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Carcinoma of the Large Intestine
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CARCINOMA OF THE LARGE INTESTINE ARTHUR
W. ALLEN, M.D., F.A.C.S. o
THE following case reports are presented to illustrate the usual procedures found to be satisfactory in the management of malignant lesions of the bowel. As will be seen, our experience leads us to believe that resection and primary anastomosis is the method of choice. This is the natural outcome of many years of the practice of this general principle in our clinic. The rare use of the exteriorization or Mikulicz type of operation has given us inadequate knowledge of this method of attack, accounting for the accentuation of the primary anastomosis technic. We do not wish to convey the idea that we feel that exteriorizations, particularly of the obstructive type of resection at one time advocated by Rankin,l are bad practice. We are aware of the fact that in many hands these operations give satisfactory results. There is a growing tendency towards primary suture of the bowel that has come about through the improvements in preparation of the patient, better surgical technic, and chemotherapeutic aids. We have felt that the morbidity could be reduced by primary suture and that the mortality rates could be kept as low as those reported by the advocates of the Mikulicz principle. In our earlier experience, we believed that aseptic anastomosis was important. 2 Now with a better bowel preparation and other measures, we can obtain completely satisfactory primary anastomosis by the so-called open technic. Also, we formerly practiced more frequent proximal decompression often before resection, otherwise as a complementary procedure. Preliminary cecostomy is now done only in the presence of acute and complete obstruction of the left colon and complementary cecostomy is rarely done. The Miller-Abbott tube is used as an added precaution in some cases. Preliminary transverse colostomy is used only in large obstructing inflammatory lesions of the sigmoid. This procedure is mandatory in diverticulitis with inflammatory extension and by this means one can count on the resolution of the acute process even in the presence of frank abscess. Since carcinoma and diverticulitis may occur in the same region, one must consider an earlier resection in some cases. If bleeding and mucous discharge continue from the defunctioned segment, the diagnosis of cancer is established and the obstructive, inflammatory feature must be secondary to the elimination of the malignant
° Chief, East Surgical Service, Massachusetts General Hospital; Lecturer in Surgery, Harvard Medical School, Boston. 1018
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process. If cancer is obvious or strongly suspected, the resection should be undertaken not later than the fourth week after transverse colostomy. If it seems reasonably certain that diverticulitis is the sole causative factor, a better procedure can be accomplished after three to six months of complete decompression. Although such practice requires three operations, the difficulties attending these are far less than can be expected by any other method at our disposal. CASE I. CARCINOMA OF THE CECUM This 56 year old nulliparous woman (M. G. H. No. 507289) was referred from Prince Edward Island with a diagnosis of regional enteritis. Her story was that of right lower quadrant tenderness and soreness of variable intensity
Fig. 322.-Barium studies in Case I reveal a constant filling defect in the region of the ileocecal valve, which appears to extend two-thirds of the way around the lumen of the bowel producing a narrow channel in the region of the lower ascending colon. The mucosa is destroyed in the narrowed area over a distance of approximately 7 cm. over a five to six months interval. She had lost 25 pounds in weight, and there had been a gradual increase in fatigability. She had no obstructive symptoms. Her appetite had remained good and her bowel habits unchanged. She had noted no unusual stools. Her past history was noncontributory except for the fact that she had had an appendectomy thirty years previously. She had worked hard, taking care of ill members of the family. On physical examination, the patient appeared undernourished and had a rather sallow complexion. A right paramedian scar. was present in the lower abdomen and there was definite tenderness lateral to this scar. Under this area a soft mass could be felt which seemed to move with respiration. She had long saphenous varicosities.
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The patient remained in the hospital for ten days of study ano preparation for surgery. Her hemoglobin was found to be 11.3 gm. and serum protein 7.3 gm. per 100 cc. X-ray studies following barium enema are shown in Figure 322. She was given 2 gm. of sulfathaladine four times a day beginning on the day following admission and this was continued until the time of operation. In addition, she was given vitamins C and B complex, and ferrous sulfate. She obtained only a fair effect from her sulfathaladine and on two occasions milk of mdgnesia was given. On the day before operation, a Miller-Abbott tube was inserted and this was readily advanced into the small bowel with the aid of 2 cc. of mercury in the balloon.
Operation.-Under spinal anesthesia, a long paramedian incision was made. Adhesions to the old appendix wound were freed. The tumor mass in the cecum was large and bulky but not fixed. There was no free fluid or evidence of extension into the liver or surrounding peritoneum. There were however enlarged lymph nodes running up along the ileocolic and right colic vessels. The lateral peritoneum was freed. The ovarian vessels were not sacrificed. The ureter and duodenum were identified. The right colic and ileocolic vessels were divided at their junction with the superior mesenteric. The transverse colon was divided within the midcolic blood supply area. The ileum was transected 30 cm. proximal to the ileocecal valve in an oblique fashion. End-to-end anastomosis with an outer layer of interrupted No. 30 cotton and inner layer of fine running chromic catgut was accomplished. The edges of the cut mesenteries were approximated by means of a running catgut 'iuture. The wound was closed' with catgut to the peritoneum and interrupted cotton to the fascia; skin and fat closure was delayed forty-eight hours. The anus was carefully dilated to the width of three fingers. The patient received one transfusion before, one during and one fonowing operation. She was given 5 gm. of sulfadiazine intravenously for two days and then 2~ gm. daily for two days. Forty-eight hours postoperatively she received Yo grain of morphine intravenously and her skin sutures were tied. The patient made an entirely uneventful convalescence, her temperature never going above 99.6° F., nor her pulse above 100. She was kept in the hospital twenty-one days because of her general depletion and the fact that she had a long trip home. At the time of discharge, her bowels were moving twice daily. Pathologic Report: Adenocarcinoma, grade II. A segment of colon measur· ing 50 cm. in length with an attached 30 cm. of tenninal ileum. In the cecum is a finn, annular mass measuring 6 cm. in diameter infiltrating the wall and constricting the lumen to a circumference of 2 cm. at the distal end. The margins are raised up to 1 cm. above the surface of the adjacent mucosa and the central portion is occupied by a cavernous irregular ulceration measuring 3.5 cm. in diameter. The overlying mucosa is reddish, injected and ulcerated, and the entire wall is infiltrated measuring up to 3 cm. in thickness. The serosa is puckered and injected and the omentum is firmly adherent in places by fibrous adhesions. The regional lymph nodes are firm and measure up to 1 cm. in diameter. On
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section, they are pinkish gray and granular. The tumor on section is gray, 'coarsely granular with yellowish stippling. The regional lymph nodes show no evidence of metastasIS. Postoperative Course.-The patient has done well and is symptom free one and one-half years after 0l2eration. She has regained her lost weight and her bowels move easily twice daily.
Comment.-This patient illustrates a typical instance of carcinoma of the right colon. The lack of obstructive symptoms associated with a palpable tender mass and anemia is often found. It was brought out in her family history that a sister had been operated upon for extensive tuberculosis of the pelvic organs. The tender right lower quadrant mass with weight loss made it necessary to consider tuberculosis in the differential diagnosis. Regional enteritis was also considered. Both of these were fairly definitely ruled out by the roentgenologic examinations. A chest film revealed no evidence of tuberculosis. There was no narrowing of the terminal ileum and the lesion had the characteristic appearance of carcinoma. At one time we felt that resection of the right colon with priImry anastomosis at one stage carried a greater risk than a two-stage attack. We still do a closed ileotransverse colostomy as a primary stage in cases with obstructing lesions of the right colon or when the patient is a pal'ticularly poor risk. We are, however, better satisfied with the present one-stage procedure. It seems apparent that the use of the long intestinal tubes for forty-eight hours before and after operation is best adapted to the right bowel lesions. Whether one does a lateral anastomosis in these cases rather than an end-to-end suture is a matter of choice. Some men prefer an endto-side hook-up. The important factors are a wide open lumen, no gross contammation, adequate blood supply and no tension on the suture line. With these principles in mind, the results will be satisfactory by any method used. CASE II. CARCINOMA OF THE TRANSVERSE COLON This 76 year old woman (M. C. H. No. 554373) had had constipation relieved by enema~ for many years. Five months previous to admission, she first noted severe, ctampy pains across the midabdomen, coming on in attacks lasting four or five days and then subsiding. Two months before admission she first developed vomiting and her abdominal pains became more severe. There was radiation of pain into. both Banks. For several months previous to admission, she had taken nothing but finely ground food prepared for her by a devoted daughter. She had had acnte glaucoma eight months previously, which necessitated the enucleation of her left eye. Physical examination revealed an edentulous, elderly female. The left eye had been enu~leated and the right eye revealed some evidence of glaucoma; in addition, she wa~ quite deaf. Her abdomen was distended and tympanitic; obstructive peristalsis was evident. Palpation revealed a definite movable mass in the midabdomen just below the level of the navel. Her blood pressure was 200/90, but
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otherwise, her examination was negative. X-ray studies following a barium enema are shown in Fig. 323. Her nonprotein nitrogen was found to be 25 mg., serum protein 5.6 gm. and hemoglobin 12.2 gm. per 100 cc. The electrocardiogram revealed evidence of left ventricular strain, compatible with hypertensive heart disease. She was placed on a low residue diet and given 2 gm. of sulfath!udine four times a day on admission. With the aid of carefully given enemas, it was possible to deflate her abdomen considerably. The sulfathalidine effect was excellent, and after four or five days she was having two stools a day. On the eighth day after admission, a laparotomy was performed under nitrous oxide gas-oxygen-ether anesthesia.
Fig. 323.-Barium studies in Case II, showing a long segment of transverse colon almost completely obstructed. The mucosal pattern is destroyed over a 10 cm. area.
Operation.-The abdomen was opened through a transverse incision across both rectus muscles above the umbilicus. The bowel was found to be well prepared. There was a large annular tumor involving the left transverse colon. There appeared to be no actual extension into the serosa, although the tumor mass was 20 to 25 cm. in diameter. The liver was entirely free of metastases and no gross lymph nodes were palpable in the mesocolon. The mesocolon was mobilized and a 21 cm. segment of the transverse colon resected with its mesentery. An open end-to-end anastomosis, using an outer row of interrupted cotton and an inner row of fine continuous chromic catgut, was accomplished. After changing gloves and instruments, the per-
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itoneum was closed with No. 0 chromic catgut, the fascia with interrupted No. 30 cotton. Sutures of heavy cotton were introduced 1.5 cm. apart through skin fat and fascia to be tied forty-eight hours later. At the conclusion of the operation, bilateral prophylactic superficial femoral vein interruption was done. Finally, the anus was carefully dilated. Pathologic Report: Adenocarcinoma, grade II: The regional lymph nodes were negative. A 21 cm. segment of large bowel including a central stenosing, annular tumor mass occupying 6 em. of the bowel. On section the tumor invades the entire thickness of bowel wall to a depth of 2.2 em. and extends into the adjacent fat. Nine lymph nodes were identified, measuring up to 0.8 cm. in diameter, and none of these contained tumor on microscopic examination. Postoperative Conrse.-The patient did very well, her temperature reaching 99.6° F. on the first and second days postoperatively, and her. pulse never going over 110. She was helped out of bed and aided in walking, increasing distances from the first postoperative day. She was taking an adequate diet on the third day. Her wound healed per primam and her bowels moved daily after the fourth day. She was discharged home in excellent condition on her fifteenth postoperative day.
Comment.-This patient illustrates several interesting features. In the first place, we believe that it is more important to accomplish resections of the transverse colon in one stage than in any other segment of the large intestine. The reason for this is based on the anatomic variations of the blood supply to this region. SingletonS has called our attention to the fact that the anastomosing radical from the left coloc ve~sel to the midcolic artery is missing in certain individuals. In the presence of complete obstruction, a well placed cecostomy will not interfere '\Jrith resection at a later date. Temptation to use preliminary ileotransverse colostomy in lesions of the proximal segment of the transverse colon has led us "into difficulty with the blood supply at the time of resection in one instance. Healing of the turned-in end of the midtransverse colon failed on account of the abnormal blood supply to the region. If such a preliminary procedure is done, the anastomosis should b~ placed well to the left of the midcolon. The prophylactic interruption of the deep veins of the legs is based on the high incidence of phlebothrombosis with fatal pulmonary embolism in aged patients following any operation, injury or illness. This is particularly striking in cases of abdominal malignancy and in those with fractures about the hip. We are convinced of the almost negligible effect on the return How of blood and lymph from the leg after the interruption of the normal femoral veins if the procedure is carried out properly. It seems obvious to us that the long, loose bland thrombus that appears in the deep veins of the legs without demonstrable evidence is more common in patients of the older age group than in others. Sudden death from this cause can be eliminated by
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the prophylactic interruption of the veins in cases that are likely to develop this complication. Early walking is practiced in nearly all of our surgical patients. Some of them, for one reason or another, cannot be given this added safeguard to their recovery. Our impression is that a properly placed and sutured wound will allow patients to move about during their early postoperative period to great adv.antage. The chiefest of these is the maintenance of muscular and joint tone. CASE III. CARCINOMA OF THE DESCENDING COLON This 81 year old married man (M. C. H. No. 586814) entered the hospital with the following story. Approximately thirty days before admission, he first noted a dull ache in his left lower quadrant. At this time he found a tender mass
Fig. 824.-Barium studies in Case III. There was a constant area of narrowing at thE! junction of the descending colon and sigmoid, which corresponds to the palpagle abdominal mass. The margins of the defect are sharply defined and sheI£!ike, but the lesions do not appear to be completely annular and there is very little evidence of mucosal destruction. in the left lower quadrant. He was then recovering from a respiratory infection. The pain lasted a day or two and together with the tenderness disappeared. One week before admission, he had a similar episode of pain and tenderness with palpable mass. In this second attack the pain became progressively worse and doubled him up. At this time the tenderness was quite marked and the mass very distinct. During the course of the night, his discomfort gradually passed off without the aid of medication. On occasion while urinating, the discomfort was increased. There were no other urinary symptoms. He had not complained of any change in bowel habits but had lost 5 pounds over the past six months. He had been well in the past save for an appendectomy nineteen years previous to admiSSion.
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The family history is interesting in that both his father and brother had had operations for "tumor of the bowel," two years and seven years previously. He was immediately given sulfathalidine-2 gm. four times a day-and a low roughage diet. Laboratory studies revealed a hemoglobin of 15.5 gm. per 100 cc. Barium enema passed readily to the cecum and entered the terminal ileum. The findings a~ given in Figure 324. After evacuation of the enema, more barium was introduced and the defect was confirmed by a second examination. The remainder of the colon appeared normal. The terminal ileum was not remarkable. The sigmoidoscope was passed well. into the sigmoid (25 cm.) and the mucOSa appeared normal throughout. After seven days of sulfathalidine preparation, operation was undertaken.
Operation.-Under spinal anasthesia, an oblique incision was made in the left lower quadrant. The rectus muscle was retracted mesially and the oblique muscles were split in the direction of their fibers. It was necessary to transect some of the internal oblique muscles' fibers. The liver was palpated and was free of metastatic nodules. The edge of the omentum was adherent to the tumor mass and was freed by resecting a portion of it, leaving the involved margin in contact with the tumor. The tumor itself was adherent to the anterior abdominal wall in the region of the internal inguinal ring. It was found necessary to remove that portion of the peritoneum and, during its removal, it was found that the vas deferens was densely adherent. Accordingly, a 2 cm. segment of the vas with the underlying left spermatic artery and vein was also sacrificed. The bowel with its. supplying mesentery was resected. Nodes were found to run up to the junction of the sigmoid and inferior mesenteric vessels. An open anastomosis was done using interrupted cotton sutures outside and a running fine chromic catgut suture within. The defect in the mesentery was clo~ed. A delayed wound closure technic was used. The anus was carefully dilated to three finger breaths. Pathologic Report: adeilOcarcinoma, grade III, with metastases to six of nine lymph nodes. The highest lymph nodes were found involved. The specimen consisted of a 16 cm. segment of large bowel containing a 3 cm. long, ulcerating tumor in its midportion, with a hemorrhagic, coarsely granular base and rllised indurated edges. It involved half the circumference of the lumen and extended through thtl wall into the serosal fat. Lymph nodes were hard and measured up to 1 cm. in diameter. . Postoperative Course.-This patient was allowed up and about from his first postoperative day. He was given enough water, tea and broth to keep his mouth and esophagus from feeling dry, but fluid balance was maintained by the intravenous route. His prothrombin level was normal and he was not given dicumarol prophylactically as would have been done had he had a low prothrombin time or had been between the ages of 40 and 60. He was given small doses of suIfathalidine daily after operation and until his bowels moved satisfactorily on the fifth postoperative day. The rectum was kept clean by the use of 8 ounces of normal salt solution instilled within it every. eight hours until his bowels moved. He was encouraged to evacuate this solution if and when he felt the urge. His wound healed per primam and he was discharged home on his thirteenth postoperative day.
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Comment.-The family history, the youth of the patient, added to the high degree of malignancy and its extension, make for a bad prognosis. Could a more radical procedure have accomplished any more? There was a wide margin of normal bowel on either side of the tumor. All the mesentery supplying the region was removed. Would • an attempt for a higher nodal dissection have been justifiable? Were there other lymph nodes involved that could have been removed? These questions are difficult to answer. All palpable nodes were included in the resection. This in itself is small proof that the spread of this process was not already out of bounds. It is discouraging to find a lesion giving such a short warning to be so fulminating in its character. CASE IV. CARCINOMA OF THE RECTOSIGMOID This 55 year old woman (M. G. H. No. 533525) had noted episodes of bleeding at stool for nearly one year. At the onset, she had gone to her physician who had done a barium enema which was reported as negative. She was found to have mild hemorrhoids. During the course of a year, she had a sensation of incomplete evacuation after moving her bowels. For the previous month, there had been a dull, aching, low back discomfort. Her bowel habits had never been regular and she had taken cathartics about once a week most of her adult life. There was no real constipation or diarrhea. There had been no vomiting and no abdominal distention. No bleeding in large amounts. She had lost no weight. Her history was otherwise irrelevant, except for the fact that her father died of cancer at the age of 74. The patient herself had cancer phobia. Sigmoidoscopy revealed a small friable, sessile, polypoid-like tumor 12 cm. from the anal ring. Biopsy revealed adenocarcinoma grade II. Her photo hemoglobin was found to be 14.4 gm. per 100 cc. Her nonprotein nitrogen was 22 mg. per 100 cc., serum protein 6.5 gm. Barium enema filled the entire colon and terminal ileum readily. At the rectosigmoid on the right lateral wall, a defect was found which was visualized with some difficulty. There were no other polyps or tnmefactions. Her blood pressure was 198/110. She was given a six day course of sulfathalidine, 2 gm. four times a day. On the day prior to operation, a Miller-Abbott tnbe, using mercury in' the baIloon, was introduced, and on the day of operation it was well down in the small intestine.
Operation.-A left paramedian incision was made. The liver was free of disease. The lesion was found just below the pelvic Hoor and could be felt through the peritoneum of the pouch of Douglas. The sigmoid was free laterally and divided in its lowest segment and the vessels and the lymphatics below the bifurcation of the iliacs were separated. No lymph nodes were palpable. Dissection was carried down to the coccyx. The lateral cardinal ligaments of the rectum were separated and the anterior surface of the rectum separated from the vagina, lengthening the rectum twofold. It was possible to place a clamp well below the lesion itself. An end-to-end open anastomosis was done, using an inner row of fine chromic catgut and an o~ter row of interrupted cotton sutures. The mesial peritoneal reHection was next sutured over the suture line medially and anteriorly, leaving the
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lateral area open to allow escape of retroperitoneal fluid. 100,000 units of penicillin were introduced locally. The wound was closed in layers, the fat and skin closure to be delayed forty-eight hours. The anus was finally dilated. Pathologic Report: Colloid adenocarcinoma, grade II. The lymph nodes were negative but the tumor had extended into a large serosal lymph vessel. Thirtythree centimeters of rectosigmoid had been removed. Two centimeters above the distal resection edge is a raised cauliflower growth measuring 3 cm. in~ diameter. Postoperative Course.-The patient did well postoperatively. On the first and third postoperative days her temperature rose to 100 0 F.; her pulse never exceeded 94. The Miller-Abbott tube was removed on the second postoperative day. She was continued on sulfathalidine postoperatively until the time of discharge on her twentieth day. At the time of discharge, the index finger palpated the anastomosis readily in the midrectum.
Comment.-The criticism that might be raised in this case is the advisability of restoring bowel continuity. The patient was extremely apprehensive and had suffered for years with cancer phobia. She had submitted elsewhere to needless excisions of portions of both breasts for cystic mastitis six years previously. The growth, as seen in the sigmoidoscopy, was small in size and the biopsy report revealed a fairly low grade adenocarcinoma. We have frequently had to take into account the p~ssibility of a more serious grading when the entire specimen was in the pathologist's hands. The colloid element was a surprise but on the other hand, there was no spread to lymph nodes. We are not aware of any cures in our hospital in colloid carcinoma of the colon and rectum no matter how extensive the operative procedure. So far, this patient has not had any local recurrence although only one year has elapsed since operation. The rectum on the stretch was divided well below the tumor; it will be noted however that the pathologist's measurement of the distal margin of normal tissue was only 2 cm. This, in my opinion, is too close for comfort and should local recurrence take place, it will be due to our willingness to abide by the wishes of her family and physician to avoid colostomy. A Miles procedure would have been better. judgment in this case. CASE V.
CARCINOMA OF SIGMOID WITH ENDOMETRIOSIS
This 49 year old bipara (M. G. H. No. 440316) was admitted to the hospital March 27, 1944. She has always been constipated and for years has been troubled with hemorrhoids; otherwise, she has been vigorous, healthy and active. Normal menopause occurred eight months ago. During the autumn of 1943, she was aware of occasional blood and mucus discharges from the rectum-almost always associated with bowel movement but recently this has occurred without stool and often with the passage of gas. Seven weeks prior to entry, she had a bout of severe abdominal cramps attributed to the ingestion of lobster. This cleared up with the· onset of diarrhea. Her physician ordered a barium enema examination on March 10, which showed an obstructing lesion at the lower sigmOid and
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ARTHUR W. ALLEN
much gas and fecal matter above the lesion in spite of a castor oil preparation (Fig. 325). Sigmoidoscopy revealed bloody mucus coming down from an obstructed area 16 cm. from the anal margin. A biopsy was attempted but was unsuccessful. Bimanually, a large mass could be felt in the left pelvic region. It was not possible to outline the uterus separately from the mass as a whole. The cervix was eroded and bulbous. The family history is of interest in that her mother now aged 78 had sigmoid resection for carcinoma three and one-half years previous to the patient's entry. Her father's sister had succumbed to cancer of the rectum.
Fig. 325.-Barium enema in Case V shows an obstructing lesion at the lower sigmoid and much gas and fecal matter above the lesion. Preparation was carried out by giving 3 gm. of sulfathalidine and low irrigations'daily for seven days. The patient was in good general condition, having a red blood count of 4,900,000 and 14.5 gm. of hemoglobin per 100 cc. Large doses of vitamin C were added to a low residue diet. Her generalized distention was considerably improved and she was free of peristaltic pain. It was felt however that her preparation was probably inadequate. We were afraid to give her further cathartics since the pre x-ray castor oil had caused great distress and had little effect on cleansing the colon.
Operation.-The first operation, exploratory laparotomy and complete transverse colostomy, was done April 4, eight days after admission. A short left paramedian incision was made in the lower abdomen. The liver was free of metastasis; the colon proximal to the obstruction was completely filled with semisolid fecal {natter. The growth was slightly above the pelvic Hoor and was attac,hed firmly to the uterus. It was decided that resection at this time would be too hazardous in view of the poor bowel preparation. A transverse incision was therefore made through the upper left rectus and a loop of transverse colon brought out. The lower wound was carefully closed. The patient did
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well after this procedure and it was possible to cleanse the lower bowel by irrigations through the distal orifice of the complete transverse colostomy. Irrigations of normal salt solution were supplemented by suspensions of sulfathalidine up to the day previous to the second operation. The second stage was done April 18, fourteen days after the first, and consisted of resection of the sigmoid and panhysterectomy en bloc, followed by primary anastomosis of the descending colon to the rectosigmoid. The exploratory left paramedian wound was opened and extended; the bowel was found to be well prepared. The tumor mass consisted of a firm tennis ball sized tumor in the sigmoid loop firmly attached to a uterus containing fibroids and endometrial implants. The lateral gutter was opened and the left ureter, which was tortuous, was dissected free of adherent tissue believed to be due to the endometriosis and not to the sigmoid carcinoma. The ovarian vessels on the left were divided high and dissection carried down retroperitoneally into the pelvis. The inferior mesenteric vessels were then identified and interrupted just below the branch supplying the lower sigmoid. The bowel at this point was then divided between clamps with the actual cautery. Dissection was continued into the pelvis to well below the tumor in the sigmoid. The right ovarian vessels were then secured and the uterine vessels interrupted at a low level. The upper vagina was then cut across. This allowed the entire tumor mass with uterus, adnexa, and sigmoid to be lifted upward. The bowel was then divided between clamps with the cautery well below the tumor. An accurate end-to-end suture of the bowel ends was then accomplished using two rows of fine chromic catgut. Peritonealization was accomplished leaving most of the suture line of the anastomosis within the peritoneal cavity. A cigarette drain was introduced from above into the vagina; the proximal end of this rested in the denuded retroperitoneal space, great care being used not to allow contact between the drain and the suture line. Pathologic Report: The specimen revealed a 23 em. segment of sigmoid with its attached mesentery, the uterus, tubes and ovaries. In the center of the resected sigmoid was an encircling lesion 5.5 cm. in length with irregular, hard, raised edges. This tumor extended through the bowel wall where a secondary 2 em. nodule was attached to an otherwise normal sigmoid by continuity. The tubes, ovaries and uterus were adherent to the sigmoid-the latter being attached firmly to the tumor site. The uterus contained numerous fibroids and endometrial implants were present on the uterus, tubes, ovaries and sigmoid. The regional lymph nodes revealed no tumor. The lesion in the sigmoid was classified as adenocarcinoma Grade II. Postoperative Course.-The p~tient was given a transfusion to replace blood lost during the operation. Intravenous water, glucose, vitamins and small amounts of sulfadiazine were given over the next three days. Nothing was given by mouth save an ounce of water, tea or broth per hour. The transverse colostomy began to function well by the third postoperative day and then normal feedings were
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resumed. The vaginal drain was removed on the third morning. The patient was sufficiently recovered by the eighth day to test the anastomosis with saline irrigations, which demonstrated unsatisfactory lumen. This procedure was repeated every four days thereafter until by the eighteenth day there was a free flow of irrigating fluid in both directions through the distal colon. The patient was then allowed to get up and about to regain some of her lost muscle tone. The thlrd procedure was closure of the transverse colostomy, which was accomplished thirty-nine days after her first operation and twenty-five days after her resection and anastomosis. The scar tissue about the colostomy was excised, saving as much skin as possible. Both ends of the colostomy were freed from the peritoneum and delivered outside the wound. The colon was transected between clamps on both limbs in healthy areas well beyond all scar tissue. A careful end-to-end anastomosis was then made and the bowel dropped free into the peritoneal cavity. The peritoneum and fascia were closed with interrupted No. 30 cotton and the skin sutures tied forty-eight hours later. The patient recovered well from this procedure and was discharged home ten days later on a normal diet. Her bowels were moving satisfactorily with small doses of mineral oil. She has remained well up to the time of this report.
Comment.-In this patient, we used too little sulfathalidine in the preparation; later cases received larger doses with better effect. We have liked this drug better than sulfasuxidine because of its less liquefying action on the fecal matter. We might have been able to reestablish continuity earlier had we used interrupted nonabsorbable sutures in the anastomosis as has been our custom for over two years. We would not institute any drainage in such a case today, having found that the peritoneal cavity takes care of any serous discharge from the denuded areas, if the peritonealization is limited to the mesial side of the dissection, leaving the lateral gutter open. Drains in previous cases either through the ischial fossa, the vagina or the abdominal wall have contributed to complications, such as fistula formation or stenosis at the point of anastomosis. Neither of these has occurred since we abandoned the use of drains. This low anastomosis was possible but the tumor with its complicating factors was too low to allow an adequate dissection of the nodal areas and exteriorization except by end colostomy, either by a Hartmann or a Miles procedure. The morbidity, as evidenced by an unusually long hospitalization, was greater in this instance than in most operations of a similar nature carried out by us. The almost complete obstruction and the patient's temperament, plus the error in using catgut in the anastomosis, all played a role in the prolonged convalescence. The endometriosis in this patient brings to mind the fact that bowel obstruction with eroding firm malignant appearing intraluminal tumefaction can occur from this disease alone. A ·few years ago, we combined a total hysterectomy with a Miles procedure under clinical impression that we were dealing with extensive and very unfavorable cancer of the rectosigmoid. This proved to be entirely endometriosis with no evidence of malignancy.
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REFERENCES 1. Rankin, F. W.: Resection and Obstruction of the Colon (Obstructive Resection). Surg. Gynec. & Obst., 50:594-598 (March) 1930. 2. Allen, A. W.: Carcinoma of the Colon. Surgery, 14:350-366 (Sept.) 1943. 3. Singleton, Albert 0.: The Blood Supply of the Large Bowel with Reference to Resection. Surgery, 14:328--342, 1943.
CARCINOMA OF THE LARGE INTESTINE ARTHUR
W. ALLEN, M.D., F.A.C.S. o
THE following case reports are presented to illustrate the usual procedures found to be satisfactory in the management of malignant lesions of the bowel. As will be seen, our experience leads us to believe that resection and primary anastomosis is the method of choice. This is the natural outcome of many years of the practice of this general principle in our clinic. The rare use of the exteriorization or Mikulicz type of operation has given us inadequate knowledge of this method of attack, accounting for the accentuation of the primary anastomosis technic. We do not wish to convey the idea that we feel that exteriorizations, particularly of the obstructive type of resection at one time advocated by Rankin,l are bad practice. We are aware of the fact that in many hands these operations give satisfactory results. There is a growing tendency towards primary suture of the bowel that has come about through the improvements in preparation of the patient, better surgical technic, and chemotherapeutic aids. We have felt that the morbidity could be reduced by primary suture and that the mortality rates could be kept as low as those reported by the advocates of the Mikulicz principle. In our earlier experience, we believed that aseptic anastomosis was important. 2 Now with a better bowel preparation and other measures, we can obtain completely satisfactory primary anastomosis by the so-called open technic. Also, we formerly practiced more frequent proximal decompression often before resection, otherwise as a complementary procedure. Preliminary cecostomy is now done only in the presence of acute and complete obstruction of the left colon and complementary cecostomy is rarely done. The Miller-Abbott tube is used as an added precaution in some cases. Preliminary transverse colostomy is used only in large obstructing inflammatory lesions of the sigmoid. This procedure is mandatory in diverticulitis with inflammatory extension and by this means one can count on the resolution of the acute process even in the presence of frank abscess. Since carcinoma and diverticulitis may occur in the same region, one must consider an earlier resection in some cases. If bleeding and mucous discharge continue from the defunctioned segment, the diagnosis of cancer is established and the obstructive, inflammatory feature must be secondary to the elimination of the malignant
° Chief, East Surgical Service, Massachusetts General Hospital; Lecturer in Surgery, Harvard Medical School, Boston. 1018
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process. If cancer is obvious or strongly suspected, the resection should be undertaken not later than the fourth week after transverse colostomy. If it seems reasonably certain that diverticulitis is the sole causative factor, a better procedure can be accomplished after three to six months of complete decompression. Although such practice requires three operations, the difficulties attending these are far less than can be expected by any other method at our disposal. CASE I. CARCINOMA OF THE CECUM This 56 year old nulliparous woman (M. G. H. No. 507289) was referred from Prince Edward Island with a diagnosis of regional enteritis. Her story was that of right lower quadrant tenderness and soreness of variable intensity
Fig. 322.-Barium studies in Case I reveal a constant filling defect in the region of the ileocecal valve, which appears to extend two-thirds of the way around the lumen of the bowel producing a narrow channel in the region of the lower ascending colon. The mucosa is destroyed in the narrowed area over a distance of approximately 7 cm. over a five to six months interval. She had lost 25 pounds in weight, and there had been a gradual increase in fatigability. She had no obstructive symptoms. Her appetite had remained good and her bowel habits unchanged. She had noted no unusual stools. Her past history was noncontributory except for the fact that she had had an appendectomy thirty years previously. She had worked hard, taking care of ill members of the family. On physical examination, the patient appeared undernourished and had a rather sallow complexion. A right paramedian scar. was present in the lower abdomen and there was definite tenderness lateral to this scar. Under this area a soft mass could be felt which seemed to move with respiration. She had long saphenous varicosities.
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ARTHUR W. ALLEN
The patient remained in the hospital for ten days of study ano preparation for surgery. Her hemoglobin was found to be 11.3 gm. and serum protein 7.3 gm. per 100 cc. X-ray studies following barium enema are shown in Figure 322. She was given 2 gm. of sulfathaladine four times a day beginning on the day following admission and this was continued until the time of operation. In addition, she was given vitamins C and B complex, and ferrous sulfate. She obtained only a fair effect from her sulfathaladine and on two occasions milk of mdgnesia was given. On the day before operation, a Miller-Abbott tube was inserted and this was readily advanced into the small bowel with the aid of 2 cc. of mercury in the balloon.
Operation.-Under spinal anesthesia, a long paramedian incision was made. Adhesions to the old appendix wound were freed. The tumor mass in the cecum was large and bulky but not fixed. There was no free fluid or evidence of extension into the liver or surrounding peritoneum. There were however enlarged lymph nodes running up along the ileocolic and right colic vessels. The lateral peritoneum was freed. The ovarian vessels were not sacrificed. The ureter and duodenum were identified. The right colic and ileocolic vessels were divided at their junction with the superior mesenteric. The transverse colon was divided within the midcolic blood supply area. The ileum was transected 30 cm. proximal to the ileocecal valve in an oblique fashion. End-to-end anastomosis with an outer layer of interrupted No. 30 cotton and inner layer of fine running chromic catgut was accomplished. The edges of the cut mesenteries were approximated by means of a running catgut 'iuture. The wound was closed' with catgut to the peritoneum and interrupted cotton to the fascia; skin and fat closure was delayed forty-eight hours. The anus was carefully dilated to the width of three fingers. The patient received one transfusion before, one during and one fonowing operation. She was given 5 gm. of sulfadiazine intravenously for two days and then 2~ gm. daily for two days. Forty-eight hours postoperatively she received Yo grain of morphine intravenously and her skin sutures were tied. The patient made an entirely uneventful convalescence, her temperature never going above 99.6° F., nor her pulse above 100. She was kept in the hospital twenty-one days because of her general depletion and the fact that she had a long trip home. At the time of discharge, her bowels were moving twice daily. Pathologic Report: Adenocarcinoma, grade II. A segment of colon measur· ing 50 cm. in length with an attached 30 cm. of tenninal ileum. In the cecum is a finn, annular mass measuring 6 cm. in diameter infiltrating the wall and constricting the lumen to a circumference of 2 cm. at the distal end. The margins are raised up to 1 cm. above the surface of the adjacent mucosa and the central portion is occupied by a cavernous irregular ulceration measuring 3.5 cm. in diameter. The overlying mucosa is reddish, injected and ulcerated, and the entire wall is infiltrated measuring up to 3 cm. in thickness. The serosa is puckered and injected and the omentum is firmly adherent in places by fibrous adhesions. The regional lymph nodes are firm and measure up to 1 cm. in diameter. On
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section, they are pinkish gray and granular. The tumor on section is gray, 'coarsely granular with yellowish stippling. The regional lymph nodes show no evidence of metastasIS. Postoperative Course.-The patient has done well and is symptom free one and one-half years after 0l2eration. She has regained her lost weight and her bowels move easily twice daily.
Comment.-This patient illustrates a typical instance of carcinoma of the right colon. The lack of obstructive symptoms associated with a palpable tender mass and anemia is often found. It was brought out in her family history that a sister had been operated upon for extensive tuberculosis of the pelvic organs. The tender right lower quadrant mass with weight loss made it necessary to consider tuberculosis in the differential diagnosis. Regional enteritis was also considered. Both of these were fairly definitely ruled out by the roentgenologic examinations. A chest film revealed no evidence of tuberculosis. There was no narrowing of the terminal ileum and the lesion had the characteristic appearance of carcinoma. At one time we felt that resection of the right colon with priImry anastomosis at one stage carried a greater risk than a two-stage attack. We still do a closed ileotransverse colostomy as a primary stage in cases with obstructing lesions of the right colon or when the patient is a pal'ticularly poor risk. We are, however, better satisfied with the present one-stage procedure. It seems apparent that the use of the long intestinal tubes for forty-eight hours before and after operation is best adapted to the right bowel lesions. Whether one does a lateral anastomosis in these cases rather than an end-to-end suture is a matter of choice. Some men prefer an endto-side hook-up. The important factors are a wide open lumen, no gross contammation, adequate blood supply and no tension on the suture line. With these principles in mind, the results will be satisfactory by any method used. CASE II. CARCINOMA OF THE TRANSVERSE COLON This 76 year old woman (M. C. H. No. 554373) had had constipation relieved by enema~ for many years. Five months previous to admission, she first noted severe, ctampy pains across the midabdomen, coming on in attacks lasting four or five days and then subsiding. Two months before admission she first developed vomiting and her abdominal pains became more severe. There was radiation of pain into. both Banks. For several months previous to admission, she had taken nothing but finely ground food prepared for her by a devoted daughter. She had had acnte glaucoma eight months previously, which necessitated the enucleation of her left eye. Physical examination revealed an edentulous, elderly female. The left eye had been enu~leated and the right eye revealed some evidence of glaucoma; in addition, she wa~ quite deaf. Her abdomen was distended and tympanitic; obstructive peristalsis was evident. Palpation revealed a definite movable mass in the midabdomen just below the level of the navel. Her blood pressure was 200/90, but
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otherwise, her examination was negative. X-ray studies following a barium enema are shown in Fig. 323. Her nonprotein nitrogen was found to be 25 mg., serum protein 5.6 gm. and hemoglobin 12.2 gm. per 100 cc. The electrocardiogram revealed evidence of left ventricular strain, compatible with hypertensive heart disease. She was placed on a low residue diet and given 2 gm. of sulfath!udine four times a day on admission. With the aid of carefully given enemas, it was possible to deflate her abdomen considerably. The sulfathalidine effect was excellent, and after four or five days she was having two stools a day. On the eighth day after admission, a laparotomy was performed under nitrous oxide gas-oxygen-ether anesthesia.
Fig. 323.-Barium studies in Case II, showing a long segment of transverse colon almost completely obstructed. The mucosal pattern is destroyed over a 10 cm. area.
Operation.-The abdomen was opened through a transverse incision across both rectus muscles above the umbilicus. The bowel was found to be well prepared. There was a large annular tumor involving the left transverse colon. There appeared to be no actual extension into the serosa, although the tumor mass was 20 to 25 cm. in diameter. The liver was entirely free of metastases and no gross lymph nodes were palpable in the mesocolon. The mesocolon was mobilized and a 21 cm. segment of the transverse colon resected with its mesentery. An open end-to-end anastomosis, using an outer row of interrupted cotton and an inner row of fine continuous chromic catgut, was accomplished. After changing gloves and instruments, the per-
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itoneum was closed with No. 0 chromic catgut, the fascia with interrupted No. 30 cotton. Sutures of heavy cotton were introduced 1.5 cm. apart through skin fat and fascia to be tied forty-eight hours later. At the conclusion of the operation, bilateral prophylactic superficial femoral vein interruption was done. Finally, the anus was carefully dilated. Pathologic Report: Adenocarcinoma, grade II: The regional lymph nodes were negative. A 21 cm. segment of large bowel including a central stenosing, annular tumor mass occupying 6 em. of the bowel. On section the tumor invades the entire thickness of bowel wall to a depth of 2.2 em. and extends into the adjacent fat. Nine lymph nodes were identified, measuring up to 0.8 cm. in diameter, and none of these contained tumor on microscopic examination. Postoperative Conrse.-The patient did very well, her temperature reaching 99.6° F. on the first and second days postoperatively, and her. pulse never going over 110. She was helped out of bed and aided in walking, increasing distances from the first postoperative day. She was taking an adequate diet on the third day. Her wound healed per primam and her bowels moved daily after the fourth day. She was discharged home in excellent condition on her fifteenth postoperative day.
Comment.-This patient illustrates several interesting features. In the first place, we believe that it is more important to accomplish resections of the transverse colon in one stage than in any other segment of the large intestine. The reason for this is based on the anatomic variations of the blood supply to this region. SingletonS has called our attention to the fact that the anastomosing radical from the left coloc ve~sel to the midcolic artery is missing in certain individuals. In the presence of complete obstruction, a well placed cecostomy will not interfere '\Jrith resection at a later date. Temptation to use preliminary ileotransverse colostomy in lesions of the proximal segment of the transverse colon has led us "into difficulty with the blood supply at the time of resection in one instance. Healing of the turned-in end of the midtransverse colon failed on account of the abnormal blood supply to the region. If such a preliminary procedure is done, the anastomosis should b~ placed well to the left of the midcolon. The prophylactic interruption of the deep veins of the legs is based on the high incidence of phlebothrombosis with fatal pulmonary embolism in aged patients following any operation, injury or illness. This is particularly striking in cases of abdominal malignancy and in those with fractures about the hip. We are convinced of the almost negligible effect on the return How of blood and lymph from the leg after the interruption of the normal femoral veins if the procedure is carried out properly. It seems obvious to us that the long, loose bland thrombus that appears in the deep veins of the legs without demonstrable evidence is more common in patients of the older age group than in others. Sudden death from this cause can be eliminated by
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ARTHUR W. ALLEN
the prophylactic interruption of the veins in cases that are likely to develop this complication. Early walking is practiced in nearly all of our surgical patients. Some of them, for one reason or another, cannot be given this added safeguard to their recovery. Our impression is that a properly placed and sutured wound will allow patients to move about during their early postoperative period to great adv.antage. The chiefest of these is the maintenance of muscular and joint tone. CASE III. CARCINOMA OF THE DESCENDING COLON This 81 year old married man (M. C. H. No. 586814) entered the hospital with the following story. Approximately thirty days before admission, he first noted a dull ache in his left lower quadrant. At this time he found a tender mass
Fig. 824.-Barium studies in Case III. There was a constant area of narrowing at thE! junction of the descending colon and sigmoid, which corresponds to the palpagle abdominal mass. The margins of the defect are sharply defined and sheI£!ike, but the lesions do not appear to be completely annular and there is very little evidence of mucosal destruction. in the left lower quadrant. He was then recovering from a respiratory infection. The pain lasted a day or two and together with the tenderness disappeared. One week before admission, he had a similar episode of pain and tenderness with palpable mass. In this second attack the pain became progressively worse and doubled him up. At this time the tenderness was quite marked and the mass very distinct. During the course of the night, his discomfort gradually passed off without the aid of medication. On occasion while urinating, the discomfort was increased. There were no other urinary symptoms. He had not complained of any change in bowel habits but had lost 5 pounds over the past six months. He had been well in the past save for an appendectomy nineteen years previous to admiSSion.
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The family history is interesting in that both his father and brother had had operations for "tumor of the bowel," two years and seven years previously. He was immediately given sulfathalidine-2 gm. four times a day-and a low roughage diet. Laboratory studies revealed a hemoglobin of 15.5 gm. per 100 cc. Barium enema passed readily to the cecum and entered the terminal ileum. The findings a~ given in Figure 324. After evacuation of the enema, more barium was introduced and the defect was confirmed by a second examination. The remainder of the colon appeared normal. The terminal ileum was not remarkable. The sigmoidoscope was passed well. into the sigmoid (25 cm.) and the mucOSa appeared normal throughout. After seven days of sulfathalidine preparation, operation was undertaken.
Operation.-Under spinal anasthesia, an oblique incision was made in the left lower quadrant. The rectus muscle was retracted mesially and the oblique muscles were split in the direction of their fibers. It was necessary to transect some of the internal oblique muscles' fibers. The liver was palpated and was free of metastatic nodules. The edge of the omentum was adherent to the tumor mass and was freed by resecting a portion of it, leaving the involved margin in contact with the tumor. The tumor itself was adherent to the anterior abdominal wall in the region of the internal inguinal ring. It was found necessary to remove that portion of the peritoneum and, during its removal, it was found that the vas deferens was densely adherent. Accordingly, a 2 cm. segment of the vas with the underlying left spermatic artery and vein was also sacrificed. The bowel with its. supplying mesentery was resected. Nodes were found to run up to the junction of the sigmoid and inferior mesenteric vessels. An open anastomosis was done using interrupted cotton sutures outside and a running fine chromic catgut suture within. The defect in the mesentery was clo~ed. A delayed wound closure technic was used. The anus was carefully dilated to three finger breaths. Pathologic Report: adeilOcarcinoma, grade III, with metastases to six of nine lymph nodes. The highest lymph nodes were found involved. The specimen consisted of a 16 cm. segment of large bowel containing a 3 cm. long, ulcerating tumor in its midportion, with a hemorrhagic, coarsely granular base and rllised indurated edges. It involved half the circumference of the lumen and extended through thtl wall into the serosal fat. Lymph nodes were hard and measured up to 1 cm. in diameter. . Postoperative Course.-This patient was allowed up and about from his first postoperative day. He was given enough water, tea and broth to keep his mouth and esophagus from feeling dry, but fluid balance was maintained by the intravenous route. His prothrombin level was normal and he was not given dicumarol prophylactically as would have been done had he had a low prothrombin time or had been between the ages of 40 and 60. He was given small doses of suIfathalidine daily after operation and until his bowels moved satisfactorily on the fifth postoperative day. The rectum was kept clean by the use of 8 ounces of normal salt solution instilled within it every. eight hours until his bowels moved. He was encouraged to evacuate this solution if and when he felt the urge. His wound healed per primam and he was discharged home on his thirteenth postoperative day.
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Comment.-The family history, the youth of the patient, added to the high degree of malignancy and its extension, make for a bad prognosis. Could a more radical procedure have accomplished any more? There was a wide margin of normal bowel on either side of the tumor. All the mesentery supplying the region was removed. Would • an attempt for a higher nodal dissection have been justifiable? Were there other lymph nodes involved that could have been removed? These questions are difficult to answer. All palpable nodes were included in the resection. This in itself is small proof that the spread of this process was not already out of bounds. It is discouraging to find a lesion giving such a short warning to be so fulminating in its character. CASE IV. CARCINOMA OF THE RECTOSIGMOID This 55 year old woman (M. G. H. No. 533525) had noted episodes of bleeding at stool for nearly one year. At the onset, she had gone to her physician who had done a barium enema which was reported as negative. She was found to have mild hemorrhoids. During the course of a year, she had a sensation of incomplete evacuation after moving her bowels. For the previous month, there had been a dull, aching, low back discomfort. Her bowel habits had never been regular and she had taken cathartics about once a week most of her adult life. There was no real constipation or diarrhea. There had been no vomiting and no abdominal distention. No bleeding in large amounts. She had lost no weight. Her history was otherwise irrelevant, except for the fact that her father died of cancer at the age of 74. The patient herself had cancer phobia. Sigmoidoscopy revealed a small friable, sessile, polypoid-like tumor 12 cm. from the anal ring. Biopsy revealed adenocarcinoma grade II. Her photo hemoglobin was found to be 14.4 gm. per 100 cc. Her nonprotein nitrogen was 22 mg. per 100 cc., serum protein 6.5 gm. Barium enema filled the entire colon and terminal ileum readily. At the rectosigmoid on the right lateral wall, a defect was found which was visualized with some difficulty. There were no other polyps or tnmefactions. Her blood pressure was 198/110. She was given a six day course of sulfathalidine, 2 gm. four times a day. On the day prior to operation, a Miller-Abbott tnbe, using mercury in' the baIloon, was introduced, and on the day of operation it was well down in the small intestine.
Operation.-A left paramedian incision was made. The liver was free of disease. The lesion was found just below the pelvic Hoor and could be felt through the peritoneum of the pouch of Douglas. The sigmoid was free laterally and divided in its lowest segment and the vessels and the lymphatics below the bifurcation of the iliacs were separated. No lymph nodes were palpable. Dissection was carried down to the coccyx. The lateral cardinal ligaments of the rectum were separated and the anterior surface of the rectum separated from the vagina, lengthening the rectum twofold. It was possible to place a clamp well below the lesion itself. An end-to-end open anastomosis was done, using an inner row of fine chromic catgut and an o~ter row of interrupted cotton sutures. The mesial peritoneal reHection was next sutured over the suture line medially and anteriorly, leaving the
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lateral area open to allow escape of retroperitoneal fluid. 100,000 units of penicillin were introduced locally. The wound was closed in layers, the fat and skin closure to be delayed forty-eight hours. The anus was finally dilated. Pathologic Report: Colloid adenocarcinoma, grade II. The lymph nodes were negative but the tumor had extended into a large serosal lymph vessel. Thirtythree centimeters of rectosigmoid had been removed. Two centimeters above the distal resection edge is a raised cauliflower growth measuring 3 cm. in~ diameter. Postoperative Course.-The patient did well postoperatively. On the first and third postoperative days her temperature rose to 100 0 F.; her pulse never exceeded 94. The Miller-Abbott tube was removed on the second postoperative day. She was continued on sulfathalidine postoperatively until the time of discharge on her twentieth day. At the time of discharge, the index finger palpated the anastomosis readily in the midrectum.
Comment.-The criticism that might be raised in this case is the advisability of restoring bowel continuity. The patient was extremely apprehensive and had suffered for years with cancer phobia. She had submitted elsewhere to needless excisions of portions of both breasts for cystic mastitis six years previously. The growth, as seen in the sigmoidoscopy, was small in size and the biopsy report revealed a fairly low grade adenocarcinoma. We have frequently had to take into account the p~ssibility of a more serious grading when the entire specimen was in the pathologist's hands. The colloid element was a surprise but on the other hand, there was no spread to lymph nodes. We are not aware of any cures in our hospital in colloid carcinoma of the colon and rectum no matter how extensive the operative procedure. So far, this patient has not had any local recurrence although only one year has elapsed since operation. The rectum on the stretch was divided well below the tumor; it will be noted however that the pathologist's measurement of the distal margin of normal tissue was only 2 cm. This, in my opinion, is too close for comfort and should local recurrence take place, it will be due to our willingness to abide by the wishes of her family and physician to avoid colostomy. A Miles procedure would have been better. judgment in this case. CASE V.
CARCINOMA OF SIGMOID WITH ENDOMETRIOSIS
This 49 year old bipara (M. G. H. No. 440316) was admitted to the hospital March 27, 1944. She has always been constipated and for years has been troubled with hemorrhoids; otherwise, she has been vigorous, healthy and active. Normal menopause occurred eight months ago. During the autumn of 1943, she was aware of occasional blood and mucus discharges from the rectum-almost always associated with bowel movement but recently this has occurred without stool and often with the passage of gas. Seven weeks prior to entry, she had a bout of severe abdominal cramps attributed to the ingestion of lobster. This cleared up with the· onset of diarrhea. Her physician ordered a barium enema examination on March 10, which showed an obstructing lesion at the lower sigmOid and
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ARTHUR W. ALLEN
much gas and fecal matter above the lesion in spite of a castor oil preparation (Fig. 325). Sigmoidoscopy revealed bloody mucus coming down from an obstructed area 16 cm. from the anal margin. A biopsy was attempted but was unsuccessful. Bimanually, a large mass could be felt in the left pelvic region. It was not possible to outline the uterus separately from the mass as a whole. The cervix was eroded and bulbous. The family history is of interest in that her mother now aged 78 had sigmoid resection for carcinoma three and one-half years previous to the patient's entry. Her father's sister had succumbed to cancer of the rectum.
Fig. 325.-Barium enema in Case V shows an obstructing lesion at the lower sigmoid and much gas and fecal matter above the lesion. Preparation was carried out by giving 3 gm. of sulfathalidine and low irrigations'daily for seven days. The patient was in good general condition, having a red blood count of 4,900,000 and 14.5 gm. of hemoglobin per 100 cc. Large doses of vitamin C were added to a low residue diet. Her generalized distention was considerably improved and she was free of peristaltic pain. It was felt however that her preparation was probably inadequate. We were afraid to give her further cathartics since the pre x-ray castor oil had caused great distress and had little effect on cleansing the colon.
Operation.-The first operation, exploratory laparotomy and complete transverse colostomy, was done April 4, eight days after admission. A short left paramedian incision was made in the lower abdomen. The liver was free of metastasis; the colon proximal to the obstruction was completely filled with semisolid fecal {natter. The growth was slightly above the pelvic Hoor and was attac,hed firmly to the uterus. It was decided that resection at this time would be too hazardous in view of the poor bowel preparation. A transverse incision was therefore made through the upper left rectus and a loop of transverse colon brought out. The lower wound was carefully closed. The patient did
•
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well after this procedure and it was possible to cleanse the lower bowel by irrigations through the distal orifice of the complete transverse colostomy. Irrigations of normal salt solution were supplemented by suspensions of sulfathalidine up to the day previous to the second operation. The second stage was done April 18, fourteen days after the first, and consisted of resection of the sigmoid and panhysterectomy en bloc, followed by primary anastomosis of the descending colon to the rectosigmoid. The exploratory left paramedian wound was opened and extended; the bowel was found to be well prepared. The tumor mass consisted of a firm tennis ball sized tumor in the sigmoid loop firmly attached to a uterus containing fibroids and endometrial implants. The lateral gutter was opened and the left ureter, which was tortuous, was dissected free of adherent tissue believed to be due to the endometriosis and not to the sigmoid carcinoma. The ovarian vessels on the left were divided high and dissection carried down retroperitoneally into the pelvis. The inferior mesenteric vessels were then identified and interrupted just below the branch supplying the lower sigmoid. The bowel at this point was then divided between clamps with the actual cautery. Dissection was continued into the pelvis to well below the tumor in the sigmoid. The right ovarian vessels were then secured and the uterine vessels interrupted at a low level. The upper vagina was then cut across. This allowed the entire tumor mass with uterus, adnexa, and sigmoid to be lifted upward. The bowel was then divided between clamps with the cautery well below the tumor. An accurate end-to-end suture of the bowel ends was then accomplished using two rows of fine chromic catgut. Peritonealization was accomplished leaving most of the suture line of the anastomosis within the peritoneal cavity. A cigarette drain was introduced from above into the vagina; the proximal end of this rested in the denuded retroperitoneal space, great care being used not to allow contact between the drain and the suture line. Pathologic Report: The specimen revealed a 23 em. segment of sigmoid with its attached mesentery, the uterus, tubes and ovaries. In the center of the resected sigmoid was an encircling lesion 5.5 cm. in length with irregular, hard, raised edges. This tumor extended through the bowel wall where a secondary 2 em. nodule was attached to an otherwise normal sigmoid by continuity. The tubes, ovaries and uterus were adherent to the sigmoid-the latter being attached firmly to the tumor site. The uterus contained numerous fibroids and endometrial implants were present on the uterus, tubes, ovaries and sigmoid. The regional lymph nodes revealed no tumor. The lesion in the sigmoid was classified as adenocarcinoma Grade II. Postoperative Course.-The p~tient was given a transfusion to replace blood lost during the operation. Intravenous water, glucose, vitamins and small amounts of sulfadiazine were given over the next three days. Nothing was given by mouth save an ounce of water, tea or broth per hour. The transverse colostomy began to function well by the third postoperative day and then normal feedings were
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ARTHUR W. ALLEN
resumed. The vaginal drain was removed on the third morning. The patient was sufficiently recovered by the eighth day to test the anastomosis with saline irrigations, which demonstrated unsatisfactory lumen. This procedure was repeated every four days thereafter until by the eighteenth day there was a free flow of irrigating fluid in both directions through the distal colon. The patient was then allowed to get up and about to regain some of her lost muscle tone. The thlrd procedure was closure of the transverse colostomy, which was accomplished thirty-nine days after her first operation and twenty-five days after her resection and anastomosis. The scar tissue about the colostomy was excised, saving as much skin as possible. Both ends of the colostomy were freed from the peritoneum and delivered outside the wound. The colon was transected between clamps on both limbs in healthy areas well beyond all scar tissue. A careful end-to-end anastomosis was then made and the bowel dropped free into the peritoneal cavity. The peritoneum and fascia were closed with interrupted No. 30 cotton and the skin sutures tied forty-eight hours later. The patient recovered well from this procedure and was discharged home ten days later on a normal diet. Her bowels were moving satisfactorily with small doses of mineral oil. She has remained well up to the time of this report.
Comment.-In this patient, we used too little sulfathalidine in the preparation; later cases received larger doses with better effect. We have liked this drug better than sulfasuxidine because of its less liquefying action on the fecal matter. We might have been able to reestablish continuity earlier had we used interrupted nonabsorbable sutures in the anastomosis as has been our custom for over two years. We would not institute any drainage in such a case today, having found that the peritoneal cavity takes care of any serous discharge from the denuded areas, if the peritonealization is limited to the mesial side of the dissection, leaving the lateral gutter open. Drains in previous cases either through the ischial fossa, the vagina or the abdominal wall have contributed to complications, such as fistula formation or stenosis at the point of anastomosis. Neither of these has occurred since we abandoned the use of drains. This low anastomosis was possible but the tumor with its complicating factors was too low to allow an adequate dissection of the nodal areas and exteriorization except by end colostomy, either by a Hartmann or a Miles procedure. The morbidity, as evidenced by an unusually long hospitalization, was greater in this instance than in most operations of a similar nature carried out by us. The almost complete obstruction and the patient's temperament, plus the error in using catgut in the anastomosis, all played a role in the prolonged convalescence. The endometriosis in this patient brings to mind the fact that bowel obstruction with eroding firm malignant appearing intraluminal tumefaction can occur from this disease alone. A ·few years ago, we combined a total hysterectomy with a Miles procedure under clinical impression that we were dealing with extensive and very unfavorable cancer of the rectosigmoid. This proved to be entirely endometriosis with no evidence of malignancy.
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REFERENCES 1. Rankin, F. W.: Resection and Obstruction of the Colon (Obstructive Resection). Surg. Gynec. & Obst., 50:594-598 (March) 1930. 2. Allen, A. W.: Carcinoma of the Colon. Surgery, 14:350-366 (Sept.) 1943. 3. Singleton, Albert 0.: The Blood Supply of the Large Bowel with Reference to Resection. Surgery, 14:328--342, 1943.