Toxic megacolon (TM) is a severe condition characterized by acute colonic dilation, with specific radiological and clinical signs. The multifactorial etiology of TM is primarily associated with inflammatory bowel disease and infections. However, TM remains a challenging complication due to its potential for rapid progression to life-threatening conditions. This report describes a rare case of TM in a 25-year-old male with a history of recurrent constipation and chronic cocaine consumption. Examination and imaging indicated acute intestinal obstruction with dilated colon segments and fecal impaction, necessitating an urgent laparotomy. Surgery revealed pan-colonic dilatation and sigmoid perforations, leading to a total colectomy and ileostomy. Chronic constipation, often perceived as benign, can escalate into a critical situation, possibly exacerbated by cocaine-induced muscle weakness and hypoxia. Evidence suggests that cocaine negatively affects the intestinal mucosa, potentially leading to ischemia. Chronic factors, including the use of enemas, may have contributed to megacolon development and perforation. Overall, this report underscores the critical elements of diagnosis and the importance of patients\' medical history, particularly those with unusual risk profiles. In addition, it highlights the need for further research to fully understand the implications of these cases.

BACKGROUND: Urgent abdominal colectomy is indicated for patients with fulminant Clostridioides difficile infection (CDI) when other medical therapies fail, yet mortality remains high. Fecal microbiota transplant is a less invasive alternative approach for patients with fulminant CDI. We report the 30-day complications of patients with fulminant CDI who underwent either abdominal colectomy, fecal microbiota transplantation (FMT), or FMT followed by abdominal colectomy (FMT-CO). Methods: We performed a single-center, retrospective case review of combined medical and surgical patients with CDI at a large academic medical center between 2008 and 2016. Cohorts were identified as patients with fulminant CDI who underwent total abdominal colectomy alone (CO), FMT alone (FMT), or FMT-CO. We analyzed patient demographics, history, comorbidities, clinical and laboratory variables, CDI severity scores, and mortality outcomes at 30 days. Results: We identified 5,150 patients with CDI at our center during the review period; 16 patients met the criteria for fulminant CDI and were included in this study, with four patients in the CO cohort, eight patients in the FMT cohort, and four patients in the FMT-CO cohort. Demographics and CDI severity scores were similar for all three groups, although the selected comorbidity profiles differed significantly among the three cohorts. The 30-day mortality rates for patients in the CO, FMT, and FMT-CO groups were 25%, 12.5%, and 25%, respectively. Conclusions: FMT is an alternative or adjunctive therapy to colectomy for patients with fulminant CDI that is not associated with increased mortality. Implementation of FMT protocols in clinical practice would be dependent on the availability of qualified transplant material and successful early identification of patients likely to benefit from FMT.

Atezolizumab is a programmed death-ligand 1 (PD-L1) targeted antibody that prevents the binding of PD-L1 to specific T-cell receptors, thereby increasing anticancer immunity. It has been regarded as a useful first-line treatment in patients with small-cell lung cancer with a more tolerable side effect profile than chemotherapeutic agents. However, few studies focusing on the severity of adverse effects from immune checkpoint inhibitors (ICPI) have been previously reported, particularly acute fulminant colitis requiring surgical invention. We report a case of fulminant colitis refractory to high dose corticosteroid treatment in a patient with known ulcerative colitis (UC) undergoing treatment for small-cell lung cancer (SCLC) with atezolizumab. The upregulation of PD-L1 expression in patients with ulcerative colitis may play a significant role in an imbalanced T-helper cell response creating a pro-inflammatory state. The use of ICPIs to treat SCLC has been reported to increase the risk of developing inflammatory colitis. Atezolizumab use in a patient with known inflammatory bowel disease (IBD) may predispose this population to a higher risk of developing severe inflammatory colitis. We present an unusual complication associated with medical intervention in an immunocompromised patient without an established pathophysiology. The suspicion of using ICPIs in patients with IBD as a potential cause for the development of fulminant colitis is relevant and essential in the diagnostic workup for this patient population complaining of significant gastrointestinal symptoms.

UNASSIGNED: Ehlers Danlos syndromes (EDS) are a group of genetic disorders, characterized by skin hyperelasticity, joint hyperlaxity and tissue weakness. Vascular EDS is rare and is differs from other types of EDS by an inconsistent acrogenic morphotype and the occurrence of severe digestive and vascular complications, which can be lifethreatening.
UNASSIGNED: We report the case of a 27-year-old man with a type IV vascular Ehlers-Danlos syndrome revealed by a colonic perforation after appendectomy for peritonitis secondary to appendicitis. The etiology of the perforation remained a challenge till a genetic research was carried out for COL3A1 gene mutation, which was positive in favor of vascular Ehlers Danlos disease. Then, a totalization of the colectomy with ileorectal anastomosis was performed.
UNASSIGNED: Vascular Ehlers Danlos syndrome (VEDS) is due to qualitative and quantitative abnormalities in the synthesis of type III collagen, which is a major constituent of the vessel wall, skin, joint capsules, uterus and gastrointestinal tract, particularly the colon. Colonic perforation, particularly sigmoidal perforation, is the most frequent complication in SEDV and most often precedes the molecular diagnosis. Colonic perforations are uncommon. The Hartmann procedure is a well-established surgical treatment modality, especially for emergency surgery. Given the iterative risk of colonic perforation and anastomotic leakage, preventive treatment by total colectomy with ileo-rectal anastomosis or definitive ileostomy is recommended by several authors.
UNASSIGNED: SEDV is a rare pathology with a difficult diagnosis. However, it should be keeped in mind when there is any spontaneous colonic perforation in the young people.

Chyle leak is a rare complication in colorectal surgery. It occurs due to disruption of the lymphatic drainage network in the abdomen or retroperitoneum. We describe the first reported case of chyle leak following total colectomy for inflammatory bowel disease. Our patient underwent total colectomy for severe ulcerative colitis not responsive to medical treatment. Four days postoperatively, a milky fluid was noted in the drainage bag. Analysis of the fluid confirmed chyle. The patient remained well and was successfully managed conservatively with a fat-free elemental diet and was discharged from hospital on day 12 postoperatively. A review of the literature suggests that conservative management with dietary modification is a common and effective management strategy; however, medical and surgical options exist for refractory cases.

BACKGROUND: Chronic idiopathic colonic pseudo-obstruction (CICP) is a rare disease, defined as a condition of the chronically damaged colon, without obstruction or stenosis, and a pathological abnormality in the myenteric plexus. To date, there is no effective medication for CICP, and existing medication is not useful, making surgery the only effective treatment. Laparoscopic surgery is useful for reducing surgical trauma and postoperative adhesion. Herein, we report a patient with recurrent laxative-uncontrolled bowel obstruction, who underwent successful treatment with laparoscopic total colectomy based on preoperative detailed evaluation of bowel function.
METHODS: A 77-year-old female patient without any past abdominal or psychological medical history was referred to our hospital because of chronic constipation and abdominal pain. Contrast-enhanced computed tomography, barium enema, cine magnetic resonance imaging, and defecography indicated an enlarged colon from the cecum to the transverse colon (proximal to the splenic flexure) without apparent mechanical obstruction, and a collapsed colon from the descending colon to the rectum, with reduced peristalsis. Bowel movements of the rectum and anorectal function were normal. Based on these findings, we diagnosed CICP and performed laparoscopic total colectomy and ileo-rectal anastomosis in this case. Postoperative recovery was good, without the need for postoperative laxatives. Pathologically, no degeneration of the muscle layers or Auerbach\'s plexus was found in the resected specimen.
CONCLUSIONS: Surgery is the only effective treatment for patients with CICP. Careful imaging before surgery is important for detecting the extent of excision required. This will reduce the need for additional surgery due to symptom relapse in the remnant colon. However, continued observation of the patient is required.

UNASSIGNED: Single-incision laparoscopic surgery (SILS) has benefits, including less postoperative pain, a shorter incision, and improved cosmesis. However, SILS is technically difficult because of the limited movement. An organ retractor is an instrument that has the potential to overcome these limitations.
UNASSIGNED: An 85-year-old woman with hematochezia was referred to our hospital. Emergency endoscopy showed diverticulosis of the entire colon and active bleeding from the ascending colon. Despite endoscopic clipping, the bleeding continued. SILS total colectomy using an organ retractor was performed due to uncontrollable diverticular bleeding. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted into the single umbilical incision. An organ retractor was used for hepatocolic ligament transection, transection of the ileocolic vessels, and transection of the mesentery of the sigmoid colon. For each transection, the tension was adjusted to provide a good operative view. The patient\'s postoperative course was uneventful.
UNASSIGNED: An organ retractor was effective for SILS total colectomy to maintain an adequate operative view, which enabled safe dissection.

BACKGROUND: An intro-abdominal hernia through the lesser omentum is a rare but severe condition that can cause intestinal obstruction and other life-threating complications. Until now, only a handful of cases have been reported worldwide. The diagnosis of lesser omental hernia remains challenging for emergency surgeons because of the unspecific symptoms. Therefore, there is a need for a better understanding of the characteristics of this condition.
METHODS: In this report, we described the case of a 73-year-old female patient who was diagnosed with a lesser omental hernia caused by previous total colectomy. The patient underwent emergency surgery, and the intraoperative findings revealed a 200-cm segment of the small intestine was herniated through a defected lesser omentum (approximately 3 × 4 cm) from the lesser retrogastric curvature of the stomach. Besides, we summarize the specific abdominal computed tomography (CT) findings of lesser omental hernia by reviewing the literature.
CONCLUSIONS: The lesser omental hernia is extremely rare but can cause serious complications. The cause of lesser omental hernia can be congenital or acquired. Careful examination of the small omentum before the closure of the abdomen is expected to reduce the occurrence of these abdominal surgery-associated complications. The specific features of abdominal CT in cases of lesser omental hernia, which are summarized in this article, can help other clinicians to obtain accurate diagnoses of lesser omentum hernia in the future.

BACKGROUND: Diversion colitis (DC) is characterized by nonspecific inflammation in the remaining colon or rectum, and loss of the fecal stream plays a major role in the disease\'s development. Although the majority of patients are asymptomatic, medical and/or surgical treatment is required for those who are symptomatic. There is a particular interest on how to manage patients with acute and severe clinical presentations, but the pathogenesis is not fully understood. We report the rare case of a man with acute and severe DC mimicking ulcerative colitis (UC) with extra-intestinal manifestations that was successfully managed with surgical treatment.
METHODS: A 68-year-old man with a history of laparoscopic intersphincteric resection of the rectum with diverting loop ileostomy for lower rectal cancer suffered from anastomotic stenosis requiring repeated endoscopic dilatation. His loop stoma was not reversed because these treatments were unsuccessful. He denied having a history of inflammatory bowel disease. Twelve years postoperatively, he developed a perineal abscess requiring drainage. Subsequently, he developed a high-grade fever, bloody discharge per anus, and skin ulcers in the right ankle and around the stoma. Because culture tests were negative for bacteria, it was deemed that his acute illness reflected an inflammatory response rather than an infectious disease. Colonoscopy revealed anastomotic stenosis, a colonic fistula, and mucosa that hemorrhaged easily, with lacerations. A pathological examination with biopsy revealed inflammatory infiltration without malignancy. After reviewing the patient\'s clinical episodes and discussing the case with physicians in multiple specialties, we performed total colectomy with end ileostomy in accordance with the abdominoperineal resection. The postoperative course was uneventful. A resected specimen showed atrophic mucosa with the disappearance of haustra in the distal colon, as well as edematous and dilated mucosa in the proximal colon. The pathological diagnosis was suggestive of UC, including erosion and ulceration in edematous wall, crypt abscess, and inflammatory infiltration into the mucosa. The skin ulcers in the right ankle and around the stoma healed over time.
CONCLUSIONS: DC can eventuate in a long-term period after fecal diversion surgery, possibly with extra-intestinal manifestations mimicking UC. Surgical treatment seems feasible for patients with acute and severe DC.

BACKGROUND: Intestinal neuronal dysplasia type B (IND-B) is an infrequent disease of the submucosal plexus of intestine manifesting chronic intestinal obstruction or severe chronic constipation. IND is rarely reported in adult patients.
METHODS: The present study reports on the case of a 36 year-old woman suffering from longstanding chronic constipation and who was diagnosed with severe constipation in more than 20 years. Although she began to take a large amount of stimulant laxatives, such as \"senna\" and \"bisacodyl\", constipation symptoms did not improve, she was admitted to our hospital. It was diagnosed with refractory constipation of the medication treatment-resistance, total colectomy with ileorectal anastomosis by single incision laparoscopic surgery (SILS) was performed. The final pathological diagnosis was IND-B.
CONCLUSIONS: Refractory constipation after medical treatment is often seen in young generation. SILS has benefits of better cosmesis, reduced morbidity, reduced postoperative pain, and reduced length of hospital stay.
CONCLUSIONS: For the patients with refractory constipation associated with neuropathy such as IND, total colectomy by SILS was very effective.