乙狀結腸癌腫瘤破裂引起大面積後腹腔膿瘍:案例報告

黎赫¹、胡哲銘²、丁慧恭¹、卓育慶¹、陳進利¹、楊明昕¹、高建璋¹、曹智惟¹、蒙恩¹

¹國防醫學院三軍總醫院外科部泌尿外科；²國防醫學院三軍總醫院外科部大腸直腸外科

Perforation of the sigmoid colon induced huge abscesses in the retroperitoneum: report of a case

Ho, Li¹, Je-Ming Hu², Hui-Kung Ting¹, Yu-Chin Jhuo¹, Chin-Li Chen¹, Ming-Hsin Yang¹, Chien-Chang Kao¹, Chih-Wei Tsao¹, En Meng¹

¹ Division of Urology, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

² Division of Colon and Rectal Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Background: Sigmoid colon is intraperitoneal and covered in mesentery. Retroperitoneal abscess is usually caused by perinephric inflammation, infections of the gastrointestinal tract, and postoperative complications. In rare cases, a retroperitoneal abscess may be associated with perforation of sigmoid colon cancer, particularly in locally advanced sigmoid colon cancer which invaded to nearby structures. The abscess may form because of infection in the cancerous tissue. To the best of our knowledge, only case reports have been documented; Here, we reported a rare case of lobulated huge retroperitoneal abscess result from sigmoid colon cancer perforation.

Case presentation: A 50-year-old man was diagnosed with sigmoid colon cancer with para-aortic lymph nodes and hepatic metastases, and regular combination chemotherapy with irinotecan, fluorouracil, and leucovorin plus bevacizumab were administered. Four months after the initiation of chemotherapy, the patient developed left abdominal pain and fever on the time he admitted for scheduled chemotherapy. Blood examination revealed generalized inflammation with a high C-reactive protein level. Non-contrast enhanced computed tomography of the abdomen and pelvis showed gas-containing collection in the retroperitoneum, suspected retroperitoneal abscess, which was managed non-operatively with broad-spectrum antibiotics. The scheduled combination chemotherapy resumed on the day 11 of antibiotics treatment, and high fever recurred after then. However, the patient refused further intravenous antibiotics treatment and discharged with oral antibiotics. On the day of next combination chemotherapy, he already developed marked painful lump over left flank. Contrast enhanced computed tomography of the abdomen and pelvis showed lobulated huge abscesses in the left retroperitoneum, adjacent to the sigmoid colon cancer with subcutaneous expansion, that the cause of abscess formation was perforation of the tumor into the retroperitoneal space. Hence, exploratory with open drainage, repeated debridement, and loop ileostomy were performed. After several times of debridement, the infection got controlled, and the primary tumor was resected after remission of the local inflammation.

Lessons: Based on intraoperative findings, the sigmoid colon cancer perforation was identified with the breach adjacent to parietal peritoneum complicated with fistula formation, leading abscess disseminated in retroperitoneal space instead of intraperitoneal space. The symptoms might be non-specific in early stage, yet it was still possible to make a diagnosis preoperatively by detecting gas-containing collection in the posterior pararenal space on CT scan. Early diagnosis of retroperitoneal abscess is critically important especially in immune-compromised patients underwent chemotherapy to prevent lethal sepsis. The mortality rate can only be reduced by early detection, accurate diagnosis, and aggressive treatment.