Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Sep 16, 2020; 12(9): 310-316
Published online Sep 16, 2020. doi: 10.4253/wjge.v12.i9.310
Laparoscopy-assisted resection of colorectal cancer with situs inversus totalis: A case report and literature review
Wei Chen, Jing-Lin Liang, Jun-Wen Ye, Yan-Xin Luo, Mei-Jin Huang
Wei Chen, Jing-Lin Liang, Jun-Wen Ye, Yan-Xin Luo, Mei-Jin Huang, Department of Colorectal Surgery, The Six Affiliated Hospital, Sun Yat-sen University, Guangzhou 510655, Guangdong Province, China
ORCID number: Wei Chen (0000-0002-6444-1724); Jing-Lin Liang (0000-0002-6090-4939); Jun-Wen Ye (0000-0002-9435-7312); Yan-Xin Luo (0000-0002-5200-3997); Mei-Jin Huang (0000-0002-5639-8092).
Author contributions: Chen W, Liang JL, Ye JW, Luo YX, and Huang MJ contributed to the study design, data collection, analysis, and interpretation, drafting of the final manuscript, and supervision; all authors approved the final version of the manuscript.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Mei-Jin Huang, PhD, Academic Fellow, Doctor, Department of Colorectal Surgery, The Six Affiliated Hospital, Sun Yat-sen University, No. 26 Yuancun Erheng Road, Tianhe District, Guangzhou 510655, Guangdong Province, China. 13924073322@139.com
Received: April 9, 2020
Peer-review started: April 9, 2020
First decision: June 8, 2020
Revised: July 9, 2020
Accepted: August 4, 2020
Article in press: August 4, 2020
Published online: September 16, 2020

Abstract
BACKGROUND

Situs inversus totalis (SIT) is a rare anomaly in which structures are located opposite to their usual positions. It is not a premalignant condition and the association with colorectal cancer (CRC) is rare. We here report a patient with SIT who underwent laparoscopic radical resection of sigmoid colon cancer, and review the pertinent literature.

CASE SUMMARY

A 53-year-old woman presented with CRC and SIT and underwent a complete examination after admission. The patient then underwent laparoscopic radical resection of sigmoid colon cancer and hyperthermic intraperitoneal chemotherapy. The operation duration was 120 min, and no intraoperative complications occurred. The final pathological report showed stage T4aN0M0. Postoperative chemotherapy was administered and no evidence of recurrence was observed during 18 mo of follow-up.

CONCLUSION

Surgery in a patient with CRC and SIT can be safely performed on the basis of routine preoperative clinical examination.

Key Words: Colorectal cancer, Situs inversus totalis, Hyperthermic intraperitoneal chemotherapy, Case report

Core Tip: Situs inversus totalis is a rare anomaly in which structures are located opposite to their usual positions. It is not a premalignant condition and the association with colorectal cancer is rare. We here report a case and review the literature. In sum, a 53-year-old woman presented with colorectal cancer and situs inversus totalis and underwent a complete examination after admission. The patient then underwent laparoscopic radical resection of sigmoid colon cancer and hyperthermic intraperitoneal chemotherapy. The final pathological report showed stage T4aN0M0. Postoperative chemotherapy was administered and no evidence of recurrence was observed during 18 mo of follow-up.



INTRODUCTION

Situs inversus totalis (SIT) refers to the complete reversal of unpaired tissues and organs in the thoracic and abdominal cavity. It is an extremely rare congenital disease with an incidence of approximately 1/4000-8000[1]. According to statistics, the incidence of intestinal cancer is about 376.3/100000, and patients with intestinal cancer and visceral transposition are even rare. When lesions of internal organs in the reverse position occur, patients are easily misdiagnosed if imaging data are not available. We here report a patient with complete visceral transposition combined with sigmoid colon cancer. To the best of our knowledge, this is the first case report of sigmoid colon cancer associated with SIT in China. We also review the relevant literature and discuss the diagnosis and treatment of this patient.

CASE PRESENTATION
Chief complaints

In December 2017, a 53-year-old woman was admitted to our hospital due to lower abdominal discomfort for 1 wk.

History of present illness

The patient’s symptoms started a week ago with recurrent lower abdominal discomfort, which had been worsened the last 24 h.

History of past illness

The patient had a free previous medical history.

Physical examination

Initial vital signs were stable, and a systemic review and physical examination revealed nothing of note. However, the apex beat of her heart was located in the fifth intercostal space of the right clavicle midline.

Laboratory examinations

Serum carcinoembryonic antigen level was elevated (68.5 ng/mL; reference range, 0–5.0 ng/mL).

Imaging examinations

Colonoscopy revealed an obstructing sigmoid mass. Histological examination of the biopsied specimen indicated a moderately differentiated adenocarcinoma. Preoperative thoracic and abdominal enhanced computed tomography showed a complete right-left reversal of the thoracic and abdominal organs, sigmoid colon wall thickening, and the surrounding mesentery scattered with lymph nodes around the primary tumor (Figure 1A). A three-dimensional vascular reconstruction technique was used to observe the anatomy and variation of mesenteric vessels, and the anatomy of the vascular arch was clearly displayed (Figure 1B and C).

Figure 1
Figure 1 Images of computed tomography, operation, and histopathological examination. A: Computed tomography showing transposition of the abdominal; B: Three-dimensional reconstruction image of computed tomography angiography showing three branches of the inferior mesenteric artery, left colic artery, sigmoid artery, and superior rectal artery; C: Postoperative three-dimensional reconstruction of computed tomography angiography; D: Sites of trocar placement. A camera was inserted into the subumbilical area through a 12-mm trocar; the 12-mm trocar marked indicates the main operation hole; E: Exposure of each blood vessel during operation; F: The anastomotic stoma; G: Placement of a perfusion tube for hyperthermic intraperitoneal chemotherapy; H: Resected specimen showing a ulcerated mass in sigmoid colon; I: Histopathological examination. IMA: Inferior mesenteric artery; LCA: Left colic artery; SA: Sigmoid artery; SRA: Superior rectal artery.
FINAL DIAGNOSIS

The final diagnosis was CRC with SIT.

TREATMENT

On January 5, 2018, under general anesthesia, laparoscopic radical sigmoidectomy was performed and hyperthermic intraperitoneal chemotherapy was administered twice (Figure 1D and G). The surgical method of low ligation in combination with highly selective lymph node dissection was adopted to preserve the left colic artery in order to lower the postoperative incidence of anastomotic fistula. Postoperative pathological staging was T4aN0M0 based on the criteria proposed by the International Union Against Cancer (Figure 1H and I).

OUTCOME AND FOLLOW-UP

The patient recovered well after surgery, and regular chemotherapy (mFOLFOX6) was performed 8 times. During the regular 18 mo of follow-up, no tumor recurrence was observed and the patient’s general condition was good.

DISCUSSION

We searched the compact disc read-only memory database of Chinese biomedical literature and the PubMed-indexed for MEDLINE search system to retrieve reports on visceral transposition combined with intestinal cancer published from January 2000 to May 2019. The Chinese search terms used were “visceral transposition” and “intestinal cancer”, and the English search terms used were “colorectal cancer” and “situs inversus”. Finally, 2 Chinese articles and 11 English articles were identified (Table 1)[1-13].

Table 1 Summary of cases with complete transposition of viscera combined with intestinal cancer.
Ref.Publication timeNumber of examplesSex/Age (yr)Tumor locationPathological examinationTherapyPrognosis
Fang et al[2]20141Female/39RectumModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Xu et al[3]20181Female/67Colon ascendensMedium-poor differentiated adenocarcinomaLaparoscopic surgeryGood
Takeda et al[4]20181Female/72Colon sigmoideumModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Sasaki et al[5]20171Female/75Colon ascendensModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Yaegashi et al[6]20151Female/71Colon sigmoideumWell differentiated adenocarcinomaLaparoscopic surgeryGood
Ito et al[7]20152Female/53; Male/60Rectum Ascending colon cancerModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Hirano et al[8]20151Male/87Carcinoma of the cecumModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Sumi et al[9]20131Male/83Carcinoma of the descending colonModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Kim et al[10]20111Male/63; Female/71Colon cancer of the hepatic flexureModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Han et al[11]20111Male/63Ascending colon cancerModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Fujiwara et al[12]20071Female/53Ascending colon cancerModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Goi et al[13]20031Female/72Ascending colon cancerModerately differentiated adenocarcinomaLaparoscopic surgeryGood
Viscott et al[14]20111Female/71Rectal carcinoma gastric cancerModerately differentiated adenocarcinomaLaparoscopic surgeryGood

Visceral transposition can be divided into complete visceral transposition and partial visceral transposition. Patients with complete visceral transposition are known as “mirror people” and are extremely rare[14]. Some patients with visceral transposition often present with other complex malformations. The incidence of visceral transposition varies in different regions. In Japan, the incidence of visceral transposition is 0.125‰ to 0.250‰. Yang et al[15] reported that the incidence rate was 0.005‰ to 0.010‰ in China. Several reports of the combination of a malignant tumor and SIT, such as cancer of the liver, stomach, lung, and colon, have been described. Only 2 cases of laparoscopic-assisted resection of CRC have been reported in China[2,3]. The patient described here had sigmoid colon cancer and underwent laparoscopic radical surgery and postoperative intraperitoneal hyperthermic perfusion chemotherapy. The procedure was uneventful, and no tumor recurrence was found after 18 mo of follow-up.

To date, the mechanism of visceral translocation is still unclear, and some scholars believe that it is related to fetal ectopic and chromosomal abnormalities during embryonic development[16]. Whether internal visceral translocation is related to tumor onset is still inconclusive. Studies have shown that there may be a correlation between internal visceral translocation and tumor onset; however, further research is needed[17]. Due to the different pathological types and tumor sites, the clinical manifestations of patients vary, especially in patients with visceral transposition, which is prone to misdiagnosis. Therefore, comprehensive examinations should be completed, such as gastrointestinal endoscopy, computed tomography, and revascularization.

As internal visceral transposition is often accompanied by congenital anatomic abnormalities, surgery can be challenging. The main difficulty is distinguishing the blood vessels. In this case, the main branch vessels supplying the intestine were clearly distinguished by revascularization before surgery, which provided a guarantee for a smooth surgical procedure. In addition, it is necessary to consider the handedness of the surgeon to determine the position of the device, operator, and trocars. Oms and other researchers have found that laparoscopic techniques in visceral transposition patients are more difficult for right-handed surgeons, and are more advantageous for left-handed surgeons[18]. The same effect can be achieved by changing the position of the operator during surgery[6].

For the diagnosis and treatment of patients with visceral transposition combined with gastrointestinal cancer, the possibility of visceral inversion should always be considered. The presence of cardiopulmonary disease should be eliminated to ensure a smooth surgical procedure. Relevant imaging examinations should be improved, and if necessary, revascularization should be performed to determine whether there are obvious vascular variations. An understanding of the anatomical location and variation involved in the operation is essential, and research on the surgical approach and possible problems during surgery should be conducted. Compared with traditional laparotomy, laparoscopic techniques have minimally invasive benefits for patients while also presenting challenges. With the continuous development of technology, there will be a further understanding of the diagnosis and treatment of patients with visceral transposition, especially those with tumor diseases. In addition, because patients with stage T4 are prone to postoperative peritoneal metastasis, hyperthermic intraperitoneal chemotherapy and adjuvant chemotherapy were used to prevent tumor peritoneum relapse[19].

CONCLUSION

CRC and SIT can be diagnosed according to colonoscopy and imaging examination. Radical resection is the most effective method for treating CRC. A clear diagnosis before surgery can reduce the risk of surgery.

Footnotes

Manuscript source: Invited manuscript

Specialty type: Gastroenterology and hepatology

Country/Territory of origin: China

Peer-review report’s scientific quality classification

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P-Reviewer: Mitsui K, Suzuki H S-Editor: Zhang L L-Editor: Wang TQ P-Editor: Wang LL

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