A Minor but Deadly Surgery of Colonic Polypectomy in an Elderly And

Yuan et al. World Journal of Surgical Oncology (2016) 14:252 DOI 10.1186/s12957-016-1010-6 CASE REPORT Open Access A minor but deadly surgery of colonic polypectomy in an elderly and fragile patient: a case report and the review of literature Xiaoming Yuan1†, Guangrong Zhou1†, Yan He2 and Aiwen Feng1* Abstract Background: Epithelial dysplasia and adenomatous polyps of colorectum are precancerous lesions. Surgical removal is still one of the important treatment approaches for colorectal polyps. Case presentation: A male patient over 78 years was admitted due to bloody stool and abdominal pain. Colonoscopic biopsy showed a high-grade epithelial dysplasia in an adenomatous polyp of sigmoid colon. Anemia, COPD, ischemic heart disease (IHD), arrhythmias, and hypoproteinemia were comorbidities. The preoperative preparation was carefully made consisting of oral nutritional supplements (ONS), blood transfusion, cardiorespiratory management, and hemostatic therapy. However, his illness did not improve but deteriorate mainly due to polyp rebleeding during preparative period. The open polypectomy was performed within 60 min under epidural anesthesia. Postoperative treatments included oxygen inhalation, bronchodilation, parenteral and enteral nutrition, human serum albumin, antibiotics, and blood transfusion. Unluckily, these did not significantly facilitate to surgical recovery on account of severe comorbidities and complications. The most serious complications were colonic leakage and secondary abdominal severe infection. The patient finally gave up treatment due to multiple organ dysfunction syndromes. Conclusions: The polypectomy for colonic polyp is a seemingly minor but potentially deadly surgery for patients with severe comorbidities, and prophylactic ostomy should be considered for the safety. Keywords: Colonic polyp, Hypoproteinemia, Anemia, COPD, Arrhythmias, Polypectomy, Intestinal leakage, Abdominal infection Background prophylactic ostomy is not explicitly elaborated in many Adenomatous polyp and epithelial dysplasia are regarded literatures [1–5]. In this case, we reported a case of deadly as precancerous lesions of colorectal cancer [1]. Endo- colonic leakage after laparotomic polypectomy for an ad- scopic intervention (e.g., EMR/ESD) and surgical removal enomatous polyp of colon. (e.g., polypectomy/colectomy) are important management approaches [1–3]. In general, surgical removal should be considered where the malignancy is suspected or concerns Case presentation about the likelihood of incomplete endoscopic resection A male patient over 78 years was admitted on Sep. 9, or endoscopic contraindications [2, 4]. The limited surgi- 2015, due to bloody stool and abdominal pain. Past his- cal resection is fit for patients with comorbidities [2], but tory included smoking, bronchitis, COPD, but no cir- rhosis and nephrotic syndrome. Physical exam showed * Correspondence: [email protected] normal vital signs, lung hyperresonance, and scattered † Equal contributors crackles. The abdomen was flat without GI pattern. 1Department of Intestinal Surgery, Affiliated Huai’an First People’s Hospital, Nanjing Medical University, Huai’an 223300, China Tenderness and rebound tenderness were negative. Full list of author information is available at the end of the article Right indirect hernia existed where gut were palpable. © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Yuan et al. World Journal of Surgical Oncology (2016) 14:252 Page 2 of 5 Mass, anal fissure, and hemorrhoid were not found in a dose of 10 g daily. During the first 3 days, the patient the rectum and anus. Lung function showed obstructive was uneventful and oral fluid diet containing ONS was ventilation dysfunction (Table 1). ECG and Doppler echo- provided after anal aerofluxus. At the fourth day, he suf- cardiography showed arrhythmias, ischemic heart disease fered from acute heart dysfunction (AHD) diagnosed by (IHD), pulmonary hypertension, and reduced left ven- manifestations of fatigue, dyspnea, oliguria, and pulmonary tricular compliance (Table 1). The heart function classifi- rales. ECG monitor showed normal BP, decreased SaO2%, cation was II. Colonoscopy revealed a pedunculated and and increased heart rate. The CVP value was >15cmH2O. easy bleeding polyp of sigmoid colon, but did not find is- Re-assessment of cardiac function classification was IV. chemic bowel disease, IBD, and diverticula. A biopsy for The clinical features of AHD rapidly resolved after injec- polyp samples showed high-grade epithelial dysplasia and tion of cardiotonic and diuretic. Laboratory test showed adenomatous polyp (Table 1). CT scan showed emphy- normal electrolytes and decreased Hb level (78 g/L) sema, right hernia where gut could be watched, prostatic (Table 2), so 1 U PRBCs were transfused. At the 7th hyperplasia, and hepatorenal cysts, but no visible masses day laboratory findings revealed abnormal renal func- in GI tract (Table 1). Laboratory findings showed anemia, tion (Table 2). At the 10th day, he complained of ab- positive FOBT, and hypoproteinemia. The coagulation, dominal distension and dramatic increase in volume of hepatorenal function, and arterial blood gas were almost right hernia. B ultrasound revealed pleural effusion and normal (Table 2). APACHE II score was 10 points. ASA massive ascites. Laboratory findings revealed worse renal classification grade was III. Goldman Cardiac Risk Index function (Table 2). At the 11th day, he was re-struck by score and European Nutritional Risk Screening (NRS AHD, which was also rapidly corrected by cedilanid and 2002) score were 15 and 3 points, respectively. furosemide. Massive pale yellow ascites outflowed from A 2-week preoperative preparation was made. Bronchitis abdominal incision and abdominal drainage tube. At the and COPD were managed by stopping smoking, low-flow 12th day, he had colonic leakage as judged by intestinal oxygen therapy, blowing balloon exercise, and administra- content outflowing from abdominal incision and drainage tion of aminophylline and levofloxacin. Anemia was tube, which had drained out little pale bloody fluid and treated by blood transfusion of 4 U PRBCs, bleeding by pale yellow ascites during past 11 days. At the 14th day, vitamin K, and arrhythmias by β-receptor blocker. Malnu- he gave up treatment due to severe infection and MODS trition was treated by amino acid, dextrose, fatty emulsion, (Table 2). vitamins, and trace elements, as well as oral bifidobacteria and peptison based on dietary supplement. After treat- Discussion ment, lung scattered rales completely resolved. Neverthe- Epithelial dysplasia and tumorous polyps are regarded as less, anemia and hypoproteinemia did not significantly precursor lesions of large bowel carcinoma. The risk of improve but deteriorate due to rebleeding from colonic adenomatous polyp is significantly increased in COPD polyp. Thus, laparotomic polypectomy was performed patients [6]. In clinic, most polyps can be treated by under epidural anesthesia on Sep. 23, 2015. An incision EMR and ESD, and only a few cases need surgery [7]. of the colonic wall was longitudinal and was sutured In this case, the patient was not a good candidate for transversely. The operative time was 60 min and blood endoscopic management according to ESGE guideline loss was little. Early postoperative management included [8]. A preparation was made according to preoperative respiratory management, restrictive fluid administration, evaluation including smoking history, cardiopulmonary combined antibiotics, octreotide, and parenteral nutrition function, nutritional status, and ASA classification. Un- (25–30 kcal/kg/day). Human serum albumin was given at luckily, this preparation was depressing because anemia Table 1 The examination findings before and after colonic polypectomy Item Examination findings ECG Sinus tachycardia, frequent premature atrial complexes, occasional ventricular premature beat, ischemic ST-T change CUS Moderate pulmonary arterial hypertension, mild aortic valvular regurgitation, reduced left ventricular compliance CT Bilateral emphysema, right indirect inguinal hernia, prostatic hyperplasia, hepatorenal cysts, normal esophagus/gastrointestine/colon, but suspicious thickness of the upper rectum PF Severe mixed ventilation dysfunction, MVV 20 L/min (24 % of predicated value), FEV1 0.72 (34 % of predicated value) CS A pedunculated neoplasm (3.0 × 2.0 × 1.5 cm in size, villous and friable and easy bleeding) of sigmoid colon POB Colonic villioustublar adenoma in accompany with epithelial high-grade dysplasia POP Colonic villioustublar adenoma in accompany with epithelial high-grade dysplasia and focal canceration ECG electrocardiography, CUS cardiac ultrasound, CT computed tomography, PF pulmonary function, MVV maximum ventilator volume, FEV1 forced expiratory volume in first second, CS colonoscopy, POB preoperative biopsy, POP postoperative pathology Yuan et al. World Journal of Surgical Oncology (2016) 14:252 Page 3

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