Synchronous colon cancer presenting as toxic megacolon in a patient with ulcerative colitis: A case report.

INTRODUCTION AND IMPORTANCE: The incidence of colorectal cancer in patients with inflammatory bowel disease is greater than the general population. Of those with inflammatory bowel disease, synchronous cancers are more common in ulcerative colitis than in Crohn's disease. It is rare for synchronous cancer to present as toxic megacolon in a patient with concomitant inflammatory bowel disease, specifically ulcerative colitis. CASE PRESENTATION: In this report, we describe the clinical presentation of a 22-year-old female, who presented with toxic megacolon ultimately requiring total abdominal colectomy with end-ileostomy and a final pathology of two synchronous colon cancers, despite normal colonoscopy one year prior. The postoperative period was unremarkable, and the patient was referred to medical oncology to pursue adjuvant treatment. CLINICAL DISCUSSION: Due to the increased incidence of colorectal cancer in patients with ulcerative colitis, screening colonoscopies are typically recommended at more frequent intervals than the general population. Toxic megacolon as the presentation for colon cancer in patients with underlying ulcerative colitis is exceedingly rare. To our knowledge, this is the first case reported of synchronous colon cancer presenting as toxic megacolon in a patient with ulcerative colitis and recent negative screening colonoscopy. CONCLUSION: Colorectal cancer should always be high in the differential diagnosis for patients with ulcerative colitis regardless of the age. The principles of oncologic resection for colorectal cancer should be followed during colonic resections in patients with ulcerative colitis, even in the acute setting.

Robotic versus laparoscopic colectomy outcomes in colon adenocarcinoma in the elderly population: a propensity-score matched analysis of the National Cancer Database.

PURPOSE: While robotic surgery is more costly and involves longer intra-operative time, it has a technical advantage over laparoscopic surgery. With our aging population, patients are being diagnosed with colon cancer at older ages. The aim of this study is to compare laparoscopic versus robotic colectomy short- and long-term outcomes in elderly patients diagnosed with colon cancer at a national level. METHODS: This retrospective cohort study was conducted using the National Cancer Database. Subjects ≥ 80-years-old who were diagnosed with stage I to III colon adenocarcinoma and underwent a robotic or laparoscopic colectomy from 2010-2018 were included. The laparoscopic group was propensity-score matched in a 3:1 ratio to the robotic group with 9343 laparoscopic and 3116 robotic cases matched. The main outcomes evaluated were 30-day mortality, 30-day readmission rate, median survival, and length of stay. RESULTS: There was no significant difference in the 30-day readmission rate (OR = 1.1, CI = 0.94-1.29, p = 0.23) or 30-day mortality rate (OR = 1.05, CI = 0.86-1.28, p = 0.63) between both groups. Robotic surgery was associated with higher overall survival (42 vs 44.7 months, p < 0.001) using a Kaplan-Meier survival curve. Robotic surgery had a statistically significant shorter length of stay (6.4 vs. 5.9 days, p < 0.001). CONCLUSION: Robotic colectomies are associated with higher median survival rates and decrease in the length of hospital stay compared to laparoscopic colectomies in the elderly population.

Does race influence the attainment of the principles of oncologic surgical resection in colon adenocarcinoma? A retrospective cohort analysis from the national cancer database.

The standard operation for colon cancer resection should follow certain principles to ensure appropriate oncologic resection, such as retrieving 12 or more nodes with the specimen and adequate surgical margins. Although these principles are well documented, there is little evidence regarding the association of race and the attainment of an adequate oncologic resection. Methods: The authors performed a retrospective cohort study of all cases of resectable colon adenocarcinoma who underwent surgical resection in the National Cancer Database between 2004 and 2018. The postoperative lymph node count and margins were grouped as 'principles of oncologic surgical resection'. A multivariate logistic regression analysis was performed to assess race and other demographic variables as independent factors influencing the attainment of the principles of oncologic resection. Results: A total of 456 746 cases were included. From this cohort, 377 344 (82.6%) achieved an adequate oncologic resection and 79 402 (17.4%) did not. On logistic regression, African American and Native American patients were less likely to attain an adequate oncologic resection. Similarly, patients with an elevated Charlson-Deyo score (2 or above), stage I cancer, and patients who underwent extended resection were less likely to achieve adequate oncologic resection. Resections performed in metropolitan areas, patients with private insurance, high-income quartiles, and patients diagnosed in more recent years were more likely to achieve adequate oncologic resection. Conclusions: There are significant racial disparities regarding the attainment of the principles of oncologic resection in colon cancer, which could be explained by unconscious biases, social discrepancies, and inadequate healthcare access. Early introduction and conscientization of unconscious biases are required in surgical training.

Metastatic colon adenocarcinoma presenting as a giant inguinal hernia: A case report.

INTRODUCTION AND IMPORTANCE: Giant inguinoscrotal hernias (GIH) are a rare form of inguinal hernia. There have been few reported cases of GIH containing colon adenocarcinoma. CASE PRESENTATION: This case describes a 72-year-old male with a right GIH containing the right colon, terminal ileum, and associated mesentery with a large heterogenous, irregular mass with necrosis involving the cecum and ascending colon measuring 14 × 8 × 9 cm. The patient initially presented with pain and evidence of partial large bowel obstruction. Due to suspected extensive local invasion of tumor, the patient was scheduled for evaluation for possible neoadjuvant chemotherapy. Unfortunately, the patient re-presented with a large bowel obstruction and was subsequently taken for an exploratory laparotomy with trans-scrotal incision for en bloc resection of cecal adenocarcinoma and involved hernia contents. CLINICAL DISCUSSION: Due to the rarity of this pathology, there is not a standard approach to management or optimal surgical technique described. In this case, a trans-scrotal incision paired with an exploratory laparotomy allowed for superior access to the adhered cancer containing bowel as well as skin excision, following standard oncologic principle of high ileocolic mesenteric excision. CONCLUSION: The complexity of management of GIH containing colon cancer has been documented, however a standard oncologic approach has not been described. This case report presents exploratory laparotomy with trans-scrotal incision as an approach.

Phytobezoar causing small bowel obstruction in a patient with Crohn's disease: A case report.

INTRODUCTION AND IMPORTANCE: Bezoars form in any location in the gastrointestinal tract with the small bowel being uncommon. The presentation with a small bowel obstruction (SBO) is rare, representing less than 1 % of cases. Phytobezoar causing a SBO in the setting of Crohn's disease is exceedingly rare with only three cases reported in the literature. CASE PRESENTATION: This case details the presentation and operative management of a phytobezoar causing small bowel obstruction in a patient with Crohn's disease. The patient is a 69-year-old male presenting with nausea, emesis, and obstipation. Imaging performed indicated a SBO with an obstructing intraluminal foreign body. The patient required exploration and a large phytobezoar was identified at the point of obstruction. This was treated with a segmental resection. The postoperative course was complicated by an anastomotic leak with re-exploration and end ileostomy. CLINICAL DISCUSSION: Phytobezoars are formed from indigestible plant residue which can accumulate and form a foreign body causing an obstruction in the small bowel. This is a rare occurrence in the setting of Crohn's disease. Most of these cases are managed surgically with a strictureplasty and enterotomy or a small bowel resection. CONCLUSION: Phytobezoars in the setting of Crohn's disease is very unusual. The pathophysiology of the disease predisposes patients to strictures and the mass-like foreign body can cause a bowel obstruction. This is typically managed surgically with a strictureplasty and enterotomy or in our case with an enterectomy.

Internal herniation of the cecum through the foramen of Winslow-a case report.

Foramen of Winslow hernias are a rare, but dangerous form of internal hernia that can present in individuals with signs and symptoms of bowel obstruction. This case report details operative management of a cecal herniation through the foramen of Winslow in an elderly male with no prior history of intra-abdominal surgery. The patient presented with worsening abdominal pain, nausea, vomiting and obstipation. Due to the clinical picture of a complete bowel obstruction and subsequent imaging findings, an urgent abdominal exploration was performed. During the procedure, the cecum was found to be ischemic and strangulated in the lesser sac, herniated through the foramen of Winslow. Following operative reduction and right hemicolectomy, it was decided to close the foramen of Winslow to prevent recurrence and future complications. The patient had an uncomplicated postoperative course with resolution of symptoms.