Liver metastases 2 years after resection of a very-low-risk duodenal gastrointestinal stromal tumor: a case report.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, but are the most common mesenchymal tumors of the gastrointestinal tract. The risk classification of GISTs is based on the tumor size, mitotic index, tumor site, and presence of tumor rupture. Recurrence in the very-low-risk group is extremely rare. We herein report a case of liver metastases 2 years after resection of a very-low-risk duodenal GIST. CASE PRESENTATION: A 57-year-old woman presented to the hospital for evaluation of melena. Esophagogastroduodenoscopy showed bleeding from the exposed blood vessels at the top of a submucosal tumor approximately 20 mm in size located in the second (descending) part of the duodenum, and the bleeding was controlled with electrocoagulation. A GIST was suspected, and the patient underwent wedge resection of the duodenum. The resected specimen contained a 16- × 12-mm (< 20-mm) white submucosal tumor composed of spindle cells with a mitotic count of 4 per 50 high-power fields, and a histologically negative margin was achieved. Immunochemical analysis revealed positive tumor staining for c-kit protein and alpha-smooth muscle actin and negative staining for CD34, desmin, and S-100 protein. Therefore, the tumor was diagnosed as a very-low-risk duodenal GIST based on the Fletcher classification and modified Fletcher classification (Joensuu classification). The postoperative course was uneventful, and the patient was discharged on postoperative day 11. At the follow-up visit 2 years postoperatively, contrast-enhanced computed tomography revealed liver tumors in S8 and S6 measuring 26 × 24 and 10 × 10 mm, respectively. Both lesions showed peripheral dominant hyperenhancement with hypoenhancement inside, indicating tissue degeneration within the tumors. These imaging findings closely resembled those of the duodenal GIST. Hence, the patient was diagnosed with liver metastases of GIST 2 years postoperatively. She was subsequently started on treatment with 400 mg of imatinib. At the time of this writing (2 months after diagnosis), the patient was clinically well and asymptomatic and was continuing imatinib therapy. CONCLUSIONS: Recurrence of very-low-risk GISTs is extremely rare. Even a small GIST with low mitotic activity can never be considered completely benign, and long-term follow-up is necessary.

Laparoscopic Left Hepatectomy for Ruptured Hepatocellular Carcinoma Controlled After Transcatheter Arterial Embolization: Case Report and Review of the Literature.

BACKGROUND: Although spontaneous tumour rupture is a life-threatening complication of hepatocellular carcinoma (HCC), staged hepatectomy for HCC controlled after transcatheter arterial embolization (TAE) could provide a better prognosis. Laparoscopic liver resection (LLR) has been accepted worldwide and has been expanded from minor resection to anatomical major resection. We herein report the first case of pure laparoscopic left hepatectomy for ruptured HCC controlled after TAE. CASE REPORT: A 66-year-old man was transferred to our Institute because of abdominal pain and decreased consciousness. Ruptured HCC in segment IV and massive intra-abdominal haemorrhage were diagnosed. Emergency TAE was performed, achieving haemostasis. Reduction of intra-abdominal haemorrhage was confirmed at the 3-month follow-up, and no intrahepatic metastasis or peritoneal dissemination was present. Therefore, we performed elective laparoscopic left hepatectomy for the remaining HCC 110 days after TAE. Although dense adhesion was found in the upper right peritoneal cavity and greater omentum enveloping the remaining haemorrhage on the underside of the liver, there was no disseminated involvement in the peritoneal cavity. The operative time was 194 minutes, and intraoperative blood loss was 100 g. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. CONCLUSION: Major LLR may be an option for staged hepatectomy in patients with ruptured HCC controlled after TAE.

Pancreatic neuroendocrine tumor with extensive intraductal invasion of the main pancreatic duct: a case report.

CONTEXT: Pancreatic neuroendocrine tumors account for only 1-3% of all pancreatic neoplasms and the intraductal invasion of the main pancreatic duct (MPD) is rare. CASE REPORT: We report a case of a 26-year-old woman with an endocrine tumor of the pancreas extensively invading into the MPD. She presented abdominal pain and her laboratory data showed abnormal liver function. Contrast-enhanced computed tomography demonstrated a well-enhanced mass on the arterial dominant phase in the head of the pancreas. The mass grew within the lumen of the MPD in the body of the pancreas, with dilatation of the upstream MPD. The contrast-enhancement pattern between the main tumor of the head and the intraductal lesion of the body was different. On T2-weighted magnetic resonance (MR) imaging, the pancreatic head lesion showed non homogeneously low signal intensity, while the intraductal lesion of the pancreatic body showed high signal intensity. MR cholangiopancreatography showed obstruction of the MPD in the pancreatic head to body, with dilatation of the upstream MPD. An endocrine tumor or acinar cell carcinoma of the pancreas was considered as preoperative diagnosis, and pancreaticoduodenectomy was performed. As a result, pancreatic endocrine tumor (G2) was confirmed pathologically. CONCLUSION: A rare case of pancreatic neuroendocrine tumor with extensive growth within the MPD was presented. The intraductal extension is a unique growth pattern of nonfunctioning pancreatic neuroendocrine tumor, and the desmoplastic reaction in this tumor may reflect the increased invasiveness.

Transrectal peritoneal access with the submucosal tunnel technique in NOTES: a porcine survival study.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) procedures have been performed via transgastric, transvaginal, or transcolonic approaches. However, the transcolonic approach has potential disadvantages including intraperitoneal infection. To avoid such disadvantages, we applied the submucosal tunnel technique to transrectal peritoneal access in this study. Study aims are to clarify the technical feasibility of a submucosal tunnel method for transrectal abdominal access and to assess the healing process of the submucosal tunnel histopathologically. METHODS: The study comprised six female pigs. The following procedures were performed: (1) The mucosa was cut after injection of sodium hyaluronate into the submucosa at the upper rectum. (2) Submucosal tunneling was performed by endoscopic submucosal dissection technique. (3) A small incision was made at the end of the tunnel. (4) After transrectal peritoneoscopy, the mucosal incision site was closed with endoclips. RESULTS: Transrectal peritoneoscopy was successfully performed in all pigs. Necropsy revealed no findings of peritonitis. Histopathologic examination showed good healing of the submucosal tunnel. The wound healing process of the submucosal tunnel on postoperative day 7 was mainly in the inflammatory phase at the mucosal incision site, the proliferative phase at the submucosal tract, and the proliferative/remodeling phase at the seromuscular incision site. CONCLUSIONS: The submucosal tunnel technique appears to be useful and safe for transrectal peritoneal access because healing at the seromuscular incision site proceeded rapidly.

Safety and efficacy of the submucosal tunnel without mucosal closure for the transgastric approach in a porcine survival model.

INTRODUCTION: Usefulness of submucosal tunneling for transgastric approach with clip closure of the mucosal incision in natural orifice translumenal endoscopic surgery (NOTES) has been described. Although the narrow longitudinal submucosal tunnel itself is considered good for wound approximation and healing, no reports have evaluated the sealing effect in this technique. This study was aimed at evaluating the technical feasibility of a submucosal tunnel technique for transgastric peritoneal access without mucosal closure. METHODS: Transgastric peritoneoscopy using submucosal tunneling with endoscopic submucosal dissection without mucosal closure was performed on six 40- to 45-kg female pigs. Measures included (a) evaluation of technical feasibility, (b) clinical monitoring for 7 days, (c) necropsy findings, and (d) pathological examination. RESULTS: NOTES transgastric peritoneoscopy was successfully performed in all pigs, and all recovered well clinically. Necropsy findings revealed no peritonitis, confirming completeness of gastric closure in 5 of the 6 pigs. One pig in which the submucosal layer of the tunnel was injured during dissection from the muscular layer showed local peritonitis. Pathological examination at the submucosal site tunnel showed wound healing with focal transmural fibrosis and inflammatory cell infiltration in 5 pigs, whereas the pig with peritonitis had a large mucosal defect with necrotic tissue, abscess formation, and focal transmural fibrosis. CONCLUSIONS: The submucosal tunnel technique without mucosal closure is safe and effective for transgastric peritoneal access and subsequent closure, when the endoscopists' learning curve is accomplished and the submucosal tunnel is produced without damaging of mucosa. It is necessary to use devices such as mucosal clips or tissue anchors in order to achieve adequate healing of mucosal defect.

The α-lipoic acid derivative sodium zinc dihydrolipoylhistidinate reduces chemotherapy-induced alopecia in a rat model: a pilot study.

PURPOSE: Alopecia is one of the most common side effects of chemotherapy for which treatments have not been developed. In the present study, we evaluated the effects of sodium zinc dihydrolipoylhistidinate (DHLHZn), a new derivative of the multifunctional antioxidant α-lipoic acid, to treat chemotherapy-induced alopecia. METHODS: Wistar rats (8 days old) were treated with cytosine arabinoside (AraC; 20 mg/kg by daily intraperitoneal injection; days 0-6) and DHLHZn (0%, 0.5%, or 1% topically applied in a white petrolatum base; days 0-12). A control group received daily saline injections (days 0-6) and topical application of white petrolatum (days 0-12). On day 12, we evaluated hair loss and histologic changes to scalp tissue for each group (n = 10). RESULTS: Rats treated with AraC and 0% DHLHZn cream exhibited complete hair loss; however, treatment with 0.5% or 1% DHLHZn significantly reduced chemotherapy-induced hair loss. Histological analysis revealed that AraC treatment promoted inflammatory cell infiltration of the hair follicles, but this inflammatory response was attenuated by DHLHZn. CONCLUSIONS: Our findings demonstrate that DHLHZn attenuates chemotherapy-induced alopecia, indicating the potential use of this α-lipoic acid derivative as a therapeutic agent against this common side effect of chemotherapy.

Cardiopulmonary and immunologic effects of transvaginal natural-orifice transluminal endoscopic surgery cholecystectomy compared with laparoscopic cholecystectomy in a porcine survival model.

BACKGROUND: A few studies have addressed the physiology related to a basic natural-orifice transluminal endoscopy surgery (NOTES) procedure, such as transgastric peritoneoscopy, but the physiologic impact of more complex NOTES procedures has not been previously examined. OBJECTIVE: To evaluate the cardiopulmonary and immunologic effects of transvaginal NOTES cholecystectomy compared with laparoscopic cholecystectomy. SETTING: Survival experiments in 10 40-kg female pigs assigned to transvaginal cholecystectomy and laparoscopic cholecystectomy groups. INTERVENTIONS: Transvaginal cholecystectomy was performed with the assistance of a needlescopic device, and laparoscopic cholecystectomy was performed in the standard manner. MAIN OUTCOME MEASUREMENTS: Cardiopulmonary and immunologic parameters in the transvaginal cholecystectomy group were compared with those in the laparoscopic cholecystectomy group. Cardiopulmonary parameters included heart rate, blood pressure, saturation pulse oximetry, intratracheal pressure, and arterial blood gases. Immunologic parameters included white blood cell count, tumor necrosis factor-α, interleukin-1ß, and interleukin-6. RESULTS: All procedures were performed successfully without complications. Although operation times were longer for transvaginal cholecystectomy than for laparoscopic surgery, cardiopulmonary changes were similar and stable in both groups. White blood cell count, interleukin-1ß, and interleukin-6 did not differ between the 2 groups, and the increase in tumor necrosis factor α after transvaginal cholecystectomy was significantly smaller on postoperative day 1 than after laparoscopic cholecystectomy (133.4 pg/mL vs 200.4 pg/mL; P < .05). LIMITATIONS: Animal model and small sample size. CONCLUSIONS: Transvaginal cholecystectomy resulted in cardiopulmonary stability and well preserved immune function similar to those of laparoscopic cholecystectomy, suggesting that NOTES may be less invasive than laparoscopic surgery.