Acute abdomen after laparoscopic sigmoid colectomy revealing a surprise diagnosis

Walter Tabarelli; Hugo Bonatti

Acute abdomen after major colonic surgery always raises suspicion for an anastomotic leak. Surgical intervention is frequently necessary despite options to temporize the process using antibiotic therapy and interventional therapy such as percutaneous drain placement.

Even in complex medical and surgical cases, acute appendicitis should always been considered in patients presenting with an acute abdomen.

A 55 year old male was diagnosed with a stenosing carcinoma of the sigmoid colon and underwent emergent colostomy placement to relief the obstruction. After recovery he underwent laparoscopic sigmoid colectomy with primary anastomosis and final pathology revealed moderately differentiated adenocarcinoma pT3N2aM0.The perioperative course was uneventful and he was started on FOLFOX chemotherapy per protocol. One week after the 4^th cycle the patient presented with an acute abdomen to the emergency room.

He had a rigid, distended abdomen, fever up to 39 centigrade and was hypotensive; WBC and CRP were elevated. After resuscitation and stabilization and initiation of antibiotic therapy he underwent CT-scan showing free air and free fluid in the right lower quadrant, dilated bowel loops and some colonic wall thickening. He was emergently taken to the operating room. The abdomen was accessed with a 10mm Hassan trocar and pneumoperitoneum was established. On exploration, foul smelling pus and stool was found and the abdomen was rinsed with normal saline. Due to poor visualization a lower abdominal midline incision was made: the anastomosis was found intact, however, a necrotic perforated appendix was found and appendectomy was done. The patient was continued on antibiotics and quickly recovered from surgery. Four weeks later chemotherapy was restarted and after the 12^th course, he underwent uneventful closure of the protective colostomy. The patient was well without evidence for recurrent cancer at his one year follow up.

This is an unusual presentation of a perforated appendicitis in a colon cancer patients and may have been triggered by chemotherapy.