resected, the mesentery tied off, and the severed portions of the bowe1 removed. The ends of both transverse coIon and iIeum were cIosed with two Iayers of sutures, and a IateraI anastomosis made between transverse coIon and iIeum, with an opening about 3 inches in Iength. After a cigarette drain had been pIaced just beneath the Iiver in the deepest part of the abdominal cavity, the incision was cIosed about it Iayer by Iayer, using pIain catgut for the peritoneum, chromic catgut for the aponeurosis, and interrupted sutures for the skin. Pathologist’s Report: The specimen consisted of a portion of the cecum some 14 cm. in length, together with about 7 cm. of the ileum. The ceca1 content was stained with bile. Adjacent to the iIeoceca1 vaIve there was a large tumor about 3 by 4 cm. in extent, Iving between mucosa and muscularis. Its
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shape was roughIy spherical, and the surface showed no evidence of uIceration. On posterior section through the muscle waI1, this tumor was found to be encapsuIated and composed entireIy of fatty tissue. A similar, smaher tumor was found about 4 cm. farther down the lumen of the cecum. MicroscopicaIIy, the appendix showed obhteration of the lumen and marked fatty infiItration, with a definite, Iow-grade inffammation. The entire tumor consisted of Iipomatous tissue. Diagnoses: Lipoma of cecum; low-grade
chronic appendicitis. The postoperative
course
was somewhat
sIow, but uneventfu1, and the patient was dismissed on the thirtieth day. When seen last, more than a year and a haIf after remova of the tumor, the woman was in excehent health and had gained 16 pounds in weight. HYPERPLASTIC
TUBERCULOSIS
OF THE
LARGE
BOWEL
The type of intestina1 tubercuIosis which is IikeIy to cause confusion with intestinal neopIasia is the hyperplastic, or, as some writers have termed it, intestinal tuberculoma. There seems to be a genera1 impression that this is an excessiveIy rare form of tubercuIosis, as it does not appear as a compIication secondary to a focus in the Iungs, but is IikeIy to be found in subjects in whom no manifestations of tubercuIous infection have previousIy appeared. AIthough the smaI1 intestine is very seIdom affected with tuberculosis (onIy 9 cases having been reported in the Iiterature), a study of avaiIabIe cIinica1 reports shows that the Iarge intestine not infrequentIy becomes infected by tubercle baciIIi independentIy of the occurrence of the disease eIsewhere in the same su.bject. In the Iast decade of the nineteenth century, severa European surgeons, BiIIroth and Hartmann among them, described tumor formations occurring in the Iarge bowe1 which produced symptoms aad gave a clinica picture identica1 with that of carcinoma but on pathoIogica1 examination proved to be tuberculous in origin. In 1906, Hartmann made a report on 2 19 operated
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cases. In nearIy a11 the reports the cecum is overwheImingIy the favored Iocation. Of IOO cases Iisted by Mummery in his textbook, 87 were either entireIy within the cecum or in cecum and ascending coIon. Etiology: As in cases of carcinoma simiIarIy Iocated, the causa1 factors favoring the estabIishment of a tubercuIous Iesion in this particuIar part of the body are obscure. PossibIy the theory of continued trauma from hard feca1 masses, which has been advanced in the instance of newgrowths of the Iarge bowe1, may be appIicabIe to invasion by tubercIe baciIIi. Linthicum6 thinks that the most pIausibIe expIanation of Iarge gut invoIvement in the hyperpIastic type of tubercuIosis is the ingestion of a weak or attenuated organism which Iodges in a spot favorable for its propagation during its passage through the Iower bowe1. IndividuaIs who are resistant to inhaIed tubercIe baciIIi might succumb to those entering the digestive tract. Thus a primary tubercuIous focus might be estabIished in the Iarge intestine, “in which the usua1 warfare goes on between . . . the tubercIe baciIIus and the individua1, with the resuIt that an inffammatory reaction is set up, with the production of fibrous tissue, which is the heaIing.” norma . . . tubercuIous Some of the difI?cuIties in Diagnosis: diagnosis have aIready been pointed out. Many of the symptoms are common to a variety of diseases, so that none can be considered pathognomonic. Progressive Ioss of strength and weight extending over a considerabIe period, if occurring in a young subject, suggests tuberculosis rather than maIignancy; yet there are enough records of abdomina1 carcinoma occurring in young persons to cause doubt. If the Iesion attains considerabIe size, it wiI1 produce symptoms characteristic of partia1 occIusion of the bowe1 Iumen, chief among which are sweIIing of the abdomen and increase in intestina1 peristaIsis, with severe paroxysma pain. In some cases these attacks may simuIate renaI coIic, and the confusion with appendicitis is so frequent that in nearIy a11 the reported cases appen-
dectomy had been previousIy performed. Linthicum suggests that differentiation from appendicitis may be accompIished by noting that there is no characteristic painfu1 spot, nor genera1 distention of the abdomen, nor the rise of temperature reguIarIy attending acute inff ammation of the appendix. The tumor, moreover, is not fixed, but is aIways more or Iess mobiIe, steadiIy increasing in size, often muItipIe, and apt to assume a cyIindrica1 form. If the possibiIity of tubercuIous infection shouId be suggested, appropriate tests wouId soon offer a substantia1 basis for diagnosis, but the rarity of the Iesion makes its detection before operative intervention practicaIIy impossibIe. CASE
REPORT
Mrs. B. K., a young married woman of twenty-three, was first admitted December 19, 1932. At that time she compIained of abdominaI pain, which she beIieved had begun after she had been in swimming some three months before. Pain had been aImost continuous for the intervening three months, with occasional vomiting and aImost compIete Ioss of appetite. However, the boweIs were said to have moved reguIarIy. There had been an appendectomy two years before, and the pain was partiaIIy referred to the site of this operation. About three weeks before, the old scar had opened and discharged about a cupfu1 of pus. At the time of entrance the fistuIa had closed. Investigation of this operative record showed that the origina appendectomy incision had remained open for five months, so that a secondary intervention was required to cIose it. The Iungs were cIear, but the patient compIained of chronic cough with morning expectoration. There was no other suggestion of tuberculosis in either the past or present history. Examination of the abdomen showed the scar of the appendectomy with evidence of extensive drainage. In the right lower quadrant a mass as Iarge as a grapefruit couId be made out. This was somewhat tender on pressure, but the abdomina1 waI1 was not rigid. The abdomen was opened on December 2, 1932, and the mass found to be denseIy adherent to the surface of the peritoneum. When exposed by both bIunt and sharp dissection, it proved
NE\~’
SI~K,ES
to be a
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XXIV. No.
I
McGrath
& E&+-Tumors
greatly thickened portion of the cecum, the mesentery especiaIIy being very hyperpIastic. The underIying portion of the mass appeared to be diseased Iymph nodes. A search was made for the appendix under the hypothesis that it might not have been removed entire at the preceding intervention, or that an abscess might have formed at the site of its remova1. Nothing of the sort was found; neither was there any evidence of a local abscess coIIection in the posterior aspect of the cecum, after it had been mobilized. The abdomen was closed in Iayers about a cigarette drain, using continuous pIain catgut sutures for the peritoneum, continuous chromic catgut for the aponeurosis, with interrupted fine silk sutures for the skin. WhiIe the appearance of the mass in the cecum might easiIy have been taken for that of maIignancy, the fact that the patient was but twenty-four years of age argued strongIy in favor of its being the product of a chronic inflammatory process, invoIving connective tissue and gIanduIar structure in the retroceca1 region as we11 as the lymph nodes aIong the course of the iIiac vesseIs. For this reason it was deemed advisabIe to confine the intervention merely to drainage of the affected area. On JuIy 18, 1933, seven months after this operation, the patient re-entered, compIaining that there was a fistuIa at the site of incision from which very profuse drainage had continued. She had aIso experienced some pain in the old wound. The abdomen was reopened by an incision running from above the umbiIicus downward toward the symphysis pubis, which reveaIed a mass some 4 by 6 inches in diameter, presenting in the iIiac fossa. This mass was firmly adherent to the waI1 of the peIvis and adjacent parts. ApparentIy it aIso involved the waIIs of the cecum and ascending coIon, as weI1 as the adjacent mesenteric grands. After being freed a11 around and brought up into the incision, it was recognized as the head of the cecum and ascending coIon. By section across the iIeum near the iIeoceca1 junction and at the hepatic fIexure, the mass was removed and a lateral anastomosis made Jletween the iIeum and the transverse coIon, using the suture method without cIamps which the senior author’ has described in his textbook. The incision was cIosed Iayer by Iayer, using the same method of cIosure as in the previous operation, with the cigarette drain emerging from the lower angIe of the wound.
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Pathological Report: The specimen consisted of a section of intestine so matted together as to be no more than 20 cm. in Iength. If straightened out, it wouId have been about 35 cm. in Iength. There was a separate smaI1 specimen of skin and sinus tract. About 11 cm. of the Length was made up of iIeum, the remainder cecum. At the iIeoceca1 junction there was an induratecl, anguIar, buIky tumor-like mass invoIving the waI1. About 6 cm. beyond the junction there was a soft, somewhat uIcerated area. In one portion of the tissue there was a smaI1 diverticuIum, and at another point what appeared to be the stump of the appendix. Above the previousIy mentioned area, another smaI1 point of uIceration appeared. The 1:ymph gIands in the fatty tissue were much enIarged. MicroscopicaIIy, there was evidence of a chronic inflammatory process with considerabIe fibrosis. In some areas an occasiona multinucIeated giant-ceI1 couId be made out. Nothing about the sIide couId be pointed out as tvpica1 of tubercuIosis, but there was a possibiI&y of tuberculosis in the background. It appeared more IikeIy, however, that it was essentialIy an inff ammatory condition arising around the diverticuIum and the stump of the appendix. The lymph glands were Iarge and showed a we11 marked simpIe Iymphadenitis. There was no evidence of maIignancy. REFERENCES I. COMFORT, M. W.
Submucous Iipomata of the gastrointestina1 tract. Surg. Gynec. Obst., 52: 101, 1931. 2. CRILE, G. W.. and MCCLINTOCK. J. C. Fibroma of the c0I0n. AM. J. SURG., n.s. 21: 82, 1933. 3. ERDMANN, J. F., and MORRIS, J. H. Polyposis coIon. Surg. Gynec. Obst., 40: 460, 1925.
of the
4. STEWART, W. H., and II-LICK, H. E. Lipoma of the coIon; report of two cases. Am. J. Roentgenol., 23: 308, ‘930. 5. WEBB, G. Two
cases of Iipoma. AM. J. SURG., n.s. 16: 522, 1932. 6. LINTHICUM,G. M. TubercuIosis of the large intestine. AM. J. SURG., n.s. 16: 471, 1932. 7. MCGRAT~I, J. J. Operative Surgery. Phila., Davis, 1913. Further
References
CUNNINGHAM,J. J., and SNEIERSON,H. Chronic hyperplastic tubercuIosis of the iIeum. AM. J. SURG., n.S. 12: 131, 1931. DOWDLE, E. Tuberculoma of the descending colon. Ann. Surg., 91: 786, 1930. FITZGIBBON and RANKIN. PoIvnosis of the coIon. J. A. M. A., 97: 575, 1931.“HERRICK, F. C. TubercuIoma of the cecum, hyperpIastic tubercuIosis. Ann. Surg., 81: 801, 1925. RATCLIFF, R. A. Submucous Iipoma of colon. Cq’s Hosp. Rep., 80: 453, 1930.