[The single-stage surgery of perforated colon carcinoma. Our experience of 46 cases].

Background: 46 cases of perforated colonic neoplasm (4.6% of the entire series): 11 (24%) of the right colon, 35 (76%) of the left colon; 19 males (41%) and 27 females (59%); mean age 67 years old, range 32-92 years. pTNM: stage II, 1 case (2%); stage III: 27 cases (59%); stage IV, 18 cases (39%). The aim of this study was to resolve the perforation and to treat the neoplasm in a single operation.

Methods: The various types of perforation included: 35/46 = 76% perforations in situ; 6/47 = 13% recent perforations upstream; and 5/46 = 11% at a distance from the neoplasia. The following types of peritonitis were observed: purulent localised 10/46 = 22%, purulent generalised 12/46 = 26%, fecaloid 18/46 = 39%, fecal 6/46 = 13%. In 24 cases/46 = 52% the perforation had occurred in an occluded colon. The preoperative finding of pneumoperitoneum in 12/46 = 26% indicated generalised fecaloid-fecal peritonitis. Surgery commenced by suturing the perforation followed wherever possible by standard colectomy: on the right in all 11 cases = 100%, on the left in 15/35 = 43%; only in the event of prohibitive local or in particular general conditions was Hartmann's segmentary colectomy used in 10 cases/35 = 29%, or a definitive preternatural anus in 10/35 = 29%. The following aspects are essential in this single-stage surgery: the emergency nature of the operation; massive dose antibiotic treatment limited to the pre- and perioperative stages and above all peritoneal cleansing using accurate, methodical, repeated and abundant lavage with 8-10-20 or more litres of polysaline isotonic solution at 37 degrees C, but only used 500 ml at a time. This lavage is essential to reduce bacterial load contributes to the rapid hydroelectrolytic re-equilibrium in severe conditions of peritonitis. When necessary, colonic preparation was carried out using direct colostomic perioperative lavage. The peritonisation of the retroperitoneum with the omentum is important, as is the protection of the anastomosis using omental wrapping and active lavage and aspiration of the colorectal anastomosis, even using the 3-way tube, in a transanal trans- or subanastomotic position. Total parenteral feeding is useful and almost indispensable for 6-8 days.

Results: Postoperative morbidity was negligible and mortality occurred in 14/46 cases = 30%, of whom 13/32 = 41% were over 60 and 1/14 = 7% under 60; if the cases are divided into two periods, pre-Gullino tube (1974-84) mortality was 8/22 = 36% and with Gullino's tube (1985-95) it was 6/24 = 25%; postoperative stay was 18 days in the first period and only 11 days in the second. The 11 cases at stage IV who survived the operation all died following the spread of neoplasms within 2-30 months, mean 10 months; the over-5-year survival rate for the only case at stage II and the 19 at stage III was 38% (Kaplan-Meier).

Conclusions: By using this courageous single-stage surgery and operating patients at such a severe stage, both the immediate and long-term results appear to be more than satisfactory. It is important to underline, however, that not all neoplastic perforations appeared to be caused by endoluminal hypertension-ischemia; in those cases with non-occluded colon, about half might have been the consequence of biological problems of immune hyperreactivity of a rejection reaction type (Arthus, Snarelli-Shwartzman phenomenon and similar).