A perforation of a duodenal diverticulum in a 97-year-old patient after total gastrectomy and Roux-en-Y reconstruction: a case report.

Most duodenal diverticula (DD) are asymptomatic and rarely develop perforations. Perforation is the most serious complication of DD and often requires emergency surgery. A 97-year-old woman who had undergone total gastrectomy and Roux-en-Y reconstruction 30 years ago was referred to our department with chief complaints of abdominal pain and fever during her hospitalization after femoral neck fracture surgery in the orthopedic department. Contrast-enhanced computed tomography showed free air and residue in the abdominal cavity and right retroperitoneum, and an emergency laparotomy was performed. The abdominal cavity was mildly contaminated, and a 6-cm DD with a 1-cm perforation in the wall of the diverticulum on the contralateral side of the mesentery of the duodenum was found. Diverticulectomy and duodenal closure were performed and a drainage tube was placed. The patient experienced no complications and was transferred to the orthopedic department on postoperative day 10. Reports of perforation of DD after gastrectomy are very rare. Particular attention should be paid to perforation of DD after Billroth-II and Roux-en-Y reconstructions as they involve the formation of a duodenal stump that differs from the normal anatomy and may be highly invasive surgical procedures, depending on the degree of inflammation and fistula formation.

A case of laparoscopic appendectomy for appendiceal bleeding.

BACKGROUND: Appendiceal bleeding is very rare, accounting for about 0.4% of all lower gastrointestinal bleeding. We present a case of laparoscopic appendectomy in a patient with a diagnosis of appendiceal bleeding. CASE PRESENTATION: A 71-year-old man came to our hospital with a complaint of bloody stools. He had progressive anemia and persistent fresh bloody stools, so he underwent lower gastrointestinal endoscopy. Active bleeding was confirmed from the orifice of the appendix, but the bleeding could not be stopped even with clips, so an emergency laparoscopic appendectomy was performed. His postoperative course was good, and he was discharged on the third postoperative day. Although the pathology results did not allow identification of the source of the bleeding, an appendiceal diverticulum was observed, and appendiceal diverticular bleeding was suspected. CONCLUSION: Appendiceal bleeding is often difficult to stop endoscopically, so appendectomy should be performed as soon as possible.

A case of superficial spreading type of poorly differentiated adenocarcinoma of the stomach with invasion to the esophagus.

BACKGROUND: Invasion is more likely to occur in gastric cancer affecting larger areas. Poorly differentiated adenocarcinoma tends to invade deep. The cardiac region prefers submucosal invasion because the submucosa is coarser than the other regions. CASE PRESENTATION: A 75-year-old man presented with a chief complaint of abdominal discomfort and weight loss. Esophagogastroduodenoscopy revealed an irregular ulcerative lesion with partial redness of the upper body and lesser curve of the stomach. A continuous shallow depressed lesion invaded the abdominal esophagus by approximately 40 mm. Poorly differentiated adenocarcinomas (por, sig) were observed on biopsy. Grossly, the cancer appeared to extend into the muscle layer; however, we could not confirm invasion into the muscle layer in our biopsy tissue. We diagnosed the lesion as a superficial spreading type of advanced gastric cancer and performed a total gastrectomy, D2-lymph node dissection (spleen preservation), Roux-en-Y reconstruction, and cholecystectomy. Postoperative histopathological examination revealed extensive infiltration of poorly differentiated adenocarcinoma (90 mm × 55 mm), and all were intramucosal lesions. The final pathological diagnosis was T1a, N0, M0, and Stage IA. The postoperative course was uneventful and the patient was discharged on postoperative day (POD) 11. Five years have passed since the operation, and the patient is alive without recurrence. CONCLUSION: We encountered a case of gastric carcinoma in which poorly differentiated adenocarcinomas expanded extensively. All lesions were intramucosal.

[A Case of Malignant Lymphoma of the Breast after Treatment of the Contralateral Breast Cancer].

A 57-year-old female was referred to our hospital due to a palpable tumor of the left breast; she was diagnosed with cancer in the left breast 3 years prior, in 201X. After the administration of FEC and docetaxel plus trastuzumab as preoperative chemotherapy, left mastectomy with axillary lymph node dissection was performed, and irradiation and trastuzumab were administered postoperatively for 1 year. During the observation, there was skin thickening around the right nipple. A skin biopsy was then performed in 201X, and the patient was diagnosed with diffuse large B-cell lymphoma(DLBCL). PET-CT revealed a slight accumulation in the peripheries of the right nipple and mammary glands. Core needle biopsy of the tumor in the mammary gland showed DLBCL similar to that observed in the skin biopsy. Imaging revealed complete response after chemotherapy, whole-body irradiation, and intrathecal administration. Currently, both breast cancer and DLBCL of the breast have not relapsed.

Clinical evaluation of modified reconstruction method after pancreatoduodenectomy.

BACKGROUND/AIMS: The new reconstruction procedure after pancreatoduodenectomy (PD) is described to evaluate its usefulness. METHODOLOGY: The jejunum was made for an end-to-side choledochojejunostomy, and the cut proximal jejunum for approximately 20 cm was led to the pancreatic stump for end-to-end anastomosis with telescoping. Approximately 20 cm of jejunum was created with a side-to-end anastomosis with the stomach, and end-to-side jejuno-jejunostomy for Roux-en Y reconstruction. As a postoperative course, separated loop method (SL, n=38) was evaluated by comparing pancreatogastrostomy (PG, n=31) and Imanaga method (IM, n=26). RESULTS: On SL, PG and IM cases, the high amylase level in drainage fluid was noted in 2.6%, 6.5% and 19.2%, respectively. The delayed gastric emptying was seen in PG and IM, but not in SL. Serum albumin levels were similar, but cholinesterase and total cholesterol levels were significant better in SL. CONCLUSIONS: SL method is safe for complications after PD.

Cryptogenic organizing pneumonia after radiotherapy for breast cancer.

We report a case of lasting fever and cough with pulmonary infiltrates progressing 4 months after adjuvant radiotherapy following surgery for breast cancer. Chest radiography and computed tomography demonstrated alveolar opacities outside the irradiated pulmonary area. Laboratory data revealed neutrophilia and increased levels of C-reactive protein. Bronchoalveolar lavage fluid displayed increased lymphocyte counts, and transbronchial lung biopsy revealed histological patterns compatible with cryptogenic organizing pneumonia (COP). Corticosteroid therapy resulted in marked clinical improvement. From the histological and clinical findings, this case was judged to be a case of COP induced after radiotherapy for breast cancer, similar to those reported recently.