Organoaxial volvulus of descending colon: a case report

“Colonic volvulus” refers to the twisting of colon, which most commonly involves sigmoid colon causing obstruction, ischemia and gangrene. But very rarely segment of descending colon can be involved. This is a case of 42 year old male with vomiting, abdomen pain and distension since one day, showing organoaxial volvulus of descending colon loop with a twist of mesentery.

Long-term survival analysis after endoscopic stenting as a bridge to surgery for malignant colorectal obstruction: comparison with emergency diverting colostomy

The use of colorectal self-expanding metal stents (SEMS) as bridge therapy for malignant colorectal obstruction was first reported more than 20 years ago. However, its use remains controversial. Objective: In this study, we aimed to compare the long-term survival of patients with potentially resectable malignant colorectal obstruction who had undergone colorectal SEMS placement and emergency surgery. Methods: This study was a retrospective analyses. Patients who received treatment between 2009 and 2017 were included. According to the eligibility criteria, 21 patients were included in the SEMS group and 67 patients were included in the surgical group.. Results: The majority of the patients in the SEMS group were female (57.1%), whereas the majority of those in the surgical group were male (53.7%). The median follow-up time was 60 months for both groups with the same interquartile range of 60 months. There was no difference in the overall survival rate (log rank p=0.873) and disease-free survival rate (log rank p=0.2821) in the five-year analysis. There was no difference in local recurrence rates (38.1% vs. 22.4%, p=0.14) or distant recurrence rates (33.3% vs. 50.7%, p=0.16) in the SEMS and the surgical groups. Technical and clinical success rates of endoscopic stenting were 95.3% and 85.7%, respectively. There were no immediate adverse events (AEs). Severe AEs included perforation (14.3%), silent perforation (4.7%), reobstruction (14.3%), and bleeding (14.3%). Mild AEs included pain (42.8%), tenesmus (9.5%), and incontinence (4.76%). The limitations of this study was retrospective and was conducted at a single center. Conclusions: No differences in disease-free and overall survival rates were observed in the five-year analysis of patients with resectable colorectal cancer who had undergone SEMS placement or colostomy for the treatment of malignant colorectal obstruction. Patients in the SEMS group had a higher rate of primary anastomosis and a lower rate of temporary colostomy than did those in the surgery group.

Endoscopic stent in malignant colonic obstruction: the risk of tumor seeding / Prótese endoscópica no carcinoma do cólon em obstrução: risco de disseminação tumoral

Abstract Introduction: Malignant colonic occlusion is traditionally considered a surgical emergency. With the development of endoscopic techniques, metallic stents have emerged to ensure the colonic patency in nonsurgical candidates and, more recently, as a temporary measure until elective resection surgery is possible. Materials and methods: The research was conducted in PubMed and collected a total of 46 articles, including cross-references. Results: Ideally, intestinal occlusion should be resolved through tumor's primary resection with direct anastomosis. To avoid dehiscence of the anastomosis, tumor's resection may be performed with Hartmann's procedure. Metal stents are an alternative to emergency surgery and show excellent results in reliving colonic obstruction. However, they may have serious complications related to colonic perforation, migration and tumor dissemination. Discussion and conclusion: Observational studies and clinical trials show discrepant results. Metal stents are increasingly accepted in palliative care but are not yet recommended as a bridge to curative surgery. Treatment should be individualized, according to surgical risk and the probability of endoscopic complications.

Resumo Introdução: A oclusão intestinal aguda maligna é tradicionalmente considerada uma emergência cirúrgica. Com o desenvolvimento das técnicas endoscópicas surgiram os stents metálicos que asseguram a patência do cólon em doentes não candidatos a cirurgia e, mais recentemente, como uma medida temporária até ser possível realizar uma cirurgia de resseção eletiva. Materiais e métodos: A pesquisa decorreu na PubMed e reuniu um total de 46 artigos, incluindo referências cruzadas. Resultados: Idealmente, a oclusão intestinal deve ser abordada através da resseção primária do tumor com anastomose primária. Para evitar a deiscência da anastomose, a resseção tumoral pode ser realizada recorrendo à cirurgia Hartmann ou a um estoma derivativo sem resseção tumoral. Os stents metálicos são uma alternativa à cirurgia de emergência com resultados excelentes na resolução da obstrução cólica. Contudo, poderão levar a complicações como a perfuração cólica, a migração e a disseminação tumoral. Discussão e conclusão: Os estudos observacionais e ensaios clínicos mostram resultados discrepantes. O uso dos stents metálicos é cada vez mais aceite como tratamento paliativo, mas ainda não são inequivocamente recomendados como ponte para uma cirurgia curativa. O tratamento deve ser individualizado de acordo com o risco cirúrgico e a probabilidade de complicações endoscópicas.

A Case of Colonic Obstruction Due to Phytobezoars / 대한소화기내시경학회지

Colonic phytobezoars are defined as conglomerate masses of fruit or vegetable matter in the colon, and these have rarely reported as a cause of colon obstruction. Because it is extremely rare, its correct diagnosis might be delayed even with the aid of abdominal computed tomography. We report here on a case of diagnosed colonic obstruction due to colonic phytobezoars in a 67-year-old female with diabetic end stage renal disease and chronic constipation. Although abdomino-pelvic computed tomography did not demonstrate the presence of phytobezoars, multiple phytobezoars impacted in the colon were found and these were removed by colonoscopy. This is a rare case in that colonic obstruction due to phytobezoar was diagnosed early and it was treated by colonoscopy.

Usefulness of an Open Cecostomy in the Treatment of a Distal Colon Obstruction

PURPOSE: Stoma formation has usually been used for bowel decompression or fecal diversion. For these, a cecostomy is rarely performed because of disadvantages such as incomplete fecal diversion or fatal complications. The aim of this study was to evaluate the usefulness of an open cecostomy in treating patients with colonic obstruction. METHODS: Between May 2005 and August 2008, 20 patients underwent an open cecostomy because of colonic obstruction. All information on the patients was reviewed retrospectively for underlying disease, obstruction site, diameter of the cecum and transverse colon, and complications. RESULTS: Of the 20 patients, 14 had colorectal cancer, 3 had stomach cancer, 1 had cervical cancer, 1 had a carcinoid tumor, and 1 had an osteosarcoma. The cause of the obstruction was the primary tumor in 7 patients, peritoneal carcinomatosis in 7 patients, local recurrence in 5, and tissue edema after cyberknife treatment in 1 patient. All patients, except for 1 patient with a hopeless discharge due to rapid disease progression, were discharged on the tenth day postoperatively. No fatal complication developed. In 2 patients, the cecostomy closed spontaneously at 5.5 mo postoperatively after the distal obstruction had been resolved. CONCLUSION: An open cecostomy may be a useful and simple method for the decompression of a colonic obstruction, even though the diversion may not be complete.

Simultaneous Colonic Obstruction and Hydroureteronephrosis due to Mesenteric Fibromatosis

Mesenteric fibromatosis (MF) is a rare benign mesenchymal lesion that can occur throughout the gastrointestinal tract, especially small bowel. Its biological behavior is intermediate between benign fibrous tissue proliferation and malignant fibrosarcoma. In previously reported cases of MF, we could find colonic obstruction or ureter obstruction, but simultaneous involvement of colon and ureter was not able to be seen. We described a patient that presented with colonic obstruction and hydroureteronephrosis due to MF at sigmoid colon which mimicked submucosal tumor such as gastrointestinal tumor. This case resulted in a positive positron emission tomography scan suggesting malignant neoplasm, but beta-catenin positivity on immunohistochemical staining separated MF from gastrointestinal stromal tumor and sclerosing mesenteritis. The clinical course of the patient was improved after surgical resection.

Abdominal Compartment Syndrome after Stent Insertion for Obstructed Colon Cancer

Colonic stenting has been suggested as an acceptable therapeutic option for the palliation of malignant colorectal obstruction or to achieve bowel decompression and preparation. It is effective as a bridge to surgery that is useful as an option to avoid emergency colostomy. However, it is associated with complications such as intestinal perforation, stent migration, bleeding, and failure of bowel decompression. Of all the complications, intestinal perforation and failure of bowel decompression are most serious and require surgical treatment. Here we report a case of abdominal compartment syndrome after stent insertion for obstructive colon cancer. The main causative factors for abdominal compartment syndrome were bowel distension associated with endoscopic gas inflation and failure to achieve bowel decompression.

Incomplete Colonoscopy in Patients with Occlusive Colorectal Cancer: Usefulness of CT Colonography According to Tumor Location

PURPOSE: We sought to evaluate the clinical usefulness of CT colonography (CTC) after incomplete conventional colonoscopy (CC) for occlusive colorectal cancer (CRC) according to the tumor location. MATERIALS AND METHODS: Seventy-five patients with occlusive CRC underwent subsequent CTC immediately after incomplete CC. Fifty-nine patients had distal CRC and 16 had proximal colon cancer. Experienced radiologists prospectively analyzed the location, length, and TNM staging of the main tumor. The colorectal polyps in the remaining colorectum and additional extraluminal findings were also recorded. Sixty-seven patients underwent colorectal resection. We retrospectively analyzed the surgical outcome and correlated CTC and CC findings. RESULTS: The overall accuracies of tumor staging were: T staging, 86%; N staging (nodal positivity), 70% (80%); and intra-abdominal M staging, 94%. Additional colonic polyps were found in 23 patients. Six synchronous carcinomas were detected (9%); three in the proximal colon and three in the distal colon of occlusion. Clinically significant localization errors at CC were noted in 8 patients (12%, 5 proximal colon cancers and 3 distal CRCs) and were corrected by CTC. After CTC, the surgeons modified the initial surgical plan in 11 cases (16%). CONCLUSION: In occlusive CRC, CTC is not only useful in the evaluation of the proximal bowel, but can also provide surgeons with accurate information about staging and tumor localization. CTC is recommended when endoscopists encounter occlusive CRC, regardless of tumor location.

Comparison of Self-Expanding Metallic Stenting with Emergency Surgery as First-Management for Obstructing Primary Left-sided Colorectal Cancer

PURPOSE: Emergency surgery has been a conventional treatment for malignant large-bowel obstruction, but is associated with high morbidity and mortality. Recently, self-expanding metallic stents (SEMS) have provided a new modality as palliation or bridge therapy for patients with obstructing colorectal cancers. The purpose of the present study is to evaluate whether SEMS is useful in patients with malignant large bowel obstruction. METHODS: Between January 1999 and June 2004, 63 patients were treated for primary obstructing left-side colorectal cancer at the Department of Surgery, Seoul National University Hospital. 32 patients were managed firstly with SEMS (stent group), and 31 patients underwent an emergency operation (emergency surgery group). Clinical data were retrospectively reviewed. The results, including perioperative outcome and survival, were compared between the two groups. RESULTS: Clinicopathological parameters, including age, gender, ASA grade, tumor location and stage, were similar between the two groups. The rate of one-stage operations was significantly higher in the stent group (52% vs 13%; P=0.004). The stent group was associated with a lower rate of stoma formation (48% vs 87%; P=0.004), a shorter length of hospital stay (19 days vs 26 days; P=0.048), and fewer complications (7% vs 30%; P= 0.035). The overall and the disease-free survival rates were similar between the two groups (P=0.973, 0.126). The stent group was associated with fewer surgeries needed, shorter length of hospital stay, and fewer complications. CONCLUSIONS: Stenting with SEMS is useful in managing malignant large-bowel cancer with obstruction and may be better than traditional open surgery.

Comparison between Colostomy and Endoscopic Stent for Obstructive Colorectal Cancer as Palliative Treatment

PURPOSE: This study compared efficacy and safety of a colostomy and stent placement as a palliative management in obstructive colorectal cancer. METHODS: The patients underwent either a colostomy (16 patients) or endoscopic stent placement (14 patients). Patients with metastatic cancer and those who rejected surgery due to their advanced age and poor systemic state were enrolled in this study. RESULTS: The mean age of patients in the colostomy group (CG) and in the stent group (SG) was 61 and 66, respectively. The mean APACHE II score in the CG and SG was 4.5 and 6.9, respectively (P=0.026). The time to the first meal after the procedure was 3.8+/-1.7 days and 1.9+/-0.8 days in the CG and the SG, respectively (P=0.002). The frequency of analgesic injections after the procedure in the CG and SG was 3.7+/-2.8 and 0.2+/-0.4, respectively (P= 0.001). The mean hospital stay in the CG and the SG was 15.8+/-13.9 days and 7.0+/-3.5 days, respectively (P=0.026). The mean healthcare cost in the CG and SG was 6,085,000+/-3,959,683 won and 4,041,000+/-2,487,857 won, respectively (P=0.212). CONCLUSION: No serious complications occurred in the endoscopic stent group. There was a statistically significant difference between the two groups in the time to the first meal, the pain control frequency, and hospital stay after the procedure. Therefore, endoscopic stent placement might be a preferable option for the palliative treatment of patients with obstructive colorectal cancer.

Complete colonic obstruction secondary to endometriosis: A case report

This is the case of a 39 year old female who underwent an urgent laparotomy because of gut obstruction. Intraoperative impression was rectosigmoid carcinoma with frozen pelvis and assessed to be unresectable. hence a transverse colostomy was done. Although subsequent endoscopic and CEA evaluations gave the impression of intestinal endometriosis, malignancy could not be ruled out. Patient was started on Danazol and when it became ineffective, surgical control was contemplated. CT scan of the abdomen was done to assess for possible presence of abdominal malignancy and with a negative report, patient underwent abdominal subtotal hysterectomy, bilateral salpingo-oophorectomy, segmental resection of the rectosigmoid and appendectomy. Transverse colostomy was closed later. The objective of this paper was to report a case of complete rectosigmoid obstruction secondary to endometriosis, in order to demonstrate the difficulty in establishing an accurate diagnosis and the propensity of colonic endometriosis to mimic colon cancer.

Hérnia diafragmática congênita simulando tumor de cólon em paciente adulto jovem / Congenital diaphragmatic hernia simulating a colon tumor in young adult patient

Os autores apresentam um caso de hérnia diafragmática congênita diagnosticada em paciente adulto jovem durante transoperatório de laparotomia exploradora. Esta, realizada visando a esclarecer quadro clínico sugestivo de obstrução colônica por etiologia neoplásica. É apresentada, ainda, uma revisão sobre o tópico, avaliando-se as semelhanças entre o caso em questão e as informações de literatura (AU)

The authors present a case of congenital diaphragmatic hernia diagnosed in a young adult patient during exploratory laparotomy. Surgery was performed to elucidate clinical findings sugestive of large bowel obstruction due to colonic neoplasia. It Is still presented a review about this subject, evaluating the similarities between the case and the literature informations (AU)

Temporary Indwelling of Self-expandable Metal Stent may Obviate the Need of Staged Operation for Malignant Colonic Obstruction

PURPOSE: Staged operation employing temporary enterostomy is still the standard treatment of malignant colonic obstruction (MCO). Expandable metal stent has been used for the palliation of unresectable gastrointestinal obstruction. We applied this metal stent technique to the MCO to achieve temporary alleviation of the obstruction so that the bowel preparation and one-stage operation were enabled. In this study we examined the efficacy of temporary indwelling of metal stent to obviate the need of staged operation in the treatment of MCO. METHODS: From December 1998 to January 2001, 35 MCO patients were treated. Patients had typical symptoms of colonic obstruction such as abdominal pain and distension. When they were admitted, an self-expandable metal stent was introduced under the guide of flexible colonoscopy. For three days, formal bowel preparation (both chemical and mechanical) were followed. With regard to achievement of bowel preparation, postoperative complications and hospital stay, these 35 patients were compared with control group (N=20) of patients who underwent two staged operations for MCO. RESULTS: The tumor locations were upper rectum (N=10), sigmoid colon (N=22) and left colon (N=3). Metal stent slipped off in one patient. Double contrast barium enema was possible in 34 patients. One stage operation was performed in all patients. Anastomotic complications were not observed in both groups. Intraabdominal abscess requiring reoperation was noted in one patient in each group. Wound infection was noted in 3 (8.6%) stent patients whereas 16 (80%) patients had wound complication in the control group (P<0.05). Mean hospital stay was 12.2 days in stent group and 29.4 days in control group (P<0.05). CONCLUSIONS: Even though our series is limited in patient number, these data suggested that temporary indwelling of self-expandable metal stent may obviate the need of staged operation in the treatment of MCO.

The treatment of acute neoplastic colorectal obstruction / 中国普通外科杂志

Objective To explore the principles and methods of surgcal treatment for acute neoplastic colorectal obstruction.Methods The clinical data of 103 patients diagnosed as acute neoplastic colorectal obstruction were analyzed retrospectively.Results In this group,80 cases underwent emergency surgical treatment,(among) which,25 cases of carcinoma of right colon underwent primary resection and anastomosis;in 45 cases of carcinoma of left colon,primary resection and anastomosis was performed in 37 cases;and emergent(operations) were performed in 10 cases of rectal cancer.23 cases received non-emergency surgery.(Anastomotic) fistula occurred in 3 patients,pulmonary infection in 2 patients,pelvic cavity infection in 1(patient),1 patient died and the rest recovered well and were discharged.Conclusions The initial treatment for acute neoplastic colorectal obstruction should be non-surgcal treatment for 1~3d to make non-emergency surgical treatment more possible.If indications are properly selected,primary tumor resection and anastomosis is safe.For patients with severe contamination of abdominal cavity and bowel perforation, primary tumor(resection) should be performed if possible.

Rectal Obstruction Caused by Ischemic Colitis with Angiodysplasia: A case report

Angiodysplasia is a vascular lesion of the gut, which reveals intestinal bleeding as a major symptom. It is the cause of as much as 5~6% of the intestinal bleeding of unkown origin. Pathologically, it reveals anomalous submucosal vascular overgrowth, which is characterized by tortuous, dilated and thin-walled vessels. Because the lesion is mainly submucosal. It is hard to diagnosis with endoscopy and even in laparotpmy. Angiography has a low detection rate for angiodysplasia, but some of this typical findings are delayed excretion of dye into the venous structure around the lesion, vascular tuft in the arterial phase, and accelerated dye secretion into venous structure in the situation of arteriovenous malformation. Endoscopy, especially colonoscopy is so effective a diagnostic method as to make interventional therapy. Conjugated estrogen therapy is effective and is regarded as choice of treatment in the not-life-threatening intestinal bleeding caused by angiodysplasia. Surgery is only indicated in the case of uncontrolled bleeding. Intestinal obstruction has rarely been reported as another manifestation of intestinal angiodysplasia. Therefore pathologic definition should be confirmed, and research for pathophysiology of mucosal hypertrophy in the angiodysplasia is needed.

Modified antegrade colonic lavage for left obstructing colorectal carcinoma / 中国普通外科杂志

Objective To analyze the outcome of patients with acute obstruction of left colorectal cancer treated by modified antegrade colonic lavage with primary tumor resection and anastomosis.Methods From April 2002 to April 2007,112 patients with acute obstruction of left colorectal cancer underwent surgery.During the operation the left colon was exteriorized and placed into a sterilized plastic bag to protect the surgical field from contamination,then a catheter was inserted via the appendix,and after antegrade colonic lavage,primary resection and anastomosis was performed.Results Tumor resection and primary anastomosis was successfully done in the 112 cases.Postoperatively,1 case had anastomotic leak which healed after reoperation with proximal colostomy,and one patient died.Conclusions Modified antegrade colonic lavage is a simple procedure,the bowel can be rapidly decompressed with essentially no contamination,and has a high level of bowel cleansing.It is possible to safely perform primary resection and anastomosis for left colon cancer after the modified antegrade lavage.