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The coexistence of carcinoma of the rectum and of ischiorectal abscess: what is the optimal therapeutic approach?
M. Safioleas, M. Stamatakos, R. Iannescu, C. Safioleas, A. Kostakis (Chirurgia, 102 (2): 221-222)

Introduction
Rectal cancer which is presented in this paper as an ischio-rectal abscess is a rare condition. In such cases the probable dilemma for the surgeon is to choose the optimal surgical procedure for rapid and efficient therapy. This report deals with a case of rectal cancer with clinical presentation of an ischiorectal abscess and the possible therapeutic options are presented.

Case report
A 72-year-old man was admitted to our department with an abscess in the ischiorectal region. Blood tests and endoscopy findings revealed that the abscess was associated with a carcinoma of the rectum. The patient was operated on and underwent drainage of the abscess through a skin incision, which developed into a fecal fistula. A fecal diversion with sigmoid loop colostomy was performed 3 days later, which resulted in rapid healing of the perineal wound. Two weeks later an abdominoperineal excision of the rectum was performed and the site of rectal perforation was marked with metallic clips. The histopathological findings of the specimen revealed that the bowel was completely involved by a moderately differentiated adenocarcinoma. The patient, after an uncomplicated postoperative course, recovered completely and was discharged from hospital on the 12th postoperative day. Linear accelerator radiotherapy was recommended targeting the marked area with clips. The patient was placed under chemotherapy (Eloxatine 80 mg/m2 and Capecitabine 500 mg).
The patient is still in life and doing well 14 months after the first admission.

Discussion
The presence of an ischiorectal abscess in cases of rectal carcinoma is a rare condition. After searching the english literature however we have failed to find a clear strategy in order to manage this particular emergency; it is rather clear that the best treatment, either for palliation or for possible cure, is excision of the rectum (1).
With this concept in mind, the abscess, should initially be drained and, after that, an abdominoperineal excision of the rectum should be performed. On the other hand, in order to avoid external drainage and the fecal fistula, which may be expected to develop, an internal drainage of the abscess through the possible point of communication, which is digitally enlarged, may be achieved (2, 3). Despite the risk of sphincter damage, this procedure will save time for the patient, as any healing period of a fistula is gained.
There is no doubt that the coexistence of ischiorectal abscess and rectal carcinoma or other neoplasms of the rectum are not very common. On the other hand it is obvious that the optimal approach to manage this condition remains uncertain (4-6).
As concerns the postoperative management of this patient, especially the recommendation for adjuvant therapy, it should be noted that in such patients the perforation of the bowel wall suggests a bad prognosis and by the communication with perianal space, the pathogenesis of ischiorectal abscess is explained; thus additional radio-chemotherapy should be employed (2).

References
1. Avill, R. - The management of carcinoma of the rectum presenting as an ischiorectal abscess. Br. J. Surg., 1984, 71:665.
2. Gamagami, R.A., Mostafavi, M., Gamagami, A., Lazorthes, F. - Fournier's gangrene: an unusual presentation for rectal carcinoma. Am. J. Gastroenterol., 1998, 93:657.
3. Kulkarni, M.V., Mehta, S.D., Burks, D.D., Shaff, M.I. - Imaging of the ischiorectal fossa. J. Comput. Tomogr., 1985, 9:329.
4. Sherlock, D., Ward, A. - Complications of ischio-rectal abscesses. Br. J. Clin. Pract., 1981, 35:203.
5. Berridge, D.C. - Leiomyosarcoma of the rectum. Report of two cases illustrating an unusual presentation and the need for repeated biopsy. Dis. Colon Rectum, 1987, 30:721.
6. Espinosa, A., Berga, C., Martin-Paredero, V., Sanchez, V., Diaz, J., Segura, J., Escuder, J., Barbod, A. - Hemangiopericytoma ischiorectal. Report of a case. J. Cardiovasc. Surg., 1998, 39:577.


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