[A Case of Elective Laparoscopic Resection for Sigmoid Colon Cancer with Irreducible Intussusception].

An 85-year-old man was hospitalized for a right greater trochanteric fracture. Rectal intussusception was found by diagnostic imaging but left untreated because of minor gastrointestinal symptoms. As a result of work-up for persistent mucous stool, he was diagnosed with sigmoid colon cancer with intussusception. The intussusception could not be reduced during barium enema examination but could undergo elective laparoscopic surgery with a good postoperative course. Adult intussusception may be asymptomatic and require no emergency treatment. In such a case, elective surgery can be performed. Many facilities employ laparotomy as a standard of care for intussusception. With the recent technological advances in endoscopic surgeries, laparoscopic surgery can be considered as a treatment option.

[A Case of Intussusception Caused by Cancer of the Sigmoid Colon in an Adult].

A 55-year-old man complaining of difficulty in defecation was referred to our hospital. A digital examination and abdominal CT led to a diagnosis of intussusception due to tumor of the sigmoid colon. The intussusception was successful reduced by enema. Following colonoscopy and abdominal enhanced CT, a sigmoid colon cancer(cT3, cN1b, cM0, cStage Ⅲb)was detected. A laparoscopic sigmoidectomy and lymph node dissection were performed on 23 days after the hospitalization. Postoperative course was uneventful. Preoperative reduction of the intussusception in this case enabled us to perform an elective surgery. We report this case with a review of the relevant literature.

[A Case of Intussusception Due to Sigmoid Colon Cancer].

A 78-year-old man was referred to our hospital with diarrhea, melena, and weight loss. During a digital rectal examination, a protuberant mass located 7-8 cm above the anal verge was palpable. Computed tomography(CT)scans of his chest, abdomen, and pelvis revealed an intestinal obstruction with a target sign in the lower rectum, indicating intussusception due to a sigmoid colon mass. A gastrografin enema examination revealed a typical filling defect with a crab claw sign in the rectum. However, the enema did not reduce the intussusception. The surgical findings showed that the sigmoid colon had slipped inside the rectum, consistent with the diagnostic imaging findings. A radical sigmoidectomy(D2)with diverting colostomy was performed to address the unprepared colon with accompanying edema. Pathology of the resected specimen revealed a type 2 tumor measuring 5 cm in size and comprising moderately differentiated adenocarcinoma(pT3pN0M0, pStage Ⅱ). The patient's postoperative course was uneventful, and his stoma was closed 2 months later. Intussusception occurs less frequently in adults than in children. In a case of bowel-within-bowel configuration, in which layers of the bowel are duplicated to form concentric rings, the target-like sign on CT images may be a useful diagnostic marker of colorectal intussusception.

Genetic predisposition resulting in sinusoidal obstruction syndrome in a patient with resected sigmoid cancer on adjuvant oxaliplatin.

A Chinese man who had undergone a curative high anterior resection for sigmoid cancer was administrated XELOX (capecitabine and oxaliplatin) as postoperative adjuvant chemotherapy. He subsequently developed sinusoidal obstruction syndrome (SOS) that resolved on discontinuation of XELOX treatment. Genetic evaluation determined that he had the GSTT1-null and GSTM1-null genotype, known to be an independent risk factor for developing oxaliplatin-induced SOS.

[Case of Laparoscopic Sigmoidectomy for a Patient with Persistent Descending Mesocolon].

A 65-year-old man with bloody stools was diagnosed with sigmoid colon cancer on colonoscopy. A preoperative barium enema and a computed tomography colonography scan showed a medial displacement of his descending colon. The preoperative clinical diagnosis was stage cT1 colon cancer, N0, M0, cStage I . Laparoscopic sigmoidectomy was performed. We found adhesions between the descending colon mesentery and the pelvic wall, and noted that the descending colon was not fused with the retroperitoneum and was shifted to the midline. The patient was diagnosed with persistent descending mesocolon (PDM). PDM is a congenital anomaly of fixation resulting from the failure of the descending colon mesentery to fuse with the parietal peritoneum. Anatomical findings should have been noted during the operation, including the fact that the descending colon artery, sigmoid colon artery, and superior rectal artery often branch radially from the inferior mesenteric artery. It is important to understand the anatomical characteristics of PDM and to improve on existing surgical procedures to ensure safe laparoscopic surgery for these patients.

[A Case of Para-Aortic Lymph Node Metastases of Sigmoid Colon Cancer Treated with Complete Resection].

We present a case of sigmoid colon cancer with isolated para-aortic lymph node metastasis in a 67-year-old male patient. We treated this patient using simultaneous curative lymph node dissection with primary tumor resection. After inserting a transanal tube and decompressing the proximal colon for obstructive colitis, we performed high anterior resection with paraaortic lymph node dissection without neoadjuvant chemotherapy. The pathology results were as follows: tub2, SE, N3, H0, P0, M1(No. 216, 280), stage Ⅳ, curability B. Adjuvant chemotherapy with the XELOX regimen was administered, and the patient remains alive with no signs of recurrence 24 months after surgery. Although simultaneous dissection of para-aortic lymph node metastasis is controversial, curative dissection is advisable for localized cases.

Prolapsed giant sigmoid lipoma: a rare cause of adult ischaemic intussusception.

Intussusception is a rare cause of obstruction in adults and has a variable, non-specific presentation. Adult intussusception is usually associated with an underlying organic pathology, such as a benign or malignant tumour which acts as the lead point. Prolapse of the lead-point mass through the anal canal is an extremely rare presentation with very few reported cases in the literature. We describe a case of a 67-year-old man who presented with rectal prolapse of a large soft tissue mass. CT of the abdomen and barium enema revealed partial intussusception of an upper sigmoid lipomatous polyp. Examination under anaesthesia was performed and the prolapse reduced. A laparoscopic sigmoid colectomy was planned. The patient subsequently re-presented clinically unwell with a recurrent necrotic prolapsing mass. Laparotomy and sigmoid colectomy was performed and the patient recovered fully. The resected mass was a 7×4.5×4.0 cm necrotic sigmoid lipoma.

[A case of sigmoid colon cancer with a sigmoidovesical fistula treated with preoperative XELOX+bevacizumab therapy and urinary bladder-conserving surgery].

A 64-year-old man presented with abdominal pain, diarrhea, urinary pain, and frequent urination.He was diagnosed with locally advanced sigmoid colon cancer accompanied by a sigmoidovesical fistula, which was determined to require total cystectomy for curative resection.Expecting tumor shrinkage and conservation of the urinary bladder, we performed loop ileostomy followed by preoperative mFOLFOX6+bevacizumab therapy.After 1 course of administration, the implanted port became infected.Therefore, the regimen was changed to 4 courses of XELOX+bevacizumab therapy.After the treatment, there was no longer any evidence of sigmoidovesical fistula.We performed a urinary bladder-conserving sigmoidectomy and finally achieved pathological curative resection.After adjuvant chemotherapy, no findings suggestive of recurrence were noted during 10 postoperative months.Preoperative XELOX+bevacizumab therapy may be worth considering as a therapeutic option for conserving the urinary bladder in cases of locally advanced colon cancer.

[A case of locally advanced colorectal cancer with abscess responding to 5-fluorouracil, leucovorin, and oxaliplatin plus bevacizumab].

We encountered a case of colorectal cancer with pelvic abscess treated with radical surgery following colostomy and chemotherapy. The patient was a man in his 60s with advanced rectal cancer. The tumor had expanded locally and formed an abscess. We evaluated the primary lesion as unresectable, and performed chemotherapy with 5-fluorouracil, Leucovorin, and oxaliplatin( mFOLFOX) plus bevacizumab after colostomy. After 13 courses of chemotherapy, the tumor shrank remarkably. We performed a low anterior resection followed by adjuvant chemotherapy with capecitabine. The patient has had no recurrence for 18 months after surgery.

Difficulty in differentiating two cases of sigmoid stenosis by diverticulitis from cancer.

The incidence of colonic diverticulosis with or without diverticulitis has increased in the Japanese population due to the modernization of food and aging. The rate of diverticulitis in colon diverticulosis ranges from 8.1% to 9.6%. However, few cases of stenosis due to diverticulitis have been reported. These reports suggest that the differentiation between sigmoid diverticulitis and colon cancer is difficult. This report describes two cases of colon stenosis due to diverticulitis that were difficult to differentiate from colon cancer. Case 1 was a 70-year-old woman with narrowed stools for 1 month who underwent colonofiberscopy (CFS). CFS revealed a diverticulum and circumferential stenosis in the sigmoid colon. Barium enema revealed a marked, hourglass-shaped, 2-cm circumferential stenosis in the sigmoid colon. Fluorodeoxyglucose (FDG)-positron emission tomography computed tomography (CT) revealed an increased FDG uptake at the affected portion of the sigmoid colon. Sigmoid colon cancer was suspected, and laparoscopic sigmoidectomy was performed. Pathological examination demonstrated active inflammation with no evidence of malignancy. Case 2 was a 50-year-old man who presented to a nearby clinic with reduced stool output despite the urge to defecate. CFS detected severe stenosis in the sigmoid colon approximately 25 cm from the dentate line. Contrast-enhanced abdominal CT revealed multiple diverticula, wall thickening, and swelling of the lymph nodes around the peritoneal aorta and the inferior mesenteric artery. A partial sigmoidectomy was performed. Pathological examination of the resected specimen revealed no changes in the mucosal epithelial surface, but a marked infiltration of inflammatory cells was observed.

5-FU-induced neurotoxicity in cancer patients with profound DPD deficiency syndrome: a report of two cases.

PURPOSE: 5-Fluorouracil (5-FU) is a mainstay for treating various solid tumours in adults, including digestive and head and neck cancers. 5-FU-related toxicities usually include haematological, digestive and cutaneous features. Additionally, 5-FU has been described as being potentially neurotoxic in patients, but these side effects are quite rare in clinical practice. Here, we report two cases of sudden and unpredictable drug-induced neurotoxicities that occurred in patients undergoing their first course of 5-FU-based chemotherapy. PATIENTS AND METHODS: None of these patients had any previous neurological disorder history, and both were treated following standard regimen (LV-5-FU2 and TPF for patient 1 and 2, respectively). Neurotoxicity included drowsiness, acute confusion plus dysarthria for the first patient and seizure, confusion and signs of metabolic encephalopathy for the second one. In addition, typical 5-FU-related severe toxicities (e.g. neutropenia and mucosities) were observed. Both patients slowly recovered from these neurological toxicities under supportive treatment. It was assumed that overexposure to 5-FU could explain the severe toxicities encountered. To test this hypothesis, we retrospectively evaluated the dihydropyrimidine dehydrogenase (DPD) activity of these patients on a phenotypic basis. RESULTS: Evaluation of the uracil-to-di-hydrouracil (U/UH2) ratio in plasma revealed a profound DPD deficiency syndrome in both patients. CONCLUSION: These cases suggest that 5-FU standard dosage administration may lead to strong overexposure, responsible for the severe toxicities observed, including the neurological features. It implies that DPD deficiency can cause neurotoxicity in 5-FU-treated patients and advocates for the prospective screening of DPD deficiency before starting any 5-FU-containing chemotherapy so as to prevent such side effects in the future.

[Seizures secondary to hypomagnesemia in patients with short bowel syndrome]. / Convulsiones secundarias a hipomagnesemia severa en paciente con intestino corto.

Magnesium (Mg) is the fourth most abundant cation in the body and plays a key role in numerous cellular functions such as glycolysis and energy metabolism. Its deficit may cause gastrointestinal disturbances, cardiovascular and neurological diseases. Among the latter, the symptoms may range from muscle weakness and numbness, to lethargy, hyperreflexia, ataxia, tetany, convulsions and coma. We report the case of a man of 65 with short bowel syndrome secondary to extensive bowel resection for sigma neoplasm and subsequent peritonitis, with end ileostomy, who presented several episodes of tonic-clonic seizures secondary to severe magnesium deficiency as a result a decrease in intestinal absorption of losses for high debit ileostomy. After beginning treatment with intravenous magnesium (iv) resulted in plasma levels normalize. Subsequently instituted dietary and pharmacologic treatment recommendations as well as magnesium and high-dose oral calcitriol to increase their absorption.

Squamous cell carcinoma arising in an ovarian mature cystic teratoma: a case report.

Malignant transformation in a mature cystic teratoma of the ovary is rare. The most common malignancy is squamous cell carcinoma, which consists of about 75% of malignant transformations. In the present report, we describe a case of advanced-stage squamous cell carcinoma arising in a mature cystic teratoma. A postmenopausal 63-year-old woman with squamous cell carcinoma arising in a mature cystic teratoma is presented. The initial investigation by ultrasound showed a left adnexal mass with mixed echo pattern, which arose the suspension of malignancy. She underwent a laparotomy and left oophorectomy. Histopatholog was compatible with squamous cell carcinoma arising in a mature cystic teratoma. After a few episodes of intestinal obstruction and colostomy, she underwent partial resection of the ileum and sigmoid colon four months after the initial oophorectomy. Histopathologic study showed metastatic poorly-differentiated squamous cell carcinoma. Subsequently, she underwent two courses of combination chemotherapy with cisplatin, leucovorin, and 5-fluorouracil with no response. She died from progression of the disease nine months after the initial operation.

Rectal prolapse as initial clinical manifestation of colon cancer.

Rectal prolapse as the initial clinical manifestation of colorectal cancer is uncommon. We describe the case of a 75-year-old woman who was diagnosed as having adenocarcinoma of the sigmoid colon after presenting with complete rectal prolapse. The tumor caused rectosigmoid intussusception and then it prolapsed out through the anus. She underwent rectosigmoidectomy and rectopexy. The postoperative course was uneventful. The relationship between colorectal cancer and rectal prolapse has not been clearly established. This case report describes an unusual presentation of colorectal cancer. It suggests that rectal prolapse can present as the initial symptom of colorectal cancer and may also be a presenting feature of the occult intra-abdominal pathology. The importance of adequate investigation such as colonoscopy should be emphasized in patients who develop a new onset of rectal prolapse.

Sigmoidorectal intussusception of adenoma of sigmoid colon treated by laparoscopic anterior resection after sponge-on-the-stick-assisted manual reduction.

We present herein a case report of sigmoidorectal intussusception as an unusual case of sigmoid adenomatous polyp. The patient was a 56-year-old man who suffered from rectal bleeding for one day. He initially visited his general practitioner and was diagnosed as having an intraluminal mass of 15 cm from the anal verge. Several hours after admission to our coloproctology clinic, he suddenly presented with lower abdominal cramping pain with rectal bleeding during his bowel preparation using polyethylene glycol electrolyte solution. An emergency colonoscopy revealed that the invaginated colon with polypoid mass was protruded to the lower rectum. Gastrograffin enema showed that the invaginated bowel segment was 3 cm from the anal verge. CT scan showed the typical finding of intussusception. We performed laparoscopic anterior resection and anastomosis after the sponge-on-the-stick-assisted manual reduction. The permanent pathologic finding showed villotubular adenoma of the sigmoid colon.

Endoscopic laser ablation of advanced rectal carcinoma--a DGH experience.

BACKGROUND: Patients with inoperable advanced rectal carcinoma require palliation for local symptoms. Endoscopic Nd-Yag laser ablation is a valid palliative treatment option in patients with advanced rectal carcinoma who are poor operative risks due to coexistent multiple comorbidities. METHODS: All patients who cannot undergo radical surgery due to various factors such as tumour size, poor risk patients, distant metastasis and refusal to undergo surgery were offered palliation with endoscopic Nd-YAG laser ablation. Indications included troublesome bleeding, local recurrence, mucous discharge and impending obstruction. Patients were admitted on the day of treatment, phosphate enema given for bowel preparation and endoscopic ablation done through a flexible sigmoidoscope under intravenous sedation with midazolam. All patients were discharged the next day after overnight observation. Patients were reviewed every 3 months and laser ablation repeated if deemed necessary. RESULTS: Eleven patients (7 males, 4 females; mean age 83.6 years, range 77-90 years) underwent endoscopic laser ablation in a District General Hospital --8 for rectal carcinoma, 2 for rectosigmoid tumour and 1 for recurrent tubulovillous adenoma. The number of treatment episodes varied from 1 to 12 with symptom free interval from 2 to 18 months between treatment episodes. There were 3 failures, one patient required defunctioning colostomy, one patient was referred for radiotherapy due to persistent symptoms and in one patient laser treatment had to be abandoned due to local extent. There were no immediate post-treatment complications, but one patient developed incontinence after 5 episodes which might be attributable to tumour infiltration. DISCUSSION: Endoscopic laser ablation is a practical and feasible alternative to other palliative treatment modalities in the management of this unfortunate category of patients due to low morbidity and mortality, short hospitalization and low complication rates.

[Sigmoid colovesical fistula associated with cancer of the sigmoid colon]. / Fístuia vesico-sigmoidea asociada con cancer de colon sigmoides.

OBJECTIVES: To report one case of colovesical fistula after the diagnosis of unresponsive urinary tract infection. METHODS: The 76-year-old patient underwent a diagnostic work up including cystography, cystoscopy and barium enema. RESULTS: Cystography revealed an image of the sigmoid colon, and cystoscopy showed a granuloma at the bladder dome. A fistula was identified underneath. A colovesical fistula was diagnosed and several intestinal germs grew on urine cultures. Partial cystectomy and end to end anastomosis of the sigmoid colon were carried out. Pathology report showed a well-differentiated adenocarcinoma which invaded down to the bladder mucosa. CONCLUSIONS: Inflammatory diseases are the main the etiology of colovesical fistula, followed by neoplasias. We reviewed around 170 cases reported in our country. It is important to identify the fistula by means of the gastro-intestinal series and the study of the lower urinary tract when treating patients with urinary tract infection difficult to control. We suggest the best radical therapy is surgery in a single procedure.

Fever of unknown origin in carcinoma of the colon.

OBJECTIVE: To report a case of fever of unknown origin in a patient with carcinoma of the colon but without gastrointestinal symptoms. CLINICAL PRESENTATION AND INTERVENTION: A 65-year-old man presented with a long-standing fever (of 38 degrees C, about two months' duration), night sweats, fatigue, malaise and anxiety. General physical examination including rectum, radiographic examinations of the chest, abdomen and bones (including ultrasonography and CT scanning) was normal. Biochemistry profile as well as other laboratory studies including blood, urine and stool cultures were normal except for erythrocyte sedimentation rate, which was 105 mm/h. A barium enema showed a rectosigmoid carcinoma. A left sigmoidal colectomy was performed. The patient recovered quickly and remained well for eight years postoperatively. CONCLUSION: This case shows that carcinoma of the colon should be included in the differential diagnosis of patients with fever of unknown origin.