LAUSR

A 49-year-old man with a long history of left-sided ulcerative colitis (UC), treated primarily with mesalamine and intermittent steroid enemas, developed recurrent flares associated with worsening bloody diarrhea. This resulted in the need for repeated courses of steroids (between 15 and 30 mg of prednisone daily) and the initiation of azathioprine. Although biologic therapy was recommended, the patient had declined this option due to concerns of possible side-effects and also refused surgical intervention. On routine surveillance colonoscopy, after almost 2 years of steroid-dependency, he was noted to have two inflammatory mass-like lesions, one in the proximal sigmoid colon and one in the distal rectum, both of which were biopsied (see Fig. 1). The biopsy results revealed spindle cell tumors with prominent capillary and slit-like vascular spaces, which tested positive on immunohistochemistry for human herpesvirus-8 (HHV-8). On physical examination, the patient had no cutaneous manifestations of Kaposi sarcoma (KS). His abdominal exam was notable for a palpable mass on digital rectal exam, 4 cm from the anal verge. The patient reported no risks factors for AIDS, tested negative for HIV, and had a normal complete blood count with differential. At that point, the patient agreed to surgery but was keen to have a restorative option and avoid a permanent stoma. Accordingly, he underwent an initial laparoscopic subtotal colectomy with end ileostomy. Pathological examination revealed focally active left-sided colitis with aphthous mucosal ulceration, mild chronic changes consistent with ulcerative colitis, and a focus of KS in the sigmoid colon submucosa (see Fig. 2). Over the next 2 months, the patient was successfully weaned from steroids and immunosuppressive agents. Proctoscopic surveillance over the next 6 months showed full resolution of his distal rectal KS lesion. Subsequently, a completion proctectomywith an ileal pouch to anal anastomosis in a double-stapled fashion was performed with creation of a temporary loop ileostomy. There was no evidence of KS on the rectum specimen on pathology. The ileostomy was ultimately reversed 3 months later to restore intestinal continuity. At 2year follow-up, the patient reported good pouch function with a normal pouch endoscopy.