Mid-transverse Colon Research Articles

Emergent Chimney Endovascular Repair of an Aortoenteric Fistula in the Setting of a Solitary Kidney

Open surgery remains the definitive therapy for secondary aortoenteric fistula, but mortality is as high as 40%. Endovascular repair has emerged as a viable option, particularly in the critically ill. We present a case of an emergent chimney endovascular repair of a juxtarenal secondary aortocolonic fistula complicated by septic and hemorrhagic shock in a patient with a solitary kidney. A 68-year-old morbidly obese man with a history of myocardial infarction, peripheral artery disease, and a solitary kidney (prior kidney donation to wife) underwent an open tube graft repair of a ruptured abdominal aortic aneurysm at an outside facility. His recovery was complicated by a large proximal anastomotic pseudoaneurysm with an aortocolonic fistula. On postoperative day 30, he was transferred to our institution for worsening hemodynamic status and evolving sepsis. Shortly after arrival, superimposed hemorrhagic shock developed after 1 L of lower gastrointestinal bleed. Imaging had demonstrated a fistula at the level of the left renal artery ostium with a broad-based communication with the mid-transverse colon (Fig, A). Given the patient’s acutely deteriorating clinical status and hostile anatomy, we decided to pursue the least invasive treatment option. A left renal artery chimney stent graft was delivered through the left brachial artery while an Endurant II (Medtronic, Santa Rosa, Calif) proximal aortic cuff was deployed to promptly seal the fistula. To exclude the entire tube graft from the systemic circulation, to avoid the need for contralateral gate cannulation, and to concomitantly address bilateral iliac occlusive disease, the AFX platform (Endologix, Irvine, Calif) was deployed with adequate overlap with the proximal cuff (Fig, B and C). The patient then underwent laparotomy for an extended left hemicolectomy and transverse colostomy. We noted prompt postoperative improvement in sepsis and hemodynamic status. Serial postoperative imaging up to 9 months has shown near-resolution of periaortic inflammatory changes and widely patent aortic and left renal artery repairs. Suppressive oral antibiotics are maintained. Chimney endovascular aortic repair is a viable option for emergent repair of secondary aortoenteric fistula in a select group of high-risk patients.

S2186 Colonic Dieulafoy's Lesion: A Rare Presentation of Lower GI Bleeding

INTRODUCTION: Dieulafoy's lesions (DL) are rare (1–2%) causes of gastrointestinal bleeding. Colonic DLs are even rarer (∼2%) cause of lower GI bleeding.Early recognition of this entity is important given its infrequent occurrence, and yet, potentially life-threatening outcome. CASE DESCRIPTION/METHODS: A 64-year-old male with HFrEF, CKD and A- Fib on Eliquis 5 mg BID and Aspirin 81 mg presented to ER with 6-week history of melena with a hemoglobin of 7.4 g/dL on admission, BP of 95/55 mmHg, pulse of 65 bpm and an oxygen saturation of 98% on 2 L O2. Abdominal examination was unremarkable. His INR was 1.3. He received 3 units of pRBC. EGD was negative. Colonoscopy performed thereafter revealed fresh blood throughout the entire colon and a pulsatile, non spurting, briskly bleeding artery in mid transverse colon. Successful hemostasis was achieved with 2 clips (Figure 1) and injection of epinephrine (1:10,000). A tattoo was placed near the lesion. He denied ongoing rectal bleeding but continued to have dark solid stools on iron supplements for chronic anemia. Follow-up colonoscopy pursued 4 months later to perform polypectomy showed a similar arterial type bleeding vessel in proximal ascending colon and was completely ablated with Argon Plasma Coagulation at 0.8 L/min flow and 20 max Watts (Figure 2). The patient was sent home on continued iron replacement, and advised to resume Elliquis the next day; and is doing well presently. DISCUSSION: DL is a normal vessel with an abnormally large diameter maintaining a constant width of 1-3 mm as it runs a tortuous course within the submucosa and typically protrudes through a small (2-5mm) mucosal defect with basal fibrinoid necrosis. DLs are mostly found in stomach (71%, 85% on lesser curvature). Colonic DLs account for 2% of cases of lower GI bleeding. Typically, patients are elderly male with cardiopulmonary and renal dysfunction, often are on antiplatelet or anticoagulant agents (AP/AC) and presents with acute, intermittent, and clinically significant melena, hematochezia, or symptoms of shock. Exact pathogenesis of spontaneous rupture is unknown but mucosal ischemia or erosion from ageing, arteriolar pulsation, cardiovascular disease, AP/AC agents and stercoral injury may unmask the silent anomaly. GI endoscopy is preferred in diagnosis and successful management (>90%) of DLs as in our patient while embolization and surgery are reserved for refractory cases.Figure 1.: Colonoscopic view of an actively bleeding Dieulafoy's lesion in transverse colon (left) and subsequent hemostasis with clips and epinephrine (right).Figure 2.: Colonoscopic view of an actively bleeding Dieulafoy's lesion in ascending colon (left) and subsequent hemostasis with argon plasma coagulation(right).

S1655 Dealing With the Inevitable: A Case of Lynch Syndrome Not Meeting the Amsterdam Criteria

INTRODUCTION: Lynch syndrome is one of the most common causes of hereditary colorectal cancer. The disease is mainly acquired by autosomal dominant inheritance and it has been found that 35% of patients diagnosed with colorectal cancer (CRC) have family history of neoplasia. The syndrome also places the patient at risk for extracolonic cancers including endometrial, brain, pancreas, stomach, among others. The most common cause of lynch syndrome is germline mutations of DNA mismatch repair genes. We present a case of Lynch syndrome in which the Amsterdam and Bethesda criteria were not met, however due to high suspicion, the disease was confirmed by genetic testing. CASE DESCRIPTION/METHODS: 33 years old Hispanic male that presented to our institution with 2 week history mild abdominal pain accompanied by weight loss. Computed tomography imaging was remarkable for concentric wall thickening of the transverse colon. Colonoscopy was performed and revealed a large mass in mid transverse colon occluding more than 90% of lumen which precluded further advance of scope. Pathology report of transverse colon biopsy revealed mucinous adenocarcinoma. Immunohistochemistry testing for mismatch repair proteins showed expression of MLH-1, MSH-2 and MSH6 and loss of nuclear expression of PMS2 which represented high probability of Lynch syndrome. The patient denied family history of colorectal cancer or any other Lynch syndrome related cancers. The patient underwent partial colectomy with resection of the adenocarcinoma. DISCUSSION: At the moment, there are no screening guidelines to detect Lynch-syndrome related cancers when Amsterdam criteria are not met. Once Lynch syndrome is diagnosed, screening is performed. It has been well documented in the literature that Lynch syndrome is frequently diagnosed when there is pertinent family history as established by Amsterdam and Bethesda criteria. Our case presents a patient with colorectal cancer with confirmed DNA mismatch repair genes consistent with Lynch syndrome, without family history Lynch syndrome related cancers. Mutations in PMS2 have a lower penetrance than other mutations, providing smaller increased risk of colorectal and endometrial cancer, but no increased risk of other Lynch syndrome related cancers. Mentioned findings can contribute to increase the awareness of this disease given the fact that 7% of individuals present with more than one related cancer at the time of diagnosis. By this means decreasing disease related complications and improving outcomes.

Robotic-Assisted Colonoscopy Platform with a Magnetically-Actuated Soft-Tethered Capsule.

Simple SummaryAlmost 2 million human beings are newly diagnosed every year with colorectal cancer. Although easy to prevent by screening colonoscopy, this is often hampered by the perception of invasiveness of the technique. We aimed to develop a new painless colonoscopy platform consisting of an active locomotion soft-tethered capsule, offering both diagnostic and therapeutic capabilities. Capsule navigation is achieved via closed-loop interaction between two permanent magnets, enhanced by accurate localization. Ex-vivo tests showed a 100% success rate in operating channel and target approach tests. Progression of the endoscopic capsule was feasible and repeatable, and interaction forces were lower if compared to conventional colonoscopy (e.g., 1.17N vs. 4.12N). The polyp detection rates were comparable between groups (91% vs. 87%, colonoscopy and Endoo respectively). The Endoo capsule allows smoother navigation than conventional colonoscopy providing comparable features. If confirmed in clinical trials, it may represent a valuable and novel screening tool for colorectal cancer.Background and Aims: Colorectal cancer (CRC) is a major cause of morbidity and mortality worldwide. Despite offering a prime paradigm for screening, CRC screening is often hampered by invasiveness. Endoo is a potentially painless colonoscopy method with an active locomotion tethered capsule offering diagnostic and therapeutic capabilities. Materials and Methods: The Endoo system comprises a soft-tethered capsule, which embeds a permanent magnet controlled by an external robot equipped with a second permanent magnet. Capsule navigation is achieved via closed-loop interaction between the two magnets. Ex-vivo tests were conducted by endoscopy experts and trainees to evaluate the basic key features, usability, and compliance in comparison with conventional colonoscopy (CC) in feasibility and pilot studies. Results: Endoo showed a 100% success rate in operating channel and target approach tests. Progression of the capsule was feasible and repeatable. The magnetic link was lost an average of 1.28 times per complete procedure but was restored in 100% of cases. The peak value of interaction forces was higher in the CC group than the Endoo group (4.12N vs. 1.17N). The cumulative interaction forces over time were higher in the CC group than the Endoo group between the splenic flexure and mid-transverse colon (16.53Ns vs. 1.67Ns, p < 0.001), as well as between the hepatic flexure and cecum (28.77Ns vs. 2.47Ns, p = 0.005). The polyp detection rates were comparable between groups (9.1 ± 0.9% vs. 8.7 ± 0.9%, CC and Endoo respectively, per procedure). Robotic colonoscopies were completed in 67% of the procedures performed with Endoo (53% experts and 100% trainees). Conclusions: Endoo allows smoother navigation than CC and possesses comparable features. Although further research is needed, magnetic capsule colonoscopy demonstrated promising results compared to CC.

Surgical management of adenocarcinoma of the transverse colon: What should be the extent of resection?

Transverse colon, owing its origin to midgut and hindgut and harbouring a flexure at both ends, continues to pose a surgical challenge. When compared to the rest of the colon, transverse colon adenocarcinoma is relatively uncommon. These cancers usually present late and lie in close proximity to the stomach, omentum, and pancreas. Adequate lymphadenectomy entails dissection around and ligation of the middle colic vessels. Hence, resectional surgery for transverse colon carcinoma is considered difficult. This is more so because of the variation of arterial and venous anatomy. From this perspective, the surgeon is tempted to perform a more radical operation like extended right or left hemicolectomy to secure an adequate lymphadenectomy. Such a cancer has also been dealt with a more limited transverse colectomy with colo‐colic anastomosis. For all these reasons, patients with transverse colon adenocarcinoma were excluded from randomised trials which compared laparoscopic resection with traditional open operation. Surgical literature is yet to establish a definite operation for transverse colon cancer and the exact procedure is often dictated by surgeon's preference. This is primarily because this is an uncommon cancer. The rapid adoption of laparoscopic operation favoured extended colectomy as transverse colectomy can be difficult by minimally invasive technique. However, in the recent past, cohort studies and meta‐analyses have shown equivalent oncological outcome between transverse colectomy and extended colectomy. It is time to resurrect transverse colectomy and consider it equivalent to its radical counterpart for cancers around the mid‐transverse colon.

Laparoscopic extended right hemicolectomy with complete mesocolic excision and central vascular ligation for mid-transverse colon cancer.

Laparoscopic extended right hemicolectomy with complete mesocolic excision and central vascular ligation for mid-transverse colon cancer.

A case of iatrogenic immunodeficiency-associated colonic lymphoma complicating ulcerative colitis

BackgroundUlcerative colitis (UC) is one of the major types of inflammatory bowel diseases and is associated with a significantly increased risk of not only lymphoproliferative disorders but also lymphomas, of which most cases are related to the long-term usage of immunosuppressants. Here, we demonstrate a very rare case of other iatrogenic immunodeficiency-associated colonic diffuse large B-cell lymphoma (Oii-DLBCL) complicating UC and rectal perforation. In addition, we reviewed the clinicopathological features of previous cases of DLBCL related to UC.Case presentationA 68-year-old man was diagnosed with left-sided UC 26 months prior. Although he was followed by immunosuppressive therapy with azathioprine and infliximab, an emergency total proctocolectomy was performed due to rectal perforation. The resected specimen exhibited irregular wall thickening and elevated multinodular lesions extending from the mid-transverse colon to the rectum, measuring up to 52 cm in length. Histologically, the lesion was diagnosed as Oii-DLBCL and crypt abscess surrounded by mixed inflammatory cell was remained.ConclusionOii-DLBCL complicating UC with rectal perforation is extremely rare. Macro- and microscopic findings are important for early diagnosis of the lesion.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study

IntroductionTransverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. Materials and methodsThis was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. ResultsThe study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). ConclusionsAccording to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Usefulness of Delayed Films of Contrast Enema for Detecting Hirschsprung's Disease.

BackgroundContrast enema (CE) in Hirschsprung’s disease (HD) provides a road map to surgeons by ascertaining the transition zone (TZ) and helps in pre-surgical planning. In our institute, we use CE as the initial investigation for HD and carry on till the whole colon is fully distended, followed by a 24-hour abdominal film which is also a part of the international protocol. The main aim of this study was to evaluate the usefulness of this 24-hour delayed film in detecting HD, compare it with gold-standard biopsy results, and to evaluate other imaging features of contrast enema for diagnosis of HD in our tertiary-care hospital in Pakistan. MethodsThis retrospective study was conducted at the Department of Radiology, Aga Khan University Hospital, Karachi. Records of pediatric patients referred for radiological evaluation of symptoms and signs suspicious of HD during the years 2007-2017 were reviewed. A delayed film was labeled positive if the contrast was not completely evacuated when the residual contrast was present till transverse colon and not beyond. Specificity and sensitivity along with positive and negative predictive values were calculated for each finding according to rectal biopsy, taken as the gold standard.ResultsIn all, 82 patients met the inclusion criteria out of 111 cases, as they had both biopsy results and delayed 24-hour films. HD was confirmed using rectal biopsy in 56 (43 patients were males and 13 were females) of 82 cases. The most sensitive radiological finding was the transition zone with a sensitivity of 91.07%. The rectosigmoid index was the second most common finding on contrast enema with a sensitivity and specificity of 91.07% and 83.93%, respectively. In all, 59% patients had a positive delayed 24-hour film and were confirmed with having HD on biopsy. The sensitivity, specificity, and positive predictive value of delay in contrast evacuation after 24 hours in our study was 81.25%, 90.91%, and 97.50% respectively.ConclusionContrast enema examinations along with the 24-hour delayed film with mid transverse colon cut-off are optimal for initially investigating HD in a developing nation, and our results show that it correlates well with biopsy. However, rectal biopsy still remains the gold standard for diagnosis.

1653 Large Cell Neuroendocrine Carcinoma of the Colon

INTRODUCTION: Neuroendocrine carcinomas heterogeneous group of tumors with variable clinical presentation and prognosis. Gastrointestinal neuroendocrine carcinomas are further divided into two types; small cell or large cell based on mitotic rate and or Ki-67 labeling by WHO or European Neuroendocrine Tumor Society guidelines. Large cell neuroendocrine carcinomas (LNEC) of primary colorectal origin are extremely rare and represent 0.25% of all colorectal cancers. LNEC are malignant and aggressive tumors which present in an advanced stage and median overall survival time is 4–16 months. LNEC can occur within the entire gastrointestinal tract and or biliary tract but are typically found within the colon, stomach and or rectum. Here, we report LNEC to highlight its clinical course and to expand clinician knowledge regarding this rare cancer. CASE DESCRIPTION/METHODS: 82-year-old male who initially presented to his primary care doctors office with 4-month history of 20-pound unintentional weight loss with associated vague left lower quadrant abdominal pain. Computed Tomography of the abdomen/pelvis revealed mass-like mucosal thickening measuring approximately 5.9 cm × 6.5 cm involving the distal transverse/proximal descending colon and with innumerable hypodense lesions throughout the liver consistent with diffuse metastatic disease. Colonoscopy revealed circumferential fungating partially obstructing large mass in the within the mid-transverse colon. Histopathologic report from the endoscopic biopsy showed positive staining for pancytokeratin and synaptophysin, which was consistent with a large cell neuroendocrine carcinoma. Patient was evaluated by oncology and has started receiving carboplatin and etoposide chemotherapy for palliative purposes. DISCUSSION: LNEC rare subtype of neuroendocrine carcinomas, which are aggressive and often present in an advanced stage. Early detection and identification is essential as this malignancy has different treatment implications when compared to adenocarcinoma. Interestingly, extrapulmonary neuroendocrine tumors resemble small cell lung cancer where carboplatin and etoposide have established utility due to high mitotic rate. This is the treatment option chosen for our patient. Further studies will need to be done to determine optimal treatment regimens for this rare disease.

1600 Follicular Lymphoma Presenting as a Colon Polyp

INTRODUCTION: Follicular lymphoma (FL) is the second most common type of Non-Hodgkin's lymphoma (NHL). There are two types of follicular lymphoma, nodal and extranodal. The gastrointestinal (GI) tract is the most common site of extranodal NHL and accounting for 30%-40% of all extranodal NHL. GI-FL comprises of only 1 to 4% of GI-NHL with less than 400 reported cases. GI-FL primarily involves the duodenum, distal ileum, and stomach. A colon is an uncommon place for GI-FL with less than 20 cases reported in the literature. We present a case of GI-FL identified on colonoscopy as a pedunculated polyp. CASE DESCRIPTION/METHODS: A 72-year-old female was seen for a positive stool occult test. She denied blood in the stool, abdominal pain, any weight loss, fatigue, night sweats, fevers, and diarrhea. She had occasional constipation which resolved with a stool softener. Physical examination was unremarkable without any palpable lymph nodes or organomegaly. During the colonoscopy, a 1.5 cm benign appearing pedunculated polyp in the mid-transverse colon was found (Figure 1). Primary histology of the polyp revealed lymphoid aggregates compatible with a lymphoid polyp. Diagnosis of GI-FL was later confirmed by immunohistopathological staining. Positron emission tomography (PET) scan showed aortocaval lymphadenopathy. The diagnosis of follicular lymphoma grade 2 stage IV is made. The oncologist has scheduled a bone marrow biopsy with consideration to immunochemotherapy. DISCUSSION: Colonic GI-FL is quite a rare disease with increasing incidence. Most patients are asymptomatic and diagnosed during endoscopy. The most common endoscopic appearance is 1 to 2 mm whitish polypoid nodules scattered or confluent together forming large nodules. Other appearances of GI-FL may include mass lesions with or without ulcer, lymphomatous polyposis, or polyps. These endoscopic features are also seen in lymphoid hyperplasia, MALT, mantle cell lymphoma. Immunohistopathological testing is the only way to confirm the diagnosis. GI-FL stains positive for CD10, CD19, CD20, and CD22, and bcl-2. It stains negative for cyclin D1 and CD5. PET scan is used for initial staging and surveillance of disease. GI-FL is an indolent lymphoma with favorable survival outcomes. A “watch and wait” approach is typically adopted. GI-FL presenting as a pedunculated polyp is an extremely rare presentation. Clinicians should be cognizant of endoscopy and immunohistopathological features of GI-FL.

1289 Transverse Colonic Stricture in a Patient With Recurrent Necrotizing Pancreatitis

INTRODUCTION: An isolated colonic stricture is a rare sequela of recurrent pancreatitis, but may present a diagnostic challenge as it presents similarly to more common etiologies of isolated colonic stricture, such as inflammatory bowel disease (IBD) and malignancy. CASE DESCRIPTION/METHODS: A 48-year-old man with a history of alcohol–induced recurrent necrotizing pancreatitis requiring multiple debridements presented with a week of colicky right- sided abdominal pain and constipation. CT abdomen revealed markedly distended cecum and ascending colon, a 13-cm mid-transverse colonic stricture with marked associated stranding, and a 6-cm intra-pancreatic fluid collection. The isolated colonic stricture was thought to be due to either colonic ischemia secondary to his history of multiple episodes of severe necrotizing pancreatitis, or extrinsic compression by the pancreatic fluid collection on the transverse colon. Initial workup showed mildly elevated inflammatory markers and ascitic fluid cytology, which was negative for malignancy. On imaging, it was unclear if the stranding in the bowel was contiguous from the peri-pancreatic inflammation. See Figures 1 and 2. Colonoscopy was attempted but the colonoscope could not be passed beyond 50 cm due to marked tortuosity. The visualized portions of the mucosa appeared normal. The patient underwent a laparoscopic diverting loop ileostomy, during which narrowing of the mid-transverse colon was noted to be grossly consistent with cicatricial reaction to prior severe necrotizing pancreatitis, with adherence to the pancreatic head and neck. No neoplastic process was noted, and there was no necrotic tissue or abscess visualized. The strictured area was thought not to be amenable to resection given the frozen nature and presence of large peri-gastric and peri-colic varices and thus diverting loop ileostomy was performed along with adhesiolysis. DISCUSSION: Colonic stricture is a rare sequela of acute or chronic pancreatitis, which is thought to occur as a consequence of diffusion of ischemia and necrosis through the mesentery to the colon. Alternatively, it has also been suggested that pancreatitis may lead to colonic stricture by way of extrinsic compression on the colon by a pancreatic pseudocyst. Although rare, in the appropriate clinical context, clinicians may consider acute and chronic pancreatitis as possible etiologies of isolated colonic stricture along with more common etiologies.

1642 Pelvic Congestion Syndrome: An Unusual Manifestation of Sigmoid Pneumatosis Cystoides Intestinalis

INTRODUCTION: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal subserosa and submucosa. We present a rare case of primary PCI affecting sigmoid colon complicated by pelvic congestion syndrome (PCS). CASE DESCRIPTION/METHODS: A 34-year-old morbidly obese female presented with diffuse lower abdominal pain and intermittent foamy diarrhea without blood or mucus for the past 5 months. CT abdomen showed small bubbles of gas in the peritoneum in the left upper quadrant and large amount of cystic pneumatosis in a loop of sigmoid colon. Lab work was unremarkable. She was given one week course of antibiotics. A repeat CT scan 5 months later showed interval resolution of free intraperitoneal air but pneumatosis bubbles had enlarged in size. A colonoscopy was performed which showed large cystic-appearing air-filled bullae in sigmoid colon causing some luminal narrowing and the scope could not be safely advanced beyond mid-transverse colon. Patient underwent laparoscopic sigmoid colectomy and intraoperatively noted to have dilated and tortuous bilateral gonadal veins. Surgical pathology showed multiple clear fluid-filled cysts throughout the length of the specimen with viable and unremarkable proximal and distal resection margins. Patient recovered well from surgery and was discharged with no further complaints. DISCUSSION: PCI is an unusual condition caused by a myriad of underlying pathophysiological processes that range from benign to life-threatening conditions. Primary PCI is rare (15%), while underlying conditions for secondary PCI can be divided into several groups; traumatic, mechanical, inflammatory, autoimmune, infectious, pulmonary and drug (steroids and chemotherapeutic agents) induced. Conservative management is preferable except in cases of clinical deterioration. This case is unique because even after the resolution of free intraperitoneal air the patient continued to have lower abdominal and pelvic pain with worsening of pneumatosis on repeat CT scan several months later. It is possible that sigmoid anatomic changes due to pneumatosis resulted in chronic intermittent venous obstruction of pelvic veins leading to gonadal veins dilation and tortuosity and hence secondary PCS which resulted in ongoing lower abdominal pain. This case highlights the fact that persistent PCI, with ongoing abdominal symptoms even in the absence of any obvious etiology warrants laparoscopic exploration to rule out any underlying disease process.

2709 Metastatic Gastric Cancer to the Colon: A Rare Entity

INTRODUCTION: Gastric cancer is one of the most common and deadly cancers worldwide, especially amongst older males. Current data suggests gastric cancer is the fifth most common neoplasm and the third most deadly cancer, with an estimated 783,000 deaths in 2018. Here we report a deadly case gastric cancer with colonic metastasis. CASE DESCRIPTION/METHODS: Patient is a 66 year old male with a medical history of hypertension and gastric cancer (status post partial gastrectomy) who presented to the emergency department complaining of progressive lower abdominal pain for the past 2 months. Notable laboratory workup included a hemoglobin of 10.1 gm/dL. Notable imaging included a computed tomography scan of the abdomen showing a mid transverse colon apple core mass measuring 30 mm × 44 mm resulting in proximal colonic obstruction. Given the size of the mass a joint endeavor between the gastroenterology service and surgery service was pursued in the operating room. A colonoscopy was initially done and showed a stenotic segment in the transverse colon with friable edematous mucosa. A stent deployment was attempted, but was unsuccessful due luminal compression by the tumor. Subsequently the surgical team performed an en bloc resection of the mass. The resected specimen was sent for biopsy and returned showing metastatic adenocarcinoma consistent with gastric origin. This diagnosis was supported by cell positivity to CK7 and negativity to CK20 and CDX2. Given his poor prognosis and complicated hospital course, the patient and his family decided to withdraw invasive care and opted for transfer to a hospice facility for end of life care. DISCUSSION: Risk factors associated with the development of gastric cancer include obesity, gastroesophageal reflux disease, helicobacter pylori infection, and low socioeconomic status. Diagnosis of gastric cancer can be accomplished by endoscopy, which allows the clinician to obtain a biopsy specimen. Endoscopic ultrasound is also an important modality that is helpful in assessing tumor invasion. The most common sites of metastatic gastric cancer in descending order are the liver, peritoneum, lung and bone. Rarely will gastric cancer metastasize to the colon. When suspected prompt evaluation with colonoscopy should occur for possible intervention and subsequent diagnosis of metastasis via biopsy. Surgery is the treatment of choice in gastric cancer limited to the stomach. In metastatic disease however, treatment with chemotherapy and targeted radiotherapy should be pursued.

1546 Idiopathic Myointimal Hyperplasia of Mesenteric Veins: A Rare Cause of Treatment Refractory Colitis

INTRODUCTION: Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare disease which mimics inflammatory bowel disease (IBD) clinically and endoscopically while showing ischemic changes without classic features of IBD on pathology. Delay in diagnosis is common; definitive diagnosis is usually only feasible after surgical resection. CASE DESCRIPTION/METHODS: A 62-year-old male with a past medical history of hypertension and hyperlipidemia presented with a 1-year history of recurrent abdominal pain, bloody diarrhea, and rectal pain. He was initially evaluated at another hospital and diagnosed with pneumatosis intestinalis and left-sided colitis. Left colon biopsies were suggestive of ischemia but computerized tomography angiogram (CTA) revealed patent mesenteric arteries. Extensive workup for thrombophilia, infectious, inflammatory, and autoimmune etiologies were negative. His symptoms did not respond to antibiotics and oral steroids. He presented to our institution for a second opinion. At presentation, he was diaphoretic, afebrile and in distress. Physical exam was significant for lower abdominal tenderness without peritoneal signs. Laboratory investigations revealed elevated inflammatory markers (Table 1). Repeat CTA showed patent mesenteric arteries. Colonoscopy revealed severe inflammation and congestion extending from the mid-transverse colon to the rectum. The terminal ileum and ascending colon were normal. Biopsies from inflamed mucosa revealed ischemic colitis with fibrinoid microvascular wall necrosis and fibrin thrombi (Figure 1). He was started on IV Methylprednisolone 40 mg daily but symptoms progressed despite IV steroids. He underwent total colectomy with end ileostomy which was curative. Histopathological analysis of the resected colon confirmed IMHMV. DISCUSSION: Current opinion suggests that IMHMV is caused by non-inflammatory, non-thrombotic obliteration of medium-to-large size mesenteric veins. IMHMV is a difficult diagnosis to make preoperatively. However, preoperative diagnosis is suggested by the presence of arterialized capillaries, subendothelial fibrin deposits and fibrin thrombi on endoscopic biopsies. IMHMV is typically refractory to steroids and biologics. Gastroenterologists and pathologists should have a high index of suspicion for IMHMV in patients with treatment refractory colitis, negative mesenteric angiography and colon biopsies showing ischemic changes without classic features of IBD. Colectomy is usually curative without recurrence of symptoms.

1606 A Very Unusual Case of Colonic Adenocarcinoma Originating From an Enterocutaneous Fistula

INTRODUCTION: Enterocutaneous fistulas are a well known sequelae of intrabdominal surgeries. Common complications of these fistulas include sepsis, electrolyte abnormalities, and nutritional deficiencies. We present an unusual case of a mucinous colonic adenocarcinoma originating from an enterocutaneous fistula. To our knowledge, there are no other known cases of colonic adenocarcinoma originating from an enterocutaneous fistula. CASE DESCRIPTION/METHODS: Patient was a 65-year-old male with a past medical history significant for Korsakoff dementia and OLT ten years ago who presented to GI clinic. He had complaints of weight loss, decreased appetite, and increased lethargy. The patient had an enterocutaneous fistula as a result of a bowel resection following perforation from ERCP nine years prior. The fistula was never repaired as the patient was thought to be a poor surgical candidate and it did not seem to interfere with his quality of life. Physical exam was notable for a tender abdomen with several scattered erythematous and excoriated lesions. There was an ostomy bag covering a 10cm fungating, necrotic appearing, malodorous mass with greenish liquid in the ostomy bag (Figure 1). This was surrounding the fistula site. Based on CT abdomen results from six months prior, it was suspected that this was an enterocutaneous fistula that may connect to the transverse colon. Biopsies were taken at bedside which revealed mucinous moderately differentiated adenocarcinoma, morphologically suspicious for colonic-type adenocarcinoma (Figure 2). Repeat CT abdomen showed a large heterogeneous abdominal wall lesion and mild wall thickening of adjacent mid-transverse colon consistent with the known mass. DISCUSSION: The prevalence of enterocutaneous fistulas in the population is not known; most are iatrogenic or postoperative in etiology (75-85%), with the ileum being the most common location. This patient’s enterocutaneous fistula was never repaired and was likely the result of a bowel resection following perforation from ERCP several years prior. As with chronic inflammatory states, such as that seen in IBD which can predispose to colorectal cancer, we hypothesize that a similar mechanism of chronic inflammation from a fistula connection to the outside environment may have contributed to this patient developing a colonic malignancy, especially in the setting of his immunosuppression. Furthermore, in patients who are unable to undergo repair of enterocutaneous fistulas, their risk of colorectal cancer may be increased.

2548 Jejunal Perforation: A Very Rare Presentation of Jejunal Adenocarcinoma

INTRODUCTION: Small bowel malignancies constitute less than 5% of all gastrointestinal malignancies. The most common histological types of small bowel cancer are adenocarcinoma, neuroendocrine cancer, lymphoma and sarcoma. Adenocarcinoma represents 25-40% of primary small bowel malignancies, with the highest incidence in the duodenum and the incidence progressively decreasing down the small intestine. CASE DESCRIPTION/METHODS: A 69 year old previously healthy women presented with periumbilical pain for four weeks. She also reported early satiety but no weight loss. The night prior to presentation abdominal pain became severe with one episode of vomiting. There was no history of chronic NSAIDs use. She had a 40 pack-years smoking history. She had two cesarean sections and a total abdominal hysterectomy with bilateral salpingo-opherectomy. She did not have routine colorectal cancer screening. On abdominal examination she had a distended abdomen and mild periumbilical tenderness. Laboratory testing revealed leukocytosis of 15000/µL and a hemoglobin level of 10.2 g/dl with a low MCV 78.6 fl. Noncontrast CT of the abdomen showed wall thickening and focal perforation in a loop of jejunum. There was no bowel obstruction and no free intraperitoneal air seen. Exploratory laparotomy revealed a large inflammatory mass in the proximal jejunum densely adherent to the mid-transverse colon. There was a large perforation (3.5 cm of greatest dimension) of a jejunal mass. The mucosa surrounding the defect was hyperemic and thickened. Microscopic examination showed a well-differentiated adenocarcinoma invading into muscularis propria. There was no lymphovascular invasion and no metastasis were identified in 13 excised regional lymph nodes. Immunostains were negative for cytokeratin 7 (expressed in lung and pancreatic adenocarcinomas), focally positive for cytokeratin 20 (colorectal adenocarcinoma) and were positive for CDX2. CDX2 is a highly sensitive and specific marker of adenocarcinoma of intestinal origin. DISCUSSION: Jejunal adenocarcinoma is an extremely rare GI malignancy. The clinical presentation is often with abdominal pain and distension; only 10% present as a bowel perforation. Surgical resection is considered curative treatment for localized adenocarcinoma. Oxaliplatin-based adjuvant chemotherapy is suggested for patients with lymphovascular invasion. In our patient perforation per se was considered a high-risk feature and the patient was advised to have post-operative adjuvant chemotherapy.

The Early Study to Laparoscopic Radical Resection of the Mid Transverse Colon Cancer

Objective: To explore the safety and the short-term curative effect of the application of assisted laparoscopic radical resection for the mid transverse colon cancer. Methods: A retrospective analysis of 25 cases clinical data of radical resection of mid transverse colon cancer from March 2006 to March 2014 in our hospital. Cases were divided into two groups, laparoscopic group with 12 cases and open group with 13 cases. Intra-operative observation indexes (operation time, bleeding volume, the number of dissected lymph nodes), post-operative recovery indexes (flatus time, liquid food intake time, ambulation time, hospitalization time), post-operative complication (incision site infection, abdominal bleeding, intra-abdominal infection, anastomotic fistula, intestinal obstruction and re-hospitalization within 30 days, mortality) and patient’s five-year overall survival were observed in two groups. Results: Operation methods including the principle of complete mesocolic excision (CME), colon dissection along the anatomical plane and safe anastomosis method were applied in Laparoscopic group. Average surgery time of Laparoscopic group was longer than open group, but there was no statistically significant difference between the two groups (p > 0.05). Intra-operative blood loss in the Laparoscopic group was obviously lower than open group; the difference was statistically significant (p < 0.05). The number of lymph node dissection in laparoscopic group was higher than open group (p < 0.05). Laparoscopic group in the postoperative recovery index including recovery of bowel function, ambulation time and hospitalization time was shorter than that of the open group after operation (P < 0.05). Conclusion: The use of laparoscopic radical resection for the mid transverse colon cancer resulted in acceptable short term curative effects.

Angiodysplasia of left colon extending to anal verge landed patient into APR: a rare finding

Angiodysplasias is a kind of vascular malformation preferably involves the veins. Angiodysplasia of colon is the second most common cause of lower gastrointestinal bleeding after diverticulosis. It usually involves caecum and ascending colon. Patient may either present with complaints of fresh bleeding per rectum or with melena. It usually occurs in elderly because of age related degeneration of small blood vessel walls. The case presented here involves a male patient of 25-year age with complains of intermittent bleeding per rectum and generalized weakness from one month. After examination it was found to have vascular ectasia involving mid transverse colon, left colon and the rectum coming down to anal verge which culminated into abdominoperineal resection. Biopsy of resected segment came to be angiodysplasia with external surface of specimen showing dilation of multiple vascular channels in entire length up to anal verge. This case report shows that though angiodysplasia is more common in old age but while exploring a young patient with lower gastrointestinal tract bleeding, and congestive changes are found in left colon possibility of angiodysplasia should also be kept in mind.

79-Year-Old Man With Shortness of Breath and Fevers

79-Year-Old Man With Shortness of Breath and Fevers