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Carcinoma of splenic flexure associated with chronic appendicitis
CARCINOMA OF SPLENIC FLEXURE ASSOCIATED WITH CHRONIC APPENDICITIS CHARLES C. SPANGLER, M.D.
Visiting Surgeon, York Hospital
T
YORK, PA.
HERE is no field of medicine in which there is greater need for a careful collection of statistics, for painstaking research, and for a judicious correlation of associated facts, than in that of cancer. It causes 5 per cent of all deaths over the age of thirty years. It is more prevalent in women than among men. The large number of cancer of the stomach help swell the male proportion, but by no means in a manner peculiar to men. Though cancer is rare among children, yet a considerable number of cases have been reported. Cancer of the stomach has been reported in a child of five weeks, and in a boy and a girl of thirteen and fourteen years respectively. Primary carcinoma of the intestinal canal is the most frequent form of cancer in children. There has been reported 37 cases, the ages varying between one and one-half to fifteen years, the majority between twelve and fifteen years. It is lamentable that many of the incipient carcinomas are not recognized in time to produce a cure. This is explained by the fact that few patients recognize the beginning of the disease, nor was it recognized by the physician. Frequently the first symptoms are of a mechanical nature, the disease remaining absolutely latent until there is interference with the function of some important organ or organs, such as from stenosis, compression, perforation, hemorrhage etc. Thus, the beginning of the disease and the occurrence of the first symptoms seldom coincide. Frequently it occurs that when the initial symptoms do make their appearance these are not considered with sufficient evidence, and a tentative diagnosis of some other condition is made.
This is due to the fact that procedures to aid in establishing the proper diagnosis have been neglected, and therefore explains the failure of early recognition of the disease, as the following case illustrates. The patient, a male, age twenty, presented himself for diagnosis and treatment on April 26, 1935, complaining of abdominal pain. Present History. His general health had been excellent until approximately five years ago, when he was seized with an attack of severe abdominal pain, very sharp and piercing, localized primarily in the region of the umbilicus, but his whole abdomen was tender on palpation. The acute pain lasted for a few hours and then subsided, but he continued to have generalized abdominal tenderness for two or three days. His condition was diagnosed as acute indigestion. About two weeks later he had a second attack which lasted about three days with the pain more localized in the region of McBurney's point. This time his condition was diagnosed as acute appendicitis. No blood count nor any other diagnostic methods had been employed. Approximately three months later he had a third attack with generalized abdominal pain, the pain being a little more severe in the region of the umbilicus than at any other point, causing the patient to flex the legs on the abdomen for relief. These attacks of pain lasted one or two hours, then subsided, with some abdominal tenderness persisting for two or three days. In the interval between attacks the patient experienced no gastric discomfort, and followed his usual occupation. These attacks occurred every three or four months for about four years, but the past year they
,60
NEW SERIES VOL.
XXXI.
NO.3
Spangler-Cancer & Appendicitis
have become more frequent and more severe. Eating seemed to exaggerate the attack. Four weeks prior to admission to the hospital the patient had an attack which did not subside completely. On admission he complained of generalized abdominal pain, nausea, occasional attacks of vomiting, headache, and constipation. He would work two or three days and then be forced to stop for two or three days due to the increase in pain. For the past year he used mineral oil for his constipation. He has never vomited blood. Three months prior to admission on one occasion he saw fresh blood in the stool. For the past month he had impaired appetite and a loss in weight of fifteen pounds, his usual weight being 145 pounds. Past History. He was injured by an automobile at the age of six years. During childhood he had measles, whooping cough, and scarlet fever. Family History. On his father's side, his grandmother died of cancer of the neck, his grandfather died of cancer of the stomach, his grandaunt died with cancer of the nose, and his aunt died with cancer of the breast. His mother and father are living and well. Physical Examination. On palpation no definite mass could be elicited, but there was tenderness over the whole abdomen, more marked in the region of McBurney's point. There was slight resistance of the abdominal muscles. He never complained of pain particularly in the left hypochondriac region. Percussion and auscultation was negative. Laboratory Findings. An intravenous Graham test was negative for gall stones. On blood count there were 4,8 I 0,000 red cells and I 1,400 white cells with polymorphonuclears 79 per cent and 15 gms. hemoglobin. The urine was normal. The Kahn test was negative. Biopsy revealed a growth encircling the bowel about the middle of the splenic flexure. The growth involved all the coats of the bowel constricting its lumen to about .3 em. in diameter. The bowel was moderately distended
American Journal of Surgery
56 I
above the growth and below it the walls were thicker and the bowel somewhat contracted. Microscopic section revealed a primary adenocarcinoma. A second specimen which was a mesenteric lymph gland, revealed a secondary carcinoma, and diagnosed as metastatic adenocarcinoma of the mesenteric glands. The third specimen revealed a rather elongated appendix with a thickened muscular coat containing a large amount of fibrous tissue. The mucosa was pale and the lumen contained two fairly large fecaliths and fecal debris. It was diagnosed a chronic fibrous appendicitis. Roentgenologist Report (L. S. Landes, M.D.) "Barium enema revealed a normal sigmoid, a redundant descending colon, a rugged, irregular funnel shaped deformity in the upper third of the descending colon. There was no pain on pressure, no difficulty in filling this lesion, and the colon was freely movable, but there was a definite delay in the passage of the enema beyond the lesion. The shadow of the involved lesion is about two inches in length. Impression-New growth of the upper third of the descending colon· involving the splenic flexure, most probably . " carCInoma. Treatment. An exploratory laparotomy was performed. A mid line incision was made from the umbilicus to the symphysis pubis, and the abdomen explored. The appendix was found retrocecal, elongated and bound down by adhesions. In the left hypochondriac region involving the splenic flexure and the upper part of the descending colon was a mass approximately the size of a small tangerine. The mass could not be resected through the midline incision, therefore the adhesions were separated from the appendix and the appendix removed. Eighteen days later a three stage Mikulicz operation was done through a left rectus incision. Approximately three inches of the transverse colon, the splenic flexure and the descending colon as far down as the sigmoid was removed, including a V shaped portion
562
American Journal of Surgery
Spangler-Cancer & Appendicitis
of the mesentery in which the glands were involved. The segment of bowel involving the tumor mass was mobilized, the adhesions broken, and the bowel and mesentery brought into the abdominal wound. The adjacent limbs of the colonic loop were not sutured together, as the custom. The parietal peritoneum and margins of the abdominal wound were sutured closely around the base of the two protruding intestinal limbs, but not tight enough to strangulate them. A clamp was applied on each limb and left in situ, and the protruding colonic loop including the growth was excised en masse. The clamps were left applied for three days and then removed. Six days later the enterotome was applied upon the intestinal spur formed by the double walls of the colon, one limb of the instrument passing into each limb of the colon. The blades of the entertome were tightened each following day for six days, when it had cut its way through the double walled spur, making into one the canal of the two limbs, down to the limit of the clamp. The patient was then sent home for two months with a colostomy bag. At the end of the two months the patient had gained eighteen pounds in weight. He returned to the hospital and the intestinal opening was closed by an extra
MARCH. 1936
peritoneal plastic operation. The immediate margins of the colonic opening were mobilized and freshened, after which they were brought together and sutured, and over this the structures of the abdominal wall were approximated and sutured. CONCLUSION 1. If trauma is an etiological factor in carcinoma, it is possible that the injury he sustained at the age of six when injured by an automobile, might have been a causative agent. 2. It is possible, from the history, that the commencement of the carcinoma was at the age of fifteen years or prior thereto, taking into consideration that the beginning of the disease and the appearance of the initial symptoms seldom coincide. 3. It is difficult to estimate the initial symptoms of the appendiceal attack, as the symptoms from the onset were rather indefinite, the patient never complaining of localized pain in the left hypochondriac region and in the course of five years only twice did he complain of localized pain in the region of McBurney's point. 4. From a history such as has been given and from the symptoms described, it is evident that in order to make a correct diagnosis, it can be reached only with the most careful and painstaking methods at our command.
Visiting Surgeon, York Hospital
T
YORK, PA.
HERE is no field of medicine in which there is greater need for a careful collection of statistics, for painstaking research, and for a judicious correlation of associated facts, than in that of cancer. It causes 5 per cent of all deaths over the age of thirty years. It is more prevalent in women than among men. The large number of cancer of the stomach help swell the male proportion, but by no means in a manner peculiar to men. Though cancer is rare among children, yet a considerable number of cases have been reported. Cancer of the stomach has been reported in a child of five weeks, and in a boy and a girl of thirteen and fourteen years respectively. Primary carcinoma of the intestinal canal is the most frequent form of cancer in children. There has been reported 37 cases, the ages varying between one and one-half to fifteen years, the majority between twelve and fifteen years. It is lamentable that many of the incipient carcinomas are not recognized in time to produce a cure. This is explained by the fact that few patients recognize the beginning of the disease, nor was it recognized by the physician. Frequently the first symptoms are of a mechanical nature, the disease remaining absolutely latent until there is interference with the function of some important organ or organs, such as from stenosis, compression, perforation, hemorrhage etc. Thus, the beginning of the disease and the occurrence of the first symptoms seldom coincide. Frequently it occurs that when the initial symptoms do make their appearance these are not considered with sufficient evidence, and a tentative diagnosis of some other condition is made.
This is due to the fact that procedures to aid in establishing the proper diagnosis have been neglected, and therefore explains the failure of early recognition of the disease, as the following case illustrates. The patient, a male, age twenty, presented himself for diagnosis and treatment on April 26, 1935, complaining of abdominal pain. Present History. His general health had been excellent until approximately five years ago, when he was seized with an attack of severe abdominal pain, very sharp and piercing, localized primarily in the region of the umbilicus, but his whole abdomen was tender on palpation. The acute pain lasted for a few hours and then subsided, but he continued to have generalized abdominal tenderness for two or three days. His condition was diagnosed as acute indigestion. About two weeks later he had a second attack which lasted about three days with the pain more localized in the region of McBurney's point. This time his condition was diagnosed as acute appendicitis. No blood count nor any other diagnostic methods had been employed. Approximately three months later he had a third attack with generalized abdominal pain, the pain being a little more severe in the region of the umbilicus than at any other point, causing the patient to flex the legs on the abdomen for relief. These attacks of pain lasted one or two hours, then subsided, with some abdominal tenderness persisting for two or three days. In the interval between attacks the patient experienced no gastric discomfort, and followed his usual occupation. These attacks occurred every three or four months for about four years, but the past year they
,60
NEW SERIES VOL.
XXXI.
NO.3
Spangler-Cancer & Appendicitis
have become more frequent and more severe. Eating seemed to exaggerate the attack. Four weeks prior to admission to the hospital the patient had an attack which did not subside completely. On admission he complained of generalized abdominal pain, nausea, occasional attacks of vomiting, headache, and constipation. He would work two or three days and then be forced to stop for two or three days due to the increase in pain. For the past year he used mineral oil for his constipation. He has never vomited blood. Three months prior to admission on one occasion he saw fresh blood in the stool. For the past month he had impaired appetite and a loss in weight of fifteen pounds, his usual weight being 145 pounds. Past History. He was injured by an automobile at the age of six years. During childhood he had measles, whooping cough, and scarlet fever. Family History. On his father's side, his grandmother died of cancer of the neck, his grandfather died of cancer of the stomach, his grandaunt died with cancer of the nose, and his aunt died with cancer of the breast. His mother and father are living and well. Physical Examination. On palpation no definite mass could be elicited, but there was tenderness over the whole abdomen, more marked in the region of McBurney's point. There was slight resistance of the abdominal muscles. He never complained of pain particularly in the left hypochondriac region. Percussion and auscultation was negative. Laboratory Findings. An intravenous Graham test was negative for gall stones. On blood count there were 4,8 I 0,000 red cells and I 1,400 white cells with polymorphonuclears 79 per cent and 15 gms. hemoglobin. The urine was normal. The Kahn test was negative. Biopsy revealed a growth encircling the bowel about the middle of the splenic flexure. The growth involved all the coats of the bowel constricting its lumen to about .3 em. in diameter. The bowel was moderately distended
American Journal of Surgery
56 I
above the growth and below it the walls were thicker and the bowel somewhat contracted. Microscopic section revealed a primary adenocarcinoma. A second specimen which was a mesenteric lymph gland, revealed a secondary carcinoma, and diagnosed as metastatic adenocarcinoma of the mesenteric glands. The third specimen revealed a rather elongated appendix with a thickened muscular coat containing a large amount of fibrous tissue. The mucosa was pale and the lumen contained two fairly large fecaliths and fecal debris. It was diagnosed a chronic fibrous appendicitis. Roentgenologist Report (L. S. Landes, M.D.) "Barium enema revealed a normal sigmoid, a redundant descending colon, a rugged, irregular funnel shaped deformity in the upper third of the descending colon. There was no pain on pressure, no difficulty in filling this lesion, and the colon was freely movable, but there was a definite delay in the passage of the enema beyond the lesion. The shadow of the involved lesion is about two inches in length. Impression-New growth of the upper third of the descending colon· involving the splenic flexure, most probably . " carCInoma. Treatment. An exploratory laparotomy was performed. A mid line incision was made from the umbilicus to the symphysis pubis, and the abdomen explored. The appendix was found retrocecal, elongated and bound down by adhesions. In the left hypochondriac region involving the splenic flexure and the upper part of the descending colon was a mass approximately the size of a small tangerine. The mass could not be resected through the midline incision, therefore the adhesions were separated from the appendix and the appendix removed. Eighteen days later a three stage Mikulicz operation was done through a left rectus incision. Approximately three inches of the transverse colon, the splenic flexure and the descending colon as far down as the sigmoid was removed, including a V shaped portion
562
American Journal of Surgery
Spangler-Cancer & Appendicitis
of the mesentery in which the glands were involved. The segment of bowel involving the tumor mass was mobilized, the adhesions broken, and the bowel and mesentery brought into the abdominal wound. The adjacent limbs of the colonic loop were not sutured together, as the custom. The parietal peritoneum and margins of the abdominal wound were sutured closely around the base of the two protruding intestinal limbs, but not tight enough to strangulate them. A clamp was applied on each limb and left in situ, and the protruding colonic loop including the growth was excised en masse. The clamps were left applied for three days and then removed. Six days later the enterotome was applied upon the intestinal spur formed by the double walls of the colon, one limb of the instrument passing into each limb of the colon. The blades of the entertome were tightened each following day for six days, when it had cut its way through the double walled spur, making into one the canal of the two limbs, down to the limit of the clamp. The patient was then sent home for two months with a colostomy bag. At the end of the two months the patient had gained eighteen pounds in weight. He returned to the hospital and the intestinal opening was closed by an extra
MARCH. 1936
peritoneal plastic operation. The immediate margins of the colonic opening were mobilized and freshened, after which they were brought together and sutured, and over this the structures of the abdominal wall were approximated and sutured. CONCLUSION 1. If trauma is an etiological factor in carcinoma, it is possible that the injury he sustained at the age of six when injured by an automobile, might have been a causative agent. 2. It is possible, from the history, that the commencement of the carcinoma was at the age of fifteen years or prior thereto, taking into consideration that the beginning of the disease and the appearance of the initial symptoms seldom coincide. 3. It is difficult to estimate the initial symptoms of the appendiceal attack, as the symptoms from the onset were rather indefinite, the patient never complaining of localized pain in the left hypochondriac region and in the course of five years only twice did he complain of localized pain in the region of McBurney's point. 4. From a history such as has been given and from the symptoms described, it is evident that in order to make a correct diagnosis, it can be reached only with the most careful and painstaking methods at our command.