Sigmoid Colectomy Research Articles

Case Report: Sigmoid volvulus associated with a torsion of an ovarian cyst

Sigmoid volvulus is a life-threatening condition rarely seen in young adults. However, adnexal torsion is one of the top causes of gynecological emergencies, with prevalence increasing with the presence of an ovarian cyst. The association of sigmoid volvulus and adnexal torsion is exceptional. We report the case of a 33-year-old woman who presented to the emergency department for abdominal pain evolving for six hours, associated with gas and fecal matter obstruction. Clinical examination showed a restless patient with tachycardia and distended abdomen with severe tenderness in the left iliac fossa. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed dilated large bowel loops showing bird beak-like narrowing of the sigmoid colon and whirl sign, suggestive of sigmoid volvulus with bowel wall compromise associated with left adnexal torsion secondary to a large pelvic mass. The patient underwent an emergency laparotomy. Exploration showed a torsion of the left adnexa secondary to a large cyst of the left ovary, carrying the sigmoid colon with it, which produces a volvulus of the sigmoid colon with 720° anticlockwise rotation. A sigmoid colectomy and Hartmann’s procedure associated with a left adnexectomy were performed. Although rare, the occurrence of a volvulus of the sigmoid in the young woman must be suggestive of torsion of the adnexa. Surgical management must be prompt, allowing both the ovary and the sigmoid to be saved.

Quality of life in uncomplicated recurrent diverticulitis: surgical vs. conservative treatment

Elective sigmoid colectomy for recurrent uncomplicated diverticulitis remains controversial and is decided on an individual basis. Eighty patients treated conservatively (44 patients) or by elective surgery (36 patients) for recurrent uncomplicated diverticulitis were contacted and assessed for quality of life. The mean difference in quality of life scores was greater after surgery (overall + 2.14%, laparoscopic resection +4.95%, p = 0.36 and p = 0.11, respectively) as compared to conservative management. Female patients undergoing laparoscopic resection had statistically significantly higher quality of life scores than women treated conservatively (+8.98%; p = 0.049). Twenty-eight of 29 responding patients stated that they were highly satisfied and would have the operation done again. Elective sigmoidectomy is a valid treatment option for recurrent uncomplicated diverticulitis in terms of quality of life. Quality of life improved most if surgery was performed laparoscopically, especially in women.

The retro-ileal pull-through technique for colorectal and coloanal anastomosis.

Performing a tension-free anastomosis following extensive left-sided colorectal resection can be challenging due to limited length. The retro-ileal pull-through approach, where the colon is carefully delivered to the pelvis through a mesenteric window made under the ileocolic vessels, is a technique to perform such an anastomosis. This series is a retrospective review of patients who underwent a colorectal or coloanal anastomosis using the retro-ileal pull-through approach. Patient demographics, operative reports, and short-term outcomes were reviewed. Seven patients had a retro-ileal pull-through technique with colorectal or coloanal anastomosis. The cohort included 3 patients who had a Hartman's reversal, 3 who had a redo colorectal anastomosis and one in whom this technique was used in an acute setting for sigmoid colectomy for acute perforated diverticulitis with primary anastomosis. Successful implementation of the technique was achieved in all patients with good short-term outcomes. In our cohort of patients, a retro-ileal pull-through technique was shown to be a successful approach to achieve a tension-free colorectal or coloanal anastomosis in various scenarios. This technique may prevent performing an ileorectal anastomosis or a permanent colostomy. We believe that this approach should be popularized among colorectal surgeons dealing with complicated colorectal operations.

Benefits of Outcomes of the Microscopic Examination of Anastomotic Donuts After Colorectal Resection for Oncological Purposes: A Medical Record-Based Study

Objective The objective of the study is to investigate the benefits of pathological assessment of donuts removed during coloanal anastomosis after anterior resection.MethodologyDuring three years, 220 patients underwent circular stapled anastomosis. It is a retrospective study with convenient sampling. Involvement of donuts, the involvement of margins, length of donuts, and margins were primarily recorded. Ethical review approval was taken from the Institutional Review Board. Hospital electronic system was used to retrieve the data.ResultsTwo hundred and twenty patients underwent circular end to end anastomosis (CEEA) stapled gun anastomosis. All had adenocarcinoma. Most of the patients had T3 disease (n=113). Low anterior resection was the most common procedure followed by anterior resection and sigmoid colectomy, respectively. We performed all rectal cancers anastomosis with a circular stapling gun. On histological analyses among 220 patients, only two patients were found to have a positive distal donut. No proximal donuts were positive. Both patients were also found to have positive distal margins. The mean length of the proximal donut was 1.79±0.45 cm. The mean length of the distal donut was 1.68±0.48 cm. Two distal margins and none of the proximal margins were positive for cancer. The mean length of the proximal margin was 8.69±4.48 cm. The mean length of the distal margin was 4.9±5.98 cm. Both patients had already received six months of pre-operative chemoradiotherapy and were not offered any additional treatment. Both patients were kept on close surveillance.ConclusionRoutine analyses of the donuts after anterior resection has no impact on the management and outcome of the disease.

Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.

Clinical impact of D3 lymph node dissection with left colic artery (LCA) preservation compared to D3 without LCA preservation: Exploratory subgroup analysis of data from JCOG0404.

AimWe investigated the clinical impact of D3 lymph node dissection preserving left colic artery (LCA) compared to D3 without LCA preservation using data from JCOG0404. LCA preservation is expected to maintain adequate blood supply, which is effective in preventing anastomotic leakage, intestinal paralysis, and bowel obstruction. Whether D3 with LCA preservation (Group A) improves clinical outcomes following resection of sigmoid colon cancer compared to D3 without LCA preservation (Group B) is unclear.MethodsProcedure type was identified from photographs of the surgical field collected for central surgical review in JCOG0404. Clinical outcomes were compared between each procedure.ResultsAmong the 1057 randomized patients in JCOG0404, 631 patients receiving sigmoid colectomy or anterior resection were included in the subgroup analysis. Group A comprised of 135 patients and Group B of 496 patients. Patient backgrounds did not differ between groups. Median operative time, blood loss, anastomotic leakage, and intestinal paralysis were not remarkably different (Group A vs Group B: 185 vs 186 minutes, 60 vs 50 mL, 3.0% vs 5.0%, and 2.2% vs 3.8%). More overall postoperative complications occurred in Group B than Group A (21.6% vs 9.6%, P = .022). Five‐year relapse‐free survival (RFS) and overall survival (OS) tended to be better in Group A than Group B (RFS: 83.7% and 80.5%, HR 0.80 [95% CI 0.51‐1.26], OS: 96.3% and 91.1%, HR 0.41 [95% CI 0.19‐0.89]).ConclusionsShort‐ and long‐term outcomes tend to be better in Group A than Group B, indicating that preservation of LCA could be an alternative treatment.

Sigmoid volvulus in a teenager

Abstract Sigmoid volvulus in the pediatric population is a rare condition. In the adult population, it is considered in the differential diagnosis of bowel obstruction for patients with a history of debilitation or chronic constipation, in association with diseases like Hirschsprung or Chagas, and seems to have regionally higher incidence in Asia, Africa and South America, and high-altitude locations. The index of suspicion for sigmoid volvulus in a healthy child is low. We present the rare case of a 16-year-old otherwise healthy male who presented with abdominal pain and was found to have sigmoid volvulus. The patient underwent emergent endoscopic detorsion followed by rectal biopsy during the same hospitalization and, one month later, laparoscopic single-site sigmoid colectomy on elective basis.

Littoral cell angioma of the spleen in a patient with cerebral palsy and sigmoid volvulus: a rare case report

Background: Littoral cell angioma (LCA) is a rare vascular tumour of the spleen with unique histologic and immunophenotypic features. LCA is generally diagnosed incidentally and has a benign clinical course. However, it has rarely been reported to behave as a malign entity. Case presentation: A 49-year-old woman with cerebral palsy admitted to the hospital suffering from abdominal pain and weight loss. Laboratory results revealed iron deficiency anaemia and mild thrombocytopenia. Computed tomography scan revealed splenomegaly with multiple hypoattenuating lesions. A diagnostic and therapeutic open splenectomy and sigmoid colectomy were performed to exclude possible lymphoproliferative disorders or malignant lesions. The histologic and immunohistochemical studies confirmed the diagnosis of LCA and sigmoid volvulus. The post-operative period was uneventful with a significant increase in haemoglobin and platelet levels. Unfortunately, the patient died due to sepsis 36 days after surgery. Conclusion: This is the first case of LCA and sigmoid volvulus. Although this association is likely to be entirely coincidental, clinicians should be aware of this rare clinicopathologic entity whilst evaluating the differential diagnosis of splenomegaly with solitary or multiple nodules.

After Elective Sigmoid Colectomy for Diverticulitis, Does Recurrence-Free Mean Symptom-Free?

After elective sigmoidectomy for diverticulitis, patients may experience persistent abdominal symptoms. This study aimed to determine the incidence and characteristics of persistent symptoms (PSs) and their risk factors in patients who had no reported recurrence after elective sigmoidectomy. Patients who underwent elective sigmoidectomy for diverticulitis from 2002 to 2016 at a tertiary academic colorectal surgery practice were included. After retrospective review of medical records, patients were contacted with a questionnaire to inquire about recurrence of diverticulitis and persistent abdominal symptoms since resection. Outcomes examined were prevalence of and risk factors for PSs after elective sigmoidectomy. Of 662 included patients, 346 completed the questionnaire and had no recurrent diverticulitis. PSs were reported by 43.9 per cent of the patients. The mean follow-up was 87 months. Female gender and preoperative diagnosis of irritable bowel syndrome were independent risk factors for PSs (Relative Risk 1.65, P < 0.001 and Relative Risk 1.41, P = 0.014). Previous IV antibiotics treatment was associated with PSs (P = 0.034) but not with a significant risk factor. As the follow-up interval increased, prevalence of PSs decreased (P = 0.006). More than 40 per cent of patients experienced persistent abdominal symptoms after sigmoidectomy for diverticulitis. Female patients and those with irritable bowel syndrome were at significantly increased risk.

Prospective evaluation of functional outcomes after laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery for diverticular disease in consecutive male patients.

To date, there has been no consensus concerning the vascular approach during sigmoid colectomy for diverticular disease. The aim of this study was to determine the functional impact of elective laparoscopic sigmoidectomy performed with high ligation of the inferior mesenteric artery for diverticulitis in consecutive male patients. Twenty-five consecutive patients of median age 53years were enrolled in a prospective single-centre pilot study at a tertiary teaching hospital. Main outcome measures were functional results. Patients were asked to complete standardized, validated questionnaires to evaluate preoperative and 6months postoperative bowel symptomatology (Jorge-Wexner Incontinence Score and KESS score), urinary function (IPSS), and sexual function (IIEF). Secondary outcomes were surgical data, morbidity, and quality of life (SF-36). There were no significant differences between preoperative and 6months postoperative total scores for bowel symptomatology, urinary function, and sexual function. There were no perioperative deaths. The morbidity rate was 12% including three minor and no major events. Quality of life demonstrated statistically better general health (p < 0.01) and better medical status over the prior 4weeks at 6months after surgery, compared to baseline. This single-centre prospective study has a limited number of patients, relatively short follow-up time, and includes only male patients. Laparoscopic sigmoidectomy with high tie of the inferior mesenteric artery for diverticular disease does not induce functional disorders at 6months after surgery. The benefit of the operation for quality of life is even greater for general health and medical status.

Comparison of preoperative versus postoperative transversus abdominis plane and rectus sheath block in patients undergoing minimally invasive colorectal surgery.

Ultrasound-guided transversus abdominis plane and rectus sheath block (TAPRSB) decreases pain scores and narcotic use postoperatively after colorectal surgery (CRS). It is unclear if the effectiveness of TAPRSB varies according to whether it is performed preoperatively or postoperatively. Our aim was to investigate this. We compared patients who underwent preoperative TAPRSB or postoperative TAPRSB during minimally invasive CRS. Primary end-points were pain scores and oral morphine milligram equivalent (MME) use postoperatively. Secondary end-points included perioperative factors affecting pain scores and postoperative MME. Summary statistics and univariate analysis by nonparametric tests were utilized. The mixed-effect model was applied to model the repeatedly measured pain score. From April 2015 until May 2018 168 patients received TAPRSB before (115) or after (53) minimally invasive CRS. The cohort included 79 (47.0%) women, and had an average age of 59.11 (±12.32) years and mean body mass index of 28.32 (±5.82) kg/m2 . Indication for surgery was cancer in 66 (39.3%), polyp in 43 (25.6%) and diverticulitis in 43 (25.6%). Right colectomy was performed in 61 (36.3%), low anterior resection in 46 (27.4%) and sigmoid colectomy in 40 (23.8%) patients. The demographics of the groups were similar. Postoperative TAPRSB was only associated with lower pain scores at 12h postoperatively. As secondary outcomes, average pain scores and MME were lower in patients who were older, had right colectomy or intracorporeal anastomosis. Postoperative TAPRSB resulted in lower pain scores than preoperative TAPRSB 12h after minimally invasive CRS, but otherwise no differences were seen in pain scores or MME use.

Impact of the NaV1.8 variant, A1073V, on post-sigmoidectomy pain and electrophysiological function in rat sympathetic neurons.

NaV1.8 channels play a crucial role in regulating the action potential in nociceptive neurons. A single nucleotide polymorphism in the human NaV1.8 gene SCN10A, A1073V (rs6795970, G>A), has been linked to the diminution of mechanical pain sensation as well as cardiac conduction abnormalities. Furthermore, studies have suggested that this polymorphism may result in a "loss-of-function" phenotype. In the present study, we performed genomic analysis of A1073V polymorphism presence in a cohort of patients undergoing sigmoid colectomy who provided information regarding perioperative pain and analgesic use. Homozygous carriers reported significantly reduced severity in postoperative abdominal pain compared with heterozygous and wild-type carriers. Homozygotes also trended toward using less analgesic/opiates during the postoperative period. We also heterologously expressed the wild-type and A1073V variant in rat superior cervical ganglion neurons. Electrophysiological testing demonstrated that the mutant NaV1.8 channels activated at more depolarized potentials compared with wild-type channels. Our study revealed that postoperative abdominal pain is diminished in homozygous carriers of A1073V and that this is likely due to reduced transmission of action potentials in nociceptive neurons. Our findings reinforce the importance of NaV1.8 and the A1073V polymorphism to pain perception. This information could be used to develop new predictive tools to optimize patient pain experience and analgesic use in the perioperative setting.NEW & NOTEWORTHY We present evidence that in a cohort of patients undergoing sigmoid colectomy, those homozygous for the NaV1.8 polymorphism (rs6795970) reported significantly lower abdominal pain scores than individuals with the homozygous wild-type or heterozygous genotype. In vitro electrophysiological recordings also suggest that the mutant NaV1.8 channel activates at more depolarizing potentials than the wild-type Na+ channel, characteristic of hypoactivity. This is the first report linking the rs6795970 mutation with postoperative abdominal pain in humans.

558P - Robot-assisted natural orifice specimen extraction surgery for radical resection of colorectal cancer

BackgroundAs an emerging technique, natural orifice specimen extraction surgery(NOSES) can avoid abdominal incision and improve cosmetic outcomes. However, the robotic application in NOSES for colorectal surgery is scarcely investigated. MethodsFor present study, all the colorectal specimen was transanally extracted. NOSES was classified into two types as following:1) Transanal eversion and extracorporal resection technique, which is mainly used for resection of lower and middle rectal cancer. 2) Intra-abdominal specimen resection and transanal extraction technique, which is mainly used for upper or middle rectal resection and sigmoid colectomy. ResultsBetween October 2013 and March 2019, there were 155 patients with colorectal cancer undergoing robot-assisted NOSES. All the procedures were performed successfully without emergency requiring conversion to open surgery. The maximum diameter of rectal lesions was average 3.9±1.7cm, and distance to the lower edge of the lesion from the anal verge was measured to be 8.4±3.9cm. The operating time for the entire procedures including rectal eversion, resection and anastomosis was 169.1±40.3min, and blood loss during the procedures was 41.6±34.7ml. Moreover, there were 16.1±5.7 lymph nodes dissected, and length to distal resection margin from tumor lower border was 1.7±0.9cm. Postoperatively, patients began first flatus and resumed fluid diet average 2.2±0.8 days and 1.3±0.3 days after surgery. Duration of postoperative hospital stay was median 7 days, while 12 patients developed anastomotic leakage, and both managed with conservative treatment. Median 15-month follow-up of all the 155 patients was performed to assess the middle/short term outcomes. During the follow-up period, there is no abdominal infection, pelvic abscess and other severe infectious complication for bacteriological outcome. For functional outcome, no dysuria, sexual function disorder and fecal incontinence were found among all the patients. Importantly, none of 155 patients were dead, and 8 patients were observed local recurrence or distant metastasis. ConclusionsRobotic NOSES for colorectal cancer is safe and feasible. However, its long-term outcomes needs further investigation. Legal entity responsible for the studyXu Jianmin, Colorectal Surgery Department, Zhongshan Hospital, Fudan University. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

1515 Portal Vein Thrombosis After Laparoscopic Sigmoid Colon Resection for Recurrent Diverticulitis

INTRODUCTION: Portal vein thrombosis (PVT) following laparoscopic surgery is a rare complication. PVT after laparoscopic colorectal surgery is usually associated with inflammatory conditions like IBD and is more likely to occur after total proctocolectomy and in presence of postoperative intra-abdominal infection. We report a case of PVT in a patient with no identifiable hypercoagulable disorder who underwent laparoscopic sigmoid colectomy for recurrent diverticulitis. CASE DESCRIPTION/METHODS: A 54 year old male with a past medical history of gout and no known history of thrombosis had recurrent diverticulitis. He also had Clostridium difficile infection secondary to antibiotic use. CT showed diverticulosis, but no portal vein thrombosis. He underwent robotic sigmoid colon resection with an uneventful postoperative course. Six months later he started noticing right upper quadrant abdomen pain and diarrhea that went on for five weeks. He denied confusion, ascites and GI bleed. His PCP ordered a CT abdomen in that showed right hepatic lobe atrophy and non-opacification of branches of right portal vein consistent with prior intrahepatic portal vein thrombosis. Lab work revealed normal CBC, negative stool studies, slightly elevated alkaline phosphatase of 137, AST of 31, ALT of 28, total bilirubin of 1. He was referred to our hepatology clinic. We repeated MR abdomen with and without contrast that confirmed chronic non-occlusive thrombus in the right portal vein, left portal vein and main portal vein were widely patent. Further lab work by hematology showed no evidence of thrombophilic condition. Repeat labs after three months showed normal LFTS and intact liver function. DISCUSSION: PVT as a complication of laparoscopic surgery is uncommon. Local and systemic factors contribute to development of post-op PVT. Thrombosis related to CO2pneumoperitoneum may be caused by hemodynamic changes like decrease in superior mesenteric arterial and portal venous blood flow. Issues with PVT have been seen related to splenectomy, bariatric procedures, and right hemicolectomy. Pneumoperitoneum induced hemodynamic changes and local inflammation due to diverticulitis might have contributed to PVT in our case.

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.

Retroileal anastomosis in hand-assisted laparoscopic left colectomy: experience at a single institution

Left hemicolectomy and complicated sigmoid colectomy require an anastomosis between the transverse colon and rectum. Generous mobilization will typically allow the colon to reach to the rectum. However, despite full mobilization of the splenic flexure and extensive work on the mesentery, there are cases in which reach to the pelvis is still an issue. Retroileal routing of the colon is one technique for overcoming such a reach problem and achieving a tension-free anastomosis. Performing retroileal routing using laparoscopic techniques has been reported rarely, and to date, there are no data on this technique when performed in a hand-assisted laparoscopic fashion. This study aimed to describe the feasibility of doing a retroileal routing using a hand-assisted laparoscopic technique. This was a retrospective chart review of patients who underwent a colon or rectal resection, either open or laparoscopic, with a pelvic anastomosis, by a single colorectal surgeon at an academic institution between 2008 and 2015 with a focus on the immediate and long-term postoperative complications, estimated blood loss, and operating room time for patients having an operation that included retroileal routing for construction of a colorectal anastomosis. A total of 340 patients fit inclusion criteria and of these, 13 underwent hand-assisted laparoscopic procedures with retroileal routing of the proximal colon to the colorectal anastomosis. Postoperative morbidity included intubation for CO2 retention in one patient and a RLL effusion in another patient; there were no anastomotic leaks. Long-term morbidities included two ventral hernias at 2years postoperatively. Mean operating room time was 208min. There were no 30- or 90-day mortalities. Hand-assisted laparoscopic retroileal routing is a feasible and safe technique in accomplishing a tension-free colorectal anastomosis when proximal colon length makes standard routing of the colon to the rectum an issue.

2019 Canadian Surgery Forum Abstracts.

# 01. The future of general surgery training: a Canadian resident nationwide Delphi consensus statement {#article-title-2} Various pedagogical models have been introduced in an attempt to improve and restructure surgical training, but significant obstacles remain. Before implementing national

P089 Small bowel Clostridium difficile masquerading as Crohn's disease

CASE: A 38-year old man with a history of perforated diverticulitis s/p sigmoid colectomy presented to the emergency room with 2 days of abdominal pain. He was without any symptoms of diarrhea, hematochezia or melena. He was previously admitted to the hospital for 4 days approximately one month prior to presentation with similar symptoms of abdominal pain. He had a CT scan of the abdomen and pelvis performed during that admission with wall thickening of the terminal ileum, but no colonic inflammation seen. He was treated with a week of ciprofloxacin and metronidazole with transient improvement in his symptoms. He denied any significant social history. Family history was negative for inflammatory bowel disease. He denied any NSAID use, but he did report a 3-day course of clindamycin approximately 3 weeks ago for a dental procedure. His lab values were notable for a mild leukocytosis of 12.6 × 109/L (ref range 4.8–10.8 × 109/L), elevated C-reactive protein at 1.89 mg/dL (ULN ≤ 0.60 mg/dL), normal lactate at 1.0 mmol/L (ref range 0.6–2.2 mmol/L), and a negative QuantiFERON TB Gold Plus. He had CT imaging repeated of his abdomen and pelvis that was significant for multiple loops of ileal wall thickening consistent with severe ileitis without any inflammation of the large intestine. Given the concern for Crohn's disease, a colonoscopy was performed and a normal terminal ileum was seen for 30 cm. There were multiple small-mouth diverticula seen in the descending, transverse and ascending colon along with a prior end-to-end colo-colonic anastomosis in the sigmoid colon. The mucosa appeared to be normal and healthy in the colon. Random biopsies taken of the terminal ileum and colon were negative for any significant pathological diagnosis. No antibiotics were given prior to colonoscopy. Stool studies returned with a positive Clostridium difficile result, but negative stool culture and parasite screen. He was treated with a 14-day course of metronidazole 500 mg Q8H with resolution of his symptoms. DISCUSSION: This case is atypical given the patient's lack of significant diarrhea, CT imaging findings of distal ileal involvement without any colonic inflammation, and normal findings on both endoscopic evaluation and pathology. While C. difficile is the most common cause of healthcare associated infectious diarrhea, small bowel infection with C. difficile is a rare presentation. The pathophysiology of C. difficile enteritis is not well understood, but most cases reported in the literature have been described in patients with altered bowel anatomy such as colectomy, pouch construction or other large and small bowel surgery. In these cases, the small bowel is postulated to be more susceptible to colonization and infection in the setting of surgical intervention. This case highlights that C. difficile can solely affect the small bowel of patients with limited colonic resections which is important for practicing gastroenterologists.

Bowel perforation in a pediatric patient with congenital generalized lipodystrophy type 4

Abstract Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive disorder that affects adipocyte development. Presentation varies based on type. A 12-year old female with CGL type 4, developed a sigmoid colon perforation in the setting of colonic wall hypertrophy after colonoscopy. She presented to the emergency room (ER) with several days of worsening abdominal pain and fevers. The initial evaluation was concerning for infectious versus inflammatory colitis. She was admitted for gastroenterology (GI) consultation for the complaint of abdominal pain. The patient had an established history of constipation management with laxatives. Full GI evaluation, including infectious panel as well as esophagogastroduodenoscopy (EGD) and colonoscopy, was negative. During the colonoscopy some difficulty with passage of the colonoscope past 25 cm was reported and therefore a gastroscope was used. She met criteria to start a clear liquid diet following the procedure. Two days after the colonoscopy, she had pneumoperitoneum on abdominal radiographs and was taken to the operating room for exploratory laparotomy. At the time of surgery, copious fibrinopurulent exudate was found throughout the abdominal cavity, as well as a thickened sigmoid colon/rectum and perforation with a contained abscess at the rectosigmoid junction. Sigmoid colectomy and end colostomy were performed. Pathologic examination demonstrated diffuse colonic wall thickening, a serosal defect that did not extended to the mucosa and several early diverticula. The pathology report stated that the presence of microscopic perforations could not be ruled out. The patient had an uneventful post-operative recovery. Congenital generalized lipodystrophy type 4 is a rare disease. We suspect an association between the muscular hypertrophy and the clinical presentation of bowel wall thickening and stricture. Given the rare nature of this disorder, clinicians that evaluate patients with CGL type 4 for constipation should have a suspicion for the possibility of colonic strictures. Rarely the condition can advance to perforation.

Plasma and wound fluid levels of eight proangiogenic proteins are elevated after colorectal resection

BACKGROUNDColorectal resection is associated with 3-5 wk long elevations in the plasma levels of at least 11 proangiogenic proteins that may stimulate tumor angiogenesis post-surgery. The increases during the first week after surgery may be related to the acute inflammatory response; the cause(s) of the week 2-5 increases is unknown. The wounds are a possible source because of the important role that angiogenesis plays in the healing process. The main hypothesis of the study is that wound fluid levels of the proteins studied will be elevated well beyond plasma levels which, in turn, are elevated from preoperative baseline levels.AIMTo determine plasma and wound fluid levels of 8 proangiogenic proteins after colorectal resection for cancer and benign pathology.METHODSBlood and wound fluid samples were taken simultaneously on postoperative (postop) day 1, 3, and later time points until wound drain removal in 35 colorectal cancer patients and 31 benign disease patients undergoing colorectal resection in whom closed wound drains had been placed in either the pelvis or the subcutaneous space of the abdominal incision. Postop plasma levels were compared to preop plasma and postop wound fluid levels (separate analyses for cancer and benign groups).RESULTSSixty-six colorectal disease patients were studied (35 cancer, 31 benign pathology). Most patients underwent minimally invasive surgery (open surgery in 11% of cancer and 6% of benign patients). The majority in the cancer group had rectal resections while in the benign group sigmoid or right colectomy predominated. Plasma levels of all 8 proteins were significantly elevated from baseline (P < 0.05) at all post-operative time points in the cancer group and at 90% of time points (29/32) in the benign group. Wound levels of all 8 proteins were 3-106 times higher (P < 0.05) than plasma levels at 87-90 percent of postop time points; of note, wound levels were more than 10 times higher at 47-50% of time points.CONCLUSIONPlasma protein levels were elevated for 3 weeks after surgery; wound fluid levels were much greater than corresponding blood levels. Healing wounds may be the source of the plasma increases.