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Description : colon cancer clinical case study

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Published on : Feb 11, 2021 | Views : 1028 | Downloads : 0

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By: HENRY CHIAGOZIEM IREMEKA Clinical case presentation
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PATIENT GENERAL INFORMATION NAME: MR ADN AGE: 72 years old GENDER: Male EDUCATION: Higher education OCCUPATION: Pensioner SOCIOECONOMIC STATUS: Middle class HOME ADDRESS: Abuja, Nigeria. DATE OF ADMISSION: 23-07-2019
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CHIEF COMPLAINTS Pain in the epigastrium, hypochondrium and left flank; Left, painful, inguinal pseudo tumoral mass, bulky, reducible; Weight loss about 8 kg in 7 months; Alternating constipation - diarrhea; Loss of appetite; General condition alterted;
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History of the present illness Onset about 7 months ago - intestinal transit disorder : alternation of constipation-diarrhea; 5 months ago - admitted for diarrhea and dehydration diagnosed as acute enterocolitis; recommendation : colonoscopy; 1 month ago : epigastric pain, hypochondrium and left flank, colitis-like, moderate intensity, associated with loss of appetite, marked decline of the intestinal transit and alteration of general condition; Weight loss
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2005 2008 LEFT INGUINAL HERNIA OPERATED WAS DIAGNOSIS OF DIABETES MELLITUS AND HYPERLIPIDEMIA PROSTATE ADENOMA 5 LOCATION: Abuja, Nigeria ALLERGIES: No Known food Allergy GENDER: Female AGE: 65 Past MEDICAL and surgical HISTORY 2014 APPENDECTOMY 1990
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Family history MOTHER: Gastric cancer, died at the age of 70 years old. Brother: Gastric ulcer, drug abuser OTHER FAMILY MEMBER: Not significant CHRONIC MEDICATION Chronic treatment with detralex and pentoxifylline
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HABBITS TOBACCO SMOKING: Yes (2packs per day) but stopped at the age of 55(10years ago) ALCOHOL CONUSUMPTION: Yes, 2 glasses of Red label per day Denies any intake of Narcotics Denies any diet or Drug allergies No history of blood transfusion OTHER INFORMATION Good living conditions Married 2 children (25 and 37 years old)
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Physical examination Hydrostatic varices lower limbs; Abdomen mobile with respiratory movements, pain spontaneously and on palpation in epigastrium, hypochondrium and left flank, without signs of peritoneal irritation; Left inguinal pseudo tumoral mass, voluminous (10/8 cm) underlying the postoperative scar, painful, reducible with impulse and expansion at the coughing effort; Rectal examination : normal, enlarged prostate, globular, median lobe hypotrophy, expanding transversally, 6cm diameter, smooth surface, well delimited.
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Provisional diagnosis The anamnesis and the objective examination orientate towards: Most likely gastrointestinal tract disorder related to the colorectal segment Secondary diagnosis Recurrent left inguinal hernia; Prostate adenoma; Chronic venous insufficiency lower limbs class II (hydrostatic varices)
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Paraclinical tests on admission : Laboratory tests: normal values; Chest x-ray : normal; Plain abdominal x-ray : marked presence of air in the colon; Abdominal ultrasound : liver - normal size, homogeneous structure, prostate with a diameter of 49 mm, diffuse non-homogeneous with adenoma of 28 mm; without free intraperitoneal fluid;
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Paraclinical tests Colonoscopy: Normal rectum; Diverticular orifices on sigmoid and descending colon, polyp of about 2- mm sessile, at 35 cm from anal sphincter, Vegetant, circumferential tumour with tight lumen stenosis on the descending colon - multiple biopsies were taken; Abdomanial-pelvic CT scan with contrast : sigmoid colon with thickened wall with presence of a vegetatnt tumor mass with circumferential development, with lumen thickening;
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COLONOSCOPY
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Clinical diagnosis DESCENDING COLON, ULCERO-VEGETANT STENOSING MASS T3NxMo COLON DIVERTICULOSIS. LEFT RECURRENT INGUINAL HERNIA PROSTATE ADENOMA CHRONIC VENOUS INSUFFICIENTY OF THE LOWER LIMBS
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ADDITIONAL PARACLINICAL TESTS : Tumour markers : CEA CEA does not have organ or disease sensitivity and specificity. A normal value does not exclude colorectal cancer, and moderately increased values can be found in a large number of benign or malignant conditions, but an increased value is suggestive of colorectal cancer. CEA values greater than 5 ng / ml are associated with an unfavourable cancer prognosis. CEA dosage is done as a post-operative follow-up measure to patients who had elevated levels of preoperative antigen and underwent radical surgery.
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Differential diagnosis of the main diagnosis General impact of the disease (weakening, asthenia, appetite loss):malignant hemopathy, psychogenic cachexia, tuberculosis, systemic disease; Pain: biliary disorder, gastric, pancreatic disorders; Tumour mass: neoplasm of any abdominal organ: spleen, kidney, small intestine, pancreas, abdominal aortic aneurysm, retroperitoneal or bone tumors;
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Hospital course and management Patient was admitted Medical: patient’s associated diseases stabilization Surgical: Absolute indication Scheduled, elective Intervention; Adjuvant: chemotherapy; DIETARY MODIFICATIONS Cessation of smoking No alcohol No NSAIDs
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Preoperative preparation Anaesthetic risk class II ASA; General : organic disorders resolution, correction of hydro-mineral imbalance. It is also important to know the patient's blood type and equip the operating room with at least two units of blood compatible with the patient’s; Deep vein thrombosis and pulmonary embolism prevention Local specific preparation : follows the quantitative diminution of the intestinal content (mechanical preparation) and decrease of colonic septicity by reducing the number and virulence of germs (antimicrobial preparation).
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Preoperative pain management A well-performed pain management plays a key role in reducing postoperative complications. Epidural anaesthesia helps reducing pain but also facilitates to resume intestinal transit in a shorter time, after the suppression of the sympathetic nerves. Alternative: Fast recovery protocol: FAST –TRACK SURGERY
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PROCEDURE Left hemicolectomy / segmental descendant-sigmoid colectomy Inguinal hernia repair - Lawson-Tait procedure
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General anesthesia with oro tracheal intubation; Operation organization : Patient in supine position; Main operator : on the side / contralateral side according to the preference; Nasogastric tube + urinary catheter; Hypothermia prevention; Elastic lower limbs contention;
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Major intervention surgical kit +/- Stapler Operating technique : The final strategy will be decided intraoperatively after the local, regional and general lesion exploration of the peritoneal cavity;
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Left hemicolectomy Supraumbilical incision with the possibility of extension in cranial or caudal direction; Exploration of the peritoneal cavity: identification of the tumoral lesion, synchronous lesions, locoregional extension, secondary determinations; Primary vascular approach: ligation and sectioning of the lower mesenteric vein and left colic artery, sigmoid branches; Tumour isolation between ligations;
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Detachment and mobilization of the descending colon; Sectioning of the left gastro-colic ligament and mobilization of the transverse colon; Section of the gastro-splenic ligament; Setting the resection limits; Section of the transversal colon with the attached omentum, section of the sigmoid segment Restoration of intestinal continuity; Closure of peritoneum and drainage;
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Technical variants intestinal continuity restoring : Mechanical Manual: separate/continuous suture; Anastomosis Termino-Terminal / Termino-Lateral / Latero-Terminal / Latero-Lateral Laparoscopic colectomy;
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INTRAOPERATIVE INCIDENTS AND ACCIDENTS: Lesions of adjacent organs or anatomical structures: ureter, spleen, small intestine, duodenum, genital vessels; Contamination of the peritoneal cavity with faeces - it requires abundant washing of the cavity with physiological serum and bactericidal substances to avoid the formation of faecaloid peritonitis;
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POST-OP COMPLICATIONS : GENERAL: - immediate: - lungs : atelectasis, aspiration pneumonia, pulmonary embolism; Cardiovascular : arrhythmias, myocardial ischemia, myocardial infarction; Late: local recurrence or metastasis; LOCAL: - anastomotic dehiscence; hemoperitoneum; Lower gastrointestinal bleeding; Intestinal transit disorder (postoperative ileus) Operation wound suppuration
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Postoperative course : Vital functions monitoring; Monitoring of fluid intake and elimination, as well as electrolyte balance; Effective pain management with intravenous analgesics Post-op antibiotic treatment for 5-7 days; Early mobilization of the patient to prevent thromboembolic incidents;
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Postoperative course : Daily check-up of abdomen, wounds and drainage tube; Bladder catheter care; Ensure an adequate caloric intake; After intestinal transit resuming (day 3-4 post-op), it is necessary to start oral nutrition meanwhile parenteral solution administration must be reduced.
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Discharge: The average duration of hospitalization after a Colo-rectal resection is 5-7 days, but the complications may prolong the hospital stay; Recommendations: Suture removal after 10 days; Anatomopathological report after 21 days; Oncological consult in order to establish the subsequent therapeutic plan; Avoid major exertion for 6 months; Check-up 30 days after surgery;
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Clinical, biological, imaging reassessment at 6 months in the first 2 years, subsequently annually up to 5 years;
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Case highlights: Diagnosis delay (patient did not cooperate); Symptomatic hernia;
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