title: Emergency management of perforated colon cancers: how aggressive should we be?
abstract: BACKGROUND
  Emergency treatment of perforated colon cancer has traditionally been linked with dismal outcomes due to the double jeopardy of a septic insult combined with a malignant disease, leaving unclear how aggressive emergency surgical procedures should be. We aimed to define short- and long-term outcomes in the current era of critical care support and oncologic advances, to provide updated data for decision making.
  
  
  METHODS
  Patients with perforations associated with a primary colon cancer were identified. Peri-operative and long-term survival were compared among free (FP; n = 41) and contained perforations (CP; n = 45) and to age-, stage-, and resection status case-matched, non-perforated (NP; n = 85), controls.
  
  
  RESULTS
  Tumors were completely resected in 67% of FP but fewer lymph nodes were harvested (median, 11 vs. 11 and 16 in CP and NP; p = 0.21 and p < 0.001). Peri-operative mortality was highest in FP: 19% vs. 0% and 5% in CP and NP (p = 0.038), respectively. After adjusting for peri-operative mortality, 5-year overall survival was comparable: 55%, 59%, and 54% for FP, CP, and NP, respectively. Advanced age, higher ASA class, presence of residual disease, and advanced stage, but not perforation, were independent predictors of poorer long-term overall survival.
  
  
  CONCLUSIONS
  Patients with malignant colonic perforation face high risk of peri-operative death, making septic source control the priority in the acute setting. Pursuit of an oncologically oriented resection and long-term cancer-directed treatments, however, may lead to improved long-term outcomes.
authors.affiliation: Department of Surgery, Mayo Clinic, Rochester, MN, USA. zielinski.martin@mayo.edu
authors.forename: Martin D
authors.initials: MD
authors.lastname: Zielinski
authors.forename: Amit
authors.initials: A
authors.lastname: Merchea
authors.forename: Stephanie F
authors.initials: SF
authors.lastname: Heller
authors.forename: Y Nancy
authors.initials: YN
authors.lastname: You
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003110:Colonic Neoplasms / Q000150:complications / Q000401:mortality / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data*; D004638:Emergency Treatment / Q000379:methods / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007416:Intestinal Perforation / Q000150:complications / Q000401:mortality / Q000601:surgery*; D007431:Intraoperative Complications; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D012042:Registries; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome