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Competing Interests: Disclosure All authors disclosed no financial relationships. Commentary During colonoscopy, most endoscopists expect to find 1 of the 5 most common types of colon polyps: tubular adenoma, villous adenoma, serrated adenoma, hyperplastic lesion, or inflammatory lesion. However, less common lesions also occur within the GI system, including lipoma, GI stromal tumors, carcinoids, and sarcomas, among others. Here the authors present the case of a mature teratoma with visible hair, removed by snare polypectomy. This demonstrates that endoscopists can successfully manage unexpected lesions by using minimally invasive techniques. Monica Saumoy, MD, MS, Center for Digestive Health, Penn Medicine Princeton Health, Philadelphia, Pennsylvania, USA Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points

We reported a case of sigmoid colon cancer with horseshoe kidney. A 79-year-old man had lower abdominal pain and underwent colonoscopy. The results of colonoscopy revealed sigmoid cancer. Preoperative computed tomography revealed horseshoe kidney. He underwent radical laparoscopic surgery. The histopathological diagnosis was pStage Ⅱa(The 9th Edition). He has not recurred 22 months later after operation. Surgery for colorectal cancer with congenital anomalies of the urinary tract requires attention to intraoperative secondary injuries. Therefore, preoperative evaluation using 3D-CT is useful tool for safety. Operating the proper dissecting normal layer would make safe laparoscopic operation possible without unexpected injuries.

The patient is a 63-year-old man. He visited his previous physician for abdominal pain. After close examinations, he was diagnosed with stenotic sigmoid colon cancer with left lateral lymph node metastasis. On the same day, colonic stenting was performed to relieve the symptoms of stenosis. After 1 month of stenting, a robot-assisted laparoscopic sigmoid colectomy and left lateral lymph node dissection were performed. Postoperative pathological examination revealed regional lymph node metastasis and left lateral lymph node metastasis(#283); the patient was diagnosed with pT4aN1bM1a(LYM), fStage Ⅳa. The patient was discharged on postoperative day 10, and is stable 5 months after surgery without recurrence. This case suggests that robot-assisted laparoscopic lateral lymph node dissection can be effective even in atypical cases of sigmoid colon cancer with lateral lymph node metastasis.

A 50-year-old man presented with fecaluria and was diagnosed with sigmoid colon cancer with a colovesical fistula. Total bladder resection was determined to be necessary for curative resection at the time of diagnosis. In anticipation of bladder preservation, 6 courses of mFOLFOX6 plus panitumumab were administered after transverse colostomy, resulting in marked tumor regression and a decision to proceed with surgery. The patient underwent robotic-assisted low anterior resection of the rectum and partial cystectomy, which yielded pathological radical treatment. We report a case of sigmoid colon cancer with a colovesical fistula complicated by bladder invasion, in which preoperative chemotherapy was effective and total cystectomy was avoided, allowing bladder preservation.

Increasing evidence based on the safety and benefits of robot-assisted surgery indicates the disadvantage of the lack of tactile feedback. A lack of tactile feedback increases the risk of intraoperative complications, prolongs operative times, and delays the learning curve. A 40-year-old female patient presented to our hospital with a positive fecal occult blood test. A colonoscopy revealed type 2 advanced cancer of the sigmoid colon, and histological examination showed a well-differentiated adenocarcinoma. Furthermore, abdominal contrast-enhanced computed tomography revealed a tumor in the sigmoid colon and several swollen lymph nodes in the colonic mesentery without distant metastases. The patient was diagnosed with cStage IIIb (cT3N1bM0) sigmoid cancer and underwent sigmoidectomy using the Saroa Surgical System, which was developed by RIVERFIELD, a venture company at the Tokyo Medical and Dental University, and the Tokyo Institute of Technology. Based on adequate simulation, surgery was safely performed with appropriate port placement and arm base-angle adjustment. The operating time was 176 min, with a console time of 116 min and 0 ml blood loss. The patient was discharged 6 days postoperatively without complications. The pathological diagnosis was adenocarcinoma, tub1, tub2, pT2N1bM0, and pStage IIIa. Herein, we report the world's first surgery for sigmoid cancer using the Saroa Surgical System with tactile feedback in which a safe and appropriate oncological surgery was performed., (© 2023. Italian Society of Surgery (SIC).)

The ideal management of perforated colorectal cancer in the hernia sac remains a challenge for general surgeons. We report such a case requiring a combined-incision surgical approach and two-stage operation. A male patient in his 80s presented with fatigue and a bulge in his left groin. Contrast-enhanced CT scan revealed a sigmoid colon perforation within the left inguinal hernia sac. A combination of midline abdominal and inguinal incisions was performed for the iliopubic tract repair and Hartmann procedure. Six months later, the recurrent inguinal hernia was repaired using the Kugel mesh. The treatment strategy for colonic perforation into the inguinal hernia remains nonstandardized, compared to those for nonperforated cases. Combined inguinal and midline abdominal incisions might be necessary for infected lesion removal and colon mesentery resection; using mesh to repair hernia is a rare option. Hernia repair using mesh can be performed in two stages when recurrence occurs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Rationale: Dermatologic toxicity has been reported as the most common immune-related side effect of programmed cell death 1 inhibitors. Previous reports related to Sintilimab include rash, pruritus, vitiligo, Stevens-Johnson syndrome, toxic epidermal necrolysis, and so on., Patient Concerns: A 66-year-old man was treated with Sintilimab as monotherapy for sigmoid colon cancer. After the second prescription, he developed a more severe and widespread rash., Diagnoses: The diagnose of erythema multiforme drug eruption induced by Sintilimab was considered., Interventions: The patient received intravenous and oral methylprednisolone, routine antihistamines and topical gluccorticoids., Outcomes: The patient's symptoms were gradually relieved during hospitalization and was discharged following resolution of symptoms. He refused to continue using Sintilimab., Lessons: This is the first reported case of Sintilimab-induced erythema multiforme drug eruption. It is advisable to inform patients of potential dermatologic toxicity that may occur after using immune checkpoint inhibitors, so that we may prevent the further development of it and avoid the discontinuation of immune checkpoint inhibitors., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

A 63-year-old woman, who were in a nursing house, visited our hospital with complaints of bloody stools and anemia. Some investigations were performed, CS and CT revealed her diagnosis with sigmoid colon cancer(cT3N0M0)and rectosigmoid adenoma with situs inversus(SI). Laparoscopic low-anterior resection was performed. Postoperative course was good without any complications, and she discharged our hospital at the day 7 after the operation. In surgery, we had to be conscious of mirror image and set operative equipment and operative staffs inversely from normal setting. Some previous reports suggested that some surgical process such as cutting and separating with left hand(non-dominant hand), especially at interior separation, were effective in laparoscopic surgery for SI patients. However, in our operation, we used ultrasonic coagulator with short-pitched incision with surgeon's right hand(dominant hand)instead of left-handed process, and it could be useful for laparoscopic surgery for SI patients. In intrapelvic processes, we proceeded with the surgery as usual because of the symmetric structure of intrapelvic organs. We could complete the laparoscopic low-anterior resection for SI patient with several ingenuity for operative processes.

We herein report a case of atypical pseudo-Meigs' syndrome without pleural effusion. A 46-year-old woman was diagnosed with an ovarian tumor and sigmoid colon cancer with massive ascites. She underwent surgical resection of the sigmoid colon and bilateral salpingo-oophorectomy. The pathological diagnosis was sigmoid colon cancer with ovarian metastasis. A few days after the operation, the massive ascites disappeared. Immunostaining for vascular endothelial growth factor (VEGF) suggested its overproduction was involved in the development of the ascites. Although cases of pseudo-Meigs' syndrome without pleural effusion are rare, reporting such cases will facilitate the choice of more appropriate treatment strategies in future.

A 76-year-old woman presented to the hospital with the colon prolapsing through the anus. The enhanced abdominal computed tomography(CT)showed intussusception of the sigmoid colon due to sigmoid colon cancer. It was difficult to reduce the intussusception, and we did not recognize the ileus and ischemic change of the colon. Therefore, we performed an elective surgery. Hartmann's procedure and lymph node dissection were performed 8 days after the hospitalization. The postoperative course was uneventful. We report a case of sigmoid colon cancer with intussusception prolapsing through the anus.

The co-occurrence of abdominal aortic aneurysm (AAA) and colorectal malignancy creates a significant surgical dilemma over which entity should be addressed first. A 73-year-old male was referred to our hospital due to a painful pulsatile abdominal mass. Computed tomographic angiography revealed an infrarenal aortic aneurysm measuring 5.8 cm in diameter and incidentally, a synchronous mass lesion in the sigmoid colon. The patient underwent an emergency EVAR using a Gore Excluder endograft. Postoperative CT staging for colon cancer revealed a type 2 endoleak on the grounds of a patent wide inferior mesenteric artery. The patient underwent a standard laparoscopic left colectomy with high ligation of the inferior mesenteric artery in order to simultaneously address the ongoing type 2 endoleak. Follow-up examinations with computed tomographic angiography were performed confirming the resolution of the endoleak. Synchronous laparoscopic sigmoidectomy and high ligation of inferior mesenteric artery for type 2 endoleak treatment appears to be applicable with hopeful results.

BACKGROUND Colorectal cancer among pregnant women is a rare entity. If colon cancer is suspected during pregnancy, the diagnosis is a therapeutic challenge that should be managed by a multidisciplinary team of specialists. Standardized therapeutic models do not exist. In this article we present a case of a pregnant patient with stenotic sigmoid colon adenocarcinoma. We describe the interdisciplinary treatment and the 2-step surgical approach used during pregnancy. CASE REPORT A 32-year-old women in week 28.8 of pregnancy was admitted to the Department of Gynecology and Obstetrics, meeting the standard pregnancy criteria of constipation. After a week of unsuccessful conservative treatment, the patient underwent magnetic resonance imaging (MRI), which disclosed a stenosed segment in the sigmoid colon. After an emergency colonoscopy with biopsy sampling, histological analysis confirmed sigmoid adenocarcinoma. In a multidisciplinary consultation of specialists, in which neonatological and oncological aspects were considered, a 2-step surgical plan was established. In the first step (gestational week 29.8), a loop transverse colostomy with intestinal decompression was performed. In the second step (gestational week 32.8), an elective primary caesarean section followed by open oncological sigmoid resection was performed. No postoperative complications occurred in either step. The neonate was healthy and had a birth weight appropriate for the gestational age. CONCLUSIONS In cases of colorectal cancer during pregnancy, staged surgical approaches should be considered to reduce maternal and fetal morbidity.

The patient was a woman in her 70 s. Computed tomography(CT)showed a sigmoid colon tumor invading the uterus and ovaries, and a fistula to the bladder. The patient was scheduled to receive neoadjuvant chemotherapy(NAC), but while waiting for treatment, generalized peritonitis due to perforation of the tumor was observed, and a laparoscopic transverse colostomy was performed. After NAC with CAPOX and FOLFIRI plus panitumumab, the tumor was found to have shrunk, and a laparoscopic posterior pelvic exenteration was performed. The bladder including the fistula was partially resected, and the tumor, uterus, and right ovary were resected in combination as R0, besides the ureter and remaining bladder could be preserved. The postoperative course was uneventful, and the patient is alive without recurrence to date. In this article, we report a case of a patient with sigmoid colon cancer with a bladder fistula who underwent laparoscopic surgery after NAC, and bladder function could be preserved, with some discussion of the literature.

A 60-year-old man was referred to our hospital for the evaluation and treatment of general malaise. Contrast-enhanced computed tomography detected sigmoid colon cancer that had invaded the bladder, multiple liver metastases, and a small intestinal tumor. Hartmann's procedure was performed, with partial bladder and small bowel resection. A pathological examination revealed that the patient had sigmoid colon cancer and a gastrointestinal stromal tumor. The biopsy findings of a tumor in segment 8 of the liver indicated the presence of adenocarcinoma, thereby indicating the origin of multiple liver metastases from sigmoid colon cancer. On chemotherapy, the tumors in liver segments 2/3 and 8 shrank. However, the tumor in segment 6 enlarged. Since radical resection of all metastatic liver tumors was possible, hepatectomy was performed 10 months after the initial surgery. A pathological examination revealed that the tumors in segments 2/3, 4, and 8 were adenocarcinomas and the tumors in segments 4, 6, and 7 had originated from the gastrointestinal stromal tumor. This suggested the coexistence of liver metastases from sigmoid colon cancer and the gastrointestinal stromal tumor. In cases involving multiple primary tumors, it is necessary to consider the possible coexistence of multiple metastases from different primary tumors., (© 2021. Japanese Society of Gastroenterology.)

We reported a case of irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.The patient complained about a right groin mass for more than 60 years with progressive enlargement for 3 years and pain for half a month.Abdominal CT examination at admission showed rectum and sigmoid colon hernia in the right inguinal area and thickening of sigmoid colon wall.Electronic colonoscopy and pathological diagnosis showed sigmoid colon cancer.Therefore,the result of preliminary diagnosis was irreducible indirect inguinal hernia caused by sigmoid colon cancer entering the right groin.We converted laparoscopic exploration to laparotomy followed by radical sigmoidectomy and employed end-to-end anastomosis of descending colon and rectum in combination with repair of right inguinal hernia.The patient recovered well after operation and was discharged.

An 85-year-old man was hospitalized for a right greater trochanteric fracture. Rectal intussusception was found by diagnostic imaging but left untreated because of minor gastrointestinal symptoms. As a result of work-up for persistent mucous stool, he was diagnosed with sigmoid colon cancer with intussusception. The intussusception could not be reduced during barium enema examination but could undergo elective laparoscopic surgery with a good postoperative course. Adult intussusception may be asymptomatic and require no emergency treatment. In such a case, elective surgery can be performed. Many facilities employ laparotomy as a standard of care for intussusception. With the recent technological advances in endoscopic surgeries, laparoscopic surgery can be considered as a treatment option.

Competing Interests: Daniel RaysonHonoraria: Ipsen, Pfizer, Advanced Accelerator ApplicationsConsulting or Advisory Role: Ipsen, Novartis Canada Pharmaceuticals Inc, Roche Canada, Pfizer, AstraZeneca Canada, Advanced Accelerator ApplicationsResearch Funding: Pfizer, Novartis, Odonate Therapeutics, Immunomedics, Cascadian Therapeutics, Sermonix Pharmaceuticals, Seattle GeneticsNo other potential conflicts of interest were reported.

A 72-year-old women was referred to our hospital because of lower left abdominal pain. Computed tomography showed prominent sigmoid colon dilation and double tumors on both the oral and anal sides. Surgical resection revealed an expanded sigmoid colon involved in double cancer that showed strong adhesion to the surrounding tissues. The pathological findings revealed obstructive colitis and minor perforation in the dilated colon. The minor perforation was considered to have been caused by fecal impaction in the closed cavity between the two tumors, resulting in an increase in colon pressure.

A 55-year-old man complaining of difficulty in defecation was referred to our hospital. A digital examination and abdominal CT led to a diagnosis of intussusception due to tumor of the sigmoid colon. The intussusception was successful reduced by enema. Following colonoscopy and abdominal enhanced CT, a sigmoid colon cancer(cT3, cN1b, cM0, cStage Ⅲb)was detected. A laparoscopic sigmoidectomy and lymph node dissection were performed on 23 days after the hospitalization. Postoperative course was uneventful. Preoperative reduction of the intussusception in this case enabled us to perform an elective surgery. We report this case with a review of the relevant literature.

A 50's man was referred to our hospital because of sigmoid colon cancer with multiple liver metastases and para-aortic lymph node metastases. Although blood test showed elevated D-dimer(50 μg/mL), there was no significant thrombus in contrast-enhanced CT scan. Since cancer pain and symptoms of bowel obstruction had continued after endoscopic stent placement, we resected primary lesion. Despite anemia and elevated D-dimer level had persisted after the operation, there were no obvious bleeding source nor thrombus. Continuous intravenous heparin infusion was started for hypercoagulability. Then, D-dimer and CRP levels were promptly decreased. Since schizocyte and giant platelets were observed in peripheral blood smear, he was eventually diagnosed with thrombotic microangiopathy as a paraneoplastic syndrome. However D- dimer and CRP levels were re-elevated, and it seemed to be necessary to control cancer progression. Thus, cetuximab monotherapy was started considering his performance status. After starting cetuximab, fever and CRP level were immediately improved. Cetuximab appeared to be very effective, but he died of acute subdural hematoma. Continuous intravenous heparin infusion was supposed to be effective in the treatment of thrombotic microangiopathy along with the management of cancer.

A 77-year-old man was diagnosed with obstructive sigmoid colon cancer invading the psoas major and iliac muscles. To avoid the postoperative paralysis of the lower limb, a self-expandable metallic stent(SEMS)was placed, and systemic chemotherapy was administered subsequently. After 4 courses of SOX, Hartmann's procedure was performed. The patient did not develop lower limb paralysis and is alive without recurrence 2 years and 3 months postoperatively. This case suggests that preoperative metallic SEMS placement and neoadjuvant chemotherapy could be an effective treatment for locally advanced colon cancer with obstruction and invasion of the adjacent tissues.

The patient was an 81-year-old man. Laparoscopic sigmoidectomy was performed for a sigmoid colon cancer(S, type 2, pT3[SS], INF a, Ly0, V0, BD1, Pn0, pPM0, pDM0, RM0, pN0, pM0, pStage Ⅲa, R0, Cur A). One year after the surgery, a blood test showed CEA as high as 68.9 ng/mL, and an abdominal enhanced computed tomography revealed a hepatic tumor showing marginal contrast in the 4th liver segment. Positron emission tomography showed an accumulation of SUVmax 19.0 at the same site, and a metastatic liver tumor was diagnosed. A laparoscopic medial hepatectomy was performed. Bleeding from the hepatectomy site increased significantly after completion. Subcutaneous emphysema spreading from the face to the trunk and thigh was observed, and blood tests revealed a pH of 7.172, PaCO2 of 71.0 mmHg, lactate of 67 mg/dL, mixed acidosis, D-dimer of 118 μg/mL, and a disseminated intravascular coagulation(DIC)syndrome was diagnosed. Following the difficulty of hemostasis, the surgery was changed to laparotomy and terminated by gauze packing. We encountered a case of acidosis exacerbated by hypercapnia that progressed to DIC during laparoscopic medial hepatectomy.

Rationale: Cancer-related stroke has been regarded as an emerging subtype of ischemic event. Acute treatment for this subtype may include the antiplatelet agents, anticoagulants, or endovascular intervention., Patient Concerns: A 63-year-old woman with sudden-onset right hemiparesis and conscious change was sent to our emergency department. The patient had underlying sigmoid adenocarcinoma and received chemotherapy FOLFIRI (FOL, folinic acid; F, fluorouracil; and IRI, irinotecan) with targeted therapy cetuximab following lower anterior resection since the diagnosis was made., Diagnoses: Brain magnetic resonance angiography revealed a filling defect in left carotid bulb, and neurosonography showed a thick atherosclerotic plaque (size 4.9 mm) in the left internal carotid artery on day 5 after the onset of stroke., Interventions: During the first three hours after onset, administration of IV tissue plasminogen activator did not resolve the thrombus. Dabigatran (110 mg bid) started on day 7., Outcomes: The atherosclerotic plaque dissolved on day 24. The patient recovered her muscle strength but still had nonfluent speech in mild extent., Lessons: Thrombolytic and anticoagulant medications in this patient suggested the thrombus formation with fibrin-rich content which may be attributable to both cancer and chemotherapy. Dabigatran, an oral anticoagulant, had a benefit for this subtype of ischemic stroke among patients with cancer.

Competing Interests: Competing interests: None declared.

A 63-year-old man was diagnosed with advanced sigmoid cancer of pT3, pN0, sM1c, sP3, fStage Ⅳ post-operation. After CAPOX plus Bmab as the first-line chemotherapy, he underwent IRIS plus Bmab as the second-line chemotherapy. After 1 course of IRIS plus Bmab, he was admitted to the hospital for fever, dyspnea, and general fatigue. The white blood cell count was 6.2×10 3/mL, and the C-reactive protein was elevated to 12.9 mg/dL. The PaO2 of the artery blood gas analysis in room air was 46.3 mmHg, suggesting respiratory failure. He was diagnosed with PCP based on the bilateral diffused ground-glass opacities on chest CT along with an elevated serum b-D-glucan. The treatment of trimethoprim-sulfamethoxazole and steroid was then initiated. After the patient's clinical condition improved, he was discharged on day 27 post-admission.

Backround: The association of rectal prolapse and colorectal cancer is quite rare and only a few cases have been reported previously in the literature. It is unclear whether colorectal cancer triggers rectal prolapse., Case Presentation: A 77-year-old male patient presented to our emergency department with complete rectal prolapse, and an anterior resection was performed after rectal digital examination revealed a mass. The pathology result came back as mucinous adenocarcinoma in the sigmoid colon and the postoperative period was uneventful., Conclusions: Considering the age group in which rectal prolapse is most commonly seen, and the change in bowel habits, chronic constipation and irritation chronic seen in rectal prolapse may be responsible for the development of rectum cancer, therefore endoscopic screening should not be overlooked in rectal prolapse cases., Key Words: Anorectal emergencies, Colon cancer, Rectal prolapse.

Case Summary: An otherwise healthy 59-year-old man presented to the emergency department with 2 weeks of narrowed stools, 5 days of obstipation, and 1 day of abdominal pain, nausea, and vomiting. Computed tomography revealed an obstructing sigmoid mass without evidence of metastatic disease, and the CEA was 1.2 ng/mL. Flexible sigmoidoscopy confirmed a circumferentially obstructing distal sigmoid neoplasm. Endoscopic stent placement was immediately followed by a firm distended abdomen. An upright radiograph obtained following the procedure demonstrated free intraperitoneal air. An emergent Hartmann procedure was performed for iatrogenic colon perforation in a patient with malignant obstruction and chronic dilation of the proximal colon.

Blowout syndrome caused by vascular invasion is a dreadful complication of late stage malignancies that carry high morbidity and poor overall prognosis in a compromised population. Endovascular management can offer minimally invasive and life-saving alternative for such acute conditions. We describe the case of a 62-year-old man with massive fresh bleeding per rectum and shock resulting from rupture of the left external iliac artery secondary to nearby infiltrative recurrent sigmoid cancer. This complication is rare, presents dramatically, and is frequently fatal. The patient was successfully treated with a stent graft deployment in order to achieve hemostasis and reinstituting the arterial integrity.

Introduction:: Aortic mural thrombosis associated with a malignant disease is rare, and whether anticoagulation therapy or surgical treatment is the more definitive primary treatment remains uncertain. This study aims to determine the best treatment strategy for aortic thrombosis in a patient with a malignant disease., Methods:: We reviewed medical literature using the PubMed database and present a case of aortic thrombosis due to a hypercoagulable state related to sigmoid colon adenocarcinoma., Results:: Of the 18 patients from 14 articles included in this study, 13 received simple anticoagulation as a primary treatment (anticoagulation group), while 5 underwent surgical treatment (surgical treatment group). Recurrence or exacerbation of embolism was found in 2 (15.4%) of the 13 patients and in 1 (20.0%) of the 5 patients ( P = 1.0). Major complications were observed in 1 (7.7%) of the patients in the anticoagulation group and in 1 (20.0%) of the 5 patients in the surgical treatment group ( P = .49). No significant differences between the groups were found., Conclusions:: A simple anticoagulation therapy may be as effective as surgical treatment in patients with aortic thrombosis associated with malignancy.

Obstructive colitis (OC) is a nonspecific inflammatory condition that occurs at the proximal side of a completely or partially stenotic lesion typically caused by colorectal cancer. Impaired blood flow caused by these stenotic changes in the colon or rectum results in this condition. During surgery for sigmoid colon carcinoma with OC, complete surgical removal of the OC lesions is required. However, it is difficult to anticipate the range of OC before surgery. Diagnosing the potential ischemia during surgery would decrease the need for re-operation. This is the first report of HyperEye Medical System (HEMS) angiography for surgery of colon cancer with OC. We report a case of sigmoid colon carcinoma in which HEMS angiography was used and found to be useful for real-time detection of the OC lesion.