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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_929_Библиотеки_им_академика_М_И_Перельмана.pdf
CASE
7
Blind Pouch Syndrome After Ileorectal Anastomosis
History
Between 1959 and 1974, the patient had suffered 4
episodes of profuse rectal bleeding requiring transfusion. Barium enema examination (1974) revealed
diverticulosis throughout the colon. The patient
resided some distance from sophisticated surgical
services and this influenced the decision to operate.
Operation (11.4.1974)
An elective operation was performed. Many diverticula were present, particularly in the transverse
and left colon. There was a focus of induration in
the transverse colon in relation to a diverticulum. A
colectomy and a high ileorectal anastomosis (IRA)
was performed (side ileum-to-end rectum). Microscopic examination of the diverticulum in the transverse colon (Figure 7.1) showed conspicuous dilated
vessels.
Female, 68* Years
occurred requiring transfusion. Sigmoidoscopy now
revealed a stricture of the IRA in addition to ulceration. A barium enema demonstrated a blind elongated pouch in relation to the IRA (Figure 7.2).
Operation (7.20.1984*)
A large length of ileum (15cm) was found projecting
from the right side of the IRA. It measured 6cm in
width. The IRA and 5cm of proximal ileum were
resected and a further IRA established with an endto-end anastomosis.
Pathology
There was ulceration and stricture formation of
the IRA and adjacent ileum. The mucosa at the
apex of the blind loop was intensely hyperemic.
Histological examination revealed nonspecific
inflammation.
Follow-Up
Sigmoidoscopy 2 years and 5 months later in 1977
demonstrated a healthy IRA at 13cm. In 1981,
profuse rectal bleeding occurred, and at this time
sigmoidoscopy revealed ulceration of the ileum
adjacent to the IRA. In 1984, further acute bleeding
BP
R
IL
Figure 6.1: Diverticulum in the transverse colon causing
bleeding (1974).
14
Figure 6.2: A barium enema demonstration of the blind
pouch. (1984). BP: blind pouch; IL: ileum; R: rectum.
Diagram 7 15
Postoperative Course
The patient’s gastrointestinal recovery from the
operation was slow but satisfactory. She was,
however, suffering from persistent angina. Investigation revealed severe, inoperable coronary artery
disease and poor left ventricular function. The
patient suffered a fatal myocardial infarct 29 days
after the operation.
Comment
This patient is another example of the blind pouch
syndrome which, in contrast to Case 6, was a complication of a side-to-end anastomosis between
ileum and large bowel. It has more frequently been
reported as a complication of ileo-colic anastomosis
1,2,3
after right hemicolectomy.
Although there was
anastomotic stenosis, the symptoms were due solely
to bleeding from the ulceration, which commenced
7 years after the ileorectal anastomosis. At this first
operation (IRA), the closure of the terminal end of
the anastomosis was adjacent to the anastomosis,
proving the large blind pouch developed subsequently. The ulceration in such a case can be
resolved only by surgery. It is unfortunate that
operation was not performed 3 years earlier (1981),
which may have avoided the fatal consequences of
her cardiovascular disease.
7.20.84
PART
II
Appendix
CASE
8
Acute Appendicitis: Diagnosis at Colonoscopy
History
The patient suffered recent acute pain in the right
iliac fossa. Admission to hospital was necessary,
and a plain x-ray of the abdomen revealed loops of
dilated small bowel. A gastrograffin enema indicated
deformity of the ileocecal region. The patient’s condition settled and he was discharged from hospital
and transferred for further investigations.
Colonoscopy
Colonoscopy revealed a “beehive” shaped polypoid
lesion at the base of the appendix (Figure 8.1). It
appeared to be inflammatory rather than neoplastic,
and appendicitis was suspected.
Operation (8.7.98)
At operation, recent acute appendicitis was confirmed with retrograde intussusception induced by
a tense and distended appendix. The distal cecum
with the appendix was resected.
Comment
This is a rare mode of acute appendicitis diagnosis.
The smooth surface, the inflammatory changes, and
the site of the lesion suggested the diagnosis.
Male, 59 Years
Figure 8.1: The inverted inflamed appendix seen at
colonoscopy.
18
Diagram 8 19
CASE
9
History
The patient was examined by colonoscopy in view
of a family history of colorectal cancer (mother).
There were no previous or current gastrointestinal
symptoms. In the base of the cecum there was a
smooth hemispherical swelling covered by normal
mucosa (Figure 9.1). This was diagnosed as a
mucocele of the appendix by the colonoscopist.
A computerized tomography (CT) examination
demonstrated that the lesion was continuous with
the appendix, which was dilated (Figure 9.2).
Operation (7.28.97)
The findings at operation confirmed the diagnosis.
The proximal appendix was significantly dilated and
continuous with a palpable intracecal swelling. The
distal half of the appendix was pale, reduced in
caliber, and firm in consistency, suggesting fibrosis.
There was no evidence of malignancy or other
intra-abdominal abnormality. A limited right hemicolectomy was performed in preference to a local
excision, since an occult cystadenocarcinoma could
not be excluded.
Pathology
The appendix was 60mm in length. Distally its
caliber was 6mm, whereas proximally it was dilated
Mucocele of the Appendix
Female, 51 Years
Figure 9.2: The CT with contrast clearly shows the lesion
in the cecum.
to 20mm. The appendix ostium was obstructed. The
lumen contained clear mucoid material. Histologically there were areas of both mucosal hyperplasia
and atrophy. There was extravasation of mucin into
the wall of the appendix (Figure 9.3). This extravasation was devoid of cells.
Figure 9.1: The endoscopic view of the mucocele.
20
Figure 9.3: Pools of mucus are present within the wall of
the appendix.
Diagram 9 21
Comment
Rokitansky is credited with first description of this
entity in 1842.1Woodruff and McDonald reported
146 mucoceles in over 43000 appendectomy specimens examined at the Mayo Clinic.2The pathology
is frequently not diagnosed until laparotomy. The
first report of a colonoscopic diagnosis was by
3
Ponsky in 1976.
Surgical treatment is necessary to
confirm the diagnosis and to prevent the complication of pseudomyxoma peritonei which may follow
perforation of a mucocele if the primary pathology
is a cystadenoma or cystadenocarcinoma.
CASE
10
History
Following an “influenza type illness,” the patient
complained of pain in the right sacral region. A
white cell count of 19,000 returned to normal after
antibiotics. A computerized tomography (CT) examination of the pelvis revealed a 4.0 × 6.5 cm cystic
mass, thick walled and partly calcified. The mass
was intimately related to the right side of the
sigmoid colon and contained multiple septations
(Figure 10.1). A calculus was demonstrated in the
right ureter. Examination under anesthetic revealed
a mobile soft mass in the pelvis. Three small hyperplastic polyps at 20cm were the only abnormalities
seen on colonoscopy. The indirect hemagglutination
test (IHA) for hydatid disease was negative.
Operation (11.4.96)
A ruptured mucocele of the appendix was diagnosed,
revealing a collection of green mucoid material in
the pelvis. Appendectomy was performed. The
ureteric calculus was removed from the lower part
of the right ureter by a urological colleague.
Pathology
There was focal calcification in the wall of the cystic
mass. Foci of atypical mucinous epithelium (Figure
10.2) and occasional papillary configuration were
present. The appearance was consistent with a
mucinous cystadenoma.
Cystadenoma: Appendix
Male, 70 Years
Comment
Mucus producing pathology of the appendix is rare,
and the diagnosis is not usually made prior to operation.1In this patient a second radiological opinion
prior to operation suggested the diagnosis was a
mucocele of the appendix, in view of the calcification in the wall of the cystic mass.2Unfortunately
the lesion had already ruptured at the time of laparotomy, thereby increasing the risk of peritoneal dissemination. Clinical and CT examination have been
normal 8 years since operation. Mucocele of the
appendix is divided into 4 distinct pathological
entities: (i) nonneoplastic mucocele due to luminal
obstruction; (ii) mucosal hyperplasia; (iii) mucinous
cystadenoma with villous adenomatous change; and
(iv) malignant mucinous cystadenoma.
cally there can be difficulty in distinguishing
between categories (iii) and (iv). These lesions can
produce a refractory mucinous ascites, which has
been referred to as pseudomyxoma peritonei.
Ronnet et al., in a review of 109 cases, have suggested subdividing this entity into disseminated
peritoneal adenomucinosis (DPAM) for benign
disease and peritoneal mucinous carcinomatosis
(PMCA) for malignant mucinous ascites.
3
Histologi-
4
Figure 10.1: The CT examination demonstrates the pelvic
mass.
22
Figure 10.2: Atypical stratified columnar epithelium
consistent with the diagnosis of a cystadenoma. Mucus
present in lumen of the appendix (left).
Diagram 10 23