We report a case treated with a reconstruction procedure using the double-flap technique (DFT) after proximal gastrectomy for removing a giant gastrointestinal stromal tumor (GIST) of the stomach. A 71-year-old woman presented with abdominal swelling. Clinical examinations revealed a large gastric GIST of 20 cm in diameter, located in the upper-middle portion of the stomach. Laparotomy with a vertical midline incision of the upper abdomen was performed, and a large tumor continuous with the posterior wall of the upper part of the stomach was found. Partial resection of the greater curvature of the stomach was attempted, including the base of the tumor. However, as the remnant stomach was narrowed, proximal gastrectomy was performed. DFT was selected as a reconstruction procedure to prevent postoperative reflux esophagitis and facilitate observation of the residual stomach. The postoperative clinical course was uneventful and the patient was discharged 14 days after surgery. The patient was in the high-risk category of the modified Fletcher classification, but she is alive without recurrence 16 months after surgery, with use of imatinib as adjuvant therapy. There were no symptoms of anastomotic stricture and reflux esophagitis after the surgery. Even for a large GIST, the basic principle of treatment is to minimize the extent of gastric resection. Therefore, for a large GIST of the upper stomach, where partial gastrectomy is difficult, proximal gastrectomy with reconstruction by DFT may be useful from the viewpoint of organ and function preservation and postoperative QOL.
A 72-year-old man underwent open total gastrectomy for gastric cancer and had cardiopulmonary arrest following loss of consciousness on the third day after surgery. After the start of cardiopulmonary resuscitation and induction of percutaneous cardiopulmonary support (PCPS), acute pulmonary thromboembolism was suspected based on findings of right ventricular enlargement and left ventricular exclusion on echocardiography. Enhanced CT showed giant emboli in both pulmonary arteries, and acute pulmonary thromboembolism was diagnosed. Since it was 3 days after the operation, surgical thrombectomy was selected instead of thrombolytic therapy based on the risk of postoperative bleeding. Immediately after thrombectomy, hemodynamics and oxygenation improved. The patient was hospitalized for a long time due to a lung abscess during the postoperative course, but there were no neurological sequelae and he was discharged from hospital 52 days after thrombectomy. We report a case of acute pulmonary thromboembolism leading to cardiopulmonary arrest after gastric cancer surgery, in which the patient was saved by rapid induction of PCPS and surgical thrombectomy.
A 72-year-old man visited our hospital for epigastric pain. Upper gastrointestinal endoscopy showed a 30-mm elevated lesion with a shallow ulcer at the superior duodenal angulus, and a biopsy revealed a duodenal neoplasm of a gastric phenotype (DNGP). In a preoperative examination, it was difficult to determine if the lesion was benign or malignant. Therefore, we performed laparoscopy and endoscopy cooperative surgery (LECS) as diagnostic treatment. The postoperative course was smooth. The final pathological diagnosis was well to moderately differentiated adenocarcinoma, gastric phenotype. There are various treatments with different surgical stress for a descending duodenal tumor, and the treatment should be selected based on individual tumor progression and malignant potential. LECS for duodenal lesions is minimally invasive and safer than endoscopic treatment alone. It is often difficult to assess the malignant potential of DNGP preoperatively. LECS may be useful as diagnostic treatment for these tumors, as illustrated in the case reported here.
Case 1 was a 62-year-old man with a hypovascular mass in the pancreatic head and a history of abdominoperineal resection for rectal cancer 4 years ago. Case 2 was a 70-year-old man with a hypovascular mass in the pancreatic body and a history of laparoscopic left hemicolectomy for colon cancer 3 years ago. In both cases, carcinoembryonic antigen levels were elevated at the time of admission. PET showed strong FDG uptake in both tumors. MRCP showed pancreatic masses without stenosis or obstruction of the main pancreatic duct. Both patients were diagnosed with primary pancreatic cancer by endoscopic ultrasound-guided fine-needle aspiration cytology and underwent pylorus-preserving pancreatoduodenectomy and distal pancreatectomy. Pathological examination showed histological findings similar to those for colorectal cancer, with immunostaining negative for CK7 and positive for CK20 and CDX2, resulting in diagnosis of pancreatic metastasis from colorectal cancer. Case 2 had lymph node metastasis in the pancreatic region. The patient in Case 1 had multiple brain and lung metastases, but is alive 3 years and 9 months after pancreatic resection. The patient in Case 2 is alive 2 years and 5 months after pancreatic resection without recurrence. Surgical resection for pancreatic metastasis from colorectal cancer may be recommended as part of multidisciplinary therapy, if there are no uncontrolled metastases in other organs and complete resection is possible.
An 86-year-old woman was admitted to our hospital for fatigue and tarry stools. Laboratory tests on admission indicated anemia, and enhanced abdominal CT revealed a heterogeneous tumor in the pancreatic body-tail, accompanied by a partial contrast effect. Upper gastrointestinal endoscopy showed blood emerging from the duodenal papilla. Hence, the patient was diagnosed with pancreatic body-tail cancer and hemosuccus pancreaticus (HP). Emergency angiography was performed, followed by coil embolization surgery. Anemia temporarily improved after surgery, but redeveloped following blood transfusion. The patient underwent distal pancreatectomy on hospital day 18. Upper gastrointestinal endoscopy performed during surgery confirmed improvement in HP. After surgery, there was immediate improvement of anemia, and the patient was discharged on hospital day 35. Histopathological examination revealed invasive ductal carcinoma of the pancreas (pT3N1M0 pStage IIB).
The patient was a 49-year-old woman who had been diagnosed with multiple endocrine neoplasia type 1 (MEN-1). Dynamic contrast-enhanced CT indicated several hypervascular tumors in the pancreas. Endoscopic US showed low-echoic lesions in the uncinate process and the tail and body of the pancreas, and a diagnosis of pancreatic neuroendocrine tumor was made by fine-needle aspiration. A selective arterial secretagogue injection test indicated an increased serum gastrin level and was considered positive in all feeding arteries of the pancreas. Under a diagnosis of MEN-1 with multiple pancreatic gastrinomas, total pancreatectomy with D2 lymph node dissection was performed. Histopathological findings showed 45 or more microgastrinomas in the whole pancreas with lymph node metastases. At 21-month follow-up, the patient remained disease-free. This case shows the need for selection of appropriate surgical treatment given that gastrinomas in MEN-1 have higher malignancy and are characterized by multiple microlesions, rather than sporadic gastrinomas.
The ileocecal fold is a structure located between the mesoappendix and the lower edge of the terminal ileum and extends as far as the cecum or appendix. There has been no previous report of use of the ileocecal fold in surgical treatment. Here, we report two cases in which the ileocecal fold was used to cover cecal perforation and gangrenous appendicitis. In case 1, acute peritonitis developed secondary to endoscopic mucosal resection performed to remove a polyp on the anterior wall of the cecum. Laparotomy revealed perforation of the anterior cecal wall. The perforation was closed with sutures and covered with the ileocecal fold. In case 2, laparotomy performed for gangrenous appendicitis with a fecalith revealed perforation at the base of the necrotic appendix, which was closed and covered with the ileocecal fold after wedge resection. These cases show that the ileocecal fold can be used to cover cecal perforation and gangrenous appendicitis with a necrotic base.
The patient was a 65-year-old woman with a history of rectal uterine prolapse who had undergone total hysterectomy and Miwa-Gant+Thiersch surgery. An Altemeier operation was then performed, but prolapse recurred. Posterior rectopexy with mesh was subsequently performed, but again there was recurrence. At the time of this recurrence, the patient was transported as an emergency because of abdominal pain and intestinal prolapse from the anus. A 60-cm small intestinal prolapse from the anus was found, and CT revealed small intestinal intrusion and prolapse from the anus due to rectal perforation. Therefore, laparotomy was performed urgently. There was no stool leak in the abdominal cavity. A 3.5-cm laceration was found in the anterior wall of the rectum at the bottom of the Douglas fossa, and the small intestine had entered the rectum through the laceration. It was difficult to pull back the small intestine from the anus, so it was resected. The small intestinal stump was pulled back and anastomosed. A Hartmann operation was subsequently performed on the perforated rectum, leaving the mesh on the dorsal side of the rectum. Transanal prolapse is an extremely rare condition that has a significant association with rectal prolapse. The case reported here may permit greater understanding of the mechanism of occurrence.
We report three cases of anorectal malignant melanoma (AMM) that were treated with laparoscopic abdominoperineal resection (APR). The first case was a 73-year-old woman with a chief complaint of melena. She was diagnosed with pT1bN2aM0 (9th edition of the Japanese classification of colorectal, appendiceal, and anal carcinoma) and adjuvant chemotherapy was performed after radical surgery. Four months after surgery, lateral lymph node metastasis was found. The second case was a 45-year-old man on hemodialysis with a chief complaint of an anal mass. He was diagnosed with pT2N1bM0 and adjuvant chemotherapy was not performed. Two months after surgery, inguinal lymph node metastasis was found. The third case was a 66-year-old woman with a chief complaint of melena. She was diagnosed with pT1bN0M0 and nivolumab was used as adjuvant chemotherapy for 1 year. She remains alive without recurrence 20 months after surgery. There are reports of 51 AMM cases in which APR was performed in Japan, and these show that regional lymph node metastasis is a risk factor for early distant recurrence after surgery.