Tubular sigmoid duplication in an adult man: an interesting incidental finding

A 61-year-old man attended an outpatient colorectal clinic for a chronic, non-specific abdominal pain, associated with rectal bleeding. He underwent a number of investigations including a CT pneumocolon, which revealed an incidental finding of 20 cm of additional sigmoid colon. This case is interesting because tubular sigmoid duplication is an extremely unusual condition, rarely diagnosed in adults; only a few cases have been reported of this condition in the adult population. Our team chose to treat this patient conservatively, in order to avoid putting the patient at risk of an unnecessary surgery.

Primary sigmoidectomy and appendicostomy for chronic idiopathic constipation

PURPOSE

To present our experience in patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence who underwent a primary sigmoidectomy and appendicostomy.

METHODS

We reviewed eight patients referred to the Colorectal Center from 2014 to 2016 with chronic idiopathic constipation and undergoing a sigmoidectomy and appendicostomy. We analyzed the previous medical treatment, indications for the surgical procedure, and outcomes.

RESULTS

Age at operation was 5-19 years. Time with constipation was 4-15 years. All patients received multiple laxatives, mainly polyethylene glycol, and all had severe social problems. Four patients have autism. The indication for surgery was an unsuccessful laxative trial, refusal to continue with rectal enemas or both, and social fear of continued fecal incontinence. Post-operatively, all patients were having daily bowel movements without fecal accidents.

CONCLUSION

Selected patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence can obtain great benefit from primary sigmoidectomy and appendicostomy.

Wandering spleen, gastric and pancreatic volvulus and right-sided descending and sigmoid colon

Wandering spleen is a rare condition, characterized by a mobile spleen that is attached only by an elongated vascular pedicle, allowing it to migrate to any part of the abdomen or pelvis. Mesenteroaxial gastric volvulus usually occurs in children and may be associated with wandering spleen. Both entities result from abnormal laxity or absence of the peritoneal attachments due to abnormal fusion of the peritoneal mesenteries. Pancreatic volvulus is a very rare anomaly, with only a few isolated case reports described in association with wandering spleen. Anomalous right sided descending and sigmoid colon is a very rare entity and its association with wandering spleen has not been previously reported. We report a case of wandering spleen associated with mesenteroaxial gastric volvulus, pancreatic volvulus and rightward shift of the splenic flexure of the colon and right sided descending and sigmoid colon in a young female.

[Peculiarities of a large bowel microstructure in children, suffering chronic constipation, caused by its inborn anomaly]

Layer-by-layer electron microscopy investigation of the large bowel microstructure in children, suffering chronic constipation (CHC), caused by inborn anomaly (dolichosigma), was conducted. There were investigated 20 intraoperative specimens of the sigmoid colon intestine. Essential changes in all layers of the large bowel were noted. For example, in CHC in decompensated stage there were characteristic features: changes in mucosal epithelium, inhibition of the goblet cells secretion activity, oedema of lamina propria and submucosal layer, the filamental structures disorders. The gut layers trophic function was disordered by the blood vessels and the hemocapillars wall damage. Destructive changes in the smooth myocytes in muscular layer reflects disorder of the organ contractile function. Destructive changes in the large bowel structure are accompanied by the lymph nodes hyperemia, diffuse leukocytic infiltration, witnessing reaction of lymphoid tissue on pathological changes in the organ. Peculiarities of the CHC clinical course, the dolichosigma staging in children were caused by morphological changes of the large bowel wall. The revealed structural reorganization of the gut wall may be considered as a "critical cusative agents", in which propulsive function of sigmoid colonic intestine is inhibited significantly and do not provide an adequate passage of a large bowel contents.

[Hepatodiaphragmal interposition of the right sigmoid segment--Chilaiditi's syndrome]

Two patients (man and woman aged 28 and 82 years respectively) are reported with accidentally diagnosed Chilaiditi's syndrome and sign (abnormality without clinical manifestation). Pathogenesis of both the syndrome and the sign appears complicated and ambiguous. The abnormality was recognized when the patients visited the clinic for planned medical examination. The patient with Chilaiditi's syndrome periodically complained of abdominal discomfort. His physical examination revealed the "lack" of hepatic dullness and the presence of very loud peristaltic sounds heard through a phonendoscope in the hepatic region. The elderly woman presented without abdominal symptoms. Intestinal interposition was associated with the upper position of the diaphragmatic cupola. Chilaiditi's syndrome requires treatment in case of serious clinical manifestations or symptoms of acute abdomen. This abnormality should be considered if invasive intervention being planned may be fraught with a risk of gut injury. The outcome of surgical correction is as a rule fairly good.

[Sigmoid colon duplication: an adult case report.]

Colonic duplication is a very uncommon congenital malformation. Most cases are detected during childhood and may occur with other systemic malformations. Since 1950, less than 90 cases of colonic duplication have been reported. In this study, we report the case of a 33-year-old female who was referred to our coloproctology service for evaluation. Since 16 years ago, she has noticed an intermittent left side painless abdominal mass that sometimes spontaneously disappears. In the last months, she reported that the frequency of this complaint has been more frequent. A barium enema X ray study revealed a significant dilation of the descendent and sigmoid colon. An exploratory laparotomy was performed and sigmoid colon duplication was found. The abnormal segment was removed and an end-to-end anastomosis was performed. There were no complications in the postoperative period and she was discharged at day 7. This case describes the difficulties in detecting this rare malformation that should be considered as part of the differential diagnosis of abdominal masses in adult patients.

Sigmoid colon duplication cysts

Enteric duplication cysts are uncommon congenital anomalies that can occur anywhere along the length of the alimentary tract or nearby organs. Overall, the colon is the least common site of congenital alimentary duplications. Colonic duplication cysts can present with symptoms of diverticulitis and can be confused with acquired giant sigmoid diverticula. We present a case of a sigmoid colon duplication cyst presenting as persistent diverticulitis in an adult male. We review the literature and attempt to differentiate congenital colonic duplication cysts from the more common, acquired giant colonic diverticula.

Anatomy of the sigmoid colon, rectum, and the rectovaginal pouch in women with enterocele and anterior rectal wall procidentia

This study describes the anatomy of the rectovaginal pouch, the sigmoid colon, and rectum in women with posterior enterocele and anterior rectal wall procidentia. The anatomy of rectovaginal pouch, sigmoid colon, and rectum was described in 36 women with an enterocele (group A) and compared with those of 43 women (group B) without pelvic organ prolapse. Women with previous incontinence or prolapse surgery were excluded. The mean age in group A was 58 years (40-75) and in group B 35 years (19-64; P < 0.001). There were 15 nulliparas in group B. Nine women in group A had an internal anterior rectal wall procidentia, and one woman had an external anterior rectal wall procidentia. In group A, the rectovaginal pouch was significantly deeper, the sigmoid mesocolon at S1 shorter and showed more often a straight course (P < 0.05). These characteristics (termed "grande fosse pelvienne") were present in 23 women (64%) in group A and in 6 (14%) in group B, three of the latter were young nulliparas (P < 0.001). Age, parity, menopausal status, body mass index, constipation, and varicose veins were not associated with a grande fosse pelvienne. The typical anatomy in women with an enterocele and anterior rectal wall procidentia was a sigmoid colon with a straight course and a short mesentery at S1 and a rectovaginal pouch that covered more than half of the vaginal length. It may be a congenital condition and important in the development of an enterocele and rectal wall procidentia.

Congenital segmental dilatation of colon with colonic atresia

Congenital segmental dilatation of the colon belongs to a group of Hirschsprung's-like diseases with normal ganglion cells. The presentation is with chronic constipation affecting older children. We report a neonate with congenital segmental dilatation of the colon associated with sigmoid atresia. The child is well after a colostomy.

Laparoscopic Resection of Duplicated Sigmoid Colon Under the Guidance of Intraoperative Colonoscopy

Colonic duplications are rare congenital malformations. Complete surgical removal is the treatment of choice. The authors report a case of sigmoid colonic duplication successfully treated by laparoscopic resection under the guidance of intraoperative colonoscopy.

Double Atresia of the Hindgut with Ileal Stenosis: A Case Report

An unusual case of imperforate anus with sigmoid colonic atresia and ileal stenosis is described. Only six cases of imperforate anus associated with colonic atresia have previously been reported in Japan. The possibility of other alimentary obstructions should thus be considered when anorectal anomalies are observed.

Urachal-sigmoid fistula in an adult male without urachal cyst

Urachal anomalies are uncommon defects arising either by incomplete obliteration of the urachus during the foetal period or by its reopening after postnatal regression. Five anomalies have been described: congenital patent urachus, urachal cyst, umbilical-urachal sinus, vesico-urachal diverticulum, and alternating sinus. Only congenital patent urachus is present at childbirth. The other forms are usually acquired disorders. Nevertheless, they commonly appear in children, being less common in the adult. Colic-urachal fistulas are quite uncommon findings. Only three cases have been reported thus far. The aim of this study is to report the fourth case of sigmoid-urachal fistula, and the first one appearing without an urachal cyst.

[Recurrent adhesive ileus after surgical treatment of ovarian teratoma, malposition of an intrauterine device and dolichosigmoid--case report] ]

A 30-year-old woman was operated for ovarian teratoma and repeatedly for adhesive ileus during 1995-1999. A partial left ovarectomy, extirpation of an intrauterine device (IUD) in malposition (greater omentum) and appendectomy were performed during the first operation. Early adhesive ileus developed on the fourth postoperative day. Adhesectomy was performed in the region of the terminal jejunum. A new adhesive ileus developed after twenty seven months when patient underwent laparoscopy for gynaecological problems with conversion to laparotomy because of greater adhesions intraperitoneally another adhesectomy was performed. During the next eleven months new adhesive obstructions of the bowel developed and a third operation had to be performed incl. resection of the dolichosigmoideum on account of chronic problems during defaecation. A special tube as a intraluminal splint was inserted as prophylaxis of mechanical ileus in the postoperative period. But during next thirteen months subileous conditions and mechanical ileus developed again (up to now). The picture of intraperitoneal conditions was disastrous: almost total fibrotic changes allowed only partial adhesectomy. The passage through bowel is limited and is restricted to dietetic and medicamentous preparations. This case-report demonstrates postoperative adhesions a very old and very serious problem at the beginning of the third millennium.

Neonatal perforation of a Y-shaped sigmoid duplication

Tubular colonic duplications are exceedingly rare; the "Y"-shaped forms are exceptional. In the absence of associated low vertebral or urogenital malformations (often fistulas), the tubular colonic malformations frequently stay hidden for several years until a complication develops. The authors report a case of a spontaneous perforation of a Y-shaped tubular colonic duplication during the neonatal period.

Delayed presentation of a congenital recto-vaginal fistula associated with a recto-sigmoid tubular duplication and spinal cord and vertebral anomalies

Tubular duplication of the recto-sigmoid colon is a rare entity. Associated anomalies including fistulae to the genitourinary tract may be found. A baby girl was found to have duplication of the recto-sigmoid colon, anomalies of sacral vertebra from S1 to S5, and solitary right kidney. The septum of this duplication was divided using staplers. Because of a history of stool coming from the vagina, a meticulous examination perioperatively was performed, but no fistula could be found. Further extensive investigation failed to show any fistula. At the age of 10 she was operated on for a tethered cord. At age 14, she experienced passage of a small amount of liquid stool per vaginum. A recto-vaginal fistula was found. Via a posterior sagittal incision, the fistula was closed by a transrectal approach. She remained asymptomatic for 16 months until the fistula recurred. Using a perineal approach, a very short fistula between the vagina and the rectum was closed. The closure was reinforced by a vaginal flap. Four months later, she remains without signs of recurrence.

Imperforate anus (anal agenesis) with rectal and sigmoid atresias in a newborn

A male baby was born to a healthy mother after an uncomplicated 39-week pregnancy. He had finger and toe syndactyly, right hemidiaphragm eventration, and a high imperforate anus (anal agenesis). The kidneys and chromosomes were normal. A right transverse colostomy was done and 5 months later he underwent a posterior sagittal anorectoplasty (Pena procedure). An intermediate imperforate anus with no urethral fistula and a rectal atresia 2 cm proximal to the distal rectal pouch were found; the distal rectal pouch was resected and the standard Pena procedure completed. Dilatations were initiated 2 weeks postoperatively and continued until the colostomy was closed. Prior to closure of the colostomy, a distal colon loopogram demonstrated an obstruction in the sigmoid; constrast introduced via the rectum outlined the same obstruction separated by 2 cm. A low sigmoid atresia was then repaired. Three weeks later, a contrast loopogram showed a narrow but intact rectosigmoid anastomois, and the colostomy was closed. The anorectal dilatations were discontinued and he remains well at 7 years of age.

[A case of a right-sided sigmoid colon]

During dissecting practice by students at Chiba University in 1991, a rare anomaly was found in a cadaver of a 50-year-old Japanese male. The distal part of the colon, including the sigmoid colon, was excessively long and formed a loop behind the ascending colon. This anomalous colon consisted of four parts. The first part began in the left iliac fossa and passed across the lower posterior abdominal wall into the right iliac fossa; the second turned upward and ascended along the posterior surface of the ascending colon to the inferior surface of the right lobe of the liver; the third turned backward and descended to the right iliac fossa and was in contact with the posterior abdominal wall; the fourth curved medially and downward and ended in the rectum at the median line. Only the anterior surface of the anomalous colon was covered with the peritoneum, and its mesocolon was not found. The inferior mesenteric artery gave off four branches toward the distal three-fourths of the excessively long colon and the superior rectal artery to the upper part of the rectum. Since it did not directly give off any branches toward the descending colon and the first part of the anomalous colon (these portions were supplied by a marginal artery), the branch supplying the second part was considered to be equivalent to the left colic artery. Thus, the proximal half of the long colon (parts 1 and 2) can be regarded as a part of the descending colon, and the distal half as the sigmoid colon.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of congenital colonic stenosis presenting as rectal prolapse

A case of colonic stenosis at the rectosigmoid junction in a 4-month-old girl presented as prolapsed rectum and was diagnosed with the help of a plain x-ray and a barium enema. The clinical presentation and surgical management are detailed.

Neuronal dysplasia. Considerations for the pathogenesis and treatment of primary chronic constipation in adults

Intestinal muscle and the autonomic nervous system constitute a neuromuscular unit. A clinical study was undertaken to seek neurogenic causes of impaired motility affecting the rectosigmoid junction and rectum. Patients with primary chronic constipation were shown by enzyme-histochemical examination of biopsies to have neuronal colonic dysplasia of the rectosigmoid, whereas the latter was normally innervated in healthy controls. The present investigations provide a fresh insight, underpinned by histological findings, into the aetiology of chronic constipation and make a contribution to its operative treatment.

[Sigmoid duplication in an adult]

Duplications of digestive tract are usually observed in new-born. In most of the case they are located on the small bowel. We observed, in a 69-year old man which complained of abdominal distension and constipation a sigmoid duplication. A colectomy was performed. Carcinoma arising in such duplication have been reported.

[Pneumatosis cystoides intestinalis in dolicho-sigmoid colon with functional signs]

We present a patient with dolicho sigmoid colon who as admitted with severe functional signs and symptoms. Sigmoid colectomy was performed because of additional radiologic and endoscopic findings revealing an atypical, circumscribed massive polyposis. On histological examination typical pneumatosis cystoides intestinalis was found. This case of pneumatosis cystoides reveals the difficulties in diagnosing this disease, mechanically induced mucosul lesions caused by impaired motility are discussed as a possible etiology in this case.

[Anatomical and clinical features of a case of gall-bladder abnormality. Results of arteriographic and micro-angiographic studies (author's transl)]

The authors describe a perplexing clinical picture in which an important factor for diagnosing the lesion in the gall-bladder was hyperselective arteriography of the coeliac trunk, and more especially the hepatic artery. The association of a truc septum in the gall-bladder, without gall-stones, and of another digestive tube lesion, megadolicho-sigmoid and diverticulosis of the sigmoid, would appear to be an extremely rare entity, and this has been the cause of the pain reported by the patient over many years. The cholecystectomy performed appears to be the right choice, and the most effective therapeutic procedure.

[Late results of operations for megadolichosigmoid in the "cold" period of the disease]

During the last 30 years the author has been performing comprehensive clinical observations of numerous patients with megadolichosigmoids. Among them 180 patients were operated for extreme pathological forms of megadolichosigmoids without a single lethal outcome. The analysis of remote results of the treatment of 173 patients is presented. The period of observation was from 3 to 25 years. The author believes that the operative method of choice in megadolichosigmoids is a one-step subtotal mesosigmoresection. It saves the patients from chronic ileus and is a reliable prophylaxis of acute volvulus of the sigmoid.