Flexure Of Colon Research Articles

Duodeno-Colonic Fistula Associated With an Intestinal Large B-Cell Lymphoma

Enterocolic fistulae are usually caused by conditions such as Crohn's disease and diverticulitis. Less commonly, it can also be seen in the setting of prior surgeries, foreign bodies, pancreatitis, or malignancy. Here we reported a rare case of a spontaneous duodeno-colonic fistula caused by intestinal large B-cell lymphoma. This is a 69 year old male with a history of diabetes mellitus who presented with diarrhea and weight loss of 20 pounds for 5 weeks. He described rapid onset of 5 to 6 daily episodes of non-bloody watery stools associated with nausea, but no vomiting, abdominal pain or fever. There was no recent use of antibiotics, no recent travel or sick contacts. He has no history of Crohn's disease or diverticulitis. He was afebrile and physical exam is unremarkable. Laboratory testing revealed normal complete blood count, electrolytes, serum calcium, thyroid-stimulating hormone, and hepatic panel. A computed tomographic (CT) scan of the abdomen showed mild wall thickening and stranding surrounding the proximal duodenum and the splenic flexure of colon that was measuring up to 15 mm in diameter and multiple enlarged lymph nodes within the mesentery. Additionally, there was suggestion of a duodeno-colonic fistula. An upper endoscopy and colonoscopy were performed. Upper endoscopy revealed a fistulous tract in the transverse duodenum with refluxing of stool, however no duodenal mucosal mass seen. On colonoscopy, a large infiltrative mass with fistula near the splenic flexure was identified, but the mass was not transferable to the proximal colon. Histology was consistent with diffuse large B-cell lymphoma which stained negative for CD3 strongly positive for CD20. The patient was taken to the operating room with colorectal and hepatobiliary surgery with plans for an en bloc left colectomy, partial gastrectomy and small bowel resection and partial pancreatectomy. His post-operative course was complicated by a pancreatic duct leak which is well managed with a percutaneous drain and he will soon be initiated chemotherapy. For sudden onset of diarrhea with associated systemic symptoms suspicious for an underlying organic cause, imaging and endoscopic evaluation should be considered. The initial treatment of enterocolic fistulae is to correct fluid and electrolyte abnormalities, but in our case, oncologic treatment of B cell lymphoma could not be initiated until after surgical resolution of nutrient wasting diarrhea.1610_A Figure 1. CT showed colonic wall thickening with possible duodeno-colonic fistula1610_B Figure 2. Colonoscopy showed a large infiltrative mass with fistula near the splenic flexure.1610_C Figure 3. Pathology showed colonic mass with fistula is identified extending from the colonic mucosa to the duodenal mucosa.

A unique case of mixed phenotype acute leukemia with t(9;22)(q34.1;q11.2);BCR-ABL1 sarcoma with epitheliotropism mimicking intestinal T cell lymphoma

Myeloid sarcomas and extramedullary manifestations of mixed phenotype acute leukemia (MPAL) without leukemic involvement are rare. We present an unusual case of myeloid sarcoma of T/myelomonocytic biphenotypic nature and BCR-ABL1 translocation demonstrating an epitheliotropism in the gastrointestinal tract and mass-forming lesions in the lungs without bone marrow involvement. A 69-year-old gentleman presented with non-bloody diarrhea and abdominal pain complicated by weight loss. CT scan showed diffuse mural thickening in the jejunum, distal ileum, transverse colon, and splenic flexure and bilateral pulmonary nodules. Biopsies of the ileum and colon were performed. An initial diagnosis of T cell lymphoma was made based on intestinal infiltration with CD4 and CD7 positive monomorphic atypical cells. Despite treatment, the patient’s lung masses grew. A comprehensive immunohistochemistry panel was performed on the lung biopsy based on the classic morphologic appearance of sheets of atypical cells and that CD4 and CD7 are also expressed in a subset of myeloid cells. The panel demonstrated CD34 (subset), CD68, muramidase/lysozyme, and CD117 expressions. Flow cytometry showed an aberrant myelomonocytic population. The presence of T lineage blasts was confirmed by a subset of blasts with cytoplasmic CD3. The diagnosis of mixed phenotype T/myeloid sarcoma with myelomonocytic differentiation and t(9;22)(q34.1;q11.2);BCR-ABL1 was made. Epitheliotropism has not been previously described as a histologic feature of intestinal myeloid sarcomas. The epitheliotropism, enteropathy-like features and gastrointestinal symptoms mimicked T cell lymphomas. This case highlighted the pivotal role of flow cytometry and clinicopathological correlation in making a diagnosis of myeloid sarcoma with MPAL phenotype.

Abstract 673: Preoperative radiation therapy in advanced carcinoma colon with post-colostomy intestinal obstruction: The first report

Abstract Introduction We report the use of preoperative radiotherapy in a moribund patient with advanced carcinoma colon with complete intestinal obstruction who had undergone colostomy for a previous episode of intestinal obstruction. Methods Fifty-five-year-old man presented in Dec 2016 with acute intestinal obstruction with pain in abdomen and vomiting for 3 months. On exploratory laparotomy, a 12x15 cm hard mass in splenic flexure of colon was found involving root of mesentery, superior mesenteric vein and third part of duodenum and abutting tail of pancreas. Finding it unresectable, loop transverse colostomy was performed. He was started on Capecitabine. In Mar 2017, he presented to us in emaciated condition weighing 28 kilograms with acute intestinal obstruction with a large abdominal mass. He was started on nasogastric aspiration with total parenteral nutrition. Imaging revealed a 14x19 cm large abdominal mass involving pancreas, duodenum, spleen and transverse colon with dilated stomach. In view of poor general condition and advanced disease, the prognosis was discussed with the family and the idea of radiotherapy to relieve intestinal obstruction was discussed with family. After taking the consent, he was started on radiation therapy with 1.8 Gy per fraction after three-dimensional conformal radiation planning to spare maximum bowel. After 11 fractions, the patient started passing stools through the stoma. He was gradually started on enteral nutrition and was discharged to continue radiation therapy on outpatient basis. After 15 fractions, planning PET-CT scan was taken for adaptive therapy to make changes as per the reducing tumor size. He was also started on capecitabine as he was taking orally well. He completed 45 Gy in 25 fractions over 5 weeks. One month after completion of radiation therapy, he was found to be doing well and was planned for definitive surgery. Six weeks after the radiation therapy completion, extended left hemicolectomy with distal pancreatico-splenectomy and colostomy closure was performed. Histopathology showed residual viable poorly differentiated adenocarcinoma invading full thickness of colonic wall into pericolic soft tissues with a discontinuous microscopic nodular tumor deposit in pericolic soft tissue with all margins and nodes negative. Postoperatively, he developed biliary leak which healed with conservative management. Six weeks after the surgery, he recovered completely and was started on adjuvant Capecitabine. Five months after the surgery, he is doing well and is on oral Capecitabine. Conclusion To our knowledge, this is the first reported case of preoperative radiation therapy in advanced carcinoma colon and also in the setting of intestinal obstruction. Radiotherapy should be further tested in setting of malignant intestinal obstruction due to unresectable carcinoma colon and may spare patients with ileo/colostomy. Citation Format: Amit Jain, Elumalai L, Punam Goswami. Preoperative radiation therapy in advanced carcinoma colon with post-colostomy intestinal obstruction: The first report [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 673.

Laparoscopic radical treatment with preservation of left colon artery and superior rectal artery for sigmoid colon cancer

During the classical radical treatment for sigmoid colon cancer, ligation of the inferior mesenteric artery (IMA) at its root is typically performed to achieve better dissection of central and intermediate lymph node groups and improve the surgical outcomes. However, the blood supply to the left colon artery (LCA), sigmoid artery, and superior rectal artery (SRA) is blocked after the ligation at the root of the IMA. Here, we report laparoscopic radical treatment with preservation of the LCA and SRA for sigmoid colon cancer to preservation of blood supply to the anastomosis. The method was indicated to treat cancer at the middle portion of sigmoid colon. In the operation, we careful dissection of IMA exposes the trunk of IMA. The surrounding lymphatic tissue is dissected from the IMA root to its distal end. The LCA is preserved. After IMA divides LCA, 2–5 sigmoid colon arteries are transected one after another at the distal end of the LCA until it further divides into left and right rectal arteries before entering the lateral wall of rectum. The inferior mesenteric vein (IMV) is transected at the lower edge of the pancreas, and the mesorectum is cut open towards the spleen curvature at the lower edge of the pancreas. Other procedures are similar with IMA high ligation surgery. Generally, LCA and SRA can be successfully preserved, and if necessary, the colonic splenic flexure should be mobilized to ensure that there is no tension at the anastomosis. The operation doesn’t significantly prolonged operation, but retrieved comparable lymph node counts with IMA high ligation surgery. Dissection of the lymphoadipose tissues at the root of IMA with the preservation of LCA and SRA is an easily performed surgery. It guarantees further prospective clinical research to compare the anastomosis leakage and oncological outcome with IMA high ligation surgery.

Clinical Significance of Lymph Node Metastasis in the Mesentery of the Terminal Ileum in Patients With Right-sided Colon Tumors at Different Locations.

There are limited reports on peri-ileal lymph node metastasis in patients with right-sided colon cancer, and little is known about their clinical significance. This study aimed to examine the role of tumor location in the prevalence and clinical significance of peri-ileal lymph node metastasis in patients with right-sided colon cancer. This is a retrospective study from a prospective cohort database. The study was conducted at a tertiary referral hospital. Patients with right-sided colon cancer treated with radical surgery in a hospital between May 2006 and September 2016 were included. The frequency of peri-ileal lymph node metastasis in the study cohort and the role of tumor location and the clinical characteristics of patients with peri-ileal lymph node metastasis were determined. We examined 752 cases with right-sided colon cancer including 82 cecal, 554 ascending colon, and 116 hepatic flexure cancer. Twenty patients (2.7%) had peri-ileal lymph node metastasis. The incidence of metastasis to peri-ileal lymph nodes was 7.3% (6/82) in patients with cecal cancer, 2.2% (12/554) in patients with ascending colon cancer, and 1.7% (2/116) in patients with hepatic flexure cancer. Three patients had stage III cancer and 17 had stage IV. All 3 patients with positive peri-ileal lymph nodes and stage III cancer had cecal tumors. In contrast, all patients with ascending colon or hepatic flexure cancer and positive peri-ileal lymph nodes had stage IV cancer. The results were limited by the retrospective design of the study and the small number of patients with peri-ileal lymph node metastasis. Peri-ileal lymph node metastasis was rare even in right-sided colon cancer and occurred mainly in stage IV. However, it occurred in some patients with locally advanced cecal cancer. These results suggest that optimal resection of the mesentery of the terminal ileum might have clinical benefit, especially in curative surgery for cecal cancer. See Video Abstract at http://links.lww.com/DCR/A556.

Laparoscopic radical treatment with preservation of left colon artery and superior rectal artery for sigmoid colon cancer

: During the classical radical treatment for sigmoid colon cancer, ligation of the inferior mesenteric artery (IMA) at its root is typically performed to achieve better dissection of central and intermediate lymph node groups and improve the surgical outcomes. However, the blood supply to the left colon artery (LCA), sigmoid artery, and superior rectal artery (SRA) is blocked after the ligation at the root of the IMA. Here, we report laparoscopic radical treatment with preservation of the LCA and SRA for sigmoid colon cancer to preservation of blood supply to the anastomosis. The method was indicated to treat cancer at the middle portion of sigmoid colon. In the operation, we careful dissection of IMA exposes the trunk of IMA. The surrounding lymphatic tissue is dissected from the IMA root to its distal end. The LCA is preserved. After IMA divides LCA, 2–5 sigmoid colon arteries are transected one after another at the distal end of the LCA until it further divides into left and right rectal arteries before entering the lateral wall of rectum. The inferior mesenteric vein (IMV) is transected at the lower edge of the pancreas, and the mesorectum is cut open towards the spleen curvature at the lower edge of the pancreas. Other procedures are similar with IMA high ligation surgery. Generally, LCA and SRA can be successfully preserved, and if necessary, the colonic splenic flexure should be mobilized to ensure that there is no tension at the anastomosis. The operation doesn’t significantly prolonged operation, but retrieved comparable lymph node counts with IMA high ligation surgery. Dissection of the lymphoadipose tissues at the root of IMA with the preservation of LCA and SRA is an easily performed surgery. It guarantees further prospective clinical research to compare the anastomosis leakage and oncological outcome with IMA high ligation surgery.

Iatrogenic spleen injury risk during robotic left colonic and rectal resections by routine left flexure mobilization technique: a retrospective study.

The routine mobilization of the left colonic flexure as a standard procedure during left colonic/rectal resection is a controversial topic in open and minimally invasive surgery. According to some authors, this maneuver may increase the risk of iatrogenic spleen damage; for others this does not change the odds. Ligaments over-traction is the most frequent injury mechanism. Some documented risk factors are reported: laparotomic approach, male gender, vascular disease, cancer, diverticulitis, surgery performed in emergency-setting. The type of procedure influences the associated risk: transverse colectomy is the riskiest, followed by left colonic resection and pancolectomy. Retrospective original paper. Sample size - a total of 125 patients have been considered. 75 robotic left colonic resections (60%), 40 robotic rectal resections (32%) and 10 robotic pancolectomy (8%). Primary outcomes - 1) percentage of iatrogenic splenic injuries; 2) conversion rate. Secondary outcomes - 1) intra-/postoperative complications; 2) anastomotic leakage rate; 3) mortality. In order to avoid potential confounding factors and technical/expertise heterogeneity, all the procedures included have been performed using the same standardized operative technique and by the same experienced surgeon (P.C.G.). We retrospectively analyzed 125 procedures. Primary outcomes - 1) iatrogenic splenic injuries: 0%; 2) conversion rate: 1.6%. Secondary outcomes - 1) intraoperative complications: 0%; 2) anastomotic leakage rate: 1 case of leakage out of 125 cases (1.3% of the left colectomy sub-sample); in this case the leakage was probably due to an infectious process rather than a vascular deficit; 3) mortality: 0%; 4) miscellanea postoperatory complications (small bowel obstructions, wound infection, pelvic collections, pneumonia and acute kidney injury) are detailed in the manuscript. In our experience, and according to some of the literature data as well, during robotic left colonic/rectal resections the routine mobilization of the left flexure as a standard procedure is not a risk factor in terms of iatrogenic spleen injury rate. Conversely, this technique may be beneficial as it does not excessively extend the operative time, increases the surgical skills acquirement, and reduces the tension-related anastomotic ischemia. It also allows a better oncological dissection. Standard laparoscopic approach reduces the rate of spleen by almost 3.5 times in comparison to open surgery. The improved technical accuracy provided by the robotic platform may decrease the rate of splenic injury. More studies are needed on the topic to confirm our findings.

Outcomes in left versus right metastatic colorectal cancer (mCRC) in patients presenting to an inner-city safety net hospital.

e15542 Background: Studies have shown that patients with left sided colon cancer (L-CRC) have better survival than the right sided ones. However, only few studies focused on minority population. We aim to assess the difference between left versus right sided colon cancer in an inner-city safety net hospital which has a significant proportion of minorities Methods: This is a retrospective study of 105 patients with mCRC who presented to the Medical Oncology clinic of John H Stroger Jr. Hospital of Cook County, Chicago from 2012-2014. Only those who were tested for KRAS mutation were included. Right colon cancer (R-CRC) was defined as tumor located in ascending colon and hepatic flexure. L-CRC were those arising in splenic flexure, descending colon and rectum. Chi-Square was used for categorical variables. Progression free survival (PFS) and overall survival (OS) were analyzed by Kaplan-Meier method, log-rank test and Cox proportional hazards regression models Results: Of the total population, 60.9% were African American (AA), 51.4% males, 48.5% R-CRC, 42.8% L-CRC, 5.7% Transverse-CRC, 3.8% Multicentric-CRC and 68.6% (n = 72) had documented progression. R-CRC showed poorer PFS compared to the left (median PFS 9.1 mo versus 15.1 mo, P = 0.003) but similar OS. KRAS mutation was found in 50.4% of the patients and the rate was higher in AA compared to Caucasians (57.8% versus 22.2%, P = 0.007). It was associated with a better PFS (HR 0.60; 95% CI 0.37, 0.98; P = 0.04) and a higher rate of lung metastasis on presentation (34.6% versus 16.9%, P = 0.03). There was no difference of KRAS mutation prevalence between R-CRC and L-CRC. In addition, having metastases at sites other than liver or lung at presentation was associated with worse PFS (HR 1.90; 95% CI 1.15, 3.14; P = 0.012) and OS (HR, 3.15; 95% CI 1.28, 7.78; P = 0.013) Conclusions: In our inner-city patient population presenting with metastatic CRC, right-sided tumor location and having metastases at sites other than liver or lung at presentation were associated with worse PFS, whereas KRAS mutation was associated with better PFS. Also, AA were more likely to have mutated KRAS than Caucasians, half of whom were Polish in our population

Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results.

To assess the frequency, risk factors and outcomes of iatrogenic spleen injury during minimally invasive colo-rectal surgery with a particular focus on the routine splenic flexure mobilization tehcnique. Exclusion criteria: 1) topic not pertinent to the main topic of the review; 2) all case reports, editorials, conference highlights were excluded. After a title and abstract first selection and a final full-text analysis has been performed. The results of the selected articles are presented. The iatrogenic splenic injury rate during colorectal surgery is 0.96%. The iatrogenic injuries cause around 20% of all splenectomy. Ligaments over-traction is the most frequent mechanism of damage. The routine splenic flexure mobilization is a matter of scientific debate. Risk factors - open surgery, male sex, peripheral vascular disease, malignant neoplasia, diverticulitis, emergency surgery and teaching-hospital status. There is a risk difference according to the procedure: transverse colectomy has the highest risk, followed by left colectomy and total colectomy. The routine mobilization of the left colonic flexure is a debated topic. However, according to some authors (including our experience), this procedure is not a risk factor and it may be advantageous: 1) it does not excessively prolong the total operative time; 2) better surgical skills development; 3) the tension-related ischemia is avoided; 4) wider oncological dissection. Technical accuracy with cautious dissection/visualization can reduce the rate of iatrogenic splenic damage. Laparoscopy decreases the rate of splenic injury by almost 3.5 times. Robotic surgery may have the potential to further reduce this complication, but more data are needed on the topic.

Toothpick injury mimicking acute cholecystitis

Introduction: Accidental foreign bodies ingestion is common in emergency department. However, if the objects are sharp, the complication rate is higher. Toothpick can cause severe complications of gastrointestinal tract due to being long, sharp ends on both sides, slender, and resistant to digestion. Case presentation: A 64-year-old man presented to the emergency department with fever and right upper abdominal pain for 3 days. The physical examination revealed severe pain with rebound tenderness in the right upper abdominal quadrant and positive Murphy’s sign. The provisional diagnosis of acute cholecystitis was made. The contrast abdominal-pelvic computed tomography scan revealed linear-shaped lesion penetrating hepatic flexure of colon and proximal transverse colon. The patient showed deterioration of vital sign, and therefore, emergency laparotomy was performed. Colon perforation by wooden toothpick was diagnosed. Discussion and conclusion: Toothpick ingestion without awareness is rare but fatal, especially when physicians failed to suspect foreign body ingestion. We think of this as one of the differential diagnoses, so we use contrast computed tomography scan.

Atresia of the Colon: Etiological Aberrations, Clinical Observations, and Challenges in Management

Objective: The objective of this study is to review the clinicoradiological profile, scheme of management and the outcome in cases of colonic atresia (CA), and ascertain an optimal approach for the treatment of CA to minimize morbidity and mortality. Design and Setting: This was a retrospective observational study carried out at a tertiary health‑care center. Duration: Total of 6 years duration (January 2011–December 2016).Materials and Methods: A retrospective analysis of 10 patients of CA managed over a 6- year period. Data related to demographics, clinical presentation, associated anomalies, radiologic, intraoperative findings, postoperative stay, complications, and outcome were analyzed.Results: There were three cases of Type II atresia involving terminal ileum, cecum, and adjacent colon. Three cases had proximal ascending colon atresia (Type IIIa [n = 2]; Type I [n = 1]) Type I [n=1], and two cases of type IIIa atresia of the hepatic flexure. Two babies had atresia involving the sigmoid colon; one had Type II atresia, while we were unable to assign a type to the other within the prevailing classification. Seven babies were initially treated with a stoma either in the ileum (n = 3), hepatic flexure (n = 2), and sigmoid colon (n = 2), whereas three were treated with a primary anastomoses. Cases treated with a primary anastomoses had lesser morbidity and a better outcome than those with an ileal or ascending colon stoma.Conclusion: Contrary to the theory of an acute antenatal vascular accident, CA may rarely result from a gradual, sequential obliteration of mesenteric vasculature. Primary anastomosis should be contemplated in proximal CA wherever possible as stomal complications, especially high stoma output can result in considerable morbidity.

Early experience of laparoscopic assisted right hemicolectomy: a single-center analysis

Background: Laparoscopic colon surgery has been currently accepted as an alternative to open surgery for colon cancer. the laparoscopic approach, also, has been shown to offer clear evidence of benefit when compared to open surgery.Methods: From July 2013 to July 2016, patients admitted via the outpatient clinics of Menofia University Hospital for elective right hemicolectomy of proved malignancy of the cecum, ascending colon, and hepatic flexure of colon were evaluated for eligibility in this study.Results: The study consisted of 22 patients; of them 13 were males (59.1%) and 9 were females (40.9%) patients, with a mean age of 43±9 years (range 25-70 years). mean operative time was 125±14 minutes (range 100-145 minutes). only four (4) intramuscular opioid injections were given as post-operative analgesia. clear fluids were started 48 hours after surgery and soft diet allowed after 72 hours. the mean length of hospital stay was 5.7 days. Only one male patient was converted to conventional surgery due to advanced tumor. two patients developed surgical site infection in the post-operative period that was mild and managed conservatively. there were no cases with intestinal leakage and mortality rate in 30 days postoperative follow up was zero.Conclusions: Laparoscopic assisted right hemicolectomy is safe and feasible technique with a good learning curve

Can sidedness predict for survival in primary locoregional colon cancers?

584 Background: Right and left-sided colon cancers are embryonically distinct and present differently. Recently, there has been growing belief that sidedness could be independently associated with survival outcomes. This has important clinical implications regarding the prognostication, management and surveillance of colon cancer patients. Hence, we aim to investigate the impact of sidedness on survival in our patient population in this study. Methods: Patients who had primary treatment naïve colon cancer who underwent curative surgical resection in our institution from September 2002 to December 2010 were included in this study. Demographic and clinicopathological data was collected from electronic records and clinical charts. Tumours arising from the cecum, ascending colon, hepatic flexure and transverse colon were considered right-sided, while those arising from splenic flexure and descending colon were considered left-sided. Cancers of the rectosigmoid junction and rectum were excluded. Kaplan-Meier curves and log-rank test were used to compare overall, locoregional recurrence-free and distant recurrence-free survivals (OS, LRFS, DRFS respectively) between both groups. Multivariate analysis was performed using Cox regression proportional hazards. Results: 389 patients were included in this study. 238 had left-sided tumours while the remaining 151 had right-sided tumours. In our cohort, right-sided tumours were associated with older age and mucinous histology. Kaplan-Meier curves plotted showed improved LRFS in left-sided tumours (p = 0.04, median survival not reached) but no significant difference in OS and DRFS. On multivariate analysis, sidedness was also found to be an independent prognostic factor for LRFS but not OS and DRFS despite factoring in age, size of tumour, pT, pN and histology. Conclusions: Our study suggests that left-sided tumours in primary colon cancer are independently prognostic for improved locoregional survival as compared to the right-sided tumours, even after taking into account other known factors such as age, staging and histology.

Experience in colon sparing surgery in North America: advanced endoscopic approaches for complex colorectal lesions.

Need for colon sparing interventions for premalignant lesions not amenable to conventional endoscopic excision has stimulated interest in advanced endoscopic approaches. The aim of this study was to report a single institution's experience with these techniques. A retrospective review was conducted of a prospectively collected database of all patients referred between 2011 and 2015 for colorectal resection of benign appearing deemed endoscopically unresectable by conventional endoscopic techniques. Patients were counseled for endoscopic submucosal dissection (ESD) with possible combined endoscopic-laparoscopic surgery (CELS) or alternatively colorectal resection if unable to resect endoscopically or suspicion for cancer. Lesion characteristic, resection rate, complications, and outcomes were evaluated. 110 patients were analyzed [mean age 64 years, female gender 55 (50%), median body mass index 29.4kg/m2]. Indications for interventions were large polyp median endoscopic size 3cm (range 1.5-6.5) and/or difficult location [cecum (34.9%), ascending colon (22.7%), transverse colon (14.5%), hepatic flexure (11.8%), descending colon (6.3%), sigmoid colon (3.6%), rectum (3.6%), and splenic flexure (2.6%)]. Lesion morphology was sessile (N = 98, 93%) and pedunculated (N = 12, 7%). Successful endoscopic resection rate was 88.2% (N = 97): ESD in 69 patients and CELS in 28 patients. Complication rate was 11.8% (13/110) [delayed bleeding (N = 4), perforation (N = 3), organ-space surgical site infection (SSI) (N = 2), superficial SSI (N = 1), and postoperative ileus (N = 3)]. Out of 110 patients, 13 patients (11.8%) required colectomy for technical failure (7 patients) or carcinoma (6 patients). During a median follow-up of 16months (range 6-41months), 2 patients had adenoma recurrence. Advanced endoscopic surgery appears to be a safe and effective alternative to colectomy for patients with complex premalignant lesions deemed unresectable with conventional endoscopic techniques.

An automatic measure of progression during colonoscopy correlates to patient experienced pain

Background: Colonoscopy screening and surveillance programs depend on patient’s tolerable experience, which is associated with competence of the endoscopist. The Colonoscopy Progression Score (CoPS) is an automated tool based on recording of the Magnetic Scope Imager (MEI) picture in order to track progression. CoPS deliver a numeric score and a graphic map. A high score expresses a rapid and smooth progression. Aims of study were to explore the correlation between CoPS and patient experienced pain and to identity locations associated with pain.Methods and materials: Patients listed for colonoscopy were included and asked to reply to pain by pressing a rubber ball. The signal was recorded simultaneous to CoPS. Patients evaluated the experience on a Visual Analogue Scale (VAS). CoPS and recorded pain events were used to create a pain sensitive CoPS-map (S-CoPS map).Results: A total of 58 complete recordings were used for evaluation. We demonstrated a moderate correlation between CoPS and patient experienced pain, Pearson’s r = −0.47 (p < .001). A low CoPS was associated with a painful colonoscopy and a high CoPS excluded severe pain. Sensitivity and specificity was 0.79 and 0.60 and AUC was 0.61 Passage of the sigmoid colon, right and left flexures were associated with pain for 51%, 33% and 25% of the patients, respectively.Conclusion: A moderate correlation between CoPS and patient experienced pain suggest that CoPS measure inserting skills but might also be a measure of a gentle performance. The graphic S-CoPS-map can be used to point-out painful passages and aid planning of future colonoscopies.

When a Warning Sign is Not a Warning Sign: Chilaiditi's Sign in a Patient with Heart Failure and Epigastric Hernia

Malposition of hepatic flexure of colon in sub diaphragmatic space, Chilaiditi syndrome, is usually an asymptomatic anatomical aberrancy of position. It is usually noted as a coincidental finding in chest X-ray. We present a case of 63 years old male who presented as an outpatient in the department of general medicine in rural hospital. The patient had features of heart failure and also had Chilaiditi syndrome as an incidental finding. This case is presented to remind ourselves of a harmless condition in the myriad of grave conditions that account for gas under the diaphragm in a chest X-ray. Birat Journal of Health SciencesVol.2/No.3/Issue 4/Sep- Dec 2017, Page: 300-302

Risk factors of postoperative prolonged ileus after colorectal cancer surgery

OBJECTIVE. The authors identified independent risk factors of postoperative prolonged ileus after colorectal cancer surgery. MATERIAL AND METHODS. Multivariate logit regression analysis was made in order to reveal independent risk factors of prolonged ileus. RESULTS. The frequency of prolonged ileus cases consisted of 13 %. The authors detected three independent risk factors such as body mass index higher than 25 kg/m² (p=0,033), taking of opioid analgetics (p=0,022) and left colon flexure mobilization (p=0,047) in multivariate statistical analysis. CONCLUSIONS. Postoperative prolonged ileus was the frequent complication in colorectal cancer surgery. There is a possibility to identify the group of patients who exposed to risk of occurrence of prolonged postoperative ileus due to application of revealed risk factors.

Complex Double Balloon-Assisted Colonic ESD: First Human Experience

Complex colorectal polyps (defined as >2cm) or those positioned in difficult anatomic locations may be major endoscopic challenges. Double-balloon systems have been predominantly confined for use in small bowel enteroscopy, however recently its utility has been explored in the lower intestine. Despite clear benefits of ESD (R0 resection and low recurrence rate), it remains a technically challenging procedure with higher perforation rates compared to EMR. In these 2 cases, we employed a unique ESD approach facilitated by a novel endoscopic double balloon system which permitted polyp tissue retraction, increased stability and improved visualization. Clinical case details: 1 - 74 year old male, 3 polyps located in the ascending colon and hepatic flexure. PMH: CHF; CAD s/p Stents; AICD; DM 2- 68 year old male, large complex polyp located in the ascending colon. PMH: OSA, PVC, HLD, HTN ESD technique (briefly): The balloons were deployed behind and in front of the lesion. After the balloons were inflated, a sealed ‘therapeutic zone' was created. A mucosal incision was made at the proximal lesion margin and developed. The incision leading edge was developed further. At the appropriate point the mucosal edge was clipped to the base of the fore balloon. Using variable tension on the fore balloon, tissue dissection continued until resection. After the procedure, the specimen was removed using the fore-balloon as a specimen retrieval bag. The technique was feasible (see Table 1), safe and effective. The double balloon system enabled complex ESD. This led to an enhanced sense of scope stability in a difficult anatomical locations. The additional benefits of retraction and specimen retrieval appeared to be additive and should be studied further.Table: Table. Case data and clinical observationsFigure: Patient 1 - polyps removed.Figure: Patient 2 - polyps removed.

Reverse takotsubo cardiomyopathy presenting as abdominal pain: An atypical presentation

Reverse takotsubo cardiomyopathy is the rarest variant of takotsubo cardiomyopathy. We present a case of reverse takotsubo cardiomyopathy presenting as abdominal pain likely due to non-occlusive mesenteric ischemia. A 58-year-old female presented with abdominal pain, nausea, vomiting, and diarrhea for 2 days. Upon presentation, she was normotensive but tachycardic. Her lactic acid level was 2.8 mmol/L and troponin-T was 0.62 ng/ml. The electrocardiogram showed non-specific ST changes. CT scan of abdomen revealed bowel wall thickening in transverse colon and splenic flexure. Patient was started on aggressive intravenous fluid therapy for possible infectious colitis.The next day, patient started becoming progressively more dyspneic, hypoxic, and hypotensive. A chest X-ray at that time showed signs of severe congestive heart failure. Echocardiogram revealed left ventricular ejection fraction of 20% with akinesis of proximal and mid-ventricular walls. Patient was intubated for hypoxic respiratory failure and started on milrinone infusion for acutely depressed cardiac function. Inotropes were weaned off the next day, and she was successfully extubated on day 4. Subsequently, gastrointestinal symptoms resolved. Cardiac catheterization was performed later during the hospitalization that showed normal coronary arteries. Repeat echocardiogram done 3 months later showed return of cardiac function to normal.

Clinical efficacy of the laparoscope-assisted transanal total mesorectal excision for middle-low rectal cancer

Objective To explore the clinical efficacy of laparoscope-assisted transanal total mesorectal excision (La-TaTME) for middle-low rectal cancer. Methods The retrospective cross-sectional study was conducted. The clinical data of 16 patients with middle-low rectal cancer who underwent La-TaTME in the Peking University Third Hospital from August 2015 to August 2016 were collected. Sequential surgery of La-TaTME was applied to patients in the same team, with laparoscopic surgery first and then transanal surgery. Observation indicators: (1) operation and postoperative recovery situations: conversion to open surgery, anastomosis method, operation time, volume of intraoperative blood loss, intraoperative complications, time for out-of-bed activity, time for liquid diet intake, postoperative complications and duration of postoperative hospital stay. (2) postoperative pathological situations: length of surgical specimen, tumor diameter, distance from tumor to resected distant intestinal canal, complete degree of mesorectum, circumferential resection margin, pathological T stage, pathological N stage, number of lymph node detected and tumor cell differentiation. (3) follow-up. Patients in stage Ⅲ-Ⅳ of TNM stage of RC underwent postoperative adjuvant chemotherapy. Follow-up using outpatient examination was performed once every 3 months postoperatively to detect the patients′ survival and tumor recurrence up to December 2016. Measurement data were represented as M (range). Results (1) Operation and postoperative recovery situations: all the 16 patients underwent successful La-TaTME without conversion to open surgery, including 10 with colorectal anastomosis, 3 with colon-canalis analis anastomosis and 3 with permanent colostomy. Operation time and volume of intraoperative blood loss were 290 minutes (range, 215-420 minutes) and 50 mL (range, 30-100 mL), respectively. One patient had intraoperative complication, showing broken ends ischemia of sigmoid colon after dragging out resected rectum from the anus, following free splenic flexure of colon, about 5 cm ischemic sigmoid colon were resected, and descending colon-rectum anastomosis was performed. Time for out-of-bed activity and time for liquid diet intake were 1 days (range, 1-3 days) and 2 days (range, 1-9 days), respectively. Among 3 patients with postoperative complications (Ⅱ stage of Clavien-Dindo), 2 with incomplete intestinal obstruction were improved by gastrointestinal decompression and total parenteral nutrition, and 1 with presacral infection was improved by drainage and antibiotic therapy. Duration of postoperative hospital stay was 7 days (range, 5-21 days). (2) Postoperative pathological situations: length of surgecal specimen, tumor diameter and distance from tumor to resected distant intestinal canal were respectively 18.0 cm (range, 12.0-24.0 cm), 3.5 cm (range, 0.5-6.8 cm) and 2.5 cm (range, 1.0-5.0 cm). Evaluation of mesorectum of surgical specimen: 14 patients had complete mesorectum of surgical specimen and 2 had nearly complete mesorectum. There was no residual tumor at circumferential resection margin, proximal and distal ends. Pathological T stage of 16 patients: T0 (pathological complete response after neoadjuvant therapy), T1, T2 and T3 stages were found in 1, 1, 4 and 10 patients, respectively. Pathological N stage: 12, 2 and 2 patients were detected in N0, N1 and N2 stages, respectively. Number of lymph node detected was 16 (range, 6-32). Tumor cell differentiation: no tumor cell (pathological complete response after neoadjuvant therapy), high-, moderate- and low-differentiated tumors were respectively detected in 1, 2, 7 and 6 patients. (3) Follow-up. All the patients were followed up for 12 months (range, 4-16 months). There were no local tumor recurrence or distant metastasis and death. Conclusion La-TaTME may be a new, safe and effective resection for middle-low rectal cancer. Key words: Rectal neoplasms, middle-low; Total mesorectal excision; Transanal; Laparoscopy