What is the Meaning of an Early Anastomotic Recurrence after Curative Right Hemicolectomy? A Synchronous, Metachronous, or What Else?

The rate of anastomotic recurrence after surgical resection for colorectal cancer ranges widely, although recent advances in diagnostics and treatment led to its reduction. Particularly, a higher incidence of anastomotic recurrence was reported after surgery of the left colon and rectum (7.8–13%) than after surgery of the right colon (0.8–1.4%), with an overall mortality of 10–15 per cent after reoperation. The peculiarity of a case of postoperative anastomotic recurrence after curative right colectomy for adenocarcinoma of the cecum gained our attention and led us to find an explanation. A 60-year-old male patient with no history of medical or surgical pathologies, nor familial history of colorectal cancer, underwent a colonoscopy for irondeficiency anemia. A 4-cm-sized tumor was found in the cecum, and the pathology report concluded for a moderately differentiated adenocarcinoma (G2). Thoracic and abdominal CT scans showed no metastatic lesions. The indication to surgical treatment without neoadjuvant treatment was confirmed. Before surgery, a second colonoscopy was carried out. Notably, preoperative endoscopic explorations were all complete and performed by experienced clinicians after optimal bowel preparation (Boston Bowel Preparation Scale: 9). After a preoperative polyethylene glycol (PEG) preparation, the patient underwent an open right hemicolectomy with side-to-side manual ileocolic anastomosis. Before anastomosis confectioning, 5 per cent povidone-iodine (PVP-I) solution swabs were introduced inside the ileal and colonic stumps and left in contact with the intestinal mucosa for 15 minutes. Postoperative recovery was fast, without severe complications. The pathological staging concluded for a T3N0 moderately differentiated adenocarcinoma with negative resection margins. An adjuvant chemotherapy was proposed, but the patient refused any postoperative oncological treatment. At the two-month endoscopic follow-up, a large and permeable anastomosis was found, but it was partially occupied by a slightly elevated irregular erythematous lesion of about 2 cm in diameter and with hard consistency. Some biopsies were carried out, and a colonic adenocarcinoma with the same characteristics of the resected primary right colon cancer was found. The samples of the right colectomy were analyzed a second time, confirming the previous diagnosis of R0 surgery. Therefore, the patient underwent resection of the previous ileocolic anastomosis with following continuity restoration. Then, an adjuvant chemotherapy was started. The pathology report of the second operation concluded for an infiltrating anastomotic recurrence with negative resection margins and lymph nodes. No other local recurrence or metastatic lesion was diagnosed during a five-year follow-up period. Anastomotic recurrence after surgery for colorectal cancer it can occur on average, about two years after the operation but not a few cases of earlier recurrence have been reported. Providing an appropriated definition of a local recurrence is often difficult. Indeed, several causes may be invoked, such as positive resection margins, synchronous lesions, lymphatic infiltration, parietal implant of exfoliated vital malignant cells, and biological changes within the tumor or the colonic mucosa next to it. If surgical resection went through neoplastic tissue or resection margins were too short, the surgery would lose its curative character. Otherwise, if an undetected small flat synchronous tumor was located next to the anastomosis, the recurrence would represent a case of synchronous cancer. Particularly, a colorectal cancer is defined as synchronous when it is diagnosed at the same time as another cancer or within six months after a previous tumor, and the histopathologic criteria of Address correspondence and reprint requests to Calogero Cipolla, M.D., Ph.D., Divisione di Chirurgia Generale ed Oncologica, Dipartimento di Discipline Chirurgiche Oncologiche e Stomatologiche, AOUP Paolo Giaccone, Palermo, Italy 129–90127. E-mail: calogero.cipolla@unipa.it.