ORIGINAL ARTICLE

SURGICAL MANAGEMENT OF CARCINOMA CAECUM

Ainul Hadi, Zahid Aman, Shehzad Akbar Khan, Mazhar Khan, Zafar Iqbal
Department of Surgery,
Hayatabad Medical Complex Peshawar - Pakistan

ABSTRACT
Objective: To determine the magnitude of carcinoma caecum and its surgical management in the department of
Surgery, Hayatabad Medical Complex Peshawar- Pakistan.
Methodology: This case series study was conducted at surgical Unit Hayatabad Medical Complex Peshawar from
July 2006 to June 2009. A total of 32 patients of carcinoma of caecum were included that were admitted either
through OPD as elective cases (22 patients) or in emergency (10 patients). In elective cases, diagnosis was made on
colonoscopic biopsy while those who presented in emergency either with intestinal obstruction or with the suspicion
of acute appendicitis, were diagnosed on the resected specimen histopathology.

Results: Out of 32, 25 patients (78%) were male and 7 (22%) female, with a male to female ratio of 3.6:1. Their
mean age at the time of presentation was 65±2.8 years. Right hemicolectomy with side to side or end to end
ileotransverse anastomosis was performed in 23 cases (71.89%). In 3 cases (9.37%) ileotransverse bypass without
resection was carried out as the tumour was locally advanced. In 3 other cases (9.37%), only omental biopsy was
taken as the carcinoma was so advanced that any curative or palliative resection was not possible. In emergency
situation, right hemicolectomy with exteriorization of bowel ends was done in 3 cases (9.37%). Postoperative
morbidity included wound infection 12.50%, faecal fistula 9.37% and intraabdominal collection 6.25%.

Conclusion: Majority of the patients were having operable disease, however late presentation is very common.
Surgical intervention may prove to be a better option in such cases.
Keywords: Carcinoma of caecum, Large gut malignancy, Intestinal obstruction.

INTRODUCTION include lung and brain, however subcutaneous

metastasis is a very rare presentation but do occur 1 0 , 11 .
Carcinoma caecum/ascendi
Although right hemicolectomy for carcinoma caecum
ng colon
may be curative, but carcinoma involving this part of
accounts for up to 14% of colorectal tumours as r e p o
colon does not have a favourable prognosis and it is
r t e d f r o m t h e d e v e l o p e d c o u n t r i e s 1,2 .
believed to be due to diagnostic delay12,13.
Carcinoma of caecum is more common in western
countries but it is not a rare disease in our country 3. It
may present in variable ways e.g. occult bleeding per The aim of this study is to review data
rectum, gross bleeding through rectum, unexplained pertaining to caecal carcinoma such as age, sex,
anaemia, mass in right iliac fossa, acute appendicitis clinical presentation, diagnosis and treatment of
and even intestinal patients admitted to the department of surgery,
obstruction3 . Rarely it may present as mega i n t u s s u Hayatabad Medical Complex Peshawar over a period
cptionandrectalmass 4.Itusually of 3 years.
metastasizes to regional lymph nodes and later on
through blood stream5, 6. Haematogenous metastasis METHODOLOGY
usually occurs by embolization of cancer cells from This was a case series study and extended
primary tumour via mesenteric and portal veins to liver over a period of three years from July 2006 to June
which is the most common site of colorectal 2009. In this study patients of all ages and
metastasis7 - 9 . Other common sites

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 SURGICAL MANAGEMENT OF CARCINOMA CAECUM

both sexes with the diagnosis of carcinoma of caecum, in all elective cases to check the extent of spread of the
managed in the surgical department of HMC Peshawar disease. CEA was done in 22 cases (68.75%) who were
were included. Patients with past history of colonic admitted through OPD and was found raised. Patients
growth or recurrent growth were excluded from the presented in emergency either with intestinal
study. Similarly patients with e x t r a a b d o m i n a l obstruction or acute appendicitis, were routinely
m e t a s t a s e s l i k e c e r v i c a l lymphadenopathy resuscitated and then investigated, followed by surgical
and pulmonary metastases were also excluded. In intervention. Blood was arranged before surgery
elective cases diagnosis was made on colonoscopic according to haemoglobin status. Right hemicolectomy
biopsy while those presented in emergency either with with ileotransverse anastomosis was the preferred
intestinal obstruction or with the suspicion of acute procedure over ileostomy or bypass, in all resectable
appendicitis were diagnosed after receiving the cases.
histopathology report of the resected specimen.
In emergency situation, right hemico-lectomy
Data regarding the history clinical signs, with exteriorization of bowel ends was done in patients
investigations, surgical treatment and the outcome of with intestinal obstruction and haemodynamically
these patients were collected on a semi-structured unstable or with peritoneal contamination. Only
profroma . Preoperatively patients admitted through omental biopsy was taken in cas es w h er e th e g r o w
OPD were shifted to liquid diet to prepare the gut while th w as d is s emin ated extensively in peritoneal cavity.
those admitted with i n t e s t i n a l o b s t r u c t i o n , Patients were advised to come to OPD for
w e r e m a n a g e d o n intravenous fluids, nasogastric
follow up, initially monthly and then after every 3
suction and Foleys catheter to keep the intake and out
months.
put record and kleen enema to evacuate the distal
faecal bulk more commonly in elective cases. RESULTS
In this study a total number of 32 cases of
In elective patients, routine investigations like carcinoma caecum were collected. There were 25
full blood count, blood urea/creatnine, blood sugar, (78%) males and 7 (22%) females with a male to
blood grouping, ECG, X-ray chest and X-ray abdomen female ratio of 3.6:1. The age range was 30-80 years
(erect and decubitus films) were performed to look for with a maximum number having age between 61-70
the signs of obstruction. Specific investigations years. The mean age of patient at the time of
included stool examination for occult blood, abdominal presentation was 65 years ± 2.8 SD (Table 1).
U/S, barium enema (in 22 patients admitted as elective
cases) and colonoscopy with biopsy. Serum electrolytes Table 2 shows the different modes of
and LFTs were done where needed. CT scan was done presentation of patients. Out of 32 patients 22

Table 1: Age and gender of the sample (n =32)

Age range Male Female Total
30-39 years 02 00 02
40-49 years 03 01 04
50-59 years 04 01 05
60-69 years 14 04 18
70-79 years 02 00 02
80 years 00 01 01
Total 25 (78%) 07 (22%) 32 (100%)

Table 2: Modes of presentation (n =32)

Clinical features No of cases %age
Mass RIF 22 68.75
Intestinal obstruction 07 21.87
Acute appendicitis 03 9.38
Total 32 100%

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 SURGICAL MANAGEMENT OF CARCINOMA CAECUM

(68.75%) cases had clinical presentation of a mass in showed evidence of tumour in all cases. Biopsy
right iliac fossa, 7 patients (21.87%) presented with specimen was taken for histopathology during
intestinal obstruction while 3 patients (9.38%) had colonscopy.
signs and symptoms suggestive of acute appendicitis.
Table 4 shows the different operative
procedures performed. Right hemicolectomy with
Palpable mass in right iliac fossa or right primary ileotransverse anastomosis was performed in
lower abdomen was the predominant finding. Pain was 23 cases (71.89%), while in 3 patients (9.37%) who
the presenting symptom in 25 patients (78.13%) which presented in emergency with intestinal o b s t r u c t i o
was generalized in 17 patients n , r i g h t h e m i c o l o e c t o m y w i t h
(53.13%) and localized in right iliac fossa in 8 patients exteriorization of bowel ends was done. In 3 patients
(25%). Twenty two patients (68.75%) had significant (9.37%), the tumour was found to be advanced and
weight loss at the time of presentation, fixed, therefore only ileotransverse bypass procedure
15 patients (46.87%) had vomiting and 14 (43.75%) was undertaken. In remaining 3 cases (9.37%) tumour
were constipated. Four patients (9.37%) were pyrexic. was wide spread involving the peritoneal cavity and
liver rendering any surgical procedure impossible. So
Table 3 shows the abnormal pre operative an open omental biopsy was the only procedure which
investigations. Twenty eight (87.50%) patients had was undertaken and two out of these 3 patients expired
haemoglobin less then 10 gm. Blood urea was raised in postoperatively within 90 days of exploration.
08 (25%) patients. Stool for occult blood was positive
in 15 cases (46%). Plain X ray abdomen (erect posture)
Table 5 shows the morbidity of this study.
was carried out in all patients and revealed signs of
Four patients (12.50%) developed wound sepsis
intestinal obstruction in 7 patients (21.87%).
Abdominal ultrasound showed abnormal findings in 17 postoperatively, which was managed by opening up the
(53.13%) out of 32 cases. Barium enema Colonoscopy wound, draining the pus and regular wash of the wound
were performed in 22 (68.75%) elective cases and with saline and antiseptic solution and dressings. Two
patients (6.25%) developed faecal

Table 3: Pre Operative Investigations (n = 32)

Investigations No. of Percentage
Patients
Haemoglobin (less than 10 gm%) 28 87.50%
Blood Urea 08 25%
Stool for occult blood 15 46%
X ray Abdomen (erect posture ) 07 21.87%
Abdominal ultrasound 17 53.13%
CT scan (abdomen and pelvis) 21 65.63%
Barium enema 22 68.75%
Colonoscopy 22 68.75%

Table 4: Operative Procedures (n = 32)

Procedure No. of %age
Cases
Rt hemicolectomy with ileotransverse anastamosis 23 71.89%
Rt hemicolectomy with exteriorization of bowel ends 03 09.37%
Ileotransvers bypass without resection 03 09.37%
Omental biopsy only 03 09.37%
Total 32 100%

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 SURGICAL MANAGEMENT OF CARCINOMA CAECUM

Table 5: Post operative complications (n =32)

Complication No. of cases %age
Wound sepsis 04 12.50%
Faecal fistula 02 06.25%
Respiratory tract infection 02 06.25%
Jaundice 01 03.13%
Intra abdominal collection 02 06.25%
Wound dehiscence 01 03.13%
Septicemia 01 03.13%
Total 13 40.64%

Table 6: Histopathology (n = 32)

Histological features No.of cases Percentage
Adenocarcinoma 32 100%
?Well differentiated 23 71.87%
?Moderately differentiated 04 12.50%
?Poorly differentiated 05 15.63%
Lymph node status 25 78.13%

fistula due to anastomotic leakage which were reported but our present study show comparable results
reexplored and after peritoneal toilet, the two ends with studies from Pakistan as well as international
were exteriorized. Other complications included studies with some distinctive features3, 14, 15.
respiratory tract infection and intraabdominal
collection in 2 cases each (06.25%). Patients with Carcinoma of caecum is a disease of old age
intraabdominal collection were reexplored and but it can occur in young people also. Most of the
peritoneal wash was done. Postoperative jaundice, patients in our study were between the age of 61-70
wound dehiscence and septicemia occurred in one years, ranging from 30-80 years. These findings are
patient each (03.13%). Tension sutures were applied to comparable to different studies conducted by
burst abdomen. Total hospital stay depended upon the Gennero15, Sadozai AK14 and Amin MA3. This age
incidence is slightly earlier than maximum age
patient condition. Postoperative stay ranged from 7-25
incidence in developed countries. Maximum age
days. Hospital mortality was 03.13% (one case of
incidence over there is about 70-80 years 3. Similarly
septicemia which expired within 10 days post high incidence in old age in developed countries may
operatively, while 2 patients with advanced disease be due to increased average life of population3. Young
died within 3 months after exploration). people are not immune to caecal cancer. The youngest
patient in our study was 30 years male. A study
reported by Khawaja from Lahore, the average age was
Table 6 shows the histopathology report. All
45 years and the youngest patient was 17 years old16.
(100%) patients were reported having adenocarcinoma.
Caecal carcinoma is reported more commonly in
Out of 32, 23 (71.87%) patients had poorly
females than in males17 in a study which was explained
differentiated, 04 (12.50%) had moderately
by the fact that females suffer from billiary disease
differentiated and 05 (15.63%) had poorly
more than males and bile acids are thought to be
differentiated adenocarcinoma. In 25 (78.13%)
carcinogenic and responsible for this occurance. 3 But in
patients, the paracolic lymph nodes were reported to be
our study the male to female ratio was 3.6:1 which is
involved.
quiet opposite to the above study but is more consistent
with the study of Gennero 15 and 3:1 by Sadozai AK14
DISCUSSION
and Amin MA3 in their studies.
The true incidence and presentation of caecal
carcinoma from Pakistan is infrequently

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 SURGICAL MANAGEMENT OF CARCINOMA CAECUM

In the present study of 32 patients, 22 patients but both require bowel preparation and are sometimes
(68.75%) presented with abdominal mass as compared intolerable for the patients, abdominal ultrasound is
to 13% by Gemmero,15 45% by Zaki M,18, 50% by another excellent diagnostic modality with high
Sadozai AK14 and Amin MA3 each, indicating that it is sensitivity and moderate specificity in experienced
the most frequent mode of presentation. hands 2 5 . Ultrasound detects the p r i m a r y l e s i o
n , i t s s i z e , e x t e n t a n d e v e n secondaries in the
liver and so helps to stage the tumour 3. In our study
Though caecal tumours rarely produce abdominal ultrasound was performed in 22 patients and
obstructive symptoms due to its wide lumen and liquid picked up tumour with 100% accuracy.
contents, that leaves the carcinogenic component in diet
to remain in contact with the caecal wall for a short The management of colonic carcinoma
period19. However 7 patients (21.87%) in our study requires a combined approach by Surgeon, oncologist
presented with intestinal obstruction. This indicated the and Gastroenterologist but surgery remains the main
advanced stage of the tumour at the time of stay of treatment of carcinoma of caecum 14,26, since the
presentation. This figure is reported 20% each by only cure / palliation for carcinoma of the caecum is
Sadozai AK14 and Amin MA3. Only 3 patients (9.38%) enbloc resection. Therefore radical surgical excision is
were febrile and presented as acute appendicitis which the procedure of choice27. Right hemicolectomy with
is a rare presentation of carcinoma of caecum. This primary ileocolic anastomosis is a safe procedure in
figure is almost equal to 10% reported by Sadozai AK 14 good surgical hands and in patients having compara-
and Amin MA3. Twenty two patients (68.75%) tively good health. In the current study curative
presented with significant weight loss and 28 patients resection i.e. right hemicolectomy with ileotran-serse
(25%) had marked anaemia (Hb less than 10 gm %) anastomosis was performed in 23 cases (71.89%) while
showing the late presentation of patients as compared in emergency situation palliative or primary resection
to Western experience but almost similar to local and exteriorization of bowel ends was carried out in 3
studies3, 14. This may explain the late presentation of patients (9.37%) due to locally advanced tumour. Three
these patients with abdominal mass or bowel patients (9.37%) underwent palliative ileotran-sverse
obstruction. So any complication that develops in bypass surgery. In the remaining 3 patients (9.37%),
relation to early carcinoma can be a blessing for the only omental biopsy was possible due to metastasis in
patient as it draws the attention when curative resection the liver and peritoneal cavity. All these operative
is possible20. findings are comparable to local and international

Bariumenema,colonoscopyand studies3, 14, 15, 18.

abdominal ultrasound are important and reliable i n v e
stigationsforthedetectionofcaecal The operative mortality can be reduced by
carcinoma21. However spiral hydro CT scan 22 and proper selection of patients for various surgical
MRI23 are helpful in assessing the extramural extension procedures and it can even further be improved if
of tumour. In the present study, contrast radiology patients are operated upon by experienced surgeons.
barium studies were performed in 22 patients (68.75%) Histology showed 16 cases (50%) in Duke's B, 9(28%)
and the diagnostic yield was i00% in these patients. in Duke's C and 7 (22%) in Duke's D. No case was
Gennero reported positive results in 50 out of 54 reported in Duke Stage A. These figures are similar to
patients15 while Zaki M reported abnormal barium those reported in local studies3, 14. Hence 50% of our
studies in 74 out of 92 cases of caecal carcinoma 18. patients were in a d v a n c e d s t a g e D u k e ' s D a t
Sadozai AK14 and Amin MA3 reported positive results t h e t i m e o f presentation, showing that there is a
in 100% patients, confirming that double contrast trend for late presentation. Moreover histopathology
enemas may be more helpful in detecting early report s h o w e d t h a t 1 0 0 % o f t h e p a t i e n t s h
lesions14. Colonoscopy was also performed in 22 a d adenocarcinoma and the para colic lymph nodes
patients ( 6 8 . 7 5 % ) a d m i t t e d a s e l e c t i v e c a were involved in 78.13% (25) cases. These figures are
s e s a n d demonstrated tumour in all cases and also comparable to different studies3, 14, 15.
specimens were taken for histopathology. Sadozai
performed Colonoscopy in only 2 patients (5%) and I n t h i s s t u d y, 4 p a t i e n t s ( 1 2 . 5 0
reported tumour in both cases (100%) 1 4 . Where the % ) developed wound infection which was managed
endosocpic facilities are not available, contrast with opening the wound, draining pus, washing the
radiology (double contrast enema) remains the main wound and dressings. Two patients (6.25%) had faecal
stay of diagnosis in developing countries24. fistula due to anastomotic leakage and were reexplored.
Two patients (6.25%) had small intra abdominal
As barium enema and cononoscopy are the collections which were reexplored and peritoneal wash
gold standard for the diagnosis of colonic tumours was done, one patient (3.13%) had

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 SURGICAL MANAGEMENT OF CARCINOMA CAECUM

wound dehiscence, for which secondary tension sutures 8. Steel RJC. Disorders of the colonoid rectum. In:
were applied. These figures are comparable to local Cushieri A, Steele RJC, Moosa AR, editors.
studies carried out by Sadozai AK14 and Amin MA3. Essential Surgical Practice. 4th ed. London:
The hospital mortality was 03.13% (one case who had Butterworth International; 2002. p. 569-645.
developed septicemia due to anastomotic leak and died
within 10 days of surgery), which is comparatively less 9. Canaran C, Abrams KR, Mayberry J. Meta
than 10% reported by Sadozai AK 14 and Amin MA3 analysis: colorectal and small bowel cancer risk in
each and 19% by Gennero15. patients with crohns disease. Aliment Pharmacol
ther 2006;15:1097-1104.
At the time of discharge, patients were 10. Talpur AH, Kalyar SB. Carcinoma of caecum with
advised to visit OPD regularly for follow up. Initially subcutaneous metastasis. J Liaquat Uni Med
31 patients attended the OPD for check up but 02 Health Sci 2004;3:82-3.
patients died within 90 days after surgery and 06 were
lost during follow up. So their number reduced to 23 11. Jess T, Gamborg M, Matzen P, Munkholm P,
after 3 months. At 2 years follow up, 03 patients Sorensen TI. Increased risk of intestinal cancer
(11.54%) developed local recurrence and 05 patients in c r o h n s d i s e a s e : a m e t a a n a l y s i s o f
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caecum15.
13. Uza N, Nakase H, Kuwabara Y, Fujii S, Chiba T.
CONCLUSION Caecal cancer associated with longstanding crohns
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Majority of the patients were having operable
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Surgical intervention may prove to be a better option as ma n a g e m e n t o f c a r c i n o m a o f c a e c u
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ileotransverse anastomosis was done in majority of the 2000;14:19-22.
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Address for Correspondence:

Dr. Ainul Hadi
Department of Surgery,
Hayatabad Medical Complex Peshawar - Pakistan

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