Early-stage gastric cancer with solitary brain metastasis four years after curative surgery: a case report and literature review.

Brain metastasis post-curative gastrectomy for early-stage gastric cancer is extremely rare. We present herein, a case of solitary brain metastasis that developed 4 years post-curative surgery for early-stage gastric cancer. A 60-year-old man had early-stage gastric cancer 4 years prior to presentation and underwent laparoscopy-assisted distal gastrectomy with lymph node dissection. The pathological TNM classification was T1b (submucosal) N0M0. He underwent scheduled examinations and had no recurrence. 4 years postoperatively, he presented to the emergency department with sudden onset of nausea, vomiting, and inability to speak clearly. Brain computed tomography revealed a 17-mm nodule in the right cerebral hemisphere and midline shift. The tumor could not be radically resected for anatomical reasons, and incisional biopsy was performed for histological examination. Histological examination confirmed the diagnosis of a poorly differentiated adenocarcinoma from the previous gastric cancer. Gamma knife radiosurgery and chemotherapy were scheduled. 28 months after brain metastasis, multiple liver and lung metastases appeared. The patient died 30 months after developing brain metastasis. Brain metastasis may occur during long-term follow-up even after curative resection of early-stage gastric cancer. In patients with a history of gastric cancer and neurological symptoms, brain metastasis should be considered.

Gastric washing by distilled water can reduce free gastric cancer cells exfoliated into the stomach lumen.

PURPOSE: Intragastric free cancer cells in patients with gastric cancer have rarely been studied. The purpose of this study was to investigate the detection rate of intragastric free cancer cells in gastric washes using two types of solutions during endoscopic examination. We further clarified risk factors affecting the presence of exfoliated free cancer cells. METHODS: A total of 175 patients with gastric cancer were enrolled. Lactated Ringer's solution (N = 89) or distilled water (DW; N = 86) via endoscopic working channel was sprayed onto the tumor surface, and the resultant fluid was collected for cytological examination. We compared the cancer-cell positivity rate between the two (Ringer and DW) groups. We also tested the correlation between cancer-cell positivity and clinicopathological factors in the Ringer group to identify risk factors for the presence of exfoliated cancer cells. RESULTS: The cancer-cell positivity rate was significantly higher in the Ringer group than that in the DW group (58 vs 6%). Cytomorphology in the Ringer group was well maintained, but not in the DW group. The larger tumor size (≥ 20 mm) and positive lymphatic involvement were significant risk factors of exfoliated free cancer cells. CONCLUSIONS: Cancer cells can be highly exfoliated from the tumor surface into the gastric lumen by endoscopic irrigation in large gastric cancer with lymphatic involvement. Gastric washing by DW can lead to cytoclasis of free cancer cells; therefore, it may minimize the possibility of cancer-cell seeding in procedures carrying potential risks of tumor-cell seeding upon transluminal communication, such as endoscopic full-thickness resection and laparoscopy-endoscopy cooperative surgery.

Establishment of pathological quantitative method for determining undifferentiated component ratio in patients with differentiated/undifferentiated mixed-type early gastric cancer and clinical significance of this ratio.

PURPOSES: The purpose of this study was to establish a pathological quantitative method for determining the undifferentiated components ratio (UCR) in patients with differentiated/undifferentiated mixed-type (Mixed-type) early gastric cancer (EGC) and to examine the clinical significance. METHODS: The subjects were 410 patients who underwent surgical resection for EGC with the invasion limited to m or sm1. Analysis 1: In 12 randomly selected patients with Mixed-type cancer, we calculated the area ratio and the ratio of the length ratio using ImageJ and analyzed the correlation between them. Analysis 2: We generated ROC curves, and determined the cutoff UCR on the basis of the predictive risk factors for lymph node metastasis (LNM). Analysis 3: We analyzed the relationship between clinicopathological factors including UCR/length of undifferentiated component (LUC = maximum dimensions of tumor × UCR) and LNM. RESULTS: Analysis 1: The length ratio can be used as a substitute parameter for the UCR (r = 0.996). Analysis 2: The cutoff UCR as a risk factor for LNM was 58% (sensitivity = 1, 1 - specificity = 0.404). Analysis 3: Lymphovascular invasion (p < 0.0001), UCR ≥58% (p = 0.023), and LUC ≥25 mm (p = 0.005) were identified as significant risk factors for LNM. No LNM was observed in patients with invasion limited to m or sm1 and negativity for lymphovascular invasion and UCR <58% (0/215). CONCLUSIONS: In the patients with Mixed-type EGC, the length ratio of undifferentiated components can be a substitute parameter for the UCR. LNM rarely occurs in patients without lymphovascular invasion and with an UCR <58%. The analysis of the UCR has great significance in determining whether additional surgical resection is required after endoscopic resection.

Endoscopic self-expandable metal stent placement for malignant afferent loop obstruction caused by peritoneal recurrence after total gastrectomy.

Afferent loop obstruction (ALO) caused by cancer recurrence after total gastrectomy (TG) can be managed by either surgical or non-surgical treatment. The general condition of patients with recurrent gastric cancer is often poor, so a less invasive non-surgical treatment is desirable. We report the case of a 75-year-old male who had undergone TG for gastric cancer 6 months previously and who presented at our hospital with abdominal pain and vomiting. Abdominal computed tomography scan showed a dilated afferent loop, and additionally a low-density lesion around jejunojejunal anastomosis, suggesting that ALO is associated with peritoneal recurrence. A self-expandable metal stent (SEMS) was endoscopically placed to treat ALO after decompression of the dilated afferent loop using an intestinal tube. He retained a good quality of life until his death due to cancer progression 5 months after the SEMS placement. Our case indicates that SEMS could be a less invasive alternative to surgery, and may confer a better quality of life for patients with ALO due to cancer recurrence after TG. This is the valuable report of case in which endoscopic metallic stent placement succeeded for ALO caused by peritoneal recurrence after TG.

Laparoscopy-assisted full-thickness resection of the duodenum for patients with gastrointestinal stromal tumor with ulceration.

INTRODUCTION: Gastrointestinal stromal tumor (GIST) with ulceration may potentially disseminate into the peritoneal cavity after laparoscopic local wedge resection (full-thickness resection) when the intestinal wall is opened under the aeroperitoneum. To prevent this intraoperative tumor seeding, we developed laparoscopy-assisted full-thickness resection (LAFTR) of the duodenum for GIST with ulceration. Here, we present the preliminary results of LAFTR. METHODS: Three patients with duodenal GIST with ulceration underwent LAFTR. LAFTR consists of four major procedures: (i) a laparoscopic Kocher maneuver (mobilization of the pancreatoduodenum); (ii) the creation of a small upper median laparotomy; (iii) the extracorporeal completion of the full-thickness resection under direct vision; and (iv) extracorporeal hand-sewn closure of the duodenal defect. RESULTS: LAFTR was successfully performed without any intraoperative adverse events. The mean operating time and estimated blood loss were 182 min and 34 mL, respectively. Postoperative contrast roentgenography showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. None of the patients developed peritoneal recurrence. CONCLUSIONS: LAFTR can eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracoporeally. Meticulously hand-sewn closures of the duodenal defect can minimize the possibilities of anastomotic insufficiency and deformity. LAFTR is a feasible, safe, and minimally invasive treatment for patients with GIST with ulceration in the first and second portions of the duodenum.

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy-assisted pancreas-sparing duodenectomy.

A 54-year-old man had a 65-mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ-preserving laparoscopic surgery, we conducted laparoscopy-assisted pancreas-sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port-site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.

Xenopericardial roll graft replacement for infectious pseudoaneurysms and graft infections of the aorta.

BACKGROUND: Which graft material is the optimal graft material for the treatment of infected aortic aneurysms and aortic graft infections is still a matter of controversy. Orthotopic aortic reconstruction with intraoperatively prepared xenopericardial roll grafts without omentopexy was performed as the "initial" operation to treat aortic infection or as a "rescue" operation to treat graft infection. Mid-term outcomes were evaluated. METHODS: Between 2009 and 2013, orthotopic xenopericardial roll graft replacement was performed to treat eight patients (male/female: 6/2; mean age: 69.5 [55-80] yr). Graft material: equine/bovine pericardium: 2/6; type of operation: initial 4/rescue 4; omentopexy 0. Additional operation: esophagectomy 2. Mean follow-up period: 2.6 ± 1.6 (1.1-5.1) years. RESULTS: Replacement: ascending 3, arch 1 (reconstruction of neck vessels with small xenopericardial roll grafts), descending 3, and thoracoabdominal 1. Pathogens: MRSA 2, MSSA 1, Candida 1, E. coli 1, oral bacillus 1, and culture negative 2. Postoperative local recurrence of infection: 0. Graft-related complications: stenosis 0, calcification 0, non-infectious pseudoaneurysm of anastomosis 2 (surgical repair: 1/TEVAR 1). In-hospital mortality: 2 (MOF: initial 1/rescue 1); Survival rate exclusive of in-hospital deaths (~3 y): 100 %, but one patient died of lung cancer (3.6 yr). CONCLUSIONS: Because xenopericardial roll grafts are not composed of synthetic material, the replacement procedure is simpler and less invasive than the standard procedure. Based on the favorable results obtained, this procedure may have the possibility to serve as an option for the treatment of aortic infections and aortic graft infections not only as a "rescue" treatment but as an "initial" treatment as well.

Laparoscopy-assisted transduodenal excision of superficial non-ampullary duodenal epithelial tumors.

INTRODUCTION: Transduodenal excision (transduodenal submucosal dissection) is an alternative to pancreaticoduodenectomy for the treatment of benign and low-grade malignant tumors of the duodenum. However, laparoscopic transduodenal excision or laparoscopy-assisted transduodenal excision (LATDE) of such tumors has been rarely reported. In this paper, we present the preliminary results of LATDE in patients with superficial non-ampullary duodenal epithelial tumors. METHODS: Three patients with superficial non-ampullary duodenal epithelial tumors (mucosal adenocarcinoma, n = 1; tubular adenoma, n = 2) underwent LATDE. LATDE consists of four major procedures: (i) laparoscopic wide Kocher maneuver (mobilization of the pancreaticoduodenum); (ii) extracorporeal approach to the fully mobilized duodenum through the upper median longitudinal incision (4 cm in length); (iii) tumor excision by submucosal dissection under direct vision through longitudinal duodenotomy (4 cm in length); and (iv) hand-sewn closure of the mucosal defect and duodenotomy. RESULTS: LATDE was successfully carried out without any intraoperative or postoperative adverse events. The mean operating time and estimated blood loss were 155 min and 17 mL, respectively. Contrast roentgenography on postoperative day 4 showed neither duodenal deformity nor disturbance of gastroduodenal emptying in any of the patients. CONCLUSIONS: LATDE could eliminate the possibility of peritoneal or port-site seeding of tumor cells because the duodenotomy and tumor excision are performed extracorporeally. The meticulously hand-sewn closures of the mucosal defect and duodenotomy can minimize the possibility of postoperative hemorrhage and/or anastomotic leakage. LATDE is a feasible, safe, and minimally invasive treatment for patients with superficial non-ampullary duodenal epithelial tumors that have no risk of lymph node metastasis in the first and second portions of the duodenum.

Recent developments in gastric endoscopic submucosal dissection: towards the era of endoscopic resection of layers deeper than the submucosa.

With technical advances in endoscopic submucosal dissection (ESD), several variations of endoscopic procedure derived from ESD and fusion procedures of endoscopy and laparoscopy for upper gastrointestinal submucosal tumor and cancer have recently been developed. The former includes endoscopic muscularis dissection (EMD), submucosal endoscopic tumor resection (SET), endoscopic submucosal tunnel dissection (ESTD) and endoscopic full-thickness resection (EFTR), and the latter includes laparoscopic and endoscopic cooperative surgery (LECS), laparoscopy-assisted endoscopic full-thickness resection (LAEFR), and laparoscopic lymphadenectomy without gastrectomy following ESD. In the present article, recent developments in gastric ESD and advanced procedures derived from ESD are discussed.

Paraesophageal hernia repair.

UNLABELLED: Paraesophageal hiatal hernia (PHH), accounting for only 5% of all hiatal hernias, may result in potentially life threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the gastric mucosa. It is traditionally believed that PHH is an indication for surgery. The repair of paraesophageal hernia is technically challenging and controversial. The purpose of this article is to overview the current status of indication of surgery; operative techniques including hernia sac resection, esophageal lengthening procedure, crural repair, and additional antireflux procedure. RESULTS: All symptomatic patients should be surgically treated, when operation is possible. It seems reasonable that asymptomatic or minimally symptomatic patients do not necessarily require surgery and that a more selective approach should be used. The penetration rate is not high, laparoscopic approach is currently the standard care. The hernia sac should be excised and resected circumferentially. Collis-Nissen procedure continues to be the method of choice also in the laparoscopic era, when lengthening procedure of the shortened esophagus is in consideration. Although symptomatic recurrence after suture closure of the crura is uncommon, primary repair is associated with a high rate of anatomic recurrence. Prosthetic mesh repair is reportedly associated with a recurrence rate as low as 5%, at the price of rare but serious complications such as erosion and fibrosis. Although scientific proof is lacking, fundoplication is the most common procedure to be added after crural repair.