A 57–year–old man with von Recklinghausen disease was referred to our hospital for melena and severe anemia. A double–balloon assisted enteroscopy revealed a protruding mass with central depression ...in the third portion of the duodenum. Moreover, contrast–enhanced CT revealed multiple enhancing tumors showing extramural growth, in the duodenum and small intestine. Based on the findings, the duodenal tumor was judged as being the likely source of the bleeding. The patient was then taken for elective partial duodenal resection, which revealed a hard, centrally depressed tumor with extramural growth, measuring 1.5 cm in diameter. In addition, multiple gastrointestinal stromal tumors(GISTs) showing extramural growth were seen throughout the length of the duodenum and small intestine. Histopathologic assessment identified the tumors as GISTs with very low–risk features. This case serves as an important reminder that the possibility of GISTs should be considered in patients with von Recklinghausen disease presenting with gastrointestinal bleeding.
An 87–year–old man who developed severe abdominal pain was diagnosed as having an intestinal perforation with an intraabdominal abscess based on CT findings. Thus, the patient underwent an emergent ...laparoscopic operation requiring a partial intestinal resection. However, the patient postoperatively had a relapse of the same symptoms. A second CT showed another abscess near the anastomosis. Thus, conservative management was performed. The patient was discharged, but he was later re–admitted with an abscess in another location. Moreover, another abscess required the patient to be hospitalized a third time. CT and intestinal endoscopy indicated a diagnosis of intestinal diverticulitis caused by multiple intestinal diverticula. However, the persistent symptoms required the patient to undergo laparoscopic surgery. The resected specimen revealed that a needle–like foreign body was in fact a wooden toothpick. This case serves as an important reminder to consider foreign bodies in investigations of all possible causes of intraabdominal abscess with a repeated history of abscess.
An 80-year-old man who had undergone nephrectomy for renal cell carcinoma(RCC)4 years before presentation was admitted to our department for further investigation of the gallbladder tumor. The ...patient was diagnosed with early gallbladder carcinoma based on CT and MRI findings and treated with laparoscopic cholecystectomy. The intraoperative frozen section revealed that the identified tumor was clear cell carcinoma. Finally, morphological similarity with a previous specimen of RCC and immunostaining resulted in the diagnosis of gallbladder metastasis from RCC. Therefore, it is important to consider metastatic carcinoma of the gallbladder in the differential diagnosis of gallbladder tumors for patients with a history of renal cell carcinoma.
The patient was a 73-year-old male who was aware of a swelling in his left inguinal region, but had never been diagnosed as having a left inguinal hernia. He was admitted to our hospital for ...colonoscopy because of a positive result of the fecal occult blood test. During the colonoscopy, we were unable to withdraw the endoscope, and at the same time, the patient complained of severe lower abdominal pain. Examination revealed a reddish swelling in the left inguinal region. Abdominal CT revealed incarceration of the sigmoid colon along with the endoscope in the hernia sac. An immediate attempt at manual reduction was unsuccessful, and we decided to perform emergency operation. Laparoscopic surgery was performed, the diagnosis of indirect hernia was made, and the incarceration was relieved by intra-abdominal operation and external manual reduction; however, serosal injury was noted in a part of the sigmoid colon. As intraoperative endoscopy showed no obvious mucosal necrosis, no sigmoid resection was performed, but the serosal injury was repaired under direct vision. The hernia hilum was repaired using the Lichtenstein method. Incarcerated hernia as a complication of colonoscopy has rarely been reported so far. We treated the patient by a minimally invasive and safe treatment method: laparoscopic surgery and intraoperative endoscopy.
A woman in her seventies visited a previous doctor because she was reported to have abnormal opacity in her right lung. Computed Tomography (CT) revealed pulmonary tuberculosis. An upper abdominal ...mass was also found, and she was referred to our hospital. Contrast-enhanced abdominal CT showed a heterogeneously mass lesion with a long diameter of approximately 83 mm in the pancreatic caudal region. Endoscopic ultrasound revealed a tumor at the pancreatic tail with distinct boundaries and internal mosaic echo. Magnetic Resonance Imaging showed a mass with heterogeneous and partially cystic degeneration. Based on these findings, solid pseudopapillary neoplasm (SPN) and other malignant lesions of the pancreas tail region were suspected. By laparotomy with subarachnoid arc incision, distal pancreatectomy, splenectomy, and regional lymph node dissection were performed. The specimen was a cystic mass covered with an 80×75×65 mm membrane in the pancreatic tail region. Initially, in the results of the pathological diagnosis, epithelial cells were not observed, and a hematoma was diagnosed. However, subsequent diagnosis indicated bizarre idioblasts and numerous osteoclast-like giant cells in the surrounding capsule. This area was initially thought to be a reactive pseudotumor lesion due to hemorrhage; however, the presence of CK7, p53-positive atypical spindle-shaped tumor cells and polynucleated tumor cells led to the diagnosis of anaplastic pancreatic carcinoma with osteoclastic polynucleic giant cells with extensive necrosis. We report a case of a rare pancreatic tumor with extensive intratumoral necrosis, which was difficult to diagnose pathologically, and present our findings with literature review.
Background
As the elderly population increases, cases of elderly advanced gastric cancer (AGC) also increase. This study aims to investigate the safety and utility of curative gastrectomy, as well as ...the efficacy of laparoscopic gastrectomy, for these elderly patients.
Methods
We retrospectively analyzed the surgical outcomes of patients with cStage IB-III AGC who underwent distal gastrectomy (DG) with D2 lymph node dissection in our institution. We compared the results between elderly patients (>75 years) and non-elderly patients (<75 years). We further divided the elderly patients into 2 groups: those who underwent laparoscopic DG (LDG) and those who underwent open DG (ODG). Further, we compared the results of the 2 groups.
Results
From January 2014 to March 2019, 84 patients underwent DG with D2 lymph node dissection for cStage IB-III AGC (52 elderly patients and 32 non-elderly patients). ASA was significantly higher in elderly patients; however, there was no significant difference in surgical outcomes nor in overall survival (OS) and recurrence-free survival (RFS) between the 2 groups. Among 52 elderly patients, 19 had LDG, whereas 33 had ODG. The LDG group had a significantly shorter length of hospital stay and a significantly less amount of blood loss. There was no significant difference in RFS and OS between these 2 groups.
Conclusions
Safety and oncologic curability may be achieved in elderly patients with AGC. LDG may be safely performed as ODG in elderly patients with AGC and it is expected to benefit them by achieving minimally invasive surgery.
We present a patient with a metachronous metastasis of a mesenchymal chondrosarcoma to the pancreas 11 years after primary tumor resection. The patient was a 40 year old male with a history of ...diabetes mellitus and hypertension. He was diagnosed with a mesenchymal chondrosarcoma at age 29 and underwent wide resection of the primary lesion with intraoperative radiation therapy after neoadjuvant chemotherapy. Postoperatively, he received adjuvant chemotherapy. He underwent metastasectomy at age 31 for a pulmonary metastasis and at age 33 for a cerebral metastasis and abdominal subcutaneous metastasis. Seven years later, there was significant elevation of serum glucose to 527mg/dl and CT scan, MRI and PET/CT scan revealed a pancreatic metastasis. Subtotal stomach-preserving pancreaticoduodenectomy was performed. At present, he is alive 6 months after operation and with intensive follow up.We investigated reports of tumors metastatic to the pancreas from bone and soft tissue and found 13 cases including the present patient. In case of a synchronous metastasis, the patients survive a relatively short time. Patients who underwent metastasectomy generally survive for nearly 10 years. If a solitary metastasis is found from bone or soft tissue tumors, metastasectomy may be appropriate.
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