Introduction
A 43-year-old man was urgently admitted to the hospital.
Complaints
The patient complained of moderate pain in the right side, fever, and dry mouth.
While taking non-steroidal anti-inflammatory drugs, the pain slightly decreased.
History
The patient had previously experienced abdominal pain and was diagnosed with a functional gastrointestinal disorder. He had been hospitalized from September 25 to 29, 2023, during which the painful symptoms decreased.
Two days after discharge, the pain returned. On October 13, fever and dry mouth developed. The patient sought medical help again and underwent a CT scan, which revealed a formation in the ascending colon and an infiltrate in the right iliac region with signs of abscess formation. He was urgently referred to the hospital, where he was admitted to the emergency surgery department.
Overall, the man grew and developed according to his age.
Examination
Upon examination, the tongue was clean and moist. The abdomen was of normal shape, symmetrical, not distended, and participated in breathing. Palpation revealed softness with tenderness in the middle part on the right side. There were no signs of peritonitis. The intestines contracted evenly.
The liver was not enlarged, and the spleen was not palpable. Percussion of the lower back was painless on both sides.
An ultrasound on October 16 showed a fluid formation measuring 4.4 × 4.2 × 3.7 cm (30–40 ml) with unclear contours. It was located in the projection of the appendix up to a depth of 2.6 cm.
On the same day, the abscess was drained, yielding about 30 ml of creamy pus. After the procedure, the patient received infusion and antibiotic therapy, with regular flushing of the abscess cavity. When the man improved, he underwent a follow-up CT scan of the abdominal organs with fistulography, which indicated that the drainage from the previously drained focus had likely migrated.
A CT scan of the abdominal organs on October 19 also revealed:
- Signs of an undrained periappendicular abscess (in the appendix area);
- Accumulation of gas in the right retroperitoneal space;
- Picture of a tumor process in the ascending colon;
- Minimal fluid accumulation in the abdominal and pelvic cavities;
- Mesadenitis (inflammation and suppuration of lymph nodes in the mesentery surrounding the small intestine).
Colonoscopy revealed a cluster of various elements in the ascending colon. Biopsy showed a protruding polyp resembling a column in the hepatic flexure of the colon (70 × 15 mm) and a villous polyp in the descending colon (50 × 17 mm).
Diagnosis
Primary multiple synchronous cancer: - Stenosing cancer (adenocarcinoma) of the ascending colon stage III with metastases to two lymph nodes (no metastases in organs – T3N1bM0), paracancerous (developed with cancer) abscess of the retroperitoneal space;
- Malignant mesothelioma of the peritoneum of the pelvis.
Polyps of the hepatic flexure of the colon and descending colon.
Treatment
After drainage and temporary improvement, the patient’s condition deteriorated again, and the temperature rose to 39°C. Taking this into account, the decision was made to urgently perform diagnostic laparoscopy.
The surgery was performed on October 21. During the procedure, a tumor with a paracancerous abscess was found in the ascending colon. The neoplasm was immediately removed along with the right half of the colon and lymph nodes. The ends of the intestine were connected “side-to-side,” part of the affected peritoneum of the pelvis was removed, the retroperitoneal abscess was opened, cleaned, and drained.
The operation lasted just over 3 hours, with a blood loss of 100 ml.
Histological examination on October 22 confirmed the growth of adenocarcinoma with invasion through the entire intestinal wall. Metastases were found in two out of 13 lymph nodes. The peritoneum of the pelvis showed signs of malignant mesothelioma (a rare form of cancer).
The postoperative period went smoothly. The wounds healed by primary intention. The patient was discharged on the 13th day after the operation.
This stage of the tumor process warrants adjuvant (additional) therapy. Therefore, in the postoperative period, the patient underwent 6 courses of chemotherapy according to the XELOX scheme.
The patient undergoes regular monitoring examinations for tumor markers levels, as well as total colonoscopy, CT scans of the chest, abdomen, and pelvis. There are no signs of tumor process recurrence.
Conclusion
This is the first published case from the practice , describing such minimally invasive treatment for complicated colorectal cancer. During such laparoscopic surgery with a retroperitoneal abscess, the right parts of the colon were removed along with all adjacent lymph nodes, and healthy intestinal segments were immediately connected.
This case demonstrates the complexity of performing radical operations on non-standard patients. To reduce the risk of postoperative complications, it is necessary to use the full range of modern diagnostic methods during preparation and planning of surgical interventions.
Moreover, there is always the possibility of following a false trail if the patient has concomitant pathologies. Therefore, it is always necessary to collect medical history very carefully and apply additional examination methods.