Transverse Colon Volvulus Secondary to the Persistent Descending Mesocolon: A Case Report.

This case report introduces a rare occurrence of transverse colon volvulus associated with persistent descending mesocolon (PDM), a congenital anomaly characterized by the medial positioning of the descending colon due to a failed fusion with the dorsal abdominal wall. We detail the case of an 18-year-old female, with a medical history of surgically corrected coarctation of the aorta and anal atresia, who presented with recurrent transverse colon volvulus despite having undergone a laparoscopic colopexy three years earlier. Physical examination revealed abdominal distension and metallic colic sounds while imaging studies confirmed the recurrence of the volvulus. Laparoscopic partial resection of the transverse colon was performed, which revealed a medially positioned descending colon due to PDM. Postoperative complications included anastomotic failure, necessitating a second operation. The patient was successfully discharged without further complications after seven days. This case underscores the clinical significance of recognizing PDM, highlighting its potential role in causing transverse colon volvulus and increasing the risk of anastomotic failure. It emphasizes the need for surgeons to remain vigilant regarding this congenital anomaly to mitigate unexpected outcomes such as recurrent volvulus and postoperative complications.

Duplication of the appendix masquerading as appendiceal tumor: a case report.

BACKGROUND: This case report highlights the exceptional rarity of appendix duplication in adults, a condition that closely mimics appendiceal tumors, posing diagnostic challenges. The novelty of this case lies in its presentation of a Type A duplication, emphasizing the diagnostic intricacies involved in distinguishing it from other pathologies. CASE PRESENTATION: We present the case of a 69-year-old male with a history of hypertension, hyperuricemia, and duodenal gastric ulcer, who presented with a positive occult blood test. Lower gastrointestinal endoscopy revealed an appendiceal orifice with atypical hyperemia and edema. Subsequent imaging and biopsy results suggested an appendiceal tumor, prompting laparoscopic ileocecal resection. Intraoperative findings revealed an unremarkable appendix, but histopathological analysis unveiled appendiceal duplication, characterized by bifurcation into two lumens within a thick serosal wall. The patient was discharged without complications. CONCLUSIONS: This case underscores the importance of recognizing appendix duplication as a rare differential diagnosis for appendiceal tumors. Surgeons should remain vigilant, especially in cases of Type A duplication, where preoperative diagnosis remains challenging. Early identification can avert potential complications and missed congenital anomalies.

Internal hernia in the medial inguinal fossa with a concurrent indirect inguinal hernia: a case report.

A 51-year-old male was presented with abdominal pain and vomiting. Contrast-enhanced computed tomography showed a dilated small intestine with a sac-like appearance in the right lower abdomen. An internal hernia in the inguinal area was found during emergency laparoscopic exploration. The incarcerated small intestine was gently reduced, and the internal hernia sac was located in the right medial inguinal fossa. An indirect inguinal hernia was identified just behind the dissected internal hernia sac. The internal hernia sac was resected, and the indirect inguinal hernia was repaired through a transabdominal preperitoneal approach. The patient had no recurrence of hernia within the 20 months of follow-up after the surgery. This is the first case of an internal hernia in the medial inguinal fossa with a concurrent indirect inguinal hernia. The topographical relationship of these two hernias suggested that an indirect inguinal hernia may cause an internal hernia in the medial inguinal fossa.

[A Case of Synchronous Bilateral Breast Cancer with Apocrine Feature].

The patient, a 79-year-old woman, noticed a lump in her left breast, prompting her visit to our hospital. A mass approximately 20 mm in size was palpated in the left A region. Mammography showed a spiculated mass in the left MIO region, while breast ultrasonography revealed an irregularly shaped hypoechoic mass in the left A region, as well as a hypoechoic area in the right C region. Puncture aspiration cytology of both lesions indicated malignancy. Bilateral partial mastectomy and left sentinel lymph node biopsy were performed. The pathological examination revealed apocrine carcinoma in the left and ductal carcinoma in situ with an apocrine feature in the right breast.

Gastric remnant necrosis secondary to cholesterol crystal embolization after distal gastrectomy in a gastric cancer patient: a case report.

BACKGROUND: Distal gastrectomy with lymph node dissection, a standard operative technique for gastric cancer treatment, is safely performed because the stomach has a rich vascular supply. Gastric remnant necrosis caused by cholesterol crystal embolization following distal gastrectomy has not been described previously. We report a case of gastric remnant necrosis in a patient with cholesterol crystal embolization. CASE PRESENTATION: A 70-year-old man with a history of cholesterol crystal embolization presented to our surgery department with complaints of anorexia and dysphasia. He was diagnosed with gastric cancer invading the pyloric antrum and underwent distal gastrectomy with Billroth 2 reconstruction. On postoperative day 11, he developed abdominal pain without fever. Emergency laparotomy revealed that most parts of the remnant stomach were necrosed. Total gastrectomy with Roux-en-Y reconstruction and abscess drainage were performed. After surgery, anastomotic leakage occurred and was treated conservatively. However, the superior pancreaticoduodenal artery aneurysm suddenly ruptured and he expired. CONCLUSIONS: Gastric remnant necrosis after distal gastrectomy can be a gastrointestinal presentation of cholesterol crystal embolization. Perioperative/intraoperative risk assessments such as preventive total gastrectomy or intraoperative assessment with indocyanine green fluorescence angiography may be desirable to avoid this complication.

Intraductal dissemination of ampullary carcinoma after pancreatoduodenectomy.

BACKGROUND: Clinical evidence of intraductal dissemination through the pancreatic duct has been rare. We herein describe a case of ampullary carcinoma that disseminated in the remnant pancreas through the pancreatic duct. CASE PRESENTATION: A 68-year-old woman underwent SSPPD for ampullary carcinoma. The tumor was diagnosed as adenocarcinoma without lymph node metastasis (T2N0M0, stage IB). Computed tomography (CT) performed 3 years later revealed a 14-mm tumor near the site of the pancreaticojejunal anastomosis. Endoscopic ultrasound-guided fine needle aspiration showed adenocarcinoma that was morphologically similar to the specimen from the first surgery. We diagnosed recurrence of ampullary carcinoma in the remnant pancreas. A total remnant pancreatectomy was performed. We found a white solid tumor at the 20-mm distal side of pancreaticojejunal anastomosis. The tumor was morphologically similar and immunostaining showed a pattern identical to that of the original tumor, suggesting that the two tumors were of the same origin. CONCLUSION: The recurrent lesion was most likely the result of tumor cells leaving the tumor and implanting in the remnant pancreatic duct epithelium. Intraductal dissemination of adenocarcinoma is thought to be a cause of remnant recurrence after SSPPD in cases of obstruction of the pancreatic duct or an iatrogenic procedure.

Laparoscopic surgery of a presacral epidermoid cyst: A case report.

INTRODUCTION: The best approach for resecting epidermoid cysts is still controversial. We describe a case of an epidermoid cyst in which laparoscopic resection was performed successfully. PRESENTATION OF CASE: 63 × 55-mm well-defined cystic mass was incidentally detected by computed tomography in the presacral cavity of a 50-year-old woman during evaluation for upper abdominal pain. Magnetic resonance imaging showed a cystic tumor with a low signal intensity on T1-weighted images and, high signal on T2-weighted images in the left dorsal side of the rectum. This tumor was diagnosed as a developmental cyst, and laparoscopic resection was performed. Resection of the tumor was performed with negative margins. This tumor was histopathologically diagnosed as an epidermoid cyst. There was no evidence of malignancy, and no postoperative event or signs of recurrence occurred 6 months postoperatively. DISCUSSION: In our patient, there was no difficulty in the field of view and forceps operability during laparoscopic surgery. Furthermore, it is possible to perform laparoscopic surgery with minimal damage to the muscles, nerves, and rectum, leading to the preservation of anal function. CONCLUSION: Laparoscopic resection of an epidermoid cyst may be a better option in carefully selected cases with consideration of the tumor size and location.

Evaluation of Hepatic Resection in Liver Metastasis of Gastric Cancer.

Gastric cancer is the second most common malignancy globally and the third most common cause of cancer-related deaths in Japan. In gastric cancer, benefit of surgical resection of liver metastasis, which was shown in colorectal cancer, is not well established. The present study aimed to examine the feasibility of hepatic resection for liver metastasis of gastric cancer. In this retrospective study, we reviewed the medical records of 10 patients with liver-only metastases of gastric cancer who underwent hepatectomy among 2043 patients with gastric cancer who underwent gastric resection between January and December 2016 at a single institution in Japan. Median 1-, 3-, and 5-year overall survival (OS) rates were 78.0%, 33.3%, and 22.2%, respectively, among 10 patients who underwent hepatic resection. There was a significant difference in OS rates between tumors measuring ≥ 5 cm and < 5 cm (hazard ratio [HR] 6.524, 95% confidence interval [CI] 1.145-37.171, p = 0.035). The longest survival was 205 months for one patient who was alive at the time of the analysis. Hepatic resection of liver metastasis in gastric cancer was associated with long-term survival in some patients. Additionally, primary tumor size was associated with long-term survival.

A case of gastric glomus tumor resection using laparoscopy endoscopy cooperative surgery (LECS).

INTRODUCTION: Gastric glomus tumors are rare submucosal mesenchymal tumors. Because gastric glomus tumors are submucosal tumors and resemble gastrointestinal stromal tumors (GISTs), preoperative diagnosis is difficult. We present a case of gastric glomus tumor that was removed by laparoscopy endoscopy cooperative surgery (LECS). CASE PRESENTATION: A 67-year-old female was taken to the emergency room at our hospital due to epigastric pain. An upper gastrointestinal endoscopy revealed a submucosal tumor (SMT) located in the lesser curvature of the upper body of the stomach. Endoscopic ultrasonography revealed an intraluminal hypoechoic tumor located in the third or fourth layer of the stomach wall. Contrast-enhanced computed tomography (CECT) of the abdomen showed a 20-mm, well-enhanced, intraluminal-type tumor located in the lesser curvature of the upper body of the stomach. Laparoscopy endoscopy cooperative surgery (LECS) was performed. Immunohistochemistry revealed the expression of smooth muscle actin and vimentin, but not of keratin, S-100 protein, C-kit, or CD34. The tumor was finally diagnosed as a gastric glomus tumor. CONCLUSION: Glomus tumors are rare submucosal tumors of the stomach, and they should be considered in the differential diagnosis of gastric submucosal tumors. LECS could be a less invasive and effective method for treatment of gastric glomus tumor.

Sewing needles in the abdominal cavity assumed to have been ingested and to have penetrated the GI tract 40 years ago: A case report.

A 60-year old woman had been hospitalized in a psychiatric hospital for 40 years for schizophrenia. An X-ray was performed when she fell, which showed needles in the abdominal field. After additional examinations and questioning, the patient was diagnosed with needles in the abdominal cavity, which were assumed to have been ingested and to have perforated the GI tract 40 years ago. They were removed by laparoscopic surgery. The needles were found in the omentum and near the left ovary. There were no inflammatory reactions around them. There have been previous reports about the removal of intra-abdominal foreign bodies, but foreign body reaction occurred in most of the reports. Our case had the longest period from ingestion of the foreign bodies to their removal. Laparoscopy and intraoperative fluoroscopy are useful for removing intra-abdominal foreign bodies because of their ability to help discriminate between structures and to navigate in real time.

[Surgical resection of a huge gastric gastrointestinal stromal tumor after preoperative adjuvant chemotherapy].

A 73-year-old man was referred to our hospital because of positive results on a fecal occult blood test. He had severe anemia, and abdominal computed tomography (CT) revealed a huge 18 × 11 cm tumor in the lower gastric corpus. Pathological analysis of a biopsy sample revealed a gastrointestinal stromal tumor (GIST). We improved the nutritional and physical statuses via total parenteral and enteral nutrition. At the same time, we initiated preoperative adjuvant chemotherapy with 300 mg/day of imatinib. After 4 weeks' of treatment, CT revealed a drastic reduction in the tumor size, regarded a partial response (PR). The patient underwent partial gastrectomy, distal pancreatectomy, and partial resection of the transverse colon. His postoperative course was uneventful. The patient received postoperative treatment with imatinib for 1 year, and remained recurrence free for 10 months after surgery.

CBDCA + Pemetrexed + Bevacizumab and Its Maintenance Chemotherapy in a Case of Solitary Breast Metastasis from a Lung Adenocarcinoma Resistant to Gefitinib.

Based on the AVAPERL trial (36th ESMO 2011), CBDCA + pemetrexed + bevacizumab and its maintenance chemotherapy with pemetrexed + bevacizumab is a new promising regimen for the treatment of advanced non-small-cell lung adenocarcinoma. Herein, we report the rare case of a patient with solitary breast metastasis from a lung adenocarcinoma, which was effectively treated using CBDCA + pemetrexed + bevacizumab and its maintenance chemotherapy. A 57-year-old female was admitted to the hospital due to pleural effusion and cardiac tamponade caused by a lung adenocarcinoma possessing a mutation of the epidermal growth factor receptor (EGFR) gene (deletion of exon 19). The patient was treated by first-line chemotherapy (gefitinib 250 mg/body/day) which resulted in complete response. After 12 months, carcinoembryonic antigen was gradually increasing and she complained of a right breast mass. With a core-needle biopsy, the breast tumor was pathologically diagnosed as recurrence and solitary metastasis of a lung adenocarcinoma. Further study of the second mutation of EGFR revealed a T790M mutation. The patient was treated by second-line chemotherapy [CBDCA + pemetrexed + bevacizumab (AUC 6 + 500 mg/m(2) + 15 mg/kg)] and its maintenance chemotherapy (pemetrexed + bevacizumab). The cases of patients with breast metastasis from other organs are very rare. Immunohistopathological analysis is very useful to diagnose whether the malignancy is primary or not. In the case of a breast tumor with present or previous malignancy, a metastatic breast tumor should be considered. Furthermore, the biopsy of the breast metastasis also revealed the second mutation of resistance to gefitinib, T790M. Of note, according to our case, CBDCA + pemetrexed + bevacizumab and its maintenance chemotherapy is feasible and well tolerated for breast metastasis from a lung adenocarcinoma which is resistant to gefitinib and possesses the T790M mutation in the EGFR gene.

High-dose toremifene as first-line treatment of metastatic breast cancer resistant to adjuvant aromatase inhibitor: A multicenter phase II study.

There is currently no standardized therapy available for metastatic breast cancer in patients with aromatase inhibitor (AI)-resistant breast cancer. We conducted a prospective study to examine the efficacy and safety of high-dose toremifene (TOR) treatment for the first-line treatment of metastatic breast cancer following AI adjuvant therapy. A multicenter phase II study was designed (Registry no.: UMIN000000489). Inclusion criteria comprised hormone-responsive postmenopausal women who had received adjuvant AI postoperatively for >1 year and had relapsed during the treatment or within 12 months of completion of adjuvant therapy. Treatment comprised oral intake of 120 mg TOR once a day. The primary endpoint was objective response rate (ORR). The secondary endpoints were evaluations of clinical benefit (CB), progression-free survival (PFS) and toxicity. A total of 13 patients were enrolled. ORR was 7.7% (1/13) [95% CI, 0.2-36.0%]. In total, 7 patients (53.8%) had stable disease (SD), 5 of whom were long SD, and 5 patients (38.5%) experienced progressive disease (PD). The CB rate was 46.2% (6/13) [95% CI, 19.2-74.9%]. The median time to PFS was 5.9 months. No serious adverse events were observed. Patients with HER2-positive disease exhibited marginally poorer PFS (p=0.08). Patients with PD had a relatively short duration of AI treatment in contrast to responders, who had a longer period of AI treatment (p=0.02). High-dose TOR as a first-line treatment following AI adjuvant therapy was effective and well tolerated. A longer duration of adjuvant AI therapy and negative HER2 overexpression may, with further studies, be beneficial as positive predictive factors for the effectiveness of TOR treatment.

Caspase activation is accelerated by the inhibition of arsenite-induced, membrane rafts-dependent Akt activation.

Renewed interest in arsenic has been shown recently due to its dual nature of being a potent toxin and a drug for treatment of acute promyelocytic leukemia (APL) because of its ability to trigger caspase activation. Here, we found that sodium arsenite (NaAsO(2)) also triggers the signal for activation of Akt and downstream glycogen synthase 3beta (GSK3beta). Such Akt/GSK3beta activation was abrogated completely by wortmannin, an inhibitor of PI-3 kinase, and greatly by pertussis toxin, a G-protein inhibitor. Arsenite-induced Akt phosphorylation also was inhibited by sequestrating membrane cholesterol with beta cyclodextrin. Reducing reagents/reactive oxygen species (ROS) scavengers reduced arsenite-induced Akt phosphorylation and beta cyclodextrin reduced arsenite-mediated ROS production, suggesting that arsenite-induced G-protein/Akt/GSK3beta pathway is membrane raft dependent and redox linked. We also found that a combination of a low concentration (1 microM) of arsenite and wortmannin triggers the signal for caspase activation, whereas neither of these elements alone did so. These results suggested that selective blockade of the arsenite-provoked PI-3 kinase/Akt pathway can promote the arsenite-triggered pathway for caspase activation, and this may open a new study area for wider applications of arsenic as a drug for treating various kinds of leukemia.