- Email: [email protected]
Malignant Lesions of the Colon: Preoperative and Postoperative Management with Comment on Prognosis
MALIGNANT LESIONS OF THE COLON Preoperative and Postoperative Management with Comment on Prognosis CLAUDE
F.
DIXON
WHEN the diagnosis of a malignant lesion of the colon has been made, no unnecessary delay should be permitted. A curable malignant lesion may change to an incurable process at some one day, and at some second of some minute of some hour of that day. The patient should be hospitalized during the necessary period of preoperative preparation, which varies from a minimum of four or five days to one or two weeks. PREOPERATIVE PREPARATION
The diet should be high protein, high caloric and as nearly as possible nonresidue during the period of preoperative preparation. Eggs, meat, macaroni, cream of wheat with cream, sweetened fruit juice, gelatin desserts, candy, coffee and tea should make up most of the diet. Whole vegetables and fruit, milk and potatoes should not be included. It is impossible to make a diet literally nonresidue, but the residue should be very low. If the patient is more than 10 per cent below his normal body weight he should be given first for ten to fourteen days a high protein, high carbohydrate, high caloric diet to rehabilitate him. When the patient's weight is 20 to 30 per cent below normal, two to three weeks or more of adequate feeding by oral and parenteral routes may be necessary before the nonresidue diet is given. In the period of preoperative preparation, urinalysis, complete blood count, determination of hemoglobin, blood urea level and blood grouping should be done on every case. If the patient has been in an area where amebiasis is prevalent, warm stools should be examined repeatedly. There is danger of operations on the colon in the presence of amebiasis. If proctosigmoidoscopic examination has not been done, it should be performed and if a roentgenogram of the chest has not been made, it should be made at this time for evidence of metastasis or pulmonary disease. A saline laxative, such as phospho-soda (Fleet's), should be given twice daily in doses of 2 to 4 fluidrams (8 to 16 cc.). The last dose should be given twenty-four hours before operation. If a colonic 1013
1014
CLAUDE F. DIXON
stoma is present, laxatives should be omitted unless the patient is constipated. For three or four days before operation, irrigations should be given twice daily in order to cleanse the colon thoroughly and remove all stool and barium. One or two quarts (lor 2 liters) of warm saline solution should be administered slowly with the patient on his left side or in the knee-chest position. Irrigations should be given carefully, especially if the patient is elderly. In the presence of a perforating lesion they should be given with caution or omitted entirely and the cleansing process left to the laxatives. The patient usually will notice more bleeding than before irrigations or blood in the stool for the first time. This is to be expected and he should be reassured. The last irrigation should be twenty-four hours before the operation. When resection is contemplated, both loops of the colonic stoma, if present, should be irrigated. If the patient is being prepared for closure of the colonic stoma the irrigations should be limited mainly to the distal loop through the anus, and irrigations through the colonic stoma should seldom be employed because they may cause irritation and edema. Poth and othersl, 8 have demonstrated the efficacy of succinylsulfathiazole (sulfasuxidine) and phthalysulfathiazole (sulfathalidine) in greatly decreasing the number of coliform organisms per gram of feces. The operative mortality rate has thus been lowered. Sulfathalidine should be given rather than sulfasuxidine if laxatives and irrigations are used in the preoperative preparation. Three grams of sulfathalidine should be given every four hours for six doses, then 1.5 gm. every four hours until the morning of operation. These doses should be doubled if severe diarrhea is present. Sulfasuxidine is not as effective gram for gram as is sulfathalidine and therefore it must be given in larger doses. It does not work effectively in the presence of diarrhea or when purgatives are used and therefore it may be given when laxatives are not used. Four grams should be given every four hours for the first twenty-four hours; thereafter 3 gm. should be given every four hours until the day of operation. The bacterial count of the contents of the colon is reduced by streptomycin as Ravdin, Zintel and Bender have demonstrated. When 0.25 gm. is given orally every six hours, the bacterial count is markedly reduced for a period of five to seven days only. Afterward, regardless of administration of streptomycin, the coliform organisms become resistant to this antibiotic agent and increase to the original number per gram of wet stool. Streptomycin is many
MALIGNANT LESIONS OF THE COLON
1015
times more efficacious than succinylsulfathiazole in reducing the bacterial flora of the colon. Paregoric is useful in putting the colon at rest the day before operation. At 2, 6 and 10 P. M. the day before operation, 2 fluidrams (8 cc.) should be given. On the morning of the operation the rectum should be aspirated with a rectal tube and a plunger syringe. This is done to remove any liquid or semisolid stool. The evening before, and the morning of, the operation, 1! grains (0.1 gm.) of phenobarbital or its equivalent should be given. Atropine grain (0.00043 gm.) and morphine in a dose of in a dose of ! grain (0.01 gm.) should be given hypodermically thirty minutes before the operation. As the bladder may be involved in the malignant process and vesical function often is impaired after resection of low sigmoidal or rectosigmoidallesions, a retention catheter should be inserted in each patient. A large rectal tube also should be inserted about It inches (4 cm.) and taped in position after the patient has been placed on the operating table. A large, gas-filled segment of the bowel may impede an operation, but with a rectal tube in place, flatus can easily be expressed.
no
MANAGEMENT OF OBSTRUCTION
In the presence of complete obstruction of the bowel it is necessary to determine whether the obstruction is of the "closed loop" variety with distention limited to the colon or if the small bowel also is distended. Roentgenograms of the abdomen should be made with the patient in the anteroposterior and postero-anterior positions, a Bucky diaphragm being used. It is well to give a plain enema before roentgenograms are taken, so that air below the le3ion can be expelled and the position of the osbtructing lesion can be more accurately determined. The ileocecal valve often is patent and the distention in the small bowel may be marked. Under such circumstances the valvulae conniventes of the mucosa of the small bowel and sometimes the "stepladder" effect produced by the layering of gas and fluid in the small intestine can be seen in the roentgenogram. A double-lumen tube should be inserted into the small bowel and advanced as quickly as possible when the roentgenogram shows evidence of distention of the small intestine. Fluids and electrolytes should be administered parenterally and the blood chloride and carbon dioxide co mbining power should be carefully observed. If the
1016
CLAUDE F. DIXON
lesion is in the left portion of the colon, enemas with the patient in the knee-chest position also should be given. Usually with these two methods of decompression the condition of the patient improves and the risk of surgical intervention lessens. Often the patient can take a nonresidue liquid diet after decompression and can be given sulfathalidine for three or four days in preparation for operation. Primary anastomosis usually should not be attempted, however, as the wall of the bowel, especially proximal to the lesion, is often edematous and friable. When, on the other hand, the ileocecal valve is closed and the distention is limited to the portion of the colon above the lesion, an attempt to relieve the obstruction by use of a double-lumen or MillerAbbott tube is a waste of time. When the lesion is in the descending colon, sigmoid or rectosigmoid, enemas with the patient in the kneechest position fairly often will permit the passage of flatus, as some of these lesions intussuscept and the inverted position plus the weight of the water will partially relieve the intussusception. Proctosigmoidoscopy should be carefully performed. This makes it possible to determine the condition of the rectum and sigmoid and help in determining the nature and extent of the lesion. Attempts to pass a catheter through the lesion almost always are unsuccessful and certainly are not without danger. Colostomy should be done if enemas do not relieve a close-loop obstruction. Usually the simplest procedure to relieve the obstruction completely is the best. In cases of obstruction low in the colon, transverse colostomy almost always fulfills this requirement, and also results in a colonic stoma which will not be in the field of a later resection. When the lesion is in the rectum or rectosigmoid and a combined abdominoperineal resection will be necessary subsequently, the first stage of a Lahey type of resection occasionally can be done. In this the distal barrel of sigmoid is brought out at the lower end of a low midline incision and the proximal barrel is brought out through a stab wound in the left lower quadrant of the abdominal wall. Although this procedure eliminates the necessity of closing a transverse colonic stoma, it is technically more difficult and necessitates the handling of more tissue. For relief of obstruction in the left portion of the colon, cecostomy or appendicostomy is unsatisfactory and furthermore, neither diverts the cecal stream. Only when the lesion is in the hepatic flexure or ascending colon with only the rare complete "closed-loop" obstruction of the right portion of the colon may cecostomy be necessary. Even then when a closed-loop obstruction is present and there is a
MALIGNANT LESIONS OF THE COLON
1017
malignant lesion in the hepatic flexure, the procedure of choice may be ileo-transverse colostomy short-circuiting the lesion. MANAGEMENT IN THE PRESENCE OF METASTASIS
The lesion is not necessarily inoperable even when there is a metastatic iesion in the liver. If the hepatic involvement is massive, the process should best be considered inoperable, even though obstruction is present. The patient then must depend on a low residue diet or nonresidue diet for relief. If the involvement of the liver is minimal, it is best to resect the primary lesion. Death from intestinal obstruction is painful, while death from hepatic involvement usually is not. Colocolostomy with a side-to-side anastomosis will sidetrack the fecal stream and prevent death by obstruction when the hepatic involvement is considerable and the lumen is constricted. The decision whether or not palliative colostomy should be performed depends on the degree of obstruction and the extent of metastasis. Unless the colostomy prevents obstruction or perforation, the patient probably will not live longer because colostomy is performed. POSTOPERATIVE TREATMENT
Most patients should receive during the operation for removal of a malignant lesion of the colon, a transfusion of 500 cc. of whole blood. Then 2,000 or 3,000 cc. of 5 per cent solution of glucose in distilled water is given slowly by the intravenous route. The danger of overadministration of solution of sodium chloride now is generally recognized. One liter of isotonic solution of sodium chloride daily may be necessary if the patient has an intranasal tube for decompression of the intestine. If a primary anastomosis has been made, oxygen may be given by mask for the first two or three days. In every case 5 per cent carbon dioxide should be inhaled for two or three minutes every hour for the first twenty-four hours. The patient should be made to cough forcibly after these inhalations in order to dislodge inspissated mucus from the bronchial tree. All patients should be encouraged and helped to move in bed the first two or three postoperative days. Early ambulation can be utilized to advantage in many cases. For the first day or two after operation, nothing is given by mouth. Mter that, t fluidounce (15 cc.) of water is given every hour for six hours; then 1 fluidounce (30 cc.) followed by 2 fluidounces (60 cc.) for a similar period, can be given. A nonresidue liquid diet then can be given for two or three days, followed by nonresidue solids for three
1018
CLAUDE F. DIXON
or four days. A low residue diet can be given nine or ten days after operation in most cases. Fluids should be given parenterally as long as is necessary to insure a daily output of urine of 1,200 to 1,500 cc. In selected cases tidal drainage for the bladder to obviate frequent catheterization may well be advantageous. At the time of operation 5 to 10 grams of sulfanilamide may be sprinkled in the abdominal cavity. Sulfadiazine should be given parenterally after operation if a perforating or abscessed lesion has been removed or if there has been gross contamination. As soon after operation as the patient can take it and retain it, sulfathalidine or sulfasuxidine may be given. Two grams of sulfathalidine five times a day will keep the stool soft, for the drug is mildly laxative. It is especially useful as it will maintain the decrease of coliform bacteria in the stool in case of a leak at the line of anastomosis. If colostomy has been performed it will help prevent infection in the abdominal incision. MANAGEMENT OF A PERMANENT COLONIC STOMA
The possibility of a permanent colonic stoma should be discussed before operation with any patient who has carcinoma of the lower part of the sigmoid or the rectosigmoid. Due largely to the lack of knowledge of the proper management of a colonic stoma, and to the use of the odorous, unsanitary colostomy bag, the idea of a colonic stoma. is repulsive to many patients. As it has been said, the chief and most vociferous objectors to colonic stomas are those who do not have them and do not need them to remain alive. To allay the patient's fears of being a social outcast, he should be told that no one need know of his condition unless he tells them. He should be told also that he will in no way be incapacitated by a colonic stoma and should be able to do anything that he previously did. He will be inconvenienced, but the inconvenience usually is minimal. He also should be told that usually he will not need, and should not wear, a bag or mechanical receptacle. The best device is to use a simple, inexpensive two-way-stretch girdle for women, or a similar elastic belt or athletic belt for men. A small gauze dressing covered with an 8 or 10 inch (20 or 25 cm.) square of plastic film or similar plastic curtain material is worn under the belt. The plastic film can be washed many times and does not retain an odor. When the dressing is soiled, the belt or girdle is simply stretched down and a clean piece of gauze, which can be carried in a pocket, is applied. A deodorant powder such as is used on sanitary napkins can be sprinkled on the gauze or an enteric-coated capsule
MALIGNANT LESIONS OF THE COLON
1019
that is effective as a deodorant can be taken by mouth. 2 At night a cloth binder can be substituted for the elastic belt. Two or three thicknesses of an old sheet sewed together and stitched from side to side to give a slight stiffness will provide several good binders. A zipper or buttons can be placed at one side. With time and tra'ning, the bowel moves once or twice a day. An enema every morning or every other morning may be necessary for a few persons whose stools are loose, in order to empty the colon and prevent constant ooze. For the occasional patient who has constipation an enema, rather than a cathartic, is better. COMMENT ON PROGNOSIS
The past two decad(;)s have witnessed great advances in the prognosis for patients with carcinoma of the colon from the standpoint of mortality, morbidity and five-year survival. Although some advance has been made for the cause of earlier diagnosis of malignant lesions of the colon through cancer detection centers, repeated pleas at medical meetings and writings in both the lay and professional press, the percentage of early cancers diagnosed still is too low. The simple diagnostic methods should be familiar to all. They are not new. All of the responsibility for this failure of early diagnosis does not belong to the medical profession. The patient must initiate the process. King and Leach, of Memorial Hospital, New York, found the greatest tendency toward delay among the following groups of patients: (1) patients whose established reaction to previous illness had been to seek medical advice only when having an acute discomfort or pain; (2) those who interpreted their illness as being a common illness or a recurrence of some previous illness; (3) patients whose chief attitudes toward medical care were fear of the examination, fear of knowledge, or fear of surgical intervention or of disfigurement, and (4) patients who believed that their financial resources were inadequate to permit payment for medical care. To remedy these conditions a long, painstaking educational process will be needed. All are agreed that time remains the greatest single factor that influences the final result in the individual case of malignant disea:e: the time between initiat'on and discove:-y of the malignant process, and the time between discovery and adequate removal of the lesion. Visceral cancer is a silent disease. The time necessary for the transformation of normal epithelial cells from' a normal mucous membrane into malignant cells is not known. The length of time before invasive features cause the appearance of symptoms is variable, perhaps averaging about a year. At sometime in this period, cancer
1020
CLAUDE F. DIXON
of the colon is curable. If digital and endoscopic examinations are performed as a routine on every patient, a larger number of persons will come to operation when the lesions are silent and curable by surgical means. Seventy-five per cent of lesions of the colon and rectum are within reach of the sigmoidoscope and the finger. Certain prognostic factors are peculiar to the patient. From neither the social, economic nor medical point of view is obesity advantageous. Not only does carcinoma tend to spread faster if the patient is obese but the presence of infection, even in a mild degree, makes the risk materially greater. If 2 patients of equal age have the same pathologic process and otherwise equal chances, the obese patient has a poorer outlook than the thin patient from the standpoint of ultimate cure and for surviving the operation. The prognosis for patients in the younger age groups is poorer than it is for members of the older age groups, regardless of the- grade of the lesion. Then too, in the young the grade of the malignant lesion tends to be higher and metastasis occurs earlier. Eleven and fivetenths per cent of the malignant lesions of the large intestine seen at the Mayo Clinic between 1907 and 19383 were in patients who were less than 40 years of age. Many physicians, however, are still not on the alert for colonic malignant lesions in patients under 40 years of age. The prognosis is influenced too by associated colonic disease. Multiple carcinomas will develop in 100 per cent of neglected cases of polyposis of familial origin while the patient is still young. With another disease of younger persons, chronic ulcerative colitis, carcinoma develops more often than for the population as a whole. Here also the outlook is poor. The number of multiple asynchronous primary carcinomas of the colon indicates that a thorough exploration must be made at each laparotomy. Concurrent degenerative diseases of cardiovascular and cardiorenal origin are of prognostic value when considering survival rates and operative procedures for older patients. The site of malignant lesion is an important prognostic factor. The prognosis usually is better for right-sided colonic malignant lesions than for left-sided lesions, both in cases with and in those without nodal involvement. The five-year survival rates in both groups show an average difference of about 10 per cent in favor of lesions in the right side of the colon. True cecal lesions have a poorer prognosis than those occurring in the ascending segment of the colon. Tumors of the descending colon and sigmoid have a great tendency to produce obstruction, owing mainly to the smaller calibers of the lumina as compared with the
.. MALIG~A~'l
LESIONS OF THE
COLO~
1021
caliber of the right colon. The poorer prognosis of obstructing lesions than of other lesions is well known. The prognosis for five-year survival is poorer for patients who have lesions of the lower two thirds of the rectum than for those who have lesions in the upper third of the rectum and lower part of the sigmoid. Lateral lymphatic spread and local extension to the bladder, prostate or vagina make it especially difficult to eradicate surgically the disease in the lower third of the rectum. For this reason I have advocated and practiced radical posterior resection in the Kraske position following previous abdominal exploration and performance of a colostomy. With this operation a hysterectomy or prostatectomy can be done if necessary. Advances in the preoperative and postoperative care of patients have demonstrated how important these clinical factors are to the prognosis. The successful decompression of mechanical obstruction of the bowel by nasal catheter suction-siphonage by Wangensteen in 1931, has been a great advance in the preoperative and postoperative care of patients. The better understanding and appreciation of the physiology and biochemistry of the body fluid compartments, along with the rational replacement and control of the body electrolytes, have favorably influenced prognosis. The summation of all factors determined preoperatively and at the time of operation, by both the surgeon and the surgical pathologist, influences the surgeon's judgment as to what technic he shall employ and the extent of the resection indicated in the individual case. The size of the tumor exerts little influence on the ultimate outcome. Of more importance in the eventual outcome is the degree of extension and penetration. The mortality rate in cases in which the lesion has invaded other sites is at least double that for cases in which the lesions are confined to their primary site. The development of multiple-stage procedures for surgery of the colon was the result of necessity to overcome the practically prohibitive mortality rate associated with colonic surgery. With the discovery and use of antibacterial agents the necessity for multiple-stage procedures became less. One-stage operations for lesions of the colon have perhaps made more radical extirpation possible and with a reduction in mortality rate. A place for multiple-stage procedures in my opinion still is advisable under certain conditions. The experience and ability of the surgeon as factors which influence the prognosis are often lost sight of when the ultimate outcome of surgical procedures for malignant lesions of the colon is considered. On the nati"e skill, judgment and experience of the surgeon the operability or in operability of the lesion will finally rest. The wider the experience of the surgeon the higher will be the operability rate.
1022
CLAUDE F. DIXON
With improvements in preoperative and postoperative care of patients, the better understanding of the modes of spread of carcinoma and the more thorough training of young surgeons, the indications for radical surgical intervention have broadened and the development, revision and reintroduction of surgical technic which, it is hoped, will improve even more the prognosis for patients will cancer of the colon. have been possible. At the end of each day in this country, 480 Americans are dead of cancer. One American dies of cancer every three minutes. All of us were profoundly shocked when 2,000 marines were killed in a single battle in the Pacific during the recent war, but more than 2,000 Americans will die of cancer within the next five days. During the recent war, 300,000 Americans were listed as dead or missing, but during the same period we lost twice that number of Americans as a result of cancer. When-and we all hope that it will be very soon-we shall be able to calculate that we have saved the lives of one person every three minutes, and when we can be assured that at the end of each day 480 persons are alive who would not have been alive at the end of a day, a year, two years or ten years ago, then we shall have earned the right to proclaim that the wisdom of man has triumphed over one of his most malignant enemies. REFERENCES 1. Allen, A. W.: Symposium on Surgical Management of Malignancy of Colon; Carcinoma of Colon. Surgery. 14:350-365 (Sept.) 1943. 2. Carroll, W. C.: Deodorant for Colostomies. Minnesota Med. 26:709--710 (Aug.) 1943. 3. Dixon, C. F. and Clark, R. L., Jr.: Cancer of the Colon and Rectum with Particular Reference to Results of Surgical Treatment. Proceedings of the Thirty-fourth Annual Clinical Congress of the American College of Surgeons, 1948, pp. 29--33. 4. King, Reva A. and Leach, J. E.: Factors Contributing to Delay by Patients in Seeking Medical Care. Cancer. 3: 571-579 (July) 1950. 5. Poth, E. J.: Succinylsulfathiazole and Phthalylsulfathiazole in Surgery of the Colon. Surgery. 17:773-780 (June) 1945. 6. Ravdin, 1. S., Zintel, H. A. and Bender, Doris H.: Adjuvants to Surgical Therapy in Large Bowel Malignancy. Ann. Surg. 126:439-447 (Oct.) 1947. 7. Wangensteen, O. H.: The Early Diagnosis of Acute Intestinal Obstruction with Comments on Pathology and Treatment, With a Report of Successful Decompression of Three Cases of Mechanical Bowel Obstruction by Nasal Catheter Suction Siphonage. West. J. Surg. 40:1-17 (Jan.) 1932. 8. Zintel, Harold, Lockwood, J. S. and Snyder, Joseph: Bacteriological Considerations in Sulfonamide Prophylaxis Against Peritonitis. Bull. Am. Coll. Surgeons. 28:51 (Feb.) 1943.
F.
DIXON
WHEN the diagnosis of a malignant lesion of the colon has been made, no unnecessary delay should be permitted. A curable malignant lesion may change to an incurable process at some one day, and at some second of some minute of some hour of that day. The patient should be hospitalized during the necessary period of preoperative preparation, which varies from a minimum of four or five days to one or two weeks. PREOPERATIVE PREPARATION
The diet should be high protein, high caloric and as nearly as possible nonresidue during the period of preoperative preparation. Eggs, meat, macaroni, cream of wheat with cream, sweetened fruit juice, gelatin desserts, candy, coffee and tea should make up most of the diet. Whole vegetables and fruit, milk and potatoes should not be included. It is impossible to make a diet literally nonresidue, but the residue should be very low. If the patient is more than 10 per cent below his normal body weight he should be given first for ten to fourteen days a high protein, high carbohydrate, high caloric diet to rehabilitate him. When the patient's weight is 20 to 30 per cent below normal, two to three weeks or more of adequate feeding by oral and parenteral routes may be necessary before the nonresidue diet is given. In the period of preoperative preparation, urinalysis, complete blood count, determination of hemoglobin, blood urea level and blood grouping should be done on every case. If the patient has been in an area where amebiasis is prevalent, warm stools should be examined repeatedly. There is danger of operations on the colon in the presence of amebiasis. If proctosigmoidoscopic examination has not been done, it should be performed and if a roentgenogram of the chest has not been made, it should be made at this time for evidence of metastasis or pulmonary disease. A saline laxative, such as phospho-soda (Fleet's), should be given twice daily in doses of 2 to 4 fluidrams (8 to 16 cc.). The last dose should be given twenty-four hours before operation. If a colonic 1013
1014
CLAUDE F. DIXON
stoma is present, laxatives should be omitted unless the patient is constipated. For three or four days before operation, irrigations should be given twice daily in order to cleanse the colon thoroughly and remove all stool and barium. One or two quarts (lor 2 liters) of warm saline solution should be administered slowly with the patient on his left side or in the knee-chest position. Irrigations should be given carefully, especially if the patient is elderly. In the presence of a perforating lesion they should be given with caution or omitted entirely and the cleansing process left to the laxatives. The patient usually will notice more bleeding than before irrigations or blood in the stool for the first time. This is to be expected and he should be reassured. The last irrigation should be twenty-four hours before the operation. When resection is contemplated, both loops of the colonic stoma, if present, should be irrigated. If the patient is being prepared for closure of the colonic stoma the irrigations should be limited mainly to the distal loop through the anus, and irrigations through the colonic stoma should seldom be employed because they may cause irritation and edema. Poth and othersl, 8 have demonstrated the efficacy of succinylsulfathiazole (sulfasuxidine) and phthalysulfathiazole (sulfathalidine) in greatly decreasing the number of coliform organisms per gram of feces. The operative mortality rate has thus been lowered. Sulfathalidine should be given rather than sulfasuxidine if laxatives and irrigations are used in the preoperative preparation. Three grams of sulfathalidine should be given every four hours for six doses, then 1.5 gm. every four hours until the morning of operation. These doses should be doubled if severe diarrhea is present. Sulfasuxidine is not as effective gram for gram as is sulfathalidine and therefore it must be given in larger doses. It does not work effectively in the presence of diarrhea or when purgatives are used and therefore it may be given when laxatives are not used. Four grams should be given every four hours for the first twenty-four hours; thereafter 3 gm. should be given every four hours until the day of operation. The bacterial count of the contents of the colon is reduced by streptomycin as Ravdin, Zintel and Bender have demonstrated. When 0.25 gm. is given orally every six hours, the bacterial count is markedly reduced for a period of five to seven days only. Afterward, regardless of administration of streptomycin, the coliform organisms become resistant to this antibiotic agent and increase to the original number per gram of wet stool. Streptomycin is many
MALIGNANT LESIONS OF THE COLON
1015
times more efficacious than succinylsulfathiazole in reducing the bacterial flora of the colon. Paregoric is useful in putting the colon at rest the day before operation. At 2, 6 and 10 P. M. the day before operation, 2 fluidrams (8 cc.) should be given. On the morning of the operation the rectum should be aspirated with a rectal tube and a plunger syringe. This is done to remove any liquid or semisolid stool. The evening before, and the morning of, the operation, 1! grains (0.1 gm.) of phenobarbital or its equivalent should be given. Atropine grain (0.00043 gm.) and morphine in a dose of in a dose of ! grain (0.01 gm.) should be given hypodermically thirty minutes before the operation. As the bladder may be involved in the malignant process and vesical function often is impaired after resection of low sigmoidal or rectosigmoidallesions, a retention catheter should be inserted in each patient. A large rectal tube also should be inserted about It inches (4 cm.) and taped in position after the patient has been placed on the operating table. A large, gas-filled segment of the bowel may impede an operation, but with a rectal tube in place, flatus can easily be expressed.
no
MANAGEMENT OF OBSTRUCTION
In the presence of complete obstruction of the bowel it is necessary to determine whether the obstruction is of the "closed loop" variety with distention limited to the colon or if the small bowel also is distended. Roentgenograms of the abdomen should be made with the patient in the anteroposterior and postero-anterior positions, a Bucky diaphragm being used. It is well to give a plain enema before roentgenograms are taken, so that air below the le3ion can be expelled and the position of the osbtructing lesion can be more accurately determined. The ileocecal valve often is patent and the distention in the small bowel may be marked. Under such circumstances the valvulae conniventes of the mucosa of the small bowel and sometimes the "stepladder" effect produced by the layering of gas and fluid in the small intestine can be seen in the roentgenogram. A double-lumen tube should be inserted into the small bowel and advanced as quickly as possible when the roentgenogram shows evidence of distention of the small intestine. Fluids and electrolytes should be administered parenterally and the blood chloride and carbon dioxide co mbining power should be carefully observed. If the
1016
CLAUDE F. DIXON
lesion is in the left portion of the colon, enemas with the patient in the knee-chest position also should be given. Usually with these two methods of decompression the condition of the patient improves and the risk of surgical intervention lessens. Often the patient can take a nonresidue liquid diet after decompression and can be given sulfathalidine for three or four days in preparation for operation. Primary anastomosis usually should not be attempted, however, as the wall of the bowel, especially proximal to the lesion, is often edematous and friable. When, on the other hand, the ileocecal valve is closed and the distention is limited to the portion of the colon above the lesion, an attempt to relieve the obstruction by use of a double-lumen or MillerAbbott tube is a waste of time. When the lesion is in the descending colon, sigmoid or rectosigmoid, enemas with the patient in the kneechest position fairly often will permit the passage of flatus, as some of these lesions intussuscept and the inverted position plus the weight of the water will partially relieve the intussusception. Proctosigmoidoscopy should be carefully performed. This makes it possible to determine the condition of the rectum and sigmoid and help in determining the nature and extent of the lesion. Attempts to pass a catheter through the lesion almost always are unsuccessful and certainly are not without danger. Colostomy should be done if enemas do not relieve a close-loop obstruction. Usually the simplest procedure to relieve the obstruction completely is the best. In cases of obstruction low in the colon, transverse colostomy almost always fulfills this requirement, and also results in a colonic stoma which will not be in the field of a later resection. When the lesion is in the rectum or rectosigmoid and a combined abdominoperineal resection will be necessary subsequently, the first stage of a Lahey type of resection occasionally can be done. In this the distal barrel of sigmoid is brought out at the lower end of a low midline incision and the proximal barrel is brought out through a stab wound in the left lower quadrant of the abdominal wall. Although this procedure eliminates the necessity of closing a transverse colonic stoma, it is technically more difficult and necessitates the handling of more tissue. For relief of obstruction in the left portion of the colon, cecostomy or appendicostomy is unsatisfactory and furthermore, neither diverts the cecal stream. Only when the lesion is in the hepatic flexure or ascending colon with only the rare complete "closed-loop" obstruction of the right portion of the colon may cecostomy be necessary. Even then when a closed-loop obstruction is present and there is a
MALIGNANT LESIONS OF THE COLON
1017
malignant lesion in the hepatic flexure, the procedure of choice may be ileo-transverse colostomy short-circuiting the lesion. MANAGEMENT IN THE PRESENCE OF METASTASIS
The lesion is not necessarily inoperable even when there is a metastatic iesion in the liver. If the hepatic involvement is massive, the process should best be considered inoperable, even though obstruction is present. The patient then must depend on a low residue diet or nonresidue diet for relief. If the involvement of the liver is minimal, it is best to resect the primary lesion. Death from intestinal obstruction is painful, while death from hepatic involvement usually is not. Colocolostomy with a side-to-side anastomosis will sidetrack the fecal stream and prevent death by obstruction when the hepatic involvement is considerable and the lumen is constricted. The decision whether or not palliative colostomy should be performed depends on the degree of obstruction and the extent of metastasis. Unless the colostomy prevents obstruction or perforation, the patient probably will not live longer because colostomy is performed. POSTOPERATIVE TREATMENT
Most patients should receive during the operation for removal of a malignant lesion of the colon, a transfusion of 500 cc. of whole blood. Then 2,000 or 3,000 cc. of 5 per cent solution of glucose in distilled water is given slowly by the intravenous route. The danger of overadministration of solution of sodium chloride now is generally recognized. One liter of isotonic solution of sodium chloride daily may be necessary if the patient has an intranasal tube for decompression of the intestine. If a primary anastomosis has been made, oxygen may be given by mask for the first two or three days. In every case 5 per cent carbon dioxide should be inhaled for two or three minutes every hour for the first twenty-four hours. The patient should be made to cough forcibly after these inhalations in order to dislodge inspissated mucus from the bronchial tree. All patients should be encouraged and helped to move in bed the first two or three postoperative days. Early ambulation can be utilized to advantage in many cases. For the first day or two after operation, nothing is given by mouth. Mter that, t fluidounce (15 cc.) of water is given every hour for six hours; then 1 fluidounce (30 cc.) followed by 2 fluidounces (60 cc.) for a similar period, can be given. A nonresidue liquid diet then can be given for two or three days, followed by nonresidue solids for three
1018
CLAUDE F. DIXON
or four days. A low residue diet can be given nine or ten days after operation in most cases. Fluids should be given parenterally as long as is necessary to insure a daily output of urine of 1,200 to 1,500 cc. In selected cases tidal drainage for the bladder to obviate frequent catheterization may well be advantageous. At the time of operation 5 to 10 grams of sulfanilamide may be sprinkled in the abdominal cavity. Sulfadiazine should be given parenterally after operation if a perforating or abscessed lesion has been removed or if there has been gross contamination. As soon after operation as the patient can take it and retain it, sulfathalidine or sulfasuxidine may be given. Two grams of sulfathalidine five times a day will keep the stool soft, for the drug is mildly laxative. It is especially useful as it will maintain the decrease of coliform bacteria in the stool in case of a leak at the line of anastomosis. If colostomy has been performed it will help prevent infection in the abdominal incision. MANAGEMENT OF A PERMANENT COLONIC STOMA
The possibility of a permanent colonic stoma should be discussed before operation with any patient who has carcinoma of the lower part of the sigmoid or the rectosigmoid. Due largely to the lack of knowledge of the proper management of a colonic stoma, and to the use of the odorous, unsanitary colostomy bag, the idea of a colonic stoma. is repulsive to many patients. As it has been said, the chief and most vociferous objectors to colonic stomas are those who do not have them and do not need them to remain alive. To allay the patient's fears of being a social outcast, he should be told that no one need know of his condition unless he tells them. He should be told also that he will in no way be incapacitated by a colonic stoma and should be able to do anything that he previously did. He will be inconvenienced, but the inconvenience usually is minimal. He also should be told that usually he will not need, and should not wear, a bag or mechanical receptacle. The best device is to use a simple, inexpensive two-way-stretch girdle for women, or a similar elastic belt or athletic belt for men. A small gauze dressing covered with an 8 or 10 inch (20 or 25 cm.) square of plastic film or similar plastic curtain material is worn under the belt. The plastic film can be washed many times and does not retain an odor. When the dressing is soiled, the belt or girdle is simply stretched down and a clean piece of gauze, which can be carried in a pocket, is applied. A deodorant powder such as is used on sanitary napkins can be sprinkled on the gauze or an enteric-coated capsule
MALIGNANT LESIONS OF THE COLON
1019
that is effective as a deodorant can be taken by mouth. 2 At night a cloth binder can be substituted for the elastic belt. Two or three thicknesses of an old sheet sewed together and stitched from side to side to give a slight stiffness will provide several good binders. A zipper or buttons can be placed at one side. With time and tra'ning, the bowel moves once or twice a day. An enema every morning or every other morning may be necessary for a few persons whose stools are loose, in order to empty the colon and prevent constant ooze. For the occasional patient who has constipation an enema, rather than a cathartic, is better. COMMENT ON PROGNOSIS
The past two decad(;)s have witnessed great advances in the prognosis for patients with carcinoma of the colon from the standpoint of mortality, morbidity and five-year survival. Although some advance has been made for the cause of earlier diagnosis of malignant lesions of the colon through cancer detection centers, repeated pleas at medical meetings and writings in both the lay and professional press, the percentage of early cancers diagnosed still is too low. The simple diagnostic methods should be familiar to all. They are not new. All of the responsibility for this failure of early diagnosis does not belong to the medical profession. The patient must initiate the process. King and Leach, of Memorial Hospital, New York, found the greatest tendency toward delay among the following groups of patients: (1) patients whose established reaction to previous illness had been to seek medical advice only when having an acute discomfort or pain; (2) those who interpreted their illness as being a common illness or a recurrence of some previous illness; (3) patients whose chief attitudes toward medical care were fear of the examination, fear of knowledge, or fear of surgical intervention or of disfigurement, and (4) patients who believed that their financial resources were inadequate to permit payment for medical care. To remedy these conditions a long, painstaking educational process will be needed. All are agreed that time remains the greatest single factor that influences the final result in the individual case of malignant disea:e: the time between initiat'on and discove:-y of the malignant process, and the time between discovery and adequate removal of the lesion. Visceral cancer is a silent disease. The time necessary for the transformation of normal epithelial cells from' a normal mucous membrane into malignant cells is not known. The length of time before invasive features cause the appearance of symptoms is variable, perhaps averaging about a year. At sometime in this period, cancer
1020
CLAUDE F. DIXON
of the colon is curable. If digital and endoscopic examinations are performed as a routine on every patient, a larger number of persons will come to operation when the lesions are silent and curable by surgical means. Seventy-five per cent of lesions of the colon and rectum are within reach of the sigmoidoscope and the finger. Certain prognostic factors are peculiar to the patient. From neither the social, economic nor medical point of view is obesity advantageous. Not only does carcinoma tend to spread faster if the patient is obese but the presence of infection, even in a mild degree, makes the risk materially greater. If 2 patients of equal age have the same pathologic process and otherwise equal chances, the obese patient has a poorer outlook than the thin patient from the standpoint of ultimate cure and for surviving the operation. The prognosis for patients in the younger age groups is poorer than it is for members of the older age groups, regardless of the- grade of the lesion. Then too, in the young the grade of the malignant lesion tends to be higher and metastasis occurs earlier. Eleven and fivetenths per cent of the malignant lesions of the large intestine seen at the Mayo Clinic between 1907 and 19383 were in patients who were less than 40 years of age. Many physicians, however, are still not on the alert for colonic malignant lesions in patients under 40 years of age. The prognosis is influenced too by associated colonic disease. Multiple carcinomas will develop in 100 per cent of neglected cases of polyposis of familial origin while the patient is still young. With another disease of younger persons, chronic ulcerative colitis, carcinoma develops more often than for the population as a whole. Here also the outlook is poor. The number of multiple asynchronous primary carcinomas of the colon indicates that a thorough exploration must be made at each laparotomy. Concurrent degenerative diseases of cardiovascular and cardiorenal origin are of prognostic value when considering survival rates and operative procedures for older patients. The site of malignant lesion is an important prognostic factor. The prognosis usually is better for right-sided colonic malignant lesions than for left-sided lesions, both in cases with and in those without nodal involvement. The five-year survival rates in both groups show an average difference of about 10 per cent in favor of lesions in the right side of the colon. True cecal lesions have a poorer prognosis than those occurring in the ascending segment of the colon. Tumors of the descending colon and sigmoid have a great tendency to produce obstruction, owing mainly to the smaller calibers of the lumina as compared with the
.. MALIG~A~'l
LESIONS OF THE
COLO~
1021
caliber of the right colon. The poorer prognosis of obstructing lesions than of other lesions is well known. The prognosis for five-year survival is poorer for patients who have lesions of the lower two thirds of the rectum than for those who have lesions in the upper third of the rectum and lower part of the sigmoid. Lateral lymphatic spread and local extension to the bladder, prostate or vagina make it especially difficult to eradicate surgically the disease in the lower third of the rectum. For this reason I have advocated and practiced radical posterior resection in the Kraske position following previous abdominal exploration and performance of a colostomy. With this operation a hysterectomy or prostatectomy can be done if necessary. Advances in the preoperative and postoperative care of patients have demonstrated how important these clinical factors are to the prognosis. The successful decompression of mechanical obstruction of the bowel by nasal catheter suction-siphonage by Wangensteen in 1931, has been a great advance in the preoperative and postoperative care of patients. The better understanding and appreciation of the physiology and biochemistry of the body fluid compartments, along with the rational replacement and control of the body electrolytes, have favorably influenced prognosis. The summation of all factors determined preoperatively and at the time of operation, by both the surgeon and the surgical pathologist, influences the surgeon's judgment as to what technic he shall employ and the extent of the resection indicated in the individual case. The size of the tumor exerts little influence on the ultimate outcome. Of more importance in the eventual outcome is the degree of extension and penetration. The mortality rate in cases in which the lesion has invaded other sites is at least double that for cases in which the lesions are confined to their primary site. The development of multiple-stage procedures for surgery of the colon was the result of necessity to overcome the practically prohibitive mortality rate associated with colonic surgery. With the discovery and use of antibacterial agents the necessity for multiple-stage procedures became less. One-stage operations for lesions of the colon have perhaps made more radical extirpation possible and with a reduction in mortality rate. A place for multiple-stage procedures in my opinion still is advisable under certain conditions. The experience and ability of the surgeon as factors which influence the prognosis are often lost sight of when the ultimate outcome of surgical procedures for malignant lesions of the colon is considered. On the nati"e skill, judgment and experience of the surgeon the operability or in operability of the lesion will finally rest. The wider the experience of the surgeon the higher will be the operability rate.
1022
CLAUDE F. DIXON
With improvements in preoperative and postoperative care of patients, the better understanding of the modes of spread of carcinoma and the more thorough training of young surgeons, the indications for radical surgical intervention have broadened and the development, revision and reintroduction of surgical technic which, it is hoped, will improve even more the prognosis for patients will cancer of the colon. have been possible. At the end of each day in this country, 480 Americans are dead of cancer. One American dies of cancer every three minutes. All of us were profoundly shocked when 2,000 marines were killed in a single battle in the Pacific during the recent war, but more than 2,000 Americans will die of cancer within the next five days. During the recent war, 300,000 Americans were listed as dead or missing, but during the same period we lost twice that number of Americans as a result of cancer. When-and we all hope that it will be very soon-we shall be able to calculate that we have saved the lives of one person every three minutes, and when we can be assured that at the end of each day 480 persons are alive who would not have been alive at the end of a day, a year, two years or ten years ago, then we shall have earned the right to proclaim that the wisdom of man has triumphed over one of his most malignant enemies. REFERENCES 1. Allen, A. W.: Symposium on Surgical Management of Malignancy of Colon; Carcinoma of Colon. Surgery. 14:350-365 (Sept.) 1943. 2. Carroll, W. C.: Deodorant for Colostomies. Minnesota Med. 26:709--710 (Aug.) 1943. 3. Dixon, C. F. and Clark, R. L., Jr.: Cancer of the Colon and Rectum with Particular Reference to Results of Surgical Treatment. Proceedings of the Thirty-fourth Annual Clinical Congress of the American College of Surgeons, 1948, pp. 29--33. 4. King, Reva A. and Leach, J. E.: Factors Contributing to Delay by Patients in Seeking Medical Care. Cancer. 3: 571-579 (July) 1950. 5. Poth, E. J.: Succinylsulfathiazole and Phthalylsulfathiazole in Surgery of the Colon. Surgery. 17:773-780 (June) 1945. 6. Ravdin, 1. S., Zintel, H. A. and Bender, Doris H.: Adjuvants to Surgical Therapy in Large Bowel Malignancy. Ann. Surg. 126:439-447 (Oct.) 1947. 7. Wangensteen, O. H.: The Early Diagnosis of Acute Intestinal Obstruction with Comments on Pathology and Treatment, With a Report of Successful Decompression of Three Cases of Mechanical Bowel Obstruction by Nasal Catheter Suction Siphonage. West. J. Surg. 40:1-17 (Jan.) 1932. 8. Zintel, Harold, Lockwood, J. S. and Snyder, Joseph: Bacteriological Considerations in Sulfonamide Prophylaxis Against Peritonitis. Bull. Am. Coll. Surgeons. 28:51 (Feb.) 1943.