Giant Paraesophageal Hernia With Obstructing Splenic Flexure Mass in the Left Hemithorax

Giant paraesophageal hernias contain greater than fifty percent of the stomach above the diaphragm. Over fifty percent of large bowel obstructions are due to colorectal adenocarcinoma. Here, we present a rare case of a 69-year-old female patient who developed a closed loop colonic obstruction caused by a colonic mass in the distal transverse colon within a giant paraesophageal hernia. We successfully performed emergent paraesophageal hernia reduction and mesh repair with extended right hemicolectomy and ileocolonic anastomosis. Emergent hernia repair via an abdominal approach can be used in this setting.

A case of esophageal squamous cell carcinoma metastasized to the colonic anastomotic site of right hemicolectomy

Introduction/Objective Although squamous cell carcinoma of the esophagus rarely metastasizes to the uncommon sites, colonic metastasis from squamous cell carcinoma of the esophagus is extremely rare. There has been no case report of colonic metastasis from squamous cell carcinoma of the esophagus to an anastomotic site of the colon. Methods/Case Report A 73-year-old female with a history of right hemicolectomy for advanced ascending colon cancer in 2006 was referred to our facility for a two-month history of solid food dysphagia. The patient has been followed up in the survivorship clinic for surveillance with no evidence of recurrence for 13 years to date. An esophagogastroduodenoscopy revealed a 7 cm fungating and ulcerated mass in the middle to lower esophagus. The biopsy from the esophageal mass showed a moderately to poorly differentiated squamous cell carcinoma. A colonoscopy showed an end-to-end ileocolonic anastomosis with a 7 mm ulceration in the transverse colon. The biopsy from the ulceration at the anastomotic site showed a moderately to poorly differentiated squamous cell carcinoma. Immunostains performed on both esophageal and colonic biopsies demonstrate that the tumor cells in both esophageal and colonic biopsies are positive for p40, p63, p16, and negative for CK7, CK20, and CDX2. The diagnosis of metastatic esophageal squamous cell carcinoma to the colonic anastomotic site of previous right hemicolectomy was rendered based on the morphology and immunoprofile. A subsequent computed tomography (CT) and positron emission tomography (PET) demonstrated no other distant metastases. Chemotherapy with 5-FU and oxaliplatin has been started. A metastasis to the anastomotic site is extremely rare. Although the anastomotic site might be a good niche for cancer cells to metastasize to, the pathogenesis of a metastasis to the anastomotic site remains unknown. Our case is very intriguing because a metastasis occurred at the anastomosis site, and no other metastasis was found. Results (if a Case Study enter NA) N/A Conclusion We have reported the first case of metastatic esophageal squamous cell carcinoma to the colonic anastomotic site of previous right hemicolectomy in a 73-year-old female. Although the pathogenesis of a metastasis to the anastomotic site remains unknown, the possibility of contribution of surgical trauma to metastasis formation at the ileocolonic anastomosis cannot be completely ruled out.

DOP17 In high-risk Crohn’s Disease patients, anastomosis configuration types have similar rates of endoscopic recurrence

Background There is conflicting data on the influence of surgical anastomosis configuration on endoscopic postoperative recurrence (POR) of Crohn’s disease (CD) following ileocolonic resection (ICR). Furthermore, whether this relationship differs by preoperative risk factors for POR has not been studied. We aimed to assess the role of ileocolonic anastomosis type on the rate and time to POR by preoperative POR risk. Methods Retrospective cohort study of adult CD patients who underwent ICR between 2009–2020 at a quaternary IBD referral center. Patients with a primary or secondary anastomosis and ≥1 postoperative colonoscopy were included. Endoscopic activity was assessed by modified Rutgeerts’ scoring. POR was defined as Rutgeerts’ ≥ i2b. Patients were categorized by anastomosis type: end-to-end (ETE), end-to-side (ETS), or side-to-side (STS). High-risk CD patients were defined by ≥1: age ≤ 30 years, active smoker, or ≥2 ICR for penetrating disease. Results 548 CD patients (52.6% female, age 35 y, 15.5% > 1 prior ICR, 19.7% on biologic prophylaxis, 74.8% high-risk for POR) were included in the study (Figure 1). The majority received a STS (52.0%, N=285), 27.2% ETS, and 20.8% ETE. Patients with an ETE were diagnosed with CD at a younger age (p=0.04), had more penetrating disease (p=0.01), hand-sewn anastomoses (p <0.001), and diverting loop ileostomies (p=0.02). There were no differences in prior ICR, smoking, biologic prophylaxis, or in median time from ICR to first post-operative colonoscopy (388.5 days, p=0.41) or POR detection (905 days, p=0.8) by anastomosis type. ETS patients had a shorter median follow-up time (3.9 y, p=0.02). The majority (55.7%) of all patients experienced POR (57% ETS; 55.4% STS; 54.4% ETE). Overall, there was no significant association between anastomosis type and POR rate (p=0.91) or time to POR (p=0.32). However, in high-risk CD patients, ETS was significantly associated with more rapid time to POR on log-rank (p=0.03) and multivariable Cox modeling (HR=1.51; p=0.04). Postoperative prophylactic biologic therapy initiated within 3 months of ICR significantly delayed POR in the overall cohort (HR=0.64; p=0.012) and the high-risk CD subgroup (HR=0.67; p=0.047). High-risk CD patients on prophylactic biologics had no difference in time to POR by anastomosis type (p=0.66). Conclusion In post-operative CD patients, there is no difference in rates of endoscopic recurrence by anastomosis configuration regardless of risk stratification. In high-risk patients, ETS was associated with more rapid endoscopic recurrence compared to other configurations, however prophylactic postoperative biologics may protect against this effect. Figure 2: KM Survival analysis of time (days) to POR

P608 Endoscopic treatment of enterocutaneous fistulas in Crohn’s disease patient

Background The management of enterocutaneous fistulas (ECF) in Crohn’s disease (CD) patients is complex and requires a multidisciplinary approach. Despite the advent of anti-TNF, the majority of patients still need surgical management. The aim of this study was to report the feasibility of endoscopic treatment of ECF in CD patient. Methods We prospectively identified CD patients with an ECF who failed to conventional medical therapies. Demographic and clinical data were collected retrospectively. Under general anaesthesia, a colonoscopy was performed to identify the fistula. At the discretion of the operator, an Ovesco® clip under or hemostatic clip were placed on the top of the fistula, with radiological opacification control. Technical success was defined by the clip placement on the EFC. The clinical success was defined by the closure of the fistula (defined by the absence of emission of stool or gas by the cutaneous orifice). Results Eight patients (female, 75 %, median age 45 years (interquartile range (IQR), 33–51)) were identified. Regarding the EFC, they evolved from a median of 3 months (IQR, 1.75–5.5) before the endoscopic management. The fistulas were localised on the ileocolonic anastomosis for 7 patients, and on the stomach in one. Two patients had an endoscopic activity, as defined by the presence of ulcer(s). Seven patients were treated with an OVESCO clip and one with Boston® resolution 360 hemostatic clips. Thirteen endoscopic procedures were performed, with a median number of 1 procedure/patient (IQR, 1–2). Technical success was observed in 100% of cases. Clinical success at 3 months was observed in 75% of cases (6/8 patients). After a median follow-up of 8 months (IQR, 5–12), 2/6 patients in clinical success underwent a new procedure due to EFC recurrence at respectively 4 and 7 months due to a clip migration. Among the 2 failures, one patient underwent a second colonoscopy with a new Ovesco® placement and the other was treated with fibrin glue. In both cases the procedure was ineffective. No complication related to the clip insertion was observed. Conclusion This demonstrates |, for the first time, the feasibility and short-term effectiveness of endoscopic clips for the treatment of EFC in CD patients. New prospective studies should confirm these results.

Management and outcomes of patients with Crohn’s disease with first vs multiple surgeries: results from the PRACTICROHN study

Background Surgery in Crohn’s disease (CD) may be associated with poor prognosis and clinical and surgical recurrence. The aim of this study was to describe and compare the post-operative management and outcomes of patients with CD who underwent first vs recurrent surgeries. Methods Observational study that included adult CD patients from 26 Spanish hospitals who underwent ileocolonic resection with ileocolonic anastomosis between January 2007 and December 2010. Data were retrospectively collected from the medical records. Results Data from 314 patients were analysed, of whom 262 (83%) underwent first surgery and 52 (17%) referred to previous CD surgeries. Baseline characteristics were similar between the two groups except for a higher rate of stricturing behavior at diagnosis among re-operated patients (P = 0.03). After surgery, a higher proportion of re-operated patients received prophylactic treatment with immunomodulators compared with patients with first surgery (P = 0.04). In re-operated patients, time to clinical recurrence was not associated with the fact of receiving or not prophylaxis, whereas, in patients with first surgery, recurrence-free survival was greater when prophylaxis was received (P = 0.03). Conclusions After surgery, a higher proportion of patients with previous surgeries received prophylactic treatment with immunomodulators compared with patients with first surgery. Although prophylactic treatment was beneficial for preventing clinical recurrence in patients operated on for the first time, it did not significantly reduce the risk of further recurrence in patients with previous surgeries. This suggests that effective prophylactic therapies are still needed in this subset of patients.