Unusual manifestation of gastric adenocarcinoma presenting with lymphedema, chylothorax, and chylous ascites.

A 62-year-old Thai man with a 2-year history of bilateral lymphedema and an unprovoked left axillary vein thrombosis presented with progressive leg, scrotal, and abdominal swelling, and shortness of breath. He denied any gastrointestinal symptoms. His lymphedema had initially been diagnosed as chronic filariasis due to positive blood tests for anti-filarial antibodies; however, treatment with anti-filarial drugs failed to improve his symptoms. Subsequently, he underwent surgical lymphaticovenular anastomosis with scrotal reduction, which proved to be of limited symptomatic relief. Later investigations revealed bilateral chylothorax and chylous ascites, with the presence of metastatic adenocarcinoma. Histopathological examination of the patient's skin and scrotum biopsy from his previous surgery revealed invasion of the lymphatics by neoplastic cells with signet ring cell formation. Gastroscopy uncovered a gastric mass, and biopsy confirmed the diagnosis of stage IV gastric adenocarcinoma with signet ring cell. He later received palliative chemotherapy. For the management of chyle leakage, he was prescribed a very low-fat diet and supplemented with parenteral nutrition. Despite treatment, he developed cutaneous metastasis and was transitioned to best supportive care. The patient passed away 14 months after diagnosis.

Clinical outcome of neoadjuvant chemoradiation in rectal cancer treatment.

ABSTRACT: To determine the clinical and pathological outcome of locally advanced rectal cancer patients treated with neoadjuvant chemoradiation (chemoradiotherapy [CRT]) followed by curative surgery and to identify predictive factors of pathological complete response (pCR).Locally advanced rectal cancer patients undergoing CRT followed by curative surgery from January 2012 to December 2017 were included. Patient's demographic data, pretreatment tumor characteristics, type of CRT regimens, type of surgery, postoperative complications, pathological reports and follow up records were analyzed. Univariate and multivariate analyses were applied to identify predictive factors for pCR. Five-year disease free and overall survival were estimated by Kaplan-Meier method and compared between pCR and non-pCR groups.A total of 85 patients were analyzed. Eighteen patients (21.1%) achieved pCR. The sphincter-saving surgery rate was 57.6%. After univariate analyses, tumor length >4 cm (P = .007) and positive lymph nodes (P = .040) were significantly associated with decreased rate of pCR. Complete clinical response was significantly associated with higher rate of pCR (P = .015). Multivariate analyses demonstrated that tumor length >4 cm (P = .010) was significantly associated with decreased rate of pCR. After a median follow-up of 65 months (IQR 34-79), the calculated 5-year overall survival and disease-free survival rates were 81.4% and 69.7%, respectively. Patients who achieved pCR tend to had longer 5-year disease-free survival (P = .355) and overall survival (P = .361) than those who did not.Tumor length >4 cm was associated with decreased rate of pCR in locally advanced rectal cancer who had CRT followed by surgery. Longer waiting time or more intense adjuvant treatment may be considered to improved pCR and oncological outcomes.

Left Paraduodenal Hernia As a Rare Cause of Small Bowel Obstruction in Elderly: A Case Report and Review of Literature.

The authors presented a case of left paraduodenal hernia as a cause of closed loop small bowel obstruction in an elderly patient. Internal hernias are a rare cause of intestinal obstruction. Paraduodenal hernias are the most frequent especially left sided, which are believed to be the result of malrotation of the midgut during embryonic period. The clinical presentations varied, ranging from asymptomatic, chronic abdominal pain, or acute abdominal pain as acute abdomen. Most of the patients usually have early presentation in adult life with average age of 38.5 years at time of diagnosis. Late presentation in elderly patient (> 70 years) is very rare due to its congenital in origin. This clinical entity is a diagnostic challenge, which happened in our case. When the diagnosis is late, the complication develops and may contribute to afatal outcome if left untreated Herein, the authors reported our case of left paraduodenal hernia with late presentation at age of 80, and reviewed literature.

Upper gastrointestinal bleeding from gastric splenosis; A case report and literature review.

Splenosis is a common condition found in a case that has a history of splenic trauma or splenectomy. It is usually a non-significant condition in clinical practice. However, splenosis can give rise to some complications including gastrointestinal hemorrhage as in the present case. The authors report here a case of gastric splenosis presenting with active upper gastrointestinal hemorrhage that was eventually managed with surgical resection, and the literature regarding splenosis was reviewed.

Transpyloric prolapse of a pedunculated polypoid gastric carcinoma: a case report and review of the literature.

Gastroduodenal intussusception is not a common clinical condition. It is usually caused by transpyloric prolapse of a benign gastric lesion into the duodenum. In the present report, the authors present an extremely rare case of gastroduodenal intussusception in which gastric carcinoma served as the lending point. Pre-operative diagnosis was made from endoscopy and biopsy. The patient was treated successfully by subtotal gastrectomy with D2 lymph node dissection. The clinical presentation, diagnosis, and management of this entity were discussed and the literature was reviewed. Both the condition itself and the leading tumor, gastric carcinoma, are extremely rare and to the authors' knowledge. This is the first report in Thailand.

Gastric schwannoma presenting with perforation and abscess formation: a case report and literature review.

Gastric schwannoma represent only 0.2% of all gastric tumors and 4% of all benign gastric neoplasms. They are usually asymptomatic but can present with variable symptoms. The authors report a case of a 29-year-old male patient who presented with fever and abdominal pain with epigastric mass. Pre-operative diagnosis was gastric lymphoma with perforation and an abscess formation. Hemigastrectomy with Billroth II anastomosis was performed The pathologic examination and immunohistochemical studies confirmed gastric schawannoma as the diagnosis. The post-operative course was uneventful. Gastric schwannoma are difficult if not impossible to diagnose preoperatively as endoscopic and radiologic findings are nonspecific. The treatment of choice is complete surgical resection because of diagnostic uncertainty and the long-term outcome is excellent. This is the first report of gastric schwannoma presenting with concealed perforation and an abscess formation. The literature was reviewed.

Surgical reduction in a delayed case of traumatic testicular dislocation.

A 27-year-old Thai male was admitted with left groin pain and he felt that he lost his left testis three weeks after his motorcycle accident-car collision. He had not been diagnosed after four days of admission at the previous hospital. Surgical reduction was performed without acute and delayed complications after three months of follow-up. Traumatic testicular dislocation is an uncommon sequel of trauma usually related to straddle injury from motorcycle accidents. Diagnosis depends on the awareness of the physician of its possibility of occurrence. Physical examination is the most helpful in diagnosis. CT scan or Doppler ultrasound, if available, may be helpful in diagnosis, particularly locating the extrascrotal testicle and detecting testicular viability. Manual reduction is the treatment of choice for acute traumatic dislocation of testis. Open reduction is indicated for the delayed case, or if there are (1) difficulty in determining the integrity of dislocated testis, (2) possibility of torsion, (3) failure of close reduction, or (4) the minimal morbidity of an inguinal exploration.

Transperineal repair of rectourethral fistula: surgical technique and a case report.

A 60-year old Thai male diagnosed as iatrogenic rectourethral fistula. Preoperative investigation with intravenous pyelogram revealed connection between urethra and rectum. Colonoscopy also revealed fistula opening at mid-rectum. He underwent surgery via transperineal approach. Intraoperative fistula localization was performed using Methylene blue injection via foley catheter. The fistula tract was identified and divided exposing blue-staining tract. Rectal opening and urethral opening were repaired Fecal and urthral diversion were performed Postoperative period was uneventful. The final pathologic report of fistula tract was fibrosis. The perineal and rectal wounds were healed without complication. The suprapubic cystostomy catheter was removed at the end of the second month together with the colostomy closure.

Effect of bowel preparation with oral sodium phosphate on serum potassium level in patients undergoing colonoscopy under IV anesthesia.

OBJECTIVE: To determine the effect of oral sodium phosphate solution, as a colon preparation agent, on the serum potassium level in patients undergoing colonoscopy under IV anesthesia. MATERIAL AND METHOD: Patients set to undergo elective colonoscopy under IV anesthesia (propofol infusion) were recruited to participate in the present study during the period between October 2008 and January 2009. All patients had normal serum potassium level prior to colon preparation, and all ingested 90 ml of sodium phosphate solution one day before colonoscopy. Blood samples for post preparation potassium level determination were taken immediately before administering IV propofol. Baseline data including age, gender, diagnosis, indication for colonoscopy, underlying illness, concurrent medications and serum potassium and creatinine levels were recorded The serum potassium levels were compared before and after colon preparation, and potentially important baseline risk factors for low potassium levels after colon preparation were determined. RESULTS: In 48 patients, there was a 0.57 mmol/L (from 4.11 to 3.54 mmol/L) average reduction in the serum potassium level after colon preparation. There were no significant adverse events during colonoscopy. No significant risk factors were identified on multivariable linear regression analysis. CONCLUSION: There was a mild reduction in serum potassium level after colon preparation with oral sodium phosphate solution, which was probably not clinically significant. Prophylactic potassium supplement or routine serum potassium monitoring after oral sodium phosphate colon preparation did not seem to be necessary for this group of patients.

Young-onset colorectal cancer in patients with no known genetic predisposition: can we increase early recognition and improve outcome?

Early recognition of colorectal cancer (CRC) in young patients without known genetic predisposition is a challenge, and clinicopathologic features at time of presentation are not well described. We conducted the current study to review these features in a large population of patients with young-onset CRC (initial diagnosis at age

A technique of extending small-bowel mesentery for ileal pouch-anal anastomosis: report of a case.

One of the keys to success in proctocolectomy with ileal pouch-anal anastomosis is obtaining adequate mesenteric length to allow the pouch to reach the anorectum without tension. A multitude of techniques have been described in the literature to gain mesenteric length; however, in most cases these techniques only allow for the correction of a small deficit in the mesenteric length. We encountered a case in which the small-bowel mesentery was severely foreshortened because of a previous small-bowel volvulus just proximal to the loop ileostomy during recovery from the initial stage of his ileal pouch procedure. In this case, the deficit in length required an interposition vein graft to the superior mesenteric artery to facilitate adequate mesenteric length and allow completion of the ileal pouch-anal anastomosis. We report this technique to add another method of mesenteric lengthening to the armamentarium of surgeons performing ileal pouch-anal anastomoses. This technique should only be used as a last resort.

Local anesthesia of upper anal canal for multiple rubber band ligation: description of technique and preliminary results.

PURPOSE: Symptoms caused by hemorrhoids are worse during defecation because of relaxation of the anal canal causing prolapse. We reviewed our experience of multiple rubber band ligations in a relaxed state of the anal canal using local anesthesia. METHODS: Forty-five patients, the majority of whom had Grade 2 or 3 symptomatic hemorrhoids, who required treatment underwent four quadrant local anesthetic infiltration in the submucosa of the upper anal canal. We used 1.5 ml of 0.25 percent bupivacaine in 1:200,000 epinephrine, 5 mm above the dentate line. RESULTS: The exposure of the relaxed anal canal was excellent, allowing multiple introductions of the anoscope and application of multiple bands without discomfort. The average number of bands applied in a single session was 3.84 (range, 1-7). Forty-two percent of the patients had banding performed at four sites. Complications following the procedure were minimal. Forty-seven percent of patients reported pain, with an average pain score of 5.29 (range, 1-10). Forty-seven percent of patients did not experience any pain after the procedure. Seventy-three percent had relief of symptoms; 16 percent had symptomatic recurrences, one-half of them were successfully treated by repeat banding after local anesthetic; only one patient required surgical hemorrhoidectomy. CONCLUSIONS: Local anesthesia of the upper anal canal results in full relaxation and maximal mucosal redundancy of the anal canal simulating the anus in a natural condition during defecation. This gives an excellent exposure of the anal canal, enabling an accurate and multiple applications of rubber bands without pain during and shortly after the procedure.