Villous Adenoma Arising in the Urethra of a Female with Bladder Augmentation History: A Case Report and Review of the Literature

Villous adenomas (VAs) in the female urethra are rare with only seven cases in the English literature to our knowledge. In patients with bladder augmentation cystoplasty, the neoplasia development risk increases and most of these develop in the neobladder or anastomosis line. Only two cases of VA developing from the native bladder mucosa have been reported. Physical examination of a 76-year-old female who had a history of augmentation cystoplasty revealed a caruncula-like structure protruding from the urethral meatus. The urinary USG showed that the lesion had no relation with the bladder. The lesion was excised. Microscopically, it consisted of villous structures covered with pseudostratified intestinal type epithelium. Low-grade dysplasia was present in the epithelium but high-grade dysplasia or in-situ/invasive carcinoma was not observed. Immunohistochemical study showed positivity for CK7, CK20, EMA, CEA and CDX2. The case was reported as VA of the urethra. We presented the first VA case arising in the urethra of a female patient with intestinal bladder augmentation. Excision is curative for pure VAs. Transformation to carcinoma or recurrence has not been reported. However, in one third of the cases, a malignant tumor may accompany the lesion. Therefore, all excision material should be examined carefully. Routine endoscopic follow-up should be performed in cases with bladder augmentation.

Giant Villous Adenoma: A Rare Case of Colorectal Adenoma that Mimic Colorectal Cancer

Colorectal cancer being the 4th most common cause of cancer death in which most arise from a preexisting adenomatous polyp. Among the various adenomas Giant villous adenoma (GVA) is less common. We came across a 65 years female with intermittent per rectal mucus discharge for last 10 years and intermittent fresh, painless, scanty per rectal bleeding along with weakness and fatigue for last 5 years. No members of her family had been suffering from colorectal malignancy. DRE revealed irregular gritty feelings of rectal mucosa starting 2cm from anal verge and the examining fingertip was blood tinged mixed with mucus. On proctoscopic examination the accessible rectum was studded with thousands of polyps with granular appearance, with variable sizes and there was mucus mixed blood within the rectum. Colonoscopy reveals- polypoid lesion starting 2cm from anal verge and extends up to 2cm with granular and velvety appearance. Biopsy was done 2 times for suspicious lesion and histopathology reveals tubulovillous adenoma with dysplasia. However as clinical suspicion of an adenocarcinoma was strong but histopathological report of colonoscopic biopsy was contradictory, intersphincteric ultra-low anterior resection with coloanal anastomosis with covering ileostomy was done. Resected specimen was sent for histopathological study and it reveals- villous adenoma with low grade dysplasia. Two months later reversal of ileostomy was done and now the patient is under regular follow up and now she is asymptomatic.

Lipoma of the transverse colon covered by tubulovillous adenoma: a rare indication for surgical treatment

Lipomas of the digestive tract are rare benign tumours which, in most cases, are totally asymptomatic. Because of their localization within the intestinal wall, endoscopy may be completely negative so contrast-enhanced computed tomography (CT) is very important for detecting and typing these lesions. The case of a 49-year-old man with abdominal pain is presented. Colonoscopy and biopsy of a polypoid lesion on the right colonic flexure concluded for tubulovillous adenoma. The subsequent CT showed a polylobate lesion of 5 cm in diameter with predominant fat density causing luminal sub-stenosis. Histological examination of the surgical specimen confirmed the presence of a voluminous submucosal lipoma. CT allows to diagnose lipomas of the large bowel thanks to the density measurement (between -40 and -120 Hunsfield Units) with an accurate detection of the site and nature of lumen stenosis.

A Rare Case of Acute Kidney Injury: McKittrick Wheelock Syndrome

McKittrick-Wheelock syndrome is a rare complication of rectosigmoid villous adenoma leading to secretory diarrhea, prerenal acute kidney injury and severe fluid and electrolyte imbalances. There are about 50 cases reported in literature. We represent a case of 71 year-old patient with persistant chronic diarrhea, prerenal azotemia, severe hypokalemia, and hyponatremia. Initially, the patient's kidney function and serum potassium values were normalized by conservative treatment, and villous adenoma was removed by surgery.

Intestinal-type adenocarcinoma of the vagina: clinico-pathologic features of a common tumor with a rare localization

Intestinal-type adenocarcinoma is a rare primary vaginal carcinoma and considerably more uncommon than metastatic lesions which represent the most frequent malignancy at this anatomic site. Among all malignant tumors, colorectal, breast and female genital tract carcinomas have the tendency to metastasize to the vagina. As morphologic and immunohistochemical features of intestinal-type adenocarcinoma occurring primarily in the vagina are not specific, clinical and radiologic information is crucial to exclude a metastatic lesion. Herein we present a rare case of intestinal-type adenocarcinoma from a villous adenoma, presenting as a polypoid mass in the posterior wall of vaginal introitus of 51-year-old menopausal woman. To the best of our knowledge, only 19 cases of intestinal-type adenocarcinoma of the vagina have been reported in the English literature so far. Notably the origin from a previous villous adenoma has been well documented only in a few cases.

Transanal Minimally Invasive Surgery (TAMIS), First in Kuwait: A Case Report

Transanal Minimally Invasive Surgery (TAMIS) is a one of new platform used to help and achieve better outcome in using transanal approach for the treatment of rectal neoplasm. High definition camera and high tech equipment are used to perform this kind of surgery. The main benefit of using this approach is to provide the best outcome or the patient compared to the traditional transanal approach. This platform can be used for a variety of cases, benign and malignant tumor and for the benign condition. We report the first TAMIS perfo b rmed in the Kuwait and probably in the Middle East with 2 years of follow up. We had no complication and patient returned home and to normal activity in next day. More studies needed to validate this technique.

Is partial thickness excision in TAMIS without defect suture safe for benign rectal lesions?

BACKGROUND

One of the minimally invasive methods used in the surgical treatment of large-based polypoid lesions located in the rectum is transanal minimally invasive surgery (TAMIS). This method, which relieves patients from the severe morbidities of invasive surgical procedures, is performed in both malign (T1-T2) and benign lesions. Difficulty of suturation after TAMIS emerges as the most important factor to prolong the procedure. We aimed to analyse the efficacy of TAMIS procedure with partial thickness resection without suturation.

MATERIALS AND METHODS

This was a retrospective study. The study was conducted in a Turkish Education and Research Hospital in 2016. Data of 10 patients who diagnosed with benign rectal masses were included in the study. Patients who were suspected for muscularis propria invasion and lymph node positivity in magnetic resonance imaging preoperatively excluded from the study. All lesions were resected with TAMIS and the mucosal defects were not closed in any patients. Demographic features, lesion's distances to anal verge, excised lesion's size, histopathological report, operation times, duration of hospital stay and complications were recorded RESULTS: Six male and 4 female patients were treated. The mean distance to the anal werge of the lesions was 8.5 (5-12) cm. The longest diameters of the lesions ranged from 1-4 cm in length. All the patients were discharged the day after the surgery. Operation times were found to be 46.1 ± 5 min (30-70). Histopathological examinations of the removed lesions revealed villous adenomas in 3 patients, villous adenoma and Tis adenocarcinoma in 5 patients, villous adenoma and T1 adenocarcinoma in 1 patient and neuroendocrine tumor in 1 patient. There were no early complications such as bleeding, and late complications such as perforation, anal incontinence or anorectal dysfunction in any patient. No evidence of recurrence was found in any of the patients under control rectosigmoidoscopy and pelvic MRI examinations.

CONCLUSION

Partial thickness resection of rectal benign lesions by TAMIS method is safe. After resection some surgeons suggest to close the defect by suture or stapler. In our study resection without closure of the defect is found safe and feasible with limited patient prejudice.

KEY WORDS

Rectal benign lesions, Transanal partial thickness excision.

Association between neuroendocrine tumor of the ileum and two colonic primary malignancies. A case report and review of literature

BACKGROUND

A high rate of association between neuroendocrine tumors (NETs) and secondary primary malignancy (SPM) has been described in literature and this association can occur either in a synchronous or a metachronous presentation. A wide range of hypothesis has been postulated to explain the high rate of association between NETs and SPM, without definitive conclusions.

CASE PRESENTATION

We report a case of an ileal neuroendocrine tumor found incidentally at the histologic examination of the surgical specimen in a 72 years old male underwent to right hemi colectomy for two colic adenomatous polips with high grade dysplasia.

CONCLUSION

Large multicentric epidemiological studies should be considered to assess the association between NETs and SPM.

KEY WORDS

Neuroendocrine tumors (NETs), Progression-Free Survival (PFS), Secondary primary malignancy (SPM).

[A Case of Large Rectal Villous Adenoma Associated with Tenesmus and Body Weight Loss]

The patient was a 78-year-old man who was hospitalized with a 1-month history of tenesmus and body weight loss. Blood tests revealed a mild increase in tumor markers(CEA 9.7 ng/mL)and an elevation of the inflammatory response. Colonoscopic examination disclosed a full circular lateral spreading tumor(LST)extending from the second Houston valve to the rectosigmoidal region with a more than 10 cm length. Since invasion to the SM layer was suspected, endoscopic resection was judged inapplicable and laparoscopic low anterior resection with D2 lymph node dissection was performed, along with covering ileostomy. The final pathology diagnosis was villous adenoma with carcinoma in adenoma, showing multiple villous structures categorized as high dysplasia. Postoperatively, he was free from tenesmus and his body weight increased. In addition, normalization of the tumor markers occurred.

Transanal endoscopic video-assisted (TEVA) resection of early rectal lesions using a SILS port A single center experience

represents a safe and complete technique to remove benign lesions of the rectum not treatable by endoscopy and malignant rectal lesions at early stage. It is a valid alternative to transanal endoscopic microsurgery (TEM), to conventional transanal surgery and to transabdominal resection.

METHODS

In our operating Unit we performed a resection of 8 voluminous adenoma in the rectal ampulla with SILSTM-Port.

RESULTS

The mean age of the patients was of 51.1 years, the mean BMI was 23. There were not intra or post-operative complications nor conversions to conventional transanal excision or major resective surgery. The postoperative course was normal. The average time of hospitalization was 3 days.

CONCLUSIONS

TEVA is easier to perform than TEM and does not require a long training and specific and expensive material as the TEM does. TEVA might go to replace completely TEM.

KEY WORDS

Rectal tumours, SILS, TEVA.

[A Case of Rectal Villous Tumor Detected with Heart Failure and Electrolyte Imbalance]

A 74-year-old woman presented to our emergency department with a chief complaint of appetite loss, and already diagnosed dehydration and heart failure. After hospitalization, the signs of heart failure were improved with liquid supplementation and electrolyte revision. At admission, computed tomography incidentally detected a rectal tumor. She underwent colonography, which revealed a huge villous tumor in the rectum. Based on the result of the initial biopsy, it was classified as a group 4 tumor, but additional biopsy of specimens obtained from 6 places led to a diagnosis of group 5 tumor. Then, we performed laparoscopic super-low anterior resection and made an ileal stoma. The electrolyte imbalance was improved and did not recur after the operation. In this case, the electrolyte imbalance caused by the huge villous tumor was electrolyte depletion syndrome (EDS).

The malignant colonic polyp Review of biological, clinical parameters and treatment

We know the significance of adenomas about the risk of neoplastic transformation defined as adenoma-carcinoma sequence. Although the majority of adenomas removed are small, it is well recognized that the risk of malignant transformation increases with an increased adenoma size. The term "malignant polyp" refers to an adenoma that macroscopically appears benign, but in which there is an invasion of malignant neoplastic cells within the submucosa through the muscularis mucosae. Malignant Polyps are substantially adenocarcinomas at an early stage; it is estimated that they represent the 0.75-5.6% of all adenomas removed during endoscopic exams. The management of a malignant polyp, diagnosed after an endoscopic removal, is complicated because the presence of residual malignant cells is a possibility. Also the presence of regional lymph nodes metastasis is different in literature and related to different prognostic factors. In this review we will analyze the incidence, the most appropriate methods of diagnosis, the biological parameters that characterize the various classes of risk of malignant polyps, in order to choice a correct treatment. The goal should be the improvement of the survival rate, decreasing the likelihood of residual disease evaluating the risk of overtreatment.

KEY WORDS

Adenoma, Adenoma-carcinoma, "Malignant polyp".

[A case of a villous tumor of the rectum with electrolyte depletion syndrome]

We report a case of a villous tumor of the rectum with electrolyte depletion syndrome (EDS). A 76-year-old woman developed general fatigue, and on investigation, we found a large laterally spreading tumor of the rectum using bowel enema and colon fiber. Pathologically, the biopsy specimen was graded Group 4. We intended to perform a laparoscopy-assisted low anterior resection in the patient. However, the operation was interrupted by a short-run type of ventricular premature contraction (VPC) due to EDS-induced hypokalemia. After treating the hypokalemia, low anterior resection or laparotomy was performed. The tumor was 19 × 13 cm in size and occupied the circumference of the rectum. Histological examination revealed well differentiated tubular adenocarcinomas with tubulovillous adenoma. Pathological staging was pTis, pN0, M0, stage 0 according to the Japanese Classification of Colorectal Carcinoma (8th edition). It is now 6 months after the operation and hypokalemia has not recurred in the patient.

[Acute renal failure and chronic diarrhea: McKittrick-Wheelock syndrome]

In 1954, McKittrick and Wheelock described for the first time a syndrome presenting chronic lost of fluid and electrolytes secondary to chronic diarrhea, associated to large rectal villous adenomas. We report a case of a 75-year-old female who presented chronic diarrhea (3 to 4 depositions per day in the last year), accompanied by acute renal failure. In the rectal tact, we objective the presence of a mass of soft consistency with an irregular surface, occupying approximately two thirds of the circumference, at about 3 cm from the anal margin. It was confirmed by the colonoscopy and the patology was informed as villous adenoma, producing chronic diarrhea or McKittrick-Wheelock syndrome. We decide the surgical approach after the normalization of patient's general status and a proctectomy with coloanal anastomosis was performed. We conclude that we must think about this syndrome in aged patients with chronic diarrhea, alterations of the electrolyte balance and presence of renal failure. Surgery treatment after the replacement of water and electrolytes is the unique curative treatment. The absence of this can cause the death of these patients.

Endoscopic full-thickness resection of a lateral spreading rectal tumor after unplanned injection of dilute hyaluronic acid into the subserosal layer (with video)

A 74-year-old woman underwent colonoscopy for investigation of a liver tumor. A lateral spreading tumor of the non-granular type (LST-NG), 25 mm in diameter, was detected at the rectosigmoid junction. As magnifying image-enhanced colonoscopy suggested a tubulovillous adenoma, endoscopic mucosal resection (EMR) was chosen for removal of the LST-NG. The lesion was effectively and evenly lifted after injection of 0.4% hyaluronic acid diluted with glycerol in the ratio of 1:1. A small amount of indigo-carmine dye was also added for coloration of the plane of resection. The lesion was completely removed en bloc. Although a blue-colored layer was identified in the resection defect, a small amount of a whitish layer was detected above the blue layer. The muscle layer was clearly located on the underside of the resected polyp. A total of 14 endoclips were used to close the defect completely. The patient was successfully treated conservatively without surgery. Histology of the resected specimen showed that it contained a tubulovillous adenoma with the submucosal layer and both layers of the muscularis propria. The surgical margin was free of neoplastic change horizontally and vertically. To the best of our knowledge, this is the first case report of full-thickness resection associated with EMR after unplanned injection of dilute hyaluronic acid into the subserosal layer rather than the intended submucosal layer. We describe how to promptly recognize this complication during colonoscopy, in order to achieve immediate closure of the defect, with the identification of a "mirror target sign" on the colonic wall.

Primary intestinal-type adenoma of the vagina arising directly from endocervical-type adenosis: a case report

BACKGROUND

Tubular or villous adenomas are common neoplasms of the gastrointestinal tract. Other locations where these adenomas are found, including the female genital tract, are very rare. A literature review documents that only eight cases of tubular or villous adenomas found within the vagina have been published.

CASE

A 25-year-old, Caucasian woman presented with a history of primary infertility and postcoital bleeding. Gynecologic examination revealed a polypoid mass attached to the lateral wall of the vagina, approximately 2 cm above the introitus. The polypectomy specimen was a soft, tan, polypoid mass measuring 2 x 1 x 0.8 cm in size. Microscopically, the lesion was identical to pure tubular adenomas of the large intestine. Positive immunohistochemical staining for cytokeratin (CK) 20, CK 7, CEA and Cdx2 were identified.

CONCLUSION

An intestinal-type adenoma should be included in the differential diagnosis of a vaginal polypoid mass lesion in women. Our review of the literature presents the risk of malignant transformation.

Villous adenoma in augmentation colocystoplasty asociated to infiltrating urotelial cancer in bladder remanent

OBJECTIVE

To report a new case of villous adenoma developed in augmentation colocystoplasty.

METHODS

Characterization of a new case and review of the literature published to date.

RESULTS

We report the case of a 66 year-old man with a villous adenoma and synchronic infiltrating transitional cell carcinoma of the bladder after augmentation colocystoplasty. The latency period until the development of villous adenoma after surgery is long. Treatment consisted of transurethral resection.

CONCLUSIONS

Villous adenoma is a benign neoplasm that occurs in the colonic mucosa and shows a high ability to become a malignant colonic cancer. Only two cases of villous adenoma in augmentation colocystoplasty have been reported. We recommend follow up with periodic cystoscopy because of its high malignancy potency.

Villous adenoma of the urinary bladder: a case report

Villous adenomas of the urinary tract are rare, in contrast to urothelial neoplasms. Most reports were scattered individual cases. Only two case series of this entity have been published. The histopathology is identical to that of the much more common villous adenoma of the gastrointestinal tract. The authors reported a case of urinary bladder villous adenoma in a 41-year-old Thai patient who complained of hematuria for one day without any other symptom. Cystoscopic examination revealed a papillary growth at the bladder neck associated with marked degree of bullous edema and bilateral mild hydroureters. The clinical diagnosis was urothelial carcinoma. Transurethral resection was performed Histologic examination revealed typical features of villous adenoma. The tumor showed identical immunohistochemical profile to colonic villous adenoma. The patient has been well for more than a year after tumor removal.

Treatment of a nephrotic syndrome by endoscopic removal of a villous adenoma of the duodenum

We report the case of a patient diagnosed with a villous adenoma of the duodenum showing high degree dysplasia who developed a nephrotic syndrome (NS) due to a membranous nephropathy (MN), demonstrated by renal biopsy. Only the endoscopic resection of the duodenal adenoma could control the NS. The first manifestation of a MN is often the development of a NS. Up to 20% of patients older than 65 years who develop a MN have cancer. Tumours most often identified are those of lung, prostate and digestive tract. A renal biopsy is required to identify this type of nephropathy. If a diagnosis of MN is made, an associated tumour should be looked for.

[Experience with treatment of patients with villous adenoma of the large intestine]

The authors analyzed an experience with treatment of 176 patients. It was shown that increasing colonoscopy allowed clear differentiation of neoplasm in the colon, decision on the strategy of treatment. The effective method is endoscopic resection of intestine mucosa.

Endoscopic ampullectomy in a patient with a duodenal diverticulum. A challenging procedure

A 65 year-old male was admitted to the University hospital with obstructive jaundice. Endoscopic examination revealed a grossly abnormal major ampulla, situated at the edge of a large duodenal diverticulum. Biopsy of the ampulla was positive for villous adenoma. We describe the technique utilized to successfully perform an end-bloc endoscopic resection of a major ampulla on a diverticulum.

[Clinical application of intersphincteric resection in the anal-preserving operation for ultra-low rectal carcinoma]

OBJECTIVE

To investigate the clinical application of intersphincter resection (ISR) combined with total mesorectal excision (TME) and colon-anal anastomosis in the treatment for ultra-low rectal carcinoma.

METHODS

To review and analyze retrospectively the data of 34 patients with ultra-low rectal carcinoma (without external anal sphincter involvement) who received treatment of ISR, TME and colon-anal anastomosis.

RESULTS

Partial resection of internal sphincter was performed in the patients with a distal edge of the tumor greater than or equal to 2 cm from the dentate line. Subtotal removal of the rectum was performed between 1 cm and 2 cm. Total resection was performed in less than 1 cm or involvement of dentate line. Reconstruction of digestive tract was done by manual colon-anal anastomosis. The average distance from distal excised margin to the tumor was 2.3 (1.8 - 3.2) cm among 34 patients. The pathological types were as follows: 28 cases of adenocarcinoma (11 were well differentiated, 17 moderately differentiated), 1 case of papillary carcinoma and 5 cases of villous adenoma with malignant change. The postoperative pathological stages were: Dukes stage A in 28 cases, stage B in 1 and stage C in 5 cases. The pTNM staging was 28 cases in phase I, 1 in phase IIa, 4 in phase IIIa and 1 in phase IIIb. The T stages of the patients were as following: 16 Tl, 17 T2 and 1 T3. Postoperative anastomotic stenosis occurred in 3 cases, anastomotic dehiscence in 2 cases and rectovaginal fistula in 2 cases. The ability of controlling feces of patients decreased significantly in the early postoperative period, and restored gradually at 6 to 12 months after operation. Anastomotic recurrence occurred in 1 case at 5 months after operation and liver metastasis in 1 case at 40 months.

CONCLUSION

With strictly grasping indications, radical resection can be attained and anal sphincter preserved by ISR combined with TME and colon-anal anastomosis. It is an effective sphincter-preserving operation.

Tubulovillous adenoma in the common bile duct causing obstructive jaundice

Villous adenomas are benign epithelial lesions with a malignant potential which can occur at any site in the gastrointestinal tract, usually in the rectum and colon, less frequently in the small bowel and very rarely in the biliary tract. Villous adenomas of the extrahepatic bile ducts are exceptional and only a few cases have been reported. Common bile duct (CBD) adenomas often present in a fashion similar to their malignant counterparts, and adenocarcinoma arising from a villous adenoma of the ampullary biliary epithelium is also extremely rare. We present here a tubulovillous adenoma, arising in the common bile duct, as a cause of obstructive jaundice, and discuss the characteristics of these lesions.

Small intestinal tubulovillous adenoma--case report and literature review

Benign small intestinal tumour, though rare, have been reported. We report a case of sessile and extensive tubulovillous adenoma in a 13-year-old girl. She presented in a private hospital with three months history of abdominal pain, abdominal distension, vomiting, constipation, weight loss and anorexia. Significant findings on examination were weight loss, dehydration, and a huge smooth, not tender, mobile and indentable mass which extended from the left lumbar region to right iliac fossa. Visible peristalsis coursing from left to right was seen on the mass. Erect and supine plain abdominal x-rays revealed features of partial intestinal obstruction and abdominal ultrasound scan revealed dilated and hypertrophied bowel segment but could not say the bowel segment affected. The affected segment was found to be a 55cm portion of terminal ileum at operation which was resected due to hypertrophied proximal and collapsed distal segments, features in keeping with chronic intestinal obstruction, and ileo-ileal anastomosis done. Histology report was that of benign tubulovillous adenoma and the girl has enjoyed stable health for more than a year on close follow up in surgical outpatient clinic. This case highlights the unusual presentation and unusual gross nature of this small intestinal adenoma, which was found to be a benign adenoma on histological examination.

[Case of villous tumor of the rectum presenting with severe diarrhea and electrolyte depletion syndrome]

A 83-year-old man with a 2-year history of diarrhea was admitted hospital because of increased diarrhea and general fatigue. He had severe dehydration, hyponatremia, hypokalemia and hypochloremia. Abdominal CT showed tumor and fluid in the rectum. Colonoscopy revealed large tumor with a villous structure in the rectum. Low anterior resection was performed. The histopathological diagnosis was adenocarcinoma with villous adenoma. The immunostaining of the tumor revealed positive COX-2 expression. The diarrhea and electrolyte disturbance disappeared after the resection of tumor.

[Subtotal or total colectomy as surgical treatment of left-sided occlusive colon cancer]

INTRODUCTION

The treatment of acutely obstructed carcinoma of the left colon and sigmoid still represents a matter of controversy. The aim of this study was to assess retrospectively the results of its management by emergency subtotal or total colectomy with primary anastomosis.

MATERIALS AND RESULTS

Sixty-seven patients were reviewed. There were 42 males and 25 females. The mean age was 70.5 years (range: 26-87 years). Mean operative time was 210 minutes. There were five synchronous colon carcinomas (7.5%) and 23 (343%) synchronous tubulous and tubulo-villous adenomas. No death was noted in the series. Ten postoperative complications (15%) occurred in nine patients including one postoperative peritonitis without evidence of anastomotic leak, one alithiasic cholecystitis, one evisceration and two intra-abdominal abscesses. The mean hospital stay was 11.4 days. Fifty-eight patients were assessed at three and twelve months for functional results. No fecal incontinence was encountered. The mean number of bowel movements per 24 hours was 3.2 at three months and 2 at twelve months. All patients were satisfied with their quality of life. Twelve patients (20.7%) occasionally needed anti-diarrheic medications.

CONCLUSION

Urgent subtotal or total colectomy with primary anastomosis is a safe and efficient procedure in the management of acutely obstructed neoplasm of the left colon. It allows to treat in one stage the cancer and the obstruction, bearing no mortality, acceptable morbidity and satisfactory postoperative functional results.

[McKittrick- Wheelock syndrome: report of one case]

Villous colorectal adenomas are common tumors that normally provoke scarce symptomatology. We report a 59 year-old female that was admitted with severe dehydration due to severe diarrhea lasting 10 days and vomiting in the last 48 hours. On rectal palpation a large tumor located 5 cm above the anus was palpated. Colonoscopy confirmed the presence of a villous adenoma that was excised surgically. In this patient, the fluid and electrolyte hypersecretion of the rectal villous adenoma provoked a depletion syndrome with serious hydroelectrolytic alterations, acute renal failure and hypovolemic shock. This syndrome was first described by McKittrick and Wheelock in 1954.

Laparoscopy-assisted endoscopic mucosal resection in the colon: a preliminary report

Endocopic mucosal resection of flat villous tumours or giant polyps (> 3 cm) may give rise to local complications such as haemorrhage or perforation because of the very thin wall of the colon, above all in the right half. Our aim was to evaluate whether laparoscopy-assisted endoscopic excision of flat villous tumours or giant polyps (> 3 cm) can be safely performed, avoiding critical septic complications and can also help in the selection of patients to be submitted to colonic resection without increasing morbidity or mortality. The procedure is a new minimally invasive therapeutic approach in selected cases with large, sessile or awkwardly located polyps. Unlike other techniques such as polypectomy, endoscopic mucosal resection completely removes the affected mucosa by resecting through the middle or deeper part of the submucosa. Another purpose of the procedure is to obtain specimens for accurate pathological staging. Our experience consisted in the treatment of two patients, one of whom with a laterally spreading tumour of the transverse colon with the suck and cut cap-assisted technique, and one with a large sessile polyp of the caecum with the lift and cut technique. The patients presented no complications and no recurrence was observed during the subsequent follow-up.

Colon invasive micropapillary carcinoma arising in tubulovillous adenoma

Invasive micropapillary carcinoma (IMPC) is defined as a carcinoma composed of small clusters of tumor cells lying within clear spaces which simulate lymphovascular channels. This histologic pattern has been described in various organs, including the breast, lung, urinary bladder, ovary, stomach, pancreas, and major salivary glands. Although rarely observed as a pure histologic component, IMPC is usually mixed with conventional carcinoma, and is therefore often referred to as carcinoma with a micropapillary component. IMPCs are invariably associated with a high degree of aggressiveness, extensive lymphovascular invasion, extensive lymph node metastases, and poor prognosis. I herein describe a case of primary IMPC originating in colon polyp as a minor histologic component.

Villous adenoma of extrahepatic bile duct: contrast-enhanced sonography findings

We report a case of villous adenoma in the extrahepatic bile duct that was successfully diagnosed with contrast-enhanced sonography (CEUS) before surgical resection. On baseline sonography, the mass appeared as a homogeneously isoechoic mass filling the bile duct from the confluence of the right and left hepatic ducts to the distal common bile duct. No intralesional flow signal was found on color Doppler imaging and power Doppler imaging. On CEUS, the mass showed homogeneous enhancement during arterial phase, thus confirming the neoplastic nature of the lesion. The enhancement decreased gradually so that the mass became hypoenhanced during portal and late phases. Surgical resection was performed, and pathologic examination confirmed a villous adenoma of the bile duct epithelium with mild dysplasia.