Gastric Signet Ring Cell Adenocarcinoma Presenting as Intermittent Volvulus of Small Bowel: A Case Presentation and Review of the Literature.

Signet ring cell carcinoma (SRCC) is an uncommon and poorly differentiated tumor. It arises mostly in the gastrointestinal tract. The incidence of gastric SRCC has increased in the past few years. Volvulus is the twisting of the bowel around its mesentery. It is classified as either primary or secondary. It is relatively common in the cecum and sigmoid colon. Volvulus of other parts of the gastrointestinal tract is relatively rare. Herein, we present a case of small bowel volvulus (SBV) secondary to advanced gastric SRCC with peritoneal carcinomatosis. The patient had presented with nausea and vomiting. Initial computed tomography (CT) scan of abdomen unveiled jejunal volvulus. SBV resolved spontaneously on a repeat CT scan. Enteroscopy with histopathology confirmed the diagnosis of gastric SRCC, which turned to be metastatic to peritoneum on laparoscopy. We believe our case is unique due to the rarity of advanced gastric SRCC presenting as secondary jejunal SBV without appreciated gastric mass on imaging.

Zenker's peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker's diverticulum: a multicenter retrospective comparison.

BACKGROUND: Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM. METHODS: Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events. RESULTS: 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05). CONCLUSIONS: There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.

Jejunal Ectopic Pancreas: A Rare Cause of Small Intestinal Mass.

Ectopic pancreas (EP) is defined as the presence of pancreatic tissue outside the pancreas with no anatomical connection to the pancreas. It is also known as pancreatic heterotopia, accessory pancreas, aberrant pancreas, or pancreatic rest. The first case of EP was described in 1727 when pancreatic tissue was identified in the ileal diverticulum. Abdominal pain and lower gastrointestinal bleeding are the most common symptoms. On histopathological examination, EP can be classified into four subtypes. Once identified and diagnosed, the treatment is surgical resection and the post-operative course is asymptomatic in most cases. We describe a rare case of EP, which was discovered on the CT scan of the abdomen as a jejunal mass and successfully treated with surgical resection. We have also described the possible role of chromogranin A for diagnosing EP cases and for post-operative follow-up.

Short-term clinical outcomes of non-curative endoscopic submucosal dissection for early esophageal adenocarcinoma.

OBJECTIVES: Few Western studies highlighted the outcomes of endoscopic submucosal dissection (ESD) for early esophageal adenocarcinoma (EAC). Data regarding the outcomes of noncurative ESDs remains scarce. In this study, we share our experience with ESD for early EAC with a focus on noncurative ESDs. METHODS: A retrospective single-center analysis of consecutive patients who underwent ESD for early EAC from August 2015 through February 2020. Primary outcomes included the clinical outcomes of noncurative ESDs along with overall en bloc, R0 and curative resection rates. Secondary outcomes included comparing results between T1a and T1b tumors. RESULTS: Final group included 23 T1a and 17 T1b EAC patients. Patients' median Charlson comorbidity index was five. En bloc resection rate was (97.5%). Compared to the T1b group, the T1a group had a statistically significantly higher R0 (78.3 vs. 41.2%; P = 0.0235), curative (73.9 vs. 11.8%; P = 0.0001) and accumulative endoscopic curative resection rates (82.6 vs. 23.5%; P = 0.0003). A study flowchart is presented in (Fig. 1). Out of the 21 noncurative ESDs, 10 patients (47.6%) underwent R0 esophagectomy, 6 patients (28.6%) are undergoing surveillance endoscopies without additional therapy, 3 patients (14.3%) underwent repeat curative ESD and 1 patient (4.76%) is receiving chemotherapy with surveillance endoscopy. Over median endoscopic follow-up of 22.5 months (IQR, 14.25-30.75), 2 out of 10 patients with noncurative ESDs had recurrent disease. CONCLUSIONS: ESD achieved a higher curative resection rate in T1a EAC when compared to T1b. Despite a lower curative resection rate in T1b EAC, certain patients might benefit from a conservative multimodal therapy.

Sister Mary Joseph's Nodule: Where Umbilicus Holds the Truth!

An umbilical metastasis from an internal visceral malignancy is defined as Sister Mary Joseph's nodule (SMJN), and, although a rare finding, it is a very poor prognostic indicator. We describe an interesting case of metastatic colon cancer with SMJN, emphasizing the significance of this classic finding. A 64-year-old female with a history of stage IV colon cancer with palliative right hemicolectomy and left hepatectomy presented to the hospital with nausea and abdominal discomfort. A computed tomography (CT) scan of the abdomen was performed, which showed small bowel obstruction secondary to metastatic tumor mass compressing the duodenum. She refused to undergo any chemotherapy or endoscopic intervention and was eventually discharged on hospice care. During the hospital stay an umbilical ulcerative lesion was also noted, which was violaceous, measuring 4.5 x 4 cm in size, firm in consistency with irregular borders, and tender to touch. Therefore, further history was obtained from the patient about it. Several months ago, she had developed localized swelling around the umbilicus, which gradually enlarged and ulcerated later. She eventually underwent the biopsy of that umbilical lesion, which confirmed it as SMJN with metastasis from the colonic primary. However, the patient refrained from the surgical intervention of the umbilical lesion. SMJN presents as a palpable periumbilical metastatic mass with diameter usually not exceeding 5 cm in size. It can be variable in color from violaceous to reddish brown. Once discovered, such lesions should be worked up with biopsy and imaging studies such as CT scan of the abdomen, as the nodule may be indicative of underlying malignancy or cancer recurrence. Its presence indicates a poor prognosis, with average survival time after diagnosis of SMJN of 10 months.

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease.

Endoscopic Papillectomy for Major and Minor Papillary Adenoma in Familial Adenomatous Polyposis.

Ampullary adenomas can occur sporadically or in the patients with adenomatous polyposis syndrome, including familial adenomatous polyposis (FAP) and MUTYH-associated polyposis. The potential for malignant transformation is high in the setting of FAP. Although endoscopic resection of major papillary adenoma has been well described, minor papilla adenomas are exceptionally rare. This is the second documented case of an endoscopic papillectomy in a patient with FAP with simultaneous ampullary adenoma of the major and minor papilla.

Bouveret's Syndrome.

Bouveret syndrome is a very rare form of gastric outlet obstruction following the passage of a gallstone from the gallbladder to the duodenum or pylorus through a bilioenteric fistula. We present a unique case of a 78-year-old male complaining of right upper quadrant abdominal pain and who was found to have a gallstone in the proximal duodenum along with pneumobilia and cholecysto-duodenal fistula suggestive of Bouveret's syndrome.

Hepatitis C Infection Patterns at a Tertiary Care Center in New York: A Cross-Sectional Study.

Introduction In the United States, 2.7 to 3.9 million patients are infected with the hepatitis C virus (HCV) with 3,500 new cases reported yearly. According to the Centers for Disease Control and Prevention, HCV was the underlying or contributing cause of death of 19,659 patients in 2014. These facts underscore the need for a better understanding of the scope of this disease. Our epidemiologic study aimed at analyzing the pattern of occurrence of HCV infection at Staten Island University Hospital (SIUH) by evaluating the characteristics of newly infected patients with hepatitis C in 2014. The identified features served to better distinguish the targets for preventive health care in our particular population. Methodology A cross-sectional study of all newly diagnosed patients with HCV infections in the year 2014 presenting to SIUH was conducted using International Classification of Disease-9 codes (ICD-9) for hepatitis C. We included all patients with a positive HCV antibody confirmed by polymerase chain reaction testing. Patients were divided into groups according to age to simulate the age groups in the 2013 - 2014 Hepatitis B and C Annual Report of the New York City (NYC) Department of Health and Mental Hygiene published in 2016 (abbreviated to 2014 NYCDOH Report, hereafter). Gender and HCV genotypes were also collected. We compared disease frequency between age groups, gender, and genotype with the results of the 2014 NYCDOH Report. Results A total of 378 newly diagnosed HCV cases were identified; 60.05% were men, and 39.95% were women. The rate of infection with genotype 1a was the highest (36. 5%) followed by 1b (25.9%). In women, genotype 1b was predominant (13.76%) versus genotype 1a as the most common in men. The mean age was 54 years for men and 57 years for women. Most cases fell into the 60 to 69-year age group (32.28%), followed by the 50 to 59-year age group (31.48%). More so, all patients 80 years and older were exclusively women. Conclusions We found most new HCV infections at SIUH were diagnosed in patients aged 60 to 69 years, and the 2014 NYC DOH Report indicates most new HCV infections occur in patients aged 40 to 59 years. Also, all HCV infections detected in patients older than 80 years of age were found in women. These findings provide a better understanding of the patient demographics for appropriate HCV screening policies. Increased awareness and strict adherence to screening policies in baby boomers and high-risk populations are paramount in order to diagnose HCV infection early, offer therapy, and prevent HCV-related mortality and morbidity.

Gastrointestinal Stromal Tumors: Deception to the Eyesight.

Gastrointestinal stromal tumors (GISTs) are rare soft tissue tumors. Despite their rarity, these tumors are the most common gastrointestinal (GI) mesenchymal tumors. They can involve various parts of the gastrointestinal tract. GISTs growth can be intramural, intraluminal or exophytic. Symptoms are usually related to GI bleeding and to adjacent organ compression by the tumor. Endoscopy can suggest the diagnosis, but tissue sampling is required for the diagnosis. Herein, we present a unique case of GIST where the patient had negative endoscopic findings despite the large size of the tumor, thus abdominal computed tomography scan and endoscopic ultrasound was required to make the diagnosis.

Solid Pseudopapillary Tumor of the Pancreas: An Unusual Cause of Abdominal Pain.

Solid-pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor that accounts for less than one percent of pancreatic tumors. The diagnosis could be challenging as SPN tend to manifest with nonspecific abdominal symptoms, variable radiological features, and inconsistent morphology. The cellular origin of SPN is unclear and might involve ductal, acinar and endocrine stem cells.  We report a rare case of a 27-year-old female who presented with intermittent abdominal pain for two years, associated with a decrease in appetite. Her medical history was significant for abdominoplasty five years ago. Vital signs were stable. Physical examination revealed mild epigastric tenderness. Laboratory tests were unremarkable. Contrast computed tomography (CT) scan of the abdomen showed a 2 x 2 cm indeterminate pancreatic tail lesion. An endoscopic ultrasound (EUS) disclosed a 2.1 x 1.8 cm hypoechoic mass in the tail of the pancreas.Trans-gastric fine needle aspiration was obtained to show clusters of uniform neoplastic cells with abundant cytoplasm and oval bean-shaped nuclei. Immunohistochemical stains were positive for beta-catenin, Vimentin, CD10, CD56, cytokeratin-7 (Ck7), Cyclin D1, and negative for chromogranin, epithelial-cadherin (E cadherin) which was consistent with a pseudopapillary tumor. The patient underwent a robotic assisted en-bloc distal pancreatectomy and splenectomy. There were no intra-abdominal metastases. SPN is a rare tumor characterized by a specific immunohistological pattern which makes it highly distinct from other pancreatic neoplasms particularly neuroendocrine tumors, acinar carcinomas, and carcinoids. It is important to differentiate SPN from other pancreatic neoplasms because it is characterized as low potential for malignancy and a favorable prognosis after resection, with a five-year survival rate approaching 85%-95%.

Metastatic tonsillar squamous cell carcinoma masquerading as a pancreatic cystic tumor and diagnosed by EUS-guided FNA.

Metastatic carcinoma to the pancreas is uncommon and head and neck squamous carcinoma metastatic to the pancreas is extremely rare. Metastatic squamous cell carcinoma to the pancreas presents a unique diagnostic challenge: in addition to mimicking the rare primary squamous cell carcinoma of the pancreas based on cytologic, histologic, and immunohistochemical features, it may be mistaken for a cystic neoplasm of the pancreas because of its high predilection for cystic degeneration in metastatic sites. Herein, we report a case of tonsillar squamous cell carcinoma with a cystic pancreatic metastasis diagnosed by ultrasound-guided fine needle aspiration biopsy (EUS-FNA). This represents a third reported case of metastatic squamous cell carcinoma to the pancreas from the head and neck region. Metastatic squamous cell carcinoma should be considered in the differential diagnosis of EUS-FNA during evaluation of pancreatic cystic lesion.

Endoscopic Ultrasound: Reaching Where Others Can't.

Endoscopic ultrasound (EUS) has been increasingly used for the diagnosis and staging of pancreatic cancer. It has recently become the modality of choice in assessing pancreatic lesions overcoming other traditional modalities. Typically lesions located at the tail of the pancreas are best accessed through the stomach. We present a patient with pancreatic tail mass occurring in the setting of a large hiatal hernia, intrathoracic stomach, and severe lumbar levoscoliosis. Due to altered anatomy and extensive vascular connections of the mass, any surgical or radiological intervention was considered high risk for the patient. EUS was the only modality capable of providing a pancreatic mass tissue sample in this patient with challenging thoraco-abdominal anatomy. Moreover, pancreatic tail lesions are traditionally best accessed through the gastric fundus; however, in view of the patient's altered anatomy, EUS-fine needle aspiration (FNA) had to be performed through the duodenum. This case raises the importance of EUS when surgical and radiological interventions are restricted.

Utilization trends in inpatient endoscopic retrograde cholangiopancreatography (ERCP): A cross-sectional US experience.

Study aims The goal of our study was to determine the current trends for inpatient utilization for endoscopic retrograde cholangiopancreatography (ERCP) and its economic impact in the United States between 2002 and 2013. Patients and methods A Nationwide Inpatient Sample from 2002 through 2013 was examined. We identified ERCPs using International Classification of Diseases (ICD-9) codes; Procedure codes 51.10, 51.11, 52.13, 51.14, 51.15, 52.14 and 52.92 for diagnostic and 51.84, 51.86, 52.97 were studied. Rate of inpatient ERCP was calculated. The trends for therapeutic ERCPs were compared to the diagnostic ones. We analyzed patient and hospital characteristics, length of hospital stay, and cost of care after adjusting for weighted samples. We used the Cochran-Armitage test for categorical variables and linear regression for continuous variables. Results A total of 411,409 ERCPs were performed from 2002 to 2013. The mean age was 59 ±â€Š19 years; 61 % were female and 57 % were white. The total numbers of ERCPS increased by 12 % from 2002 to 2011, which was followed by a 10 % decrease in the number of ERCPs between 2011 and 2013. There was a significant increase in therapeutic ERCPs by 37 %, and a decrease in diagnostic ERCPs by 57 % from 2002 to 2013. Mean length of stay was 7 days (SE = 0.01) and the mean cost of hospitalization was $20,022 (SE = 41). Conclusions Our large cross-sectional study shows a significant shift in ERCPs towards therapeutic indications and a decline in its conventional diagnostic utility. Overall there has been a reduction in inpatient ERCPs.