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Tahara S, Kohyama M, Nakamitsu A, Sugiyama Y, Tazaki T, Taogoshi H, Komo T, Yamaguchi T, Ueda M, Ishikawa A, Takahashi S, Sasaki M. Surgical strategies for localized colorectal amyloidosis. Surg Case Rep 2023; 9:66. [PMID: 37103609 PMCID: PMC10140200 DOI: 10.1186/s40792-023-01649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/13/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Localized colorectal amyloidosis has a good prognosis, but cases involving bleeding or perforation may require surgery. However, there are few case reports discussing the differences in the surgical strategy between the segmental and pan-colon types. CASE PRESENTATION A 69-year-old woman with a history of abdominal pain and melena was diagnosed with amyloidosis localized in the sigmoid colon by colonoscopy. Since preoperative imaging and intraoperative findings could not rule out malignancy, we performed laparoscopic sigmoid colectomy with lymph-node dissection. Histopathological examination and immunohistochemical staining revealed a diagnosis of AL amyloidosis (λ type). We diagnosed localized segmental gastrointestinal amyloidosis, because there was no amyloid protein in the margins, and the tumor was localized. There were no malignant findings. CONCLUSIONS Unlike systemic amyloidosis, localized amyloidosis has a favorable prognosis. Localized colorectal amyloidosis can be classified into the segmental type, in which amyloid protein is deposited locally, and the pan-colon type, in which amyloid protein is deposited extensively in the colon. Amyloid protein causes ischemia due to vascular deposition, weakening of the intestinal wall due to muscle layer deposition, and decreased peristalsis due to nerve plexus deposition. No amyloid protein should remain outside the resection area. The pan-colon type is often reported to cause complications such as anastomotic leakage, and primary anastomosis should be avoided. On the other hand, if there is no contamination or tumor remnants in the margin, the segmental type may be considered for primary anastomosis.
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Affiliation(s)
- Shunya Tahara
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Mohei Kohyama
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan.
| | - Atsushi Nakamitsu
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Yoichi Sugiyama
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Tatsuya Tazaki
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Hiroyuki Taogoshi
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Toshiaki Komo
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Takuro Yamaguchi
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjou, Chuo Ward, Kumamoto, Kumamoto, 860-8556, Japan
| | - Akira Ishikawa
- Department of Molecular Pathology, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami Ward, Hiroshima, Hiroshima, 734-0037, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami Ward, Hiroshima, Hiroshima, 734-0037, Japan
| | - Masaru Sasaki
- Department of Surgery, JA Hiroshima General Hospital, 1-3-3 Jigozen, Hatsukaichi, Hiroshima, 738-8503, Japan
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Ussia A, Vaccari S, Lauro A, Caira A, Tardio ML, Leone O, Marino IR, D'Andrea V, Cervellera M, Tonini V. Colonic Perforation as Initial Presentation of Amyloid Disease: Case Report and Literature Review. Dig Dis Sci 2020; 65:391-398. [PMID: 31728786 DOI: 10.1007/s10620-019-05948-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Amyloidosis is an uncommon disease caused by the deposition of amyloid fibrils in tissues. This disease does not usually require surgical intervention, which could be warranted in the presence of complications such as bleeding, obstruction, or perforation. We present a case of primary amyloidosis of the colon in a patient affected by polymyositis who underwent Hartmann's procedure after a spontaneous colonic perforation. After 2 months of well-being, the patient underwent two consecutive surgical procedures for stenosis of the ostomy orifice. AREAS COVERED A review of the literature has been performed, gathering case reports highlighting the distribution of this disease by age, gender, location, and treatment when available. EXPERT COMMENTARY Gastrointestinal amyloid disease is a rare condition, and it could be considered among the rare causes of intestinal perforation. Timely surgical management is often necessary.
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Affiliation(s)
- A Ussia
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - S Vaccari
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - A Lauro
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy.
| | - A Caira
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - M L Tardio
- Department of Pathology, St. Orsola University Hospital, Bologna, Italy
| | - O Leone
- Department of Pathology, St. Orsola University Hospital, Bologna, Italy
| | - I R Marino
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - V D'Andrea
- Department of Surgical Sciences, La Sapienza University, Umberto I Hospital, Rome, Italy
| | - M Cervellera
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
| | - V Tonini
- Department of Emergency Surgery, St. Orsola University Hospital, Bologna, Italy
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Shaulov A, Avivi I, Cohen Y, Duek A, Leiba M, Gatt ME. Gastrointestinal perforation in light chain amyloidosis in the era of novel agent therapy - a case series and review of the literature. Amyloid 2018; 25:11-17. [PMID: 29241368 DOI: 10.1080/13506129.2017.1416350] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Gastrointestinal (GI) perforation is remarkably rare in patients with light chain (AL) amyloidosis and has not yet been reported in patients with AL amyloidosis treated with novel agents. Only 24 cases of GI perforation have previously been reported in the setting of AL amyloidosis of which 15 had available information in English. All 15 did not receive novel agent therapy and six died early after experiencing GI perforation. This study reports the characteristics and outcome of AL patients that developed GI perforation in the era of novel agent treatment. Seven patients were reviewed. In two patients, GI perforation was the presenting symptom of AL amyloidosis, whereas five patients developed GI perforations following initiation of an anti-AL therapy (three after bortezomib-based, 1 after lenalidomide-based and 1 after thalidomide-based therapy). All patients underwent surgery and survived the perforation. Treatment was renewed following surgery in six of seven patients, with no further GI complications. In conclusion, GI perforation in AL amyloidosis is rare and mostly reported after treatment initiation. Urgent surgery appears to be lifesaving and renewal of the anti-AL novel therapy appears to be safe, with no significant risk for re-perforation or GI toxicity. Prognosis in these patients is related to severity of the disease and response to therapy rather than the development of GI perforation.
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Affiliation(s)
- Adir Shaulov
- a Department of Haematology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Irit Avivi
- b Department of Haematology and Bone Marrow Transplantation , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel
| | - Yael Cohen
- b Department of Haematology and Bone Marrow Transplantation , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel
| | - Adrian Duek
- c Department of Haematology , Sheba-Tel HaShomer Medical Center , Tel Aviv , Israel
| | - Merav Leiba
- c Department of Haematology , Sheba-Tel HaShomer Medical Center , Tel Aviv , Israel
| | - Moshe E Gatt
- a Department of Haematology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
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Amyloidosis of the gastrointestinal tract and the liver: clinical context, diagnosis and management. Eur J Gastroenterol Hepatol 2016; 28:1109-21. [PMID: 27362550 DOI: 10.1097/meg.0000000000000695] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a group of disorders that can manifest in virtually any organ system in the body and is thought to be secondary to misfolding of extracellular proteins with subsequent deposition in tissues. The precursor protein that is produced in excess defines the specific amyloid type. This requires histopathological confirmation using Congo red dye with its characteristic demonstration of green birefringence under cross-polarized light. Gastrointestinal (GI) manifestations are common and the degree of organ involvement dictates the symptoms that a patient will experience. The small intestine usually has the most amyloid deposition within the GI tract. Patients generally have nonspecific findings such as abdominal pain, nausea, diarrhea, and dysphagia that can often delay the proper diagnosis. Liver involvement is seen in a majority of patients, although symptoms typically are not appreciated unless there is significant hepatic amyloid deposition. Pancreatic involvement is usually from local amyloid deposition that can lead to type 2 diabetes mellitus. In addition, patients may undergo either endoscopic or radiological evaluation; however, these findings are usually nonspecific. Management of GI amyloidosis primarily aims to treat the underlying amyloid type with supportive measures to alleviate specific GI symptoms. Liver transplant is found to have positive outcomes, especially in patients with specific variants of hereditary amyloidosis.
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