Background: Ischemic colitis can occur after colectomy and is sometimes difficult to treat. We report 4 cases of refractory, delayed onset, regional congestive colitis occurring on the anal side of the anastomosis after laparoscopic left hemicolectomy. Case presentation: A total of 191 patients underwent surgery for left colon cancer (transverse, descending, and sigmoid colon cancer) at our hospital from January 2012 to December 2017. During the procedures, the left colic artery (LCA) or sigmoid colic artery (SA) was dissected, the superior rectal artery (SRA) was preserved, and the inferior mesenteric vein (IMV) was dissected at the inferior margin of the pancreas. Congestive ischemic colitis due to venous return dysfunction occurred in 4 cases (2.1%), 5 to 34 months postoperatively. The patients had diarrhea and blood in the stool. On computed tomography (CT), the patients exhibited continuous intestinal edema and high-density adipose tissue from the anastomosis site to the rectum. Contrast enhancement showed dilation of the vasa recti and arteries from the inferior mesenteric artery (IMA) to the SRA. Three patients improved with long-term intestinal rest; in 1 case, the stenosis did not improve and required colorectal resection. Conclusion: Diagnoses were easy in these cases, but treatment was prolonged and surgery was necessary in 1 case. While this condition is rare, caution is warranted as it is difficult to treat.
The patient was an 81-year-old man who underwent laparoscopy assisted transverse colectomy for transverse colon cancer located a little to the splenic flexure in April 2013, when the reconstruction was performed by functional end-to-end anastomosis between the transverse colon and descending colon. The patient had been given magnesium oxide and had bowel movement almost every day after the operation. He and his family were not aware of having constipation. The patient presented to our hospital because of abdominal pain and vomiting in October 2014. An abdominal contrast-enhanced CT scan showed free air in the abdominal cavity ; an intestine had dilated at the functional end-to-end anastomosis in the left upper quadrant of abdomen, and a fecal mass 6.7 cm in diameter was present within the intestine. A perforation 4 mm in diameter was suspected to be on the dorsal wall at the same area. Perforative peritonitis caused by the fecal mass at the anastomosis was diagnosed and the patient was operated on. Upon surgery, there was a rupture at the anastomosis, through which the fecal mass had exposed. The anastomosis including the perforation was resected and colostomy was performed. In creating a functional end-toend anastomosis, we of course have to anastomose not to cause stricture of the anastomosis, however, we must also alert for a risk that an extremely great anastomosis diameter can cause a diverticulum like change, resulting in retention of fecal masses.
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