Necrotizing Fasciitis of the Thigh as Unusual Colonoscopic Polypectomy Complication: Review of the Literature with Case Presentation

Necrotizing fasciitis (NF) is an infection characterized by necrosis of the superficial muscle fascia and surrounding soft tissues. It usually occurs following skin breaches from penetrating traumas or high-degree burns. Less frequently, it could be related to major abdominal surgery. However, no cases of thigh NF after minor abdominal procedures have ever been reported. A previously healthy 59-year-old male patient underwent a colonoscopic polypectomy. After the procedure, the patient developed an increasing right groin pain. The CT scan showed a gas collection in the right retroperitoneum space and in the right thigh soft tissues. Thus, a right colon perforation was hypothesized, and the patient was moved to the nearest surgery department and underwent a right hemicolectomy procedure. During surgery, the right thigh was also incised and drained, with gas and pus leakage. Nevertheless, the right lower limb continued to swell, and signs of systemic infection appeared. Afterward, clinical conditions continued to worsen despite the drainage of the thigh and antibiotic therapy, and the patient died of septic shock after just two days. This case shows that, although rare, lower limb NF should be considered among the causes of early post-operative local painful symptoms.

LAMN as a differential diagnosis for abdominal pain: a case report from Syria

Low-grade appendiceal mucinous neoplasms (LAMNs) are papillary or flat mucinous tumors with low-grade cytologic atypia found in <0.3% of appendectomy specimens among older population. They are the most frequent source of pseudomyxoma peritonei. They can be easily misdiagnosed, due to unspecific symptoms, with acute appendicitis, retroperitoneal tumors or adnexal mass. Macroscopically, the appendix may appear normal or be variably dilated. Microscopic study determines whether the studied specimen is LAMN or mucinous adenocarcinomas. We report a 77-year-old patient presented with 15-day abdominal pain accompanied with chills and hyperthermia. Decision was made for right hemicolectomy as a result of the findings on ultrasound and computed tomography scan. Diagnosis was made after the pathologic study, which revealedLAMN.

A Rare Cause of Gastric Variceal Bleeding

A 68-year-old woman with stage III colon cancer status after right hemicolectomy and adjuvant FOLFOX (5-fluorouracil/leucovorin/oxaliplatin) chemotherapy was hospitalized for melena and found to have new-onset esophageal and gastric varices on esophagogastroduodenoscopy. Her workup did not reveal an underlying liver disease, but her liver biopsy showed noncirrhotic portal hypertension from obliterative portal venopathy (OPV). The development of OPV is likely from her use of oxaliplatin-based chemotherapy.

The Association of Vitamin D3 With Early Anastomotic Leakage in Patients Undergoing Hemicolectomy Surgery

Background Anastomotic leak (AL) is one of the most important postoperative complications after hemicolectomy with stapled anastomosis. This study aimed to evaluate the association of preoperative vitamin D3 with early anastomotic leakage after right colon cancer surgery with stapled anastomosis. Method In this prospective cohort study, 535 patients who underwent right colon cancer surgery (right hemicolectomy) with stapled anastomosis were enrolled. A subset of 315 patients was included in the study after meeting the inclusion criteria. Preoperative vitamin D level was measured and analyzed for association with early AL using univariable and multivariable logistic regression analyses. Result This study included 315 cases; among them, 18 (5.71%) patients developed early AL. Vitamin D3 was significantly higher among patients without early AL ( P < .001). Low vitamin D3 status was reported among 111 patients (35.2%) and 204 (64.8%) of patients did not have low vitamin D3 status (sufficient level = 30-100 ng/mL). Sufficient vitamin D3 levels before right colon cancer surgery with stapled anastomosis was associated inversely with early AL (crude OR = .89, 95% CI = .85-.94, P < .001 and adjusted OR = .89, 95% CI = .82-.98, P = .02). Conclusion The vitamin D3 level has a protective association with early AL. As a result, low vitamin D3 status may be a risk factor for early AL development, suggesting that it can be one of the predictors of early AL occurrence.

Is Prophylactic Abdominal Drainage Necessary After Laparoscopic Colectomy For Colon Cancer? A Propensity Score-Matched Analysis

Background: In 2018, the Enhanced Recovery After Surgery (ERAS) Society recommended against routine drainage after colorectal surgery. However, the evidence is relatively old and few studies were performed in low-to-middle income country (LMIC) setting. This study aimed to compare outcomes of laparoscopic colectomy with and without prophylactic drainage for colon cancer.Methods: A retrospective study was performed from 2018 to 2021 with patients who underwent laparoscopic colectomy with D3 lymphadenectomy for colon cancer. The use of prophylactic drainage was depended on routine practice of surgeons. Outcomes were postoperative complications and postoperative hospital length of stay. The drain and no-drain groups were compared using propensity score-matched (PSM) analysis.Results: The study included 143 patients (59 in the drain group and 84 in the no-drain group). The PSM resulted in 94 patients (47 in each group). Median age was 62 years. The most frequent was right hemicolectomy (33.6%), followed by left hemicolectomy (32.2%), sigmoid colectomy (21%), extended right hemicolectomy (9.8%), transverse hemicolectomy (2.1%), and total colectomy (1.4%). Postoperative hospital stay was significantly shorter in the no-drain group (median of 5 versus 6 days). The no-drain group also had lower rate of complications (23.8% versus 30.5% and 23.4% versus 34% before and after matching respectively) and less severe complications based on Clavien-Dindo classification, but the difference was not significant.Conclusions: Laparoscopic colectomy without prophylactic drainage is safe in the treatment of colon cancer. This approach can shorten postoperative hospital stay and should be applied even in the LMIC setting.Main novel aspect: Laparoscopic colectomy without prophylactic drainage for colon cancer can be applied in low-to-middle income settings.

Laparoscopic right colectomy with intracorporeal ileotransverse anastomosis (results of the pilot study)

AIM: to evaluate the safety of intra- and extracorporeal ileotransverse anastomosis in laparoscopic right hemicolectomy.PATIENTS AND METHODS: a pilot «case-control» study included two groups of patients, who underwent laparoscopic right colectomy according to a standardized technique. An intracorporeal anastomosis (IA) was formed in the main group (n = 20), in the control group — extracorporeal anastomosis (EA) (n = 18).RESULTS: in main group the postoperative complications rate was 20%, in the control group — 28% (p = 0.71). The postoperative hospital stay in the main group was significantly less than in control (5.0 vs 7.3 days) (p < 0.001).CONCLUSION: the postoperative complications rate in both groups was not significant, but postoperative hospital stay was shorter in IA group. A randomized controlled trial is required.

Unusual Presentation of Treated Colon Cancer with Extramural Venous Invasion: a Case Report

Introduction: Colon cancer is one of the leading malignancies globally and continues to be one of the most typical causes of cancer-related mortality. The clinical outcome of the disease depends on the primary tumor stage, regional nodal involvement, and distant disease dissemination. It often presents with hematogenous spread to the liver at the time of diagnosis. Another factor for increased mortality is the presence of extramural venous invasion (EMVI). This is exceedingly important as it has significant prognostic significance and helps predict survival. Case Description: A middle-aged female with a recent history of cesarean delivery presented with abdominal pain and occasional constipation, which led to a series of investigations. Initial Computed Tomography (CT) scan showed proximal to mid transverse colonic tumoral thickening with locoregional lymphadenopathy and solitary distant metastasis in the left hepatic lobe. This was followed by extended right hemicolectomy and hepatic metastasectomy. The patient remained on follow-up and later presented with thrombus formation in the splenoportal circulation. Initially, this was considered a bland thrombus, and the patient was advised a close follow-up. However, the patient was lost to follow and later presented with extensive thrombosis of the portal and splenic veins. Practical Implications: Confident differentiation of the bland versus malignant thrombosis is crucial to ascertain disease stage and appropriate management. Invasive tissue sampling gives a confident diagnosis of benign versus malignant thrombus. However, using a noninvasive imaging modality, we can still distinguish between the two with reasonable certainty.

Intracorporeal versus Extracorporeal Anastomosis for Laparoscopic Right Hemicolectomy: Short-Term Outcomes

Laparoscopic right hemicolectomy represents an effective therapeutic approach for right colon cancer (RCC). The primary aim of this study was to evaluate bowel function recovery, length of hospital stay, operative time, and the number of general and anastomosis-related postoperative complications from intracorporeal anastomosis (ICA) vs. extracorporeal anastomosis (ECA); the secondary outcome was the number of lymph nodes retrieved. This observational study was conducted on 108 patients who underwent right hemicolectomy for RCC; after surgical resection, 64 patients underwent ICA and 44 underwent ECA. The operative time was slightly longer in the ICA group than in the ECA group, even though the difference was not significant (199.31 ± 48.90 min vs. 183.64 ± 35.80 min; p = 0.109). The length of hospital stay (7.53 ± 1.91 days vs. 8.77 ± 3.66 days; p = 0.036) and bowel function recovery (2.21 ± 1.01 days vs. 3.45 ± 1.82 days; p < 0.0001) were significantly lower in the ICA group. There were no significant differences in postoperative complications (12% in ICA group vs. 9% in ECA group), wound infection (6% in ICA group vs. 7% in ECA group), or anastomotic leakage (6% in ICA group vs. 9% in ECA group). We did not observe a significant difference between the two groups in the number of lymph nodes collected (19.46 ± 7.06 in ICA group vs. 22.68 ± 8.79 in ECA group; p = 0.086). ICA following laparoscopic right hemicolectomy, compared to ECA, could lead to a significant improvement in bowel function recovery and a reduction in the length of hospital stay in RCC patients.

Schwannoma of the Appendix Orifice

Schwannomas are rare mesenchymal tumors. They are usually diagnosed incidentally during endoscopic or diagnostic imaging for another reason. Malignant transformation is rare. In this case report, we present an incidental schwannoma protruding through the appendiceal orifice diagnosed during endoscopy. A healthy 56-year-old female underwent a surveillance colonoscopy for family history of colorectal cancer. A prominent and edematous appendiceal orifice was noted, and the area was aggressively biopsied. Histopathological assessment revealed a benign schwannoma. Computerized topography was unremarkable. Subsequently, the patient underwent a right hemicolectomy. Patient is scheduled to undergo routine surveillance in three years. Grossly, schwannomas are white, encapsulated, and well-circumscribed lesions that stain strongly positive for S100, GFAP, and CD57. Histologically, schwannomas demonstrate spindle cell proliferation. Several imaging modalities have been utilized in the diagnosis and management of mesenchymal neoplasms. Despite the benign nature of the diagnosis, complete surgical resection with clear margins remains the gold standard management strategy. Our case highlights the presence of a relatively uncommon tumor in an unusual anatomical location.

Nonoperative Management for Peri-Appendiceal Abscesses after Percutaneous Drainage Without Interval Appendectomy

Background: Initial non-operative management (NOM) with percutaneous drainage for peri-appendiceal abscesses has been proven to be safe and effective. However, the appropriateness of interval appendectomy after NOM is still a matter of debate. The aim of this study was to investigate the feasibility of NOM without performing interval appendectomy.Methods: A retrospective review of medical records was performed for patients who were admitted with peri-appendiceal abscesses between January 2009 and December 2019. After percutaneous drainage for the abscesses, whether to undergo interval appendectomy was decided by the patients. Their clinical courses were reviewed thoroughly through their medical records. Telephone contact with these patients was made when necessary. Results: Twenty-seven patients were enrolled, with a mean age of 63.1 years (± 11.9 years). The median follow-up period was 25.7 months. The most common co-morbidities were cardiovascular disorders (eight patients) and underlying malignancies (eight patients). The mean size of the abscesses was 5.4 x 4.1 ㎝. Three patients consequently received surgery for the recurrence of appendicitis or peri-appendiceal abscesses. One patient received a right hemicolectomy, and another two received open appendectomies. Four patients (14.8%) died within the follow-up period due to underlying diseases.Conclusion: Initial NOM without interval appendectomy was a safe option in selected patients with peri-appendiceal abscess.