Segment Of Small Bowel Research Articles

Bir çocuk hastada Chilaiditi Sendromu: vaka sunumu

Chilaiditi syndrome is a rare disease which is characterized by recurrent abdominal pain, respiratory distress, constipation, and vomiting. It is usually asymptomatic, and the anomaly is diagnosed incidentally on chest or abdominal radiographs. The radiographs show interposed segment of colon or small bowel between the right lobe of the liver and the diaphragm. Treatment is not required for asymptomatic cases. In symptomatic patients, the initial treatment is conservative. Surgical treatment is performed in patients with obstruction, colonic volvulus or perforation. Beeing a rare syndrome in pediatric patients, we aimed to present an 8 year old female patient diagnosed as Chilaiditi syndrome, who has chronic abdominal pain, vomiting, and cough. Key words: Chilaiditi syndrome, children, abdominal pain, colopexy

Surgical strategies in paediatric inflammatory bowel disease.

Inflammatory bowel disease (IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid (distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum (pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.

Abdominal wall blow out causing bowel evisceration due to high voltage electrocution: A unique presentation

A 32-year-old male presented to surgical casualty after 3 h of sustaining high voltage electrocution through palm of the right upper limb with prolapse of bowel from the anterior abdominal wall. Apparently, the current flow through the right upper limb exited from the right lower abdomen wall resulting in full-thickness abdominal wall defect causing small bowel to prolapse. He had clawing of right hand and semi-flexion at elbow with blackening and dry gangrene from mid-arm onward with distal two-third of the right upper limb being parched and black. There was 9 cm × 7 cm wound over right abdominal wall through which small bowel had eviscerated with multiple perforations discharging feculent content. Exploratory laparotomy with resections of perforated segments of small bowel with end-to-end anastomosis and right mid-arm guillotine amputation were done. The abdominal wound was debrided and temporarily covered with overlay plastic bag to prevent bowel herniation. A small enterocutaneous fistula arising from the small bowel was noted through the abdominal wound of blow out site, which was managed conservatively. The entry point of electricity is usually the skull or the upper extremity with resultant exit through the lower extremity. The exit point through the abdominal wall with resultant abdominal wall loss is rare and even remorsely seen is the abdominal wall blow out with the evisceration of bowel, a rare phenomenon.

Jejunal Intussusception: A Rare Presentation of Carcinoid Tumor.

A 55-year-old male presented to the emergency department with sudden onset of diffuse abdominal pain for one day. Physical examination was remarkable for tenderness in the umbilical region. A CT scan of the abdomen showed intussusception involving the jejunum without any mass. The patient then underwent an exploratory laparotomy. During surgery, the distal jejunum was intussuscepted with mesenteric lymphadenopathy. Liver showed nodular deposits in both lobes of the liver. The involved small bowel segment was resected with primary anastomosis and liver was biopsied. Pathological examination showed multifocal deposits of well-differentiated carcinoids in the jejunum. The liver and mesenteric deposits were positive for metastatic carcinoid. Patient recovered well without any complications.

Traumatic Abdominal Hernia Masquerading as Strangulated Spigelian Hernia

ABSTRACTSpigelian hernia is a rare hernia constituting 0.1 to 2% of all hernias and needs high degree of clinical suspicion to diagnose. It has high chances of strangulation and hence operative management is advised. Traumatic abdominal wall hernia (TAWH) is yet another type of rare hernia usually occurring due to blunt trauma. This patient presented with TAWH with features of strangulation, at the anatomical site of Spigelian hernia mimicking a strangulated Spigelian hernia. He underwent emergency exploratory laparotomy, resection and anastomosis of involved small bowel segment with anatomical repair of defect. Patient recovered uneventfully in postoperative period.How to cite this articleNagarajan D, Chandrasekhar M, Jebakumar J, Menon A. Traumatic Abdominal Hernia Masquerading as Strangulated Spigelian Hernia. Panam J Trauma Crit Care Emerg Surg 2015;4(2):103-106.

An unusual appearance of giant Meckel’s diverticulum

Meckel's diverticulum (MD) results from incomplete involution of the proximal portion of the vitelline duct. Although MD is the most commonly diagnosed congenital gastrointestinal anomaly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagnosis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD (B5 cm) are relatively rare and associated with more severe forms of the complications. Herein, we report a 43-year-old male patient presented at the Emergency Department with a complaint of abdominal pain, associated with fever (38,5C), nausea and anorexia. The clinical examination revealed pain in the right lower quadrant, as well as abdominal guarding and rebound tenderness. The leucocyte count was elevated at 18 × 109/L. Plain abdominal xray depicted multiple air-fluid levels. An abdominal and pelvic CT scan revealed a fluid-filled structure in the pelvis adjacent to the distal small bowel. The surgical method of exploration can be either by laparoscopy or through an open incision. Exploratory laparotomy was performed and revealed oedema throughout the entire small bowel, dilation of small bowel segments, and a giant Meckel's diverticulum (10 cm long) with mushroom appearance on the antimesenteric border of the small bowel at 70 cm proximal to the ileocaecal valve . Resection of the small bowel was performed with a linear stapler and an ileoileal anastomosis was generated using a 80 mm endo-GIA stapler. Patient was discharged on post-operative day 4 without any complications. Histopathologic examination indicated Meckel's diverticulitis without gastric or pancreatic metaplasia. Pan African Medical Journal 2015; 21

Afferent Loop Syndrome With Associated Perforation 15 Years After Gastrectomy and Roux-en-y Reconstruction

An elderly patient presented to our institution with abdominal pain, nausea and vomiting. She had an extensive surgical background including gastrectomy with Roux-en-y reconstruction undertaken 15 years earlier. A CT abdomen demonstrated a small bowel obstruction proximal to the jejunojejunostomy with features suggestive of afferent loop syndrome (ALS), a rare but known complication following Roux-en-y reconstruction. Initial surgery identified a band adhesion and an associated ischemic small bowel segment, which was resected with primary anastomosis. A further operation was required at post-operative day five due to clinical deterioration. A retroperitoneal collection was identified secondary to perforation of the afferent loop.

Small Bowel Obstruction due to Intestinal Xanthomatosis.

Vast majority of bowel obstruction is due to postoperative adhesions, malignancy, intestinal inflammatory disease, and hernias; however, knowledge of other uncommon causes is critical to establish a prompt treatment and decrease mortality. Xanthomatosis is produced by accumulation of cholesterol-rich foamy macrophages. Intestinal xanthomatosis is an uncommon nonneoplastic lesion that may cause small bowel obstruction and several cases have been reported in the English literature as obstruction in the jejunum. We report a case of small intestinal xanthomatosis occurring in a 51-year-old female who presented with one day of copious vomiting and intermittent abdominal pain. Radiologic images revealed jejunal loop thickening and inflammatory changes suggestive of foreign body obstruction, diagnostic laparoscopy found two strictures at the jejunum, and a pathologic examination confirmed a segmental small bowel xanthomatosis. This case illustrates that obstruction even without predisposing factors such as hyperlipidemia or lymphoproliferative disorders.

A Rare Case of Hypermobile Mesentery With Segmental Small Bowel Pneumatosis Cystoides Intestinalis.

Pneumatosis intestinalis is a rare condition that affects 0.03% of the population. Pneumatosis cystoides intestinalis (PCI) is characterized by the presence of multiple gas-filled cysts in the intestinal wall and the submucosa and/or intestinal subserosa. It is usually a secondary finding caused by a wide variety of underlying gastrointestinal or extragastrointestinal diseases. Here, we present the case of a 47-year-old man who was referred to our gastroenterology department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain. Abdominal computed tomography demonstrated PCI of the small bowel. The mesentery and branches of the superior mesenteric artery and superior mesenteric vein were twisted with minimal pneumoperitoneum. Exploratory laparotomy was performed, and demonstrated segmental small bowel PCI secondary to hypermobile mesentery. The affected segment of the ileum was resected, and jejunoileal anastomosis was performed. Here, we report a rare case of segmental PCI probably due to repeated twisting of hypermobile mesentery. The clinical and imaging features of this disorder may mimic those of visceral perforation or bowel ischemia. PCI can be a cause of severe abdominal pain that may require surgical intervention.

MDCT and MR imaging of the jejunum.

Recent refinements in cross-sectional imaging have dramatically modified the investigation of the jejunum. Improvements in multidetector row computed tomography (MDCT) and magnetic resonance (MR) imaging technology have made detection and characterization of jejunal abnormalities easier. Current options include MDCT and MR imaging using either enterography or enteroclysis. The goal of this pictorial review is to outline the current imaging techniques that are used to investigate the jejunum and illustrate the most common conditions that affect this small bowel segment with a specific focus on MDCT and MR imaging using enterography or enteroclysis. MR imaging used in conjunction with optimal jejunal distension appears as the modality of choice for the diagnosis of a wide range of jejunal abnormalities. MDCT remains the first line imaging modalities because of an acute presentation in a substantial number of patients.

Erratum to: Identifying decreased peristalsis of abnormal small bowel segments in Crohn's disease using cine MR enterography: the frozen bowel sign.

The purpose of this study was to evaluate whether affected bowel in Crohn's disease patients can be identified by observing decreased peristalsis (frozen bowel sign) using cine balanced steady-state free precession (cine BSSFP) images. 5 radiologists independently reviewed cine BSSFP sequences from randomized MR Enterography (MRE) exams for 30 normal and 30 Crohn's disease patients, graded overall small bowel peristalsis from slowest to fastest, and graded peristalsis for the most abnormal small bowel segment. Sensitivity and specificity of the frozen bowel sign for diagnosing Crohn's disease were calculated. T tests of the peristalsis difference between abnormal segments and overall small bowel were conducted. For 5 readers, the sensitivity and specificity of cine BSSFP of the frozen bowel sign for diagnosing Crohn's disease ranged from 70% to 100% and 87% to 100%, respectively. There were significant differences in peristalsis between abnormal small bowel segments and the overall small bowel for Crohn's patients, but not in the overall small bowel between normal-MRE patients and Crohn's disease patients. Abnormal Crohn's small bowel segments have significantly decreased peristalsis compared to normal small bowel, which can be identified using cine BSSFP sequences as the frozen bowel sign.

Suprapubic single-incision laparoscopic segmental small bowel resection with intracorporeal manual anastomosis

A 40 year old lady presenting an unknown anemiawas admitted to consultation. Preoperative work-up evidenced an adenocarcinoma of the small bowel at 120 cm from the pylorus [2,3]. A suprapubic SIL segmental small bowel resection was proposed to the patient. The procedure was performed with the surgeon between the patient's legs, using three reusable trocars above the pubic bone. Curved reusable instruments permitted to surgeon to work under ergonomic conditions, maintaining a low cost of SIL (Fig. 1a). For the insertion of the linear stapler, a temporary 5-mm scope was used and the intestinal continuity was established by a completely intracorporeal manual end-to-end anastomosis (Fig. 1b). The mesenteric windowwas closed as well. The specimen was extracted suprapubically, after protection and have joined together the three windows of trocars.

Identifying decreased peristalsis of abnormal small bowel segments in Crohn's disease using cine MR enterography: the frozen bowel sign.

The purpose of this study was to evaluate whether affected bowel in Crohn's disease patients can be identified by observing decreased peristalsis (frozen bowel sign) using cine balanced steady-state free precession (cine BSSFP) images. 5 radiologists independently reviewed cine BSSFP sequences from randomized MR Enterography (MRE) exams for 30 normal and 30 Crohn's disease patients, graded overall small bowel peristalsis from slowest to fastest, and graded peristalsis for the most abnormal small bowel segment. Sensitivity and specificity of the frozen bowel sign for diagnosing Crohn's disease were calculated. T tests of the peristalsis difference between abnormal segments and overall small bowel were conducted. For 5 readers, the sensitivity and specificity of cine BSSFP of the frozen bowel sign for diagnosing Crohn's disease ranged from 70% to 100% and 87% to 100%, respectively. There were significant differences in peristalsis between abnormal small bowel segments and the overall small bowel for Crohn's patients, but not in the overall small bowel between normal-MRE patients and Crohn's disease patients. Abnormal Crohn's small bowel segments have significantly decreased peristalsis compared to normal small bowel, which can be identified using cine BSSFP sequences as the frozen bowel sign.

English

Duplication of bowel represents one of many congenital abnormalities of the gastrointestinal tract. It is a not uncommon cause of acute abdominal pain but remains a consideration in the pediatric population. It is well known that exploratory laparotomy is undertaken in pediatric patients. But in adults it will be difficult to diagnose this as the cause of chronic abdominal pain. We present the case of a patient who was admitted to hospital several times for recurrent abdominal pain in whom we eventually diagnosed intestinal duplication. KEYWORDS: Bowel duplication, Congenital anomaly. CASE REPORT: A 23-year-old man presented to the emergency department at the District Hospital Belgaum, attached to Belgaum Institute of Medical Sciences, Belgaum with a history of acute onset of cramping per umbilical pain and vomiting. His medical history included multiple admissions over a 6- year period for similar symptoms. Physical examination revealed mild abdominal tenderness but no peritonitis. Soon after admission, his acute abdominal pain resolved. An ultra sonological report of abdomen revealed a multiloculated cystic mass, suggesting a mesenteric cyst. In view of chronic pain in the abdomen, we obtained consent for exploratory laparotomy. The procedure revealed an ileal duplication 38-cm long with a cystic dilatation that had adhesions to the transverse colon (Fig.1). The base of the cyst was fibrotic, suggesting that recurrent obstruction at this level resulted in the patient's periodic episodes of abdominal pain. We resected the cyst and the parallel segment of small bowel and conducted a primary anastomosis. The patient had an uneventful postoperative period. DISCUSSION: Gross and colleagues 1 first defined intestinal duplication as spherical or tubular structures that possess a well-developed smooth muscle layer and are lined with a mucous membrane; they are found at any level from tongue to anus and usually are intimately attached to some portion of the alimentary tube. One large study 2 suggests that most duplications are intra- abdominal and of these, ileal and ileocecal duplications are the most common. Clinical presentation is similar to that in our patient's case and includes recurrent abdominal pain, vomiting, abdominal distension, gastrointestinal hemorrhage and sometimes peritonitis if a peptic ulcer perforation occurs in the duplicated segment with ectopic gastric mucosa or in the adjacent normal bowel. 3,4 The duplication can be the lead point in intussusception2,4 or the site of volvulus.2 Pre-natal ultrasound or ultrasound at the time of clinical presentation may lead to the diagnosis of these benign lesions. Differentiation from mesenteric cysts can sometimes be made during that initial ultrasound based on the thinner nature of the intestinal wall. Preoperative diagnosis is more commonly made with intestinal duplications of foregut than of mid gut or hindgut origin. 4 The universally accepted management of this condition is surgical intervention, and the

Crohn’s Disease: How Sure is Sure?

Introduction: Endoscopy with biopsy has been the gold standard for diagnosis of Crohn’s disease. A 33-year-old male presented with mid epigastric discomfort and constipation. Miralax and protonix was initiated. Over the ensuing 6 weeks, his symptoms of abdominal pain and bloating worsened. He lost 15 pounds, and had night sweats, early satiety, and abdominal tenderness. A CT scan of the abdomen showed abnormally thickened proximal ileal loops consistent with Crohn’s disease, and prednisone was started. He returned within days with worsening abdominal pain. Urgent colonoscopy with ileal visualization showed no significant abnormalities. Steroids were continued. CT enterography showed a segment of small bowel within the mid abdomen extending right to left with diffuse wall thickening as well as cystic implants within the omentum and adenopathy at the mesenteric root. Eventually, he experienced worse abdominal pain, fever, and vomiting. CT showed intra-peritoneal air consistent with a perforated hollow viscous. Emergent laparotomy with biopsy of peritoneal implants confirmed the diagnosis of intermediate grade follicular center cell lymphoma. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Bowel perforation in GI lymphomas is seen in approximately 9% of intestinal lymphoma cases, half of which occur after initiation of chemotherapy. Clinical entities that mimic intestinal lymphoma include Crohn’s disease, carcinomatosis, carcinoid tumors, and ischemic injury. Clues in this case that Crohn’s disease was not the right diagnosis was the rapid progression of disease, night sweats, weight loss, and absence of diarrhea. CT enterography showed progression of disease uncharacteristic of Crohn’s disease. Radiographs often depict abnormalities in patients with inflammatory bowel disease (IBD). However, a false positive rate of 16-20% with the low positive predictive value of a normal radiograph (62%) make radiography a poor diagnostic test. The empiric use of steroids in this patient may have not only increased the risk of bowel perforation, but was likely the cause for inconclusive histopathology on colonoscopic biopsy. This serves to reinforce that it is still crucial to have a biopsy-proven diagnosis of Crohn’s disease prior to initiation of steroids.Figure 1

Small Bowel Variceal Bleeding Secondary to Gyno-Enteric Shunt

Introduction: A 70-year-old woman with a history of cirrhosis secondary to hemochromatosis and prior alcohol abuse (with long-term abstinence) was admitted for large-volume hematochezia. She had a history of esophageal variceal bleeding in the past, which was effectively treated with esophageal variceal band ligation. Her last EGD and banding was performed 4 years prior to presentation with obliteration of esophageal varices. Two years prior to admission, she had a negative surveillance colonoscopy for a personal history of colon polyps. A bleeding scan was performed shortly after admission. Accumulation of radiotracer was noted in the right lower quadrant, suggesting active hemorrhage from the distal small bowel or right colon. Mesenteric angiography was performed with the intention of hemostasis following the positive bleeding scan. A clear bleeding site was not identified. At this point, the patient had received 20 units of red blood cells, several units of FFP, and vitamin K. The platelet count remained above 60 K/μL. She did not receive platelet transfusion. Her fibrinogen level was normal. As the site of bleeding remained unclear, a colonoscopy was performed to the distal 30 cm of ileum. This demonstrated blood clots and fresh blood to the proximal extent of the exam. EGD was performed using a pediatric colonoscope. The proximal 80 cm of small bowel was examined. EGD-enteroscopy did not demonstrate a clear bleeding source. No esophageal or gastric varices were seen. To further define the bleeding site, abdominal and pelvic CT angiography was performed. A portosystemic shunt between the parametrial veins and the superior mesenteric vein was identified (Figure 1). A partial portal venous thrombosis was also seen. The patient was taken to the operating room for exploratory laparatomy. The involved segment of small bowel was resected and suture ligation of the shunt was performed. Following surgery, there was no further hematochezia.Figure 1: Small bowel varices with communication to the superior mesenteric vein and parametrial veins.

Analysis of a Grading System to Assess Quality of Small Bowel Preparation for Capsule Endoscopy: In Search of the Holy Grail

Introduction: Capsule endoscopy (CE) diagnostic yield is vulnerable to inadequate visualization related to residual bile or chyme remaining in the lumen despite intestinal lavage. There remains no consensus on the reliability of qualitative, quantitative, or computer-derived quality assessments for CE. This study evaluates the intra-observer and inter-observer agreement of a previously validated scale. Methods: The digital images of 34 patients who underwent CE were independently reviewed by 2 blinded physicians according to a previously validated grading scale. One of the physicians reviewed and graded the patients a second time, also in blinded fashion. The luminal bowel preparation quality was assessed using a qualitative parameter (fluid transparency) and a more quantitative one (mucosal invisibility) for each of 3 small intestinal segments. An overall small bowel score for each parameter was assigned as well. A weighted kappa coefficient was used to calculate the intra-observer (Observer 1A and 1B) and inter-observer (Observer 1A and Observer 2) agreement. A kappa of 0.60 or more suggests strong agreement, 0.40 to 0.60 moderate agreement, and less than 0.40 is indicative of low agreement. Results: The intra-observer weighted kappa index was 0.52 for both fluid transparency and mucosal visibility, which is consistent with moderate agreement. The inter-observer weighted kappa indices were 0.29 and 0.42 for fluid transparency and mucosal visibility, respectively, demonstrating suboptimal interobserver agreement. Individual segment inter-observer kappa indices were better for mucosal visibility (0.52, 0.39, and 0.47 for small bowel segments 1, 2 and 3, respectively) as compared to fluid transparency (0.18, 0.38 and 0.31). Conclusion: The proposed grading scale for assessment of CE preparation quality has inadequate interobserver and intra-observer agreement. Capsule endoscopy preparation grading scales which focus more on quantitative than qualitative assessment may demonstrate more reliable performance characteristics.Table 1

Mysterious Intussusception in an Adult Without a Lead Point

Introduction: Intussusception is defined as telescoping or prolapsing of the proximal bowel segment into the distal segment. The mechanism is not fully understood in primary or idiopathic intussusception; however, secondary intussusception is believed to result from a lesion in the bowel wall that alters the peristaltic pattern of the bowel causing invagination. This is a very rare phenomenon. Case Report: A 40-year-old male with history of GERD, gastritis, cholecystectomy, and appendectomy presented to the emergency department with 1-year history of intermittent abdominal pain located in the mid-epigastric area described as squeezing and non-radiating pain, associated with bilious, non-bloody vomiting, and weight loss of 20 lbs for the past 3 months. The patient denies any hematemesis, diarrhea, constipation, hematochezia, or melena. Because of recent weight loss, CT with contrast was obtained, which revealed small bowel intussusception of 6 cm length without any obvious small bowel lesions or lead points causing the intussusception. He underwent exploratory laparotomy with segmental small bowel resection. Pathology of the resected bowel showed normal mucosa and muscular intestinal wall without any lead points or lesions. Discussion: Intussusception in adult patients represents 5% of all intussusceptions. This pathology can be explained 90% of the time to be due to an origination of lead point such as a carcinoma, polyp, diverticula, stenosis, or benign neoplasm. Thus, most surgeons agree that intussusceptions in adults require surgical resection due to intraluminal lesions as lead points, and therefore, its risk of malignancy. In adult patients, 90% of intussusceptions occur with a lesion of the intestinal wall or any irritant factor in its lumen that alters normal peristaltic activity, which serves as a trigger to start an intussusception of 1 bowel segment over another. In cases where no lead points are identified, intussusception may be due to submucosal bowel edema, fibrous adhesions, or dysrhythmic contractions. However, 8-20% of cases are idiopathic, without a lead point lesion. Transient non-obstructing intussusception without a lead point has been described in patients with celiac disease and Crohn’s disease, but is more frequently idiopathic and resolves spontaneously without any specific treatment. Conclusion: Intussusceptions in adults is a rare and challenging diagnosis. It is often initially missed or delayed due to its vague, non-specific symptoms. Abdominal CT is the most sensitive imaging modality, and can be helpful in distinguishing the presence or absence of a lead point. Treatment in adult intussusception is almost always by surgery due to frequent association with malignant organic lesions.

Abstracts and Case Studies From the College of American Pathologists 2014 Annual Meeting (CAP '14)

Abstracts and Case Studies From the College of American Pathologists 2014 Annual Meeting (CAP '14)

Ileocecal intussusception due to the intestinal metastasis of malignant melanoma

Intestinal obstruction due to ileocecal intussusception is very rare in adult age. Primary and secondary tumors, inflammatory or proliferative processes of the bowel are the causative factors. Malignant melanoma is a common disease in the western world with high metastatic rates, and is also a common extra-abdominal source of gastrointestinal metastases. We present a 55-year-old woman with the complaints of an abrupt colicky abdominal pain, nausea and vomiting. Her history revealed cutaneous melanoma that was excised five years ago. Her physical examination revealed abdominal distention with generalized abdominal tenderness. multidetector computed tomography (MDCT) revealed a mass at ileocecal junction with dilatation of entire small bowel segments. Metastasis was confirmed by laparotomy. After a right-sided hemicolectomy, patient died of disease with widespread metastasis with of one year after colectomy.