Neoadjuvant imatinib treatment and laparoscopic anus-preserving surgery for a large gastrointestinal stromal tumor of the rectum.

BACKGROUND: Resection of a gastrointestinal stromal tumor (GIST) of the rectum can be difficult because of the particular location in the pelvis, and a large rectal GIST often requires abdominoperineal resection. Recent reports demonstrate that neoadjuvant imatinib treatment improves surgical outcomes in patients with a rectal GIST, and there are only a few reports of the effectiveness of laparoscopic surgery for a rectal GIST. CASE PRESENTATION: A 46-year-old man was found to have a rectal GIST that measured 80 mm and was located on the anterior wall of the lower rectum. After 6 months treatment with imatinib, the tumor decreased in size to 37 mm, and laparoscopic low anterior resection was performed. The patient is currently alive without any evidence of recurrence 37 months after surgery. CONCLUSIONS: Neoadjuvant imatinib should be a treatment of choice for a large rectal GIST. When marked tumor shrinkage is achieved, laparoscopic surgery may be the preferred procedure.

Isolated spontaneous dissection of the splanchnic arteries.

OBJECTIVES: Isolated dissection of a splanchnic artery, including the celiac artery, superior mesenteric artery (SMA), and inferior mesenteric artery, and their branches, is a relatively rare condition. This study was conducted to define the characteristics of patients with splanchnic artery dissection and the clinical course of isolated splanchnic artery dissection. METHODS: The records of 19 patients were reviewed to survey demographic data, the location of dissection, symptoms, diagnostic modalities, treatment, and long-term outcome. RESULTS: The locations of dissection were the superior mesenteric artery (SMA) in 11 patients, celiac artery in 3, both celiac artery and SMA in 2, and common hepatic artery, celiac artery to splenic artery, and celiac artery to proper hepatic artery in 1 each. In all but one with systemic sclerosis and Sjögren syndrome, the underlying cause of dissection was unclear. There were 12 asymptomatic and seven symptomatic patients. All cases were diagnosed by computed tomography. Surgical treatment was performed in one patient with a large aneurysm of the common hepatic artery, and the remaining 18 patients were followed-up conservatively. The mean follow-up duration was 20.9 +/- 25.4 months (range, 2-116 months). No expansion or progression of the false lumen was observed in these patients. CONCLUSION: Patients with spontaneous dissection of the splanchnic arteries are often asymptomatic, and in this series, none developed significant end organ ischemia. Most patients with this rare condition can be managed expectantly with clinical follow-up including computed tomography imaging to assess aneurysm formation.

Simultaneous Left Ventricular and Deep Vein Thrombi Caused by Protein C Deficiency.

Protein C deficiency is a risk of venous thrombosis because of poor fibrinolytic activity. It remains controversial whether protein C deficiency causes arterial thrombosis. A 21-year-old woman was referred with a chief complaint of right leg pain and numbness. Contrast-enhanced computed tomography revealed a low-density mass in the left ventricle (LV), splenic infarction, and peripheral arterial obstructions in her right leg. Thrombosis extending from the renal vein to the inferior vena cava was also detected. Electrocardiography revealed ST depression in leads II, III, and aVF. Transthoracic echocardiography revealed hypokinesis of the apex and interventricular septum and a hypoechoic mass in the LV (26 × 20 mm). She was diagnosed with acute arterial obstruction caused by the LV thrombus, which might have resulted from previous myocardial infarction. Protein C activation turned out to be low (41%) 5 days after admission. The anticoagulant therapy was switched from heparin to rivaroxaban 16 days after admission. The LV thrombus disappeared 24 days after initial treatment, and she has had no thrombotic episodes for 2.8 years under rivaroxaban therapy. Thrombophilia should be investigated for cases of simultaneous left ventricular and deep venous thrombi. Rivaroxaban can be effective in prevention of further thrombotic events.

Pseudo-Meigs' syndrome secondary to metachronous ovarian metastases from transverse colon cancer.

Pseudo-Meigs' syndrome associated with colorectal cancer is extremely rare. We report here a case of pseudo-Meigs' syndrome secondary to metachronous ovarian metastases from colon cancer. A 65-year-old female with a history of surgery for transverse colon cancer and peritoneal dissemination suffered from metachronous ovarian metastases during treatment with systemic chemotherapy. At first, neither ascites nor pleural effusion was observed, but she later complained of progressive abdominal distention and dyspnea caused by rapidly increasing ascites and pleural effusion and rapidly enlarging ovarian metastases. Abdominocenteses were repeated, and cytological examinations of the fluids were all negative for malignant cells. We suspected pseudo-Meigs' syndrome, and bilateral oophorectomies were performed after thorough informed consent. The patient's postoperative condition improved rapidly after surgery. We conclude that pseudo-Meigs' syndrome should be included in the differential diagnosis of massive or rapidly increasing ascites and pleural effusion associated with large or rapidly enlarging ovarian tumors.

Laparoscopic resection of adult colon duplication causing intussusception.

Gastrointestinal duplications are uncommon congenital malformations that can occur anywhere along the gastrointestinal tract. Most cases are recognized before the age of 2 years, and those encountered in adults are rare. We describe here a case of ascending colon duplication in a 20-year-old male that caused intussusception and was treated laparoscopically. Although computed tomography revealed a cystic mass filled with stool-like material, the preoperative diagnosis was a submucosal tumor of the ascending colon. We performed a laparoscopic right colectomy, and the postoperative pathological diagnosis was duplication of the ascending colon, both cystic and tubular components. We conclude that gastrointestinal duplications, although rare, should be considered in the differential diagnosis of all abdominal and submucosal cystic lesions and that laparoscopy is a preferred approach for the surgical treatment of gastrointestinal duplications.

Transabdominal approach assisted by thoracoscopic drainage for lower esophageal perforation.

The effectiveness of use of thoracoscopy for esophageal perforation has not been fully evaluated. We herein report a case of esophageal perforation for which a transabdominal approach assisted by thoracoscopic drainage was performed.