Risk Factors for Recurrence of Crohn's Disease After Ileocecal Resection and Management Strategies.

INTRODUCTION: Pediatric patients with ileocecal Crohn's Disease (CD) refractory to medical management frequently require ileocecectomy. However, risk factors for post-operative ileocecal recurrence and appropriate management strategies are poorly defined in the pediatric literature in the biologic era. METHODS: We queried our institutional database from 1/1/2012-12/31/2022 for patients aged 1-21 who underwent primary ileocecectomy for CD. We analyzed baseline characteristics, operative details, medical management, recurrence patterns, and management patterns. RESULTS: We identified 208 patients who underwent primary ileocecal resection, of which 66 (23%) demonstrated endoscopic recurrence at 2.1 ± 0.5 years and 28 (13%) developed clinical recurrence at 2.5 ± 0.8 years. Recurrence was at the surgical anastomosis in 43 (21%). Before surgery, 138 (66%) were treated with a biologic, of which 25 (18%) were transitioned to a second line biologic pre-operatively. Requiring a separate intervention for perianal or intestinal disease increased the odds of recurrence on multivariable analysis, as did requiring a second line biologic. Of those with endoscopic recurrence, most [62/66 (94%)] were successfully managed with medical optimization alone. Only four (6.7%) required procedural intervention with two being managed with endoscopic balloon dilation and two requiring repeat resection and re-anastomosis. Median follow up was 2.6 years [IQR 1.2-4.5]. CONCLUSION: Requiring separate interventions for perianal or intestinal disease and demonstrating disease difficult to medically control may increase the risk of recurrent post-operative ileocecal CD. Such patients should be closely surveilled for endoscopic recurrence and may warrant more aggressive medical regimens. Recurrence can typically be managed medically with few patients requiring procedural intervention. LEVEL OF EVIDENCE: III.

Appendiceal Elastofibroma Requiring Ileocecectomy.

Elastrofibromas are rare lesions characterized by collagen and elastic fiber deposition. They are generally found in soft tissues and throughout the gastrointestinal tract. The pathogenesis of this lesion is still uncertain, but it is hypothesized to be a reactive process. We present a case of an appendiceal elastofibroma, a unique anatomic location that necessitated surgical removal, with pathologic findings suggestive of an inciting event from a sclerosed vascular abnormality.

Low-Grade Appendiceal Mucinous Neoplasm Adhered to the Posterior Cecum: A Case Report.

Low-grade appendiceal mucinous neoplasms (LAMN) constitute a rare subset of epithelial tumors and represent the second most common form of appendiceal cancer. LAMN typically presents as acute appendicitis, with definitive diagnosis often occurring incidentally during appendectomy surgery. While contrast-enhanced computed tomography (CECT) is the imaging of choice, misdiagnoses are common, highlighting the need for additional diagnostic modalities that are often underutilized. There is ongoing debate about treatment recommendations which typically involve a simple appendectomy, but controversy persists regarding the intraoperative necessity of a cecectomy, ileocecectomy, or formal right hemicolectomy. Here, we present a case featuring a 72-year-old African American female referred to our surgery clinic presenting solely with bloating and constipation rather than classical acute appendicitis, discrepancies between CT and MR imaging, and an unusual intraoperative finding of a posteriorly positioned mucocele adhered to the cecum, necessitating right hemicolectomy.

Management of Crohn's Disease and Its Complexities: A Case Report and Literature Review.

This case report and literature review explore Crohn's disease (CD), a chronic inflammatory disorder of the gastrointestinal tract characterized by unpredictable flare-ups and remissions. The study highlights the diverse clinical manifestations, including abdominal pain, diarrhea, and weight loss, which significantly affect quality of life. It examines the interplay of genetic, environmental, and immune factors in CD's pathogenesis and the complexities in managing the disease. Through a case study of a 20-year-old male, the report addresses various treatment strategies, including medications and surgery, and emphasizes the challenges, particularly post-surgical complications like small bowel leaks. The findings underscore the need for vigilant postoperative care to enhance patient outcomes in this complex condition.

Outcomes Among Malnourished Patients With Crohn's Disease Undergoing Elective Ileocecectomy: A Nationwide Analysis.

BACKGROUND: Crohn's patients' nutritional status can be suboptimal given disease pathophysiology; the effect of a malnourished state prior to elective surgery on post-operative outcomes remains to be more clearly elucidated. This study aims to characterize the effect of malnutrition on post-operative outcomes and readmission patterns for Crohn's patients undergoing elective ileocecectomy using a nationally representative cohort. METHODS: The colectomy-targeted National Surgical Quality Improvement Program Database (2016-2020) was used to identify patients with Crohn's disease without systemic complications who underwent elective ileocecectomy; emergency surgeries were excluded. Malnourished status was defined as pre-operative hypoalbuminemia <3.5 g/dL, weight loss >10% in 6 months, or body mass index <18.5 kg/m2 prior to surgery. RESULTS: Of 1464 patients (56% female) who met inclusion criteria, 1137 (78%) were well-nourished and 327 (22%) were malnourished. Post-operatively, malnourished patients had more organ space surgical site infections (SSI) (9% vs 4% nourished groups, P < .001) and more bleeding events requiring transfusion (9% vs 3% nourished, P < .001). 30-day unplanned readmission was higher in the malnourished group (14% vs 9% nourished, P = .032). Index admission length of stay was significantly longer in the malnourished group (4 days [3-7 days] vs the nourished cohort: 4 days [3-5 days], P < .001). DISCUSSION: Poor nutritional status is associated with organ space infections and bleeding as well as longer hospitalizations and more readmissions in Crohn's patients undergoing elective ileocecectomy. A detailed nutritional risk profile and nutritional optimization is important prior to elective surgery.

Symptomatic ileocolic pseudoaneurysm following laparoscopic ileocecectomy for Crohn's disease: A case report.

INTRODUCTION: Crohn's disease is prevalent worldwide. It is an idiopathic, chronic and relapsing disease, characterized by chronic inflammation of any part of the gastrointestinal tract. Vascular involvement rarely occurs in Crohn's patients. However, the chronic inflammatory process leads to structural and functional changes in the vascular endothelium. We present a case of ileocolic artery pseudoaneurysm after laparoscopic ileocecectomy in a Crohn's patient. CASE PRESENTATION: We report a case of a 26-years-old male diagnosed with Crohn's disease 4 months prior to an elective laparoscopic ileocecectomy. Before the operation, the patient suffered from severe terminal ileitis and typhlitis with signs of micro perforation. 3 weeks following his discharge, the patient arrived at the ER complaining of severe right lower abdominal pain. Computerized Tomography (CT) scans revealed a 35 mm ileocolic pseudoaneurysm that was treated urgently with coil-embolization via angiography. DISCUSSION: Until recently, few reports regarding the involvement of pseudoaneurysm of mesenteric arteries in relation to bowel resection surgeries have been reported. It is believed that the chronic inflammatory process induces a potent effect on the vascular endothelium, leading to thick, inflamed and highly friable mesenteric vessel walls. We propose that the pseudoaneurysm occurred as a result of surgical intervention on a thickened and diseased mesentery artery branch. CONCLUSION: Inclusion of mesenteric resection in Crohn patients' undergoing bowel resection may be an innovative way to avoid this complication and to reduce recurrence.

Surgical Treatment of Neuroendocrine Tumors of the Terminal Ileum or Cecum: Ileocecectomy Versus Right Hemicolectomy.

BACKGROUND: Simple ileocecectomy and right hemicolectomy are two potential operative approaches to treat patients with neuroendocrine neoplasm in the terminal ileum and/or cecum (IC-NENs). We sought to define the long-term outcome of patients undergoing ileocecectomy versus right hemicolectomy for IC-NENs, as well as characterize number of nodes evaluated and lymph node metastasis (LNM) associated with each procedure. METHODS: Patients who underwent curative-intent resections for IC-NENs between 2000 and 2016 were identified from a multi-institutional database. The clinicopathologic characteristics, surgical procedures, and the overall (OS) and recurrence-free survival (RFS) were compared among patients who underwent formal right hemicolectomy versus ileocecectomy only. RESULTS: Among 127 patients with IC-NENs, median size of the largest tumor size was 2.0 (IQR 1.2-2.9) cm; 35 (27.6%) patients had multiple lesions. At the time of surgery, 93 (73.2%) patients underwent a right hemicolectomy, whereas 34 (26.8%) had ileocecectomy only. Every patient had a lymph node dissection (LND) with a median number of 16 (IQR 12-22) nodes evaluated. A majority (n = 110, 86.6%) of patients had LNM with a median number of 3 (IQR 2-5) LNM. Patients who underwent hemicolectomy had more lymph nodes evaluated versus patients who had an ileocecectomy only (median, 18 vs. 14, p = 0.004). Patients who underwent formal right hemicolectomy versus ileocecectomy had a similar OS (median OS, 101.9 vs. 144.5 months, p = 0.44) and RFS (median RFS, 70.3 vs. not attained, p = 0.80), respectively. CONCLUSIONS: Ileocecectomy had similar long-term outcomes versus right hemicolectomy in treatment of IC-NENs despite a difference in the lymph node harvest.

Does microscopic involvement of the surgical margins after ileocecectomy in Crohn's patients predict early recurrence?

OBJECTIVE: The primary aim of this study was to determine whether the microscopic presence of Crohn's disease (CD) in the resected specimen margins in patients undergoing ileocecectomy predicts disease recurrence. The secondary aim was to identify other risk factors which can predict recurrence. METHODS: All CD patients who underwent ileocecectomy in a single colorectal unit between 2000 and 2015 were retrospectively evaluated. The diagnosis of CD and margin involvement status were retrieved from pathology reports. Recurrence was determined according to medical records or via a telephone questionnaire. Demographic, clinical, and surgical parameters were compared between patients with and without histopathologic evidence of CD in the resected margins. RESULTS: A total of 202 CD patients were included, 49 with and 153 without evidence of microscopic involvement in the resected margins. The main demographic characteristics, surgical approach and procedure, and postoperative course, including medical treatment, clinical or endoscopic recurrence, and reoperation rates, were similar for both groups. Patients who were operated laparoscopically (n=58, p 0.016), conversion from laparoscopic to open (n=25, p 0.016), stapled anastomosis (n=150, p 0.004), when stricturoplasty was required (n=12, p 0.046), and those with perianal disease (n=32, p 0.045) had shorter time to recurrence. Male gender had increased hazard ratio (n=106, HR 1.38) for reoperation, but not significantly (p=0.058). CONCLUSIONS: The presence of microscopic CD at the resected specimen margins was not associated with the risk of disease recurrence. Other demographic, clinical, and technical features that did correlate with early recurrence were identified. These results support a conservative approach to the extent of resection in CD patients undergoing ileocecectomy. TRIAL REGISTRATION: Not relevant.

Morbidly Obese Patients with Ileocolic Crohn's Disease May Benefit from Robotic Surgery.

BACKGROUND AND OBJECTIVES: Obesity is increasing as a comorbid condition for patients requiring surgery for Crohn's disease. Minimally invasive colectomy is ideal for a patient with combined obesity and Crohn's disease. However laparoscopic colon resection is associated with high operative conversion rates in these cases. Data examining the use of robotic surgery in the obese patient with Crohn's disease is sparse. METHODS: We examined the feasibility and outcomes of performing a minimally invasive colectomy using the Da Vinci robot in a prospective case series of morbidly obese patients with ileal Crohn's disease. RESULTS: A robotic ileocolectomy was performed in four morbidly obese patients with Crohn's disease. There were no operative conversions or complications with a median length of stay of 3 days. CONCLUSION: A robotic approach is a promising minimally invasive surgical alternative to laparoscopic surgery for these complex patients.

Robotic and laparoscopic surgical techniques in patients with Crohn's disease.

BACKGROUND: Crohn's disease has historically been managed medically with sparing use of surgical resection. With the development of strictures or fistulas, surgical management such as an ileocecal resection may become necessary. Minimally invasive options such as laparoscopic and robotic-assisted techniques are alternatives to open surgery. The purpose of this study was to evaluate the safety of minimally invasive surgery for Crohn's disease. METHODS: We performed a retrospective review of the National Surgical Quality Improvement Program (NSQIP) database to select 5158 patients with Crohn's disease who underwent ileocecal resection (open, laparoscopic, or robotic-assisted). Preoperative, perioperative, and 30-day postoperative outcomes were compared between the groups using both univariate and multivariate logistical regression models. SAS was used for data analysis with p < 0.05 considered significant. RESULTS: The three treatment groups (open, laparoscopic, and robotic-assisted ileocecal resection) had 30-day postoperative outcomes reported in NSQIP. The average BMI was 25 kg/m2 and the average age was 41. The rate of anastomotic leaks was significantly higher in the open surgery group compared to the minimally invasive groups (p = 0.001). The open surgery group had a significantly higher reoperation rate (p = 0.0002) and wound infection rate (p < 0.0001). The robotic-assisted group had significantly longer operative times compared to the laparoscopic and open groups (p < 0.0001). CONCLUSIONS: The decision to operate on a patient with Crohn's disease involves selecting an approach based on patient factors, surgeon preference, and availability of equipment. When evaluating the short-term postoperative outcomes in patients that have undergone ileocecal resection for management of Crohn's, minimally invasive techniques have had a lower incidence of wound infections, anastomotic leaks, and re-intervention in carefully selected patients. This retrospective review of a large national database demonstrates the efficacy of minimally invasive techniques in managing Crohn's disease in selected patients.

Laparoscopic ileo-cecectomy for ileo-ceco-colic double intussusception due to a cecal adenoma harboring multifocal high grade dysplasia in a 24 years old male: A case report.

INTRODUCTION: Intestinal Intussusception is defined as invagination of the intussusceptum into the intussuscepien, and is responsible of 1% of all bowel obstructions. It is rare in adults and common in children. It is mostly due to organic causes in adults that form lead points. Enteroenteric intussusception is the most common type. Signs and symptoms are more classic in children but nonspecific in adults. Usually diagnosis is made intraoperatively, while abdomino-pelvic CT scan is the best preoperative imaging modality. Intestinal Intussusception in adults, especially when the colon is involved, is best treated by surgical resection. CASE PRESENTATION: A 24 years old previously healthy male with no surgical or documented familial history presenting for severe crampy abdominal pain and distention, obstipation and palpable right lower quadrant abdominal mass. Abdominal Multi-slice CT diagnosed an ileo-colic intussusception without signs of bowel suffering. Laparoscopic ileo-cecetomy. Final Pathology showed a 4 cm cecal tubular adenomatous polyp with multifocal high grade dysplasia. CONCLUSION: Intestinal intussusception in adults is an interesting rare entity that have the interest of general surgeons. Malignant lesions can be lead-points and they form a great counterpart among other colonic lesions. Minimally invasive laparoscopic surgery is gaining interest in management, and surgical resection remains the gold standard while reduction before surgery is debatable and can be considered in selected cases.

Appendiceal intussusception requiring an ileocecectomy: a case report and comment on the optimal surgery.

BACKGROUND: Appendiceal intussusception is very rare condition with an estimated incidence of 0.01%. Therefore, it is likely to be overlooked. In addition, making the diagnosis before or during surgery is very difficult. CASE PRESENTATION: A 60-year-old male who was referred to our gastroenterology center with cecal inflammation found during a colonoscopy. An abdominal computed tomography (CT) following endoscopy revealed a 5 × 2.5 × 4 cm mass-like lesion in the cecum around the ileocolic (IC) valve and appendiceal orifice. The main lesion seemed to be an inflammatory mass rather than a malignancy because it appeared to be an extraluminal or extramucosal lesion. Ultrasonography revealed diffuse wall thickening of the cecum around the appendiceal orifice that was suspicious for an inflammatory mass or a benign mass. A diagnosis was uncertain. The differential diagnosis included chronic appendicitis, appendiceal neoplasm such as appendiceal mucocele, low grade appendiceal mucinous neoplasm. The patient underwent a laparoscopic partial cecectomy. In the surgical field, there was a large mass in the appendiceal orifice. The cecum was partially resected, with care taken to preserve the IC valve. Final histopathological analysis of the surgical specimen revealed an appendiceal intussusception without any mucosal lesion of the appendix. Narrowing of the terminal ileum with a small bowel obstruction and stenosis of the IC valve occurred postoperatively. Therefore, ileocecectomy was performed via a laparoscopic approach. The patient was discharged 11 days after the second surgery without another significant postoperative complication. CONCLUSIONS: We report a rare case of appendiceal intussusception that required reoperation due to ileocolic valve stenosis. If the correct diagnosis of appendiceal intussusception is made, we can select an appropriate surgical treatment based on the classification of appendiceal intussusceptions.

Amyand's hernia with acute gangrenous appendicitis and cecal perforation: A case report and review of the literature.

INTRODUCTION: An Amyand's hernia is a heterogeneous clinical condition defined by the presence of the vermiform appendix within an inguinal hernia sac, which may or may not contain other abdominal contents or pathologic inflammatory changes. Herein we present an exceptionally rare case of an Amyand's hernia containing acute appendicitis and a perforated cecum. PRESENTATION OF CASE: A 46-year-old male with a right inguinal hernia of 2-3 year duration presented to our Emergency Department complaining of acute onset abdominal and groin pain. The patient was diagnosed with an incarcerated right inguinal hernia and underwent emergent surgical repair. Intraoperatively a reactive fluid was found within the hernia sac that prompted an exploratory laparotomy for suspected bowel perforation. The hernia was then found to contain an inflamed gangrenous appendix with an inflamed and perforated cecum. An ileocecectomy and enteroenterostomy was performed and the hernia defect was repaired without mesh. DISCUSSION: With an estimated incidence of only 1%, Amyand's hernias are rare and lack a clear evidence-based management scheme. Moreover, they can contain a diverse range of pathologic features and presentations that can complicate diagnosis and treatment. To avoid potential morbidity and mortality, the surgeon must consider an Amyand's hernia on his or her differential when operating on inguinal hernias and be aware of the associated presentations, complications, and management schemes. CONCLUSION: There is a paucity of reports describing simultaneous appendicitis and cecal perforation within an Amyand's hernia. In our case, ileocecectomy and Bassini hernia repair with close follow-up led to a favorable outcome.

Yersinia pseudotuberculosis infection intractable by antibiotics: A rare case report.

INTRODUCTION: Yersinia pseudotuberculosis infection is usually cured spontaneously or with administration of antibiotics. PRESENTATION OF CASE: The patient is a twelve-year-old boy with right lower quadrant pain who had enterocolitis one month previously. Contrast-enhanced abdominal computed tomography showed a distended and edematous ileum and an intra-abdominal abscess adjacent to the mesentery with a normal appendix. The patient's general condition did not improve with antibiotics, so an ileocecectomy was performed. DISCUSSION: Yersinia pseudotuberculosis infection requiring an operation is rare. In our case, antibiotics were not effective in treating the abscess therefore surgery was required. An early diagnosis using serological studies, ultrasound of the abdomen, and fecal culture, with appropriate administration of antibiotics, may have avoided the need for surgery. Considering YP infection as a differential diagnosis is therefore important when encountering patients with enterocolitis, especially with right lower quadrant pain. Early diagnosis may assist in avoiding unnecessary operations. CONCLUSION: Diagnosis of YP infection may be missed or delayed because it is rare and difficult to detect, and must be distinguished from appendicitis. Although most YP infections are self-limiting, some rare cases will require surgery, therefore early diagnosis is essential.

Single-incision laparoscopic surgery (SILS) for children with Crohn's disease.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been described in adults with Crohn's disease, but its use in pediatric Crohn's patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn's disease. METHODS: A retrospective review was performed for patients diagnosed with Crohn's disease who underwent small bowel resection or ileocecectomy at a freestanding children's hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes. RESULTS: Analysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4 %) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7 % vs. OS 68.4 %, p = 0.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2 % vs. OS 100 % OS). Operative times were longer for SILS (135 ± 50 vs. 105 ± 37 min, p = 0.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3 ± 34.2 vs. OS 105 ± 36.5, p = 0.12). No difference was noted in postoperative length of stay (SILS 6.5 ± 2.2 days vs. OS 7.4 ± 2.2 days, p = 0.16) or overall complication rate (SILS 24.4 % vs. OS 26.3 %, p = 0.16). CONCLUSION: SILS ileocecectomy is feasible in pediatric patients with Crohn's disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.

Management of Appendiceal Mass and Abscess. An 11-Year Experience.

The aim of our study is to compare the results of emergency surgery versus conservative treatment with interval surgery in patients diagnosed with appendiceal mass and abscess. A retrospective review of 48 patients with appendiceal mass and abscess treated from January 2002 to January 2013 at General Surgery Department of Kipshidze Central University Hospital was performed. Patients with emergency surgery were compared to patients treated by nonoperative management with interval surgery. Demographics, clinical profile, and operative outcomes were studied. The emergency surgery group included 25 patients, and the interval surgery group included 23 patients. The clinical characteristics of the emergency surgery and interval surgery groups were not statistically different. In the emergency surgery group, an open appendectomy was performed on 17 patients, and colonic resections (ileocecectomy or right hemicolectomy) were performed on 8 patients. In the interval surgery group, an open appendectomy was performed on 21 patients, and colonic resections were performed on 2 patients. There were no statistical differences in types of surgery, postoperative complications, operation time without colonic resections, and postoperative hospitalization period among these 2 groups. Operation time with colonic resections was of greater duration in the emergency surgery group than in the interval surgery group (P = 0.04). Both treatment methods for appendiceal mass and abscess have the same results. The surgeon must consider clinical symptoms and results of investigations in each particular case when choosing an appropriate treatment method. Prospective randomized controlled trials are required for comparing the results of all 3 treatment methods of appendiceal mass.

Factors influencing disease recurrence after ileocolic resection in adult and pediatric onset Crohn's disease.

BACKGROUND: Factors influencing recurrence of ileocecal Crohn's disease (CD) after surgical resection may differ between adolescents and adults. METHODS: CD patients who underwent ileocecectomy were retrospectively divided into pediatric onset (age at diagnosis ≤ 16 years, n = 34) and adult onset (>16, n = 108) patients to evaluate differences in risks of endoscopic and clinical recurrence. RESULTS: In 142 patients, rates of any recurrence, endoscopic recurrence, and clinical recurrence at 5 years were 78%, 88%, and 65%, respectively. Risks of recurrence were similar between groups. Younger patients were more likely to be on immunologics preoperatively and more likely to be started on immunoprophylaxis postoperatively. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in the older group. CONCLUSIONS: Despite increased preoperative and postoperative immunoprophylaxis in younger patients, recurrence rates of CD after ileocecectomy do not differ between these groups. Immediate postoperative prophylaxis was predictive of delayed clinical recurrence only in patients with adult onset CD.

Clinical Analysis of 42 Cases Who Underwent Colectomy for Suspected Acute Appendicitis

PURPOSE: When patients underwent emergency surgery for suspected appendicitis, colon resection could be performed at the time of the initial operation. The aim of this study was to evaluate 42 cases underwent colectomy for suspected acute appendicitis. METHODS: A retrospective analysis of 42 patients underwent colectomy for suspected acute appendicitis was performed over the period from January 1997 to December 2003 at the department of surgery, Kangnam Sacred Heart hospital, Hallym university. RESULTS: The sex ratio were 1.2:1. The mean age was 37.7 years. Right lower quadrant pain was present in all patients. Nausea and vomiting occurred in 18 cases (42.8%). Preoperative fever was 11 cases (26.1%). Abdominal ultrasound was most commonly performed preoperatively. The operative findings showed cecal mass with pericecal abscess was 20 cases (47.5%) and cecal mass with inflammation, 11 cases (26.1%), etc. The pathologic findings showed cecal diverticular abscess was 18 cases (42.8%) and pericecal abscess, 9 cases (21.4%), periappendiceal abscess, 5 cases (11.9%), etc. Type of operation was ileocecectomy, 29 cases (69.04%), and right hemicolectomy, 12 cases (28.57%), and extended right hemicolectomy, 1 case. Postoperative complications developed in 12 cases (28.57%), but those were uneventful. CONCLUSIONS: When an unexpected and suspicious cecal mass was found at operation for suspected appendicitis, the resection of all clinically apparent disease including colectomy could be considered. So, the surgeon must be aware of the possibility of these condition and choose the appropriate treatment.