Discussion
Patients suffering from colorectal malignancy most of the time require surgery as a part of treatment; however, there might be other comorbidities contradictory to surgery. Similarly, patients with severe coronary artery disease require surgery, but it can be problematic if the patient has other health conditions. Patients having both CAD and colon cancer are always a challenge for physicians since these two conditions are contradictory to each other. There are high risks in both surgeries, and for patients having two diseases consecutive surgeries can be associated with extremely high risk of lethality. In these situations, simultaneous surgery can help to avoid many risks. Although simultaneous surgeries can be very attractive in some cases, the most important thing to consider is the general state of each individual patient and possible complications related to age, sex and other health conditions.
In a study by Garatti et al. (2020) out of 4079 patients referred for cardiac surgery, 103 of them (2,5%) had a history of cancer [1]. There are no guidelines of the treatment of these patients. Literature search reveals numerous cases of different treatment tactics. In one case, a patient with colon cancer and heart tumor underwent anterior resection for sigmoid tumor and two weeks after the first surgery he had a heart surgery with a good outcome [2]. In another study, Komarov et al. (2023) described a series of 9 patients, which underwent simultaneous surgery. There was no difference in outcomes of two types of treatment. However, this result is not statistically significant due to very low number of patients [3].
In the decision-making process with such patients, it is important to treat each one individually. For example, two-stage surgery was not feasible for our patient, because the patient already had a bleeding from patient’s rectal tumor, and usage of heparin during CABG would most likely lead to lethal outcome. On the other hand, patient’s coronary arteries stenosis was so critical, that the risk of lethal outcome with colon surgery was too high. Another possible way of treatment was performing percutaneous transluminal coronary angioplasty (PTCA) prior to colon surgery. However, as mentioned before, since patient was bleeding from tumor side, this way of treatment was excluded. In addition, the study by Marcucci concluded that coronary stenting increases the risk of ischemic cardiac event during the following surgery, even with recommended 6-weeks interval [4]. Chassot et al. (2002) suggested that optimal time between PCI and surgical intervention is 3 months, which minimizes the risk of in-stent thrombosis [5].
Other sources recommend CABG as a first step of treatment, but this would prolong recovery time, during which tumor can spread.
Therefore, today numerous studies recommend simultaneous surgery as the best way of treating patients with concomitant disease. With improvement of surgeons’ technique and development of surgical instrumentation, simultaneous surgeries are becoming more and more practiced worldwide. For heart and lung disease, simultaneous surgeries are very well practiced and almost became a standard treatment [6].
It can be seen how little is known of how such patients should be taken care of. Another possible concern among surgeons is an addition of clean-contaminated surgery to cardiac surgery, which could possibly increase the risk of infections and sepsis. However, no data was found in literature, and our patient did not have any infection. We conclude that following clear recommendations about sterilization techniques, surgical techniques, antibiotic prophylaxis, and wound care can adequately prevent development of infectious process.
During simultaneous surgeries on heart and colorectal cancer there is a discussion of whether to use off-pump or on-pump surgery due to the possible risk of tumor spread. However, it was shown by other studies that using CPB (cardiopulmonary bypass) does not carry any risk of disease spreading [7]. In addition, other sources confirm a better result of the off-pump and on-pump coronary artery bypass grafting compared to percutaneous coronary intervention  [8]. Another study indicated that off-pump heart surgery does help to avoid possible tumor spread [9].
Today, the survival rate after simultaneous surgeries is very much dependent on the nature and stage of tumor [10]. The relatively poor prognosis of patients with lung and gastrointestinal disease and relatively good prognosis of patients with kidney tumor suggests that the survival of patients depends very much on the biology of malignancy.