Elective staged proctocolectomy and living donor liver transplantation for colon cancer with sclerosing cholangitis-related ulcerative colitis: a case report

Abstract

Background: Primary sclerosing cholangitis (PSC) is a well-known complication of ulcerative colitis (UC), but it is rare to encounter patients requiring both living donor liver transplantation (LDLT) and proctocolectomy. We report a case of elective two-stage surgery involving proctocolectomy performed after LDLT for a patient with early colon cancer concurrent with PSC-related UC. To our knowledge, this is the first report of concurrent cancer successfully treated with both LDLT and proctocolectomy.

Case presentation: A 32-year-old Japanese man with colon cancer associated with UC underwent restorative proctocolectomy at 3 months after living donor liver transplantation (LDLT) for PSC. He was diagnosed with PSC and UC when he was a teenager. Conservative therapy was initiated to treat both PSC and UC. He had experienced recurrent cholangitis for years; therefore, a biliary stent was placed endoscopically. However, his liver function progressively deteriorated. Colonoscopic surveillance revealed early colon cancer; hence, surgical treatment was considered. PSC progressed to cirrhosis and portal hypertension; hence, LDLT was performed before restorative proctocolectomy. Three months after LDLT, we performed restorative proctocolectomy with ileal pouch-anal anastomosis. The postoperative course was uneventful. The patient was well, with good liver and bowel functions and without tumor recurrence, more than 1 year after proctocolectomy.

Conclusions: With strict patient selection and careful patient management and follow-up, elective proctocolectomy may be performed safely and effectively after LDLT for concurrent early colon cancer with PSC-related UC. There are no previous reports of the use of both LDLT and proctocolectomy for the successful treatment of PSC-related UC and concurrent cancer.

Keywords: Colitis-related colon cancer; Ileal pouch–anal anastomosis; Inflammatory bowel disease; Small-for-size syndrome.

Fig. 1

The imaging findings of primary sclerosing cholangitis (PSC) are shown. a Magnetic resonance cholangiopancreatography revealed typical features of PSC with irregular narrowing of bile ducts, stenoses, and focal dilatation of bile ducts. b Computed tomography revealed a cirrhotic liver with an enlarged caudate lobe and splenomegaly

Fig. 2

Surveillance colonoscopy image showing an elevated lesion in the ascending colon (arrowheads). This lesion was diagnosed as well-differentiated adenocarcinoma based on the biopsy findings (arrow shows the biopsy area)

Fig. 3

a Macroscopic findings of the resected lesion. Severe inflammation was observed in the whole colonic mucosa and the right colon was brown because of mucosal hemorrhages. b Slightly elevated lesion in the ascending colon. c Slightly elevated lesion in the transverse colon. d Histological examination of the tumor revealed well-differentiated to moderately differentiated adenocarcinoma in the mucosa of the ascending colon (hematoxylin and eosin staining; magnification, ×200)

Fig. 4

Clinical course of the patient since PSC and UC were diagnosed