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Medicine Feb 2024Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and...
RATIONALE
Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and subsequent duodenal ulcerative bleeding following a radical nephrectomy.
PATIENT CONCERNS
A 77-year-old woman was admitted to our hospital for lower back pain, and she had severe right hydronephrosis and a urinary tract infection.
DIAGNOSES
The patient was diagnosed and confirmed as high-grade urothelial carcinoma.
INTERVENTIONS
After ineffective conservative treatments, a right radical nephrectomy and ureteral stump resection were performed. The patient received proton pump inhibitors to prevent stress ulcer formation and bleeding. On the first day post-surgery, she had normal gastrointestinal (GI) endoscopy findings. On the second day post-surgery, abdominal computed tomography revealed a retroperitoneal hematoma. Notably, 14 days post-surgery, massive GI bleeding occurred, and GI endoscopy identified an almost perforated ulcer in the bulbar and descending duodenum.
OUTCOMES
The patient died on day 15 after surgery.
LESSONS
Duodenal ulceration and bleeding might occur following a retroperitoneal hematoma in patients treated with nephrectomy. Timely intervention may prevent duodenal ulcers and complications, and thus could be a promising life-saving intercession.
Topics: Female; Humans; Aged; Ulcer; Carcinoma, Transitional Cell; Urinary Bladder Neoplasms; Duodenum; Gastrointestinal Hemorrhage; Hematoma; Duodenal Ulcer; Nephrectomy; Peritoneal Diseases
PubMed: 38306569
DOI: 10.1097/MD.0000000000033765 -
Medicine Jan 2024One of the risk factors for esophageal adenocarcinoma is achalasia, an esophageal motility disorder that is typically treated surgically through laparotomy or...
BACKGROUND
One of the risk factors for esophageal adenocarcinoma is achalasia, an esophageal motility disorder that is typically treated surgically through laparotomy or laparoscopic surgery. The risk factors of gastric cardia cancer are also similar to esophageal adenocarcinoma due to the anatomical location of the gastric cardia close to the esophagus. There is currently no clinical evidence that achalching has a correlation with gastric cardia cancer.
CASE SUMMARY
We report the case of an 85-year-old female patient was admitted to our department with dysphagia for 6 months. She underwent a dissecting Heller myotomy for pancreatic achalasia in 2006, with occasional postoperative symptoms of reflux and heartburn. Outpatient upper gastrointestinal imaging was suggestive of cardia cancer, and gastroscopic pathological findings were suggestive of moderately-lowly-differentiated adenocarcinoma. The patient was admitted to the operating room on August 30, 2022 to undergo radical pancreatic cancer surgery plus abdominal adhesion release, and postoperative review of the upper gastrointestinal imaging showed a patent anastomosis with no spillage, filling of the residual stomach, and duodenal visualization.
CONCLUSION
Postoperative patients with achalasia often have symptoms of reflux, which may be one of the factors for the development of pancreatic cancer in this patient, thus requiring clinicians to pay more attention to the use of antireflux procedures in the surgical treatment of pancreatic achalasia. And the choice of which modality to perform surgery in patients with previous surgical history is also one of the points to be discussed.
Topics: Aged, 80 and over; Female; Humans; Adenocarcinoma; Carcinoma; Cardia; Esophageal Achalasia; Gastroesophageal Reflux; Heller Myotomy; Laparoscopy; Pancreatic Neoplasms; Stomach Neoplasms; Treatment Outcome
PubMed: 38277562
DOI: 10.1097/MD.0000000000036924 -
VideoGIE : An Official Video Journal of... Jan 2024Video 1Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection: A 75-year-old woman...
Video 1Gastrogastric intussusception and acute pancreatitis caused by a large pyloric gland adenoma treated with endoscopic submucosal dissection: A 75-year-old woman with a several-week history of intermittent postprandial nausea and vomiting presented to the emergency room after experiencing syncope, following several hours of persistent abdominal pain, nausea, and vomiting. A contrast-enhanced CT scan of the abdomen and pelvis was arranged. Axial images show gastrogastric intussusception with the intussusceptum, indicated by the dashed lines, telescoping into the intussuscipiens indicated by the arrowheads. There is a lobulated mass indicated by the asterisk, serving as the lead point for the intussusception, and there is also a small volume of fluid indicated by the arrow, which delineates the mass from the duodenum. In the coronal images, we can again see a long-segment intussusception indicated by the dashed line with a lobulated mass indicated by the asterisk serving as the lead point and extending into the proximal duodenum. Then the lobulated mass occupying and expanding the duodenal lumen can be seen, indicated by the asterisk. Upon entry into the stomach through endoscopy, the gastrogastric intussusception can be seen. The lobulated mass serving as the lead point can be seen being pulled distally. With air insufflation, the intussusception spontaneously resolved. With continued insufflation, within a few minutes, the native confirmation of the polyp was established. It was located in the proximal body along the greater curve with a lobulated appearance with a Paris 1sp morphology. In addition, there was panatrophy in the background mucosa, which was consistent with autoimmune atrophic gastritis that was subsequently confirmed on histopathology and positive anti-parietal cell antibiotics. An EUS was performed and did not show any evidence of T2 disease. Doppler showed large central feeding vessel. A plan was made for endoscopic submucosal dissection (ESD). The strategy for the ESD was an initial circumferential incision and trimming with subsequent application of multipoint traction. After a circumferential incision, a rich vascular supply is seen. After completion of the incision and trimming, the snare was advanced over the scope and the clip advanced through the instrument channel. Multiple clips were then used to secure the snare to the distal end of the lesion. With traction applied, access to the submucosa became much easier and the ESD proceeded easily. For the final remnant of submucosa, it was more easily dissected in a forward view. Chess is one of the merits of multipoint traction in that traction can be applied both proximally and distally to the lesion. The lesion was resected en bloc. The specimen was retrieved using the attached snare, but unfortunately, some of the friable head was fragmented because of its large size, yet the base remained intact. Final pathology demonstrated PGD+HGD with clear margins vertically and laterally along the base. This case of gastrogastric intussusception, causing gastric outlet obstruction and acute pancreatitis secondary to a large pyloric gland adenoma, highlights several rare clinical entities. First, gastrogastric intussusception in adults is an exceptionally rare phenomenon, with only a few documented cases reported in the literature. Second, in the case of large gastric neoplasms causing intussusception, rarely the neoplasm may extend down into the duodenum and obstruct the ampulla of Vater causing acute pancreatitis. Furthermore, pyloric gland adenomas are rare gastric neoplasms that tend to be polypoid in morphology and are associated with autoimmune gastritis, predominantly occurring in female patients, as in this case. Lastly, the traditional management for lesions causing gastroduodenal intussusception is surgical because of the risk of malignancy. However, in this case, the patient underwent successful curative and therapeutic endoscopic resection with ESD.
PubMed: 38261839
DOI: 10.1016/j.vgie.2023.09.003 -
Annals of Gastroenterological Surgery Jan 2024Lymph node metastasis (LNM) is associated with poor prognosis in patients with duodenal cancer (DC). However, the efficacy and optimal extent of lymph node (LN)...
BACKGROUND
Lymph node metastasis (LNM) is associated with poor prognosis in patients with duodenal cancer (DC). However, the efficacy and optimal extent of lymph node (LN) dissection have not been thoroughly discussed.
METHODS
A total of 98 consecutive patients with DC who underwent surgical resection (pancreatoduodenectomy, = 55; partial resection, = 32; pancreas-sparing total duodenectomy, n = 9) were retrospectively analyzed. The LN stations located upstream of the lymphatic flow were defined as Np stations according to tumor location, whereas the others were defined as Nd stations. The association between the dissection of each LN station and survival outcome was investigated using the efficacy index (EI; percentage of metastases to lymph nodes in each station multiplied by the 5-year survival rate of metastatic cases).
RESULTS
The survival of patients with LNM at the Nd stations ( = 6) was significantly worse than that of patients with LNM only at the Np stations ( = 20) (relapse-free survival, median survival time [MST], 6.0 vs. 48.4 months, < 0.001; overall survival, MST, 15.1 vs. 96.0 months, < 0.001). Multivariate analysis identified LNM at Nd stations as an independent prognostic factor for overall survival (hazard ratio 9.92; = 0.015). The Np stations had a high EI (range, 8.34-20.88), whereas the Nd stations had an EI of 0, regardless of the tumor location.
CONCLUSIONS
LN dissection of the Np stations contributed to acceptable survival, whereas LNM of the Nd stations led to poor survival, possibly reflecting advanced tumor progression to systemic disease in patients with DC.
PubMed: 38250683
DOI: 10.1002/ags3.12731 -
Abdominal Radiology (New York) Mar 2024To develop a diagnostic model for distinguishing pancreatobiliary-type and intestinal-type periampullary adenocarcinomas using preoperative contrast-enhanced computed...
PURPOSE
To develop a diagnostic model for distinguishing pancreatobiliary-type and intestinal-type periampullary adenocarcinomas using preoperative contrast-enhanced computed tomography (CT) findings combined with clinical characteristics.
METHODS
This retrospective study included 140 patients with periampullary adenocarcinoma who underwent preoperative enhanced CT, including pancreaticobiliary (N = 100) and intestinal (N = 40) types. They were randomly assigned to the training or internal validation set in an 8:2 ratio. Additionally, an independent external cohort of 28 patients was enrolled. Various CT features of the periampullary region were evaluated and data from clinical and laboratory tests were collected. Five machine learning classifiers were developed to identify the histologic type of periampullary adenocarcinoma, including logistic regression, random forest, multi-layer perceptron, light gradient boosting, and eXtreme gradient boosting (XGBoost).
RESULTS
All machine learning classifiers except multi-layer perceptron used achieved good performance in distinguishing pancreatobiliary-type and intestinal-type adenocarcinomas, with the area under the curve (AUC) ranging from 0.75 to 0.98. The AUC values of the XGBoost classifier in the training set, internal validation set and external validation set are 0.98, 0.89 and 0.84 respectively. The enhancement degree of tumor, the growth pattern of tumor, and carbohydrate antigen 19-9 were the most important factors in the model.
CONCLUSION
Machine learning models combining CT with clinical features can serve as a noninvasive tool to differentiate the histological subtypes of periampullary adenocarcinoma, in particular using the XGBoost classifier.
Topics: Humans; Retrospective Studies; Adenocarcinoma; Tomography, X-Ray Computed; Machine Learning; Duodenal Neoplasms
PubMed: 38236405
DOI: 10.1007/s00261-023-04151-1 -
European Journal of Cancer (Oxford,... Mar 2024Small intestinal adenocarcinomas (SIAs) are rare. Hence, randomized controlled trials are lacking and understanding of the disease features is limited. This nationwide...
BACKGROUND
Small intestinal adenocarcinomas (SIAs) are rare. Hence, randomized controlled trials are lacking and understanding of the disease features is limited. This nationwide cohort investigates incidence, treatment and prognosis of SIA patients, to improve disease outcome.
PATIENTS AND METHODS
Data of 2697 SIA patients diagnosed from January 1999 through December 2019 were retrieved from the Netherlands Cancer Registry and Pathology Archive. Incidence was calculated using the revised European Standardized Rate. The influence of patient and tumor characteristics on overall survival (OS) was studied using survival analyses.
RESULTS
The age-standardized incidence rate almost doubled from 0.58 to 1.06 per 100,000 person-years, exclusively caused by an increase in duodenal adenocarcinomas. OS did not improve over time. Independent factors for a better OS were a younger age, jejunal tumors, Lynch syndrome and systemic therapy. Only 13.8% of resected patients was treated with adjuvant chemotherapy, which improved OS compared to surgery alone in stage III disease (HR 0.47 (0.35-0.61)), but not in the limited group of deficient mismatch repair (MMR) patients (n = 53, HR 0.93 (0.25-3.47)). In the first-line setting, CAPOX was associated with improved OS compared to FOLFOX (HR 0.51 (0.36-0.72)). For oligometastatic patients, a metastasectomy significantly improved OS (HR 0.54 (0.36-0.80)).
CONCLUSIONS
The incidence of SIAs almost doubled in the past 20 years, with no improvement in OS. This retrospective non-randomized study suggests the use of adjuvant chemotherapy for stage III disease and first-line CAPOX for metastatic patients. For selected oligometastatic patients, a metastasectomy may be considered. MMR-status testing could aid in clinical decision-making.
Topics: Humans; Adenocarcinoma; Cohort Studies; Incidence; Jejunal Neoplasms; Prognosis; Retrospective Studies
PubMed: 38232410
DOI: 10.1016/j.ejca.2024.113529 -
The Journal of Pathology Mar 2024Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are heterogeneous malignancies that arise from complex cellular interactions within the tissue microenvironment....
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are heterogeneous malignancies that arise from complex cellular interactions within the tissue microenvironment. Here, we sought to decipher tumor-derived signals from the surrounding microenvironment by applying digital spatial profiling (DSP) to hormone-secreting and non-functional GEP-NETs. By combining this approach with in vitro studies of human-derived organoids, we demonstrated the convergence of cell autonomous immune and pro-inflammatory proteins that suggests their role in neuroendocrine differentiation and tumorigenesis. DSP was used to evaluate the expression of 40 neural- and immune-related proteins in surgically resected duodenal and pancreatic NETs (n = 20) primarily consisting of gastrinomas (18/20). A total of 279 regions of interest were examined between tumors, adjacent normal and abnormal-appearing epithelium, and the surrounding stroma. The results were stratified by tissue type and multiple endocrine neoplasia I (MEN1) status, whereas protein expression was validated by immunohistochemistry (IHC). A tumor immune cell autonomous inflammatory signature was further evaluated by IHC and RNAscope, while functional pro-inflammatory signaling was confirmed using patient-derived duodenal organoids. Gastrin-secreting and non-functional pancreatic NETs showed a higher abundance of immune cell markers and immune infiltrate compared with duodenal gastrinomas. Compared with non-MEN1 tumors, MEN1 gastrinomas and preneoplastic lesions showed strong immune exclusion and upregulated expression of neuropathological proteins. Despite a paucity of immune cells, duodenal gastrinomas expressed the pro-inflammatory and pro-neural factor IL-17B. Treatment of human duodenal organoids with IL-17B activated NF-κB and STAT3 signaling and induced the expression of neuroendocrine markers. In conclusion, multiplexed spatial protein analysis identified tissue-specific neuro-immune signatures in GEP-NETs. Duodenal gastrinomas are characterized by an immunologically cold microenvironment that permits cellular reprogramming and neoplastic transformation of the preneoplastic epithelium. Moreover, duodenal gastrinomas cell autonomously express immune and pro-inflammatory factors, including tumor-derived IL-17B, that stimulate the neuroendocrine phenotype. © 2024 The Pathological Society of Great Britain and Ireland.
Topics: Humans; Neuroendocrine Tumors; Gastrinoma; Neuroimmunomodulation; Interleukin-17; Duodenal Neoplasms; Pancreatic Neoplasms; Tumor Microenvironment; Intestinal Neoplasms; Stomach Neoplasms
PubMed: 38229586
DOI: 10.1002/path.6241 -
Journal of Investigative Medicine High... 2024Gastrointestinal clear cell sarcoma (GICCS)/malignant gastrointestinal neuroectodermal tumor (GNET) is an extremely rare form of cancer with aggressive clinical... (Review)
Review
Gastrointestinal clear cell sarcoma (GICCS)/malignant gastrointestinal neuroectodermal tumor (GNET) is an extremely rare form of cancer with aggressive clinical behavior. It has distinct pathological, immunohistochemical, ultrastructural, and molecular features. Herein, we present the case of a 20-year-old woman with no notable medical history who presented to the outpatient department with complaints of abdominal pain and vomiting. Symptoms had been evolving for 3 months. The physical examination revealed slight abdominal tenderness and melena. Biological investigations revealed iron-deficiency anemia. The upper and lower endoscopies showed no abnormalities. Magnetic resonance enterography revealed small bowel wall thickening of 15 mm × 2 mm. Exploratory laparotomy revealed an ileal mass with mesenteric lymphadenopathy. A wide resection of the mass was then performed. The final pathological report confirmed the diagnosis of small bowel GICCS/GNET. After 11 months of follow-up, the patient presented with mesenteric lymph node metastases.
Topics: Female; Humans; Young Adult; Adult; Sarcoma, Clear Cell; Intestine, Small; Gastrointestinal Neoplasms; Neuroectodermal Tumors; Duodenal Neoplasms
PubMed: 38229428
DOI: 10.1177/23247096231225869 -
African Health Sciences Jun 2023To investigate the demographic features, primary endoscopic findings, and the status of Helicobacter Pylori (H. pylori) infection of the enrolled subjects who underwent...
BACKGROUND/OBJECTIVES
To investigate the demographic features, primary endoscopic findings, and the status of Helicobacter Pylori (H. pylori) infection of the enrolled subjects who underwent upper gastrointestinal endoscopy (UGIE) in the Zanzibar Archipelago, Tanzania.
METHODS
Between December 2013 and October 2021, a total of 3146 eligible participants were finally recruited in present retrospective cohort. Demographic information and endoscopic findings of each participant was retrieved. H. pylori infection was confirmed by rapid-urease test of gastric antral and body biopsies at endoscopy.
RESULTS
Among the recruited subjects, 1691 (53.76%) are females, remaining 1455 (46.24%) are males. The median age of this retrospective cohort was 40 years ranging from 8 to 97 years. The common identified endoscopic findings included gastro-duodenitis, normal endoscopic finding, peptic ulcer disease (PUD), esophagitis, esophagogastric varices, esophageal and gastric cancer, respectively. After adjustment for sex and age, a significant risk of gastric and/or duodenal ulcer (OR, 2.51; 95% CI, 1.82-3.48, P<0.001) and gastric cancer (OR, 3.49; 95% CI, 1.27-9.58, P=0.015) in H. positive group was observed. Stratified analysis indicated a significant relationship between duodenal ulcer with younger age (adjusted OR, 0.98; 95% CI, 0.97-0.99, p = 0.002), and the presence of H. pylori (OR, 2.01; 95% CI, 1.12-3.91, p= 0.021).
CONCLUSIONS
The present study revealed that gastro-duodenitis, PUD, and normal finding are the most common endoscopic diagnoses in Zanzibar. The presence of H. is significantly associated with duodenal ulcer and gastric cancer.
Topics: Male; Female; Humans; Adult; Duodenal Ulcer; Retrospective Studies; Tanzania; Duodenitis; Stomach Neoplasms; Esophageal Neoplasms; Peptic Ulcer; Helicobacter pylori; Endoscopy, Gastrointestinal; Helicobacter Infections
PubMed: 38223625
DOI: 10.4314/ahs.v23i2.45 -
Digestive and Liver Disease : Official... Apr 2024The present paper reflects the position of the Italian Association for Neuroendocrine Tumors (Itanet), the Italian Society of Gastroenterology (SIGE), and the Italian... (Review)
Review
Endoscopic management of gastric, duodenal and rectal NETs: Position paper from the Italian Association for Neuroendocrine Tumors (Itanet), Italian Society of Gastroenterology (SIGE), Italian Society of Digestive Endoscopy (SIED).
The present paper reflects the position of the Italian Association for Neuroendocrine Tumors (Itanet), the Italian Society of Gastroenterology (SIGE), and the Italian Society of Digestive Endoscopy (SIED) regarding the management of patients affected by gastric, duodenal, and rectal neuroendocrine neoplasms (NENs) amenable to endoscopic treatment. The key questions discussed in this paper are summarized in Table 1. Data were extracted from the MEDLINE database through searches; expert opinions and recommendations are provided in accordance with the available scientific evidence and the authors' expertise. Recommendations are presented alongside a level of evidence and grade of recommendation based on the GRADE system. This paper specifically focuses on subgroups of NENs considered suitable for endoscopic management according to current international guidelines: i. well-differentiated gastric neuroendocrine tumors (gNET) type 1 < 2 cm and selected cases of type 3; ii. well-differentiated duodenal, non-functioning, non-ampullary NET with size < 2 cm; and well-differentiated rectal NET with size < 2 cm.
Topics: Humans; Neuroendocrine Tumors; Gastroenterology; Endoscopy, Gastrointestinal; Stomach Neoplasms; Italy
PubMed: 38216439
DOI: 10.1016/j.dld.2023.12.015