Right side fixation of sigmoid colon with a hepato-sigmoidocolic fistula in patient with hepatocellular carcinoma and midgut malrotation
The case was a 71-year-old male with a history of alcoholic liver cirrhosis. After being diagnosed with hepatocellular carcinoma 6 years ago, he was treated with transarterial chemoembolization (TACE) 7 times at other hospital. He visited our emergency room with lower GI bleeding. At the time of admission, the level of hemoglobin (Hb) was 7.5 g/dL, aspartate aminotransferase/alanine aminotransferase 27.8/13.8 U/L, alkaline phosphatase 41 U/L, albumin 2.8 g/dL, a-fetoprotein 26 ng/mL, and bilirubin 1.6 mg/dL. After he stabilized with transfusion of packed red blood cell (PRC), emergency colonoscopy was performed. A solitary diverticular-like lesion or ulceration with a brownish base in the sigmoid colon, 25 cm from the anal verge, was detected on colonoscopy, but the evidence of active bleeding was not shown (). Endoscopic clips were applied at the lesionto prevent recurrent bleeding. After bleeding was controlled, an abdominopelvic computerized scan was checked for evaluation of liver mass and other abnormalities (). The symptom improved and he was discharged 3 days later with plans to follow up using colonoscopy 2 months after. However, lower GI bleeding recurred after 7 weeks and the patient was admitted again. At the time of admission, Hb was 7.8 g/dL and PRC transfusion was given to stabilize the patient. The patient was diagnosed with recurrent sigmoid diverticular bleeding and was scheduled for laparoscopic segmental resection of the involved lesion of sigmoid colon. His preoperative Child-Pugh classification was grade A with serum albumin 3.3 g/dL, serum bilirubin 0.94 mg/dL, prothrombin time 12.3 seconds, no ascites, and no encephalopathy. The operation showed that the sigmoid colon was absent in the left lower abdomen, and it was not connected to the left peritoneum. The upper rectum was attached to the peritoneum of the right pelvis and extended to the upper right area, and thus the entire sigmoid mesocolon was fixed to the right parietal peritoneum and continued to the lower margin of the liver. Besides this, the cecum and the appendix were located in the central area of the abdominal cavity with no fixation and floated freely in the cavity. The finding was consistent with midgut malrotation ().\nUnder laparoscopic operative condition, the operator had to move the position from the right side to the left side of the patient, and the right side fixation of the sigmoid colon was dissected. Laparoscopic surgery was limited due to serious adhesion of proximal sigmoid colon to the liver and thus converted to laparotomy with upper midline incision. The upper fixation area of the sigmoid colon could be mobilized with concomitant en bloc nonanatomical excision of the liver (segment 6) containing hepatocellular carcinoma. After complete mobilization of the sigmoid colon with a part of the liver, segmental resection of the sigmoid colon was performed with about 10 cm resection margins proximally and distally, respectively. After surgery, the patient was treated for ascites and hydrothorax for about 20 days, which were free of malignant cells, and recovered without additional complications. Gross findings of the specimen showed a perforation hole between the sigmoid colon and liver, and hepatocellular carcinoma tissue. The microscopic findings revealed a 4.5 cm × 5 cm sized metastatic hepatocellular carcinoma invading the sigmoid colon. The central part of the tumor presented with necrosis with the peripheral part constituting intact cancer cells, suggesting marginal recurrence at the previous tumor site after TACE ().