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.