[A Case of Acute Afferent Loop Obstruction after Total Gastrectomy, Successfully Managed by Endoscopic Treatment].

The patient was a 76-year-old man who had 3 times previously undergone laparotomies, including distal gastrectomy with a Billroth Ⅰ operation. In the current case, a total gastrectomy, end-to-side esophagojejunostomy, and a Roux-en-Y anastomosis for adenocarcinoma of the remnant stomach were performed. On postoperative day (POD) 7, he complained of epigastralgia. Abdominal CT revealed a markedly dilated duodenum, and a diagnosis of acute afferent loop obstruction was made. Emergency endoscopy revealed edematous stenosis of the Y-anastomotic site. A nasal endoscope could not pass the stricture, but an endoscopic nasobiliary drainage (ENBD) catheter was successfully inserted into the duodenum. Epigastralgia decreased after drainage. Stenosis of the Y-anastomotic site was still observed 18 days after onset; therefore, we inserted 1 endoscopic retrograde biliary drainage (ERBD) tube, in addition to the ENBD catheter. Twenty-five days after onset, slight improvement of the stenosis was observed. By inserting 2 more ERBD tubes, the ENBD catheter could be removed. On day 28, abdominal CT revealed reduced dilatation of the duodenum. On day 29, oral intake was initiated, and the patient was discharged from the hospital on POD 66. During the early post-operative phase, the use of nasal endoscope drainage is an effective, minimally invasive, and safe procedure for decompression of the duodenum in afferent loop obstruction.

[A case of pathologically complete response of esophageal carcinoma treated with low-dose 5-FU/CDDP as neoadjuvant chemotherapy].

The patient was a 75-year-old woman with advanced esophageal cancer and lymph-node swelling in the mediastinum(cStage RR). We administered preoperative chemotherapy(5-FU 500mg/body×10, CDDP 10mg/body×10). She received the two courses without showing any serious side effects. The primary tumor revealed remarkable improvement, but the rigidity of the esophagus wall and swelling of the lymph nodes were not resolved, and images showed that the patient exhibited a partial response to the treatment. Radical resection of the esophageal carcinoma was performed. Pathological examination of the resected specimens revealed no malignant cells in the esophagus, no metastasis of the lymph node, and the response evaluation was grade 3. The patient showed no recurrence 4 years and eleven months after the operation. In lonclusion, this rare case of esophageal carcinoma showed a pathologically complete response when treated with low-dose 5-FU/CDDP as neoadjuvant chemotherapy.

[A case of gastric cancer with rhabdoid features showing better prognosis through S-1/CDDP chemotherapy].

Although gastric cancers(GCs)with rhabdoid features are rare, they are known to show a poorer prognosis compared with conventional GCs. Indeed, more than half of reported GCs with rhabdoid features died within 6 months after receiving any kind of initial treatment. Obviously, no effective chemotherapy has been reported. In this study, we present a case of GC with rhabdoid features which showed a better response to a chemotherapy, S-1/CDDP, and lived for over 12 months after the initial chemotherapy. A 75-year-old man was seen in our hospital for epigastralgia. Detailed examinations revealed that he had GC at Stage IV. Consequently, he underwent S-1/CDDP treatment. This treatment produced a good response for 6 months, minimizing the size of the primary tumor and eradicating distant metastases. Re-growth of the primary tumor without uprising distant metastasis was confirmed 8 months after the initialS -1/CDDP treatment, and the patient went through a gastrectomy for curative care. After surgery, a precise pathological examination revealed that the primary tumor possessed a poorly differentiated adenocarcinoma that contained tumor cells with typical rhabdoid features. In the end, the patient died of liver metastasis 13 months after the initial S-1/CDDP chemotherapy.

Importance of mediastinal screening-based observation during endoscopic ultrasound to examine gastrointestinal pathologies.

In all endoscopic ultrasound (EUS) examinations performed at our hospital, the heart, vasculature, and mediastinal lymph nodes from the esophagus are observed after checking for gastrointestinal pathologies. Since the introduction of EUS using a convex linear-array echoendoscope at our hospital in April 2015, EUS examinations have been performed in 371 cases for examining pancreaticobiliary diseases, submucosal tumors, and other pathologies during the 3-year period, till March 2018. We diagnosed 2 patients with asymptomatic cardiovascular disease while observing the mediastinum during EUS examination to examine identified pancreaticobiliary disease. No subjective symptoms associated with cardiovascular disease were observed and the respective conditions had not been identified previously in either case. One case involved a left atrial myxoma while the other involved a saccular aortic aneurysm in the thoracic aorta. A left atrial tumor resection and aortic replacement surgery were performed in each case. Their postoperative courses have been favorable. As cardiovascular diseases are often life-threatening, as in the present 2 cases, observational screening of the cardiovascular system from the esophagus should also be performed during EUS examinations just as the pharyngeal region is examined during upper gastrointestinal endoscopy.

Ureteral metastasis from appendiceal cancer: report of a case.

We report a case of primary appendiceal cancer that metastasized to the ureter. The patient was a 51-year-old woman who complained of persistent left back pain and right lower abdominal pain. After a detailed examination she was diagnosed to have cancer of the appendix, multiple liver metastases, and left hydronephrosis. Since an obstruction of the ileocecum was obvious, she underwent an ileocecal resection and a resection of the spindle-shaped tumor invading the left ureter. Lymph node metastases were found at the root of the superior mesenteric artery. The spindle-shaped tumor was considered to be due to invasion of the appendiceal cancer to the left ureter. The patient died 5 months postoperatively.

Ciliated foregut cyst of the gallbladder: report of a case.

We report the rare case of a gallbladder cyst arising from the foregut remnants. A 36-year-old woman was referred to our hospital after screening ultrasonography (US) detected a tumor in the gallbladder. On admission, she was well and her blood analyses were all normal. US showed a cystic mass with internal high-echoic lesions, and computed tomography (CT) demonstrated a protruding tumor with slight enhancement in the gallbladder. Angiography provided no additional information; however, sequential CT-arteriography (CTA) clearly demonstrated that this tumor was a cystic lesion. Surgical exploration was performed, first because of the difficulty in establishing a definite diagnosis, and also because the patient wanted the tumor removed. The resected specimen contained a unilocular cystic tumor that looked like a submucosal tumor. Histologically, the wall of the cyst was lined by ciliated stratified columnar epithelium with interspersed goblet cells and underlying smooth muscle fibers. The mass was finally diagnosed as a congenital ciliated foregut cyst of the gallbladder. Cysts of the gallbladder are uncommon and the majority are acquired. To our knowledge, this represents only the fourth report of a ciliated foregut cyst of the gallbladder in the literature. Although rare, an awareness of this entity could allow a preoperative diagnosis to be made, whereby surgical exploration may be avoided. CT-A is a very useful diagnostic tool, especially when the nature of the tumor presents a difficult differential diagnosis.

A gastric duplication cyst with an aberrant pancreatic ductal system: report of a case.

We report an extremely rare case of a gastric duplication cyst together with an aberrant pancreatic ductal system, which communicated with the stomach rather than the pancreatic ductal system with no evidence of pancreatitis. A 46-year-old woman developed severe abdominal pain after a 10-year history of occasional mild abdominal pain. Upper gastrointestinal barium radiography showed a rigidity of the stomach wall, and gastroscopy revealed a fistula orifice at a greater curvature of the gastric body. Subsequent endoscopic suction of mucous secretion from within the fistula provided immediate pain relief. Abdominal computed tomography and ultrasonography showed a cystic mass contiguous with the stomach wall. Surgical exploration revealed an uncommon anomaly of a gastric duplication cyst with the aberrant pancreatic lobe. The patient made an uneventful recovery and remains well 4 years after surgery. We also herein review ten other similar cases of this uncommon congenital anomaly reported in the literature.