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Lateral Spreading Tumor Arising in an Interposed Colonic Segment

Simões, Carolina MD1; Moura, Miguel MD1; Noronha Ferreira, Carlos MD1; Rosa, Rosario MD2; Freire, José Paulo MD2; Carrilho Ribeiro, Luís MD, PhD1; Tato Marinho, Rui MD, PhD1

doi: 10.14309/crj.0000000000000245
CASE REPORT
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ABSTRACT A 57-year-old woman developed dysphagia 30 years after esophagectomy with partial gastrectomy and colonic interposition due to severe and extensive caustic esophageal stricture. Upper gastrointestinal endoscopy showed a lateral spreading tumor in the colonic tube with a granular surface measuring 40 mm in diameter. The lesion was removed by piecemeal endoscopic mucosal resection. Histology revealed tubular adenoma with low/high-grade dysplasia. Although colonic interposition replacement is a relatively common procedure, especially in the past, the development of adenoma or adenocarcinoma as a late complication is very rare.

1Department of Gastroenterology and Hepatology, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal

2Department of General Surgery, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, Lisboa, Portugal

Correspondence: Carolina Simões, MD, Department of Gastroenterology and Hepatology, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal (carolinabaptistasimoes@gmail.com).

Received April 26, 2019

Accepted September 11, 2019

Online date: October 21, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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INTRODUCTION

For many years, the use of a segment of the colon as a substitute for the esophagus was the procedure of choice for esophageal replacement.1–3 The development of an adenomatous polyp or an adenocarcinoma in the colonic tube is a rare long-term complication. We present a woman with tubular adenoma with low-grade and high-grade dysplasia arising in the interposed colon 30 years after subtotal esophagectomy and partial gastrectomy due to extensive and severe strictures after accidental caustic ingestion.

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CASE REPORT

A 57-year-old woman developed dysphagia for soft food. She had undergone esophagectomy with partial gastrectomy and colonic interposition 30 years ago because of severe and extensive esophageal strictures caused by accidental ingestion of sulphuric acid. Endoscopic dilatation of postoperative esophagogastric anastomotic stricture had been required in the past. Comorbidity includes pulmonary emphysema secondary to smoking (30 packs a year). She had no history of alcohol intake and no personal or family history of colorectal cancer.

The patient underwent an upper endoscopy, which showed a laterally spreading tumor in the middle third of the colonic tube with granular surface (Paris 0-IIa, laterally spreading tumor–granular, NBI International Colorectal Endoscopic 2) and a maximal diameter of 40 mm (Figures 1 and 2). The lesion was removed by piecemeal endoscopic mucosal resection. Four through-the-scope clips were applied to close the endoscopic mucosal resection scar. Histology revealed a tubular adenoma with low-grade and high-grade dysplasia. After the procedure, the patient presented with fever and chest pain and laboratory results showed an increase in inflammatory parameters. Thoracic computed tomography showed thickening of the wall of the colonic tube with some air bubbles. She was started on broad-spectrum empiric antibiotics with clinical improvement and hospital discharge 7 days later. Fifteen days later, the thoracic computed tomography was performed with resolution of the alterations described. The patient is waiting for follow-up upper endoscopy to ensure complete resection.

Figure 1

Figure 1

Figure 2

Figure 2

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DISCUSSION

Colonic interposition for esophageal reconstruction was first reported in 1911 and, for many years, it was the procedure of choice for esophageal reconstruction.1,2 Currently, colonic interposition is performed when gastric pull-up is not technically feasible. This procedure is associated with serious early and late complications, such as anastomotic dehiscence and fistula formation, necrosis of the anastomotic site, fibrosis, and strictures (22%).2,3 Development of a malignant neoplasm in the colonic graft is extremely rare, with 24 reported cases in the literature: 4 adenomatous polyps and 20 adenocarcinomas.4–15

The pathogenesis for development of malignancy is not yet fully understood. Reflux disease, positive family history for colorectal carcinoma, colitis, and a history of colonic polyps are associated with greater risk.1,5,6 Therefore, before colon interposition, colonic diseases such as extensive polyposis, malignancy, diverticulosis, or inflammatory bowel disease need to be excluded because these are contraindications for the procedure.1–3

Currently, there are no screening protocol or guidelines for these patients. Some studies recommend the upper endoscopic screening within 1 year of colonic interposition and periodic surveillance at every 2–5 years.1–3

Although colonic interposition replacement is a relatively common procedure, especially in the past, the development of adenoma or adenocarcinoma as a late complication is very rare. This is particularly significant for patients with benign esophageal diseases with long-term survival. We recommend upper endoscopic screening in all patients with colonic interposition because lesions may be detected early and removed safely by endoscopy.

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DISCLOSURES

Author contributions: C. Simões, M. Moura, and C. Noronha Ferreira wrote the manuscript. R. Rosa, JP Freire, L. Carrilho Ribeiro, and R. Tato Marinho revised the manuscript. C. Simões is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

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REFERENCES

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© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.