Ouchi et al. Surgical Case Reports (2015) 1:7 DOI 10.1186/s40792-014-0011-3

REPORT Open Access

Staple-line recurrence arising 10 years afterfunctional end-to-end anastomosis for coloncancer: a case reportAkira Ouchi*, Masahiko Asano, Keiya Aono, Tetsuya Watanabe and Shingo Oya

Abstract

We report a rare case of late staple-line recurrence arising 10 years after functional end-to-end anastomosis forsplenic flexure colon cancer. An 80-year-old man, who underwent partial colectomy with functional end-to-endanastomosis for splenic flexure colon cancer 10 years earlier, presented with a chief complaint of anorexia.Complete blood count showed anemia, and the fecal occult blood test was positive. Lower gastrointestinal seriesshowed an irregular defect of the splenic flexure, and colonoscopy showed an ulcerated tumor on the staple lineof the primary surgery. Partial colectomy was performed, and the tumor was pathologically diagnosed as moderatelydifferentiated tubular adenocarcinoma, resembling the pathology of primary colon cancer. This case suggests theimportance of considering staple-line recurrence after functional end-to-end anastomosis for colon cancer evenmore than 5 years after primary surgery.

Keywords: Staple-line recurrence; Colon cancer; Functional end-to-end anastomosis

BackgroundMechanically stapled anastomosis (MSA) is a widely usedtechnique in various digestive surgeries, and functionalend-to-end anastomosis (FEEA) is often used in lowergastrointestinal surgeries. Several studies have reportedthat FEEA commensurates the surgical technique ofsurgeons and decreases anastomotic leakage, the risk ofsurgical site infection, and the surgery time [1,2]. FEEAis an easy and safe technique compared with conventionalhand-sewn anastomosis; and in recent years, it has beenused by many surgeons for reconstruction after a lowergastrointestinal surgery.Meanwhile, it is presumed that FEEA occasionally causes

staple-line recurrence, which is due to the implantation offree intraluminal cancer cells [3]. Staple-line recurrenceoccurs few years after primary surgery, and careful follow-up is required during this period. We report a rare case oflate staple-line recurrence arising 10 years after FEEA forsplenic flexure colon cancer. This case report highlightsthe importance of considering staple-line recurrence

* Correspondence: akira.ouc@gmail.comDepartment of Surgery, Chita City Hospital, 2-1 Nagai, Shinchi, Chita, Aichi478-8640, Japan

© 2015 Ouchi; licensee Springer. This is an OpeAttribution License (http://creativecommons.orin any medium, provided the original work is p

and a careful follow-up for patients with FEEA for coloncancer.

Case presentationAn 80-year-old Japanese male, with a history of hyperten-sion, had undergone partial colectomy with FEEA usingautosutures (Endo GIA™, Covidien, Ireland) for splenicflexure colon cancer and distal gastrectomy with hand-sewn retrocolic Billroth-II gastrojejunostomy 10 years be-fore. Pathological examination had revealed moderatelydifferentiated tubular adenocarcinoma with KRAS wild-type, positive immunohistochemical staining for p53 andcdx2, negative for CD10 and MUC5AC, invading the sub-serosa without lymph node metastases. The cancer wasresected with distal and proximal margin of each 10 cm,and no tumor cells had been identified at the surgicalmargins. Carcinoembryonic antigen (CEA) and carbohy-drate antigen 19–9 (CA 19–9) were within the normalrange. He had been well without any signs of locoregionalrecurrence and distant metastases. He had undergone thelatest colonoscopy 7 years before and contrast-enhancedcomputed tomography (CECT) 5 years before.The patient presented to our clinic with a chief com-

plaint of anorexia. He had slight conjunctival pallor, and

n Access article distributed under the terms of the Creative Commonsg/licenses/by/4.0), which permits unrestricted use, distribution, and reproductionroperly credited.

Figure 2 Colonoscopy showed an ulcerated macroscopic type 2tumor on the staple line (arrows).

Ouchi et al. Surgical Case Reports (2015) 1:7 Page 2 of 5

a complete blood count and blood biochemistry showeda low red blood cell count (397 × 104/mL) and a lowhemoglobin count (12.9 g/dL). CEA and CA 19–9 werewithin the normal range. We performed a fecal occultblood test twice, and it was positive on both occasions.We suspected metachronous colorectal cancer andperformed lower gastrointestinal series and colonoscopyfor further examination. Lower gastrointestinal seriesshowed an irregular defect of the splenic flexure nearthe anastomosis line of the primary surgery (Figure 1),and colonoscopy showed an ulcerated macroscopic type 2tumor on the staple line of the primary surgery (Figure 2).Pathological examination of a biopsy specimen obtainedby colonoscopy revealed moderately differentiated tubu-lar adenocarcinoma. CECT showed a colon tumor of thesplenic flexure at the staple line, but no distant metasta-ses were found (Figure 3). The suspicion of staple-linerecurrence after FEEA of the primary surgery was con-firmed, and we performed open partial colectomy forradical resection. For reconstruction after partial colec-tomy, we performed hand-sewn end-to-end colocolost-omy by the Gambee method using 3–0 Vicryl™ (EthiconEndo-surgery; Johnson & Johnson K.K., USA). The sur-gery time was 159 min, and blood loss was 250 g. Aresected specimen during the surgery contained an ul-cerated macroscopic type 2 tumor, 4 × 4 cm in diameter,destructive of crossed staple line (Figure 4). A patho-logical examination revealed moderately differentiatedtubular adenocarcinoma, invading the subserosa (Figure 5).The pathology of resected specimen resembled thepathology of primary colon cancer with KRAS wild-type, positive immunohistochemical staining for p53and cdx2 and negative for CD10 and MUC5AC (Figure 6).We thus finally diagnosed the patient with staple-linerecurrence, arising 10 years after FEEA of the primarysurgery.

Figure 1 Lower gastrointestinal series showed an irregulardefect of the splenic flexure (arrows).

Although the patient developed symptomatic anasto-motic leakage (Clavien-Dindo Grade IIIA; [4]), he im-proved after treatment with percutaneous drainage andwas discharged from the hospital 45 days after the sur-gery in good health. The patient underwent a colonos-copy 12 months after the secondary surgery, and thecolonoscopy showed no signs of anastomotic recurrence.He has remained well without any signs of further recur-rence at the 15-month follow-up.

DiscussionLocoregional recurrence is the most frequent recurrencein patients with resected colon cancer apart from livermetastasis and lung metastasis [5]. Locoregional recur-rence is classified as either local recurrence or regional re-currence. Local recurrence is defined as tumor regrowthat anastomosis or immediately within or contiguous to the

Figure 3 Contrast-enhanced computed tomography (CECT)showed a splenic flexure colon tumor at the staple line (arrows).

Figure 4 A resected specimen contained an ulcerated macroscopic type 2 tumor destructive of crossed staple line.

Figure 5 Pathological examination revealed moderatelydifferentiated tubular adenocarcinoma (H.E. stain; a × 4, b × 40).

Ouchi et al. Surgical Case Reports (2015) 1:7 Page 3 of 5

operative area, and the tumor regrowth at anastomosis isusually called anastomotic recurrence [6]. The mechanismof tumor regrowth in anastomotic recurrence is as follows:free intraluminal cancer cells of colonic origin penetratethrough watertight anastomoses, implant on the anasto-motic surface, and initiate tumor regrowth [3]. MSA suchas functional end-to-end anastomosis or double staplingtechnique (DST) reportedly has a higher risk of anasto-motic recurrence (in particular, staple-line recurrence)than hand-sewn anastomosis [7-9]. However, the reasonfor the high recurrence rate in MSA is unclear. Intraoper-ative intestinal irrigation reportedly reduces staple-line re-currence with DST for rectal cancer and now is widelyperformed [10]. In contrast, intraoperative intestinal irri-gation is not often performed during FEEA for colon can-cer mainly because of the challenging procedure and thehigh risk of surgical field contamination. Hasegawa et al.reported that surgical bowel occlusion around the tumorand intraluminal lavage can prevent or eliminate exfoli-ated malignant cells at anastomotic sites [11], but it is un-clear whether intraoperative intestinal irrigation in FEEAfor colon cancer decreases staple-line recurrence. Tilldate, there are no recommendations on how to decreasestaple-line recurrence with FEEA for colon cancer.Most postoperative recurrences in patients with resected

colon cancer occur during the first 5 years; especially,almost all staple-line recurrences occur within the first3 years after primary surgery [12,13]. In many countries,the follow-up period in patients with resected coloncancer is 5 years, similar to Japan [14-16]. There are fewreports on late recurrence, including staple-line recur-rence, of colon cancer more than 10 years after primary

Figure 6 The pathology of resected specimen (a) resembled the pathology of primary colon cancer (b).

Ouchi et al. Surgical Case Reports (2015) 1:7 Page 4 of 5

surgery. To the best of our knowledge, this is the firstreport on late staple-line recurrence arising 10 yearsafter FEEA for colon cancer.Colonoscopy is useful for finding staple-line recurrence

after FEEA for colon cancer, and it is recommended forsurveillance in patients with resected colon cancer inaddition to history taking, physical examination, CEAmeasurement, and CECT scan in several guidelines[14-16]. For example, NCCN clinical practice guidelinesfor colon cancer suggest that patients with resectedcolon cancer should undergo colonoscopy 1 year afterprimary surgery and the subsequent examination is rec-ommended 3 years from first examination, if normal,and the third examination 5 years from the secondexamination, if normal. Colonoscopy at this stage, how-ever, is not performed for the detection of locoregionalrecurrence of primary cancer, enabling curative treatment,but it is performed for the detection of metachronouscolorectal cancer [17]. Several randomized controlled tri-als of intensive surveillance with colonoscopy and meta-analyses of these trials have shown no survival benefitfrom primary cancer by performing colonoscopy at annualor shorter intervals; therefore, the goal of surveillance withcolonoscopy in patients with resected colon cancer is todetect metachronous colorectal cancer at an early stage[18-23]. Routine colonoscopy is not appropriate in all pa-tients with resected colon cancer to detect staple-line recur-rence after FEEA considering the relatively low incidence ofstaple-line recurrence in colon cancer. To detect staple-linerecurrence after FEEA, careful work-ups must be per-formed only on patients with a history of resected coloncancer who complain of any digestive organ symptoms.

ConclusionsOur case suggests the possibility of late staple-line recur-rence after FEEA for colon cancer even more than 5 years

after primary surgery. Consideration of staple-line recur-rence and careful work-up is important when patientswith FEEA for colon cancer complain of any digestiveorgan symptoms.

ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsMA, KA, TW, and AO diagnosed and performed operation of our patient. Themanuscript was prepared by AO under the supervision of SO. All authorsread and approved the final manuscript.

AcknowledgementsWe thank Dr. Yoshikazu Mizoguchi (Banbuntane Hotokukai Hospital, Departmentof Diagnostic Pathology II) and Dr. Midoriko Watanabe (Chita City Hospital,Department of Diagnostic Pathology) for pathological diagnosis of primarycolon cancer and local recurrence. We thank Crimson Interactive Pvt. Ltd.for providing English proofreading of our manuscript.

Received: 25 August 2014 Accepted: 22 December 2014

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