Retroperitoneal solitary neurofibroma mimicking lymph node metastasis of colon cancer: a case report

BACKGROUND

A neurofibroma is a benign tumor that arises from Schwann cells and neurofibromas occur throughout the skin of neurofibromatosis type 1 (NF-1: Von Recklinghausen's disease) patients. A retroperitoneal solitary neurofibroma without any clinical signs of NF1 has been rarely reported. Herein, we present a case of a retroperitoneal solitary neurofibroma mimicking lymph node metastasis of colon cancer as well as a literature review.

CASE PRESENTATION

An 80-year-old woman with abdominal pain and nausea was transported and diagnosed with bowel obstruction arising from sigmoid colon cancer A colonic stent was inserted to alleviate the bowel obstruction. A computed tomography scan with contrast revealed a liver tumor in segment 3, and an enlarged lymph node around the abdominal aorta. Whole-body 18F-fluorodeoxyglucose-positron emission tomography-CT (FDG-PET-CT) examine revealed increased FDG uptake in the liver tumor and enlarged lymph node. Liver and distant lymph node metastasis were diagnosed and we made a plan for a two-stage operation of the colon cancer and the metastatic lesions because laparotomy resection was needed for the retroperitoneal lymph node. Laparoscopic sigmoid colectomy was performed first. Pathological examination showed a tubular adenocarcinoma. A laparotomy for the metastatic lesions was performed to ensure complete lymph node dissection secondly. Histopathological findings of the liver tumor showed metastasis of sigmoid colon cancer. However, the tissue regarded as the enlarged lymph node was diagnosed as a neurofibroma. No metastasis and recurrence were observed.

CONCLUSION

Although most neurofibromas are benign, malignant transformation of a neurofibroma is possible. PET-CT showed our patient had a high accumulated retroperitoneal tumor co-existing with colon cancer and liver metastasis. The treatment strategy of a solitary neurofibroma must be selected carefully considering the site of occurrence and the patient's background and aggressive resection of a tumor co-existing with another malignant tumor is needed.

Periappendiceal fluid collection on preoperative computed tomography can be an indication for interval appendectomy: a retrospective study

Background

The treatment strategies for acute appendicitis, such as emergency appendectomy (EA), interval appendectomy (IA), and repeating nonoperative management (NOM), are controversial. In this study, we examined the preoperative factors that can be used to distinguish which patients should undergo IA.

Methods

We retrospectively identified 902 patients who underwent surgery for appendicitis in our hospital from January 2010 to December 2021. Of these patients, 776 were included in this study. The patients were divided into two groups: those with a periappendiceal fluid collection (PAFC) on preoperative computed tomography (PAFC-positive group, n = 170) and those without a PAFC (PAFC-negative group, n = 606). In each group, we compared patients who underwent EA and IA.

Results

In the PAFC-positive group, patients who underwent EA had a significantly higher postoperative complication rate than those who underwent IA (40.5% vs. 24.0%, p = 0.037). In the multivariate analysis, only the presence of PAFC was significantly associated with an increased risk of postoperative complications (odds ratio, 7.11; 95% confidence interval, 2.73–18.60; p < 0.001). The presence of PAFC alone was not significantly associated with an increased risk of IA or NOM failure (odds ratio, 1.48; 95% confidence interval, 0.19–11.7; p = 0.71). The rate of neoplasia on pathologic examination was significantly higher in the PAFC-positive than PAFC-negative group (7.6% vs. 1.5%, p < 0.001); the rate of carcinoma was also higher in the PAFC-positive group (2.4% vs. 0.17%, p = 0.02).

Conclusions

The presence of PAFC on preoperative computed tomography was found to be a risk factor for postoperative complications but not IA or NOM failure. It was also correlated with neoplasia as the etiology of appendicitis. Therefore, PAFC positivity is useful as an indication for IA.

[Two Cases of Pneumocystis Jirovecii Pneumonia during Chemotherapy for Gastrointestinal Cancer]

BACKGROUND

In recent years, there has been an increasing incidence of Pneumocystis jirovecci pneumonia(PCP)in immunosuppressed non-HIV patients. However, only a few studies on PCP developed during chemotherapy for gastrointestinal cancer have been reported. Case 1: A 72-year-old man was complaining of dyspnea during chemotherapy for unresectable gastric cancer. The patient showed high β-D-glucan levels, and his sputum tested positive for sputum Pneumocystis PCR. Even after TMP-SMX administration, the patient's respiratory condition worsened; hence, intubation was needed. Finally, he died without showing any improvement. Case 2: A 75-year-old man underwent chemotherapy for a recurrence of cecal cancer and received steroid pulse for adverse events of optic neuritis. However, his respiratory condition worsened. Furthermore, his sputum tested positive for Pneumocystis PCR. Intensive care including TMP-SMX administration followed to improve his condition.

DISCUSSION

PCP with non-HIV has a more acute onset and a poorer prognosis than that with HIV. It is necessary to identify PCP when there is a rapid progression of respiratory symptoms and pneumonia in cancer patients undergoing chemotherapy or steroid treatment.

Emergency gastrointestinal surgery in patients undergoing antithrombotic therapy in a single general hospital: a propensity score-matched analysis

BACKGROUND

This study aimed to review and evaluate the surgical outcomes, particularly intraoperative severe blood loss and postoperative blood complications, of emergency gastrointestinal surgery in patients undergoing antithrombotic therapy (AT). Emergency surgeries for patients with antithrombotic medication have been increasing in the aging population. However, the effect of AT on intraoperative blood loss and perioperative complications remains unclear.

METHODS

We retrospectively reviewed 732 patients who underwent emergency gastrointestinal surgery between April 2014 and March 2019. Patients were classified into AT group and Non-AT group, and propensity score-matched analysis was performed to compare the short surgical outcomes between the groups. Additionally, risk factors in severe estimated blood loss (EBL) and postoperative bleeding complications were assessed.

RESULTS

Altogether, 64 patients received AT; 50 patients and 12, and 2 were given antiplatelet and anticoagulant, and both drugs, respectively. After propensity score matching, EBL (101 vs. 99 mL; p = 0.466) and postoperative complications (14 vs. 16 patients; p = 0.676) were similar between the groups (63 patients matched paired). Intraoperative severe bleeding (EBL ≥ 492 mL) occurred in 44 patients. Multivariate analysis using the full cohort revealed that antithrombotic drug use was not an independent risk factor for severe bleeding and postoperative bleeding complications.

CONCLUSIONS

This study demonstrated antithrombotic drugs do not adversely affect the perioperative outcomes of emergency gastrointestinal surgery.

Emergency laparoscopic ileocecal resection for a low-grade appendiceal mucinous neoplasm with impending rupture: A case report

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Appendiceal mucinous neoplasms account for less than 1% of all cancers.

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LAMNs have an aggressive biological potential.

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Preoperative diagnosis of appendiceal mucinous neoplasms is difficult.

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Here, we used emergency MRI to identify nodules in the appendix before operation.

Introduction and importance

We report the case of a patient with a low-grade appendiceal mucinous neoplasm (LAMN) who underwent emergency laparoscopic ileocecal resection to avoid the metastatic spread of tumor cells due to an impending rupture.

Case presentation

A 55-year-old woman presented to our hospital with pain in the right lower quadrant of the abdomen. Computed tomography revealed a markedly tense appendiceal mucinous tumor with surrounding inflammation, and laboratory test results showed elevated serum C-reactive protein (7.47 mg/dL), indicating impending rupture of the appendix. Magnetic resonance imaging revealed nodules inside the appendix, suggesting the possibility of appendiceal cancer. We performed emergency laparoscopic ileocecal resection with regional lymph node dissection. The tumor was pathologically diagnosed as a LAMN without rupture.

Clinical discussion

LAMN is classified as a clinically malignant tumor because it can cause pseudomyxoma peritonei due to perforation or the presence of residual tissue. Although an appendectomy would be appropriate for LAMN if the tumor margin is secured, ileocecal resection with lymph node dissection is necessary when preoperative discrimination of appendiceal cancer is impossible.

Conclusion

Further studies of preoperative imaging for appropriate differential diagnosis were necessary.

[Two Cases of Peritoneal Dissemination of Gastric Cancer Treated with CART Followed by Chemotherapy]

BACKGROUND

Cell-free and concentrated ascites reinfusion therapy(CART)is useful for relief of the symptoms caused by malignant ascites. We experienced 2 cases of untreated gastric cancer with massive ascites due to peritoneal dissemination, to whom chemotherapy was successfully introduced as a result of improvement of general conditions achieved by CART. Case 1: A 56-year-old woman with massive ascites was introduced for the treatment of gastric cancer. After a CART, oral ingestion became possible and S-1 plus oxaliplatin(SOX)therapy was introduced. Three courses of SOX therapy were possible until just before her death with 6 times of maintenance CART in total. Case 2: An 80-year-old man was introduced for the same reason. After a CART, he was treated with 4 courses of trastuzumab plus capecitabine plus oxaliplatin(Tra plus CapeOX)therapy with 5 times of maintenance CART in total.

DISCUSSION

CART is useful for alleviating symptoms caused by malignant ascites and makes systemic chemotherapy possible because it improves and maintains the general conditions.

Study on laparoscopic spleen preserving distal pancreatectomy procedures comparing splenic vessel preservation and non-preservation

BACKGROUND

The purpose of this study is to investigate whether two types of laparoscopic spleen-preserving distal pancreatectomy (Lap-SPDP) techniques are being implemented safely. The study compares the clinical outcomes from laparoscopic Warshaw operation (Lap-W) with those from laparoscopic splenic vessels preserving SPDP (Lap-SPDP-VP) and considers the role of those operations.

METHODS

On August 2013, the Warshaw technique was introduced to our institution and 17 patients with a lesion in the distal pancreas who underwent Lap-SPDP by December 2015 were enrolled. Six patients who underwent a Lap-W and 11 patients who underwent a Lap-SPDP-VP were investigated retrospectively.

RESULTS

In the Lap-W and Lap-SPDP-VP patients, the sizes of the tumors were 46.5±31.2 and 25.7±14.9 mm [Probability (P) value =0.0913)]; the operative times were 287 min (range, 225-369 min) and 280 min (range, 200-496 min); the blood loss was 95 mL (range, 50-200 mL) and 60 mL (range, 0-650 mL); the length of the postoperative hospital stay was 12 days (range, 8-43 days) and 11 days (range, 7-28 days); median follow-up was 19 months (range, 13-28 months) and 23 months (range, 6-28 months), respectively. There was no case of symptomatic spleen infarction in either group. However, partial infarctions of the spleen without symptoms were observed by computed tomography in three out of six cases (50%) in the Lap-W. No patient required reoperation and the postoperative mortality was zero in both groups. All patients were alive and recurrence-free at the end of the follow-up period. Collateral veins around the spleen developed in 83.3% (five out of six patients) in the Lap-W and developed in 12.5% (one out of eight patients) in the Lap-SPDP-VP. A significant difference was observed between groups (P=0.0256). Gastric varices developed in 33.3% (two out of six patients) in the Lap-W. However, no case of rupture of varices, or other late phase complications was observed in either group.

CONCLUSIONS

Both the Lap-W and Lap-SPDP-VP were found to be safe and effective, and in cases in which the detachment work of the splenic vessels from the tumor or the pancreatic parenchyma is difficult, performing Lap-W, rather than Lap-SPDP-VP, is considered appropriate. While Lap-SPDP is recommended for patients with benign or low grade malignant diseases, long-term follow-up to monitor hemodynamic changes in splenogastric circulation is considered needed.

Clinical outcomes for 14 consecutive patients with solid pseudopapillary neoplasms who underwent laparoscopic distal pancreatectomy

INTRODUCTION

The postoperative results of laparoscopic distal pancreatectomy for solid pseudopapillary neoplasm of the pancreas (SPN), including the effects of spleen-preserving resection, are still to be elucidated.

METHODS

Of the 139 patients who underwent laparoscopic pancreatectomy for non-cancerous tumors, 14 consecutive patients (average age, 29.6 years; 1 man, 13 women) with solitary SPN who underwent laparoscopic distal pancreatectomy between March 2004 and June 2015 were enrolled. The tumors had a mean diameter of 4.8 cm. Laparoscopic spleen-preserving distal pancreatectomy was performed in eight patients (spleen-preserving group), including two cases involving pancreatic tail preservation, and laparoscopic spleno-distal pancreatectomy was performed in six patients (standard resection group).

RESULTS

The median operating time was 317 min, and the median blood loss was 50 mL. Postoperatively, grade B pancreatic fistulas appeared in two patients (14.3%) but resolved with conservative treatment. No patients had postoperative complications, other than pancreatic fistulas, or required reoperation. The median postoperative hospital stay was 11 days, and the postoperative mortality was zero.None of the patients had positive surgical margins or lymph nodes with metastasis. The median follow-up period did not significantly differ between the two groups (20 vs 39 months, P = 0.1368). All of the patients are alive and free from recurrent tumors without major late-phase complications.

CONCLUSION

Laparoscopic distal pancreatectomy might be a suitable treatment for patients with SPN. A spleen-preserving operation is preferable for younger patients with SPN, and this study demonstrated the non-inferiority of the procedure compared to spleno-distal pancreatectomy.

Clinical outcomes of 15 consecutive patients who underwent laparoscopic insulinoma resection: The usefulness of monitoring intraoperative blood insulin during laparoscopic pancreatectomy

BACKGROUND

Insulinoma is a very serious functional tumor. Surgeons should confirm complete resection of insulinomas before completing the operation, even in laparoscopic surgery.

METHODS

Between August 2007 and September 2014, 15 consecutive patients with biochemical evidence of an insulinoma underwent laparoscopic pancreatectomy. Intraoperatively, a peripheral arterial blood sample was taken, and insulin was measured by quick insulin assay. Insulin levels were determined before anesthesia induction, every 30 min thereafter, and every 30 min for at least 1 h after tumor resection to confirm insulin levels did not increase before surgery was completed.

RESULTS

All 15 patients (3 men and 12 women, average age 57.2 years) successfully underwent laparoscopic resection. One patient had two tumors, and the remaining 14 patients had one tumor each (three in the head, five in the body, and eight in the tail of the pancreas). Preoperative localization and regionalization studies identified the tumor correctly through CT (12/15 [80.0%]), MRI (9/12 [75.0%]), angiography (11/13 [84.6%]), endoscopic ultrasonography (7/10 [70.0%]), and selective arterial calcium injection (14/14 [100%]). Intraoperative ultrasonography detected 13 of 15 tumors (86.7%), and intraoperative blood insulin monitoring confirmed the complete resection of 16 of 16 tumors (100%). All patients were discharged with normal insulin levels and have been followed up for 3-88 months. There has been no recurrence of symptoms in any patients and none has died.

CONCLUSION

Complete removal of an insulinoma can be reliably predicted by intraoperative blood insulin monitoring even in laparoscopic pancreatectomies.

Laparoscopic distal pancreatectomy: Educating surgeons about advanced laparoscopic surgery

INTRODUCTION

Laparoscopic distal pancreatectomy (Lap-DP) has been recognized worldwide as a feasible and highly beneficial procedure. The aim of this study is to investigate whether Lap-DP techniques are being implemented safely by surgeons training to perform this procedure.

METHODS

We retrospectively compared the perioperative outcomes of Lap-DP in patients operated on by the surgeon originating this procedure at our hospital (expert surgeon group [E group], n = 47) and patients operated on by surgeons training to perform this procedure (training surgeons group [T group], n = 53).

RESULTS

The median operating times for the E group and T group were 321 min (range, 150-653 min) and 314 min (range, 173-629 min), respectively; these times were not significantly different (P = 0.4769). The median blood loss in the T group (100 mL; range, 0-1950 mL) was significantly smaller than in the E group (280 mL; range, 0-1920 mL) (P = 0.0003). There were no significant intergroup differences in other operative results: combined operation ratio, spleen- and splenic vessels-preserving ratio, hand-assisted procedure ratio, and the ratio of transition to open. The frequency of pancreatic fistulas in the E group and T group was 12.8% and 16.9%, respectively; these rates were not significantly different (P = 0.5886). There were no significant differences between the two groups in terms of other complications and reoperation rates. The median hospital stay for the E group was significantly shorter than for the T group (10 vs 13 days; P = 0.0307).

CONCLUSION

This retrospective analysis shows that teaching safe Lap-DP techniques to surgeons is reflected in stable perioperative outcomes.

[Radical resection of a locally advanced pancreatic tail adenosquamous carcinoma treated with S-1 and gemcitabine as neoadjuvant chemotherapy - a case report]

We report a case of locally advanced pancreatic tail adenosquamous carcinoma that was treated by performing R0 resection after neoadjuvant chemotherapy with S-1 and gemcitabine. A 75-year-old man visited our hospital because of left lateral abdominal pain. On the basis of computed tomography and endoscopic biopsy findings, an 80-mm locally advanced pancreatic tail carcinoma with direct invasion to the gastric upper body, splenic flexure of the colon, and left kidney was diagnosed. Combined chemotherapy with S-1 and gemcitabine was initiated for reduction in the tumor size. After 11 courses of treatment, computed tomography revealed a partial response in tumor size reduction. Grade 3 neutropenia was observed as an adverse event. Distal pancreatectomy, proximal gastrectomy, partial resection of the descending colon, resection of the left kidney and left adrenal gland, and D2 lymph node dissection were performed. The pathological diagnosis was adenosquamous carcinoma in the pancreatic tail, and an R0 resection was achieved. However, a month after surgery, multiple distant liver metastases were observed. Neoadjuvant chemotherapy with S-1 and gemcitabine may reduce the tumor size in locally advanced pancreatic tail adenosquamous carcinoma and increase the R0 resection rate. However, treatment for distant metastasis is warranted in cases of pancreatic adenosquamous carcinoma.

Multicentric pancreatic intraepithelial neoplasias (PanINs) presenting with the clinical features of chronic pancreatitis

A 46-year-old woman was readmitted to our hospital in August 2005 because of severe abdominal pain and nausea. Computed tomography demonstrated a huge cystic lesion in the retroperitoneal space behind the hepatoduodenal ligament and lesser peritoneal cavity. Endoscopic retrograde pancreatography revealed communication between the dilated main pancreatic duct and a pseudocyst. The condition was preoperatively diagnosed as chronic pancreatitis associated with a pseudocyst or an intraductal papillary mucinous neoplasm without mucin hypersecretion. The patient underwent a distal pancreatectomy with splenectomy. The pathologic diagnosis was multicentric pancreatic intraepithelial neoplasia (PanIN), and histological examination revealed a positive surgical margin around the remnant pancreas. Four months after the surgery, the patient underwent a total pancreatectomy. Macroscopic observation revealed diffuse fibrosis of the pancreatic parenchyma compatible with chronic pancreatitis. Histological examination revealed a constellation of noninvasive intraductal neoplasias with high-grade atypia, diffusely distributed in the small pancreatic ducts of the resected pancreas. Localized fibrosis and cystic dilation of the small ducts were detected in a lobule of exocrine glands draining into a ductule involved by PanIN lesions in the head of the pancreas. In summary, multicentric PanIN lesions are associated with lobular atrophy of the pancreatic parenchyma and chronic pancreatitis-like changes that follow. Total pancreatectomy may be recommended for patients with multicentric precursor lesions throughout the entire pancreas.

Efficacy of a Blake drainR on pancreatic fistula after pancreaticoduodenectomy

BACKGROUND/AIMS

The aim of this study was to evaluate the efficacy of the Blake drain for the management of pancreatic fistula (PF) in comparison with the Duple drain.

METHODOLOGY

Our study consisted of two parts: a retrospective review of 33 patients with PF after pancreaticoduodenectomy, and a basic experiment to investigate the effects of the Blake drain on the management of PF in an animal model.

RESULTS

In the clinical study, 19 patients received Blake drains (B-group) and 14 received Duple drains (D-group). Grade C fistulas with abdominal bleeding developed in only 2 patients in the B-group. All the patients in the B-group healed with conservative treatment (P<0.01). and none of them required percutaneous drainage or reoperation (P<0.05). In the basic experiment, no collections of fluid were detected around the Blake drains. When leakage occurred, it did not lead to abdominal abscess, and a "drain canal" formation linking the anastomosis with the extracorporeal orifice was demonstrated all along the drainage route.

CONCLUSIONS

Blake drains may be efficient therapeutic tools in patients with grade B fistulas. The basic experiment affirms that Blake drains provide excellent drainage and contribute to the formation of "drain canals" effective in localizing and controlling PF.

Improvement of intraoperative frozen section diagnosis in patients with biliary strictures by Levovist injection into the bile duct on color Doppler ultrasonography

BACKGROUND

This study evaluates the efficiency of color Doppler ultrasonography-guided intraoperative pancreatic biopsy (CDUS-IPB) using Levovist injected into the bile duct in conjunction with stimulated acoustic emission (SAE) in patients with biliary strictures.

METHODS

The study was performed on 12 patients. After completing a conventional intraoperative pancreatic biopsy (c-IPB), each subject underwent CDUS with SAE imaging using Levovist. Upon identification of the biliary stricture, the IPB was taken from the area surrounding the stricture on the same imaging setting. Section diagnosis of the CDUS-IPB specimen was compared to that of the c-IPB specimen and resected tissue.

RESULTS

Biliary strictures were identified as enhanced areas of color Doppler signal on CDUS. CDUS-IPB provided adequate specimens from the biliary strictures in all cases and corrected false-negative diagnoses by c-IPB in three cases. Section diagnosis by CDUS-IPB corresponded to the permanent section diagnosis. There were no complications.

CONCLUSIONS

CDUS-IPB with Levovist is an accurate diagnostic tool. The method is especially useful for patients with a suspected malignant biliary stricture who show no tumor mass in preoperative images and no evidence of malignancy on cytologic examinations.

Adenoma of the minor papilla associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare. We report the first documented case of an adenoma of the minor papilla complicating pancreas divisum. A 52-year-old woman was admitted to our hospital for treatment of an asymptomatic duodenal tumor detected by computed tomography scan. Endoscopy showed an 18-mm, whitish-colored, sessile mass located in the descending duodenum proximal to a normal appearing major papilla. Endoscopic retrograde pancreatography revealed divisum of the pancreas with dilatation of pancreatic duct ranged in the dorsal pancreas. Transduodenal minor papillectomy was performed because there is malignant potential of the tumor and the possibility of acute pancreatitis. The Santorini orifice was then re-approximated to the duodenal wall for protection against acute pancreatitis caused by scarring and stenosis of the duct orifice as a possible late complication. The patient's postoperative course was uneventful and she has been asymptomatic without evidence of tumor recurrence or stenosis of the Santorini orifice on endoscopic examination for the last 4 years.

Preventing liver metastasis by resecting the primary pancreatic carcinoma at an early stage of intrapancreatic transplantation in hamsters

PURPOSE

To determine whether early primary pancreatic tumor resection can prevent liver metastases of intrapancreatic transplantation in a hamster model.

METHODS

Cells from the PGHAM-1 cell line were transplanted into the pancreases of 30 Syrian golden hamsters. A suspension of 5 x 10(6) cells was injected into the splenic lobe of each pancreas. The primary pancreatic tumor was resected in 15 of the hamsters 10 days after transplantation (resection group). Fifteen other animals with transplantation but without resection served as controls (control group). All hamsters were killed 21 days after transplantation. The primary pancreatic tumors were measured for size and volume and examined histologically and immunohistologically for angiogenesis and tumor proliferation.

RESULTS

In the resection group, small pancreatic tumors 4.7 +/- 0.94 mm in diameter were found and resected 10 days after transplantation. Neither pancreatic tumors nor liver metastases were found in the resection group at the end of the experiment. All animals in the control group had pancreatic tumors 12.3 +/- 3.29 mm in size, and 11 of 15 (73.3%) had liver metastases. The primary pancreatic tumors in the group with liver metastasis were significantly larger in diameter and volume than those in this group without liver metastasis (p<0.01). In the control group, proliferation of the primary pancreatic tumor, evaluated according to argyrophilic nucleolar organizer region, showed no differences within the pancreatic tumor group. On the other hand, the microvessel density of pancreatic tumors with liver metastases was significantly higher than that of tumors without liver metastases.

CONCLUSIONS

Our results suggest that 10 days after transplantation, the pancreatic tumors were small in size and volume and ready to proliferate but not yet ready to begin metastasizing through angiogenesis. This is one reason why early resection of the primary tumor prevents liver metastasis.

Boerhaave syndrome treated conservatively following early endoscopic diagnosis: a case report

We report on a 41-year-old man with hematemesis and severe epigastric pain. Three hours after the onset of symptoms, we carefully performed upper gastrointestinal endoscopy for suspected upper gastrointestinal perforation. Endoscopy revealed a 2.5-cm-long longitudinal laceration of the lower esophagus without active gastric or duodenal ulcers. The laceration could be partially closed with endoscopic clipping. Computed tomography of the chest revealed a small amount of extraluminal air in the mediastinum. Neither pleural effusion nor pneumothorax was detected. We treated the patient conservatively on the basis of the following factors: a stable general condition without sepsis, limitation of the esophageal disruption to the mediastinum, and early diagnosis. The treatment course was uneventful, and the patient was discharged from the hospital after we had confirmed with endoscopy that the esophageal ulcer was completely healed. Although Boerhaave syndrome is generally considered to have poor prognosis, conservative therapy may be effective in select cases with early detection of the perforation.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Clinicopathologic study on pancreatic groove carcinoma

OBJECTIVES

Pancreatic groove carcinoma usually presents with duodenal stenosis. This report describes the clinicopathologic features of 5 cases.

METHODS

All the clinical and radiological features were reviewed retrospectively and analyzed to identify correlations with the histological findings.

RESULTS

Vomiting was an initial symptom in all cases, but obstructive jaundice was not inevitable until the disease progresses. Hypotonic duodenography demonstrated severe postbulbar stenosis. Pathological findings of biopsy specimens showed no evidence of malignancy at the early stage. Computed tomography revealed a hypovascular mass. Magnetic resonance imaging indicated a hypointense mass on T1-weighted images and an isointense to slightly hyperintense mass on T2 images. Macroscopically, the stenosis seemed to be the result of a hard yellowish-white tumor invading the duodenal wall. Histopathologically, an adenocarcinoma arising from the groove infiltrated the submucosal layer of the duodenum circumferentially. No cancer cells were found in the mucosa at the early stage. The intrapancreatic common bile duct was involved at the advanced stage.

CONCLUSIONS

We believe that these features resulted from the anatomical characteristics of the groove involvement and that the string stricture of the duodenum resulted from invasion of the groove tumor into the submucosal layer around the wall.

Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis: a case report

A 69-year-old man presented with obstructive jaundice and dark urine. Contrast-enhanced computed tomography revealed an enlarged pancreas with homogenous enhancement. Endoscopic retrograde pancreatography demonstrated short-segmental, irregular narrowing of the main pancreatic duct. The patient underwent exploratory laparotomy and needle biopsies of the pancreas, which showed marked fibrotic change with lymphocyte infiltration. These clinicopathologic findings suggested autoimmune pancreatitis. Four years later, computed tomography demonstrated marked periaortic soft tissue surrounding a calcified infrarenal abdominal aorta compatible with retroperitoneal fibrosis. We diagnosed retroperitoneal fibrosis with noncontiguous pancreatic fibrosis. This patient responded well to corticosteroid treatment. Autoimmune pancreatitis associated with idiopathic retroperitoneal fibrosis seems to be extremely rare, and to our knowledge, only a few cases have been reported.

Pancreatic Arteriovenous Malformation Involving Adjacent Duodenum with Gastrointestinal Bleeding: Report of a Case

A 54-year-old man was admitted to our hospital with the symptoms of palpitation, dyspnea, and tarry stool. Upper gastroduodenal endoscopy revealed submucosal lesions with vascular ectasia in the second part of the duodenum. Dynamic computed tomography (CT) detected a hypervascular lesion in the pancreatic head and the duodenum. Selective angiography showed proliferation of a vascular network and early filling of the portal vein at the early arterial phase. With a diagnosis of pancreatic arteriovenous malformation (AVM), we performed pylorus-preserving pancreaticoduodenectomy. At laparotomy, localized and meandering vessels were seen on the surface of the head of the pancreas. Histological examination showed dilated tortuous vessels accompanied by severed elastic fibers in the vessel media and blood clot formation. The incidence of pancreatic AVM remains extremely low, and recurrent gastrointestinal bleeding is a frequent complication. To prevent recurrent bleeding and progressive portal hypertension, surgery may be the definitive management of symptomatic AVM.

Changes to levels of serum neuron-specific enolase in a patient with small cell carcinoma of the pancreas

Small cell carcinoma (SCC) of the pancreas is a rare disease, with an extremely poor prognosis; only 24 cases have been reported in the literature. However, as some patients have been successfully treated with combination chemotherapy, it is important to obtain both a definite diagnosis and a precise evaluation of the effect of the treatment. A 69-year-old woman presented with an abdominal tumor and pain. She had been observed for sensory neuropathy and swelling of the pancreatic head by the referring doctor over the previous 9 months. The patient was diagnosed with SCC of the pancreas after surgery and had two courses of combination chemotherapy (cisplatin and etoposide). Initially, the tumor disappeared completely on computed tomography (CT) scans, but she died of disease recurrence 3 months after completing the chemotherapy. Changes in serum neuron-specific enolase (NSE) levels were monitored constantly during the progress of the disease. NSE levels had already increased above the upper limit of normal 8 months before the patient's admission to our hospital, and levels changed concurrently not only with tumor growth but also subsequently with remission and then relapse of the disease after treatment. These results indicate that NSE is a good marker, both as a diagnostic indicator for SCC of the pancreas and as a means of evaluating response to treatment.

Celiac artery aneurysm: a case evaluated preoperatively with three-dimensional computed tomographic angiography

In a 63-year-old woman computed tomography (CT) incidentally detected a celiac artery aneurysm approximately 3 cm in diameter. While conventional angiography suggested that the splenic artery and common hepatic artery arose from the celiac artery aneurysm, three-dimensional CT angiography indicated that the aneurysm involved only the mid portion of the celiac artery. Considering the risk of eventual aneurysm rupture, surgery was performed. Aneurysmectomy and devascularization of hepatic, splenic, and celiac arteries were carried out following complete cross-clamping of the celiac artery. The distal segment of the celiac artery was directly anastomosed to the proximal segment in an end-to-end fashion. Histologically, the aneurysm wall showed atheromatous changes. Contrast-enhanced abdominal CT confirmed complete removal of the celiac artery aneurysm, and postoperative angiography confirmed good arterial flow. The patient recovered uneventfully after surgery, with normalization of transiently abnormal hepatic function parameters. In this case of celiac artery aneurysm, three-dimensional CT angiography was found to be valuable in determining the relationships of the aneurysms to important arterial branches.