Chilaiditi's syndrome: what should every surgeon know?

Demetrius Chilaiditi first described an incidental radiological finding of hepatodiaphragmatic interposition of bowel in 1910. The condition could be mistaken for pneumoperitoneum. This radiographic entity, known as Chilaiditi's sign, is found in asymptomatic patients and must be distinguished from Chilaiditi's syndrome, which produces symptomatology associated with the bowel interposition. A review of the literature yielded 27 published cases of Chilaiditi's syndrome. These cases were compiled to evaluate various aspects of this rare but important entity.

Endocuff-assisted colonoscopy is associated with a lower adenoma miss rate: a multicenter randomized tandem study

Background and study aims The Endocuff (ARC Medical Design, Leeds, UK) is a device that, when mounted on the tip of an endoscope, may assist with inspection of a greater surface of the colonic mucosa by pulling backwards, flattening, and stretching the colonic folds as the endoscope is gradually withdrawn. We aimed to compare the adenoma miss rates of Endocuff-assisted colonoscopy with those of conventional colonoscopy. Patients and methods The included patients underwent same-day, back-to-back, (Endocuff-assisted colonoscopy as the index procedure followed by conventional colonoscopy or vice versa, randomly assigned 1:1) colonoscopies, performed by six endoscopists with documented adenoma detection rates > 35 %, in four tertiary endoscopy facilities. Results We randomized 200 patients (mean age 61.2 years [standard deviation 9.8]; 86.5 % colorectal cancer screening surveillance cases). Overall, there were seven incomplete examinations using Endocuff and one with conventional colonoscopy (P = 0.03). Times for endoscope insertion (5.0 minutes [0.8 - 21.0] vs. 5.0 minutes [1.0 - 16.0]; P = 0.49) and withdrawal (6.0 minutes [3.2 - 29.0] vs. 6.0 minutes [3.1 - 17.0]; P = 0.06) were similar for Endocuff-assisted and conventional colonoscopy. We detected one cancer and 195 adenomas; 84 in the proximal colon. Endocuff-assisted colonoscopy showed significantly lower overall and proximal colon adenoma miss rates compared with conventional colonoscopy (14.7 % [8.0 % - 21.0 %] vs. 38.4 % [28.1 % - 48.6 %] and 10.4 % [1.8 % - 19.1 %] vs. 38.9 % [23.0 % - 54.8 %], respectively). No difference between the two arms was shown regarding advanced adenoma miss rates, either overall or in the proximal colon. There were no serious adverse events related to the procedures. Conclusions In comparison with conventional colonoscopy, Endocuff-assisted colonoscopy has a significantly lower adenoma miss rate when performed by high-detector endoscopists. However, the incomplete colonoscopy rate with Endocuff is higher.ClinicalTrials.gov Identifier: NCT02340065.

Prevalence and distribution of colonic diverticula assessed with CT colonography (CTC)

OBJECTIVES

This study aimed to evaluate the prevalence of colonic diverticula according to age, gender, distribution, disease extension and symptoms with CT colonography (CTC).

METHODS

The study population included 1091 consecutive patients who underwent CTC. Patients with diverticula were retrospectively stratified according to age, gender, clinical symptoms and colonic segment involvement. Extension of colonic diverticula was evaluated using a three-point quantitative scale. Using this data, a multivariate regression analysis was applied to investigate the existence of any correlation among variables.

RESULTS

Colonic diverticula were observed in 561 patients (240 men, mean age 68 ± 12 years). Symptomatic uncomplicated diverticular disease (SUDD) was present in 47.4% of cases. In 25.6% of patients ≤40 years, at least one diverticulum in the colon was observed. Prevalence of right-sided diverticula in patients >60 years was 14.2% in caecum and 18.5% in ascending colon. No significant difference was found between symptomatic and asymptomatic patients regarding diverticula prevalence and extension. No correlation was present between diverticula extension and symptoms.

CONCLUSION

The incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding, with their prevalence increasing with patient age. SUDD does not seem to be related to diverticula distribution and extension.

KEY POINTS

Incidence of colonic diverticula appears to be greater than expected. Right colon diverticula do not appear to be an uncommon finding. SUDD does not seem to be related to diverticula distribution and extension.

Lower adenoma miss rate with FUSE vs. conventional colonoscopy with proximal retroflexion: a randomized back-to-back trial

Background and study aims Full-spectrum colonoscopy (FSC) promises to increase adenoma detection by providing a wider field of view. The aim of this study was to compare adenoma miss rates of FSC with those of conventional colonoscopy complemented by right-colon re-examination using scope retroflexion (CC/R). Patients and methods At two tertiary endoscopy facilities, patients who were scheduled for colonoscopy for the assessment of symptoms or for colorectal cancer screening/surveillance were randomized (1:1) to undergo same-day, back-to-back colonoscopies (FSC or CC/R first), performed by one of five endoscopists who had documented adenoma detection rates > 35 %. Per-protocol data were analyzed. Results We randomized 220 patients. There were five FSC technical failures (three air pump and two left screen); therefore, 107 and 108 cases were analyzed in the FSC and CC/R index procedure arms, respectively. Withdrawal times were similar for FSC and CC/R (7.7 minutes vs. 7.6 minutes). Overall, we detected 3 cancers and 153 adenomas (FSC = 92; CC/R = 61); 81 were detected in the proximal colon, 3 of which were detected by retroflexed examination. By per-lesion analysis, FSC showed a significantly lower adenoma miss rate compared with CC/R overall (10.9 % [95 % confidence interval (CI) 3.8 to 18.1] vs. 33.7 % [95 %CI 23.4 to 44.1]) and in the proximal colon (13.9 % [95 %CI 2.6 to 25.2] vs. 42.2 % [95 %CI 27.8 to 56.7]). The advanced adenoma miss rate was lower with FSC overall (4.3 % [95 %CI - 4.0 to 12.7] vs. 25.9 % [95 %CI 9.4 to 42.5]). There were no adverse events. Conclusions FSC outperformed conventional colonoscopy with right-colon scope retroflexion in the detection of missed adenomas, both overall and in the proximal colon, even when performed by experienced endoscopists.Trial registered at ClinicalTrials.gov (NCT02117674).

Laparoscopic complete mesocolic excision via combined medial and cranial approaches for transverse colon cancer

PURPOSE

To evaluate the safety and feasibility of laparoscopic complete mesocolic excision via combined medial and cranial approaches with three-dimensional visualization around the gastrocolic trunk and middle colic vessels for transverse colon cancer.

METHODS

We evaluated prospectively collected data of 30 consecutive patients who underwent laparoscopic complete mesocolic excision between January 2010 and December 2015, 6 of whom we excluded, leaving 24 for the analysis. We assessed the completeness of excision, operative data, pathological findings, length of large bowel resected, complications, length of hospital stay, and oncological outcomes.

RESULTS

Complete mesocolic excision completeness was graded as the mesocolic and intramesocolic planes in 21 and 3 patients, respectively. Eleven, two, eight, and three patients had T1, T2, T3, and T4a tumors, respectively; none had lymph node metastases. A mean of 18.3 lymph nodes was retrieved, and a mean of 5.4 lymph nodes was retrieved around the origin of the MCV. The mean large bowel length was 21.9 cm, operative time 274 min, intraoperative blood loss 41 mL, and length of hospital stay 15 days. There were no intraoperative and two postoperative complications.

CONCLUSION

Our procedure for laparoscopic complete mesocolic excision via combined medial and cranial approaches is safe and feasible for transverse colon cancer.

Laparoscopic management of Chilaiditi?s syndrome

Chilaiditi's syndrome refers to the symptoms of abdominal pain, distention, vomiting, anorexia, and constipation caused by hepatodiaphragmatic interposition of the intestine. Although patients with this radiographic finding are commonly asymptomatic, presentation with symptoms is rare and accurately refers to this syndrome. There is an increased incidence of Chilaiditi's syndrome among mentally ill adults. Traditionally, Chilaiditi's syndrome is managed medically by discontinuing causative medicines. However, among the mentally ill population whose psychotropic medications precipitate the interposition of the colon, ceasing these psychotropic medications is not an appropriate option. The case presented involves a mentally ill patient with Chilaiditi's syndrome who was successfully managed with laparoscopic colopexy. At follow-up, the patient reported marked improvement of abdominal symptoms.

Re-interpreting mesenteric vascular anatomy on 3D virtual and/or physical models, part II: anatomy of relevance to surgeons operating splenic flexure cancer

BACKGROUND

The splenic flexure is irrigated from two vascular areas, both from the middle colic and the left colic artery. The challenge for the surgeon is to connect these two vascular areas in an oncological safe procedure.

MATERIALS AND METHODS

The vascular anatomy, manually 3D reconstructed from 32 preoperative high-resolution CT datasets using Osirix MD, Mimics Medical and 3-matic Medical Datasets, were exported as STL-files, video clips, stills and supplemented with 3D printed models.

RESULTS

Our first major finding was the difference in level between the middle colic and the inferior mesenteric artery origins. We have named this relationship a mesenteric inter-arterial stair. The middle colic artery origin could be found cranial (median 3.38 cm) or caudal (median 0.58 cm) to the inferior mesenteric artery. The lateral distance between the two origins was 2.63 cm (median), and the straight distance 4.23 cm (median). The second finding was the different trajectories and confluence pattern of the inferior mesenteric vein. This vein ended in the superior mesenteric/jejunal vein (21 patients) or in the splenic vein (11 patients). The inferior mesenteric vein confluence could be infrapancreatic (17 patients), infrapancreatic with retropancreatic arch (7 patients) or retropancreatic (8 patients). Lastly, the accessory middle colic artery was present in ten patients presenting another pathway for lymphatic dissemination.

CONCLUSION

The IMV trajectory when accessible, is the solution to the mesenteric inter-arterial stair. The surgeon could safely follow the IMV to its confluence. When the IMV trajectory is not accessible, the surgeon could follow the caudal border of the pancreas.

Computed tomography of gastrocolic ligament: involvement in malignant tumors of the stomach

BACKGROUND

This study investigated computed tomographic (CT) features and anatomic bases of gastrocolic ligament involvement in malignant neoplasms of the stomach.

METHODS

We retrospectively reviewed CT scans of 34 patients known to have gastric malignant neoplasm and gastrocolic ligament involvement. Emphasis was placed on direct invasion, lymph node metastasis, and omental seeding.

RESULTS

CT manifestations of gastrocolic ligament involvement included direct invasion (38.2%, 13 of 34), enlargement of lymph nodes (50%, 17 of 34), "smudged" appearance (26.5%, nine of 34), "omental caking" (5.9%, two of 34), cystic mass (2.9%, one of 34), and varices of the omentum (2.9%, one of 34). We also found that gastric carcinoma and gastrointestinal stromal tumor invaded the transverse colon through the gastrocolic ligament in six patients (17.6%, six of 34).

CONCLUSION

CT scan is useful for detecting gastrocolic ligament involvement in gastric malignant neoplasm. The imaging features consist of a mass sign, enlargement of lymph nodes, smudged appearance, omental caking, and so on. Gastric malignant neoplasm also may involve the transverse colon through the gastrocolic ligament.

Asymptomatic tubular duplication of the transverse colon in an adult

Colonic duplication is a rare congenital anomaly of the alimentary tract. In most cases, symptomatic duplications of the colon are recognized and treated by childhood. It is uncommon for these lesions to be detected in the adulthood since they present with vague symptoms if at all. We experienced a case of asymptomatic tubular duplication of the transverse colon in a 40-year-old female. Barium enema revealed a tubular duplication of the transverse colon. The duplicated segment arose from the mid ascending colon and incorporated just proximal to the splenic flexure, running parallel to the transverse colon and communicating with it at both ends. Colonoscopy demonstrated a normal colonic mucosa in the duplicated segment. The diameter of its lumen gradually narrowed proximally and the colonoscope could not be passed through the proximal opening of the segment. The patient did not need any treatment. Duplications of the alimentary tract can be found at any age. The possibility of congenital lesions in the adult population should not be overlooked.

Novel variant of reversed midgut rotation - retro-arterial proximal jejunum and transverse colon: a case report and review of the literature

BACKGROUND

Reversed rotation of the midgut is the rarest variation of midgut malrotations, which are congenital disorders that result from aberrant rotation and fixation of the midgut during embryological development. Common complications of these disorders are small bowel obstruction by volvulus or peritoneal bands, usually occurring in early infancy.

CASE PRESENTATION

A 23-year-old Caucasian woman presented with recurrent abdominal pain. A contrast-enhanced multidetector computed tomography study revealed a novel variant of reversed rotation of the midgut. Besides the specific finding of a retro-arterial transverse colon, we also found the proximal jejunum to cross posterior to the mesenteric root, a variation that has not been reported in the literature so far. In this case, substantial symptomatic relief was achieved with conservative management.

CONCLUSIONS

The hypothesis of a double reversed rotation of the pre-arterial segment of the umbilical loop around the superior mesenteric artery axis provides a possible explanation for this anomaly. There is no evidence-based consensus on the management of patients presenting with non-symptomatic or mildly symptomatic intestinal malrotations. In this case, radiologic and clinical presentations excluded acute small bowel obstruction, and surgical intervention was avoided.

Isolated colonic hernia through the esophageal hiatus

We report on a 75-year-old woman with an isolated colonic hernia through the esophageal hernia. The patient had suffered from cough, palpitation and dyspnea. A chest X-ray showed a colon loop gas in the mediastinum. Simultaneous barium swallow and enema showed the herniation of the only transverse colon into the mediastinum and displacement of the distal esophagus by the migrated colon. The patient underwent an open-mesh cruroplasty and a Hill's posterior gastropexy. The postoperative clinical course was uneventful. The patient has cessation of the symptoms. To our knowledge, there are only five reports presenting patients with isolated colonic hernia through the esophageal hiatus, including our case.

Rotavirus gastroenteritis complicated with toxic megacolon

Rotavirus is a leading cause of gastroenteritis in young children, which may indicate hospitalization due to dehydration and electrolyte imbalance. Most cases are self-limited with good prognosis. The association between rotavirus and toxic megacolon has never been mentioned in the literature. We report a case of toxic megacolon secondary to rotavirus gastroenteritis.

CONCLUSION

Toxic megacolon can occur in patients with rotavirus gastroenteritis. An abdominal radiograph should be taken for patients with rotavirus gastroenteritis who have systemic toxicity and persistent abdominal fullness.

Emergency surgery for splenic flexure cancer: results of the SFC Study Group database

BACKGROUND

The effectiveness of surgical treatment for splenic flexure carcinomas (SFCs) in emergency settings remains unexplored. This study aims to compare the perioperative and long-term outcomes of different alternatives for emergency SFC resection.

METHOD

This multicenter retrospective study was based on the SFC Study Group database. For the present analysis, SFC patients were selected if they had received emergency surgical resection with curative intent between 2000 and 2018. Extended right colectomy (ERC), left colectomy (LC), and segmental left colectomy (SLC) were evaluated and compared.

RESULTS

The study sample was composed of 90 SFC patients who underwent emergency ERC (n = 55, 61.1%), LC (n = 18, 20%), or SLC (n = 17, 18.9%). Bowel obstruction was the most frequent indication for surgery (n = 75, 83.3%), and an open approach was chosen in 81.1% of the patients. A higher incidence of postoperative complications was observed in the ERC group (70.9%) than in the LC (44.4%) and SLC groups (47.1%), with a significant procedure-related difference for severe postoperative complications (Dindo-Clavien ≥ III; adjusted odds ratio for ERC vs. LC:7.23; 95% CI 1.51-34.66; p = 0.013). Anastomotic leakage occurred in 8 (11.2%) patients, with no differences between the groups (p = 0.902). R0 resection was achieved in 98.9% of the procedures, and ≥ 12 lymph nodes were retrieved in 92.2% of patients. Overall and disease-free survival rates at 5 years were similar between the groups and were significantly associated with stage pT4 and the presence of synchronous metastases.

CONCLUSION

In the emergency setting, ERC and open surgery are the most frequently performed procedures. ERC is associated with increased odds of severe postoperative complications when compared to more conservative SFC resections. Nonetheless, all the alternatives seem to provide similar pathologic and long-term outcomes, supporting the oncological safety of more conservative resections for emergency SFCs.

Acquired segmental sigmoid hypoganglionosis: A case report

RATIONALE

Intestinal hypoganglionosis most commonly presents in infancy or childhood, with only a few cases reported in adults. Those are mainly diagnosed after elective surgery for long-standing constipation and megacolon.

PATIENT CONCERNS

We report a case of a 48-year-old female from China who presented with symptoms of discontinuation of bowel movements for 2 months. A hard, round mass could be felt in her right lower abdomen.

DIAGNOSIS

The following examination methods diagnosed acquired segmental sigmoid hypoganglionosis. An abdominal computed tomography revealed a dilatation of the colon and suspicious wall thickening of the sigmoid colon. Anorectal manometry revealed relaxation of the anal sphincter. Histological examination revealed lower numbers and the degeneration of ganglion cells.

INTERVENTIONS

Sigmoidectomy and transverse colostomy.

OUTCOMES

The patient recovered well from surgery. Three months after the surgery, barium enema revealed a recovery in colorectal dilatation.

LESSONS

This case could help raise awareness of acquired segmental hypoganglionosis. Resection of TZ and enterostomy presents an effective remission strategy for patients at risk of anastomotic leakage due to poor intestinal conditions.

Metachronous colorectal carcinoma with massive submucosal invasion detected by annual surveillance in a Lynch syndrome patient: a case report

BACKGROUND

Lynch syndrome is the most common form of hereditary colorectal carcinoma. It is characterized by the presence of germline mutations in DNA mismatch repair genes. Mutation carriers have a lifetime risk of developing colorectal carcinoma of approximately 80%. Current treatment guidelines recommend periodic surveillance for colorectal carcinoma in patients with Lynch syndrome. However, the optimal interval between colonoscopies has not yet been determined.

CASE PRESENTATION

We describe a 54-year-old man with Lynch syndrome who was undergoing annual colonoscopy surveillance for the development of colorectal carcinoma. At 54, 57, 59, and 60 years old, a colonoscopy showed high-grade dysplasia and adenoma. Therefore, endoscopic mucosal resection was performed. At 61 years old, a colonoscopy showed metachronous colorectal carcinoma with massive submucosal invasion. He subsequently underwent laparotomy for colorectal carcinoma.

CONCLUSIONS

Annual surveillance using colonoscopy can detect colorectal carcinoma at an early stage, leading to reduced mortality. However, some patients might require a laparotomy, as was the case here. More frequent colonoscopic surveillance might be necessary to avoid surgery for colorectal carcinoma in Lynch syndrome patients with multiple risk factors for interval cancer.

Transverse colonic volvulus due to mesenteric fibromatosis: a case report

BACKGROUND

Colonic volvulus, a condition in which a colonic segment partially twists around its base, is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. However, volvulus of the transverse colon is the rarest type of large intestinal volvulus. Moreover, the occurrence of transverse colonic volvulus secondary to a benign tumor originating from outside the intestine has never been reported. We hereby report a case of transverse colonic volvulus caused by mesenteric fibromatosis.

CASE PRESENTATION

A 53-year-old female with a history of rheumatoid arthritis and thyroid tumor presented with abdominal pain for 1 day. Abdominal computed tomography revealed intestinal torsion at the hepatic flexure. Twisted and obstructed mucosa of the transverse colon was observed during colonoscopy, but no tumor invasion of the mucosal surface was detected. A solid mass of a mesenteric origin with involvement of the transverse colon was observed during surgery. The mass was diagnosed surgically as transverse colonic volvulus induced by a mesenteric tumor. Hence, the patient underwent a right hemicolectomy. Histopathological results indicated mesenteric desmoid-type fibromatosis. The postoperative recovery was uneventful, and the patient was discharged 8 days after surgery.

CONCLUSIONS

Although mesenteric fibromatosis is rare, this disease should be considered when managing transverse colonic volvulus resulting from nonmucosal tumors.

Effective Endoscopic Closure of Cholecysto-duodenal and Transverse Colon Fistulas Due to Squamous Cell Carcinoma of the Gallbladder Using Polyglycolic Acid Sheets and a Covered Metal Stent

An 81-year-old woman presented with abdominal distension and right hypochondrial pain. Abdominal contrast computed tomography and magnetic resonance imaging revealed an 11-cm gallbladder tumor. The patient was diagnosed with squamous cell carcinoma of the gallbladder by endoscopic ultrasound-guided fine-needle aspiration from the gastric antrum. Thereafter, the gallbladder tumor enlarged, and cholecysto-duodenal and transverse colon fistulas were formed. A covered metal stent was placed on the transverse colon, and polyglycolic acid sheets were injected into the duodenum to close the fistulas endoscopically. Endoscopic closure is less invasive than surgery and considered effective for patients with poor general health conditions.

Percutaneous Antegrade Colonic Stent Insertion Using a Proximal Trans-peritoneal Colopexy Technique

INTRODUCTION

Conventionally, colonic stents are inserted with a retrograde trans-anal approach-however, stenting of right-sided or proximal transverse colon lesions may pose a challenge due to tortuosity or long distances. We report three successful cases of percutaneous antegrade colonic stenting in patients using a proximal trans-peritoneal colopexy technique.

MATERIALS AND METHODS

Three patients underwent a proximal trans-peritoneal colopexy technique for antegrade colonic stent placement. The patients included three males, ages 89, 92 and 55, who were unsuitable for conventional methods. All patients had a colopexy with the aid of three gastropexy sutures performed under CT or fluoroscopic guidance and subsequent colonic access, followed by the crossing lesion and subsequent deployment of an uncovered colonic stent. A 10-Fr pigtail catheter was exchanged for the sheath, capped and left in place along with the colopexy suture anchors.

RESULTS

Percutaneous antegrade colonic stent placement was technically successful in all patients with no complications. Follow-up at 10 days, a tubogram confirmed stent patency. The pigtail drain and suture anchors were subsequently removed.

CONCLUSION

Antegrade colonic stenting with the use of a three point colopexy is a straightforward well-tolerated procedure and is a useful technique in a cohort of patients in whom conventional stenting has failed/is unsuitable. Additionally, we believe we have reported the first two cases involving transverse colon access for stenting.