Neuroendocrine carcinoma of the gastric stump:A case report and literature review

We herein report a case of neuroendocrine carcinoma of the gastric stump found 47 years after Billroth II gastric resection for a benign gastric ulcer. A 74-yearold man was referred to another hospital with melena. Endoscopic examination revealed a localized ulcerative lesion at the gastrojejunal anastomosis. The diagnosis by endoscopic biopsy was neuroendocrine carcinoma. A total gastrectomy of the remnant stomach with D2 lymphadenectomy was performed at our hospital. The lesion invaded the subserosa, and metastasis was found in two of nine the lymph nodes retrieved. The lesion was positive for synaptophysin and chromogranin A, and the Ki-67 labeling index was 60%. The diagnosis of neuroendocrine carcinoma of the gastric stump was confirmed using World Health Organization 2010 criteria. Subsequently, the patient underwent one course of adjuvant chemotherapy with the etoposide plus cisplatin(EP) regimen; however, treatment was discontinued due to grade 3 myelosuppression. The patient showed lymph node metastasis in the region around the gastrojejunal anastomosis in the abdominal cavity 7 mo post-surgery. He then underwent radiotherapy and platinum-based combination chemotherapy; however, the disease progressed and liver recurrence was observed on follow-up computedtomography at 16 mo post-surgery. The patient then received chemotherapy with regimens used for the treatment of small cell lung cancer in first-and secondline settings. The patient died of disease progression 31 months after surgery.     

Prognostic factors and survival in patients with gastric stump cancer

AIM:To elucidate the clinicopathological characteristics and prognostic factors of gastric stump cancer(GSC).METHODS:The clinical data for 92 patients with GSC were collected at Fudan University Shanghai Cancer Center.The prognostic factors were analyzed with Cox proportional hazard models.RESULTS:GSC tended to occur within 25 years following the primary surgery,when the initial disease is benign,whereas it primarily occurred within the first15 years post-operation for gastric cancer.Patients with regular follow-up after primary surgery had a better survival rate.The multivariate Cox regression analysis revealed that Borrmann type?Ⅰ/Ⅱ(HR=3.165,95%CI:1.055-9.500,P=0.040)and radical resection(HR=1.780,95%CI:1.061-2.987,P=0.029)were independent prognostic factors for GSC.The overall 1-,3-,and 5-year survival rates of the 92 patients were78.3%,45.6%and 27.6%,respectively.The 1-,3-,and 5-year survival rates of those undergoing radical resection were 79.3%,52.2%,and 37.8%,respectively.The 5-year survival rates for stages?Ⅰ,Ⅱ,Ⅲ,andⅣwere 85.7%,47.4%,16.0%,and 13.3%,respectively(P=0.005).CONCLUSION:The appearance of GSC occurs sooner in patients with primary malignant cancer than in patients with a primary benign disease.Therefore,close follow-up is necessary.The overall survival of patients with GSC is poor,and curative resection can improve their prognosis.     

幽门螺旋杆菌与残胃癌发生的研究进展

残胃癌发病率呈上升趋势,其发生机制与多种因素有关,其中幽门螺旋杆菌感染被认为是重要因素,但尚无肯定的结论.本文就残胃幽门螺旋杆菌感染与残胃癌发生及相关机制作一综述.     

幽门螺杆菌感染与十二指肠球部黏膜胃上皮化生的关系

目的 研究十二指肠球部黏膜幽门螺杆菌(Hp)感染与黏膜胃上皮化生的关系，探讨其在十二指肠球部炎症和溃疡发生中的作用。方法 2002年十二指肠球部黏膜活检的存档蜡块82例，作H-E、改良Giemsa和AB／PAS染色。内镜诊断为基本正常球部黏膜10例；十二指肠球炎47例(其中充血糜烂型16例；隆起型31例)和球部溃疡25例。结果 (1)内镜诊断基本正常的十二指肠球部黏膜，组织学60％有轻中度的炎症细胞浸润，但无胃上皮化生和Hp定植。(2)胃上皮化生是十二指肠球部黏膜最常见的病理变化(37／82，45％)。(3)Hp只有在胃上皮化生的黏膜中才能找到，检出率为76％(28／37)。十二指肠球部溃疡边缘黏膜胃上皮化生发生率(72％)明显高于球炎黏膜(40％)，差异有显著性(P=0．0078)。(4)虽然十二指肠球部溃疡边缘胃上皮化生黏膜的Hp检出率(89％，16／18)明显高于十二指肠球炎黏膜(63％，12／19)，但是两者差异无显著性(P=0．062)。不论何期溃疡Hp检出率均很高，本研究中溃疡活动期、愈合期和瘢痕期分别为15例、6例和4例，其溃疡边缘胃上皮化生中Hp检出率分别高达9／10、5／6和2／2例。结论 十二指肠球部溃疡周围黏膜高发胃上皮化生，使Hp更易于定植，推测如不根除Hp感染，可成为十二指肠球部溃疡复发的重要原因。     

胃癌与十二指肠溃疡患者血清胃蛋白酶原比较

目的 比较胃癌患者与十二指肠溃疡患者血清胃蛋白酶原水平的差异及探讨其与H．pylori感染的关系。方法 采用时间分辨荧光免疫分析方法检测108例胃癌和96例十二指肠溃疡患者血清胃蛋白酶原Ⅰ、Ⅱ（PGⅠ，PGⅡ），ELISA方法检测血清H．pylori抗体。结果 胃癌和十二指肠溃疡患者之间PGⅠ水平有显著性差异，胃癌组和十二指肠溃疡组中H．pylori阳性和阴性间PGⅠ、PGⅡ、PGⅠ，PGⅡ水平等无显著性差异。结论 胃癌患者血清PGⅠ水平显著低于十二指肠溃疡患者，H．pylori感染对胃癌和十二指肠溃疡患者血清胃蛋白酶原水平和PGⅠ，PGⅡ比值均无影响。     

Management of gastric and duodenal neuroendocrine tumors

Gastrointestinal neuroendocrine tumors(GI-NETs) are rare neoplasms, like all NETs. However, the incidence of GI-NETS has been increasing in recent years. Gastric NETs(G-NETs) and duodenal NETs(D-NETs) are the common types of upper GI-NETs based on tumor location. G-NETs are classified into three distinct subgroups: type?Ⅰ, Ⅱ, and Ⅲ. Type?Ⅰ?G-NETs, which are the most common subtype(70%-80% of all G-NETs), are associated with chronic atrophic gastritis, including autoimmune gastritis and Helicobacter pylori associated atrophic gastritis. Type Ⅱ G-NETs(5%-6%) are associated with multiple endocrine neoplasia type 1 and Zollinger-Ellison syndrome(MEN1-ZES). Both type?Ⅰ?and Ⅱ G-NETs are related to hypergastrinemia, are small in size, occur in multiple numbers, and are generally benign. In contrast, type Ⅲ G-NETs(10%-15%) are not associated with hypergastrinemia, are large-sized single tumors, and are usually malignant. Therefore, surgical resection and chemotherapy are generally necessary for type Ⅲ G-NETs, while endoscopic resection and followup, which are acceptable for the treatment of most type?Ⅰ?and Ⅱ G-NETs, are only acceptable for small and well differentiated type Ⅲ G-NETs. D-NETs include gastrinomas(50%-60%), somatostatin-producing tumors(15%), nonfunctional serotonin-containing tumors(20%), poorly differentiated neuroendocrine carcinomas( 3%), and gangliocytic paragangliomas( 2%). Most D-NETs are located in the first or second part of the duodenum, with 20% occurring in the periampullary region. Therapy for D-NETs is based on tumor size, location, histological grade, stage, and tumor type. While endoscopic resection may be considered for small nonfunctional D-NETs(G1) located in the higher papilla region, surgical resection is necessary for most other D-NETs. However, there is no consensus regarding the ideal treatment of D-NETs.     

Delayed duodenal stump fistula after laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer: A case report

Duodenal stump fistula (DSF) is one of the most serious complications of gastrectomy. The mean time to diagnosis of DSF is approximately 9 days after operation. Our report describes an extremely rare case of delayed DSF 144 days after a laparoscopic distal gastrectomy.A 58-year-old man with drug-induced liver cirrhosis (Child-Pugh class A) underwent laparoscopic distal gastrectomy with Billroth-II reconstruction for early gastric cancer. On postoperative day 1, he underwent reoperation because of intra-abdominal bleeding. Ongoing bleeding was observed in the stapler line of the duodenal stump and was controlled using metallic surgical clips. The patient was discharged on postoperative day 14, without complications. After 144 days following the first operation, he visited the emergency room with right flank pain and high fever. Computed tomography revealed free air and abscess near the duodenal stump site.Emergency laparotomy, abscess unlooping, and drain insertion were performed. After surgery, bile was drained by intra-abdominal drainage, and fistulography showed a duodenal fistula.The patient was discharged 55 days after his third surgery.This is an extremely rare case of DSF, which may be caused by the metallic surgical clips used for hemostasis of the duodenal stump stapler line. We believe that the use of metallic surgical clips for hemostasis of the duodenal stump after Billroth-II reconstruction should be avoided.     

Treatment of gastric outlet and duodenal obstructions with uncovered expandable metal stents

AIM： To investigate and evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided peroral uncovered expandable metal stent placement to treat gastric outlet and duodenal obstructions.
METHODS： Fifteen consecutive patients underwent peroral placement of WallstentTM Enteral Endoprosthesis to treat gastric outlet and duodenal obstructions （14 malignant, 1 benign）. All procedures were completed under fluoroscopic guidance without endoscopic assistance. Follow-up was completed until the patients died or were lost, and the clinical outcomes were analyzed.
RESULTS： The technique success rate was 100%, and the oral intake was maintained in 12 of 14 patients varying from 7 d to 270 d. Two patients remained unable to resume oral intake, although their s-tents were proven to be patent with the barium study. One patient with acute necrotizing pancreatitis underwent enteral stenting to treat intestinal obstruction, and nausea and vomiting disappeared. Ten patients died during the follow- up period, and their mean oral intake time was 50 d. No procedure-related complications occurred. Stent migration to the gastric antrum occurred in one patient 1 year after the procedure, a tumor grew at the proximal end of the stent in another patient 38 d post-stent insertion.
CONCLUSION： Fluoroscopically guided peroral metal stent implantation is a safe and effective method to treat malignant gastrointestinal obstructions, and complications can be ignored based on our short-term study. Indications for this procedure should be discreetly considered because a few patients may not benefit from gastrointestinal insertion, but some benign gastrointestinal obstructions can be treated using this procedure.     

Endoscopic mucosal resection of duodenal bulb adenocarcinoma with neuroendocrine features: An extremely rare case report

Duodenal adenocarcinoma, especially duodenal bulb with neuroendocrine features (NEF), is extremely rare. Here, we report one such case of duodenal bulb adenocarcinoma with neuroendocrine features. A 63-year-old Han Chinese woman was admitted to our department with the diagnosis of a duodenal bulb polyp and underwent an endoscopic mucosal resection. The pathological findings confirmed it as duodenal bulb adenocarcinoma with NEF. The patient remains curative after one and half a years of follow-up. Duodenal adenocarcinoma with NEF might be a low malignant neuroendocrine tumor rather than a conventional adenocarcinoma. Endoscopic treatment, including endoscopic mucosal resection, might be an ideal option for the adenocarcinomas with NEF.     

Bleeding duodenal hemangioma: morphological changes and endoscopic mucosal resection

Recently, the development of endoscopic procedures has increased the availability of minimally invasive treatments; however, there have been few case reports of duodenal hemangioma treated by endoscopic mucosal resection. The present report describes a case of duodenal hemangioma that showed various endoscopic changes over time and was treated by endoscopic mucosal resection. An 80-year-old woman presented with tarry stools and a loss of appetite. An examination of her blood revealed severe anemia, and her hemoglobin level was 4.2 g/dL. An emergency upper gastrointestinal endoscopy was performed. A red, protrusive, semipedunculated tumor (approximately 20 mm in diameter) with spontaneous bleeding on its surface was found in the superior duodenal angle. Given the semipedunculated appearance of the tumor, it was suspected to be an epithelial tumor with a differential diagnosis of hyperplastic polyp. The biopsy results suggested a telangiectatic hemangioma. Because this lesion was considered to be responsible for her anemia, endoscopic mucosal resection was performed for diagnostic and treatment purposes after informed consent was obtained. A histopathological examination of the resected specimen revealed dilated and proliferated capillary lumens of various sizes, which confirmed the final diagnosis of duodenal hemangioma. Neither anemia nor tumor recurrence has been observed since the endoscopic mucosal resection (approximately 1 year). Duodenal hemangiomas can be treated endoscopically provided that sufficient consideration is given to all of the possible treatment strategies. Interestingly, duodenal hemangiomas show morphological changes that are influenced by various factors, such as mechanical stimuli.     

Impact of postoperative complications on long-term survival after radical resection for gastric cancer

AIM: To investigate the potential impact of complications in gastric cancer patients who survive the initial postoperative period. METHODS: Between January 1, 2005 and December 31, 2006, 432 patients who received curative gastrectomy with D2 lymph node dissection for gastric cancer at our department were studied. Associations between clinicopathological factors [age, sex, American Society of Anesthesiologists grade, body mass index, tumornode-metastases (TNM) stage and tumor grade], including postoperative complications (defined as any deviation from an uneventful postoperative course within 30 d of the operation and survival rates) and treatment-specific factors (blood transfusion, neoadjuvant therapy and duration of surgery). Patients were divided into 2 groups: with (n = 54) or without (n = 378) complications. Survival curves were compared between the groups, and univariate and multivariate models were conducted to identify independent prognostic factors. RESULTS: Among the 432 patients evaluated, 61 com-plications occurred affecting 54 patients (12.50%).Complications included anastomotic leakages, gastric motility disorders, anastomotic block, wound infections, intra-abdominal abscesses, infectious diarrhea, bleeding, bowel obstructions, arrhythmias, angina pectoris, pneumonia, atelectasis, thrombosis, unexplained fever, delirium, ocular fungal infection and multiple organ failure. American Society of Anesthesiologists grade, body mass index, combined organ resection and median duration of operation were associated with higher post-operative complications. The 1-, 3- and 5-year survival rates were 83.3%, 53.2% and 37.5%, respectively. In the univariate analysis, the size of lesions, TNM stage, blood transfusion, lymphovascular invasion, perineural invasion, neoadjuvant chemotherapy, and postoperative complications were significant predictors of overall survival. In the multivariate analysis, only TNM stage and the presence of complications remained significant predictors of reduced survival. CONCLUSION: The     

Excluded gastric mucosa presenting as a polypoid tumor in the duodenal stump after B II resection

We present endoscopic findings of a polypoid tumor in the duodenal stump after Billroth II partial gastric resection in a 61-year-old male. Histologic examination of the tumor revealed gastric mucosa of antral type. Accordingly, Congo red dyeing test failed to show acid secretion. The excluded antral mucosa did not gain any clinical significance in this patient since there was no history of peptic ulcer relapse within the 25 years after gastric operation.     

胃出口、十二指肠和近端小肠恶性梗阻的内镜治疗

目的 探讨经内镜金属支架置入术治疗胃出口、十二指肠和近端小肠恶性梗阻的临床价值.方法 对1999年3月至2005年3月经内镜放置金属支架治疗的21例胃出口、十二指肠和近端小肠恶性梗阻患者的临床资料进行回顾性分析.结果 21例中20例放置支架成功,成功率为95.2%,其中4例采取经内镜钳道（TTS）方式释放支架,16例为经导丝直接释放支架.19例支架放置后1-3d梗阻症状得到缓解或消除,临床有效率为90.5%,平均生存期4.5个月.1例术后出血,予保守治疗而愈.1例术后1个月支架移位,1例术后2个月肿瘤向支架内浸润生长,导致梗阻复发,均予放置第2根支架后缓解.结论 经内镜放置金属支架治疗胃出口、十二指肠和近端小肠恶性梗阻是一种简单可行、安全有效的方法.     

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection (EFTR), with or without laparoscopic assistance, is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors (SMTs) arising from the muscularis propria (MP), especially of the gastric wall. To date, evidence concerning duodenal exposed EFTR is lacking, mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure. However, given the non-negligible morbidity and mortality associated with duodenal surgery, the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers. The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.     

Prevention of the inefficiency of sutures in the duodenal stump upon gastric resection]

The neuropeptide sandostatin influence on the excretory function of the liver, pancreas and stomach was studied in the experiment on mongrel dogs. Its dramatic depression and significant reduction of the intracavitary pressure in the duodenal stump after gastric resection were revealed. Sandostatin was applied successfully in 15 patients in the clinical conditions.     

福建省胃癌和十二指肠溃疡患者白细胞介素1基因多态性的比较

目的了解福建省胃癌和十二指肠溃疡患者中白细胞介素1（IL-1）基因多态性的分布并进行比较。方法病理确诊的144例胃癌及排除非甾体类抗炎药服用史的102例十二指肠溃疡患者，采用PCR—RFLP分析检测IL-1基因多态性。结果（1）胃癌患者中，IL-1B-511基因型CC、CT、rlT分别占18．1％、48．6％和33，3％，IL-1RN等位基因检测到A1、A2、A4三种，基因型A1／A1、A1／A4、A1／A2、A2／A2分别占88．9％、1．4％、9．0％、0，7％；十二指肠溃疡患者中，IL-1B-511基因型CC、CT、TT分别占19．6％、59，8％和20．6％，IL-1RN等位基因检测到A1、A2两种，基因型A1／A1、A1／A2分别占90，2％、9，8％。（2）IL．1B-511 TT基因型在胃癌患者中的比例与在十二指肠溃疡患者中的比例差异显著（x^2=4.806，P=0．028）；不同IL-1 RN基因型在胃癌的比例与在十二指肠溃疡中的比例无统计学差异。结论福建省胃癌和十二指肠溃疡患者IL-1基因型均以IL-1B-511基因CT型、IL-1RN基因型以A1／A1为主。IL-1 B-511 TT基因型可能与福建省胃癌的高发有关。     

Effectiveness and safety of endoscopic resection for duodenal gastrointestinal stromal tumors: A single center analysis

BACKGROUNDEndoscopic resection for duodenal gastrointestinal stromal tumors (GISTs) is still considered a great challenge with a high risk of complications, including perforation, bleeding, tumor rupture, and residual tumor.AIMTo assess the effectiveness and safety of endoscopic resection for duodenal GISTs.METHODSBetween January 2010 and January 2022, 11 patients with duodenal GISTs were treated with endoscopic resection. Data were extracted for the incidence of complete resection, bleeding, perforation, postoperative infection, recurrence, and distant metastasis.RESULTSThe incidence of successful complete resection of duodenal GISTs was 100%. Three cases (27.3%) had suspected positive margins, and the other 8 cases (72.7%) had negative vertical and horizontal margins. Perforation occurred in all 11 patients. The success rate of perforation closure was 100%, while 1 patient (9.1%) had suspected delayed perforation. All bleeding during the procedure was managed by endoscopic methods. One case (9.1%) had delayed bleeding. Postoperative infection occurred in 6 patients (54.5%), including 1 who developed septic shock and 1 who developed a right iliac fossa abscess. All 11 patients recovered and were discharged. The mean hospital stay was 15.3 d. During the follow-up period (14-80 mo), duodenal stenosis occurred in 1 case (9.1%), and no local recurrence or distant metastasis were detected.CONCLUSIONEndoscopic resection for duodenal GISTs appears to be an effective and safe minimally invasive treatment when performed by an experienced endoscopist.     

Efficacy of Helicobacter pylori eradication for the prevention of metachronous gastric cancer after endoscopic resection for early gastric cancer

Helicobacter pylori(H.pylori)plays an important role in gastric carcinogenesis,as the majority of gastric cancers develop from H.pylori-infected gastric mucosa.The rate of early gastric cancer diagnosis has increased in Japan and Korea,where H.pylori infection and gastric cancer are highly prevalent.Early intestinal-type gastric cancer without concomitant lymph node metastasis is usually treated by endoscopic resection.Secondary metachronous gastric cancers often develop because atrophic mucosa left untreated after endoscopic treatment confers a high risk of gastric cancer.The efficacy of H.pylori eradication for the prevention of metachronous gastric cancer remains controversial.However,in patients who undergo endoscopic resection of early gastric cancer,H.pylori eradication is recommended to suppress or delay metachronous gastric cancer.Careful and regularly scheduled endoscopy should be performed to detect minute metachronous gastric cancer after endoscopic resection.     

改良支气管残端闭合法对支气管胸膜瘘的预防

目的通过改良肺切除支气管残端处理方法,减少支气管胸膜瘘(BPF)等并发症的发生。方法我科完成各种肺叶或全肺切除患者239例,分为实验组(163例),采用缝合器+连续往返交叉缝合改良技术,对照组(76例),采用间断缝合,或直线缝合器缝合,或者腔外双重结扎的传统方法,比较两组BPF、脓胸、早期刺激性咳嗽、咳血、术后早期漏气等临床指标。结果实验组163例,发生BPF仅1例(0.61%),对照组76例,发生BPF3例(3.94%),两组比较具有显著的统计学差异(P0.05)。其他并发症发生率较对照组均有明显减少,两组比较具有统计学差异(P0.05)。结论该方法效果明显,简单易行,费用低廉,特别适合基层医院应用。