Synchronous primary anorectal melanoma and colorectal adenocarcinoma is extremely rare, with only 5 cases reported in the literature. Here, a case is reported and the currently available literature is summarized. A 72-year-old white male presented with changes in his bowel habits and unintentional weight loss. Colonoscopy revealed a polypoid mass in the distal rectum extending to the anal verge anteriorly and a circumferential polypoid mass in the distal sigmoid colon. Biopsies were taken, which revealed poorly differentiated melanoma of the anorectal mass and moderately differentiated adenocarcinoma of the sigmoid mass with nodal involvement. Computed tomography of the abdomen showed liver metastasis. An extended abdominoperineal resection was undertaken for palliation, relief of symptoms, and definitive histology to guide further management. Consequently, a resection of the hepatic metastasis was attempted; however, macroscopic deposits were discovered on 7 of 8 liver segments perioperatively. He was subsequently referred to medical oncology for palliative chemotherapy. Synchronous primary anorectal melanoma and colorectal adenocarcinoma is rare, this being the sixth report found in the literature. In summary of the available cases, all synchronous cancers were located in the rectosigmoid and had very similar presentations. Most presented relatively late and were generally treated with abdominoperineal resection, which appears to be the best treatment option. Overall, prognosis appears to be dismal. General and colorectal surgeons should always be aware of the possibilities of simultaneous primary cancers because this can affect treatment modalities and prognosis for the patient.
SUMMARY BackgroundColonic diverticular disease is common among older individuals whereas colonic symptoms, such as those of irritable bowel syndrome, are frequent in the general population.
A 34-year-old woman was brought in post high speed T-bone collision which resulted in a car rollover and significant intrusion of the vehicle. On presentation, she was alert but haemodynamically unstable. There was clinical suspicion of a right-sided haemothorax due to reduced oxygen saturations and air entry over her right hemithorax. A chest X-ray (CXR) showed a dense opacity in the right hemithorax with collapsed lung in the right middle zone (Fig. 1).An intercostal catheter (ICC) was inserted and computed tomography (CT) scan revealed that the liver was extensively lacerated and was in a high intrathoracic position with the superior part at the level of T4, consistent with a right diaphragmatic rupture (Fig. 2). The ICC appeared to be in close proximity to the hepatothorax, raising the question of further iatrogenic injury to the liver; however, the tip was directed towards the apex and did not penetrate the liver.The patient underwent emergency exploratory laparotomy. Intraoperative findings confirmed that the liver was in the right hemithorax through a large diaphragmatic defect with coronary ligaments avulsed off the diaphragm. The posterior liver surface was lacerated in multiple areas with bleeding from the parenchyma and bare area of the liver. The liver was reduced back into the abdomen and the large diaphragmatic defect was repaired with 0-Prolene sutures (Ethicon, Somerville, NJ, USA). Her bleeding injuries were repaired and haemostasis was achieved. The abdomen was packed and the patient transferred to the intensive care unit. She returned for a re-look laparotomy the following day and the packs were removed. A repeat CT scan 6 days postoperative showed successful reduction of the hepatothorax with healing liver lacerations (Fig. 3). She was discharged home 2 weeks later.Acute diaphragmatic ruptures are rare and its reported incidence after blunt trauma ranges from 0.8 to 7%. 1-5 The true incidence however, is unknown as they are underdiagnosed in approximately 7-66% of trauma victims. 3,4 This delayed diagnosis leads to an increase in morbidity and can manifest later as obstruction, strangulation and rupture of abdominal viscera. Thus, prompt diagnosis and treatment is necessary. 6 Right-sided ruptures were reported to be far less common than left-sided ruptures with an incidence of around 22.5-32%. 3,4 This discrepancy in incidence is thought to be attributed to the cushioning effect of the liver, increased strength of the right hemidiaphragm, under diagnosis of right-sided ruptures and congenital weakness of the left hemidiaphragm. 3,7 The extent of organ herniation varies depending on the size of the rupture. This can range from a small portion of the liver to the entire liver in addition to other abdominal viscera. Small herniations are typically asymptomatic and diagnosis can be delayed. These asymptomatic herniations are often found 10 years (average) post
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