Ileus due to severe aggravation of retroperitoneal fibrosis after sigmoidectomy

Dear Editor, Retroperitoneal fibrosis (RPF) is an uncommon inflammatory disorder of unclear etiology, which may present with compression/obstruction syndromes. Here, we report an unusual case of a 56-year-old man that developed prolonged ileus associated with retroperitoneal and mesenterial fibrosis after conventional sigmoidectomy for colon cancer. A 56-year-old man, originally from Korea, was admitted with a histology-proven diagnosis of adenocarcinoma located in the sigmoid colon together with two adenomas (in the coecum and ascending colon) and mild hydronephrosis of the left kidney. The patient had neither relevant past medical history nor long-term use of medication, previous abdominal operation, radiation therapy, or history of familial adenomatous polyposis. His physical examination at admission was unremarkable and the routine laboratory values were normal. The serum carcinoembryonic antigen level was measured at normal levels (2.3 μg/l). Intraoperatively, mild RPF affecting the left ureter was diagnosed for the first time. The tumor was restricted to the colon without signs of inflammation or infection. The sigmoid colon was resected and the transit reconstructed with an end-to-end descendo-rectostomy. Ureterolysis due to periureteral fibrosis was also performed. The operation was carried out uneventfully and the tumor was resected in sano. Histopathological examination revealed an ulcerated, moderate differentiated adenocarcinoma of the colon (40× 40×8 mm), along with infiltration of the pericolic fat and angioinvasive infiltration of the pericolic fat and subserosa (pT3, pN1, G2, L1, V1, R0). In the early postperative course (day 3), the patient presented with intolerance to enteral feeding (nausea, abdominal distension, and vomiting). Despite treatment with a nasogastric tube and oral administration of prokinetic agents (erythromycin and metoclopramide po), the gastrointestinal motility dysfunction progressed, requiring total parenteral feeding. The patient had no signs of peritonitis. Electrolytes, reactive C-protein (0.17 mg/dl), and leukocyte count (7.4 n/l) were at normal levels. On day 15, a gastrointestinal series after administration of contrast agent showed reduced peristalsis without contrast passage distal to ligament of Treitz. Because of the protracted course of ileus, we decided to perform a diagnostic laparotomy. At relaparotomy on postoperative day 17, adherences, brides, torsion, herniation, abscess, peritonitis, or ischemic complications were ruled out as a cause of ileus. However, thickened jejunal loops, as well as extensive mesenterial and RPF, were found. After adhesiolysis, it was necessary to resect segments of the small and large bowels with pronounced wall thickening, which we thought to be causing obstruction of the intestinal transit. Results of the microbiological examination (including fungi andmycobacteria), taken from the abdominal cavity during relaparotomy, were negative, as were investigaInt J Colorectal Dis DOI 10.1007/s00384-007-0311-1