Int J Colorectal Dis (2015) 30:275–276 DOI 10.1007/s00384-014-1970-3
LETTER TO THE EDITOR
Left colon cancer presenting as fecopneumothorax: a case report and review of literature Malek Tabbara & Marco Nencioni & Sergio Carandina
Accepted: 16 July 2014 / Published online: 26 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor:
Background Atraumatic colopleural fistula (CPF) is an unusual complication of intra-abdominal disease with only very few cases reported in the literature so far. Diverticulitis, inflammatory bowel disease, and advanced colon cancer as presented in our case have been incriminated as the underlying abdominal disease leading to this life-threatening complication [1–4]. Fecopneumothorax occurring as a result of the CPF complicating a colon cancer is extremely rare, and very few reports exist in the literature [4]. We present herein a case of an 80year-old male with fecopneumothorax as a result of CPF complicating a splenic flexure colon cancer.
Case presentation This is an 80-year-old male who presented to our emergency department with altered mental status. The patient had been complaining of abdominal pain for the last 7 days. The pain was mostly localized at the epigastrium and the left upper quadrant (LUQ) and worsened progressively; it was accompanied by fever, shortness of breath, and generalized fatigue. The patient also complained of anorexia since 5 days and obstipation since 3 days. He noted that he had unintentionally lost 10 kg in the last 2 months. On his initial physical exam, he was found to be febrile (T=38 °C) with a pulse of 70 bpm, M. Tabbara (*) : M. Nencioni : S. Carandina Department of Digestive and Metabolic Surgery, Jean Verdier Hospital, Paris XIII University—University Hospitals of Paris Seine Saint-Denis, Ave du 14 Juillet, 93140 Bondy, France e-mail: [email protected]
blood pressure of 110/60, and SatO2 of 92 %. Lung auscultation revealed markedly decreased breath sounds on the left lower lung field, and his abdominal exam was pertinent for moderate tenderness on palpation of his LUQ and left costovertebral angle. Laboratory test showed anemia (hemoglobin 10.7 g/dL), elevated white blood cell (WBC) count (13,400/ mm3), an increased CRP of 380, and mild hypoxia Spo2 90 %. Initial chest radiograph was done and showed abundant left pleural effusion, collapsed left lung. A CT scan of the chest, abdomen, and pelvis was then performed and revealed an abundant left pleural effusion and near-complete collapse of the left lung with mild pneumothorax with evidence of CPF. An abscedated left colonic flexure mass and thickened left colonic wall were also identified on the abdominal scan. The patient was taken emergently to the operating room. Under general anesthesia, a thoracostomy tube was inserted in the left fifth intercostal space. This drained 1,200 ml of feculent fluid. A midline laparotomy was then performed and revealed an extensive left colonic flexure mass (~10 cm) that had invaded the diaphragm, the greater curvature of the stomach, and the tail of the pancreas. The mass was also in close contact with the left lobe of the liver, left Gerota’s fascia, and the spleen. The colonic mass was dissected off of its adhesions and mobilized allowing access to the diaphragm, stomach, and pancreas. The diaphragm was extensively invaded (~50 %), and thus, we were unable to remove the entire tumor seeding on it. The greater curvature of the stomach, where the tumor had invaded, was resected using two 80-mm GIA stapler reloads. The pancreatic tail was resected using one 80-mm GIA stapler reload. The stapler lines were reinforced using a running 3.0 Prolene sutures. We then proceeded by mobilizing the left colon and sigmoid colon, and an oncologic left colectomy with lymphadenectomy was performed. Irrigation with 2 L of normal saline was done, hemostasis was obtained, drains were positioned in the chest and abdomen, and abdomen was closed. A left transverse colostomy was then created.
276
The patient tolerated the procedure without any complications and was transferred to the intensive care unit. His postoperative course was complicated by high-grade fever starting on POD 10. A left sub-diaphragmatic collection and left inflammatory pleural thickening were diagnosed on CT scan. The patient underwent a video-assisted thoracoscopic lavage and pleurodesis. The patient had an uneventful hospital stay after his second procedure and was discharged home on POD 30. Final pathology report confirmed the diagnosis: welldifferentiated adenocarcinoma of the left colonic flexure invading the colon wall and gastric fundus sub-serosa. Resection margins for the colon and the gastric fundus were negative for tumor cells, and none of the excised lymph nodes were found metastatic (0/17). His TNM stage was pT4bN0Mx. A multidisciplinary meeting including surgeons and oncologist decided that the patient would benefit from adjuvant chemotherapy and radiotherapy, and he was scheduled to undergo his therapy.
Discussion Atraumatic CPF is a rare complication of advanced colon cancer, and only little about its diagnosis and management is reported in the literature. Due to its complexity, CPF almost always presents a diagnostic challenge. Delay in diagnosis and management can lead to increased morbidity and mortality [1, 4]. Thus, a high index of suspicion is essential to the diagnosis of CPF [1]. Typically, patients are admitted mainly for respiratory symptoms ranging from mild dyspnea due to small pleural effusion, to respiratory arrest due to tension pneumothorax [2, 4]; clinical findings in the abdomen can be nonspecific and often normal [4]. Our patient presented in an advanced stage of his disease and yet he only had mild dyspnea and mild to moderate abdominal pain, which point again to the fact that CPF does not correlate always with the severity of the patient’s symptoms. Therefore, accurate diagnosis can be difficult and challenging despite a careful evaluation of the findings from clinical examination, and thus, further clinical hints and radiologic workup remain a must for final diagnosis [1–4]. An unexplainable pleural effusion with combined abdominal pain and dyspnea along with a
Int J Colorectal Dis (2015) 30:275–276
feculent discharge from a thoracostomy tube inserted to drain the pleural effusion or presence of colonic flora in the pleural fluid should always raise the suspicion of CPF [1]. Chest and abdominal x-rays along with contrast enema are essential for early and prompt diagnosis leading to appropriate management. An abdominal and thoracic CT scan or MRI could provide additional information about the stage of the disease and can exclude the presence of abscess or fluid collection in abdominal cavity. In our case, the patient chest x-ray showed a left pleural effusion and a collapsed left lung; however, it was the chest and abdominal CT scan which showed the abscedated mass and the CPF that made the diagnosis. The diagnosis was confirmed upon the insertion of the thoracostomy tube that drained abundant feculent fluid. The management of CPF can be complex and must include a multidisciplinary surgical and medical team, namely general surgery, thoracic surgery, and intensive care team, and later on, oncology should join forces to save such complicated patients. Surgical management is essential when there is associated complex pleural pathology, with or without colonic pathology such as distal obstruction, ischemic bowel necrosis, malignancy, or a complex network of established true fistulas [1]. CPF presenting in the same context of our patient is a surgical emergency. Any delay in diagnosis can render the management more difficult, escalate hospitalization cost, and increase morbidity and mortality risks [1–4].
References 1. Papagiannopoulos K, Gialvalis D, Dodo I, Darby MJ (2004) Empyema resulting from a true colopleural fistula complicating a perforated sigmoid diverticulum. Ann Thorac Surg 77(1):324–326 2. Sran H, Shaikh I, Coxon J, Wegstapel H (2011) Tension faecopneumothorax: a rare presentation of colonic diverticular perforation. J Surg Case Rep. doi:10.1093/jscr/2011.5.5 3. Barisiae G, Krivokapiae Z, Adziae T, Pavloviae A, Popoviae M, Gojniae M (2006) Fecopneumothorax and colopleural fistula—uncommon complications of Crohn’s disease. BMC Gastroenterol. doi:10. 1186/1471-230X-6-17 4. Heppner HJ, Wagner JT, Sieber CC (2009) Clinical challenges and images in GI fecopneumothorax caused by a malignant colopleural fistula. Gastroenterology 136(1):50–367
LETTER TO THE EDITOR
Left colon cancer presenting as fecopneumothorax: a case report and review of literature Malek Tabbara & Marco Nencioni & Sergio Carandina
Accepted: 16 July 2014 / Published online: 26 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor:
Background Atraumatic colopleural fistula (CPF) is an unusual complication of intra-abdominal disease with only very few cases reported in the literature so far. Diverticulitis, inflammatory bowel disease, and advanced colon cancer as presented in our case have been incriminated as the underlying abdominal disease leading to this life-threatening complication [1–4]. Fecopneumothorax occurring as a result of the CPF complicating a colon cancer is extremely rare, and very few reports exist in the literature [4]. We present herein a case of an 80year-old male with fecopneumothorax as a result of CPF complicating a splenic flexure colon cancer.
Case presentation This is an 80-year-old male who presented to our emergency department with altered mental status. The patient had been complaining of abdominal pain for the last 7 days. The pain was mostly localized at the epigastrium and the left upper quadrant (LUQ) and worsened progressively; it was accompanied by fever, shortness of breath, and generalized fatigue. The patient also complained of anorexia since 5 days and obstipation since 3 days. He noted that he had unintentionally lost 10 kg in the last 2 months. On his initial physical exam, he was found to be febrile (T=38 °C) with a pulse of 70 bpm, M. Tabbara (*) : M. Nencioni : S. Carandina Department of Digestive and Metabolic Surgery, Jean Verdier Hospital, Paris XIII University—University Hospitals of Paris Seine Saint-Denis, Ave du 14 Juillet, 93140 Bondy, France e-mail: [email protected]
blood pressure of 110/60, and SatO2 of 92 %. Lung auscultation revealed markedly decreased breath sounds on the left lower lung field, and his abdominal exam was pertinent for moderate tenderness on palpation of his LUQ and left costovertebral angle. Laboratory test showed anemia (hemoglobin 10.7 g/dL), elevated white blood cell (WBC) count (13,400/ mm3), an increased CRP of 380, and mild hypoxia Spo2 90 %. Initial chest radiograph was done and showed abundant left pleural effusion, collapsed left lung. A CT scan of the chest, abdomen, and pelvis was then performed and revealed an abundant left pleural effusion and near-complete collapse of the left lung with mild pneumothorax with evidence of CPF. An abscedated left colonic flexure mass and thickened left colonic wall were also identified on the abdominal scan. The patient was taken emergently to the operating room. Under general anesthesia, a thoracostomy tube was inserted in the left fifth intercostal space. This drained 1,200 ml of feculent fluid. A midline laparotomy was then performed and revealed an extensive left colonic flexure mass (~10 cm) that had invaded the diaphragm, the greater curvature of the stomach, and the tail of the pancreas. The mass was also in close contact with the left lobe of the liver, left Gerota’s fascia, and the spleen. The colonic mass was dissected off of its adhesions and mobilized allowing access to the diaphragm, stomach, and pancreas. The diaphragm was extensively invaded (~50 %), and thus, we were unable to remove the entire tumor seeding on it. The greater curvature of the stomach, where the tumor had invaded, was resected using two 80-mm GIA stapler reloads. The pancreatic tail was resected using one 80-mm GIA stapler reload. The stapler lines were reinforced using a running 3.0 Prolene sutures. We then proceeded by mobilizing the left colon and sigmoid colon, and an oncologic left colectomy with lymphadenectomy was performed. Irrigation with 2 L of normal saline was done, hemostasis was obtained, drains were positioned in the chest and abdomen, and abdomen was closed. A left transverse colostomy was then created.
276
The patient tolerated the procedure without any complications and was transferred to the intensive care unit. His postoperative course was complicated by high-grade fever starting on POD 10. A left sub-diaphragmatic collection and left inflammatory pleural thickening were diagnosed on CT scan. The patient underwent a video-assisted thoracoscopic lavage and pleurodesis. The patient had an uneventful hospital stay after his second procedure and was discharged home on POD 30. Final pathology report confirmed the diagnosis: welldifferentiated adenocarcinoma of the left colonic flexure invading the colon wall and gastric fundus sub-serosa. Resection margins for the colon and the gastric fundus were negative for tumor cells, and none of the excised lymph nodes were found metastatic (0/17). His TNM stage was pT4bN0Mx. A multidisciplinary meeting including surgeons and oncologist decided that the patient would benefit from adjuvant chemotherapy and radiotherapy, and he was scheduled to undergo his therapy.
Discussion Atraumatic CPF is a rare complication of advanced colon cancer, and only little about its diagnosis and management is reported in the literature. Due to its complexity, CPF almost always presents a diagnostic challenge. Delay in diagnosis and management can lead to increased morbidity and mortality [1, 4]. Thus, a high index of suspicion is essential to the diagnosis of CPF [1]. Typically, patients are admitted mainly for respiratory symptoms ranging from mild dyspnea due to small pleural effusion, to respiratory arrest due to tension pneumothorax [2, 4]; clinical findings in the abdomen can be nonspecific and often normal [4]. Our patient presented in an advanced stage of his disease and yet he only had mild dyspnea and mild to moderate abdominal pain, which point again to the fact that CPF does not correlate always with the severity of the patient’s symptoms. Therefore, accurate diagnosis can be difficult and challenging despite a careful evaluation of the findings from clinical examination, and thus, further clinical hints and radiologic workup remain a must for final diagnosis [1–4]. An unexplainable pleural effusion with combined abdominal pain and dyspnea along with a
Int J Colorectal Dis (2015) 30:275–276
feculent discharge from a thoracostomy tube inserted to drain the pleural effusion or presence of colonic flora in the pleural fluid should always raise the suspicion of CPF [1]. Chest and abdominal x-rays along with contrast enema are essential for early and prompt diagnosis leading to appropriate management. An abdominal and thoracic CT scan or MRI could provide additional information about the stage of the disease and can exclude the presence of abscess or fluid collection in abdominal cavity. In our case, the patient chest x-ray showed a left pleural effusion and a collapsed left lung; however, it was the chest and abdominal CT scan which showed the abscedated mass and the CPF that made the diagnosis. The diagnosis was confirmed upon the insertion of the thoracostomy tube that drained abundant feculent fluid. The management of CPF can be complex and must include a multidisciplinary surgical and medical team, namely general surgery, thoracic surgery, and intensive care team, and later on, oncology should join forces to save such complicated patients. Surgical management is essential when there is associated complex pleural pathology, with or without colonic pathology such as distal obstruction, ischemic bowel necrosis, malignancy, or a complex network of established true fistulas [1]. CPF presenting in the same context of our patient is a surgical emergency. Any delay in diagnosis can render the management more difficult, escalate hospitalization cost, and increase morbidity and mortality risks [1–4].
References 1. Papagiannopoulos K, Gialvalis D, Dodo I, Darby MJ (2004) Empyema resulting from a true colopleural fistula complicating a perforated sigmoid diverticulum. Ann Thorac Surg 77(1):324–326 2. Sran H, Shaikh I, Coxon J, Wegstapel H (2011) Tension faecopneumothorax: a rare presentation of colonic diverticular perforation. J Surg Case Rep. doi:10.1093/jscr/2011.5.5 3. Barisiae G, Krivokapiae Z, Adziae T, Pavloviae A, Popoviae M, Gojniae M (2006) Fecopneumothorax and colopleural fistula—uncommon complications of Crohn’s disease. BMC Gastroenterol. doi:10. 1186/1471-230X-6-17 4. Heppner HJ, Wagner JT, Sieber CC (2009) Clinical challenges and images in GI fecopneumothorax caused by a malignant colopleural fistula. Gastroenterology 136(1):50–367
