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Giant leiomyosarcoma of the remnant stomach: report of a case.

We describe herein the case of a 73-year-old woman who developed a giant leiomyosarcoma in the remnant stomach 4 years after undergoing a distal gastrectomy for gastric carcinoma. Abdominal ultrasonography and computed tomography revealed a huge tumor, 22 cm in maximum diameter, in the left hypochondrial region. Selective abdominal angiography showed a hypervascular tumor fed by the branches of the splenic artery and left inferior phrenic artery. The tumor arose from the posterior wall of the remnant stomach, and demonstrated marked extragastric growth and direct invasion of the pancreas, transverse colon, and diaphragm on the left side. Total resection of the remnant stomach with en bloc resection of these adjacent organs was subsequently carried out. We reviewed the Japanese literature on this extremely rare tumor and evaluated its clinical profile. In comparison with leiomyosarcoma of the unresected stomach, that of the remnant stomach more frequently showed endogastric-type growth and was accompanied by ulceration of the gastric mucosa. The prognosis of patients with leiomyosarcoma of the remnant stomach appears to be greatly affected by the presence of liver metastases and the tumor diameter, similar to that of patients with leiomyosarcoma of the unresected stomach.

Aged↗

Sclerosing mesocolitis.

A case report of sclerosing mesocolitis is presented. This is an unusual and poorly understood entity. A 49-year-old woman presented with episodic abdominal pain and a palpable abdominal mass. A fibrotic mass causing extensive compression of her cecum and transverse colon was found at laparotomy. The pathologic findings and treatment of sclerosing mesocolitis are discussed.

Colitis↗

Constipation. An uncommon etiology.

An uncommon cause of chronic constipation is presented in a case report. The patient presented with chronic cough and constipation. Work-up revealed a loop of transverse colon herniated through a right diaphragmatic tear resulting from an old, blunt, abdominal injury. The diaphragmatic hernia was repaired through a right thoracotomy without complications. Diaphragmatic hernia should be ruled out in patients who present with chronic respiratory or vague abdominal symptoms, especially after a history of blunt abdominal trauma. Once the diagnosis is confirmed, expeditious surgical treatment should be undertaken to prevent the development of obstruction or strangulation and its grave consequences. Thoracotomy is the incision of choice, as it affords good exposure for lysis of adhesions, reduction of the hernia, and repair of the diaphragmatic defect.

Adult↗

Retrograde spread of 5-aminosalicylic acid enemas in patients with active ulcerative colitis.

In an attempt to know the exact retrograde spread of high-dosage 5-aminosalicylic acid enemas, we have studied eight patients with active left-sided colitis, by adding a small amount of barium sulfate to the enemas and by checking the spread radiologically after 15 minutes, 1 hour, and 6 hours. Four grams of 5-aminosalicylic acid in 100-ml enemas and 4 gm in 200-ml enemas were used. The same experiment was repeated in a subsequent attack, with enemas labeled with technetium-99m and checked by scintiscans in five of these patients. We always have observed a volume-dependent spread of enemas but, interestingly, in the patients studied with technetium-99m there was always a wider spread than that which was detected with barium enemas. In all five patients, 100-ml enemas reached the splenic flexure. In two patients with total colitis, a progression of 100-ml technetium-99m enemas was performed in the transverse colon, but the maximum opacity remained in the left side. We can conclude that 4 gm of 5-aminosalicylic acid in 100-ml enemas can be suitable for treating patients with left-sided colitis, and will represent a valid addition for patients with more extensive colitis.

Adult↗

Radiographic and clinical sequelae of the duodenocolic anatomic relationship: two cases of Crohn's disease with fistulization to the duodenum.

The posterior surface of the proximal transverse colon and the anterior surface of the descending duodenum are intimately related. The clinical importance of this apposition is re-emphasized with presentation of two cases which had the uncommon phenomenon of benign duodenocolic fistula. These two rare cases of duodenocolic fistulas secondary to Crohn's disease are added to the literature. It is also suggested that in some cases, duodenal mucosal alterations with adjacent Crohn's disease of the colon might be the result of reactive inflammatory changes, and do not necessarily indicate continuous extension of the granulomatous disease.

Adult↗

Granular-cell myoblastoma of the cercum: report of a case.

A 9-mm granular-cell myoblastoma of the cecum found incidentally during appendectomy in a 17-year-old-girl is reported. Electronmicroscopic findings favor origin of the granular cells from an undifferentiated mesenchymal (fibroblast-like) cell. Review of the small number of previously reported cases revealed three involving the cecum, one each in the ascending and transverse colon and two in the rectum. Four patients were asymptomatic and their lesions were found incidentally. Three lesions simulated maligancy clinically; these patients underwent right hemicolectomy.

Adolescent↗

Spontaneous massive gastrointestinal hemorrhage in patients with pancreatitis.

Spontaneous massive gastrointestinal hemorrhage occurring in patients with pancreatitis is an uncommon and difficult clinical problem, especially in a tropical third world country where the underlying causes of pancreatitis and facilities for its diagnosis and management are different from those in the developed West. Of 7 such cases seen by us in 3 years, 2 were due to hemosuccus pancreaticus, 2 were due to gastric variceal hemorrhage consequent to splenic vein obstruction, and one each due to contiguous pancreatic inflammation involving the duodenum, an aneurysmal bleed from the left gastric artery and a pseudocyst rupturing into the transverse colon. A fiberoptic endoscopic examination was helpful in all the 7 cases and delineated the cause of bleeding, whereas angiography, performed in 4 patients contributed little to management. The mortality rate was 14%. It is suggested that a timely endoscopic examination during active bleeding, which may be repeated if necessary, is extremely rewarding in the diagnosis and management of such patients and often obviates the necessity of angiography which is a time-consuming and cumbersome investigation in a critically ill patient and facilities for which are usually not available in most third world country hospitals.

Adult↗

Massive gastrointestinal bleeding as the initial manifestation of pancreatic carcinoma.

Pancreatic carcinoma is a rare cause of GI bleeding. We have studied eight patients in whom major digestive hemorrhage was the first sign of a subsequently proven pancreatic malignancy. Bleeding was characteristically severe and unremitting, including hematochezia (four), melena (three), and hematemesis (one). In seven cases, direct tumor invasion into a contiguous portion of the GI tract was present. Tumor erosion occurred into the third portion of the duodenum (three) descending (two), stomach (one), and transverse colon (one). In one patient, a metastatic bleeding lesion was present in the sigmoid colon. The four patients who required urgent laparotomy for control of major hemorrhage died during the initial hospitalization. Conventional diagnostic evaluation by endoscopic and roentgenographic techniques was commonly unsuccessful. Our retrospective analysis suggested that a more aggressive approach, including early angiography in unrelenting and undiagnosed bleeding, might have aided diagnosis and averted laparotomy in a population with dismal prospects for a surgical solution. Clinicians should be aware that pancreatic malignancy may present with a varying spectrum of GI bleeding ranging from occult to potentially exsanguinating hematemesis, hematochezia, or melena.

Aged↗

[Intestinal distention during elective abdominal surgery: should nitrous oxide be banished?].

High concentrations (70-80 per cent) of nitrous oxide (N2O) have been shown to cause distension of gas-containing distensible structures such as the intestines and are, for this reason, avoided by some during elective abdominal operations on the GI tract. We undertook this study to determine if N2O was responsible of a measurable change in intestinal diameter or of clinical difficulty in closing the abdomen in patients undergoing elective intestinal surgery of intermediate duration. Twenty patients scheduled for elective abdominal surgery were studied. Premedication and induction were identical in all patients. Maintenance of anesthesia in Group I was with enflurane in air/oxygen, and fentanyl. Patients in Group II received enflurane in N2O/oxygen, and fentanyl. FIO2 was 0.4 in both groups and monitored neuromuscular blockade with pancuronium was kept optimal throughout the operation. The surgeon was blinded as to the random distribution of patients to either group. Girth measurements at the level of the umbilicus were recorded before induction and after surgery. The circumferences of the terminal ileum and of the transverse colon were measured at the beginning and at the end of surgery. The surgeon was asked to rate the difficulty in closing the abdomen as 0 = none, 1 = slight, 2 = moderate, 3 = severe, 4 = impossible. Data were analysed using Student's paired t test, unpaired t test and Fisher's exact test. P less than 0.05 was considered statistically significant. There was no significant difference between groups in age, sex distribution, weight and duration of surgery (approximately 90 minutes in both groups).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

A patient with undifferentiated carcinoma of gallbladder presenting with hemobilia.

Hemobilia is relatively rare among hemorrhages in the digestive tract, and hemobilia caused by tumors of the biliary tract is particularly rare. We treated a 74-year-old-man with undifferentiated carcinoma of the gallbladder presenting with hemobilia. During hospitalization for neurogenic bladder at the Department of Urology, he showed progressive anemia. Since hemorrhage in the digestive tract was suspected, endoscopy of the upper gastrointestinal tract was performed, and bleeding from the papilla of Vater was observed. On ultrasound examination, findings were indicative of cholecystic cancer, and hemorrhage from the cystic duct was found on percutaneous transhepatic cholangioscopy. On perioral cholecystoscopy, however, masses of coagulated blood were found only in the gallbladder. Abnormalities such as dense staining of tumors or extravasation were not found on angiography. The patient died of hepatic failure due to rapid invasion of the liver by the tumor, associated with biliary infection and disseminated intravascular coagulation. At autopsy, a nodal tumor was found in the gallbladder, and the cavity of the gallbladder was filled with coagulated masses of blood. Direct invasion of the tumor to the liver, diaphragm, and transverse colon was found. The histopathological diagnosis was undifferentiated carcinoma (pleomorphic large-cell type).

Aged↗

Advanced gastric carcinoma successfully treated with TS-1 as neoadjuvant chemotherapy.

We report a patient with advanced gastric carcinoma successfully treated with the novel oral fluoropyrimidine anticancer drug TS-1 as neoadjuvant chemotherapy. The patient was a 76-year-old man who had gastric cancer clinically diagnosed as N2T4, invading the pancreas, the duodenum, and the transverse colon. He was treated as an outpatient with TS-1, 120 mg, administered orally every day for 28 days, followed by 14 days' rest, as one course. Two courses resulted in a marked reduction of the tumor without severe toxicity. Subsequently, the patient underwent curative surgery consisting of distal gastrectomy with D2 lymph node dissection. No surgical complications were observed. On microscopic examination, a few tumor cells were detected in the ulcer scar of the resected stomach and in the regional lymph nodes. Our report is the first to demonstrate the advantages of TS-1 as neoadjuvant chemotherapy for the treatment of advanced gastric carcinoma.

Journal Article↗

Prognostic factors in patients with advanced gastric cancer with macroscopic invasion to adjacent organs treated with radical surgery.

BACKGROUND: The prognosis of patients with gastric cancer with invasion to adjacent organs is poor. The prognostic factors of patients with advanced gastric cancer with macroscopic invasion to adjacent organs (T4) who were treated with radical surgery was determined in the present study.METHODS: A total of 86 consecutive patients with advanced gastric cancer who underwent radical (potentially curable) gastrectomy with combined resection of other organs for macroscopic invasion to adjacent organs during surgery, were investigated. The organs invaded macroscopically were the pancreas in 43 patients, mesocolon in 29, liver in 7, transverse colon in 5, adrenal gland in 3, spleen in 1, diaphragm in 1, and other organs in 5. The prognostic factors were evaluated by univariate and multivariate analysis.RESULTS: The cumulative 5-year survival rate of the patients treated by radical surgery with the combined resection of invaded organs was 35.0%. Multivariate analysis demonstrated that location of the tumor, lymph node metastasis, histological depth of invasion, and extent of lymph node dissection were significant prognostic factors in advanced gastric cancer patients treated by radical surgery with combined resection of adjacent organs for macroscopic invasion.CONCLUSION: For patients with macroscopic T4 gastric cancer located in the middle- or lower-third of the stomach, aggressive resection of invaded adjacent organs with extended lymph node dissection should be performed to improve long-term outcome.

Journal Article↗

Gastrointestinal hemorrhage in hepatocellular carcinoma: management with transheptic arterioembolization.

Gastrointestinal hemorrhage in patients with hepatocellular carcinoma is common and a major contributor to mortality. These patients tend to have a very poor prognosis. This report describes five such cases in which gastrointestinal bleeding was one of the presenting problems and required urgent management. The causes of massive intermittent gastrointestinal bleeding were variceal (two cases), direct invasion of the duodenum (one case), transverse colon (one case), and stomach (one case). All five patients were inoperable because of locally advanced disease, poor general condition, or comorbid disorders and were managed with angioembolization. After transcatheter embolization, the bleeding stopped completely in two patients and was reduced significantly in the remaining three. We report the role of transhepatic arterioembolization in the management of gastrointestinal bleed in such patients, and we recommend its use more often in similar situations.

Adult↗