Ghost ileostomy in anterior resection for rectal carcinoma: is it worthwhile?

BACKGROUND: There is no consensus in the literature as to whether all patients who undergo anterior resection of the rectum with total mesorectal excision should have a defunctioning stoma or only those at high risk of anastomotic dehiscence. OBJECTIVE: The aim of this retrospective study was to evaluate the results of placing a removable Silastic band around the ileum during the abdominal phase to exteriorize it and create a loop ileostomy postoperatively without the need for laparotomy in case of an anastomotic complication. This approach is known as "ghost ileostomy." INTERVENTIONS: A vascular loop was passed around the terminal ileum through a window adjacent to the ileal wall. The loop was then exteriorized, through the abdominal wall, without tension, and secured to the skin on a rod. Two 24F Silastic drains were placed next to the anastomosis (anteriorly and posteriorly). PATIENTS: From May 1997 to May 2011, 168 patients underwent anterior resection of the rectum with total mesorectal excision plus ghost ileostomy. RESULTS: Symptomatic anastomotic dehiscence was observed in 20 of 168 patients (11.96%) and developed on postoperative days 4 to 12 (median, postoperative day 7). In 13 of 20 cases, an ileostomy was fashioned with the patient under local anesthesia, and there was no need for relaparotomy. In 5 of 20 cases, the complication resolved with conservative management. In 2 of 20 cases, the patient's clinical condition rapidly deteriorated, generalized peritonitis developed, and surgical reintervention with abdominal toilette and colostomy was required. CONCLUSIONS: Ghost ileostomy allows selective loop ileostomy formation after low anterior resection of the rectum without the need for laparotomy in most cases. However, the technique should be reserved for instances in which the risk of leak is relatively low, such as anastomoses performed in the absence of neoadjuvant therapy. The role of routine ghost ileostomy following higher-risk anastomoses remains to be determined.

Rectal hepatoid carcinoma with liver metastases in a patient affected by ulcerative colitis.

BACKGROUND: Hepatoid tumors (HTs) are rare extra-hepatic neoplasms with the histological features, biochemical profile and, sometimes, even clinical course of hepatocellular carcinoma. We present a case of rectal hepatoid adenocarcinoma with metachronous liver metastases. METHODS: Four months after total procto-colectomy for a rectal adenocarcinoma (Astler-Coller C2), a 42-year-old man with ulcerative colitis showed hypoechoic masses in the hepatic parenchyma by abdominal ultrasonography. Carcinoembryonic antigen was normal, but alpha-fetoprotein was 32,000 microg/L. Fine-needle biopsy revealed that liver masses were positive for hepatocellular carcinoma. The patient underwent left hepatectomy and alcoholisation of a small deep nodule in segment 8. RESULTS: Immunohistochemistry and albumin mRNA in situ hybridization suggested that the nodules were metastases of a HT. The patient was well during the first 6 months and refused any adjuvant chemotherapy. He died from liver failure 19 months after initial diagnosis. CONCLUSIONS: HT is a rare colon cancer. The preoperative diagnosis of this tumor requires a high degree of suspicion, the availability of a panel of immunohistochemical markers, and a certain amount of luck. The prognosis is poor despite an aggressive and multimodal therapeutic strategy. So far, none of the hypotheses proposed about the origin and the biology of these tumors is convincing.

Rare abdominal metastases from occult lobular breast cancer: report of two cases.

Intra-abdominal metastases from breast carcinomas are rarely reported in the literature. Least are those originating from occult breast primary. We report, one case of pancreatic metastasis and one case of metastatic infiltration of the colonic wall, both by occult lobular breast carcinoma. The first patient underwent pancreaticoduodenectomy for obstructive jaundice, with unexpected histological finding of infiltration of distal bile duct, pancreatic gland, portal vein and retroperitoneal soft tissue by lobular carcinoma of the breast. The second patient complained of diffuse abdominal pain associated with constipation and rectal bleeding and underwent endoscopic biopsy of three intestinal strictures, revealing metastatic lobular carcinoma with signet-ring cell morphology. In both cases, a subsequent complete diagnostic work-up demonstrated asymptomatic multiple breast nodules, diagnosed as lobular carcinoma by fine needle aspiration cytology.