Penetration of cryotherapy in treatment after shoulder arthroscopy

The authors describe the case of a female patient affected with large symptomatic gastric leiomyoma, six centimeters in diameter, who presented to clinical observation referring gastric pain and melena. The first gastroscopy showed massive bleeding from a submucosal gastric lesion. The lesion was not endoscopically resectable and the injective endoscopic treatment of bleeding failed. The patient was surgically treated with laparotomic excision of the leiomyoma. She was back home in ten days. The authors describe this case to discuss the possibility to resect large gastric leiomyomas using endoscopic resection indeed surgical approach. They also enhance the validity of surgical treatment for its safety and radical approach to large lesions.     

A case of esophageal cancer required jejunal reconstruction because of a gastric ulcer scar

Recently, with increase of number of esophagectomy for esophageal cancer, the cases having the lesion in the organs for esophageal substitute have been increasing. The case of esophageal cancer, required reconstruction using the pedicled jejunum, because of impaired submucosal blood perfusion of the stomach caused by a ulcer scar, was reported. The patient was a 72-year-old female, with the ulcerative and infiltrative cancer lesion in the anterior wall of the mid-thoracic esophagus. Barium swallow revealed shortening of the lesser curvature and indentation of the greater curvature of the stomach. Endoscopy showed the lesion occupying anterior two thirds of the esophageal wall circumferentialy from 30 to 34 cm from the incisor tooth. The lineal scar of ulcer on the lesser curvature of the body of the stomach was also found. Following esophagectomy through right thoracotomy, the stomach was mobilized for reconstruction by dividing left gastric artery and short gastric artery, but the stomach oral to the ulcer scar became ischemic and bleeding was not found at the tip of the stomach. Therefore, reconstruction was performed using the pedicled jejunum through antesternal route. The gastric cardia is rich in the vascular network in the submucosal layer. The ulcer or ulcer scar of this region can cause ischemia in the tip of the gastric tube for esophageal substitute. Care should be taken to detect the ulcer lesion at the stomach preoperatively. In the case with the ulcer lesion blood supply to the tip of the gastric tube should be critically evaluated.     

Two cases of gastric involvement of esophageal cancer: intramural metastasis and intramural lymph node metastasis

Cases of esophageal cancer with intramural metastasis to the stomach and esophageal cancer with metastasis to an intramural lymph node of the stomach are herein reported. The former patient was a 52 year-old male. Squamous cell carcinoma (SCC) of the lower esophagus with an intramural metastasis located at the gastric cardia and a small leiomyoma at the fornix were resected. The latter patient was a 70 year-old female. SCC of the lower esophagus and an intramural lymph node metastasis located at the anterior wall of the gastric cardia were resected. The patient died nevertheless of multiple liver metastases. These gastric involvements were detectable by endoscopy before surgery. The clinicopathological features of these esophageal cancers were characterized; the sites were the lower part of the esophagus, and extreme lymphatic and vascular invasions were shown histologically. The gastric tumors were located in the upper third of the stomach, and the findings revealed submucosal tumors. It is therefore important to discriminate other gastric tumors, and to resect them simultaneously with esophageal cancer when a gastric tube has been used for reconstruction after esophagectomy.     

A case of advanced gastric cancer resembling submucosal tumor of the stomach

We report a case of primary gastric carcinoma with a macroscopic appearance indistinguishable from that of a submucosal tumor. A 48-year-old man visited our hospital with a chief complaint of epigastric discomfort. Endoscopic examination revealed a protruding lesion with a well defined margin on the anterior wall of the gastric antrum. Most of the tumor surface was covered with apparently normal gastric mucosa and a shallow recess with mild erosion was observed on the top. Abdominal ultrasonography showed a hypoechoic lesion with an irregular margin under the gastric mucosa. Laboratory examination revealed an elevated CA19-9 level of 106.9 U/ml. In spite of repeated bouling biopsies, no histological diagnosis could be obtained before surgery. However, gastrectomy with regional lymph node dissection was performed because of the high likelihood of gastric cancer, in view of the markedly elevated CA19-9 level and irregular tumor margin demonstrated by abdominal ultrasonography. The tumor was diagnosed histologically as papillo-tubular adenocarcinoma invasive to the serosa with marked vessel infiltration. No metastasis was found in the regional lymph nodes. Gastric cancer resembling submucosal tumor is rare and often difficult to diagnose. Careful estimation of the possibility of gastric cancer and the informed consent of the patient are critically important, in cases of suspected primary gastric cancer resembling submucosal tumor, in order to decide the form of treatment.     

Gastric leiomyosarcoma mimicking a cystic tumor at the pancreatic tail--one case report

A 73 year-old female patient suffered from anemia and a palpable abdominal mass. Abdominal ultrasonography and magnetic resonance imaging revealed a lesion with papillary excrescences at the pancreatic tail. Endoscopic retrograde cholangiopancreatography showed a normal pancreatic duct, but a small submucosal tumor was found in the stomach incidentally. Laparotomy disclosed an exophytic tumor arising from the submucosal layer of the stomach. Pathology revealed a gastric leiomyosarcoma with remarkable liquefaction and cystic change. Gastric leiomyosarcoma can be so necrotic as to be mistaken for a cystic tumor. It is critically important to differentiate the peripancreatic cystic lesion because the treatment strategy is totally different.     

Comment. Sensory testing of the hands in leprosy

Early gastric cancer is now treated successfully by endoscopic mucosal resection (EMR). This technique, however, is not indicated when the tumoral lesion is located near the esophagogastric (EG)-junction, on the lesser curvature, or in the upper body or near the pylorus ring, and not indicated when the tumor size is greater than 20 mm. For these cases, we have developed what we term, "transgastrostomal endoscopic surgery" (TGES), using a Buess-type scope system. The aim of this study was to evaluate the efficacy of this technique in the treatment of those gastric cancers that could not be treated by EMR. In 4 patients selected for TGES, a Buess-type tube (external diameter: 40 mm) was inserted into the stomach through a temporary gastrostoma, and the whole operation was performed through the Buess-tube, using a video-camera for visualization. Using electrocautery scissors and forceps, complete resection of each lesion was performed, and the wound was closed by sutures. The average operation duration was 195 (130-240) minutes and the average blood loss was 59 (30-100) ml. The average size and margin of the resected specimens were 48 (30-59) and 13 (5-23) mm respectively. TGES is a substitutive, minimally invasive surgery to treat an early gastric cancer for which EMR would be difficult. This technique appeared to be simpler and easier than that of laparoscopic resection especially for a lesion on the posterior side of the stomach.     

Comparison of two different trauma assessment scores in predicting trauma outcome

We treated two patients with gastric cancer for whom surgery was delayed and the natural course of the tumor could be observed pre and postoperatively. A 70-year-old man with a well differentiated adenocarcinoma in the upper portion of the stomach underwent resection 6 years after the clinical diagnosis. Despite extension upwards towards the lower esophagus during a 6-year period, the tumor could be resected. In a poorly differentiated adenocarcinoma in the lower third of the stomach in a 40-year-old woman, the primary lesion was not distinct on the upper GI series done 6 months before, while at the time of laparotomy, disseminating metastases and pancreas invasion made it impossible to resect the stomach together with the tumor. The tumor in the man had a low DNA ploidy, while the lesion in the woman was characterized by a high ploidy. These findings show the distinct difference in the biological behavior of the tumor in these two patients. The possible correlation between DNA content with speed of growth warrants further attention.     

Curative laparoscopic surgery for early gastric cancer: five years experience

Sixty-one patients who were diagnosed with mucosal gastric cancer have been successfully treated with two laparoscopic techniques at our institute from March 1992 to March 1997. One is laparoscopic wedge resection of the stomach using a lesion-lifting method for lesions of the anterior wall, the lesser curvature, and the greater curvature of the stomach. The other is laparoscopic intragastric mucosal resection for lesions of the posterior wall of the stomach and near the cardia or the pylorus. Indications are as follows: (1) preoperatively diagnosed mucosal cancer; (2) <25 mm diameter elevated lesions; and (3) <15 mm diameter depressed lesions without ulcer formation. Patients were discharged in 4 to 8 days uneventfully. There was no major complication or mortality. The resected specimens had sufficient surgical margins horizontally (16 +/- 5 and 8 +/- 4 mm, respectively) and vertically. In one patient histologic examination revealed slight tumor infiltration into the submucosal layer with lymphatic invasion. He underwent gastrectomy with lymph node dissection 1 month after surgery. Otherwise, histologic examination revealed curative surgery. All patients in the series have survived during the 4- to 65-month follow-up period. There have been two recurrences in the series, both of which were found near the staple line 2 years after the initial surgery and were still mucosal lesions. They were successfully treated by open gastrectomy and laser irradiation. A separate early gastric cancer was found 2 years after the initial surgery in one patient, who then underwent curative open gastrectomy. In conclusion, if the patients are selected properly, these laparoscopic procedures are curative, minimally invasive treatment for early gastric cancer.     

Diffuse cystic malformation and neoplasia-associated cystic formation in the stomach. Endosonographic features and diagnosis of tumor depth

We have evaluated the endoscopic ultrasonography (EUS) features of cystic malformation of the stomach and the depth of associated neoplasia. We included 15 patients with multiple cystic components identified on EUS: 6 patients with multiple cysts restricted focally to gastric neoplasia and 9 patients with diffusely distributed cysts. We categorized the former findings as focal cystic malformation (FCM), and the latter as diffuse cystic malformation (DCM) of the stomach and reviewed the endosonographic features. Both FCM and DCM tended to show male preponderance and develop in older patients. Cystic changes in FCM extended from the neoplastic lesion to the submucosa regardless of the location in the stomach. Diffuse cystic malformation was located predominantly in the gastric body and mainly was shown as the thickened submucosa and/or deep mucosa with multiple cystic components. The boundary between the mucosal layer or the tumor echo and the submucosal layer was indistinct in eight patients, which led to a lower accuracy in EUS diagnosis of tumor depth. Diffuse cystic malformation has characteristic EUS features and occasionally is accompanied by gastric neoplasia. Endoscopic ultrasonography is inaccurate in determining tumor depth when multiple submucosal cysts are present.     

Pathological appearance of the stomach after endoscopic mucosal resection for early gastric cancer

BACKGROUND: The pathological findings of the resected stomach after endoscopic mucosal resection (EMR) for early gastric cancer were reviewed. EMR was indicated when a lesion consisting of well or moderately differentiated adenocarcinoma had a diameter of less than 2 cm. METHODS: Of 39 patients with early gastric cancer were treated with EMR between 1990 and 1995, 11 required additional surgery. RESULTS: Malignant tissue in the gastric wall was completely removed in four patients, while cancer cells remained in the mucosa adjacent to the scar in five and infiltrated into the submucosa in two. Most of these residual cancers were characterized by a lesion with a diameter exceeding 15 mm and by the location in the body or cardia of the stomach. Lymph node metastases were observed in one patient whose carcinoma invaded the deeper submucosal layer. Assessment of the depth of entire invasion from the endoscopically-resected specimen was correct for six of 11 patients. CONCLUSION: Gastric carcinomas to be resected by EMR should be smaller, especially if located in the body or cardia. Accurate diagnosis of the width and depth of invasion is indispensable before proceeding to EMR. Surgery may be the treatment of choice when there is submucosal invasion.     

T-cell response to HIV in natural infection: optimized culture conditions for detecting responses to gag peptides

We report a case of successful laparoscopic resection of a solitary schwannoma of the gastric fundus performed on emergency. The patient was a 52-year-old man who presented with an upper gastrointestinal hemorrhage. At admission, the endoscopy and hydro-CT scan showed a submucosal tumor, 2.5 cm in maximum diameter, with an area of central ulceration arising from the anterior wall of the gastric fundus. A wedge laparoscopic resection of the gastric wall was performed under endoscopic guidance. The defect in the anterior wall was repaired in part by linear stapler and in part using a continuous suture. The postoperative recovery was uneventful and the patient was discharged on the 4th postoperative day. Laparoscopic approach represents a safe and efficient approach for the treatment of benign tumors of the stomach, also on emergency basis.     

Compression filming with high-density barium suspensions

A method is described for use of high-density barium suspension (250% wt/vol) during compression filming performed in conjunction with the double-contrast examination of the stomach. The technique employs control of the distribution of barium within the stomach by table tilting and use of the vertebral column to stabilize the posterior wall of the stomach. The technique allows routine demonstration of the area gastricae and gastric erosions on compression films, as well as detection of anterior wall lesions that may be undetected by double-contrast films.     

Quantification of exercise-induced pulmonary haemorrhage with bronchoalveolar lavage

Primary liposarcoma of the stomach is rare and only seven cases have been described in the English literature. Here we report the eighth case, which occurred in a 68-year-old woman who presented with repeated tarry stools and hematemesis. Endoscopic examination revealed a large ulcerated submucosal mass at the gastric angle. The patient was treated by total gastrectomy. On microscopic examination, the tumor showed the features of a well differentiated sclerosing liposarcoma. Immunohistochemically, many spindle to stellate tumor cells were diffusely positive for vimentin and CD34. Positivity for S-100 protein was found in the adipocytic component, including lipoblasts, in addition to some spindle-shaped tumor cells. On ultrastructural examination, the spindle to stellate cells had features characteristic of fibroblasts. No recurrence or metastasis was seen during 13 months. Liposarcoma of the stomach has to be considered in the differential diagnosis with other submucosal lesions, such as gastric lipoma and gastrointestinal stromal tumor.     

Cystic lymphangioma of the colon. Endoscopic and histologic features

Cystic lymphangiomas are rare benign tumors of the gastrointestinal tract. Such a lesion was found in the colon of a man who presented with diarrhea and rectal bleeding. The colonoscopic appearances of a smooth, soft polypoid lesion on a broad base should alert the clinician to suspect such a lesion. Histologically the lesion is characterized by submucosal lymphatic spaces with a smooth muscle component in the wall. Though colonoscopic excision, injection, or rupture of the cyst have been advocated as possible modes of treatment, surgical excision is still considered to be the treatment of choice.     

"Cre"-ating mouse mutants-a meeting review on conditional mouse genetics

BACKGROUND: The antireflux capacity of various gastric fundoplications combines the creation of a valve (flapper or nipple) with recreation of a sharp cardioesophageal angle. Experimental comparison of valve competency and appropriate valve geometry is incomplete despite wide application of these techniques. Our primary aim was to compare the competency of several antireflux valves in explanted cadaver stomachs. Our secondary aim was to understand better the geometry of the gastric fundus in empty and full stomachs. METHODS: Stomachs with 6-8 cm of distal esophagus were harvested from 18 fresh cadavers. With the stomach empty, the greater and lesser curvature length and the transverse dimensions of the anterior and posterior surface of the stomach in the fundus, body, and antrum were measured. The pylorus was tied off over a catheter; the stomachs were inflated with water; and reflux occurred. Intragastric pressure was measured during inflation with a needle inserted in the side of the stomach. A clamp was then placed on the esophagus, and the stomach was inflated to a pressure of 10 mmHg. Gastric measurements were recalculated in the distended stomach. The stomachs were deflated, the clamp removed, and a 2-cm Nissen fundoplication as well as 270 degrees and 180 degrees posterior fundoplications were performed over a 60 Fr dilator. The stomachs were reinflated while the pressure was transduced. The inflation was stopped when reflux occurred or when the fundoplication disrupted. RESULTS: The stomachs expanded symmetrically when filled with water except for the fundus in which the anterior gastric wall lengthened by more than 100% and the posterior gastric wall lengthened by about 50%. In the untreated stomachs, reflux occurred at a pressure of 3.0 +/- 1.0 mmHg. After fundoplication, reflux never occurred, but the sutures pulled out of the stomach or esophagus at 28.6 +/- 16.8 mmHg. Posterior fundoplications refluxed water in several stomachs. CONCLUSIONS: When filled, the anterior fundus expands to a greater degree than the posterior fundus, offering more tissue for creation of floppy fundoplication. The "floppy" Nissen fundoplication is completely competent, suffering a degradation before allowing reflux. The posterior partial fundoplication is unpredictable in its competency.     

A case of thoracoscopic pulmonary lobectomy for lung cancer

A case of thoracoscopic right lower pulmonary lobectomy is reported. A 79-year-old man was admitted to our hospital after the accidental finding of a right pulmonary growth. A computed tomography (CT) scan of the thorax confirmed the presence of a neoplasm, 2.5 cm in diameter, at the posterior-basal segment of the right lower lobe. Considering the general condition of the patient and the characteristics of the lesion, we decided to perform a assess the possibility of a thoracoscopic lobectomy instead of the traditional posterolateral approach. The pulmonary artery was dissected with the new endoscopic cherry dissector, and ligated with the polyester suture material and Endo Clip then dived with Endo scissors. The lower pulmonary vein was dissected with this endoscopic cherry dissector and divided with Endo GIA 30 clamping the new thoracoscopic De Bakey type vascular clamp. The specimen was extracted through the minimal thoracotomy (15 cm). The postoperative course was uneventful with minimal postoperative pain, and the patient was discharged after complete surgical recovery with excellent functional and cosmetic results.     

Sonographically guided intravascular biopsy of an intraluminal mass in the inferior vena cava

In a 48-year-old Japanese man there was an uncontrollable and recurrent bleeding from a gastric ulcer and laparoscopic surgery was done. Two cannulae were placed in the gastric cavity through the abdominal wall and suture ligation of the bleeding vessel at the posterior wall of the stomach was done under video-visual control with endoscopic guidance. The bleeding ceased, complications were nil, and he remains well. This article reports on surgery done to repair uncontrollable, recurrent bleeding from a gastric ulcer. Two cannulae were placed in the gastric cavity through the abdominal wall and suture of the vessel at the posterior wall of the stomach was done with videovisual control and endoscopic guidance. This approach is concluded to have supplied minimal-access surgery, cost effectiveness, early discharge, less pain, and doctor-patient satisfaction.     

Adverse reactions associated with autologous blood transfusion: evaluation and incidence at a large academic hospital

Malignant fibrous histiocytoma (MFH) in the stomach is very rare, and only four cases have been reported. As a result, there is still little understanding of its clinical and pathological features. We recently experienced two cases of gastric MFH. The first case was a 78-year-old man with epigastralgia and a loss of body weight. Endoscopy revealed an ulcerated submucosal tumor. A gastrectomy was performed and the diagnosis of MFH was made histopathologically. The second case was a 77-year-old man with pulmonary symptoms. An image diagnosis indicated a strong suspicion of lung cancer, and a right middle and lower lobectomy was thus performed. One month after the operation, a bleeding gastric tumor was found and therefore a gastrectomy was performed. Both tumors were diagnosed as MFH. From the analysis of six reported cases including ours, a preoperative correct diagnosis is found to be difficult although the lesion has grown to a considerable size at the time of operation. Since a metastatic lung lesion was first detected in two out of six cases, it is thus recommended that the stomach should be examined when lung MFH is found. Considering the high mortality and the short survival in the six cases, the prognosis for gastric MFH seems to be poorer than that in the extremities. However, lymph node metastasis is uncommon, and a curative resection is possible in some cases such as in our second case.     

Intraluminal duodenal diverticulum with malposition of the ampulla of Vater

Intraluminal duodenal diverticulum is a rare congenital anomaly, sometimes associated with malposition of the ampulla of Vater. When the diverticulum is excised, the position of the ampulla should be determined carefully to avoid injury to pancreaticobiliary ducts. We report two patients with symptomatic intraluminal duodenal diverticulum and malposition of the ampulla. The ampulla was located on the rim of the diverticulum in one patient; in the others, the ampullary site was the posterior wall of the duodenum. Both patients underwent successful excision of the diverticulum without ductal injuries. As we have been unable to find any case with an ampullary location on the anterior wall of the duodenum, anterior duodenotomy followed by identification of the ampulla must precede excision of the diverticulum in order to avoid pancreaticobiliary ductal injuries.     

Reduced nicotinamide adenine dinucleotide phosphate-diaphorase activity in the paraventricular nucleus of the rat hypothalamus is modulated by estradiol

Leiomyomas represent 2% of gastric tumors. Commonly, gastric leiomyomas are clinically silent. Most often they become clinically apparent due to bleeding from ulceration of the overlying gastric mucosa. Surgical extirpation of the tumor is the standard treatment. Gastric leiomyomectomy was done routinely through open laparotomy until availability of laparoscopic equipment and techniques. Recently, there have been a few published reports regarding laparoscopic or laparoscopic-assisted removal of smooth muscle gastric tumors. There is little data, however, describing or discussing a laparoscopic approach to gastric leiomyomas located on the posterior gastric wall. We describe two different laparoscopic approaches to posterior wall gastric leiomyomas that we used in two patients. The postoperative recovery of both patients was remarkably quick and uneventful.