Br. J. Surg. VoJ. 62 (1975) 830-832

Is a ‘second look operation’ justified in suspected recurrences after abdominal H A R O L D ELLIS*

SUMMARY Seventy-three patien ts have been submifted to 74 further laparotomies for suspected recurrent malignant abdo- minal disease over a period of 13 months. The original tumour was situated in the large bowel in 42, oesophagus or stomach in 24, ovary in 3, small intestine in 2 and pancreas and retroperitoneum in I instance each.

There were I0 examples of benign lesions, 16 of further primary cancer and 24 of resectable local recurrences or metastases. Seventeen patients under- went some palliative procedure, and only 7 were beyond any surgical help.

WHEN a patient who has had what was thought to be a curative resection of an abdominal cancer pre- sents with symptoms or signs which suggest recurrent disease, this is all too often regarded as a death sentence. While it is true that very often such clinical features do indeed represent the development of hopeless recurrent or metastatic disease, the picture is not entirely one of gloom. Some cancers may recur locally and may be controlled by further radical resection. In other instances the apparent ‘recur- rence’ is, in fact, a second cancer, either developing metachronously in the same organ or arising in another viscus. Finally, in some happy instances the clinical picture may be the result of an entirely benign situation, for example, a granulomatous stricture at the anastomosis, an adhesive band or a deeply placed chronic abscess.

This paper presents the results of a policy carried out over the past 13 years in which a second laparo- tomy is offered to patients who are suspected to have recurrences or local metastases. It goes without say- ing that further surgery is contraindicated when there is undoubted clinical or radiological evidence of hope- less dissemination or when the patient’s condition precludes meddlesome interference.

Between April 1962 and February 1975, 73 patients have undergone a second laparotomy for suspected recurrent disease. The original tumour was situated in the large bowel in 42 patients, oesophagus or stomach in 24, ovary in 3, small intestine in 2 and the pancreas and retroperitoneum in a single instance each.

Analysis of these patients allows subdivision into five categories of increasing optimism:

1. A group in which nothing at all could be achieved surgically (7 patients).

2. Those in whom some palliative surgical proce- dure was possible (17 patients).

3. Those in whom recurrent cancer or localized metastatic disease could be resected (24 patients).

cancer surgery?

4. Those in whom a second, operable, primary tumour was found, either in the same organ (I2 patients) or in another viscus (4 patients).

5. Those in whom an altogether benign condition was discovered which was misdiagnosed as recurrence of the original cancer (10 patients).

(Note that this totals 74 operations; 1 patient appears in both categories 2 and 5.)

1. Laparotomy only It has already been stressed that careful selection is carried out preoperatively to exclude, as far as possible, further surgery in patients with disseminated cancer. Only 7 of the 73 patients were found to be entirely beyond surgical aid at the second laparotomy.

2. Palliative surgery Severe obstructive symptoms due to irremovable recur- rent disease may be palliated by a simple short circuit or, in the case of recurrent oesophageal and upper gastric disease, by intubation by means of a plastic tube. Although survival will only be measured in weeks, or at the most months, useful symptomatic relief can be achieved.

Mrs H. S., aged 65, had a local excision of a carcinoma of the ampulla of Vater in July 1966. In October 1968 she developed intractable gastric outlet obstruction. A palliative gastro- jejunostomy was performed the following month. She remained symptom-free for over a year and died in June 1970. Autopsy confirmed extensive recurrence of the pancreatic tumour.

3. Resection of recurrent or metastatic disease Local recurrence after alimentary cancer resection may result from inadequate excision of the original growth or implantation of tumour cells at the suture line (Ellis, 1974a). Although the incidence of the latter can be reduced by careful lavage of the bowel lumen with mercury perchloride, cetrimide or other cytotoxic agents, examples are still unfortunately not uncommon. Such recurrences are not invariably in- operable and encouraging results have been reported following further radical surgery. This is especially true of large bowel growths (Dunphy, 1959; Ellis, 1974b).

Mr I. P., aged 54, underwent an emergency resection of a perforated carcinoma of the transverse colon in January 1968. Tumour cells were found at the cut edge of the specimen on subsequent histological examination. A recurrence at the anastomosis produced subacute obstruction, and exactly 4 years later, in January 1972, further resection was carried out together with excision of a wide area of the greater curvature of the stomach which was involved by the tumour. Two of the three lymph nodes in the resected specimen were involved. He remains well and is working full time 3 years later.

* Westminster Hospital, London.

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‘Second look operation’ in abdominal cancer

Malignant cells liberated at the time of operation can implant not only at the anastomotic line but also into the raw tissues exposed in the pelvis or perineum in abdominoperineal excision of the rectum. Cells dislodged from the serosal aspect of the cancer when the overlying peritoneum is involved may seed into the peritoneal cavity and also produce a Krukenberg tumour of the ovary. In other instances recurrence may develop in lymph nodes left behind at the original operation. Although in many cases these recurrences are disseminated, occasionally radical surgery may be both possible and rewarding.

Mr L. W., aged 69, had an abdominoperineal excision for a well-differentiated Dukes B adenocarcinoma of the rectum in October 1967. A recurrent nodule was discovered in the perineal wound and was widely resected in February 1969. He remained well for 4 years, when he developed carcinomatosis and died in August 1973. There was no perineal recurrence at the time of death.

Miss S. P., aged 8, underwent a hysterectomy and bilateral salpingo-oophorectomy in January I965 for a dysgerminoma of the left ovary. This was followed by a course of abdominal radiotherapy. She developed an enormous mass of left-sided para-aortic abdominal nodes which was resected en bloc in January 1968 and was followed by further radiotherapy. She remains well 7 years later (Ellis and Stoker, 1972).

The development of liver secondaries following resection is all too common and in the majority of cases represents a hopeless surgical situation. How- ever, from time to time (although not in the present series) long term survival may follow resection of metachronous hepatic deposits. This is especially true in the case of carcinoid tumours, where even simple enucleation of hepatic secondaries may be effective.

4. Second primary tumour It is far from rare for a patient to develop a second primary cancer, and this is usually misdiagnosed as a hopeless recurrence, rather than as the appearance of a second, perhaps curable, lesion. The tumour may arise in an entirely separate viscus (4 patients) or in the same organ (12 patients). The latter situation is particularly likely to occur in large bowel cancer, where figures from many large series give an incidence of synchronous multiple tumours varying from 1.5 to 2.5 per cent and of metachronous tumours ranging from 0.5 to 7 per cent of all patients. Our series con- tained 10 examples of a second tumour of large bowel and 1 patient who had no less than three successful resections. A metachronous tumour in the stomach is rare, perhaps because of the overall gloomy prognosis of carcinoma of the stomach which leaves only a small pool of surviving patients with the possibility of further tumour formation in the gastric stump. We have one such example of a metachronous growth occurring in the gastric stump 24 years after a partial gastrectomy. The two tumours were dissimilar on histological examination (Ellis and Jayasekara, 1975).

Miss D. M., aged 45, had a papillary cysto-adenocarcinoma of the left ovary removed in 1948. This was followed by radio- therapy and she remained under review until 1970, when the gynaecologist detected a large mass in the lower right abdomen which was diagnosed as a further malignant ovarian tumour. At operation this proved to be a carcinoma of the caecum, and

Table I: FINDINGS AT ‘SECOND LOOK SURGERY’ AFTER COLORECTAL CANCER

Finding Total Good results

Non-malignant disease 4 3 (1) Second non-bowel cancer 3 Metachronous cancer 1 1 5 Local recurrence-resected 9 3 (1) Distant recurrence-resected 7 1 ( 1 ) Short circuit 4 Lauarotomv onlv 4

-

- -

Total 42 12 (3)

Figures in parentheses indicate additional early good results.

Table 11: FINDINGS AT ‘SECOND LOOK SURGERY’ AFTER OESOPHAGOGASTRIC CANCER

Finding Total Good results

Non-malignant 6 3 ( I * ) Metachronous cancer 1 Local recurrence-resected 3 1 Distant recurrence-resected 2 ( I t ) Palliative 10 Laparotomy only 3

-

- -

4 (2) Total 253:

* Patient lost to follow-up. t Early good result. 2 In 24 patients.

Table 111: FINDINGS AT ‘SECOND LOOK SURGERY’ AFTER VARIOUS CANCERS*

Finding Total Good results

Second primary elsewhere 1 1 Recurrence resected 3 1 (1)

- Palliative short circuit 3

Total 7 2 (1)

* Types of cancer: 3 ovarian, 1 pancreatic, 1 carcinoid of small intestine, 1 leiomyosarcoma of small intestine and 1 retroperitoneal xanthogranuloma. Figures in parentheses indicate additional early good result.

a right hemicolectomy was performed. She remains well 4& years later.

Mr S. P., aged 52, had a sigmoid resection for Dukes A adenocarcinoma in 1950. In 1966 he developed a well- differentiated adenocarcinoma of the rectum and underwent an abdominoperineal resection of the rectum. In February 1973, at the age of 75, he was subjected to aright hemicolectomy for a mucoid carcinoma of the caecum, and he remains well.

5. Benign lesion which mimics recurrent disease It is all too easy to consider that every symptom a patient develops after cancer surgery is attributable to recurrent disease. In the majority of cases this is probably true, but it is important to remember that a benign stricture at the anastomosis can mimic a stoma1 recurrence, intra-abdominal adhesions pro- ducing intestinal obstruction may mimic widespread tumour dissemination, a chronic sterile abscess may give the appearance of a recurrent mass, a benign cyst of the liver may be misdiagnosed as hepatic deposits, stones in the common bile duct may be mistaken for malignant jaundice, fibroids and other benign intra- abdominal masses are difficult to distinguish from tumour deposits, while intra-abdominal starch granu- lomas, which result from the reaction to glove dusting powder, may simulate carcinomatosis peritonei (Cox, 1970).

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Harold Ellis

There are 10 examples of this happy situation in the present series. In 4 patients with colorectal cancer 1 subsequently developed a twisted ovarian cyst, 1 subacute obstruction due to adhesions and 2 a benign anastomotic stricture. Three achieved long term satis- factory results and the remaining case only recently underwent operation. In 6 patients in the oesophago- gastric cancer group there was a chronic abscess of the abdominal wall, an afferent loop syndrome, func- tional obstruction at the pylorus after an upper gastric resection, a benign stoma1 ulcer and 2 examples of anastomotic stricture. Two patients developed early widespread metastatic disease, 1 patient had a recur- rence 4 years following his ‘second look operation’, 1 patient has been lost to review and 2 remain well.

Results A summary of the results in this series is given in Tables Z, ZZ and IZZ. In these tables ‘good results’ mean that the patient has survived a minimum of 2 years following the ‘second look‘ resection. Of the 42 patients with colorectal cancer, 12 achieved good long term results and 9 are still alive and well. In addition, 3 patients are alive and well less than 2 years following surgery. In the oesophagogastric group of 24 patients, 4 achieved good long term results and all of these are still alive. In addition, 1 patient is in the early postoperative period and 1 has been lost to follow-up. In the miscellaneous group of 7 patients, 2 have achieved good long term results and both are still alive. The patient with the recurrent retroperitoneal xanthogranuloma is well 10 months postoperatively (Pigott, 1975).

Conclusions The experience presented here suggests that there is much to gain if further laparotomy is advised when

features suggesting apparent recurrence occur follow- ing resection of intra-abdominal cancer. Patients with obvious disseminated disease should not, of course, be submitted to further surgery. Occasionally, a com- pletely benign situation may be found which is entirely curable, and this possibility alone is probably worth all the endeavour. However, long term survival may follow resection of a new primary or the removal of a localized recurrence. Even if resection is impossible, obstructive symptoms may be relieved by a short circuit, intubation or a palliative colostomy. If the laparotomy reveals a hopeless state of affairs, at least both the patient and his relatives have the satisfaction of knowing that the surgeon has spared no effort before giving the final hopeless prognosis.

References cox K. R. (1970) Starch granuloma (pseudo-malignant

seedlings). Br. J . Surg. 57, 650-653. DUNPHY J. E. (1959) Metastatic and recurrent cancer

of the colon and rectum: surgical significance and management. Dis. Colon Rectum 2, 77-81.

ELLIS H. (1974a) Prevention of recurrent cancer of the large bowel. Proc. R. SOC. Med. 67, 857-858.

ELLIS H. (1974b) Second look surgery for suspected recurrences in cancer of the large bowel. Cancer Treatment Rev. 1, 205-220.

ELLIS H. and JAYASEKARA G. (1975) Is ‘second look surgery’ justified in suspected recurrences of cancer of the stomach? Br. J. Surg. 62, 226-230.

ELLIS H. and STOKER T. A. M. (1972) ‘Second look’ operation for ovarian dysgerminoma. Postgrud. Med. J. 48, 59-61.

PIGOTT H. w. s. (1975) Recurrent retroperitoneal xanthogranuloma. Proc. R. SOC. Med. In the press.

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