Duodenal stenosis caused by cystic dystrophy in heterotopic pancreas: Report of a case

We herein describe the first reported case of duodenal stenosis caused by cystic dystrophy in heterotopic pancreas (CDHP) in Asia. A 63-year-old man was admitted to the hospital presenting with nausea and vomiting of 2 days’ duration. Laboratory examinations showed an elevation in both the serum amylase level (275 IU/l) and white blood cell count (13 600/μl). A 3-cm-diameter tumor close against the duodenum was pointed out from the results of computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP); the tumor contained a cystic and solid component. Endoscopic examinations and an upper gastrointestinal series showed stenosis of the second portion of the duodenum without any mucosal change. The tumor was considered to be located at the submucosal layer of the second duodenum. The biopsy specimen of the duodenum revealed no malignancy. We strongly doubted the presence of a malignant submucosal tumor in the duodenum based on the findings of diagnostic imaging, and a pancreaticoduodenectomy was thus performed. Histopathologically, the lesion was diagnosed to be CDHP. The postoperative course was uneventful. The patient was symptomatic but was free of any symptoms after surgery. He continues to be regularly followed up on an outpatient basis and has had no recurrence of symptoms. This case demonstrates the need to consider CDHP in the differential diagnosis as a rare cause of duodenal stenosis.     

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.     

Neuroendocrine tumor of the extrahepatic bile duct: A case report

IntroductionNeuroendocrine tumors (NETs) of the extrahepatic bile ducts are extremely rare neoplasms arising from endocrine cells and have variable malignant potential. They most commonly occur in young females and usually present with painless jaundice.Presentation of caseHere we present the case of an asymptomatic 57-year-old woman with NET of the common bile duct that was incidentally discovered on abdominal ultrasound during a medical examination. She was admitted to our hospital with a diagnosis of hepatic hilar tumor. Computed tomography revealed the tumor surrounding the hepatic hilum and duodenum. Magnetic resonance cholangiopancreatography revealed a filling defect of the common bile duct with morphology suggestive of external compression. Endoscopic ultrasound confirmed a submucosal tumor of the duodenal bulb measuring 30 × 20 mm in size. The patient qualified for surgery with a preoperative diagnosis of submucosal tumor of the duodenal bulb. Intraoperative examination revealed that the tumor location involved the common bile duct and/or cystic duct with no signs of invasion to other organs or metastatic lymph nodes. Excision of the biliary ducts and tumor was followed by Roux-en-Y anastomosis. Histological results showed NET grade 1.DiscussionPreoperative diagnosis of NETs is difficult because of their rarity. A definitive diagnosis is usually established intraoperatively or after histopathological evaluation.ConclusionFor these tumors, surgical resection is currently the only treatment modality for achieving a potentially curative effect and prolonged disease-free survival.     

Laparoscopic and endoscopic cooperative surgery for duodenal neuroendocrine tumor (NET) G1: Report of a case

INTRODUCTION

We report a case of duodenal neuroendocrine tumor (NET) G1 resected by laparoscopic and endoscopic cooperative surgery (LECS) technique.

PRESENTATION OF CASE

A 58-year-old woman underwent esophagastroduodenoscopy, revealing an 8-mm, gently rising tumor distal to the pylorus, on the anterior wall of the duodenal bulb. Endoscopic ultrasonography suggested the tumor might invade the submucosal layer. The tumor was pathologically diagnosed as a G1 duodenal NET, by biopsy. Endoscopic submucosal dissection was attempted, but was unsuccessful because of the difficulty of endoscopically performing an inversion operation in the narrow working space. The case was further complicated by the patient''s duodenal ulcer scar. We performed a full-thickness local excision using laparoscopic and endoscopic cooperative surgery. The tumor was confirmed and endoscopically marked along the resection line. After full-thickness excision, using endoscopy and laparoscopy, interrupted full-thickness closure was performed laparoscopically.

DISCUSSION

Endoscopic treatment is generally recommended for G1 NETs <10 mm in diameter and extending only to the submucosal layer. However, some cases are difficult to resect endoscopically because the wall of duodenum is thinner than that of stomach, and endoscope maneuverability is limited within the narrow working space. LECS is appropriate for early duodenal G1 NETs because they are less invasive and resection of the lesion area is possible.

CONCLUSION

We demonstrated that LECS is a safe and feasible procedure for duodenal G1 NETs in the anterior wall of the first portion of the duodenum.     

Carcinosarcoma of the duodenum: Report of a case

This report describes a case of carcinosarcoma of the duodenum. Carcinosarcoma of the duodenum is a very rare tumor. A 72-year-old man was referred to the hospital because of appetite loss. Endoscopy demonstrated an irregularly depressed lesion (type 3) in the descending portion of the duodenum opposite to the ampulla of Vater. Computed tomography showed a thickened duodenal wall and swelling of the abdominal para-aortic lymph nodes. A biopsy specimen revealed a well-differentiated adenocarcinoma. A diagnosis of duodenal carcinoma was made (cT3, cN1, cM1, cStage IV according to the TNM classification). A subtotal stomach-preserving pancreatoduodenectomy and a lymph node resection were performed. On microscopic examination, adenocarcinoma cells and spindle type sarcoma cells were observed separately in the descending portion of the duodenum opposite to the ampulla of Vater. The adenocarcinoma cells were stained with antibodies against epithelial markers keratin and carcinoembryonic antigen for immunohistochemical analyses. In contrast, the sarcoma cells were stained with antibodies to vimentin and smooth muscle actin. The pathological diagnosis of a true duodenal carcinosarcoma was thus made.     

Schwannoma of the stomach with elevated preoperative serum carbohydrate antigen 19-9: report of a case

We herein report a case of a gastric schwannoma with elevated preoperative serum carbohydrate antigen 19-9 (CA19-9) (155.2 U/ml, normal range 0-36.9 U/ml). A 59-year-old Japanese man was admitted to our hospital for treatment of a submucosal tumor of the stomach detected by barium meal, upper gastrointestinal endoscopy, and computed tomography. Endoscopic examination revealed a 3-cm diameter submucosal tumor in the antrum of the stomach, but biopsy of the lesion was unable to confirm the diagnosis. Positron emission tomography to evaluate the malignant potential showed a high uptake of (18)F-fluorodeoxyglucose in the tumor. Laparoscopy-assisted distal gastrectomy was therefore performed. The histopathological findings of the surgical specimen revealed a benign gastric schwannoma, positive for S-100 protein. The postoperative serum CA19-9 levels gradually decreased and normalized. To the best of our knowledge, this is the first report of a gastric schwannoma with elevated serum CA19-9.     

Pancreatic and duodenal metastases from renal cell carcinoma 13 years after radical nephrectomy: a case report

A 52-year-old male was admitted to our hospital complaining of orthostatic vertigo, fatigue and weight loss, who underwent right total nephrectomy for renal cell carcinoma(RCC) with curative operation 13 years ago (in 1992). Endoscopic examination revealed a submucosal tumor with erosion in the duodenum. The diagnosis made from the biopsy specimens was metastatic RCC in the duodenum. Abdominal CT scan revealed that his metastasis has spread to the pancreas. Five million units of interferon a was administered intramuscularly three times a week for 1 month. He received blood transfusions and palliative care. He died 5 months later because of disease progression. Metastases of RCC have been often reported in the lungs, the liver, and the bones, but rarely in the gastrointestinal tract. This is a very rare case of metastatic RCC in the duodenum, which was diagnosed 13 years after curative right nephrectomy. Since late recurrence is characteristic of renal cell carcinoma, careful long-term follow-up is needed. To our knowledge, this is the 19th case of duodenal metastasis from RCC reported in the literature.     

Rhabdomyosarcoma of the duodenum: report of a case

This report presents a case of primary pleomorphic rhabdomyosarcoma arising in the duodenum. A 63-year-old male with persistent melena was referred for a solid tumor in his right upper abdomen detected using ultrasonography. Gastrofiberscopy revealed a protrusion in the upper part of the duodenum, with a large ulcer on the top of it. Enhanced computed tomography showed that the tumor extended to the pancreas. Pancreaticoduodenectomy was performed, despite the absence of malignant cells in the biopsy specimen, with a preoperative diagnosis of duodenal cancer. The tumor consisted of multiple cell types, and immunohistochemical staining was positive for desmin, HHF-35 and alpha smooth muscle actin. Electron microscopy revealed primitive Z-band structures in the tumor. The final diagnosis was pleomorphic rhabdomyosarcoma of the duodenum. This is the first report of primary rhabdomyosarcoma occurring in the duodenum, confirmed by immunohistochemical staining and electron microscopy.     

Intraductal papillary mucinous tumor of the pancreas degenerated and fistulisated in the stomach, the duodenum and colon

We report a case of intraductal papillary mucinous tumor of the pancreas (IPMT) degenerated and fistulized into the stomach, the duodenum and the colon. Diagnoses of malignancy and fistulization were proven preoperatively. Pancreaticoduodenectomy extended to the body was performed. Pathological examination revealed a malignant IPMT with an invasive component. Of the 3 fistulizations tracts, both gastric and duodenal ones were malignant. To our knowledge, this is the first reported case of IPMT with colonic fistulization. Twelve months later, the patient is alive without signs of recurrence.     

Wilkie’s syndrome: an uncommon cause of intestinal obstruction

A 10-year-old boy presented with 9 months history of gradually worsening, recurrent postprandial upper abdominal pain, bilious vomiting and loss of weight. On examination the child was undernourished, had epigastric fullness and succusion splash was positive. Ultrasonography of the abdomen suggested a massively distended stomach, while an upper gastrointestinal contrast study showed a hugely dilated stomach along with dilated first and second parts of the duodenum with abrupt cut off at the level of third part of duodenum. Contrast enhanced CT scan of the abdomen revealed dilatation of the second part of the duodenum without any obvious abnormality of the aorta-superior mesenteric artery angle. Upper gastrointestinal endoscopy showed retained fluid and food material within a dilated stomach and second part of the duodenum; scope could not be negotiated into the third part because of an extrinsic compression. The child was diagnosed to be suffering from Wilkie’s syndrome. Exploratory laparotomy, performed when conservative management failed, revealed compression of the third part of duodenum by a shortened ligament of Trietz and dense peritoneal bands near the third part of duodenum. The duodenal obstruction was bypassed by performing duodenojejunostomy. The child had an uneventful postoperative recovery. He gained around 6.8 kilograms within next five months.     

Laparoscopic treatment of duodenal carcinoid tumor

A 46-year-old man with epigastralgia and slight elevation of urinary 5-hydroxyindole acetic acid (5HIAA) was found to have a well-demarcated carcinoid tumor in the duodenal bulb. The tumor measured 8 mm in size, and showed submucosal involvement but no metastasis to the liver and regional lymph nodes. After laparoscopic exposure and lifting of the duodenal wall around the tumor, wedge resection of the duodenal bulb including the tumor was performed successfully with a laparoscopic endostapler under direct endoscopic control. The postoperative course of the patient was uneventful. Laparoscopic wedge resection of the duodenum would be an appropriate minimally invasive treatment for selected duodenal neoplasms with special preoperative assessments and intraoperative considerations. Received: 27 January 1997/Accepted: 4 December 1997     

A malignant granular cell tumor of the stomach: Report of a case

We report herein what to our knowledge is the first documented case of a malignant granular cell tumor of the stomach. A 64-year-old woman was admitted to our hospital for investigation of gastric submucosal tumor. Endoscopy disclosed a large hemispherical mass located on the lesser curvature at the gastric antrum with a normal mucosal surface, and computed tomography (CT) revealed a solid tumor about 7 cm in diameter with clear margins. A laparotomy was carried out under the preoperative diagnosis of leiomyosarcoma of the stomach. A tumor was found in the gastric antrum, with extragastric extension to the hepatic hilum, and a distal partial gastrectomy was performed. However, a follow-up CT scan performed 21 months postoperatively revealed a solid tumor of about 10 cm in diameter with clear margins, situated between the liver and the transverse colon. This was subsequently diagnosed as local recurrence and a resection was carried out. Microscopic examination of both the first and second specimens showed that the tumor cells were large and polygonal, with medullary proliferation and finely granular eosinophilic cytoplasm. Mitotic figures were also present. Thus, the lesion was diagnosed as a malignant granular cell tumor of the stomach from the clinical and pathological findings.     

Duodenal gangliocytic paraganglioma as a radiological moving defect

BACKGROUND: Gangliocytic paraganglioma of the duodenum is a peculiar neuroendocrine tumor, often revealed as an incidental radiographic finding or as a result of gastrointestinal hemorrhage, due to frequent ulceration of the overlying mucosa. Most lesions are pedunculated and submucosal with distinctive histology, consisting of endocrine, ganglion and spindle-shaped Schwann cells. METHODS: A case of a duodenal gangliocytic paraganglioma is reported in a 50-year-old woman presenting with episodes of melena. Enteroclysis revealed a pedunculated tumor observed either in the second or third portion of the duodenum. Upper gastrointestinal endoscopy revealed a pedunculated ulcerated tumor which was subsequently confirmed by computed tomography. The tumor was simply excised through a duodenotomy. RESULTS: The size of the tumor was 4.5 x 3 x 1.5 cm. Immunohistochemical and ultrastructural features of the tumor classified it as a typical duodenal gangliocytic paraganglioma with positive cellular reaction for neuron-specific enolase, chromogranin, somatostatin, gastrin and S100. CONCLUSION: Forty-six months after surgery, the patient is well with no evidence of recurrence. The majority of the reported duodenal gangliocytic paragangliomas were of benign nature. However, the fact that in 4 isolated cases there was lymph node involvement indicates that thorough investigation for lymph node metastases is needed, as well as thorough postoperative follow-up.     

Two case of bilateral approach in laparoscopic pancreas-sparing distal duodenectomy for duodenal neoplasms arising from the distal duodenum

IntroductionLaparoscopic pancreas-sparing distal duodenectomy is a less invasive surgical therapy; however, the anatomical complexity of the duodenum increases the difficulty of laparoscopic procedures. We introduce our technique for laparoscopic pancreas-sparing distal duodenectomy for distal duodenal tumors.Presentation of casesA first patient was 47-year-old woman who had 30 mm of duodenal tumor which located in third portion of duodenum. A second patient was 66-year-old man who had 35 mm of submucosal tumor which located in the third portion of duodenum. Laparoscopic pancreas-sparing duodenectomy was performed using bilateral approach for both cases. We began by dissecting an avascular area on the right side of the transverse mesocolon to mobilize the second and third portions of the duodenum with the uncinate process of the pancreas. Next, from the left side, the jejunum and the fourth portion of the duodenum were fully mobilized orally from the surrounding tissue, connecting the dissection plane with the right-side area. The jejunum and duodenum were cut with a linear stapler. Intracorporeal reconstruction was performed in an overlapped manner. We performed this procedure in two patients. Operative time was 326 and 370 min, respectively. Patients were discharged on postoperative days 9–12 without postoperative complications.DiscussionDuodenal tumors are found increasingly often because of developments in endoscopic technology and techniques; therefore, establishing safe surgical procedures for duodenal tumor excision is imperative. Our surgical approach was simple and safe procedure.ConclusionLaparoscopic pancreas-sparing distal duodenectomy with a bilateral approach is a useful approach without wide mobilization of duodenum.     

Lymphangioma of the duodenum: Report of a case

A case of lymphangioma of the duodenum with a successful preoperative diagnosis is reported herein. A 76-year-old man who complained of tarry stool was found to have a hemorrhagic polypoid tumor in the third portion of the duodenum. The tumor was diagnosed histologically as cavernous lymphangioma by endoscopic biopsy. Since such a tumor is essentially benign, a partial resection of the duodenum including the tumor was performed. Therefore, an endoscopic biopsy seems to be valuable in the diagnosis of duodenal lymphangioma.     

Successful resection,using pancreas-sparing duodenectomy,of extrahepatically growing hepatocellular carcinoma associated with direct duodenal invasion

A 50-year-old man with extrahepatically growing hepatocellular carcinoma (HCC) associated with direct duodenal invasion underwent a right posterior segmentectomy associated with pancreas-sparing duodenectomy. Neither periduodenal lymph-node metastasis nor pancreatic invasion was detected, thus we separated the supra-ampullary duodenum from the pancreatic head and performed pancreas-sparing supra-ampullary duodenectomy. The resected specimen was observed to be a centrally necrotic tumor that had infiltrated the duodenal wall, resulting in exposure of the lumen. Pathology examination revealed that the tumor consisted of poorly differentiated HCC, which had extensively infiltrated the mucosa of the duodenum. Gastrointestinal tract involvement in patients with HCC is rare, and pancreas-sparing duodenectomy is a safe and effective treatment for patients with HCC associated with direct duodenal invasion. Received: December 31, 2001 / Accepted: April 14, 2002     

An unusual case of neurinofibroma in the distal part of the duodenum

A case of a neurinofibroma in the distal part of duodenum is reported by the author. It has caused a so-called blind resection of the stomach by Billroth II-type as the result of not clarified bleeding. But after restoration of the duodenal transit by the procedure reverting into Billroth I-operation there was the possibility of the accurate diagnosis of the origin of bleeding by means of gastroduodenoscopy and X-ray examination by duodenal hypotension and with it the definitive healing.     

Synchronous multiple primary cancers of the stomach and duodenum in aged patients: Report of two cases

We describe herein the cases of two aged patients found to have synchronous multiple primary cancers of the stomach and duodenum. The first patient was an 82-year-old man who was preoperatively diagnosed as having gastric cancer after presenting with signs of pyloric stenosis. At laparotomy, duodenal cancer was incidentally found to have infiltrated the transverse colon. A pancreatoduodenectomy and right hemicolectomy with radical lymph node dissection was performed. Two early well-differentiated adeno-carcinomas of the stomach and an advanced poorly differentiated adenocarcinoma of the duodenum were confirmed. This patient is now well without any evidence of recurrence more than 5 years after surgery. The second patient was a 77-year-old man who was also diagnosed as having gastric cancer after presenting with signs of pyloric stenosis. Preoperatively, duodenal cancer was detected by endoscopy. A pancreatoduodenectomy and partial colectomy with radical lymph node dissection was performed because the duodenal cancer was suspected of having infiltrated the trans-verse colon. An early moderately differentiated adenocarcinoma of the stomach and an advanced moderately differentiated adenocarcinoma of the duodenum were confirmed, but the duodenal cancer was not seen to invade the transverse colon microscopically. This patient died of cancer 7 months after surgery. Because multiple primary cancers commonly develop in elderly patients, a precise preoperative diagnosis must be made and optimal treatment applied. Received: March 5, 1999 / Accepted: March 24, 2000     

Duodenal teratoma: Rare case of extragonadal germ cell tumors and review of literature

IntroductionDuodenal teratoma is a rare condition with only four cases reported in the English literature. Radiological imaging and tissue sample are necessary for diagnosis in addition to tumor markers. The most effective treatment is still complete excision with safety margins.Case presentationWe report a case of 26 years-old-man, in whom epigastric pain, decreased appetite, and postprandial bilious vomiting had been prevalent for 5–6 months and had exacerbated prior to the emergency room.Enhanced abdominal computed tomography revealed a 10 × 15cm heterogeneous solid mass with cystic component in the third duodenum segment. The inferior veina cava and aorta were both compressed, although there was no sign of lymphadenopathy or ascites. An ulcerating non-bleeding lesion at the D2-D3 junction of the duodenum was discovered during a gastroduodenoscopy. Biopsies and immunohistochemical investigations revealed findings that were consistent with a mixed non-seminomatous germ cell tumor. A PET-CT scan was performed, which revealed FDG uptake by the duodenal lesion but no evidence of metastatic lesions.A distal duodenal segmentectomy is performed, and then a duodeno-jejunal anastomosis is used to restore continuity. The final diagnosis was teratomatous tumor of the duodenum without malignant changes.ConclusionThis is the second adult case of main duodenal teratoma that has been reported. We publish it to encourage surgeons to think about this differential diagnosis and carefully plan surgery using a multidisciplinary approach.     

Duodenal cancer arising from the remaining duodenum after pylorus-preserving pancreatoduodenectomy for ampullary cancer in familial adenomatous polyposis

We herein report a rare occurrence of duodenal cancer arising from the remaining duodenum after pylorus-preserving pancreatoduodenectomy for ampullary cancer in familial adenomatous polyposis (FAP). In this patient, proctocolectomy and ileoanal anastomosis for FAP had been performed 11 years earlier. During the current admission, the patient was diagnosed with adenocarcinoma in the Vater’s ampulla using imaging and pathological examinations. In addition, a pylorus-preserving pancreatoduodenectomy was performed. The tumor was a well-differentiated tubular adenocarcinoma and no other polyps were identified in the duodenum by pathological examination. However, 1 year after surgery, a polypoid lesion measuring 15 * 15 mm was indicated in the remaining duodenum by endoscopic surveillance. This lesion was completely resected by endoscopic mucosal resection and the resected specimen revealed well-differentiated tubular adenocarcinoma in an adenomatous lesion. This report suggests that resection of the total duodenum is essential for duodenal neoplasms in FAP to prevent a recurrence in the remaining duodenum.