Clinicopathological features and management strategy for superficial nonampullary duodenal tumors: a multi-center retrospective study

Purpose@#We investigated the clinicopathological features and management for superficial nonampullary duodenal tumors (SNADTs). The safety and feasibility of laparoscopic management, especially laparoscopic endoscopic cooperative surgery (LECS), were evaluated. @*Methods@#A total of 59 patients with SNADTs who underwent operations from January 2009 to December 2018 at all 8 institutions of the Catholic Medical Center were identified in our comprehensive multi-institutional database. Clinicopathological and surgical data on the 4 anatomical regions of the duodenum were collected and compared.Characteristics of laparoscopic procedure (laparoscopy-only) and LECS procedures were also compared. @*Results@#There were significantly more asymptomatic patients with tumors in the first and second vs. third and fourth duodenal regions. Gastrointestinal stromal tumors (GISTs), carcinoids, and ectopic pancreatic tumors were identified in 32, 12, and 5 cases, respectively. Forty-two patients (71.2%) underwent laparoscopy. Of patients undergoing laparoscopy, the LECS group exhibited significantly more endophytic features and smaller tumor sizes (P < 0.001 and P < 0.001, respectively). Although no significant difference in the wedge resection or postoperative complication rate was seen between the 2 groups (P = 0.096 and P = 0.227, respectively), the wedge resection rate was higher, and the complication rate lower, in the LECS group than the conventional laparoscopic surgery group. @*Conclusion@#Most of the SNADTs located in proximal duodenum were detected incidentally. GISTs were the most common diagnoses of SNADTs in all locations. In treating these tumors, laparoscopic resection is safe and feasible. Especially, LECS may be ideal for treating small endophytic tumors, minimizing over-resection and postoperative complications.

A 13-year experience with gastric neuroendocrine tumors: A single institute study

PURPOSE: Gastric neuroendocrine tumors (GNETs) are relatively uncommon. Although they frequently follow indolent clinical courses, GNETs have the potential for metastasis. The aim of this study was to analyze the clinicopathological characteristics of GNETs and explore the prognostic factors associated with overall survival of patients with GNETs.METHODS: All patients who underwent resection of GNETs from 2003 to 2016 at St. Vincent's Hospital were identified retrospectively. Demographic data, tumor characteristics, and survival results were evaluated.RESULTS: Of the 32 patients with GNETs, 10 patients (31.3%) had an endoscopic resection and 22 (68.7%) had a surgical resection. In terms of the European Neuroendocrine Tumor Society (ENETS) tumor-node-metastasis (TNM) staging systems, three (9.4%), seven (21.9%), five (15.6%), 13 (40.6%), and four patients (12.5%) were classified as stages 0, I, II, III, and IV, respectively. Overall survival differed significantly according to disease stage. Patients with positive symptoms, larger tumor size, and advanced stage had lower survival rates than those with other types.CONCLUSION: ENETS TNM stage is a reliable parameter for assessment of the prognosis of patients with GNETs. Clinical symptoms, tumor size, and TNM stage are associated with survival of patients with GNETs.

Safety of Laparoscopic Radical Gastrectomy in Gastric Cancer Patients with End-Stage Renal Disease

PURPOSE: The surgical outcomes of end-stage renal disease (ESRD) patients undergoing radical gastrectomy for gastric cancer were inferior compared with those of non-ESRD patients. This study aimed to evaluate the short- and long-term surgical outcomes of ESRD patients undergoing laparoscopic gastrectomy (LG) and open gastrectomy (OG) for gastric cancer. MATERIALS AND METHODS: Between 2004 and 2014, 38 patients (OG: 21 patients, LG: 17 patients) with ESRD underwent gastrectomy for gastric cancer. Comparisons were made based on the clinicopathological characteristics, surgical outcomes, and long-term survival rates. RESULTS: No significant differences were noted in the clinicopathological characteristics of either group. LG patients had lower estimated blood loss volumes than OG patients (LG vs. OG: 94 vs. 275 mL, P=0.005). The operation time and postoperative hospital stay were similar in both the groups. The postoperative morbidity for LG and OG patients was 41.1% and 33.3%, respectively (P=0.873). No significant difference was observed in the long-term overall survival rates between the 2 groups (5-year overall survival, LG vs. OG: 82.4% vs. 64.7%, P=0.947). CONCLUSIONS: In ESRD patients, LG yielded non-inferior short- and long-term surgical outcomes compared to OG. Laparoscopic procedures might be safely adopted for ESRD patients who can benefit from the advantages of minimally invasive surgery.

The Detection of Messenger RNA for Carcinoembryonic Antigen and Cytokeratin 20 in Peritoneal Washing Fluid in Patients with Advanced Gastric Cancer / 대한소화기학회지

BACKGROUND/AIMS: Peritoneal micrometastasis is known to play an important role in the recurrence of gastric cancer. However, its effects remain equivocal. Herein, we examine the messenger RNA (mRNA) as tumor markers, carcinoembryonic antigen (CEA), and cytokeratin 20 (CK20), in peritoneal washing fluid. Moreover, we evaluate whether these results could predict the recurrence of gastric cancer following curative resection. METHODS: We prospectively enrolled 132 patients with gastric cancers, who had received an operation, between January 2010 and January 2013. The peritoneal lavage fluid was collected at the operation field and semi-quantitative PCR was performed using the primers for CEA and CK20. We excluded patients with stage IA (n=28) early gastric cancer, positive cytologic examination of peritoneal washings (n=7), and those who were lost during follow up (n=18). RESULTS: A total of 79 patients with gastric cancers were enrolled, and the mean follow-up period was 39.95±19.25 months (range, 5-72 months). According to the multivariate analysis, T4 stage at the initial diagnosis was significantly associated with recurrence. All cases of recurrence were CEA positive and 6 cases were CK20 positive. The positive and negative predictive values of CEA were 32.0% and 100%, respectively, whereas those of CK20 were 37.5% and 71.4%, respectively. Disease free survival of CK20-negative cases was 36.17±20.28 months and that of CK20-positive cases was 32.06±22.95 months (p=0.39). CONCLUSIONS: It is unlikely that the real time polymerase chain reaction results of mRNA for CEA and CK20 in peritoneal washing fluid can predict recurrence. However, negative results can convince surgeons to perform curative R0 resection.

Leptomeningeal carcinomatosis from gastric cancer: single institute retrospective analysis of 9 cases

PURPOSE: The aim of this study is to investigate the clinical features and outcomes of 9 consecutive patients who suffered with leptomeningeal carcinomatosis (LMC) originating from gastric cancer. METHODS: Between January 1995 and December 2010, we retrospectively reviewed the medical records of 9 patients with gastric LMC who had been treated at St. Vincent's Hospital, The Catholic University of Korea. RESULTS: With the exception of 1 patient, the primary gastric cancer was Borrmann type III or IV, and 5 cases had poorly differentiated or signet ring cell histology. TNM stage of the primary gastric cancer was III in 6 patients. The median interval from diagnosis of the primary malignancy to the diagnosis of LMC was 9 months. Headache (6 cases), altered mental status (4 cases), and dysarthria (3 cases) were presenting symptoms of LMC. Computed tomography findings were abnormal in 4 of 7 cases, while magnetic resonance imaging revealed abnormality in 4 of 5 cases. Radiation therapy was administered to 5 patients and intrathecal chemotherapy was administered to only 1 patient. Median overall survival duration from the diagnosis of LMC was 3 months. CONCLUSION: LMC originating from gastric cancer had a fatal clinical course and treatment strategies remain challenging.

Susceptibility of gastric cancer according to leptin and leptin receptor gene polymorphisms in Korea / 대한외과학회지

PURPOSE: Leptin plays an important role in the control of body weight and also has a growth-factor-like function in epithelial cells. Abnormal expression of leptin and leptin receptor may be associated with cancer development and progression. We evaluated the relationship among leptin and leptin receptors polymorphisms, body mass index (BMI), serum leptin concentrations, and clinicopathologic features with gastric cancer and determined whether they could be the risk factor of gastric cancer. METHODS: We measured the serum leptin concentrations of 48 Korean patients with gastric cancer and 48 age- and sex-matched controls. By polymerase chain reaction-restriction fragment length polymorphism, we investigated one leptin gene promoter G-2548A genotype and four leptin receptor gene polymorphisms at codons 223, 109, 343, and 656. RESULTS: There was no significant difference between the mean leptin concentrations of the patient and control groups, while BMI was significantly lower in gastric cancer cases (22.9 +/- 3.6 vs. 24.5 +/- 2.8 kg/m2, P = 0.021). There was significant association between the LEPR Lys109Arg genotype and gastric cancer risk, heterozygotes for GA genotype had been proved to increased the risk of gastric cancer, and its corresponding odds ratio was 2.926 (95% confidence interval, 1.248 to 6.861). CONCLUSION: Our results suggested that LEPR gene Lys109Arg polymorphism is associated with gastric cancer in Korean patients.

A Case of Gastric Adenocarcinoma Presenting as Portal Hypertension / 대한소화기학회지

Portal vein thrombus has been detected in patients with liver cirrhosis, pancreatitis, ulcerative colitis, septicemia, myeloproliferative disorder, and neoplasm. The formation of portal tumor thrombus by hepatocellular carcinoma is well recognized, because of its high incidence, and subsequent development of portal hypertension such as rupture of varices, ascites and liver failure indicates the poor prognosis. In gastric cancer, portal hypertension as an initial presentation is extremely rare. Herein we report a case presenting as portal hypertension caused by tumor thrombus without invasion of liver parenchyma. It is presumed to be intraluminal tumor thrombus originating from primary foci of gastric adenocarcinoma. Tumor thrombus in the portal vein is demonstrated on the PET-CT.

A Case of Steroid Dependent Eosinophilic Gastroenteritis Presenting as a Huge Gastric Ulcer

Eosinophilic gastroenteritis is defined as primary eosinophilic infiltration of the gastrointestinal tract. Endoscopic findings of this disease entity are non-specific, and huge gastric ulceration as initial presentation is extremely rare. We experienced a case of eosinophilic gastroenteritis presenting with abdominal pain in a 38 year-old-woman. Deep and huge ulceration in gastric antrum and body looked like advanced gastric cancer. Surgical resection was performed and histopathological examination showed dense infiltration of eosinophil without malignant cells. 5 years after surgery, diffuse abdominal pain and generalized edema developed and computed tomography showed entire wall thickening of the gastrointestinal tract. Random mucosal biopsy of the remnant stomach and terminal ileum showed mucosal eosinophilic infiltrations. She was treated with steroids and azathioprine but experienced frequent relapses and was dependent on steroids to maintain remissions. After 3 years, she died from infective endocarditis due to the prolonged use of immunosuppressive agents.

Primary gastric Hodgkin's lymphoma / 대한외과학회지

Gastric Hodgkin's lymphoma is extremely rare. We present a case of primary Hodgkin's lymphoma arising in the stomach of a 65-year-old woman. The patient complained of epigastric discomfort and reflux for one month. Endoscopic examination revealed a protruding lesion characterized by a smooth surface at the antrum. An abdominal computed tomography uncovered a 2.5 x 2.0 cm, exophytic submucosal mass. After the tentative preoperative diagnosis of a gastrointestinal stromal tumor, a gastric wedge resection was performed. Microscopic examination of the mass demonstrated a diffuse proliferation of large atypical lymphoid cells with mono- and binucleated pleomorphic nuclei and prominent nucleoli. Immunohistochemically, the tumor cells were positive for CD30, CD20, and CD79a, whereas they were negative for cytokeratin, carcinoembryonic antigen, CD3, CD15, epithelial membrane antigen, and anaplastic lymphoma kinase-1. Based on the morphological features and immunohistochemical results, in addition to the clinical findings, a diagnosis of primary gastric Hodgkin's lymphoma was established.

Gastrointestinal Stromal Tumor with Accelerated Growth Pattern in the Stomach

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and can be benign or malignant. To date, there have been no clear standards for the preoperative assessment of GIST malignancy. Currently it is believed that tumors with diameter smaller than 2.0 cm is benign. Herein, we experienced two cases of GISTs that showed an accelerated growth pattern during the follow-up period. In both cases, the tumors were <2.0 cm in size initially and became larger unexpectedly. The resected tumors revealed GIST with intermediate risk and high risk of malignancy according to National Institutes of Health (NIH) consensus symposium.

A Case of Eosinophilic Gastroenteritis Presenting with Fever and Multiple Lymphadenopathy / 대한소화기내시경학회지

Eosinophilic gastroenteritis is an unusual disease that is associated with various clinical gastrointestinal manifestations. Its severity depends on the area involved as well as the wall layer involved. Eosinophilic gastroenteritis often causes abdominal pain, nausea, vomiting and diarrhea. To date, there has been an extremely rare case of eosinophilic gastroenteritis with systemic symptoms, such as fever or lymphadenopathy (LAP). We experienced a case of a 68-year-old-woman with fever and abdominal pain. Abdominal computed tomography revealed diffuse wall thickening of the gastric antrum as linitis plastica. Multiple hot uptakes of lymph nodes were visualized on fludeoxyglucose-positron emission tomography. The gastric biopsy pathological report demonstrated eosinophilic infiltration without malignant cells. We could not exclude malignancy and performed an exploratory laparoscopy. A lymph node specimen showed reactive hyperplasia, and her illness was finally diagnosed as eosinophilic gastroenteritis. Herein, we report the case with a brief review.

Clinicopathological features of retrorectal tumors in adults: 9 years of experience in a single institution / 대한외과학회지

PURPOSE: Primary tumors of the retrorectal space in adults are very rare. Most of them are benign masses, but malignant masses are reported on occasion. This study aimed to investigate the clinicopathological features of retrorectal tumors. METHODS: The medical records of fifteen patients who underwent surgical resection of a retrorectal tumor from March 2002 to April 2010 in our hospital were reviewed retrospectively. RESULTS: Out of 15 patients, thirteen were females and two males. About 1.7 patients were diagnosed with retrorectal tumor annually in our hospital. The incidence is one per 1,500 surgeries performed under general anesthesia. An anterior approach was performed in eight patients and a posterior approach with excision of the coccyx in five patients. Combined approach was performed in two patients. Four patients (three in abdominal approach and one in combined approach) underwent laparoscopic resection. The mean size of tumors was 6.2 +/- 2.9 cm. Mature teratoma (four) and neurilemmoma (four) were the most common tumors. Except for one case of chondrosarcoma, fourteen tumors were confirmed to be of benign nature in histologic examination. Patients who underwent a transabdominal approach with laparoscopic surgery had no postoperative complication and had a tendency to experience earlier recovery than those with open surgery. CONCLUSION: Surgical resection of a retrorectal tumor is recommended to relieve pressure symptoms and to confirm the diagnosis. A laparoscopic approach may offer excellent visualization of the deep structures in the retrorectal space, reduce surgical trauma, and be helpful for early postoperative recovery.

Synchronous Incidental Occurrence of Gastric Gastrointestinal Stromal Tumor and Colon Adenocarcinoma / 대한소화기내시경학회지

A few cases of gastrointestinal stromal tumor (GIST) synchronous cancers with other malignancies have been reported, such as gastric cancer, pancreatic cancer, renal cell carcinoma, colon cancer, and carcinoid tumor. However, little is known about their coincidence with other tumors with a different histogenesis. A 62-year-old man visited our hospital with generalized weakness and intermittent hematochezia. A colonoscopic examination showed an ulcerating mass in the ascending colon, and a biopsy specimen revealed adenocarcinoma. A lobulated submucosal mass in the gastric fundus was found incidentally during the preoperative staging procedures, including computed tomography (CT) and positron emission tomography-CT. The colon cancer and gastric tumor were removed simultaneously (laparoscopy assisted right hemicolectomy and total gastrectomy). Immunohistochemical studies on the gastric tumor surgical specimen showed that it was CD117 (+) and CD34 (+), and the final diagnosis was a GIST of the stomach. Herein, we report a case of the synchronous occurrence of colon adenocarcinoma and gastric GIST.

The Comparative Analysis between Laparoscopic Total Extraperitoneal Repair and Open Tissue Repair: Initial Experience of a Single Institute

PURPOSE: Laparoscopic herniorrhaphy has been recognized as one of the treatment options for inguinal hernia. This study compared the short-term results of two methods of repair: totally extraperitoneal (TEP) repair and open tissue based repair. METHODS: A retrospective review was conducted on all patients who underwent laparoscopic TEP repair (LH, 105 cases) and open repair (OH, 57 cases) at our hospital between September 2007 and December 2008. Posterior wall repairs in open technique follow as McVay (25 cases) and Bassini (32 cases). Demographic data, operation time, perioperative complications, consumption of analgesics, and hospital stay were compared. RESULTS: There was no significant difference in relation to patient characteristics; age, gender, BMI, medical and surgical history and hernia type. Also, there was no difference of operation time for both groups. Patients in the LH group consumed fewer analgesics (P=0.002). Intraoperative complications occurred more frequently in the LH group (P=0.036) but postoperative complications were similar. Hospital stay was shorter in LH (P<0.001). There was no difference of recurrence between LH group and OH group for 16 months. CONCLUSION: Laparoscopic TEP repair shows similar postoperative complications and recurrences and with less postoperative pain and hospital stay, compared with open tissue based hernia repair. However, further study with longer follow up data is necessary.

Comparison of Clinical Outcomes between Laparoscopic and Open Appendectomy: A Retrospective Analysis of 2,745 Patients

PURPOSE: Despite the reported advantages of laparoscopic appendectomy (LA), there is debate about the postoperative complication rates. Our study attempts to determine if laparoscopic appendectomy is safe and feasible compared with open appendectomy (OA). METHODS: A retrospective review was conducted of all patients who underwent open appendectomy (OA, 2,109 cases) and laparoscopic appendectomy (LA, 500 cases) at our hospital between 1997 and 2007. Incidental and interval appendectomies were excluded from this study. Demographic data, pathology, operation time, length of hospital stay, days to regular diet, and in hospital complication rate were identified. RESULTS: The peak age was 27 years. Seven of the 500 were converted to OA, yielding a conversion rate of 1.2%. The presence of non-visualized appendix, adhesion and technical failures were reasons for conversion. The distribution of histological stages of inflammation was comparable in both groups. The mean operating time was longer for the laparoscopic (64 min) than for the open procedure (58 min) (P<0.001). The complication rate after OA (7%) was significantly higher than that following LA (2.8%) (P=0.001). Hospital stay and frequency of analgesic administration were significantly lower in LA group than in OA group. CONCLUSION: Laparoscopic appendectomy is a safe and clinically beneficial operating procedure even in patients with appendicitis with peritonitis, perforation and abscess, resulting in shorter hospital stays and lower complication rates.

Is a Fast-track Critical Pathway Possible in Gastric Cancer Surgery?

PURPOSE: The postoperative hospital stay after gastric cancer surgery is usually 8 to 14 days. The main reason for a prolonged hospital stay may be the 3 to 4 day period of postoperative starvation. The aim of this study is to investigate the feasibility of a critical pathway for early recovery after gastric cancer surgery, and this pathway included early postoperative feeding. MATERIALS AND METHODS: One hundred three consecutive patients who underwent gastric resection and reconstruction for gastric cancer from October 2007 to June 2008 at St. Mary's Hospital were prospectively enrolled in a fast-track critical pathway. The pathway included minimal preoperative procedures, optimal pain relief, proper fluid administration, early mobilization and early enteral nutrition at postoperative 1 day. The exclusion criteria were determined preoperatively, intraoperatively and postoperatively. RESULTS: Of the 103 patients, 19 patients were excluded for preoperative (5), intraoperative (7) and postoperative (7) reasons. Eighty-four patients (81.6%) were included in the fast-track critical pathway. Sixty-eight (88.6%) of 84 patients were discharged at the planned 8 day after surgery during the initial period of the study, and the postoperative hospital stay was shortened up to 6 days during the more recent period. Postoperative complications occurred in 22 patients (26.2%), and these were gastrointestinal track-related complications in 6 cases (3 cases of ileus, 1 case of stasis and 2 cases of leakage) and infection-related complications in 8 cases. There was no statistical difference in the incidence of morbidity according to the clinic-operative features that included age, gender, stomach resection and lymphadenectomy. CONCLUSION: The fast-track critical pathway with using the available exclusion criteria was a valid option for patients who underwent gastric cancer surgery.

Hepatic Resection in Patients with Liver Metastasis from Gastric Cancer

The clinical significance of hepatic resection for gastric metastases is controversial, even though hepatic resection has been widely accepted as a modality for colorectal metastases. Very few patients with gastric hepatic metastases are good candidates for hepatic resection because of multiple bilateral metastases, extrahepatic disease, or advanced cancer progression, such as peritoneal dissemination or extensive lymph node metastases. Therefore, several authors have reported the clinical significance of hepatic resection for gastric metastases in a small number of patients. Considering the present results with previous reports. The number and distribution of tumors in hepatic metastases from gastric cancer was considered based on the present and previous reports. Several authors have reported significantly better survival in patients with metachronous metastasis than in those with synchronous disease. However, metachronous hepatic resection necessitates the dissection of adhesions between the pancreas, liver, and residual stomach to prepare for Pringle's maneuver. Patients with unilobar liver metastasis, and/or metastatic tumors <4 cm in diameter may be good candidates for hepatic resection. Synchronous metastasis is not a contraindication for hepatic resection. Most of the long-term survivors underwent anatomic hepatic resection with a sufficient resection margin. After hepatic resection, the most frequent site of recurrence was the remaining liver, which was associated with a high frequency of mortality within 2 years. A reasonable strategy for improvement in survival would be to prevent recurrence by means of adjuvant chemotherapy and careful follow-up studies.

Primary Gastric Choriocarcinoma

The majority of choriocarcinomas occur in the uterus as gestational malignant tumors. Rarely, a choriocarcinoma appears in the gastrointestinal tract, and the tumor is assumed to arise from a different histogenetic origin as compared to tumors of other sites. A primary gastric choriocarcinoma is a rare aggressive, widely metastatic malignant tumor, and has a poor prognosis. Reported here is a case of a 69-year-old woman with a primary gastric choriocarcinoma who presented with melena, epigastric pain, and was diagnosed with a poorly differentiated adenocarcinoma based on a preoperative endoscopic biopsy. Gastrectomy with lymph node dissection, followed by postoperative chemotherapy, is the treatment of choice. Therefore, in the case of a poorly differentiated adenocarcinoma with a bleeding tendency, a meticulous examination with the suspicion of a choriocarcinoma should be undertaken.

Modified FOLFOX-6 Chemotherapy for Recurrent or Inoperable Gastric Cancer Patients

PURPOSE: We wanted to evaluate the efficacy and toxicity of modified FOLFOX-6 chemotherapy for treating recurrent or inoperable gastric cancer patients. MATERIALS AND METHODS: From April 2006 to August 2007, 35 patients with recurrent gastric cancer after curative resection and 43 patients with inoperable gastric cancer underwent chemotherapy, and the results were retrospectively investigated. RESULTS: 78 patients were assessable for response and toxicity, and they underwent an average of 7.1 cycles of chemotherapy. The response was evaluated according to the RECIST criteria. 11 partial responses (14.1%), 35 cases of stable disease (44.9%), and 32 cases of progressive disease (41%) were observed. The median time to progression was 6 months, and the average overall survival was 13 months. CTCAE grade 1 or 2 anemia (52.6%) was the most prevalent toxicity. Other common toxicities included thrombocytopenia (17.9%) and peripheral neuropathy (30.8%). There were 13 changes in the chemotherapy regimen to S1-cisplatin due to disease progression, but only an average of 1.76 cycles of S1-cisplatin were delivered due to severe toxicities and poor compliance. CONCLUSION: Acceptable efficacy and toxicity were seen as 59% of the patients showed non-progression, and no grade 3 or 4 toxicities were observed. In conclusion, the modified FOLFOX-6 chemotherapy is considered to be the proper 1st-line choice as a palliative treatment for recurrent or inoperable gastric cancer patients.

A Case of the Common Bile Duct Web Treated with a Retrievable Covered Metallic Stent / 대한소화기내시경학회지

The web of the common bile duct is an extremely rare condition and is attributed to obstructive jaundice. Most cases have been found incidentally during a surgical procedure, since no specific preoperative clinical manifestations exist. Typically, the web of the biliary tree appears as a slit- or shelf-like radiolucent narrowing on a cholangiography. We experienced a case of the web of the common bile duct with obstructive jaundice in a 62 year- old female who complained of right upper quadrant pain. The patient was diagnosed via an endoscopic retrograde cholangiopancreaticography, and treated by way of a cholecystectomy, membranectomy and T-tube insertion. Four months after the surgical procedure, the patient had a recurrence of the web-like structure in the common bile duct and was subsequently treated successfully using a retrievable covered metallic stent insertion.