Metastatic gastric adenocarcinoma and synchronous carcinoid tumour mimicking appendicitis: A case report.

INTRODUCTION: Silent metastatic gastric adenocarcinoma presenting as appendicitis is very rare. Rare pathologies may be encountered during common operations such as appendicectomy and an awareness of possible alternative pathological entities would be helpful in a surgeon's wealth of knowledge. PRESENTATION OF CASE: A 63-year-old man presented with a three-day history of acute abdominal pain suggestive of appendicitis. Intra-operatively, a macroscopically inflamed and perforated appendix was found. There were however some atypical features, which included multiple inflamed ulcerated lesions throughout the small bowel mesentery and along the terminal ileum. Appendicectomy was performed and biopsies of these lesions were taken. Subsequent histopathology revealed that there were metastatic deposits of poorly differentiated adenocarcinoma in the appendix and mesenteric biopsies, as well as a neuroendocrine (carcinoid) tumour of the appendix. Upper endoscopy confirmed a gastric primary leading to peritoneal dissemination. The patient was scheduled to undergo a course of palliative chemotherapy. DISCUSSION: Metastatic gastric adenocarcinomas with peritoneal dissemination have a very poor prognosis and often the first choice of treatment is chemotherapy as a complete cure through surgery is often not feasible. As for classical carcinoid tumours smaller than 2 cm towards the tip of the appendix with low proliferative index and without angiolymphatic or mesoappendiceal extension, then appendicectomy alone is indicated. Synchronous neoplastic pathologies presenting as appendicitis is largely unknown. CONCLUSION: To our knowledge, this is the first report in the literature of synchronous carcinoid tumour and metastatic gastric cancer co-existing within an inflamed appendix.

De Garengeot hernia-Use of a novel surgical approach and literature review.

INTRODUCTION: De Garengeot hernia is a rare type of femoral hernia, defined as a sac containing a vermiform appendix. Due to its rare occurrence the information available on diagnosis and management is scarce. We report the use of a recently described technique for femoral hernia repair and appendicectomy. PRESENTATION OF CASE: A 67 year old female presented to the emergency department with features of incarcerated femoral hernia. CT imaging revealed an incarcerated appendix within a femoral hernia. The patient subsequently underwent surgery, where the femoral hernia was repaired and appendicectomy performed concurrently. DISCUSSION: Clinical diagnosis is difficult, and there have only been a few documented cases of pre-operative CT diagnoses in the literature. The usual risk factors for developing a hernia would apply to this pathology, and other anatomical and embryological considerations are explored. The King's College technique for femoral hernia repair involves an incision that allows repair of the hernia and also the ability to enter the peritoneal cavity using the same incision. This approach was used in this case, where the abdominal cavity had to be entered to perform the appendicectomy, before the femoral hernia could be repaired. CONCLUSION: Pre-operative diagnosis of De Garengeot hernia is difficult, as it may mimic an incarcerated femoral hernia containing other contents. The diagnosis becomes apparent intra-operatively. The clinical significance lies in that intra-abdominal access may be required to safely perform an appendicectomy before the repair of the hernia defect, and this article includes a description of a suitable technique for this particular pathology.

Regadenoson in Europe: first-year experience of regadenoson stress combined with submaximal exercise in patients undergoing myocardial perfusion scintigraphy.

PURPOSE: Regadenoson was approved for clinical use in Europe in 2011. Since then, it has become the default form of stress at our institution. We have assessed the side-effect profile and tolerability of regadenoson in patients undergoing clinically indicated myocardial perfusion scintigraphy between July 2011 and July 2012. METHODS: Clinical, stress and imaging data were recorded prospectively. Symptoms during stress were recorded and defined as mild, moderate or severe. An adverse event was defined as any symptom that persisted for more than 30 min or that required investigation or treatment. RESULTS: Of 1,764 consecutive patients, 1,581 (90%) received regadenoson combined with submaximal exercise unless contraindicated. Symptoms were common (63%) but transient and well-tolerated. The severity of symptoms was recorded in most patients as mild (84%). Dyspnoea (36%) and chest discomfort (12%) were the commonest side effects. Adverse events were reported in eight patients (0.5%), thought to be vasovagal in seven of these. All patients recovered fully without sequelae. There were no deaths, myocardial infarction or hospital admissions. Regadenoson stress was performed in 206 patients (12%) with asthma or chronic obstructive pulmonary disease (COPD) without bronchospasm or any other major side effect. CONCLUSION: We studied the symptom profile of regadenoson in the largest European cohort to date. Regadenoson combined with submaximal exercise was well tolerated, notably also in patients with asthma or COPD. The majority of regadenoson-related adverse events were vasovagal episodes without sequelae.

Triple carcinomas of the biliary tract associated with congenital choledochal dilatation and pancreaticobiliary maljunction.

We report a rare case of triple carcinomas of the biliary tract associated with congenital choledochal dilatation (CCD) and pancreaticobiliary maljunction (PBM). The patient was a 58-year-old Japanese man who complained of epigastralgia. Ultrasonography and computed tomography revealed an elevated lesion inside the markedly dilated extrahepatic bile duct, thickening of the gallbladder wall, and small polypoid lesions in the gallbladder. Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed CCD and PBM. With a diagnosis of carcinoma of the bile duct and cholesterol polyps in the gallbladder, pylorus-preserving pancreaticoduodenectomy was performed. The resected specimen showed two elevated lesions in the dilated bile duct, cholesterol polyps, and an area of irregular mucosa in the gallbladder. Histopathological examination showed two carcinomas in the bile duct, an adenosquamous cell carcinoma, and a moderately differentiated tubular adenocarcinoma, and a well differentiated tubular adenocarcinoma of the gallbladder. Two years and 6 months after the operation, a solitary metastatic liver tumor was detected. Left hepatic lobectomy was performed. At present, 7 months after the second operation, the patient is doing well with no signs of recurrence. Multiple carcinomas in the biliary tract associated with CCD and PBM, including the details in the present patient, were reviewed.

[Carcinoma of the pancreatic head].

Focusing mainly on invasive ductal carcinoma of the pancreas, the history of radical surgery for this type of cancer is reviewed, including pancreatoduodenectomy, total pancreatectomy, extended radical surgery with main vascular resection and extended lymphadenectomy/retroperitoneal soft-tissue clearance, pylorus-preserving pancreaticoduodenectomy. In addition, duodenum-preserving pancreatic head resection, which has recently attracted attention in this field, as an operative technique for less-malignant, noninvasive intraductal papillary adenocarcinoma is also reviewed.

Successful surgical treatment for implanted intraperitoneal metastases of ruptured small hepatocellular carcinoma: report of a case.

We report herein the case of a 53-year-old man with disseminated intraperitoneal metastases caused by the rupture of small hepatocellular carcinoma (HCC). He was admitted to our hospital in shock after suffering a trauma injury to the upper abdomen. Ultrasonography revealed a massive hemoperitoneum. At surgery, 4000 ml of blood was drained from the abdominal cavity and a ruptured tumor, 2 cm in diameter, was found in the right lobe of the liver. The tumor was resected with an adequate surgical margin and subsequent microscopic examination confirmed a diagnosis of moderately differentiated HCC without associated liver cirrhosis. The patient was readmitted 14 months later following the development of right lower quadrant pain. Ultrasonography and computed tomography revealed extrahepatic abdominal tumors, and abdominal angiography demonstrated four intraperitoneal tumors. At surgery, four implanted metastases adhered to the greater omentum were found and resected. No other tumors were detected. Microscopically, all four tumors were confirmed as moderately differentiated hepatocellular carcinoma. Ruptured HCC may lead to implanted intraperitoneal metastasis, but rupture of small HCC is very rare. While hepatic resection is the treatment of choice for ruptured HCC, according to our review of the literature, only a few patients have survived long-term after resection of implanted metastasis.

The prognostic significance of lymph node metastasis and intrapancreatic perineural invasion in pancreatic cancer after curative resection.

To investigate the prognostic factors of pancreatic cancer, a retrospective analysis of 193 patients who underwent curative resection was conducted. Of the 193 patients, 38 (20%) survived for more than 5 years, the 5-year survival rates for stages I, II, II, and IV disease being 41%, 17%, 11%, and 6%, respectively. According to a multivariate analysis, lymph node metastasis, intrapancreatic perineural invasion, and portal vein invasion were significant prognostic factors. Subsequently, a subgroup analysis concerning nodal metastasis and intrapancreatic perineural invasion was performed in 126 patients with records of these histological findings. In the group of patients without nodal metastasis, the 5-year survival rate for those without perineural invasion was 75%, whereas that for those with perineural invasion was 29%, the difference in survival of these subgroups being significant (P < 0.02). In the group of patients with nodal metastasis, the 5-year survival rate for those without perineural invasion was 17%, while that for those with perineural invasion was 10%. The most favorable 5-year survival of 89% was observed in the subgroup of patients with stage I disease without perineural invasion. Thus, pancreatic adenocarcinoma categorized by the combination of these independent types of biological behavior showed 5-year survival rates ranging from very high to low, indicating that these two factors play an important role in the prognosis of this disease.

Solid cystic tumor of the pancreas in elderly men: report of a case.

Solid cystic tumor of the pancreas is a primary pancreatic neoplasm of unknown etiology that most commonly occurs in young women and ordinarily contains hemorrhagic tissue. We report herein the unusual case of a 75-year-old man found to have a solid cystic tumor in the body and tail of the pancreas, who is the oldest such male patient to be documented in Japan. The results of laboratory data and imaging studies indicated that the patient had a nonfunctioning islet tumor or solid cystic tumor of the pancreas, and distal pancreatectomy with splenectomy was performed. The diagnosis of solid cystic tumor was confirmed based on macroscopic and histological findings of the resected pancreatic tumor. The patient is currently in good health, without any signs of tumor recurrence 1 year and 4 months after his operation. A total of 181 cases of solid cystic tumors of the pancreas reported in the Japanese literature, including our case, were reviewed to evaluate the clinical differences between patients aged 50 years or over and those younger than 50 years.

Duodenal duplication cyst communicating with an accessory pancreatic duct of Santorini.

A 16 year-old girl with recurrent attacks of acute pancreatitis and upper gastrointestinal bleeding was found to have an aberrant pancreatic duct communicating with a duodenal duplication cyst and a pancreatic pseudocyst on endoscopic retrograde pancreatography (ERP). A partial gastrectomy combined with resection of the aberrant pancreas was performed. The patient is doing well without any problems 17 years after surgery. ERP was of great value in diagnosing this rare disease. Gastroduodenal duplication cysts communicating with the pancreatic duct are rare; only 21 cases, including our own, have been reported in the English-language literature since 1958.

Central bisegmentectomy of the liver plus caudate lobectomy for carcinoma of the gallbladder.

Central bisegmentectomy of the liver is recommended as a radical surgical procedure for patients with liver-bed gallbladder carcinoma, which tends to directly invade the hepatic parenchyma through the liver bed. In this article, we describe the indications and our surgical techniques for central bisegmentectomy of the liver plus caudate lobectomy for carcinoma of the gallbladder. We employ combined resection of the caudate lobe, because the caudate lobe often becomes involved even in patients with liver-bed carcinoma. Resection of the extrahepatic bile duct is also required to achieve complete lymphadenectomy within the hepatoduodenal ligament, because tumor invasion of the hepatoduodenal ligament is frequently found. Extensive lymphadenectomy around the head of the pancreas together with removal of the para-aortic lymph nodes should be performed in patients with extensive lymph node metastases.

Arteriovenous malformation of the rectum: report of a case.

We report herein the case of a 38-year-old man found to have a rectal arteriovenous malformation (AVM). The patient was admitted to our hospital for investigation of fresh anal bleeding and general malaise. Barium-enema examination showed a slightly elevated lesion in the rectum, and a selective superior rectal angiogram subsequently revealed an AVM in the peripheral region of the superior rectal artery, which was presumed to be the cause of the anal bleeding. Colonoscopic examination disclosed a submucosal tumor-like lesion in the left posterior wall of the rectum, 3cm above the anal verge. After marking the boundaries by clipping, transanal resection of the lesion was performed. Histological examination revealed an irregularly expanded arteriovenous aggregation in the submucosal layer. The patient had a favorable postoperative course, and no residual AVM was seen on a postoperative selective inferior mesenteric arteriogram. There have been no signs of recurrence in the 2 years since his operation.

Treatment of pancreas head carcinoma in a 91-yr-old man. Report of a case successfully treated with pylorus-preserving pancreatoduodenectomy.

The case of a 91-yr-old man who had a tumor of the pancreas head successfully resected is reported. He was admitted to our hospital because of obstructive jaundice, and then percutaneous transhepatic biliary drainage (PTBD) was performed. Cholangiography via PTBD tube showed marked stenosis of the bile duct in the head of the pancreas. Endoscopic retrograde pancreatography (ERP) showed obstruction of the main pancreatic duct in the head of the pancreas, and carcinoma in the head of the pancreas was diagnosed. Abdominal angiography showed stenosis of the celiac trunk caused by compression from the median arcuate ligament, but no tumor stain or encasement in the pancreas was detected. Because the patient had lived an extremely healthy life and had no serious concurrent disease before admission, laparotomy was performed. The tumor in the head of the pancreas was about 2 cm in diameter and restricted inside the pancreas. Pylorus-preserving pancreatoduodenectomy (PpPD) with regional lymph node dissection was performed. The tumor was 1.5 cm in its maximal diameter, and histopathologically was diagnosed as an invasive ductal carcinoma of the pancreas with moderately differentiated tubular adenocarcinoma. The patient had an uneventful postoperative course and now, 3 yr after surgery, he is doing very well and leading a normal daily life.

Giant leiomyosarcoma of the remnant stomach: report of a case.

We describe herein the case of a 73-year-old woman who developed a giant leiomyosarcoma in the remnant stomach 4 years after undergoing a distal gastrectomy for gastric carcinoma. Abdominal ultrasonography and computed tomography revealed a huge tumor, 22 cm in maximum diameter, in the left hypochondrial region. Selective abdominal angiography showed a hypervascular tumor fed by the branches of the splenic artery and left inferior phrenic artery. The tumor arose from the posterior wall of the remnant stomach, and demonstrated marked extragastric growth and direct invasion of the pancreas, transverse colon, and diaphragm on the left side. Total resection of the remnant stomach with en bloc resection of these adjacent organs was subsequently carried out. We reviewed the Japanese literature on this extremely rare tumor and evaluated its clinical profile. In comparison with leiomyosarcoma of the unresected stomach, that of the remnant stomach more frequently showed endogastric-type growth and was accompanied by ulceration of the gastric mucosa. The prognosis of patients with leiomyosarcoma of the remnant stomach appears to be greatly affected by the presence of liver metastases and the tumor diameter, similar to that of patients with leiomyosarcoma of the unresected stomach.

Effect of hepatic invasion on the choice of hepatic resection for advanced carcinoma of the gallbladder: histologic analysis of 32 surgical cases.

The purpose of this study was to assess the patterns of hepatic invasion in advanced carcinoma of the gallbladder by histologically examining surgical specimens obtained in 32 cases of hepatectomy for that carcinoma. Two modes of microscopic tumor extension were observed. The expansive pattern was restricted to liver-bed carcinomas, in which the tumor extends into the liver, primarily from the liver bed. Most of the infiltrating patterns were found with hepatic-hilar carcinomas, in which the tumor invades the hepatic hilum along Glisson's sheath, especially tumors exhibiting a discontinuous front of tumor invasion. The average width for wedge resection of the liver bed was 15.6 +/- 2.9 mm, in contrast to 25.6 +/- 8.1 mm for resection of segments IVa and V and 44.1 +/- 10.3 mm for extensive hepatic resection (both p < 0.01). When the hepatic invasion distance is more than 20 mm, the tumor should be selectively managed by extensive hepatic resection, such as extended right hepatic lobectomy or central bisegmentectomy. The results suggest that wedge resection of the liver bed and resection of segments IVa and V are advisable for carcinoma localized to the gallbladder alone and for liver-bed carcinoma with slight hepatic invasion and an expansive tumor growth pattern. Extensive hepatic resection, however, is recommended for carcinoma of the invasive liver-bed type and carcinoma of the hepatic-hilar type.

Clinicopathologic factors influencing the long-term prognosis following hepatic resection for large hepatocellular carcinoma more than 10 cm in diameter.

We resected 158 cases of hepatocellular carcinoma (HCC), including 20 (12.6%) cases of large HCC. These 20 cases were divided into group 1 (curative resection, n = 9) and group 2 (noncurative resection, n = 11). The clinicopathologic features and long-term survival of the cases were evaluated. In groups 1 and 2, portal vein invasion (Vp+) was noted in 44.4% and 63.3%, intrahepatic metastasis (IM+) in 77.8% and 100%, absence of a fibrous capsule (Fc-) in 55.6% and 63.6%, and stage III or IV in 77.8% and 100%, respectively. The DNA ploidy pattern was aneuploid in 44.4% of group 1 and 100% of group 2. In group 1, the 1-, 3-, and 5-year cumulative survival rates were 75%, 62.5%, and 62.5%, respectively (the longest survivor is alive after 11 years 1 month). Five cases survived more than 3 years in group 1, and all were Vp(-) and nonaneuploid. On the other hand, in group 2, the 1-year survival rate was only 33.3%; none survived more than 2 years. These results suggest that even patients with large HCC have a favorable long-term prognosis if their clinicopathologic factors are Vp(-) and nonaneuploid, and if curative resection can be performed.

Idiopathic perforation of the gallbladder: report of a case and a review of the Japanese literature.

A 79-year-old man was admitted to our hospital because of severe epigastric pain. Ultrasonography and computed tomography revealed a slightly distended gallbladder with a small amount of free intraabdominal fluid. At emergency laparotomy, perforation of the gallbladder was recognized and thus a cholecystectomy was performed. Histopathologically, localized necrosis was seen at the site of perforation: however, the inflammation of the surrounding tissue was mild and no thrombus was detected within the intramural vessels. In addition, the gallbladder contained no stones and a bile culture was negative. Postoperatively, the diagnosis of idiopathic perforation of the gallbladder was established. The findings of this case help to emphasize the importance of considering this disorder in elderly patients presenting with peritonitis of unknown origin.

Primary adenosquamous carcinoma of liver resected by right trisegmentectomy: report of a case and review of the literature.

A case of primary adenosquamous carcinoma of the liver in a patient with an elevated level of serum squamous cell carcinoma-related antigen is reported. A 68-year-old man was admitted to our hospital with a 10-day history of fever and jaundice. From the results of laboratory and imaging studies before surgery, a diagnosis of cholangiocellular carcinoma was made, and the patient underwent right trisegmentectomy with regional lymph node dissection. Histopathological examination of the resected specimen revealed adenocarcinoma, squamous cell carcinoma, and a transitional area containing both types of cancer cells. The number of argyrophilic nucleolar organizer regions and the labeling index of proliferating cell nuclear antigen were markedly elevated and the deoxyribonucleic acid ploidy pattern was aneuploid in the squamous component. The patient died due to liver metastases 3 months after the operation. We reviewed the 31 cases of adenosquamous carcinoma of the liver reported in the Japanese and English language literature, including the present case.

Pathophysiological effect of hepatic ischemia and reperfusion after hepatectomy in dogs with obstructive jaundice, focusing on the effect of coenzyme Q10 and styrene-co-maleic acid superoxide dismutase.

The purpose of the present study was to elucidate the effect of hepatic reflow following ischemia on the remnant liver after hepatectomy with occluded hepatic blood inflow in dogs with obstructive jaundice. When 40% hepatectomy was performed with 10-min occlusion of hepatic blood inflow in dogs with obstructive jaundice, the lipid peroxide content in the remnant liver increased significantly, together with a reduction in superoxide dismutase (SOD)-like activity. The levels of endotoxin and beta-N-acetyl hexosaminase (NAH) in peripheral blood also increased. The phagocytic index increased transiently after 30 min, followed by a marked decrease after 3h. Histologically, degeneration and necrosis of the hepatic parenchymal cells were demonstrated, and survival rate at 7 days was only 23.1%. With the administration of coenzyme Q10 (CoQ10) or styrene-co-maleic acid SOD (SM-SOD), these phenomena were significantly inhibited, and the survival rate improved. After hepatectomy, Kupffer cells in the remnant liver were activated by increased endotoxin levels in the portal vein, inducing the production of free radicals, which, in turn, damaged the Kupffer cells by reducing endotoxin clearance. Finally, the impaired functional reserve in the remnant liver provoked liver failure. The administration of CoQ10 or SM-SOD prevented the occurrence of these phenomena triggered by the free radicals generated by Kupffer cells, stimulated by endotoxin in the portal vein.

Hepatocellular carcinoma associated with anabolic steroid therapy: report of a case and review of the Japanese literature.

We report herein the case of a 35-year-old woman with aplastic anemia who developed hepatocellular carcinoma after long-term therapy with oxymetholone. She was treated with 60 mg/day of oxymetholone for 3 years (total dose 64.8 g). Alpha-fetoprotein, hepatitis B surface antigen, and hepatitis C antibody were all negative, but serum titers of carcinoembryonic antigen and carbohydrate antigen were elevated. Lateral segmentectomy of the liver was performed. The histopathological findings were compatible with those of multiple hepatocellular carcinoma without liver cirrhosis. Three years since the operation, the patient is doing well and no signs of tumor recurrence have been detected. According to our review of Japanese cases of hepatocellular carcinoma associated with anabolic steroid therapy, in all instances the tumors developed after long-term administration of anabolic steroids for hematologic diseases. In patients under long-term anabolic steroid therapy, routine screening of the liver by ultrasonography and computed tomography should be performed to detect liver tumors in the early stages.