Mesocolic hernia after laparoscopic transverse colectomy: A case report.

INTRODUCTION: Internal hernias are rare after laparoscopic colorectal resections. We report a patient with an internal hernia through a defect in the transverse mesocolon following laparoscopic resection. PRESENTATION OF CASE: A 52-year-old male underwent laparoscopic colectomy for transverse colon cancer and had an unremarkable postoperative course. Thirty days postoperatively, he presented to the emergency room with sudden onset abdominal pain and vomiting. Enhanced abdominal computed tomography scan showed strangulated small intestine in the left upper abdomen. An internal hernia through the mesenteric defect created during the recent colon resection was suspected, and emergency laparotomy was performed. One hundred thirty cm of small intestine was found herniated through a mesenteric defect. After repositioning the ischemic-appearing intestine, a 5 cm defect in the transverse mesocolon was found which had not been closed during the previous laparoscopic operation. No intestinal resection was needed, and the mesenteric defect closed with non-absorbable sutures. The post-operative course was unremarkable except for paralytic ileus, which resolved without further intervention. DISCUSSION: The incidence of internal hernia through a mesenteric defect after laparoscopic colorectal resection is quite low. Therefore, routine closure of the mesenteric defect after laparoscopic colorectal resection is not required. However, a left sided defect in the transverse mesocolon might be at higher risk of causing an internal hernia on anatomic grounds. CONCLUSION: We believe that mesenteric defects should be closed after laparoscopic resection of the left side of transverse colon, regardless of their size.

Magnetic resonance lymphography of sentinel lymph nodes in patients with breast cancer using superparamagnetic iron oxide: a feasibility study.

BACKGROUND: The sentinel lymph node (SLN) biopsy technique using superparamagnetic iron oxide (SPIO) as a tracer instead of radioisotopes has been described. To further advance this technique, we evaluated preoperative SPIO-MR sentinel lymphography to facilitate the accurate identification of the lymphatic pathways and primary SLN. METHODS: A prospective study was performed in ten patients with breast cancer and clinically negative axillary lymph nodes. None of the patients received preoperative chemotherapy. After 1.6 ml of SPIO (ferucarbotran) was injected in the subareolar breast tissue, sentinel axillary lymph nodes were detected by MRI in T2*-weighted gradient echo images and resected using the serial SPIO-SLN biopsy procedure with a handheld magnetometer. RESULTS: In one patient, gadolinium-enhanced MR imaging was performed at the same time as SPIO-MR lymphography, and this patient was excluded from further analysis. In all patients (9/9) SLNs were detected by SPIO-MR sentinel lymphography and successfully identified at surgery. The number of SLNs detected by lymphography (mean 2.7) significantly correlated with SLNs identified at surgery (mean 2.2). One patient had nodal metastases. In one patient, skin color changed to brown at the injection site and resolved spontaneously. There were no severe reactions to the procedure or complications in any patient. CONCLUSIONS: This is the first study to evaluate SPIO both as a contrast material in MR sentinel lymphography and as a tracer in SLN biopsy using an integrated method. The acquired three-dimensional imaging demonstrated excellent image quality and usefulness to identify SLN in conjunction with SLN biopsy.

Sentinel lymph node biopsy in patients with breast cancer using superparamagnetic iron oxide and a magnetometer.

BACKGROUND: Some hospitals lack facilities for radioisotopes in sentinel node biopsy. A novel method is used with a superparamagnetic tracer and a magnetometer instead of a radioisotope. METHODS: Thirty patients were included in the study after obtaining IRB approval. Superparamagnetic iron oxide and patent blue dye were injected in the subareolar breast tissue. Following a few minutes of massage to promote migration of the iron tracer and blue dye throughout the lymphatic vessels, the axillary lymph nodes were detected transdermally using a handheld magnetometer and followed by standard axillary dissection in all patients. RESULTS: Of 30 patients evaluated, sentinel lymph nodes were identified in 90% (27/30) using both blue dye and magnetic tracer. Sentinel lymph nodes were identified using the magnetic method in 23/30 (77%) and blue dye in 24/30 (80%). There was one false-negative sentinel node, resulting in an overall sensitivity of 6/7 (86%). CONCLUSIONS: This is the first study to use a magnetic tracer to identify sentinel lymph nodes in patients with breast cancer. This new technique may alter the role of radioisotopes with further refinement and experience.

Spontaneous regression of pulmonary metastases from a malignant phyllodes tumor.

We report a case of spontaneous regression of pulmonary metastases from a malignant phyllodes tumor. A 50-year-old woman was diagnosed with a breast phyllodes tumor. Computed tomography and positron emission tomography revealed multiple lung metastases. She underwent a mastectomy to control the pain of the enlarging breast mass. Histopathologic examination diagnosed a malignant phyllodes tumor. Without the administration of any adjuvant therapy, the follow-up chest computed tomography scan and positron emission tomography scan showed disappearance of the lung metastases 2 months after surgery.

Carcinoma Arising from Brunner's Gland in the Duodenum after 17 Years of Observation - A Case Report and Literature Review.

A 60-year-old man presented with melena and hematemesis in 1984. Esophagogastroduodenoscopy (EGD) detected a small protruding lesion in the duodenal bulb, which was diagnosed as Brunner's adenoma. No significant change was detected in subsequent annual EGD and biopsies for 10 years, after which the patient was not observed for 7 years. The patient presented with melena again in 2001. The lesion had changed shape to become a 10 mm sessile tumor with a central depression, and following a biopsy was diagnosed as an adenocarcinoma. The patient underwent partial resection of the duodenum. Histopathological assessment showed acidophilic cells with swollen nuclei, and clear cells forming a tubular or papillary tubule in the mucosal lamina propria and submucosal layer. The tumor cells stained positive for lysozyme, indicating that they arose from Brunner's gland. The patient showed no sign of recurrence and was disease-free for more than 34 months after surgery. The patient died of pneumonia. This is an extremely rare case of primary duodenal carcinoma arising from Brunner's gland in a patient observed for 17 years.

[An outpatient with unresectable pancreatic cancer treated with gemcitabine showing prolonged NC (22 months)].

A 76-year-old man developed jaundice and was hospitalized in January 2002. A 3 cm tumor was found in the head of the pancreas by abdominal CT, and the patient underwent laparotomy. The tumor was histologically diagnosed as a well-differentiated adenocarcinoma, and showed extensive invasion to the portal vein (T4NXM 0 Stage IV a). Incisional biopsy and hepaticojejunostomy were performed. On the basis of a drug sensitivity test, chemotherapy with 800 mg/m2/week gemcitabine was administered. The patient showed prolonged NC without any symptoms for 22 months, although the CEA and DUPAN-2 levels gradually increased during this time and massive ascites were detected in a routine abdominal CT at 22 months postsurgery. The patient died after 25 months of chemotherapy. Here we report a case of unresectable pancreatic cancer treated with gemcitabine on the basis of a drug sensitivity test.

Post-ERCP pancreatogastric fistula associated with an intraductal papillary-mucinous neoplasm of the pancreas--a case report and literature review.

BACKGROUND: Fistula formation has been reported in intraductal papillary-mucinous neoplasms (IPMNs) with or without invasion of the adjacent organs. The presence or absence of invasion is mostly determined by postoperative histological examination rather than by preoperative work-up. CASE PRESENTATION: A 72 year-old Japanese woman showed remarkable dilatation of the main pancreatic duct (MPD) in the distal region of the pancreas. Subsequent ERCP also showed MPD dilatation, after which the patient suffered moderate pancreatitis. A subsequent gastroscopy revealed a small ulceration that had not been observed in a gastroscopy performed 3 months prior. Mucinous discharge from the ulceration suggested it might be the orifice of a fistula connected to the MPD. En bloc resection including the distal region of the pancreas, spleen, stomach and part of the transverse colon was performed under the pre- and intraoperative diagnosis of an invasive malignant IPMN. However, histopathology revealed the lesion to be of "borderline malignancy" without apparent invasion of the stomach. Light microscopy showed inflammatory cellular infiltrates (mainly neutrophils) around the pancreatogastric fistula, but there was no evidence of neoplastic epithelia lining the fistulous tract. CONCLUSION: This case highlights that a pancreatogastric fistula can develop after acute inflammation of the pancreas in the absence of cancer invasion. Further information regarding IPMN-associated fistulae is necessary to clarify the pathogenesis, diagnosis, appropriate surgical intervention and prognosis for this disorder.

Single-branch resection of the pancreas.

The treatment of intraductal papillary mucinous tumors (IPMT) of the pancreas is still controversial. In this report we describe a single-branch resection of the pancreas (SBRP), which is a new method for the removal of branch-type IPMT of the head of the pancreas. A multilobular cystic lesion (50 x 40 mm) in the head of the pancreas was incidentally detected in an asymptomatic 40-year-old man who underwent a routine ultrasound examination. The tumor was carefully removed along the border of the cyst and the normal parenchyma, with complete preservation of the main pancreatic duct and the common bile duct. A pancreatic fistula developed during the postoperative period, but was well-controlled by endoscopic naso-pancreatic drainage. SBRP is a technically feasible procedure and this operation represents a minimally invasive alternative to any other segmental resection of the pancreas.

Primary small-cell neuroendocrine carcinoma of the duodenum - a case report and review of literature.

BACKGROUND: Small-cell neuroendocrine carcinoma in the duodenum is an extremely rare neoplasm with poor prognosis. CASE PRESENTATION: A 57-year-old man presented with sudden onset gastrointestinal bleeding and fainting attacks. Duodenoscopy and hypotonic duodenography revealed a 3 x 3 cm protruding tumor with ulcerations situated opposite the ampulla of Vater in the second part of the duodenum. Local excision of the tumor was performed, followed by adjuvant chemotherapy with 5-fluoro uracil and leucovorin. Examination of the tumor by immunohistochemistry and electron microscopy indicated it to be neuroendocrine in nature, expressing synaptophysin and AE1/AE3, and containing dense core granules. The patient showed no sign of recurrence and has been disease-free for more than 48 months after surgery. CONCLUSIONS: Most cases of small-cell neuroendocrine carcinoma in the duodenum show rapid progression of the disease, and even radical surgery with or without chemotherapy do not prevent death. We report a rare subtype of small-cell neuroendocrine carcinoma. This subtype appears to have a much better prognosis, and may be amenable to local excision, if the lesion is away from the ampulla of Vater.

Long-term survivor without recurrence after resection of simultaneous solitary pancreatic metastasis from thyroid medullary carcinoma.

A 43-year-old Japanese man had an increasing level of serum CEA pointed out by annual physical check-ups. No abnormal findings were detected in the lungs or gastrointestinal tract. The only pathological lesions were a 1.5-cm-sized nodule in the pancreatic tail and a 5-cm-sized thyroid tumor. The thyroid tumor was shown to be medullary carcinoma by aspiration cytology. He underwent total thyroidectomy with extensive lymph node dissection. After thyroid surgery, the patient received distal pancreatectomy 2 weeks later. Pathological examination revealed the pancreatic tumor to be a metastasis of thyroid medullary carcinoma. The patient is alive and well without recurrence 5 years after thyroidectomy and pancreatectomy. The serum levels of CEA and calcitonin remain within normal limits. Thus, the patient seems to have had a solitary metastatic tumor from thyroid medullary cancer.