[Distal Gastrectomy under Management of Intra-Aortic Balloon Pumping Therapy for an Elderly Patient with Carcinomatous Pyloric Stenosis Complicated by Severe Coronary Stenosis].

This case involved an 82-year-old man with a history of diabetes mellitus and myocardial infarction. He was undergoing treatment with 2 oral antiplatelet agents. The patient presented to our hospital for carcinomatous pyloric stenosis caused by type 4 advanced gastric cancer. Although distal gastrectomy was planned, preoperative coronary angiography revealed triple- vessel coronary artery disease. Therefore, surgery was performed under management of intra-aortic balloon pumping (IABP)therapy. The patient's hemodynamics at the time of the operation were stable, and no perioperative cardiovascular complications occurred. However, the patient was not able to start an oral diet because of impaired swallowing function. Although he underwent daily swallowing rehabilitation, he died of aspiration pneumonia 40 days postoperatively. There are many reports of cancer resection under IABP management for patients with severe heart disease. Because the perioperative hemodynamics were stable in all 21 reported cases of digestive malignant tumor resections in Japan, an IABP is suggested to be very effective for patients with severe heart disease. However, early death has also occurred, as in the present case. Close attention to the indications for IABP therapy is needed, especially in elderly patients, in consideration of not only cancer and heart disease but also preoperative activities of daily living.

Adenocarcinoma of the minor duodenal papilla treated with pancreas-sparing segmental duodenectomy: case report and review of the literature.

Carcinoma of the minor duodenal papilla is extremely rare. We present the case of a 69-year-old man diagnosed with a tumor of the second portion of the duodenum by upper gastrointestinal endoscopy, which revealed a 1.5-cm elevated tumor with slight ulceration at the minor duodenal papilla. Biopsy revealed adenocarcinoma, and a computed tomography scan showed an enhanced tumor in the duodenum, with no abnormality in the pancreatic head. A pancreas-sparing segmental duodenectomy was performed, and the duodenum reconstructed with an end-to-end anastomosis. Microscopically, the tumor was a well-differentiated adenocarcinoma, with no infiltration at the cut end of the accessory pancreatic duct. The postoperative course was uneventful and the patient discharged on postoperative day 11. We reviewed previously reported cases of carcinoma of the minor duodenal papilla. Early and exact preoperative diagnosis of duodenal neoplasms makes it possible to select a less invasive treatment, which also maintains curability.

Prospective observation of small adenomas in patients after colorectal cancer surgery through magnification chromocolonoscopy.

PURPOSE: This study was designed to confirm the safety of not removing small adenoma in patients who undergo colorectal cancer surgery. METHODS: Patients who underwent surveillance colonoscopy after surgery were enrolled. The study was approved by our institutional review board. Colonoscopy was performed with magnification chromocolonoscopy. Benign adenomas of 6 mm or less in size, diagnosed based on both nonmagnified and magnified observation, were left unresected with a maximum of three polyps per patient. The sites of the polyps were marked by tattooing. Interval colonoscopy was performed predominantly yearly or biennially. Increase in size by 2 mm or larger was defined as significant. In follow-up, polyps were removed if they grew larger than 6 mm, were suspicious for high-grade dysplasia, or the patients requested to have polyps removal. RESULTS: Five hundred polyps in 284 patients met the above criteria and were not resected, and 412 polyps were followed by repeat colonoscopy. The mean observation period was 3.6+/-2.2 years and the mean number of repeat colonoscopy was 3.6+/-1.6. At the final colonoscopy, 71 percent of 412 polyps showed no change in size, 15 percent increased, 3 percent decreased, and 11 percent could not be identified. Eighty-eight polyps were resected endoscopically, and histology showed neither cancer nor adenomas with high-grade dysplasia. Two hundred fifty-five polyps detected in the same patient cohort during index/repeat colonoscopy were removed, including four adenomas with high-grade dysplasia and two T1 cancers. CONCLUSIONS: Leaving small polyps is safe even in patients who have undergone colorectal cancer surgery, provided that careful observation is guaranteed.

Follicular lymphoma of the pancreas: a case report and proposed new strategies for diagnosis and surgery of benign or low-grade malignant lesions of the head of the pancreas.

CONTEXT: Primary pancreatic lymphoma is a rare form of extranodal lymphoma originating in the pancreas. The present report describes a case of follicular lymphoma of the pancreas with unique CT and MRI findings. CASE REPORT: A 58-year-old male complained of sudden abdominal pain, and routine ultrasonography detected an 8 cm hypoechoic tumor in the head of the pancreas. The 3D image generated using multi-cholangiography and virtual duodenography provided the information necessary for a laparotomy. The tumor was enucleated for diagnosis. Follicular lymphoma is quite rare in the pancreas and gastrointestinal tract. A considerable number of pancreatic lymphoma subtypes have been reported. The expression "pancreatic lymphoma" has been used to describe both primary lymphoid neoplasms originating in the pancreatic parenchyma and tumors invading from a peri-pancreatic lymphadenopathy. The present case belongs to the latter, which might explain the unique imaging findings and histological type. These subtypes display different imaging findings and different clinical characteristics. In the future, primary pancreatic lymphoma should be discussed separately depending on the subtype. CONCLUSION: We propose a new subtype of primary pancreatic lymphoma. Multi-cholangiography and virtual duodenography provided the information necessary for a laparotomy in the present case. Enucleation is indicated for benign and low-grade malignant tumors of the pancreas, even if the tumor is located in the head of the pancreas.

[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.