Polypoid-Type Adenomyomatous Lesion of the Cystic Duct: Report of a Case and Review of Literature.

Adenomyomatous hyperplasia, a common non-neoplastic lesion in the gallbladder, is rarely identified in the extrahepatic bile duct. Typically, these lesions appear as a nodule or mural thickening/elevation. However, in exceptional circumstances, pedunculated/polypoid adenomyomatous lesion occurs in the biliary tract; two cases in the gallbladder and only one case in the common bile duct have been reported. Despite their benign nature, adenomyomatous lesions, especially those with a polypoid appearance, are clinically difficult to exclude a possibility of malignant neoplasms. We describe a case of polypoid-type adenomyomatous lesion of the cystic duct in a 72-year-old man, which was considered as a cystic duct neoplasm preoperatively. Gross examination of the resected specimen revealed that the 9 mm-sized cystic duct polyp. Histologically, the polypoid lesion consisted of glands without atypia, fibrous stroma, smooth muscle bundles, and accompanying stromal inflammation, leading to the diagnosis of benign adenomyomatous lesion. The lesion might be considered as adenomyomatous hyperplasia arising in the valve of Heister, while true nature of the lesion is uncertain. Recognition and accumulating for this rare disease will contribute to better clinical management in the future.

Small bowel obstruction caused by appendiceal and ileal endometriosis: a case report.

Endometriosis is characterized by the presence of an ectopic endometrial gland. Intestinal endometriosis with small bowel obstruction is uncommon. In this case, a 37-year-old woman with no history of endometriosis presented with a chief complaint of abdominal pain. Computed tomography revealed a distal small bowel obstruction. Surgical intervention was performed because of the emergent abdominal condition and the potential resistance to conservative management. Histopathological examination revealed appendiceal and ileal endometriotic lesions. Preoperative diagnosis was difficult because there were no specific clinical features. Intraoperatively, it is difficult to distinguish intestinal endometriosis and bowel malignancy; thus, oncological resection should be performed.

Duodenal stenosis associated with an ectopic opening of the common bile duct into the duodenal bulb: a case report.

BACKGROUND: Ectopic opening of the common bile duct is a rare congenital biliary anomaly. Herein, we present a case of duodenal stenosis with ectopic opening of the common bile duct into the duodenal bulb. CASE PRESENTATION: A 54-year-old man was referred with fever, nausea, and vomiting. He had experienced epigastric pain several times over the past 30 years. Endoscopy showed a post-bulbar ulcer, a submucosal tumor of the duodenum, and a small opening with bile secretion. Contrast duodenography revealed duodenal stenosis and bile reflux with a common bile duct deformity. Pancreatoduodenectomy was performed because of the clinical suspicion of a biliary neoplasm or groove pancreatitis. The resected specimen showed an ectopic opening of the common bile duct into the duodenal bulb and no tumor. CONCLUSIONS: Ectopic opening of the common bile duct into the duodenal bulb is complicated by a duodenal ulcer, deformity, and stenosis mimicking groove pancreatitis or pancreatic tumors. Although rare, we should be aware of this anomaly for an accurate diagnosis.

A case of intrahepatic cholangiocarcinoma that was difficult to diagnose prior to surgery: A case report.

The present study reports a case of mass-forming intrahepatic cholangiocarcinoma (ICC), which mimicked cholangiocellular carcinoma (CoCC) during imaging and a needle biopsy examination. A 51-year-old female with no relevant medical history was referred to the National Defense Medical College hospital with an intrahepatic tumor. Computed tomography demonstrated non-homogeneous enhancement in the early arterial phase and persistent enhancement in the portal and equilibrium phases, together with notable swelling of the para-aortic lymph nodes. Gadolinium-ethoxybenzyl diethylenetriamine-pentaacetic acid-enhanced magnetic resonance imaging revealed low signal intensity in the hepatobiliary phase. The liver tumor and lymph nodes exhibited increased radiotracer uptake (maximum standardized uptake value=14.0) with positron emission tomography. A histological examination of a percutaneous needle biopsy specimen of the liver tumor indicated a diagnosis of CoCC. The patient underwent left hepatectomy and lymphadenectomy. The surgical specimen contained a poorly differentiated adenocarcinoma with anaplastic changes, which was immunohistochemically positive for epithelial membrane antigen (at the luminal membrane), cytokeratins 7 and 19, and negative for α-fetoprotein, hepatocyte-specific antigen, cluster of differentiation 56 and KIT. Based on these histopathological and immunohistochemical findings, the patient was diagnosed with ICC.

Laterally spreading features of gastrointestinal stromal tumors: A clinicopathological study.

To elucidate the histopathological features of laterally spreading gastrointestinal stromal tumors (GISTs), we retrospectively examined 52 GISTs grossly completely resected from 50 patients. Laterally spreading features were identified in 7 GISTs (13%), and were localized within non­thickened regions of the muscularis propria adjacent to the main GISTs, ranging in length from 0.12 to 0.7 cm (mean, 0.3 cm). The laterally spreading features involved the muscular surgical margins in 2 cases. The morphologies of the laterally spreading cells resembled those of tumor cells in 4 cases, but were comprised of more slender spindle cells with smaller nuclei compared with those in the respective main GISTs. Compared with the main GISTs, KIT+ and discovered on GIST 1+ immunostaining features of the spreading lesions were similar in 4 cases, and were weaker or diminished in the other 3 cases. There were no differences in CD34+ staining features between the main GISTs and the laterally spreading lesions. One patient with laterally spreading GIST succumbed to the disease 2.5 years after the surgery, while the other 6 patients were alive without the recurrence of disease 0.4­19.2 years after the surgery. The laterally spreading features were associated with a pedunculated GIST (P=0.006), but not older age (P=0.312), sex (P=0.969), tumor size (P=0.430), mucosal invasion (P=0.666) or higher risk category (P=0.872). Results of the present study indicate that resection of a ≥1­cm muscular safety margin, and not mucosa or submucosa, is required for microscopically negative surgical margins, particularly for pedunculated GISTs.

Acute gastric volvulus associated with wandering spleen in an adult treated laparoscopically after endoscopic reduction: a case report.

A 43-year-old female was referred to our hospital for sudden onset of abdominal pain, fullness, and vomiting. Physical examination revealed abdominal distension with mild epigastric tenderness. Abdominal radiography showed massive gastric distension and plain computed tomography (CT) a markedly enlarged stomach filled with gas and fluid. A large volume of gastric contents was suctioned out via a nasogastric (NG) tube. Contrast-enhanced CT showed a grossly distended stomach with displacement of the antrum above the gastroesophageal junction, and the spleen was dislocated inferiorly. Upper gastrointestinal (GI) series showed the greater curvature to be elevated and the gastric fundus to be lower than normal. Acute mesenteroaxial gastric volvulus was diagnosed. GI endoscopy showed a distortion of the gastric anatomy with difficulty intubating the pylorus. Various endoscopic maneuvers were required to reposition the stomach, and the symptoms showed immediate and complete solution. GI fluoroscopy was performed 3 days later. Initially, most of the contrast medium accumulated in the fundus, which was drawn prominently downward, and then began flowing into the duodenum with anteflexion. Elective laparoscopic surgery was performed 1 month later. The stomach was in its normal position, but the fundus was folded posteroinferiorly. The spleen attached to the fundus was normal in size but extremely mobile. We diagnosed a wandering spleen based on the operative findings. Gastropexy was performed for the treatment of gastric volvulus and wandering spleen. The patient remained asymptomatic, and there was no evidence of recurrence during a follow-up period of 24 months. This report describes a rare adult case of acute gastric volvulus associated with wandering spleen. Because delay in treatment can result in lethal complications, it is critical to provide a prompt and correct diagnosis and surgical intervention. We advocate laparoscopic surgery after endoscopic reduction because it is a safe and effective procedure with lower invasiveness.

Mucinous carcinoma of the duodenum associated with hereditary nonpolyposis colorectal cancer: report of a case.

We herein report a rare case of primary mucinous carcinoma of the duodenum associated with hereditary nonpolyposis colorectal cancer (HNPCC). A 50-year-old man known to have HNPCC based on the Amsterdam criteria I was admitted because of the presence of a duodenal tumor. Duodenoscopy revealed an ulcerated tumor in the posterior wall of the second portion of the duodenum and the malignancy was confirmed by a biopsy. He underwent a pylorus-preserving pancreaticoduodenectomy with a regional lymph node dissection. The histological diagnosis was mucinous carcinoma of the duodenum with lymph node metastasis. High-frequency microsatellite instability (MSI-H) was identified in both the colon and a duodenal specimen based on a microsatellite assay. A germline mutation in the hMSH2 gene was also identified. Even though extracolonic malignancies are associated with HNPCC, duodenal cancer is nevertheless very rare, and only two cases have been reported over the past 20 years. The present case is therefore only the third such case and the patient is herein described with a brief review of the literature.

[A case of 5-FU-resistant recurrent colon cancer treated with low-dose CPT-11/CDDP on an outpatient basis].

We report a case of recurrent colon cancer resistant to 5-FU, whose QOL and PS has been well maintained with low-dose CPT-11/CDDP administered on an outpatient basis for more than 28 months. A 42-year-old male had lymph node recurrence 27 months after curative resection of colon cancer. He had been administered pharmacokinetic modulating chemotherapy (PMC, oral tegafur/uracil plus fluorouracil infusion) after surgery. Combined treatment with CPT-11 (50 mg/m2)/CDDP (6 mg/m2) was performed on an outpatient basis. Nine months of NC was obtained without any severe side effect. Modified administration of this treatment with 5'-DFUR and TS-1 lead to further maintenance of quality of life and performance status. This case suggests the efficacy of low-dose CPT-11/CDDP for cases of 5-FU-resistant colon cancer in terms of QOL and PS.

[A case of highly advanced ascending colon cancer with multiple bone and liver metastases and pleuritis carcinomatosa treated with pharmacokinetic modulating chemotherapy and low-dose CPT-11].

A 54 year-old male was admitted for highly advanced ascending colon cancer with multiple bone and liver metastases and pleuritis carcinomatosa. He was treated with pharmacokinetic modulating chemotherapy (PMC) and low-dose CPT-11. UFT (400 mg) was orally administered daily and a 2-hour infusion of l-leucovorin (250 mg/m2/day) with a continuous infusion of 5-FU (600 mg/m2/24 h) was given once a week on an outpatient basis. CPT-11 (80 mg/body/2 h) was administered every 2 weeks. Partial response was obtained in the liver for 6 months and in the primary lesion for 9 months. Significant decrease of pain from the multiple bone metastases was observed for 4 months without severe side effects, which led to an improvement in performance status and quality of life for the patient. He survived more than 11 months after initial treatment. The duration of his stay at home was 288 days, accounting for 83% of the treatment period. This case suggests the efficacy of home anticancer therapy with PMC and low-dose CPT-11 for highly advanced colon cancer in terms of QOL.

The Impact of Technology on the Resolution of Minimally Invasive Training and Credentialing Challenges of the 21st Century.

After the meteoric entry of minimally invasive surgery onto the general surgery scene 9 years ago, it currently stands at a crossroads with regard to the 21st century. Many challenges hamper safe and costeffective deployment of minimally invasive techniques. There must be a stabilization and reduction of complication rates associated with laparoscopic cholecystectomy. Common bile duct injuries are in fact two to three times higher for laparoscopic cholecystectomy than for the open procedure. This matter has been discussed only at local morbidity and mortality conferences or at national meetings. Patients are being injured. The surgical community has failed to police itself and the public knows it. This led in 1992 to New York State health officials setting standards of training and surgeon preparedness for performing laparoscopic cholecystectomy. If surgeons don't handle the problem, the politicians and the lawyers soon will.