Coexistence of gastrointestinal stromal tumor,esophageal and gastric cardia carcinomas

Gastric gastrointestinal stromal tumor (GIST), esophageal squamous cell carcinoma and gastric cardia adenocarcinoma are distinct neoplasms originating from different cell layers; therefore, simultaneous development of such carcinomas is relatively rare. Auxiliary examinations revealed coexistence of esophageal and gastric cardia carcinoma with lymph node metastasis in a 77-year-old man. Intraoperatively, an extraluminal tumor (about 6.0 cm × 5.0 cm × 6.0 cm) at the posterior wall of the gastric body, a tumor (about 2.5 cm × 2.0 cm) in the lower esophagus, and an infiltrative and stenosing tumor (about 1.0 cm × 2.0 cm) in the gastric cardia were detected. Wedge resection for extraluminal gastric tumor, radical esophagectomy for lower esophageal tumor, and cardiac resection with gastroesophageal (supra-aortic arch anastomoses) were performed. Postoperative histological examination showed synchronous occurrence of gastric GIST, esophageal squamous cell carcinoma, and gastric cardia adenocarcinoma. Furthermore, immunohistochemistry indicated strong staining for c-Kit/CD117, Dog-1, Ki-67 and smooth muscle, while expression of S-100 and CD34 was negative.     

Long-term survival after enucleation of a giant esophageal gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract. Less than 1% occurs in the esophagus. Surgery is the primary treatment for patients with GISTs. We report a 29-year-old male was admitted after the detection of a posterior mediastinal mass during work-up with routine examination. He did not have any disease-related symptoms. The physical examination was unremarkable. Chest computed tomographic scan, the barium esophagogram and endoscopic esophageal ultrasound showed benign neoplasm. The patient was performed an enucleation surgery through the right posterolateral thoracotomy. The pathology revealed a 13.0 cm × 12.0 cm × 5.0 cm mass. The tumor was CD117 (C-kit), PDGFRA and DOG1 positive. These findings were consistent with a GIST of the esophagus. So the diagnosis of GIST of esophagus was confirmed. The pathological diagnosis of low grade of GIST of esophagus was confirmed. The patient has no evidence of recurrence and is in good clinical conditions up-to date, five years after surgery.     

Gastric intramural hematoma accompanied by severe epigastric pain and hematemesis after endoscopic mucosal resection

Gastric intramural hematoma is a rare injury of the stomach, and is most often seen in patients with underlying disease. Such injury following endoscopic therapy is even rarer, and there are no universally accepted guidelines for its treatment. In this case report, we describe a gastric intramural hematoma which occurred within 6 h of endoscopic mucosal resection (EMR). Past medical history of this patient was negative, and laboratory examinations revealed normal coagulation profiles and platelet count. Following EMR, the patient experienced severe epigastric pain and vomited 150 mL of gastric contents which were bright red in color. Subsequent emergency endoscopy showed a 4 cm × 5 cm diverticulum-like defect in the anterior gastric antrum wall and a 4 cm × 8 cm intramural hematoma adjacent to the endoscopic submucosal dissection lesion. Following unsatisfactory temporary conservative management, the patient was treated surgically and made a complete recovery. Retrospectively, one possible reason for the patient’s condition is that the arterioles in the submucosa or muscularis may have been damaged during deep and massive submucosal injection. Thus, endoscopists should be aware of this potential complication and improve the level of surgery, especially the skills required for submucosal injection.     

食管黏膜下肿物的特性以及超声内镜的诊断和治疗意义

背景：食管病变内镜下或手术治疗的风险均较高,术前准确判断病变的层次和性质,对决定手术的方式十分重要。目的：探讨食管黏膜下肿物的特性以及超声内镜对食管黏膜下肿物的诊断、治疗意义。方法：由内镜检查发现的116例食管黏膜下肿物患者行超声内镜检查,并给予相应的切除治疗,总结超声内镜下食管黏膜下肿物的特性。结果：超声内镜下88例（75．9％）食管黏膜下肿物的直径〈1cm,104例（89．7％）病变起源于黏膜肌层,多数（85．3％）表现为低回声或混合偏低回声的声像图。80例接受切除治疗,其中67例（83．8％）行EMR治疗,肿物直径〈1cm者占89．6％,局限于黏膜肌层占97．0％。组织病理学分析表明食管黏膜下肿物以平滑肌瘤最为常见（86．3％）。超声内镜诊断与病理诊断的符合率约为82％。结论：大多数食管黏膜肌层起源的肿物行EMR治疗简便、安全,对于较大的病灶,或起源于固有肌层者ESD仍是一种安全有效的方法。超声内镜可判断食管黏膜下肿物起源并进行定性诊断,从而指导临床合理选择黏膜下肿物的治疗方法。     

Primary hepatic neuroendocrine tumor with multiple liver metastases:A case report with review of the literature

We herein present a case involving a 41-year-old woman in whom ultrasound examination revealed multiple liver hemangiomas more than 3 years ago.Follow-up ultrasound examination revealed that the masses had significantly increased;the largest was located in the right lobe(about 8.2 cm×7.4 cm×6.0cm).Abdominal multidetector computed tomographyrevealed multiple well-circumscribed,heterogeneous,hypodense masses(largest,6.4 cm×6.3 cm×5.0cm)with significant contrast enhancement during the arterial and portal phases and with contrast washout and peripheral enhancement during the delayed phases.Magnetic resonance images demonstrated multiple well-circumscribed,heterogeneous,hypointense hepatic masses with significant contrast enhancement(largest,6.4 cm×6.5 cm×5.1 cm);multiple enlarged porta lymph nodes;and multiple s l i g h t l y e n l a rg e d re t ro p e r i t o n e a l l y m p h n o d e s.Histological and immunohistochemical examination of the right mass biopsy specimen suggested a malignant neoplasm that had originated from a neuroendocrine cell type(grade 2 well-differentiated neuroendocrine carcinoma).After performing a systemic examination to exclude metastasis from an extrahepatic primary site,we considered that the masses had arisen from a primary hepatic neuroendocrine tumor with multiple liver metastases.The patient underwent transcatheter arterial chemoembolization using a combination of oxaliplatin(150 mg)mixed with one bottle of gelatin sponge particles(560-710μm)and lipiodol(6 m L).Primary neuroendocrine tumors of the liver are extremely rare.This case is interesting because of the rarity of this neoplasm and previous misdiagnosis as multiple liver hemangiomas.Previously reported cases in the literature are also reviewed.     

Giant primary angiosarcoma of the small intestine showing severe sepsis

Primary malignant tumors of the small intestine are rare,comprising less than 2%of all gastrointestinal tumors.An 85-year-old woman was admitted with fever of 40℃ and marked abdominal distension.Her medical history was unremarkable,but blood examination showed elevated inflammatory markers.Abdominal computed tomography showed a giant tumor with central necrosis,extending from the epigastrium to the pelvic cavity.Giant gastrointestinal stromal tumor of the small intestine communicating with the gastrointestinal tract or with superimposed infection was suspected.Because no improvement occurred in response to antibiotics,surgery was performed.Laparotomy revealed giant hemorrhagic tumor adherent to the small intestine and occupying the peritoneal cavity.The giant tumor was a solid tumor weighing 3490 g,measuring24 cm×17.5 cm×18 cm and showing marked necrosis.Histologically,the tumor comprised spindle-shaped cells with anaplastic large nuclei.Immunohistochemical studies showed tumor cells positive for vimentin,CD31,and factorⅧ-related antigen,but negative for c-kit and CD34.Angiosarcoma was diagnosed.Although no postoperative complications occurred,the patient experienced enlargement of multiple metastatic tumors in the abdominal cavity and died 42 d postoperatively.The prognosis of small intestinal angiosarcoma is very poor,even after volume-reducing palliative surgery.     

Assessment of the validity of the clinical pathway for colon endoscopic submucosal dissection

AIM: To determine the effective hospitalization period as the clinical pathway to prepare patients for endoscopic submucosal dissection (ESD). METHODS: This is a retrospective observational study which included 189 patients consecutively treated by ESD at the National Cancer Center Hospital from May 2007 to March 2009. Patients were divided into 2 groups; patients in group A were discharged in 5 d and patients in group B included those who stayed longer than 5 d. The following data were collected for both groups: mean hospitalization period, tumor site, median tumor size, post-ESD rectal bleeding requiring urgent endoscopy, perforation during or after ESD, abdominal pain, fever above 38 ℃, and blood test results positive for inflammatory markers before and after ESD. Each parameter was compared after data collection. RESULTS: A total of 83% (156/189) of all patients could be discharged from the hospital on day 3 postESD. Complications were observed in 12.1% (23/189) of patients. Perforation occurred in 3.7% (7/189) of patients. All the perforations occurred during the ESD procedure and they were managed with endoscopic clipping. The incidence of post-operative bleeding was 2.6% (5/189); all the cases involved rectal bleeding. We divided the subjects into 2 groups: tumor diameter ≥ 4 cm and 4 cm; there was no significant difference between the 2 groups (P = 0.93, χ 2 test with Yates correction). The incidence of abdominal pain was 3.7% (7/189). All the cases occurred on the day of the procedure or the next day. The median white blood cell count was 6800 ± 2280 (cells/μL; ± SD) for group A, and 7700 ± 2775 (cells/μL; ± SD) for group B, showing a statistically significant difference (P = 0.023, t-test). The mean C-reactive protein values the day after ESD were 0.4 ± 1.3 mg/dL and 0.5 ± 1.3 mg/dL for groups A and B, respectively, with no significant difference between the 2 groups (P = 0.54, t -test). CONCLUSION: One-day admission is sufficient in the absence of complications during ESD or early postoperative bleeding.     

Plexiform angiomyxoid myofibroblastic tumor treated by endoscopic submucosal dissection: A case report and review of the literature

BACKGROUNDPlexiform angiomyxoid myofibroblastic tumor (PAMT) is a rare mesenchymal tumor characterized by multiple nodular plexiform growth patterns and an immunophenotype with myofibroblasts. The pathological characteristics, immunohistochemistry, diagnostic criteria, differential diagnosis, and gene-level changes of PAMT have been reported in many studies. At present, the main treatment for PAMT in the reported cases is surgery; only eight cases were treated via endoscopy (excluding 1 thoracoscopic resection), and the lesions were all smaller than 5 cm. There are no reports on the prognosis and follow-up of young patients with lesion sizes reaching 5 cm who undergo endoscopic submucosal dissection (ESD). Herein, we present the first case of a young patient with a lesion size reaching 5 cm who was diagnosed with PAMT via endoscopic submucosal dissection.CASE SUMMARYA 15-year-old young man with upper abdominal pain for 2 years presented to the Gastroenterology Department of our hospital. Painless gastroscopy showed a semicircular bulge approximately 5 cm in size in the lesser curvature near the cardia of the fundus; the surface was eroded, and shallow ulcers had formed. The pathological manifestations of the biopsy were spindle cell proliferative lesions with interstitial mucinous changes, and the surface mucosa showed chronic inflammatory changes with active lesions; immunohistochemistry showed smooth muscle actin (SMA) (+), CD117 (-), CD34 (-), DOG-1 (-), S-100 (-), and Ki67 (LI: < 1%). We performed ESD on the patient. The lesion that we removed was 5 cm × 4 cm × 2 cm in size. Pathologically, the resected tissue displayed typical manifestations, such as fat spindle-shaped fibroblasts and myofibroblast-like cells showing irregular nodular hyperplasia. Immunohistochemistry staining of the tumor cells revealed the following: CD34 (partially +), SMA (weakly +), CD117 (-), DOG-1 (-), S-100 (-), SDHB (+), PCK (-), and Ki67 (labelling index: 2%). There was no recurrence or metastasis during the 3-mo follow-up after the operation, and the treatment effect was good. We also performed a review of the literature on the clinical manifestations, pathological features, immunohistochemistry, and differential diagnosis of PAMT.CONCLUSIONAt present, the diagnostic criteria for PAMT are relatively clear, but the pathogenesis and genetic changes require further study. PAMT is benign in nature, and these patients are less likely to experience local or metastatic recurrence. The main treatment is still surgery if the lesion is in the stomach. Partial gastrectomy and distal gastrectomy are the most frequently performed surgical treatments for PAMT, followed by local resection, subtotal gastrectomy, and wedge resection. But for comprehensive evaluation of the disease, ESD can be considered a suitable method to avoid excessive treatment.     

Cavernous hemangioma of adult pancreas: A case report and literature review

Pancreatic hemangioma is a rare type of benign vascular tumor.Low clinical suspicion and inability of current cross sectional imaging techniques to differentiate it from other pancreatic lesions,contribute to the difficulty in making the correct diagnosis.Without a definitive diagnosis,and due to concern for malignancy,in many instances,surgery is performed.We report a case of pancreas cavernous hemangioma in an 18-yearold female.The patient presented with three-month history of epigastric pain.Physical examination and routine blood tests were normal.Abdominal Computed Tomography scan revealed a 5 cm × 6 cm complex nonenhancing cystic mass in the head of pancreas.Magnetic resonance imaging,endoscopic ultrasonography(EUS) and EUS guided fine needle aspiration cytology were non-diagnostic.Because of uncontrolled symptoms,the patient underwent surgical resection.Histopathology and Immunohistochemical staining confirmed the diagnosis of cavernous hemangioma of pancreas.     

Esophageal reconstruction with remnant stomach:A case report and review of literature

The number of patients developing esophageal cancer after gastrectomy has increased.However,gastric remnant is very rarely used for reconstruction in esophageal cancer surgery because of the risk of anastomotic leakage resulting from insufficient blood flow.We present a case of esophageal cancer using gastric remnant for esophageal substitution after distal gastrectomy in a 57-year-old man who presented with a 1-month history of mild dysphagia and a background history of alcohol abuse.Gastroscopy showed a 1.2 cm × 1.0 cm bulge tumor of the lower third esophagus with the upper margin located 39 cm from the dental arcade.Computed tomography of the chest showed lower third esophageal wall thickening.The patient underwent en bloc radical esophagectomy with a two-field lymph node dissection of the upper abdomen and mediastinum via a left-sided posterolateral thoracotomy through the seventh intercostal space.The upper end of the esophagus was resected 5 cm above the tumor.The gastric remnant was used for reconstruction of the esophago-gastrostomy and placed in the left thoracic cavity.The patient started a liquid diet on postoperative day 8 and was discharged on the 10 th postoperative day without complications.In this report,we demonstrate that the gastric remnant may be used for reconstruction in patients with esophageal cancer as a substitute organ after distal gastrectomy.     

Endoscopic en bloc resection of an exophytic gastrointestinal stromal tumor with suction excavation technique

Here, we report the first successful endoscopic resection of an exophytic gastrointestinal stromal tumor(GIST) using a novel perforation-free suction excavation technique. A 49-year-old woman presented for further management of a gastric subepithelial tumor on the lesser curvature of the lower body, originally detected via routine upper gastrointestinal endoscopy. Abdominal computed tomography and endoscopic ultrasound showed a 4-cm extraluminally protruding mass originating from the muscularis propria layer. The patient firmly refused surgical resection owing to potential cardiac problems, and informed consent was obtained for endoscopic removal. Careful dissection and suction of the tumor was repeated until successful extraction was achieved without serosal injury. We named this procedure the suction excavation technique. The tumor's dimensions were 3.5 cm × 2.8 cm × 2.5 cm. The tumor was positive for C-KIT and CD34 by immunohistochemical staining. The mitotic count was 6/50 high-power fields. The patient was followed for 5 years without tumor recurrence. This case demonstrated the use of endoscopic resection of an exophytic GIST using the suction excavation technique as a potential therapy without surgical resection.     

Endoscopic resection using band ligation for esophageal SMT in less than 10mm

AIM:To evaluate the safety and feasibility of endoscopic resection using band ligation(EMR-B) for the diagnostic and therapeutic removal of tumors located in the esophageal subepithelial region having originated from the submucosa.METHODS:From May 2009 to September 2014,after medical chart and endoscopic ultrasonography report review,a total of 15 esophageal tumors located in the submucosal layer were resected by EMR-B.Previous symptom,location,pathology,complete resection rate,incidence of complications,incidence of minor complication,size,length of procedures time and follow up months were evaluated.To evaluate local recurrence at the resection site,periodic follow-up endoscopic examination was undertaken in all of the patients.The first endoscopic examination was performed about 6 mo after the endoscopic resection.Thereafter,the endoscopic follow up were scheduled annually.RESULTS:The mean age was 50.3 ± 9.67 years.The mean tumor size was 6.93 ± 3.15 mm and most of the lesions size was between 5-10 mm in diameter(10/15,66.6%).In all patients,endoscopic en bloc resection was achieved.In one patient,the vertical margin was involved.The mean procedural time was 8.86 ± 3.66 min.In all patients,no evidence of severe complications such as perforation or bleeding occurred.Minor complications such as chest pain(2/15,13.3%) and heartburn(3/15,13.3%) were reported but they symptoms were controlled by proton pump inhibitors,ulcermin and/or analgesics.Histologic assessments of the removed specimens revealed 10 granular cell tumors(66.6%),4 leiomyomas(16.6%) and one lipoma(6.6%).No recurrence was observed during the mean follow up period of 45 ± 3.5 mo(range:5-64 mo).CONCLUSION:EMR-B might be considered safe and effective for the diagnosis and treatment of lesions measuring less than 10 mm in diameter.     

Endoscopic stenting and concurrent chemoradiotherapy for advanced esophageal cancer: a case-control study

AIM: To evaluate the role of endoscopic stenting with or without concurrent 3-dimensional conformal chemoradiotherapy (3D-CRT) in patients with inoperable esophageal cancer.METHODS: Advanced esophageal cancer patients indicated for esophagectomy received esophageal stents. A part of patients completed 3D-CRT after stenting. Efficacy was assessed by endoscopy and computed tomographic scan before and 4 wk after completion of the treatment. The median survival, 3D-CRT toxicity and complications were compared between 3D-CRT and control groups.RESULTS: From 1999 to 2008, 99 consecutive patients with T3/T4 disease and unsuitable for esophagectomy were placed with esophageal stents. Sixty-seven patients received 3D-CRT, while 36 patients treated with endoscopic stents alone were recruited as controls. After 3D-CRT treatment, the median tumor volume of 3D-CRT patients were reduced significantly from 43.7 ± 10.2 cm³ to 28.8 ± 8.5 cm³ (P < 0.05). The complete and partial response rate was 85.1%, and no response was 14.9%. After 3D-CRT, the incidence rate of T2 and T3 disease evident on CT scan increased to 78.4% while T4 decreased from 66.7% to 21.6% (P < 0.05). 3D-CRT Karnofsky Performance Status improved in 3D-CRT patients compared with the control group (P = 0.031). 3D-CRT patients had a longer survival than the control group (251.7 d vs 91.1 d, P < 0.05). And the median half-year survival rate in 3D-CRT group (91%) was higher than in the control group (50%, P < 0.05). The most common toxicity was leukocytopenia in the 3D-CRT group (46.7% vs 18.8%, P = 0.008). The control group had a higher rate of restenosis than the 3D-CRT group (81.3% vs 9.0%, P < 0.05). The rate of nephrotoxicity was increased in 3D-CRT as compared with the control group (31.3% vs 15.6%, P < 0.05).CONCLUSION: 3D-CRT can improve dysphagia in patients with inoperable esophageal carcinoma. 3D-CRT combined with stenting results in better survival as compared with endoscopic stents used alone.     

Hepatic Metastasis from Adrenocortical Carcinoma Fifteen Years after Primary Resection

We report the case of a 73-year-old man who presented with an asymptomatic hepatic mass during investigation of mild chronic obstructive pulmonary disease by a plain chest radiograph, followed by ultrasonography, which revealed a solitary hepatic lesion measuring 7.1 cm × 6.5 cm × 5.8 cm in dimension. Fine- needle aspiration of the mass revealed malignant cells compatible with hepatocellular carcinoma. Interestingly, the patient had a left adrenalectomy and complete left nephrectomy in 1987, for a non-functioning left adrenocortical carcinoma (ACC). The ACC was diagnosed as stage two, with no evidence of local invasion or distant metastases. No adjuvant therapy was recommended postoperatively. After a five-year follow-up, there was no evidence of ACC recurrence and the patient was declared cured from his ACC. The patient underwent a complete segmental resection of the right lobe of the liver successfully. The final diagnosis of the mass was a well-differentiated metastatic adrenocortical carcinoma.     

Successful removal of a giant pulmonary hamartoma coexisting with an anomalous common pulmonary venous trunk

We present an extremely rare case of a giant pulmonary hamartoma (PH) coexisting with an anomalous common pulmonary venous trunk (ACPVT). An asymptomatic 39-year-old man was referred for evaluation of a giant pulmonary lesion in his left thorax detected on chest X-ray during a routine medical examination. After clinical work-up, the patient underwent left exploratory thoracotomy. Since the extent of the tumor and coexistence of an ACPVT, a left pneumonectomy was performed. The specimen measured 28 cm × 18 cm × 17 cm and weighted for 2.1 kg. Histology revealed a blend of pieces of rounded cartilage separated by fibrous bands in which mature adipose tissue and cleft-like structures lined. The features were consistent with those of a chondromatous hamartoma. The patient made a satisfactory recovery and 10 months after the operation was asymptomatic.     

Correlations between endoscopic and clinical disease activity indices in intestinal Behcet's disease

AIM:To develop a novel endoscopic severity model of intestinal Behcet's disease(BD) and to evaluate its feasibility by comparing it with the actual disease activity index for intestinal Behcet's disease(DAIBD).METHODS:We reviewed the medical records of 167 intestinal BD patients between March 1986 and April 2011.We also investigated the endoscopic parameters including ulcer locations,distribution,number,depth,shape,size and margin to identify independent factors associated with DAIBD.An endoscopic severity model was developed using significant colonoscopic variables identified by multivariate regression analysis and its correlation with the DAIBD was evaluated.To determine factors related to the discrepancy between endoscopic severity and clinical activity,clinical characteristics and laboratory markers of the patients were analyzed.RESULTS:A multivariate regression analysis revealed that the number of intestinal ulcers(≥ 2,P = 0.031) and volcanoshaped ulcers(P = 0.001) were predictive factors for the DAIBD.An endoscopic severity model(Y) was developed based on selected endoscopic variables as follows:Y = 47.44 + 9.04 × non-Ileocecal area + 11.85 ×≥ 2 of intestinal ulcers + 5.03 × shallow ulcers + 12.76 × deep ulcers + 4.47 × geographicshaped ulcers + 26.93 × volcano-shaped ulcers + 8.65 ×≥ 20 mm of intestinal ulcers.However,endoscopic parameters used in the multivariate analysis explained only 18.9% of the DAIBD variance.Patients with severe DAIBD scores but with moderately predicted disease activity by the endoscopic severity model had more symptoms of irritable bowel syndrome(21.4% vs 4.9%,P = 0.026) and a lower rate of corticosteroid use(50.0% vs 75.6%,P = 0.016) than those with severe DAIBD scores and accurately predicted disease by the model.CONCLUSION:Our study showed that the number of intestinal ulcers and volcano-shaped ulcers were predictive factors for severe DAIBD scores.However,the correlation between endoscopic severity and DAIBD(r = 0.434) was weak.     

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC pa     

Recurrent acute pancreatitis secondary to a duodenal duplication cyst in an adult. A case report and literature review

Duodenal duplication cysts are rare congenital abnormalities that are most commonly diagnosed in infancy and childhood. However, in rare cases, the lesion can remain asymptomatic until adulthood. An extremely rare case of a previously healthy adult patient with recurrent acute pancreatitis, who was diagnosed with a duodenal duplication cyst is presented. At laparotomy, a duplication cyst measuring 4.8 cm × 4 cm × 4 cm was found adjacent to the ampulla of Vater. A partial cyst excision and marsupialization into the duodenal lumen was performed. The patient is healthy and asymptomatic four years after surgery. The present case illustrates the necessity of considering a duodenal duplication cyst in the differential diagnosis of recurrent acute pancreatitis in previously healthy adults.     

Full-thickness excision using transanal endoscopic microsurgery for treatment of rectal neuroendocrine tumors

AIM:To assess the efficacy of full-thickness excision using transanal endoscopic microsurgery(TEM) in the treatment of rectal neuroendocrine tumors.METHODS:We analyzed the data of all rectal neuroendocrine tumor patients who underwent local full-thickness excision using TEM between December 2006 and December 2014 at our department. Data collected included patient demographics,tumor characteristics,operative details,postoperative outcomes,pathologic findings,and follow-ups. RESULTS:Full-thickness excision using TEM was performed as a primary excision(n = 38) or as complete surgery after incomplete resection by endoscopic polypectomy(n = 21). The mean size of a primary tumor was 0.96 ± 0.21 cm,and the mean distance of the tumor from the anal verge was 8.4 ± 1.4 cm. The mean duration of the operation was 57.6 ± 13.7 min,and the mean blood loss was 13.5 ± 6.6 m L. No minor morbidities,transient fecal incontinence,or wound dehiscence was found. Histopathologically,all tumors showed typical histology without lymphatic or vessel infiltration,and both deep and lateral surgical margins were completely free of tumors. Among 21 cases of complete surgery after endoscopic polypectomy,9 were histologically shown to have a residual tumor in the specimens obtained by TEM. No additional radical surgery was performed. Norecurrence was noted during the median of 3 years' follow-up.CONCLUSION:Full-thickness excision using TEM could be a first surgical option for complete removal of upper small rectal neuroendocrine tumors.