Bilious Emesis and Failure to Pass Meconium in the Nursery

Introduction: In this case we review important newborn nursery management strategies and unique surgical diagnostic measures in a severe case of intestinal obstruction due to small left colon syndrome (SLCS) - illustrating an impressive relationship between intestinal dysmotility and meconium plug formation that increases risk of intestinal perforation in the newborn. Case Description: We present a case of an infant born to a mother with symptomatic COVID-19, who at 24 hours of life was treated for failure to pass meconium with a glycerin suppository and went on to develop bilious emesis and severe abdominal distention as feeding continued over the next several hours. After a normal upper GI, a barium enema identified a distal obstruction and the pediatric surgical team used rectal irrigation to remove a large meconium plug which mimicked the appearance of the descending colon on plain film, ultimately leading to the diagnosis of SLCS. The infant went on to stool normally after removal, however due to the severity of his initial clinical picture, a multi-disciplinary team was consulted, and concluded that given the severity of the meconium plug, a workup for cystic fibrosis was indicated, but deferred a rectal biopsy for Hirschprung disease due to normal return of bowel function upon removal of the obstruction. Discussion: Meconium plug syndrome is a transient distal GI obstruction in the lower colon or rectum with thick meconium and is thought to be due to poor intestinal motility. A contrast enema is typically diagnostic, showing a decrease in bowel caliber distal to the plug, and therapeutic, as the plug is often passed during the procedure. A sharp transition zone at the splenic flexure followed by a narrow descending colon on imaging is consistent with SLCS with a meconium plug at the transition zone. Infants presenting with both meconium plug syndrome and SLCS may require an evaluation for an underlying diagnosis of cystic fibrosis or Hirschprung disease. Delayed meconium passage is present in 11.9% of infants diagnosed with cystic fibrosis, while 15% of infants with meconium plugs have an aganglionic segment on rectal biopsy, indicative of Hirschprung disease. The decision to perform additional tests in an infant with SLCS should be guided by the patient's clinical course and in conjunction with a pediatric surgical team. Conclusion: Although intestinal obstruction in the newborn is rather rare, it is imperative that it is promptly diagnosed and treated to avoid negative outcomes. Despite being considered a mild form of obstruction due to its transient nature, meconium plug syndrome can lead to an impressive clinical illness and urgent consultation with a surgical team is vital due to the risk of intestinal perforation if the obstruction is not relieved.

OVERSTITCH SUTURE OF PARIETAL DEFECTS AFTER ESD AND EFTR IS FEASIBLE, SAFE AND REDUCE THE NEED FOR HOSPITALIZATION

Background and aim: Endoscopic submucosal dissection (ESD) and endoscopic full thickness resection (EFTR) are recognized as valid advanced techniques for the treatment of pre-neoplastic/neoplastic lesions of the gastrointestinal tract. However, complication rate and need of hospitalization still remain a matter of discussion. The application of suturing devices have been suggested as an option to prevent complications and reduce hospital stay. The aim of our study was to analyse the feasibility and safety of Overstitch suturing devices applied after large and deep ESD/EFTR. The secondary aim was to evaluate the efficacy of suturing system to reduce hospital stay and complication rate. Materials and methods: From September 2020 to November 2021 (in Covid-19 pandemic era) all consecutive patients sutured with Apollo SX Overstich after complex resection were prospectively enrolled. Feasibility, complications, hospital stay were analyzed. Results: Fourteen patients(6 female, mean 79 +-8 yo) were enrolled;lesions were located in the stomach (3), in the rectum (7), in the sigmoid colon (2), in the descending colon (2). Final diagnosis were 10 HGD/T1 (sm1) and 4 lesions T1 (sm2/3) or T2 colo-rectal cancer. Eight patients were treated with ESD as outpatients whereas 4 underwent eFTR as inpatients with uneventful medium hospital stay of 4.7 days (range 4-6). Overstich suture was feasible in all the lesions, and all locations. No major complications occurred. One minor complications (colonic luminal stenosis) occurred and was successfully treated with temporaray placement of covered metal stent. (Figure Presented) Conclusions: Endoscopic overstitch system is safe and a useful tool to close large wall defect after ESD/EFTR.

RARE CASE OF ILEOCOLIC MESENTERY PRIMARY MELANOMA WITH LIVER METASTASIS

Purpose/Background: Although GI melanoma is commonly a metastatic disease, it is very unusual to see the mesenteric mass of the cecum and terminal ileum as the primary origin of melanoma. Hypothesis/Aim: This is a case report and presentation showing a rare occasion of primary melanoma in the cecum and the terminal ileum mesentery along the ileocolic pedicle causing cecal complete bowel obstruction. Methods/Interventions: The reported case is a rare occasion of large bowel obstruction near the cecum resulted from primary mesenteric melanoma invading into the wall of the descending colon. Primary melanoma of the GI tract is still controversial and only a limited of cases have been reported in the literature. We added a review of the other published case reports to this case report using Endnote. Results/Outcome(s): This is a 68-year-old female who was seen in the outpatient setting with increasing abdominal girth in addition to nausea and vomiting and obstipation. The patient had alternating bowel habits for over 2 months which she felt this was related to Covid as she was tested Covid positive and diagnosed with Covid pneumonia at the same time. She was directly admitted from the office to the inpatient and she had a CAT scan of the abdomen pelvis that demonstrated cecal obstruction related to possibly cecal mass/mesenteric mass with multiple liver metastatic diseases. She underwent exploratory laparotomy which resulted in Right extended hemicolectomy en bloc with a loop of jejunum and part of the terminal ileum. We tested later serum S100 the protein and it was elevated to 18,000, she had serum negative alpha-fetoprotein and negative CEA. This is a 68-year-old female who was seen in the outpatient setting with increasing abdominal girth in addition to nausea and vomiting and obstipation. The patient had alternating bowel habits for over 2 months which she felt was related to Covid as she was tested Covid positive and diagnosed with Covid pneumonia at the same time. She was directly admitted from the office to the inpatient service and she had a CAT scan of the abdomen pelvis that demonstrated cecal obstruction related to possibly cecal mass/ mesenteric mass with multiple liver metastatic diseases. She underwent exploratory laparotomy which resulted in Right extended hemicolectomy en bloc with a loop of jejunum and part of the terminal ileum. She had also intraoperative liver biopsy that demonstrated metastasis of the melanoma to the liver. We tested later serum S100 the protein and it was elevated to 18,000, she had serum negative alpha-fetoprotein and negative CEA. Limitations: Case report study with reported cases reviewed. Conclusions/Discussion: Large bowel obstruction could be related to unusual diagnoses like melanoma of the bowel mesentery. Although, primary GI melanoma is rare this showed the possibility of such diagnosis. (Figure Presented).

OBSTRUCTIVE LARGE CELL NEUROENDOCRINE COLON CANCER: CASE REPORT OF A RARE DISEASE

Purpose/Background: Colonic large cell type neuroendocrine carcinoma (LCNEC) is a rare type of neuroendocrine tumor with only 13 reported cases in the literature. Due to their rarity, there is currently no standardized management. Hypothesis/Aim: We present a case of colonic LCNEC presenting with obstruction requiring urgent surgical intervention. Methods/Interventions: A 43-year-old male presented to the emergency department with several days of abdominal pain and constipation for 48 hours. Physical exam revealed diffuse abdominal pain. A computed tomography scan of the abdomen and pelvis was concerning for a distal transverse colon mass causing obstruction and multiple hepatic lesions. (Figure 1, A-C). The patient was taken to the operating room for urgent exploration and was found to have a transverse colonic mass was identified just proximal to the splenic flexure. Resection was performed and a side-to-side anastomosis of the right and descending colon was created with a protective loop ileostomy. Liver lesions were biopsied. Pathologic analysis revealed invasion into the peri-colorectal tissue consistent with a T3 lesion. Lymphovascular (LV) and perineural invasion were also present. Seven out 27 total lymph nodes (LN) were positive for cancer and the hepatic nodule was positive for cancer. Histological analysis revealed large cells with prominent nucleoli, abundant cytoplasm, marked pleomorphism, frequent mitosis, and apoptotic bodies consistent with LCNEC (Figure 1, D). Immunohistochemistry showed that the tumor was positive for AE1/1, CK 20, synaptophysin, and chromogranin A. The Ki-67 index was over 95%. Results/Outcome(s): Postoperatively the patient was started on a regimen of cisplatin and etoposide. He was readmitted during his second cycle of chemotherapy with high ileostomy output, E. coli bacteremia and COVID-19. Repeat imaging showed progression of his disease (Figure 1, E). The patient had a precipitous decline in helath and decided to pursue comfort measures. He had a survival time of 3 months after diagnosis. Limitations: The limitation of this study is that it is a single case. Conclusions/Discussion: NECs account for 0.6% of all colorectal cancers with LCNECs responsible for ~0.2% of NECs. At the time of diagnosis, LV invasion, LN spread, and distant metastases are usually present, which coincides with a median survival of 4-16 months. First line treatment for localized colorectal NECs is primary resection. The National Comprehensive Cancer Network (NCCN) guidelines recommend combined cisplatin and etoposide may be appropriate for locally advanced tumors;however, multiple studies have shown to show no improvement in median survival. Our patient presented with obstruction requiring surgical intervention, which extended the patients life by 3 additional months. Further research to define the best course of treatment for advanced colonic LCNECs will be difficult due to the infrequency of the disease. (Figure Presented).