A Proximal Ascending Colon Lesion of a Crohn Disease Patient

Arthur M. Barrie, MD, PhD


August 13, 2015

Clinical Course

Upon diagnosis of NP-CRN, the patient was referred to a colorectal surgeon for consideration of elective colon resection, as the lesion was deemed to be too large to completely and safely resect endoscopically. The surgeon and the patient discussed three resection options: right hemicolectomy, total proctocolectomy with end ileostomy, and total colectomy with ileorectal anastomosis.

Right hemicolectomy would allow the patient to keep his transverse and left colon and rectum, which were spared of disease, but would require the patient to undergo aggressive colonoscopy surveillance given the potential risk for a new colorectal cancer. Total proctocolectomy with end ileostomy would completely eliminate the need for surveillance and the risk for a new colorectal cancer, but an ostomy would significantly alter the patient's quality of life. An ileal pouch-anal anastomosis was not considered, as it is contraindicated for patients with Crohn disease. A total colectomy with ileorectal anastomosis was determined to be the patient's best option. The reasoning was that it would leave behind only the rectum to survey, decreasing most of his risk for a new colorectal cancer, and would not require an ostomy, thereby maintaining his current quality of life, with the expectation of having four to six bowel movements per day.

The patient underwent successful laparoscopic-assisted total abdominal colectomy with ileorectal anastomosis. Surgical pathology demonstrated a 0.4-cm intramucosal adenocarcinoma involving the colonic side of the ileocecal valve in the setting of multiple polypoidal nodules of villiform low-grade dysplasia in the cecum spanning 3.3 cm. All 13 resected lymph nodes were determined to be benign, and there was no lymphovascular invasion found. The pathologic tumor stage was concluded to be Tis N0 M0.


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