Carcinoma located in a right-sided sigmoid colon: A case report

lNTRODUCTlON

Recognizing variations in the sigmoid colon is of key importance to surgeons and radiologists. Here, we report an atypical anatomic variation of a right-sided sigmoid colon with carcinoma, which was incidentally observed during an emergency computed tomography (CT) scan for abdominal pain. To the best of our knowledge, this is the first clinical case of a carcinoma located in a right-sided sigmoid colon detected by a preoperative CT scan. We present the following case in accordance with the CARE Reporting Checklist.

CASE PRESENTATlON

Chief complaints

A 56-year-old Chinese man was admitted to our hospital with abdominal pain in the right lower quadrant for 3 days.

History of present illness

The surgeons found a mass that almost completely blocked the lumen of the sigmoid colon. The redundant sigmoid colon was located on the right side of the ascending colon and cecum and was supplied by the branches of the inferior mesenteric artery, which ran to the right instead of its standard left-sided course. The descending colon started at the splenic flexure and crossed to the right at the level of the L4 vertebra, and occupied the subhepatic region to continue as the sigmoid colon. The small intestine was normal. Pathological examination revealed an infiltrative mucinous adenocarcinoma with two lymph node metastases, pT4N1M0 stage IIIB (UICC-TNM: 8edition).

History of past illness

The patient had no previous surgical history.

3. 另行解釋執(zhí)行依據(jù)。即由執(zhí)行機(jī)關(guān)商請(qǐng)作出生效法律文書的審判組織或其他機(jī)構(gòu)作出進(jìn)一步解釋。該種做法主要是：執(zhí)行機(jī)關(guān)對(duì)于執(zhí)行依據(jù)不明確的執(zhí)行案件，不能直接采取相關(guān)駁回申請(qǐng)或終結(jié)執(zhí)行的方式結(jié)案，而是應(yīng)當(dāng)有所作為，即可以通過一定的解釋方法來(lái)界定執(zhí)行依據(jù)中所列明的內(nèi)容。對(duì)于解釋方法，應(yīng)該緊緊圍繞執(zhí)行依據(jù)本身進(jìn)行，首先運(yùn)用文義解釋的方法，相對(duì)客觀地來(lái)解讀執(zhí)行依據(jù)所列舉的執(zhí)行內(nèi)容；如果通過文義解釋可以解釋出多個(gè)結(jié)論，則為了合理平衡當(dāng)事人之間的權(quán)益，適宜結(jié)合個(gè)案的具體情況，明確執(zhí)行依據(jù)的相關(guān)內(nèi)容[2]。

Personal and family history

The patient did not have a history of smoking or drinking. There was no personal or family history of acute or chronic diseases.

Physical examination upon admission

The patient was 169 cm tall and weighed 65 kg. Physical examination revealed tenderness in the right lower quadrant, but no palpable mass was found.

Laboratory examinations

Laboratory tests showed moderate increases in platelets and CA724, and normal levels of white blood cells and CA199. No abnormal results were found in other biochemical tests.

Imaging examinations

We report a rare anomaly of the right-sided sigmoid colon with carcinoma that could be detected by careful examination with a preoperative CT scan. This is a major congenital colon anomaly that should be recognized preoperatively and needs to be differentiated from the ascending colon and pericecal hernia to prevent errors and other surgical complications.

Colonoscopy showed an annular stricture of the sigmoid colon caused by a tumor 28 cm from the anus. Subsequent biopsy indicated malignancy.

FlNAL DlAGNOSlS

Due to inconclusive radiological signs, the patient underwent laparoscopic exploration. Intraoperatively, the surgeons detected atypical positions of both the sigmoid colon and descending colon. They converted the surgery to an open operation for safety considerations.

The patient had experienced irregular and formless bowel movements for three months prior to presentation at our hospital. The patient also had right lower quadrant abdominal pain, which could not be relieved after defecation. The patient had no other accompanying symptoms, including any obvious symptoms of bowel obstruction.

（三）促進(jìn)文明城市建設(shè)。一個(gè)城市的閱讀數(shù)量和質(zhì)量，是一個(gè)城市文明形成的顯性和潛在的雙向元素。“書中自有黃金屋，書中自有千鐘粟……”而一個(gè)文明的、高素質(zhì)的人文環(huán)境構(gòu)架下的城市，文明、和諧皆為水到渠成之事。

三峽旅游作為大旅游空間，僅靠少數(shù)經(jīng)典景區(qū)的“只言片語(yǔ)”是不夠說(shuō)服游客的，況且三峽部分景區(qū)已明顯處于衰退期，亟需挖掘資源存量，三峽旅游需要核心擴(kuò)散，即對(duì)三峽核心元素進(jìn)行提煉，這個(gè)核心元素不能是局部的、片面的，形成覆蓋全域的中心節(jié)點(diǎn)是未來(lái)三峽的旅游發(fā)展之道。

TREATMENT

Lyu LJ and Yao WW wrote the manuscript; all authors have read and approve the final manuscript.

OUTCOME AND FOLLOW-UP

創(chuàng)新是事物發(fā)展的源泉，改革是事物發(fā)展的不竭動(dòng)力，新時(shí)代我國(guó)群眾體育領(lǐng)域研究應(yīng)當(dāng)以健康中國(guó)戰(zhàn)略為引領(lǐng)，關(guān)注城鄉(xiāng)群眾體育協(xié)調(diào)發(fā)展，以全民健身戰(zhàn)略為引領(lǐng)，關(guān)注群體與競(jìng)體的協(xié)調(diào)發(fā)展，以體育強(qiáng)國(guó)戰(zhàn)略為引領(lǐng)，關(guān)注我國(guó)群眾體育文化發(fā)展，從而最終實(shí)現(xiàn)我國(guó)群眾體育的全面、可持續(xù)發(fā)展。

DlSCUSSlON

The sigmoid colon shows the greatest variation in length and position[1]. The variation in length is mainly related to racial differences and a high-fiber diet[2], the position of the sigmoid colon loop is a means of adapting to the general length of the sigmoid colon[2]. A study by Saxena[3] suggested that the sigmoid colon of young children (age ＜ 5 years) is often situated entirely on the right side for redundancy; this is not the case in adults. The presence of a right-sided sigmoid colon is very rare in adults and may be related to fixation anomalies[1], redundancy of the colon, or secondary rotation of the colon during embryogenesis[4].

In most cases of right-side colon carcinoma, the carcinoma is observed to be located in the ascending colon. In our case, circumferential wall thickening of the colon occupied the subhepatic region on the right of the ascending colon, and the ileocecal junction was displaced toward the left at the level of the L4 transverse process instead of the right pelvic region, indicating that the cecum was undescended due to midgut malrotation during embryogenesis[4]. Colonoscopy revealed a stricture 28 cm from the anus,demonstrating a sigmoid colon other than the ascending colon. The identification of the tumor location is crucial for determining the appropriate clinical course because the sigmoid colon and ascending colon have different embryological origins[5], and a recent study[6] demonstrated that right-sided colon carcinomas exhibit exophytic pathological behavior and poorer overall survival than left-sided colon carcinomas.

按季節(jié)分析IMERG估計(jì)降水的空?qǐng)?bào)率FAR,結(jié)果表明:中國(guó)大陸的FAR在夏季最低,約為0.52;其次是秋季和春季,分別為0.65和0.64;冬季最高,約為0.75。中國(guó)大陸東、西部的FAR的季節(jié)變化趨勢(shì)與整個(gè)中國(guó)大陸完全相同,各季都是西部地區(qū)高、東部地區(qū)低。西部夏季FAR最低時(shí)也超過了0.6,冬季最高時(shí)約為0.9。除秋季相差約0.1之外,其他季節(jié)東、西部地區(qū)的FAR相差約0.2(圖5b)。

Shrivastava[8] first described the right-sided sigmoid colon in a cadaveric study in 2013. Flores-R íos[9] reported a case of secondary right-sided descending and sigmoid colon caused by a wandering spleen due to laxity or abnormal development of the peritoneal ligaments, which was different from our case. Subsequently, there were two case reports[1,10] of right-sided sigmoid colons,which were discovered incidentally during surgery.

To the best of our knowledge, this is the first clinical case of carcinoma located in the right-sided sigmoid colon revealed by a preoperative CT scan and confirmed by surgery. Surgeons and radiologists should be aware of this rare variation when examining patients experiencing abdominal pain in the right lower quadrant.

The limitation of our case was the lack of appropriate intraoperative images compatible with the volume rendering image (Figure 2C), which could have provided readers with an intuitive understanding.

利用商業(yè)保險(xiǎn)分擔(dān)農(nóng)業(yè)風(fēng)險(xiǎn)，發(fā)揮市場(chǎng)對(duì)災(zāi)后可持續(xù)經(jīng)營(yíng)的補(bǔ)償作用；對(duì)于安全要求和生產(chǎn)水平高的農(nóng)業(yè)經(jīng)濟(jì)作物，應(yīng)讓市場(chǎng)多多參與，加快經(jīng)濟(jì)作物的農(nóng)業(yè)保險(xiǎn)商業(yè)化進(jìn)程；減少政府干預(yù)，分清公共資源與私人物品的界限，提高政府工作效率，發(fā)揮市場(chǎng)在資源配置中的基礎(chǔ)作用［3］。

選取云南省第三人民醫(yī)院2017年1月—2017年6月收治的肥胖2型糖尿病患者95例，按治療方法分為對(duì)照組47例、觀察組48例。兩組一般資料比較無(wú)顯著差異，見表1。本研究已通過本院倫理委員會(huì)審核和批準(zhǔn)。

In the present case, the colon with wall thickening on the right side of the ascending colon was similar to a rare type of internal hernia occurring near the cecum, namely, pericecal hernia[7]. However,pericecal hernia usually involves a small bowel other than the sigmoid colon; such pericecal hernias usually produce acute intestinal obstruction, which can be confirmed by CT. In addition, it is expected that the descending colon and sigmoid colon should be observed in the standard position relative to the pericecal hernia and the inferior mesenteric artery. On CT images of the present case, no small bowel herniation or obvious dilation was observed. The descending colon crossed to the right side at the level of the L4 vertebra, where it entered the peritoneal cavity and continued as the sigmoid colon on the right side. Notably, the inferior mesenteric artery ran to the right instead of its normal left-sided course.

CONCLUSlON

CT showed an atypical location of the redundant sigmoid colon with heterogeneously enhanced circumferential wall thickening on the right side of the cecum and ascending colon (Figures 1 and 2). We reported the atypical location of the sigmoid colon with a mass, suspected the presence of a pericecal hernia, and informed the surgeons accordingly.

FOOTNOTES

The surgeons performed a hemicolectomy with regional lymphadenectomy during laparotomy. No bowel perforation was observed.

Written informed consent was obtained from the patient for publication of this report.

The patient was discharged on postoperative day 7 without any complications. Moreover, there were no signs of recurrence or metastasis during the 3-month follow-up period.

The authors declare that they have no conflicts of interest.

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

新課程改革下的高中物理教學(xué)不再是教師一個(gè)人完成的教學(xué)活動(dòng)，在課堂中更多是突出了學(xué)生的主體地位.在物理實(shí)驗(yàn)課程中，學(xué)生是實(shí)驗(yàn)的實(shí)際操作主體，在實(shí)驗(yàn)過程中，學(xué)生能都獨(dú)立思考實(shí)驗(yàn)步驟和實(shí)驗(yàn)過程，從而得出實(shí)驗(yàn)結(jié)果，可以通過反復(fù)的實(shí)驗(yàn)驗(yàn)證自己的猜測(cè)，培養(yǎng)自身獨(dú)立思考物理的能力.學(xué)生在自身實(shí)際操作過程中還可以發(fā)現(xiàn)問題，對(duì)于自己操作過程中的不足之處能夠及時(shí)的發(fā)現(xiàn)和彌補(bǔ)，不僅能夠有效地掌握相關(guān)的知識(shí)，更能夠不斷的提升自身的實(shí)際操作能力.

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China

Liang-Jing Lyu 0000-0003-4643-9740; Wei-Wu Yao 0002-1536-9324.

Ma YJ

A

自由自在、夢(mèng)想理想、獨(dú)立自主、健康美貌、事業(yè)成功、喜歡就好、想愛就愛、世界和平、保護(hù)地球等，都被她們羅列了一遍，興奮無(wú)比。那一刻蒲琳覺得，原來(lái)有張盈盈陪伴著自己的這些年里，自己什么都沒有缺過。

Ma YJ