**4.2 Tumor perforation with the peritoneal syndrome**

Perforation followed by localized or generalized peritonitis is the second most common cause of complications in transverse colon cancer [3, 28].

Due to generalized peritonitis, septic shock, and multiple organ failure (MSOF), the patient becomes hemodynamically and respiratory unstable, leading to postoperative management governed by other principles, namely hydro electrolytic rebalancing and stabilization, exploratory laparotomy, identification of exact perforation site, and rapid surgical gestures.

Perforations in this situation are frequently diastatic and the most frequent localization is in the cecum region. In this situation, subtotal colectomy is required, followed by ileosigmoid anastomosis. In some rare cases, there is the possibility of parietal perforation through tumor necrosis and localized peritonitis, which prolongs the patient's addressability to the doctor. This situation is more common with the transverse colon or splenic flexure. However as long as the general condition of the patient is stable, a limited resection such as transversectomy can be attempted, but with the establishment of a diversion colostomy or by emptying the colon on the operating table with a first intent digestive anastomosis being recommended especially by Asian authors [28].

The hemorrhagic syndrome represents the 3rd emergency form of transverse colon cancer, the rarest form being an uncompensated hypovolemic shock with hemodynamic instability [28].

The presence of hemorrhage in cancer pathology is common in about 50% of cases [28]. The general form of manifestation, however, is occult hemorrhage, with minimal blood loss that does not suddenly undermine the patient. Thus, exsanguinating shock is rare [3].

If the endoscopic intervention cannot stop the hemorrhage or if embolization is not successful, then resection surgery is required when more than 6 units of blood [31] are transfused, followed by either a double colostomy or an anastomosis depending on the patient's hemodynamic stability [3, 28].
